Feasibility cluster randomised controlled trial phase 2: results

In this section of the report, we describe the nursery and child recruitment rates at baseline and retention (which relate to progression criteria 1a, 3a, 3c, 3d; see Chapter 4, Progression criteria, for the full criteria) and the characteristics of the nurseries and children participating in the study. The findings related to the other progression criteria are presented in Chapter 7, Process evaluation, where the process evaluation is presented. We report the quantitative data analyses examining the secondary outcomes and mediators, followed by the pilot health economic and quality-of-life outcome measures.

Recruitment, retention and participant characteristics

Figure 4 summarises participation in the feasibility trial, with reasons for withdrawal from the study following the Consolidated Standards of Reporting Trials (CONSORT) guidance. Of the 14 nurseries approached in North Somerset, six (42.9%) gave consent to take part in the study. In Gloucestershire, of the 24 approached, six (25.0%) consented to participate, giving an overall consent rate of 31.6%. No large nurseries in the highest deprivation group were recruited in Gloucestershire. At least one nursery was recruited in each of the other five groups. Reasons for declining to take part included being too busy, staffing issues, financial issues and feeling that they did not need the intervention. No nurseries were lost to follow-up.

FIGURE 4 The Consolidated Standards of Reporting Trials (CONSORT) flow diagram. (Figure not reproduced here; see the original article.)

There were estimated to be 476 children potentially eligible to take part in the study. Of the 221 potentially eligible children in North Somerset, 97 (43.9%) parents provided consent for their child to take part in the measurements and 80 (31.4%) out of 255 potentially eligible children in Gloucestershire were given consent. The parental consent for all children was 37.2%. The 177 consented children were invited to take part in baseline data collection; one (0.6%) child’s consent was withdrawn by the parents prior to data collection commencing. A total of 175 out of the 176 remaining children provided some baseline data (99.4%) (one child was absent from nursery and parents did not complete baseline parental questionnaire). A further eight (4.5%) children were removed because they were ineligible, leaving 167 out of 168 children with data in the baseline analysis.

At the follow-up data collection, 147 (87.5%) out of 168 children at baseline participated in data collection. Two (1.2%) children had consent withdrawn, two (1.2%) refused to participate in measurements and their parents did not return follow-up questionnaires, eight (4.8%) moved nursery and nine (5.4%) moved to primary school and did not take up the offer to continue participation. Out of the 476 potentially eligible children at baseline, 147 (30.9%) children provided data at baseline and follow-up. This comprised 66 children in the intervention arm and 81 children in the control arm. Sending a link to the parental questionnaire by e-mail to a subgroup of parents at follow-up yielded a completion rate of 28% with 87% for those parents sent the questionnaire by post at follow-up. In the pilot of collecting weekend food and drink consumption CADET data from parents in two nurseries, 51.6% of parents returned the paper copy. For the parents in the two nurseries where data were collected over the telephone, the research staff had difficulty reaching the parents/carers even after four attempts at phoning.

The completeness of data by item for nurseries, children and parents is shown in Table 8 and the characteristics of nurseries, children and parents by study arm at baseline are shown in Table 9.

Outcomes

Physical activity and sedentary time

The number of children who met the criteria of ≥ 480 minutes per day of accelerometer wear time is shown in Appendix 4, Table 31. The results of complete-case PA and sedentary time are presented in Table 10. The mean minutes of activity per day was 152 and 148 minutes in the intervention and control arms, respectively. This highlighted that, on average, children did not meet the Chief Medical Officer’s recommended 180-minute daily activity guideline.7 The data show suggestion of promise for the intervention increasing MVPA on nursery days in the intervention arm (24.0–32.5 minutes) compared with the control arm (21.6–24.4 minutes) and total activity (151.6–172.1 minutes in the intervention arm vs. 148.1–154.2 minutes in the control arm); differences between arms were not seen on non-nursery days. Some caution is required in interpreting these data because not all children had valid wear-time data.

Anthropometric

Results of complete-case zBMI are presented in Table 11. The proportions of children in each arm of the study at baseline and follow-up who were overweight and obese are given, as determined by the UK1990 age and gender reference charts84 at 85% and 95% centiles and International Obesity Task Force (IOTF) reference points.85 There were some differences at baseline, with children in the control arm being taller (97.2 cm in the control arm; 95.3 cm in the intervention arm) being heavier (15.9 kg in the control arm; 15.1 kg in the intervention arm) and having a greater zBMI (0.46 in the control arm; 0.39 in the intervention arm). There was also a lower proportion of overweight and obese children in the control arm by both measures (23.2% UK1990 and 19.6% IOTF in the control arm; 31.7% UK1990 and 26.8% IOTF in the intervention arm) and there were more obese children by the UK1990 measure (10.7% in the control arm; 7.3% in the intervention arm). At follow-up, the mean height and weight increased in both arms, with a greater increase in zBMI in the intervention arm (0.46 to 0.29 in the control arm; 0.39 to 0.49 in the intervention arm). The proportion overweight or obese decreased in both arms by both measures (23.2% to 19.6% UK1990 in the control arm and 31.7% to 24.4% UK1990 in the intervention arm; 19.6% to 12.5% IOTF in the control arm and 26.8% to 17.1% IOTF in the intervention arm) except IOTF obesity, which increased in the control arm (1.8% to 3.6%). However, because the numbers are small, these differences in proportion should be considered with caution.

Diet

The proportions of children who consumed two or more main meals at nursery (control, n = 18; intervention, n = 30) and adhered to the NAP SACC UK Nutrition Best Practice Standards are shown in Table 12. Overall, there was good adherence to the standards, where the average scores at follow-up were 6.9 and 6.4 out of 9.0 in the control and intervention arms, respectively. There was little difference between the two arms post intervention. However, the proportion of children who met the recommendation for starchy foods (three per day) was higher in the intervention arm than in the control arm. Conversely, a smaller proportion of children in the intervention arm consumed a portion of fruit and a portion of vegetables at each meal. Nevertheless, children in the intervention arm appeared more likely to consume a variety (four types) of fruit and vegetables over the course of the day. In both arms, the proportion of children who did not eat processed meat or fish products was relatively low (≤ 60%).

The diet quality of children who consumed one main meal (control, n = 27; intervention, n = 14) was generally good (Table 13). There were differences between the arms for the average NAP SACC UK Nutrition Best Practice Standard scores at follow-up (6.6 vs. 5.1 out of 8.0 in the control and intervention arms, respectively). In both arms, < 40% of the children met the standard regarding one portion of fruit and one portion of vegetables.

Tables 14 and 15 show the proportion of children who met the NAP SACC UK Nutrition Best Practice Standards for snacks. There was high adherence to the standards for children who had one or two snacks at nursery. Among children who had two snacks, the average NAP SACC UK Nutrition Best Practice Standard scores at follow-up were 3.7 and 4.4 out of 5.0 in the control and intervention arms, respectively. There was suggestion of promise that the mean score in the intervention arm was higher than in the control arm. A higher proportion of children in the intervention arm met the standards regarding starchy food, fruit and vegetables, and high-sugar or high-fat snacks than did those the control arm. Among children who had one snack only, the average NAP SACC UK Nutrition Best Practice Standards score was also higher in the intervention arm.

Screen-viewing and sedentary activities

Parents reported their child’s time spent screen-viewing across a range of screen devices and in quiet play before and after nursery and on Saturdays. Table 16 shows that in the intervention arm from baseline to follow-up, fewer children watched TV or took part in sedentary activities for between 1 and 2 or ≥ 2 hours on nursery days, in contrast with the control arm where more children did. Fewer children in the intervention arm watched TV or engaged with sedentary activities for > 2 hours on a Saturday and there was no change or an increase in the control arm for each.

Environment and Policy Assessment and Observation

The EPAO total score and subscale scores were scored from zero to three. The mean EPAO scores for the total, subscores of nutrition and PA and subheadings are shown in Table 17. At baseline the total score and all subscores (with the exception of beverages provided and feeding environment) were scored slightly higher in the control nurseries. The lowest recorded subscore was in nutrition education and professionalism in intervention and control nurseries and the highest subscores were beverages, oral health and screen time. At follow-up, there were overall small decreases in subscores in the control arm and a combination of increases and some decreases in the intervention arm. The greatest change was recorded to be in oral health in the intervention arm.

Review and Reflect

The six intervention nursery managers completed the Review and Reflect 80 questions, where they self-rated themselves on a scale from one to four, with one being the lowest level of acceptable practice and four being best practice. Table 18 shows the self-reported data for the three nurseries whose managers returned the completed Review and Reflect forms at baseline and follow-up. The reported nutrition summary score was higher than any of the PA, outdoor play or screen scores. The oral health and policies were the lowest scored sections of the Review and Reflect. The self-reported scores increased from baseline to follow-up in all four summary scores with an overall improvement of 9% and mean difference of 0.26 (95% CI –0.15 to 0.67).

Mediators

The mediators identified in the logic model were assessed by parents and nursery staff completing questionnaires that assessed motivation, self-efficacy and knowledge across the domains of nutrition and PA, with each question having a five point rating of agreement. Table 19 shows the parental mediators and Table 20 shows the nursery staff mediators at baseline and follow-up by study arm. In the intervention arm, there were small increases from baseline to follow-up in all parental mediator measures except PA knowledge. In the control arm, there were small increases in all parental PA mediators and decreases or no meaningful change in any of the parental nutrition mediators. In the intervention arm, there were small increases from baseline to follow-up in all nursery staff mediator measures, except no change in nutrition self-efficacy. In the control arm, there were decreases in all nursery mediators, except for a small increase in PA self-efficacy.

Data linkage

Parents (n = 138) were asked at the end of data collection to give consent (in principle) for data linkage to the NCMP66 height and weight data (which is collected in primary schools in Reception and Year 6). Fifty-six (41%) parents returned the consent form and 51 (91%) of these gave consent for data linkage and four (7%) declined; therefore, 37% of all invited parents gave consent. This study did not intend to undertake data linkage because of the timescales.

Health economics

Intervention costs

The costs associated with the health visitors’ training were £1355.71 (see Appendix 7, Table 34). Health visitors travelled from North Somerset and Gloucestershire to Bristol for this training. The total cost of the workshop delivery in nurseries, including trainers’ time, refreshments, equipment and administration was £4372.83. Workshop costs only varied in terms of travel expenses, but nursery 12 participated in part of the intervention only, so the costs for this nursery were less (see Appendix 7, Table 35). The reported time of the health visitors’ attendance at each of the nurseries, attendance at the workshops, their preparation time and travel costs for each nursery are shown in Appendix 7, Table 36. Again, nursery 12 did not undertake the whole intervention, so the health visitor only attended this nursery for 2.5 hours. The total cost of the health visitors delivering the intervention and workshop attendance was £2181.13.

The mean (SD) cost incurred by each nursery of the intervention delivery was £717.22 (£260.05) (Table 21). The mean (SD) cost of health visitor intervention delivery, including workshop delivery, per nursery was £1092.32 (£197.90). The NAP SACC UK at Home element cost £11,946.95 (see Appendix 7, Table 37), but this was not included in the cost–consequence table as this was a one-off cost and NAP SACC UK at Home will not be continued.

Health-related quality of life

A total of 124 parents (72.1%) completed the questionnaire about the child’s quality of life, expenditure on food and PA and child health-care use at baseline. A total of 86 parents (50%) completed the questionnaire at follow-up. The complete case for HRQoL analysis was 77 (44.8%). Parents reported few problems with their child’s HRQoL, the median score for the physical health, social health and nursery health domains being between 90 and 100. There were minimal changes in domain scores between baseline and follow-up for children in both the intervention and the control nurseries (Table 22). There was no change in the total score for intervention nurseries. The mean difference (SD) for the total score at follow-up was 0.41 (7.39) for the intervention arms and –1.67 (8.58) for the control arms (see Table 21).

Food and physical activity costs

There was a small increase in self-reported family food expenditure between baseline and follow-up in both the intervention and the control arms (Table 23). This increase may be the result of inflation. Total weekly expenditure in both arms at follow-up was approximately £110 with large variances in expenditure between families. Some of the variance may be attributed to household size. Most expenditure was spent on supermarket food. More than 90% of parents stated that their reported spending on food and drink in the last week/month was typical at baseline and follow-up.

There was a small increase in weekly PA expenditure for parents in both the intervention and the control nurseries (Table 24). The mean (SD) increase at follow-up was £4.47 (£12.91) for the intervention arm and £4.73 (£28.00) for the control arm. Total time spent by parents on their child’s weekly PA including travel and waiting time also increased for both the intervention and the control nurseries. Baseline data collection occurred in autumn/winter and follow-up data collection in July, which may have had an impact on these results.

Child health-care use

Parents reported infrequent health-care use at baseline and follow-up (Table 25). There were small changes in total (SD) monthly child health-care costs from baseline to follow-up in intervention nursery children [£6.59 (£112.91)] and control nursery children [–£8.13 (£41.22)] (see Table 25). Parents in intervention and control arms reported < 1 day of time off work due to illness of their child at follow-up (see Appendix 7, Table 38).

Process evaluation

Data collected

Non-participant observations of both PA and nutrition nursery workshops were conducted in five out of the six intervention nurseries. Nursery 12 did not fully implement the intervention and, therefore, did not hold any workshops. Observations of NAP SACC UK partner/nursery manager meetings were conducted in the five intervention nurseries implementing the intervention. One observation (nursery 3) was of an initial meeting between the NAP SACC UK partner and the nursery manager and focused on discussing the Review and Reflect form. The remaining four meetings were of subsequent meetings between the NAP SACC UK partner and the nursery manager, and focused on reviewing progress made, changes implemented and outstanding actions.

Interviews were conducted with all NAP SACC UK partners and all managers in both intervention and control nurseries. Interviews with nursery staff members were conducted in four of the six intervention nurseries: nursery 12 did not implement the intervention and, therefore, no interview was carried out; one staff member (from nursery five) declined to be interviewed. We did not interview staff members in control nurseries. We aimed to interview 20 parents with invitations sent out by post. In total, 97 invitations were sent and 20 parents [intervention, n = 10; control, n = 10 (all mothers)] agreed to be interviewed (21% response rate). Interviews with NAP SACC UK partners and nursery managers lasted approximately 1 hour. Interviews with nursery staff were shorter (between 30 minutes and 1 hour) and interviews with parents were between 15 and 30 minutes.

Three NAP SACC UK partners returned completed logs documenting the interactions with nurseries. One partner did not return a log as her assigned nursery (12) did not fully implement the intervention. Baseline Review and Reflect forms were completed for four intervention nurseries: two nurseries (9 and 12) did not return their forms. Follow-up Review and Reflect forms were available for four nurseries: one form was not returned (nursery three) and one did not fully implement the intervention (nursery 12) and, therefore, did not complete the follow-up form.

Documents outlining the agreed goals set for each intervention nursery were available for the five nurseries implementing the intervention.

Progression criteria 1: feasibility

This section of the process evaluation aims to answer the following question: was it feasible to implement the NAP SACC UK intervention in child-care providers? Overall, the NAP SACC UK intervention was implemented with good fidelity (Table 26), with two exceptions. First, the parent website was not well used. Second, one intervention nursery (nursery 12) did not fully implement the intervention (but participated in data collection).

NAP SACC UK partner training

The training session for three NAP SACC UK partners was held in December 2015. This half-day session included an overview of the NAP SACC UK research study and training on how to support nurseries to improve nutrition, PA and oral health. Training was provided by local topic experts: a senior early years nutrition specialist, an independent PA trainer and an oral health promotion specialist. NAP SACC UK partners were provided with a resource pack containing relevant national guidance on nutrition, PA and oral health and copies of relevant study documents (e.g. Review and Reflect tool and resource log). One NAP SACC UK partner (Partner_Int_21) was unable to attend this training session and received a one-to-one session with Ruth Kipping in January 2016, providing her with the same information and documentation.

A second ‘top-up’ training session for NAP SACC UK partners was held in May 2016 to assess the nurseries’ progress and identify any problems or need for additional support. It was attended by three of the four NAP SACC UK partners, as well as the trial principal investigator, the trial manager and the nutrition, PA and oral health trainers.

Nursery staff workshops

Two workshops for nursery staff (focusing on PA and nutrition) were held in five out of the six intervention nurseries between March and April 2016. Nursery 12 did not fully implement the intervention and, therefore, did not implement any workshops. However, a 20-minute one-to-one session was conducted between the nutrition facilitator and the nursery’s cook on 14 April 2016.

The workshops were held either on a Saturday morning (n = 3) or on a workday evening (after the nursery had closed, n = 8), according to nursery preference. Workshops lasted between 2 and 3 hours (mean = 2 hours and 35 minutes) and refreshments were provided.

The PA workshops were all facilitated by the same person, an independent PA partner. The nutrition workshops were delivered by two different facilitators: a senior early years nutrition specialist (two workshops) and an early years health improvement specialist (three workshops). Both nutrition facilitators work in local authority public health teams, but were employed directly by NAP SACC UK to deliver the workshops.

The workshop facilitators used a variety of activities to engage nursery staff, including Microsoft PowerPoint^® (Microsoft Corporation, Redmond, WA, USA) presentations, group discussions, quizzes, food props and games. Observations of workshops described all three facilitators as highly enthusiastic and engaging. Information was delivered in a straightforward and uncomplicated way and was pitched at the right level to keep the staff engaged. As one partner described:

[the workshop] was very hands on . . . a really good way to tap into people’s skill levels really. People had a laugh, they were relaxed.

The workshop observers noted facilitators adapted the content of the workshop to the needs and interests of the nurseries, for example by considering how the physical spaces available to the nurseries could be best used to promote PA.

Review and Reflect

Review and Reflect forms were completed in all six intervention nurseries. It was intended that the nursery manager would fill in the Review and Reflect form in advance (in collaboration with other staff, when necessary) and then discuss it with the NAP SACC UK partner during their initial meeting; however, it is only clear that this happened in two nurseries (nurseries 1 and 3). The NAP SACC UK partner assigned to nurseries 8 and 9 said that neither manager had filled in the Review and Reflect form before their initial meeting because ‘they just didn’t have time’ (Partner_Int_14), although this contradicts interview data from the manager of nursery 8. It is unclear what happened in the two remaining nurseries (5 and 12). Most interviewees did not comment on the benefits of filling in the form independently or with the NAP SACC UK partner. However, one partner (Partner_Int_14) noted that although it ‘slowed us down’, completing the form together generated more conversation and ‘made it easier for me to work with them to set the goals’.

Nursery goal-setting

Goals were set in five out of the six nurseries. Nurseries were asked to set three nutrition and three PA goals, and two additional goals that could relate to nutrition, PA or oral health, according to their own priorities. As described in the phase 1 results, oral health was a novel element of the UK NAP SACC UK study added because of formative research in stage 1 of the study. However, to ensure comparability with the US version of the NAP SACC UK study, the research team specified that only a maximum of two goals could focus on oral health. Three nurseries set eight goals and two nurseries set seven goals.

There was some confusion as to when goals were meant to be set (either before or after the workshops). Although it was intended that nurseries would set specific goals during the workshops, this did not happen in any nursery. This did not appear to be because they ran out of time, and several workshops ran for less than the scheduled 3 hours. In four nurseries (1, 5, 8 and 9), goals were set during manager–partner meetings, with the workshops happening afterwards. In the fifth nursery (3) the Review and Reflect form and goal-setting were completed after the workshops because of scheduling problems.

Two partners (Partner_Int_14 and Partner_Int_25) felt that the nurseries should have completed the workshops first and then set their goals. This would have meant that they were ‘a bit more equipped with the knowledge’ to be able to identify suitable goals (Partner_Int_14), with the other partner adding ‘it’s difficult for them to know what they want to change when they’ve not done the workshops’ (Partner_Int_25). However, one partner noted that it was important to ensure that the Review and Reflect form (if not the goal-setting) was complete before the workshops to prevent managers providing biased answers. This view was confirmed by the manager at nursery 3 (where the Review and Reflect form was completed after the workshops):

I feel my judgement was hindered slightly because I already had the knowledge of the [workshops] in my brain when I done the Review and Reflect score . . . so I was maybe slightly semi-biased when I done it . . . Saying I was maybe slightly better than what we were.

Examples of the types of nutrition goals set included staff role modelling positive eating behaviours, asking children ‘are you still hungry?’ rather than ‘do you want some more?’, changes to menus (e.g. providing more varied breakfast foods, removing biscuits as snacks or increasing oily fish portions), increasing heathy eating activities offered and providing information on healthy eating to parents. PA goals included developing a nursery PA policy, providing more active stories and games, staff role modelling of PA and providing information to parents on PA. Three nurseries (1, 5 and 8) also included specific goals on promoting oral health through nursery activities and dental visits.

Specific goals set by each nursery and progress made, are set out in Appendix 8, Table 42. Progress was made on most goals, in part because many were relatively simple to implement. For example, many menu changes (e.g. offering fruit at breakfast or removing biscuits as snacks) were quick and easy to achieve. Interview data also suggested that goals requiring behavioural change (e.g. adult’s role modelling more PA or asking children if they were still hungry) had also been implemented.

Although some managers noted some initial resistance or scepticism from staff about behavioural changes, all explained that this resistance had been overcome. For example, staff in one nursery did not believe that the portion sizes (which had been revised in light of the NAP SACC UK nutrition workshop) were correct. However, the manager discussed the guidance with the staff and explained that ‘the fact that obesity is so high, this is the reason why, because it’s down to us overfeeding them’. She continued, ‘it took a little while for some staff to come round but we’re kind of getting there now which is good’ (Manager_Int_1). Similarly, the manager and deputy manager at one nursery noted how staff seemed daunted by the idea of ensuring three hours of PA every day, but worked with the staff to find ways to achieve this:

So it was, you know, ‘Go and research it,’ or, ‘We’ll try and give you ideas’ . . . Or they might come back and say, ‘Well, I can’t do this for this.’ We’ll have a look at it, ‘Well actually you can,’ or, ‘Actually, no, you’re right. You can’t. Let’s have a look at doing it a different way’.

Some goals had not yet been achieved; these tended to be those which required more time and effort, particularly on the part of the nursery manager (e.g. writing new nursery policies). For example, managers at nurseries 1 and 5 had not yet written their nutrition and/or PA policies.

On-going support

Intervention nurseries were offered support from NAP SACC UK partners in order to discuss their Review and Reflect forms, set goals and support the nursery manager and staff in making the specified changes. Support was provided via e-mails, telephone calls or further face-to-face meetings. The details of this support were collated from the NAP SACC UK partner logs and are summarised in Appendix 8, Table 39.

Initial partner–manager meetings took place face to face on nursery premises and all lasted > 2 hours. Of the five nurseries implementing the intervention, all had at least one further face-to-face meeting with their NAP SACC UK partner to review progress made. Additional support was offered via e-mails and telephone calls, although some of these telephone calls were to set up subsequent face-to-face meetings rather than offering substantive support. NAP SACC UK partners described using e-mails and telephone calls to pass on relevant information to nurseries (e.g. about National Smiles Month, Partner_Int_21) or to check on progress and offer general support and encouragement.

Parent website

A summary of the use of the NAP SACC UK website is shown in Appendix 8, Table 40. The website was promoted to parents at the six intervention nurseries with a free child’s mug featuring the website address, a flyer and a parent information sheet. All intervention parents with an e-mail address were e-mailed with a link to the website and a parent newsletter including a link to the website was sent out 1 month later. Parents were offered a free family swimming voucher at the local authority’s swimming pools as an incentive, if they completed the ‘Healthy Habits’ section and set a goal on the website. The parent website was not well used, with only 12 parents (14%) logging on to the website. All 12 parents completed the ‘Healthy Habits’ survey and seven set a goal (see Appendix 8). Goals focused on sleep (n = 3), increasing outdoor play (n = 2), eating (n = 1) and screens and seated time (n = 1) (see Appendix 8, Table 41). All 12 parents were sent e-mails to encourage the setting of a (further) goal, but none did so.

As part of the website registration process, parents provided a mobile phone number. Targeted text messages based on the parents’ answers to the ‘Healthy Habits’ survey were sent to the 12 parents. Parents received between one and three text messages, depending on how early they signed-up to the website. No parent received more than one text message per week to avoid overload, and no parent unsubscribed from these messages.

A NAP SACC UK closed Facebook group was set up for intervention parents to complement the website. The plan was for the research team to send suggestions for goals, information about health changes and recipes, with the aim of generating discussion and support between parents. No parents at any intervention nursery joined the Facebook group.

Withdrawal from the intervention: nursery 12

One intervention nursery (12) did not fully implement the NAP SACC UK intervention (but participated in follow-up data collection). The nursery manager completed the Review and Reflect form with the NAP SACC UK partner, but no goals were set and no staff workshops were held. The primary reason for the nursery withdrawing was staff found the requirement to attend after-hours training workshops unacceptable. The letter of agreement between the nursery and the university stated that participation in the study would involve two out-of-hours training workshops. However, the letter of agreement was signed by the nursery’s deputy manager and it became clear in the manager interview that she was unaware of this requirement.

It is important to note, however, that the out-of-hours training was unacceptable because nursery staff had very recently completed several weeks of mandatory (out-of-hours) first aid training. Out-of-hours training was therefore not inherently unacceptable to staff, rather the specific timing of the NAP SACC UK workshops (following shortly after other mandatory training in this nursery) made it so. Indeed much training in nursery settings is conducted out of hours and the five other intervention nurseries all rated the NAP SACC UK workshops extremely highly.

Although NAP SACC UK staff offered alternative solutions to this problem (including conducting workshops during the nursery day), none was acceptable to the manager. A series of communication problems between the nursery manager, the NAP SACC UK partner and NAP SACC UK study staff led to the point when the manager discussed withdrawing her nursery from the study. As a result, the study principal investigator (RK) was unblinded in order to discuss the situation with the manager, resulting in the nursery agreeing to remain within the study for data collection purposes, but not fully implementing the intervention. Therefore, nursery 12 did not set any goals nor did it hold any staff workshops. However, a 20-minute one-to-one session was held between the nursery cook and the nutrition workshop facilitator where key points from the nutrition training workshop were summarised.

Progression criteria 2: intervention acceptability

This section of the process evaluation aims to answer the following question: was the intervention acceptable to NAP SACC UK partners and the majority of child-care managers, staff and parents?

Overall, levels of acceptability of the NAP SACC UK intervention to NAP SACC UK partners and nursery managers and staff was high. One manager explained that: ‘It’s been thoroughly enjoyable to take part in it . . . it’s been an absolute benefit . . . I would recommend it to any other nursery’ (Manager_Int_1). A staff member from a different nursery described the intervention as ‘eye-opening’, explaining that for ‘us who have been in for a long [time] . . . you sort of get stuck in your ways and it’s just shown us different ways of doing things’ (Staff_Int_6). NAP SACC UK partners were also generally positive about the intervention, describing it as ‘a practical, useful intervention’ (Partner_Int_25) and ‘a fantastic idea’ (HV_ Int_14), although this partner explained that it worked well because the ‘nurseries are really buying in to it’, noting that ‘it would be very difficult, I think, to be with a nursery that aren’t quite so keen’.

In general, parents were unaware of specific changes occurring in the nursery because of NAP SACC, but were supportive of the nurseries’ participation in research and their child’s involvement in it. For example, one parent noted: ‘I just think it’s a very useful thing to be doing to be honest. I’m glad to be part of it’ (Parent_Int_38). However, the very low uptake of the website suggests this intervention element was unacceptable to parents.

NAP SACC UK partner training

The partners appreciated the NAP SACC UK training describing it as ‘useful’ (Partner_Int_16) and ‘well done’ (Partner_Int_25) and that it ‘ironed out any questions, made it clear what we had to do’ Two partners had not expected to learn much from the nutrition session as this topic was well-covered in their health visiting role. However, both reported finding it useful, for example in making them aware of the Children’s Food Trust Voluntary Guidance for Early Years settings28 or in demonstrating the amount of sugar present in certain drinks. The PA session particularly appreciated because, as one partner explained, ‘that wasn’t something I’d had . . . formal training on’, adding ‘[health visitors] focus a lot on what people are eating but you forget about the other side which is very important’ (Partner_Int_25). The training lasted 2.5 hours; two partners felt it should have been longer, describing how each of the three trainers (for nutrition, PA and oral health) were ‘tied for time’ (Partner_Int_25) and that one session (oral health) had run out of time.

A second ‘top-up’ training session was held for NAP SACC UK partners in May 2016. This aimed to provide study staff with a sense of how the intervention was progressing and to assess whether partners required additional information or resources in order to support the nurseries. One partner (Partner_Int_16) found it helpful to hear about other partners’ experiences working with their nurseries. Another (Partner_Int_25) felt it was useful ‘because we all came in with specific things, challenges that we’d had’ and were able to share learning and ideas. However, she added ‘it was all a bit late, we’d nearly finished by then. So we probably could have done with that one a bit sooner’. Additional resources, particularly on oral health, were requested by the partners and were e-mailed out shortly after this meeting. Although the partners perceived this top-up training to be useful, for a group of experienced staff such as these health visitors, it does not appear to be an essential part of the NAP SACC UK intervention. In terms of this feasibility study, it was however useful in checking progress and allowing an opportunity for any specific problems to be identified and resolved.

Although not a specific requirement of the intervention, all four partners described how they did some additional preparation outside the two training workshops to prepare for working with the nurseries. This involved familiarising themselves with the literature and resources provided by NAP SACC UK and ensuring that they understood what they needed to do with the nurseries. As one partner explained:

I wanted to prepare myself. I think I couldn’t have walked out of that room at that training session and gone straight to a nursery. I wanted to be able to read through the Review and Reflect tool and also I was cross-referencing with the . . . guidance that the nursery would adhere to.

How long each partner spent preparing was not specifically logged but one partner said she spent ‘about a day in total’ (Partner_Int_14) and all partners were reimbursed for one day of preparation time.

Nursery staff workshops

Nursery managers, nursery staff and the NAP SACC UK partners were all highly enthusiastic about the two NAP SACC UK training workshops. Indeed, the enthusiasm and inspiration created by the workshops appears to have been the most important part of the whole NAP SACC UK intervention for many of the nursery staff. The workshops were variously described as ‘invaluable’ (Manager_Int_10), ‘absolutely brilliant’ (Staff_Int_6) and ‘inspiring’ (Partner_Int_21). One manager explained:

The [staff] that did the workshops thoroughly enjoyed them, and they were really good, and you know I would recommend them to anybody. They were definitely worth doing.

One manager admitted to feeling nervous beforehand about having external staff come in to run the training, explaining:

It’s always a bit hard when you have a professional coming into your setting, you feel as though you’re being sort of criticised.

However, these fears were not realised and her staff found the workshops to be extremely positive: ‘Luckily none of that came into play or anything. Yeah, they were absolutely brilliant both of them.’

Workshop style and facilitation

The interactive nature of the workshops and the lively and engaging manner of the facilitators were important in engaging the staff, particularly at the end of a long working day. As one manager explained:

We had the physical activity training after a long day at work for most of us, and we were kind of all like, ‘Oh it’s training.’ And actually we all kind of came away like, ‘My gosh, I’ve got so much energy. I just want to do this and I want to do this . . . and it kind of re-inspired us’.

Both workshops were reported as being pitched at the right level for staff. As one manager noted, her staff had a range of academic abilities and backgrounds from apprentices to staff with degrees, but the workshops were ‘very tailored to absolutely everybody’ (Manager_Int_1). This was echoed by another manager who said ‘everybody got something out of it’ (Manager_Int_7).

The skill and personality of the facilitators appeared crucial in creating the right atmosphere for the workshops and in inspiring staff. One staff member described how during a quiz activity in the nutrition session some friendly competition emerged between groups and the nutrition facilitator ‘sort of went with that’ and ‘she really got us engaged’ (Staff_Int_12). The PA facilitator, in particular, was highly praised for his ability to engage staff. The NAP SACC UK partner attended one nursery workshop explained:

I think they were a little shy to begin with some of them, and then he got them really going . . . He was really good and really engaged them and people started to relax.

This was corroborated by the manager of this nursery who explained:

[The facilitator] had like a funny character to him . . . So it was kind of like we felt like we knew him, and that was funny . . . I guess you just kind of felt at home or felt at ease. So you took on a lot more and you had a laugh and a joke, but you didn’t lose sight of where you were going.

Physical activity workshops

Several participants explained how the PA workshops made them think more creatively about ways to help children be physical active and reflect on their own practice:

It wasn’t until we actually had the training days that we realised actually that we could have done more, and had specific activities outside. It tended to just be free flow, so children were spending most of the time sat on the floor not participating in the activity. And we kind of just thought ‘oh it’s ok, they’re outside, they’re running in and out, that’s fine, that’s all the activity that they need.

Several participants described how the PA facilitator had given them many creative ideas for incorporating PA into the everyday activities of the nursery. One staff member described with enthusiasm being shown different ways to use ordinary objects for PA:

For example, with tennis racquets, you don’t need just for playing tennis. You can do various activities with them. I think it’s just opened our eyes to think, ‘Actually, there are new ways of doing it’.

The NAP SACC UK partner attending this same workshop also noted how the facilitator:

. . . got them thinking about story time, how can you have story time just not where they’re sat on their bottoms watching you with your book, how can you bring that story to life and have the children going on a bear hunt round the room?

A NAP SACC UK partner (Partner_Int_21) described how, for a different nursery (3), some staff felt ‘out of their comfort zone’ being asked to act ‘as if they were on CBeebies [BBC, London, UK]’ to encourage PA during story time. She explained that this was ‘gently talked about [in the workshop] . . . and that’s something they’ve worked on’, adding that one member of staff had subsequently received funding from the local authority to attend storytelling workshops.

The PA workshop in particular received high praise from the participants. One manager, for example, said ‘We absolutely loved the physical activity [workshop]. Absolutely loved it’ (Manager_Int_11), while another felt that they got more from this workshop than the nutrition session (Manager_Int_4). One exception to this came from nursery 9 where the manager and staff member interviewed, despite describing the workshop as ‘very good’ (Staff_Int_6), felt that the session could have been more interactive:

The physical activity one was less interactive . . . it was more sort of PowerPoint based, so it was more talk . . . I think because it was physical activity we expected it to be active.

Observation of this workshop did not suggest the delivery of this particular session was different from any of the other PA workshops delivered.

Nutrition workshops

Some of the enthusiasm for the PA sessions appears to be because this was often a novel training topic for them; nurseries were much more likely to have received other training on nutrition and healthy eating. Nonetheless, the nutrition workshops were also praised and several participants commented on how much they had learnt. One staff member commented that ‘we came out [of the nutrition workshop] and actually we wanted to know more . . . we could have stayed there another hour’ (Staff_Int_6), while another was reminded that nutrition is ‘not something to be sort of shoved on a shelf somewhere and forgotten about’ (Manager_Int_10). Participants seemed to particularly appreciate advice on portion sizes. One manager explained that they had been looking for information on portion control prior to NAP SACC UK but:

. . . everywhere we looked everyone was saying something completely different with regards to how much children should be eating . . . So it was great to have [the nutrition workshop facilitator] to come in and for us to actually share this is what we’re doing, is this all correct? That was absolutely perfect for us.

One manager noted a discrepancy between the advice they received from NAP SACC UK and that from an oral health programme (Smiles Better) which they had recently been involved in. The NAP SACC UK training recommended including oily fish on their menu once every week, while the Smiles Better training suggested including it three out of four weeks. The staff member at this same nursery also noted the NAP SACC UK nutrition training ‘did overlap quite a lot’ with the training they had received from the Smiles Better programme (Staff_Int_3).

Timing and attendance

Workshops were held either on a workday evening (n = 8) or on a Saturday morning (n = 3), according to nursery staff preference. Attendance at the workshops ranged from four to eight staff, with a mean of six.

The timing of these session elicited mixed views from participants, with some nurseries reporting good attendance while others reported poorer participation. The manager of nursery 3 explained that despite the voluntary nature of the workshops, staff attendance has been ‘absolutely great’ (Manager_Int_1), although she did acknowledge that having both workshops as part of a scheduled nursery inset day would have been easier for them. Other participants described their lack of enthusiasm at the thought of training after a long day, but reported coming away from the workshops feeling inspired and enthused (Manager_Int_11_and_12).

Nonetheless, asking staff to attend training out of hours did pose difficulties for some nurseries and consequently limited attendance. One staff member at nursery 9 noted that only five people attended the Saturday morning session, explaining that ‘some of the staff work 40 plus hours a week and they’ve obviously got stuff that they do on a weekend and they just couldn’t make it’ (Staff_Int_3). The nursery manager also commented on this, saying that ‘it would have been nice if more had attended but . . ., we do a long day and then having to do a couple of hours in an evening, I can understand why’ (Manager_Int_4).

A similar problem was reported at nursery 8 where only 4 out of 13 staff attended the evening nutrition workshop. The staff member noted that ‘that’s not unusual for staff meetings’ (Staff_Int_6), with the manager acknowledging that ‘a lot of [staff] have got children of their own, and their children are doing things, or they’ve got partners who work away and all those sort of complications.’ (Manager_Int_7). However, attendance at this particular nursery was complicated by the fact it had recently been taken over by a nursery chain. New staff were contractually obliged to attend out-of-hours staff training, while staff on the old contracts were not. The manager noted this issue (although not confined to NAP SACC UK training) had created ‘a little bit of . . . tension’ (Manager_Int_7).

Because of the voluntary nature of the out-of-hours NAP SACC UK training, it was not always possible to ensure that the ‘right’ staff were attending. The priority for the study was to ensure that early years practitioners with responsibility for NAP SACC UK’s target age range (2- to 4-year-olds) attended the training. However, one manager noted that ‘it tended to be more the baby practitioners that attended the physical workshop’ than those working with 2- to 4-year-olds (Manager_Int_4). We did not record how many staff working with 2- to 4-year-olds attended the training in each nursery.

Participants reported the length of the sessions (ranging from 2–3 hours) as being appropriate, although one manager commented that they ‘could have been a little bit longer and certain things more in depth’ (Manager_Int_1). Another manager commented it had been difficult to ask staff to attend a 3-hour session as their after-work team meetings only usually lasted 1–1.5 hours. However, splitting the two 3-hour workshops over four 1.5-hour sessions would have been equally difficult to expect staff to attend. Having the training as part of an inset day would have improved attendance but as they had recently been taken over by a chain no inset days were being scheduled at that time (Manager_Int_7).

NAP SACC UK partner attendance and delivery

Three NAP SACC UK partners attended at least one workshop in each nursery that they were working with (no workshops were held at nursery 12 so the partner could not attend). Partners did not report any problems in attending these out-of-hours workshops. One noted that attending the evening workshop meant a very long day (08.00 to 20.00) but that ‘it wasn’t a problem because . . . the trainers were so engaging, it was actually fine’ (Partner_Int_25).

All three partners found it beneficial to attend the workshops. One explained that it was ‘really helpful to do those workshops with the nurseries, just so you can kind of see the staff and what their attitudes are’ (HV_Int_25). Another suggested it had been important in establishing a good rapport with the nursery staff:

It gave me a chance to meet the staff, and also hopefully it gave them a chance to see, as the Health Visitor, I was also saying ‘Oh wow, this has got a lot of sugar in hasn’t it?’ That kind of showed we’ve all got something to learn.

However, one partner suggested that the role of the partner at these workshops should be made clearer:

I suppose it’s helpful to know, if you’re going along, are you going along to support delivery of the workshops or are you a participant?

One partner admitted that ‘how much [attending the workshop] actually altered my meetings with the managers and our goals and things like that [is] hard to say’ (Partner_Int_14); however, another partner felt that it had been very useful in helping her with the rest of her NAP SACC UK role in the nursery. She explained that it had been useful to see:

. . . which bits [the staff] were enthusiastic about because then it really helped when you were then doing the goal-setting. You’ve got an idea in your head of – because they’re not going to make changes about things they aren’t in the least bit interested in . . . And then when you’re doing the goal-setting with them you can kind of say, ‘Oh, well, you know, people seemed to be quite enthusiastic about this’.

Partners were asked how they would feel about delivering these workshops in any future roll-out of NAP SACC UK. All three agreed that with further training they would be happy to take on this role, noting that they have a lot of experience in delivering this type of training within their health visiting roles, albeit to parents rather than nursery staff (note, this is in contrast to the findings from the formative focus groups discussed in phase 1). However, one partner noted that ‘I don’t think I’d be ever quite as enthusiastic as [the PA facilitator], because he’s so passionate about it’ (Partner_Int_14). Given the success of these workshops appeared largely related to the enthusiasm and personality of the facilitators, the skills and attributes of the workshop facilitators in any subsequent roll-out would require careful consideration.

Staff training budgets

Although NAP SACC UK workshops were provided free of charge, they did potentially incur a cost to nurseries in terms of paid overtime or time off in lieu; the acceptability of this was explored in nursery manager interviews. In addition, we asked about nursery staff training budgets and their views on paying for the NAP SACC UK workshops.

Of the five nurseries implementing the workshops, all but one (nursery 9) paid staff for attending the training or gave them time off in lieu. The manager at nursery 9 explained that staff were not usually paid to attend training, but were expected to attend voluntarily as part of their personal development. The staff member interviewed (Staff_Int_3) at this nursery felt that this accounted for the poorer attendance at the workshops. The costs incurred by the nurseries for these workshops were estimated to range from £478 to £691 (mean £610) and are discussed in greater detail in Chapter 6, Health economics.

Of the 12 nurseries participating in this study, four had dedicated staff training budgets. Exact figures were only given for two nurseries: a total of £100 and £150 per term for the whole nursery. In the remaining nurseries, training requests were considered on a case-by-case basis according to the needs of the nursery and interests of staff, with mandatory training (e.g. child first aid) taking priority. In at least two nurseries it appeared staff were sometimes expected to pay the course costs for any non-mandatory training they wished to attend (although they may have been paid or given time off in lieu for attending). Unsurprisingly, free training was more likely to be approved by nursery management than courses with registration fees. Often only one or two staff would be sent on a training course, with the expectation they would cascade the information back to other staff.

Most staff were not in favour of charging for NAP SACC UK workshops, with one manager noting that the free training was a major incentive to take part in the study (Manager_Int_10). One staff member felt that her nursery would not have paid for the nutrition workshops ‘because there was nothing [new]. We were hot on that anyway’ (Staff_Int_3). However, her manager was more equivocal saying they ‘possibly’ would have considered the training if there had been a charge but would only have allowed one person to attend (Manager_Int_4). This was echoed by managers at nurseries 1 and 5, who would also have limited the number of staff attending to limit costs. The manager at nursery 8 noted that any training charge would require approval from their chain head office, making participation in the study more problematic. Interestingly, one manager explained that now she knew how good the workshops were she would have paid for them, but that ‘at the time, most probably not’ (Manager_Int_1).

Review and Reflect

Both the NAP SACC UK partners and the nursery managers reported finding the process of completing and discussing the Review and Reflect form very useful. One manager explained that ‘it showed us what we are doing good and just the tweaks we needed to change that improved it’ (Manager_Int_4). It was, however, also described as ‘extremely time-consuming’ (Manager_Int_1), often taking about 2 hours to complete, which led one partner to quip ‘by the end of it I needed a lie down!’ (HV_Int_14). Finding time to complete the lengthy form within a busy nursery day was problematic, meaning that it was sometimes put ‘on the backburner slightly’ (Manager_Int_1) or even compromised the quality of the data provided:

[It] was really longwinded . . . By the end of it we were just like, ‘Oh, we’ll just tick that one, and we’re not really too sure’.

Another staff member felt that it was too repetitive, explaining that ‘we just felt that we were just ticking the same thing over and over again’ (Staff_Int_11). Revising the form to be simpler, shorter, and less ‘wordy’ was suggested by one partner (Partner_Int_25).

None the less, the benefits of completing the process were reported, with one manager noting that ‘once you actually got into doing it, it was absolutely fine’ (Manager_Int_7). One partner felt that it was a useful way to get the managers really thinking about their practice:

Certainly with them all pulling their menus out and it’s like, ‘Oh gosh, no, I didn’t think about that’, and, ‘Oh yeah, look at that pattern, look at that. We’re offering too many biscuits there’. Just gets them really thinking about it.

Some managers had filled in the form before meeting with the NAP SACC UK partner, while others completed it with the partner during their first meeting. Some of those who did the latter commented on the benefits of completing it in this way (the former group did not mention this in interviews). One partner explained that ‘because I’d been involved in actually the completion of the questionnaire . . . that made it easier for me to work with them to set the goals’ (Partner_Int_14). This was backed up by the nursery manager who said ‘you could do it on your own, but it was nicer to have somebody to sort of bounce things off’ (Manager_Int_4). Equally, another partner felt that completing the form with the manager ‘gave me an oversight really, and also what restrictions they have from a financial point of view’ (Partner_Int_21).

Nursery goal-setting

Both nursery staff and NAP SACC UK partners appreciated the fact that many of the goals set were simple and easy to implement – little ‘tweaks’ to menus or practice, rather than more daunting changes. Examples of these changes included cutting up fruit rather than offering whole pieces, adding details of local dentists to registration packs, taking chairs away to encourage children to stand, creating an ‘open door’ policy that allowed children to choose to play inside or out, and using resources that they already had but in new ways. As one staff member explained that the changes ‘were easy things to do. They weren’t major things’ (Staff_Int_3). One partner felt that these easily achievable goals were key to getting the nurseries on-board:

They’re just small goal-setting . . . they’re inexpensive goal-setting . . . and I liked that because I thought that was practical, not too big a jump for the nurseries.

Some nursery staff talked about how the process of being involved in NAP SACC UK and setting goals had provided a welcome opportunity to reflect on their usual practice and be more mindful about their interactions with the children:

Quite a lot of us we found were dug down in routine, more so thinking, ‘We need to do this now, we need to do this, we need to do this in our routine’, rather than thinking, ‘Actually what are we doing as adults that promote what children are doing, and like physically wise and activity wise?’.

Another manager talked about how the changes implemented as a result of NAP SACC UK had become ingrained in their nursery practice:

I think because it has become so ingrained in what we do. For example, our chef, she devised all of our menus for the summer taking some of the learning that we’ve gained through NAP SACC, and so therefore every time she puts the menus together that’s how she will write them, informed with that as well. So, it now has become part of our make-up and it’s quite early on . . . but at the moment it’s quite ingrained in what we do.

Nutrition goals

All nurseries who had set goals to modify their menus had achieved them (although see Barriers to setting or implementing goals for barriers to changing the menu in nursery 1). Staff at one nursery commented on their improved understanding of portion control as a result of the NAP SACC UK nutrition workshop, with the manager explaining that ‘we’re not overfeeding them any more’ (Manager_Int_1). However, one of the changes most frequently commented on, and implemented by several nurseries, was simply changing the language staff used when offering second helpings of food:

I think the thing that was actually the most useful was this thing about asking children whether they’re still hungry or not [rather than ‘do you want some more’] . . . I’d never thought about it . . . And actually that whole concept of just changing one phrase that you use when you interact with a child, but actually that makes a massive difference, because they’re making a decision based on their own body and their own needs, not on what the child next to them is doing.

Another positive change was that one (nursery 3) now allowed staff to eat for free to encourage them to eat with the children and role modelling positive eating behaviours. As this nursery was part of a local chain, this new practice had been rolled out to three other nurseries (not involved in the NAP SACC UK trial). The NAP SACC UK partner for this nursery felt that this was a hugely positive change because ‘socialisation and eating, that’s the key element to children’s healthy attitude to food’ (HV_Int_21). The staff member interviewed at this nursery also felt that this change had resulted in considerable benefits:

I can see personally with some children who are not too sure about food, and it’s kind of ‘I don’t want to try that’, I’ve noticed if I sit with them . . . they have watched me and they have eaten what I’m eating, and they will try it with me. And I think that’s such a benefit to those children and for all children as well to see I am eating my vegetables, and they can copy me and copy that behaviour as well.

Changes were also made with regard to providing parents with extra information on nutrition. One nursery held a parents evening including nutritional information, displaying a noticeboard signposting parents to relevant resources and provided information on their website (nursery 5). The manager of this nursery noted that staff were now more willing to speak to parents about nutritional issues (e.g. suggesting healthier alternatives to chocolate bars in lunchboxes). The manager explained that they can now ‘provide some background information as to why we’re actually saying it, as opposed to it’s just a personal opinion, it’s got some more clout behind it now [because of NAP SACC UK]’ (Manager_Int_10).

Another manager (Manager_Int_11) set a goal to provide parents with information on healthy packed lunches and explained it had made a ‘massive difference’ with the children now coming ‘in with healthier lunches, or I should say a balanced lunch.’ This nursery now included the packed lunch guidance in their welcome packs for all new families, explaining that:

As soon as they say, ‘Oh, we’re thinking of bringing a packed lunch’, rather than kind of feeling like we’re targeting them, it’s just, ‘Oh, this is standard that we give out’, just so that the information is there for them ready.

Physical activity goals

Physical activity goals tended to fall into three categories: devising policies, engaging with parents, and changes to staff practices and/or use of equipment and space. Of the three nurseries planning to write and implement a new PA policy, only one (nursery 9) had done so; progress had been hampered in the other two nurseries because of managers’ lack of time. Four nurseries (1, 3, 8 and 9) set goals to provide parents with information about PA. All four nurseries had done this, although in one case (nursery 1) it was not clear whether or not the changes made (e.g. moving parent information display to a more accessible area) were specifically attributable to NAP SACC UK.

Interviews tended to focus on the changes to staff practices and the use of their space and equipment in creating more opportunities for PA. For example, one nursery (1) had ‘revamped’ their garden to make better use of it by introducing wooden boxes at different heights to encourage jumping, as well as creating a ‘mud kitchen’. A manager at nursery 3 explained how they had changed their approach to using their outdoor space:

We did have set garden times before, but during our [NAP SACC UK PA workshop] he said it was best for children to choose whether they want to play inside or outside which is what we now do, down to his advice.

Other examples of changes to practice included buying a compact disc (CD) player to encourage children (and staff) to be physically active to music even when it was very wet outside, using different games or equipment while outside to get the children to be more active or staff discussing their own hobbies and interests (e.g. hockey or gymnastics) with children.

An important consequence of the intervention was the space it gave to staff to concentrate on the importance of children’s PA. One staff member commented that their involvement in NAP SACC UK had ‘opened their eyes’ to new ways of promoting PA and that ‘it just made us reflect on our practice’ (Staff_Int_6). Another manager felt that the NAP SACC UK training had given staff permission to focus on encouraging and enjoying PA with the children:

It was just quite nice to like see the staff actually relaxing a bit more and not worried about, ‘Oh, we need to go to do that next because actually so and so is already in there doing it and we’re out here enjoying our time’. And obviously for the children it was, ‘Oh, the adults do it too, they have fun, they play the spot game, they chase us round’.

Barriers to setting or implementing goals

As noted above, most goals set by the nurseries had been achieved. The exceptions to this were where policies had not been written or specific activities (e.g. a Fitness Fun week or dental visit) had not yet been arranged (see Appendix 8, Table 42). However, it became apparent from the interviews that some nurseries had chosen not to set certain goals because they were aware that they were not achievable. For example, one NAP SACC UK partner explained that she did not broach creating a PA policy with one of her nurseries as it was part of a large, national chain and it ‘would have been far more challenging for them to actually try and implement policies without a huge delay . . . it would have gone through a lot of red tape and wouldn’t have been achieved within the timeframe that we had.’ (HV_Int_14, referring to nursery 8). By way of contrast, one manager wondered if being part of a chain would have helped him achieve his goal of creating a new PA policy because ‘because you’ll have other departments that put that sort of thing together and it’s not down to one individual’ (Manager_Int_10).

A lack of space was also noted as a barrier in some nurseries. Toothbrushing was not set as a goal in one nursery because they did not have space to accommodate the extra movement of children and staff needed to facilitate this. Another manager commented on their limited outdoor space as a barrier to increasing PA, but went on to add that this meant that they just had ‘to use that [space] wisely’ (Manager_Int_1).

One NAP SACC UK partner raised the issue of a potential conflict of interest between running the nursery as a profitable business and introducing healthy changes that might prove unpopular with parents. She felt that one of her nurseries would not have been keen to introduce a ‘water only’ policy for fear of this reason:

[Nursery 1] wouldn’t have gone for a water only [policy] . . . because that might alienate some of the parents. . . So I suppose, as a private nursery, there is a balance between wanting to put these healthy things in place . . . it’s difficult, because you’re wanting people to carry on sending them and paying. And they can equally go to another nursery down the road if they don’t like the food.

However, it was not clear from this interview whether or not this was a goal that had been discussed and subsequently rejected or an assumption on the part of the partner; neither the manager nor staff member interviewed at this nursery mentioned this issue.

Two partners raised some concerns about having the right nursery staff involved in the planning and goal-setting process to ensure that actions were followed through. The partner working with nursery 3 was disappointed that NAP SACC UK activities were delegated to the nursery’s ‘graduate leader’ and that the nursery’s cook did not attend the nutrition workshop or any meetings between the partner and the deputy. She noted that although the planned changes to the menu (e.g. including oily fish) appeared to have been implemented, she ‘couldn’t actually pin [the graduate leader] down to how the cook had integrated that’, and had not seen the new menus to verify this change (Partner_Int_21).

The partner for nursery 1 similarly noted problems with ensuring the right people were involved. As she noted, ‘the person I was dealing with didn’t have any say on budget. And they did try to make changes that they couldn’t, couldn’t do really, because the owners wouldn’t agree to it’ (HV_Int_25). This frustration was echoed by the nursery manager who described the difficulties of trying to implement without having the authority to purchase the necessary resources:

So we are still waiting for the resources to come through. [The owners] did say, ‘Yes, go and buy them’, but they haven’t given me a budget. So I’m a bit reluctant to just go out and buy things and then them tell me, you have spent too much, or not enough.

Budgetary constraints were a significant barrier for this nursery and prevented the manager from making changes to the nursery menu. This nursery operated on a very tight budget that the owners (who were not involved in the NAP SACC UK goal-setting process) were unable or unwilling to increase. The manager felt that the children were currently served too much bread at teatime (both toast and sandwiches) and wanted to offer alternatives, such as hummus and vegetable wraps. However, this had not been possible:

[The owners] know it’s too much bread, but it works in the budget . . . So when you can’t exceed like 40p for a loaf of bread, how could you possibly buy a thing of wraps and something to fill the wraps?

The owners had tried to be flexible on this issue by allowing the manager to use any underspend on new items like hummus, but as the manager explained that ‘we are so tight on budget, it’s very rare that we would have enough to buy hummus and wraps’ (Manager_Int_11).

Because of these constraints, changing the teatime menu was not set as specific NAP SACC UK goal. However, the staff were continuing to push for changes with the owners, for example by feeding back the fact the children were not eating the food provided at teatime, which led to a lot of food wastage (something that was confirmed by the whole-day EPAO observation for this nursery). The manager also used their participation in NAP SACC UK study as leverage:

I don’t think it will ever be at a point where it’s changed fully. But I do think [the owners] are being more flexible. And I think that has come from the study, and that we’ve come back and said, ‘We’re learning this. We want to try it, please let us’.

Nonetheless, their inability to implement the changes that they wanted had affected the staff’s enjoyment and engagement with NAP SACC UK. As the manager explained, staff struggled with the nutrition workshops because they knew they would be unable to make the changes suggested:

Obviously we took everything on-board, but I think deep down a lot of us kind of thought, maybe we were a little bit more deflated because we kind of thought, ‘Actually we know we can’t do that’.

Length of intervention

Managers and nursery staff felt that the amount of time they had to set goals, attend workshops and implement changes (approximately 5 months) was appropriate. One manager explained that ‘it’s not something that can be done in a few weeks and it has to be allowed to embed, not only in the minds of staff, but also to see the differences in children as well’ (Manager_Int_10). Another manager acknowledged if they had had to make lots of substantial changes they may have needed longer, but ‘because we were quite good with it all already I suppose it was fine. We didn’t need that much [time]’ (Manager_Int_7). However, one manager commented that although they had achieved their goals, ‘I feel we need more time to ensure everything is completely embedded’ (Manager_Int_1). She felt that being followed up after an additional 6 months would be an incentive to continue working on their goals. One NAP SACC UK partner felt that because it had taken time to arrange dates for the staff workshops, it had felt a bit rushed towards the end, although her two nurseries had still managed to achieve most of their goals: ‘By the time we’d done the workshops and the goal-setting, it was nearly time to finish’ (Partner_Int_25).

On-going support

On-going support was provided in the form of e-mails or telephone calls, and was used as an informal means of checking progress towards the nurseries’ goals. The level of support appeared to be quite light touch, with one partner explaining that she had not needed to provide ‘a lot of support really, more guidance to what their goals were and signposting them to what resources there were and how they could achieve the goals’ (Partner_Int_25). Another partner felt that neither nursery she was assigned to required much support as they were already highly motivated and had quickly met their goals:

When I e-mailed [both nurseries] a month afterwards . . . both of them came back with, ‘We’re pretty much there’ . . . They didn’t need any help because, like I said, they were great to start with, there wasn’t a huge amount to work with.

Nonetheless, managers reported finding this on-going support useful. For example, the manager from nursery 1 appreciated the outside perspective offered by the partner and found the positive feedback received very motivating: ‘to actually have somebody outside that actually picked up on [the changes made] . . . that was quite positive and just kind of kept you going really’ (Manager_Int_11). Other managers appreciated the opportunity to build relationships with the partners as child health professionals. One manager (nursery 5) described the contact with the partner as ‘an important link’ and ‘invaluable’ (Manager_Int_10), and another described the benefits of their growing relationship:

[It’s] been useful to know that someone who knows what we are doing, we could just give a [tele]phone call to or drop an e-mail to and say, ‘Oh, we’re looking for this. Do you have anything?’ Or, vice versa, she might see something and think, ‘Oh yeah, [nursery 1] might want that’.

One partner appeared to be unclear as to what was expected of her in this support role and, at times, uncomfortable in pursuing it. She noted that both nursery managers were very busy and she had struggled to arrange meetings to offer support admitting that ‘I do feel like I’m harassing them’ (Partner_Int_25). She did not feel she that offered the nurseries a lot of support, but ‘more guidance to what their goals were and signposting them to what resources there were and how they could achieve the goals’ and went on to add:

I don’t think I really got to that point where . . . they were ringing me up saying, ‘Oh, how can we do this?’ I didn’t really have that relationship with them. I don’t know quite why that was.

Parent website

Only 12 parents (14%) used the website, indicating low acceptability for this intervention element. Of the 10 intervention parents interviewed, five had used the website and five had not. Three parents were unaware of its existence, while the remaining two parents knew about it but did not ‘get around to looking at it’ (Parent_Int_32). As one explained: ‘it was just one of those things that I just, it hasn’t been a priority really’ (Parent_Int_19).

Of the parents who did use the website, two explicitly mentioned they had been motivated by the free swimming voucher offered. Another parent accessed the website briefly but did not set any goals, explaining that: ‘I think probably if I wanted advice or anything I would turn to the internet anyway and good old Google for ideas’ (Parent_Int_22) rather than consulting a site like NAP SACC UK. Other comments included that the website was ‘bright and colourful’ (Parent_Int_23) and that logging on, completing the Healthy Habits form and setting goals ‘wasn’t difficult’ (Parent_Int_17) and was ‘pretty self-explanatory’ (Parent_Int_29).

Two parents discussed whether or not setting goals had made any difference to their interactions with their child. One parent said, ‘I wouldn’t say it made any difference to what I was doing’ (Parent_Int_29). She did try to find new ways of making fruit and vegetable more appealing to her daughter; for example, by arranging fruit in the shape of a butterfly, but that ‘the novelty wore off after about a minute’. Another felt she did ‘try to be much more conscious of what I was giving her [to eat]’ (Parent_Int_34) but noted progress on this goal had tailed off over the summer holidays when they were out of their normal routine.

One parent appreciated the e-mails she received from NAP SACC UK, but two parents who received text messages found these less helpful. One explained that the messages were ‘nothing that I didn’t know’ (Parent_Int_29), while another felt the texts (on screen time) were irrelevant to her:

I thought it was quite silly because we don’t give her really screen time anyway. They were clearly sort of generic texts, which I expected from the study that I’d set this goal and then I’d kind of have text encouragement re the goal [that I’d set on healthy eating].

Future delivery of NAP SACC UK: the NAP SACC UK partner role

Within the NAP SACC UK trial, the partner role was taken on by health visitors. This group of professionals was deemed to be most similar in terms of skills and professional background to the child-care health partners used in the US NAP SACC study. Health visitors are qualified nurses with specific training and responsibility for children aged 0–5 years and their families. Four health visitors were employed within the NAP SACC UK trial, two from each local authority area, with this work taking place and being remunerated outside their normal contracted hours.

The health promotion work that NAP SACC UK enabled them to do with the nurseries was seen by all four health visitors as a ‘fundamental part’ of their role because they were commissioned to ‘work with children under the age of 5 [years] and their families within the community setting’ (Partner_Int_25). One health visitor felt that they were the ‘best partners to work with nurseries’ because they were the ‘only consistent professionals that are seeing that age group, outside of the nurseries’ (Partner_Int_21).

Although other staff were suggested as being able to take on parts of the NAP SACC UK partner role, there was a feeling that the health visitors’ training and experience brought something to the role that others could not. For example, one health visitor described their approach as more ‘in-depth’ and ‘holistic’ and felt strongly that the NAP SACC UK partner needed to have a specific background in health.

The professional status of the health visitors was highly valued by the nursery staff. One manager explained that: ‘So she, being a health visitor . . . that is her profession so I think it is a good thing doing [the Review and Reflect form] with her’ (Manager_Int_4). Another staff member focused specifically on the benefit of establishing a ‘professional relationship’ with their health visitor:

It’s nice that I’ve got that professional relationship now with our health visitor. So I know that I can call her any time and she’ll come down even after the study has finished and come and see us, which I’m sure she would have done anyway but I know now that I’ve got that professional relationship . . . Probably it would be nice for all settings to have that one named health visitor that you’ve really got that professional relationship with, that you can just contact at any time, I think is really beneficial to every nursery.

However, one health visitor queried if the partner role was making the best use of their skills as health visitors. As she explained, ‘I think what we did, you didn’t need to be a health visitor to do that’ (Partner_Int_25). She would have preferred to have more interaction with the parents and children (rather than just nursery staff), which fitted better with her skills and experience as a health visitor:

Ideally I would have been more involved with the nursery and seeing the kids eating, but that didn’t really happen . . . I didn’t have any contact with the children at all . . . I think it would be nice to have some sort of face-to-face input with the parents, rather than just being a separate person that helps the nursery. So being a bit more involved with the whole thing.

In her view, her skills were in these areas and her time would have been better spent on this, rather than filling in the time-consuming Review and Reflect form:

It probably wasn’t the best use of time . . . we deal with public and groups and things on a daily basis – it would be better to not be doing form filling so much.

Although the health visitors all enjoyed their NAP SACC UK role and felt strongly that it was (or at least should be) an important part of their role, they were also very clear they did not have the capacity to deliver it at present. Their existing workload was so great that even their commissioned services were not always being fulfilled. As one explained: ‘We can’t even do our basic, provide the basic service . . . we’re missing out bits because we haven’t got the capacity to do it’ (Partner_Int_6). While another commented:

We are commissioned to do certain things . . . [and] although part of it is building community capacity and that kind of health promotion thing . . . that’s what disappears by the wayside when we are swamped with child protection, high levels of need . . . We just don’t have the time unfortunately.

In light of this pressure, any additional workload (such as NAP SACC UK) would simply not be delivered: ‘I mean if you put this on health visitors to do routinely, I think it just wouldn’t get done.’ (Partner_Int_16).

One solution to this capacity issue would be to create a specialist health visiting role, exempt from other health visitor duties, to deliver NAP SACC UK to a series of nurseries:

You could employ health visitors, just health visitors to do that . . . but I think, you’d have to be dedicated to do that work. You couldn’t be doing [other health visiting work] because unfortunately, when it comes up against child protection work, you end up having to prioritise the child protection work.

One health visitor felt that this ‘would be a really good health visiting role’ and would ensure that you had ‘somebody doing it that’s really enthusiastic and passionate about it’, which she felt was important to its success (Partner_Int_25). Importantly, this model of ‘specialist’ roles already exists within the health visiting service (e.g. with specialist mental health positions).

Another issue with asking health visitors to take on this role routinely was identified by one participant who pointed out the lack of overlap between the geographical area in which health visitors work and nursery catchment areas:

The difficulty is that we work within a geographical post coded area, so all our families would be in a particular area. As we know, if there was a nursery sitting in the middle they could be coming from anywhere . . . sounds a bit jobs worth, but . . . that nursery wouldn’t necessarily be totally our patch.

Both family support workers (FSWs) and nursery nurses were suggested by health visitors as potentially being able to act as NAP SACC UK partners. FSWs are employed by local children’s centres, providing outreach to families identified as being in need, and running parent training and support programmes. Nursery nurses work as part of the health visiting team undertaking a variety of tasks, such as child development reviews and weaning classes.

Although both groups of staff potentially had skills and experience relevant to the NAP SACC UK partner role, neither routinely work with nursery settings, and one partner raised concerns about their lower levels of training (particularly the FSWs) and the impact that this might on the integrity of the intervention:

Sometimes we’ve found that [the FSWs have] said something different to what we’ve said. And then some families pick up on that and then there’s a big issue about, ‘Oh she told us that and she said that,’ and it’s a bit disjointed . . . So there was a bit of conflict going on there.

She also expressed reservations about whether or not FSWs could be adequately trained up to the on the NAP SACC role:

It depends how well you want to deliver it. And that sounds awful, doesn’t it? I don’t mean it like that. I mean how much in-depth, how holistic you want it to be?

Nursery nurses were felt to be a more obvious choice for the NAP SACC UK partner role because of their specific background in health. However, it was also noted they are unlikely to have spare capacity to take on this role and one participant noted that some health visiting teams no longer employed nursery nurses.

Progression criteria 3: trial design acceptability

This section of the process evaluation aims to answer the following question: were the trial design and methods acceptable? We also explored any potential harms or additional benefits arising from the study and any changes occurring within control settings as a result of their involvement with the study.

Nursery participation

Nursery and child recruitment rates in Gloucestershire were lower than in North Somerset. There are a number of possible reasons for this. First, the recruitment period was longer in North Somerset. Gloucestershire was chosen later in the study to replace Cardiff, resulting in a shorter period in which to recruit nurseries, coinciding with the busy Christmas/New Year period. Second, because of the longer recruitment period, promotion of the NAP SACC UK study at local authority meetings for early years providers took place in North Somerset prior to recruiting nurseries, but not in Gloucestershire. Third, there were fewer on-going initiatives (e.g. the Bristol Standard or ‘Smiles Better’ oral health programme) in early years settings in North Somerset, suggesting that NAP SACC UK faced less ‘competition’ for participation.

In interviews, nursery staff were asked their reasons for participating in the study. These are discussed below with no discernible differences in responses identified between nursery staff in the two different areas.

Several managers took part in the study because they had a particular interest in child nutrition and had previously undertaken study in this area (e.g. on a foundation child-care degree). Others described a general interest in seeing what they could learn as a nursery from participating: “We just kind of thought, ‘Why not? We haven’t got anything to lose, and probably stuff to gain, things to learn” (Manager_Int_11). Another was keen to support research in general, explaining ‘as a company we love new research and we love being part of new ideas’ (Manager_Int_1).

The intervention happening at the just right time was an incentive for two nurseries. One manager explained that ‘every year we look for a focus for the nursery, and [NAP SACC UK] came around at the right time’ (Manager_Int_10), while the other nursery was in the process of updating their menus and the manager felt that ‘it would be a positive to look at the guidelines and see what we’re expected to do’ (Staff_Int_3). For both of these nurseries, the fact that the intervention seemed manageable and ‘quite an easy process to deliver’ (Manager_Int_10) was another incentive. As one described: ‘It was something that I felt, you know, that as a nursery we could do this’ (Manager_Int_4).

For some managers, the opportunity to reflect on their own practice was a particular incentive. One manager wanted to take part ‘just to sort of reassure that we’re doing everything that we should be doing and just picking up anything that we were not doing correctly’ (Manager_Int_4). Another explained that she had worked in child care for 20 years and ‘I don’t want to get to the stage when you get complacent. So I’m always looking at things, how we can improve things, or ways that we can do things better’ (Manager_Int_9).

Other managers were keen to take part in something that could improve their children’s health. It was a way ‘to get the best for our children . . . one way of actually helping these children, the adults of the future, to actually learn more about their diet and what choices they can make’ (Manager_Int_8). For one manager working with a more deprived nursery intake, it was particularly appealing because she had already identified these health issues in her children:

We do have children here that have significant issues like with the dental care, and the children that are overweight. And we also have a significant number of children who live in flats, who obviously that physical exercise issue is more of an issue for them . . . I thought it was something that would be good to reflect on and good to think about, and maybe sort of prioritise.

Recruiting children

For children to take part in the NAP SACC UK study, parents had to provide written consent. Parent information sheets and consent forms were sent to parents of eligible children in sealed envelopes via nurseries. Participation rates ranged from 18.9% to 81.3% of eligible children.

Most nursery staff acknowledged the difficulty of engaging parents in new initiatives, such as NAP SACC UK. As one manager explained that:

[The parents] just didn’t seem very involved at all. And I don’t think that’s down to NAP SACC, I just think that is down to the parents really. When we tried new things and provide open evenings . . . they don’t really seem interested either.

A number of staff acknowledged that ‘parents don’t read the correspondence’ (Staff_Int_3) and it was often a challenge to get required forms and signatures back to the nursery. As a result, two nurseries said they now ask parents to complete important forms at the nursery rather than send them home.

Because initial child recruitment to the study was slow, a NAP SACC UK member of staff attended all 12 nurseries on 29 occasions in total at pick-up times to speak with parents about the study. Several managers felt that this had helped with recruitment:

Because we weren’t getting many consent forms back, the suggestion was maybe [NAP SACC staff] actually came in physically in person to the nursery and actually sat, and during our busiest period when we knew parents were going to be in and out. And that worked because it just gave the parents a bit more reassurance of what it was . . . I think that definitely helped with them actually coming out in person.

However, a couple of managers expressed some reservations about this method suggesting that ‘parents felt a bit put upon’ (Manager_Int_9) or even might have found this ‘a little bit intimidating’ (Manager_Int_7).

Some nursery staff suggested that they should be more involved in the recruitment process to increase participation. To reduce burden on nurseries, staff were not asked to get involved in recruitment but were simply handed sealed information packs to parents. However, some staff found this frustrating as parents would ask them about the study but they were unable to help:

Where the parents were getting envelopes with information and I think it would have been handy for the [staff] to have had some information. Because obviously the parents were then asking the [staff] questions and they didn’t necessarily know the answer.

Two managers also felt it would have been useful to have a list of who had signed up so they knew who needed to be chased up:

Because we had a list of the parents who had taken the information . . . and we didn’t know [if they had signed up]. Some [forms] was coming back to us and some didn’t. And so we were chasing them and we didn’t know because they might have sent [the form] back [to NAP SACC].

Randomisation

Although some managers of control nurseries expressed disappointment at not receiving the intervention, all accepted and understood the importance of the randomisation process. However, it became apparent in interviews that two nurseries did not fully understand their allocation to the control arm. One manager was unaware that her nursery was in the control arm; she thought that the intervention consisted solely of the children’s height, weight and accelerometry assessments. Another control manager thought that her nursery had been allocated to the control arm because they had been assessed as already doing everything they needed to do with regard to nutrition and PA:

Height and weight measures

Nursery staff reported few problems with regard to weighing and measuring children in the nursery setting. Several staff said the children were to take part ‘because [they] love doing that sort of thing’ (Manager_Int_10). Another explained that:

One or two had little meltdown . . . but that’s to be expected with 2-, 3-year-olds, but generally it went absolutely fine. It was absolutely brilliant.

Taking the measurements created some disruption to the nursery day because each child had to be accompanied by a member of nursery staff. One manager provided an extra member of staff on these days to ensure that the correct adult–child ratio was maintained while one staff member left the room. Another manager explained that they used a quiet area of the room to take the measurements rather than taking the children outside. She admitted ‘if we’d have had to take them out of the room it could have been a bit more of a problem’ (Manager_Int_5).

Staff in one nursery prepared children for the measurements, explaining the day before exactly what would happen and reassuring them about the process. The way in which the NAP SACC UK research staff handled the measurements was praised by several nurseries, both in terms of their interactions with the children and in being flexible to fit in with the usual nursery schedule and practices as far as possible. No parent reported any reservations about allowing their child to be measured.

Accelerometry measures

The majority of nursery staff and parents reported the children enjoyed wearing the accelerometry belts, particularly because NAP SACC UK staff presented them as ‘superhero’ belts:

The children absolutely loved them. A couple of children didn’t want to take them off after the end of the week . . . they thought it gave them superpowers.

In most cases, nursery staff reported few problems with getting the children to wear the belts, in part because the children could see their peers wearing them too. Some parents reported finding it more difficult to get their child to wear the belt at home. Both nursery staff and parents found it harder to persuade the children to wear the belts for the follow-up measurements because the novelty had worn off.

Although the majority of children wore the belts (87.5% at baseline and 73.5% at follow-up), a number of minor problems were reported by nursery staff and parents. Some children found the belts uncomfortable to wear (e.g. straps were too tight or too long, or rubbed against their skin, especially in hot weather). There were also some issues with ensuring that the children were wearing the belts at the right time. One manager, for example, explained that ‘most of them will take them off before they go out in the garden, which is probably the time when they’re moving around,’ adding that the children got too hot when they were running around or were frustrated with staff constantly moving the belts back into the right position on the hip (Manager_Int_11). Some parents reported forgetting to put the belt on, especially after swimming or having a bath. In addition, some nurseries reported issues with belts getting mixed up or misplaced. Although most accelerometers were returned, one manager felt awkward having to ‘nag’ parents to bring them back in, but went on to add that ‘we’re used to doing that!’ (Manager_Int_24). There was only one comment about the safety of the belts, where a manager reported a parent was reluctant to let her child wear the belt because she might put it round her neck.

Observations

In general, nursery staff did not report many problems with either the mealtime observations or the whole-day EPAO observation: ‘That was fine . . . They just sort of melted to the background and didn’t really cause any issues or anything. You just hardly know they’re there’ (Manager_Int_10). However, some practical issues were raised regarding the logistics of having extra people in the nursery setting conducting the observations. One staff member noted that their nursery is very small and having two extra observers in their small kitchen was difficult (Staff_Int_12). Another manager spoke about the inconvenience of letting the observers in and out of the nursery between the mealtimes:

We have five mealtimes a day including the snacks. So you’ve got breaks in-between them, and like where are they going to go and what are they going to do? It kind of takes up space in the nursery. I think most of them did go out off site. And then it’s letting them back in and signing them back in again.

There were mixed comments regarding how staff felt about being observed. In several cases, nursery staff reported being used to being observed, for example by visiting parents, Ofsted and other professionals: ‘We are quite used to that, we have staff being observed . . . so they are used to that and it doesn’t faze them’ (Manager_Int_9). Some participants also reported the friendly and unobtrusive manner of the NAP SACC UK researchers meant that it was easy to carry on as normal. As one staff member (Staff_Int_2) commented that ‘They just kind of tucked themselves out the way and were quietly watching and observing’. However, others reported finding it ‘a little bit strange’ (Manager_Int_7) or even ‘scary’ (Staff_Int_12) being watched so closely. One manager described how her staff found the whole-day EPAO observation a bit intrusive:

Staff did find that quite evasive [sic] and obviously rifling through the books . . . it’s like someone coming into your home and start looking through your cupboards . . . That was the only bit they’ve obviously said they found uncomfortable.

There were mixed responses regarding the impact that the observations had on staff behaviour. Several participants felt that staff had not significantly changed their interactions as a result: ‘[The staff] just carried on as normal and you actually end up forgetting they’re there really’ (Staff_Int_6). However, two managers believed that their staff may have changed their behaviour. In one case this was because staff were feeling uncomfortable:

I think that some of them were maybe a little bit more sort of nervous, in the same way that they would be when Ofsted are here and you kind of like become a little bit edgy . . . So I wouldn’t say it changed what they did, but it may have changed the way they did it a little bit.

In the other, the manager felt the staff may have been trying to give a good impression:

Because they knew what NAP SACC were there for I think they made sure our targets were being achieved and that you can clearly see that they were.

By contrast, the children appeared to be unaffected by and often unaware of the observations, again partly because they are used to having visitors to the nursery. Most participants therefore felt that ‘it didn’t really change the children’s behaviour at all’ (Staff_Int_2), with only one participant stating that ‘the children sort of played up a tiny little bit, because I think obviously there was new people in the room’ (Staff_Int_12).

The only negative comments about the observations came from staff at nursery 12, and appeared to relate to a misunderstanding about the purpose of the two different observations: the mealtime observations of children’s food consumption for completion of the CADET food diary and the EPAO. During her interview, the manager described the difference between the two sets of observers who came to her nursery:

So we had two different lots of people that came out to observe, and they were just so different. The one group that came, they came in the room with the children, saw what they were eating, came outside to play with them, observed them, really good. And the other lot, oh, they just sat in the office the WHOLE DAY!

Although we cannot verify this, we believe that the first pair of observers were completing the EPAO assessment, which comprises an extremely detailed observation of all aspects of the nursery environment and staff practices. These observers would therefore have been present at the nursery all day, interacting with staff and children in order to check details to complete the EPAO form. The second pair of observers were probably there to record only what the children ate at mealtimes and, in order to stay out of the way, would return to the office in between meals.

The difference between these pair of observers clearly frustrated the manager, who felt that the second observers simply were not getting an accurate reflection of what their nursery was like.

Parent questionnaires

Parents were sent a questionnaire to complete at baseline and follow-up, comprising questions on the child’s quality of life (PedsQL), spending on food and physical activities, health-care use and mediators such as knowledge, self-efficacy and motivation.

In most cases, parents reported no problems with the questionnaire, describing it as ‘straightforward’ and ‘self-explanatory’. Some parents noted that it was ‘quite thorough’ and took some time to fill out, but no-one described this as a particular problem. As one parent commented that ‘it did take quite a bit of time, but you could see the relevance in it so I didn’t mind doing it’ (Parent_Int_18).

Part of the questionnaire asked about their child’s use of GP, health visitor or A&E health-care services. At follow-up this questionnaire was modified so that parents were randomly selected to receive a questionnaire asking about this health-care use either over the past month or since February 2016 (last 5 months). Parents who were asked about use in the past month reported no problems recalling these details. Those asked to think about the previous 5 months also generally reported no problems because their children were generally very healthy and, therefore, had not used any/many of these services: ‘It was quite easy, because he hadn’t been [ill]. . . so there wasn’t anything to remember’ (Parent_Int_18).

However, some parents did find this question difficult to answer:

. . . I was thinking, ‘Gosh, how am I going to remember from February?’ So I don’t think I do remember very well. So I think I kind of [laughs] guessed.

This was particularly the case if the child had accessed health-care services on more than one occasion:

[my son] has been to the Doctor a few times but I wouldn’t be able to remember if it was in the last 5 months or not. Hospital would be a bit more significant, so I would remember that I think.

Most parents agreed that being asked to recall only the previous month would have been much easier.

The questionnaire also assessed potential mediators including knowledge, self-efficacy and motivation. A minority of parents reported some problems with the phrasing of these questions and they may need to be modified for use in any further trial. For example, one parent was unable to distinguish between questions that asked ‘I feel able to [e.g. provide my children with fruit at all main meals]’ and ‘I am motivated to . . .’. For her, ‘they weren’t any different to me. You kind of completed them the same.’ (Parent_Int_29). Another parent felt that the answers from these questions could be ‘misleading’ with people ticking the same response for very different reasons. As she explained:

You know the questions ‘Do you feel able to reduce the amount of fizzy drinks . . .?’ [My daughter’s] never had fizzy drinks in her life, ever. So do I feel able to reduce it? ‘No’ because she never has it. What do I put? She never has it . . . But you could also answer, if you have a child that really loves Coke [Coca-Cola^®; The Coca-Cola Company, Atlanta, GA, USA] and you were really struggling with their behaviour and you were pulling your hair out, then you may feel that I’ve got trapped into this behaviour, which I don’t feel happy with, but I can’t reduce the Coke because it would be even worse. So you could end up with two people on the far ends of the spectrum answering the same thing.

One parent admitted that it was hard to answer these questions completely honestly ‘because obviously every parent likes to think they would feed their child lots of fruit and veg’, while another admitted some questions ‘ended up making me feel a bit guilty’ because ‘I know what the right answer is, and am I, you know, am I giving an answer that makes me a bad parent?’ (Parent_Int_30).

Food diary

Many parents reported no difficulties in completing the food diary. It was variously described as ‘fine’, ‘straightforward’ and ‘easy’. However, other parents admitted finding some elements of the form confusing. Several parents reported being unclear as to which days and which meals they were supposed to complete. For example, one parent commented:

I didn’t understand whether you wanted, the day she goes to nursery, do I then check up the menu and put that in, or do the nursery fill that out? . . . So like today, do I then go and ask what she’s had for lunch and put that down?

Another parent found it difficult to decide which category to put certain foods under.

[My son] likes brioche but it’s not listed. Is it bread? Is it a cake? I don’t know . . . And so I was like it’s not toast, it’s not pastry, it’s just brioche. So I was struggling a bit, like should I just write it down, I don’t know what to do.

Another parent felt that because the form was so detailed with different options, it was difficult to complete. She felt that it would have been easier to simply write down what her child ate at each meal rather than having to flick through pages of different options (Parent_Int_22). Another suggestion was to reorder the listed food items to make it easier to complete (e.g. including ‘milk’ next to the breakfast cereals category).

Nursery staff interviews confirmed some parents were confused over how to complete the food diary. One manager explained that some parents ‘found the food diary quite difficult to understand’ (Manager_Int_7) with other staff confirming parents were often confused about which days/meals they were meant to complete. As one manager explained:

Some parents just did that day that they had that [accelerometer] belt on, so they just did the food for that day. Some parents did the food for the whole week, or however long the booklet was for. Some people just did for the nursery day and just put ‘Not applicable, at nursery’. So it was a bit of a mixture of things.

Although nursery staff were generally willing to explain the diary to the parents, one staff member noted that they had not actually seen the instructions given to parents (sent out in sealed packs), which made it difficult for them to help:

Because obviously they’re sealed so we don’t – we can’t like explain it to them. So obviously we just gave them the packs. So maybe it might be nice if we had a copy of the pack so we know what’s in them . . . so we could say like, ‘You’ve got to do this’ when we’re doing our handover.

Involvement in research study

In general, nursery managers did not report finding participation in the NAP SACC UK study burdensome. One manager commented that the NAP SACC UK staff had taken on much of the administration of the study and ‘that was probably one of the best things about the study’. As she explained:

When we first got involved I was a little bit apprehensive about how much extra work it would mean for us. But no they have actually been great, they’ve been the ones taking on the admin role and then everything, so really good.

Another manager added:

A lot of it has been managed really well, almost to kind of take the pressure off us a little bit . . . It’s not been a burden on us at all.

However, one manager did admit that there had been ‘more to [the study] than I perhaps initially perceived’ and that his lack of time to dedicate to the study was why some goals (e.g. writing policies) had not been met (Manager_Int_10). A couple of managers mentioned the height and weight measurements had created some disruption in the nursery because each child needed to be accompanied by a member of nursery staff, but as one explained, ‘we knew in advance when it was coming, so as long as we were able to prepare for that and accommodate for it, that was fine’ (Manager_Int_11). Another manager said their staff had had to help some parents filling in their food diaries, but they had been happy to do this (Manager_Int_7).

The NAP SACC UK staff were praised by many nursery staff for their ability to interact positively with the children and to undertake their role with the minimum disruption to the nursery. One manager, for example, described the NAP SACC UK researchers as ‘fantastic’ and said ‘your team were great in adapting to us’ and fitting in with the nursery schedule and practices (Manager_Int_24).

The majority of nursery managers felt communication between the NAP SACC UK team and themselves had been good. As one commented: ‘I think the communication has been fine all the way through. I don’t think it’s been too much and I don’t think it’s been too little. I think it’s been just right.’ (Manager_Int_5). Most communication had been with the trial manager via e-mails and telephone calls. Managers felt that e-mails were generally the most appropriate method of communication as they were able to respond at a convenient time and provided with written confirmation of arrangements. However, one manager felt that personal telephone calls had been useful at the start of the project to build rapport with the NAP SACC UK staff and another explained that they appreciated being telephoned as a prompt to act on e-mails that they may have forgotten about.

Some minor issues were raised regarding communication. One manager felt that ‘things were very done sort of last-minutey, which doesn’t work quite well with us as a setting’ (Manager_Int_1). She explained that they needed at least 2 weeks’ notice for data collection to arrange enough staff cover. Two other managers suggested that being given a timetable at the start of the study explaining when things would be happening (e.g. data collection, staff workshops, observations) would have been helpful. There were also comments about the number of different NAP SACC UK staff who came into the nursery for different reasons. For example, one manager said:

[It] would have been nice if we had the same people come in. Because each time it was someone different and each day it was someone different as well, that just the consistency of the same person, just because from our point of view we’re quite strict on who we let in and everything and who can just wander.

Communication appeared to have been more difficult with nursery 12 and lack of full understanding of what the intervention entailed contributed to their decision to not take part in the intervention. As described in Withdrawal from the intervention: nursery 12, staff at nursery 12 were unwilling to attend the out-of-hours NAP SACC UK workshops and the nursery manager interview revealed she had been unaware of the requirement for this training:

The letter of agreement between the nursery and NAP SACC UK stated that nurseries allocated to the intervention arm would need to ‘ensure as many nursery staff as possible attend two workshop sessions’ and that these workshops ‘will take place during an evening and on a Saturday morning’. In this nursery, the letter of agreement was signed by the deputy manager and thus the manager was not fully aware of the requirements of the study.

The nursery manager also added the fact that both she and the trial manager worked part time had not helped matters:

When you rang the office [the trial manager] works part time, I work part time, that’s the nature of the job, you know, it was someone else you were speaking to and like I say, it was different people organising different appointments, and things like that.

Harms and wider benefits

No significant harms were reported by nursery staff, partners or parents regarding the NAP SACC UK trial. However, some wider benefits from participation in the study were noted by partners and nursery staff.

One partner provided her nursery with health advice for children outside the NAP SACC UK age range by providing them with updated guidance on baby weaning best practice. She also explained:

It’s highlighted things for me that now going into other nurseries I would probably take some leaflets with me if I was just going to observe a child, and say ‘Oh actually I’ve brought this for you, maybe you might like to look it up on the website and tap into that?’.

Another partner described how, as a result of her involvement with NAP SACC UK, her health visiting team were now asking other nurseries and children’s centres to include questions about dental registration on their registration forms (Partner_Int_25).

As noted earlier, one nursery now allowed staff to eat a free meal with the children and this practice had since been rolled out to other nurseries in their local chain. This same nursery had also rolled out their new menus, revised in light of NAP SACC UK Best Practice Standards, to their other nurseries.

Changes in control settings

Managers of control nurseries were asked whether or not they had made any changes around PA, nutrition and oral health during the intervention period and, if so, if these changes were related to their participation in the NAP SACC UK trial.

In most cases, managers indicated that they had continued with their normal practice, which may have included providing activities for the children around, for example, healthy eating. However, in two nurseries there appeared to have been some more direct changes resulting from their involvement with the NAP SACC UK study. The manager of nursery 7, for example, explained that her staff may have changed what they were eating in front of the children because the nursery was involved in the study:

I think it’s probably made the [staff] a bit more aware about what they’re doing when they’re bringing in their own snacks and stuff. Rather than bringing in a fizzy drink to have, they’re bringing their water or at snacktimes they make sure they’re having fruit, the same as what the children are having, and that kind of thing.

Another manager explained that her nursery had started raising awareness of the sugar content of foods with parents by promoting sugar apps and putting up displays in nursery corridors. When asked if this had happened as a result of their involvement with NAP SACC UK, she answered:

I guess . . . I think it’s just because we’re now part of the programme we’ve actually been able to sort of, it gives us a bit more clout. We’ve said we’ve been part of this research programme and we want to address it, so in the newsletter we’ve been giving information to parents about taking part in the research. We’ve got the display up in the corridor for them to look at. We’ve been sending out leaflets with their packs.

However, it should be noted that this nursery was also participating in the ‘Smiles Better’ programme at the same time and this campaign had provided the information and leaflets that the nursery were giving out. This activity was therefore likely to have happened anyway, regardless of their participation in the NAP SACC UK study.

Summary

Progress against the progression criteria is summarised in Table 27. Recruitment of nurseries (31.6%) and children (35.3%) was lower than the progression criteria of 40%, but both were exceeded in one of the two study areas. No nurseries withdrew from the study. The intervention was delivered as planned in five out of the six intervention nurseries with high levels of feasibility and acceptability (there were particular circumstances in the sixth nursery), with the exception of the home component. It was feasible to recruit and train health visitors to deliver the intervention, but health visitors reported that they may not have capacity to deliver the intervention in the future alongside their usual workload.

The trial methods and design were acceptable and feasible. The number of children lost to follow-up was 24 (14.2%), and this was due to withdrawing consent (1.8%), child refusal to participate on the day (1.2%), children moving to primary school (6.5%) or children moving nursery (4.7%). The response rate was 145 (85.8%) at follow-up. Although the study was not powered to measure effectiveness, accelerometer measured total PA and MVPA were higher in the intervention arm than in the control arm after the intervention. The ICC for total activity was estimated at 0.02 (95% CI < 0.0001 to 0.95). Assuming a coefficient of variation in participating children per nursery of 0.4, 30% incomplete data and an ICC of 0.05, 720 children at 52 nurseries will give 90% power at the 5% significance level to detect a 17-minute increase. The average cost of delivering the intervention was estimated at £1184 per nursery, and nurseries incurred, on average, an additional £717 for staff to attend the two workshops.