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

Abstract

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.

Keywords

childcare center menu guideline nutrition interventions interventions

Purpose

Based on evidence suggesting that dietary patterns developed in childhood are maintained into adulthood,^1,2 a number of countries including the United States, United Kingdom, Canada, and Australia have developed public health dietary guidelines specific to young children (aged 0-5 years).^3

–6 Despite this evidence, research internationally and in Australia indicates that more than half of children do not meet guidelines for consumption of fruit and vegetables.^7,8 This is of concern given poor diet including inadequate fruit and vegetable intake and excessive consumption of foods high in saturated fat, sugar, and sodium are risk factors for the most prevalent chronic diseases.^9
–11

Center-based childcare has been recognized as an important setting to improve children’s nutrition¹² as they provide broad reach to young children¹³ and can provide a large proportion (50%-67%) of their daily dietary requirements during attendance.^14,15 In recognition, governments and private organizations internationally have developed specific nutritional guidelines recommending that childcare centers provide food to children consistent with population dietary guidelines.^3,16,17 Despite such recommendations, few childcare centers adhere to these guidelines. For example, audits of childcare menus conducted in Australia,¹⁸ the United Kingdom¹⁹ and, the United States²⁰ found that none fully complied with nutrition guidelines. A number of barriers to providing foods in accordance with nutrition guidelines have been reported. These include food service staff challenges with modifying recipes, inadequate access to updated menu planning resources, lack of training opportunities, and incorrect assumptions by food service staff that menus and recipes adhere to nutrition guidelines.^21

–25

In order to fully realize the public health benefits of nutrition guidelines for the childcare sector, effective interventions that are suitable for delivery to large numbers of centers and address these challenges are required. Although a previous randomized trial evaluating a low-intensity highly scalable intervention involving the dissemination of printed theory-based education materials has reported improvements in center cook knowledge, self-efficacy, and intentions to use nutrition guidelines, no significant change was observed in menu compliance. This suggests that as a stand-alone strategy provision of printed educational resource materials is unlikely to be sufficient to support behavioral change required to apply the guidelines to improve menu compliance.^26,27 A recent Cochrane review has identified 2 further randomized trials targeting the implementation of nutrition guidelines within childcare centers.²⁸ Although these interventions included provision of printed resources and were effective in improving selected menu nutrition practices, they also included provision of on-site staff training and provision of face-to-face support by trained health consultants,^29,30 strategies that may not be feasible or cost-effective to deliver to large numbers of centers across large geographic areas. Given this evidence, the combination of providing geographically accessible off-site group training conducted with 1 or 2 center representatives (ie, manager and cook) with provision of printed resource materials may represent a potentially effective, feasible, and more scalable means of supporting guideline implementation. Off-site group training offered to center representatives in combination with provision of printed resources is also a strategy frequently employed by governments to support nutrition guideline implementation. Despite this, the impact of such an intervention has yet to be rigorously evaluated. In this context, the primary aim of this study was to determine the effectiveness of an intervention including training, and provision of written menu feedback and printed resources, on increasing childcare center compliance with nutrition guidelines. The study also sought to measure acceptability of the intervention and any unintended adverse effects.³¹

Methods

Design

The study employed a parallel group randomized controlled trial design with 44 center-based childcare services³² (see Figure 1). An additional sample of 26 centers were recruited and randomized to receive a higher intensity intervention. The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615001058561) and approved by the Hunter New England Area Human Research Ethics Committee (approval no 06/07/26/4.04).

Figure 1.

Consort flow diagram.

Setting

The trial was conducted in a sample of eligible centers across one local health district (Hunter New England) located in New South Wales, Australia. Center-based childcare in Australia refers to any public (government funded) or privately operated facilities that provide care to children aged 0 to 6 years outside the home in licensed centers.³³

Sample

A list of all such centers was supplied by the New South Wales Ministry of Health. There were 368 childcare centers in the study region, 106 of which were open for 8 or more hours a day, which prepare and provide food on-site to children while in care. These served as the sampling frame. Centers that did not prepare and provide all meals and snacks to children on-site (ie, those where parents provide some or all food) or did not have a cook with some responsibility for menu planning (for example, centers that provide food via contractual food service providers) were excluded from the study, as the study specifically targeted cooks involvement in menu planning. Further, centers catering exclusively for children requiring specialist care were excluded, as were mobile preschools and family day-care homes given their different operational characteristics.

Information statements and consent forms were mailed out approximately 1 week prior to a telephone follow-up where eligibility was assessed and consent was obtained through the center manager agreement to provide the center’s current 2-week menu for baseline assessment. A random number function in Microsoft Excel was used to determine the order in which centers were approached to participate. Recruitment was conducted from October to December 2015. After consent was received from the center manager, childcare centers were immediately randomly allocated to an intervention or control group using a central concealed random allocation process. Centers were randomized in a 1:1 ratio via block randomization using a random number function in SAS (version 9.3 or later) statistical software. Block size ranged between 2 and 6. All trial outcome data collectors were blinded. Childcare center staff were aware of their group allocation.

Intervention

Implementation strategy development

The implementation strategies included in this trial were selected on the basis of its scalability and ability to target a range of identified barriers to guideline implementation. These barriers included limited knowledge about required serve sizes, outdated skills in menu planning, inadequate skills to self-monitor and assess their menus, limited experience in setting goals and developing action plans, limited support from management and colleagues, and limited access to appropriate resources. To aid the selection of strategies employed and increase potential impact of this intervention, the Theoretical Domains Framework (TDF) was used to comprehensively assess the determinants (factors that may influence, ie, enable or impede) of implementation of nutrition guidelines among cooks.^34,35 Literature reviews of previous implementation interventions targeting food provision in childcare,²⁸ semistructured interviews with cooks (n = 7; using a modified TDF questionnaire),³⁶ and on-site observations of food service practices and menu planning processes were undertaken to identify such determinants. Identified barriers were then grouped according to the relevant TDF domain and mapped to behavior change techniques recommended to address each determinant³⁷ using Michie behavior change matrix.³⁸ The implementation strategies were selected on the basis of this mapping process led by an experienced team of health promotion practitioners, implementation scientists, dietitians, and behavioral researchers in consultation with childcare center cooks and managers.^34,38 Table 1 describes the identified determinants, TDF domains, suggested behavior change techniques, and implementation strategies.

Table 1.

Identified Determinants, TDF Domains, Behavior Change Techniques, and Implementation Strategies.

Determinants (Barriers and Enablers) of Guideline Implementation	TDF Domain	Behavior Change Technique (BCT) Identified as Effective	Implementation Strategies Based Upon Suggested Behavior Change Technique (BCT)
Limited knowledge about required serves outlined in the guidelines	Knowledge	Information regarding behavior, outcome	Training: Components to increase participant’s awareness of importance of nutrition for children and the role of childcare. Information on AGHE food groups, discretionary foods, serve sizes, and the daily recommended serves per child Printed resources: Provision of Caring for Children guidelines and written fact sheets on recommended serve sizes
Outdated skills in planning a menu that is compliant with the nutrition guidelines	Skills	Problem-solving, decision-making, rehearsal, modelling demonstration	Training: Components to develop and facilitate participant’s skills including opportunities to practice undertaking serve size calculations, recipe modifications, reading nutrition information panels, and using the Caring for Children menu planning checklist. For example, an activity to assess an example main meal and determine what food groups were provided through this main menu and what recipe modifications or additional foods would need to be included at mid meals within the daily menu to meet requirements
Lacking skills to self-monitor or to assess menu compliance	Skills	Self-monitoring, decision-making, modelling demonstration	Training: Each center was asked to bring their current 2-week service menu to the workshop and an activity was conducted where each service participant was asked to reflect on their menu, considering if it was meeting guidelines and identify how they knew if their menu was meeting a child’s nutritional requirements while in care. Participants were then shown how to assess their menu.
Limited experience in setting SMART goals and action plans to enable service cooks and managers to work toward menu compliance	Action planning	Planning, implementation	Training: Activity identifying barriers to menu changes, involving a whole-group discussion about possible solutions with participants sharing ideas and brainstorming ways to make change that work within their service drawing on their experience and expertise. Activity providing opportunity to practice setting joint goals and action plan to work toward menu compliance using SMART (specific, measurable, achievable, realistic, appropriate timeframe) goals. This included assigning responsibilities to each goal, setting both menu goals and service goals, using a whole of service approach and linking to existing quality improvement practices within the sector such as mandated quality improvement plans. Printed resources: Goal setting and action planning templates
Limited support from management and colleagues to plan a menu that is compliant with nutrition guidelines	Professional identity	Social processes of encouragement, pressure, support	Training: Facilitated discussions between managers and cooks to determine clear roles and responsibilities with managers encouraged to update nutrition policy and cook position description to reflect roles in healthy menu planning
	Beliefs about consequences (reinforcement)	Persuasive communication, self-monitoring, feedback	Training: Case study video was shown of a service that had made positive changes. An activity was conducted where each center participant was asked to reflect on their menu, considering if it was meeting guidelines, and identify how they knew if their menu was meeting a child’s nutritional requirements while in care. Written menu feedback: Reports provided outlining center compliance with the Caring for Children guidelines via a summary of daily and fortnightly serves provided per child for each food group and discretionary foods Printed resources: Fact sheets targeting key barriers (budget, recipe modification) and menu feedback report provided after the workshop to guide goal setting
Limited access to appropriate resources to assist with planning a service menu	Environmental context and resources	Environmental changes (eg objects to facilitate behavior)	Training: Content targeting ways to adapt the center environment to be more supportive of the implementation of dietary guidelines, for example, displaying the nutrition guidelines and serve size posters in highly visible areas in the kitchen and storing menu planning resources where they are easily accessible Printed resources: Caring for Children guidelines. Fact sheets targeting key barriers (budget, recipe modification)

Abbreviations: AGHE, Australian Guide to Healthy Eating; TDF, Theoretical Domains Framework.

Implementation strategies

Provision of training

Given their roles in overseeing menu planning and food preparation, center managers and cooks were both targeted to support guideline implementation. One full-day group training workshop was offered to center managers and cooks. Based on a formative evaluation identifying an association between cooks’ skills in dietary guideline implementation and menu compliance,²⁷ the workshops aimed to support the development of relevant skills (see Table 1 for content). The workshops combined didactic and interactive components, including opportunities to practice new skills, share ideas, problem-solve, and practice healthy menu planning processes together, case studies, and group discussions. These elements have been suggested to be more effective than didactic education alone.^39
–41 Training workshops were delivered by early childhood education and care health promotion implementation support staff, all of whom had at least 5 years’ experience working as a dietitian and/or experience working on obesity prevention initiatives in center-based childcare.

Written menu feedback

To inform the written feedback, the center menu was assessed by a dietitian in accordance with best practice protocols as part of baseline data collection.^42,43 These data were used to populate a report outlining the number of serves per child provided by the center menu for each of the 5 food groups (vegetables; fruit; wholegrain cereal foods and breads; lean meat and poultry, fish, eggs, tofu, seeds, and legumes/alternative; milk, yoghurt, and cheese). The report also described the number of serves per child of discretionary foods (high-energy, low-nutrient foods) provided by the menu. The report included a summary of serves provided by the menu compared to the nutrition guideline recommendations. The report included both daily and 2-week (fortnightly) summaries for the serves provided and tailored comments outlining tips for menu changes to increase compliance. The report was e-mailed to the center manager 1 month after their participation in the workshop.

Provision of printed resources

Centers were provided with a printed copy of the sector nutrition guidelines, the Caring for Children resource, which has been publically available online since October 2014.³ Australian childcare centers must meet mandatory accreditation standards that require them to provide healthy foods in line with the Australian Dietary Guidelines. The New South Wales government developed the Caring for Children resource as a way of operationalizing these standards for menu services. This resource is utilized by the personnel responsible for undertaking accreditation reviews. The Caring for Children resource provides explicit recommendations regarding the number of serves of foods from each core food group per child that menus should provide to children while they attend care to meet Australian Dietary Guidelines. These food group recommendations form the basis of our assessment of compliance.

The resource provides guidance on menu planning and the number of serves of foods that need to be provided on a center menu to be compliant with guidelines. Additional printed resources were provided at the training and included fact sheets targeting identified barriers to nutrition guideline implementation such as budget (cost) and recipe modification, goal setting and action planning templates, and recommended serve sizes. Further information on the training, menu audit, and resources is available from a published protocol and intervention for an alternative trial.^43,44

Centers randomized to the control group were posted a hard copy of the sector nutrition guidelines, the Caring for Children resource, and wait-listed to receive the intervention after completion of 12-month follow-up.

Measures

Baseline data collection occurred between November 2015 and February 2016 and postintervention follow-up data were collected 6 months later (May to September 2016).

Center and cook characteristics

Childcare center operational characteristics were collected via a recruitment telephone call and mailed pen-and-paper questionnaire completed by the manager of intervention and control centers at baseline. The data collected included the center hours of operation, total number of children enrolled, number of children who attend each day, daily budget allocated for food provision per child, and the center nutrition environment (including the presence of a nutrition policy, role modeling behavior of staff, and staff provision of positive comments and prompts to children during meal times). The items used in the questionnaire have been used in previous Australian surveys of center-based childcare managers conducted by the research team.^45,46

Cook demographic characteristics were similarly collected by a mailed pen-and-paper questionnaire at baseline. Information collected by the questionnaire included data regarding the cook (education level, years employed as a cook, age, and weekly hours worked) and information about their menu planning processes (such as how frequently the center plans a menu) and the provision of healthy foods. Questions were adapted from items previously used in a state-based survey of childcare centers conducted by the research team.³⁶

Primary trial outcome: Overall menu compliance with nutrition guidelines

The primary outcome was defined as the proportion of centers providing food servings (per child) compliant with nutrition guideline recommendations for all 5 Australian Guide to Healthy Eating (AGHE) food groups across every day of a 2-week menu (10 days).

As shown in Table 2, nutrition guideline recommendations indicate menus must provide 50% of the recommended daily serves of the 5 food groups specified in the AGHE across a 2-week menu cycle (10 days). Specifically, to be compliant, centers must provide on their menu each day over a 2-week period (fortnight) (1) 2 serves of vegetables and legumes/beans, (2) 1 serve of fruit, (3) 2 serves of wholegrain cereal foods and breads, (4) 0.75 serves of lean meat and poultry, fish, eggs, tofu, seeds, and legumes, and (5) 1 serve of milk, yoghurt, cheese, and alternatives.³

Table 2.

Baseline Childcare Service and Cook Characteristics.

At Baseline	Intervention (n = 24), Mean (SD)	Control (n = 20), Mean (SD)
Service characteristics
Average number of children attending each day	55 (17.03)	53 (17.04)
Daily budget allocated for food provision per child,^a AUD	1.92 (0.5)	2.23 (0.82)
Geographic locality	n (%)	n (%)
Major city and inner regional	83.33 (20)	85.00 (17)
Outer regional or remote	16.67 (4)	15.00 (3)
Services in high socioeconomic area (SEIFA in top half of state)	37.50 (9)	40.00 (8)
Cook demographic characteristics
Female	19 (82.61)	18 (90.0)
Number of hours worked per week
20 hours or less	4 (17.39)	5 (25.00)
21-29 hours	13 (56.52)	12 (60.00)
30 hours or more	6 (26.09)	3 (15.00)
Qualification (TAFE, registered training or university)	13 (54.17)	18 (90.00)
Age
<40 years	9 (42.86)	5 (26.32)
40-49 years	5 (23.81)	8 (42.11)
50+ years	7 (33.33)	6 (31.58)
Years worked in current position
5 years or less	14 (60.87)	12 (75.00)
>5 years	9 (39)	4 (25)
Years as a cook in any childcare center
5 years or less	13 (56.52)	13 (65.00)
>5 years	10 (43.5)	7 (35.00)

Abbreviations: AUD, Australian Dollars; SEIFA, Socio-Economic Indices for Areas; TAFE, Technical and Further Education.

Compliance was assessed via comprehensive menu reviews, similar to those previously undertaken by the research team.⁴³ Centers provided a copy of their 2-week menu along with additional recipe information (on a standardized cover sheet) to enable food group classification. The dietitian contacted the cooks via telephone or a face-to-face visit for additional information if it was not adequately reported via the cover sheet. An independent dietitian, blinded to group allocation, assessed the menu and calculated serves of food groups per child based on the AGHE food groups. To generate the number of serves for each individual food group, all food items on the menu were first classified into their appropriate food group. For each day, the total quantity of each food group was summed, then divided by the number of children attending on the day, and then divided by a single recommended food group serve outlined in the Caring for Children resource and based on the AGHE recommendations. Compliance to the nutrition guidelines was determined based on the calculations of serves of each food group provided per child each day. The calculated serves of each food group were rounded to the nearest 0.25 of a serve.

Secondary trial outcomes

A secondary outcome, compliance with nutrition guidelines for each individual AGHE food groups and discretionary foods, was included to provide greater description of any changes occurring in measures of menu compliance. Six measures were used to assess compliance with nutrition individual guideline recommendations for each 5 food groups specified above and discretionary foods. Discretionary foods are those which are high in kilojoules, saturated fat, added sugars and added salt, and are not recommended for provision in childcare. Specifically for this outcome, we assessed the proportion of centers providing, across every day of a 2-week menu, the recommended serves of each food group described above, as well as zero serves of “discretionary” foods. This outcome was not prospectively registered.

Knowledge

Cook knowledge of menu nutrition guidelines included items assessing correct knowledge of the recommended number of serves for each of the AGHE 5 food groups and discretionary foods. This was collected via a pen-and-paper questionnaire completed by intervention and control center cooks at baseline and follow-up.

Adverse events

Information on adverse events was assessed via items included in the cook’s pen-and-paper questionnaire completed at baseline and follow-up. Measures included receipt of negative feedback about the menu in the last month (received from the center manager, educators, children, and/or parents), estimated average percentage of each meal not consumed by the children and classified as waste (morning tea, lunch, and/or afternoon tea), and daily budget allocated per child.

Intervention uptake and fidelity

Project records maintained by implementation support staff were used to monitor intervention uptake and fidelity. Measures of intervention uptake included overall center, center manager, and cook participation rate in intervention training. Fidelity was measured through an assessment of the number of implementation strategies delivered as planned.

Intervention acceptability

Postintervention acceptability was assessed via written surveys completed by both center managers and cooks at 6-month follow-up for intervention group centers only. Items were similar to those used previously by the research team⁴⁷ and assessed the acceptability and helpfulness of the training workshop, menu feedback report, and printed workshop resources (menu planning tools and fact sheets). The items were rated using a 10-point Likert scale (1 = not acceptable at all and 10 = very acceptable).

Theoretical Domains Framework Constructs

At postintervention, barriers and enablers related to the TDF constructs targeted by the intervention (knowledge, skills, goals/action planning, social/professional role, beliefs about consequences, environmental context, and resources) were assessed via an online survey completed by service cooks for both intervention and control groups. The survey was previously validated with long day-care service cooks in Australia.³⁶ Cooks were asked to rate their barriers and enablers to implementing the Caring for Children nutrition guidelines on a 7-point Likert scale from “strongly disagree” to “strongly agree.”

Sample size and power calculations

Based on results of formative research conducted by the research team, the recruitment of 29 centers in the intervention group and 29 centers in the control group was identified to enable the detection of an absolute difference of 32% between groups in the primary outcome at follow-up, allowing for a 13% overall compliance rate in the control group, with 80% power, with a 2-sided α of .05.

Analysis

All statistical analyses were performed with SAS (version 9.3 or later). All statistical tests were 2-tailed with an α value of .05 and all available data were used for the analysis. All primary and secondary outcomes were analyzed under the intention-to-treat principle using all available data with centers analyzed based on the groups to which they were allocated. Logistic regression models, adjusted for baseline values of the outcome, were used to determine the effectiveness of the intervention in improving overall compliance with nutrition guidelines and explore the potential impact of the intervention on compliance with each of the AGHE and discretionary food guideline recommendations separately. The model included terms for time, group (intervention or control), and group × time interaction. Descriptive statistics were used to describe the center characteristics of intervention and control group centers at baseline and intervention acceptability and adverse events. The percentage of participants scoring intervention component acceptability as greater than or equal to 8 was calculated and reported, which was deemed equivalent to strongly agreeing. Socioeconomic characteristics were determined using center postcodes, which were classified as being in the top or bottom 50% of New South Wales according to the Socio-Economic Indices for Areas.⁴⁸ Geographic characteristics of the center locality were classified as either major city and inner regional or outer regional or remote according to the Australian Statistical Geography Standard. Similar to previous studies, average scores for each TDF construct were calculated by summing all scores for all items within the domain (“strongly disagree” = 1 to “strongly agree” = 7) and dividing by the total number of responses within the domain. T tests were used to assess between-group differences between barriers and enablers related to the TDF constructs at follow-up.

Results

Of the 106 eligible childcare centers in the study region, 90 (85%) were eligible, 79 (87%) consented to participate, and 44 were randomized into this study (intervention n = 25; control n = 28). The remaining 26 were allocated to receive an alternate high-intensity intervention consisting of training and follow-up support (Figure 1). Of the 53 centers recruited in the study, 9 centers (intervention n = 1; control n = 8) withdrew consent prior to baseline data collection. Of the remaining, all completed follow-up data collection. The baseline characteristics of the childcare centers at both baseline and follow-up are described in Table 2.

Center and Cook Characteristics

The intervention group had a higher percentage of cooks who had worked at the center for greater than 5 years (39 vs 25), who worked greater than 30 hours per week (26.09 vs 15), and who were aged less than 40 years (42.8 vs 26.32) than control. The control group had a higher proportion of cooks with a qualification technical and further education (TAFE), registered training or university; 90.00 vs 54.17), aged between 40 and 49 years (42.11 vs 23.81), and centers with a higher budget per child per day (2.23 vs 1.92) compared to intervention.

Trial Outcomes

Primary trial outcome: Overall menu compliance

At both baseline and follow-up, zero centers in both the intervention and control groups were compliant with overall menu nutritional guidelines (compliant with all 5 out of 5 food groups over the full 2 weeks; Table 3). Statistical analyses were not able to be performed given zero values across multiple cells.

Table 3.

Menu Outcomes Over Time by Group.

Measure	Intervention (n = 24)		Control (n = 20)		Analysis Using all Available Data (Controlled for Baseline)
Measure	Baseline	Follow-Up	Baseline	Follow-Up	OR (95% CI)	Adjusted P Value^a
Overall menu compliance (2-week menu compliant), n (%)
	0 (0)	0 (0)	0 (0)	0 (0)	-	-
Compliance for each food group guideline and discretionary foods (compliance with nutrition guidelines for individual AGHE food groups), n (%)
Vegetables	0 (0)	0 (0)	0 (0)	0 (0)	-	-
Fruit	1 (4.17)	4 (16.67)	5 (25)	2 (10)	3.67 (0.32-196.79)	.48
Breads and cereals	4 (16.67)	2 (8.33)	2 (10)	2 (10)	0.77 (0.05-11.43)	1.00
Meat and alternatives	0 (0)	0 (0)	0 (0)	0 (0)	-	-
Dairy	9 (37.50)	10 (41.67)	5 (25)	3 (15)	3.53 (0.68-24.56)	.16
Discretionary	3 (12.50)	8 (33.33)	0 (0)	1 (5)	5.71 (0.56-295.28)	.18

Abbreviations: AGHE, Australian Guide to Healthy Eating; CI, confidence interval; OR, odds ratio.

^a Using all available data and controlling for baseline.

Secondary outcome

Relative to the control group, there were no significant between-group differences observed for the proportion of centers compliant for each AGHE food group and discretionary foods examined separately (Table 3).

Knowledge

Relative to the control group, intervention group centers showed a significantly greater increase in correct knowledge for vegetable servings (P = .008; Table 4).

Table 4.

Knowledge of Recommendations for Food Groups and Adverse Events by Group Over Time.

Measure	Intervention		Control		Adjusted P Value^a
Measure	Baseline (n = 24)	Follow-Up (n = 23)	Baseline (n = 20)	Follow-Up (n = 18)	Adjusted P Value^a
Cook knowledge of correct serves, n (%)					-
Vegetables	5 (31.3)	14 (93.3)	4 (30.8)	4 (36.4)	.008
Fruit	14 (87.5)	12 (80.0)	7 (53.9)	4 (36.4)	.15
Breads and cereals	6 (37.50)	12 (80.0)	7 (53.9)	6 (54.5)	.18
Meat and alternatives	3 (18.8)	12 (85.7)	2 (16.7)	2 (18.2)	.91
Dairy	4 (25.0)	9 (60.0)	2 (16.7)	3 (27.3)	.12
Discretionary	12 (85.7)	12 (92.3)	8 (80.0)	7 (70.0)	.93
Adverse events
Average percentage of food classified as waste, n (%)
Morning tea	5.2	5.2	6.5	6.0	.80
Lunch	11.6	10.9	11.5	13.3	.57
Afternoon tea	5.2	4.4	4.9	6.0	.09
Negative feedback reported about the menu in the last month, n (%)
From educators	37.5	28.6	18.2	25.0	.98
From children	12.5	19.1	9.0	6.3	.94
From parents	5.2	4.4	4.9	6.0	.95
Daily budget allocated per child (A$), mean (SD)	1.9	2.0	2.1	2.2	.55

Abbreviation: SD, standard deviation.

^a Controlling for baseline.

Adverse events

Relative to the control group, intervention group centers showed no significantly greater increases in measures of adverse events including average percentage of foods classified as waste, negative feedback about menu, and daily budget allocated per child (Table 4).

Intervention uptake and fidelity

Overall, 75% (n = 18) of centers had 1 staff member and 50% of centers had (n = 12) both targeted staff attend the workshop (manager and cook). After the group workshops were completed, a shorter (3-hour) training session was developed and offered to center managers and cooks who had been unable to attend the group workshop and was taken up by 42% (n = 10; either center manager or cook). A total of 50% of centers received all implementation strategies as originally planned (both center manager and cook attending the group workshop and receiving the menu review and feedback report) and overall 96% (n = 23) of center managers and cooks received training (either method), with 100% (n = 24) receiving the review and feedback report.

Intervention acceptability

The percentage of participants scoring intervention component acceptability as greater than or equal to 8 (equivalent to strongly agreeing with the statement) ranged from 77% to 94% among cooks and 71% to 95% among managers.

Theoretical Domains Framework constructs

At follow-up, there was no significant difference between the intervention and control groups in the targeted TDF barrier and enabler domain scores. These included knowledge (P = .53), skills (P = .08), goals/action planning (P = .70), social/professional role and identity (P = .21), beliefs about consequences (P = .63), and environmental context and resources (P = .90).

Discussion

This randomised controlled trial sought to assess the impact of an intervention providing training, a written feedback report, and nutrition resources on increasing childcare center compliance with sector nutrition guidelines. These findings are of particular relevance for current government initiatives as such strategies are typically employed to improve guideline implementation in this setting. The trial is novel in regard to its application of theory to inform the selection of implementation strategies to target key implementation barriers, assessment of potential unintended adverse effects, and its ability to be delivered at scale. The findings indicate that while the intervention was considered highly acceptable, and resulted in no adverse effects, there was no statistically significant effect on overall menu compliance. In regard to additional compliance outcomes, the intervention showed no effect on compliance with each of the guideline recommendations individually. Broadly, the findings suggest that training, coupled with a single feedback report and resource provision, may not be an effective strategy to increase childcare center compliance with dietary guidelines.

Several factors may have contributed to these results and could be considered as opportunities for enhancing future interventions. First, the findings for correct knowledge of recommended serve guidelines suggest that individuals planning menus remain unclear with respect to the majority of the targeted food groups. Even where the intervention significantly increased cooks knowledge of the correct serves of vegetables required to be planned on the menu per day (P = .008), no intervention effect for compliance with the vegetable food group was observed. This could be due to the complexity of implementing the guidelines. Such findings corroborate the experience of other researchers reporting complexity as a barrier to center staff ensuring that foods are consistent with guidelines and other regulatory standards^19,49,50 and could explain similar findings reported by 2 previously published randomized controlled trials.^29,30 For example, Alkon and colleagues reported no significant difference in food and beverage provision among centers exposed to a program targeting 15 nutrition and physical activity policies and practices, including a component addressing food provision involving training for center staff, resources, and 6-month ongoing technical assistance (visits and calls) delivered by trained childcare health consultants, compared to controls.²⁹ A simpler menu planning guide for center-based childcare centers, similar to traffic light guides used by schools,⁵⁰ or use of a tool that can automatically perform the required serve calculations and recommended amendments to menus, is being investigated in a trial currently underway⁵¹ and may help to overcome this challenge.^52,53

Second, while one-off group training, provision of written feedback, and resource materials may represent a pragmatic and scalable approach to increasing childcare compliance with menu nutrition guidelines, interventions in this setting will only be of benefit where they are able to comprehensively influence barriers and enablers to practice change. Although the application of the TDF in the development of the intervention produced a potentially broader understanding of nutrition guideline implementation determinants, the selected implementation strategies did not change the targeted TDF constructs as reported by center cooks at follow-up. It is possible that training and a single round of menu feedback may not have provided enough dose to produce meaningful changes to the targeted implementation determinants. Such findings suggest that in order to produce a significant change in the determinants, and in turn a significant change in the primary outcome, a greater dose of implementation support may be required. This corroborates findings of previous research from the setting that positive practice change can take place when ongoing follow-up support is provided.²⁸ Alternatively, the findings may reflect challenges in measuring implementation determinants using the TDF. Although validated and used in previous randomized trials, TDF scores for a number of constructs were high and skewed. Such ceiling effects may hinder the capacity of the measure to detect meaningful changes.

Finally, while participation and training uptake overall were high, just 50% of centers received the intervention as originally intended, that is, attended by both center manager and cook together at a full-day group workshop. Adaptations to improve the training uptake via offering a shorter on-site training session may have compromised the intervention’s ability to address targeted barriers and enablers. Future initiatives considering using training as an implementation strategy may need to consider such barriers to attending training and incorporate strategies to improve attendance.

Strengths of this study include its use of a randomized controlled design, broad inclusion criteria, application of theory for intervention design, gold standard menu assessments undertaken by a dietitian blinded to group allocation, and assessment of adverse events. Several limitations are important to consider. Compliance outcomes for each of the guideline recommendations separately were not prospectively registered, introducing some potential for selective reporting. In addition, the evaluation surveys did not include measures of TDF constructs for center managers. This represents a missed opportunity to obtain greater clarity on barriers faced by participating center managers. Finally, the quantitative nature of the survey limited the ability to gain greater context around identified barriers and also prevented us from identifying any additional factors, not previously assessed, which may further impact the ability of the service manager or cooks to implement menu changes. For example, while center managers and cooks are primarily responsible for the oversight of menu planning and food preparation, Australian accreditation standards also encourage centers to consult and seek feedback from parents as part of menu planning, a potentially influential factor that was not assessed in this study. Additional examples may include cost factors beyond allocated budget per child and information on food restrictions or allergies that limit menu options.

So What? Implications for Health Promotion Practitioners and Researchers

What is already known on this topic?

Although childcare centers provide an opportune setting to improve children’s nutrition, most do not adhere to nutritional guideline recommendations. In order to fully realize the health benefits of such guidelines, effective interventions that are suitable for delivery to large numbers of centers and target reported practice barriers to implementation are required.

What does this article add?

Strategies such as training and provision of printed resources, frequently used to support nutrition guideline implementation, had not been rigorously evaluated in this setting. This study examined the effect of a theoretically informed and potentially scalable intervention on menu nutrition guideline compliance in childcare centers specifically designed to address barriers to their implementation.

What are the implications for health promotion practice or research?

Findings indicated that the implementation strategies were not effective in improving menu nutrition guideline compliance. 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 to improve menus.

Footnotes

Acknowledgments

The authors would like to thank Christophe Lecathelinais for statistical advice. The authors also acknowledge the contribution of the Hunter New England Population Health project team in delivering the intervention and collecting the data and sincerely thank center managers, cooks, and educators for their participation.

Author Contributions

Meghan Finch led the development of this manuscript. Sze Lin Yoong, Kirsty Seward, Jannah Jones, Luke Wolfenden, and Meghan Finch conceived the intervention. Sze Lin Yoong, Alice Grady, Luke Wolfenden, and Meghan Finch designed the research and advised on implementation of the intervention. Kirsty Seward, Taya Wedesweiler, Jannah Jones, and Fiona Stacey conducted the research. All authors contributed to, read, and approved the final version of this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Hunter New England Population Health and University of Newcastle Australia provided in-kind support conduct to undertake the trial. Intervention delivery was undertaken as part of usual service provided within Hunter New England Population Health. Infrastructure support was also provided by Hunter Medical Research Institute. Dr Meghan Finch is a clinical research fellow funded by Hunter New England Population Health and the Health Research and Translation Center, Partnerships, Innovation and Research, Hunter New England Local Health District. Dr Sze Lin Yoong is a postdoctoral research fellow funded by the National Heart Foundation. Associate Professor Luke Wolfenden receives salary support from a National Health and Medical Research Council (NHMRC) Career Development Fellowship (grant ID: APP1128348) and Heart Foundation Future Leader Fellowship (grant ID: 101175). The contents of this manuscript are the responsibility of the authors and do not reflect the views of the NHMRC. The trial was also supported by funding, in part, by a Cancer Council NSW program grant (PG 16-05).

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