Theorizing child nutrition interventions: a scoping review of the behavior change wheel

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Although preventable, child malnutrition persists due to suboptimal nutrition interventions. Mounting evidence has demonstrated that nutrition interventions informed by sound theoretical frameworks are effective in improving child nutrition outcomes. This scoping review aimed to map the coverage of the behavior change wheel (BCW) underlying the design, implementation, and evaluation of child nutrition interventions. Methods: In accordance with the Preferred Reporting for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, seven electronic databases were searched via the Population, Concept, and Context (PCC) framework. Peer-reviewed English-language articles published from January 2016 to June 2024 that applied BCW in nutrition interventions for children (aged <18 years) were identified. Data were extracted from eligible articles and analyzed viathematic content analysis. Results: The initial search yielded 2,460 articles. After deduplication and application of the inclusion criteria, 22 articles were included in the final review. The findingsshow that (i) BCW interventionfunctions are more commonly used than policy categories are; (ii) most articles explicitly use the COM-B model, but the behavior to change is not explicit; and (iii) all interventions are implemented in stable, high-income contexts, with one exception reported in one low-/middle-income country. Most articles converge toward using the BCW as the most comprehensive framework. Conclusion: This review consolidates evidence on the use of the BCW in child nutrition interventions, with little illumination of the differential contributions of each model component. It highlights a predominant focus on contexts in high-income countries and on outcomes such as overall nutritional improvement and obesity prevention, whereasinterventions addressing stunting, wasting, and micronutrient deficiencies remain scarce. Future research should investigate the limited use of BCW in low- and middle-income countries and in emergency and humanitarian contexts. Nutrition & Dietetics child nutrition scoping review behavior change theory behavior change wheel COM-B model intervention design implementation program evaluation Figures Figure 1 Figure 2 Figure 3 Background Malnutrition, which involves both insufficient and excessive nutrient and energy intake [1], has profound adverse effects on children’s physical growth, cognitive development, overall well-being and lifelong performance, with long-lasting effects reflected in adulthood among early-year malnutrition survivors [1, 2]. In its various manifestations in the form of undernutrition, micronutrient deficiencies, and overnutrition [1, 3], malnutrition remains a leading cause of child mortality and morbidity and later underperformance in adulthood. For example, undernutrition contributes to approximately 45% of under-five-year child deaths worldwide, stunting affects 149 million children, and wasting affects 49 million children [4]. Children are vulnerable to malnutrition owing to their dependency upon caregivers and other stakeholders resulting from their unique age-specific developmental needs and requirements. Although preventable through effective behavior change and theory-informed nutrition interventions, child malnutrition relentlessly continues to claim lives worldwide, causing far-reaching negative health and developmental impacts. A meta-analysis to estimate the global double burden of malnutrition among children in 65 low- and middle-income countries by Akombi et al . reported high pooled prevalences for stunting (29.0%), wasting (7.5%), underweight (15.5%), and overweight (5.3%) [1]. Worth noting, undernutrition and overnutrition coexist in several contexts, with the former being more prevalent, for example, in South Africa (27.4% vs. 13.3%), Sao Tome and Principe (29.0% vs. 10.5%), Eswatini (28.9% vs. 10.8%), Comoros (30.0% vs. 9.3%), and Equatorial Guinea (25.9% vs. 9.7%) [1]. Diets of children have been associated with physical and cognitive development reflected in the risk of poorer (resulting from unhealthy diets) or better health (resulting from quality diets) [5]. Without adequately designed, implemented, and evaluated behavior change and theory-informed nutrition interventions, children continue paying the ultimate price: hunger-driven deaths globally [6]. Behavioral factors, particularly those undermining healthy dietary practices, stand among the prominent factors contributing to global child mortality and morbidity [7]. Thus, there is a pressing need for comprehensive, theory-driven, and child-focused interventions to address malnutrition. Several scholars [8–12] have demonstrated that nutrition interventions, especially those whose design, implementation, and evaluation are grounded in sound behavior change theories and a contextual understanding of behaviors, lead to greater positive impacts. Several behavioral change theories, including the health belief model, the theory of reasoned action, the theory of planned behavior, the transtheoretical model, the socioecological model, the social cognitive theory, and the diffusion of innovation theory, among others, have informed interventions [7, 10, 13–17]. Many of these theoretical frameworks fall short in addressing complex, multifaceted issues and factors underlying malnutrition, oftentimes overlooking pertinent contextual and behavioral factors, whether deliberately or inadvertently. As a result, one of the challenges undermining child nutrition interventions is the lack of holistic approaches and evidence-informed theories, which, according to Deeney and Harris-Fry [18], are piecemeal and theoretically underdeveloped. The behavior change wheel in behavioral interventions The theoretical lacuna in nutrition interventions can be filled with the behavior change wheel (BCW), a behavior model integrating 19 distinct theoretical frameworks with the potential to comprehensively inform the design, implementation, and evaluation by establishing behavioral targets and delineating specific components of the behavior change pathways [9, 17, 19–21]. In its multifaceted approach, according to Michie [22] and Atkins and Michie [9], the BCW, which encompasses diverse sources of behavior along with various intervention functions and policy categories, has been empirically proven effective in behavior change interventions. The BCW framework, armed with its conceptual and theoretical comprehensiveness, illuminates success and risk factors. After many theories were explored, Michie, Van Stralen and West [19] reported that no existing theoretical framework is sufficiently comprehensive or conceptually coherent, hence the BCW framework. The BCW framework is structured into three layers: an inner layer representing the capability-opportunity-motivation and behavior (COM-B) model, a middle layer encompassing intervention functions, and an outer layer comprising policy categories [17] (see Figure 1). As implied by Faija et al . [23] and advocated by Michie, Van Stralen, and West [19], the BCW system empirically addresses and accounts for multiple determinants of behavior achievable through targeted intervention functions and policy categories. As a BCW inner layer, the COM-B model is a framework that postulates that the occurrence of any behavior is contingent upon indispensable interactions among capability, opportunity and motivation factors [24]. The model comprises six subcomponents: (i) psychological capability, (ii) physical capability, (iii) physical opportunity, (iv) social opportunity, (v) reflective motivation, and (vi) automatic motivation [17, 19]. Each subcomponent is connected to one or more intervention functions and policy categories of the BCW system, thereby facilitating the attainment of the desired behavior [19, 24]. Consequently, through the BCW framework, multiple change pathways can be explored, pinpointing both facilitating and inhibiting factors at the personal, social, environmental, and/or structural levels, thus allowing for the prioritization of requisite factors that should be promoted or discouraged to achieve optimal nutritional outcomes [25, 26]. Behavior change is an inherently complex, multifactor process [13, 27–29]; more so, child nutrition interventions necessitate changes at multiple levels and the engagement of diverse stakeholders to achieve the desired nutritional outcomes. As noted by Raingruber [13], Glanz and Bishop [7], and Trewern, Chenoweth, and Christie [29], behavior change interventions concurrently address multiple factors and levels, thereby affirming the assertion by Glanz and Bishop [7]: “ no single factor or set of factors adequately accounts for why people eat as they do” (p.400). The robustness of the theoretical foundation upon which interventions rest is as important as the outcomes they seek to achieve. Shaky theoretical foundations invariably lead to ineffective interventions, thus compromising the expected results. There is less likelihood of success for interventions decoupled from the evidence base and uninformed by theories [10] and that are unaware of multiple positive and negative factors operating at the personal, group, social, environmental, and structural levels. The evidence indicates that interventions informed by behavioral change theories outperform those that are not theory driven [7, 19, 24, 30, 31]. Effective nutrition interventions for children, according to Daelmans et al. [32], Gately and Curtis [33], Di Noia et al. [34], and Al-Walah et al. [35], necessitate a complex and holistic theoretical approach, a systematic understanding of the context, prioritizing intervention packages, and integrating delivery modalities, including cultural features and customization throughout the design, implementation, and evaluation phases. As Munn et al. [36] suggested, the extent to which behavior change theories are currently applied in nutrition interventions for children remains empirically unknown yet indispensable for designing and implementing impactful interventions, a view also shared with Webb Girard et al. [37] and Watson et al. [12]. Without evaluation and evidence thereof, no one would tell what components are effective, how and why they work, or fail to work, who they benefit, and under which conditions. Consequently, rigorous evaluation is essential to ascertain whether hypothesized change pathways are valid and to assess whether pursued outcomes are being achieved or achievable and to illuminate requisite adjustments for optimal impact. In contemporary practice, no longer is having a nutrition intervention in place sufficient to achieve the desired results; rather, a profound understanding of and active collaboration and consultations with stakeholders in their emotional, socio-relational, behavioral, influential, and environmental connections are crucial to achieving nutritional outcomes. Among the existing peer-reviewed publications on child nutrition interventions, none have investigated the coverage of BCW, a framework that has been theoretically and empirically demonstrated to effectively inform behavior change interventions. While Timlin et al . [21] reported less rigor in the application of behavioral change theories in intervention design and Watson et al. [12] recommended the deliberate inclusion of behavioral change functions derived from the BCW, no scoping review to date has examined their coverage and utilization. This scoping review aims to fill this gap by exploring the use of the BCW framework in the design, implementation, and evaluation of child nutrition interventions. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) extension for scoping reviews checklist [38], this scoping review examines the extent to which the BCW is incorporated in child nutrition interventions. All the data and publications used in this review were publicly available and therefore did not require ethical clearance since no personally identifying information was accessible or used in this research. The protocol underlying this review was not registered, as these procedures are not mandatory in scoping reviews [39]. As discussed in the sections below, the five stages of the scoping review methodological framework developed by Arksey and O'Malley [40] and the associated recommendations proposed by Levac, Colquhoun, and O’Brien [41] were adapted to inform the design and execution of this scoping review. Stage one: Scoping question and its rationale Research questions are like a compass guiding researchers on their discovery journey. In accordance with the recommendations of Levac, Colquhoun, and O’Brien [41] on sound-scoping studies, a single broad, overarching question was formulated: What is the state of research using the BCW in child nutrition interventions? This broad question was further broken down into specific facets: (i) identifying the types of interventions that utilize the BCW and/or its constituent parts; (ii) determining the extent to which the theoretical foundations underlying the interventions are explicitly informed by the BCW during their design, implementation, and/or evaluation; and (iii) elucidating the justifications for employing the BCW to the detriment of other behavior change theories. Recognizing that some theoretical frameworks may be utilized in different types, and at various stages of interventions, three crucial phases were targeted to gauge the state of BCW: the design, implementation, and evaluation phases. Given the heterogeneity of the child population, which evolves and operates within different socio-educational contexts, this review targeted all children under 18 years of age to ensure a comprehensive understanding of the field. Stage 2: Search strategy to identify relevant articles Although Arksey and O’Malley [40] and Peters et al. [39] suggest including published and unpublished studies that include various nonresearch sources, this scoping review was confined to peer-reviewed publications to ensure that a certain level of quality emanates from the peer review process. A set of key terms emanating from the overarching question and its constituent facets were used to create a detailed list of key search terms. The search strategy was developed via the population, concept, and context (PCC) framework [39] in alignment with the following study objectives: population (children under 18 years of age), concept (BCW as the theoretical foundation), and context (child nutrition projects, programs, or initiatives designed, implemented, and/or evaluated in their quest address nutritional issues worldwide). The PCC terms were combined via the Boolean operator AND, whereas the terms of the same semantic content within each PCC component were combined via OR. In view of the interdisciplinary application of BCW, this review resorted to a mix of databases focusing on public health, social science, and psychology. The electronic search databases searched included PubMed, Academic Search Complete, CINAHL Plus, Medline, APA PsycInfo, Child Development & Adolescent Studies, and APA PsycArticles with the number of hits for each specified in Annex 4. From these databases, a systematic search was confined to English-language, peer-reviewed articles published between 1 st January 2016 and 15 th June 2024. The start date aligns with the launch of the Sustainability Development Goals, which emphasize improved nutrition and health outcomes for children. The following search terms were used. An example for a search string for PubMed: (((children OR adolescent OR infant OR teenager) AND (behaviour change wheel OR behavior change wheel OR com-b OR capability OR opportunity OR motivation)) AND (nutrition OR diet OR food OR eating)) AND (Intervention OR project OR program*) were used to search the article titles. Similar search strings were utilized in other databases but were extended to the abstracts to maximize the number of relevant articles retrieved. Stage 3: Criteria for article selection Eligible studies were peer-reviewed journal articles published in English from 1 st January 2016 to 15 th June 2024, which explicitly focused on BCW and/or its constituent parts and examined nutritional interventions for children under 18 years of age in the title or abstract. The synonymous words for children (e.g., adolescent, infant, and teenager), nutrition-related terms (e.g., diet, food, eating, vegetables, fruit, and nutrients) and the main forms of malnutrition (e.g., obesity/overweight, underweight, stunting, wasting, and anemia) were part of the inclusion criteria. For BCW, the explicit mention of this theoretical framework or its constructs in the title and/or abstract was an inclusion criterion. Finally, included were articles with, in their title and/or abstract, the mention of terms such as evaluation, randomized control trials, feasibility or design studies, provided that these related to interventions, projects, or programs aimed at addressing malnutrition across the globe. Articles that targeted children older than 17 years, paywalled, study protocols, scoping reviews, or publications unrelated to child nutrition interventions were excluded. Three principal keywords or phrases, namely, (i) child , (ii) BCW or COM-B model , and (iii) child nutrition interventions, served as the benchmarks for prima facie inclusion. After meeting at least two priority inclusion criteria (i.e., children and nutrition intervention), articles were scrutinized in their title and/or abstracts to determine whether they (i) included the BCW or its constructs; (ii) described an intervention, program, or project; and (iii) were about the evaluation of or study for child nutrition intervention. Duplicate articles were removed. Stage 4: Data charting process and data items One author (JPN) conducted a systematic search of electronic databases and retrieved articles using inclusion and exclusion criteria jointly developed by both authors (JPN and AH). In view of the initially indeterminate nature and coverage of the content, approximately one-fourth of the included articles (n=5) were first scrutinized to refine the data charting process. Insights gleaned from the preliminary data charting phase were subsequently utilized to finetune the data charting form prior to undertaking full scoping. Drawing upon the researchers’ field experience and positionalities, scholarly works, and insights from similar scoping reviews [31, 42, 43], a set of relevant variables were identified, as presented in Annex 2 (Data charting). These a priori codes from the data charting form were used in the Atlas.ti software for qualitative data analysis, as described below. Upon finalizing and agreeing upon the list of articles included in the review, the first author (JPN) systematically extracted the data, which were subsequently reviewed and discussed with the second author (AH) utilizing the following a priori codes. First, the set of codes encompassed study characteristics. These specifically included the publication year, author(s), publication title, country/region (thereby indicating the geographical location of the intervention), sample size (used in the review articles), age (or age group of the child, sometimes of other relevant study participants), and research design (classified as experimental, quasiexperimental, cross-sectional, qualitative, quantitative, systematic or other) to highlight the methodological rigor without delving into detail. Second, the coding schema included codes to capture intervention contexts, with an emphasis on the pivotal role of contextual factors (secure or stable, emergency, and protracted crisis settings) in shaping and impacting intervention effectiveness [28]. Third, the main foci of the nutrition intervention were also coded under the major forms of malnutrition (i.e., stunting, wasting, overweight/obesity, and micronutrient deficiencies as defined by the World Health Organization)[44] or other targeted nutritional outcomes to gauge their presence or absence in the reviewed articles. Finally, following the adaptation of the framework provided by Michie, Van Stralen and West [19], each of the BCW intervention functions, policy categories, and COM-B model components were coded as a thematic category to ascertain their explicit presence in studies that claim employing such a theoretical framework, as described in Annex 10. Reference to the BCW was checked to determine whether it was congruent with the design, implementation and/or evaluation of the nutritional intervention. There were no additional analyses of the significant differences in the outcomes resulting from using or not using BCW. Acknowledging that BCW is not the sole theoretical framework for behavior change (albeit one of the most comprehensive, as it integrates multiple other theories), this study identified and coded other theories used in the published articles. This approach enabled an assessment of the theoretical rationale for utilizing either the BCW in its entirety or other alternative frameworks. The temporal integration of the BCW was coded for its presence at the (i) design, (ii) implementation and (iii) evaluation stages to ascertain the timing of the theoretical reference to the BCW. Finally, any justifications related to the BCW and other theoretical frameworks, particularly those aligned with the nature of the intervention, as well as any highlighted strengths or gaps reported in the articles, were coded for extraction. Stage 5: Collating, synthesizing and reporting the results The articles included in this review were thematically analyzed to extract content directly pertinent to the study’s objectives and research questions. As detailed in the data charting section, the analysis commenced with two foundational steps in thematic content analysis: (i) preliminary charting to refine the data extraction and (ii) generating and selecting a priori themes via data charting (refer to Annex 2) [45]. Subsequently, four additional steps were followed: (i) semantic and thematic coding in Atlas.ti qualitative data analysis software; (ii) retrieval and review of coded themes from Atlas.ti; (iii) tabulation of the confirmed themes; and (iv) summary reporting [45], as outlined in Annex 3. The coded instances illustrating key themes were then extracted for interpretation and summary write-up in accordance with the research objectives and questions. By utilizing the predetermined a priori codes from the data charting items, the text segments coded in Atlas.ti were iteratively scrutinized by the first author (JPN) and reviewed by and discussed with the second author (AH). These segments were ultimately designated the final instances of the BCW in child nutrition interventions. Within Atlas.ti, the presence or the coded text was extracted with a value label of “1”, and its absence was automatically counted as “0”. Results The search of electronic databases retrieved 2,460 articles (see Annex 4). After deduplication, 1,216 studies were deemed eligible for the subsequent stage of the review process. After screening titles and abstracts for their relevance, 40 articles were retained for content and thematic scrutiny. This process led to a final list of 22 articles (refer to Fig. 2 ). The state of research using the BCW and COM-B models in child nutrition As summarized in Annex 5, the included studies employed various, nonmutually exclusive designs and methods, including mainly qualitative (n = 8), quantitative (n = 1), mixed methods (n = 5), (quasi)experimental (n = 7), and systematic reviews (n = 1). The various research designs deliberately aim at assessing the effectiveness of nutrition interventions across different contexts and target populations from design through implementation and evaluation. Apart from one documentary review [ 47 ], the primary target population segments for the studies included children (n = 7, [ 48 – 54 ]), parents or guardians (n = 12, [ 50 , 52 , 55 – 64 ]), and/or stakeholders such as schoolteachers, health professionals and other relevant actors (n = 9, [ 50 , 55 , 58 , 62 , 64 – 68 ]), all of whom contributed to efforts aimed at optimizing nutritional outcomes among children. Articles reporting child nutrition interventions from eight countries were found, with the largest number of articles originating from the United Kingdom (n = 10, [ 47 , 50 , 52 , 53 , 58 , 59 , 63 – 66 ]) and Australia (n = 6, [ 48 , 56 , 57 , 61 , 62 , 67 ]). In each of the remaining six countries (i.e., Denmark [ 54 ], Ireland [ 55 ], South Africa [ 68 ], South Korea [ 49 ], Spain [ 51 ] and Thailand [ 60 ]), one article was published. Notably, nearly all studies (i.e., 21 out of 22) were conducted in high-income, developed countries, with almost half of the interventions (10 out of 22) in the United Kingdom, compared with a single study in South Africa. With a slight check of significant differences, although outside the scope of this review, few interventions reported statistically significant results in the application of the BCW framework and in the comparison of groups or components of interest in child nutrition interventions ( n = 8/22, 36%). Studies that statistically test significant differences between groups or components of interest may add more confidence for replication in other similar settings or interventions, insomuch as negative and positive factors correlated with outcomes are identified and can thus be incorporated accordingly. Types of child nutrition interventions using the BCW and COM-B models The interventions in this review encompassed key child nutrition outcomes , with sample sizes varying across participating population groups (i.e., children as well as their parents, guardians, and other pertinent stakeholders). These studies were conducted in stable, nonemergency, and nonhumanitarian contexts. As detailed in Annex 6, two salient, nonmutually exclusive patterns were identified: (i) fourteen articles (64%) covered overall improved child nutrition outcomes [ 47 , 48 , 51 , 53 , 54 , 56 – 58 , 60 – 63 , 65 , 67 ], and (ii) thirteen articles (59%) focused on issues related to overweight and obesity [ 49 , 50 , 52 – 57 , 59 , 62 , 64 , 66 , 68 ]. Only one article (5%) incorporated measures of energy intake [ 53 ], suggesting that the primary underlying concerns addressed were either obesity or undernutrition. Pregnancy, neonatal, and breastfeeding nutrition interventions Nine articles (41%) examined interventions related to pregnancy, neonatal, and breastfeeding nutrition interventions (Annex 6). For example, Grant et al. [ 63 ] utilized the COM-B model to map behavioral variations in alcohol consumption, smoking and infant feeding during pregnancy, contending that context-specific behaviors related to pregnancy and motherhood influence the elements of capability, opportunity and motivation (COM) constructs. Similarly, Litterbach et al. [ 61 ], Russell et al. [ 57 ], and Toomey et al. [ 55 ] examined infant feeding practices and their determinants, including sociodemographic characteristics and parental COM constructs. A few articles further investigated feasibility and effectiveness by retrospectively applying the theoretical framework, one to the development of a mobile health app [ 47 ] and another to evaluate the suitability of the COM-B model in designing and implementing interventions for optimal breastfeeding outcomes [ 60 ]. Guided by the BCW framework to develop a peer-support intervention, Phillips et al. [ 58 ] shed light on effective interventions that elucidated strategies for prolonging the duration of breastfeeding. In a related study, Thomson and Crossland [ 65 ] attributed the efficacy of an infant-feeding peer support intervention to the combined use of (i) BCW’s intervention functions, (ii) the BCW’s policy categories, and (iii) behavior-related components to delineate change pathways for enhancing women’s COM-related knowledge regarding breastfeeding. Finally, Page et al. [ 67 ] demonstrated how to identify and address barriers to neonatal nutrition by employing both the BCW and COM-B models as the foundational theoretical framework. School-based nutrition interventions Four articles (18%) covered school-based nutrition interventions. Bestle et al. [ 54 ] examined children’s consumption of discretionary beverages and foods within school environments, whereas Sutherland et al. [ 56 ] investigated the high consumption of discretionary foods by children at school, emphasizing the role of additional actors and factors through BCW-informed, codesigned interventions. Sutherland et al. [ 56 ] also highlighted the importance of integrating school lunchbox nutrition guidelines, curriculum lessons, and digital parental communications to address barriers across multiple levels. Hart and Page [ 50 ] focused on aspects of school food education and culture to improve knowledge, skills, motivations, and environmental conditions, whereas Erzse et al. [ 68 ] investigated the shift in dietary practices for healthier options and identified external barriers such as the affordability and availability of unhealthy foods on school premises. Home- or family-based child nutrition interventions Three articles (14%) dealt with home- or family-based child nutrition interventions. According to the BCW and COM-B models, changing behavior in children’s dietary practices within the familial context necessitates the targeted involvement of key family members, particularly both parents [ 62 ]. Curtis, Atkins and Brown [ 64 ] demonstrated that the interaction among parents’ COM factors significantly influence meal portion sizes served to children. Similarly, Livingstone et al. [ 48 ] posited that the distribution of COM-related characteristics within home environments may reveal area-level disadvantages, consequently necessitating tailored intervention priorities for distinct target subgroups to improve diet quality during adolescence. Healthcare- and practitioner-focused nutrition interventions for children in social and clinical settings Six articles (27%) investigated healthcare- and practitioner-focused nutritional interventions for children in social and clinical settings. In their study on cultural adaptation for children’s weight management, Pallan et al. [ 59 ] reiterated the advantages offered by BCW, noting its capacity to address, inter alia, structural and environmental factors. Similarly, Ray et al. [ 66 ] demonstrated that the systematic application of BCW intervention functions, combined with collaboration with target recipients, facilitates the identification of behavioral barriers and enables the prevention of excess weight gain among children. They describe the categorization of interventions into workflow-focused interventions, interventions that target systemic barriers, and practitioner-focused interventions, which address individual health visitors’ capabilities through various modalities. Using theory and patient-led research iteratively, Cox et al. [ 52 ] contributed to an effective intervention aimed at addressing adolescent obesity, whereas Costello et al. [ 53 ] assessed the food and beverage intake of adolescent athletes and underscored the importance of the COM-B model as a theoretical behavioral approach. Furthermore, Fernández-Álvarez et al. [ 51 ], employing the BCW framework, examined adherence to and maintenance of healthy eating habits via an educational intervention in sporting venues. Finally, an additional study on nutritional interventions for moderately to severely obese children and adolescents reported improved outcomes, including increased motivation [ 49 ]. Locating the BCW framework in child nutrition interventions Across all the articles, the following BCW intervention functions were used to varying degrees as depicted below: The detailed mapping of the intervention functions is presented in Annex 7. The policy categories of the BCW framework were less frequently referenced. Environmental/social planning was the most prominently mentioned policy category, appearing in 8 out of 22 articles. The prominence of environmental and structural factors aligns with findings from other studies [ 69 , 70 ], which highlight the context and resources reflected in COM-B’s opportunity as driving factors needed in the physical environment more than capacity or motivation factors to achieve healthy diets. This finding mirrors the potential of structural factors to change or control the physical, social, or regulatory context, which can either undermine or promote the desired behavior. The policy categories are presented in Annex 8. The COM-B model is prominently used across the reviewed articles. As delineated in the COM-B model, the capability factors were explicitly mentioned in all the articles except that of Sutherland et al. [ 56 ] and implicit mention, without direct reference to the model component and its constituting parts in one article by Bestle et al. [ 54 ] encapsulated in the capability-building materials.. The opportunity factors were explicitly covered in 20 articles, although one article by Bestle et al. [ 54 ] implicitly and ambiguously mentioned them through the mere mention of new guidelines. Similarly, motivation -related factors were evident in all the articles, with the exception of Sutherland et al. [ 56 ]. Slightly more than half of the articles (12 out of 22) clearly stated promoted behavior . Despite the overt presence of the BCW and COM-B model in 18 articles during the design stage, only seven articles referenced this theoretical framework during the implementation stage, and only five articles did so as part of the evaluation process. The use of BCW and other theoretical frameworks The BCW, in conjunction with additional theoretical frameworks, was employed to varying degrees across the reviewed articles. Specifically, the Transtheoretical Model in Lee et al. [ 49 ], the Social Cognitive Theory (SCT) in Bestle et al. [ 54 ], and the Self-Determination Theory in Cox et al. [ 52 ] were utilized alongside elements of the COM-B model, the mapping of which is in Annex 9. After alternative theories—such as the theory of planned behavior—and their application in other contexts were assessed, Thomson and Crossland [ 65 ] opted for the BCW framework for its comprehensive ecological perspective. With the exception of the study by Lee et al. [ 49 ], which integrated a different theory and a motivational component of the BCW subsumed in the Transtheoretical Model, 21 articles provided justification for employing the BCW and COM-B Model. In contrast to SCT’s emphasis on self-efficacy, Hart and Page [ 50 ] contend that focusing solely on knowledge “ is limited without a supportive school food culture and opportunities ” (p.690). For most authors, the BCW theoretical framework and its inner layer COM-B model are utilized for their comprehensive nature to capture key theoretical domains. This framework is utilized for its demonstrated effectiveness in promoting desired change through the dynamic interplay among its components and integrated processes, with certain elements being flexibly and explicitly emphasized more than others [ 52 , 60 , 64 , 66 ]. Recognizing the critical need for both internal and external factors (i.e., multistakeholder engagement alongside socioeducational and environmental influences) in enabling multisectoral actions to leverage and enhance the COM, a handful of articles [ 50 , 51 , 62 , 68 ] have applied the model to effect change within its context. Other studies justified the application of specific COM-B constructs by emphasizing the use of capability to foster increased confidence or enhance infant feeding, the opportunity to facilitate access to comprehensible information and strengthen social and healthcare network support, and the motivation to provide the guidance necessary to sustain behavior [ 61 , 65 ]. In addressing the adoption and maintenance of breastfeeding, Musgrave et al. [ 47 ] and Nuampa et al. [ 60 ] underscored the significance of personal, social, environmental, and cognitive-behavioral attributes as encapsulated in the COM-B model. In other articles, the merits of using the BCW and COM-B models include the capacity to delineate target behaviors and alternatives, alongside the identification of associated drivers and inhibitors, thus informing the selection of appropriate behavior change techniques [ 57 – 59 ]. Page et al. [ 67 ], Livingstone et al. [ 48 ], and Sutherland et al. [ 56 ] resorted to the COM-B model with a diverse array of evidence sources to elucidate the drivers and inhibitors of the behavior of interest. They modeled change pathways by selecting strategies tailored to address specific behavioral determinants within the BCW framework. Finally, a couple of articles recognize COM-B factors as essential prerequisites for behavior to occur, mapping empirical findings to the model’s six domains to uncover and understand the behavioral change process [ 55 , 63 ]. The BCW is justified over other theories for explicitly incorporating emotional and automatic motivational influences alongside capability and opportunity factors. Another justification for employing BCW over other behavior change theories is its systematic, comprehensive, stakeholder-informed operationalization through behavior change techniques to address behavior change determinants. Several interventions explicitly and prospectively integrate the BCW framework as central theoretical underpinnings in their design, including integration of the COM-B model with other models, BCW in codesigning and structuring intervention packages, and delineating sources of behaviors [ 50 , 56 , 58 , 62 , 62 ]. Nutrition interventions are, to a great extent, explicitly informed by BCW, shaping both conceptualization and practical intervention design. To a lesser extent, instances of BCW to inform the evaluation of nutrition interventions are limited. Discussion This scoping review represents, to the best of our knowledge, the first appraisal of the designability, implementability, and evaluability of child nutrition interventions underpinned by the BCW framework. Drawing from various study designs and methods, this review identified a handful of findings. First, the current state of research on BCW-informed nutrition interventions underscores the complexity inherent in altering behaviors related to child nutrition outcomes, similar to Li and Li’s [ 71 ] findings in a systematic review of pregnancy dietary interventions using the COM-B model. When individual, social, structural, and environmental factors are included, multidimensional interventions (as theoretically and empirically supported by the BCW framework) demonstrate effectiveness. The majority of the reviewed articles concentrated on overall improvement in child nutritional outcomes, particularly those addressing overweight and obesity, which are typically prevalent challenges in high-income countries. In contrast, issues such as stunting, wasting, and nutrient deficiencies prevalent in low- and middle-income countries are rarely covered, reflecting the unequal coverage of the global burden of malnutrition, as evidenced elsewhere [ 72 ]. Complementing the BCW system in child nutrition interventions with other theoretical frameworks, such as Amartya Sen’s capability approach [ 50 ], indicates a deliberate and thoughtful integration of the COM-B model with the capability approach’s broader perspective on individual freedoms and social factors to achieve healthy nutrition outcomes. The BCW system plays dual roles in child nutrition research as both an analytical framework and a prospective guide for intervention design and implementation. Thomson and Crossland [ 65 ] describe the use of the BCW retrospectively “to structure the analysis of the findings from an evaluation of an infant feeding peer support service”, unlike Sutherland et al.’s [ 56 ] prospective application, which reported the use of the BCW to codesign and integrate the multicomponent intervention. This unique retro-prospective application indicates that the BCW framework is primarily a theoretical exploratory and explanatory tool for designing, implementing, and evaluating interventions, thus enhancing the understanding and shaping of behaviors within child nutrition contexts. The reviewed articles, in their alignment with the core elements of BCW, collectively highlight the critically multifaceted role of social and environmental factors in influencing child nutrition behaviors [ 50 , 52 , 54 , 58 , 63 , 73 ], hence context-sensitive and holistic intervention strategies. Eating habits are not isolated but rather collective actions nurtured through, or pressurized by, social and environmental dimensions. This finding aligns with evidence indicating the importance of including more behavior change functions, such as environmental restructuring [ 74 ]. These insights confirm that interventions informed by BCW must address social opportunity and motivational components alongside the ability to effectively promote behavior change. Current research using the BCW framework emphasizes collaboration and multidisciplinarity in the codesign of nutrition interventions, as exemplified by the reviewed articles [ 55 , 56 , 58 , 62 , 65 , 66 ], to enhance relevance, contextual acceptability, local ownership, wider support, and uptake of the promoted change. The application of BCW across multiple behaviors and diverse populations in child nutrition interventions is limited by its shortcomings. In some contexts, where multibehaviour complexities and socioeconomic diversity are insufficiently considered, as alluded to by Watson et al. [ 74 ], BCW-informed interventions are less effective. Although children constitute the ultimate target group of the reviewed articles, the engagement of multiple stakeholders, including parents, policymakers, schools, and health personnel, is a critical springboard for optimizing outcomes across school, home, and broader social contexts. The review findings revealed the effectiveness of nutrition interventions when these diverse actors, as well as social food environments, are holistically integrated. This conclusion aligns with the principles of theory-informed intervention design, which advocates for intentional intervention mapping to link theory and practice, address challenges, and promote determinants of behavior [ 75 ]. There are other theoretical frameworks used in the reviewed articles, which further substantiate the complexity of behavior change nutrition interventions. These interventions combine educational, motivational, environmental, and social strategies; are often delivered through participatory, digital, and face-to-face modalities; and frequently involve codesign with target populations to ensure contextual relevance and acceptability. Second, various types of nutritional interventions exist for children. Antenatal (i.e., pregnancy), neonatal (i.e., infant feeding and breastfeeding), and postnatal (i.e., child feeding practices outside schools and homes) interventions were prioritized differently. Interventions directed at teenagers and adolescents are relatively rare, with only a few studies addressing these age groups through initiatives in sports settings, such as soccer [ 51 ] and rugby [ 53 ]. Additionally, evidence indicates that enhancing the nutrition of school-aged children requires more than interventions confined to school premises. The influence of home environments and other broader social and environmental factors and actors is indispensable in shaping eating habits and achieving the desired child nutrition outcomes. In this context, the role of primary child carers (predominantly mothers) from pregnancy through the neonatal and breastfeeding stages and extending into childhood and school age is paramount. In addition to home-based interventions, which remain central to improving child nutrition, initiatives implemented in social or clinical settings exhibit distinct characteristics that necessitate the involvement of additional actors and factors for effective child nutrition interventions. Finally, the results of this review substantiate the utility of the BCW framework in the design and implementation of child nutrition interventions, although its application in evaluation is comparatively limited. Although evidence abounds in guiding the design of interventions targeting changes in eating behavior [ 76 ], as reflected in this scoping review, the use of BCW in implementation and evaluation is limited. The findings indicate that the BCW intervention functions were employed more frequently than the policy categories were. The COM-B model was explicitly referenced in all the articles except that of Sutherland et al. [ 56 ], and not all the articles clearly articulated the promoted behavior. The varying degrees of application of the BCW and COM-B models between the design and implementation stages, as opposed to the evaluation phase, suggest that evaluation may be inherently more complex and less amenable to theoretical underpinnings that inform intervention development. This discrepancy may be partially attributed to the temporal lag between the design (theoretical thinking), implementation (theoretical action), and evaluation (empirical observations) and may explain the loss of theoretical memory at a later stage. To preserve the memory of the theoretical underpinnings of child nutrition interventions, evaluation design is expected to be part of the design and implementation to generate and embed in the intervention’s testable hypotheses. Although continuous evaluation throughout intervention is not mandatory, developing at least a dynamic evaluation protocol at early stages when all minds are fresh with the design memory to inform the evaluation at later specific stages avoids theoretical decay. A major reason for this limited application lies in the inherent complexity of evaluating multifaceted interventions. Complex interventions often operate across multiple levels (e.g., individual, organizational, community) and incorporate a variety of strategies (e.g., education, environmental restructuring, and policy changes). This layering makes it difficult to attribute outcomes directly to specific components or to align evaluation methods with theoretical models like COM-B. Moreover, evaluations typically prioritize pragmatic outcome measures (e.g., health improvements, behaviour adoption) rather than explicitly mapping changes back to the theoretical constructs of capability, opportunity, and motivation. This results in a missed opportunity to test and refine the theory itself. Overall, interventions confined solely to the individual level (and consequently omit the social, structural, and environmental dimensions characteristic of schools, homes, and other settings) are less effective in addressing the diverse needs of targeted participants with respect to the COM-B components as highlighted in two articles [ 57 , 73 ]. This finding is similar to evidence from a systematic review pointing out inconsistent application of theory throughout the intervention stages [ 77 ], whereby some are limited to a mere mention of the theories at the design stage. This review reveals that the presence of the theoretical underpinning at the design stage is not consistently translated into the subsequent implementation actions, nor does it uniformly inform the evaluation process all the time. As evidence from this review indicates, using a theoretical framework in the design stage underscores the critical importance of sound theoretical foundations to drive behavior change, such use does not guarantee that the theoretical underpinnings are maintained during implementation or referenced to inform the evaluation. The selective application of the BCW (when confined to a single phase of intervention such as design, implementation, or evaluation) provides a fragmented, temporally limited understanding of the contextual actors and factors that drive or inhibit the effectiveness of child nutrition interventions. Strengths and limitations This scoping review, which is global in design, followed the established guidelines and elucidated the benefits of incorporating the comprehensive BCW theoretical framework in the design, implementation, and evaluation of child nutrition interventions. However, its intended geographical coverage and temporal scope present certain limitations. First, nearly all eligible articles were derived from developed countries. Second, the review might have excluded relevant nonpeer reviewed, unpublished study reports, presumably including those from low- and middle-income countries where authors may have limited access to publishing outlets and/or reduced incentives. Third, although additional pertinent publications may exist from prior to the advent of the SDGs, the review deliberately focused on the period from January 2016 to mid-June 2024 to establish a temporal benchmark for future studies that may contribute to SDG measurement. Finally, most of the articles focused on child overweight to the detriment of other forms of malnutrition, which may have the highest prevalence rates in low- and middle-income countries. Conclusion and recommendations This review consolidates the literature on child nutrition interventions, which are informed by the BCW framework. This theoretical framework is predominantly used in stable contexts within developed countries, with a primary focus on addressing overweight and overall child nutrition. No single occurrence was traceable in emergency and humanitarian contexts despite high prevalence rates of stunting, wasting, and micronutrient deficiencies resulting from the constrained access to adequate diets and health services in such contexts. The findings emphasize the multifaceted nature of child nutrition interventions, which extend across various domains, such as homes, schools, parents, governments, policymakers, food suppliers, and health practitioners. Interventions tend to selectively address certain behavioral determinants while deprioritizing others. While the BCW framework can accommodate, or be integrated with, other theoretical models, it uniquely provides a range of options, namely, intervention functions and policy categories, across the design, implementation, and evaluation stages, although emphasis on evaluation is limited. The incorporation of structural factors, as informed by the BCW framework, appears to be critical for the effectiveness of child nutrition interventions. The findings from this review demonstrate that BCW-informed child nutrition interventions are effective in addressing malnutrition. This review reveals that the presence of the theoretical underpinning at the design stage is not consistently translated into the subsequent implementation actions, nor does it uniformly inform the evaluation process all the time. As evidenced from this review, incorporating a theoretical framework in the design stage underscores the critical importance of sound theoretical foundations to drive behavior change. However, such incorporation and use at design stage do not guarantee that theoretical underpinnings are upheld during implementation or systematically referenced to inform the evaluation. The selective application of the BCW framework (when confined to a single phase of an intervention such as the design, implementation, or evaluation) provides a fragmented, temporally limited understanding of the contextual actors and determinants that drive or inhibit the effectiveness of child nutrition interventions. This review highlights the need for further investigation of the differential and additive effects of the BCW components on intervention outcomes, particularly when different combinations (not necessarily all) of BCW intervention functions, policy categories, and COM-B components are employed. Accordingly, additional research should elucidate the potential additive effect of each component of the model to inform targeted capacity-strengthening initiatives for child nutrition interventions. Furthermore, development agencies involved in child nutrition interventions should commission further policy research in low- and middle-income countries as well as in emergency and humanitarian contexts to identify obstacles to using the BCW framework. The current limited coverage of the BCW framework illustrates the empirical lacuna undermining the holistic understanding of barriers to and facilitators of child nutrition outcomes. Therefore, funding and nutrition policies for child nutrition should require deliberate integration of the BCW (or any other relevant behavior change theory) in the design, implementation, and evaluation of interventions to determine their efficacy. Declarations Ethics approval and consent to participate Ethical approval was not required for this study as it involved a review of published literature and did not include any human participants or personal data. Regardless, the original proposal was subjected to Brunel Research Ethics Online (BREO) decision tool to determine whether the research required ethical approval through a series of questions about the research design, data collection methods, human participants, and collection of personally identifying data and information. Based on this assessment, the research study was classified as not requiring ethical approval. Consent for publication Not applicable. Availability of data and materials The search strings and data generated and used in the current study are included within the article. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors' contributions JPN conceptualized and designed the study, conducted a systematic search of electronic databases and retrieved articles using inclusion and exclusion criteria developed by JPN under the academic supervision of AH. JPN systematically extracted data, which were subsequently reviewed and discussed with AH utilizing the agreed-upon a priori codes. JPN conducted the analysis in Atlas.ti using the predetermined a priori codes from the data charting items and drafted the research report. Upon the successful submission of the research report in partial fulfillment for the degree award at Brunel University London, JPN revisited the analysis and produced a publishable draft manuscript. The manuscript was reviewed by AH who also contributed to its content. Both authors iteratively reviewed and finalized the manuscript to ensure analytical rigor. All authors read and approved the final manuscript. Acknowledgments Not applicable. 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Food Nutr Bull 45:24–37 Atkins L, Michie S (2015) Designing interventions to change eating behaviours. Proc Nutr Soc 74:164–170 Willmott TJ, Pang B, Rundle-Thiele S (2021) Capability, opportunity, and motivation: an across contexts empirical examination of the COM-B model. BMC Public Health 21:1014 Additional Declarations The authors declare no competing interests. Supplementary Files Appendices.docx Cite Share Download PDF Status: Posted Version 1 posted 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7483112","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":507579375,"identity":"8f577986-6d6e-4c2d-ac24-0ef717127133","order_by":0,"name":"Dr. Jean Providence Nzabonimpa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYFCCA1CamcEARMmBxR6QosUYLJZApH1gLYkNIBKfFnPGwwc/F+64J2dwnHnj44Iam/T5YYcfAm2xk9NtwK7FsuFYsvTMM8XGBofZio1nHEvL3Xg7zQCoJdnY7AB2LQYHzhhI87YlJM5s5jGT5m04nLtxdgJIy4HEbTi1nP/8G6rF/Ddvw/90w9npHwhoOcMGtqWfmceMmbfhQIK8dA4hW46ZWfOeSTDmZ2YrluY5lmy4QTqn4ECCAR6/3Dj8+DbvjgQ5Nv7DGz/z1NjJy89O3/zhQ4WdHC4tDBJACcYGFHvBJA7lIMDfgKZFvgG7wlEwCkbBKBi5AABBwmJFXOFoPwAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-8058-2562","institution":"Brunel University London","correspondingAuthor":true,"prefix":"Dr.","firstName":"Jean","middleName":"Providence","lastName":"Nzabonimpa","suffix":""},{"id":507579376,"identity":"7b9a3eaf-dcf5-4df6-8c60-c9334be0469d","order_by":1,"name":"Dr. Arnd Hofmeister","email":"","orcid":"https://orcid.org/0009-0000-8778-4677","institution":"Brunel University London","correspondingAuthor":false,"prefix":"Dr.","firstName":"Arnd","middleName":"","lastName":"Hofmeister","suffix":""}],"badges":[],"createdAt":"2025-08-28 20:18:01","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7483112/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7483112/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90383143,"identity":"64c632d4-2460-443c-ae74-4b0be6589ae7","added_by":"auto","created_at":"2025-09-02 06:55:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":283762,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe behavior change wheel\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSource: Michie, Van Stralen and West [19]\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7483112/v1/00e1dc665f5a79888dbc51ee.png"},{"id":90383237,"identity":"7c6c77e6-a438-4951-b098-d855dad93b8b","added_by":"auto","created_at":"2025-09-02 06:55:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":66748,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePRISMA 2020 flow diagram of the literature (adapted from Page \u003c/em\u003eet al\u003cem\u003e. \u003c/em\u003e[46])\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7483112/v1/e276cde0e0f99129dcfbc5fe.png"},{"id":90383234,"identity":"b3c6494a-1aa8-4258-9b1f-b767b457e5ef","added_by":"auto","created_at":"2025-09-02 06:55:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":16515,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 1. Presence of intervention functions in the reviewed articles (n=22)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7483112/v1/b085f1889488c45dee96ff5d.png"},{"id":90383295,"identity":"97ebbc59-f2c4-435c-b778-dfefecff5b83","added_by":"auto","created_at":"2025-09-02 06:55:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1261451,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7483112/v1/79e998be-b116-47d6-82d0-27c08425516b.pdf"},{"id":90383140,"identity":"1e7483d1-302d-41e3-b10b-5c51bcd481c0","added_by":"auto","created_at":"2025-09-02 06:55:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":115071,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-7483112/v1/baa96755c51e3379267fcfc3.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cem\u003eTheorizing child nutrition interventions: a scoping review of the behavior change wheel\u003c/em\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eMalnutrition, which involves both insufficient and excessive nutrient and energy intake [1], has profound adverse effects on children\u0026rsquo;s physical growth, cognitive development, overall well-being and lifelong performance, with long-lasting effects reflected in adulthood among early-year malnutrition survivors [1, 2]. In its various manifestations in the form of undernutrition, micronutrient deficiencies, and overnutrition [1, 3], malnutrition remains a leading cause of child mortality and morbidity and later underperformance in adulthood. For example, undernutrition contributes to approximately 45% of under-five-year child deaths worldwide, stunting affects 149 million children, and wasting affects 49 million children [4]. Children are vulnerable to malnutrition owing to their dependency upon caregivers and other stakeholders resulting from their unique age-specific developmental needs and requirements. Although preventable through effective behavior change and theory-informed nutrition interventions, child malnutrition relentlessly continues to claim lives worldwide, causing far-reaching negative health and developmental impacts.\u003c/p\u003e\n\u003cp\u003eA meta-analysis to estimate the global double burden of malnutrition among children in 65 low- and middle-income countries by Akombi et al\u003cem\u003e.\u003c/em\u003e reported high pooled prevalences for stunting (29.0%), wasting (7.5%), underweight (15.5%), and overweight (5.3%) [1]. Worth noting, undernutrition and overnutrition coexist in several contexts, with the former being more prevalent, for example, in South Africa (27.4% vs. 13.3%), Sao Tome and Principe (29.0% vs. 10.5%), Eswatini (28.9% vs. 10.8%), Comoros (30.0% vs. 9.3%), and Equatorial Guinea (25.9% vs. 9.7%) [1]. Diets of children have been associated with physical and cognitive development reflected in the risk of poorer (resulting from unhealthy diets) or better health (resulting from quality diets)\u0026nbsp;[5]. Without adequately designed, implemented, and evaluated behavior change and theory-informed nutrition interventions, children\u0026nbsp;continue paying the ultimate price: hunger-driven deaths globally [6].\u0026nbsp;Behavioral factors, particularly those undermining healthy dietary practices, stand among the prominent factors contributing to global child mortality and morbidity [7]. Thus, there is a pressing need for comprehensive, theory-driven, and child-focused interventions to address malnutrition.\u003c/p\u003e\n\u003cp\u003eSeveral scholars\u0026nbsp;[8\u0026ndash;12]\u0026nbsp;have demonstrated that nutrition interventions, especially those whose design, implementation, and evaluation are grounded in sound behavior change theories and a contextual understanding of behaviors, lead to greater positive\u0026nbsp;impacts. Several behavioral change theories, including the health belief model, the theory of reasoned action, the theory of planned behavior, the transtheoretical model, the socioecological model, the social cognitive theory, and the diffusion of innovation theory, among others, have informed interventions [7, 10, 13\u0026ndash;17]. Many of these theoretical frameworks fall short in addressing complex, multifaceted issues and factors underlying malnutrition, oftentimes overlooking pertinent contextual and behavioral factors, whether deliberately or inadvertently. As a result, one of the challenges undermining child nutrition interventions is the lack of holistic approaches and evidence-informed theories, which, according to Deeney and Harris-Fry [18],\u0026nbsp;are\u0026nbsp;piecemeal\u0026nbsp;and\u0026nbsp;theoretically underdeveloped.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe behavior change wheel in behavioral interventions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe theoretical lacuna in nutrition interventions can be filled with the behavior change wheel (BCW), a behavior model integrating 19 distinct theoretical frameworks with the potential to comprehensively inform the design, implementation, and evaluation by establishing behavioral targets and delineating specific components of the behavior change pathways [9, 17, 19\u0026ndash;21]. In its multifaceted approach, according to Michie\u0026nbsp;[22]\u0026nbsp;and Atkins and Michie\u0026nbsp;[9], the BCW,\u0026nbsp;which encompasses diverse sources of behavior along with various intervention functions and policy categories, has been empirically proven effective in behavior change interventions. The BCW framework, armed with its conceptual and theoretical comprehensiveness, illuminates success and risk factors. After many theories were explored, Michie, Van Stralen and West [19]\u0026nbsp; \u0026nbsp;reported\u0026nbsp;that no existing theoretical framework is sufficiently comprehensive\u0026nbsp;or\u0026nbsp;conceptually coherent, hence the BCW framework.\u0026nbsp;The BCW framework is structured into three layers:\u0026nbsp;an inner layer representing the\u0026nbsp;capability-opportunity-motivation and behavior\u0026nbsp;(COM-B) model, a middle layer encompassing intervention functions, and an outer layer comprising policy categories\u0026nbsp;[17]\u0026nbsp;(see Figure 1). As implied by Faija et al\u003cem\u003e.\u003c/em\u003e [23]\u0026nbsp;and advocated by\u0026nbsp;Michie, Van Stralen, and West [19],\u0026nbsp;the BCW system empirically addresses and\u0026nbsp;accounts\u0026nbsp;for multiple determinants of\u0026nbsp;behavior\u0026nbsp;achievable through targeted intervention functions and policy categories.\u003c/p\u003e\n\u003cp\u003eAs a BCW inner layer, the COM-B model is a framework that postulates that the occurrence of any behavior is contingent upon indispensable interactions among capability, opportunity and motivation factors [24]. The model comprises six subcomponents: (i) psychological capability, (ii) physical capability, (iii) physical opportunity, (iv) social opportunity, (v) reflective motivation, and (vi) automatic motivation [17, 19]. Each subcomponent is connected to one or more intervention functions and policy categories of the BCW system, thereby facilitating the attainment of the desired behavior [19, 24]. Consequently, through the BCW framework, multiple change pathways can be explored, pinpointing both facilitating and inhibiting factors at the personal, social, environmental, and/or structural levels, thus allowing for the prioritization of requisite factors that should be promoted or discouraged to achieve optimal nutritional outcomes [25, 26].\u003c/p\u003e\n\u003cp\u003eBehavior change is an inherently complex, multifactor process [13, 27\u0026ndash;29];\u0026nbsp;more so,\u0026nbsp;child nutrition interventions\u0026nbsp;necessitate changes at multiple levels and the engagement of diverse stakeholders to achieve the desired nutritional outcomes. As noted by Raingruber [13], Glanz and Bishop\u0026nbsp;[7], and Trewern, Chenoweth, and Christie\u0026nbsp;[29],\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ebehavior change interventions concurrently address multiple factors and levels, thereby affirming the assertion by Glanz and Bishop\u0026nbsp;[7]: \u0026ldquo;\u003cem\u003eno single factor or set of factors adequately accounts for why people eat as they do\u0026rdquo;\u003c/em\u003e (p.400).\u003c/p\u003e\n\u003cp\u003eThe robustness of the theoretical foundation upon which interventions rest is as important as the outcomes they seek to achieve. Shaky theoretical foundations invariably lead to ineffective interventions, thus compromising the expected results. There is less likelihood of success for interventions decoupled from the evidence base and uninformed by theories [10] and that are unaware of multiple positive and negative factors operating at the personal, group, social, environmental, and structural levels.\u0026nbsp;The evidence indicates that interventions informed by behavioral change theories outperform those that are not theory driven [7, 19, 24, 30, 31].\u003c/p\u003e\n\u003cp\u003eEffective nutrition interventions for children, according to Daelmans et al. [32], Gately and Curtis [33], Di Noia et al. [34], and Al-Walah et al. [35], necessitate a complex and holistic theoretical approach, a systematic understanding of the context, prioritizing intervention packages, and integrating delivery modalities, including cultural features and customization throughout the design, implementation, and evaluation phases. As Munn et al. [36] suggested, the extent to which behavior change theories are currently applied in nutrition interventions for children remains empirically unknown yet indispensable for designing and implementing impactful interventions, a view also shared with Webb Girard et al. [37]\u0026nbsp;and Watson et al.\u0026nbsp;[12].\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eWithout evaluation and evidence thereof, no one would tell what components are effective, how and why they work, or fail to work, who they benefit, and under which conditions. Consequently, rigorous evaluation is essential to ascertain whether hypothesized change pathways are valid\u0026nbsp;and to assess\u0026nbsp;whether pursued outcomes are being achieved or achievable and\u0026nbsp;to illuminate\u0026nbsp;requisite adjustments for optimal impact. In contemporary practice, no longer is having a nutrition intervention in place sufficient to achieve\u0026nbsp;the\u0026nbsp;desired results; rather, a profound understanding of and active collaboration and consultations with stakeholders in their emotional,\u0026nbsp;socio-relational, behavioral, influential, and environmental connections are crucial to achieving nutritional outcomes.\u003c/p\u003e\n\u003cp\u003eAmong the existing peer-reviewed publications on child nutrition interventions, none have investigated the coverage of BCW, a framework that has been theoretically and empirically demonstrated to effectively inform behavior change interventions. While Timlin et al\u003cem\u003e.\u003c/em\u003e [21] reported less rigor in the application of behavioral change theories in intervention design and Watson et al. [12] recommended the deliberate inclusion of behavioral change functions derived from the BCW, no scoping review to date has examined their coverage and utilization. This scoping review aims to fill this gap by exploring the use of the BCW framework in the design, implementation, and evaluation of child nutrition interventions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIn accordance with\u0026nbsp;the Preferred Reporting Items for Systematic\u0026nbsp;Reviews and Meta-Analyses\u0026nbsp;(PRISMA-ScR) extension for scoping reviews checklist [38], this scoping review examines the extent to which the BCW is incorporated in child nutrition interventions. All the data and publications used in this review were publicly available and therefore did not require ethical clearance since no personally identifying information was accessible or used in this research. The protocol underlying this review was not registered, as these procedures are not mandatory in scoping reviews [39]. As discussed in the sections below, the five stages of the scoping review methodological framework developed by Arksey and O\u0026apos;Malley [40] and the associated recommendations proposed by Levac, Colquhoun, and O\u0026rsquo;Brien [41] were adapted to inform the design and execution of this scoping review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage one: Scoping question and its rationale\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch questions are like a compass guiding researchers on their discovery journey. In accordance with the recommendations of Levac, Colquhoun, and O\u0026rsquo;Brien [41] on sound-scoping studies, a single broad, overarching question was formulated: \u003cem\u003eWhat is the state of research using the BCW in child nutrition interventions?\u003c/em\u003e This broad question was further broken down into specific facets: (i) identifying the types of interventions that utilize the BCW and/or its constituent parts; (ii) determining the extent to which the theoretical foundations underlying the interventions are explicitly informed by the BCW during their design, implementation, and/or evaluation; and (iii) elucidating the justifications for employing the BCW to the detriment of other behavior change theories.\u003c/p\u003e\n\u003cp\u003eRecognizing that some theoretical frameworks may be utilized in different types, and at various stages of interventions, three crucial phases were targeted to gauge the state of BCW: the design, implementation, and evaluation phases. Given the heterogeneity of the child population, which evolves and operates within different socio-educational contexts, this review targeted all children under 18 years of age to ensure a comprehensive understanding of the field.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 2: Search strategy to identify relevant articles\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough Arksey and O\u0026rsquo;Malley [40] and Peters et al.\u0026nbsp;[39] suggest including published and unpublished studies that include various nonresearch sources, this scoping review was confined to peer-reviewed publications to ensure that a certain level of quality emanates from the peer review process. A set of key terms emanating from the overarching question and its constituent facets were used to create a detailed list of key search terms. The search strategy was developed via the population, concept, and context (PCC) framework [39] in alignment with the following study objectives: population (children under 18 years of age), concept (BCW as the theoretical foundation), and context (child nutrition projects, programs, or initiatives designed, implemented, and/or evaluated in their quest address nutritional issues worldwide).\u003c/p\u003e\n\u003cp\u003eThe PCC terms were combined\u0026nbsp;via\u0026nbsp;the Boolean operator\u0026nbsp;AND,\u0026nbsp;whereas\u0026nbsp;the terms of the same semantic content within each PCC component were combined\u0026nbsp;via\u0026nbsp;OR. In view of the interdisciplinary application of BCW, this review resorted to a mix of databases focusing on public health, social science, and psychology.\u0026nbsp;The electronic search databases searched included PubMed, Academic Search Complete, CINAHL Plus, Medline, APA PsycInfo, Child Development \u0026amp; Adolescent Studies, and APA PsycArticles with the number of hits for each specified in Annex 4. From these databases, a systematic search was confined to English-language, peer-reviewed articles published between 1\u003csup\u003est\u003c/sup\u003e January 2016 and 15\u003csup\u003eth\u003c/sup\u003e June 2024. The start date aligns with the launch of the Sustainability Development Goals, which emphasize improved nutrition and health outcomes for children. The following search terms were used.\u003c/p\u003e\n\u003cp\u003e\u003cspan id=\"_Toc185280903\"\u003eAn example for a search string for PubMed: (((children OR adolescent OR infant OR teenager) AND (behaviour change wheel OR behavior change wheel OR com-b OR capability OR opportunity OR motivation)) AND (nutrition OR diet OR food OR eating)) AND (Intervention OR project OR program*) were used to search the article titles. Similar search strings were utilized in other databases but were extended to the abstracts to maximize the number of relevant articles retrieved.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 3: Criteria\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;for article selection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEligible studies were peer-reviewed journal articles published in English from 1\u003csup\u003est\u003c/sup\u003e January 2016 to 15\u003csup\u003eth\u003c/sup\u003e June 2024, which explicitly focused on BCW and/or its constituent parts and examined nutritional interventions for children under 18 years of age in the title or abstract. The synonymous words for children (e.g., adolescent, infant, and teenager), nutrition-related terms (e.g., diet, food, eating, vegetables, fruit, and nutrients) and the main forms of malnutrition (e.g., obesity/overweight, underweight, stunting, wasting, and anemia) were part of the inclusion criteria. For BCW, the explicit mention of this theoretical framework or its constructs in the title and/or abstract was an inclusion criterion. Finally, included were articles with, in their title and/or abstract, the mention of terms such as evaluation, randomized control trials, feasibility or design studies, provided that these related to interventions, projects, or programs aimed at addressing malnutrition across the globe. Articles that targeted children older than 17 years, paywalled, study protocols, scoping reviews, or publications unrelated to child nutrition interventions were excluded. Three principal keywords or phrases, namely, (i)\u0026nbsp;\u003cem\u003echild\u003c/em\u003e, (ii) \u003cem\u003eBCW\u0026nbsp;\u003c/em\u003eor\u003cem\u003e\u0026nbsp;COM-B model\u003c/em\u003e, and (iii) \u003cem\u003echild nutrition interventions,\u003c/em\u003e served as the benchmarks for prima facie inclusion. After meeting at least two priority inclusion criteria (i.e., children and nutrition intervention), articles were scrutinized in their title and/or abstracts\u0026nbsp;to determine\u0026nbsp;whether they (i)\u0026nbsp;included\u0026nbsp;the BCW or its constructs;\u0026nbsp;(ii)\u0026nbsp;described\u0026nbsp;an intervention, program, or project;\u0026nbsp;and (iii)\u0026nbsp;were\u0026nbsp;about\u0026nbsp;the\u0026nbsp;evaluation of or study for child nutrition intervention. Duplicate articles were removed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan id=\"_Toc185280905\"\u003eStage 4: Data charting process and data items\u0026nbsp;\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne author (JPN) conducted a systematic search of electronic databases and retrieved articles using inclusion and exclusion criteria jointly developed by both authors (JPN and AH). In view of the initially indeterminate nature and coverage of the content, approximately one-fourth of the included articles (n=5) were first scrutinized to refine the data charting process. Insights gleaned from the preliminary data charting phase were subsequently utilized to finetune the data charting form prior to undertaking full scoping. Drawing upon the researchers\u0026rsquo; field experience and positionalities, scholarly works, and insights from similar scoping reviews [31, 42, 43], a set of relevant variables were identified,\u0026nbsp;as presented in Annex 2 (Data charting). These a\u0026nbsp;priori codes from\u0026nbsp;the\u0026nbsp;data charting form were used in the Atlas.ti software for qualitative data analysis, as described below.\u003c/p\u003e\n\u003cp\u003eUpon finalizing and agreeing upon the list of articles included in the review, the first author (JPN) systematically extracted the data, which were subsequently reviewed and discussed with the second author (AH) utilizing the following a priori codes. First, the set of codes encompassed study characteristics. These specifically included the publication year, author(s), publication title, country/region (thereby indicating the geographical location of the intervention), sample size (used in the review articles), age (or age group of the child, sometimes of other relevant study participants), and research design (classified as experimental, quasiexperimental, cross-sectional, qualitative, quantitative, systematic or other) to highlight the methodological rigor without delving into detail.\u003c/p\u003e\n\u003cp\u003eSecond, the coding schema included codes to capture intervention contexts, with an emphasis on the pivotal role of contextual factors (secure or stable, emergency, and protracted crisis settings) in shaping and impacting intervention effectiveness [28]. Third, the main foci of the nutrition intervention were also coded under the major forms of malnutrition (i.e., stunting, wasting, overweight/obesity, and micronutrient deficiencies as defined by the World Health Organization)[44] or other targeted nutritional outcomes to gauge their presence or absence in the reviewed articles. Finally, following the adaptation of the framework provided by Michie, Van Stralen and West [19], each of the BCW intervention functions, policy categories, and COM-B model components were coded as a thematic category to ascertain their explicit presence in studies that claim employing such a theoretical framework, as described in Annex 10. Reference to the BCW was checked to determine whether it was congruent with the design, implementation and/or evaluation of the nutritional intervention. There were no additional analyses of the significant differences in the outcomes resulting from using or not using BCW.\u003c/p\u003e\n\u003cp\u003eAcknowledging that BCW is not the sole theoretical framework for behavior change (albeit one of the most comprehensive, as it integrates multiple other theories), this study identified and coded other theories used in the published articles. This approach enabled an assessment of the theoretical rationale for utilizing either the BCW in its entirety or other alternative frameworks. The temporal integration of the BCW was coded for its presence at the (i) design, (ii) implementation and (iii) evaluation stages to ascertain the timing of the theoretical reference to the BCW. Finally, any justifications related to the BCW and other theoretical frameworks, particularly those aligned with the nature of the intervention, as well as any highlighted strengths or gaps reported in the articles, were coded for extraction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStage 5: Collating, synthesizing and reporting the results\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe articles included in this review were thematically analyzed to extract content directly pertinent to the study\u0026rsquo;s objectives and research questions. As detailed in the data charting section, the analysis commenced with two foundational steps in thematic content analysis: (i) preliminary charting to refine the data extraction and (ii) generating and selecting a priori themes via data charting (refer to Annex 2) [45]. Subsequently, four additional steps were followed: (i) semantic and thematic coding in Atlas.ti qualitative data analysis software; (ii) retrieval and review of coded themes from Atlas.ti; (iii) tabulation of the confirmed themes; and (iv) summary reporting [45], as outlined in Annex 3. The coded instances illustrating key themes were then extracted for interpretation and summary write-up in accordance with the research objectives and questions. By utilizing the predetermined a priori codes from the data charting items, the text segments coded in Atlas.ti were iteratively scrutinized by the first author (JPN) and reviewed by and discussed with the second author (AH). These segments were ultimately designated the final instances of the BCW in child nutrition interventions. Within Atlas.ti, the presence or the coded text was extracted with a value label of \u0026ldquo;1\u0026rdquo;, and its absence was automatically counted as \u0026ldquo;0\u0026rdquo;.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe search of electronic databases retrieved 2,460 articles (see Annex 4). After deduplication, 1,216 studies were deemed eligible for the subsequent stage of the review process. After screening titles and abstracts for their relevance, 40 articles were retained for content and thematic scrutiny. This process led to a final list of 22 articles (refer to Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eThe state of research using the BCW and COM-B models in child nutrition\u003c/h3\u003e\n\u003cp\u003eAs summarized in Annex 5, the included studies employed various, nonmutually exclusive designs and methods, including mainly qualitative (n\u0026thinsp;=\u0026thinsp;8), quantitative (n\u0026thinsp;=\u0026thinsp;1), mixed methods (n\u0026thinsp;=\u0026thinsp;5), (quasi)experimental (n\u0026thinsp;=\u0026thinsp;7), and systematic reviews (n\u0026thinsp;=\u0026thinsp;1). The various research designs deliberately aim at assessing the effectiveness of nutrition interventions across different contexts and target populations from design through implementation and evaluation. Apart from one documentary review [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], the primary target population segments for the studies included children (n\u0026thinsp;=\u0026thinsp;7, [\u003cspan additionalcitationids=\"CR49 CR50 CR51 CR52 CR53\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]), parents or guardians (n\u0026thinsp;=\u0026thinsp;12, [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56 CR57 CR58 CR59 CR60 CR61 CR62 CR63\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]), and/or stakeholders such as schoolteachers, health professionals and other relevant actors (n\u0026thinsp;=\u0026thinsp;9, [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan additionalcitationids=\"CR65 CR66 CR67\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]), all of whom contributed to efforts aimed at optimizing nutritional outcomes among children. Articles reporting child nutrition interventions from eight countries were found, with the largest number of articles originating from the United Kingdom (n\u0026thinsp;=\u0026thinsp;10, [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan additionalcitationids=\"CR64 CR65\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]) and Australia (n\u0026thinsp;=\u0026thinsp;6, [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]). In each of the remaining six countries (i.e., Denmark [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], Ireland [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e], South Africa [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e], South Korea [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], Spain [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] and Thailand [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]), one article was published. Notably, nearly all studies (i.e., 21 out of 22) were conducted in high-income, developed countries, with almost half of the interventions (10 out of 22) in the United Kingdom, compared with a single study in South Africa. With a slight check of significant differences, although outside the scope of this review, few interventions reported statistically significant results in the application of the BCW framework and in the comparison of groups or components of interest in child nutrition interventions (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8/22, 36%). Studies that statistically test significant differences between groups or components of interest may add more confidence for replication in other similar settings or interventions, insomuch as negative and positive factors correlated with outcomes are identified and can thus be incorporated accordingly.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTypes of child nutrition interventions using the BCW and COM-B models\u003c/h2\u003e\u003cp\u003eThe interventions in this review encompassed \u003cb\u003ekey child nutrition outcomes\u003c/b\u003e, with sample sizes varying across participating population groups (i.e., children as well as their parents, guardians, and other pertinent stakeholders). These studies were conducted in stable, nonemergency, and nonhumanitarian contexts. As detailed in Annex 6, two salient, nonmutually exclusive patterns were identified: (i) fourteen articles (64%) covered overall improved child nutrition outcomes [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan additionalcitationids=\"CR57\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan additionalcitationids=\"CR61 CR62\" citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], and (ii) thirteen articles (59%) focused on issues related to overweight and obesity [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53 CR54 CR55 CR56\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Only one article (5%) incorporated measures of energy intake [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], suggesting that the primary underlying concerns addressed were either obesity or undernutrition.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePregnancy, neonatal, and breastfeeding nutrition interventions\u003c/strong\u003e\u003cp\u003eNine articles (41%) examined interventions related to pregnancy, neonatal, and breastfeeding nutrition interventions (Annex 6). For example, Grant et al. [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] utilized the COM-B model to map behavioral variations in alcohol consumption, smoking and infant feeding during pregnancy, contending that context-specific behaviors related to pregnancy and motherhood influence the elements of capability, opportunity and motivation (COM) constructs. Similarly, Litterbach et al. [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e], Russell et al. [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e], and Toomey et al. [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] examined infant feeding practices and their determinants, including sociodemographic characteristics and parental COM constructs. A few articles further investigated feasibility and effectiveness by retrospectively applying the theoretical framework, one to the development of a mobile health app [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] and another to evaluate the suitability of the COM-B model in designing and implementing interventions for optimal breastfeeding outcomes [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Guided by the BCW framework to develop a peer-support intervention, Phillips et al. [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] shed light on effective interventions that elucidated strategies for prolonging the duration of breastfeeding. In a related study, Thomson and Crossland [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] attributed the efficacy of an infant-feeding peer support intervention to the combined use of (i) BCW\u0026rsquo;s intervention functions, (ii) the BCW\u0026rsquo;s policy categories, and (iii) behavior-related components to delineate change pathways for enhancing women\u0026rsquo;s COM-related knowledge regarding breastfeeding. Finally, Page et al. [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] demonstrated how to identify and address barriers to neonatal nutrition by employing both the BCW and COM-B models as the foundational theoretical framework.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSchool-based nutrition interventions\u003c/strong\u003e\u003cp\u003eFour articles (18%) covered school-based nutrition interventions. Bestle et al. [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] examined children\u0026rsquo;s consumption of discretionary beverages and foods within school environments, whereas Sutherland et al. [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] investigated the high consumption of discretionary foods by children at school, emphasizing the role of additional actors and factors through BCW-informed, codesigned interventions. Sutherland et al. [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] also highlighted the importance of integrating school lunchbox nutrition guidelines, curriculum lessons, and digital parental communications to address barriers across multiple levels. Hart and Page [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] focused on aspects of school food education and culture to improve knowledge, skills, motivations, and environmental conditions, whereas Erzse et al. [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e] investigated the shift in dietary practices for healthier options and identified external barriers such as the affordability and availability of unhealthy foods on school premises.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHome- or family-based child nutrition interventions\u003c/strong\u003e\u003cp\u003eThree articles (14%) dealt with home- or family-based child nutrition interventions. According to the BCW and COM-B models, changing behavior in children\u0026rsquo;s dietary practices within the familial context necessitates the targeted involvement of key family members, particularly both parents [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Curtis, Atkins and Brown [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] demonstrated that the interaction among parents\u0026rsquo; COM factors significantly influence meal portion sizes served to children. Similarly, Livingstone et al. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] posited that the distribution of COM-related characteristics within home environments may reveal area-level disadvantages, consequently necessitating tailored intervention priorities for distinct target subgroups to improve diet quality during adolescence.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHealthcare- and practitioner-focused nutrition interventions for children in social and clinical settings\u003c/strong\u003e\u003cp\u003eSix articles (27%) investigated healthcare- and practitioner-focused nutritional interventions for children in social and clinical settings. In their study on cultural adaptation for children\u0026rsquo;s weight management, Pallan et al. [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] reiterated the advantages offered by BCW, noting its capacity to address, inter alia, structural and environmental factors. Similarly, Ray et al. [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e] demonstrated that the systematic application of BCW intervention functions, combined with collaboration with target recipients, facilitates the identification of behavioral barriers and enables the prevention of excess weight gain among children. They describe the categorization of interventions into workflow-focused interventions, interventions that target systemic barriers, and practitioner-focused interventions, which address individual health visitors\u0026rsquo; capabilities through various modalities. Using theory and patient-led research iteratively, Cox et al. [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] contributed to an effective intervention aimed at addressing adolescent obesity, whereas Costello et al. [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] assessed the food and beverage intake of adolescent athletes and underscored the importance of the COM-B model as a theoretical behavioral approach. Furthermore, Fern\u0026aacute;ndez-\u0026Aacute;lvarez et al. [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], employing the BCW framework, examined adherence to and maintenance of healthy eating habits via an educational intervention in sporting venues. Finally, an additional study on nutritional interventions for moderately to severely obese children and adolescents reported improved outcomes, including increased motivation [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLocating the BCW framework in child nutrition interventions\u003c/h2\u003e\u003cp\u003eAcross all the articles, the following BCW intervention functions were used to varying degrees as depicted below:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe detailed mapping of the intervention functions is presented in Annex 7. The policy categories of the BCW framework were less frequently referenced. \u003cem\u003eEnvironmental/social planning\u003c/em\u003e was the most prominently mentioned policy category, appearing in 8 out of 22 articles. The prominence of environmental and structural factors aligns with findings from other studies [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e], which highlight the context and resources reflected in COM-B\u0026rsquo;s opportunity as driving factors needed in the physical environment more than capacity or motivation factors to achieve healthy diets. This finding mirrors the potential of structural factors to change or control the physical, social, or regulatory context, which can either undermine or promote the desired behavior. The policy categories are presented in Annex 8.\u003c/p\u003e\u003cp\u003eThe COM-B model is prominently used across the reviewed articles. As delineated in the COM-B model, the \u003cem\u003ecapability\u003c/em\u003e factors were explicitly mentioned in all the articles except that of Sutherland et al. [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] and implicit mention, without direct reference to the model component and its constituting parts in one article by Bestle et al. [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] encapsulated in the capability-building materials.. The \u003cem\u003eopportunity\u003c/em\u003e factors were explicitly covered in 20 articles, although one article by Bestle et al. [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] implicitly and ambiguously mentioned them through the mere mention of new guidelines. Similarly, \u003cem\u003emotivation\u003c/em\u003e-related factors were evident in all the articles, with the exception of Sutherland et al. [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Slightly more than half of the articles (12 out of 22) clearly stated promoted \u003cem\u003ebehavior\u003c/em\u003e. Despite the overt presence of the BCW and COM-B model in 18 articles during the design stage, only seven articles referenced this theoretical framework during the implementation stage, and only five articles did so as part of the evaluation process.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eThe use of BCW and other theoretical frameworks\u003c/h2\u003e\u003cp\u003eThe BCW, in conjunction with additional theoretical frameworks, was employed to varying degrees across the reviewed articles. Specifically, the Transtheoretical Model in Lee et al. [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], the Social Cognitive Theory (SCT) in Bestle et al. [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], and the Self-Determination Theory in Cox et al. [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] were utilized alongside elements of the COM-B model, the mapping of which is in Annex 9. After alternative theories\u0026mdash;such as the theory of planned behavior\u0026mdash;and their application in other contexts were assessed, Thomson and Crossland [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] opted for the BCW framework for its comprehensive ecological perspective. With the exception of the study by Lee et al. [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], which integrated a different theory and a motivational component of the BCW subsumed in the Transtheoretical Model, 21 articles provided justification for employing the BCW and COM-B Model. In contrast to SCT\u0026rsquo;s emphasis on self-efficacy, Hart and Page [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] contend that focusing solely on knowledge \u0026ldquo;\u003cem\u003eis limited without a supportive school food culture and opportunities\u003c/em\u003e\u0026rdquo; (p.690).\u003c/p\u003e\u003cp\u003eFor most authors, the BCW theoretical framework and its inner layer COM-B model are utilized for their comprehensive nature to capture key theoretical domains. This framework is utilized for its demonstrated effectiveness in promoting desired change through the dynamic interplay among its components and integrated processes, with certain elements being flexibly and explicitly emphasized more than others [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Recognizing the critical need for both internal and external factors (i.e., multistakeholder engagement alongside socioeducational and environmental influences) in enabling multisectoral actions to leverage and enhance the COM, a handful of articles [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e] have applied the model to effect change within its context. Other studies justified the application of specific COM-B constructs by emphasizing the use of \u003cem\u003ecapability\u003c/em\u003e to foster increased confidence or enhance infant feeding, \u003cem\u003ethe opportunity\u003c/em\u003e to facilitate access to comprehensible information and strengthen social and healthcare network support, and \u003cem\u003ethe motivation\u003c/em\u003e to provide the guidance necessary to sustain behavior [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. In addressing the adoption and maintenance of breastfeeding, Musgrave et al. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] and Nuampa et al. [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] underscored the significance of personal, social, environmental, and cognitive-behavioral attributes as encapsulated in the COM-B model.\u003c/p\u003e\u003cp\u003eIn other articles, the merits of using the BCW and COM-B models include the capacity to delineate target behaviors and alternatives, alongside the identification of associated drivers and inhibitors, thus informing the selection of appropriate behavior change techniques [\u003cspan additionalcitationids=\"CR58\" citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Page et al. [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], Livingstone et al. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], and Sutherland et al. [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] resorted to the COM-B model with a diverse array of evidence sources to elucidate the drivers and inhibitors of the behavior of interest. They modeled change pathways by selecting strategies tailored to address specific behavioral determinants within the BCW framework. Finally, a couple of articles recognize COM-B factors as essential prerequisites for behavior to occur, mapping empirical findings to the model\u0026rsquo;s six domains to uncover and understand the behavioral change process [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe BCW is justified over other theories for explicitly incorporating emotional and automatic motivational influences alongside capability and opportunity factors. Another justification for employing BCW over other behavior change theories is its systematic, comprehensive, stakeholder-informed operationalization through behavior change techniques to address behavior change determinants. Several interventions explicitly and prospectively integrate the BCW framework as central theoretical underpinnings in their design, including integration of the COM-B model with other models, BCW in codesigning and structuring intervention packages, and delineating sources of behaviors [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Nutrition interventions are, to a great extent, explicitly informed by BCW, shaping both conceptualization and practical intervention design. To a lesser extent, instances of BCW to inform the evaluation of nutrition interventions are limited.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis scoping review represents, to the best of our knowledge, the first appraisal of the designability, implementability, and evaluability of child nutrition interventions underpinned by the BCW framework. Drawing from various study designs and methods, this review identified a handful of findings.\u003c/p\u003e\u003cp\u003eFirst, the current state of research on BCW-informed nutrition interventions underscores the complexity inherent in altering behaviors related to child nutrition outcomes, similar to Li and Li’s [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e] findings in a systematic review of pregnancy dietary interventions using the COM-B model. When individual, social, structural, and environmental factors are included, multidimensional interventions (as theoretically and empirically supported by the BCW framework) demonstrate effectiveness. The majority of the reviewed articles concentrated on overall improvement in child nutritional outcomes, particularly those addressing overweight and obesity, which are typically prevalent challenges in high-income countries. In contrast, issues such as stunting, wasting, and nutrient deficiencies prevalent in low- and middle-income countries are rarely covered, reflecting the unequal coverage of the global burden of malnutrition, as evidenced elsewhere [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eComplementing the BCW system in child nutrition interventions with other theoretical frameworks, such as Amartya Sen’s capability approach [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], indicates a deliberate and thoughtful integration of the COM-B model with the capability approach’s broader perspective on individual freedoms and social factors to achieve healthy nutrition outcomes. The BCW system plays dual roles in child nutrition research as both an analytical framework and a prospective guide for intervention design and implementation. Thomson and Crossland [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] describe the use of the BCW retrospectively “to structure the analysis of the findings from an evaluation of an infant feeding peer support service”, unlike Sutherland et al.’s [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] prospective application, which reported the use of the BCW to codesign and integrate the multicomponent intervention. This unique retro-prospective application indicates that the BCW framework is primarily a theoretical exploratory and explanatory tool for designing, implementing, and evaluating interventions, thus enhancing the understanding and shaping of behaviors within child nutrition contexts.\u003c/p\u003e\u003cp\u003eThe reviewed articles, in their alignment with the core elements of BCW, collectively highlight the critically multifaceted role of social and environmental factors in influencing child nutrition behaviors [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e], hence context-sensitive and holistic intervention strategies. Eating habits are not isolated but rather collective actions nurtured through, or pressurized by, social and environmental dimensions. This finding aligns with evidence indicating the importance of including more behavior change functions, such as environmental restructuring [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. These insights confirm that interventions informed by BCW must address social opportunity and motivational components alongside the ability to effectively promote behavior change. Current research using the BCW framework emphasizes collaboration and multidisciplinarity in the codesign of nutrition interventions, as exemplified by the reviewed articles [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e], to enhance relevance, contextual acceptability, local ownership, wider support, and uptake of the promoted change. The application of BCW across multiple behaviors and diverse populations in child nutrition interventions is limited by its shortcomings. In some contexts, where multibehaviour complexities and socioeconomic diversity are insufficiently considered, as alluded to by Watson et al. [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e], BCW-informed interventions are less effective.\u003c/p\u003e\u003cp\u003eAlthough children constitute the ultimate target group of the reviewed articles, the engagement of multiple stakeholders, including parents, policymakers, schools, and health personnel, is a critical springboard for optimizing outcomes across school, home, and broader social contexts. The review findings revealed the effectiveness of nutrition interventions when these diverse actors, as well as social food environments, are holistically integrated. This conclusion aligns with the principles of theory-informed intervention design, which advocates for intentional intervention mapping to link theory and practice, address challenges, and promote determinants of behavior [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. There are other theoretical frameworks used in the reviewed articles, which further substantiate the complexity of behavior change nutrition interventions. These interventions combine educational, motivational, environmental, and social strategies; are often delivered through participatory, digital, and face-to-face modalities; and frequently involve codesign with target populations to ensure contextual relevance and acceptability.\u003c/p\u003e\u003cp\u003eSecond, various types of nutritional interventions exist for children. Antenatal (i.e., pregnancy), neonatal (i.e., infant feeding and breastfeeding), and postnatal (i.e., child feeding practices outside schools and homes) interventions were prioritized differently. Interventions directed at teenagers and adolescents are relatively rare, with only a few studies addressing these age groups through initiatives in sports settings, such as soccer [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] and rugby [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Additionally, evidence indicates that enhancing the nutrition of school-aged children requires more than interventions confined to school premises. The influence of home environments and other broader social and environmental factors and actors is indispensable in shaping eating habits and achieving the desired child nutrition outcomes. In this context, the role of primary child carers (predominantly mothers) from pregnancy through the neonatal and breastfeeding stages and extending into childhood and school age is paramount. In addition to home-based interventions, which remain central to improving child nutrition, initiatives implemented in social or clinical settings exhibit distinct characteristics that necessitate the involvement of additional actors and factors for effective child nutrition interventions.\u003c/p\u003e\u003cp\u003eFinally, the results of this review substantiate the utility of the BCW framework in the design and implementation of child nutrition interventions, although its application in evaluation is comparatively limited. Although evidence abounds in guiding the design of interventions targeting changes in eating behavior [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e], as reflected in this scoping review, the use of BCW in implementation and evaluation is limited. The findings indicate that the BCW intervention functions were employed more frequently than the policy categories were. The COM-B model was explicitly referenced in all the articles except that of Sutherland et al. [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], and not all the articles clearly articulated the promoted behavior. The varying degrees of application of the BCW and COM-B models between the design and implementation stages, as opposed to the evaluation phase, suggest that evaluation may be inherently more complex and less amenable to theoretical underpinnings that inform intervention development. This discrepancy may be partially attributed to the temporal lag between the design (theoretical thinking), implementation (theoretical action), and evaluation (empirical observations) and may explain the loss of theoretical memory at a later stage.\u003c/p\u003e\u003cp\u003eTo preserve the memory of the theoretical underpinnings of child nutrition interventions, evaluation design is expected to be part of the design and implementation to generate and embed in the intervention’s testable hypotheses. Although continuous evaluation throughout intervention is not mandatory, developing at least a dynamic evaluation protocol at early stages when all minds are fresh with the design memory to inform the evaluation at later specific stages avoids theoretical decay. A major reason for this limited application lies in the inherent complexity of evaluating multifaceted interventions. Complex interventions often operate across multiple levels (e.g., individual, organizational, community) and incorporate a variety of strategies (e.g., education, environmental restructuring, and policy changes). This layering makes it difficult to attribute outcomes directly to specific components or to align evaluation methods with theoretical models like COM-B. Moreover, evaluations typically prioritize pragmatic outcome measures (e.g., health improvements, behaviour adoption) rather than explicitly mapping changes back to the theoretical constructs of capability, opportunity, and motivation. This results in a missed opportunity to test and refine the theory itself.\u003c/p\u003e\u003cp\u003eOverall, interventions confined solely to the individual level (and consequently omit the social, structural, and environmental dimensions characteristic of schools, homes, and other settings) are less effective in addressing the diverse needs of targeted participants with respect to the COM-B components as highlighted in two articles [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. This finding is similar to evidence from a systematic review pointing out inconsistent application of theory throughout the intervention stages [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e], whereby some are limited to a mere mention of the theories at the design stage. This review reveals that the presence of the theoretical underpinning at the design stage is not consistently translated into the subsequent implementation actions, nor does it uniformly inform the evaluation process all the time. As evidence from this review indicates, using a theoretical framework in the design stage underscores the critical importance of sound theoretical foundations to drive behavior change, such use does not guarantee that the theoretical underpinnings are maintained during implementation or referenced to inform the evaluation. The selective application of the BCW (when confined to a single phase of intervention such as design, implementation, or evaluation) provides a fragmented, temporally limited understanding of the contextual actors and factors that drive or inhibit the effectiveness of child nutrition interventions.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThis scoping review, which is global in design, followed the established guidelines and elucidated the benefits of incorporating the comprehensive BCW theoretical framework in the design, implementation, and evaluation of child nutrition interventions. However, its intended geographical coverage and temporal scope present certain limitations. First, nearly all eligible articles were derived from developed countries. Second, the review might have excluded relevant nonpeer reviewed, unpublished study reports, presumably including those from low- and middle-income countries where authors may have limited access to publishing outlets and/or reduced incentives. Third, although additional pertinent publications may exist from prior to the advent of the SDGs, the review deliberately focused on the period from January 2016 to mid-June 2024 to establish a temporal benchmark for future studies that may contribute to SDG measurement. Finally, most of the articles focused on child overweight to the detriment of other forms of malnutrition, which may have the highest prevalence rates in low- and middle-income countries.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion and recommendations","content":"\u003cp\u003eThis review consolidates the literature on child nutrition interventions, which are informed by the BCW framework. This theoretical framework is predominantly used in stable contexts within developed countries, with a primary focus on addressing overweight and overall child nutrition. No single occurrence was traceable in emergency and humanitarian contexts despite high prevalence rates of stunting, wasting, and micronutrient deficiencies resulting from the constrained access to adequate diets and health services in such contexts. The findings emphasize the multifaceted nature of child nutrition interventions, which extend across various domains, such as homes, schools, parents, governments, policymakers, food suppliers, and health practitioners. Interventions tend to selectively address certain behavioral determinants while deprioritizing others. While the BCW framework can accommodate, or be integrated with, other theoretical models, it uniquely provides a range of options, namely, intervention functions and policy categories, across the design, implementation, and evaluation stages, although emphasis on evaluation is limited. The incorporation of structural factors, as informed by the BCW framework, appears to be critical for the effectiveness of child nutrition interventions.\u003c/p\u003e\u003cp\u003eThe findings from this review demonstrate that BCW-informed child nutrition interventions are effective in addressing malnutrition. This review reveals that the presence of the theoretical underpinning at the design stage is not consistently translated into the subsequent implementation actions, nor does it uniformly inform the evaluation process all the time. As evidenced from this review, incorporating a theoretical framework in the design stage underscores the critical importance of sound theoretical foundations to drive behavior change. However, such incorporation and use at design stage do not guarantee that theoretical underpinnings are upheld during implementation or systematically referenced to inform the evaluation. The selective application of the BCW framework (when confined to a single phase of an intervention such as the design, implementation, or evaluation) provides a fragmented, temporally limited understanding of the contextual actors and determinants that drive or inhibit the effectiveness of child nutrition interventions.\u003c/p\u003e\u003cp\u003eThis review highlights the need for further investigation of the differential and additive effects of the BCW components on intervention outcomes, particularly when different combinations (not necessarily all) of BCW intervention functions, policy categories, and COM-B components are employed. Accordingly, additional research should elucidate the potential additive effect of each component of the model to inform targeted capacity-strengthening initiatives for child nutrition interventions.\u003c/p\u003e\u003cp\u003eFurthermore, development agencies involved in child nutrition interventions should commission further policy research in low- and middle-income countries as well as in emergency and humanitarian contexts to identify obstacles to using the BCW framework. The current limited coverage of the BCW framework illustrates the empirical lacuna undermining the holistic understanding of barriers to and facilitators of child nutrition outcomes. Therefore, funding and nutrition policies for child nutrition should require deliberate integration of the BCW (or any other relevant behavior change theory) in the design, implementation, and evaluation of interventions to determine their efficacy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was not required for this study as it involved a review of published literature and did not include any human participants or personal data. Regardless, the original proposal was subjected to Brunel Research Ethics Online (BREO) decision tool to determine whether the research required ethical approval through a series of questions about the research design, data collection methods, human participants, and collection of personally identifying data and information. Based on this assessment, the research study was classified as not requiring ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe search strings and data generated and used in the current study are included within the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJPN conceptualized and designed the study, conducted a systematic search of electronic databases and retrieved articles using inclusion and exclusion criteria developed by JPN under the academic supervision of AH. JPN systematically extracted data, which were subsequently reviewed and discussed with AH utilizing the agreed-upon a priori codes. JPN conducted the analysis in Atlas.ti using the predetermined a priori codes from the data charting items and drafted the research report. Upon the successful submission of the research report in partial fulfillment for the degree award at Brunel University London, JPN revisited the analysis and produced a publishable draft manuscript. The manuscript was reviewed by AH who also contributed to its content. \u0026nbsp;Both authors iteratively reviewed and finalized the manuscript to ensure analytical rigor. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAkombi BJ, Chitekwe S, Sahle BW, Renzaho AMN (2019) Estimating the Double Burden of Malnutrition among 595,975 Children in 65 Low- and Middle-Income Countries: A Meta-Analysis of Demographic and Health Surveys. Int J Environ Res Public Health. https://doi.org/10.3390/ijerph16162886\u003c/li\u003e\n\u003cli\u003eAbimpaye M, Dusabe C, Nzabonimpa JP, Ashford R, Pisani L (2020) Improving parenting practices and development for young children in Rwanda: Results from a randomized control trial. 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Nutr Res N Y N 84:53\u0026ndash;62\u003c/li\u003e\n\u003cli\u003eHart CS, Page A (2020) The capability approach and school food education and culture in England: \u0026ldquo;gingerbread men ain\u0026rsquo;t gonna get me very far\u0026rdquo;. Camb J Educ 50:673\u0026ndash;693\u003c/li\u003e\n\u003cli\u003eFern\u0026aacute;ndez-\u0026Aacute;lvarez MM, Mart\u0026iacute;n-Payo R, Garc\u0026iacute;a-Garc\u0026iacute;a R, Cuesta M, Carrasco-Santos S (2020) A nutrition education intervention in adolescents who play soccer: The IDEHA-F project. Psicothema 32:359\u0026ndash;365\u003c/li\u003e\n\u003cli\u003eCox JS, Searle A, Thornton G, Hamilton-Shield J, Hinton EC (2023) Integrating COM-B and the person-based approach to develop an ACT based therapy programme to raise self-determination in adolescents with obesity. 23:1\u0026ndash;11\u003c/li\u003e\n\u003cli\u003eCostello N, Deighton K, Dyson J, Mckenna J, Jones B (2017) Snap-N-Send: A valid and reliable method for assessing the energy intake of elite adolescent athletes. Eur J Sport Sci 17:1044\u0026ndash;1055\u003c/li\u003e\n\u003cli\u003eBestle SMS, Lassen AD, Biltoft-Jensen AP, Matthiessen J, Gibbons SJ, Christensen BJ, Ersb\u0026oslash;ll BK, Trolle E (2024) Reduction in intake of discretionary foods and drinks among Danish schoolchildren: dietary results from the real-life cluster-randomised controlled trial \u0026ldquo;Are You Too Sweet?\u0026rdquo;. Public Health Nutr 27:e111\u003c/li\u003e\n\u003cli\u003eToomey E, Matvienko‐Sikar K, Doherty E, et al (2020) A collaborative approach to developing sustainable behaviour change interventions for childhood obesity prevention: Development of the Choosing Healthy Eating for Infant Health (CHErIsH) intervention and implementation strategy. Br J Health Psychol 25:275\u0026ndash;304\u003c/li\u003e\n\u003cli\u003eSutherland R, Brown A, Nathan N, et al (2021) A Multicomponent mHealth-Based Intervention (SWAP IT) to Decrease the Consumption of Discretionary Foods Packed in School Lunchboxes: Type I Effectiveness-Implementation Hybrid Cluster Randomized Controlled Trial. J Med Internet Res 23:e25256\u003c/li\u003e\n\u003cli\u003eRussell CG, Denney-Wilson E, Laws RA, Abbott G, Zheng M, Lymer SJ, Taki S, Litterbach E-KV, Ong K-L, Campbell KJ (2018) Impact of the Growing Healthy mHealth Program on Maternal Feeding Practices, Infant Food Preferences, and Satiety Responsiveness: Quasi-Experimental Study. 20:\u003c/li\u003e\n\u003cli\u003ePhillips R, Copeland L, Grant A, et al (2018) Development of a novel motivational interviewing (MI) informed peer-support intervention to support mothers to breastfeed for longer. 18:\u003c/li\u003e\n\u003cli\u003ePallan M, Griffin T, Hurley K, et al (2019) Cultural adaptation of a children\u0026rsquo;s weight management programme: Child weigHt mANaGement for Ethnically diverse communities (CHANGE) study. BMC Public Health 19:848\u003c/li\u003e\n\u003cli\u003eNuampa S, Sirithepmontree S, Sudphet M, Patil CL (2024) \u0026ldquo;The way to obtain freedom and equality\u0026rdquo;: Experiences and needs of Thai adolescent mothers in terms of the use smartphone applications for breastfeeding support. 19:1\u0026ndash;17\u003c/li\u003e\n\u003cli\u003eLitterbach E-K, Laws RA, Campbell1 KJ, Russell CG, Taki S, Denney-Wilson E (2017) Factors Influencing Engagement and Behavioral Determinants of Infant Feeding in an mHealth Program: Qualitative Evaluation of the Growing Healthy Program. 19:1\u003c/li\u003e\n\u003cli\u003eChai LK, May C, Collins CE, Burrows TL (2019) Development of text messages targeting healthy eating for children in the context of parenting partnerships. Nutr Diet 76:515\u0026ndash;520\u003c/li\u003e\n\u003cli\u003eGrant A, Morgan M, Mannay D, Gallagher D (2019) Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (Capability, Opportunity, Motivation-Behaviour) model. 19:\u003c/li\u003e\n\u003cli\u003eCurtis K, Atkins L, Brown K (2017) Big hearts, small hands: a focus group study exploring parental food portion behaviours. 17:1\u0026ndash;14\u003c/li\u003e\n\u003cli\u003eThomson G, Crossland N (2019) Using the behaviour change wheel to explore infant feeding peer support provision; insights from a North West UK evaluation. Int Breastfeed J 14:41\u003c/li\u003e\n\u003cli\u003eRay D, Sniehotta F, McColl E, Ells L, O\u0026rsquo;Neill G, McCabe K (2022) A collaborative approach to develop an intervention to strengthen health visitors\u0026rsquo; role in prevention of excess weight gain in children. BMC Public Health 22:1735\u003c/li\u003e\n\u003cli\u003ePage D, Gilroy M, Hurrion E, Clark L, Wilkinson S (2017) Optimising early neonatal nutrition using translational research methodology. 74:460\u0026ndash;470\u003c/li\u003e\n\u003cli\u003eErzse A, Karim SA, Rwafa-Ponela T, Kruger P, Hofman K, Foley L, Oni T, Goldstein S (2023) Participatory prioritisation of interventions to improve primary school food environments in Gauteng, South Africa. BMC Public Health Comput File. https://doi.org/10.1186/s12889-023-16101-z\u003c/li\u003e\n\u003cli\u003eBriazu RA, Masood F, Hunt L, Pettinger C, Wagstaff C, McCloy R (2024) Barriers and facilitators to healthy eating in disadvantaged adults living in the UK: a scoping review. BMC Public Health 24:1770\u003c/li\u003e\n\u003cli\u003eHunt L, Pettinger C, Wagstaff C (2023) A critical exploration of the diets of UK disadvantaged communities to inform food systems transformation: a scoping review of qualitative literature using a social practice theory lens. BMC Public Health 23:1970\u003c/li\u003e\n\u003cli\u003eLi Q, Li J (2025) Behavior change techniques in pregnancy dietary interventions: a systematic review through the lens of the COM-B model. BMC Pregnancy Childbirth 25:798\u003c/li\u003e\n\u003cli\u003eAdeyeye SAO, Ashaolu TJ, Bolaji OT, Abegunde TA, Omoyajowo AO (2023) Africa and the Nexus of poverty, malnutrition and diseases. Crit Rev Food Sci Nutr 63:641\u0026ndash;656\u003c/li\u003e\n\u003cli\u003eRay D, Sniehotta F, McColl E, Ells L, O\u0026rsquo;Neill G, McCabe K (2022) A collaborative approach to develop an intervention to strengthen health visitors\u0026rsquo; role in prevention of excess weight gain in children. BMC Public Health 22:1735\u0026ndash;1735\u003c/li\u003e\n\u003cli\u003eWatson D, Mushamiri P, Beeri P, et al (2023) Behaviour change interventions improve maternal and child nutrition in sub-Saharan Africa: A systematic review. PLOS Glob Public Health 3:e0000401\u003c/li\u003e\n\u003cli\u003eNabuuma D, Ekesa B, Faber M, Mbhenyane X (2024) Designing a Contextualized Food-Based Strategy to Improve the Dietary Diversity of Children in Rural Farming Households in Central Uganda. Food Nutr Bull 45:24\u0026ndash;37\u003c/li\u003e\n\u003cli\u003eAtkins L, Michie S (2015) Designing interventions to change eating behaviours. Proc Nutr Soc 74:164\u0026ndash;170\u003c/li\u003e\n\u003cli\u003eWillmott TJ, Pang B, Rundle-Thiele S (2021) Capability, opportunity, and motivation: an across contexts empirical examination of the COM-B model. BMC Public Health 21:1014\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Not applicable","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"child nutrition, scoping review, behavior change theory, behavior change wheel, COM-B model, intervention design, implementation, program evaluation","lastPublishedDoi":"10.21203/rs.3.rs-7483112/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7483112/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003eChild malnutrition undermines holistic development and contributes to premature death and developmental disability. Although preventable, child malnutrition persists due to suboptimal nutrition interventions. Mounting evidence has demonstrated that nutrition interventions informed by sound theoretical frameworks are effective in improving child nutrition outcomes. This scoping review aimed to map the coverage of the behavior change wheel (BCW) underlying the design, implementation, and evaluation of child nutrition interventions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods: \u003c/strong\u003e\u003c/em\u003eIn accordance with the Preferred Reporting for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, seven electronic databases were searched via the Population, Concept, and Context (PCC) framework. Peer-reviewed English-language articles published from January 2016 to June 2024 that applied BCW in nutrition interventions for children (aged \u0026lt;18 years) were identified. Data were extracted from eligible articles and analyzed viathematic content analysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003eThe initial search yielded 2,460 articles. After deduplication and application of the inclusion criteria, 22 articles were included in the final review. The findingsshow that (i) BCW interventionfunctions are more commonly used than policy categories are; (ii) most articles explicitly use the COM-B model, but the behavior to change is not explicit; and (iii) all interventions are implemented in stable, high-income contexts, with one exception reported in one low-/middle-income country. Most articles converge toward using the BCW as the most comprehensive framework.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003eThis review consolidates evidence on the use of the BCW in child nutrition interventions, with little illumination of the differential contributions of each model component. It highlights a predominant focus on contexts in high-income countries and on outcomes such as overall nutritional improvement and obesity prevention, whereasinterventions addressing stunting, wasting, and micronutrient deficiencies remain scarce. Future research should investigate the limited use of BCW in low- and middle-income countries and in emergency and humanitarian contexts.\u003c/p\u003e","manuscriptTitle":"Theorizing child nutrition interventions: a scoping review of the behavior change wheel","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-02 06:53:47","doi":"10.21203/rs.3.rs-7483112/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3ecf032a-3160-4c15-b825-892018ce80a0","owner":[],"postedDate":"September 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":53920152,"name":"Nutrition \u0026 Dietetics"}],"tags":[],"updatedAt":"2025-09-02T06:53:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-02 06:53:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7483112","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7483112","identity":"rs-7483112","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}