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A cross-sectional study assessing barriers and facilitators to the sustainability of physical activity and nutrition interventions in early childhood education and care settings

International Journal of Behavioral Nutrition and Physical Activity volume 22, Article number: 2 (2025) Cite this article

Abstract

Background

Effective evidence-based physical activity and nutrition interventions to prevent overweight and obesity and support healthy child development need to be sustained within Early Childhood Education and Care (ECEC) services. Despite this, little is known about factors that influence sustainability of these programs in ECEC settings. Therefore, the aim of this study was to describe the factors related to sustainability of physical activity and nutrition interventions in ECEC settings and examine their association with ECEC service characteristics.

Methods

A cross-sectional study was undertaken with a nationally representative sample of 473 Australian ECEC services. Factors related to the sustainability of ECEC-based physical activity and nutrition interventions were assessed using the validated Integrated Measure of PRogram Element SuStainability in Childcare Settings (IMPRESS-C), measuring Outer Contextual Factors, Inner Contextual Factors, Processes and Characteristics of the Intervention domains for interventions that supervisors reported as currently implementing. Participants responded using a 5-point Likert scale, with responses ranging from 1 (completely disagree) to 5 (completely agree). Domain scores were calculated for each service by averaging item responses. Linear regression models between ECEC service characteristics and the IMPRESS-C domains were undertaken.

Results

Data from 473 Australian childcare services nationally found that the domains: Processes (\(\overline{x }\)=3.78, SD = 0.64), consisting of partnership/engagement and training/support/supervision; and Outer Contextual Factors (\(\overline{x }\)=3.93, SD = 0.63), including policy and legislation, and socio-political context had the lowest mean scores indicating they may likely be barriers to sustainability. Linear regression analyses revealed no statistically significant associations between examined factors and ECEC service characteristics. There was a statistically significant association between the number of years services delivered their interventions and the Characteristics of the Intervention domain (p = 0.035) suggesting that this domain may influence sustainability of programs.

Conclusions

This study suggests that factors related to the Processes and Outer Contextual Factors domains had the lowest scores and as such, strategies to support the sustainability of physical activity and nutrition interventions implemented in ECEC settings may need to consider how to best address these factors.

Background

Overweight and obesity are major risk factors and are associated with leading causes of poor health and early death, contributing to significant health and economic challenges globally [1]. In 2020, 39 million children under five years worldwide were classified as overweight or obese [2]. Low levels of physical activity and suboptimal diets are primary risk factors for excess body weight [3]. The World Health Organization (WHO) recommends supporting the development of healthy behaviours such as physical activity and healthy eating in children at a young age as a way of preventing excess weight gain and improving child wellbeing more generally, given habits developed early in life track into adulthood [4,5,6,7,8]. Promoting healthy eating and physical activity in children is essential for their growth and development, as it helps prevent obesity, supports mental and physical health, and reduces future risks of chronic illnesses such as diabetes and heart disease [9, 10].

Key international and national bodies have recommended Early Childhood Education and Care (ECEC) services (including preschools, family day care, long day care, kindergarten and nurseries) as an ideal setting to reach young children with obesity prevention efforts as they provide care to 87% of children aged 3–5 years globally [9, 11,12,13]. In addition, children aged 3–5 years spend an average of 25–35 h a week in ECEC services, and therefore, are an important environment to influence behaviour change [14]. In recent years there has been growth in the empirical evidence demonstrating the positive impact of ECEC-based physical activity and healthy eating interventions on children’s health [15,16,17,18,19,20]. Findings from systematic reviews suggest that interventions that include opportunities for adult-led, structured child activity [21], staff encouraging physical activity [22], opportunities for children to develop gross motor and movement skills [23], parents packing of lunchboxes [24], increasing access to fruit and/or vegetables [25], and healthy eating educational activities [26] can improve child physical activity, dietary behaviours and/or obesity outcomes. In order to realise the population health impact of these programs, it is important they are both implemented sustained long-term.

Sustainability is defined as the ongoing delivery of a program “(1) measured after a defined period of time, (2) the program, clinical intervention, and/or implementation strategies continue to be delivered and/or (3) individual behaviour change (i.e., clinician, patient) is maintained; (4) the program and individual behaviour change may evolve or adapt while (5) continuing to produce benefits for individuals/systems” [27]. Ensuring public health interventions are sustained, is important to: (i) realise the public health impact of such programs; (ii) protect the significant resource allocation and public health investment in program delivery in this setting; and (iii) foster community trust and confidence in the delivery of future programs [28,29,30].

Despite the importance of sustainability, evidence suggests that up to 40% of all new public health interventions, are not sustained beyond the first few years after termination of initial implementation support [31,32,33]. Similarly, studies in ECEC settings, schools and more broadly examining public health initiatives indicate that implementation is most likely to attenuate after support is withdrawn [28, 33,34,35,36]. To help address this, it is important to develop a comprehensive understanding of the factors that influence intervention sustainability [28, 37, 38]. Employing theoretical frameworks such as the Integrated Sustainability Framework [38], can provide a holistic approach to understanding the potential factors influencing sustainability of these interventions. The Integrated Sustainability Framework helps to identify and organise multi-level factors important in facilitating sustainability, informed by available empirical research [38, 39]. This allows for a comprehensive assessment and addressing of these determinants. A number of validated measures exist to do this, such as the Program Sustainability Assessment Tool [40] or the Integrated Measure of PRogram Element SuStainability in Childcare Settings (IMPRESS-C) [41], the latter of which was developed by the research team to assess constructs related to sustainability, specifically in ECEC settings. Using such frameworks and measures to assess the factors influencing sustainability is crucial for guiding the development of strategies that address and overcome experienced barriers, ultimately supporting intervention sustainment. Sustainment is defined as “the sustained use or delivery of an intervention in practice following external implementation support” [39, 42, 43].

There are, however, a lack of studies examining sustainability of ECEC-based physical activity and healthy eating interventions. A review by Shoesmith and colleagues (2021) identified that only two of the 31 included articles (6%) explored the barriers of sustaining evidence-based interventions (EBIs) in ECEC settings [39]. Consistent with this review, Asada and colleagues (2022) found that only six of 24 studies (25%) (of which two of these studies were included in the review by Shoesmith and colleagues (2021)) reported findings related to the barriers and facilitators to sustainability of physical activity and healthy eating interventions in ECEC settings with children aged 2–5 years [44]. Collectively, these reviews highlighted the most common reported on factors influencing sustainability to be: (1) integration of the program within the existing curricula, (2) available resources, such as high staff turnover, staff motivation, parent engagement, resistance to change and available equipment, (3) financial resources, cost effectiveness, and, (4) staff trainings, executive/leadership support [39, 44]. Together, these reviews identified only six studies focusing on the factors of sustainability in ECEC settings [39, 44]. A large proportion of these studies were conducted in school settings or involved small sample sizes ranging from four to 113 educators in ECEC services [39, 44]. Further, these studies may have overlooked important determinants influencing the sustainability of EBIs, given the lack of application of theoretical frameworks to explore barriers and facilitators as well as the lack of validated measures to identify such determinants in the ECEC studies included in these reviews.

Additionally, there is a limited exploration of barriers and facilitators of program sustainability by different service characteristics such as low-resource settings [45]. Factors such as socio-economic status, rurality, service type, size, and operating hours are associated with implementation and have been theorised to impact on an EBI’s sustainability in several studies but have not been examined in regards to sustainability [46, 47]. Therefore, exploration of barriers by such service characteristics are needed to better understand potential differences by these socio-demographic characteristics.

To address this gap, this study aimed to describe the barriers and facilitators related to the sustainability of physical activity and healthy eating interventions in ECEC services using a validated measure of sustainability determinants; IMPRESS-C [41]. In addition, this study aims to explore the association between the barriers and facilitators to the sustainability of physical activity and healthy eating interventions in ECEC settings and various ECEC service characteristics including socio-economic status, rurality, service type, size, and operating hours.

Methods

Study design and setting

A cross-sectional study was undertaken with a random sample of Australian ECEC services currently implementing selected physical activity or healthy eating interventions between August 2021 and May 2022. ECEC services included long day care and preschools, in which long day care services usually operate from 7am to 6 pm Monday through Friday and cater for children from birth to school age, while preschools cater for children from 3–5 years and usually operate from 9am to 3.30 pm [48]. Services were eligible if they were a centre-based ECEC service (long day care and preschools) approved by the Australian Children Education and Care Quality Authority (ACECQA), which provides guidance, resources and services to support the sector to improve outcomes for children [49]. ECEC services were not eligible if they were: (1) a family day care service or an outside school hours care service; (2) a Department of Education primary or central school due to differing ethical requirements; (3) closed (4) catered exclusively to children requiring specialist care; (5) did not have a staff member with sufficient English to complete the survey; or (6) were a service located in the Hunter New England Local Health District (HNELHD) as they were participating in other surveys to assess implementation of physical activity and healthy eating research. Ethical approval was provided by Hunter New England Human Research Ethics Committee (HREC) (06/07/26/4.04 2019/ETH12353) and ratified with the University of Newcastle HREC (H-2008–0343) and Deakin University HREC (2023–062).

Study recruitment and procedures

Across Australia, 2,050 ECEC services were randomly selected from the ACECQA national register and were invited to participate in an online or telephone survey for the broader study [50]. Both online and telephone approaches were utilised to maximise survey completion rate consistent with previously undertaken processes by the team. Services were recruited using a staggered approach, whereby services were invited via email and mail to participate in the online survey. Each email contained a link that directed them to an information statement and the online survey. A reminder email was sent approximately one week after the initial invitation. If the survey was not completed online within one week, services were called by trained interviewers and invited to complete the survey over the phone. The nominated supervisor, or another staff member with knowledge of the service implementation of physical activity and healthy eating programs, responded to items on behalf of the service.

Data collection procedures and measures

Data collection occurred between August 2021 and May 2022. Services were assessed on 13 selected physical activity or healthy eating interventions determined as evidence-based via systematic review evidence [20, 51]. The specific interventions are outlined in Appendix 1 and are consistent with that recommended by national and international policies to improve child health and wellbeing. To reduce participant burden, allocation of this survey was based on the services current implementation status of these interventions (i.e. implementing based on set criteria) and a predetermined hierarchy to improve the likelihood of equal distribution. While no active program was delivered by the research team to support implementation, there are a number of state-wide programs in Australia (e.g. Munch &Move, the Achievement Program) that work with ECECs to implement healthy eating and physical activity interventions.

ECEC service characteristics

Service demographic information was collected during the online or telephone interview with the service and included type of centre (i.e., long day care or preschool), number of full-time, part-time, and casual educators working at the service, and number of children enrolled. The role of the responder was also captured. Service postcode was obtained from the ACECQA national register and Australian ECEC service postcodes ranked in the top 50% according to the 2016 Socio-Economic Indexes for Areas (SEIFA) were classified as least disadvantaged (i.e., high socio-economic status), whilst the lower 50% of postcodes were classified as most disadvantaged (i.e., low socio-economic status) [52]. The Australian Statistical Geography Standard was used to classify service locality as either urban or regional/remote [53].

Barriers and facilitators associated with the sustainability of physical activity and healthy eating interventions in ECEC services

Online or telephone surveys were used to assess the barriers and facilitators to the sustainability of physical activity and healthy eating interventions. The interventions assessed in the current study were based on extensive reviews indicating likely positive outcomes on child behaviours [54] – see Appendix 1 for definitions. These selected interventions included; four physical activity interventions; activities with children (defined as engaging children with activities at least once per week), Energisers (defined as three, five minute educator led activity breaks [55] on more than one day per week), providing fundamental movement skills (defined as an activity to intentionally develop fundamental movement skills at least one day a week) and outdoor time with a planned activity at least once per week, and nine healthy eating interventions; two or more serves of fruit per day, two or more serves of vegetables per day, exposure to different vegetables at least once per month, healthy eating-themed special days at least once per month, interactive healthy eating activities at least once per month, observations of children’s lunchboxes at least one to two times per week, planned healthy eating lessons at least monthly, play based healthy eating activities at least once per month, and strategies to encourage consumption of age appropriate beverages at least two times per week (see Appendix 1). Barriers and facilitators were identified using the IMPRESS-C [41]. This measure was developed based on the Integrated Sustainability Framework [38], a framework informed by available empirical research on factors identified as important determinants of sustainability across a range of contexts and interventions. The 26-item IMPRESS-C examines sustainability determinants across four domains including: Outer Contextual Factors (3 items) e.g., the socio-political context or the funding environment; Inner Contextual Factors (8 items) e.g., financial resources, program champions, and organisational support; Processes (5 items) e.g., training, stakeholder engagement and partnerships; and Characteristics of the Intervention (10 items) e.g., adaptability, fit within the context and population [41] (see Appendix 2). The IMPRESS-C was developed and validated by the research team for completion of service executives within the ECEC setting (details published elsewhere) [41], which was then used in the current study. In a sample of 405 ECEC services, the IMPRESS-C displayed good structural validity (Standardized Root Square Residual = 0.056, Comparative Fit Index = 0.993, Root Mean Square Error of Approximation = 0.067), and illustrated: good internal consistency (Cronbach’s a: 0.53 to 0.92); emerging concurrent validity; good norms, and good overall pragmatic qualities (cost, readability, length, and assessor burden) [41]. An overview of the measure is provided in Table 1. Service nominated supervisors were asked to rate their level of agreement to items based on a 5-point Likert scale from ‘1’ (completely disagree) to ‘5’ (completely agree).

Table 1 Overview of the IMPRESS-C domains [41]
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Analysis

Data was analysed in R 4.0.3 [56]. Descriptive statistics, including median, interquartile range (IQR), minimum, maximum, means, and standard deviations, were calculated for each of the four domains; Outer Contextual Factors, Processes, Inner Contextual Factors, Characteristics of the Intervention domains. These descriptive statistics were also used to describe ECEC service characteristics and provide mean score for each domain for physical activity and healthy eating interventions overall and for each individual intervention. The frequency (percentage) of responses for each survey question is presented. Mean values were used to describe domains as potential barriers and facilitators [57]. No cut points for classifying barriers were selected however lower domains scores were considered as more likely to be barriers, while higher domain scores were considered as more likely to be facilitators. To investigate the association between each ECEC service characteristic and domain score, linear regression models were also run between service socio-economic status (as classified using service postcode), rurality, service type, service size, operating days and hours, and overall mean score for each IMPRESS-C domains; Outer Contextual Factors, Processes, Inner Contextual Factors, Characteristics of the Intervention domains (i.e., barriers and facilitators perceived to influencing sustainability of physical activity and healthy eating interventions). The domain scores were modelled individually as fixed effects. Socio-economic status, Accessibility/Remoteness Index of Australia, service type and service size were dichotomised. For socio-economic status, the bottom five Australian Bureau of Statistics deciles were considered lower socio-economic status, while the top five deciles were considered higher socio-economic status [58]. A binomial distribution with a logistic link was used for socio-economic status, Accessibility/Remoteness Index of Australia, service type and service size, while a normal distribution with an identity link was used for number of days open and hours of operation. The association between whether the service had delivered their health promotion program for ≥ 2 years, and the domain score was modelled using a generalised linear model with a binomial distribution and logistic link. The odds ratio with corresponding 95% confidence intervals and p-values were presented. The reference group was “delivered program < 2 years”. Additionally, any statistically significant differences in service socio-economic status area/geographical location between consenters and non-consenters were examined. Statistical significance was defined as p < 0.05. “Refused” and “Don’t know” responses for the survey were imputed using a single imputation with predictive mean matching (0 knots). If a participant was “Refused” / “Don’t know” for all responses to the survey, then they were excluded. The imputed data were included for all analyses.

Results

Of the 2,050 ECEC services that were invited to participate in the larger study, 993 ECEC services completed the survey. Following contact, ECEC services consented to the study and were assessed for eligibility, with 116 (6%) services deemed ineligible. This was most commonly due to the services being part of a Department of Education primary or central school. Overall, 473 ECEC services responded to the sustainability items based on the intervention (either physical activity or healthy eating) that they were implementing.

The demographic characteristics of services which received items around sustainability are described in Table 2. The majority of the services were long day care services (n = 430, 91%). Approximately 59% (n = 281) of ECEC services were in high socioeconomic area and 93% (n = 442) were located in a major city (see Table 2).

Table 2 Demographic characteristics of participating ECEC services
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Barriers and facilitators according to the IMPRESS-C scale domains

Each of the 473 services responded to one of the 13 physical activity and healthy eating interventions, depending on the intervention they were currently implementing. The physical activity interventions included; activities with children (n = 70), Energisers (n = 97), fundamental movement skills (n = 30), and outdoor time with a planned activity (n = 35). The healthy eating interventions included; two or more serves of fruit per day (n = 11), two or more serves of vegetables per day (n = 48), exposure to different vegetables (n = 16), healthy eating-themed special days (n = 13), interactive healthy eating activities (n = 53), observations of children’s lunchboxes (n = 9), planned healthy eating lessons (n = 17), play based healthy eating activities (n = 50), and strategies to encourage consumption of age appropriate beverages (n = 24).

The IMPRESS-C scale resulted in the identification of a number of potential barriers and facilitators including; (1) Outer Contextual Factors domain, which comprised of the sociopolitical context, funding environment and availability, external partnerships and leadership and the extent to which the intervention fits with national, state or local priorities, needs and values; (2) Inner Contextual Factors domain, which involves programme champions, organisational leadership/support, organisational readiness/resources, and organisational stability such as staffing attrition; (3) Processes domain which comprises of partnership/engagement, training/supervision/support and programme evaluation/data, adaption and communications and strategic planning; (4) Characteristics of the Intervention domain, which focuses on the adaptability/fidelity of the intervention, its fits within the context/population/organisation, the perceived benefits of the intervention and the perceived need for the intervention [41]. The Outer Contextual Factors and Processes domains had the lowest mean scores of less than four on average, indicating they may be considered barriers to sustainability (see Table 3). Inner Contextual Factors and the Characteristics of the Interventions, had the highest mean score of more than four on average, indicating they may be considered facilitators to sustainability (see Table 3).

Table 3 Descriptive statistics of the IMPRESS-C domains and identification of barriers and facilitators to sustainability
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When looking at the individual interventions, the number of responses ranged from nine to 98. As shown in Table 4, for physical activity, the scores within the ‘Energisers’ intervention had the lowest scores (means ranging from 3.61 to 4.16), while ‘activities with children’ had higher scores across all domains (means ranging from 3.98 to 4.28). For the IMPRESS-C domains, across physical activity interventions, the Outer Contextual Factors (means ranging from 3.79 to 4.02) and Processes (means ranging from 3.61 to 3.98) domains means were consistently lower than the Inner Contextual Factors (means ranging from 4.00 to 4.20) and Characteristics of the Intervention (means ranging from 4.16 to 4.30) domain means and (see Table 4).

Table 4 Descriptive statistics for services delivering physical activity interventions
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While in Table 5, for healthy eating, scores were the lowest across all domains for ‘strategies to encourage consumption of age-appropriate beverages’ (mean scores ranging between 3.42 and 3.94) and generally, the highest scores were found in the ‘healthy eating-themed special days’ intervention (means ranging from 4.13 to 4.38). For the IMPRESS-C domains, across healthy eating interventions, the Outer Contextual Factors (means ranging from 3.62 to 4.21) and Processes (means ranging from 3.42 to 4.14) domains also had lower means compared to the Inner Contextual Factors (means ranging from 3.85 to 4.29) and Characteristics of the Intervention (means ranging from 3.94 to 4.38) domains (see Table 5). In general, healthy eating interventions had higher means in all domains compared to physical activity interventions.

Table 5 Descriptive statistics for services delivering healthy eating interventions
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Association between barriers/facilitators of sustainability and ECEC service characteristics

Linear regression analyses revealed no statistically significant independent associations between the overall means scores of IMPRESS-C domains and service characteristics including socio-economic status, Accessibility/Remoteness Index of Australia, type of service, service size, days of operation and service operating hours and time delivering its health program for at least two years (see Table 6). The odds of a service having delivered its health program for at least two years was 52% lower for each additional score of the “Characteristics of the Intervention” domain.

Table 6 Linear regression estimates of the association between the service characteristics and barriers and facilitators to the sustainability of physical activity and healthy eating interventions
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Discussion

This study describes the barriers and facilitators to the sustainability of physical activity and healthy eating interventions for children in ECEC settings in the Australian context. It uses a validated measure of sustainability determinants completed by service executives and explored the association between intervention sustainability factors and ECEC service characteristics.

Overall, amongst the 473 ECEC services, our analysis found that the Outer Contextual Factors and Processes domains scored the lowest suggesting that external support such as existing policies and regulations, the funding environment and service partnerships/engagement, training and adaptation processes that may potentially address these barriers are essential for overall intervention sustainability. Our analysis found that Inner Contextual Factors and Characteristics of the Intervention domains scored the highest, suggesting that internal support such as financial resources, program champions, and organisational support, as well as the interventions adaptability, and fit within the context and population may be important for these interventions to be sustained. Such findings are perhaps unsurprising given that Outer Contextual factors (inadequate existing policies or guidelines, limited future external financial support), and Processes (insufficient professional development opportunities, and limited training or stakeholder engagement) have been previously reported as potential barriers to intervention sustainability [35, 44, 59,60,61,62,63]. Moreover, our results align with previous review findings highlighting the critical contribution of human and financial resources, as well as ongoing professional development to the sustainability of obesity prevention interventions more broadly [64]. Similarly, in the school setting, insufficient funding, equipment, materials and/or physical space, as well as a lack of training have been identified as barriers to intervention sustainability [34, 39, 44].

To address the Outer Contextual Factors domain, future interventions may need to consider alignment with existing outer context levers. This includes ensuring alignment with policies, guidelines, or standards and working with accreditation agencies to embed such programs within National Quality Standards. Previous research with ECECs suggests that alignment with such policies and guidelines are important predictors of implementation and ongoing delivery of programs within usual context [65,66,67]. Unsurprisingly outer contextual factors including funding and external policies also emerged as key predictors of sustainment consistent with previous literature [35, 44, 59,60,61,62,63]. Partnerships with external funders or supporters of the intervention, including universities, health, government and non-government organisations may be one way to address such gaps in funding to support ongoing implementation and sustainment [60]. Importantly, such funding should focus on capacity building and enhancing sustainment specifically by ensuring procedures are bedded into organisational policies, and that capacity building and training efforts are accessed in an ongoing way to address staff turnover [60]. Further, it has been suggested that these efforts should commence during the inception of the intervention focusing on ensuring a congruence between the intervention and its context, rather than addressing sustainability at the end of the program [38, 60, 68, 69].

Additionally, the regression analyses, which controlled for various ECEC service characteristics found no statistically significant association between socioeconomic status, remoteness, type of service, service size, days of operation and service operating hours. This suggests that barriers to sustainability may not be contingent upon any specific service characteristic. These findings were surprising given that prior studies have recommended tailoring interventions to service characteristics, although our analysis via linear regression may not have identified a meaningful difference and linear regression to determine association is recommended [44, 70, 71]. However, given that the majority of our sample were long-day care services (91%) located in in urban areas (93%) it is possible that further research with a broader sample of ECEC services located in rural/regional settings are needed. Our results found a statistically significant association between the number of years services deliver their interventions and the Characteristics of the Intervention domain (p = 0.035), suggesting that this domain could be an important facilitator to length of implementation. Other research suggests that an intervention which lends itself to being adaptable to the service, meets a perceived need, is low-intensive and low-cost as to not burden the service, is more likely to be delivered ≥ 2 years [28].

Strengths and limitations

This study describes for the first time, factors associated with sustainability of a range of physical activity and healthy eating interventions delivered in ECEC services in the Australian context using the validated IMPRESS-C. It further reinforces the domains related to Outer Contextual Factors and Processes as needing to be considered as a way of ensuring sustainment of these interventions.

A strength of this study is the use of a validated measure to assess determinants influencing sustainability of physical activity and healthy eating interventions in ECEC settings from the perspective of the service executive. However, a number of limitations exist. Firstly, while the study included an appropriate sample size of ECEC services, there were limited numbers of services within each specific intervention (ranging from nine to 98). Additionally, the majority of services were located in New South Wales (NSW) (42.0%), which may affect the generalisability of the findings to other states. Similarly, as majority of our sample were long-day care services in urban areas, future studies should employ more representative sampling procedures to ensure the findings are generalisable to all Australian ECECs. Secondly, many of the responses were primarily on the upper end of the scale, indicating a possible ceiling effect and limited range of responses captured. Thirdly, the reliance on quantitative measurement of determinants for the intervention implementation may have resulted in reporting or recall bias and may not be reflective of actual practice. In future, a mixed-methods study assessing these determinants may be used to help mitigate information bias [72]. Lastly, the study assessed the sustainability determinants from the perspective of nominated supervisors. To obtain a full range of perceptions and a comprehensive understanding of factors influencing intervention sustainability, it is important to also capture determinants from the implementer perspective of service educators. Educators possess an understanding of the day-to-day operations and delivery of interventions and what may impact their ongoing delivery [73, 74]. Nevertheless, the data generated by this study provides valuable insights into the primary barriers and facilitators experienced by ECEC services to inform future efforts to improve sustainability of such interventions.

Implications for research, policy and practice

This study found that key factors from the Outer Contextual Factors and Processes domains including external funding, guidelines, community partnerships, and adequate training, may be important for the sustainability of ECEC-based physical activity and healthy eating interventions. While such findings are perhaps unsurprising, the growing body of research on sustainability determinant and strategies is starting to offer guidance for program developers and implementers on how to address these potential barriers. Nathan and colleagues (2022) have suggested a number of amendments to implementation strategies that could be of use to inform the development of future strategies targeting the factors identified here [75].

The authors have undertaken a rigorous systematic mapping process to develop sustainment strategies to primarily address the Outer Contextual factors and Processes domains [76]. This pilot randomised controlled trial utilised strategies including but not limited to identifying opinion leaders, engaging with family members, providing educational materials on external policies and guidelines, and embedding change into policy, which will likely provide initial insight into the potential impact of sustainment strategies on addressing such determinants.

Conclusions

For population health impact to be realised, interventions in ECEC settings must be effectively implemented and sustained. It is recommended that future physical activity and healthy eating interventions in these settings consider Outer Contextual Factors and Processes domains, and their deliberate integration into intervention design. Recommendations to address these barriers include ensuring services are equipped with sufficient information of state requirements and funding opportunities, as well as the potential to implement the intervention into sector policy to ensure continuous training and improvement of ECEC service staff. Our findings hold significant relevance for policy makers, interventionists, researchers, and health promotion staff involved in the design of physical activity and healthy eating interventions in ECEC settings.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ACECQA:

Australian Children Education and Care Quality Authority

EBI:

Evidence-Based Interventions

ECEC:

Early Childhood Education and Care

HNELHD:

Hunter New England Local Health District

HREC:

Human Research Ethics Committee

IMPRESS-C:

Integrated Measure of PRogram Element SuStainability in Childcare Settings

IQR:

Interquartile Range

LCL:

Lower Control Limit

NSW:

New South Wales

OR:

Odds Ratio

SD:

Standard Deviation

SEIFA:

Socio-Economic Indexes for Areas

UCL:

Upper Control Limit

WHO:

World Health Organization

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Acknowledgements

The authors wish to acknowledge participating ECEC service staff, data collection staff at HNELHD who undertook Computer Assisted Telephone Interviewing surveys, Data Sciences, HMRI and Deakin University Biostatistics department, for statistical support.

Funding

This study was supported by a National Health and Medical Research Council (NHMRC) Partnership grant (APP1170042). S.Y. receives salary support via a Heart Foundation Future Leader Fellowship (106654). N.I. receives salary support from a PhD scholarship from Deakin University. A.G. receives salary support from the Heart Foundation Postdoctoral Fellowship (102518). N.N. is supported by an NHMRC MRFF Investigator Grant (GS2000053). Cash and in-kind support are provided by Hunter New England Population Health (HNEPH). N.I., S.Y., A.G., A.S., M.L., and N.N. are researchers within the National Centre of Implementation Science (NCOIS), an NHMRC funded Centre of Research Excellence (APP1153479). NHMRC had no role in the design of this study and will not have a role in its execution or analyses, nor in the interpretation of the data or the decision to publish the results. N.P. is a representative from HNEPH is a co-author on this manuscript, as part of co-production and community-engagement processes. Hunter New England Population provided in-kind support as part of this trial.

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Authors and Affiliations

  1. Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Burwood, VIC, 3125, Australia

    Noor Imad, Melanie Lum & Serene Yoong

  2. Hunter New England Population Health, Wallsend, NSW, 2287, Australia

    Noor Imad, Nicole Nathan, Adam Shoesmith, Nicole Pearson, Alice Grady & Serene Yoong

  3. School of Health Sciences, Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, VIC, 3122, Australia

    Noor Imad

  4. School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, 2308, Australia

    Alix Hall, Nicole Nathan, Adam Shoesmith, Nicole Pearson, Alice Grady, Erin Nolan & Serene Yoong

  5. Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia

    Alix Hall, Nicole Nathan, Adam Shoesmith, Nicole Pearson, Melanie Lum, Alice Grady, Erin Nolan & Serene Yoong

  6. The National Centre of Implementation Science (NCOIS), The University of Newcastle, Newcastle, NSW, Australia

    Alix Hall, Nicole Nathan, Adam Shoesmith, Nicole Pearson, Alice Grady, Erin Nolan & Serene Yoong

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  1. Noor Imad
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Contributions

N.I. drafted all versions of the manuscript. A.G. provided substantive edits on all iterations of the manuscript. A.H. developed the evaluation plan and provided extensive comments on the manuscript. S.Y. was CIA for the funding and provided extensive comments on the manuscript. All authors provided comments. All authors have read and agreed to the published version of the manuscript.

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Ethical approval was provided by Hunter New England HREC (06/07/26/4.04 2019/ETH12353) and University of Newcastle HREC (H-2008–0343).

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Appendices

Appendix 1

Table 7 Healthy eating interventions included and their criteria
Full size table
Table 8 Physical activity interventions included and their criteria
Full size table

Appendix 2

Table 9 ECEC CATI executive scale sustainability items – IMPRESS-C [41]
Full size table

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Imad, N., Hall, A., Nathan, N. et al. A cross-sectional study assessing barriers and facilitators to the sustainability of physical activity and nutrition interventions in early childhood education and care settings. Int J Behav Nutr Phys Act 22, 2 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12966-024-01699-z

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Keywords

International Journal of Behavioral Nutrition and Physical Activity

ISSN: 1479-5868

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