De-Implementation of Detrimental Feeding Practices in Childcare: Mixed Methods Evaluation of Community Partner Selected Strategies.

This pilot evaluated strategies to decrease detrimental feeding practices in early care and education, which are hypothesized to compete with evidence-based feeding and obesity prevention practices. This study made two key comparisons: (1) a between-site comparison of sites receiving (a) no implementation or de-implementation strategies (i.e., Basic Support; B), (b) implementation strategies only (i.e., Enhanced Support; E), and (c) implementation and de-implementation strategies (i.e., De-implementation + Enhanced Support; D + E) and (2) a within-site pre-post comparison among sites with D + E. At nutrition lessons, the D + E group had more Positive Comments (Hedege's g = 0.60) and higher Role Model fidelity (Hedege's g = 1.34) compared to the E group. At meals, assistant teachers in the D + E group had higher Positive Comments than in the B group (g = 0.72). For within-group comparisons, the D + E group decreased Negative Comments (t(19) = 2.842, p = 0.01), increased Positive Comments (t(20) = 2.314, p = 0.031), and improved use of the program mascot at nutrition lessons (t(21) = 3.899, p = 0.001). At meals, lead teachers' Negative Comments decreased (t(22) = 2.73, p = 0.01). Qualitative data identified strengths and opportunities for iteration. Despite a COVID interruption, mid-point comparisons and qualitative feedback suggest promise of the de-implementation strategy package.

Implementation fidelity, attitudes, and influence: a novel approach to classifying implementer behavior.

BACKGROUND: The current study sought to (1) describe a new classification approach for types of implementer behavior and (2) explore the implementer behavior change in response to tailored implementation facilitation based on the classifications. METHODS: A small-scale, cluster-randomized hybrid type III implementation trial was conducted in 38 early care and education classrooms that were part of the Together, We Inspire Smart Eating (WISE) program. WISE focuses on 4 evidence-based practices (EBPs), which are implemented by teachers to promote nutrition. External facilitators (N = 3) used a modified Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) to complete immersion (i.e., observations) and thematic content analyses of interviews to identify the characteristics of teachers' behavior at varying levels of implementation fidelity. Three key factors-attitudes toward the innovation, fidelity/adaptations, and influence-were identified that the research team used to classify teachers' implementation behavior. This process resulted in a novel classification approach. To assess the reliability of applying the classification approach, we assessed the percent agreement between the facilitators. Based on the teachers' classification, the research team developed a tailored facilitation response. To explore behavior change related to the tailored facilitation, change in fidelity and classification across the school year were evaluated. RESULTS: The classifications include (1) enthusiastic adopters (positive attitude, meeting fidelity targets, active influence), (2) over-adapting adopters (positive attitude, not meeting fidelity targets, active influence), (3) passive non-adopters (negative attitude, not meeting fidelity targets, passive influence), and (4) active non-adopters (negative attitudes, not meeting fidelity targets, active influence). The average percent agreement among the three facilitators for classification was 75%. Qualitative data support distinct patterns of perceptions across the classifications. A positive shift in classification was observed for 67% of cases between the mid-point and final classification. Finally, we generated an expanded classification approach to consider additional combinations of the three factors beyond those observed in this study. CONCLUSIONS: Data from this study support the ability to apply the classification approach with moderate to high reliability and to use the approach to tailor facilitation toward improved implementation. Findings suggest the potential of our approach for wider application and potential to improve tailoring of implementation strategies such as facilitation.

Obesity prevention practices in early care and education settings: an adaptive implementation trial.

BACKGROUND: Despite the potential for Early Care and Education (ECE) settings to promote healthy habits, a gap exists between current practices and evidence-based practices (EBPs) for obesity prevention in childhood. METHODS: We will use an enhanced non-responder trial design to determine the effectiveness and incremental cost-effectiveness of an adaptive implementation strategy for Together, We Inspire Smart Eating (WISE), while examining moderators and mediators of the strategy effect. WISE is a curriculum that aims to increase children's intake of carotenoid-rich fruits and vegetables through four evidence-based practices in the early care and education setting. In this trial, we will randomize sites that do not respond to low-intensity strategies to either (a) continue receiving low-intensity strategies or (b) receive high-intensity strategies. This design will determine the effect of an adaptive implementation strategy that adds high-intensity versus one that continues with low-intensity among non-responder sites. We will also apply explanatory, sequential mixed methods to provide a nuanced understanding of implementation mechanisms, contextual factors, and characteristics of sites that respond to differing intensities of implementation strategies. Finally, we will conduct a cost effectiveness analysis to estimate the incremental effect of augmenting implementation with high-intensity strategies compared to continuing low-intensity strategies on costs, fidelity, and child health outcomes. DISCUSSION: We expect our study to contribute to an evidence base for structuring implementation support in real-world ECE contexts, ultimately providing a guide for applying the adaptive implementation strategy in ECE for WISE scale-up. Our work will also provide data to guide implementation decisions of other interventions in ECE. Finally, we will provide the first estimate of relative value for different implementation strategies in this setting. TRIAL REGISTRATION: NCT05050539 ; 9/20/21.

Stakeholder selected strategies for obesity prevention in childcare: results from a small-scale cluster randomized hybrid type III trial.

BACKGROUND: Together, We Inspire Smart Eating (WISE) is an intervention for the early care and education setting to support children's exposure to and intake of fruits and vegetables. WISE emphasizes 4 evidence-based practices (EBPs): (1) use of a mascot; (2) educators' role modeling; (3) positive feeding practices; and (4) hands-on exposures. The current study reports on a small-scale implementation trial aimed at improving the use of WISE EBPs by teachers. METHODS: A Hybrid Type III Cluster Randomized Design compared a Basic and Enhanced implementation strategy. The Basic Strategy included training and reminders only; the Enhanced strategy was a multi-faceted package of stakeholder-selected strategies including a leadership commitment, an implementation blueprint, a local champion, an environmental reminder of the EBPs, facilitation, and tailored educational resources and incentives. All study sites were Head Starts. Sites were randomized using a balancing technique that considered site characteristics; 4 sites (20 classrooms, 39 educators, 305 children) received Enhanced support; 5 sites (18 classrooms, 36 educators, 316 children) received Basic support. RE-AIM guided the evaluation, and implementation fidelity was the primary outcome. Strategies were assessed using examination of data distributions and unadjusted comparisons (t tests) as well as general linear and mixed effects models controlling for covariates. RESULTS: For the primary outcome of fidelity, the Enhanced group had significantly higher means for 3 of 4 EBPs. Multivariate models explained a significant portion of variance for both mascot use and hands-on exposure with a significant positive effect observed for treatment condition. The Enhanced group also had higher rates of Appropriateness and Organizational Readiness for Implementing Change (as indicators of implementation and adoption, respectively). There was no significant difference between groups for indicators of Reach, Effectiveness or Maintenance. Formative interviews indicated key targets for iteration and potential mechanisms. Key events were catalogued to provide context for interpretation (e.g., 61% of classrooms with turnover). CONCLUSIONS: Findings were mixed but suggested promise for the Enhanced strategy, especially considering key events of the study. Implementation fidelity improvements occurred mainly in the last 3 months of the school year; additional time may be needed to translate to improvements in child outcomes. TRIAL REGISTRATION: NCT03075085 Registered 20 February 2017.

A mixed-methods protocol for identifying successful sustainability strategies for nutrition and physical activity interventions in childcare.

BACKGROUND: Despite the importance of sustainability for nutrition and physical activity in public health interventions, limited studies have explored the factors that promote and inhibit evidence-based program sustainment in the childcare setting. This study protocol describes a mixed-methods approach to develop novel sustainability strategies based on real-world settings and stakeholder feedback, with the goal of providing support for future obesity prevention programs and related studies on intervention sustainability. Two interventions, Together, We Inspire Smart Eating (WISE) and The Food Friends' (FF) Fun with New Foods and Get Movin' with Might Moves, are studied to this end. METHODS: The study will deploy an explanatory, sequential mixed-methods design. First, the research team will collect a quantitative survey to assess rates of sustainment among WISE and Food Friends sites. We expect to collect 150 surveys from WISE and FF sites combined. Data from these surveys will be used to purposively sample sites for 12 to 18 site visits. Specifically, we will purposively sample low, partial, and high sustaining sites where we will conduct key informant interviews and focus groups as well as validate self-reports on sustainability. Survey content, qualitative interviews, and coding will be based on the Dynamic Sustainability Framework. We will draw on findings from the quantitative survey on predictors of sustainment and the qualitative site visits to understand varying levels of program sustainment. Then, we will utilize evidence-based quality improvement sessions to engage stakeholders in developing a multi-component sustainability strategy. DISCUSSION: This study will provide a stakeholder-informed sustainability strategy ready for testing in a full-scale trial examining effects on sustainment of evidence-based nutrition and physical activity practices in childcare. We expect this strategy to be relevant for educators and consistent with the views of administrators as a guide for future practice for the targeted nutrition and physical activity interventions and beyond.

Pester Power: Examining Children's Influence as an Active Intervention Ingredient.

OBJECTIVE: To determine if children's pester power related to a classroom-based nutrition program, Together, We Inspire Smart Eating (WISE), is related to familial dietary habits and parental food purchases and practices. METHODS: Classroom teachers delivered weekly WISE lessons at 7 Head Start sites across 2 states in the southern US. Before and after the intervention, parents were interviewed on the consumption of WISE fruits and vegetables, intake of nutrient-poor foods, parenting practices related to food, and exposure to WISE through the child's pester power. RESULTS: After controlling for baseline levels of outcome variables, child willingness to try new foods at baseline, and the effect of state, pester power predicated significant variance in the outcomes of consumption of WISE foods (F3, 229 = 34.7, P < .001, ΔR2 = 0.03, P = .002) and parenting practices that support healthy dietary intake and attitudes for young children (F2, 264 = 77.2, P < .001, ΔR2 = 0.02, P = .006). CONCLUSIONS AND IMPLICATIONS: The findings of this study highlight the potential for children's influence on food consumption and habits at home.