Improving the implementation of healthy eating, physical activity and/or obesity prevention policies, practices or programmes in childcare services

The review question
This review aimed to look at the effects of strategies to improve the implementation (or correct undertaking) of policies, practices or programmes by childcare services that promote children's healthy eating, physical activity and/or obesity prevention. We also looked at whether these strategies improved childcare service staff knowledge, skills or attitudes. We also wanted to determine the cost or cost-effectiveness of providing implementation support, whether support strategies were associated with any adverse effects and whether there was an impact on child nutrition, physical activity or weight status.

Background
A number of childcare service-based interventions have been found to be effective in improving child diet, increasing child physical activity and preventing excessive weight gain. Despite the existence of such evidence and best-practice guideline recommendations for childcare services to implement these policies and practices, many childcare services fail to do so. Without proper implementation, children will not benefit from these child health-directed policies and practices.

Study characteristics
The review identified 10 trials, eight of which examined implementation strategies versus usual practice, and two that compared different types of implementation strategies. The trials sought to improve the implementation of policies and practices targeting healthy eating (two trials), physical activity (two trials) or both healthy eating and physical activity (six trials). Collectively the implementation strategies tested in the 10 trials included educational materials, educational meetings, audit and feedback, opinion leaders, small incentives or grants, educational outreach visits or academic detailing. The strategies tested were only a small number of those that could be applied to improve implementation in this setting.

Search date
The evidence is current to August 2015.

Key results
None of the strategies identified in the review improved implementation of all the targeted policies or practices. However, most strategies reported improvement for at least one policy or practice. The findings provide weak and inconsistent evidence of the effects of these strategies on improving the implementation of policies, practices and programmes, childcare service staff knowledge or attitudes, or child diet, physical activity or weight status. The lack of consistent terminology in this area of research may have meant some relevant studies were not picked up in our search. Nonetheless, the few identified trials suggest that research to implement such policies and practices in childcare services is only in the early stages of development.

Quality of the evidence
We rated the evidence for all outcomes as very low quality and thus we cannot be overly confident in the findings.

Authors' conclusions: 

Current research provides weak and inconsistent evidence of the effectiveness of such strategies in improving the implementation of policies and practices, childcare service staff knowledge or attitudes, or child diet, physical activity or weight status. Further research in the field is required.

Read the full abstract...
Background: 

Despite the existence of effective interventions and best-practice guideline recommendations for childcare services to implement policies, practices and programmes to promote child healthy eating, physical activity and prevent unhealthy weight gain, many services fail to do so.

Objectives: 

The primary aim of the review was to examine the effectiveness of strategies aimed at improving the implementation of policies, practices or programmes by childcare services that promote child healthy eating, physical activity and/or obesity prevention.

The secondary aims of the review were to:

1. describe the impact of such strategies on childcare service staff knowledge, skills or attitudes;
2. describe the cost or cost-effectiveness of such strategies;
3. describe any adverse effects of such strategies on childcare services, service staff or children;
4. examine the effect of such strategies on child diet, physical activity or weight status.

Search strategy: 

We searched the following electronic databases on 3 August 2015: the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, ERIC, CINAHL and SCOPUS. We also searched reference lists of included trials, handsearched two international implementation science journals and searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp/) and ClinicalTrials.gov (www.clinicaltrials.gov).

Selection criteria: 

We included any study (randomised or non-randomised) with a parallel control group that compared any strategy to improve the implementation of a healthy eating, physical activity or obesity prevention policy, practice or programme by staff of centre-based childcare services to no intervention, 'usual' practice or an alternative strategy.

Data collection and analysis: 

The review authors independently screened abstracts and titles, extracted trial data and assessed risk of bias in pairs; we resolved discrepancies via consensus. Heterogeneity across studies precluded pooling of data and undertaking quantitative assessment via meta-analysis. However, we narratively synthesised the trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

Main results: 

We identified 10 trials as eligible and included them in the review. The trials sought to improve the implementation of policies and practices targeting healthy eating (two trials), physical activity (two trials) or both healthy eating and physical activity (six trials). Collectively the implementation strategies tested in the 10 trials included educational materials, educational meetings, audit and feedback, opinion leaders, small incentives or grants, educational outreach visits or academic detailing. A total of 1053 childcare services participated across all trials. Of the 10 trials, eight examined implementation strategies versus a usual practice control and two compared alternative implementation strategies. There was considerable study heterogeneity. We judged all studies as having high risk of bias for at least one domain.

It is uncertain whether the strategies tested improved the implementation of policies, practices or programmes that promote child healthy eating, physical activity and/or obesity prevention. No intervention improved the implementation of all policies and practices targeted by the implementation strategies relative to a comparison group. Of the eight trials that compared an implementation strategy to usual practice or a no intervention control, however, seven reported improvements in the implementation of at least one of the targeted policies or practices relative to control. For these trials the effect on the primary implementation outcome was as follows: among the three trials that reported score-based measures of implementation the scores ranged from 1 to 5.1; across four trials reporting the proportion of staff or services implementing a specific policy or practice this ranged from 0% to 9.5%; and in three trials reporting the time (per day or week) staff or services spent implementing a policy or practice this ranged from 4.3 minutes to 7.7 minutes. The review findings also indicate that is it uncertain whether such interventions improve childcare service staff knowledge or attitudes (two trials), child physical activity (two trials), child weight status (two trials) or child diet (one trial). None of the included trials reported on the cost or cost-effectiveness of the intervention. One trial assessed the adverse effects of a physical activity intervention and found no difference in rates of child injury between groups. For all review outcomes, we rated the quality of the evidence as very low. The primary limitation of the review was the lack of conventional terminology in implementation science, which may have resulted in potentially relevant studies failing to be identified based on the search terms used in this review.

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