Creating healthy eating and active environments in early learning settings: protocol of the CHEERS eHealth intervention study.

Background: Early childhood educators through their daily interactions with children, play a central role in shaping young children's health behaviors. Given their influential role, early childhood educators are often targeted in interventions aiming at enhancing their nutrition and physical activity practices. Methods: This paper presents the design of the CHEERS eHealth program to improve nutrition and physical activity practices within Early Childhood Education and Care (ECEC) centers. The study has a longitudinal quasi-experimental design with recruitment of ECECs across Alberta Canada. ECEC intervention group educators complete 12 weekly online nutrition and physical activity modules and participate in weekly communities of practice sessions to discuss practical applications within their centers. Outcome assessments are scheduled at baseline (T1), mid-point at 5 months (T2), and end of program after 10 months (T3). Outcome measures include the Creating Healthy Eating and Active Environments survey (CHEERS), Mindful Eating Questionnaire (MEQ), Canadian Behavior, Attitude and Nutrition Knowledge Survey (C-BANKS 2.0), Physical Literacy Knowledge, Attitude, Self-Efficacy, and Behavior (PLKASB-ECE), the Environment and Policy Assessment and Observation (EPAO) derived variables, and an objective measure of children's physical activity using ActiGraph GT3X accelerometers. Linear mixed model analyses will be used to evaluate the effectiveness of the intervention. Qualitative assessments comprise exit interviews and open-response questions embedded within the educational modules. Results: Preliminary baseline data from the 2019 cohort indicate no statistically significant differences between the intervention and control groups for the primary outcome variables, except age. Educators' personal nutrition-related knowledge, attitude and behaviors were positively associated with their self-assessments of the nutrition environment and practices in ECECs. A significant correlation was observed between educators' self-reported physical activity practices and observed activity practices. The CHEERS survey Food Served subscale showed a positive correlation with the objective measures of EPAO-Foods Provided and Nutrition Policy subdomains. Discussion: We propose that this eHealth intervention would be an effective scaling up approach to enhancing the nutrition and physical activity environments of ECECs by fostering improved nutrition and physical activity-related knowledge, attitudes, and adherence to best practices which will potentially lead to improved outcomes for children in their care.

eHealth Tools Supporting Early Childhood Education and Care Centers to Assess and Enhance Nutrition and Physical Activity Environments: Protocol for a Scoping Review.

BACKGROUND: Many children today are growing up in environments that predispose them to develop noncommunicable diseases. While no single preventive solution exists, evidence supports interventions in childcare settings for establishing good nutrition and physical activity behaviors as a "critical window" that could reduce the risk of developing noncommunicable diseases later in life. Emerging eHealth tools have shown potential in promoting best practices for nutrition and physical activity environments in early childhood education and care (ECEC) settings. OBJECTIVE: The primary objective of this review is to map the breadth of available evidence on eHealth tools currently available to assess and support best practices for nutrition, physical activity, or both in ECEC settings and to highlight potential research directions. METHODS: This scoping review will be conducted in accordance with the Joanna Briggs Institute Manual for Scoping Reviews with adherence to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist guidelines. Eligibility is based on the Population, Concept, and Context criteria as follows: (1) early childhood educators (population); (2) eHealth (digital) technology, such as websites, smartphone apps, email, and social media (concept); and (3) measurement and intervention tools to support best practices for nutrition, physical activity, or both in ECEC settings (context). The information sources for this review are the bibliographic databases PubMed, Scopus, CINAHL Plus, ERIC, and Embase in English and French with no date restrictions. Following this, a scan of gray literature will be undertaken. The electronic search strategy was developed in collaboration with two librarians. Two independent reviewers will screen the titles and abstracts of all relevant publications against inclusion criteria, followed by a full-text review using a data extraction tool developed by the reviewers. A synthesis of included papers will describe the publication, assessment, and intervention tool details. A summary of the findings will describe the types of eHealth assessment tools available, psychometric properties, eHealth intervention components, and theoretical frameworks used for development. RESULTS: Preliminary searches of bibliographic databases to test and calibrate the search were carried out in May 2023. Study selection based on titles and abstracts was started in August 2023. The developed search strategy will guide our search for gray literature. The findings will be presented in visualized data map format, waffle chart, or tabular format accompanied by a narrative discussion. The scoping review is planned for completion in 2024. CONCLUSIONS: A structured review of the literature will provide a summary of the range and type of eHealth tools available for ECEC programs to assess and improve nutrition environments, physical activity environments, or both in order to identify gaps in the current evidence base and provide insights to guide future intervention research. TRIAL REGISTRATION: Open Science Framework XTRNZ; https://osf.io/xtrnz. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52252.

Update and validation of the Canadian Behavior, Attitude and Nutrition Knowledge Survey (C-BANKS 2.0).

Aim: Understanding knowledge, attitudes and behaviors related to nutrition is crucial in developing effective intervention strategies to promote healthy eating habits. This study revised and updated the Canadian Behavior, Attitude and Nutrition Knowledge Survey (C-BANKS) to align with the current Canada's Food Guide and dietary guidance and report on its reliability and validity with a new population. Method: Data from 167 early childhood educators were recruited to test the revised C-BANKS' reliability and validity. Reliability, as measured by internal consistency, was assessed using Cronbach's alpha, while concurrent validity was determined by correlating the C-BANKS 2.0 scores with the CHEERS (Creating Healthy Eating and Active Environments Survey) and Mindful Eating Questionnaire (MEQ). Responsiveness was assessed by comparing a baseline C-BANKS 2.0 score to a post-test score after completing an online healthy eating and physical activity educational intervention. Results: The adapted C-BANKS 2.0 questionnaire demonstrated good internal consistency (Cronbach's alpha >0.70) and construct validity with related measures CHEERS and MEQ (p < 0.05). The C-BANKS 2.0 demonstrated strong responsiveness. Specifically, C-BANKS 2.0 scores increased after the nutrition education intervention (p < 0.001). Additionally, there were no signs of floor or ceiling effects. Conclusion: The adapted C-BANKS 2.0 demonstrated satisfactory internal consistency, construct validity, and responsiveness to measure of nutrition knowledge, attitudes, and behaviors in an early childhood educator population. The revised C-BANKS 2.0 provides insight into the key factors that influence dietary habits thereby informing the design and evaluation of effective nutrition community intervention programs.

Is the online 'creating healthy eating and active environments survey' (CHEERS) tool reliable for early childhood educators in Alberta, Canada: a randomized crossover trial.

BACKGROUND: The creating healthy eating and active environments survey (CHEERS) is an audit tool used to assess the nutrition and physical activity environment in early childhood education and care (ECEC) centres. Availability of the tool has been limited to paper-based versions. Digital health initiatives offer improved reach and immediacy of support for community-based clients through novel technology products. In order to provide increased access to the CHEERS tool, an online version was developed. The objective of this study was to assess the reliability of an online version of CHEERS. METHODS: Utilizing a randomized crossover design, ECEC educators completed either a paper-based or online-based survey and then the opposite mode with a two to three-week interval. The intraclass correlation coefficient (ICC, with 95% confidence interval) was used to determine the reliability between test and retest. Absolute index of reliability in the original measurement was assessed through the standard error of measurement (SEM = SD × âˆš1-ICC). The smallest amount of change not due to inherent variation was assessed by determining minimal detectable change at the 95% confidence level (MDC95 = SEM × 1.96 ×√2; MDC95% = MDC95/mean ×100). RESULTS: Test-retest reliability was good to excellent for the online-based CHEERS total score (ICC = 0.86) and for each of the four subscales: food served (ICC = 0.82), healthy eating environment (ICC = 0.76), program planning (ICC = 0.76), and physical activity environment (ICC = 0.79). The SEM, MDC95, and MDC95% for the CHEERS overall score were 0.79, 2.19, and 9.6%, respectively. CONCLUSIONS: The results of this study demonstrate that the online-based and paper-based versions of the CHEERS audit tool share comparable accuracy. The CHEERS tool can be reliably implemented in an online environment and this provides users an alternative means to complete the centre-based health assessment. The advantage of the online-based version includes user accessibility and the potential to develop a feedback response for participants using digitally collected data.

The Impact of COVID-19 on Eating Environments and Activity in Early Childhood Education and Care in Alberta, Canada: A Cross-Sectional Study.

Early childhood education and care (ECEC) environments influence children's early development and habits that track across a lifespan. The purpose of this study was to explore the impact of COVID-19 government-mandated guidelines on physical activity (PA) and eating environments in ECEC settings. This cross-sectional study involved the recruitment of 19 ECEC centers pre-COVID (2019) and 15 ECEC centers during COVID (2020) in Alberta, Canada (n = 34 ECEC centers; n = 83 educators; n = 361 preschoolers). Educators completed the CHEERS (Creating Healthy Eating and activity Environments Survey) and MEQ (Mindful Eating Questionnaire) self-audit tools while GT3X+ ActiGraph accelerometers measured preschooler PA. The CHEERS healthy eating environment subscale was greater during COVID-19 (5.97 ± 0.52; 5.80 ± 0.62; p = 0.02) and the overall score positively correlated with the MEQ score (r = 0.20; p = 0.002). Preschoolers exhibited greater hourly step counts (800 ± 189; 649 ± 185), moderate-to-vigorous PA (MVPA) (9.3 ± 3.0 min/h; 7.9 ± 3.2 min/h) and lower sedentary times (42.4 ± 3.9 min/h; 44.1 ± 4.9 min/h) during COVID-19 compared to pre-COVID, respectively (p < 0.05). These findings suggest the eating environment and indices of child physical activity were better in 2020, which could possibly be attributed to a change in government-mandated COVID-19 guideline policy.

Impact of COVID-19 on Early Childhood Educator's Perspectives and Practices in Nutrition and Physical Activity: A Qualitative Study.

Government guidelines for relaunching early childhood education and care (ECEC) programs during the COVID-19 pandemic have required the implementation of various practices to minimize the risk of infection transmission. These directives include recommendations regarding serving and handling food, shared spaces, and physical distancing which have a direct impact on the health and development of children in care. The purpose of this study was to explore early childhood educators' perspectives on how COVID-19 guidelines have impacted the nutrition and physical activity practices within their ECEC environment. A qualitative description approach was used to explore a purposive sample of 17 educators working full time in ECEC centres during the pandemic between July and August 2020. Semi-structured, individual interviews were conducted, audio-recorded, transcribed verbatim, and analysed using a thematic analysis. Educators identified environmental changes in their environments noting a reduction in the quality food available for children juxtaposed with increased outdoor opportunities and a perceived increase in physical activity time. Teaching practices were also identified as being impacted by the COVID-19 guidelines. Curriculum, life skills, and social connectedness around healthy eating education was disrupted. Promoting physical activity education was challenged due to equipment, space, and curriculum enrichment opportunities losses. These findings demonstrate pronounced negative effects of COVID guidelines on nutrition and physical activity best practices within the ECEC environment. There is a need to support educators in maintaining healthy and active environments for preschoolers while following guidelines to minimize the risk of COVID infection transmission.

Creating a healthy eating and active environment survey (CHEERS) for childcare: an inter-rater, intra-rater reliability and validity study.

BACKGROUND: The CHEERS is a self-administered tool to measure gaps, weaknesses, and strengths of an early childhood education and care (ECEC) centre-based nutrition and physical activity environment. ECEC settings have the potential to profoundly influence early dietary and physical activity behaviours. Content validation of the CHEERS tool has been previously reported. The purpose of this study was to develop reliability and validity evidence for the CHEERS audit tool and the proposed subscales of food served, healthy eating environment, program planning, and physical activity environment in ECEC centre-based programs. METHODS: This cross-sectional study consisted of 2 phases: Phase 1 included inter-, intra-rater and Cronbach's α. A subset of this sample was invited to participate in a second survey (Trial 2) for intra-rater assessment within 3 weeks of completing the first survey (Trial 1). Phase 2 included concurrent validity assessment between a nutrition expert and the ECEC director using within a one-week period. RESULTS: One hundred two directors and 85 educators (total of 187) returned the survey. Of these, there were 75 matched pairs for inter-rater reliability analysis providing a CHEERS ICC score of 0.59 and ICC scores ranging from 0.40 to 0.58 for the subscales. The ICC for intra-rater reliability of the CHEERS score was 0.81 for 40 participants completing the survey a second time and a range of 0.72 to 0.79 for the subscales. The CHEERS tool demonstrated very good internal consistency (α = 0.91) and α scores ranging from 0.73 to 0.79 for the subscales. In phase 2, concurrent validation was ICC = 0.65 (n = 30) CHEERS scores with a range of 0.42 to 0.69 for the subscales. CONCLUSIONS: This study provides evidence of inter-, intra-rater reliability, internal consistency, and concurrent validity of an environmental assessment audit tool to assess the nutrition and physical activity environment of ECEC centre-based programs. The results demonstrate that the self-administered CHEERS instrument is stable overtime and between evaluators at the same ECEC centre. The scores obtained with CHEERS self-administered audit tool are reasonably accurate compared to an expert rater (dietitian) assessment. This study adds additional support to establishing the psychometric soundness of the CHEERS tool.

Content Validity for a Child Care Self-assessment Tool: Creating Healthy Eating Environments Scale (CHEERS).

The purpose of this project was to develop and content validate both a formative and summative self-assessment scale designed to measure the nutrition and physical activity environment in community-based child care programs. The study followed a mixed-method modified Ebel procedure. An expert group with qualifications in nutrition, physical activity, and child care were recruited for content validation. The survey was subjected to expert review through digital communication followed by a face-to-face validation meeting. To establish consensus for content validity beyond the standard error of proportion (P < 0.05) the content validity index (CVI) required was ≥0.78. Of the initial 64 items, 44 scored an acceptable CVI for inclusion. The remaining items were discussed, missing concepts identified, and a final CVI employed to determine inclusion. The final tool included 62 items with 5 subscales: food served, healthy eating program planning, healthy eating environment, physical activity environment, and healthy body image environment. Content validation is an integral step in scale development that is often overlooked or poorly carried out. Initial content validity of this scale has been established and will be of value to researchers and practitioners interested in conducting healthy eating interventions in child care.

The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI): development and pilot.

BACKGROUND CONTEXT: Owing to mobility limitations, people with lumbar spinal stenosis (LSS) are at risk for diseases of inactivity, including obesity. Therefore, weight management in LSS is critical. Body mass index is the strongest predictor of function in LSS, suggesting that weight loss may promote physical activity and provide a unique treatment option. We propose a lifestyle modification approach of physical activity and nutrition education, delivered through an e-health platform. PURPOSE: The purpose of this study was to develop and pilot an e-health intervention aimed at increasing physical activity and decreasing fat mass in people with LSS. STUDY DESIGN: The study design was based on intervention development and pilot. PATIENT SAMPLE: Ten overweight or obese individuals with LSS were confirmed clinically and on imaging. OUTCOME MEASURES: Self-reported measures were food record, Short-Form 36 (SF-36), pain scales, Swiss Spinal Stenosis Symptom and Physical Function Scales, Oswestry Disability Index (ODI), Pain Catastrophizing Questionnaire, Tampa Scale for Kinesiophobia, Center for Epidemiologic Studies(Depression) Scale, Behavioral Regular in Exercise Questionnaire, and Regulation for Eating Behavior Scale and physiologic measures were dual-energy X-ray absorptiometry (DXA), blood draw, 7-day accelerometry, self-paced walking test, and balance test. METHODS: The e-health platform was developed. INTERVENTION: during Week 1, participants received a pedometer and a personalized consultation with a dietitian and an exercise physiologist. For 12 weeks, participants logged on to the e-health Web site to access personal step goals, nutrition education videos, and a discussion board. Follow-up occurred at Week 13. RESULTS: Nine participants had a mean age of 67.5±6.7 years (60% women). Significant improvements were observed for fat mass (DXA), trunk fat mass, symptom severity (Swiss Symptom Scale), energy intake, maximum continuous activity (accelerometry), and mental health (SF-36) (p<.05). Nonsignificant improvements were observed for waist circumference, pain, ODI, and obesity biomarkers. Seventy percent lost weight, 50% increased walking capacity, and 60% increased quality of life. The mean increase in steps was 15%. CONCLUSIONS: The spinal stenosis pedometer and nutrition lifestyle intervention was shown to be feasible, attractive to participants, and effective in this small sample. This intervention provides people with LSS the opportunity to participate in their own health management, potentially improving access to care. Efficacy is currently being assessed in a randomized trial.

The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI) randomized controlled trial protocol.

BACKGROUND: Because of symptoms, people with lumbar spinal stenosis (LSS) are often inactive, and this sedentary behaviour implies risk for diseases including obesity. Research has identified body mass index as the most powerful predictor of function in LSS. This suggests that function may be improved by targeting weight as a modifiable factor. An e-health lifestyle intervention was developed aimed at reducing fat mass and increasing physical activity in people with LSS. The main components of this intervention include pedometer-based physical activity promotion and nutrition education. METHODS/DESIGN: The Spinal Stenosis Pedometer and Nutrition Lifestyle INTERVENTION (SSPANLI) was developed and piloted with 10 individuals. The protocol for a randomized controlled trail comparing the SSPANLI intervention to usual non-surgical care follows. One hundred six (106) overweight or obese individuals with LSS will be recruited. Baseline and follow-up testing includes dual energy x-ray absorptiometry, blood draw, 3-day food record, 7-day accelerometry, questionnaire, maximal oxygen consumption, neurological exam, balance testing and a Self-Paced Walking Test. INTERVENTION: During Week 1, the intervention group will receive a pedometer, and a personalized consultation with both a Dietitian and an exercise specialist. For 12 weeks participants will log on to the e-health website to access personal step goals, walking maps, nutrition videos, and motivational quotes. Participants will also have access to in-person Coffee Talk meetings every 3 weeks, and meet with the Dietitian and exercise specialist at week 6. The control group will proceed with usual care for the 12-week period. Follow-up testing will occur at Weeks 13 and 24. DISCUSSION: This lifestyle intervention has the potential to provide a unique, non-surgical management option for people with LSS. Through decreased fat mass and increased function, we may reduce risk for obesity, chronic diseases of inactivity, and pain. The use of e-health interventions provides an opportunity for patients to become more involved in managing their own health. Behaviour changes including increased physical activity, and improved dietary habits promote overall health and quality of life, and may decrease future health care needs in this population. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01902979.