Parent Fruit and Vegetable Consumption Outcomes from the Translational 'Time for Healthy Habits' Trial: Secondary Outcomes from a Partially Randomized Preference Trial.

Healthy eating and active living interventions targeting parents of young children could have benefits for both children and parents. The aim of this study was to assess the effectiveness of two remotely delivered healthy eating and active living interventions delivered at scale to parents, in increasing parent vegetable and fruit consumption (pre-specified secondary outcomes). Parents of children aged 2-6 years residing in New South Wales, Australia (n = 458), were recruited to a partially randomized preference trial consisting of three groups (telephone intervention (n = 95); online intervention (n = 218); written material (Control) (n = 145)). This design allowed parents with a strong preference to select their preferred intervention, and once preference trends had been established, all parents that were subsequently recruited were randomized to obtain robust relative effects. Parent vegetable and fruit consumption was assessed via telephone interview at baseline and 9 months later. At follow-up, randomized parents who received the telephone intervention (n = 73) had significantly higher vegetable consumption compared to those who received the written control (n = 81) (+0.41 serves/day, p = 0.04), but there were no differences in parents allocated to intervention groups based on preference. No differences in fruit consumption were found for randomized or preference participants for either the telephone or online intervention. There may be some benefit to parents participating in the Healthy Habits Plus (telephone-based) intervention aimed at improving the eating behaviors of their children.

Telephone and Web-Based Delivery of Healthy Eating and Active Living Interventions for Parents of Children Aged 2 to 6 Years: Mixed Methods Process Evaluation of the Time for Healthy Habits Translation Trial.

BACKGROUND: Few translational trials have provided detailed reports of process evaluation results. OBJECTIVE: This study reported on findings from a mixed methods process evaluation of a large translational trial comparing 2 remotely delivered healthy eating and active living interventions with an active control, targeting parents of young children. METHODS: Mixed methods process evaluation data were collected as part of a 3-arm, partially randomized preference trial targeting parents of children aged 2 to 6 years from New South Wales, Australia. Recruitment strategies were assessed through the participant baseline questionnaire and a questionnaire completed by the health promotion staff involved in recruitment. Data on participants' intervention preferences were collected at baseline and after the intervention. Intervention acceptability and demographic data were collected via a postintervention questionnaire (approximately 3 months after baseline), which was supplemented by qualitative participant interviews. Implementation data on intervention fidelity and withdrawal were also recorded. Differences in intervention acceptability, fidelity, and withdrawal rates between telephone and web-based interventions and between randomized and nonrandomized participants were analyzed. The significance level was set at P<.05 for all tests. The interview content was analyzed, key themes were drawn from participant responses, and findings were described narratively. RESULTS: Data were collected from 458 participants in the baseline survey and 144 (31.4%) participants in the 3-month postintervention survey. A total of 30 participants completed the qualitative interviews. A total of 6 health promotion staff members participated in the survey on recruitment strategies. Most participants were recruited from Early Childhood Education and Care services. There was a broad reach of the study; however, better take-up rates were observed in regional and rural areas compared with metropolitan areas. Parents with a university education were overrepresented. Most participants preferred the web-based medium of delivery at baseline. There was high acceptability of the web-based and telephone interventions. Participants found the healthy eating content to be the most useful component of the modules (web-based) and calls (telephone). They regarded text (web-based) or verbal (telephone) information as the most useful component. A high proportion of participants completed the telephone intervention compared with the web-based intervention; however, more participants actively withdrew from the telephone intervention. CONCLUSIONS: This is one of the first studies to comprehensively report on process evaluation data from a translation trial, which demonstrated high acceptability of all interventions but a strong participant preference for the web-based intervention. This detailed process evaluation is critical to inform further implementation and be considered alongside the effectiveness outcomes.

The influence of maladaptive coping modes, resilience, and job demands on emotional exhaustion in psychologists.

Although it is well established that emotion-focused coping is associated with burnout, the schema therapy model may improve the prediction of who is most vulnerable to using emotion-focused coping and what kinds of emotion-focused coping carry the greatest risk of burnout. It is also unknown the extent to which resilience might buffer against maladaptive coping in protecting against burnout. The present study investigated whether maladaptive coping modes would incrementally predict emotional exhaustion (EE) adjusting for resilience and whether resilience might moderate the effect of maladaptive coping on EE. The possible role of maladaptive coping as a mediator of job demands on EE was also explored. Four hundred and forty-three clinical and counselling psychologists completed online measures of job demands, EE, resilience, and maladaptive coping modes. The Detached Protector mode was associated with greater EE after adjusting for resilience. Bully and Attack mode was associated with greater EE when considered separately from other coping modes but associated with decreased EE when considered together. Resilience did not moderate the effect of job demands on EE, or the effect of coping modes on EE, except for Compliant Surrenderer. Coping modes only partially mediated the effect of job demands on EE accounting for 20% or less of its effect. Maladaptive coping modes appear to make independent contributions to the risk of EE and efforts to reduce burnout in psychologists should focus dually on increasing resilience-building practices and decreasing maladaptive coping.

The effectiveness of canteen manager audit and feedback reports and online menu-labels in encouraging healthier food choices within students' online lunch orders: A pilot cluster randomised controlled trial in primary school canteens in New South Wales, Australia.

Online school canteen lunch ordering systems may offer a unique opportunity to support the implementation of school canteen nutrition polices, while delivering behavioural interventions directly to consumers to influence healthy student purchasing. This cluster randomised controlled trial aimed to test the effectiveness of a menu audit and feedback strategy alone, and in combination with online menu labels in encouraging healthier purchasing from an online school canteen ordering system. Five intervention schools received a menu audit and feedback strategy, plus online menu labels; and five control schools received a delayed menu audit and feedback strategy. Data from 19,799 student lunch orders, containing over 40,000 items were included in the evaluation. Outcomes were assessed at baseline (pre-intervention), follow-up 1 (menu audit and feedback vs control), and follow-up 2 (menu audit and feedback plus online menu labels vs menu audit and feedback alone). From baseline to follow-up 1, the menu audit and feedback strategy alone had no significant effect on the proportion of healthy ('Everyday') and less healthy ('Occasional' or 'Should not be sold') items purchased. From baseline to follow-up 2, schools that received menu audit and feedback plus online menu labels had significantly higher odds of students purchasing 'Everyday' items (OR: 1.19; p = 0.019), and significantly lower odds of students purchasing 'Occasional' (OR: 0.86; p = 0.048) and 'Should not be sold' (OR: 0.52; p < 0.001) items. Menu audit and feedback with the addition of online menu labels was effective in increasing the proportion of healthy items purchased relative to menu audit and feedback in isolation. There may be a greater role for online menu labelling as part of a suite of strategies to improve public health nutrition in schools.

Long-term Effectiveness of a Multistrategy Behavioral Intervention to Increase the Nutritional Quality of Primary School Students' Online Lunch Orders: 18-Month Follow-up of the Click & Crunch Cluster Randomized Controlled Trial.

BACKGROUND: School food services, including cafeterias and canteens, are an ideal setting in which to improve child nutrition. Online canteen ordering systems are increasingly common and provide unique opportunities to deliver choice architecture strategies to nudge users to select healthier items. Despite evidence of short-term effectiveness, there is little evidence regarding the long-term effectiveness of choice architecture interventions, particularly those delivered online. OBJECTIVE: This study determined the long-term effectiveness of a multistrategy behavioral intervention (Click & Crunch) embedded within an existing online school lunch-ordering system on the energy, saturated fat, sugar, and sodium content of primary school students' lunch orders 18 months after baseline. METHODS: This cluster randomized controlled trial (RCT) involved a cohort of 2207 students (aged 5-12 years) from 17 schools in New South Wales, Australia. Schools were randomized to receive either a multistrategy behavioral intervention or the control (usual online ordering only). The intervention strategies ran continuously for 14-16.5 months until the end of follow-up data collection. Trial primary outcomes (ie, mean total energy, saturated fat, sugar and sodium content of student online lunch orders) and secondary outcomes (ie, the proportion of online lunch order items that were categorized as everyday, occasional, and caution) were assessed over an 8-week period at baseline and 18-month follow-up. RESULTS: In all, 16 schools (94%) participated in the 18-month follow-up. Over time, from baseline to follow-up, relative to control orders, intervention orders had significantly lower energy (-74.1 kJ; 95% CI [-124.7, -23.4]; P=.006) and saturated fat (-0.4 g; 95% CI [-0.7, -0.1]; P=.003) but no significant differences in sugar or sodium content. Relative to control schools, the odds of purchasing everyday items increased significantly (odds ratio [OR] 1.2; 95% CI [1.1, 1.4]; P=.009, corresponding to a +3.8% change) and the odds of purchasing caution items significantly decreased among intervention schools (OR 0.7, 95% CI [0.6, 0.9]; P=.002, corresponding to a -2.6% change). There was no between-group difference over time in canteen revenue. CONCLUSIONS: This is the first study to investigate the sustained effect of a choice architecture intervention delivered via an online canteen ordering systems in schools. The findings suggest that there are intervention effects up to 18-months postbaseline in terms of decreased energy and saturated fat content and changes in the relative proportions of healthy and unhealthy food purchased for student lunches. As such, this intervention approach may hold promise as a population health behavior change strategy within schools and may have implications for the use of online food-ordering systems more generally; however, more research is required. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000855224; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375075.

School-Based Nutrition Interventions in Children Aged 6 to 18 Years: An Umbrella Review of Systematic Reviews.

Schools are identified as a key setting to influence children's and adolescents' healthy eating. This umbrella review synthesised evidence from systematic reviews of school-based nutrition interventions designed to improve dietary intake outcomes in children aged 6 to 18 years. We undertook a systematic search of six electronic databases and grey literature to identify relevant reviews of randomized controlled trials. The review findings were categorised for synthesis by intervention type according to the World Health Organisation Health Promoting Schools (HPS) framework domains: nutrition education; food environment; all three HPS framework domains; or other (not aligned to HPS framework domain). Thirteen systematic reviews were included. Overall, the findings suggest that school-based nutrition interventions, including nutrition education, food environment, those based on all three domains of the HPS framework, and eHealth interventions, can have a positive effect on some dietary outcomes, including fruit, fruit and vegetables combined, and fat intake. These results should be interpreted with caution, however, as the quality of the reviews was poor. Though these results support continued public health investment in school-based nutrition interventions to improve child dietary intake, the limitations of this umbrella review also highlight the need for a comprehensive and high quality systematic review of primary studies.

Translation of Two Healthy Eating and Active Living Support Programs for Parents of 2-6-Year-Old Children: Outcomes of the 'Time for Healthy Habits' Parallel Partially Randomised Preference Trial.

This translation study assessed the effectiveness of two remotely delivered healthy eating and active living interventions for parents of 2- to 6-year-old children in improving child fruit and vegetable intake, non-core food intake, body mass index (BMI), physical activity, screen time, and sleep. Parents (n = 458) were recruited to a partially randomised preference trial comprising three intervention groups. Healthy Habits Plus comprised six telephone calls, Time2bHealthy comprised six online modules, and the active control comprised ten information sheets and a summary booklet. Data were collected from parents via a telephone questionnaire at baseline and nine months post-baseline. Data were analysed for randomised participants alone (n = 240), preference participants alone (n = 218), and all participants combined (n = 458). There was no significant improvement in fruit and vegetable intake (primary outcome) when comparing the telephone and online interventions to the control. In both the randomised only and all participants combined analyses, there was a significant improvement in non-core food intake for the telephone intervention compared to the control (p < 0.001). Differences between interventions for other outcomes were small. In conclusion, the telephone and online interventions did not improve child fruit and vegetable intake relative to written materials, but the telephone intervention did improve non-core food intake.

Effectiveness of a Multistrategy Behavioral Intervention to Increase the Nutritional Quality of Primary School Students' Web-Based Canteen Lunch Orders (Click & Crunch): Cluster Randomized Controlled Trial.

BACKGROUND: School food outlets represent a key setting for public health nutrition intervention. The recent proliferation of web-based food ordering systems provides a unique opportunity to support healthy purchasing from schools. Embedding evidence-based choice architecture strategies within these routinely used systems provides the opportunity to impact the purchasing decisions of many users simultaneously and warrants investigation. OBJECTIVE: This study aims to assess the effectiveness of a multistrategy behavioral intervention implemented via a web-based school canteen lunch ordering system in reducing the energy, saturated fat, sugar, and sodium content of primary students' web-based lunch orders. METHODS: The study used a parallel-group, cohort, cluster randomized controlled trial design with 2207 students from 17 Australian primary schools. Schools with a web-based canteen lunch ordering system were randomly assigned to receive either a multistrategy behavioral intervention that included choice architecture strategies embedded in the web-based system (n=9 schools) or the standard web-based ordering system only (n=8 control schools). Automatically collected student purchasing data at baseline (term 2, 2018) and 12 months later (term 2, 2019) were used to assess trial outcomes. Primary trial outcomes included the mean energy (kJ), saturated fat (g), sugar (g), and sodium (mg) content of student lunch orders. Secondary outcomes included the proportion of all web-based lunch order items classified as everyday, occasional, and caution (based on the New South Wales Healthy School Canteen Strategy) and canteen revenue. RESULTS: From baseline to follow-up, the intervention lunch orders had significantly lower energy content (-69.4 kJ, 95% CI -119.6 to -19.1; P=.01) and saturated fat content (-0.6 g, 95% CI -0.9 to -0.4; P<.001) than the control lunch orders, but they did not have significantly lower sugar or sodium content. There was also a small significant between-group difference in the percentage of energy from saturated fat (-0.9%, 95% CI -1.4% to -0.5%; P<.001) but not in the percentage of energy from sugar (+1.1%, 95% CI 0.2% to 1.9%; P=.02). Relative to control schools, intervention schools had significantly greater odds of having everyday items purchased (odds ratio [OR] 1.7, 95% CI 1.5-2.0; P<.001), corresponding to a 9.8% increase in everyday items, and lower odds of having occasional items purchased (OR 0.7, 95% CI 0.6-0.8; P<.001), corresponding to a 7.7% decrease in occasional items); however, there was no change in the odds of having caution (least healthy) items purchased (OR 0.8, 95% CI 0.7-1.0; P=.05). Furthermore, there was no change in schools' revenue between groups. CONCLUSIONS: Given the evidence of small statistically significant improvements in the energy and saturated fat content, acceptability, and wide reach, this intervention has the potential to influence dietary choices at a population level, and further research is warranted to determine its impact when implemented at scale. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000855224; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375075. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2019-030538.

A Cluster Randomized Controlled Trial Evaluating the Impact of Tailored Feedback on the Purchase of Healthier Foods from Primary School Online Canteens.

Few online food ordering systems provide tailored dietary feedback to consumers, despite suggested benefits. The study aim was to determine the effect of providing tailored feedback on the healthiness of students' lunch orders from a school canteen online ordering system. A cluster randomized controlled trial with ten government primary schools in New South Wales, Australia was conducted. Consenting schools that used an online canteen provider ('Flexischools') were randomized to either: a graph and prompt showing the proportion of 'everyday' foods selected or a standard online ordering system. Students with an online lunch order during baseline data collection were included (n = 2200 students; n = 7604 orders). Primary outcomes were the proportion of foods classified as 'everyday' or 'caution'. Secondary outcomes included: mean energy, saturated fat, sugar, and sodium content. There was no difference over time between groups on the proportion of 'everyday' (OR 0.99; p = 0.88) or 'caution' items purchased (OR 1.17; p = 0.45). There was a significant difference between groups for average energy content (mean difference 51 kJ; p-0.02), with both groups decreasing. There was no difference in the saturated fat, sugar, or sodium content. Tailored feedback did not impact the proportion of 'everyday' or 'caution' foods or the nutritional quality of online canteen orders. Future research should explore whether additional strategies and specific feedback formats can promote healthy purchasing decisions.

The Effectiveness of Interventions Delivered Using Digital Food Environments to Encourage Healthy Food Choices: A Systematic Review and Meta-Analysis.

Digital food environments are now commonplace across many food service and retail settings, influencing how the population orders and accesses foods. As such, digital food environments represent a novel platform to deliver strategies to improve public health nutrition. The purpose of this review was to explore the impact of dietary interventions embedded within online food ordering systems, on user selection and purchase of healthier foods and beverages. A systematic search of eight electronic databases and grey literature sources was conducted up to October 2020. Eligible studies were randomized controlled trials and controlled trials, designed to encourage the selection and purchase of healthier products and/or discourage the selection and purchase of less-healthy products using strategies delivered via real-world online food ordering systems. A total of 9441 articles underwent title and abstract screening, 140 full-text articles were assessed for eligibility, and 11 articles were included in the review. Meta-analysis of seven studies indicated that interventions delivered via online food ordering systems are effective in reducing the energy content of online food purchases (standardized mean difference (SMD): -0.34, p = 0.01). Meta-analyses including three studies each suggest that these interventions may also be effective in reducing the fat (SMD: -0.83, p = 0.04), saturated fat (SMD: -0.7, p = 0.008) and sodium content (SMD: -0.43, p = 0.01) of online food purchases. Given the ongoing growth in the use of online food ordering systems, future research to determine how we can best utilize these systems to support public health nutrition is warranted.

Improving implementation of school-based healthy eating and physical activity policies, practices, and programs: a systematic review.

Although best practice recommendations exist regarding school-based healthy eating and physical activity policies, practices, and programs, research indicates that implementation is poor. As the field of implementation science is rapidly evolving, an update of the recent review of strategies to improve the implementation of healthy eating and physical activity interventions in schools published in the Cochrane Library in 2017 was required. The primary aim of this review was to examine the effectiveness of strategies that aim to improve the implementation of school-based policies, practices, or programs to address child diet, physical activity, or obesity. A systematic review of articles published between August 31, 2016 and April 10, 2019 utilizing Cochrane methodology was conducted. In addition to the 22 studies included in the original review, eight further studies were identified as eligible. The 30 studies sought to improve the implementation of healthy eating (n = 16), physical activity (n = 11), or both healthy eating and physical activity (n = 3). The narrative synthesis indicated that effect sizes of strategies to improve implementation were highly variable across studies. For example, among 10 studies reporting the proportion of schools implementing a targeted policy, practice, or program versus a minimal or usual practice control, the median unadjusted effect size was 16.2%, ranging from -0.2% to 66.6%. Findings provide some evidence to support the effectiveness of strategies in enhancing the nutritional quality of foods served at schools, the implementation of canteen policies, and the time scheduled for physical education.

An exploratory analysis to identify behavior change techniques of implementation interventions associated with the implementation of healthy canteen policies.

Empirical studies to disentangle the effects of multicomponent implementation interventions are needed to inform the development of future interventions. This study aims to examine which behavior change techniques (BCTs) primarily targeting canteen manager are associated with school's healthy canteen policy implementation. This is a secondary data analysis from three randomized controlled trials assessing the impact of a "high," "medium," and "low" intensity intervention primarily targeting canteen managers on school's implementation of a healthy canteen policy. The policy required primary schools to remove all "red" (less healthy items) or "banned" (sugar sweetened beverages) items from regular sale and ensure that "green" (healthier items) dominated the menu (>50%). The delivery of BCTs were retrospectively coded. We undertook an elastic net regularized logistic regression with all BCTs in a single model. Five k-fold cross-validation elastic net models were conducted. The percentage of times each strategy remained across 1,000 replications was calculated. For no "red" or "banned" items (n = 162), the strongest BCTs were: problem solving, goal setting (behavior), and review behavior goals. These BCTs were identified in 100% of replications as a strong predictor in the cross-validation elastic net models. For the outcome relating to >50% "green" items, the BCTs problem solving, instruction on how to perform behavior and demonstration of behavior were the strongest predictors. Two strategies were identified in 100% of replications as a strong (i.e., problem solving) or weak predictor (i.e., feedback on behavior). This study identified unique BCTs associated with the implementation of a healthy canteen policy.

Economic evaluation of a web-based menu planning intervention to improve childcare service adherence with dietary guidelines.

BACKGROUND: Despite the known benefits of healthy eating in childhood, few Australian childcare services provide food that is consistent with dietary guidelines. The effectiveness of a web-based menu planning intervention to increase childcare service provision of healthy foods and decrease provision of discretionary foods in long day-care services in Australia was assessed in a randomised controlled trial. Here we consider the costs, consequences, cost-effectiveness and budget impact of the intervention using data collected within the trial. METHODS: The prospective trial-based economic evaluation involved 54 childcare services across New South Wales (NSW), Australia. Services were randomised to a 12-month intervention or usual care. The intervention involved access to a web-based menu planning and decision support tool and online resources. Effectiveness measures included mean number of food groups, overall menu and individual food group compliance with dietary guidelines, and mean servings of food groups at 12 months. Costs (reported in $AUD, 2017/18) were evaluated from both health sector and societal perspectives. The direct cost to support uptake of the intervention was calculated, as were costs to each childcare service. The incremental cost of the intervention was calculated as the net difference in the cost to undertake menu planning and review plus the direct cost of the intervention. Incremental cost-effectiveness ratios (ICERs) including uncertainty intervals were estimated for differences in costs and effects between intervention and control groups. A relative value index was calculated to determine overall value for money. RESULTS: Over the 12 months of the trial, we calculated a difference in cost between usual practice and intervention groups of - $482 (95% UI - $859, - $56). While the measured increase in menu and food group compliance within the trial did not reach statistical significance, there were significant improvements in mean servings of fruit and discretionary food, represented in the cost-consequence analysis. The calculated relative value index of 1.1 suggests that the intervention returns acceptable value for money for the outcomes generated. CONCLUSION: Compared to usual practice, web-based programmes may offer an efficient and sustainable alternative for childcare services to improve the provision of healthy foods to children in their care. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12616000974404.

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

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

Nudge strategies to improve healthcare providers' implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews.

BACKGROUND: Nudge interventions are those that seek to modify the social and physical environment to enhance capacity for subconscious behaviours that align with the intrinsic values of an individual, without actively restricting options. This study sought to describe the application and effects of nudge strategies on clinician implementation of health-related guidelines, policies and practices within studies included in relevant Cochrane systematic reviews. METHODS: As there is varied terminology used to describe nudge, this study examined studies within relevant systematic reviews. A two-stage screening process was undertaken where, firstly, all systematic reviews published in the Cochrane Library between 2016 and 2018 were screened to identify reviews that included quantitative studies to improve implementation of guidelines among healthcare providers. Secondly, individual studies within relevant systematic reviews were included if they were (i) randomised controlled trials (RCTs), (ii) included a nudge strategy in at least one intervention arm, and (iii) explicitly aimed to improve clinician implementation behaviour. We categorised nudge strategies into priming, salience and affect, default, incentives, commitment and ego, and norms and messenger based on the Mindspace framework. SYNTHESIS: The number and percentage of trials using each nudge strategy was calculated. Due to substantial heterogeneity, we did not undertake a meta-analysis. Instead, we calculated within-study point estimates and 95% confidence intervals, and used a vote-counting approach to explore effects. RESULTS: Seven reviews including 42 trials reporting on 57 outcomes were included. The most common nudge strategy was priming (69%), then norms and messenger (40%). Of the 57 outcomes, 86% had an effect on clinician behaviour in the hypothesised direction, and 53% of those were statistically significant. For continuous outcomes, the median effect size was 0.39 (0.22, 0.45), while for dichotomous outcomes the median Odds Ratio was 1.62 (1.13, 2.76). CONCLUSIONS: This review of 42 RCTs included in Cochrane systematic reviews found that the impact of nudge strategies on clinician behaviour was at least comparable to other interventions targeting implementation of evidence-based guidelines. While uncertainty remains, the review provides justification for ongoing investigation of the evaluation and application of nudge interventions to support provider behaviour change. TRIAL REGISTRATION: This review was not prospectively registered.

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

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

Effectiveness of a Web-Based Menu-Planning Intervention to Improve Childcare Service Compliance With Dietary Guidelines: Randomized Controlled Trial.

BACKGROUND: Foods provided in childcare services are not consistent with dietary guideline recommendations. Web-based systems offer unique opportunities to support the implementation of such guidelines. OBJECTIVE: This study aimed to assess the effectiveness of a Web-based menu planning intervention in increasing the mean number of food groups on childcare service menus that comply with dietary guidelines. Secondary aims were to assess the impact of the intervention on the proportion of service menus compliant with recommendations for (1) all food groups; (2) individual food groups; and (3) mean servings of individual food groups. Childcare service use and acceptability of the Web-based program were also assessed. METHODS: A single-blind, parallel-group randomized controlled trial was undertaken with 54 childcare services in New South Wales, Australia. Services were randomized to a 12-month intervention or usual care control. Intervention services received access to a Web-based menu planning program linked to their usual childcare management software system. Childcare service compliance with dietary guidelines and servings of food groups were assessed at baseline, 3-month follow-up, and 12-month follow-up. RESULTS: No significant differences in the mean number of food groups compliant with dietary guidelines and the proportion of service menus compliant with recommendations for all food groups, or for individual food groups, were found at 3- or 12-month follow-up between the intervention and control groups. Intervention service menus provided significantly more servings of fruit (P<.001), vegetables (P=.03), dairy (P=.03), and meat (P=.003), and reduced their servings of discretionary foods (P=.02) compared with control group at 3 months. This difference was maintained for fruit (P=.03) and discretionary foods (P=.003) at 12 months. Intervention childcare service staff logged into the Web-based program an average of 40.4 (SD 31.8) times and rated the program as highly acceptable. CONCLUSIONS: Although improvements in childcare service overall menu and individual food group compliance with dietary guidelines were not statistically significant, findings indicate that a Web-based menu planning intervention can improve the servings for some healthy food groups and reduce the provision of discretionary foods. Future research exploring the effectiveness of differing strategies in improving the implementation of dietary guidelines in childcare services is warranted. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ANZCTR): 16000974404; http://www.anzctr.org.au/ACTRN12616000974404.aspx.

Child-level evaluation of a web-based intervention to improve dietary guideline implementation in childcare centers: a cluster-randomized controlled trial.

BACKGROUND: Although it is recommended that childcare centers provide foods consistent with dietary guidelines, the impact of implementing sector-specific guidelines on child outcomes is largely unknown. OBJECTIVES: This study aims to examine the impact of a web-based program and support to implement dietary guidelines in childcare centers on children's 1) diet; 2) BMI z scores; and 3) child health-related quality of life (HRQoL). METHODS: This study was a cluster-randomized controlled trial utilizing a Type-3 Hybrid implementation-effectiveness design conducted between October 2016 and March 2018. This study reports on child outcomes. Fifty-four childcare centers in New South Wales, Australia were randomly assigned to the intervention (a web-based menu-planning tool and support) or control group (usual care). The intervention was designed to address barriers and enablers to dietary guideline implementation according to the Theoretical Domains Framework. A quota of 35 consenting childcare centers undertook child-level evaluation of dietary intake where 522 parents consented to completing ≥1 component of data collection for their child. Child consumption of core and discretionary (unhealthy) foods while in care was assessed via dietary observations by blinded research assistants, childcare diet quality was assessed via educator-completed questionnaires, BMI z scores were assessed via measured weight and height, and child HRQoL was assessed via parent report at baseline and 12-mo follow-up. RESULTS: There was a significant increase in mean child consumption of fruit (0.39 servings; 95% CI: 0.12, 0.65 servings) and dairy foods (0.38 servings; 95% CI: 0.19, 0.57 servings) and a significant reduction in consumption of discretionary foods (-0.40 servings; 95% CI: -0.64, -0.16 servings) in care in the intervention group, relative to control at 12-mo follow-up. No significant differences were observed in diet quality, BMI z scores, or HRQoL. CONCLUSIONS: A web-based intervention to support planning of childcare menus consistent with dietary guidelines can improve child consumption of healthier foods in daycare. This trial was registered at www.anzctr.org.au as ACTRN12616000974404.

Menu planning practices in early childhood education and care - factors associated with menu compliance with sector dietary guidelines.

ISSUE ADDRESSED: Despite recommendations, early childhood education and care services do not plan menus in accordance with sector dietary guidelines. This study aimed to examine the following among Australian long day care services: (a) menu planning practices; (b) prevalence of menu compliance with sector dietary guidelines; and (c) menu planning practices associated with higher menu compliance with sector dietary guidelines. METHODS: Long day care services within Hunter New England, NSW participated in a pen and paper survey assessing menu planning practices and socio-demographic and service characteristics. Two-week menus were assessed for compliance with sector dietary guidelines, based on the number of servings of food groups and discretionary foods provided per child, per day. RESULTS: Staff from 72 services completed the survey and 69 provided their menu. Results indicated the service cook was fully responsible for planning the menu in 43% of services, and 57% had received written support to assist with menu planning. Service menus were compliant with an average of 0.68 out of six food groups and discretionary foods. In poisson regression models, a shorter menu cycle length (P = .04) and the receipt of training opportunities to support menu planning (P < .01) were significantly associated with higher menu compliance. CONCLUSIONS: Menu compliance with sector dietary guidelines is low among participating long day care services. SO WHAT?: The implementation of practices such as shortening of the menu cycle and the provision of training opportunities may assist in the planning of menus that are more compliant with dietary guidelines in this setting.