A Pilot Randomised Controlled Trial Examining the Potential Impact of the Sustaining Play, Sustaining Health (SPSH) Program in Early Childhood Education and Care Services

The 6-month pilot intervention will be delivered specifically in Early Childhood Education and Care (ECEC) services and will target ECEC service Nominated Supervisors (NS) and Educators to support their implementation of a sustainability strategy to continue to provide indoor-outdoor free play routines. The potential unstructured free play activities that may occur throughout this intervention will be either outdoor free play only or indoor-outdoor free play (where periods of free play are located in both the indoor and outdoor environments, where children can move freely between the two). Specifically, ECEC services will be supported to implement a sustainability strategy that will help to integrate indoor-outdoor free play routines into their daily routine and service policy. The intervention was designed to target 20 barriers associated with the sustainment of physical activity programs in the ECEC setting, mapped to the domains of the Integrated Sustainability Framework developed by Shelton and colleagues (2018). This resulted in the development of eight strategies that sought to address these barriers and support the sustainment of improving implementation outcomes in the setting. The sustainability strategy, includes i) identifying an opinion leader to act as a key driver of the sustainability strategy, ii) re-affirming the services' intent for continuity, iii) providing the service with technical support and educational resources to self-direct the strategy, iv) developing a formal sustainment blueprint, v) engaging family and community members, vi) reviewing and changing service policy to integrate indoor-outdoor free play routines and vii) developing an ongoing monitoring plan to self-direct the sustainment of the Evidence-Based Intervention (EBI) well after the intervention period. The delivery of the strategy will include a minimum of 4 remotely delivered scheduled contacts including, 2 meetings via videoconference, and 2 support emails. Contacts will target the NS and an educator responsible for supporting the implementation of physical activity programs in the ECEC service. The intervention will be delivered by experienced health promotion officers employed by a local health promotion unit with tertiary qualifications in health. The development of the 6-month sustainability strategy was overseen by an advisory group consisting of implementation and behavioural scientists, health promotion staff and health policymakers. a) Identify opinion leaders at the service: To target the barriers; lack of administrative buy-in and support/leadership/management and lack of program leaders/facilitators/champions, ECEC services will be asked to identify any key drivers of implementation or “educationally influential” colleagues, who could be the service manager or another existing staff member e.g., Room Leader. This person(s) will be invited to participate in service contacts along with the centre manager/NS. The health promotion officer will determine the existing roles and influence of these staff members in current implementation processes as a component of the first 30–60-minute introductory meeting video call contact. The sustainability strategy will be discussed and additional roles or tasks for these key staff members will be co-developed as part of the process of undertaking a sustainability action plan (see strategy d for more detail). b) Re-affirm intent of continuity: To address the barriers; lack of motivation/interest, limited cost-effectiveness/feasibility of program, time required to implement and record uptake of the program, and competing resources, responsibilities and curriculum demands, services will be supported to reaffirm the services’ intent of continuity and readiness for long term implementation of the EBI. To do this, the health promotion officer will explicitly ask the NS and the opinion leader regarding their intention to continue the implementation of their current indoor-outdoor free play program during the introductory videoconference call. To explore the likelihood of sustaining long-term change, the health promotion officer will also ascertain the services’ motivations behind their original implementation, determine any barriers and facilitators to ongoing EBI implementation, and readiness to implement a sustainability strategy to enhance integration into usual care. As part of supporting a commitment to long-term change, the health promotion officer will facilitate the services to draft ideas for a formal “motivational statement” for the implementation of the EBI. Services will be supported to use this as part of the staff and community communications, as well as for inclusion in policy and procedure updates as appropriate. c) Provide local technical assistance to support integrating strategies: To address the barriers; lack of training/professional development opportunities to upskill, and lack of clear data on effectiveness of program, we will provide local technical assistance in the form of 2, 30–60-minute videoconference calls from the health promotion officer at months 1 and 3, and a minimum of 2 policy review emails at months 2 and 4. throughout the intervention period to assist them with implementing the sustainability strategy. Each contact will draw on continuous quality improvement principles to review progress on the sustainability action plan and provide feedback on the integration of sustainability strategies. The first call will occur after recruitment and will focus on introducing the trial, explaining the roles of the opinion leader and the NS (see a), understanding any determinants of sustainability for the service (see b), and discussing the development of the sustainability action plan (see d). The second video call will be at the 3-month time point which will focus on the services’ progress with their sustainability action plan and any experienced challenges. The first email will be before the initial support call at recruitment to provide the service with a resource pack. The 2 emails will consist of providing feedback on the services’ policy, through the use of a template and suggestions of amendments (see g). Additional support contacts may occur at time points outside of those specified if further support is required and will be recorded as part of adaptations to the program. d) Develop a formal sustainment blueprint: Services will be supported to develop an action plan t implement the sustainability strategy. This action plan will allow for the identification of strategies to be put in place as well as sustainability strategies that may have already been undertaken (fully or partially). Examples of strategies include notifying families, community members and staff of indoor-outdoor free play, updating the service policy, and conducting indoor-outdoor free play as part of daily routine. Progress with the plan will be monitored at the second 3-month contact and support provided to meet the plan as required. e) Distribute educational materials: A digital resource pack developed or adapted from materials previously used by the research team to target determinants of sustainability will be emailed to the services. The health promotion officer will then discuss the content of the resource pack as part of the introductory video call. The resources provided are designed to assist with potential determinants to both maintaining long-term EBI implementation and support implementation of the sustainability action plan. Resources include fact sheets of external organisations which support outdoor free play, how outdoor free play aligns with the sector accreditation standards, a summary of the general health recommendations during the pandemic relating to outdoor play, Australian Physical Activity guidelines, family and service templates to include as part of orientation packages, a service policy template and tips for maintaining indoor-outdoor free play routines across all seasons. Additionally, to support ongoing support from families, newsletter communication snippets to be used in service family newsletters will be provided. Further resources will be developed and provided tailored to the service’s specific needs. f) Engaging with family members: This strategy will include the provision of resources including 6 newsletter communication snippets including information around benefits of outdoor free play, outdoor play in various seasons and outdoor play and general health recommendations. These are to be used in service family newsletters or service social media groups at the perusal of the service, with a minimum to send out 1 newsletter snippet throughout the 6-month intervention. Another strategy to engage with family members and the community is through the use of a template for the inclusion of indoor-outdoor free play in the family orientation package. Services will be asked to distribute these using their usual communication channels. g) Reviewing and embedding change into policy: This strategy aims to ensure that the commitment to sustain indoor-outdoor free play routines is reflected in relevant service policy. At the 2-month and 4-month timepoint contact, the health promotion officer will review the services policies and suggest potential changes to promote the continuation of indoor-outdoor free play practices. h) Develop an ongoing monitoring strategy: At the initial contact, an “ongoing monitoring plan” item will be added to the sustainability action plan to develop a way of ensuring ongoing monitoring. Services will be encouraged to develop their own plan during the intervention contacts with the health promotion officers to ensure the EBI continues to be implemented long-term. Alternatively, services are provided with the option to continue to use the Free Play Record (FPR) developed by the research team as a way of continuing to document implementation twice a year.