Kirsty Seward

Measuring implementation behaviour of menu guidelines in the childcare setting: confirmatory factor analysis of a theoretical domains framework questionnaire (TDFQ)

BackgroundWhile there are number of frameworks which focus on supporting the implementation of evidence based approaches, few psychometrically valid measures exist to assess constructs within these frameworks. This study aimed to develop and psychometrically assess a scale measuring each domain of the Theoretical Domains Framework for use in assessing the implementation of dietary guidelines within a non-health care setting (childcare services).MethodsA 75 item 14-domain Theoretical Domains Framework Questionnaire (TDFQ) was developed and administered via telephone interview to 202 centre based childcare service cooks who had a role in planning the service menu. Confirmatory factor analysis (CFA) was undertaken to assess the reliability, discriminant validity and goodness of fit of the 14-domain theoretical domain framework measure.ResultsFor the CFA, five iterative processes of adjustment were undertaken where 14 items were removed, resulting in a final measure consisting of 14 domains and 61 items. For the final measure: the Chi-Square goodness of fit statistic was 3447.19; the Standardized Root Mean Square Residual (SRMR) was 0.070; the Root Mean Square Error of Approximation (RMSEA) was 0.072; and the Comparative Fit Index (CFI) had a value of 0.78.ConclusionsWhile only one of the three indices support goodness of fit of the measurement model tested, a 14-domain model with 61 items showed good discriminant validity and internally consistent items. Future research should aim to assess the psychometric properties of the developed TDFQ in other community-based settings.

Multistrategy childcare-based intervention to improve compliance with nutrition guidelines versus usual care in long day care services: a study protocol for a randomised controlled trial

Introduction Interventions to improve child diet are recommended as dietary patterns developed in childhood track into adulthood and influence the risk of chronic disease. For child health, childcare services are required to provide foods to children consistent with nutrition guidelines. Research suggests that foods and beverages provided by services to children are often inconsistent with nutrition guidelines. The primary aim of this study is to assess, relative to a usual care control group, the effectiveness of a multistrategy childcare-based intervention in improving compliance with nutrition guidelines in long day care services. Methods and analysis The study will employ a parallel group randomised controlled trial design. A sample of 58 long day care services that provide all meals (typically includes 1 main and 2 mid-meals) to children while they are in care, in the Hunter New England region of New South Wales, Australia, will be randomly allocated to a 6-month intervention to support implementation of nutrition guidelines or a usual care control group in a 1:1 ratio. The intervention was designed to overcome barriers to the implementation of nutrition guidelines assessed using the theoretical domains framework. Intervention strategies will include the provision of staff training and resources, audit and feedback, ongoing support and securing executive support. The primary outcome of the trial will be the change in the proportion of long day care services that have a 2-week menu compliant with childcare nutrition guidelines, measured by comprehensive menu assessments. As a secondary outcome, child dietary intake while in care will also be assessed. To assess the effectiveness of the intervention, the measures will be undertaken at baseline and ∼6 months postbaseline. Ethics and dissemination The study was approved by the Hunter New England Human Research Ethics Committee. Study findings will be disseminated widely through peer-reviewed publications.

A pragmatic randomised controlled trial of an implementation intervention to increase healthy eating and physical activity-promoting policies, and practices in centre-based childcare services: study protocol

Background Promotion of healthy eating and physical activity in early childhood is recommended as a global chronic disease prevention strategy. Centre-based childcare services represent a promising setting to provide children with opportunities to improve healthy eating and physical activity. Evidence to inform implementation of childcare obesity prevention guidelines into routine practice in childcare, however, is lacking. This study aims to assess the effectiveness of an intervention, delivered to childcare staff, aiming to increasing service implementation of healthy eating and physical activity-promoting policies and practices. Methods and analysis A pragmatic parallel group randomised controlled trial will be undertaken with 165 childcare services in the Hunter New England region of New South Wales, Australia. Services will be randomised to receive either a 10-month evidence-based performance review intervention with other resources to support practice change, or to a waitlist control group. The primary trial outcome is the proportion of services implementing all of the following recommended healthy eating and physical activity promoting practices: written nutrition, physical activity and small screen recreation policies; providing information to families regarding healthy eating (including breastfeeding), physical activity and small screen time; providing twice weekly healthy eating learning experiences to children; providing water and only plain milk to children; providing fundamental movement skills activities for children every day; and limiting and using electronic screen time more for educational purposes and learning experiences. Effectiveness will be assessed using a telephone interview of practice implementation with childcare staff at baseline and 12 months following baseline. Ethics and dissemination The study was approved by the Hunter New England Human Research Ethics Committee and the University of Newcastle Human Research Ethics Committee. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. Trial registration number Australian New Zealand Clinical Trials Registry ACTRN12614000972628.

A randomised controlled trial of an online menu planning intervention to improve childcare service adherence to dietary guidelines: a study protocol

Introduction The implementation of dietary guidelines in childcare settings is recommended to improve child public health nutrition. However, foods provided in childcare services are not consistent with guidelines. The primary aim of the trial is 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 regarding food provision to children in care. Methods and analysis A parallel group randomised controlled trial will be undertaken with 54 childcare services that provide food to children within New South Wales, Australia. Services will be randomised to a 12-month intervention or usual care. The experimental group will receive access to a web-based menu planning and decision support tool and online resources. To support uptake of the web program, services will be provided with training and follow-up support. The primary outcome will be the number of food groups, out of 6 (vegetables, fruit, breads and cereals, meat, dairy and ‘discretionary’), on the menu that meet dietary guidelines (Caring for Children) across a 1-week menu at 12-month follow-up, assessed via menu review by dietitians or nutritionists blinded to group allocation. A nested evaluation of child dietary intake in care and child body mass index will be undertaken in up to 35 randomly selected childcare services and up to 420 children aged approximately 3–6 years. Ethics and dissemination Ethical approval has been provided by Hunter New England and University of Newcastle Human Research Ethics Committees. This research will provide high-quality evidence regarding the impact of a web-based menu planning intervention in facilitating the translation of dietary guidelines into childcare services. Trial findings will be disseminated widely through national and international peer-reviewed publications and conference presentations. Trial registration Prospectively registered with Australian New Zealand Clinical Trial Registry (ANZCTR) ACTRN12616000974404.

A theory-based evaluation of a dissemination intervention to improve childcare cooks’ intentions to implement nutritional guidelines on their menus

BackgroundChildcare services represent a key setting to implement nutritional interventions to support the development of healthy eating behaviours in young children. Childcare-specific nutritional guidelines outlining recommendations for provision of food in care have been developed. Despite this, research suggests that few childcare services currently implement these guidelines. This study aimed to examine the impact of providing printed educational materials on childcare service cooks’ intentions to use nutritional guidelines and provide fruit and vegetables on their menu.FindingsA randomised controlled trial was conducted with 77 childcare services (38 control and 39 intervention). Intervention service cooks were mailed a two-page educational material together with a menu planning checklist. Intervention development and evaluation was guided by the theory of planned behaviour. Outcome data assessing intentions to use nutritional guidelines and serves of fruit and vegetables provided on menus (primary outcomes) as well as secondary outcomes (attitudes, behavioural regulation and social norms) were collected via a telephone interview with cooks. Relative to the comparison group, cooks in the intervention arm had significantly higher intentions to use the guidelines (p value 0.0005), accompanied by significant changes in perceived behavioural control (p value 0.0008) and attitudes (p value 0.0071). No significant difference in serves of fruit (p value 0.7278) and vegetables (p value 0.0573) was observed.ConclusionsThe use of educational materials can improve childcare service cooks’ intentions to use nutritional guidelines; however, as a standalone strategy, it may not improve provision of food on menus.

Improving the implementation of nutrition guidelines in childcare centres improves child dietary intake: findings of a randomised trial of an implementation intervention

OBJECTIVE Evidence suggests that improvements to the childcare nutrition environment can have a positive impact on child dietary intake. The primary aim of the present study was to assess, relative to usual care, the effectiveness of a multi-strategy implementation intervention in improving childcare compliance with nutrition guidelines. As a secondary aim, the impact on child dietary intake was assessed. DESIGN Parallel-group, randomised controlled trial design. The 6-month intervention was designed to overcome barriers to implementation of the nutrition guidelines that had been identified by applying the theoretical domains framework. SETTING Hunter New England region, New South Wales, Australia. SUBJECTS Forty-five centre-based childcare services. RESULTS There were no differences between groups in the proportion of services providing food servings (per child) compliant with nutrition guideline recommendations for all five (5/5) food groups at follow-up (i.e. full compliance). Relative to control services, intervention services were more likely to be compliant with guidelines (OR; 95 % CI) in provision of fruit (10·84; 1·19, 551·20; P=0·0024), meat and meat alternatives (8·83; 1·55, -; P=0·023), dairy (8·41; 1·60, 63·62; P=0·006) and discretionary foods (17·83; 2·15, 853·73; P=0·002). Children in intervention services consumed greater servings (adjusted difference; 95 % CI) of fruit (0·41; 0·09, 0·73; P=0·014) and vegetables (0·70; 0·33, 1·08; P<0·001). CONCLUSIONS Findings indicate that service-level changes to menus in line with dietary guidelines can result in improvements to childrens dietary intake. The study provides evidence to advance implementation research in the setting as a means of enhancing child public health nutrition.

Barriers and Enablers to Implementation of Dietary Guidelines in Early Childhood Education Centers in Australia: Application of the Theoretical Domains Framework

Objective: To identify perceived barriers and enablers to implementation of dietary guidelines reported by early childhood education center cooks, and barriers and enablers associated with greater implementation based on assessment of center menu compliance. Design: Cross‐sectional telephone interview. Setting: Early childhood education centers, New South Wales, Australia. Participants: A total of 202 cooks responsible for menu planning; 70 centers provided a menu for review of compliance with dietary guidelines. Main Outcome Measure: Barriers and enablers to dietary guideline implementation were determined using a tool assessing constructs of the Theoretical Domains Framework (TDF). Higher scores (≥6) for each construct indicated enablers to guideline implementation; lower scores (<6) suggested barriers. Analysis: Multivariable linear regression identified TDF constructs associated with greater guideline implementation. Results: Scores were lowest for reinforcement (mean, 5.85) and goals (mean, 5.89) domains, and highest for beliefs about consequences (mean, 6.51) and social/professional role and identity (mean, 6.50). The skills domain was positively associated with greater implementation of guidelines based on menu review (P = .01). Conclusions and Implications: Cooks perceived social/professional role and identity, and beliefs about consequences to be enablers to dietary guideline implementation; however, only the skills domain was associated with greater implementation. There are opportunities to target the incongruence in perceptions vs reality of the barriers and enablers to implementation. Future research could examine the utility of the TDF to identify barriers and enablers to implementation to inform intervention development and for evaluating interventions to examine intervention mechanisms.

Mechanisms of implementing public health interventions: a pooled causal mediation analysis of randomised trials

BackgroundThe World Health Organization recommends that nations implement evidence-based nutritional guidelines and policies in settings such as schools and childcare services to improve public health nutrition. Understanding the causal mechanism by which implementation strategies exert their effects could enhance guideline implementation. The aim of this study was to assess the mechanisms by which implementation strategies improved schools and childcare services’ adherence to nutrition guidelines.MethodsWe conducted a mechanism evaluation of an aggregated dataset generated from three randomised controlled trials conducted in schools and childcare services in New South Wales, Australia. Each trial examined the impact of implementation strategies that targeted Theoretical Domains Framework constructs including knowledge, skills, professional role and identity, environmental context and resources. We pooled aggregated organisation level data from each trial, including quantitative assessments of the Theoretical Domains Framework constructs, as well as measures of school or childcare nutrition guideline compliance, the primary implementation outcome. We used causal mediation analysis to estimate the average indirect and direct effects of the implementation strategies and assessed the robustness of our findings to varying levels of unmeasured and unknown confounding.ResultsWe included 121 schools or childcare services in the pooled analysis: 79 allocated to receive guideline and policy implementation strategies and 42 to usual practice. Overall, the interventions improved compliance (odds ratio = 6.64; 95% CI [2.58 to 19.09]); however, the intervention effect was not mediated by any of the four targeted Theoretical Domains Framework constructs (average causal mediation effects through knowledge = − 0.00 [− 0.05 to 0.04], skills = 0.01 [− 0.02 to 0.07], professional role and identity = 0.00 [− 0.03 to 0.03] and environmental context and resources = 0.00 [− 0.02 to 0.06]). The intervention had no significant effect on the four targeted Theoretical Domains Framework constructs, and the constructs were not associated with school or childcare nutrition guideline compliance. Potentially, this lack of effect could be explained by imprecise measurement of the mediators. Alternatively, it is likely that that the interventions were operating via alternative mechanisms that were not captured by the four Theoretical Domains Framework constructs we explored.ConclusionsEven though public health implementation strategies led to meaningful improvements in school or childcare nutrition guideline compliance, these effects were not mediated by key targeted constructs of the Theoretical Domains Framework. Future research should explore the mechanistic role of other Theoretical Domains Framework constructs and evaluate system-level mechanisms informed by an ecological framework.Trial registrationAll trials were prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613000543785. Registered 15/05/2013; ACTRN12614001148662. Registered 30/10/2014; ACTRN12615001032549. Registered 1/10/2015).

Challenges of Increasing Childcare Center Compliance With Nutrition Guidelines: A Randomized Controlled Trial of an Intervention Providing Training, Written Menu Feedback, and Printed Resources

Purpose: To assess the effectiveness of an intervention including training, provision of written menu feedback, and printed resources on increasing childcare compliance with nutrition guidelines. Design: Parallel group randomized controlled trial. Setting: Hunter New England region, New South Wales, Australia. Participants: Forty-four childcare centers that prepare and provide food on-site to children while in care. Intervention: The intervention was designed using the Theoretical Domains Framework, targeted managers, and cooks and included implementation strategies that addressed identified barriers. Measures: Outcomes included the proportion of menus providing food servings (per child) compliant with overall nutrition guideline recommendations and each individual food group assessed via menu assessments. Cook knowledge of recommendations, intervention acceptability, adverse events, and barriers were also assessed via questionnaires with cooks and managers. Analysis: Logistic regression models, adjusted for baseline values of the outcome. Results: At baseline and follow-up, zero centers in the intervention and control groups were compliant with the overall menu guidelines or for the vegetable and meat food groups. Follow-up between-group differences in compliance for discretionary (33.3 vs 5, P = .18), dairy (41.7 vs 15, P = .16), breads and cereals (8.3 vs 10 P = 1.00), and fruit (16.7 vs 10, P = .48) were all nonsignificant. Relative to the control group, intervention centers showed a significantly greater increase in percentage of cooks with correct knowledge for vegetable servings (93.3 vs 36.4, P = .008). Conclusion: Although the application of the theoretical framework produced a broader understanding of the determinants of menu compliance, due to the complexity of guidelines, limited follow-up support, lower training uptake, and low intervention dose, the intervention was not effective in supporting the practice change required.