Enhancing And Supporting Early Development to Better Children's Lives (EASEL) Trial
Phase: NA
Conditions: Child Development
Sponsor: National University of Singapore

STUDY PROTOCOL
Assessing the effectiveness and
implementation of a universal classroom-
based set of educator practices to improve
preschool children’s social-emotional
outcomes: Protocol for a cluster randomized
controlled type 2 hybrid trial in Singapore
Evelyn S. TanID1,2*, Bryce D. McLeod1,3, Robyn A. Mildon1,2, Aron Shlonsky4, Cheryl K.
F. Seah1,2, Keri McCrickerd1,5, Esther Goh1,2, Gayatri Kembhavi1,2
1 Centre for Holistic Initiatives for Learning and Development, Yong Loo Lin School of Medicine, National
University of Singapore, Singapore, Singapore, 2 Centre for Evidence and Implementation, Melbourne,
Victoria, Australia, 3 Department of Psychology, Virginia Commonwealth University, Richmond, VA, United
States of America, 4 Department of Social Work, Monash University, Clayton, Victoria, Australia,
5 Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR),
Singapore, Singapore
* evelyn.tan@partner.nus.edu.sg
Abstract
Background
Providing high-quality early childhood care and education is understood as key to maximiz-
ing children’s potential to succeed later in life, as it stimulates young children’s development
of skills and competencies needed to promote optimal outcomes and success later in life.
Despite the government’s efforts to support the early childhood sector, educators in Singa-
pore continue to report difficulties in implementing practices in classrooms that promote chil-
dren’s social, emotional, and cognitive development. To enhance educators’ skills in these
domains, we developed the Enhancing And Supporting Early development to better chil-
dren’s Lives (EASEL) Approach, a set of universal, educator-delivered practices for use with
3-6-year-old children in early childhood settings to improve social, emotional, behavioral,
and executive functioning (SEB+EF) outcomes.
Methods
This study will evaluate the effectiveness and implementation of the EASEL Approach in
improving early childhood educators’ teaching practices and, in turn, children’s SEB+EF
outcomes. We will conduct a cluster randomized controlled trial with a type 2 hybrid effec-
tiveness-implementation study in 16 childcare centers. The EPIS (Explore, Prepare, Imple-
ment, Sustain) Framework will be used to inform the implementation of the EASEL
Approach. Implementation strategies include training, educator self-assessments, practice-
based coaching, and data monitoring. Our primary outcome is educators’ teaching
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OPEN ACCESS
Citation: Tan ES, McLeod BD, Mildon RA,
Shlonsky A, Seah CKF, McCrickerd K, et al. (2023)
Assessing the effectiveness and implementation of
a universal classroom-based set of educator
practices to improve preschool children’s social-
emotional outcomes: Protocol for a cluster
randomized controlled type 2 hybrid trial in
Singapore. PLoS ONE 18(9): e0291723. https://doi.
org/10.1371/journal.pone.0291723
Editor: Qin Xiang Ng, Singapore General Hospital,
SINGAPORE
Received: January 10, 2023
Accepted: September 5, 2023
Published: September 20, 2023
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0291723
Copyright: © 2023 Tan et al. This is an open access
article distributed under the terms of the Creative
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in
any medium, provided the original author and
source are credited.

practices. Secondary outcomes include educators’ adoption of the EASEL Approach in
everyday practice, the acceptability and feasibility of the EASEL Approach, and children’s
SEB+EF outcomes. Quantitative and qualitative data will be collected at baseline, six
months, and after implementation.
Conclusion
Findings from this study will provide significant evidence on the effectiveness of the EASEL
Approach in improving educators’ teaching practices and its impact on children’s SEB+EF
outcomes and the implementation of the EASEL Approach in early childhood classrooms in
Singapore.
Trial registration
This study was prospectively registered on ClinicalTrials.gov, Identifier: NCT05445947 on
6th July 2022.
Introduction
The Lancet’s series on advancing early childhood development [1] identified providing high-
quality early childhood care and education as one of the main factors that can maximize chil-
dren’s potential to succeed in later life, particularly children from vulnerable or disadvantaged
backgrounds. High-quality early childhood care and education are widely understood to be
necessary for stimulating children’s development of skills and competencies across academic
and non-academic areas, which increases school readiness and has long-reaching impacts on
outcomes later in life [2–7].
A holistic approach to early learning and development integrates children’s social-emo-
tional development, behavioral competency, and executive functioning. Social-emotional
development and behavioral competency (SEB) refer to children’s ability to understand, expe-
rience, express, and regulate their emotions and behaviors, and promote their ability to
develop meaningful relationships with others [8]. The development of children’s SEB signifi-
cantly overlaps with executive functioning (EF), a set of cognitive processes necessary for regu-
lating behavior [5]. Promoting the development of skills and competencies in these domains
in the early years is essential for success in children’s everyday interactions and subsequent
development. In recognition of the importance of children’s early development, there have
been changes to the public policy agenda in Singapore to increase the quality of early child-
hood care and education [7, 9]. This has been supported by increased funding for the early
childhood care and education sector and the establishment of a national regulatory agency for
the early childhood sector, the Early Childhood Development Agency (ECDA).
Despite efforts by the government to support the early childhood sector in Singapore, sev-
eral challenges remain. The Vital Voices for Vital Years 2 report [10] revealed difficulties expe-
rienced by early childhood educators in meeting the diverse needs of children. These
difficulties include low educator-to-children ratios and insufficient knowledge or training to
implement universal practices to support SEB+EF skills in early childhood classrooms. The
report highlighted the need for greater awareness in the sector to enhance the provision of
more equitable opportunities in early childhood care and education for children with a wide
range of needs. This would include increasing early childhood educators’ awareness about
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Data Availability Statement: No datasets were
generated or analysed during the current study. All
relevant data from this study will be made available
upon study completion.
Funding: This work was supported by an
endowment from the Lien Foundation to the Yong
Loo Lin School of Medicine, National University of
Singapore.
Competing interests: The authors have declared
that no competing interests exist.

children with disabilities and the specific needs of vulnerable or low-income families. Training
is also required to build educators’ skills and enhance their ways of working with these chil-
dren and their families.
Early childhood programs that facilitate high-quality educator-child relationships and safe,
stable learning environments are more likely to result in better social-emotional outcomes in
children [11]. In an exploratory study in Singapore, early childhood educators ranked chil-
dren’s development of SEB skills as the most critical learning area in early childhood educa-
tion. Yet, they also reported high professional development needs in their capacity to promote
children’s SEB skills and other pre-academic skills [12]. Considering findings from the Vital
Voices for Vital Years 2 report [10] and the push to improve early childhood programming
internationally [11], there is a need to expand efforts to improve early childhood educators’
knowledge in developing children’s SEB and EF as well as increasing educators’ understanding
of how to ensure their classroom practices are universal while catering for children with
diverse needs.
Several published, validated, manualized school-wide interventions aimed at improving
SEB+EF outcomes are used across a diverse range of countries (e.g., Incredible Years [13], Sec-
ond Step [14]). However, importing and directly implementing interventions developed and
tested overseas may not be acceptable or feasible for the early childhood sector in Singapore.
Practices and concepts in early childhood interventions designed overseas must consider and
incorporate Singapore educators’ current practices and skillsets when implemented locally [9].
These interventions must be re-aligned to Singapore educators’ unique needs, the local infra-
structure, and existing learning frameworks. Without this, readiness to adopt new practices
will likely be low [15], reducing the success of implementation and, in turn, the impact on chil-
dren’s outcomes.
The EASEL Approach
To address the need to enhance early childhood educators’ teaching practices and to ensure
that these practices align with and fit with the local context, the Centre for Holistic Initiatives
for Learning and Development (CHILD) has developed a universal classroom-based approach
for early childhood educators, The Enhancing And Supporting Early development to better
children’s Lives (EASEL) Approach. The EASEL Approach consists of educator-led practices
that can be incorporated into the daily classroom environment for children three to six years
of age. This approach aims to enhance early childhood educators’ teaching practices that pro-
mote children’s SEB+EF development.
Objectives
The EASEL trial has two objectives designed to accelerate the use of research evidence in prac-
tice. The first objective is to test the effectiveness of the EASEL Approach in enhancing educa-
tors’ classroom practices to improve SEB+EF outcomes in preschool children. We hypothesize
that the EASEL Approach will improve educators’ teaching practices in promoting preschool
children’s SEB+EF outcomes. In turn, improvements in children’s outcomes in these domains
will also be observed at the end of the intervention (i.e., end of the school year). The research
questions under this objective are: Does the EASEL Approach result in (1) improvements in
educators’ outcomes, namely teaching practices (e.g., quality of educator-child interactions,
instructional support provided by educator, behavior management); and (2) improvements in
children’s SEB+EF outcomes as secondary outcomes?.
The second objective of the trial is to explore how educators implement the EASEL
Approach within their classroom and identify factors that affect the implementation of the
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EASEL Approach. We hypothesize that with the implementation strategies proposed for the
trial (i.e., educator training, educator self-assessment of intention to use and self-efficacy, prac-
tice-based coaching, and data monitoring), the EASEL Approach will be adopted by educators,
implemented sustainably, and achieve its desired effects. Research questions under this objec-
tive include: (1) how do educators use the EASEL Approach in the classroom, including the
extent to which the EASEL Approach was integrated into educators’ daily practice (i.e., pene-
tration, fidelity); (2) how acceptable, feasible, and appropriate was the EASEL Approach for
the early education context in Singapore; (3) what factors were associated with effective imple-
mentation and which implementation strategies were required for good uptake and adoption
of the EASEL Approach; and (4) how sustainable is the EASEL Approach and how can it be
scaled to other childcare sites nationwide? This would include identifying further adaptations
or modifications required for the EASEL Approach to best meet the needs of early childhood
classrooms and educators in Singapore.
Methods and design
Study design
The effectiveness of the EASEL Approach and its implementation will be evaluated with a type
2 hybrid effectiveness-implementation study, using a non-blinded, parallel groups, cluster ran-
domized controlled design [16]. A type 2 hybrid study assesses both effectiveness outcomes
(e.g., educator’s teaching practices; children’s SEB+EF outcomes) and implementation out-
comes (e.g., fidelity; feasibility of the EASEL Approach), and is used when both the effective-
ness of the intervention and the effectiveness of implementation are not well-known and need
to be measured simultaneously. Specifically, four questions must be considered when selecting
a hybrid study type [17]. First, what is known about the effectiveness of the intervention of
interest? The EASEL Approach is rooted in the literature on effective classroom-based manua-
lized interventions. These interventions, however, have not yet been implemented or tested in
the Singapore context. Second, what is the extent to which an intervention needs to be
adapted? In this case, there are substantial cultural and procedural differences in schools that
could very well affect implementation and subsequent outcomes. EASEL’s common elements
approach to building a context-sensitive intervention allows for substantial adaptations to con-
text while still delivering the essential components common to existing interventions. Third,
what is the extent of knowledge about implementation determinants for the intervention in
the context of interest? From the literature, we know that training alone is insufficient in trans-
ferring newly learned skills into applied use and that other strategies, such as coaching, will
likely be required [18], thus suggesting a type 2 or 3 hybrid study. Finally, is the intervention
ready for a “real world" application of implementation strategies. With the EASEL Approach,
implementation strategies have been developed with relevant key partners, but we also need to
focus on establishing the effectiveness of the intervention. Therefore, a type 2 hybrid study is
recommended.
A cluster randomized controlled design allows for comparisons between childcare centers
implementing the EASEL Approach with those continuing with business as usual. The study
has been approved by the National University of Singapore (NUS) Institutional Review Board
(NUS-IRB-2021-993).
Procedure, setting, and participants
The sample for the EASEL trial will include 16 childcare centers in Singapore. Once recruited,
the centers will be randomized to the intervention group (eight centers) or control group
(eight centers) using a random number generator at a 50:50 allocation ratio. Due to the nature
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of the intervention, there will be no concealment once the assignment has been made. Educa-
tors working at childcare centers in the intervention group will be trained and provided with
ongoing coaching in the EASEL Approach. Those in the control group will continue with busi-
ness as usual. Control group educators will be offered the opportunity to receive training in
the EASEL Approach after the completion of the trial. After trial completion, primary caregiv-
ers of children in both intervention and control groups will receive a caregiver resource sheet
briefly describing how they can implement the EASEL practices at home in interactions with
their children.
We estimate that three classes in each childcare center will be eligible for the trial based on
the age of the children (levels N2 –the second year of nursery where children are aged three
years old at the start of the school year, K1 –the first year of kindergarten where children are
aged four years old at the beginning of the school year, and K2 –second year of kindergarten
where children are aged five years old at the start of the school year). In childcare centers with
more than one class at each level, classes will be randomly selected for inclusion in the trial.
We anticipate there will be approximately 15 children and one educator per class. The esti-
mated target sample of children in the trial will be 600–700, and the estimated target sample of
educators is 48 (one educator per class with at least one classroom per level in each childcare
site) (see Fig 1).
Eligibility criteria are as follows: (1) the childcare center provides full-day programming for
children at the N2, K1, and K2 levels (children aged three to five years old at the start of the
Fig 1. Illustration of sample for EASEL trial.
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school year); (2) the childcare center has at least one of each class level that can participate in
the EASEL trial; (3) the childcare center has close or equivalent to the national staff-to-child
regulatory ratio of 1:20 for N2 classes, 1:25 for K1 classes and 1:30 for K2 classes; (4) the child-
care center is not currently implementing other substantial interventions or involved in other
trials evaluating either educator or student-focused interventions; (5) the educators have com-
pleted at least a diploma in early childhood care and education; and (6) the educators teach in
English.
Recruitment.
The research team will partner with local government agencies to identify
and recruit early childhood center operators. In Singapore, large early childhood center opera-
tors can run and supervise multiple individual childcare centers. Once operators have expressed
interest in participating in the EASEL trial, they will be asked to provide signed letters of com-
mitment. Each operator will be asked to nominate several childcare centers participating in the
trial (e.g., two centers for smaller operators and four centers for larger operators). Individual
educators in nominated centers will be recruited–at least one educator per class level is required.
The research team will conduct a short introductory workshop at each center for leadership
staff and educators about the EASEL Approach and trial. All aspects of the research study will
be explained in these sessions, and written informed consent will be obtained from individual
educators at all sites, consistent with institutional review board protocols.
After the introductory workshop, the research team will provide childcare centers with an
email or letter to be sent out to primary caregivers of children in classrooms participating in
the trial. These documents will include an information sheet about the EASEL trial and a care-
giver consent form. If required, follow-up emails and phone calls will be used to remind care-
givers to complete their consent forms online if they wish to participate in the study.
Development of the EASEL Approach
The educator-led practices in the EASEL Approach have been systematically drawn from effec-
tive classroom interventions using a common elements approach. The common elements
approach offers an alternative way of synthesizing evidence for practice. It enables the design
of interventions that can be easily tailored to the needs of different sites, practitioners, and chil-
dren. Programs targeting the same outcome often consist of common core practices or tech-
niques across programs. Common elements are these individual practices or techniques
common across various programs that target a desired outcome and have demonstrated effec-
tiveness [17]. Identifying common elements found in effective programs facilitates the promo-
tion of a shared understanding of using evidence to improve SEB+EF outcomes in preschool
children amongst early childhood educators. The common elements approach has been
employed internationally in projects related to child protection, youth mental health, and early
childhood [18–21].
In the EASEL Approach, common elements for use by educators were identified in the liter-
ature across manualized programs with evidence of effectiveness. These common elements or
practices are used independently of the prescribed structure in many manualized programs,
making them more accessible and flexible to implement in diverse settings.
The research team completed two systematic reviews to identify Common Elements from
educator-led interventions to improve preschool children’s SEB and EF outcomes. We built
on McLeod et al.’s recent work [22] that identified educator-delivered practice elements to
improve SEB outcomes of young children in early childhood classrooms. We updated this sys-
tematic review and conducted a separate systematic review using the same methodology for
interventions targeting EF outcomes in preschool children to identify common elements for
the EASEL Approach. These common elements were identified from programs that have
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demonstrated effectiveness across multiple studies. A total of 25 common elements (referred
to as EASEL practices) were identified across both reviews.
To increase the feasibility of implementing the EASEL practices (e.g., considering educa-
tors’ time and resource constraints), a final list of nine EASEL practices was selected from the
complete list of 25. The nine practices were chosen as core fundamental practices that are: (1)
common across effective programs, (2) practices that expert stakeholders identified as ones for
which local early childhood educators may need additional training, and (3) practices that are
not already thoroughly covered in pre-service training to avoid replication for educators. Fur-
thermore, the nine EASEL practices were compiled to ensure a balance of standard practices
that local educators may already be implementing in their classrooms but can be enhanced
and new practices for which educators require additional training before using. Finally, the
nine EASEL practices were chosen to balance antecedent and consequential practices (i.e.,
practices that can be implemented before and after a target behavior) to ensure that educators
both anticipate and respond to target behaviors.
The final list of nine EASEL practices was selected through an initial review by an internal
team of experts with extensive experience in early childhood development and utilization of
common elements approaches. A series of focus group discussions were also conducted with
external experts in the early childhood education field (e.g., university lecturers of early child-
hood educators) to elicit their views on the terminology used in the EASEL Approach and
practices that should be prioritized amongst local early childhood educators. The final set of
practices to be implemented in the EASEL Approach is listed in Table 1, along with each prac-
tice’s target SEB+EF outcome(s). The Executive Function Playbook (EF Playbook), developed
by National University of Singapore, was used for one of the EASEL practices.
Practice Guides were written for each EASEL practice that identified the target behavior,
suggested ways to use the EASEL practice, and provided examples of when to implement the
practice in the classroom. The manual further includes information about how the EASEL
Approach fits within Singapore’s education frameworks: the NEL Framework and iTEACH
principles. More details about the development process of the EASEL Approach are reported
by Tan et al. [23].
Use of the EPIS framework
The EASEL trial will be guided by the EPIS (Explore, Prepare, Implement, Sustain) Frame-
work, an evidence-informed framework frequently used in program implementation and
Table 1. List of practices to be implemented in the EASEL trial.
EASEL practices
Outcomes targeted
S
E
B
EF
Active Listening
✓
✓
✓
✓
Rules & Routines
✓
✓
✓
✓
Constructive Feedback
✓
✓
Praise
✓
✓
✓
✓
Prompt, Wait Then Respond
✓
✓
✓
✓
Providing Choices
✓
✓
✓
✓
Encourage Child Ownership
✓
Games Promoting EF (EF Playbook)
✓
✓
Dramatic Play
✓
✓
S = social skills; E = emotional regulation; B = behaviors; EF = executive functioning
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evaluation [24]. The EPIS Framework considers the multilevel nature of service systems (e.g.,
the early childhood sector in Singapore), the organizations within the service systems (e.g.,
individual early childhood center operators in Singapore), and the ’client’ needs (e.g., the
needs of children and early childhood educators) when implementing a new program. It high-
lights four key phases that guide and describe the implementation process: Exploration, Prepa-
ration, Implementation, Sustainment (see Fig 2).
Research has shown that attention to implementation factors before, during, and after the
trial of a new practice leads to better implementation outcomes than if these factors were not
deliberately considered [25, 26]. The EPIS Framework will guide the implementation and eval-
uation of the EASEL trial. See Fig 3 for the application of EPIS to the implementation and eval-
uation of the EASEL Approach. Implementation strategies and activities related to the
evaluation trial are detailed under each of the four EPIS phases. Table 2 presents an implemen-
tation strategies matrix describing the implementation strategies for the EASEL Approach and
the corresponding study period, EPIS stage, and parties involved.
Phase 1: Exploration
The Exploration phase involves identifying the problem, developing appropriate and evi-
denced solutions, and considering factors that might impact implementation (e.g., acceptabil-
ity, feasibility, and appropriateness of the EASEL Approach). In this context, the problem is
the gap in educators’ skills to enhance children’s SEB+EF development, and the solution is the
EASEL Approach.
Stakeholder engagement.
Initial engagement meetings with community partners will be
held to gather input about the acceptability and feasibility of the EASEL Approach. These
Fig 2. EPIS framework [45].
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consultations will typically involve key government representatives, early childhood center
operators, childcare center leadership (e.g., principals), and educators. Regular meetings with
key stakeholders will occur throughout all trial phases.
Baseline assessment.
Baseline assessments for the trial will be conducted before randomi-
zation to ensure researchers are blind and naïve to the group condition. Outcome measures
are detailed in the section on data collection.
Phase 2: Preparation
The Preparation phase consists of a planning process with key stakeholders (e.g., relevant gov-
ernment agencies, early childhood center operators, and individual childcare centers) for
implementing the new program by adapting and contextualizing the EASEL implementation
plan with the Intervention Group childcare sites based on the information about feasibility
gathered from stakeholders in the Exploration Phase.
Processes for implementation and outcome data monitoring.
During this phase, the
research team will establish processes for data monitoring with individual childcare sites.
These processes will be incorporated into the local implementation plan for each childcare
center. Data on the quality of implementation will be used in the ongoing coaching of
Fig 3. Proposed flow of the rollout of the EASEL Approach and trial.
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Table 2. Implementation strategies matrix.
Implementation strategy applied
EPIS stage(s)
1. Educator training
Preparation
2. Educator self-assessment (e.g., intention to use, self-efficacy)
Preparation, Implementation
3. Practice-based coaching using observational data and educator self-assessment
Implementation
4. Implementation and outcome data monitoring for continual quality improvement
Implementation
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educators through the Implementation phase to stimulate reflection about barriers to imple-
mentation, and outcome data will be used to assess the effectiveness of the EASEL Approach.
Training.
All educators in the Intervention Group will receive training on the EASEL
Approach. The training will be designed and delivered by the research team. This will involve
a one-day in-person workshop for early childhood educators (format subject to negotiation
with the participating childcare providers). Supplementary resources will also be available to
educators online after the workshop for use throughout the trial and coaching sessions. These
materials will be freely accessible through an online learning management platform, Thinkific.
Phase 3: Implementation
When sufficient preparation has occurred, the Implementation phase commences (i.e., imple-
mentation of the EASEL Approach by educators in their classrooms). Factors affecting imple-
mentation include outer and inner contextual issues (e.g., resource availability, fit with
educators’ current practices, organizational culture, and attitudes) and consumer concerns
(e.g., the applicability of practices for educators and children’s needs).
Implementation of the EASEL Approach.
Early childhood educators will implement the
EASEL Approach in their daily teaching practice to all children in their classrooms. Imple-
mentation support will be provided during ongoing coaching sessions.
Practice-based coaching.
Ongoing practice-based coaching of early childhood educators
by CHILD coaches will occur throughout the EASEL trial. Although training can be helpful
for teaching new skills or practices, training alone is insufficient in transferring newly learned
skills into applied use [27]. Practice-based coaching bridges this gap between training and
embedding the new skills into business-as-usual. Practice-based coaching occurs within the
context of a collaborative partnership, with the cyclical approach generally involving: (1)
shared goals and action planning, (2) focused observations, and (3) reflection and feedback
[28]. Elek and Page [29] identified four critical features of effective coaching for early child-
hood educators through a comprehensive review of the literature. These features (i.e., observa-
tions, feedback, goal-setting, and reflection) will be incorporated into the practice-based
coaching provided by the CHILD research team.
Coaching in the EASEL trial may take the form of regular group discussions with educators;
a childcare center-based community of practice where educators at each site have a chance to
discuss issues with the implementation of the EASEL Approach with facilitation from the
research team; regular ’check-ins’ between the educator and a coach; a review of online
resources on Thinkific by the educator and a coach; and observation and feedback sessions
where the coach conducts real-time observations and provides immediate feedback to the edu-
cator. The specific frequency and nature of the coaching in the EASEL trial will be determined
after the training workshop through consultation with the childcare sites. The frequency of
coaching will be at least fortnightly. The approach to coaching will also depend on the ability
of the research team to enter childcare centers (based on prevailing COVID-related
restrictions).
Educator self-assessments.
At regular intervals through the trial, educators will be asked
to complete a short questionnaire to determine attitudes, perceived norms, intention to use
the EASEL Approach, and self-efficacy about adopting the EASEL Approach. It is well-estab-
lished that the strength of educators’ intentions and attitudes about a new program or practice
can influence the extent to which it is implemented [e.g., 30–33]. Educator self-assessments
during the EASEL trial will allow the research team to understand potential barriers and facili-
tators to each educator’s implementation of the EASEL Approach in their classrooms. The
self-assessment questionnaire will be completed at three timepoints: upon completion of the
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in-person training workshop, mid-intervention (6 months from the start of implementation),
and post-intervention (at the end of the school year, i.e., approximately 9 months from the
beginning of implementation). Measurement of self-assessment is described in more detail in
the Measurement section.
Implementation and outcome data monitoring.
The implementation of the EASEL
Approach will be tracked through monitoring data. In addition to administrative data already
being collected by childcare centers, this can include, but is not limited to, monitoring the fre-
quency of use (uptake), adherence to the approach (e.g., through educator self-report and
observational data by the research team) and the impact of the approach (e.g., outcome mea-
sures). Data monitoring will also include mid- and post-intervention assessments detailed in
the Measurement section. Data monitoring allows the research team to understand the adop-
tion and implementation of the EASEL Approach. Monitoring data can identify barriers and
challenges to implementation as they arise rather than waiting for the trial to finish before
addressing implementation issues [34].
Phase 4: Sustainment
When the new program is routinely used, the Sustainment phase can begin. This involves the
sustainment of the new program in the current setting and may also include scaling up to
other settings and systems, using the evidence and implementation insights gained from the
first three phases. Any further research or activity plans resulting from this work will be done
in collaboration with key stakeholders. Findings from the trial will be shared with participating
educators, and training on the EASEL approach will also be offered to educators in the Control
Group.
Data collection
A multilevel approach to measurement is necessary for our understanding of (1) the effective-
ness of the EASEL Approach, and (2) the implementation of the EASEL Approach. Effective-
ness outcomes of the EASEL Approach will be assessed at two data collection periods: baseline
(i.e., at the start of the school year) and after implementation (i.e., at the end of the school
year). Educator implementation outcomes will be assessed at three data collection periods:
immediately post-training, midway through implementation, and post-implementation (i.e.,
at the end of the school year). See Table 3 for details of the measurements of implementation
and effectiveness in the EASEL trial and Table 4 for more information on the assessments.
Assessing effectiveness.
Most of the following measures have not been validated or used
previously in Singapore but have often been evaluated elsewhere and were chosen due to their
capacity for assessing key outcomes in Singapore as well as their requirements for administra-
tion (e.g., response burden, cost, training requirements).
Early Childhood Classroom Observation Measure (ECCOM). Educators’ teaching practices
will be assessed on the ECCOM before training and post-intervention [35]. The ECCOM is an
observational assessment that involves a 3-hour classroom observation by a trained researcher.
Although the ECCOM has not previously been used or validated in Singapore, it has good face
validity with locally used observational measures of classroom quality. Furthermore, the
ECCOM is freely available and relatively easy to administer and code and thus can be factored
into later sustainment and scaling-up plans if appropriate. See Table 5 for domains and subdo-
mains of the ECCOM and EASEL practice(s) they map onto. The ECCOM subdomains of Lit-
eracy Instruction, Math Instruction, and Math Assessment will not be included because they
are not the EASEL Approach’s target outcomes.
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Researchers rate each domain on two dimensions: (1) child-centered practices and (2) edu-
cator-directed practices. Child-centered practices refer to educators’ use of practices that pro-
vide shared responsibility with the child for both classroom management and learning,
educators’ active guidance, and support of children’s learning efforts and their development.
When educators implement child-centered practices, they provide clear, developmentally
appropriate instructional goals that are balanced and integrated with the child’s initiative and
interests. A child-centered classroom environment is sensitive to and focused on children’s
needs and interests, but not to the extent that children have complete authority and control.
The second dimension of ’educator-directed practices’ refers to practices that are controlled
and directed to a large extent by the educator and focuses primarily on the acquisition of aca-
demic skills that the educator prioritizes. Rather than child-centered, an educator-directed
Table 3. Details of measurements and related outcomes in the EASEL trial.
Measure
Outcome
EPIS stage
Study period
Key stakeholders involved
Pre-
training
Post-
training
Mid-
intervention
Post-
intervention
Effectiveness
Early Childhood Classroom
Observation Measure
(ECCOM)
• Educators’ teaching
practices
Implementation
✓
✓
CHILD researcher
Child Self-Regulation &
Social Behaviour
Questionnaire (CSBQ)
• Child’s social-emotional
development
• Child’s behavior
• Child’s self-regulation
skills
Implementation
✓
✓
Educators
Behaviour Rating Inventory
of Executive Function–
Preschool (BRIEF-P)
• Child’s development
• Child’s executive
functioning
Implementation
✓
✓
Primary caregivers
The Singapore Whole Child
Panel
• Child’s pre-academic,
theory of mind, executive
functioning
Implementation
✓
Children, CHILD
researchers
Implementation
Educator self-assessments
• Acceptability
• Appropriateness
• Uptake/adoption
Preparation,
Implementation
✓
✓
✓
Educators
Observational assessments by
coaches (regularly)
• Uptake/adoption
• Fidelity
Implementation
✓
✓
✓
CHILD coaches, educators
Student engagement data on
Thinkific
• Uptake/adoption
Implementation
✓
✓
Educators
Focus Group Discussion
• Uptake/adoption
• Penetration
• Sustainability
Sustainment
✓
Centre leadership,
educators, key government
representatives
https://doi.org/10.1371/journal.pone.0291723.t003
Table 4. Time requirement for assessments in the EASEL trial.
Measure
Completed by
Duration
Researcher
Educator
Primary Caregiver
Educator self-assessment (of attitudes, perceived norms, intention to use, self-efficacy)
✓
5 min per educator
Observational assessment by coaches of EASEL practices
✓
3 hours per educator
Early Childhood Classroom Observation Measure (ECCOM)
✓
3 hours per class
The Singapore Whole Child Panel (WCP)
✓
20 mins per child
Child Self-Regulation & Social Behavior Questionnaire (CSBQ)
✓
5–7 mins per child
Behaviour Rating Inventory of Executive Function–Preschool (BRIEF-P)
✓
10–15 mins per child
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curriculum is based on the educators’ predetermined agenda. In educator-directed classrooms,
peer interactions are minimized, and educators are more likely to impose solutions when con-
flicts arise rather than try to problem-solve with the children.
Researchers rate each domain on the two dimensions using a 5-point scale (1 = practices
are rarely seen [<20% of the time], 2 = practices are not seen very much [20–40% of the time],
3 = practices are sometimes seen [40–60% of the time], 4 = practices are prominent [60–80%
of the time], 5 = practices are predominant [80–100% of the time]). Domain scores will be
averaged to generate a dimension score: Child-Centered Dimension Score and Educator-
Directed Dimension Score.
Training on the ECCOM will involve a 4-hour training session to introduce researchers to
the ECCOM dimensions and domains and general guidelines for observations and scoring. A
second training session will include viewing two 30-minute videos of early childhood class-
rooms, and researchers will be asked to code them independently during the session. Ratings
will be compared between coders, and discrepancies will be discussed. To be certified for reli-
ability in coding the ECCOM, researchers will conduct a 3-hour practice coding with a senior
coder in three early childhood classrooms that are not participating in the study. Ratings
within one point of the senior coder’s ratings reflect an acceptable degree of accuracy. During
the data collection period, one in four early childhood classrooms will be double-coded by a
senior coder with the same inter-rater reliability rules (i.e., a discrepancy of one point). If rat-
ings are discrepant (i.e., more than one point difference), the researcher and senior coder will
discuss to reach an agreement.
Child outcomes will be assessed through educator reports, caregiver reports, and assess-
ments by the research team.
Table 5. Mapping domains and subdomains of the ECCOM onto EASEL practices.
Domain
Subdomain
EASEL Practice(s) That Subdomain Maps Onto
Management
Child Responsibility
• Encourage Child Ownership
• Prompt, Wait Then Respond
(Classroom) Management
• Rules & Routines
Choices of Activities
• Providing Choices
Discipline Strategies
• Constructive Feedback
Climate
Support for Communication Skills
• Active Listening
• Prompt, Wait Then Respond
• Dramatic Play
Support for Interpersonal Skills
NA
Student Engagement
• Providing Choices
• Active Listening
Individualization of Learning Activities
• Praise
Educator Warmth/Responsiveness
• Active Listening
Instruction
Learning Standards
• Encourage Child Ownership
Coherence of Instructional Activities
• Games Promoting EF
• Dramatic Play
Teaching Concepts
Instructional Conversation
• Active Listening
• Prompt, Wait then Respond
Relevance of Activities to Children’s Experience
NA
Note. The scales for Literacy Instruction, Math Instruction and Math Assessment in the original ECCOM were excluded because these are not intended outcomes of the
EASEL Approach.
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Behavior Rating Inventory of Executive Functioning–Preschool version (BRIEF-P). To assess
children’s development and executive functioning, primary caregivers will be asked to complete
the BRIEF-P at baseline (i.e., before implementation) and post-intervention (i.e., at the end of
the school year) [36]. The BRIEF-P is a 63-item self-report questionnaire for primary caregivers
to indicate how often a child has had problems with various behaviors in the past six months
(0 = Never, 1 = Sometimes, 2 = Often). The BRIEF-P has been used to characterize children’s
EF in Singapore [37] and consists of the following indices: Inhibitory Self-Control Index, Flexi-
bility Index, Emergent Metacognition Index, and Global Executive Composite; and the follow-
ing domains: Inhibit, Shift, Emotional Control, Working Memory, Plan/Organize.
Child Self-Regulation and Behavior Questionnaire (CSBQ). To assess children’s social-emo-
tional development, behavior, and self-regulation skills, educators will be asked to complete
the CSBQ at baseline (i.e., before implementation) and post-intervention (i.e., at the end of the
school year) [38]. The CSBQ is a 34-item self-report questionnaire for educators to indicate
the option that best fits what each child is like (1 = Not True to 5 = Very True). Items on the
CSBQ cover the following domains: Self-regulation (cognitive, emotional, behavioral), Socia-
bility, Prosocial Behavior, Externalizing and Internalizing Behavior, and General Child
Development.
The Singapore Whole Child Panel (WCP) 2.2. Children’s EF will be screened at baseline
using the EF tasks in the WCP 2.2 [39]. The WCP has been validated in the local population
and developed with inputs from curriculum specialists in the education sector. This school
readiness screening assessment will only be administered to children at baseline (i.e., before
the implementation of the EASEL Approach). It will be used to discern which profiles of chil-
dren improve more from the EASEL Approach (e.g., children with poorer or better EF at
baseline).
The child will be brought to a quiet space in the childcare center, and the WCP 2.2 will be
administered by a researcher using tablets. The assessment takes approximately 10 minutes,
and the child will receive a small gift at the end of the administration.
Assessing implementation.
Educator self-assessments. Early childhood educators will be
asked to complete a short survey comprising four domains [30–33]: (1) their attitude toward
the EASEL practices, (2) perceived norms of the EASEL practices, (3) intention to use the
EASEL practices, and (4) self-efficacy with the EASEL practices. These four domains will be
completed for each of the nine practices in the EASEL Approach. The self-assessments will be
collected online by the research team. They will occur after completion of the training work-
shop (i.e., post-training), mid-intervention (i.e., 6 months), and post-intervention (i.e., end of
the school year). Shorter versions focusing on specific EASEL practices may be completed reg-
ularly to inform reflections and learnings in coaching sessions.
Observational assessments by coaches. To facilitate reflection and feedback in coaching ses-
sions, coaches will use a study-derived observational measure during regular classroom obser-
vations of early childhood educators’ teaching practices. This measure will provide data on
educators’ fidelity to the nine EASEL practices (i.e., how often the educator implements the
EASEL Approach in the classroom) and is rated on a 5-point scale (1 = practice is rarely seen,
<20% of the time to 5 = practice is predominant, 80–100% of the time) for each practice. This
measure is fully completed by coaches at three timepoints (i.e., baseline or first month of
coaching, mid-intervention and post-intervention) and will be used as a measure of EASEL
fidelity in the analyses.
Student engagement data on Thinkific. Data on the online learning management system,
which houses the supplementary resource for the EASEL Approach, Thinkific, will be collected
mid-intervention and post-intervention. These data allow us to assess the extent to which
these online resources were accessed and completed by educators.
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Focus group discussion (FGD). At the end of the Implementation phase, FGDs will be con-
ducted with groups of key stakeholders (e.g., center leadership and educators in the Interven-
tion Group) to discuss the uptake/adoption during the trial, barriers to implementation,
implementation strategies that helped prevent or resolve these barriers and sustainability (i.e.,
the usefulness of training and coaching for effective implementation of practices by educators)
and scaling-up of the EASEL Approach. FGDs will be facilitated by members of the research
team who were not involved in coaching educators.
Data analysis
Quantitative analysis.
Baseline data on effectiveness and implementation will be summa-
rized along with demographic characteristics with descriptive statistics. The minimum, maxi-
mum, mean, and standard deviation will be reported for continuous variables. For ordinal and
categorical variables, proportions will be reported. Between-group comparisons at baseline
will be made to verify whether the randomization process was effective. Descriptive statistics
for each subsequent timepoint will also be reported.
Intraclass correlations (ICCs) will be calculated for each outcome variable (i.e., educator
teaching practices, child social-emotional outcomes) with baseline variables measured at the
individual level by using childcare centre groupings as clustering variables to determine the
proportion of the total variance attributable to specific childcare centre classrooms.
Separate ANCOVA multilevel models will be used to assess individual educator and child
change scores between intervention and control groups while accounting for group member-
ship (i.e., educators nested within childcare centers; children nested within both classrooms
and childcare centers). Fixed or random effects models will be fit according to considerations
of sample size, number of independent variables, and heterogeneity of sample. Heterogeneity
of sample will be tested using either the Hausman or likelihood ratio test. We do not anticipate
having to adjust for many individual differences as this is an RCT. However, we will test for
baseline differences and, if such differences emerge, we will run sensitivity tests and adjust the
analyses accordingly (i.e., statistically adjust for individual differences related to the
outcomes).
Our primary outcomes will be educators’ child-centeredness and educator-directedness on
the ECCOM, and secondary outcomes will be children’s SEB+EF outcomes on the BRIEF-P
and CSBQ. EASEL fidelity from the classroom observational measure will be examined as a
continuous mediator in the multilevel models. All outcome variables are continuous. A signifi-
cance level of p = 0.05 will be used for all analyses.
Sample size and power. We drew on a meta-analysis by Luo and colleagues [40] to generate
estimated effect sizes they estimated on child social competence, emotional competence, and
challenging behaviors (g = 0.42, 0.33, -0.31, respectively) [40]. Anticipated ICCs were drawn
from findings on educators’ teaching behaviors reported in Landry et al. [41] and Flook et al.
[42]. Power analyses were conducted using Shiny CRT [43].
To achieve 80% power to detect a significant difference in educator teaching behaviors, a
sample size of at least five clusters (i.e., childcare sites of three educators per site) in each condi-
tion is needed (i.e., a total of 10 clusters with 30 educators), assuming ICC is at 0.25. To achieve
80% power to detect a significant difference in child social-emotional outcomes, a sample size
of at least two clusters (i.e., childcare sites of 45 children per site) in each condition is needed
(i.e., a total of four clusters with 180 children), assuming ICC is at 0.22.
Qualitative analysis.
A phenomenological approach will be used in the qualitative data
analysis. Thematic analysis of data collected from coaching session notes and FGDs will be
conducted using a priori codes. These codes will be based on domains of the EPIS framework,
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with particular focus on the Inner Context and Innovation Factors, and the linkages between
these factors. Thematic analysis will provide insight into potential barriers and facilitators to
implementing the EASEL approach and the usefulness of the implementation strategies
employed in the trial. Thematic analysis of the coaching notes will also provide insights about
the influence of coaching on the implementation of the EASEL approach.
Two independent researchers will use the a priori codes to analyze the same FGD transcript.
Coding will be discussed between the researchers to ensure consistency and to determine if
additional codes need to be added to the codebook. One researcher will then analyze the
remaining FGD transcripts and coaching notes. The second researcher will provide oversight
and decision-making support. All qualitative analysis will be managed in qualitative analysis
software (e.g., Dedoose). Using the coded data, both researchers will develop a thematic struc-
ture that focuses on the implementation of the EASEL Approach–barriers, facilitators, influ-
ence and effect of coaching, sustainment, and scalability.
Mixed methods analysis. The purpose of using mixed methods analysis in this study is
that of complementarity–quantitative data will be used primarily to evaluate effectiveness
while qualitative data will mainly be used to evaluate implementation of the EASEL Approach
[44]. In general, quantitative and qualitative data will be collected in parallel (i.e., outcome
measures and coaching notes), but the FGD with key stakeholders will be conducted at the
conclusion of the trial. Data will be connected–that is, quantitative and qualitative data will be
used to provide answers to related questions about the effectiveness and implementation of the
EASEL Approach. Mixed methods analysis will be used to provide a more in-depth under-
standing of the barriers and facilitators to the implementation of the EASEL Approach. For
example, quantitative outcomes using the ECCOM will be further explored using FGD data
and educator self-assessments to provide additional insights about why there were or were not
changes in the classroom environment after implementing the EASEL Approach. Child out-
come data, reported by educators, will be connected to FGD data and coaching notes to pro-
vide some explanations for why children have or have not shown a change in their SEB+EF
development.
Data storage and management
The research team at CHILD, which is housed at the Yong Loo Lin School of Medicine,
National University of Singapore, will oversee data management for this study with aid from
the Data Management Team at the Singapore Institute for Clinical Sciences. Data will be
stored on a database run from a locally hosted, secure server accessible only to CHILD
researchers. As much as possible, data collection will be completed electronically and stored
directly on the server. Where paper documents are used, data will be entered into the database
after collection. The paper documents will be filed in a secure storage cabinet per guidelines
from the Institutional Review Board. Focus group discussions will be recorded and tran-
scribed. All audio recordings will be stored on the secure server and destroyed after data
analysis.
All child and educator participants will be assigned a unique identifier. Identifiable infor-
mation (e.g., name, contact details) will be stored separately and with highly secure and
restricted access.
Dissemination plan
Following the completion of the study, EASEL training materials and resources will be revised
based on feedback from key stakeholders throughout the trial. The revised materials and
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resources will be made freely accessible via an online platform to all early childhood educators
in Singapore.
The research team will also take responsibility for the following activities in support of pub-
lic dissemination: (1) register the awarded study with clinicaltrials.gov within 21 calendar days
of the enrolment of the first participant, (2) submit the study’s final results to clinicaltrials.gov
within one year of the study’s primary completion date, (3) disseminate the study results in
peer-reviewed scientific journals, and abstract presentations at scientific conferences that are
appropriate to the content of the study, (4) develop a community-centered fact sheet detailing
the EASEL Approach and summarizing the key findings from the trial, and (5) present the
study findings to local key stakeholders including but not limited to the Early Childhood
Development Agency (ECDA), Ministry of Education (MOE) and National Institute of Early
Childhood Development (NIEC).
Discussion
The EASEL Approach will be evaluated using a cluster randomized controlled trial utilizing a
type 2 hybrid effectiveness-implementation study. If the EASEL Approach is found to be suc-
cessful, it can enhance Singapore’s early childhood sector and equips educators to better sup-
port children in Singapore to gain the skills they need to succeed later in life. The first aim of
the trial is to test the effectiveness of the EASEL Approach, a universal classroom-based
approach, in enhancing educators’ practices. The second aim of the trial is to understand how
educators implement the EASEL Approach within their classrooms and the factors that affect
implementation. At the end of this trial, we will have sufficient data to understand whether
this approach is beneficial to the early childhood sector in Singapore and the barriers and facil-
itators for its implementation.
This study has significant potential benefits to the scientific community and communities
of early childhood educators and preschool children. It is one of the first studies to use a com-
mon elements approach to develop an intervention for early childhood educators and the first
to utilize a hybrid study to examine both the effectiveness and implementation of such an
intervention. Findings from this study can inform the development of future interventions of
this nature and enhance the professional development of early childhood educators, providing
educators with the necessary skills and practices to promote children’s development.
Supporting information
S1 Checklist. SPIRIT 2013 checklist: Recommended items to address in a clinical trial pro-
tocol and related documents*.
(DOC)
S1 Fig. SPIRIT schedule of enrolment, interventions, and assessments.
(DOC)
Acknowledgments
We would like to acknowledge the significant contributions of the teams from the Early Child-
hood Development Agency (ECDA) for their advice and suggestions for the design for this
trial.
Date and protocol version identifier: 27th July 2023 Version 1.1
Protocol amendments: Important amendments to the trial protocol will be communicated
to investigators, NUS IRB, ClinicalTrails.gov registry and journal that the protocol is published
in.
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Author Contributions
Conceptualization: Evelyn S. Tan, Bryce D. McLeod, Robyn A. Mildon, Cheryl K. F. Seah,
Esther Goh, Gayatri Kembhavi.
Methodology: Evelyn S. Tan, Bryce D. McLeod, Robyn A. Mildon, Aron Shlonsky, Cheryl K.
F. Seah, Keri McCrickerd, Esther Goh, Gayatri Kembhavi.
Project administration: Evelyn S. Tan.
Supervision: Bryce D. McLeod.
Writing – original draft: Evelyn S. Tan, Bryce D. McLeod, Gayatri Kembhavi.
Writing – review & editing: Evelyn S. Tan, Bryce D. McLeod, Robyn A. Mildon, Aron
Shlonsky, Cheryl K. F. Seah, Keri McCrickerd, Esther Goh, Gayatri Kembhavi.
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