An environmental physical activity and nutrition intervention in early childhood education and care settings: process evaluation of the NAPSACC UK multi-centre cluster RCT

BACKGROUND: Most children attend early childhood education care settings (ECEC settings), commonly known as nurseries in the United Kingdom. ECEC settings provide opportunities to improve health through improved nutritional quality and physical activity for young children. There is evidence from the US that the NAPSACC intervention improves nutrition and physical activity in ECEC settings. We adapted NAPSACC for the UK and investigated its fidelity, acceptability and sustainability within a multi-centre trial. METHODS: Embedded process evaluation within a 12-month cluster randomised controlled trial with 52 ECEC settings (25 intervention and 27 control). The NAPSACC UK intervention comprised two six-month cycles of nutrition and activity self-assessment, staff workshops and goal setting, supported by public health practitioners. Data included: observations during training and workshop delivery, questionnaires to practitioners and ECEC setting staff; 11 interviews with practitioners who delivered the intervention, 11 ECEC setting managers, 5 commissioners, and two focus groups with the research team. Document analysis of self-assessment and goal setting forms was undertaken. Thematic analysis was conducted with both deductive and inductive codes, a coding framework and triangulation across data sources. RESULTS: Three-quarters (19/25) of intervention ECEC settings implemented the NAPSACC intervention across one cycle. Only 40% implemented a second cycle, mainly due to delays in scheduling staff workshops caused by sector-wide staffing challenges. ECEC setting managers valued the opportunity to reflect on practice and the support offered by the practitioner. ECEC setting staff highly rated the workshops and valued support given by public health practitioners. 83% of nutrition and 70% of physical activity goals set by the ECEC settings were achieved (fully or partially) and self-assessment scores increased, with greater gains for ECEC settings implementing two cycles. ECEC setting managers planned to maintain the changes made but varied in their intention to continue self-assessment and goal-setting processes. CONCLUSIONS: Despite sector-wide staffing challenges, we saw high engagement from ECEC settings in self-assessment and setting goals to improve child nutrition and activity. However, future development and use of NAPSACC UK need to be considered in the context of a lack of measurable impact on objective measures of child health and the significant challenges of staff capacity and time. TRIAL REGISTRATION: ISRCTN33134697, 31/10/2019.