BACKGROUND:Many health and government organisations have developed recommendations to promote the healthy eating and physical activity of children attending early childhood education and care (ECEC) settings. However, the evidence supporting these recommendations is not well described. An examination of the current evidence is needed to support decision-makers to understand and prioritise practices for implementation. AIM:To utilise a novel systematic evidence-mapping process which: (i) examines the evidence-base underpinning ECEC-based healthy eating and physical activity practice elements; and (ii) classifies practice elements according to the World Health Organization (WHO) Standards for Healthy Eating, Physical Activity, Sedentary Behaviour and Sleep in Early Childhood and Care Settings to examine alignment with current global guidelines. METHODS:We undertook a two-stage, five-step systematic process, involving identifying existing evidence and conducting a secondary data analysis and synthesis of the evidence underpinning practice elements. RESULTS:Sixteen healthy eating and 19 physical activity practice elements were assessed as likely beneficial. Most of these mapped to WHO Standard 2: Creating supportive environments. Seven practice elements were assessed as possibly beneficial, two as possibly not beneficial and none as not beneficial. There was insufficient evidence to assess 39 practice elements. CONCLUSIONS:This study provides insights into the evidence underpinning practice elements included in ECEC-based guidelines, identifies evidence-based practice elements not included in existing guidelines and highlights opportunities where evidence can be strengthened. SO WHAT?: The evidence underpinning guideline recommendations is variable or non-existent. Evaluation around the implementation of guidelines within funded programs is needed.

Get Outside Get Active (GOGA) is a multi-component implementation strategy (six strategies) to increase the provision of outdoor free play opportunities in early childhood education and care (ECEC). A randomized controlled trial with 84 ECECs within New South Wales, Australia found an increase of 61 min of outdoor free play opportunities per day, per service in the intervention compared with usual care at 6-months follow-up (P = .041). This study estimated the absolute costs associated with delivery of GOGA, and cost-effectiveness in terms of cost per additional minute of outdoor free play opportunities per day, per service. Costs ($AUD) were evaluated from health and ECEC service perspectives. Total and average costs per service to deliver GOGA and costs per strategy, per ECEC were calculated. Incremental cost-effectiveness ratios (ICERs) were estimated for differences in costs and effects between intervention and usual care. The total cost of GOGA (42 intervention services) was $69 351 (average $1651 per service). Educational outreach visits were most expensive at $32 498 (average $774 per service, average one visit per service), with develop and distribute educational materials least expensive at $1490 (average $35 per service). The difference in mean cost between usual care and intervention (adjusted for baseline) was $3740 (95% CI $418, $11 218) per service, with an adjusted ICER of $64 (95% CI -$10, $809) per additional minute of outdoor free play opportunity per day, per service. Findings suggest GOGA may be considered cost-effective compared with a school-based physical activity implementation programme. Economic evaluations of similar ECEC-based programmes are recommended.

Building research capacity in health settings is essential for improving the relevance and application of health research. Rigorous evaluation of research capacity in health settings optimizes the development, implementation and improvement of such initiatives. Cooke’s 2005 framework was the earliest peer-reviewed framework to evaluate research capacity in health settings. While subsequent frameworks exist, it is not clear how they were developed and are used in practice. This review investigates the development, composition and utilization of peer-reviewed frameworks designed to evaluate research capacity in health settings. This two-phased methodological review was informed by the JBI scoping review methodology. Phase 1 involved a systematic search of seven databases on 1 May 2025 to identify peer-reviewed frameworks for evaluating research capacity. Phase 2 involved a forward citation search of included frameworks using Google Scholar, finalized on 18 September 2025, to identify the number and nature of citing studies. Data extraction and narrative synthesis were informed by the review aims. Phase 1 database searches yielded 2581 unique citations, of which 8 met the inclusion criteria. An additional framework was identified through citation searching, totalling 9 frameworks. The frameworks were developed via retrospective processes (reviews of literature and local data) or prospective methods (engagement workshops). Several were informed by earlier frameworks. Frameworks typically comprised an overarching structure, substructural components and a series of outcome indicators. Framework authors defined research capacity building in nuanced ways. Phase 2 forward citation searching of the nine frameworks revealed 881 citations. Of these, 37 citing articles met the inclusion criteria. Most (31/37) citing studies utilized Cooke’s 2005 framework. Frameworks were largely used to inform data collection and analysis, and most citing authors only used only some framework components. Limitations and strengths of the frameworks related to the development process and practical application were identified by framework and citing authors. This review facilitated new insights into the development, characteristics and utilization of frameworks to evaluate research capacity building in health settings. There are nine peer-reviewed, published frameworks, several informed by and expanding on earlier frameworks, which is essential for advancing the evaluation of research capacity in health settings.

ISSUE ADDRESSED:The early childhood and education care (ECEC) sector has faced substantial contextual changes over the years. It is unknown whether prevalence of adoption of health promotion policies and practices has been impacted over this time. This study aimed to assess the prevalence of these policies and practices within New South Wales (NSW) ECEC services between 2013 and 2021-2022. METHODS:A repeat cross-sectional survey was undertaken in 2013 and 2021-2022 with NSW ECEC services to assess their adoption of eight evidence-based healthy eating and physical activity practices. Separate logistic regression models were used to compare the difference in prevalence of adoption at the two time points. RESULTS:In 2013, 214 (85.3% consent rate) services participated, while 512 (49.9%) services completed the 2021-2022 survey (271 receiving healthy eating version and 241 physical activity version). The majority of services (> 60%) had adopted each of the practices at both time points. There was a significant increase in prevalence of adoption for five of the eight practices, no difference for two practices, and a reduction in one practice (providing staff professional development for physical activity) between 2013 and 2021-2022. CONCLUSIONS:This study suggests that at a population level, services have maintained or increased their adoption of the majority of health promotion policies and practices over time. SO WHAT?: State-funded implementation support provided to ECECs can result in the continued delivery of health-promoting policies and practices within ECEC services to create Healthy Settings for child health promotion.

ISSUE ADDRESSED:Schools are recommended settings for promoting healthy eating, but to achieve population-level impact, initiatives must be widely implemented. Limited data are available to assess the implementation of Australian school-based healthy eating initiatives. This study examined the implementation of healthy eating initiatives in Australian primary schools and whether implementation is associated with school characteristics (school size, remoteness, socio-economic status). METHODS:A cross-sectional study surveyed a nationally representative sample of Australian primary school principals (August 2022-October 2023) regarding 32 healthy eating initiatives across five opportunities for healthy eating: healthy food in the classroom, at school, brought to school, outside of school and other. Initiatives were identified from recent systematic reviews aligned with Australian and global guidelines. Prevalence estimates were weighted to the national school population, and logistic regression models examined associations with school characteristics. RESULTS:Of the 669 participating schools, 569 completed the healthy eating survey, with implementation rates ranging from 7% to 97%. The most frequently implemented initiatives were: in the classroom, 'Permission or breaks to drink water in class time in ≥ 80% of classes daily' (97%); at school, 'Install water stations for free access to cooled plain or optionally carbonated water' (64%); brought to school, 'Information on healthy eating sent home to parents' (88%); and outside of school, 'Healthy eating programs delivered in partnership with community organisations or services' (31%). Ten initiatives were associated with school size (n = 5), remoteness (n = 7), or socio-economic status (n = 3). CONCLUSIONS:Implementation rates of the 32 healthy eating initiatives varied substantially, and most initiatives had similar rates across school characteristics (school size, remoteness, socio-economic status). SO WHAT?: This first national study provides crucial information on the implementation of individual healthy eating initiatives in Australian primary schools, highlighting which initiatives and school subgroups require policy and practice investment to support implementation.

Inequities in cancer outcomes for rural populations highlight the need for equity-oriented implementation research. Implementation science strategies that support adoption of evidence-based practices are not always applied with an understanding of diverse service contexts. This study reflects on design approaches that enable equity-oriented implementation research in rural cancer care settings, using implementation of Australian Optimal Care Pathways as an example. This was a mixed-methods discovery phase study of a broader program to improve implementation of Optimal Care Pathways in rural and remote Australian health services. An online survey and semi-structured interviews with health care professionals in three Australian states were conducted. The Theoretical Domains Framework was used as a guiding scaffold to explore determinants of implementation. The research team reflexively examined study processes to surface practical methodological considerations focused on flexibility, partnership, and rigour that could apply to broader equity-oriented implementation research. We conducted 74 interviews with health professionals providing cancer care. The number of interviews and sampling frame was expanded in response to emerging insights to reflect diversity of services in different states. Established governance structures and partnership-based recruitment enabled high engagement and collection of in-depth data. Flexible application of the Theoretical Domains Framework facilitated meaningful enquiry across different contexts. This enabled us to surface context-specific determinants that will be used to co-design implementation strategies for rural health services. Equity-oriented implementation research in rural health care settings requires design choices that accommodate contextual complexity, including latency to enable trust-building and flexibility in study design.

Background: Child overweight and obesity is a critical global health issue with substantial individual and societal impacts necessitating early intervention to establish healthy habits. Health promoting early childhood education (ECE) settings are important as most young children attend ECEs in high- and middle-income countries. Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC) is an evidence-based approach to support improvements to ECE environment for improving child health. While adapting proven child obesity prevention interventions from other countries offers efficiency, the process is frequently underreported and insufficiently documented. Methods: Guided by the ADAPT framework, this article describes the adaptation of NAPSACC in the United States (US), Australia (AU), and the United Kingdom (UK) from 2012 to 2023. Contextual differences in ECE systems in the US, AU, and UK and reflections on the process of adaptation were explored. Results: NAPSACC was successfully adapted, maintaining core theoretical components while allowing for implementation flexibility to meet varying contexts. The iterative adaptation process revealed that a flexible dynamic approach was essential for maintaining the relevance and effectiveness of the NAPSACC intervention in different contexts. Conclusions: Our experience highlights the importance of ongoing iteration, international collaboration, research, and responsiveness to evolving circumstances in adaptation processes. Strong and flexible leadership, such as that demonstrated by NAPSACC's founder, Dr. Dianne S. Ward, facilitates successful adaptation and continuous improvement of public health programs. Trial registration: This paper includes multiple registered trials - NCT02889198, ACTRN12619001158156, ISRCTN16287377, and ISRCTN33134697.

Introduction Infant feeding practices in the first 2 years of life are linked to long-term weight trajectories. Despite the importance of obesity prevention interventions, there are no randomised controlled trials (RCTs) evaluating early childhood education and care (ECEC) and primary caregiver-targeted interventions on child weight and feeding outcomes.Aim To assess the efficacy of an 18-month digital health intervention (Tiny Bites) delivered to ECEC services and primary caregivers of children aged 4 to ≤12 months on child age-adjusted and sex-adjusted body mass index-for-age z-score (zBMI) relative to usual care control in the Hunter New England (HNE) region of New South Wales, Australia.Methods and analysis This type 1 hybrid cluster RCT will include up to 60 ECEC services and 540 children/caregiver dyads. The intervention supports ECEC services and caregivers to deliver recommended responsive feeding practices to infants. ECEC services will receive access to an online assessment platform, training and resources, and implementation support. Primary caregivers will receive text messages, monthly e-newsletters, online links and direct communication from ECEC services. We will assess the impact on child zBMI at 18-month follow-up. Secondary outcomes include duration of consuming any breastmilk, child diet and caregiver responsive feeding practices. We will also assess ECEC policy and practice implementation related to targeted feeding practices, programme cost effectiveness, adverse effects and engagement with the programme (ECECs and caregivers). For the primary outcome, between-group differences will be assessed for paired data using two-level hierarchical linear regression models.Ethics and dissemination Ethics approval has been provided by HNE Human Research Ethics Committee (HREC) (2023/ETH01158), Deakin University (2024-202) and University of Newcastle HREC (R-2024-0039). Trial results will be submitted for publication in peer-reviewed journals, presented at scientific conferences locally and internationally and to relevant practice stakeholders.Trial registration number ACTRN12624000576527.

Increased outdoor free play is associated with health and developmental benefits for preschool-aged children. It is therefore recommended that early childhood education and care (ECEC) services provide increased time for outdoor free play. This study seeks to understand the impact of a multi-component implementation strategy (Get Outside Get Active) on ECEC service provision of opportunities for outdoor free play. This was a parallel-group randomised controlled trial involving 84 ECEC services located in one region of New South Wales, Australia. Forty-one services were randomised to a 6-month multi-component implementation strategy or to a usual care group (n = 43). To increase total scheduled outdoor free play time, services were supported to modify their routines to increase provision of outdoor free play and/or indoor-outdoor free play opportunities (whereby children are allowed to move freely between indoor and outdoor spaces). The primary trial outcome, mean minutes per day of outdoor free play opportunities provided in ECEC services, was measured at baseline, 6-months (primary endpoint), and 18-months. Secondary outcomes were mean minutes of indoor-outdoor free play only and proportion implementing indoor-outdoor free play for the full day. The quality of the movement environment was assessed using direct observations in 30 ECECs at 6 months only. At 6 months, the intervention group showed a significant increase in mean daily minutes of outdoor free play (61.3 min; 95

Globally, people living in rural and remote areas experience poorer healthcare access and outcomes than urban populations. Applying implementation strategies that support the translation of evidence-based healthcare interventions may help reduce these inequities; however, real-world implementation is complex, and it remains unclear how strategies are applied and tailored to rural and remote contexts. This scoping review synthesised evidence on implementation strategies for healthcare interventions in rural and remote settings of high-income countries. Five databases (Ovid MEDLINE, Embase, Cochrane CENTRAL, CINAHL, Web of Science) were searched for peer-reviewed studies published between 1/1/2000 and 25/10/2024. Extracted data were synthesised using a descriptive narrative approach. From 11,887 records, 78 papers (75 studies) met inclusion criteria. Implementation efforts were multifaceted, commonly drawing on strategies from three Expert Recommendations for Implementing Change clusters: train and educate stakeholders (n = 70, 93%), use evaluative and iterative strategies (n = 55, 73%), and develop stakeholder interrelationships (n = 48, 64%). Few studies (n = 21; 28%) reported rural-specific design features. Although implementation in rural and remote contexts has focused on provider-level strategies, there is a need to also address system-level determinants to implementation. Context-specific design, meaningful engagement with local communities and stakeholders, and clearer reporting are essential to optimise implementation and reduce rural-urban health disparities.

INTRODUCTION:This paper presents the protocol for the effectiveness-implementation trial: Systems Thinking with Active Implementation Research (STAIR) for childhood obesity prevention. STAIR's objective is to protect primary school children in Victoria, Australia from unhealthy weight and test implementation strategies for sustaining healthy school environments. STAIR is a 3-year cluster-randomised controlled trial with repeat-cross-sectional child-level data collection utilising an effectiveness-implementation type-1 hybrid design. Schools will be recruited from non-metropolitan government primary schools in Southwest Victoria, Australia, with consenting schools (target = 28) randomly assigned (1:1) to intervention or control, and students in grades 1-6 (n = 3000-6000) recruited using an opt-out approach. INTERVENTION:The intervention, co-designed by each school community, will involve multi-step group model building and action formulation process using community-based systems dynamics and baseline data (i.e., child weight status, HRQoL, health behaviours, and school environment characteristics). Implementation strategies will be guided by an active implementation framework, and coordinated by a leadership team of school representatives, community partners, and researchers. PRIMARY AND SECONDARY OUTCOME MEASURES:Primary outcomes are to measure (1) change in standardised body mass index (z-BMI) between intervention and control groups after three year and (2) change in acceptance and adoption of STAIR interventions and support. Secondary outcomes include differences in obesity prevalence, health behaviour measures and HRQoL, between intervention and control groups after three years. Implementation outcomes will focus on strategy effectiveness, acceptability, and utilisation. Secondary data will be collected from schools and partner organisations. An economic evaluation will assess the cost-effectiveness of intervention and implementation support. CONCLUSION:STAIR aims to create lasting changes in schools to prevent childhood obesity by supporting healthy environments and providing insights into interventions' cost-effectiveness and feasibility. The findings will guide policymakers and educational institutions in adopting sustainable health promotion strategies. TRIAL REGISTRATION:ANZCTR-ACTRN12624000461594p.

Background: A large number of guideline recommendations have been developed by local-, state- and national-level health organisations available to promote the healthy eating and physical activity of children attending early childhood education and care (ECEC) settings. However, the evidence supporting these recommendations is often not well-described. An examination of the current evidence is needed to support decision-makers to understand and prioritise practices for implementation.Aim: To describe a novel systematic evidence-mapping process which: i) examines the evidence-base underpinning ECEC-based healthy eating and physical activity practice elements; and ii) classifies practice elements according to the World Health Organization (WHO) Standards for Healthy Eating, Physical Activity, Sedentary Behaviour and Sleep in Early Childhood and Care Settings to examine alignment with current global guidelines. Methods: We undertook a two-stage, five-step systematic process. Stage 1 involved identifying the existing ECEC-based guideline recommendations and randomised controlled trial evidence which evaluated child diet and physical activity outcomes. Stage 2 involved conducting a secondary data analysis and synthesis of the evidence underpinning practice elements by: extracting practice elements of RCTs and mapping these to existing guideline recommendations, where possible, or included these as additional practices; using vote-counting approaches and a framework to assess the evidence underpinning each practice element; and, classifying practice elements according to the WHO Standards for Healthy Eating, Physical Activity, Sedentary Behaviour and Sleep in Early Childhood and Care Settings. Results: We found 16 healthy eating (e.g. Educators discuss the food served with children) and 19 physical activity (e.g. Educators embed physical activity into educational activities) practice elements were assessed as likely beneficial. Most of these mapped to WHO Standard 2: Creating supportive environments. Seven practice elements were assessed as possibly beneficial, two as possibly not beneficial and none as not beneficial. There was insufficient evidence to assess 39 practice elements. Conclusions: This study provides insights into the evidence underpinning practice elements included in ECEC-based healthy eating and physical activity guidelines, identifies evidence-based practice elements not included in existing guidelines and highlights opportunities where evidence can be strengthened.

Individuals in rural areas consistently demonstrate higher mortality and morbidity rates, and poorer access to healthcare, compared to their metropolitan counterparts. Optimizing the implementation of evidence-based interventions can reduce these inequities. Existing literature outlines numerous barriers and facilitators to the implementation of healthcare interventions, but these are generally not specific to rural areas. This rapid review aims to synthesize barriers and facilitators to the implementation of healthcare interventions in regional and rural healthcare services as reported by healthcare staff, including clinicians, managers, and administrators. A systematic search for peer-reviewed publications was conducted using CINAHL, PsycINFO, Medline, and Embase databases (1/1/2000–29/08/2023). Eligible publications were primary research articles published in English, assessing staff-reported barriers and facilitators to implementing healthcare interventions within regional and rural areas of high-income countries. Qualitative, quantitative, and mixed-methods designs were included. Eligible healthcare settings encompassed acute, sub-acute, primary care, community health, and aged care. Barrier and facilitator data were coded and grouped into sub-themes and broader themes, with results presented narratively. Thirty-nine publications met the inclusion criteria. Most studies were conducted in Australia or the USA (both n = 18, 46

ISSUE ADDRESSED:Schools are a key setting for influencing children's physical activity and sedentary behaviour. The broad adoption of guideline-informed initiatives is essential to achieve population-wide health benefits. However, there is limited evidence on the implementation of recommended physical activity initiatives in Australian primary schools. This study aims to assess the implementation of these initiatives and their associations with school characteristics. METHODS:A cross-sectional study surveyed a nationally representative sample of Australian primary school principals (August 2022-October 2023) regarding 32 physical activity initiatives across four opportunities for physical activity: in the classroom; outside the classroom/during break times; outside of school/involving families; and other. Initiatives were identified from recent systematic reviews aligned with Australian and global guidelines. Prevalence estimates were weighted to the national school population, and logistic regression models examined associations with school characteristics (school size, remoteness, socio-economic status). RESULTS:Of the 669 participating schools, 360 completed the physical activity survey, with implementation rates ranging from 4% to 98%. The most implemented initiative inside the classroom was 'Physical activity units of work in PDHPE/HPE' (98%); outside the classroom/during break times was 'School infrastructure that supports physical activity during breaks' (96%); and outside of school/involving families was 'School provides end-of-trip facilities to encourage active school travel' (75%). Nine initiatives were associated with school size (6 initiatives), remoteness (4 initiatives), or socio-economic status (1 initiative). CONCLUSIONS:Implementation rates of the 32 physical activity initiatives varied substantially and most initiatives had similar rates across school characteristics (school size, remoteness, socio-economic status). SO WHAT?: This first national study provides crucial information on the implementation of individual physical activity initiatives in Australian primary schools, highlighting areas where policy and practice investment is needed to support implementation.

This review assessed the effectiveness of ECEC-based interventions to improve child physical activity, and intervention impact on child weight-based anthropometrics, fundamental movement skills (FMS), cognitive functioning, and social-emotional wellbeing. Adverse effects and costs were assessed. Finch et al's 2014 systematic review was updated. Electronic databases were searched 10 September 2014 to 27 October 2022. Included studies were randomized controlled trials of ECEC interventions targeting physical activity among children aged 0-6 years. The methodological quality of studies was assessed using Cochrane's Risk of Bias tool v2. Standardized mean differences (SMD) were calculated for each outcome with meta-analysis undertaken; otherwise, findings were described narratively. Fifty-three studies were included. ECEC-based interventions were found to significantly improve child physical activity (SMD 0.193, 95% confidence interval [CI] 0.09 to 0.3; p < 0.001) and FMS (SMD 0.544, 95% CI 0.1 to 0.98; p = 0.015), compared to control. Small positive, but non-significant, effects were found for weight-based anthropometrics, cognitive functioning, and social-emotional wellbeing. Few studies reported adverse effects (n = 10), and no studies reported formal economic analyses. While ECEC-based interventions can significantly improve child physical activity and FMS, further evidence of their impact on cognitive functioning, social-emotional wellbeing, and the cost-effectiveness of such interventions is required to inform policy and practice.

Background: Promoting healthy eating and physical activity in early childhood education and care (ECEC) is recommended within guidelines and supported by health promotion programs; however, implementation is suboptimal. Evidence suggests implementation within the sector varies over time; however, this has not been empirically examined in relation to implementation barriers. This study aims to: (1) describe changes in the prevalence of, and barriers to, implementation of priority healthy eating and physical activity practices; and (2) explore the associations between such barriers and implementation.Methods: This was a repeated cross-sectional study over an 8-month period. A cross-section of 150-180 Australian ECEC services were prospectively randomly sampled for each month (April-November 2023), with 1127 ECEC services sampled in total and 20% of services sampled twice. Services reported via survey their implementation of two priority practices: (1) healthy menu standards and (2) educating and engaging parents in child physical activity. They also reported on implementation status, implementation stage, and five core implementation barriers.Results: Overall, 716 services completed 809 surveys. There were no significant differences in the prevalence of implementation or general trends in barriers to implementation of the two priority practices across that time. Services reporting less barriers were significantly more likely to be implementing the priority practices, and services in more advanced implementation stages were significantly less likely to report barriers.Conclusions: To enhance the implementation of priority practices in ECEC services, key barriers to implementation need to be understood and targeted to progress services through to advanced implementation stages.

BACKGROUND:Over a quarter of children aged 2-17 years living in Australia are overweight or obese, with a higher prevalence reported in regional and remote communities. Systems thinking approaches that seek to support communities to generate and implement locally appropriate solutions targeting intertwined environmental, political, sociocultural, and individual determinants of obesity have the potential to ameliorate this. There have however been reported challenges with implementation of such initiatives, which may be strengthened by incorporating implementation science methods.METHODS:This pilot randomised controlled trial protocol outlines the development and proposed evaluation of a multicomponent implementation strategy (Action-RESPOND). to increase the implementation of community-based systems thinking child obesity prevention initiatives The target of this intervention is ten rural and regional communities (or local government areas as the unit of allocation) within Northeast Victoria who were participants in a whole-of-systems intervention (RESPOND). Action-RESPOND builds on this intervention by assessing the impact of offering additional implementation strategies to five communities relative to usual care. The development of the multicomponent implementation strategy was informed by the Promoting Action on Research Implementation in Health Services (PARIHS) framework and consists of seven implementation strategies primarily delivered via 'facilitation' methods. Implementation strategies aimed to ensure initiatives implemented are i) evidence-based, ii) address community's specific needs and iii) are suitable for local context. Strategies also aimed to increase the community's capacity to implement, through iv) improving the health promotion team's implementation knowledge and skills, fostering v) leadership, vi) physical resources and vii) community culture to drive implementation. The feasibility, acceptability, potential impact, and cost of the strategy will be assessed at baseline and follow up using surveys administered to key representatives within the community and internal records maintained by the research team.DISCUSSION:By leveraging an existing community-based whole-of-systems intervention, Action-RESPOND offers a unique opportunity to collect pilot feasibility and early empirical data on how to apply implementation and systems science approaches to support obesity prevention in rural and regional communities in Victoria.

ISSUE ADDRESSED:The Get Outside, Get Active (GOGA) program is a randomised controlled trial which tested the impact of a multi-component implementation strategy to support early childhood education and care (ECEC) services to replace indoor-only free play with indoor-outdoor-free play. This cross-sectional study aims to describe the extent and nature of modifications made to implementation strategies and Behaviour Change Techniques (BCTs) using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) and to describe the fidelity of BCT delivery throughout GOGA. METHODS:An audit of records was undertaken throughout the intervention delivery period in the intervention arm. GOGA included 14 standard BCTs within six implementation strategies. Modifications and BCT delivery were recorded by Health Promotion Officers via project records. Modifications were categorised according to the FRAME-IS. BCT delivery was recorded using a checklist. RESULTS:Forty-four ECEC services received the GOGA program. Overall, 60 modifications were recorded. According to FRAME-IS categories, most modifications related to: content; format; pragmatic or practical considerations; tailoring/tweaking/refining in nature; fidelity was inconsistent; the goal was to increase the acceptability, appropriateness, or feasibility of the implementation effort; the rationale was at the practitioner level; and were unplanned/reactive. Overall, 96.4% of standard BCTs were delivered as intended. CONCLUSIONS:GOGA was delivered with high fidelity to protocol as indicated by the level of BCT delivery. This article details a thorough approach to documenting modifications and provides guidance for future studies. SO WHAT?: This article contributes to the emerging evidence regarding documentation of adaptations and modifications to public health implementation interventions.