Adoption, implementation, and sustainability of early childhood feeding, nutrition and active play interventions in real-world settings: a systematic review.

BACKGROUND: Instilling healthy dietary habits and active play in early childhood is an important public health focus. Interventions supporting the establishment of nutrition and active play behaviours in the first years of life have shown positive outcomes and long-term cost-effectiveness, however, most are research trials, with limited evidence regarding real-world application. Implementation science theories, models and frameworks (TMFs) can guide the process of research translation from trial to real-world intervention. The application of TMFs within nutrition and active play intervention studies in early childhood (< 5 years) is currently unknown. This systematic review identified the use of TMFs and barriers/ enablers associated with intervention adoption, implementation, and sustainability in early childhood nutrition and active play interventions implemented under real-world conditions. METHODS: Six databases were searched for peer-reviewed publications between 2000-2021. Studies were included if primary outcomes reported improvement in diet, physical activity or sedentary behaviours amongst children aged < 5 years and interventions were delivered under real-world conditions within a community and/or healthcare setting. Two reviewers extracted and evaluated studies, cross checked by a third and verified by all authors. Quality assessment of included studies was completed by two authors using the Mixed Methods Appraisal Tool (MMAT). RESULTS: Eleven studies comprising eleven unique interventions were included. Studies represented low, middle and high-income countries, and were conducted across a range of settings. Five TMFs were identified representing four of Nilsen's implementation model categories, predominantly 'evaluation models'. Ninety-nine barriers/facilitators were extracted across the three intervention phases-Implementation (n = 33 barriers; 33 facilitators), Sustainability (n = 19 barriers; n = 9 facilitators), Adoption (n = 2 barriers; n = 3 facilitators). Identified barriers/facilitators were mapped to the five domains of the Durlak and DuPre framework, with 'funding', 'compatibility' and 'integration of new programming' common across the three intervention phases. CONCLUSIONS: Findings demonstrate that there is no systematic application of TMFs in the planning, implementation and/or evaluation of early childhood nutrition and active play interventions in real-world settings, and selective and sporadic application of TMFs occurs across the intervention lifespan. This apparent limited uptake of TMFs is a missed opportunity to enhance real-world implementation success. TRIAL REGISTRATION: PROSPERO (CRD42021243841).

A systems thinking approach to understanding youth active recreation.

BACKGROUND: Active recreation contributes to child and adolescent physical activity, however, factors affecting uptake are poorly understood at the systems level. The aims of this study were: (1) to use systems analysis methods to understand youth active recreation in Victoria, Australia, (ii) identify potential system leverage points to enhance active recreation, and (iii) explore stakeholder views of systems analysis methods for informing practice and policy decision-making. METHODS: Phase 1: Umbrella review of systematic reviews (2013-2018), synthesising evidence for correlates, determinants and intervention evidence for promoting active recreation. Phase 2: Development of three systems models (ActorMap and two ActivMaps), depicting active recreation actors/organisations, correlates, determinants and intervention evidence. Phase 3: Development of causal loop diagrams (CLDs) and identification of leverage points based on the Action Scales Model. Phase 4: Model feedback via stakeholder interviews (n = 23; 16 organisations). RESULTS: From the literature, 93 correlates and determinants, and 49 intervention strategies were associated with child and adolescent active recreation; the majority located at a social or individual level. Ten potential system leverage points were identified in the CLDs, which differed for pre-schoolers versus children and adolescents. Only time outdoors (an event leverage point) emerged for all age groups. Changes to the built and natural environment (i.e., land use planning, urban design) as a complete domain was a key structural leverage point for influencing active recreation in children and adolescents. Subject matter experts and stakeholder interviews identified 125 actors operating across seven hierarchical active recreation system levels in Victoria. Stakeholder interviews identified 12 areas for future consideration and recommendations for practice/policy influence. CONCLUSIONS: Our findings underscore the need for dynamic models of system behaviour in active recreation, and to capture stakeholder influence as more than a transactional role in evidence generation and use. Effective responses to youth inactivity require a network of interventions that target specific leverage points across the system. Our models illustrate areas that may have the greatest system-level impact, such as changes to the built and natural environment, and they provide a tool for policy, appraisal, advocacy, and decision-making within and outside of government.

Mechanisms of scaling up: combining a realist perspective and systems analysis to understand successfully scaled interventions.

BACKGROUND: Sustainable shifts in population behaviours require system-level implementation and embeddedness of large-scale health interventions. This paper aims to understand how different contexts of scaling up interventions affect mechanisms to produce intended and unintended scale up outcomes. METHODS: A mixed method study combining a realist perspective and systems analysis (causal loop diagrams) of scaled-up physical activity and/or nutrition interventions implemented at a state/national level in Australia (2010-18). The study involved four distinct phases: Phase 1 expert consultation, database and grey literature searches to identify scaled-up interventions; Phase 2 generating initial Context-Mechanism-Outcome configurations (CMOs) from the WHO ExpandNet framework for scaling up; Phase 3 testing and refining CMOs via online surveys and realist interviews with academics, government and non-government organisations (NGOs) involved in scale up of selected interventions (Phase 1); and Phase 4 generating cross-case mid-range theories represented in systems models of scaling up; validated by member checking. Descriptive statistics were reported for online survey data and realist analysis for interview data. RESULTS: Seven interventions were analysed, targeting nutrition (n = 1), physical activity (n = 1), or a combination (n = 5). Twenty-six participants completed surveys; 19 completed interviews. Sixty-three CMO pathways underpinned successful scale up, reflecting 36 scale up contexts, 8 key outcomes; linked via 53 commonly occurring mechanisms. All five WHO framework domains were represented in the systems models. Most CMO pathways included 'intervention attributes' and led to outcomes 'community sustainability/embeddedness' and 'stakeholder buy-in/perceived value'. Irrespective of interventions being scaled in similar contexts (e.g., having political favourability); mechanisms still led to both intended and unintended scale up outcomes (e.g., increased or reduced sustainability). CONCLUSION: This paper provides the first evidence for mechanisms underpinning outcomes required for successful scale up of state or nationally delivered interventions. Our findings challenge current prerequisites for effective scaling suggesting other conditions may be necessary. Future scale up approaches that plan for complexity and encourage iterative adaptation throughout, may enhance scale up outcomes. Current linear, context-to-outcome depictions of scale up oversimplify what is a clearly a complex interaction between perceptions, worldviews and goals of those involved. Mechanisms identified in this study could potentially be leveraged during future scale up efforts, to positively influence intervention scalability and sustainability.

The Use of Digital Platforms for Adults' and Adolescents' Physical Activity During the COVID-19 Pandemic (Our Life at Home): Survey Study.

BACKGROUND: Government responses to managing the COVID-19 pandemic may have impacted the way individuals were able to engage in physical activity. Digital platforms are a promising way to support physical activity levels and may have provided an alternative for people to maintain their activity while at home. OBJECTIVE: This study aimed to examine associations between the use of digital platforms and adherence to the physical activity guidelines among Australian adults and adolescents during the COVID-19 stay-at-home restrictions in April and May 2020. METHODS: A national online survey was distributed in May 2020. Participants included 1188 adults (mean age 37.4 years, SD 15.1; 980/1188, 82.5% female) and 963 adolescents (mean age 16.2 years, SD 1.2; 685/963, 71.1% female). Participants reported demographic characteristics, use of digital platforms for physical activity over the previous month, and adherence to moderate- to vigorous-intensity physical activity (MVPA) and muscle-strengthening exercise (MSE) guidelines. Multilevel logistic regression models examined differences in guideline adherence between those who used digital platforms (ie, users) to support their physical activity compared to those who did not (ie, nonusers). RESULTS: Digital platforms include streaming services for exercise (eg, YouTube, Instagram, and Facebook); subscriber fitness programs, via an app or online (eg, Centr and MyFitnessPal); facilitated online live or recorded classes, via platforms such as Zoom (eg, dance, sport training, and fitness class); sport- or activity-specific apps designed by sporting organizations for participants to keep up their skills (eg, TeamBuildr); active electronic games (eg, Xbox Kinect); and/or online or digital training or racing platforms (eg, Zwift, FullGaz, and Rouvy). Overall, 39.5% (469/1188) of adults and 26.5% (255/963) of adolescents reported using digital platforms for physical activity. Among adults, MVPA (odds ratio [OR] 2.0, 95% CI 1.5-2.7), MSE (OR 3.3, 95% CI 2.5-4.5), and combined (OR 2.7, 95% CI 2.0-3.8) guideline adherence were higher among digital platform users relative to nonusers. Adolescents' MVPA (OR 2.4, 95% CI 1.3-4.3), MSE (OR 3.1, 95% CI 2.1-4.4), and combined (OR 4.3, 95% CI 2.1-9.0) guideline adherence were also higher among users of digital platforms relative to nonusers. CONCLUSIONS: Digital platform users were more likely than nonusers to meet MVPA and MSE guidelines during the COVID-19 stay-at-home restrictions in April and May 2020. Digital platforms may play a critical role in helping to support physical activity engagement when access to facilities or opportunities for physical activity outside the home are restricted.

Embedding Active Pedagogies within Pre-Service Teacher Education: Implementation Considerations and Recommendations.

The physical activity levels of children in Australia are critically low and correlate with reduced academic achievement and poor health outcomes. Schools provide an ideal setting for physical activity interventions to help children move more. Instead of targeting in-service teachers, this study embedded an evidence-based active pedagogy program called Transform-Ed! into pre-service teacher education. Pre/post surveys and post-program interviews and focus group discussions were conducted with key stakeholders (n = 5), lecturers (n = 6), and pre-service teachers (n = 274) involved with the 12-week program. The design, implementation, and evaluation of the study were systematically guided by all five dimensions of Glasgow and colleagues' RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Linear mixed models, descriptive analysis and a framework approach were used to analyse the data. Significant improvements were observed in pre-service teachers' willingness, confidence, and competence to implement physically active pedagogic strategies following the intervention. Pre-service teacher perceived effectiveness of such strategies on student outcomes also significantly increased and perceived barriers decreased. High adherence was consistently reported and the program was maintained after completion of the implementation trial by all lecturers. Four key themes spanning multiple dimensions and participant levels informed recommendations for program scalability: an "inter-systemic approach", a "co-design" approach, "embedded in professional practice", and "evidence of impact" on teacher practice. Anchored in real-world settings and tethered by implementation science, Transform-Ed! could have the potential to advance the teaching capability of teachers, and transform the learning experience and physical and academic outcomes of primary school students.

Effects of a Nine-Month Physical Activity Intervention on Morphological Characteristics and Motor and Cognitive Skills of Preschool Children.

(1) Background: Regular physical activity (PA) plays an important role during early childhood physical and psychological development. This study investigates the effects of a 9-month PA intervention on physiological characteristics and motor and cognitive skills in preschool children. (2) Methods: Preschool children (n = 132; age 4 to 7 years) attending regular preschool programs were nonrandomly assigned to PA intervention (n = 66; 60 min sessions twice per week) or a control group (n = 66; no additional organized PA program) for 9 months. Exercise training for the intervention group included various sports games, outdoor activities, martial arts, yoga, and dance. Anthropometry, motor skills (7 tests), and cognitive skills (Raven's Colored Progressive Matrices and Cognitive Assessment System) were assessed before and after an intervention period in both groups. Data were analyzed using repeated-measures ANOVA. (3) Results: Body weight significantly increased in both groups over time. Compared to the changes observed in the control group, the intervention group significantly increased in chest circumference (p = 0.022). In contrast, the control group demonstrated an increase in waist circumference (p = 0.001), while these measures in the intervention group remained stable. Participants in the intervention group improved running speed (p = 0.016) and standing broad jump (p = 0.000). The flexibility level was maintained in the intervention group, while a significant decrease was observed in the control group (p = 0.010). Children from the intervention group demonstrated progress in the bent-arm hang test (p = 0.001), unlike the control group subjects. Varied improvements in cognitive skills were observed for different variables in both intervention and control groups, with no robust evidence for PA-intervention-related improvements. (4) Conclusions: Preschool children's participation in a preschool PA intervention improves their motor skills.

Adoption, implementation and sustainability of school-based physical activity and sedentary behaviour interventions in real-world settings: a systematic review.

BACKGROUND: Globally, many children fail to meet the World Health Organization's physical activity and sedentary behaviour guidelines. Schools are an ideal setting to intervene, yet despite many interventions in this setting, success when delivered under real-world conditions or at scale is limited. This systematic review aims to i) identify which implementation models are used in school-based physical activity effectiveness, dissemination, and/or implementation trials, and ii) identify factors associated with the adoption, implementation and sustainability of school-based physical activity interventions in real-world settings. METHODS: The review followed PRISMA guidelines and included a systematic search of seven databases from January 1st, 2000 to July 31st, 2018: MEDLINE, EMBASE, CINAHL, SPORTDiscus, PsycINFO, CENTRAL, and ERIC. A forward citation search of included studies using Google Scholar was performed on the 21st of January 2019 including articles published until the end of 2018. Study inclusion criteria: (i) a primary outcome to increase physical activity and/or decrease sedentary behaviour among school-aged children and/or adolescents; (ii) intervention delivery within school settings, (iii) use of implementation models to plan or interpret study results; and (iv) interventions delivered under real-world conditions. EXCLUSION CRITERIA: (i) efficacy trials; (ii) studies applying or testing school-based physical activity policies, and; (iii) studies targeting special schools or pre-school and/or kindergarten aged children. RESULTS: 27 papers comprising 17 unique interventions were included. Fourteen implementation models (e.g., RE-AIM, Rogers' Diffusion of Innovations, Precede Proceed model), were applied across 27 papers. Implementation models were mostly used to interpret results (n = 9), for planning evaluation and interpreting results (n = 8), for planning evaluation (n = 6), for intervention design (n = 4), or for a combination of designing the intervention and interpreting results (n = 3). We identified 269 factors related to barriers (n = 93) and facilitators (n = 176) for the adoption (n = 7 studies), implementation (n = 14 studies) and sustainability (n = 7 studies) of interventions. CONCLUSIONS: Implementation model use was predominately centered on the interpretation of results and analyses, with few examples of use across all study phases as a planning tool and to understand results. This lack of implementation models applied may explain the limited success of interventions when delivered under real-world conditions or at scale. TRIAL REGISTRATION: PROSPERO (CRD42018099836).

Physical Activity and Sedentary Behaviour Patterns in 326 Persons with COPD before Starting a Pulmonary Rehabilitation: A Cluster Analysis.

This study applies a cluster analysis to identify typical physical activity (PA) and sedentary behaviour (SB) patterns in people with chronic obstructive pulmonary disease (COPD) before starting pulmonary rehabilitation (PR). We implemented an observational design which assessed baseline data of objectively measured PA and SB from the STAR (Stay Active after Rehabilitation) study. A total of 355 persons wore an accelerometer (Actigraph wGT3X) for seven days before the start of their PR. Sociodemographic and disease-related parameters were assessed at the start of PR. We applied cluster analysis and compared clusters applying univariate variance analyses. Data was available for 326 persons (31.6% women; age ø = 58 years). Cluster analysis revealed four movement clusters with distinct PA and SB patterns: Sedentary non-movers (28.5%), sedentary occasional movers (41.7%), sedentary movers (19.6%), and sedentary exercisers (10.1%). The four clusters displayed varying levels of moderate PA before rehabilitation (Ø daily min: 9; 28; 38; 70). Notably, all four clusters displayed considerably long average sedentary time per day (Ø daily minutes: 644; 561; 490; 446). The clusters differed significantly in disease-related parameters of GOLD severity, FEV1, CAT, and 6-Min-Walk-Test. In addition to PA promotion, PR programs should consider the reduction of sedentary behaviour as a valuable goal.