Child-care self-assessment to improve physical activity, oral health and nutrition for 2- to 4-year-olds: a feasibility cluster RCT
Authors: Kipping Ruth , Langford Rebecca , Brockman Rowan , Wells Sian , Metcalfe Chris , Papadaki Angeliki , White James , Hollingworth William , Moore Laurence , Ward Dianne , Campbell Rona , Kadir Bryar , Tinner Laura , Er Vanessa , Dias Kaiseree , Busse Heide , Collingwood Jane , Nicholson Alexandra , Johnson Laura , Jago Russell 
Published: July 2019

Background
The Nutrition And Physical Activity Self Assessment for Child Care (NAP SACC) intervention has shown evidence of effectiveness in the USA but not been adapted or assessed for effectiveness in the UK.

Objectives
To evaluate the feasibility and acceptability of implementing NAP SACC in the UK.

Design
Adaptation and development of NAP SACC and feasibility cluster randomised controlled trial (RCT) including process and economic evaluations. Substudies assessed mediator questionnaire test–retest reliability and feasibility of food photography methods.

Setting
Nurseries, staff and parents in North Somerset, Cardiff, Gloucestershire and Bristol.

Participants
Development – 15 early years/public health staff and health visitors, 12 nursery managers and 31 parents. RCT – 12 nurseries and 31 staff, four partners and 168 children/parents. Mediator substudy – 82 parents and 69 nursery staff. Food photography substudy – four nurseries, 18 staff and 51 children.

Intervention
NAP SACC UK partners supported nurseries to review policies and practices and set goals to improve nutrition, oral health and physical activity (PA) over 5 months. Two workshops were delivered to nursery staff by local experts. A home component [website, short message service (SMS) and e-mails] supported parents. The control arm continued with usual practice.

Main outcome measures
Feasibility and acceptability of the intervention and methods according to prespecified criteria.

Data sources
Qualitative data to adapt the intervention. Measurements with children, parents and staff at baseline and post intervention (8–10 months after baseline). Interviews with nursery managers, staff, parents and NAP SACC UK partners; observations of training, workshops and meetings. Nursery environment observation, nursery Review and Reflect score, and resource log. Child height and weight, accelerometer-determined PA and sedentary time, screen time and dietary outcomes using the Child and Diet Evaluation Tool. Staff and parent questionnaires of knowledge, motivation and self-efficacy. Child quality of life and nursery, family and health-care costs. Food photography of everything consumed by individual children and staff questionnaire to assess acceptability.

Results
Thirty-two per cent (12/38) of nurseries and 35.3% (168/476) of children were recruited; no nurseries withdrew. The intervention was delivered in five out of six nurseries, with high levels of fidelity and acceptability. Partners found it feasible but had concerns about workload. The child loss to follow-up rate was 14.2%. There was suggestion of promise in intervention compared with control nurseries post intervention for snacks, screen time, proportion overweight or obese and accelerometer-measured total PA and moderate to vigorous PA. Many parental and nursery knowledge and motivation mediators improved. The average cost of delivering the intervention was £1184 per nursery excluding partner training, and the average cost per child was £27. Fourteen per cent of parents used the home component and the mediator questionnaire had good internal consistency and test–retest reliability. Photography of food was acceptable and feasible.

Limitations
Following nursery leavers was difficult. Accelerometer data, diet data and environmental assessment would have been more reliable with 2 days of data.

Conclusions
The NAP SACC UK intervention and methods were found to be feasible and acceptable to participants, except for the home component. There was sufficient suggestion of promise to justify a definitive trial.

Future work
A multicentre cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of NAP SACC UK has been funded by NIHR and will start in July 2019 (PHR NIHR 127551).

Trial registration
Current Controlled Trials ISRCTN16287377.

Funding
This project was funded by the National Institute for Health Research (NIHR) Public Health
Research programme and will be published in full in Public Health
Research; Vol. 7, No. 13. See the NIHR Journals Library website
for further project information. Funding was also provided by the North
Somerset and Gloucestershire Councils, Development and Evaluation of Complex
Interventions for Public Health Improvement (DECIPHer) (MR/KO232331/1), and
the Elizabeth Blackwell Institute.