Professor Luke Wolfenden

Issue addressed: Lowering the rates of adolescent overweight and obesity is a public health priority. The implementation of nutrition policies and practices in schools is recommended by various health organisations, but there is little information on the extent of their implementation. The aim of this study is to describe the prevalence of the implementation of recommended school-level nutrition policies and practices in secondary schools in New South Wales (NSW), Australia, and reported barriers and facilitators to the adoption of such policies and practices in school plans. Methods: A cross-sectional study was undertaken with school principals and canteen managers. All eligible secondary schools in NSW were approached to participate in a telephone survey (n¿=¿440). Descriptive statistics were used to describe prevalence, and associations between school characteristics and implementation were examined using univariate statistics. Results: A total of 137 school principals and 80 canteen managers completed the survey. The implementation of practices on drinking water during class, healthy food and beverage marketing and learning opportunities regarding healthy eating was high (>90% of participating schools). The implementation of practices regarding the restriction of unhealthy drinks in school canteens, healthy school fundraisers and staff training related to healthy eating was reported in under 25% of participating schools. There were no significant differences in implementation by school sector, socio-economic status and geographic location. The main barrier to inclusion of nutrition policies and practices in the school plan was having other priorities and commitments (28.5%), and the main facilitator was support from stakeholders, the staff, students and their parents (37.2%). Conclusions: There is opportunity to improve the implementation of nutrition policies and practices in NSW secondary schools. So What?: Strategies are needed for targeting barriers. These include: gaining support from school staff, students and parents, provision of resources and funding and staff training.

Background: Public health nutrition interventions, including school-based programs, are a recommended approach to improve child dietary behaviours. However, the adoption of effective school-based nutrition programs face numerous challenges, including the limited evidence on effective strategies to maximise implementation and adoption of such programs. This study aimed to address this evidence gap by employing a novel collaborative network trial design to evaluate a series of implementation strategies employed by three NSW Local Health Districts, to improve school adoption of an effective school-based nutrition program ('SWAP IT'). Methods: Three independent, two arm parallel group randomised controlled trials were conducted simultaneously to examine the potential effectiveness of implementation strategies on school adoption of SWAP IT. Schools were randomised to either a high intensity (various implementation strategies), or a business as usual (minimal support) group. Measures and data collection processes were harmonised across the three trials to provide individual school-level data for planned pooled analyses. The primary outcome was school adoption of SWAP IT, objectively measured via electronic registration records. Logistic regression analyses were used to assess school adoption of SWAP IT for each trial. Meta-analyses were also conducted to pool the effects of the three trials and allow the comparison of the potential relative effects of the different strategies. Results: A total of 287 schools were included in the study: Trial 1 (n = 164), Trial 2 (n = 64) and Trial 3 (n = 59). Relative to control, we found increased odds of adoption in Trial 1 that employed a combination of the educational materials and local facilitation strategies (OR 8.78; 95%CI 2.90, 26.56; p < 0.001), but no significant differences in adoption in Trial 2 or 3 that employed solely the educational materials strategy. Pooled data suggests the combination of educational materials and local facilitation has a greater effect on adoption compared to educational materials alone (OR 4.18; 95%CI 1.60, 10.04; n = 3 studies; indirect effect). Conclusion: Findings of this study indicate that local facilitation is an important strategy to increase school adoption of SWAP IT, and potentially other health promotion programs. Trial registration: The trials were prospectively registered with Australia New Zealand Clinical Trials Register: ANZCTR, ACTRN12622000257763, Registered 11/2/2022, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383515&isReview=true ANZCTR, ACTRN12622000406707, Registered 9/3/2022 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383701&isReview=true ANZCTR, ACTRN12622000252718, Registered on 11/2/2022, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383513&isReview=true

Background: Telephone support services are a viable means of providing population-level support to reduce health risk behaviours. While research exists on the effectiveness of Quitlines to reduce smoking, there is limited other research investigating whether telephone services can provide effective behaviour change support for people with a mental health condition for behaviours including physical activity, healthy eating, and weight management. The aims of this trial were to evaluate the effectiveness of referral of people with a mental health condition to a population-level telephone coaching service to improve health risk behaviours and increase attempts to do so. Methods: A parallel-group randomised controlled trial was conducted. Participants with a mental health condition (N = 681) were assigned to a control (health information pack) or intervention group (information pack and referral by the research team to a coaching program). Data were collected via telephone surveys at baseline and six months post-recruitment. Primary outcomes were: (1) weekly minutes of moderate-to-vigorous physical activity, (2) daily fruit serves, (3) daily vegetable serves, and (4) attempted behaviour change/weight loss (yes/no; composite measure). Secondary outcomes included weight, Body Mass Index (BMI), and attempts to change each health behaviour individually. Results: Intention-to-treat analyses found no significant differential change between groups from baseline to six months for primary or secondary outcomes. By follow-up, 242/549 (44%) of intervention participants had enrolled in coaching and completed at least one call, with 16/242 having completed the program, 79 ongoing, and 147 withdrawn. Per-protocol analyses found attempting to improve at least one health behaviour/lose weight was significantly greater in enrolees (OR = 3.7, 95% CI 1.03¿13.23) than the control group. Conclusions: Referral to the program did not improve risk behaviours or weight/BMI but did support behaviour change attempts. Contributing factors may include low program completion by follow-up and impact of COVID-19. Further research is required to better understand participation in and benefits of telephone coaching services for people with a mental health condition. Trial registration: Registered retrospectively with the Australian New Zealand Clinical Trials Registry (ACTRN12620000351910).

Background: Public health attempts to prevent obesity in children and young people should aim to minimize health inequalities. Two Cochrane reviews examining interventions aiming to prevent childhood obesity found that interventions promoting (only) physical activity have a small beneficial effect on BMI for people aged 5¿18 years, as do interventions promoting physical activity alongside healthy eating for 5¿11 year olds. We examined whether the effectiveness of the interventions included in these reviews differed according to eight factors associated with inequity: place, race/ethnicity, occupation, gender/sex, religion, education, socio-economic status, and social capital (the PROGRESS framework). Methods: We collected data on change in BMI (standardized or unstandardized), subgrouped by baseline measures of PROGRESS factors, for intervention and control groups, from trial authors. We calculated the intervention effect per subgroup (mean difference), then contrasted these to estimate interactions between intervention and the baseline factors. We combined interaction estimates for each factor across trials using meta-analyses. Findings: We collected subgrouped data from 81 trials that took place between 2001 and 2020, involving 84,713 participants. We found no substantial differences in effectiveness of interventions for PROGRESS subgroups in most scenarios. However, in the younger age group (5¿11 years), the effect of interventions on standardized BMI appeared to be higher in boys (average difference in mean differences 0.03; 95% CI 0.01 to 0.06; 45 studies, n = 44,740), which was consistent in direction with the BMI effect (average difference in mean differences 0.06 kg/m2; 95% CI -0.02 to 0.13; 31 studies, n = 27,083). Interpretation: Our findings suggest that those responsible for public health can promote these beneficial interventions without major concerns about increasing inequalities but should be mindful that these interventions may work better in boys aged 5¿11 years than girls. More data are needed, so we encourage future trialists to perform subgroup analyses on PROGRESS factors. Funding: National Institute for Health and Care Research (NIHR).

Background: Early childhood education and care (ECEC) settings are key for improving health behaviors, including physical activity (PA) and nutrition. In 2017, the province of British Columbia (BC) implemented a provincial-level Active Play policy supported by a capacity-building intervention. Significant improvements in all PA policies and practices and the majority of nutrition policies were observed post-implementation. The purpose of this study was to understand if PA and nutrition policies and practices were maintained at 5+ years post-provincial policy implementation. Methods: This study employed a repeated cross-sectional design to distribute surveys querying about PA and nutrition policies and practices to ECEC centers across BC at three time points: time 1, prior to implementation of the Active Play standard (2016-2017) and capacity-building intervention, time 2, 1-2 years post-implementation (2018-2019), and time 3, 5+ years post-implementation (2022-2023). Results: The majority of PA and all nutrition policies were maintained from time 2 (n = 378) to time 3 (n = 639). Prevalence of policies related to the provision of activities that address fundamental movement skills (odds ratio [OR] = 0.30) and total amount of active play (OR = 0.56) significantly decreased from time 2 to time 3. All reported PA practice prevalence levels decreased to time 1 levels. Conclusions: Center-level health behavior policies were largely maintained 5 years post-implementation, except some PA policies and practices returned to pre-implementation levels. Staff capacity and turnover as well as change in implementation support may explain these changes. Ongoing implementation support is needed to ensure maintenance of health promoting policies and practices in ECEC.

Objectives: Obesity remains a contributor to the burden of disease globally. Suboptimal diet and physical inactivity are two rising risk factors of obesity in youth; both are targeted for obesity prevention. Further, these risk behaviours cluster and may be associated with other risks including smoking and alcohol intake. Few studies, however, have examined the extent to which interventions targeting obesity also impact on other health behaviours. The aim of this study is to synthesise the effects of child obesity prevention programs on diet, physical activity, tobacco smoking and alcohol intake, and to investigate differential effects by interventions that target different behaviours. Methods: A secondary data analysis of an existing systematic review was conducted. Literature searches identified any additional papers from 1990 to 2023 associated with the originally included studies. All papers were screened and were eligible if they reported any diet, physical activity, smoking or alcohol outcomes. Results for each health behaviour outcome were selected. Meta-analysis was conducted where possible to calculate standardised mean differences. Results: One hundred and four studies were eligible for inclusion. Fruit and vegetable intake (standardised mean difference (SMD) 0.104; 95 % (CI) (0.03, 0.17)), and sugar-sweetened beverage intake (SMD -0.126; 95 % CI (-0.22, -0.04)) were positively impacted by obesity prevention, as were physical activity (SMD 0.168; 95 % CI (0.05, 0.28)) and sedentary behaviour (SMD -0.021; 95 % CI (-0.03, -0.01)). Findings were mixed for tobacco smoking and alcohol intake. Conclusion: Independent of weight status, school obesity prevention programs may improve some measures of child dietary intake and physical activity. Study registration: Prospectively registered: PROSPERO: CRD42021281106.

This review assessed the effect of strategies designed to sustain the delivery of evidenced based interventions (EBIs) which target behavioural risk factors linked to leading causes of chronic disease in clinical and community settings. Seven electronic databases were searched for randomised controlled studies published from earliest record to November 2022. Studies were included if they tested a strategy to sustain the delivery of an EBI within clinical or community settings. Results were synthesised using vote counting based on direction of effect, and reported in accordance with non-meta-analytic review standards following the Synthesis Without Meta-analysis (SWiM) guidelines. Three studies met the study inclusion criteria. Two studies were community-based, with one conducted in Australian community sports clubs and the second in afterschool clubs in the United States. The single clinical-based study was conducted in community health care centres in the United States. Across the three studies, 25 strategies were employed and only two strategies were common across all studies. Synthesis using vote counting based on direction of effect indicated that two of three studies favoured the intervention as positively impacting sustainment of EBIs. Few studies have been conducted to assess the effect of strategies designed to support sustainment of EBIs for chronic disease prevention in clinical and community settings. As such, it is difficult to determine the effect of strategies designed to support sustainment. Further research with comprehensive reporting of the selection, use and testing of sustainment strategies is needed to advance understanding of how to sustain EBIs in clinical and community settings.

Background: Early childhood obesity prevention interventions that aim to change parent/caregiver practices related to infant (milk) feeding, food provision and parent feeding, movement (including activity, sedentary behaviour) and/or sleep health (i.e. target parental behaviour domains) are diverse and heterogeneously reported. We aimed to 1) systematically characterise the target behaviours, delivery features, and Behaviour Change Techniques (BCTs) used in interventions in the international Transforming Obesity Prevention for CHILDren (TOPCHILD) Collaboration, and 2) explore similarities and differences in BCTs used in interventions by target behaviour domains. Methods: Annual systematic searches were performed in MEDLINE, Embase, Cochrane (CENTRAL), CINAHL, PsycINFO, and two clinical trial registries, from inception to February 2023. Trialists from eligible randomised controlled trials of parent-focused, behavioural early obesity prevention interventions shared unpublished intervention materials. Standardised approaches were used to code target behaviours, delivery features and BCTs in both published and unpublished intervention materials. Validation meetings confirmed coding with trialists. Narrative syntheses were performed. Results: Thirty-two trials reporting 37 active intervention arms were included. Interventions targeted a range of behaviours. The most frequent combination was targeting all parental behaviour domains (infant [milk] feeding, food provision and parent feeding, movement, sleep health; n[intervention arms] = 15/37). Delivery features varied considerably. Most interventions were delivered by a health professional (n = 26/36), included facilitator training (n = 31/36), and were interactive (n = 28/36). Overall, 49 of 93 unique BCTs were coded to at least one target behaviour domain. The most frequently coded BCTs were: Instruction on how to perform a behaviour (n[intervention arms, separated by domain] = 102), Behavioural practice and rehearsal (n = 85), Information about health consequences (n = 85), Social support (unspecified) (n = 84), and Credible source (n = 77). Similar BCTs were often used for each target behaviour domain. Conclusions: Our study provides the most comprehensive description of the behaviour change content of complex interventions targeting early childhood obesity prevention available to date. Our analysis revealed that interventions targeted multiple behaviour domains, with significant variation in delivery features. Despite the diverse range of BCTs coded, five BCTs were consistently identified across domains, though certain BCTs were more prevalent in specific domains. These findings can be used to examine effectiveness of components and inform intervention development and evaluation in future trials. Trial registration: PROSPERO registration no. CRD42020177408.

This overview of reviews synthesizes the effectiveness of obesity prevention interventions in children and adults on BMI/zBMI, following JBI and Cochrane Handbook guidelines. The protocol was prospectively registered in OSF in September 2020. Searches for eligible reviews were run in five databases and gray literature in May 2022. Systematic reviews published in 2010 and assessed BMI/zBMI outcomes of obesity prevention interventions were eligible. Screening, data extraction, and quality assessment were performed independently and in duplicate using standardized tools. For similar interventions, the more recent, higher-quality review was included. Thirty reviews reporting on 60 discrete interventions (i.e., a specific intervention component), mapped to 14 of 21 IOM sub-domains, were included. Nine interventions were classified as effective in improving BMI outcomes, including digital health or counseling interventions for adults in 'healthcare environments', behavioral interventions for children (broadly nutrition education), physical education curriculum modifications, and policies targeting food and beverages in 'School environments'. This review extends on previous reviews by consolidating evidence from high-quality, recent reviews to identify effective intervention components. Thus, this review provides direction for implementation efforts and highlights research gaps, where future research is warranted. However, as primary studies were not directly analyzed, gaps may reflect a lack of systematic reviews rather than primary research.

Community-based interventions (CBIs) can be effective and feasible for the prevention of childhood obesity. The aim of this umbrella review is to determine if systematic reviews report sufficient information to guide replication or adaptation of CBIs to a variety of contexts and aid in further development of childhood obesity prevention CBIs. Six databases were searched for systematic reviews including obesity prevention CBIs involving 0¿18 year olds and reporting weight-related outcomes. Two researchers screened results. Evidence-to-decision frameworks guided which details may be required for decision-makers to design and carry-out a CBI, including information on intervention characteristics, outcome reporting and translation factors. From 3935 search results, 40 studies were included. The most frequently reported relevant pieces of information were behaviors targeted (100% of systematic reviews), intervention duration (90%) and settings involved (97.5%). Less frequently reported factors included specific actions implemented (48%), intervention intensity (30%) and organizations, or contributors involved (40%). There was a low level of reporting of equity considerations (27.5%), adverse events (20%), and costs/cost-effectiveness (17.5%). Multilevel interventions for child obesity prevention have demonstrated effectiveness, yet additional documentation of successful intervention processes is needed.

Introduction: E-cigarette use has rapidly increased amongst young people in Australia, however the prevalence of use amongst pregnant people is not known. The aim of this study was to examine the prevalence of e-cigarette use and dual use of e-cigarettes and tobacco cigarettes, characteristics associated with use and reasons for use amongst a sample of pregnant Australian people attending public antenatal clinics. Methods: A cross-sectional survey was conducted with 4024 pregnant people attending antenatal appointments, between July 2021 and December 2022, in one local health district in New South Wales, Australia. Main outcome measures were current use of e-cigarettes, dual use with tobacco cigarettes, participant characteristics associated with use and reasons for use. Results: 1.24% of pregnant people used e-cigarettes, 34% of these were dual smokers. Being a current smoker (OR 39.49; 95% CI 9.99¿156.21) or ex-smoker (OR 29.86; 95% CI 8.75¿101.95) were associated with e-cigarette use. Quitting smoking was the most reported reason for use (52%). Discussion and Conclusions: This study is the first to report on the prevalence of e-cigarette use amongst pregnant people in Australia. We found that a small proportion of pregnant people use e-cigarettes and that many are dual users or ex-smokers. E-cigarette use and rates of dual use in pregnancy in Australia appear lower than internationally, however they are similarly being used as a smoking-cessation aid by many. As regulatory environments relating to e-cigarette access change in Australia, large-scale studies are required to continue to monitor e-cigarette use and dual use in pregnancy.

Background: Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review. Objectives: To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods: We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria: Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis: We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (= 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome. Main results: This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control. The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control. Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI...

Background: Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review. Objectives: To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. Search methods: We used standard, extensive Cochrane search methods. The latest search date was February 2023. Selection criteria: Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. Data collection and analysis: We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (= 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome. Main results: This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control. Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control. Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95%...

Background: A key role of public health policy-makers and practitioners is to ensure beneficial interventions are implemented effectively enough to yield improvements in public health. The use of evidence to guide public health decision-making to achieve this is recommended. However, few studies have examined the relative value, as reported by policy-makers and practitioners, of different broad research outcomes (that is, measures of cost, acceptability, and effectiveness). To guide the conduct of research and better inform public health policy and practice, this study aimed at describing the research outcomes that Australian policy-makers and practitioners consider important for their decision-making when selecting: (a) public health interventions; (b) strategies to support their implementation; and (c) to assess the differences in research outcome preferences between policy-makers and practitioners. Method: An online value-weighting survey was conducted with Australian public health policy-makers and practitioners working in the field of non-communicable disease prevention. Participants were presented with a list of research outcomes and were asked to select up to five they considered most critical to their decision-making. They then allocated 100 points across these ¿ allocating more points to outcomes perceived as more important. Outcome lists were derived from a review and consolidation of evaluation and outcome frameworks in the fields of public health knowledge translation and implementation. We used descriptive statistics to report relative preferences overall and for policy-makers and practitioners separately. Results: Of the 186 participants; 90 primarily identified as policy-makers and 96 as public health prevention practitioners. Overall, research outcomes of effectiveness, equity, feasibility, and sustainability were identified as the four most important outcomes when considering either interventions or strategies to implement them. Scores were similar for most outcomes between policy-makers and practitioners. Conclusion: For Australian policy-makers and practitioners working in the field of non-communicable disease prevention, outcomes related to effectiveness, equity, feasibility, and sustainability appear particularly important to their decisions about the interventions they select and the strategies they employ to implement them. The findings suggest researchers should seek to meet these information needs and prioritize the inclusion of such outcomes in their research and dissemination activities. The extent to which these outcomes are critical to informing the decision of policy-makers and practitioners working in other jurisdictions or contexts warrants further investigation.

Background: Quality reporting contributes to effective translation of health research in practice and policy. As an initial step in the development of a reporting guideline for scaling, the Standards for reporting stUdies of sCaling evidenCEd-informED interventions (SUCCEED), we performed a systematic review to identify relevant guidelines and compile a list of potential items. Methods: We conducted a systematic review according to Cochrane method guidelines. We searched the following databases: MEDLINE, Embase, PsycINFO, Cochrane Library, CINAHL, Web of Science, from their respective inceptions. We also searched websites of relevant organizations and Google. We included any document that provided instructions or recommendations, e.g., reporting guideline, checklist, guidance, framework, standard; could inform the design or reporting of scaling interventions; and related to the health sector. We extracted characteristics of the included guidelines and assessed their methodological quality using a 3-item internal validity assessment tool. We extracted all items from the guidelines and classified them according to the main sections of reporting guidelines (title, abstract, introduction, methods, results, discussion and other information). We performed a narrative synthesis based on descriptive statistics. Results: Of 7704 records screened (published between 1999 and 2019), we included 39 guidelines, from which data were extracted from 57 reports. Of the 39 guidelines, 17 were for designing scaling interventions and 22 for reporting implementation interventions. At least one female author was listed in 31 guidelines, and 21 first authors were female. None of the authors belonged to the patient stakeholder group. Only one guideline clearly identified a patient as having participated in the consensus process. More than half the guidelines (56%) had been developed using an evidence-based process. In total, 750 items were extracted from the 39 guidelines and distributed into the 7 main sections. Conclusion: Relevant items identified could inform the development of a reporting guideline for scaling studies of evidence-based health interventions. This and our assessment of guidelines could contribute to better reporting in the science and practice of scaling.

Objectives: Childcare services such as preschools and long day care centres have been identified as a key setting to promote physical activity in early childhood as they provide access to large numbers of children for prolonged periods. Yet, specific standards for the type and amount of physical activity (PA) children accumulate whilst attending childcare are lacking. The purpose of this study was to derive population-referenced percentile values for children's total movement and energetic play whilst attending early childhood education and care services. Design: We analysed accelerometer data collected in four Australian studies involving over 150 long day care services and 3893 accelerometer records from 1945 children to derive population-referenced percentile values for total movement and energetic play whilst attending formal early childhood education and care. Methods: Accelerometer data were processed into time spent in total movement and energetic play using a random forest physical activity classification model. Total movement and energetic play estimates were transformed to a standard normal distribution and percentiles were calculated for a 4-, 6-, 8-, and 10-hour early childhood education and care day. Results: On an average 8-hour early childhood education and care day (50th percentile), Australian pre-schoolers spend between 269 and 292 min, or 60 % of their day in movement. In contrast, Australian pre-schoolers only accumulate between 15 and 29 min of energetic play. Conclusions: The percentile reference values can be used to monitor young children's physical activity and energetic play levels whilst attending childcare. Educators can use the percentiles to assign norm-referenced ratings to identify children who could benefit from additional support for physical activity.

Objectives: To enhance equity in clinical and epidemiological research, it is crucial to understand researcher motivations for conducting equity-relevant studies. Therefore, we evaluated author motivations in a randomly selected sample of equity-relevant observational studies published during the COVID-19 pandemic. Study Design and Setting: We searched MEDLINE for studies from 2020 to 2022, resulting in 16,828 references. We randomly selected 320 studies purposefully sampled across income setting (high vs low¿middle-income), COVID-19 topic (vs non¿COVID-19), and focus on populations experiencing inequities. Of those, 206 explicitly mentioned motivations which we analyzed thematically. We used discourse analysis to investigate the reasons behind emerging motivations. Results: We identified the following motivations: (1) examining health disparities, (2) tackling social determinants to improve access, and (3) addressing knowledge gaps in health equity. Discourse analysis showed motivations stem from commitments to social justice and recognizing the importance of highlighting it in research. Other discourses included aspiring to improve health-care efficiency, wanting to understand cause-effect relationships, and seeking to contribute to an equitable evidence base. Conclusion: Understanding researchers' motivations for assessing health equity can aid in developing guidance that tailors to their needs. We will consider these motivations in developing and sharing equity guidance to better meet researchers' needs.

Background: There is a large number of research studies about the prevention of non-communicable diseases (NCD), with findings taking several years to be translated into practice. One reason for this lack of translation is a limited understanding of how to best disseminate NCD research findings to user-groups in a way that is salient and useful. An understanding of barriers and facilitators to dissemination is key to informing the development of strategies to increase dissemination. Therefore, this review aims to identify and synthesise the barriers and facilitators to dissemination of NCD research findings. Methods: A mixed studies systematic review was performed following JBI (formerly known as Joanna Briggs Institute) methodology. The search included articles from January 2000 until May 2021. We conducted a comprehensive search of bibliographic and grey literature of five databases to identify eligible studies. Studies were included if they involved end-users of public health research that were decision-makers in their setting and examined barriers/facilitators to disseminating research findings. Two pairs of reviewers mapped data from included studies against the Framework of Knowledge Translation (FKT) and used a convergent approach to synthesise the data. Results: The database search yielded 27,192 reports. Following screening and full text review, 15 studies (ten qualitative, one quantitative and four mixed methods) were included. Studies were conducted in 12 mostly high-income countries, with a total of 871 participants. We identified 12 barriers and 14 facilitators mapped to five elements of the FKT. Barriers related to: (i) the user-group (n = 3) such as not perceiving health as important and (ii) the dissemination strategies (n = 3) such as lack of understanding of content of guidelines. Several facilitators related to dissemination strategies (n = 5) such as using different channels of communication. Facilitators also related to the user-group (n = 4) such as the user-groups' interest in health and research. Conclusion: Researchers and government organisations should consider these factors when identifying ways to disseminate research findings to decision-maker audiences. Future research should aim to build the evidence base on different strategies to overcome these barriers. Systematic review registration: The protocol of this review was deposited in Open Science Framework (https://doi.org/10.17605/OSF.IO/5QSGD).

Background: A range of school-based interventions are effective in improving student diet and physical activity (e.g. school food policy interventions and classroom physical activity interventions), and reducing obesity, tobacco use and/or alcohol use (e.g. tobacco control programmes and alcohol education programmes). However, schools are frequently unsuccessful in implementing such evidence-based interventions. Objectives: The primary review objective is to evaluate the effectiveness of strategies aiming to improve school implementation of interventions to address students' (aged 5 to 18 years) diet, physical activity, obesity, tobacco use and/or alcohol use. The secondary objectives are to:. 1. determine whether the effects are different based on the characteristics of the intervention including school type and the health behaviour or risk factor targeted by the intervention;¿2. describe any unintended consequences and adverse effects of strategies on schools, school staff or students; and¿3. describe the cost or cost-effectiveness of strategies. Search methods: We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), five additional databases, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and the US National Institutes of Health registry (clinicaltrials.gov). The latest search was between 1 May 2021 and 30 June 2023 to identify any relevant trials published since the last published review. Selection criteria: We defined 'implementation' as the use of strategies to adopt and integrate evidence-based health interventions and to change practice patterns within specific settings. We included any randomised controlled trial (RCT) or cluster-RCT conducted on any scale, in a school setting, with a parallel control group that compared a strategy to improve the implementation of policies or practices to address diet, physical activity, obesity, tobacco use and/or alcohol use by students (aged 5 to 18 years) to no active implementation strategy (i.e. no intervention, inclusive of usual practice, minimal support) or a different implementation strategy. Data collection and analysis: We used standard Cochrane methods. Given the large number of outcomes reported, we selected and included the effects of a single outcome measure for each trial for the primary outcome using a decision hierarchy (i.e. continuous over dichotomous, most valid, total score over subscore). Where possible, we calculated standardised mean differences (SMDs) to account for variable outcome measures with 95% confidence intervals (CI). We conducted meta-analyses using a random-effects model. Where we could not combine data in meta-analysis, we followed recommended Cochrane methods and reported results in accordance with 'Synthesis without meta-analysis' (SWiM) guidelines. We conducted assessments of risk of bias and evaluated the certainty of evidence (GRADE approach) using Cochrane procedures. Main results: We included an additional 14 trials in this update, bringing the total number of included trials in the review to 39 trials with 83 trial arms and 6489 participants. Of these, the majority were conducted in Australia and the USA (n = 15 each). Nine were RCTs and 30 were cluster-RCTs. Twelve trials tested strategies to implement healthy eating practices; 17 physical activity, two tobacco, one alcohol, and seven a combination of risk factors. All trials used multiple implementation strategies, the most common being educational materials, educational meetings, and education outreach visits, or academic detailing. Of the 39 included trials, we judged 26 as having high risks of bias, 11 as having some concerns, and two as having low risk of bias across all domains. Pooled analyses found, relative to a control (no active implementation strategy), the use of implementation strategies probably results in a large increase in the implementation of interventions in schools (SMD 0.95, 95% CI 0.71, 1.19; I2...

Background: There is a need for valid and reliable measures of determinants of sustainability of public health interventions in early childhood education and care (ECEC) settings. This study aimed to develop and evaluate the psychometric and pragmatic properties of such a measure ¿ the Integrated Measure of PRogram Element SuStainability in Childcare Settings (IMPRESS-C). Methods: We undertook a two-phase process guided by the COnsensus-based Standards for the selection of health status Measurement INstruments checklist (COSMIN) and Psychometric and Pragmatic Evidence Rating Scale (PAPERS). Phase 1 involved measure development; i.e., determining items and scales through an iterative process and assessment of face and content validity. Phase 2 involved the evaluation of psychometric and pragmatic properties. The 29-item measure completed by service executives (directors and nominated supervisors) was embedded in a larger survey from a national sample of Australian ECEC services assessing their implementation of nutrition and physical activity programs. Structural validity, concurrent validity, known groups validity, internal consistency, floor and ceiling effects, norms, and pragmatic qualities of the measure were assessed according to the PAPERS criteria. Results: The final measure contained 26 items, with respondents reporting how strongly they agreed or disagreed on a five-point Likert scale. Phase 1 assessments confirmed the relevance, and face and content validity of the scale. In Phase 2, we obtained 482 completed surveys, of which 84% (n = 405) completed the entire measure across 405 ECEC settings (one executive¿per service). Three of the four fit indices for the confirmatory factor analysis met the pre-specified criteria (SRMR = 0.056, CFI = 0.993, RMSEA = 0.067) indicating 'good' structural validity. The IMPRESS-C illustrated: 'good' internal consistency, with Cronbach's alpha values from 0.53 to 0.92; 'emerging' concurrent validity; 'poor' known groups validity; 'good' norms; and 'good' overall pragmatic qualities (cost, readability, length, and assessor burden). Conclusions: The IMPRESS-C possesses strong psychometric and pragmatic qualities for assessing service executive-level perceptions of determinants influencing sustainment of public health interventions within ECEC settings. To achieve a full range of perspectives in this setting, future work should be directed to also develop and test measures of sustainability determinants at the implementer level (e.g., among individual educators and staff).

Policy Points More rigorous methodologies and systematic approaches should be encouraged in the science of scaling. This will help researchers better determine the effectiveness of scaling, guide stakeholders in the scaling process, and ultimately increase the impacts of health innovations. The practice and the science of scaling need to expand worldwide to address complex health conditions such as noncommunicable and chronic diseases. Although most of the scaling experiences described in the literature are occurring in the Global South, most of the authors publishing on it are based in the Global North. As the science of scaling spreads across the world with the aim of reducing health inequities, it is also essential to address the power imbalance in how we do scaling research globally. Context: Scaling of effective innovations in health and social care is essential to increase their impact. We aimed to synthesize the evidence base on scaling and identify current knowledge gaps. Methods: We conducted an umbrella review according to the Joanna Briggs Institute Reviewers' Manual. We included any type of review that 1) focused on scaling, 2) covered health or social care, and 3) presented a methods section. We searched MEDLINE (Ovid), Embase, PsycINFO (Ovid), CINAHL (EBSCO), Web of Science, The Cochrane Library, Sociological Abstracts (ProQuest), Academic Search Premier (EBSCO), and ProQuest Dissertations & Theses Global from their inception to August 6, 2020. We searched the gray literature using, e.g., Google and WHO-ExpandNet. We assessed methodological quality with AMSTAR2. Paired reviewers independently selected and extracted eligible reviews and assessed study quality. A narrative synthesis was performed. Findings: Of 24,269 records, 137 unique reviews were included. The quality of the 58 systematic reviews was critically low (n = 42). The most frequent review type was systematic review (n = 58). Most reported on scaling in low- and middle-income countries (n = 59), whereas most first authors were from high-income countries (n = 114). Most reviews concerned infectious diseases (n = 36) or maternal¿child health (n = 28). They mainly focused on interventions (n = 37), barriers and facilitators (n = 29), frameworks (n = 24), scalability (n = 24), and costs (n = 14). The WHO/ExpandNet scaling definition was the definition most frequently used (n = 26). Domains most reported as influencing scaling success were building scaling infrastructure (e.g., creating new service sites) and human resources (e.g., training community health care providers). Conclusions: The evidence base on scaling is evolving rapidly as reflected by publication trends, the range of focus areas, and diversity of scaling definitions. Our study highlights knowledge gaps around methodology and research infrastructures to facilitate equitable North¿South research relationships. Common efforts are needed to ensure scaling expands the impacts of health and social innovations to broader populations.

Objectives: Health Promotion Units within New South Wales (NSW) local health districts (LHDs) frequently collaborate and test innovations to address priority health issues or approaches to support the implementation of a health promotion program in a way that is consistent with the needs, resources, and contexts of their regions. Compatible with learning health system approaches, mechanisms to facilitate the exchange of evidence and expertise across districts could improve the collective impact of health promotion services across the state. This study aimed to assess the use of a health promotion Community of Practice (CoP) model as a strategy to achieve this. Type of program or service: This paper describes and shares experiences from the development and piloting process of a CoP model to develop, evaluate and exchange learnings to improve approaches to support the adoption of an effective healthy lunchbox program ('SWAP IT') across three LHDs. Results: The functioning of the CoP was supported by key activities, funding and infrastructure over a 2-year period, including: planning workshops, implementation check-ins, and knowledge exchange meetings. A particularly novel aspect of the CoP was the harmonised evaluation of different, locally developed strategies to facilitate program adoption across the three LHDs. The alignment of the CoP with local and state priorities, as well as the operation of the CoP in a way that did not impose significant time demands, was seen as important for the sustainability of the CoP.

Background: In 2016¿17, the government of British Columbia (BC) enacted a mandatory policy outlining Active Play Standards (AP Standards) alongside a capacity building initiative (Appetite to Play) focused on implementing policies and practices to support physical activity in childcare centres. We aimed to identify factors at the provider and organizational levels as well as attributes of the Standards hypothesized to influence implementation (i.e., changes in policies and practices). Methods: We conducted surveys before (2016¿2017) and after (2018¿2019) enforcement of the AP Standards among 146 group childcare centres across BC. The 2018¿19 surveys measured theoretically based constructs associated with implementation of policies and practices (9 childcare- and 8 provider- level characteristics as well as 4 attributes of the licensing standards). Characteristics that were associated in simple regression models were entered in multivariable regression models to identify factors associated with policy and practice changes related to fundamental movement skills (FMS), screen time, total amount of active play (AP) and total amount of outdoor AP from baseline to follow-up. Results: In multivariable analyses, higher staff capacity (OR = 2.1, 95% 1.2, 3.7) and perceived flexibility of the standards (OR: 3.3, 95% 1.5, 7.1) were associated with higher odds of a policy change related to FMS. Higher staff commitment to the AP standards was associated with a higher odds of policy changes related to screen time (OR = 1.6, 95% CI: 1.1, 2.4) and amount of AP (OR: 1.5, 95% 1.0, 2.3). Higher institutionalization of PA policies was associated with a higher odds of policy changes related to the amount of AP (OR: 5.4, 95% CI: 1.5, 20). Higher self-efficacy was associated with a higher odds of policy changes related to outdoor AP (OR = 2.9, 95% 1.1, 7.8). Appetite to Play training was a positively associated with practice changes related to FMS (ß = 0.5, 95% CI: 0.1, 0.9). Conclusions: A hierarchy of theoretically defined factors influenced childcare providers' implementation of the AP Standards in BC. Future research should test the feasibility of modifying these factors to improve the implementation of PA policy and practice interventions in this setting.

Early childhood education and care (ECEC) services are a key setting to support improvements in the physical activity of young children. This umbrella review gathered and synthesised systematic review evidence of the effectiveness of interventions in the ECEC setting on the physical activity levels of children aged 0¿6. We also mapped the current evidence to the existing ECEC sector-specific physical activity practice recommendations. Five electronic databases were searched to identify systematic reviews that evaluated the impact of any ECEC-based interventions on the physical activity levels (e.g., moderate-to-vigorous physical activity, total physical activity) of children aged 0¿6. One reviewer extracted data on intervention effectiveness and quality of the reviews, checked by a second reviewer. Ten reviews were included. Overall, the majority of the reviews found interventions delivered in ECEC improved child physical activity. Across reviews, the impact of six intervention strategies were identified, mapped to four (of eight) broad recommendations (i.e., providing opportunity, offering educator training, educators promoting the benefits of physical activity, creating a physical activity-promoting environment). The impact of the majority of recommendations, however, did not have systematic review evidence. Further investigation of the effectiveness of ECEC-based physical activity strategies is required to demonstrate support for the existing recommended practices.

Online school canteen lunch ordering systems may offer a unique opportunity to support the implementation of school canteen nutrition polices, while delivering behavioural interventions directly to consumers to influence healthy student purchasing. This cluster randomised controlled trial aimed to test the effectiveness of a menu audit and feedback strategy alone, and in combination with online menu labels in encouraging healthier purchasing from an online school canteen ordering system. Five intervention schools received a menu audit and feedback strategy, plus online menu labels; and five control schools received a delayed menu audit and feedback strategy. Data from 19,799 student lunch orders, containing over 40,000 items were included in the evaluation. Outcomes were assessed at baseline (pre-intervention), follow-up 1 (menu audit and feedback vs control), and follow-up 2 (menu audit and feedback plus online menu labels vs menu audit and feedback alone). From baseline to follow-up 1, the menu audit and feedback strategy alone had no significant effect on the proportion of healthy ('Everyday') and less healthy ('Occasional' or 'Should not be sold') items purchased. From baseline to follow-up 2, schools that received menu audit and feedback plus online menu labels had significantly higher odds of students purchasing 'Everyday' items (OR: 1.19; p = 0.019), and significantly lower odds of students purchasing 'Occasional' (OR: 0.86; p = 0.048) and 'Should not be sold' (OR: 0.52; p < 0.001) items. Menu audit and feedback with the addition of online menu labels was effective in increasing the proportion of healthy items purchased relative to menu audit and feedback in isolation. There may be a greater role for online menu labelling as part of a suite of strategies to improve public health nutrition in schools.

Objectives: Assess the impact of an implementation intervention on student's physical activity, health-related quality of life (HRQoL) and on-task behaviour. Design: A cluster-randomised controlled trial. Methods: Following baseline 61 eligible schools were randomised to a 12-month, implementation intervention to increase teacher scheduling of physical activity, or a waitlist control. Whole school-day and class-time physical activity of students from grades 2 and 3 (~ages 7 to 9) were measured via wrist-worn accelerometers and included: moderate-to-vigorous physical activity, light physical activity, sedentary behaviour and activity counts per minute. Children's health related quality of life (HRQoL) and out-of-school-hours physical activity was measured via parent-proxy surveys. Class level on-task behaviour was measured via teacher self-report surveys. Student and teacher obtained outcomes were measured at baseline and 12-month follow-up. Parent reported outcomes were measured at 12-month follow-up. Linear mixed models compared between group differences in outcomes. Differential effects by sex were explored for student and parent reported outcomes. Results: Data from 2485 students, 1220 parents and >500 teachers were analysed. There was no statistically significant between group differences in any of the outcomes, including accelerometer measured physical activity, out-of-school-hours physical activity, HRQoL, and on-task behaviour. A statistically significant differential effect by sex was found for sedentary behaviour across the whole school day (3.16 min, 95% CI: 0.19, 6.13; p = 0.028), with females illustrating a greater difference between groups than males. Conclusions: Only negligible effects on student physical activity were found. Additional strategies including improving the quality of teacher's delivery of physical activity may be required to enhance effects.

Background: Effectively scaled-up physical activity interventions are urgently needed to address the high prevalence of physical inactivity. To facilitate scale-up of an efficacious school-based physical activity program (Physical Activity 4 Everyone [PA4E1]), provision of implementation support to physical education (PE) teachers was adapted from face-to-face and paper-based delivery modes to partial delivery via a website. A lack of engagement (usage and subjective experience) with digital delivery modes, including websites, may in part explain the typical reduction in effectiveness of scaled-up interventions that use digital delivery modes. A process evaluation focused on the PA4E1 website was undertaken. Objective: The 2 objectives were to (1) describe the usage of the PA4E1 program website by in-school champions (PE teachers leading the program within their schools) and PE teachers using quantitative methods; (2) examine the usage, subjective experience, and usability of the PA4E1 program website from the perspective of in-school champions using mixed methods. Methods: The first objective used website usage data collected across all users (n=273) throughout the 9 school terms of the PA4E1 implementation support. The 4 usage measures were sessions, page views, average session duration, and downloads. Descriptive statistics were calculated and explored across the duration of the 26-month program. The second objective used mixed methods, triangulating data from the first objective with data from a think-aloud survey and usability test completed by in-school champions (n=13) at 12 months. Qualitative data were analyzed thematically alongside descriptive statistics from the quantitative data in a triangulation matrix, generating cross-cutting themes using the "following a thread" approach. Results: For the first objective, in-school champions averaged 48.0 sessions per user, PE teachers 5.8 sessions. PE teacher sessions were of longer duration (10.5 vs 7.6 minutes) and included more page views (5.4 vs 3.4). The results from the mixed methods analysis for the second objective found 9 themes and 2 meta-themes. The first meta-theme indicated that the website was an acceptable and appropriate delivery mode, and usability of the website was high. The second meta-theme found that the website content was acceptable and appropriate, and identified specific suggestions for improvement. Conclusions: Digital health interventions targeting physical activity often experience issues of lack of user engagement. By contrast, the findings from both the quantitative and mixed methods analyses indicate high usage and overall acceptability and appropriateness of the PA4E1 website to school teachers. The findings support the value of the website within a multidelivery mode implementation intervention to support schools to implement physical activity promoting practices. The analysis identified suggested intervention refinements, which may be adopted for future iterations and further scale-up of the PA4E1 program.

Background: There is significant opportunity to improve the nutritional quality of foods packed in children's school lunchboxes. Interventions that are effective and scalable targeting the school and home environment are therefore warranted. Objective: This study aimed to assess the effectiveness of a multicomponent, mobile health-based intervention, SWAP IT, in reducing the energy contribution of discretionary (ie, less healthy) foods and drinks packed for children to consume at school. Methods: A type I effectiveness-implementation hybrid cluster randomized controlled trial was conducted in 32 primary schools located across 3 local health districts in New South Wales, Australia, to compare the effects of a 6-month intervention targeting foods packed in children's lunchboxes with those of a usual care control. Primary schools were eligible if they were not participating in other nutrition studies and used the required school communication app. The Behaviour Change Wheel was used to co-design the multicomponent SWAP IT intervention, which consisted of the following: school lunchbox nutrition guidelines, curriculum lessons, information pushed to parents digitally via an existing school communication app, and additional parent resources to address common barriers to packing healthy lunchboxes. The primary outcome, mean energy (kilojoules) content of discretionary lunchbox foods and drinks packed in lunchboxes, was measured via observation using a validated school food checklist at baseline (May 2019) and at 6-month follow-up (October 2019). Additional secondary outcomes included mean lunchbox energy from discretionary foods consumed, mean total lunchbox energy packed and consumed, mean energy content of core lunchbox foods packed and consumed, and percentage of lunchbox energy from discretionary and core foods, all of which were also measured via observation using a validated school food checklist. Measures of school engagement, consumption of discretionary foods outside of school hours, and lunchbox cost were also collected at baseline and at 6-month follow-up. Data were analyzed via hierarchical linear regression models, with controlling for clustering, socioeconomic status, and remoteness. Results: A total of 3022 (3022/7212, 41.90%) students consented to participate in the evaluation (mean age 7.8 years; 1487/3022, 49.22% girls). There were significant reductions between the intervention and control groups in the primary trial outcome, mean energy (kilojoules) content of discretionary foods packed in lunchboxes (-117.26 kJ; 95% CI -195.59 to -39.83; P=.003). Relative to the control, the intervention also significantly reduced secondary outcomes regarding the mean total lunchbox energy (kilojoules) packed (-88.38 kJ; 95% CI -172.84 to -3.92; P=.04) and consumed (-117.17 kJ; 95% CI -233.72 to -0.62; P=.05). There was no significant difference between groups in measures of student engagement, consumption of discretionary foods outside of school hours, or cost of foods packed in children's lunchboxes. Conclusions: The SWAP IT intervention was effective in reducing the energy content of foods packed for and consumed by primary school-aged children at school. Dissemination of the SWAP IT program at a population level has the potential to influence a significant proportion of primary school-aged children, impacting weight status and associated health care costs.

Abstract Objective: The aim of the study was to assess the impact of different lunchbox messages on parents' intention to pack a healthy lunchbox. Design: This study employed an experimental design. Setting: A series of messages were developed to align with the six constructs of the Health Belief Model. Messages were also developed that were (and were not) personalised and varied based on the source of the information provided (university, school, dietitian and health promotion service). During a telephone survey, participants were read the content of each message and asked about their intention to pack a healthy lunchbox. Participants: Parents of primary school-aged children were randomised to receive different messages to encourage the packing of healthy lunchboxes. Results: The study was completed by 511 parents. Linear mixed regression analyses identified significant differences (P < 0·05) in intention scores between variant messages targeting the same behavioural constructs for 'susceptibility', 'severity', 'benefits' and 'barriers' but not 'cues to action' or 'self-efficacy'. The highest mean behavioural intention score was for 'benefits', whilst the lowest mean score was for 'barriers'. There were no significant differences in intention scores of parents receiving messages from a dietitian, university, health promotion team or school (P = 0·37). Intention scores did not differ in which messages were personalised based on child's name (P = 0·84) or grade level (P = 0·54). Conclusions: The findings suggest that messages that focus on the benefits of packing healthy lunchboxes may be particularly useful in improving intentions of parents to pack healthy foods for their children to consume at school.

Background: Physical Activity 4 Everyone (PA4E1) is an evidence-based program effective at increasing adolescent physical activity (PA) and improving weight status. This study aimed to determine a) the effectiveness of an adapted implementation intervention to scale-up PA4E1 at 24-month follow-up, b) fidelity and reach, and c) the cost and cost-effectiveness of the implementation support intervention. Methods: A cluster randomised controlled trial using a type III hybrid implementation-effectiveness design in 49 lower socio-economic secondary schools, randomised to a program (n = 24) or control group (n = 25). An adapted implementation intervention consisting of seven strategies was developed to support schools to implement PA4E1 over 24-months. The primary outcome was the proportion of schools implementing at least four of the 7 PA practices, assessed via computer assisted telephone interviews (CATI) with Head Physical Education Teachers. Secondary outcomes included the mean number of PA practices implemented, fidelity and reach, cost and cost-effectiveness. Logistic regression models assessed program effects. Results: At baseline, no schools implemented four of the 7 PA practices. At 24-months, significantly more schools in the program group (16/23, 69.6%) implemented at least four of the 7 PA practices than the control group (0/25, 0%) (p < 0.001). At 24-months, program schools were implementing an average of 3.6 more practices than control schools (4.1 (1.7) vs. 0.5 (0.8), respectively) (P < 0.001). Fidelity and reach of the implementation intervention were high (> 75%). The total cost of the program was $415,112 AUD (2018) ($17,296 per school; $117.30 per student). Conclusions: The adapted implementation intervention provides policy makers and researchers with an effective and potentially cost-effective model for scaling-up the delivery of PA4E1 in secondary schools. Further assessment of sustainability is warranted. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12617000681358 prospectively registered 12th May 2017.

There is a lack of valid and reliable measures of determinants of sustainability specific to public health interventions in the elementary school setting. This study aimed to adapt and evaluate the Program Sustainability Assessment Tool (PSAT) for use in this setting. An expert reference group adapted the PSAT to ensure face validity. Elementary school teachers participating in a multi-component implementation intervention to increase their scheduling of physical activity completed the adapted PSAT. Structural validity was assessed via confirmatory factor analysis. Convergent validity was assessed using linear mixed regression evaluating the associations between scheduling of physical activity and adapted PSAT scores. Cronbach's alpha was used to evaluate internal consistency and intracluster correlation coefficients for interrater reliability. Floor and ceiling effects were also evaluated. Following adaptation and psychometric evaluation, the final measure contained 26 items. Domain Cronbach's alpha ranged from 0.77 to 0.92. Only one domain illustrated acceptable interrater reliability. Evidence for structural validity was mixed and was lacking for convergent validity. There were no floor and ceiling effects. Efforts to adapt and validate the PSAT for the elementary school setting were mixed. Future work to develop and improve measures specific to public health program sustainment that are relevant and psychometrically robust for elementary school settings are needed.

Empirical studies to disentangle the effects of multicomponent implementation interventions are needed to inform the development of future interventions. This study aims to examine which behavior change techniques (BCTs) primarily targeting canteen manager are associated with school's healthy canteen policy implementation. This is a secondary data analysis from three randomized controlled trials assessing the impact of a "high,""medium,"and "low"intensity intervention primarily targeting canteen managers on school's implementation of a healthy canteen policy. The policy required primary schools to remove all "red"(less healthy items) or "banned"(sugar sweetened beverages) items from regular sale and ensure that "green"(healthier items) dominated the menu (>50%). The delivery of BCTs were retrospectively coded. We undertook an elastic net regularized logistic regression with all BCTs in a single model. Five k-fold cross-validation elastic net models were conducted. The percentage of times each strategy remained across 1,000 replications was calculated. For no "red"or "banned"items (n = 162), the strongest BCTs were: problem solving, goal setting (behavior), and review behavior goals. These BCTs were identified in 100% of replications as a strong predictor in the cross-validation elastic net models. For the outcome relating to >50% "green"items, the BCTs problem solving, instruction on how to perform behavior and demonstration of behavior were the strongest predictors. Two strategies were identified in 100% of replications as a strong (i.e., problem solving) or weak predictor (i.e., feedback on behavior). This study identified unique BCTs associated with the implementation of a healthy canteen policy.

Background: The overarching objective was to examine the effectiveness of intervention strategies to promote fruit and vegetable consumption. To do this, systematic review evidence regarding the effects of intervention strategies was synthesized; organized, where appropriate, by the setting in which the strategies were implemented. Additionally, we sought to describe gaps in the review of evidence; that is, where evidence regarding the effectiveness of recommended policy actions had not been systematically synthesised. Methods: We undertook a systematic search of electronic databases and the grey literature to identify systematic reviews describing the effects of any intervention strategy targeting fruit and/or vegetable intake in children or adults of any age. Results: The effects of 32 intervention strategies were synthesised from the 19 included reviews. The strategies were mapped across all three broad domains of the NOURISHING framework (i.e. food environment, food system and behaviour change communication), but covered just 14 of the framework's 65 sub-policy areas. There was evidence supporting the effectiveness of 19 of the 32 intervention strategies. The findings of the umbrella review suggest that intervention strategies implemented within schools, childcare services, homes, workplaces and primary care can be effective, as can eHealth strategies, mass media campaigns, household food production strategies and fiscal interventions. Conclusions: A range of effective strategy options are available for policy makers and practitioners interested in improving fruit and/or vegetable intake. However, the effects of many strategies ¿ particularly those targeting agricultural production practices, the supply chain and the broader food system ¿ have not been reported in systematic reviews. Primary studies assessing the effects of these strategies, and the inclusion of such studies in systematic reviews, are needed to better inform national and international efforts to improve public health nutrition. Trial registration: The review protocol was deposited in a publicly available Open Science framework prior to execution of the search strategy. https://osf.io/unj7x/.

The association between healthy eating practices and child dietary intake in childcare centres where parents pack foods from home has received little attention. This study aimed to: (1) Describe the nutritional content of foods and beverages consumed by children in care; and (2) Assess the association between centre healthy eating practices and child intake of fruit and vegetable servings, added sugar(grams), saturated fat(grams) and sodium(milligrams) in care. A cross-sectional study amongst 448 children attending 22 childcare centres in New South Wales, Australia, was conducted. Child dietary intake was measured via weighed lunchbox measurements, photographs and researcher observation, and centre healthy eating practices were assessed via researcher observation of centre nutrition environments. Children attending lunchbox centres consumed, on average 0.80 servings (standard deviation 0.69) of fruit and 0.27 servings (standard deviation 0.51) of vegetables in care. The availability of foods within children's lunchboxes was associated with intake of such foods (p < 0.01). Centre provision of intentional healthy eating learning experiences (estimate -0.56; p = 0.01) and the use of feeding practices that support children's healthy eating (estimate -2.02; p = 0.04) were significantly associated with reduced child intake of saturated fat. Interventions to improve child nutrition in centres should focus on a range of healthy eating practices, including the availability of foods packed within lunchboxes.

Objective: This study assessed the effectiveness of a school-based intervention in reducing adolescents' sugar-sweetened beverage (SSB) consumption and percentage of energy from SSBs. Secondary outcomes were SSB consumption within school, average daily energy intake, and body mass index z-scores. Methods: Six secondary schools located in New South Wales, Australia were recruited to participate in a six-month pilot randomised controlled trial (1:1). The intervention included components targeting the school nutrition environment, curricula and community. Outcomes were collected via online surveys, observations, anthropometric measurements and project records. Between-group differences were assessed via linear mixed models. Results: At the six-month intervention endpoint (n=862) there were no statistically significant differences between students in intervention or control schools for mean daily intake of SSBs (8.55mL; CI -26.77, 43.87; p=0.63), percentage daily energy from SSBs (0.12% kJ; CI -0.55, 0.80; p=0.72), or for secondary outcomes. Acceptability of the school-based strategies were high, however intervention fidelity varied across schools. Conclusion: While acceptable, improving fidelity of implementation and increasing the duration or intensity of the intervention may be required to reduce SSB intake. Implications for public health: Engaging parents and education stakeholders in the development phase to co-design interventions may prove beneficial in improving intervention fidelity and enhance behavioural outcomes.

Objective: To assess differences between traditional paper bag ordering and online ordering from primary school canteens in terms of menu, usage and lunch order characteristics. Design: A cross-sectional study. Setting: New South Wales (NSW) primary schools that offered both paper bag and online canteen ordering. Participants: Students (aged 5-12 years) with a lunch order on the day of the observation. Results: Across the six school canteens, 59-90 % of all available items were listed on both the online and paper menus, with no significant differences in the nutritional quality ('Everyday'/'Occasional') or nutritional content (kJ/saturated fat/sugar/sodium) of menu items. In total, 387 student lunch orders were placed, containing 776 menu items. Most orders (68 %) were placed online. There were no significant differences between order modality in the quantity of items ordered or the cost of orders, or the nutritional quality of orders based on the classification system of the NSW Healthy School Canteen Strategy ('Everyday'/'Occasional'). However, nutritional analysis revealed that paper bag orders contained 222 fewer kJ than online orders (P = 0·001), 0·65 g less saturated fat (P = 0·04) and 4·7 g less sugar (P < 0·001). Conclusions: Online canteens are commonly used to order canteen lunches for primary school children. This is the first study to investigate differences between traditional paper bag ordering and online ordering in this setting. Given the rapid increase in the use of online ordering systems in schools and other food settings and their potential to deliver public health nutrition interventions, additional research is warranted to further investigate differences in ordering modalities.

Unhealthy dietary patterns in adolescence are associated with an increased risk of future chronic disease. This study aimed to assess online canteen lunch purchases made by high school students to identify: (1) the nutrient composition of purchases (energy, saturated fat, sugar, sodium, percent energy from saturated fat and total sugar); (2) the proportion of items classified as healthier ('Everyday') and less healthy ('Occasional' or 'Should not be sold') according to the New South Wales Healthy Canteen Strategy; (3) the frequency of purchases by product type (e.g., salty snacks), their classification and nutrient composition; and (4) associations between student characteristics and the nutrient composition and classification of purchases. The average order contained 2075 kJ of energy, 6.4 g of saturated fat, 18.4 g of sugar and 795 mg of sodium. Less healthy ('Occasional' and 'Should not be sold') items combined accounted for 56% of purchases. The most frequently purchased products were burgers and crumbed/coated foods. Students in higher grades purchased a significantly higher mean percent of 'Everyday' items, compared to students in grades 7 or 8. The majority of high school student purchases were less healthy ('Occasional' or 'Should not be sold') items, warranting further investigation of factors influencing online canteen purchasing behaviour in this setting.

Aim: To (a) describe lunchbox foods packed and consumed by children attending early childhood education and care services; (b) compare the serves of foods packed and consumed with nutrition guideline recommendations; and (c) explore associations between parent characteristics and serves of food groups packed in lunchboxes. Methods: A cross sectional study was conducted on a sample of early childhood education and care services where parents provide food in the Hunter New England region of NSW, Australia. Lunchbox contents were assessed using photography and pre- and post-meal weights. Descriptive statistics were used to describe packing and consumption of core food groups and discretionary foods. Results: Data on food packed and consumed were collected for 355 children's lunchboxes from 17 services (preschools n¿=¿14, long day care services n¿=¿3). Less than half (44%) of lunchboxes contained vegetables, and 54% contained at least one serve of discretionary foods. Less than 1% of lunchboxes met all setting-specific nutrition guidelines. On average, children consumed 68% of lunchbox contents, with the lowest consumption rate being for vegetables. An association was found between parent education level and packing of discretionary foods (-0.36, P¿= <.01) but not for packing of fruit or vegetables. Conclusions: Lunchboxes contained an over-representation of discretionary foods and under-representation of vegetables, and children had a low preference for consuming vegetables compared with other food groups. Interventions to support parent packing of lunchboxes in line with nutrition guidelines and strategies to expand child preference for foods such as vegetables are warranted.

Few online food ordering systems provide tailored dietary feedback to consumers, despite suggested benefits. The study aim was to determine the effect of providing tailored feedback on the healthiness of students' lunch orders from a school canteen online ordering system. A cluster randomized controlled trial with ten government primary schools in New South Wales, Australia was conducted. Consenting schools that used an online canteen provider ('Flexischools') were randomized to either: a graph and prompt showing the proportion of 'everyday' foods selected or a standard online ordering system. Students with an online lunch order during baseline data collection were included (n = 2200 students; n = 7604 orders). Primary outcomes were the proportion of foods classified as 'everyday' or 'caution'. Secondary outcomes included: mean energy, saturated fat, sugar, and sodium content. There was no difference over time between groups on the proportion of 'everyday' (OR 0.99; p = 0.88) or 'caution' items purchased (OR 1.17; p = 0.45). There was a significant difference between groups for average energy content (mean difference 51 kJ; p-0.02), with both groups decreasing. There was no difference in the saturated fat, sugar, or sodium content. Tailored feedback did not impact the proportion of 'everyday' or 'caution' foods or the nutritional quality of online canteen orders. Future research should explore whether additional strategies and specific feedback formats can promote healthy purchasing decisions.

There has been a proliferation of digital health interventions (DHIs) targeting dietary in-take. Despite their potential, the effectiveness of DHIs are thought to be dependent, in part, on user engagement. However, the relationship between engagement and the effectiveness of dietary DHIs is not well understood. The aim of this review is to describe the association between DHI engagement and dietary intake. A systematic search of four electronic databases and grey literature for records published before December 2019 was conducted. Studies were eligible if they examined a quantitative association between objective measures of engagement with a DHI (subjective experience or usage) and measures of dietary intake in adults (aged = 18 years). From 10,653 citations, seven studies were included. Five studies included usage measures of engagement and two examined subjective experiences. Narrative synthesis, using vote counting, found mixed evidence of an association with usage measures (5 of 12 associations indicated a positive relationship, 7 were in-conclusive) and no evidence regarding an association with subjective experience (both studies were inconclusive). The findings provide early evidence supporting an association between measures of usage and dietary intake; however, this was inconsistent. Further research examining the association between DHI engagement and dietary intake is warranted.

Active Kids is a government-led, universal voucher program that aims to reduce the cost of participation in structured physical activity for all school-enrolled children in New South Wales (NSW), Australia. As part of the Active Kids program evaluation, this cross-sectional study examined the Active Kids' program's reach to children in NSW and their physical activity behaviors, before voucher use. Demographic registration data from all children (4.5¿18 years old) who registered for an Active Kids voucher in 2018 (n = 671,375) were compared with Census data. Binary and multinomial regression models assessed which correlates were associated with meeting physical activity guidelines and participation in the sessions of structured physical activity. The Active Kids program attracted more than half (53%) of all eligible children in NSW. Children who spoke a primary language other than English at home, were aged 15¿18 years old, lived in the most disadvantaged areas, and girls, were less likely to register. Of the registered children, 70% had attended structured physical activity sessions at least once a week during the previous 12 months, whilst 19% achieved physical activity guidelines. Active Kids achieved substantial population reach and has the potential to improve children's physical activity behaviors.

Background: To determine Australian primary school principals', teachers', and parents' attitudes to changing school uniform policies to allow students to wear sports uniforms every day and to assess associations between participant characteristics and their attitudes. A secondary aim was to identify principals' and teachers' perceived barriers to uniform changes. Methods: Cross-sectional surveys of principals, teachers, and parents of children in grades 2 to 3 (age 7-10 y) from 62 Australian primary schools (Oct 2017-Mar 2018) were undertaken. Mixed logistic regression analyses assessed the associations between participant characteristics and attitudes toward uniform changes. Results: In total, 73% of the principals (38/52) who responded reported that their school only allowed children to wear a sports uniform on sports days. Overall, 38% of the principals (18/47), 63% of the teachers (334/579), and 78% of the parents (965/1231) reported they would support a policy that allowed children to wear daily sports uniforms. The most commonly reported barrier was the perception that sports uniforms were not appropriate for formal occasions. Conclusions: Although the majority of the principals were not supportive of a change to a daily sports uniform, the majority of the teachers and parents were. Strategies to improve principal support may be required if broader adoption of physical activity-supporting uniforms is to be achieved.

Background: As dietary behaviours developed during early childhood are known to track into adulthood, interventions that aim to improve child nutrition at a population level are recommended. Whilst early childhood education and care (ECEC) is a promising setting for interventions targeting children's nutrition behaviours, previous interventions have largely used high intensity, face-to-face approaches, limiting their reach, implementation and potential impact at a population level. Web-based modalities represent a promising means of supporting the delivery of childcare-based interventions whilst overcoming challenges of previous approaches; however, the feasibility of using such modalities to support implementation is largely unknown. As such, this study sought to collect feasibility and pilot data to inform the design of a web-based intervention together with health promotion officer support within childcare centres. Child dietary intake will also be assessed to provide an estimate of the impact of the implementation intervention. Methods: A superiority cluster randomised controlled trial with repeat cross-sectional data collection employing an effectiveness-implementation type-II hybrid design will be conducted with childcare centres within the Hunter New England region of New South Wales, Australia. Type-II hybrid designs provide the opportunity to assess intervention efficacy whilst piloting the feasibility of the implementation strategies. Centres allocated to the intervention group will receive access to a web-based program together with health promotion officer support to implement targeted healthy eating practices to improve child diet in care. A number of outcomes will be assessed to inform the feasibility to conduct a larger trial, including childcare centre and parent recruitment and consent rates for each component of data collection, uptake of the implementation strategies, acceptability of the intervention and implementation strategies, appropriateness of the implementation strategies and the contextual factors influencing implementation. Discussion: This study will provide high-quality evidence regarding the potential feasibility of a web-based intervention and the impact of healthy eating practices on child diet in care. Web-based modalities provide a promising approach for population-wide implementation support to childcare centres given their potential reach and consistency with existing infrastructure. Trial registration: Prospectively registered with Australian New Zealand Clinical Trial Registry (ACTRN12619001158156).

Issue addressed: Modifying the scheduling of physical activity opportunities to provide children with more frequent opportunities for outdoor free play has been demonstrated to increase child physical activity while in care. The primary aim of this study was to describe the implementation of continuous free play schedules to allow children to access outdoor play areas, consistent with sector guidelines in a national sample of Australian childcare services. Secondary aims were to investigate the associations between the implementation of such schedules and service characteristics, and assess the perceived barriers and enablers to implementation. Methods: A cross-sectional study was undertaken with a random sample of 326 centre-based childcare services located across Australia. Childcare service characteristics, continuous free play scheduling and perceived barriers and enablers to implementation were assessed via a survey administered to service managers online or via telephone. Results: A total of 203 service managers (62%) reported implementing a continuous free play schedule, for three periods of 126¿minutes per period, each day on average. Service type (long day care services), size (services with higher numbers of child enrolments [=80 children]) and socio-economic area (services located in lower socio-economic areas) were associated with the implementation of a continuous free play schedule. The most prevalent barriers to implementation included insufficient staff to ensure adequate supervision of children (69%) and service layout being unsuitable (65%), while the most prevalent enablers included advice on how to overcome staffing or supervision issues (89%) and to re-orientate the service layout (54%). Conclusions: There is scope to support the implementation of continuous free play schedules consistent with childcare sector guidelines. So what?: Future intervention research that targets the reported barriers and enablers to implementation is needed.

Aim: To assess the impact of a multistrategy intervention designed to improve teachers' implementation of a school physical activity (PA) policy on student PA levels. Methods: A cluster-randomized controlled trial was conducted in 12 elementary schools. Policy implementation required schools to deliver 150 minutes of organized PA for students each week via physical education, sport, or class-based activities such as energizers. Schools received implementation support designed using the theoretical domains framework to help them implement the current policy. Results: A total of 1,502 children in kindergarten to grade 6 participated. At follow-up compared with control, students attending intervention schools had, measured via accelerometer, significantly greater increases in school day counts per minute (97.5; 95% confidence interval [CI], 64.5 to 130.4; P <.001) and moderate to vigorous physical activity (MVPA) (3.0; 95% CI, 2.2-3.8, P <.001) and a greater decrease in sedentary time (-2.1; 95% CI, -3.9 to -0.4, P =.02) per school day. Teachers in intervention schools delivered significantly more minutes (36.6 min) of PA to their students at follow-up (95% CI, 2.7-70.5, P =.04). Conclusions: Supporting teachers to implement a PA policy improves student PA. Additional strategies may be needed to support teachers to implement activities that result in larger gains in student MVPA.

Introduction and Aims: People who use substances have a high prevalence of modifiable chronic disease health risk behaviours. Preventive care to address such risks has not traditionally been provided during substance use treatment. This study aimed to assess clinicians' attitudes towards preventive care and their association with care provision. Design and Methods: A cross-sectional study utilising computer-assisted telephone interviews was undertaken with clinicians (n = 54) of community-based substance use treatment services in one health district, Australia. Clinicians indicated their agreement with 10 attitudinal statements regarding their perceived role and self-efficacy in providing preventive care and perceptions of client interest in modifying behaviours. Logistic regression analyses examined the association between clinician attitudinal items and self-reported care provision. Results: Fifty-four clinicians (74%) agreed to participate. The most positive attitudes were preventive care being part of their role (100%), and they have the knowledge and skills to provide preventive care (100%). The least favourable attitude was clients were interested in changing their health risk behaviours (60%). Clinicians who reported that preventive care left little time to undertake acute care were more likely to assess for smoking (OR 8.06 [95% CI 1.31, 49.46]) and less likely to provide brief advice for all risks combined (OR 0.11 [95% CI 0.02, 0.63]). Discussion and Conclusions: Overall, clinicians reported positive attitudes regarding the preventive care provision for modifiable health risk behaviours in substance use treatment settings. Further research is required to investigate why, despite such positive attitudes, clinicians in substance use treatment settings do not routinely provide preventive care.

There has been a well-documented gap between research (e.g., evidence-based programs, interventions, practices, policies, guidelines) and practice (e.g., what is routinely delivered in real-world community and clinical settings). Dissemination and implementation (D&I) science has emerged to address this research-to-practice gap and accelerate the speed with which translation and real-world uptake and impact occur. In recent years, there has been tremendous development in the field and a growing global interest, but much of the introductory literature has been U.S.-centric. This piece provides an introduction to D&I science and summarizes key concepts and progress of the field for a global audience, provides two case studies that highlight examples of D&I research globally, and identifies opportunities and innovations for advancing the field of D&I research globally.

Physical activity (PA) is critical to early childhood health and development, and childcare is a key setting for establishing physically active play. In British Columbia (BC), a provincial standard for active play in childcare was enacted, identified here as the Active Play (AP) standard. Pragmatic constraints limit real-world data collection for evaluating policy impact. We explored whether information about policies, practices, and the environment varied when it was collected from managers or staff. Surveys were distributed to BC childcare centers before AP standard enactment to ascertain current PA and fundamental movement skill policies and practices. The full sample (n = 1037 from 625 facilities) and a subsample of paired managers and staff (n = 261 centers) were used to explore agreement across managers and staff in reported prevalence and relationships among indicators. The policy prevalence and relationships for active play and outdoor play variables were relatively similar for manager and staff data, although the matched data had modest agreement and less than optimal intraclass correlations. The prevalence of manager-reported PA policies ranged from 47% for screen-time limits to 77% for fundamental movement skill activities. The manager and staff data highlighted indoor and outdoor space as a primary factor in AP standard adherence. With reliance on sampling staff unfeasible, it appears that the manager data may adequately describe the policies and practices of childcare providers with some notable issues.