An environmental physical activity and nutrition intervention in Early Childhood Education and Care settings: process evaluation of the NAP SACC UK multi-centre cluster RCT

An environmental physical activity and nutrition intervention in Early Childhood Education and Care settings: process evaluation of the NAP SACC UK multi-centre cluster RCT | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An environmental physical activity and nutrition intervention in Early Childhood Education and Care settings: process evaluation of the NAP SACC UK multi-centre cluster RCT Jemima Cooper, Kim Hannam, Stephanie Chambers, Tom Reid, Russell Jago, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6471820/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Feb, 2026 Read the published version in International Journal of Behavioral Nutrition and Physical Activity → Version 1 posted 10 You are reading this latest preprint version Abstract Background Most children attend early childhood education care settings, commonly known as nurseries in the United Kingdom. Nurseries 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 nurseries. We adapted NAPSACC for the UK and investigated its fidelity, acceptability and sustainability within a multi-centre trial. Methods Embedded process evaluation within a cluster randomised controlled trial with 52 nurseries (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 nursery staff; 11 interviews with practitioners who delivered the intervention, 11 nursery 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 (76%) of intervention nurseries 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. Nursery managers valued the opportunity to reflect on practice and the support offered by the practitioner. Nursery 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 nurseries were achieved (fully or partially) and self-assessment scores increased, with greater gains for nurseries implementing two cycles. Nursery 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 nurseries 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 obesity physical activity nutrition childcare pre-school children process evaluation qualitative UK prevention Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background On a global scale, young children are not meeting physical activity or dietary national recommendations 1,2 . In the UK, only 9% of 2-4 year-olds met the recommended minimum of three hours physical activity per day 3 and 15% of 1.5-3 year olds consumed the recommended amount or less of free sugars 4 . Lower than recommended levels of physical activity and dietary factors, including consumption of energy-dense foods, large portions sizes and snacking contribute to a complex dynamic of biological, environmental and behavioural associations with obesity 5 . Consequently, there is a critical need to improve young children’s physical activity and diet. Early childhood education and care (ECEC) settings (such as nurseries, pre-schools or day-care – hereafter referred to as nurseries) are an important environment in which young children spend a substantial amount of time. A systematic review of the implementation of policies, practices or programmes by childcare services for child healthy eating, physical activity and obesity prevention concluded they may improve the implementation of these but have little to no impact on child diet, physical activity or weight 6 . Consistently, a systematic review of childhood services aimed at improving child diet quality reported that these approaches may do so slightly for this outcome, but there was little to no difference in BMI 7 . It is common in developed countries for most children to spend significant periods of time in nurseries in the years before starting school, with many governments around the world encouraging attendance with funding or subsidies 8,9,10,11 . In England and Scotland, government-funded childcare has increased to 30 hours per week 12 . As such, nurseries are key settings to improve nutrition and physical activity in young children. The Nutrition and Physical Activity Self-Assessment for Childcare (NAPSACC) intervention was developed in the United States to improve nutrition and physical activity in nursery settings through modifications to the environment, policies and practices of nurseries via a process of self-assessment and targeted technical assistance 13 . Randomised Controlled Trials (RCTs) of NAPSACC in the US have shown effectiveness across several outcomes including: body mass index (zBMI); environmental audit nutrition score; accelerometer-measured physical activity; and health knowledge of nursery staff 13,14,15 . The intervention is currently used in over 30 states across the US 16,17 . The NAPSACC intervention was adapted for the UK and a feasibility cluster-RCT was conducted in 2015-2016 18,19,20 . The intervention was acceptable and feasible. A full-scale cluster-RCT 21 to evaluate the effectiveness and cost-effectiveness of NAPSACC UK commenced in 2019, seeking to improve nutritional quality and physical activity, while reducing sedentary time and portion size in line with national recommendations. See Box 1 for a brief outline of the intervention, with further details in the study protocol 21 . The trial found no evidence of an intervention effect for the co-primary outcomes of average kcal/occasion consumed at nurseries or minutes of total physical activity (mean difference -2.13 [-10.96,6.70], p=0.64). There was some evidence that the intervention reduced Kcal served and consumed at lunch 22 . Box 1: NAPSACC UK intervention NAPSACC UK Partners* are trained to work with nursery staff to improve child physical activity and nutrition through a process of self-assessment and goal setting. Partners work with nurseries over a period of a year, to complete two 6-month cycles of self-assessment and goal setting. The planned delivery of intervention components comprised: Partner training: Two days training from physical activity and nutrition specialists on how to deliver staff workshops and support nursery staff. Self-assessment form : A 101-item multiple-choice questionnaire completed by nursery manager on current nursery practice in nutrition, physical activity and play, outdoor play and learning and screen time. Staff workshops: 2x3 hours of training in physical activity and nutrition delivered by Partners to nursery staff, followed by two hours training 6 months after. Goal setting and action planning: Nursery manager and Partner agree on eight goals (three nutrition, three physical activity and two of nursery’s choice) and develop action plan for improvement Tailored technical assistance: Ongoing regular support and advice (approximately once every two weeks during the intervention period) for nursery staff from Partners to help them meet their goals *Partners are public health practitioners with expertise in public health, nutrition or physical activity working in Local Authorities or NHS Boards This paper reports the findings of the embedded process evaluation of NAPSACC UK. Drawing on complex intervention and process evaluation frameworks 23,24 , we sought to explore whether the intervention had been implemented with fidelity, and in a way which was acceptable and sustainable. In addition, we explored how context affected the above to aid interpretation of the study findings to draw appropriate recommendations for future implementation, policy and practice 21 . Methods Sample and recruitment NAPSACC UK is a multicentre, parallel-group, two-arm, cluster-RCT with a repeated cross-sectional design 21 . The trial includes nurseries from four areas across England (Somerset, Sandwell, Swindon) and Scotland (Ayrshire & Arran) selected to represent differing levels of deprivation and ethnicity. Nurseries were eligible to participate if they were: private nurseries, maintained (local authority-funded) nurseries, nurseries attached to primary schools, private day nurseries, or preschools where lunch was consumed. In each area, all eligible nurseries were invited to participate with consenting nurseries randomly allocated to the NAPSACC UK intervention or usual practice (control) group. We asked intervention nurseries to complete two 6-month cycles of training, self-assessment and goal setting, supported by public health practitioners (‘Partners’) as outlined in Box 1. Data collection We used both qualitative and quantitative methods to gain a detailed understanding of how NAPSACC UK was implemented and received (Table 1). Observations We observed Partner training sessions and nursery staff workshops to explore fidelity and quality of implementation. Researchers were trained prior to observations to ensure a consistent approach. Observations were semi-structured and included both quantitative scoring and open qualitative observations of: participants attending, training/workshop format, topics covered, what worked well/less well and participant engagement. Questionnaires Questionnaires were developed asking partners and nursery staff to rate training elements using a score of 0-5. Partners completed questionnaires to capture views on quality and usefulness of training in preparing them for their role. Nursery staff completed a similar evaluation questionnaire after each workshop. Participants completed questionnaires either on paper or online depending on training delivery. Control nursery managers completed a short questionnaire at the end of the study to assess any changes to usual practice and/or potential contamination. Interviews and focus groups We interviewed NAPSACC UK Partners, intervention nursery managers and local commissioners in each area upon completion of their involvement in the intervention to explore their experiences and views of the NAPSACC UK programme. All Partners were invited for interview. A sub-sample of nursery managers were interviewed to provide variation in terms of deprivation level, nursery type, nursery size, and level of engagement in NAPSACC UK (informed through conversations with local Research Site Managers (RSMs)). Local commissioners responsible for child health were identified through their original involvement in commissioning NAPSACC UK and invited to participate. Interviews took place before the results of the trial were known. We also conducted two focus groups with the research staff to gather further insight into intervention implementation. Nursery managers were renumerated for taking part in the interviews with a £20 voucher. Semi-structured topic guides were used to structure the conversations, specific to participant type (Partner, nursery manager, commissioner or research team, Additional File 1). We conducted interviews/focus groups online via Microsoft Teams or telephone, recorded with consent and transcribed verbatim. Document analysis Nursery managers completed self-assessment and goal setting forms with Partner support at the start and end of each cycle. The self-assessment forms comprised 101 multiple choice questions across different categories including: child nutrition (food/drink provided, feeding environment, menus and variety, education and professional development, and policy), lunchboxes (food/drink provided, education and professional development, policy, feeding environment), physical activity and play (time provided, indoor play environment, staff practices, education and professional development, and policy), outdoor play and learning (outdoor play, outdoor physical environment, education and professional development, and policy), and screen time. See Kipping et al. 25 for more detail. Goal setting forms recorded areas for improvement and specific goals in those areas. Managers and Partners reviewed goals at the end of each cycle, noting whether they had been fully, partially or not achieved. Partner support logs recorded support given to nurseries throughout the intervention including format, frequency and duration of support. Fieldnotes Process evaluation leads (RL, JC) used fieldnotes to record relevant discussions and reflection throughout the study. Data management All qualitative data were anonymised and uploaded to NVIVO 14 to facilitate data management and analysis. Partner/staff questions and documents (self-assessments, goal and support logs) were uploaded to the REDCAP data management system. We assigned anonymised IDs to interview participants; the two-letters included in quote attributions indicate research area (SW-Swindon; SS-Somerset; SD-Sandwell; AA-Ayrshire & Arran). Table 1: Summary of process evaluation methods Method Details Observations Partner training sessions (England and Scotland) (n=3) Staff workshops covering physical activity and nutrition workshops across all four sites (n=12). Workshops were sampled to ensure variation in site, topic, nursery size and deprivation level. Questionnaires Partner training evaluation forms (n=15) Staff workshop evaluation forms (n=200) Control manager questionnaires (n=15) Interviews Intervention Manager interviews (n=11) Partner interviews (n=11) Local commissioners (Local Authority or Health Board staff) interviews (n=5) Focus groups with Research Site Managers, Trial Manager and Project Administrator (n=2, 6 participants in total) Document Analysis Self-assessment forms (from all intervention nurseries at start and end of each cycle) Goal-setting forms (from all intervention nurseries at start and end of each cycle) Partner support log (from all intervention nurseries at end of study) Fieldnotes Fieldnotes taken throughout the study relevant to process evaluation aims Analysis Qualitative data were analysed using thematic analysis. An initial coding framework was developed by including deductive codes derived from research questions and topic guides. JC and RL used this framework to independently code two transcripts, leading to additional inductive codes being developed. The coding framework was revised through discussion, and applied to three further transcripts by JC and checked by RL. The final framework was applied to all qualitative data from transcripts, observations, and fieldnotes, with additional revisions made where necessary. We calculated summary (mean and median) scores and standard deviations for Partner and staff evaluation questionnaire data, examining this for differences between topic (physical activity or nutrition), research area, or delivery type (in person or pre-recorded). Goals set by nurseries in each cycle were collated and mapped to the self-assessment form categories. Mean scores for each self-assessment category were calculated, as well as percentage change across mean category scores at different points (end of cycle 1, end of cycle 2). Partner support log data were analysed using descriptive statistics. Triangulation was used to identify confirmatory or contradictory results by comparing different data sources: observations, questionnaires, document analysis and interviews. We found that across the data sources, there was strong congruence. Ethical approval The University of Bristol Faculty of Health Sciences Research Ethics Committee gave ethical approval for this study (Ref: 93764). Written or verbal informed consent were obtained from participants for all data collection as specified in the protocols agreed by the ethics committee. Results Contextual factors affecting fidelity, acceptability, feasibility and sustainability of NAPSACC UK are discussed throughout and summarised in Box 2. Box 2: Major contextual changes occurring during trial COVID-19 global pandemic: The coronavirus global pandemic started in 2020 and increased financial pressures on providers and instability in the childcare provider sector. The pandemic also exacerbated existing staffing issues with recruitment and retention of staff, particularly highly-qualified staff 26 . ‘Brexit’: The UK’s decision to leave the European Union came into effect in 2020 and led to increased difficulty in recruiting new staff across the social care sector 27 . Cost of living : The UK ‘cost of living crisis’ started in 2021 and refers to a fall in average household disposable incomes, meaning that the cost of everyday household essentials such as energy and grocery bills are increasing at a faster rate than income 28 . Since 2021 there has been an increase in the percentage of families experiencing difficulties meeting childcare costs 29 . Increase in Government-funded free childcare hours in England and Scotland : In England, he entitlement of 30 free hours childcare for three-to-four year olds for eligible parents (those that earn less than £100,000 a year each) is being expanded to include children from nine months old in phases from April 2024 onwards with full entitlement in place from September 2025 26 . In Scotland, the amount of funded childcare for three-to-four year olds and eligible two-year olds was expanded from 600 hours to 1,140 hours in August 2021 (delayed from August 2020 due to the pandemic) 8 . Increased closure of childcare providers: Since 2015, there has been a steady decrease in the number of childcare providers in England 26 . From 2022 to 2023 there was an estimated 5% decrease in the total number of providers, and a 10% decline in the number of childminders 30 . Fidelity Fifty-two nurseries were randomised, with 25 allocated to NAPSACC UK (Table 2). Six nurseries did not implement the intervention: two formally withdrew; four cited staffing issues; one closed following a government inspection; and one did not provide a reason. Ten intervention nurseries (40%) completed two cycles of self-assessment and goal setting and nineteen (76%) completed one cycle. No nurseries implemented two cycles lasting the full six months, as originally intended. Table 2: NAPSACC UK implementation NAPSACC UK Intervention component Cycle 1 Cycle 2 Partners Partner training 18/18 Partners trained (100%) Partner support 13/13 Partners provided support throughout intervention (100%) 318 contacts in total across 21 nurseries Nurseries Cycles Cycle 1 Cycle 2 19/25 nurseries (76%) Mean length* 5.5 months (range 3-9 months) 10/25 nurseries (40%) Mean length* 3.5 months (range 2-5 months) Self-assessment Cycle 1 Cycle 2 20/25 nurseries (80%) 10/25 nurseries (40%) Goal setting Cycle 1 Cycle 2 20/25 nurseries (80%) 10/25 nurseries (40%) Staff workshops Cycle 1 Initial workshops Cycle 2 Top-up workshop 20/25 nurseries (80%) 9 in-person, 9 online, 2 mixed 9/25 nurseries (36%) All online *Cycle length is an approximation calculated using the halfway point between the initial workshops and final Partner-manager meeting. Twenty nurseries completed the self-assessment, set goals and implemented staff workshops at cycle 1 (including the nursery which subsequently closed before implementing any changes). Scheduling staff workshops was challenging. Several nurseries were at risk of dropping out with time constraints and staffing issues preventing in-person workshops. In response, we provided pre-recorded videos covering the same content (minus interactive group elements). Consequently, nine nurseries completed in-person workshops, nine accessed were pre-recorded training and two received a mix of both. To examine potential contamination, we sent questionnaires to control nurseries, with 15 responding (56%). Seven reported introducing physical activity initiatives (e.g. visits from sports coaches, indoor yoga, or outdoor obstacle courses) and six implemented nutrition work (e.g. weekly cooking sessions or reviewing menus) but no evidence of ‘contamination’ (e.g. sharing NAPSACC materials) was found. NAPSACC UK components Partner training Partners were trained August-September 2022 in hybrid in-person/online training sessions, facilitated by nutrition and physical activity (PA) experts. Two thirds attended in-person. Training covered the trial overview, staff workshops delivery, self-assessment and goal setting processes, and their role in providing on-going support. Overall, Partners rating the training highly, reporting it prepared them well for their role (Figure 1). Observations noted Partners appeared engaged and responsive. Partners also reflected positively on training in interviews, with one noting: “I couldn’t have delivered the program without the training” (Partner_SD302) . Partners reported lower levels of confidence after physical activity training, with some finding the content and language too technical: “Some of the physical health messages, there were technical words that I’d never heard before.... there was no way I was going to take them on and then teach somebody else.” (Partner_SS101). Partners found face-to-face training preferable “because you tried the activities, and you could have that back-and-forth conversation” (Partner_SD304). However, for those unable to attend in person, online training was seen as a good alternative that did not affect learning. Nursery Staff Workshops Partners delivered workshops to nursery staff throughout 2022. Observation, interview, and questionnaire data indicated nursery staff rated the training highly (Figure 2). Nursery managers felt Partners were the right people to deliver the training, demonstrating good knowledge and expertise: “they really knew their stuff” (Manager_AA5023). Staff workshop questionnaires and observations indicated staff particularly valued training on portion sizes and serving practices. We identified some minor modifications to workshop content, including shortening workshops to fit with nursery timescales, and removing ‘technical’ physical activity content which Partners judged staff might struggle with: “The language was very technical, I couldn’t even say some of the words… proprio[ceptor]…? ” (Partner_SS104). However, some staff (in preschools or school-based nurseries) reported wanting more in-depth content: “We already knew most of it and the bits we didn't know, they tended to skim over… there was some stuff that was quite interesting, but they didn't really go into depth on that... So the higher-level stuff would have been of more interest.” (Manager_SW2034) Consequently, some managers felt workshop content should have been tailored to each setting: “If we met beforehand, we could have discussed [it]... It could have been more bespoke for us. ” (Manager_SS1041). Staff workshops were challenging to organise; scheduling delays meant several nurseries only completed one cycle. Managers often struggled to free up staff for the workshops: “I think our biggest barrier is just having that time off the floor to do things” (Manager_SS1041). Other barriers included low staff numbers, and reluctance to ask staff to work extra hours, even if paid. These scheduling delays presented difficulties for Partners: “There was a big gap between training and going into the nurseries, so we then felt that we had kind of forgotten what we had learnt” (Partner_SW201). Staff workshops were held in-person (as intended) in nine nurseries with 139 staff attending. Staff reported in-person training helped encourage exchange of ideas and provided a rare opportunity for staff to meet together: “We don’t often get a chance to sit down together because we’re always with the children... So it did help ignite a little bit of, ‘we can do that, we can do this.’” (Manager_SS1006) Partners also highlighted the benefits of in-person training, particularly the opportunity to develop relationships: “It helped build those relationship where the nursery knows what we are, what we do, who to go to if they need any support.” (Partner_SD302). Staff receiving pre-recorded training (n= 9 nurseries) rated it marginally lower than in-person training, but still with high levels of acceptability (Additional File 2). Managers appreciated this flexibility in training provision, noting they would have been unable to continue with NAPSACC UK without this option. Self-assessment Self-assessment forms were completed by 20 nurseries in cycle 1 and 10 nurseries in cycle 2 (Table 2). Scores increased for all five assessment areas (Figure 3), with greater increases in nurseries completing two cycles (Additional File 3). Across all items, average scores increased by 22%. Nurseries in the most deprived area started with lower scores, but ended with similar or higher scores to the less deprived nurseries, indicating greater progress. Full scores are presented in Additional File 3. Nursery managers found the self-assessment form useful in identifying their strengths and areas for improvement e, with one commenting “It really made me step back and look at what we need to do as a setting” (Manager_SD3016). Completing the assessment at the start and end of the cycle(s) helped them recognise their progress: “If we didn't do [the self-assessment] at the beginning, halfway through and at the end, you may not have noticed the changes because you implement them and they become normal everyday things. But when you look back, it's because of [NAPSACC] that these things have happened.” (Manager_SS1041) Partners similarly felt the self-assessment provided managers with a rare opportunity to reflect on current practices in a busy nursery setting. Managers and Partners reported no issues with completing the form but felt it needed better tailoring to different settings (e.g. not all nurseries provided lunchtime meals). Goal setting Nurseries were asked to set eight goals at the start of each cycle. Only 55% (n=11) set eight goals in cycle 1 (range 5-8), and only 20% (n=5) set eight goals in cycle 2 (range 1-8). On average, 77% of goals were fully or partially achieved (83% for nutrition, 70% for physical activity) (Additional File 4). Nurseries generally set goals in areas with lower self-assessment scores. For both nutrition and physical activity, most focused on increasing knowledge e.g. staff training or parent/child education (Figures 6 and 7). Nurseries also set goals to write/update around policies (e.g. physical activity, nutrition or screentime). Notably policy goals were least likely to be achieved, with managers struggling to find time or encountering barriers to approval: “When you implement the policy it's gotta go to head office. It's gotta go to head [teacher] and then it's gotta go to governors. And then when they have a meeting that then needs to be approved, then it can go through.” (Manager_SS1041) While most goals were at least partially achieved, managers felt staff capacity sometimes limited progress. Staff shortages meant managers had to prioritise maintaining safe staff-child ratios rather than “getting together to brainstorm ideas” about how to achieve goals (Manager_SD3016). The goal-setting experience varied across cycles. Some nurseries struggled to set additional goals in cycle 2, feeling they were doing well in most areas and had already made key changes in cycle 1: “The second goal setting is harder because they’ve done a lot of it... [they] were scrabbling around to find goals ” (Partner_SS104). However, other nurseries saw it as an opportunity to build on progress: “When we set the second lot, we could take [it] up to the next level, make it bigger and fully implement it ” (Manager_SS1041). Nursery staff mostly set goals as a team, with both managers and Partners feeling the staff workshops and self-assessment helped with that process. However, many goals lacked specificity, indicating a need for further training to set goals. Partner support On average, Partners contacted each nursery 12 times, mostly via email. We observed no differences in level of Partner support by nursery deprivation level. Nursery managers found the Partner support useful, but varied in how much they drew on this. One manager valued knowing the support was there but had not used it much (Manager SW2034). In contrast, others found Partner support crucial in making the intervention feasible: “The Partner was a massive part of me carrying on with the study. When she said you've got to do targets and I was just like, ‘I don't have time!’. My staff were working to the max!’...But once she simplified it and we looked through it, it was not as challenging as I first thought.” (Manager_SS1050) Partners supported nurseries by assisting with the self-assessment and goal setting, signposting to local resources or national guidance, and generally “ keeping them on track” (Manager AA4020). However, Partners needed on-going support (beyond their initial training) to fulfil their role. Partners valued support from the NAPSACC UK research team in resolving any issues or nursery queries. Partners also found it helpful to connect with other local NAPSACC Partners: “Just being able to have that network of people on the same project helps a lot because you can just discuss things .” (Partner_SD303). A significant challenge for Partners was managing their workload. All Partners had to incorporate NAPSACC into their existing role, meaning they struggled to prioritise NAPSACC activities. Their own team staff shortages created additional pressures: “We’ve lost three members of staff that haven’t been replaced. It’s been difficult... for me to fit NAPSACC in as well as the increased workload” ( Partner_SS104). All Partners agreed any future implementation of NAPSACC would require protected time to properly engage in the role. Sustainability Most managers reported they would sustain the changes made due to NAPSACC UK. They noted positive changes to improve children’s nutrition and activity, such as improving mealtime practices, encouraging activity in all weather, and staff role modelling healthy behaviours to children. Policy goals were less often achieved, but where implemented, managers expected them to continue. Managers had mixed views on continuing with the self-assessment and goal setting. Some managers found them useful tools for planning and reflection, while others felt unlikely to use them again unless shortened and tailored to their setting. Managers felt that staffing issues (including turnover, shortages, and illness) were a significant barrier to implementing and sustaining NAPSACC UK. Staffing issues were experienced by all nurseries, but particularly affected smaller nurseries: “we’re a small team as well so when we’re one person down it makes a big impact” (Manager_SS1006). Though staffing challenges were not new, managers felt they had worsened across the sector, exacerbated by the Covid-19 pandemic: “We were short staffed when we started it and we’re still short staffed now. It’s becoming more and more challenging but that’s how early years is at the moment.” (Manager_SS1041) Several Partners felt NAPSACC UK should be better targeted to nurseries in higher-need areas, with some Partners questioning if the ‘right’ nurseries had been reached. Some enrolled nurseries were, in their opinion, already excelling in many areas and may not have needed the intervention: “The nurseries we were going into were already doing very good things and perhaps weren’t in those pockets of deprivation that we should be in” (Partner_SW201). These Partners suggested using local knowledge to better target nurseries who would most benefit NAPSACC UK support, rather than those participating as “a tick box exercise to put another credit on their front page” (Partner_SS101). Commissioners’ views Overall, commissioners felt the NAPSACC UK aligned well with their strategic focus on enhancing health and wellbeing in early years through upskilling existing staff due to budgetary constraints. Commissioners saw NAPSACC as filling a gap in early years support and felt the autonomy given to settings as a key strength. Commissioners also emphasised the need for effective, evidence-based, and cost-effective interventions: “If it shows an evidence base and effectiveness then that's what we're all quite desperate for really, in terms of early years settings” (Commissioner_11). Commissioners acknowledged a need for a more coordinated effort between Local Authorities and nursery providers to improve early years health. Commissioners valued the relationships NAPSACC fostered between Local Authority/NHS staff and early years practitioners enabled by NAPSACC UK, and felt this co-operation would be sustained. Echoing Partner views, commissioners recognised a need to allocate limited resources strategically by targeting settings where most in need. Commissioners in two areas (Somerset and Sandwell) felt they lacked the infrastructure to embed programmes like NAPSACC UK, suggesting further investment in early years support would be needed to expand NAPSACC UK to more nurseries. Discussion NAPSACC UK was implemented with high fidelity for one cycle (76%), but moderate-to-low fidelity for the intended dose of two cycles (40%). Staff availability and scheduling issues for staff workshops led to delays, preventing some nurseries from completing two cycles. Despite this, engagement was high: all Partners completed their training, and 80% of nurseries engaged with self-assessment, goal setting and workshops during cycle 1. Most goals were achieved (77%), and self-assessment scores improved, with greater gains for those completing two cycles and nurseries from more deprived areas. The intervention was well received by Partners and nursery staff. Most managers were keen to maintain changes but suggested the self-assessment tool could be better tailored to different settings. However, Partners felt their role would not be feasible without protected time. The intervention was implemented amid a childcare crisis in the UK with staff shortages and increased nursery closures 31 . We reflect below on what the process evaluation tells us about implementing NAPSACC in the UK and how our findings can help interpret the main study results. Nursery managers valued the protected time for reflection afforded by the self-assessment and goal setting processes. However, in busy settings, completing this every six months was unfeasible. An annual process linked to other yearly planning activities may be more feasible. The assessment form itself also needs better tailoring to ensure relevance to settings with different provisions. Despite being an environmental intervention, nurseries mostly set goals targeting staff or parent education and often lacked specificity (e.g. ‘professional development on nutrition’ or ‘give information to parents’). It is well-established that information alone is unlikely to drive behaviour change 32 . Research suggests tackling childhood obesity requires both downstream (education/behaviour change) and upstream (policy/environmental) approaches 33 . Some nurseries attempted upstream policy changes, but these were least likely to be achieved due to time constraints and bureaucratic procedures, especially in school-based nurseries or nursery chains. Training was highly valued by nursery staff but was challenging to schedule. In-person training developed staff enthusiasm and strengthened nursery-Partner relationships. However, recorded training also proved acceptable, with broadly comparable quality ratings. Qualitative comments from managers and Partners did not suggest differing levels of enthusiasm or commitment depending on type of training received (in-person vs. pre-recorded), but we were unable to formally test this. In the US, NAPSACC has been optimized into an exclusively online, self-directed format (known as GoNAPSACC), with training moved online and partner support provided remotely via ‘technical assistance’ 34 . A randomized pilot study found this approach effective, with results suggesting the online format can drive changes in nursery environments and practice 34 . High staff turnover in the UK’s early years sector is a potential threat to the sustainability of NAPSACC practices. While in-person training offers benefits in developing shared practice and enthusiasm, inducting new staff into the ‘NAPSACC ethos’ via recorded training may offer a potential solution, but warrants further testing. The Partner support role requires further careful consideration. Nurseries valued the support offered, but Partners struggled to balance NAPSACC within their already-stretched existing roles. They also required additional support (beyond their initial training) to understand their role, and how best to support nurseries. The process evaluation findings provide evidence for self-reported improvements in physical activity and nutrition provision, practices and policies in early years settings. The intervention also proved feasible for nurseries in areas of high deprivation, who made significant gains without need of additional Partner support. However, the main trial found no evidence these changes increased child physical activity or reduced overall energy consumption (although there was evidence of fewer calories consumed at lunchtimes) 22 . One reason for this may be the lower-than-intended intervention ‘dose’ received: only 40% of nurseries implemented two full cycles as intended. This lower dose is largely explained by the challenging implementation: on-sector-wide staffing shortages and Partner work pressures delayed initial staff workshops, leaving many without enough time to implement a second cycle. Nurseries implementing two cycles showed greatest self-assessment improvements, suggesting benefits to repeating the process. However, the original US-based NAPSACC intervention included only one cycle, with evidence of improvements in child zBMI 14 . Another reason for the lack of impact may be that nurseries set goals unlikely to measurably improve physical activity or energy intake. Most goals targeted staff (or parent) knowledge with far fewer specifically setting goals to change menus or increase activity opportunities. Additionally, policy-based goals which would influence practice across the setting were least likely to be implemented. The areas in which goals were set, while improving quality, may have been less directly related to frequency or intensity of physical activity. Similarly, many areas of nutrition targeted by NAPSACC UK were related to broader aspects of nutrition and feeding (such as menu variety, staff eating meals with the children, cooking skills) which were not measured in the main trial outcomes. It is interesting to note however the main trial reported lower lunch energy servings and consumption in the intervention arm. Free-text questionnaire comments and workshop observations suggested nursery staff were particularly influenced by trained on appropriate portion sizes for young children. The change observed in lunchtime energy consumption may result from staff changing portions sizes and checking satiety before offering additional servings. Box 3: Lessons learned from NAPSACC UK Provide nurseries with protected time to reflect on practice NAPSACC UK self-assessment and goal setting tools could be incorporated into annual review practices Prioritise in-person training where possible In-person training provides valuable opportunities to build collective practice and commitment But capitalise on the benefits of online training too Online pre-recorded training could be used to induct new staff into the ‘NAPSACC’ ethos Streamline self-assessment to increase relevance Tailor the self-assessment content to each nursery by removing irrelevant content Encourage specific, measurable, achievable goals Use the self-assessment to support nurseries to set specific and measurable goals to improve physical activity and nutritional quality And goals that go beyond increasing knowledge Providing information alone won’t drive behaviour change. Goals should target both downstream changes (increasing education and knowledge on healthy diets and physical activity) and upstream changes (changing policy or physical environments) Provide protected time for Partner support Allowing partners protected time within their job role to provide support to nurseries Focus on nurseries with greatest need Where time and resources are limited, focusing attention on nurseries with children from more deprived backgrounds may help address inequalities. Strengths and limitations Our multi-method analysis comprehensively assessed the feasibility, acceptability, sustainability and implementation context of NAPSACC UK. We spoke to key actors (managers, Partners, researchers and commissioners) to understand how it was implemented, with analysis conducted blind to main trial outcomes. Congruence between triangulated data sources lends credibility to our findings. Three managers could not be interviewed due to capacity issues. Instead, relevant information was gathered from Partner interviews and discussions with the research staff and Trial Manager. One Partner did not respond to an interview request, but we obtained relevant information from another Partner working with the same nurseries. We did not include parent perspectives on NAPSACC UK. As NAPSACC is an environmental intervention targeting nursery setting we feel this was justified but acknowledge parent interviews could have provided valuable insights into the changes observed in home-provided lunchboxes. We were able to record how many staff were given access to the pre-recorded training, but not how many accessed it. However, we received over 100 evaluation forms for the pre-recorded training suggesting a substantial staff engagement. Finally, mapping nursery-set goals to the self-assessment categories was both difficult and, to an extent, subjective. Other researchers may have mapped the goals differently, but this is unlikely to have changed our overall conclusions. Conclusions Despite unprecedented pressures in the early years sector, engagement with NAPSACC UK was high. Nurseries reported improvements in nutrition and physical activity provision, practices and policies. Most goals were achieved and self-assessment scores increased in all areas. However, the intervention did not improve children’s physical activity or total energy consumption 22 . This may be due to a lack of dose (60% of nurseries completed only one cycle) or because goals often focused on increasing knowledge rather than specific behavioural changes. Given the lack of impact on child health outcomes and the challenges of staff capacity and time, broader policy-level and statutory changes, such as free lunches with mandated nutritional standards, may be more effective in improving child health and addressing inequalities. Abbreviations BTC Bristol Trials Centre ECEC Early Childhood Education and Care settings NAPSACC Nutrition and Physical Activity Self-Assessment for Childcare NIHR National Institute for Health and Care Research RCTs Randomised Controlled Trials RSMs Research Site Managers Declarations Ethical approval and consent to participate The University of Bristol Faculty of Health Sciences Research Ethics Committee gave ethical approval for this study (Ref: 93764). Written or verbal informed consent were obtained from participants for all data collection as specified in the protocols agreed by the ethics committee. Consent for publication Not applicable. Availability of data and materials Data for the NAP SACC UK study is available upon request after approval with a signed data access agreement ( https://data.bris.ac.uk/data/). The study protocol was published in the BMC public health and is available at: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-16229-y. The statistical analysis plan is available at: (Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC UK Trial): Statistical Analysis Plan - University of Bristol) and the health economics analysis plan is available at: (HEALTH ECONOMICS ANALYSIS PLAN (HEAP) NAP SACC UK - University of Bristol). Competing interests The authors declare that they have no competing interests. Funding The NAP SACC UK study is funded by the UK National Institute for Health and Care Research (NIHR) Public Health Research Programme (12/75/51). This study was designed and delivered in collaboration with the Bristol Trials Centre (BTC), a UKCRC Registered Clinical Trials Unit which is in receipt of NIHR CTU Support Funding. RJ is partly supported by National Institute for Health and Care Research (NIHR) Applied Research Collaboration West (NIHR ARC West). SAS and SC were supported by the Medical Research Council (MC_UU_00022/1) and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates (SPHSU16). None of the funders nor the study sponsor had involvement in the Trial Steering Committee, the collection, analysis, or interpretation of data or writing of the paper. Authors’ contributions JC/KH/SC/RJ/ZT/SAS/MP/MC/RK/RL contributed to study conceptualisation, design and management. RL led the process evaluation. JC/KH/RK/RL/SC contributed to development of data collection tools and analysis methodologies. JC conducted all interviews and JC/RL/TR performed data analysis. JC wrote the first draft of the manuscript with input from RL. All authors (JC/KH/SC/TR/RJ/ZT/SAS/MP/MC/RK/RL) critically reviewed and revised the manuscript, and all authors have read and approved the final manuscript. Authors’ information 1 Bristol Medical School, University of Bristol, Bristol, United Kingdom, 2 School of Social and Political Sciences, University of Glasgow, Glasgow, United Kingdom, 3 National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), Bristol, United Kingdom, 4 School for Policy Studies, University of Bristol, Bristol, United Kingdom, 5 MRC/CSO Social & Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom, 6 Department of Applied Health Sciences, University of Birmingham, Birmingham, United Kingdom. Acknowledgements We wish to express our thanks to the Public Health staff who delivered the intervention within Sandwell Borough Council, Somerset County Council, Swindon Borough Council and Ayrshire and Arran NHS Health board. We would like to thank everyone within the NAPSACC UK team, with a particular thanks to Kate Willis, Liping Wen, Esther Kissane-Webb, Megan Pardoe, Alex Dobell, Anne Martin, Fieldworkers, Administrators, Coders, Data and Finance managers who have contributed during the study. We would like to express our thanks to our Trial Steering Committee, chaired by Ashley Adamson, for their advice and support. We would like to express our sincere thanks to all the participants, without whom this research would not have been possible. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the UK Department of Health. References Development Initiatives. Development Initiatives, 2018. 2018 Global Nutrition Report: shining a light to spur action on nutrition. Bristol, UK: Development Initiatives. Available at who.int/nutrition/globalnutritionreport/2018_Global_ Nutrition_Report.pdf?ua=1 Accessed 11/01/2025. Dias KI, White J, Jago R, Cardon G, Davey R, Janz KF, Pate RR, Puder JJ, Reilly JJ, Kipping R. International Comparison of the Levels and Potential Correlates of Objectively Measured Sedentary Time and Physical Activity among Three-to-Four-Year-Old Children. Int J Environ Res Public Health. 2019 May 31;16(11):1929 Neave, A. NHS England: Health Survey for England 2015 Physical activity in children. 2016. [Available from: https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/health-survey-for-england-2015] England Public Health. National Diet and Nutrition Survey Rolling Programme Years 9 to 11 (2016/2017 to 2018/2019). 2020. [Available from: https://www.gov.uk/government/statistics/ndns-results-from-years-9-to-11-2016-to-2017-and-2018-to-2019] Jebeile H, Kelly A, O’Malley G, Baur L. Obesity in children and adolescents: epidemiology, causes, assessment and management. The Lancet: Diabetes and endocrinology. 2022:10(5);351-365 Wolfenden L, Barnes C, Jones J, Finch M, Wyse RJ, Kingsland M, Tzelepis F, Grady A, Hodder RK, Booth D, Yoong SL. Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services. Cochrane Database of Systematic Reviews 2020, Issue 2. Art. No.: CD011779. Yoong SL, Lum M, Wolfenden L, Jackson J, Barnes C, Hall AE, McCrabb S, Pearson N, Lane C, Jones JZ, Nolan E, Dinour L, McDonnell T, Booth D, Grady A. Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years. Cochrane Database of Systematic Reviews 2023, Issue 8. Art. No.: CD013862. DOI: 10.1002/14651858.CD013862.pub3. Scottish Government. 2024. Policy: Early education and care (Early learning and childcare expansion programme. [Accessed 11 November 2024]. [Available from: https://www.gov.scot/policies/early-education-and-care/early-learning-and-childcare/ - :~:text=Secondary%20legislation%20was%20passed%20in%202019%20amending%20the,would%20have%20increased%20to%201%2C140%20hours%20a%20year.] Naumann I, McLean C, Koslowski A, Tisdall K and Lloyd E. Early childhood education and care provision: international review of policy, delivery and funding: final report. Scottish Government Social Research, 2013. [Accessed on 18 th December 2024]. [Available at: 8 Country report: France - EARLY CHILDHOOD EDUCATION AND CARE PROVISION: INTERNATIONAL REVIEW OF POLICY, DELIVERY AND FUNDING - gov.scot] Australian Government. 2024. About early childhood education and care in Australia. [Accessed on 18 th December 2024]. [Available at: About early childhood education and care in Australia - Department of Education, Australian Government]. Friendly M, Beach J, Aruran G, Cossette A, Lillace J and Forer B. The state of Candian early childhood education and care in 2024. Childcare Resource and Research Unit. [Available at: The state of Canadian early childhood education and care in 2024 | childcarecanada.org]. HM Government: Childcare choices. Childcare expansion: early years childcare 2024 [Available from: https://www.childcarechoices.gov.uk/childcare-expansion/early-years-childcare.] Ward D, Benjamin S, Ammerman A, Ball S, Neelon B, Bangdiwala S. Nutrition and physical activity in childcare: results from an environmental intervention. Am J Prev Med. 2008;35(4):352-6. Alkon A, Crowley A, Neelon S, Hill S, Pan Y, Nguyen V, et al. Nutrition and physical activity randomized control trial in in child care centers improves knowledge, policies, and children's body mass index. BMC Public Health. 2014;14(1). Bonis M, Loftin M, Ward D, Tseng T, Clesi A, Sothern M. Improving physical activity in daycare interventions. Child Obesity. 2014;10(4):334-41. Smith FT, Kipping R, Yoong S, Hannam K, Langford R, Barnes C, Cooper J, Pallan M, Lum M, Hales D, Burney R, Herr M and Willis EA. Adapting the nutrition and physical activity self-assessment (NAPSACC): a cross-country case study of improving early childhood health environments in the Unites States, Australia and the United Kingdom. Childhood obesity. (in press) West M, Dooyema C, Smith FT, Willis EA, Clarke E, Starr AS, Hall K, Hales DP and Ward DS. Multi-state implementation of Go NAPSACC to support healthy practices in the early care and education setting. Health Promotion Pract. 2023;24(1 Suppl):145S-151S. doi: 10.1177/15248399221118890 Kipping R, Jago R, Metcalfe C, White J, Papadaki A, Campbell R, et al. NAP SACC UK: protocol for a feasibility cluster randomised controlled trial in nurseries and at home to increase physical activity and healthy eating in children aged 2–4 years. BMJ Open. 2016;6. Langford R, Jago R, White J, Moore L, Papadaki A, Hollingworth W, et al. A physical activity, nutrition and oral health intervention in nursery settings: process evaluation of the NAP SACC UK feasibility cluster RCT. BMC Public Health. 2019;19. Kipping R, Langford R, Brockman R, Wells S, Metcalfe C, Papadaki A, et al. Child-care self-assessment to improve physical activity, oral health and nutrition for 2- to 4-year-olds: a feasibility cluster RCT. Public Health Research. 2019. Kipping R, Pallan M, Hannam K, Willis K, Dobell A, Metcalfe C, et al. Protocol to evaluate the efectiveness and cost-efectiveness of an environmental nutrition and physical activity intervention in nurseries (Nutrition and Physical Activity Self Assessment for Child Care - NAP SACC UK): a multicentre cluster randomised controlled trial. BMC Public Health. 2023;23. Kipping R, Simpson SA, Hannam K, Blair P, Jago R, Martin CK, et al. Effectiveness of an environmental nutrition and physical activity intervention in early childhood education and care settings: A multicentre cluster randomised controlled trial (NAP SACCUK). Lancet Public Health. 2025. (To submit) Moore G F, Audrey S, Barker M, Bond L, Bonell C, Hardeman W et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015; 350 :h1258 doi:10.1136/bmj.h1258 Skivington K, Matthews L, Simpson S A, Craig P, Baird J, Blazeby J M et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021; 374 :n2061 doi:10.1136/bmj.n2061 Kipping R, Langford R, Brockman R, Wells S, Metcalfe C, Papadaki A, et al. Child-care self-assessment to improve physical activity, oral health and nutrition for 2-to 4-year-olds: a feasibility cluster RCT. Public Health Res 2019;7(13). Goddard J. Early years education: Trends, issues and the impact of Covid-19. UK Parliament: House of Lords Library. 2023. [Available at: Early years education: Trends, issues and the impact of Covid-19 - House of Lords Library]. [Accessed on November 26 th 2024]. Martin C., Hockaday C., Stevenson S. and Pollok M. The Contribution of EU Workers in the Social Care Workforce in Scotland 2022. 2022. [Available at: Supporting documents - The Contribution Of EU Workers In The Social Care Workforce In Scotland 2022 - gov.scot]. [Accessed on November 26 th 2024]. Webster P and Neal K. The ‘cost of living crisis’. Journal of Public Health, 2022:44(3):475–476. https://doi.org/10.1093/pubmed/fdac080 Department for Education. Childcare and early years survey of parents. 2024a. [Available at: Childcare and early years survey of parents, Reporting year 2023 - Explore education statistics - GOV.UK]. [Accessed on November 26 th 2024]. Department for Education. Childcare and early years providers survey. 2024b. [Available at: Childcare and early years provider survey, Reporting year 2023 - Explore education statistics - GOV.UK]. [Accessed December 5 th 2024]. House of Commons Education Committee. Support for childcare and the early years. 2023. Available at: https://publications.parliament.uk/pa/cm5803/cmselect/cmeduc/969/report.html. [Accessed 20 November 2024]. Kelly MP and Barker M. Why is changing health-related behaviour so difficult?. Public Health, 2016:136:109-116. https://doi.org/10.1016/j.puhe.2016.03.030 Spiga F, Davies AL, Tomlinson E, Moore THM, Dawson S, Breheny K, Savović J, Gao Y, Phillips SM, Hillier-Brown F, Hodder RK,Wolfenden L, Higgins JPT, Summerbell CD. Interventions to prevent obesity in children aged 5 to 11 years old. Cochrane Database of Systematic Reviews. 2024, Issue 5. Art. No.: CD015328. DOI: 10.1002/14651858.CD015328.pub2. Ward, D.S., Vaughn, A.E., Mazzucca, S. et al. Translating a child care based intervention for online delivery: development and randomized pilot study of Go NAPSACC. BMC Public Health 17 , 891 (2017). https://doi.org/10.1186/s12889-017-4898-z Additional Declarations No competing interests reported. Supplementary Files NAPSACCUKPEIJBNPAsubmissionAdditionalfiles.pdf Cite Share Download PDF Status: Published Journal Publication published 13 Feb, 2026 Read the published version in International Journal of Behavioral Nutrition and Physical Activity → Version 1 posted Editorial decision: Revision requested 29 Jul, 2025 Reviews received at journal 28 Jul, 2025 Reviewers agreed at journal 07 Jul, 2025 Reviews received at journal 26 May, 2025 Reviewers agreed at journal 07 May, 2025 Reviewers agreed at journal 06 May, 2025 Reviewers invited by journal 05 May, 2025 Editor assigned by journal 21 Apr, 2025 Submission checks completed at journal 21 Apr, 2025 First submitted to journal 17 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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RCT","fulltext":[{"header":"Background","content":"\u003cp\u003eOn a global scale, young children are not meeting physical activity or dietary national recommendations\u003csup\u003e1,2\u003c/sup\u003e. In the UK, only 9% of 2-4 year-olds met the recommended minimum of three hours physical activity per day\u003csup\u003e3\u003c/sup\u003e and 15% of 1.5-3 year olds consumed the recommended amount or less of free sugars\u003csup\u003e4\u003c/sup\u003e. Lower than recommended levels of physical activity and dietary factors, including consumption of energy-dense foods, large portions sizes and snacking contribute to a complex dynamic of biological, environmental and behavioural associations with obesity\u003csup\u003e5\u003c/sup\u003e. Consequently, there is a critical need to improve young children\u0026rsquo;s physical activity and diet.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEarly childhood education and care (ECEC) settings (such as nurseries, pre-schools or day-care \u0026ndash; hereafter referred to as nurseries) are an important environment in which young children spend a substantial amount of time. A systematic review of the implementation of policies, practices or programmes by childcare services for child\u0026nbsp;healthy eating, physical activity and\u0026nbsp;obesity\u0026nbsp;prevention concluded they may improve the implementation of these but have little to no impact on child\u0026nbsp;diet, physical activity or weight\u003csup\u003e6\u003c/sup\u003e. Consistently, a systematic review of childhood services aimed at improving child diet quality reported that these approaches may do so slightly for this outcome, but there was little to no difference in BMI\u003csup\u003e7\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIt is common in developed countries for most children to spend significant periods of time in nurseries in the years before starting school, with many governments around the world encouraging attendance with funding or subsidies\u003csup\u003e8,9,10,11\u003c/sup\u003e. In England and Scotland, government-funded childcare has increased to 30 hours per week\u003csup\u003e12\u003c/sup\u003e. As such, nurseries are key settings to improve nutrition and physical activity in young children.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Nutrition and Physical Activity Self-Assessment for Childcare (NAPSACC) intervention was developed in the United States to improve nutrition and physical activity in nursery settings through modifications to the environment, policies and practices of nurseries via a process of self-assessment and targeted technical assistance\u003csup\u003e13\u003c/sup\u003e. Randomised Controlled Trials (RCTs) of NAPSACC in the US have shown effectiveness across several outcomes including: body mass index (zBMI); environmental audit nutrition score; accelerometer-measured physical activity; and health knowledge of nursery staff\u003csup\u003e13,14,15\u003c/sup\u003e. The intervention is currently used in over 30 states across the US\u003csup\u003e16,17\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe NAPSACC intervention was adapted for the UK and a feasibility cluster-RCT was conducted in 2015-2016\u003csup\u003e18,19,20\u003c/sup\u003e. The intervention was acceptable and feasible. A full-scale cluster-RCT\u003csup\u003e21\u003c/sup\u003e to evaluate the effectiveness and cost-effectiveness of NAPSACC UK commenced in 2019, seeking to improve nutritional quality and physical activity, while reducing sedentary time and portion size in line with national recommendations. See Box 1 for a brief outline of the intervention, with further details in the study protocol\u003csup\u003e21\u003c/sup\u003e. \u0026nbsp;The trial found no evidence of an intervention effect for the co-primary outcomes of average kcal/occasion consumed at nurseries or minutes of total physical activity (mean difference -2.13 [-10.96,6.70], p=0.64). There was some evidence that the intervention reduced Kcal served and consumed at lunch\u003csup\u003e22\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBox 1: NAPSACC UK intervention\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eNAPSACC UK Partners* are trained to work with nursery staff to improve child physical activity and nutrition through a process of self-assessment and goal setting. Partners work with nurseries over a period of a year, to complete two 6-month cycles of self-assessment and goal setting.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThe planned delivery of intervention components comprised:\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePartner training:\u003c/strong\u003e Two days training from physical activity and nutrition specialists on how to deliver staff workshops and support nursery staff.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-assessment form\u003c/strong\u003e: A 101-item multiple-choice questionnaire completed by nursery manager on current nursery practice in nutrition, physical activity and play, outdoor play and learning and screen time.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eStaff workshops:\u003c/strong\u003e 2x3 hours of training in physical activity and nutrition delivered by Partners to nursery staff, followed by two hours training 6 months after.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGoal setting and action planning:\u003c/strong\u003e Nursery manager and Partner agree on eight goals (three nutrition, three physical activity and two of nursery\u0026rsquo;s choice) and develop action plan for improvement\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTailored technical assistance:\u0026nbsp;\u003c/strong\u003eOngoing regular support and advice (approximately once every two weeks during the intervention period) for nursery staff from Partners to help them meet their goals\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e*Partners are public health practitioners with expertise in public health, nutrition or physical activity working in Local Authorities or NHS Boards\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis paper reports the findings of the embedded process evaluation of NAPSACC UK. Drawing on complex intervention and process evaluation frameworks\u003csup\u003e23,24\u003c/sup\u003e, we sought to explore whether the intervention had been implemented with fidelity, and in a way which was acceptable and sustainable. In addition, we explored how context affected the above to aid interpretation of the study findings to draw appropriate recommendations for future implementation, policy and practice\u003csup\u003e21\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eSample and recruitment\u003c/h2\u003e\n\u003cp\u003eNAPSACC UK is a multicentre, parallel-group, two-arm, cluster-RCT with a repeated cross-sectional design\u003csup\u003e21\u003c/sup\u003e. The trial includes nurseries from four areas across England (Somerset, Sandwell, Swindon) and Scotland (Ayrshire \u0026amp; Arran) selected to represent differing levels of deprivation and ethnicity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNurseries were eligible to participate if they were: private nurseries, maintained (local authority-funded) nurseries, nurseries attached to primary schools, private day nurseries, or preschools where lunch was consumed. In each area, all eligible nurseries were invited to participate with consenting nurseries randomly allocated to the NAPSACC UK intervention or usual practice (control) group. We asked intervention nurseries to complete two 6-month cycles of training, self-assessment and goal setting, supported by public health practitioners (\u0026lsquo;Partners\u0026rsquo;) as outlined in Box 1.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData collection\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eWe used both qualitative and quantitative methods to gain a detailed understanding of how NAPSACC UK was implemented and received (Table 1). \u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eObservations\u003c/h3\u003e\n\u003cp\u003eWe observed Partner training sessions and nursery staff workshops to explore fidelity and quality of implementation. Researchers were trained prior to observations to ensure a consistent approach. Observations were semi-structured and included both quantitative scoring and open qualitative observations of: participants attending, training/workshop format, topics covered, what worked well/less well and participant engagement.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eQuestionnaires\u003c/h3\u003e\n\u003cp\u003eQuestionnaires were developed asking partners and nursery staff to rate training elements using a score of 0-5. Partners completed questionnaires to capture views on quality and usefulness of training in preparing them for their role. Nursery staff completed a similar evaluation questionnaire after each workshop. Participants completed questionnaires either on paper or online depending on training delivery. Control nursery managers completed a short questionnaire at the end of the study to assess any changes to usual practice and/or potential contamination.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eInterviews and focus groups\u003c/h3\u003e\n\u003cp\u003eWe interviewed NAPSACC UK Partners, intervention nursery managers and local commissioners in each area upon completion of their involvement in the intervention to explore their experiences and views of the NAPSACC UK programme. All Partners were invited for interview. A sub-sample of nursery managers were interviewed to provide variation in terms of deprivation level, nursery type, nursery size, and level of engagement in NAPSACC UK (informed through conversations with local Research Site Managers (RSMs)). Local commissioners responsible for child health were identified through their original involvement in commissioning NAPSACC UK and invited to participate. Interviews took place before the results of the trial were known. \u0026nbsp;We also conducted two focus groups with the research staff to gather further insight into intervention implementation. Nursery managers were renumerated for taking part in the interviews with a \u0026pound;20 voucher.\u003c/p\u003e\n\u003cp\u003eSemi-structured topic guides were used to structure the conversations, specific to participant type (Partner, nursery manager, commissioner or research team, Additional File 1). We conducted interviews/focus groups online via Microsoft Teams or telephone, recorded with consent and transcribed verbatim.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eDocument analysis\u003c/h3\u003e\n\u003cp\u003eNursery managers completed self-assessment and goal setting forms with Partner support at the start and end of each cycle. The self-assessment forms comprised 101 multiple choice questions across different categories including: child nutrition (food/drink provided, feeding environment, menus and variety, education and professional development, and policy), lunchboxes (food/drink provided, education and professional development, policy, feeding environment), physical activity and play (time provided, indoor play environment, staff practices, education and professional development, and policy), outdoor play and learning (outdoor play, outdoor physical environment, education and professional development, and policy), and screen time. See Kipping et al.\u003csup\u003e25\u003c/sup\u003e for more detail. Goal setting forms recorded areas for improvement and specific goals in those areas. Managers and Partners reviewed goals at the end of each cycle, noting whether they had been fully, partially or not achieved. Partner support logs recorded support given to nurseries throughout the intervention including format, frequency and duration of support.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eFieldnotes\u003c/h3\u003e\n\u003cp\u003eProcess evaluation leads (RL, JC) used fieldnotes to record relevant discussions and reflection throughout the study.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData management\u003c/h3\u003e\n\u003cp\u003eAll qualitative data were anonymised and uploaded to NVIVO 14 to facilitate data management and analysis. Partner/staff questions and documents (self-assessments, goal and support logs) were uploaded to the REDCAP data management system. We assigned anonymised IDs to interview participants; the two-letters included in quote attributions indicate research area (SW-Swindon; SS-Somerset; SD-Sandwell; AA-Ayrshire \u0026amp; Arran).\u003c/p\u003e\n\u003cp\u003eTable 1: Summary of process evaluation methods\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.4145%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDetails\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObservations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.4145%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePartner training sessions (England and Scotland) (n=3)\u003c/li\u003e\n \u003cli\u003eStaff workshops covering physical activity and nutrition workshops across all four sites (n=12). Workshops were sampled to ensure variation in site, topic, nursery size and deprivation level.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestionnaires\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.4145%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePartner training evaluation forms (n=15)\u003c/li\u003e\n \u003cli\u003eStaff workshop evaluation forms (n=200)\u003c/li\u003e\n \u003cli\u003eControl manager questionnaires (n=15)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterviews\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.4145%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eIntervention Manager interviews (n=11)\u003c/li\u003e\n \u003cli\u003ePartner interviews (n=11)\u003c/li\u003e\n \u003cli\u003eLocal commissioners (Local Authority or Health Board staff) interviews (n=5)\u003c/li\u003e\n \u003cli\u003eFocus groups with Research Site Managers, Trial Manager and Project Administrator (n=2, 6 participants in total)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDocument Analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.4145%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSelf-assessment forms (from all intervention nurseries at start and end of each cycle)\u003c/li\u003e\n \u003cli\u003eGoal-setting forms (from all intervention nurseries at start and end of each cycle)\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePartner support log (from all intervention nurseries at end of study)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18.5855%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFieldnotes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81.4145%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFieldnotes taken throughout the study relevant to process evaluation aims\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eQualitative data were analysed using thematic analysis. An initial coding framework was developed by including deductive codes derived from research questions and topic guides. JC and RL used this framework to independently code two transcripts, leading to additional inductive codes being developed. The coding framework was revised through discussion, and applied to three further transcripts by JC and checked by RL. The final framework was applied to all qualitative data from transcripts, observations, and fieldnotes, with additional revisions made where necessary.\u003c/p\u003e\n\u003cp\u003eWe calculated summary (mean and median) scores and standard deviations for Partner and staff evaluation questionnaire data, examining this for differences between topic (physical activity or nutrition), research area, or delivery type (in person or pre-recorded).\u003c/p\u003e\n\u003cp\u003eGoals set by nurseries in each cycle were collated and mapped to the self-assessment form categories. Mean scores for each self-assessment category were calculated, as well as percentage change across mean category scores at different points (end of cycle 1, end of cycle 2).\u003c/p\u003e\n\u003cp\u003ePartner support log data were analysed using descriptive statistics.\u003c/p\u003e\n\u003cp\u003eTriangulation was used to identify confirmatory or contradictory results by comparing different data sources: observations, questionnaires, document analysis and interviews. We found that across the data sources, there was strong congruence.\u003c/p\u003e\n\u003ch3\u003eEthical approval\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe University of Bristol Faculty of Health Sciences Research Ethics Committee gave ethical approval for this study (Ref: 93764). Written or verbal informed consent were obtained from participants for all data collection as specified in the protocols agreed by the ethics committee.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eContextual factors affecting fidelity, acceptability, feasibility and sustainability of NAPSACC UK are discussed throughout and summarised in Box 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBox 2: Major contextual changes occurring during trial\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eCOVID-19 global pandemic:\u003c/strong\u003e The coronavirus global pandemic started in 2020 and increased financial pressures on providers and instability in the childcare provider sector. The pandemic also exacerbated existing staffing issues with recruitment and retention of staff, particularly highly-qualified staff\u003csup\u003e26\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e\u0026lsquo;Brexit\u0026rsquo;:\u003c/strong\u003e The UK\u0026rsquo;s decision to leave the European Union came into effect in 2020 and led to increased difficulty in recruiting new staff across the social care sector\u003csup\u003e27\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCost\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of living\u003c/strong\u003e: The UK \u0026lsquo;cost of living crisis\u0026rsquo; started in 2021 and refers to a fall in average household disposable incomes, meaning that the cost of everyday household essentials such as energy and grocery bills are increasing at a faster rate than income\u003csup\u003e28\u003c/sup\u003e. Since 2021 there has been an increase in the percentage of families experiencing difficulties meeting childcare costs\u003csup\u003e29\u003c/sup\u003e.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIncrease in Government-funded free childcare hours in England and Scotland\u003c/strong\u003e: In England, he entitlement of 30 free hours childcare for three-to-four year olds for eligible parents (those that earn less than \u0026pound;100,000 a year each) is being expanded to include children from nine months old in phases from April 2024 onwards with full entitlement in place from September 2025\u003csup\u003e26\u003c/sup\u003e. In Scotland, the amount of funded childcare for three-to-four year olds and eligible two-year olds was expanded from 600 hours to 1,140 hours in August 2021 (delayed from August 2020 due to the pandemic)\u003csup\u003e8\u003c/sup\u003e.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIncreased closure of childcare providers:\u0026nbsp;\u003c/strong\u003eSince 2015, there has been a steady decrease in the number of childcare providers in England\u003csup\u003e26\u003c/sup\u003e. From 2022 to 2023 there was an estimated 5% decrease in the total number of providers, and a 10% decline in the number of childminders\u003csup\u003e30\u003c/sup\u003e.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eFidelity\u003c/h2\u003e\n\u003cp\u003eFifty-two nurseries were randomised, with 25 allocated to NAPSACC UK (Table 2). Six nurseries did not implement the intervention: two formally withdrew; four cited staffing issues; one closed following a government inspection; and one did not provide a reason. Ten intervention nurseries (40%) completed two cycles of self-assessment and goal setting and nineteen (76%) completed one cycle. No nurseries implemented two cycles lasting the full six months, as originally intended.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eTable 2: NAPSACC UK implementation\u003c/h4\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"547\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNAPSACC UK Intervention component\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePartners\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePartner training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e18/18 Partners trained (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePartner support\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 331px;\"\u003e\n \u003cp\u003e13/13 Partners provided support throughout intervention (100%)\u003c/p\u003e\n \u003cp\u003e318 contacts in total across 21 nurseries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNurseries\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycles\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e19/25 nurseries (76%)\u003c/p\u003e\n \u003cp\u003eMean length* 5.5 months\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(range 3-9 months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e10/25 nurseries (40%)\u003c/p\u003e\n \u003cp\u003eMean length* 3.5 months\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(range 2-5 months)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-assessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e20/25 nurseries (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e10/25 nurseries (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGoal setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e20/25 nurseries (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e10/25 nurseries (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff workshops\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInitial workshops\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTop-up workshop\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e20/25 nurseries (80%)\u003c/p\u003e\n \u003cp\u003e9 in-person, 9 online, 2 mixed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e9/25 nurseries (36%)\u003c/p\u003e\n \u003cp\u003eAll online\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e*Cycle length is an approximation calculated using the halfway point between the initial workshops and final Partner-manager meeting.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwenty nurseries completed the self-assessment, set goals and implemented staff workshops at cycle 1 (including the nursery which subsequently closed before implementing any changes). Scheduling staff workshops was challenging. Several nurseries were at risk of dropping out with time constraints and staffing issues preventing in-person workshops. In response, we provided pre-recorded videos covering the same content (minus interactive group elements). Consequently, nine nurseries completed in-person workshops, nine accessed were pre-recorded training and two received a mix of both.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo examine potential contamination, we sent questionnaires to control nurseries, with 15 responding (56%). Seven reported introducing physical activity initiatives (e.g. visits from sports coaches, indoor yoga, or outdoor obstacle courses) and six implemented nutrition work (e.g. weekly cooking sessions or reviewing menus) but no evidence of \u0026lsquo;contamination\u0026rsquo; (e.g. sharing NAPSACC materials) was found.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eNAPSACC UK components\u0026nbsp;\u003c/h2\u003e\n\u003ch3\u003ePartner training\u003c/h3\u003e\n\u003cp\u003ePartners were trained August-September 2022 in hybrid in-person/online training sessions, facilitated by nutrition and physical activity (PA) experts. Two thirds attended in-person. Training covered the trial overview, staff workshops delivery, self-assessment and goal setting processes, and their role in providing on-going support.\u003c/p\u003e\n\u003cp\u003eOverall, Partners rating the training highly, reporting it prepared them well for their role (Figure 1). Observations noted Partners appeared engaged and responsive. Partners also reflected positively on training in interviews, with one noting: \u003cem\u003e\u0026ldquo;I couldn\u0026rsquo;t have delivered the program without the training\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Partner_SD302)\u003cem\u003e.\u003c/em\u003e Partners reported lower levels of confidence after physical activity training, with some finding the content and language too technical:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Some of the physical health messages, there were technical words that I\u0026rsquo;d never heard before.... there was no way I was going to take them on and then teach somebody else.\u0026rdquo; (Partner_SS101).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePartners found face-to-face training preferable \u003cem\u003e\u0026ldquo;because you tried the activities, and you could have that back-and-forth conversation\u0026rdquo;\u003c/em\u003e (Partner_SD304). However, for those unable to attend in person, online training was seen as a good alternative that did not affect learning.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eNursery Staff Workshops\u003c/h3\u003e\n\u003cp\u003ePartners delivered workshops to nursery staff throughout 2022. Observation, interview, and questionnaire data indicated nursery staff rated the training highly (Figure 2). \u0026nbsp;Nursery managers felt Partners were the right people to deliver the training, demonstrating good knowledge and expertise: \u003cem\u003e\u0026ldquo;they really knew their stuff\u0026rdquo;\u003c/em\u003e (Manager_AA5023). Staff workshop questionnaires and observations indicated staff particularly valued training on portion sizes and serving practices.\u003c/p\u003e\n\u003cp\u003eWe identified some minor modifications to workshop content, including shortening workshops to fit with nursery timescales, and removing \u0026lsquo;technical\u0026rsquo; physical activity content which Partners judged staff might struggle with: \u003cem\u003e\u0026ldquo;The language was very technical, I couldn\u0026rsquo;t even say some of the words\u0026hellip; proprio[ceptor]\u0026hellip;?\u003c/em\u003e\u0026rdquo; (Partner_SS104). However, some staff (in preschools or school-based nurseries) reported wanting more in-depth content:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We already knew most of it and the bits we didn\u0026apos;t know, they tended to skim over\u0026hellip; \u0026nbsp;there was some stuff that was quite interesting, but they didn\u0026apos;t really go into depth on that... So the higher-level stuff would have been of more interest.\u0026rdquo; (Manager_SW2034)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsequently, some managers felt workshop content should have been tailored to each setting: \u003cem\u003e\u0026ldquo;If we met beforehand, we could have discussed [it]... It could have been more bespoke for us.\u003c/em\u003e\u0026rdquo; (Manager_SS1041).\u003c/p\u003e\n\u003cp\u003eStaff workshops were challenging to organise; scheduling delays meant several nurseries only completed one cycle. Managers often struggled to free up staff for the workshops: \u003cem\u003e\u0026ldquo;I think our biggest barrier is just having that time off the floor to do things\u0026rdquo;\u003c/em\u003e (Manager_SS1041). Other barriers included low staff numbers, and reluctance to ask staff to work extra hours, even if paid. These scheduling delays presented difficulties for Partners:\u003cem\u003e\u0026nbsp;\u0026ldquo;There was a big gap between training and going into the nurseries, so we then felt that we had kind of forgotten what we had learnt\u0026rdquo;\u003c/em\u003e (Partner_SW201).\u003c/p\u003e\n\u003cp\u003eStaff workshops were held in-person (as intended) in nine nurseries with 139 staff attending. Staff reported in-person training helped encourage exchange of ideas and provided a rare opportunity for staff to meet together:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We don\u0026rsquo;t often get a chance to sit down together because we\u0026rsquo;re always with the children... So it did help ignite a little bit of, \u0026lsquo;we can do that, we can do this.\u0026rsquo;\u0026rdquo; (Manager_SS1006)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePartners also highlighted the benefits of in-person training, particularly the opportunity to develop relationships: \u003cem\u003e\u0026ldquo;It helped build those relationship where the nursery knows what we are, what we do, who to go to if they need any support.\u0026rdquo;\u003c/em\u003e (Partner_SD302).\u003c/p\u003e\n\u003cp\u003eStaff receiving pre-recorded training (n= 9 nurseries) rated it marginally lower than in-person training, but still with high levels of acceptability (Additional File 2). Managers appreciated this flexibility in training provision, noting they would have been unable to continue with NAPSACC UK without this option.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eSelf-assessment\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eSelf-assessment forms were completed by 20 nurseries in cycle 1 and 10 nurseries in cycle 2 (Table 2). Scores increased for all five assessment areas (Figure 3), with greater increases in nurseries completing two cycles (Additional File 3). Across all items, average scores increased by 22%. Nurseries in the most deprived area started with lower scores, but ended with similar or higher scores to the less deprived nurseries, indicating greater progress. Full scores are presented in Additional File 3.\u003c/p\u003e\n\u003cp\u003eNursery managers found the self-assessment form useful in identifying their strengths and areas for improvement e, with one commenting \u003cem\u003e\u0026ldquo;It really made me step back and look at what we need to do as a setting\u0026rdquo;\u003c/em\u003e (Manager_SD3016). Completing the assessment at the start and end of the cycle(s) helped them recognise their progress:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If we didn\u0026apos;t do [the self-assessment] at the beginning, halfway through and at the end, you may not have noticed the changes because you implement them and they become normal everyday things. But when you look back, it\u0026apos;s because of [NAPSACC] that these things have happened.\u0026rdquo; (Manager_SS1041)\u003c/p\u003e\n\u003cp\u003ePartners similarly felt the self-assessment provided managers with a rare opportunity to reflect on current practices in a busy nursery setting. Managers and Partners reported no issues with completing the form but felt it needed better tailoring to different settings (e.g. not all nurseries provided lunchtime meals).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eGoal setting\u003c/h3\u003e\n\u003cp\u003eNurseries were asked to set eight goals at the start of each cycle. Only 55% (n=11) set eight goals in cycle 1 (range 5-8), and only 20% (n=5) set eight goals in cycle 2 (range 1-8). On average, 77% of goals were fully or partially achieved (83% for nutrition, 70% for physical activity) (Additional File 4).\u003c/p\u003e\n\u003cp\u003eNurseries generally set goals in areas with lower self-assessment scores. For both nutrition and physical activity, most focused on increasing knowledge e.g. staff training or parent/child education (Figures 6 and 7). Nurseries also set goals to write/update around policies (e.g. physical activity, nutrition or screentime). Notably policy goals were least likely to be achieved, with managers struggling to find time or encountering barriers to approval:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When you implement the policy it\u0026apos;s gotta go to head office. It\u0026apos;s gotta go to head [teacher] and then it\u0026apos;s gotta go to governors. And then when they have a meeting that then needs to be approved, then it can go through.\u0026rdquo; (Manager_SS1041)\u003c/p\u003e\n\u003cp\u003eWhile most goals were at least partially achieved, managers felt staff capacity sometimes limited progress. Staff shortages meant managers had to prioritise maintaining safe staff-child ratios rather than \u003cem\u003e\u0026ldquo;getting together to brainstorm ideas\u0026rdquo;\u003c/em\u003e about how to achieve goals (Manager_SD3016).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe goal-setting experience varied across cycles. Some nurseries struggled to set additional goals in cycle 2, feeling they were doing well in most areas and had already made key changes in cycle 1: \u003cem\u003e\u0026ldquo;The second goal setting is harder because they\u0026rsquo;ve done a lot of it... \u0026nbsp;[they] were scrabbling around to find goals\u003c/em\u003e\u0026rdquo; (Partner_SS104). However, other nurseries saw it as an opportunity to build on progress: \u003cem\u003e\u0026ldquo;When we set the second lot, we could take [it] up to the next level, make it bigger and fully implement it\u003c/em\u003e\u0026rdquo; (Manager_SS1041).\u003c/p\u003e\n\u003cp\u003eNursery staff mostly set goals as a team, with both managers and Partners feeling the staff workshops and self-assessment helped with that process. However, many goals lacked specificity, indicating a need for further training to set goals.\u003c/p\u003e\n\u003ch3\u003ePartner support\u003c/h3\u003e\n\u003cp\u003eOn average, Partners contacted each nursery 12 times, mostly via email. We observed no differences in level of Partner support by nursery deprivation level. Nursery managers found the Partner support useful, but varied in how much they drew on this. One manager valued knowing the support was there but had not used it much (Manager SW2034). In contrast, others found Partner support crucial in making the intervention feasible:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The Partner was a massive part of me carrying on with the study. When she said you\u0026apos;ve got to do targets and I was just like, \u0026lsquo;I don\u0026apos;t have time!\u0026rsquo;. My staff were working to the max!\u0026rsquo;...But once she simplified it and we looked through it, it was not as challenging as I first thought.\u0026rdquo; (Manager_SS1050)\u003c/p\u003e\n\u003cp\u003ePartners supported nurseries by assisting with the self-assessment and goal setting, signposting to local resources or national guidance, and generally \u0026ldquo;\u003cem\u003ekeeping them on track\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Manager AA4020).\u003c/p\u003e\n\u003cp\u003eHowever, Partners needed on-going support (beyond their initial training) to fulfil their role. Partners valued support from the NAPSACC UK research team in resolving any issues or nursery queries. Partners also found it helpful to connect with other local NAPSACC Partners: \u003cem\u003e\u0026ldquo;Just being able to have that network of people on the same project helps a lot because you can just discuss things\u003c/em\u003e.\u0026rdquo; (Partner_SD303).\u003c/p\u003e\n\u003cp\u003eA significant challenge for Partners was managing their workload. All Partners had to incorporate NAPSACC into their existing role, meaning they struggled to prioritise NAPSACC activities. Their own team staff shortages created additional pressures: \u003cem\u003e\u0026ldquo;We\u0026rsquo;ve lost three members of staff that haven\u0026rsquo;t been replaced. It\u0026rsquo;s been difficult... for me to fit NAPSACC in as well as the increased workload\u0026rdquo; (\u003c/em\u003ePartner_SS104). All Partners agreed any future implementation of NAPSACC would require protected time to properly engage in the role.\u003c/p\u003e\n\u003ch2\u003eSustainability\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eMost managers reported they would sustain the changes made due to NAPSACC UK. They noted positive changes to improve children\u0026rsquo;s nutrition and activity, such as improving mealtime practices, encouraging activity in all weather, and staff role modelling healthy behaviours to children. Policy goals were less often achieved, but where implemented, managers expected them to continue.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eManagers had mixed views on continuing with the self-assessment and goal setting. Some managers found them useful tools for planning and reflection, while others felt unlikely to use them again unless shortened and tailored to their setting.\u003c/p\u003e\n\u003cp\u003eManagers felt that staffing issues (including turnover, shortages, and illness) were a significant barrier to implementing and sustaining NAPSACC UK. Staffing issues were experienced by all nurseries, but particularly affected smaller nurseries: \u003cem\u003e\u0026ldquo;we\u0026rsquo;re a small team as well so when we\u0026rsquo;re one person down it makes a big impact\u0026rdquo;\u003c/em\u003e (Manager_SS1006). Though staffing challenges were not new, managers felt they had worsened across the sector, exacerbated by the Covid-19 pandemic:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We were short staffed when we started it and we\u0026rsquo;re still short staffed now. It\u0026rsquo;s becoming more and more challenging but that\u0026rsquo;s how early years is at the moment.\u0026rdquo; (Manager_SS1041)\u003c/p\u003e\n\u003cp\u003eSeveral Partners felt NAPSACC UK should be better targeted to nurseries in higher-need areas, with some Partners questioning if the \u0026lsquo;right\u0026rsquo; nurseries had been reached. Some enrolled nurseries were, in their opinion, already excelling in many areas and may not have needed the intervention:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The nurseries we were going into were already doing very good things and perhaps weren\u0026rsquo;t in those pockets of deprivation that we should be in\u0026rdquo; (Partner_SW201).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese Partners suggested using local knowledge to better target nurseries who would most benefit NAPSACC UK support, rather than those participating as \u003cem\u003e\u0026ldquo;a tick box exercise to put another credit on their front page\u0026rdquo;\u003c/em\u003e (Partner_SS101).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eCommissioners\u0026rsquo; views\u003c/h3\u003e\n\u003cp\u003eOverall, commissioners felt the NAPSACC UK aligned well with their strategic focus on enhancing health and wellbeing in early years through upskilling existing staff due to budgetary constraints. Commissioners saw NAPSACC as filling a gap in early years support and felt the autonomy given to settings as a key strength. Commissioners also emphasised the need for effective, evidence-based, and cost-effective interventions:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If it shows an evidence base and effectiveness then that\u0026apos;s what we\u0026apos;re all quite desperate for really, in terms of early years settings\u0026rdquo; (Commissioner_11).\u003c/p\u003e\n\u003cp\u003eCommissioners acknowledged a need for a more coordinated effort between Local Authorities and nursery providers to improve early years health. Commissioners valued the relationships NAPSACC fostered between Local Authority/NHS staff and early years practitioners enabled by NAPSACC UK, and felt this co-operation would be sustained. Echoing Partner views, commissioners recognised a need to allocate limited resources strategically by targeting settings where most in need. Commissioners in two areas (Somerset and Sandwell) felt they lacked the infrastructure to embed programmes like NAPSACC UK, suggesting further investment in early years support would be needed to expand NAPSACC UK to more nurseries.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eNAPSACC UK was implemented with high fidelity for one cycle (76%), but moderate-to-low fidelity for the intended dose of two cycles (40%). Staff availability and scheduling issues for staff workshops led to delays, preventing some nurseries from completing two cycles. Despite this, \u0026nbsp;engagement was high: all Partners completed their training, and 80% of nurseries engaged with self-assessment, goal setting and workshops during cycle 1. Most goals were achieved (77%), and self-assessment scores improved, with greater gains for those completing two cycles and nurseries from more deprived areas. The intervention was well received by Partners and nursery staff. Most managers were keen to maintain changes but suggested the self-assessment tool could be better tailored to different settings. However, Partners felt their role would not be feasible without protected time. The intervention was implemented amid a childcare crisis in the UK with staff shortages and increased nursery closures\u003csup\u003e31\u003c/sup\u003e. We reflect below on what the process evaluation tells us about implementing NAPSACC in the UK and how our findings can help interpret the main study results.\u003c/p\u003e\n\u003cp\u003eNursery managers valued the protected time for reflection afforded by the self-assessment and goal setting processes. However, in busy settings, completing this every six months was unfeasible. An annual process linked to other yearly planning activities may be more feasible. The assessment form itself also needs better tailoring to ensure relevance to settings with different provisions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite being an environmental intervention, nurseries mostly set goals targeting staff or parent education and often lacked specificity (e.g. \u0026lsquo;professional development on nutrition\u0026rsquo; or \u0026lsquo;give information to parents\u0026rsquo;). It is well-established that information alone is unlikely to drive behaviour change\u003csup\u003e32\u003c/sup\u003e. Research suggests tackling childhood obesity requires both \u003cem\u003edownstream\u0026nbsp;\u003c/em\u003e(education/behaviour change) and \u003cem\u003eupstream\u0026nbsp;\u003c/em\u003e(policy/environmental) approaches\u003csup\u003e33\u003c/sup\u003e. Some nurseries attempted upstream policy changes, but these were least likely to be achieved due to time constraints and bureaucratic procedures, especially in school-based nurseries or nursery chains.\u003c/p\u003e\n\u003cp\u003eTraining was highly valued by nursery staff but was challenging to schedule. In-person training developed staff enthusiasm and strengthened nursery-Partner relationships. However, recorded training also proved acceptable, with broadly comparable quality ratings. Qualitative comments from managers and Partners did not suggest differing levels of enthusiasm or commitment depending on type of training received (in-person vs. pre-recorded), but we were unable to formally test this. In the US, NAPSACC has been optimized into an exclusively online, self-directed format (known as GoNAPSACC), with training moved online and partner support provided remotely via \u0026lsquo;technical assistance\u0026rsquo;\u003csup\u003e34\u003c/sup\u003e. A randomized pilot study found this approach effective, with results suggesting the online format can drive changes in nursery environments and practice\u003csup\u003e34\u003c/sup\u003e. High staff turnover in the UK\u0026rsquo;s early years sector is a potential threat to the sustainability of NAPSACC practices. While in-person training offers benefits in developing shared practice and enthusiasm, inducting new staff into the \u0026lsquo;NAPSACC ethos\u0026rsquo; via recorded training may offer a potential solution, but warrants further testing. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Partner support role requires further careful consideration. Nurseries valued the support offered, but Partners struggled to balance NAPSACC within their already-stretched existing roles. They also required additional support (beyond their initial training) to understand their role, and how best to support nurseries.\u003c/p\u003e\n\u003cp\u003eThe process evaluation findings provide evidence for self-reported improvements in physical activity and nutrition provision, practices and policies in early years settings. The intervention also proved feasible for nurseries in areas of high deprivation, who made significant gains without need of additional Partner support. \u0026nbsp;However, the main trial found no evidence these changes increased child physical activity or reduced overall energy consumption (although there was evidence of fewer calories consumed at lunchtimes)\u003csup\u003e22\u003c/sup\u003e.\u0026nbsp;One reason for this may be the lower-than-intended intervention \u0026lsquo;dose\u0026rsquo; received: only 40% of nurseries implemented two full cycles as intended. This lower dose is largely explained by the challenging implementation: on-sector-wide staffing shortages and Partner work pressures delayed initial staff workshops, leaving many without enough time to implement a second cycle. Nurseries implementing two cycles showed greatest self-assessment improvements, suggesting benefits to repeating the process. However, the original US-based NAPSACC intervention included only one cycle, with evidence of improvements in child zBMI\u003csup\u003e14\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother reason for the lack of impact may be that nurseries set goals unlikely to measurably improve physical activity or energy intake. Most goals targeted staff (or parent) knowledge with far fewer specifically setting goals to change menus or increase activity opportunities. Additionally, policy-based goals which would influence practice across the setting were least likely to be implemented. The areas in which goals were set, while improving quality, may have been less directly related to frequency or intensity of physical activity. Similarly, many areas of nutrition targeted by NAPSACC UK were related to broader aspects of nutrition and feeding (such as menu variety, staff eating meals with the children, cooking skills) which were not measured in the main trial outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is interesting to note however the main trial reported lower lunch energy servings and consumption in the intervention arm. Free-text questionnaire comments and workshop observations suggested nursery staff were particularly influenced by trained on appropriate portion sizes for young children. The change observed in lunchtime energy consumption may result from staff changing portions sizes and checking satiety before offering additional servings.\u003c/p\u003e\n\u003cp\u003eBox 3: Lessons learned from NAPSACC UK\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eProvide nurseries with protected time to reflect on practice\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eNAPSACC UK self-assessment and goal setting tools could be incorporated into annual review practices\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003ePrioritise in-person training where possible\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eIn-person training provides valuable opportunities to build collective practice and commitment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eBut capitalise on the benefits of online training too\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eOnline pre-recorded\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003etraining could be used to induct new staff into the \u0026lsquo;NAPSACC\u0026rsquo; ethos\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eStreamline self-assessment to increase relevance\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eTailor the self-assessment content to each nursery by removing irrelevant content\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEncourage specific, measurable, achievable goals\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eUse the self-assessment to support nurseries to set specific and measurable goals to improve physical activity and nutritional quality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAnd goals that go beyond increasing knowledge\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eProviding information alone won\u0026rsquo;t drive behaviour change. Goals should target both downstream changes (increasing education and knowledge on healthy diets and physical activity) and upstream changes (changing policy or physical environments)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eProvide protected time for Partner support\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eAllowing partners protected time within their job role to provide support to nurseries\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eFocus on nurseries with greatest need\u003c/strong\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eWhere time and resources are limited, focusing attention on nurseries with children from more deprived backgrounds may help address inequalities.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003eStrengths and limitations\u003c/h3\u003e\n\u003cp\u003eOur multi-method analysis comprehensively assessed the feasibility, acceptability, sustainability and implementation context of NAPSACC UK. We spoke to key actors (managers, Partners, researchers and commissioners) to understand how it was implemented, with analysis conducted blind to main trial outcomes. Congruence between triangulated data sources lends credibility to our findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThree managers could not be interviewed due to capacity issues. Instead, relevant information was gathered from Partner interviews and discussions with the research staff and Trial Manager. One Partner did not respond to an interview request, but we obtained relevant information from another Partner working with the same nurseries. We did not include parent perspectives on NAPSACC UK. As NAPSACC is an environmental intervention targeting nursery setting we feel this was justified but acknowledge parent interviews could have provided valuable insights into the changes observed in home-provided lunchboxes. We were able to record how many staff were given access to the pre-recorded training, but not how many accessed it. However, we received over 100 evaluation forms for the pre-recorded training suggesting a substantial staff engagement. Finally, mapping nursery-set goals to the self-assessment categories was both difficult and, to an extent, subjective. Other researchers may have mapped the goals differently, but this is unlikely to have changed our overall conclusions.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDespite unprecedented pressures in the early years sector, engagement with NAPSACC UK was high. Nurseries reported improvements in nutrition and physical activity provision, practices and policies. Most goals were achieved and self-assessment scores increased in all areas. However, the intervention did not improve children\u0026rsquo;s physical activity or total energy consumption\u003csup\u003e22\u003c/sup\u003e. This may be due to a lack of dose (60% of nurseries completed only one cycle) or because goals often focused on increasing knowledge rather than specific behavioural changes. Given the lack of impact on child health outcomes and the challenges of staff capacity and time, broader policy-level and statutory changes, such as free lunches with mandated nutritional standards, may be more effective in improving child health and addressing inequalities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eBTC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eBristol Trials Centre\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eECEC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eEarly Childhood Education and Care settings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eNAPSACC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eNutrition and Physical Activity Self-Assessment for Childcare\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eNIHR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eNational Institute for Health and Care Research\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRCTs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eRandomised Controlled Trials\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRSMs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 497px;\"\u003e\n \u003cp\u003eResearch Site Managers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe University of Bristol Faculty of Health Sciences Research Ethics Committee gave ethical approval for this study (Ref: 93764). Written or verbal informed consent were obtained from participants for all data collection as specified in the protocols agreed by the ethics committee. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eData for the NAP SACC UK study is available upon request after approval with a signed data access agreement ( https://data.bris.ac.uk/data/). The study protocol was published in the BMC public health and is available at: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-16229-y. The statistical analysis plan is available at: (Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC UK Trial): Statistical Analysis Plan - University of Bristol) and the health economics analysis plan is available at: (HEALTH ECONOMICS ANALYSIS PLAN (HEAP) NAP SACC UK - University of Bristol). \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe NAP SACC UK study is funded by the UK National Institute for Health and Care Research (NIHR) Public Health Research Programme (12/75/51). This study was designed and delivered in collaboration with the Bristol Trials Centre (BTC), a UKCRC Registered Clinical Trials Unit which is in receipt of NIHR CTU Support Funding. RJ is partly supported by National Institute for Health and Care Research (NIHR) Applied Research Collaboration West (NIHR ARC West). SAS and SC were supported by the Medical Research Council (MC_UU_00022/1) and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates (SPHSU16). None of the funders nor the study sponsor had involvement in the Trial Steering Committee, the collection, analysis, or interpretation of data or writing of the paper.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eJC/KH/SC/RJ/ZT/SAS/MP/MC/RK/RL contributed to study conceptualisation, design and management. RL led the process evaluation. JC/KH/RK/RL/SC contributed to development of data collection tools and analysis methodologies. JC conducted all interviews and JC/RL/TR performed data analysis. JC wrote the first draft of the manuscript with input from RL. All authors (JC/KH/SC/TR/RJ/ZT/SAS/MP/MC/RK/RL) critically reviewed and revised the manuscript, and all authors have read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eBristol Medical School, University of Bristol, Bristol, United Kingdom, \u003csup\u003e2\u003c/sup\u003eSchool of Social and Political Sciences, University of Glasgow, Glasgow, United Kingdom, \u003csup\u003e3\u003c/sup\u003eNational Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), Bristol, United Kingdom, \u003csup\u003e4\u003c/sup\u003eSchool for Policy Studies, University of Bristol, Bristol, United Kingdom, \u003csup\u003e5\u003c/sup\u003eMRC/CSO Social \u0026amp; Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom, \u003csup\u003e6\u003c/sup\u003eDepartment of Applied Health Sciences, University of Birmingham, Birmingham, United Kingdom.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWe wish to express our thanks to the Public Health staff who delivered the intervention within Sandwell Borough Council, Somerset County Council, Swindon Borough Council and Ayrshire and Arran NHS Health board. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe would like to thank everyone within the NAPSACC UK team, with a particular thanks to Kate Willis, Liping Wen, Esther Kissane-Webb, Megan Pardoe, Alex Dobell, Anne Martin, Fieldworkers, Administrators, Coders, Data and Finance managers who have contributed during the study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe would like to express our thanks to our Trial Steering Committee, chaired by Ashley Adamson, for their advice and support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere thanks to all the participants, without whom this research would not have been possible. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the UK Department of Health.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eDevelopment Initiatives. Development Initiatives, 2018. 2018 Global Nutrition Report: shining a light to spur action on nutrition. Bristol, UK: Development Initiatives. Available at who.int/nutrition/globalnutritionreport/2018_Global_ Nutrition_Report.pdf?ua=1 Accessed 11/01/2025.\u003c/li\u003e\n\u003cli\u003eDias KI, White J, Jago R, Cardon G, Davey R, Janz KF, Pate RR, Puder JJ, Reilly JJ, Kipping R. International Comparison of the Levels and Potential Correlates of Objectively Measured Sedentary Time and Physical Activity among Three-to-Four-Year-Old Children. Int J Environ Res Public Health. 2019 May 31;16(11):1929\u003c/li\u003e\n\u003cli\u003eNeave, A. NHS England: Health Survey for England 2015 Physical activity in children. 2016. [Available from: https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/health-survey-for-england-2015]\u003c/li\u003e\n\u003cli\u003eEngland Public Health. National Diet and Nutrition Survey Rolling Programme Years 9 to 11 (2016/2017 to 2018/2019). 2020. [Available from: https://www.gov.uk/government/statistics/ndns-results-from-years-9-to-11-2016-to-2017-and-2018-to-2019]\u003c/li\u003e\n\u003cli\u003eJebeile H, Kelly A, O\u0026rsquo;Malley G, Baur L. Obesity in children and adolescents: epidemiology, causes, assessment and management. The Lancet: Diabetes and endocrinology. 2022:10(5);351-365 \u003c/li\u003e\n\u003cli\u003eWolfenden L, Barnes C, Jones J, Finch M, Wyse RJ, Kingsland M, Tzelepis F, Grady A, Hodder RK, Booth D, Yoong SL. Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services. Cochrane Database of Systematic Reviews 2020, Issue 2. Art. No.: CD011779. \u003c/li\u003e\n\u003cli\u003eYoong SL, Lum M, Wolfenden L, Jackson J, Barnes C, Hall AE, McCrabb S, Pearson N, Lane C, Jones JZ, Nolan E, Dinour L, McDonnell T, Booth D, Grady A. Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years. Cochrane Database of Systematic Reviews 2023, Issue 8. Art. No.: CD013862. DOI: 10.1002/14651858.CD013862.pub3. \u003c/li\u003e\n\u003cli\u003eScottish Government. 2024. Policy: Early education and care (Early learning and childcare expansion programme. [Accessed 11 November 2024]. [Available from: https://www.gov.scot/policies/early-education-and-care/early-learning-and-childcare/ - :~:text=Secondary%20legislation%20was%20passed%20in%202019%20amending%20the,would%20have%20increased%20to%201%2C140%20hours%20a%20year.]\u003c/li\u003e\n\u003cli\u003eNaumann I, McLean C, Koslowski A, Tisdall K and Lloyd E. Early childhood education and care provision: international review of policy, delivery and funding: final report. Scottish Government Social Research, 2013. [Accessed on 18\u003csup\u003eth\u003c/sup\u003e December 2024]. [Available at: 8 Country report: France - EARLY CHILDHOOD EDUCATION AND CARE PROVISION: INTERNATIONAL REVIEW OF POLICY, DELIVERY AND FUNDING - gov.scot]\u003c/li\u003e\n\u003cli\u003eAustralian Government. 2024. About early childhood education and care in Australia. [Accessed on 18\u003csup\u003eth\u003c/sup\u003e December 2024]. [Available at: About early childhood education and care in Australia - Department of Education, Australian Government].\u003c/li\u003e\n\u003cli\u003eFriendly M, Beach J, Aruran G, Cossette A, Lillace J and Forer B. The state of Candian early childhood education and care in 2024. Childcare Resource and Research Unit. [Available at: The state of Canadian early childhood education and care in 2024 | childcarecanada.org].\u003c/li\u003e\n\u003cli\u003eHM Government: Childcare choices. Childcare expansion: early years childcare 2024 [Available from: https://www.childcarechoices.gov.uk/childcare-expansion/early-years-childcare.]\u003c/li\u003e\n\u003cli\u003eWard D, Benjamin S, Ammerman A, Ball S, Neelon B, Bangdiwala S. Nutrition and physical activity in childcare: results from an environmental intervention. Am J Prev Med. 2008;35(4):352-6.\u003c/li\u003e\n\u003cli\u003eAlkon A, Crowley A, Neelon S, Hill S, Pan Y, Nguyen V, et al. Nutrition and physical activity randomized control trial in in child care centers improves knowledge, policies, and children\u0026apos;s body mass index. BMC Public Health. 2014;14(1).\u003c/li\u003e\n\u003cli\u003eBonis M, Loftin M, Ward D, Tseng T, Clesi A, Sothern M. Improving physical activity in daycare interventions. Child Obesity. 2014;10(4):334-41.\u003c/li\u003e\n\u003cli\u003eSmith FT, Kipping R, Yoong S, Hannam K, Langford R, Barnes C, Cooper J, Pallan M, Lum M, Hales D, Burney R, Herr M and Willis EA. Adapting the nutrition and physical activity self-assessment (NAPSACC): a cross-country case study of improving early childhood health environments in the Unites States, Australia and the United Kingdom. Childhood obesity. (in press)\u003c/li\u003e\n\u003cli\u003eWest M, Dooyema C, Smith FT, Willis EA, Clarke E, Starr AS, Hall K, Hales DP and Ward DS. Multi-state implementation of Go NAPSACC to support healthy practices in the early care and education setting. Health Promotion Pract. 2023;24(1 Suppl):145S-151S. doi: 10.1177/15248399221118890\u003c/li\u003e\n\u003cli\u003eKipping R, Jago R, Metcalfe C, White J, Papadaki A, Campbell R, et al. NAP SACC UK: protocol for a feasibility cluster randomised controlled trial in nurseries and at home to increase physical activity and healthy eating in children aged 2\u0026ndash;4 years. BMJ Open. 2016;6.\u003c/li\u003e\n\u003cli\u003eLangford R, Jago R, White J, Moore L, Papadaki A, Hollingworth W, et al. A physical activity, nutrition and oral health intervention in nursery settings: process evaluation of the NAP SACC UK feasibility cluster RCT. BMC Public Health. 2019;19.\u003c/li\u003e\n\u003cli\u003eKipping R, Langford R, Brockman R, Wells S, Metcalfe C, Papadaki A, et al. Child-care self-assessment to improve physical activity, oral health and nutrition for 2- to 4-year-olds: a feasibility cluster RCT. Public Health Research. 2019.\u003c/li\u003e\n\u003cli\u003eKipping R, Pallan M, Hannam K, Willis K, Dobell A, Metcalfe C, et al. Protocol to evaluate the efectiveness and cost-efectiveness of an environmental nutrition and physical activity intervention in nurseries (Nutrition and Physical Activity Self Assessment for Child Care - NAP SACC UK): a multicentre cluster randomised controlled trial. BMC Public Health. 2023;23.\u003c/li\u003e\n\u003cli\u003eKipping R, Simpson SA, Hannam K, Blair P, Jago R, Martin CK, et al. Effectiveness of an environmental nutrition and physical activity intervention in early childhood education and care settings: A multicentre cluster randomised controlled trial (NAP SACCUK). Lancet Public Health. 2025. (To submit)\u003c/li\u003e\n\u003cli\u003eMoore G F, Audrey S, Barker M, Bond L, Bonell C, Hardeman W et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015; 350 :h1258 doi:10.1136/bmj.h1258\u003c/li\u003e\n\u003cli\u003eSkivington K, Matthews L, Simpson S A, Craig P, Baird J, Blazeby J M et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021; 374 :n2061 doi:10.1136/bmj.n2061\u003c/li\u003e\n\u003cli\u003eKipping R, Langford R, Brockman R, Wells S, Metcalfe C, Papadaki A, et al. Child-care self-assessment to improve physical activity, oral health and nutrition for 2-to 4-year-olds: a feasibility cluster RCT. Public Health Res 2019;7(13).\u003c/li\u003e\n\u003cli\u003eGoddard J. Early years education: Trends, issues and the impact of Covid-19. UK Parliament: House of Lords Library. 2023. [Available at: Early years education: Trends, issues and the impact of Covid-19 - House of Lords Library]. [Accessed on November 26\u003csup\u003eth\u003c/sup\u003e 2024].\u003c/li\u003e\n\u003cli\u003eMartin C., Hockaday C., Stevenson S. and Pollok M. The Contribution of EU Workers in the Social Care Workforce in Scotland 2022. 2022. [Available at: Supporting documents - The Contribution Of EU Workers In The Social Care Workforce In Scotland 2022 - gov.scot]. [Accessed on November 26\u003csup\u003eth\u003c/sup\u003e 2024].\u003c/li\u003e\n\u003cli\u003eWebster P and Neal K. The \u0026lsquo;cost of living crisis\u0026rsquo;. Journal of Public Health, 2022:44(3):475\u0026ndash;476. https://doi.org/10.1093/pubmed/fdac080\u003c/li\u003e\n\u003cli\u003eDepartment for Education. Childcare and early years survey of parents. 2024a. [Available at: Childcare and early years survey of parents, Reporting year 2023 - Explore education statistics - GOV.UK]. [Accessed on November 26\u003csup\u003eth\u003c/sup\u003e 2024].\u003c/li\u003e\n\u003cli\u003eDepartment for Education. Childcare and early years providers survey. 2024b. [Available at: Childcare and early years provider survey, Reporting year 2023 - Explore education statistics - GOV.UK]. [Accessed December 5\u003csup\u003eth\u003c/sup\u003e 2024].\u003c/li\u003e\n\u003cli\u003eHouse of Commons Education Committee. Support for childcare and the early years. 2023. Available at: https://publications.parliament.uk/pa/cm5803/cmselect/cmeduc/969/report.html. [Accessed 20 November 2024].\u003c/li\u003e\n\u003cli\u003eKelly MP and Barker M. Why is changing health-related behaviour so difficult?. Public Health, 2016:136:109-116. https://doi.org/10.1016/j.puhe.2016.03.030\u003c/li\u003e\n\u003cli\u003eSpiga F, Davies AL, Tomlinson E, Moore THM, Dawson S, Breheny K, Savović J, Gao Y, Phillips SM, Hillier-Brown F, Hodder RK,Wolfenden L, Higgins JPT, Summerbell CD. Interventions to prevent obesity in children aged 5 to 11 years old. Cochrane Database of Systematic Reviews. 2024, Issue 5. Art. No.: CD015328. DOI: 10.1002/14651858.CD015328.pub2.\u003c/li\u003e\n\u003cli\u003eWard, D.S., Vaughn, A.E., Mazzucca, S. et al. Translating a child care based intervention for online delivery: development and randomized pilot study of Go NAPSACC. BMC Public Health \u003cstrong\u003e17\u003c/strong\u003e, 891 (2017). https://doi.org/10.1186/s12889-017-4898-z\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-behavioral-nutrition-and-physical-activity","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijbn","sideBox":"Learn more about [International Journal of Behavioral Nutrition and Physical Activity](http://ijbnpa.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ijbn/default.aspx","title":"International Journal of Behavioral Nutrition and Physical Activity","twitterHandle":"@IJBNPA","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"obesity, physical activity, nutrition, childcare, pre-school children, process evaluation, qualitative, UK, prevention","lastPublishedDoi":"10.21203/rs.3.rs-6471820/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6471820/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost children attend early childhood education care settings, commonly known as nurseries in the United Kingdom. Nurseries 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 nurseries. We adapted NAPSACC for the UK and investigated its fidelity, acceptability and sustainability within a multi-centre trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEmbedded process evaluation within a cluster randomised controlled trial with 52 nurseries (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 nursery staff; 11 interviews with practitioners who delivered the intervention, 11 nursery 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree-quarters (76%) of intervention nurseries 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. Nursery managers valued the opportunity to reflect on practice and the support offered by the practitioner. Nursery 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 nurseries were achieved (fully or partially) and self-assessment scores increased, with greater gains for nurseries implementing two cycles. Nursery managers planned to maintain the changes made but varied in their intention to continue self-assessment and goal-setting processes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite sector-wide staffing challenges, we saw high engagement from nurseries 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eISRCTN33134697, 31/10/2019\u003c/p\u003e","manuscriptTitle":"An environmental physical activity and nutrition intervention in Early Childhood Education and Care settings: process evaluation of the NAP SACC UK multi-centre cluster RCT","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-12 12:45:45","doi":"10.21203/rs.3.rs-6471820/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-29T19:32:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-28T21:37:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220421543678846312423809443780424126509","date":"2025-07-07T13:38:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-26T08:22:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52887982051836842204164271800535984585","date":"2025-05-07T09:03:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"290738697532988404742240761370597853556","date":"2025-05-06T10:07:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-05T05:38:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-21T10:26:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-21T10:25:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Behavioral Nutrition and Physical Activity","date":"2025-04-17T12:33:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-behavioral-nutrition-and-physical-activity","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijbn","sideBox":"Learn more about [International Journal of Behavioral Nutrition and Physical Activity](http://ijbnpa.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ijbn/default.aspx","title":"International Journal of Behavioral Nutrition and Physical Activity","twitterHandle":"@IJBNPA","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5956c6c2-884e-4112-95c1-4e9feb9a1fe4","owner":[],"postedDate":"August 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:08:11+00:00","versionOfRecord":{"articleIdentity":"rs-6471820","link":"https://doi.org/10.1186/s12966-026-01882-4","journal":{"identity":"international-journal-of-behavioral-nutrition-and-physical-activity","isVorOnly":false,"title":"International Journal of Behavioral Nutrition and Physical Activity"},"publishedOn":"2026-02-13 15:59:22","publishedOnDateReadable":"February 13th, 2026"},"versionCreatedAt":"2025-08-12 12:45:45","video":"","vorDoi":"10.1186/s12966-026-01882-4","vorDoiUrl":"https://doi.org/10.1186/s12966-026-01882-4","workflowStages":[]},"version":"v1","identity":"rs-6471820","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6471820","identity":"rs-6471820","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}