Abstract
BackgroundTogether, We Inspire Smart Eating (WISE) is an intervention for the early care and education setting to support children’s exposure to and intake of fruits and vegetables. WISE emphasizes 4 evidence-based practices (EBPs): (1) use of a mascot; (2) educators’ role modeling; (3) positive feeding practices; and (4) hands-on exposures. The current study reports on a small-scale implementation trial aimed at improving the use of WISE EBPs by teachers.MethodsA Hybrid Type III Cluster Randomized Design compared a Basic and Enhanced implementation strategy. The Basic Strategy included training and reminders only; the Enhanced strategy was a multi-faceted package of stakeholder-selected strategies including a leadership commitment, an implementation blueprint, a local champion, an environmental reminder of the EBPs, facilitation, and tailored educational resources and incentives. All study sites were Head Starts. Sites were randomized using a balancing technique that considered site characteristics; 4 sites (20 classrooms, 39 educators, 305 children) received Enhanced support; 5 sites (18 classrooms, 36 educators, 316 children) received Basic support. RE-AIM guided the evaluation, and implementation fidelity was the primary outcome. Strategies were assessed using examination of data distributions and unadjusted comparisons (t tests) as well as general linear and mixed effects models controlling for covariates.ResultsFor the primary outcome of fidelity, the Enhanced group had significantly higher means for 3 of 4 EBPs. Multivariate models explained a significant portion of variance for both mascot use and hands-on exposure with a significant positive effect observed for treatment condition. The Enhanced group also had higher rates of Appropriateness and Organizational Readiness for Implementing Change (as indicators of implementation and adoption, respectively). There was no significant difference between groups for indicators of Reach, Effectiveness or Maintenance. Formative interviews indicated key targets for iteration and potential mechanisms. Key events were catalogued to provide context for interpretation (e.g., 61% of classrooms with turnover).ConclusionsFindings were mixed but suggested promise for the Enhanced strategy, especially considering key events of the study. Implementation fidelity improvements occurred mainly in the last 3 months of the school year; additional time may be needed to translate to improvements in child outcomes.Trial registrationNCT03075085 Registered 20 February 2017.
Highlights
Together, We Inspire Smart Eating (WISE) is an intervention for the early care and education setting to support children’s exposure to and intake of fruits and vegetables
Implementation fidelity improvements occurred mainly in the last 3 months of the school year; additional time may be needed to translate to improvements in child outcomes
III trial to assess stakeholder-selected implementation strategies in a community setting. – This study provides an example of rigorous tracking and reporting of a package of multi-faceted implementation strategies, including facilitation, during the course of an implementation trial in the community. – Reporting of results includes a log of key events influencing the process and findings of our trial, which may provide a model for other studies to illustrate key contextual events surrounding the research process
Summary
We Inspire Smart Eating (WISE) is an intervention for the early care and education setting to support children’s exposure to and intake of fruits and vegetables. The American Academy of Nutrition and Dietetics outlines research-based benchmarks for the early care and education setting (ECE, i.e., childcare) to meet children’s dietary needs and provide an environment for healthy growth [7, 8] These include providing healthy foods, respecting child hunger and satiety, encouraging role modeling by educators, providing nutrition education, and providing training for educators. The strongest interventions on Obesity-related outcomes were those that addressed multiple components (e.g., child behavior, educator behavior, center policy) and engaged parents These findings support that the ECE setting is an important context for implementation of evidence-based practices and programs to improve children’s diets and reduce risk for obesity
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