As this feasibility study was not designed to assess efficacy, effectiveness or cost-effectiveness, data collection was designed primarily to assess feasibility and acceptability. All measurements were completed at baseline and again at follow-up, except for the baseline nursery audits and demographic information provided on consent forms. Data collection methods comprised the following.
Accelerometry measured activity
We used ActiGraph GT1M accelerometers (Actigraph, Pensacola, FL, USA), which have been extensively validated for assessment of PA among children. Accelerometers were fitted by NAP SACC UK researchers on the day of data collection, and instructions for their use were given to parents/carers on the same day.
Anthropometric measures of children
All anthropometric measurements were completed by DBS-checked trained fieldworkers with a member of nursery staff present. Weight was measured without shoes in light clothing to the nearest 0.1 kg using a Seca digital scale (Seca, Birmingham, UK). Height was measured to the nearest 0.1 cm without shoes using a portable Harpenden stadiometer (Holtain Ltd, Pembrokeshire, UK). Fieldworkers were trained to ensure correct position for height assessment. The ethics committee requested that the research team wrote to nursery managers alerting them to any children who were on or above the 99th zBMI centile for their age and sex, with context regarding the concerns about obesity in children, and advising them to follow their usual child protection procedures.
Children’s food and drink intake specifically fruit and vegetables, snacks and sugar-sweetened drinks
Dietary assessment was performed using the Child and Diet Evaluation Tool (CADET) prospective ticklist record for all foods consumed in a 24-hour period, an instrument validated for use in intervention studies with young children.75,76The CADET assesses the intake of 15 food groups, and CADET data were recorded
by researchers undertaking observation of the children at all snacktimes and mealtimes at the nurseries and by parents/carers completing the CADET form at home for the child’s food and drink consumption before and after nursery. At baseline, the data were collected on paper forms with four children observed by one researcher. At follow-up, the data were recorded on paper and transferred to Google Nexus (Google Inc., Mountain View, CA, USA) tablets in the nursery. In a sample of four nurseries, CADET data collection at home was piloted over a weekend in addition to the weekday of nursery data collection; for two of these
TABLE 5 The NAP SACC UK: TIDieR checklist (continued )
Item Description
Tailoring The technical assistance offered by the NAP SACC UK partner would depend on the goals that the nursery had set
NAP SACC at Home
The NAP SACC at Home component was specifically tailored to suit the parents’ needs. Parents answered a questionnaire when they registered and this enabled appropriate information, hints and tips to be sent to them, depending on which areas they set goals in
Modifications The intervention was originally intended to be 6 months long. This was reduced to 5 months part-way through the study to allow time for data collection
How well: planned
A process evaluation was conducted alongside the RCT, which looked at both adherence and fidelity. This involved the use of observations, logs, semistructured interviews and document analysis
How well: actual The NAP SACC UK intervention was implemented as planned, with two exceptions: (1) the parent website was used by only 14% of parents and (2) one intervention nursery did not fully implement the intervention
nurseries, the data were returned by parents on paper and in two nurseries they were collected from the parents by a researcher over the telephone. For the two nurseries where CADET was provided over the telephone, a NAP SACC UK researcher made up to four attempts to contact the parents/carers by telephone.
Sedentary time
Sedentary time was assessed by gathering details of screen time and quiet play time on a weekend day; the questions were based on those used in the Toybox study.77Sedentary time was assessed via questions
at the end of the CADET tool completed by parents/carers.
Environment and Policy Assessment and Observation instrument score
The EPAO instrument was developed for the NAP SACC programme and assesses child-care nutrition and PA environments, policies, and practices. It was developed using the standards, recommendations and research literature on which the NAP SACC intervention itself was based. It has been tested for validity and reliability in nursery settings in the USA.78The EPAO, modified to accommodate the expanded best
practices in 2014, consists of a 1-day observation and review of pertinent centre documents using 189-item questions and 16 free-text sections, with the average of all subscale scores representing total nutrition, indoor play, outdoor play and sedentary time scores. The EPAO from the USA was adapted to ensure consistency with the NAP SACC UK intervention and consistency with English descriptions of food. The EPAO instrument was administered at each of the nurseries by researchers who received specific training. This task was usually shared between two fieldworkers (morning and afternoon) as the form was long and required constant attention.
Parental and nursery staff mediators
Parental and nursery staff knowledge (e.g. nutrition, oral health, PA and sedentary behaviours), self-efficacy and motivation were assessed using tools created for this study. The reliability and validity of the tools are being explored in a separate study to inform whether or not they need further refinement for use in a full-scale trial. A paper questionnaire covering parent/carer mediators was completed by parents/carers.
Data linkage
The feasibility of zBMI data linkage with the NCMP data held by Local Authorities in England66in the first
year of primary school at age 4–5 years was examined in principle. All parents/carers of consented children were sent a further consent form in the post at the end of the study to request consent to link their child’s height and weight data measured through the NCMP (the data linkage did not take place because the study finished before the data were collected in schools).
Intervention data collection procedures comprised the following.
The home component
This was evaluated with respect to data from the record of parental use of the website, goal-setting, sent text messages, sent e-mails and Facebook group activity.
The Review and Reflect tool
Nursery staff completed a Review and Reflect tool at the beginning and end of the intervention. This provided an indication of the staff’s assessment of any changes in the nursery environment, policy and practice relating to nutrition, PA, sedentary behaviours and oral health. This tool is based on the original and revised NAP SACC self-assessment tool.
Goal-setting forms
Nursery staff completed a form to outline their eight intended goals at the beginning of the intervention and this was sent to the research team.
Data were collected by the research team and casual fieldworkers. Training for all staff took place prior to data collection, which covered background of the trial, the structure of nursery visits and role of the fieldworkers, practice measurements in pairs, an explanation of the study protocols and standard operating procedures including the call-in protocol, the policy on working hours, the lone working policy, and the protocol for concern about a child observed during fieldwork. Fieldworkers for follow-up data collection were trained prior to data collection. Google Nexus tablets were trialled for collecting nursery CADET data at all nurseries during follow-up data collection. The tablets were encrypted and made secure with a passcode. Data were entered offline and uploaded later when the tablet was connected to the internet.