Nursery recruitment
In North Somerset, the NAP SACC UK study was discussed with nursery managers at a meeting convened by the local council, and advertised in the Council’s Early Years newsletter. Gloucestershire was included as recruitment site after North Somerset, meaning we were unable to hold a similar meeting in this area. Instead, nurseries were sent a letter from the Council, alongside a project information sheet, and a form to return indicating their willingness to take part. In both areas, the study was called ‘NAP SACC UK’ and nurseries were informed it was based on an American programme, adapted for use in the UK. Nurseries were informed the study was being run the University of Bristol, with intervention costs provided by North Somerset Council and Gloucestershire County Council.
Of the 14 nurseries approached in North Somerset, six (43%) agreed to participate. In Gloucestershire, participation rates were lower, with 25 nurseries approached to achieve the required sample of six settings (participation rate 25%). We were unable to recruit a large nursery in the highest deprivation group in Gloucestershire, but met recruitment targets for all other size/deprivation categories. Nurseries declined to participate in the study because they were too busy, were experiencing staffing or financial issues, were already participating in other initiatives or felt they did not need the intervention. No nurseries were lost to follow-up.
We identified two reasons to explain the difference in participation rate between the two areas. First, there were fewer on-going nursery-based initiatives in North Somerset, with nurseries therefore more willing to participate in a new programme. In Gloucestershire, many nurseries were involved in other health-related initiatives such as the ‘Bristol Standard’ [
24] and the ‘Smiles Better’ oral health pilot programmes, both of which overlapped in content with NAP SACC UK. Second, as noted above, Gloucestershire was included as a recruitment site later in the study, resulting in a shorter recruitment period which included the Christmas period when nurseries are closed for up to two weeks.
NAP SACK UK partner training
A training session for NAP SACC UK Partners was held in December 2015, facilitated by local experts. It provided an overview of the study, and training on how to support nurseries to review practice, set goals and implement changes. Partners found the training useful although noted “it was a bit rushed” (Partner_N12/16) and the sessions “could have all been a bit longer” (Partner_N1&5/25). The participants particularly appreciated the physical activity training, not having received formal training on this in their Health Visitor role. All four Partners undertook additional preparation outside of the training sessions to prepare for working with the nurseries, such as familiarising themselves with the literature, resources and documents provided by NAP SACC UK.
Review and Reflect self-assessment
All six intervention nurseries completed the Review and Reflect assessment at baseline, with five completing it again at follow-up. However, only three nurseries returned completed forms for both baseline and follow-up required for inclusion in the analysis (Tables
1 and
2). (In three cases, interviews confirmed the forms were completed but were subsequently misplaced). Self-reported summary scores increased from baseline to follow-up for all four areas, with the greatest improvement seen for ‘Physical Activity and Play’. Of the four individual items where no improvement was made, three related to policy development (see later section on goal setting). Across all items, there was a 9% increase and a mean difference of 0.26 (− 0.15, 0.67).
Table 2
Nursery self-reported Review & Reflect scores at baseline and follow-up (mean and SD)
Child Nutrition and Oral Health Summary Score | 3.07 (0.20) | 3.24 (0.18) |
Food provided | 3.07 (0.20) | 3.38 (0.21) |
Beverages provided | 3.44 (0.51) | 3.56 (0.51) |
Oral health | 2.00 (0.33) | 2.11 (0.51) |
Feeding environment | 3.24 (0.29) | 3.51 (0.16) |
Menus and variety | 3 (1.00) | 3 (0.00) |
Nutrition education and professional development | 2.29 (0.38) | 2.95 (0.08) |
Nutrition policy | 2 (1.00) | 2.33 (1.15) |
Physical Activity and Play Summary Score | 2.67 (0.29) | 2.98 (0.15) |
Time provided | 2.78 (0.12) | 3.22 (0.19) |
Indoor play environment | 3.33 (0.76) | 3.50 (0.50) |
Physical activity staff practices | 3.08 (0.14) | 3.25 (0.25) |
Physical activity education and professional development | 2.33 (0.31) | 2.80 (0.35) |
Physical activity policy | 1 (0.00) | 1 (0.00) |
Outdoor Play and Learning Summary Score | 2.57 (0.90) | 2.71 (0.10) |
Outdoor play | 3.25 (0.75) | 3.42 (0.52) |
Outdoor physical environment | 2.63 (0.45) | 2.74 (0.53) |
Outdoor play education and professional development | 2 (0.88) | 2.22 (0.51) |
Outdoor play policy | 1 (0.00) | 1 (0.00) |
Screen Time Summary Score | 2.48 (0.33) | 2.6 (0.23) |
Screen time availability and staff practices | 3.25 (0.50) | 3.58 (0.52) |
Screen time education | 1.33 (0.58) | 1.66 (0.58) |
Screen time policy | 1.0 (0.00) | 1.0 (0.00) |
The in-depth nature of the assessment meant it was time-consuming. Nonetheless, all managers found it a positive process with one commenting, “it showed us what we are doing good and just the tweaks we needed to change that improved it” (Manager_N9/4). The assessment was equally valued by the Partners as a way of getting managers to reflect critically on their current practice:
“Certainly with them all pulling their menus out and it’s like, ‘Oh gosh, no, I didn’t think about that,’ and, ‘Oh yeah, look at that pattern, look at that. We’re offering too many biscuits there.’ Just gets them really thinking about it.” (Partner_N8&9/14)
Some managers undertook their assessment independently while others completed it with their NAP SACC UK Partner. Partners who had done this felt it had aided their discussion, helping them understand the nursery context and set relevant goals. For one nursery in a more deprived area, the Partner noted this process
“gave me an oversight really, and also what restrictions they have from a financial point of view” (Partner_N3/21).
Staff workshops
Two workshops (on physical activity and nutrition) were held for nursery staff in five of the six intervention nurseries. Workshops were conducted on Saturday mornings or after work, lasted between 2 and 3 h and were facilitated by local experts. The number of staff attending ranged from four to eight, with the NAP SACC UK Partner also often in attendance. Activities included presentations, quizzes, group discussions and games.
Nursery managers, staff and Partners were highly enthusiastic about the NAP SACC UK workshops, describing them as “invaluable” (Manager_N5/10), “absolutely brilliant” (Staff_N8/6) and “inspiring” (Partner_N8&9/14). Despite often occurring after work, participants reported feeling energised by the sessions: “We all kind of came away like, ‘My gosh, I’ve got so much energy! ... It kind of re-inspired us.” (Manager_N1/11). Observation and interview data highlighted the interactive tasks and the lively manner of the facilitators as being critical in engaging staff. The facilitators appeared skilled at adapting content and activities to the needs and interests of each group. One facilitator noticed and built upon the friendly competition emerging between groups during a quiz, while another facilitator was praised for helping staff overcome their shyness and enjoy the session. This was echoed by the nursery manager who commented:
“[The facilitator] had like a funny character to him … it was kind of like we felt like we knew him … you just kind of felt at home or felt at ease. So you took on a lot more and you had a laugh and a joke, but you didn’t lose sight of where you were going.” (Manager_N1/11)
Nursery staff appreciated the opportunity to reflect on their own practice, with one participant remarking the workshop had
“opened our eyes to think, ‘Actually, there are new ways of doing it.’” (Staff_N8/6). Often changes suggested at the workshops were simple but perceived to be very powerful, for example, incorporating physical activity into story time or simply asking children ‘are you still hungry?’ instead of ‘do you want some more?’
While workshops received much praise, some issues were also identified. One Partner noted some staff were uncomfortable acting “as if they were on CBEEBIES [children’s television]” (Partner_N3/21) to encourage physical activity, but that this has been “gently talked about [in the workshop] … and that’s something they’ve worked on”. She added a staff member had subsequently been funded by the Local Authority to attend a storytelling workshop. Staff from another nursery in a deprived area reported feeling frustrated during workshops knowing they would be unable to implement many ideas due to budget restrictions: “we were a little bit more deflated because we kind of thought, ‘Actually we know we can’t do that.’” (Manager_N1/11).
While the workshops were offered free-of-charge, nurseries did incur costs in terms of staff time-off-in-lieu, ranging from £478–£691 (mean £610) per nursery. However, no manager raised this incurred cost as being problematic during interviews. When asked if they would have been prepared to pay for the workshops, most were equivocal suggesting they may have done, but would have limited the number of staff attending.
Goal setting
Goals were set in five of the six intervention nurseries with the majority achieved within the intervention period (see Table
1); those that required more effort on the part of the manager (e.g. writing new policies) had not yet been achieved. Many goals were easy and simple to implement, which one Partner felt was key to engaging nurseries:
“They’re just small, inexpensive goal setting … I thought that was practical, not too big a jump for the nurseries.” (Partner_N12/16).
Three nurseries set goals to modify their menus by, for example, providing more fruit, removing biscuits as snacks and offering oily fish once a week. Others modified portion sizes, with one manager commenting “we’re not over feeding them anymore” (Manager_N3/1). One nursery let staff eat for free to encourage them to role model positive eating behaviours, leading one staff member to comment, “that’s such a benefit to those children … to see I am eating my vegetables, and they can copy me and copy that behaviour” (Staff_N3/2). Four nurseries set goals to provide nutritional information to parents via parents’ evenings, notice boards, leaflets and websites. One manager felt the nursery’s involvement with NAP SACC UK provided the legitimacy and “clout” needed to raise nutrition topics with parents (Manager_N5/10), while another described how they now included a healthy lunchbox guide in their welcome pack as standard (Manager _N1/11).
Physical activity goals focused on three areas: writing policies; providing information to parents; and changing staff practice and/or use of space or equipment to promote physical activity. Only one nursery had devised a physical activity policy, while two other nurseries selected this goal but time constraints limited its achievement. It was suggested that providing template policies would help nurseries achieve this goal. Interview participants tended to focus on the new ways they had found to increase physical activity throughout the day. One nursery had improved their outside space, while another moved from having set garden times to allowing children to choose to play indoors or out. Importantly, the intervention allowed staff to reflect on their own practice and gave them permission to focus on physical activity:
“It was just quite nice to see the staff actually relaxing a bit more and not worried about, ‘Oh, we need to go to do that next’ … And for the children it was, ‘Oh, the adults do it too, they have fun, they play the spot game, they chase us round.’” (Manager_N1/11)
Though most goals had been met, it became apparent that some nurseries had chosen not to set certain goals, knowing they would be unachievable. For example, one Partner had not suggested writing new policies in one nursery as it was part of a national chain and “
would have gone through a lot of red tape and wouldn’t have been achieved within the timeframe” (Partner_N8&9/14). Another nursery discussed, but did not set, tooth brushing as a goal as they did not have space to accommodate the extra movement of children and staff.
Budgetary constraints were a significant barrier in one nursery operating in a very deprived area. The manager wanted to reduce the amount of bread offered at teatime and provide healthier alternatives but the nursery owners were unable or unwilling to increase the budget. As the manager explained, “when you can’t exceed 40p for a loaf of bread, how could you possibly buy a thing of wraps and something to fill the wraps?” (Manager_N1/11).
On-going partner support
Partners and managers from the five nurseries that fully implemented the intervention all met in person at least twice: first, to review practice and set goals, and second, to assess progress. Additional support was provided via phone calls and emails. Managers and staff reported finding this on-going contact with Partners useful. One manager appreciated the Partner’s outside perspective and found the positive feedback she received very motivating. Others valued the opportunity to develop a relationship with another child health professional: “It’s nice that I’ve got that professional relationship now with our [Partner]. So I know that I can call her any time and she’ll come down even after the study has finished” (Staff_N3/2). However one Partner appeared uncomfortable in providing this support to busy nursery managers, admitting “I do feel like I’m harassing them” (Partner_N1&5/25). Though she provided guidance and signposting to relevant resources she explained: “I don’t think I really got to that point where … they were ringing me up saying, “Oh, how can we do this?” I didn’t really have that relationship with them.” (Partner_N1&5/25).
Within NAP SACC UK, the role of Partner was taken on by local Health Visitors who were deemed to be similar in skills and professional background to the child-care health Partners used in NAP SACC in the United States [
15]. For this study, Partners were employed by NAP SACC UK, with this work occurring outside of their normal Health Visiting role and contracted hours. Partners felt taking on the NAP SACC role was appropriate as Health Visitors are the
“only consistent professionals that are seeing that age group, outside of the nurseries” (Partner_N3/21). While one Partner queried the necessity of using Health Visitors for this role, others felt the
“in-depth” and
“holistic” approach of the Health Visitor was important and their professional status appeared to be valued by nursery managers. However, all Partners raised concerns regarding the capacity of Health Visitors to deliver this role in any subsequent roll-out, noting that their existing workload was so great that
“if you put this on health visitors to do routinely, I think it just wouldn’t get done.” (Partner_N12/16). Family Support Workers and Nursery Nurses were suggested as possible alternatives for the Partner role, although it was noted that these staff have similar capacity constraints and lower levels of training than Health Visitors.
Web-based parent element
The web-based parent element of NAP SACC UK was not well-used. The site was launched in April 2016 and promoted to parents at intervention nurseries via information sheets, flyers and a promotional mug. They were also offered a free family swimming voucher if they completed the ‘Healthy Habits’ questionnaire and set a goal. However, only 12 parents (14%) logged onto the website and only seven set a goal. All 12 parents were emailed to encourage them to set a (further) goal, but none did so.
Five of the ten intervention parents interviewed had used the website. Of the remaining five, three had been unaware of it, while one did not “get around to looking at it” (Parent_32) and the other explained, “it hasn’t been a priority really” (Parent_19).
Those using the website found logging on, completing the ‘Healthy Habits’ questionnaire and setting goals easy to do. However, one parent questioned the usefulness of the site explaining “I think probably if I wanted advice or anything I would turn to the internet anyway and good old Google for ideas” (Parent_22). Two parents discussed setting goals but neither felt it had made much difference to their interactions with their child. One tried to make fruit and vegetables more appealing by arranging them in the shape of a butterfly but “the novelty wore off after about a minute” (Parent_29). The other tried to be more mindful of what she was giving her child to eat but this had tailed off over the summer holidays while they were out of their normal routine. Text messages sent to two parents were not well received because they were too generic and “nothing that I didn’t know” (Parent_29).
Withdrawal from the intervention: nursery 12
As noted above, one nursery (12) did not fully implement the intervention; the manager completed the self-assessment with the Partner, but no goals were set and no workshops held. The primary reason for this withdrawal was that the staff were unwilling to attend the required out-of-hours workshops because they had recently completed several weeks of mandatory out-of-hours first aid training. Importantly, therefore, it was the timing rather than the out-of-hours nature of the workshops that was problematic.
A letter of agreement setting out what participation in the study would involve (including the two workshops) had been sent to all nurseries at recruitment. However in Nursery 12 this letter had been signed by the deputy manager; it became clear during the manager interview that she had been unaware of this requirement. Although alternative solutions were presented (including offering workshops during the day), none was acceptable to the manager. This led the nursery to withdraw from the intervention, but they participated in follow-up data collection.
The NAP SACC UK intervention draws on components of social cognitive theory, framed within a socioecological framework [
21,
25]. The intervention logic model therefore theorised that changes in knowledge, motivation and self-efficacy in nursery staff and parents would be important mediators through which the intervention impacted on key child health outcomes such as BMI (see Additional file
1 and [
26]). For nursery staff receiving the intervention, there were small increases in all mediators from baseline to follow-up, except for nutrition self-efficacy (Table
3). In control nurseries, there were small decreases in all mediators apart from physical activity knowledge and self-efficacy. Intervention parents reported small increases in all mediators but physical activity knowledge; in control parents, all three physical activity mediators increased slightly, with decreases or minimal change in nutrition mediators (Table
4).
Table 3
Nursery staff reported mediators of knowledge, self-efficacy and motivation (mean and SD)
Physical activity, play & sedentary time |
Knowledge | 16 | 4.19 (1.64) | 12 | 5.08 (0.90) | 15 | 4.07 (1.28) | 11 | 4.64 (1.69) |
Motivation | 15 | 4.54 (0.45) | 11 | 4.76 (0.32) | 15 | 4.45 (0.84) | 11 | 4.36 (0.76) |
Self-efficacy | 16 | 4.43 (0.47) | 12 | 4.58 (0.39) | 15 | 4.46 (0.57) | 10 | 4.54 (0.43) |
Nutrition & oral health |
Knowledge | 16 | 10.88 (3.30) | 12 | 12.09 (2.02) | 15 | 11.00 (1.13) | 11 | 10.20 (2.66) |
Motivation | 15 | 4.47 (0.50) | 11 | 4.66 (0.38) | 15 | 4.58 (0.51) | 10 | 4.28 (0.89) |
Self-efficacy | 16 | 4.36 (0.36) | 10 | 4.35 (0.54) | 15 | 4.58 (0.29) | 10 | 4.38 (0.49) |
Table 4
Parent reported mediators of knowledge, self-efficacy and motivation (mean and SD)
Physical activity, play & sedentary time |
Knowledge | 32 | 4.00 (1.30) | 32 | 3.78 (1.41) | 41 | 4.15 (1.15) | 41 | 4.56 (1.23) |
Motivation | 32 | 4.12 (0.52) | 32 | 4.33 (0.53) | 40 | 4.24 (0.60) | 40 | 4.29 (0.49) |
Self-efficacy | 32 | 4.20 (0.51) | 32 | 4.28 (0.58) | 41 | 4.39 (0.52) | 41 | 4.43 (0.47) |
Nutrition & oral health |
Knowledge | 32 | 9.97 (2.24) | 32 | 10.69 (1.84) | 41 | 10.34 (2.16) | 41 | 10.22 (2.12) |
Motivation | 32 | 4.25 (0.66) | 32 | 4.39 (0.55) | 41 | 4.32 (0.55) | 41 | 4.34 (0.51) |
Self-efficacy | 32 | 4.37 (0.49) | 32 | 4.49 (0.54) | 40 | 4.52 (0.45) | 40 | 4.49 (0.47) |
Acceptability of trial design and methods
As few interventions have been conducted in Early Years settings, we assessed the feasibility and acceptability of collecting a range of data from staff, parents and children.
Child height, weight and accelerometry
Staff reported few problems with regards to weighing and measuring children in the nursery setting, noting that most children enjoyed it. As each child being measured needed to be accompanied by a staff member, there was some disruption, but this was managed by providing extra staff or by using a private, quiet area in the same room. None of the parents interviewed reported any reservations about having their child weighed or measured.
The majority of children enjoyed wearing the accelerometry belts according to staff and parents, particularly because study staff presented them as ‘superhero belts’. Staff found it easier than parents to get children to wear the belts because other children in the class were also doing so. However, both staff and parents found it more challenging to persuade children to wear them at follow-up because the novelty had worn off: 88% children wore belts at baseline vs. 74% at follow-up. Few problems were reported, but included: belts being uncomfortable; forgetting to wear them; misplacing or mixing up belts; and having to move belts back to the correct position often. One manager reported a mother was concerned her child might put the belt around her neck, but otherwise there were no comments about safety.
Observations in nurseries: EPAO and CADET
Two sets of observations were carried out in each nursery: a comprehensive whole-day assessment of the nursery environment (EPAO); and mealtime observations to record what children were eating (CADET). In general, few issues were reported with either observation, with one manager explaining the NAP SACC UK observers “just sort of melted to the background ... You hardly know they’re there” (Manager_N5/10). However, one staff member mentioned the logistical difficulties of accommodating two extra adults in their very limited space, while another talked about the inconvenience of letting the observers in and out of the nursery every meal time.
There were mixed comments regarding how staff felt about being observed. Several noted they were used to being observed (for example during official inspections) and were unconcerned, while others reported finding it “a little strange” (Manager_N8/7) or “uncomfortable” (Manager_N10/8). Equally, some managers felt their staff had been unaffected by being observed, while two explained their staff may have changed their behaviour somewhat: “I wouldn’t say it changed what they did, but it may have changed the way they did it a little bit.” (Manager_N8/7).
NAP SACC staff were often praised by managers regarding the various data collection processes. Managers appreciated the study staff being flexible to fit in with the usual nursery schedule and minimise disruption as far as possible, as well as their friendly and reassuring interactions with the children. Due to the logistics of the study, different NAP SACC UK staff attended different nurseries at each data collection point, leading some managers to suggest they would have preferred a more consistent relationship with study staff allowing them to build rapport with nursery staff and children.
Parent questionnaires and food diaries
Parents were sent a questionnaire at baseline and follow-up, including questions on the child’s quality of life (PedsQL), spending on food and physical activities, healthcare usage and mediators such as knowledge, self-efficacy and motivation. Most parents reported the questionnaires to be “straightforward”, albeit time consuming. Equally, most completing the food diary found it unproblematic. A minority however reported finding it confusing and were unclear as to which days/meals they needed to complete or which category certain foods fell into. Nursery staff confirmed some parents appeared unsure how to complete the diary, but because they had not seen the instructions given to parents they found it difficult to help.