Feasibility study phase 1: methods

This chapter provides an overview of the study aims and objectives, study design, methods and results of phase 1 of the study where we adapted NAP SACC to the UK setting and developed a home component.

Phase 1 eligibility and recruitment

A purposive sample of eight child-care providers in North Somerset and eight child-care providers in Cardiff were sent a letter inviting the child-care provider staff to take part in a focus group or telephone interview to inform the development of the NAP SACC UK trial. A letter, project information sheet, reply envelope and form indicating if they wish to participate in a focus group or telephone interview were sent. The sample of child-care providers included private day nurseries as well as community preschools and Children’s Centre nurseries but did not include parent-and-child playgroups or crèches. North Somerset and Cardiff were selected because these are the areas where the RCT was originally intended to take place, Gloucestershire was substituted for Cardiff for phase 2. The two areas provided diverse localities within England and Wales, including urban and rural settings, with a range of deprivation and ethnicity indices.

Health visitors in North Somerset, Wales Healthy and Sustainable Pre-School Scheme (WHASPS) staff in Cardiff and early years staff working at local authorities in North Somerset and Cardiff were sent the same information inviting them to take part in separate focus groups. Written informed consent was taken before the focus groups and telephone interviews commenced.

Phase 1 data collection procedures

Twelve (75%) nurseries were recruited, eight in North Somerset and four in Cardiff. The recruited child-care settings were asked to send parents with children aged 2–4 years a letter, project information sheet, reply envelope and form indicating if they wish to participate in a telephone interview to discuss the NAP SACC UK intervention and trial.

Interviews were conducted with parents in sufficient numbers until saturation was reached and followed a semistructured format with follow-up probes on key topics of interest. Questions focused on ways in which the NAP SACC intervention could be adapted to involve parents and methods of maximising participation in the trial. Each telephone interview lasted 30–45 minutes, was conducted by a trained researcher and was recorded using an Olympus DS-2200 Digital recorder (Olympus DS-2200 Digital recorder, 2 Corporate Center Drive, Melville, NY, USA).

Focus groups were initially chosen as the method of data collection for nursery, early years and public health staff. Focus groups are an effective method of collecting qualitative data as the thoughts and ideas of some members of the group can often encourage others to verbalise their responses in a comfortable, safe and supportive environment.68 Each focus group lasted 45–60 minutes, was conducted by a trained moderator and was recorded using an Olympus DS-2200 digital recorder.

The focus groups had a semistructured design with follow-up probes on key topics of interest. Questions focused on which aspects of NAP SACC needed to be adapted to incorporate UK guidance, recommendations and terminology; how NAP SACC could be adapted to include parents; what additional training could be provided to child-care staff to increase structured active play; how the intervention could be promoted to child-care providers; what factors might influence low participation and adherence to the programme and study; and what strategies should be used to maximise participation.

Owing to the logistical difficulties of arranging focus groups with nursery staff, it was later decided to hold telephone interviews for most nursery staff. The same topic guides were used for the nursery staff interviews as they were for the focus groups and ethics approval was given for the change.

In addition to discussing how NAP SACC could be adapted to the UK during focus groups and interviews, potential changes to NAP SACC were discussed during meetings with a group of local experts, including a community dietitian, oral health and PA specialists, as well as with the study Trial Management Group, the TSC and the founder of NAP SACC (and co-applicant), Dianne Ward.

Phase 1 data analysis

The interview and focus group recordings were transcribed verbatim and anonymised. Tapes were erased and destroyed after transcription. All identifying data were removed from the transcripts. The qualitative software analysis package NVivo (Version 10, QSR International, Warrington, UK) was used to support analysis and data management. As the data were exploratory, a thematic analytical approach was used. A member of the research team indexed a subset of transcript data to construct a coding framework. Codes were then applied to the remaining transcript data. Codes were assembled to construct emergent themes, which were refined and agreed through discussions between the research team. All participant narratives were equally privileged in the generation of new theoretical and empirical insights. Anonymised data were presented in the form of quotes.

Feasibility study phase 1: results

This chapter presents the results from phase 1 of the feasibility study, which aimed to inform the adaptation of the NAP SACC intervention for use in the UK and the creation of a home component and to refine the RCT methods.

Recruitment

Participant characteristics are shown in Table 2. A total of 12 nursery managers, 31 parents and 15 public health and early years staff participated in the study. More than 90% of the participants were female. Four focus groups were conducted with public health and early years staff, along with one focus group for nursery staff. All 31 parents were interviewed by telephone.

Child-care context

Table 3 shows the breakdown of nurseries by location, socioeconomic status (SES), type of nursery, number of 2- to 4-year-old children registered at the nursery, and meal and/or snack provision. The SES of the nursery was based on the Index of Multiple Deprivation (IMD)69 in England and the Welsh Index of Multiple Deprivation (WIMD)70 in Wales. The IMD is an English Government-produced measure of deprivation that includes assessments of income, employment, health and education.69 WIMD is the official measure of relative deprivation for small areas in Wales, which includes assessments of income, employment, health, education, access to services, community safety, physical environment and housing.70 The IMD/WIMD was obtained for the postcode of each nursery and thus represented a measure of deprivation for the nursery and not the individual participant. The nurseries were then stratified into low-, middle- and high-SES tertiles.

Eight nurseries were based in North Somerset, of which four were registered as private day nurseries, three as community preschools and one as a children’s centre nursery. Four nurseries were based in Cardiff, of which three were registered as private day nurseries and one as a community preschool. Across both sites, two nurseries were classified as low SES, five were middle SES and five were high SES. The number of 2- to 4-year-old children registered at the nurseries ranged from 16 to 105. A total of 75% of the sample of nurseries provided meals and snacks for children, which were prepared in-house. The remainder, all of which were community preschools offering sessional care, provided snacks only. Information regarding the ethnic diversity of the child-care settings was unavailable but one-third of the nurseries were based in Cardiff, which is ethnically diverse (17.2% from a non-white background).70

Nursery environment

Healthy nursery environment: nutrition (parents and nursery managers)

Parents and nursery staff generally reported a good standard of nutrition in nurseries:

We take fruit in, in the morning. So that’s part of the routine, is putting the fruit together in a bowl. And . . . if you bring in something more unusual than just an apple or a banana then they . . . sort of talk about it with the children.

With us the majority of the time we have fruit and natural yoghurt for dessert, there’s always veg either in with the meal or as part of the meal.

However, knowledge of and use of nutritional guidance varied between settings, ranging from specific food safety guidance for caterers, to recipes from early years magazines, to no guidance at all:

. . . the owner and the management team and the cook . . . we all throw ideas about what we are going to provide.

We usually follow the Safer Food Better Business for Caterers guidance and also the schools’ guidance as well, the local authority guidance as well . . . and of course anything else that comes out via research . . .

. . . that’s between me, as the owner, and my cook as what we can cook and what we can afford . . .

. . . Um at the moment we just get it from, you know, early years magazines, etc.

Interestingly, none of the North Somerset settings had used, or even heard of, the Children’s Food Trust’s 2012 report, Eat Better, Start Better: Voluntary Food and Drink Guidelines for Early Years Settings in England.28

Healthy nursery environment: physical activity (parents and nursery managers)

Parents and staff of most nurseries reported that there was space and equipment for children to be physically active:

It’s a new building and they’ve got a very large central play area, as well as a separate outdoor play area.

They’ve got an outdoor area at the front and back . . . they are always out on bikes or they have a couple of little plastic cars, so they are always charging around out there.

. . . we’ve got . . . the Sticky Kids’ CDs [compact discs] which we do, and we’re outside nearly all day.

However, one setting had only indoor space available to children:

This playgroup doesn’t have a garden . . . so they are very much confined to indoors . . . with regards to physical activity as far as I know there’s not massive of stuff organised.

The majority of parents also reported that their children spent time outdoors at their nursery, but there was variation in whether this was ‘all weather’ or only on fine days:

My son especially loves the outside and I think that’s why he really enjoys it there. He has in the past got upset because he couldn’t go outside because it’s raining.

We have to make sure they have wellies and waterproofs so yes they can go out anytime.

Some parents reported that their child’s nursery never took children off premises for PA or outdoor play, which they had mixed reactions to:

Because they’ve got quite good outdoor facilities, the garden is big enough, they don’t really need to. They are in the city centre so I don’t think it’s very practical to be honest.

I don’t think they take them outside. It is a shame . . . there is park land within 2 minutes of where they are, so they definitely could take them outside.

Screen time mainly consisted of children taking turns on a computer, and was reasonably limited across settings:

We’ve only literally got one computer, and to be fair that’s not on every day.

However, one nursery reported that they relied on the television to keep children occupied while cleaning the nursery:

This week’s been particularly bad weather, so while I need to clear up my dining room, which is also our playroom, I use the television because it’s been wet and windy and they haven’t wanted to go outside.

NAP SACC intervention

Nursery staff were asked to look at the questions on the self-assessment form and provide feedback on their clarity, appropriateness and fit with UK standards. They were also asked to comment on the length of the draft document. Overall, nursery staff were positive about the NAP SACC approach of self-assessment:

. . . I thought they were quite . . . reflective and . . . not too off-putting either . . . and you just literally tick boxes, which is what we always like.

You know, when you said 70 questions I thought, ‘Ooh’. But actually they’re quite straightforward.

However, the absence of a section on oral health in the self-assessment form was noted to be a growing concern in nurseries:

. . . one thing that has come to our attention in nurseries . . . is children’s teeth . . . more so than obesity, I feel. We have three children at the nursery . . . one . . . is 2 years old and her teeth are rotten . . . another little boy . . . has a hole in his tooth . . . another little girl . . . has got holes in her teeth . . . to the point where she needs them out. And I think . . . we need to put . . . oral health in there somewhere.

Regarding the action-planning document, nursery staff suggested reducing the number of goals required to be set over a 6-month period:

I don’t know whether 10 would be manageable in 6 months, besides everything else that people have to do as well. 10 just seems quite a lot. I’ve got action plans that I might have 10 on but I’m going to spend a whole year covering those. 6 months to do 10 is quite a lot I think.

We usually have, when we do anything in child care, we usually use three or four goals, targets.

They also welcomed improved links with health visitors:

We never ever see a health visitor, so I think that’s amazing.

However, health visitors and WHASPS expressed concern over their capacity to deliver training workshops for nursery staff:

My area, there’s lots of health visitors, so we’d probably be able to achieve it. But in other places, like here, [town name], they may not be able to because there’s quite a few nurseries and not many health visitors, so they might struggle to get round each one, with getting their work done as well.

I think having to give presentations maybe takes us into a different level of time commitment.

When asked if the proposed workshop topics of ‘childhood overweight’, ‘nutrition for children, ‘physical activity for children’ and ‘personal health and wellness for staff’ would be of interest to child-care staff, nursery managers expressed a particular need for more staff training in children’s PA:

. . . although physical development is now a prime area for us to promote, a lot of us have not had any training about how to promote that, you know, the types of activities, and it’s not easily available.

However, concerns were raised about the sensitivity of the topic ‘personal health and wellness for staff’:

. . . that could be quite a tricky area, couldn’t it? Um especially if you’re modelling the obesity one, because you could have some staff that could be slightly overweight that could take offence at that . . . it would have to be handled very carefully, wouldn’t it?’

Developing a home component

In general, parents welcomed the idea of including a home learning component in the NAP SACC UK intervention:

If I was given something like that . . . um I’d have just welcomed the advice and I wouldn’t think you were trying to tell me what to do; you’re just trying to help me in the right direction. If there are a few things that I can improve upon, then brilliant.

However, many parents were concerned that this part of the intervention could be deemed to be invasive or ‘preachy’:

There’s a fine line with becoming too involved with how a parent is raising their child, so I would be cautious.

I think sometimes some people might think it’s a bit patronising. It’s quite obvious that children shouldn’t just sit around and watch TV [television], they need exercise.

Some parents cautioned that the home component may be received differently depending on social background:

I think there are some types of parents that will be hard to reach, so if you approach it in a non-judgemental way and you make it easily accessible for everyone no matter what background, I imagine there are some people who don’t have much money . . . they will feel different and I think it’s making those people feel welcome because it’s help for everyone.

Healthy/low-cost recipe and PA ideas were reported to be most attractive to parents as part of the home component:

Sometimes it’s cheaper or easier to buy junk food. So I think recipes is a good one, giving ideas.

I think a lot more should be available for children, I’ve been looking at gymnastics and dance classes for my daughter and they are just so expensive . . . you would love to send your children to all these classes, but you need ideas of things that don’t cost, or don’t cost a lot of money.

Many parents welcomed the idea of sharing healthy eating and PA ideas with others, and tip-sharing forums were suggested, either online (e.g. using social media) or at a physical meet-up:

You could probably maybe do workshops for parents, ways of getting vegetables into foods, things like that. It would give you a boost to do the right thing, wouldn’t it?

It would be really handy to have a Facebook page with ideas of what you could cook for dinner tonight. A healthy meal that you could do, or something that you could do with the children.

Others suggested that the home component would be most successful if linked in with the nursery’s activities:

You could do something coming from the nurseries, like a welcome pack, or once a quarter maybe linked to the seasons, something like that. Different vegetables and things . . . In that you could have a couple of recipe ideas, or activities you can do at this time of year, or even go for a long walk and collect autumn leaves, pine cones to make Christmas decorations, all that sort of stuff. Seasonal fruit and veg and a couple of nice recipes to do with it. A little fun activity pack.

Parent–child cookery sessions and demonstrations at the nursery were also appealing:

I wonder whether if you had some kind of demo maybe, I don’t know whether the preschool would be involved with that. You could have a kind of demo, someone come along and cook something, and the children and the parents all stay together and have like a buffet or party, that maybe encourages the children to try something they haven’t and maybe the parents as well.

Finally, parents highlighted the importance of involving children in the home component as much as possible, as they were regarded by parents as ‘key’ to change in the home:

So anything that involves the parent going IN, I think they would be keen on and involving the children as well will mean once you’ve left this event, you take it home and if the children’s imagination has been captured and you’ve been there together, then I think that would be a very good way of getting the information home.

Development of NAP SACC UK and NAP SACC UK at Home

NAP SACC UK

Following discussions with nursery managers, it was decided to change the name of the NAP SACC UK self-assessment form to the Review and Reflect form as the research team felt that the word self-assessment evoked a sense that the nursery was being examined in a manner similar to Ofsted (England) or Estyn (Wales), which was potentially off-putting for staff. The form itself was also revised using the English guidelines Eat Better, Start Better – Voluntary Food and Drink Guidelines for Early Years Settings in England,28 as these are seen as current best practice for nurseries in the UK. This meant including questions on salt, breakfast, types of protein and dairy served, puddings and snacks, as well as adapting foods originating in the USA to UK alternatives. Given the concerns raised by the nursery manager and NHS oral health specialist about oral health in nursery-aged children, three questions on oral health were added to the child nutrition section of the form, including how staff promote oral health to children, capacity for professional development and training in oral health, information and support for families and existence of a policy on oral health. Furthermore, after discussion with Welsh Healthy and Sustainable Pre-School Scheme staff, a question was also added about whether or not the nursery had a PA policy that included active travel. After making these amendments and adaptations, the original Go NAP SACC form (excluding the breastfeeding section) was reduced to 80 items.

Following feedback from nursery staff about the manageable number of goals to be achieved in 6 months, the action-planning document was reduced from 10 goals to 8. Owing to the concerns of some nursery managers about their ability to release staff for training, and also the potential sensitivity of some of the workshop topics, the number of training workshops available to nursery staff was condensed from five workshops on ‘obesity’, ‘healthy eating’, ‘physical activity’, ‘personal health and wellness’ and ‘working with families’, to two workshops, each lasting 3 hours, on ‘nutrition and oral health’ and ‘physical activity’. Instead of being delivered by a ‘nurse partner’, as in the USA, these workshops were delivered by a local expert. This differed to the original plan for workshops to be delivered by health visitors and Welsh Healthy and Sustainable Preschool staff, as feedback suggested that this would be burdensome for staff who already had large caseloads. However, because of the interest from nurseries in improving links with health visitors, these workshops were attended by a health visitor, who then became the NAP SACC UK partner for that nursery, maintaining regular contact with the facility to provide support and guidance in making their improvements over a 6-month period. Table 4 summarises the changes made from NAP SACC US to NAP SACC UK.

Development of NAP SACC UK at Home

Drawing on feedback from parents about the proposed home component of NAP SACC UK, a digital media intervention was developed (NAP SACC UK at Home). The steps of NAP SACC UK at Home are outlined below:

1. Sign up: parents are invited to sign up to take part in NAP SACC UK at Home. This involved logging on to the NAP SACC UK at Home website and registering an e-mail address and mobile phone number for correspondence or returning the information on paper to the NAP SACC UK office.
2. Tailoring support: parents were asked to complete a questionnaire about their family habits at home with respect to the areas covered by the home component to allow tailoring of support. An e-mail or text was sent in response, suggesting areas of focus for the goals. The first 50 parents who completed the questionnaire received a free family swimming voucher, redeemable at local swimming pools.
3. Goal-setting and action-planning: parents were asked to set goals for change and plan actions to meet the goals in the areas of eating, drinking, oral health, sleeping, indoor play, outdoor play, television (TV) and screen-viewing behaviours.
4. Tailored suggestions: parents received fortnightly tips and suggestions to prompt behaviour changes in the areas where support was requested. These were sent via Facebook, text and e-mails or by post for those not online.
5. Review: parents were encouraged to review their goals and actions, to consider what worked and what could be approached differently, to set new goals and actions and consider other areas for change.

Summary

The phase 1 study found that nurseries reported a generally good standard of nutrition, but the extent to which nutrition guidance was used varied between settings, with some using no nutritional guidance at all. Most nurseries had space for the children to be physically active, which was usually outdoors. There was variation in the extent to which the outdoor space was used ‘all weather’ or on fine days only. Screen time was limited across settings, with few including television time in their daily routines. Children’s oral health was highlighted to be a growing concern in nurseries, and this concern was reinforced by an NHS oral health specialist, who was a member of our group of expert advisors to NAP SACC UK. Adaptations to NAP SACC were made in the light of the phase 1 study and NAP SACC UK at Home was created.