Dr Nicole Nathan

© The Authors 2018Â. Objective To (i) describe the proportion of foods and beverages available on school canteen menus classified as having high ('green'), moderate ('amber') or low ('red') nutritional value; (ii) describe the proportion of these items purchased by students; and (iii) examine the association between food and beverage availability on school canteen menus and food and beverage purchasing by students.Design A cross-sectional study was conducted as part of a larger randomised controlled trial (RCT).Setting A nested sample of fifty randomly selected government schools from the Hunter New England region of New South Wales, Australia, who had participated in an RCT of an intervention to improve the availability of healthy foods sold from school canteens, was approached to participate.Subjects School principals, canteen managers and students.Results The average proportion of green, amber and red items available on menus was 47·9, 47·4 and 4·7 %, respectively. The average proportion of green, amber and red items purchased by students was 30·1, 61·8 and 8·1 %, respectively. There was a significant positive relationship between the availability and purchasing of green (R 2=0·66), amber (R 2=0·57) and red menu items (R 2=0·61). In each case, a 1 % increase in the availability of items in these categories was associated with a 1·21, 1·35 and 1·67 % increase in purchasing of items of high, moderate and low nutritional value, respectively.Conclusions The findings provide support for school-based policies to improve the relative availability of healthy foods for sale in these settings.

© 2018 The Author(s). Background: Implementation interventions delivered in schools to improve food provision have been found to improve student diet and reduce child obesity risk. If the health benefits of food availability policies are to be realised, interventions that are effective need to be implemented at scale, across an entire population of schools. This study aims to assess the potential effectiveness of an intervention in increasing the implementation, at scale, of a healthy canteen policy by Australian primary schools. Methods: A non-controlled before and after study was conducted in primary schools located in the Hunter New England region of New South Wales, Australia. Schools received a multi-component intervention adapted from a previous efficacious and cost-effective randomised control trial. The primary trial outcome was the proportion of canteen menus compliant with the state healthy canteen policy, assessed via menu audit at baseline and follow-up by dietitians. Secondary outcomes included policy reach and adoption and maintenance policy implementation. Results: Of the 173 schools eligible for inclusion in the trial, 168 provided menus at baseline and 157 menus were collected at follow-up. At follow-up, multiple imputation analysis found 35% (55/157) of schools compared to 17% (29/168) at baseline (OR = 2.8 (1.6-4.7), p = < 0.001) had menus compliant with the state healthy canteen policy. As an assessment of the impact of the intervention on policy reach, canteen manager and principal knowledge of the policy increased from 64% (n = 76) and 38% (n = 44) respectively at baseline to 69% (n = 89) and 60% (n = 70) at follow-up (p = 0.393, p = 0.026). Adoption of the policy increased from 80% (n = 93) at baseline to 90% (n = 104) at follow-up (p = 0.005) for principals, and from 86% (n = 105) to 96% (n = 124) (p = 0.0001) for canteen managers. Multiple imputation analysis showed intervention effects were maintained six-months post intervention (33% of menus compliant OR = 2.6 (1.5-4.5), p = < 0.001 compared to baseline). Conclusions: This study found school canteen compliance with a healthy food policy increased in association with a multi-strategy intervention delivered at scale. The study provides evidence for public health policy makers and practitioners regarding strategies and modes of support required to support improvement in nutrition policy implementation across entire populations of schools.

© 2017 Background Front-of-pack graphical nutritional rating of products is becoming an important strategy in many countries to improve healthy food purchases by consumers. Evidence of the effectiveness of such on facilitating healthy food choices by school food service providers has not been reported. The primary aim of the study was to assess the impact of providing front-of-pack nutritional rating information on school canteen managers¿ likely food selections. Secondary outcomes were canteen manager awareness, attitudes and reported barriers to using the front-of-pack information. Methods A randomised controlled trial involving primary school canteen managers was conducted in a single region in New South Wales, Australia. Eligible participants were randomised to an intervention or control group and asked in a telephone interview which of 12 common food products sold in school canteens they would sell. Both groups received product name and brand information. The intervention group also received information regarding the nutritional rating of products. Results Canteen managers in the intervention group were significantly more likely than those in the control group to indicate they would sell three of the six ¿healthier¿ products (p = 0.036, 0.005, 0.009). There was no difference between groups in the likelihood of making available for sale any of the six ¿less healthy¿ products. The majority of canteen managers who had heard of a product nutritional rating system agreed that it was helpful in identifying ¿healthier¿ foods (88%, n = 31). Conclusions The inclusion of product nutritional rating information has the potential to improve the availability of some ¿healthier¿ items on canteen menus and contribute to improving child dietary intake. Further research is required to determine whether the use of product nutritional rating information actually makes a difference to canteen manager choices.

© 2017 Children attending centre based childcare services consume as much as two thirds of their daily dietary requirements while in care. However, such services often fail to provide foods that are consistent with guideline recommendations. Developing strategies to improve childcare service adherence to menu dietary guidelines requires a comprehensive understanding of factors that may impede or promote implementation. The primary aim of this systematic review is to describe factors (barriers and facilitators) that may influence the implementation of menu dietary guidelines regarding food provision in centre-based childcare services and to map these factors to a theoretical framework. Over 7000 citations were identified from all sources. Duplicate abstracts were removed and selection criteria applied. Twelve studies (1994¿2015) were included in the review. Dual data extraction was conducted and the reported factors were synthesised using the theoretical domains framework (TDF). Barriers and facilitators identified in qualitative studies were classified into 8 and 10 of the 14 TDF domains. Barriers and facilitators reported in quantitative studies covered 6 and 3 TDF domains respectively. The most common domain of which both barriers and facilitators to the implementation of menu dietary guidelines were identified was ¿environmental context and resources¿. This is the first study that comprehensively assesses literature to identify factors that influence the implementation of menu dietary guidelines in childcare services utilising a theoretical framework. Findings provide guidance to support researchers and policy makers design strategies to improve menu dietary guideline implementation and, as such have the potential to improve food provision in care.

© Australian Health Promotion Association 2017. Issue addressed: This study of primary school principals assessed the awareness, use, barriers to use and acceptability of online canteens. Methods: A telephone survey of 123 primary school principals within the Hunter New England Region of New South Wales, Australia was conducted from September 2014 to November 2014. Results: Fifty-six percent of principals were aware of the existence of online canteens, with 8% having implemented such a system, and 38% likely to do so in the future. Medium/large schools were more likely to be aware of or to use online canteens, however there were no differences in awareness or use in relation to school rurality or socioeconomic advantage. Principals cited parent internet access as the most commonly identified perceived barrier to online canteen use, and the majority of principals (71-93%) agreed that it would be acceptable to implement a range of consumer behaviour strategies via an online canteen. Conclusions: Study findings suggest that despite relatively low levels of current use, online canteens have the potential to reach a large proportion of school communities in the future, across geographical and socioeconomic divides, and that the nutrition interventions which they have the capacity to deliver are considered acceptable to school principals. So what? Online canteens may represent an opportunity to deliver nutrition interventions to school communities. Future research should examine the feasibility and potential effectiveness of interventions delivered via this modality.

© 2017 World Obesity Federation Objective: The aims of this systematic review and meta-analysis are (i) to determine the impact of school-based interventions on objectively measured physical activity among adolescents and (ii) to examine accelerometer methods and decision rule reporting in previous interventions. Methods: A systematic search was performed to identify randomized controlled trials targeting adolescents (age: =10¿years), conducted in the school setting, and reporting objectively measured physical activity. Random effects meta-analyses were conducted to determine the pooled effects of previous interventions on total and moderate-to-vigorous physical activity. Potential moderators of intervention effects were also explored. Results: Thirteen articles met the inclusion criteria, and twelve were included in the meta-analysis. The pooled effects were small and non-significant for both total physical activity (standardized mean difference¿=¿0.02 [95% confidence interval¿=¿-0.13 to 0.18]) and moderate-to-vigorous physical activity (standardized mean difference¿=¿0.24 [95% confidence interval¿=¿-0.08 to 0.56]). Sample age and accelerometer compliance were significant moderators for total physical activity, with a younger sample and higher compliance associated with larger effects. Conclusion: Previous school-based physical activity interventions targeting adolescents have been largely unsuccessful, particularly for older adolescents. There is a need for more high-quality research using objective monitoring in this population. Future interventions should comply with best-practice recommendations regarding physical activity monitoring protocols.

© 2017 The Author(s). Background: Schools play an important role in physical activity promotion for adolescents. The systematic review aimed to determine the proportion of secondary (middle and high) school physical education (PE) lesson time that students spend in moderate to vigorous physical activity (MVPA), and to assess if MVPA was moderated by school level (middle and high school), type of physical activity measurement and type of PE activities. Methods: A systematic search of nine electronic databases was conducted (PROSPERO2014:CRD42014009649). Studies were eligible if they were published between 2005 and 2014; written in English; assessed MVPA in PE lessons of secondary (middle and high) school students; and used a quantitative MVPA measure (i.e., accelerometry, heart rate monitoring, pedometers or observational measures). Two reviewers examined the retrieved articles, assessed risk of bias, and performed data extraction. Random effects meta-analysis was used to calculate a pooled estimate of the percent of PE lesson time spent in MVPA and to assess moderator effects where data allowed. Results: The search yielded 5,132 potentially relevant articles; 28 articles representing 25 studies (7 middle and 18 high school) from seven countries were included. Twelve studies measured MVPA through observational measures, seven used accelerometers, five used heart rate monitors and four used pedometers (including three studies using a mix of measures). Meta-analysis of 15 studies found that overall, students spent a mean (95% CI) of 40.5% (34.8-46.2%) of PE in MVPA. Middle school students spent 48.6% (41.3-55.9%) of the lesson in MVPA (n=5 studies) and high school students 35.9% (28.3-43.6%) (n=10 studies). Studies measuring MVPA using accelerometers (n=5) showed that students spent 34.7% (25.1-44.4%) of the lesson in MVPA, while 44.4% (38.3-50.5%) was found for lessons assessed via observation (n=9), 43.1% (24.3-61.9%) of the lesson for a heart rate based study, and 35.9% (31.0-40.8%) for a pedometer-measured study. Conclusions: The proportion of PE spent in MVPA (40.5%) is below the US Centre for Disease Control and Prevention and the UK Associations for Physical Education recommendation of 50%. Findings differed according to the method of MVPA assessment. Additional strategies and intervention research are needed to build more active lesson time in PE.

© 2015 Elsevier Inc. Objective: To examine elementary school students' moderate-to-vigorous physical activity (MVPA) levels during physical education (PE) lessons. Methods: A systematic search of nine electronic databases was conducted (PROSPERO2014:CRD42014009649). Studies were eligible if they were in English; published between 2005-April 2014; assessed MVPA levels in PE lessons of elementary school children (aged four-12 years); and used an objective MVPA measure. Two reviewers retrieved articles, assessed risk of bias, and performed data extraction. The findings were synthesised using a meta-analysis. Results: The search yielded 5132 articles. Thirteen studies from nine countries met the inclusion criteria. Eight studies measured MVPA through observational measures, five used accelerometry and one used heart rate monitoring. The percentage of PE lesson time spent in MVPA ranged between 11.4-88.5%. Meta-analysis of seven studies (direct observations; 4 accelerometers) found that children spent a mean (95% CI) 44.8 (28.2-61.4)% of PE lesson time in MVPA. When measured using direct observation and accelerometers, children spent 57.6 (47.3-68.2) and 32.6 (5.9-59.3)% of PE lesson time in MVPA, respectively. The review has limitations; the search strategy was restricted to studies in English; theses, dissertations and conference abstracts were excluded; and six studies that provided insufficient data were excluded from the meta-analysis. Conclusion: MVPA levels during elementary school PE lessons do not meet the United States Centre for Disease Control and Prevention and the United Kingdom's Association of Physical Education recommendation (50% of lesson time), but is higher than estimated in the previous review (34.2%). Interventions to increase MVPA in PE lessons are needed.

© 2016 The Author(s). Background: Few school-based interventions have been successful in reducing physical activity decline and preventing overweight and obesity in adolescent populations. As a result, few cost effectiveness analyses have been reported. The aim of this paper is to report the cost and cost effectiveness of the Physical Activity 4 Everyone (PA4E1) intervention which was a multi-component intervention implemented in secondary schools located in low-income communities. Cost effectiveness was assessed using both the physical activity and weight status trial outcomes. Methods: Intervention and Study Design: The PA4E1 cluster randomised controlled trial was implemented in 10 Australian secondary schools (5 intervention: 5 control) and consisted of intervention schools receiving seven physical activity promotion strategies and six additional strategies that supported school implementation of the intervention components. Costs associated with physical activity strategies, and intervention implementation strategies within the five intervention schools were estimated and compared to the costs of usual physical activity practices of schools in the control group. The total cost of implementing the intervention was estimated from a societal perspective, based on the number of enrolled students in the target grade at the start of the intervention (Grade 7, n = 837). Economic Outcomes: The economic analysis outcomes were cost and incremental cost effectiveness ratios for the following: minutes of moderate-to-vigorous physical activity (MVPA) per day gained, MET hours gained per person/day; Body Mass Index (BMI) unit avoided; and 10 % reduction in BMI z-score. Results: The intervention cost AUD $329,952 over 24 months, or AUD$394 per student in the intervention group. This resulted in a cost effectiveness ratio of AUD$56 ($35-$147) per additional minute of MVPA, AUD$1 ($0.6-$2.7) per MET hour gained per person per day, AUD$1408 ($788-$6,570) per BMI unit avoided, and AUD$563 ($282-$3,942) per 10 % reduction in BMI z-score. Conclusion: PA4E1 is a cost effective intervention for increasing the physical activity levels and reducing unhealthy weight gain in adolescence, a period in which physical activity typically declines. Additional modelling could explore the potential economic impact of the intervention on morbidity and mortality. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12612000382875.

© 2016 Society for Nutrition Education and Behavior. Because physical inactivity and unhealthy diets are highly prevalent, there is a need for cost-effective interventions that can reach large populations. Electronic health (eHealth) and mobile health (mHealth) solutions have shown promising outcomes and have expanded rapidly in the past decade. The purpose of this report is to provide an overview of the state of the evidence for the use of eHealth and mHealth in improving physical activity and nutrition behaviors in general and special populations. The role of theory in eHealth and mHealth interventions is addressed, as are methodological issues. Key recommendations for future research in the field of eHealth and mHealth are provided.

© Australian Health Promotion Association 2016. Bridging the gap between research-based evidence and public health policy and practice is a considerable challenge to public health improvement this century, requiring a rethinking of conventional approaches to health research production and use. Traditionally the process of research translation has been viewed as linear and unidirectional, from epidemiological research to identify health problems and determinants, to efficacy and effectiveness trials and studies of strategies to maximise the implementation and dissemination of evidence-based interventions in practice. A criticism of this approach is the considerable time it takes to achieve translation of health research into practice. Hybrid evaluation designs provide one means of accelerating the research translation process by simultaneously collecting information regarding intervention impacts and implementation and dissemination strategy. However, few health promotion research trials employ such designs and often fail to report information to enable assessment of the feasibility and potential impact of implementation and dissemination strategies. In addition to intervention effects, policy makers and practitioners also want to know the impact of implementation strategies. This commentary will define the three categories of effectiveness-implementation hybrid designs, describe their application in health promotion evaluation, and discuss the potential implications of more systematic use of such designs for the translation of health promotion and evaluation.So what?Greater use of effectiveness-implementation hybrid designs may accelerate research translation by providing more practice- and policy-relevant information to end-users, more quickly.

© 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians) Aim: Despite ongoing investments to improve the obesogenic environments of childcare settings, little is known regarding how these services have changed their physical activity and nutrition-promoting practices. This study aims to describe changes in the proportion of Australian childcare services that have adopted best-practice healthy eating and physical activity practices between 2006 and 2013 and to assess whether adoption varied by socio-economic status and locality. Methods: A randomly selected sample of nominated supervisors (n = 358) from childcare services located in New South Wales, Australia, participated in a telephone survey in 2006, 2009, 2010 and 2013. Supervisors reported on their service's adoption of six practices: (i) having written nutrition and physical activity policies; (ii) staff trained in physical activity and nutrition in the past year; (iii) scheduled time for fundamental movement skills and (iv) outdoor play; (v) weekly or less screen time opportunities; and (vi) serving only non-sweetened beverages. Results: A significant increase in the prevalence of services adopting all but one practice, between 2006 and 2013 was identified. Ninety one percent of services adopted four or more practices, a significant increase from 38% in 2006. There were no differences in the proportion of services adopting each practice by locality and socio-economic status. Conclusions: Government investment in obesity prevention programmes can equitably improve childcare service's adoption of healthy eating and physical activity promoting practices on a jurisdiction-wide basis. The establishment of a routine system to monitor adoption of a broader range of practices by childcare services is warranted.

© Australian Health Promotion Association 2016. Issue addressed In order to assess the impact of healthy school canteen policies on food availability for students, valid methods of measuring compliance are needed that can be applied at scale. The aim of this study is to assess the validity and direct cost of four methods to assess policy compliance: 1) principal and 2) canteen manager self-report via a computer-assisted telephone interview; and 3) comprehensive and 4) quick menu audits by dietitians, compared with observations. Methods A cross-sectional study took place in the Hunter region of NSW, Australia, in a sample of 38 primary schools that had previously participated in a randomised controlled trial to improve healthy canteen policy compliance. Policy compliance was assessed using the four methods specified above. Percentage agreement, kappa, sensitivity and specificity compared with observations was calculated together with the direct time taken and costs of each method. Indirect costs (including set-up costs) for all measures have not been included. Results Agreement with observations was substantial for the quick menu audit (kappa=0.68), and moderate for the comprehensive menu audit (kappa=0.42). Principal and canteen manager self-report resulted in poor agreement and low specificity with the gold standard. The self-reported measures had the lowest cost, followed by the quick menu audit and lastly the comprehensive menu audit. Conclusion The quick menu audit represents a valid and potentially low-cost method of supporting policy implementation at scale. So what? This study demonstrates that a quick menu audit represents a valid measure of undertaking assessment of school canteen policy compliance at a population level.

© 2014. Objectives: Physical education (PE) plays an important role in contributing to students' physical activity (PA); however, moderate-to-vigorous PA (MVPA) within PE is lower than recommended. Little is known about the PA levels of students from disadvantaged schools within PE. This study aimed to describe: (i) the PA levels of students from disadvantaged secondary schools during PE lessons, (ii) the lesson context and teacher interactions occurring during PE, and (iii) the associations between teacher, school or PE lesson characteristics with student physical activity levels in PE. Design: Cross-sectional study of 100 Grade 7 PE lessons across 10 secondary schools. Methods: System for observing fitness instruction time (SOFIT) was used to assess student PA, lesson context, and teacher interaction. Teacher and school characteristics were collected via survey. Mean proportion of lesson time was used to describe PA, lesson context and teacher interaction. Associations between each outcome variable and each characteristic were examined using 2-sample t-tests, ANOVAs and linear regression. Results: Thirty-nine percent of PE lesson was spent in MVPA, and less than 10% spent in VA. Lessons in schools in urban areas included significantly more MVPA than rural areas (P = 0.04). Male teachers and more experienced teachers conducted lessons with significantly more VA than female and less experienced teachers (P = 0.04 and 0.02). MVPA was also higher in lessons conducted by more experienced teachers. Conclusions: PA during PE lessons within disadvantaged secondary schools is below international recommendations. Male teachers, more experienced teachers and schools in urban regions teach more active lessons.

Background: Adolescence is a recognised period of physical activity decline, particularly among low-income communities. We report the 12-month (midpoint) effects of a 2-year multicomponent physical activity intervention implemented in disadvantaged secondary schools. Methods: A cluster randomised trial was undertaken in 10 secondary schools located in disadvantaged areas in New South Wales, Australia. Students in Grade 7 were recruited, with follow-up in Grade 8. The intervention was guided by socioecological theory and included seven physical activity strategies, and six implementation adoption strategies. The primary outcome was mean minutes of moderate-to-vigorous physical activity (MVPA) per day assessed using Actigraph GT3X accelerometers. Outcome data were analysed using repeated measures linear mixed models. Results: At baseline, 1150 (93%) students participated in the data collection (mean age 12 years, 48% boys) and 1050 (79%) students participated at 12-month follow-up. By the 12-month follow-up, the six implementation adoption strategies had been used to support schools to deliver four of the seven physical activity elements. There was a significant group-by-time interaction for mean minutes of MVPA per day in favour of the intervention group (adjusted difference between groups at follow-up=3.85 min, 95% CI (0.79 to 6.91), p=0.01), including significantly more vigorous physical activity (2.45 min, p=0.01), equating to 27 min more MVPA per week. Summary: At 12-month follow-up, the intervention had reduced the decline in physical activity among adolescents from disadvantaged schools. The intervention may assist students to meet physical activity guidelines.

© 2015 The Cochrane Collaboration. This is the protocol for a review and there is no abstract. The objectives are as follows: The primary aims of the review are to examine the effectiveness of strategies aiming to improve the implementation of school-based policies, programs or practices that aim to promote healthy or reduce unhealthy behaviours relating to child diet, physical activity, obesity, or tobacco or alcohol use. Secondary objectives of the review are to: examine the effectiveness of implementation strategies on health behavioural (e.g. fruit and vegetable consumption) and anthropometric outcomes (e.g. BMI, weight); describe the impact of such strategies on the knowledge, skills or attitudes of stakeholders involved in implementing health promoting policies, programs or practices; describe the cost or cost effectiveness of such strategies; describe any unintended adverse effects of strategies on schools, school staff or children.

© 2015 Australian Health Promotion Association. Issue addressed Since 2005, a government-endorsed strategy guiding food sold in New South Wales school canteens has been in place. This study describes the changes in school canteen food between 2007 and 2010 and characterises schools most likely to adhere to strategy guidelines. Methods Menus obtained from a cohort of primary and central schools in the Hunter New England region of New South Wales were audited using a traffic light system of classification. Energy dense, nutrient-poor or 'red' items are restricted; 'amber' are to be selected carefully and healthier 'green' items are encouraged. Results In 2007, 7% of schools had no red items on their menu. In 2010, this improved to 22% (P<0.05). In 2010, small schools (OR=1.9, 95% CI=1.25-3.05, P=0.003); lower socioeconomic schools (OR=1.3, 95% CI=1.02-1.78, P=0.03); non-government (OR=1.7, 95% CI=1.22-2.23, P=0.001) and rural schools (OR=1.7, 95% CI=1.30-2.25, P<0.001) had higher odds of having red items on the menu. No significant change occurred in the proportion of green foods listed for sale between 2007 and 2010. Conclusions Proportion of schools adhering to strategy guidelines had increased slightly, however, most continue to list red items for regular sale. So what? For health policies to improve public health they need implementation. Findings suggest more work is required, particularly in small schools, rural schools and non-government schools.

© 2015, Society of Behavioral Medicine. Many early childhood education and care (ECEC) services fail to implement recommended policies and practices supportive of healthy eating and physical activity. The purpose of this study was to assess whether certain theoretically-based factors are associated with implementation of healthy eating and physical activity policies and practices in a sample of ECEC services. A cross-sectional survey was conducted with Service Managers of ECEC services. The survey assessed the operational characteristics, policy, and practice implementation, and 13 factors were suggested by Damschroder¿s Consolidated Framework for Implementation Research to impede or promote implementation. Logistic regression analyses found a significant association between implementation factor score and full implementation (OR 1.38; 95% CI 1.18¿1.61; p = <0.01), indicating that for every one point increase in implementation score, ECEC services were 38¿% more likely to be fully implementing the policies and practices. The findings highlight the opportunities for improving implementation of obesity prevention interventions in this setting by developing interventions that address such factors.

© 2015 American Journal of Preventive Medicine. Introduction Schools represent a valuable setting for interventions to improve children's diets, as they offer structured opportunities for ongoing intervention. Modifications to the school food environment can increase purchasing of healthier foods and improve children's diets. This study examines the availability of healthy food and drinks, implementation of pricing and promotion strategies in Australian primary school canteens, and whether these varied by school characteristics. Methods In 2012 and 2013, canteen managers of primary schools in the Hunter New England region of New South Wales reported via telephone interview the pricing and promotion strategies implemented in their canteens to encourage healthier food and drink purchases. A standardized audit of canteen menus was performed to assess the availability of healthy options. Data were analyzed in 2014. Results Overall, 203 (79%) canteen managers completed the telephone interview and 170 provided menus. Twenty-nine percent of schools had menus that primarily consisted of healthier food and drinks, and 11% did not sell unhealthy foods. Less than half reported including only healthy foods in meal deals (25%), labeling menus (43%), and having a comprehensive canteen policy (22%). A significantly larger proportion of schools in high socioeconomic areas (OR=3.0) and large schools (OR=4.4) had primarily healthy options on their menus. School size and being a Government school were significantly associated with implementation of some pricing and promotion strategies. Conclusions There is a need to monitor canteen environments to inform policy development and research. Future implementation research to improve the food environments of disadvantaged schools in particular is warranted.

Introduction: A number of jurisdictions internationally have policies requiring schools to implement healthy canteens. However, many schools have not implemented such policies. One reason for this isthat current support interventions cannot feasibly be delivered to large numbers of schools. A promising solution to support population-wide implementation of healthy canteen practices is audit and feedback. The effectiveness of this strategy has, however, not previously been assessed in school canteens. This study aims to assess the effectiveness and cost-effectiveness of an audit and feedback intervention, delivered by telephone and email, in increasing the number of school canteens that have menus complying with a government healthy-canteen policy. Methods and analysis: Seventy-two schools, across the Hunter New England Local Health District in New South Wales Australia, will be randomised to receive the multicomponent audit and feedback implementation intervention or usual support. The intervention will consist of between two and four canteen menu audits over 12 months. Each menu audit will be followed by two modes of feedback: a written feedback report and a verbal feedback/support via telephone. Primary outcomes, assessed by dieticians blind to group status and as recommended by the Fresh Tastes @ School policy, are: (1) the proportion of schools with a canteen menu containing foods or beverages restricted for sale, and; (2) the proportion of schools that have a menu which contains more than 50% of foods classified as healthy canteen items. Secondary outcomes are: the proportion of menu items in each category ('red', 'amber' and 'green'), canteen profitability and cost-effectiveness. Ethics and dissemination: Ethical approval has been obtained by from the Hunter New England Human Research Ethics Committee and the University of Newcastle Human Research Ethics Committee. The findings will be disseminated in usual forums, including peer-reviewed publication and conference presentations.

Background: Overweight and obesity is a significant public health problem that impacts a large number of children globally. Supporting childcare centers to deliver healthy eating and physical activity-promoting policies and practices is a recommended strategy for obesity prevention, given that such services provide access to a substantial proportion of children during a key developmental period. Electronic Web-based interventions represent a novel way to support childcare service providers to implement such policies and practices. Objective: This study aimed to assess: (1) childcare centers' current use of technology, (2) factors associated with intention to use electronic Web-based interventions, and (3) Web-based features that managers rated as useful to support staff with implementing healthy eating and physical activity-promoting policies and practices. Methods: A computer-Assisted telephone interview (CATI) was conducted with service managers from long day care centers and preschools. The CATI assessed the following: (1) childcare center characteristics, (2) childcare centers' use of electronic devices, (3) intention to use a hypothetical electronic Web-based program-Assessed using the Technology Acceptance Model (TAM) with ratings between 1 (strongly disagree) and 7 (strongly agree), and (4) features rated as useful to include in a Web-based program. Results: Overall, 214 service centers out of 277 (77.3%) consented to participate. All service centers except 2 reported using computers (212/214, 99.1%), whereas 40.2% (86/214) used portable tablets. A total of 71.9% (151/210) of childcare service managers reported a score of 6 or more for intention to use a hypothetical electronic Web-based program. In a multivariable logistic regression analysis, intention to use the program was significantly associated with perceived ease of use (P=.002, odds ratio [OR] 3.9, 95% CI 1.6-9.2) and perceived usefulness (P<.001, OR 28,95% CI 8.0-95.2). Features reported by service managers as useful or very useful for a Web-based program included decision-support tools to support staff with menu planning (117/129, 90.7%), links to relevant resources (212/212, 100%), updated information on guidelines (208/212, 98.1%), and feedback regarding childcare center performance in relation to other childcare centers (212/212, 100%). Conclusions: Childcare service managers reported high intention to use a Web-based program and identified several useful features to support staff to implement healthy eating and physical activity policies and practices. Further descriptive and intervention research examining the development and use of such a program to support childcare centers with the implementation of healthy eating and physical activity-promoting policies and practices is warranted.

Childcare services represent a valuable obesity prevention opportunity, providing access to a large portion of children at a vital point in their development. Few rigorously validated measures exist to measure healthy eating and physical activity policies and practices in this setting, and no such measures exist that are specific to the childcare setting in Australia. Methods. This was a cross sectional study, comparing two measures (pen and paper survey and observation) of healthy eating and physical activity policies and practices in childcare services. Research assistants attended consenting childcare services (n = 42) across the Hunter region of New South Wales, Australia and observed practices for one day. Nominated Supervisors and Room Leaders of the service also completed a pen and paper survey during the day of observation. Kappa statistics and proportion agreement were calculated for a total of 43 items relating to healthy eating and physical activity policies and practices. Results: Agreement ranged from 38%-100%. Fifty one percent of items showed agreement of greater than or equal to 80%. Items assessing the frequency with which staff joined in active play with children reported the lowest percent agreement, while items assessing availability of beverages such as juice, milk and cordial, as well as the provision of foods such as popcorn, pretzels and sweet biscuits, reported the highest percent agreement. Kappa scores ranged from -0.06 (poor agreement) to 1 (perfect agreement). Of the 43 items assessed, 27 were found to have moderate or greater agreement. Conclusions: The study found that Nominated Supervisors and Room Leaders were able to accurately report on a number of healthy eating and physical activity policies and practices. Items assessing healthy eating practices tended to have higher kappa scores than those assessing physical activity related policies or practices. The tool represents a useful instrument for public health researchers and policy makers working in this setting. © 2014Dodds et al.; licensee BioMed Central Ltd.