The current study explored the experiences and views of ECEC teachers/champions regarding five implementation strategies employed during the implementation of a healthy eating e-learning resource within an ECEC setting. An iterative approach was applied for evaluation.
The role of being a champion suited ECEC teachers well due to their accustomed leadership roles, but they were not in a position to decide whether the implementation process should continue beyond the project period in the ECEC centers. The findings offer valuable insights into how the selected strategies function in practice and are perceived by the target users. The lessons learned further illuminate the practical application of these strategies, highlighting their real-world relevance. The strategies seemed to serve as effective reminders for champions, and many reported that the content was useful. However, there were barriers such as limited time and personnel available for full utilization of the strategies. The discussion of the findings will explore certain aspects of the chosen implementation strategies, aligning with the ERIC taxonomy [13]. The discussion further focuses on relating the results to the standardized implementation outcomes acceptability, appropriateness, and feasibility following Proctor et al. (2011) [14].
Valuable lessons learnt from the strategy identify and prepare champions is that champions played a crucial and positive role in the implementation of the e-learning resource in ECEC. The champions reported that the role fitted them well and was in line with their current responsibilities. It seems reasonable that a high level of education and familiarity with being a leader [10] made ECEC teachers especially suitable for the role of ‘champion’. In recent years, a notion that champions play a pivotal role in ensuring the effectiveness of healthcare-related implementation has obtained widespread acceptance [32]. The use of champions has also been related to increased use of best practices and programs [33]. These experiences are supported by our findings. However, the findings both contrast with and align with those of Barnes et al. (2021), in a comparable feasibility study of a web-based implementation intervention to improve child dietary intake in ECECs. They experienced a low uptake of the strategy to identify and prepare a center champion but high acceptability among those who selected a champion [34]. Barnes et al. suggest that different organizational structure could explain their low uptake, which was seen among the smaller settings [34]. We found no such differences in uptake in our study. Based on feedback from the champions in our study, the strategy to identify and prepare champions is proposed to be highly acceptable, appropriate, and feasible within the ECEC setting. Furthermore, based on our findings we suggest that this strategy can potentially be applicable to implementation research projects in other fields. However, one should keep in mind the differences regarding organizational structure as commented by Barnes et al. [34].
A few of the champions experienced some resistance initially from staff who thought the project would be too time consuming, however, this diminished over time with familiarity and some use of the Nutrition Now intervention. Limited time for preparation may have contributed to the initial resistance from colleagues [35]. Champions in our study were given only two weeks to prepare coworkers for the specific assigned tasks. Providing earlier access to the digital resource might have been helpful for the champions. Other factors, such as general resistance to change, may also be relevant. Wanberg et al. (2000), have suggested that more information about a change, participation, change-related self-efficacy can lead to increased openness to change [36]. This highlights the importance of allocating time for the champion or manager to prepare their colleagues for upcoming changes. Ross et al. (2016), further support this, recommending that champions should be included as early as possible in the implementation process [37].
At the end of the planned five-month implementation period, many champions could not confirm whether their ECEC center would continue to use the intervention. The promotion of sustained use was only mentioned in the e-learning resource and briefly in the final newsletter. In hindsight, it could have been beneficial to mention this during the educational meetings and interviews, and to suggest dialogues with ECEC leaders to promote further use of the intervention. Additionally, the results showed that decisions related to sustainability [38] were beyond the authority of the teachers but rested with the ECEC managers, who make final decisions. There seems to be a need for exploring additional and alternative implementation strategies to encourage sustainability.
During the exploration of the strategy to conduct educational meetings, valuable insights were uncovered. Champions expressed a desire for more opportunities to share experiences with peers during these meetings, which suggests that the ERIC strategy promote network weaving should be explored in future studies [13]. This aligns with Rogers et al. (2020), who suggest that peer support, akin to coaching, aiding practitioners in refining and applying professional learning and development, appears effective [39]. Investigating peer-to-peer support among different ECEC centers to promote network weaving is therefore suggested in similar settings. Our findings support holding two digital meetings over five months, which originally was decided in dialog with local stakeholders prior to the intervention. However, the reduction in attendance rates suggest long-term feasibility challenges due to logistical issues at ECECs.
From the strategy of distributing educational materials via monthly digital newsletters to champions, it was learned that newsletters were generally perceived as helpful for raising awareness and serving as reminders of the project. This aligns with findings from Finch et al. (2019), in an implementation of healthy eating policies and practices in ECEC settings, who reported that most participants found newsletters useful, although preferences regarding frequency varied [40]. Similarly, Jones et al. (2015), found that bimonthly newsletters were acceptable to around 60% of participants in their ECEC healthy eating implementation [41]. However, challenges such as time constraints or limited opportunities led to inconsistent readership among champions in the current study. This contrasts with findings from other studies reporting higher readership rates [42, 43]. These differences highlight the importance of considering contextual factors and preferences when designing and using newsletters as an implementation strategy. Our results emphasize the need to develop strategies to overcome readership barriers, such as lack of time. Further research into strategies to enhance newsletter acceptability and feasibility could offer valuable insights for future implementations. In summary, it appears that educational materials, educational meetings, and regular interviews served as reminders for the e-learning resource and were acceptable for champions in an ECEC setting. Due to their stated relevance, newsletters, as part of the strategy to distribute educational materials, were also considered appropriate.
The strategy of creating a learning collaborative was explored. Champions were encouraged through newsletters and educational meetings to allocate time to evaluate their work and learn from each other to improve the implementation of the e-learning resource. Their tasks included ongoing internal evaluations and maintaining focus on enhancing the implementation process. Some champions noted that the guidance highlighted the importance of regular evaluation, which varied across ECEC centers from structured meetings to informal conversations or a mix of both. These findings show that ECEC centers adapt recommendations for evaluation to their organizational structures, capacity, or preferences. Feedback from champions didn’t confirm the creation of a learning collaborative as defined by Powell et al. (2015) [13], but the iterative interviews suggest partial success. Time constraints and inconsistent readership of newsletters raise doubts regarding the feasibility of implementing this strategy solely through newsletters and online educational meetings.
The iterative interviews with the champions served to monitor the implementation processes and outcomes for quality assurance, using staff and champions’ feedback to increase implementation efforts. Some champions viewed the regular, short phone interviews as reminders for implementation and support. This aligns with Gruß et al. (2020), who found that the phone check-ins served as reminders and positively influenced implementation activities [44]. Finch et al. (2012), reported that 49% of service managers found support calls very useful in helping to implement a physical activity program in ECECs [43], and participants in their healthy eating ECEC implementation study also found calls helpful, motivating, and acceptable [40]. Similarly, Jones et al. (2015), and Barnes et al. (2021) found that most participants viewed telephone support as acceptable [34, 41]. These findings support our findings, and the high interview response rate of 88% over time, suggest that monthly, short phone interviews are highly acceptable, appropriate, and feasible for ECEC champions during an implementation process. The brief, conveniently scheduled calls likely contributed to the high response rate. Further research is warranted regarding the effectiveness of the use of regular, short phone interviews to support intervention implementation within time-poor settings. To some extent, our findings align with a process evaluation of an intervention in family childcare homes in Massachusetts (USA) aimed at improving diet quality. This evaluation revealed high participation in monthly support calls that included brief motivational interviewing and newsletters, but low participation in group meetings [45].
Although this is a qualitative study, we believe our findings are in line with those of Wolfenden et al. (2020), who found in their review that “current research suggests implementation strategies, to improve the implementation (or correct undertaking) of policies, likely improve the implementation of practices, or programs by childcare services” [15].
To summarize our findings, we found that the strategies to identify and prepare champions, conduct educational meetings, distribute educational materials, create a learning collaborative, and remind clinicians were acceptable in an ECEC setting. Additionally, the strategies to identify and prepare champions and conduct regular short interviews (as reminders) were deemed both appropriate and feasible. However, barriers such as limited time and available personnel hindered the feasibility of distributing educational materials and impacted the appropriateness and feasibility of creating a learning collaborative. Additionally, reduced attendance rates at a second educational meeting affected the appropriateness and feasibility of conducting these meetings.
Strengths and limitations
One strength of this study was the use of qualitative methods to contextualize the role of champions and the selected implementation strategies in driving the digital healthy eating resource in ECEC. Another strength was the involvement of municipal- and ECEC management. The research group also had prior knowledge of barriers, facilitators, and practical needs in the ECEC environment from previous studies on diet quality and mealtime environment [16, 22]. High response rates and consistent interviewing by one person allowed for continuous tracking of implementation-related changes over time. This approach may also have facilitated the development of a trusting relationship with champions, potentially leading to more substantial responses as they grew accustomed to the interviewer and the interview format. However, relying on local implementation personnel may have introduced social desirability bias, where responses could have been influenced by the desire to present positively or meet interviewer expectations. One weakness is that some authors were part of both the Nutrition Now project’s inception and the development of the digital healthy eating resource. This could introduce biases like partiality and limited diversity of perspectives, potentially affecting the objectivity of reporting. However, the interviewer’s lack of involvement in the development may have mitigated these biases. Furthermore, interview notes, including direct quotations, were taken during the interviews instead of audio-recording with verbatim transcripts. Although the interviewer aimed to take accurate notes which contributed to not capturing all details in the interview and being less accurate compared to verbatim transcripts, which may undermine the study’s trustworthiness. This study is in effect a re-analysis of the interviews which therefore limits the interpretation of meaning in participants’ accounts [46]. Despite the brief responses due to the short duration of each interview, conducting them as a series with many participants over time still provided valuable insights into the implementation process.
