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Abstract

This study evaluated the effectiveness of an online short course based on the Health Promoting Schools Framework and specifically designed for Early Childhood Education and Care (ECEC) professionals. The short course aimed to enhance ECEC professionals’ nutrition knowledge, confidence, role legitimacy and adequacy to model healthy behaviours, teach healthy food habits and create health-promoting environments. Participants (n = 116) working at Australian ECEC services were assigned to control (n = 62) or intervention (n = 54) groups. Both groups completed a pre-intervention survey. The intervention group accessed the four-week course and completed the post-intervention survey. The control group completed a second survey after four weeks but before accessing the course. Statistical analyses revealed significant positive changes in confidence, nutrition information utilisation and role perception for the intervention group. This study’s findings suggest that evidence-based online nutrition training could be used to improve ECEC professionals’ practice to foster better nutrition outcomes for young children.

Keywords

Health promotion nutrition early childhood education professional development whole-service-approach online short course

Introduction

Globally, rates of overweight and obesity have tripled since 1975, with the World Health Organisation (WHO, 2021a) reporting 39 million children (to age five years) are affected by this preventable disease. In Australia, one in four children is affected by overweight/obesity, increasing their risk of chronic disease (Australian Institute of Health & Welfare [AIHW], 2020). Overweight/obesity is a complex health issue influenced by genetics, health inequalities, environmental and societal factors, with diet being a major contributing factor (Australian Institute of Health & Welfare, 2021; Sambell et al., 2020). According to the National Health Survey (Australian Bureau of Statistics [ABS], 2018), discretionary foods contribute 38.5% of a child’s daily energy intake, raising concerns about the quality of children’s diets and effects on overweight/obesity (Jakobsen et al., 2023).

Approximately 1.4 million Australian children attend an ECEC service for, on average, 27 hours/week (Australian Government Department of Education, 2023), presenting an opportunity for services to promote lifelong healthy food habits and preferences for children; recommended by the WHO (2016) and Australian National Obesity Strategy (Commonwealth of Australia, 2022). In addition, the National Quality Standards (Element 2.1.3) mandate the promotion of food and drinks that are “nutritious and appropriate for each child” (Australian Children’s Education & Care Quality Authority [ACECQA], 2017, p. 62). Therefore, ECEC professionals are expected to role-model healthy eating behaviours and provide nutrition education to children, which should be captured in a comprehensive healthy eating policy (ACECQA, 2017).

However, a review of 523 ECEC services found 12.6% had no nutrition policy, while 50.5% had only a partially implemented policy (Lum et al., 2023), highlighting an urgent need for ongoing monitoring and support to ensure policies translate into practice (Ramia et al., 2023). ECEC Directors have reported difficulties establishing a healthy food environment at their service across all domains, from tailored nutrition policies to providing nutrition education to children in a workplace constrained by time and resources (Kirkegaard et al., 2023).

When food is prepared on site and provided to children, it often does not meet the Australian Dietary Guidelines standards for young children (Yoong et al., 2014). Discretionary foods are overprovided (Wallace et al., 2017a) and role modelling healthy eating behaviours at mealtimes is inconsistent (Byrne et al., 2022). Additionally, ECEC professionals may lack the skills and confidence needed to teach children basic nutritional concepts (Wallace et al., 2017b), which may lead to diminished perceptions of their role adequacy and legitimacy regarding promoting healthy eating (Forde et al., 2021).

Offering evidence-based food and nutrition training to ECEC professionals is important as it can help them to provide healthy food environments (Wallace, 2016) and enhance their perceptions of role adequacy and legitimacy (Forde et al., 2021), leading to greater job satisfaction and motivation (Skinner et al., 2009). Training can also increase ECEC professionals’ confidence to share food and nutrition information with children and their families (Devine et al., 2019), important as professionals can be misinformed by less credible sources of food and nutrition information (Devine et al., 2019; Wallace et al., 2017b).

Adopting a whole-of-service approach is essential to consider all aspects of the food environment, including the nutritional quality of food, staff role modelling healthy behaviours, teaching healthy food habits to children and creating a health promoting environment (Matwiejczyk et al., 2018). The WHO (2021b) recommends strengthening the ECEC workforce’s capability to improve food environments by establishing systems within services for ongoing competency-based training and programs to address sector-specific needs. However, there is a lack of evaluated online nutrition training specifically designed for ECEC settings, and professionals receive limited food and nutrition training as part of their education (Wallace, 2016).

This study sought to develop and test an online short course, called ‘SNACing_101’, specifically designed to enhance the nutrition knowledge of ECEC professionals. We aimed to improve participants confidence as effective role models for children and to communicate appropriate nutrition messages to families. We hypothesised that increased knowledge, delivered through specific training, would enable professionals to improve the quality of food environments within ECEC settings – crucial for wider health promotion (Walker & Littlewood, 2018).

Methods

This study was approved by Edith Cowan University Human Research Ethics Committee (approval number 19469-WALLACE), with informed consent obtained from all participants.

Evidence-based content was developed by nutrition experts and learning designers at Edith Cowan University to ensure the training was pedagogically sound and pitched at the appropriate educational level. The short course followed a ‘whole-service-approach’, based on the Health Promoting Schools Framework (Gillies et al., 2011), with three interrelated components: curriculum; environment; and partnerships (Figure 1). Within the curriculum domain, online nutrition-focused training was provided to enable professionals to incorporate nutrition knowledge into their teaching practice. The environment domain considered the physical and cultural aspects of ECEC settings, including food quality, attitudes towards healthy eating, role modelling healthy eating behaviours, and understanding Australian food and nutrition guidelines. Finally, partnerships examined relationships between professionals, children and parents/caregivers.

Figure 1.

Whole-service-approach to healthy eating in early childhood education and care used to frame ‘SNACing_101’ (adapted from the Health Promoting School Framework).

An advisory group of 10 professionals from ECEC and nutrition-related organisations provided input and piloted ‘SNACing_101’. The course, delivered via the university’s Learning Management System, comprised four modules and 16 learning activities (Table 1), taking participants approximately 3 hours to complete. Participants received an online workbook to support their learning.

Table 1.

SNACing_101 modules and learning activities mapped to whole-centre approach domains.

Module	Activity	Whole-centre approach domain(s)
Food foundations	• Understanding the Australian dietary guidelines and the Australian guide to healthy eating^a • Food and nutrition policy • Estimating serve sizes • Identifying core and discretionary foods	Curriculum Environment
Making good food choices	• Fad diet checklist • Food label reading • Communicating with parents about dietary requests	Environment Partnerships
At your service	• Food environments – food sharing and self-service • Role modelling • Food and rewards; celebrations and fundraising	Environment
Putting it all together	• Reflections • Sharing learning with others • Checklist completion to assess service healthy eating environment

^aNational Health and Medical Research Council [NHMRC] (2013).

In July 2018, recruitment emails were sent to all Australian ECEC services (n = 7,826) identified through publicly available lists (ACECQA, 2023) and through our existing networks. Eligible participants were ECEC professionals aged over 18 years. Participants were allocated to intervention or control groups using a simple computer-generated randomisation list, with only the research assistant aware of allocations. During October 2018, intervention participants completed the pre-survey, the course and post-survey, then received a certificate of completion and a $30 gift card. Control participants completed the same survey twice, one month apart, and were then provided with access to the course (November, 2018) and entry into a draw to win one of four $50 gift cards. Assuming a two-sided significance threshold of α = 0.05, a standardised mean difference of d = 0.5 and retention rate of 90%, the target sample size was calculated to be 69 participants per group to achieve a statistical power of .8 (Lu et al., 2008).

The survey, administered electronically via Qualtrics (2023), was designed to capture nutrition knowledge based on the Australian Dietary Guidelines (NHMRC, 2013), attitudes toward healthy eating, food provision at their workplace, confidence, role legitimacy and adequacy and, for intervention participants only, the useability and likeability of the online short course. Devine et al. (2019) provides the survey design, validity and scoring details.

Data analysis was performed using R version 4.1 (R Core Team, 2021). Demographic comparisons between control and intervention groups were conducted using chi-square or Fisher exact tests, as appropriate. Linear mixed effect modelling was used to determine any statistically significant differences in confidence, and role legitimacy and adequacy, between and within control and intervention groups. Generalised linear mixed-effect models were used to assess changes in knowledge. Group membership and time were treated as fixed effects and individual participants as random effects. Linear modelling assumptions were checked by inspecting residual plots.

Results

Demographic data are followed by survey results, organised according to the three course modules (Table 1).

Demographic data

There were no significant differences in characteristics between intervention (n = 54) and control (n = 62) groups (Table 2). Participants were predominately female, 36–55 years old, TAFE or university qualified, experienced and employed at a LDC service.

Table 2.

Participant demographic profile.

	Intervention n (%)	Control n (%)	Total n (%)	p-value
Role
Educator	22 (40.74%)	27 (43.55%)	49 (42.24%)	.893
Food coordinator/cook	14 (25.93%)	17 (27.42%)	31 (26.72%)
Director/manager/2IC	17 (31.48%)	16 (25.80%)	33 (28.45%)
Other	1 (1.85%)	2 (3.23%)	3 (2.59%)
Total	54 (100%)	62 (100%)	116 (100%)
Type of ECEC
LDC	38 (70.37%)	38 (61.29%)	76 (65.51%)	.307
Family day care	7 (12.96%)	16 (25.80%)	23 (19.83%)
Out of school hours care	1 (1.85%)	2 (3.23%)	3 (2.59%)
Other	8 (14.82%)	6 (9.68%)	14 (12.07%)
Total	54 (100%)	62 (100%)	116 (100%)
Age (years)
18–25	1 (1.85%)	2 (3.17%)	3 (2.56%)	.78
26–35	10 (18.52%)	8 (12.70%)	18 (15.38%)
36–45	16 (29.63%)	24 (38.10%)	40 (34.19%)
46–55	21 (38.88%)	21 (33.33%)	42 (35.89)
>55	6 (11.12%)	8 (12.70%)	14 (11.98%)
Total	54 (100%)	63 (100%)	117 (100%)
Gender^a
Female	53 (98.15%)	61 (98.34)	114 (98.27%)	1.0
Male	1 (1.85%)	1 (1.66%)	2 (1.73%)
Total	54 (100%)	62 (100%)	116 (100%)
Work experience (years)
<1	1 (1.85%)	0 (0.00%)	1 (0.86%)	.8
1–3	7 (12.96%)	8 (12.91%)	15 (12.93%)
4–6	7 (12.96%)	10 (16.13%)	17 (14.65%)
7–9	8 (14.82%)	7 (11.29%)	15 (12.93%)
>10	31 (57.41%)	37 (59.67%)	68 (58.62%)
Total	54 (100%)	62 (100%)	116 (100%)
Education
Year 10 or 11	7 (12.96%)	3 (4.84%)	10 (8.62%)	.528
Year 12	4 (7.41%)	3 (4.84%)	7 (6.04%)
Trade qualification	3 (5.55%)	5 (8.06%)	8 (6.89%)
TAFE	18 (33.33%)	25 (40.33%)	43 (37.07%)
University	22 (40.75%)	26 (41.93%)	48 (41.38%)
Total	54 (100%)	62 (100%)	116 (100%)

^aAll variables analysed using Chi-Sq tests, except for gender which used a Fisher Exact test.

At the time of the survey, commercial companies delivering pre-prepared food to ECEC services was rare. Thus, food provision in these results relates to food prepared on site. Almost 80% of participants reported their service provided some or all food for children. Nearly all participants reported they made a conscious effort to provide healthy food all or most of the time, but approximately 20% (n = 23) felt the food was not healthy enough.

Food foundations

Before and after the intervention, participants from both groups rated their confidence (1 = not at all; 12 = totally) that their service’s menu met the recommended servings (NHMRC, 2013) of core food groups for children aged two to three years (Table 3).

Table 3.

Participant confidence in menu meeting core food recommendations.

Food group provision	InterventionT1	InterventionT2	ControlT1	ControlT2	p-value^∧
Cereals and grains
Minimum 2 serves/d	8.93 ± 0.30^c	9.91 ± 0.29^c	9.54 ± 0.29	9.23 ± 0.29	.0025*
50% wholegrain	8.5 ± 0.35^c	9.45 ± 0.33^c	8.88 ± 0.33	8.79 ± 0.32	.05*
Only unsweetened cereal	8.32 ± 0.43^c	9.58 ± 0.42^c	8.44 ± 0.42	8.39 ± 0.40	.023*
Vegetables
Minimum of 1 serve/d	9.8 ± 0.34	10.0 ± 0.34	9.23 ± 0.34	9.31 ± 0.34	.723
Variety of vegetables	9.30 ± 0.37^c	9.94 ± 0.36^c	8.97 ± 0.36	8.87 ± 0.37	.051
Fruit
Minimum half serve/d	10.02 ± 0.20	10.40 ± 0.20	10.50 ± 0.20	10.10 ± 0.20	.062
100% juice provided only	10.90 ± 0.31	11.10 ± 0.32	11.30 ± 0.30	11.30 ± 0.31	.66
Dairy
75% of daily serve/d	9.05 ± 0.33	9.46 ± 0.33	9.60 ± 0.33	9.39 ± 0.34	.12
Reduced or low fat	7.78 ± 0.65	8.58 ± 0.52	7.34 ± 0.66	7.31 ± 0.56	.27
Mostly water or fat free milk	9.24 ± 0.34	9.89 ± 0.33	9.64 ± 0.32	9.80 ± 0.34	.357
No sugar sweetened beverages	10.2 ± 0.35	10.4 ± 0.27	10.6 ± 0.35	10.6 ± 0.27	.43
Meat and meat alternatives
1/2 serve/d	9.04 ± 0.31	9.33 ± 0.30	9.56 ± 0.30	9.37 ± 0.31	.241
Only lean meat/alternative options	8.67 ± 0.33^c	9.23 ± 0.32^c	9.29 ± 0.33	9.15 ± 0.33	.087

^∧p-value of time versus group interaction.

^cstatistically significant within group difference p < .05.

*denotes statistically significant at the 95% level.

Statistically significant improvements were observed for participant confidence that the menu provided the recommended serves of cereal/grains, vegetables and meat/meat alternatives food groups (NHMRC, 2013).

Participants rated their confidence on a scale of 0 (strongly disagree) to 6 (strongly agree) when estimating the recommended food serve sizes for children (NHMRC, 2013). A statistically significant difference in confidence was observed between groups over time (p = .001). Intervention group confidence scores increased by an average of 0.94 (95% CI 0.59, 1.29), while no change was detected in the control group.

Participants were then tested on their knowledge of the recommended serve sizes for core foods (Table 4; NHMRC, 2013). Although intervention participants’ knowledge increased for all questions, there were no statistically significant differences in responses between groups. Post-training, approximately half the intervention participants answered questions incorrectly for tinned fruit (51.9%), pasta serves (43%), fruit serves (57%), vegetable serves (41%) and dairy type (46.3%).

Table 4.

Participant knowledge of core food serve sizes.

Question	Correct answer
How many serves of fruit are in one cup of tinned fruit?	One serve
How many serves of cereals/grains are in one cup of cooked pasta?	Two serves
How many serves of fruit are recommended for children (aged two-three years) per day?	One serve
How many serves of vegetables are recommended for children (aged two-three years) per day?	Two-three serves
Which of the following dairy foods are recommended for children aged two-three years?	Lower fat dairy foods

Participants answered a series of questions about fat, saturated fat, sugar, sodium, protein and fibre content of specific foods, selecting response options: high, low or unsure. Overall, knowledge about foods containing added sugar and fat was high across both groups and time points. Concerning sodium, the only statistically significant difference between groups related to sausages (p = .0082). Despite an increase in knowledge about sodium content among intervention participants (p = .013), they did not correctly identify cheese (42%), peanut butter (21%) and bread (82%) as typically high sodium foods. There was no difference in knowledge about protein or high-fibre foods between groups or time points. For saturated fatty acids, knowledge about salmon (a food low in saturated fat) changed significantly between groups (p = .0057). Among intervention participants, no change was detected, but control participants exhibited a decrease in knowledge (p = .01). Participants were asked to identify the healthiest choices for a variety of children’s snacks and meals. No differences were detected between groups and time points. Only half the intervention participants (50.9%) correctly identified a whole fresh orange as the healthiest snack when choosing from strawberry yogurt, muesli bar, and crackers and cheese.

Using a scale from one (never) to five (always), participants indicated how often they examined food label information when purchasing packaged food for children at their service (Table 5).

Table 5.

Food package label information use.

Information type	Intervention T1	InterventionT2	ControlT1	ControlT2	p^∧
Ingredient list	4.06 ± 0.12^c	4.38 ± 0.12^c	4.12 ± 0.12	4.08 ± 0.12	.034*
Nutritional information panel	3.82 ± 0.14^c	4.23 ± 0.14^c	3.94 ± 0.13	3.98 ± 0.14	.031*
Nutritional claims	3.32 ± 0.17^c	2.86 ± 0.17^c	3.25 ± 0.16	3.31 ± 0.17	.028*
Health claims	3.21 ± 0.16^c	2.85 ± 0.16^c	3.01 ± 0.15	3.13 ± 0.16	.022*
Serve size	3.44 ± 0.15	3.69 ± 0.15	3.26 ± 0.14	3.39 ± 0.15	.602
Percentage daily intake	3.33 ± 0.15	3.53 ± 0.15	3.24 ± 0.14	3.43 ± 0.15	.983

^∧p-value of time versus group interaction.

^cstatistically significant within group difference p < .05.

*denotes statistically significant at the 95% level.

Making good food choices

Participants ranked their confidence (1 = not at all; 12 = totally) to make nutritional recommendations to parents around limiting unhealthy snacks and drinks with added sugar, eating low-sodium foods, avoiding solid fats and eating lean meats/poultry. Both groups reported between 60%–80% confidence in making these dietary recommendations to parents. Statistically significant differences were observed between the groups over time for eating low sodium foods (p = .022) and avoiding solid fats (p = .0005). The intervention group showed an average increase of 1.03 (95% CI 0.26, 1.81) in the former and 1.43 (95% CI 0.64, 2.22) in the latter.

Participants reported their perceptions of role legitimacy and adequacy in relation to healthy eating and child nutrition (1 = Strongly disagree; 7 = Strongly agree) (Table 6).

Table 6.

Perceptions of role legitimacy and adequacy.

Variable	InterventionT1	InterventionT2	ControlT1	ControlT2	p ^∧
Role adequacy
I have a working knowledge of child nutrition	5.14 ± 0.15^c	6.04 ± 0.15^c	5.28 ± 0.14	5.32 ± 0.15	<.0001*
I understand the factors that put children at risk if they eat unhealthily	5.15 ± 0.17^c	6.10 ± 0.17^c	5.45 ± 0.16	5.51 ± 0.17	<.0001*
I can encourage children to make healthy food choices	6.04 ± 0.13	6.47 ± 0.13	6.02 ± 0.12	6.32 ± 0.13	.456
I can encourage parents to make healthy food choices for their children	5.12 ± 0.17^c	6.05 ± 0.17^c	5.49 ± 0.16	5.82 ± 0.17	.022*
Role legitimacy
I understand my responsibilities in helping children to make healthy food choices	6.06 ± 0.13	6.50 ± 0.13	6.04 ± 0.13	6.19 ± 0.13	.124
I can access help when dealing with a child’s nutritional requirements	5.37 ± 0.19	6.26 ± 0.19	5.41 ± 0.17	5.83 ± 0.19	.063
I understand the nutritional requirements of children	5.55 ± 0.15	6.40 ± 0.15	5.72 ± 0.15	5.66 ± 0.15	<.0001*

^∧p-value of time versus group interaction.

^cstatistically significant within group difference p < .05.

*denotes statistically significant at the 95% level.

There was a positive effect on three of the four role adequacy indicators for the intervention group (Table 6). For role legitimacy, only one indicator, understanding the nutritional requirements of children, was statistically significant between time and group (Table 6).

Using a scale from one (never) to five (always), participants reported how often they limited certain foods and provided healthy options for children at their service (Table 7).

Table 7.

Food choices made for children.

Recommendation	InterventionT1	InterventionT2	ControlT1	ControlT2	p ^∧
Limiting high sodium foods	4.20 ± 0.13	4.33 ± 0.13	4.06 ± 0.12	3.93 ± 0.13	.102
Limiting butter	3.84 ± 0.14	4.08 ± 0.14	3.78 ± 0.13	3.73 ± 0.20	.174
Choosing fruit and vegetables	4.59 ± 0.09^c	4.83 ± 0.09^c	4.77 ± 0.08	4.66 ± 0.09	.023*
Limiting foods high in added sugar	4.48 ± 0.11	4.51 ± 0.11	4.50 ± 0.10^c	4.15 ± 0.34^c	.012*
Choosing whole grain products	4.23 ± 0.12	4.38 ± 0.12	4.26 ± 0.12	4.15 ± 0.11	.135
Choosing a variety of foods from each core food group	4.38 ± 0.11	4.59 ± 0.11	4.37 ± 0.10	4.31 ± 0.11	.075
Choosing foods low in saturated fats	4.29 ± 0.12	4.25 ± 0.12	4.02 ± 0.11	3.99 ± 0.12	.947
Choosing brightly coloured vegetables daily	4.10 ± 0.13^c	4.41 ± 0.13^c	4.05 ± 0.13	4.11 ± 0.13	.118
Choosing foods low in trans fats	4.08 ± 0.13^c	4.33 ± 0.13^c	4.05 ± 0.13	3.91 ± 0.13	.016*
Choosing sources of unsaturated fats	4.01 ± 0.14^c	4.37 ± 0.14^c	4.11 ± 0.13	3.87 ± 0.14	.00075*
Offering milk or calcium-fortified alternatives	3.97 ± 0.15	4.11 ± 0.15	4.13 ± 0.14	4.11 ± 0.16	.493

^∧p-value of time versus group interaction.

^cstatistically significant within group difference p < .05.

*denotes statistically significant at the 95% level.

At your service

Participants rated their level of agreement with six statements on a Likert scale (1 = strongly disagree; 5 = strongly agree) (Table 8).

Table 8.

Participant beliefs about healthy eating and food choices.

Statement	InterventionT1	InterventionT2	ControlT1	ControlT2	p^∧
Diet and physical activity can contribute to a child having a healthy body	4.75 ± 0.09	4.83 ± 0.09	4.74 ± 0.08	4.78 ± 0.09	.849
What children eat can make a big difference to their chances of being healthy	4.76 ± 0.08	4.83 ± 0.08	4.79 ± 0.08	4.76 ± 0.08	.496
The foods children receive at ECEC services can influence their food choices	4.55 ± 0.09	4.70 ± 0.09	4.62 ± 0.09	4.62 ± 0.10	.386
The way ECEC staff talk to children about food can influence their attitudes towards food	4.70 ± 0.09	4.81 ± 0.09	4.64 ± 0.08	4.71 ± 0.09	.781
Recommendations on healthy eating for children change so often, it is hard to know what to believe	3.40 ± 0.15^c	2.99 ± 0.15^c	3.22 ± 0.14	3.39 ± 0.15	.012*
The foods available at my ECEC service are already healthy, so there is no reason to make a change to the menu	3.07 ± 0.13^c	3.47 ± 0.13^c	3.01 ± 0.12	3.08 ± 0.13	.085

^∧p-value of time versus group interaction.

^cstatistically significant within group difference p < .05.

*denotes statistically significant at the 95% level.

Post-course completion, intervention participants rated the useability and likeability of the online short course, from 1 (Strongly disagree) to 7 (Strongly agree). Most reported the course was engaging (>90%), adequate (>92%) and easy to understand (94%). The downloadable resources were deemed informative by 98% of respondents, 90% felt that the course improved their confidence in making changes at their service and 94% believed it enhanced their nutrition knowledge.

Discussion

This study demonstrated that an online short course could improve ECEC professionals’ role adequacy and legitimacy, confidence to make dietary recommendations to parents and ability to understand food packaging labels. However, high levels of confidence contrasted apparent gaps in nutrition knowledge, highlighting the need for multilevel approaches to ensure healthy eating environments are promoted at services. This discussion is organised according to the three course modules.

Food foundations

No statistically significant changes were seen in nutrition knowledge for either group. Almost half of the intervention group did not correctly identify the recommended serves of core foods for children and were unable to identify the ‘healthiest’ snack, indicating a lack of understanding regarding the key nutrient content of foods/meals (Bhawra et al., 2023). These findings are consistent with a previous study that provided online nutrition curriculum resources to ECEC professionals (Devine et al., 2019). Kang (2016) suggests professionals may require repeated sessions over time to enhance learning outcomes, memory retention, problem-solving skills and the transfer of learning to new contexts. Furthermore, a moderated online community of support in addition to online nutrition curriculum resources (Devine et al., 2019) as part of a multilevel strategy, could better support healthy eating at ECEC services (Wallace, 2016).

Despite gaps in nutrition knowledge, participants demonstrated high levels of confidence regarding core food provision and estimation for children, highlighting disparities in these professionals’ knowledge, confidence and practices. This finding aligns with Devine et al.’s (2019) study, which reported a concerning lack of knowledge among ECEC professionals about the nutritional requirements of young children. Wallace and Mills (2019) similarly reported poor nutrition knowledge among family daycare educators about core food serve sizes for children. Wallace (2016) also noted high levels of participant confidence around the provision of food that meets nutrition guidelines for children after receiving nutrition education, which did not align with participants lower levels of nutrition knowledge.

A lack of nutrition knowledge (and potentially overconfidence in their skills) may result in the provision of food that does not meet nutrition guidelines – as reported elsewhere (Yoong et al., 2014) – impacting children’s weight status and risk of chronic disease (Wood et al., 2020). Nutrition is a complex topic and we cannot expect ECEC professionals to be nutrition experts (Boyd, 2015). Therefore, we should consider a range of options to embed nutrition education, like support from a ‘mentor or nutrition specialist’ (Kirkegaard et al., 2023), and implement these multilevel and holistic approaches (Wallace, 2016) to address complex health issues (Forde et al., 2021).

Regarding food label reading, findings indicated intervention participants relied on credible ingredient lists and nutrition information to make healthy food choices for children, rather than manufacturers claims about nutrition and health, highlighting the value of the course to teach professionals how to discern credible nutrition information. This finding is important because previous research showed that ECEC professionals searched the internet even though they acknowledged the validity and reliability of the information sourced could not be assured (Wallace et al., 2017b). Therefore, the inclusion of evidence-based resources to build sound nutrition knowledge should be a basic feature in any nutrition education and training.

Making good food choices

Participants reported confidence in making dietary recommendations to parents about their children’s food choices, particularly for foods containing sodium and solid fat. However, they demonstrated a lack of knowledge about high sodium foods. This knowledge gap has implications for the nutritional quality of foods offered at ECEC services and the potential accuracy of information provided by ECEC professionals to parents. Given reports that children consume 38.5% of their daily energy needs from discretionary foods (often high in sodium) that could impact their long-term health (Jakobsen et al., 2023), this finding is concerning and underscores the need for ongoing ECEC professional nutrition education.

For role adequacy, participants demonstrated a significant increase in confidence regarding nutrition knowledge, awareness of the health risks of unhealthy diets for children and confidence to encourage parents to make healthy choices for their children. For role legitimacy, there was a significant improvement in participants understanding children’s nutritional requirements. These findings show that online nutrition education, just like face-to-face (Branscum & Sharma, 2012; Forde et al., 2021), can increase the role adequacy and legitimacy of ECEC professionals. Importantly, online education may be more feasible for the ECEC workforce than face-to-face, and could enable scalability, which aligns with Love et al.’s (2020) recommendation for systemic, rather than individual level change, potentially also at a reduced cost for the sector.

Participants responses showed statistically significant improvements in choosing plenty of fruit and vegetables and limiting foods high in added sugar (Table 7), suggesting the course had a positive effect on participants’ awareness of healthy food choices. There were, however, no statistically significant changes in the reported provision of discretionary foods typically high in sugar and saturated fat, despite the course emphasising avoiding such foods as stipulated in the National Quality Standards (ACECQA, 2017, 2023), which align with the Australian Dietary Guidelines (NHMRC, 2013). These guidelines advocate for menu planning that excludes discretionary foods and includes core foods in each meal. Considering the impact of discretionary foods on overweight/obesity prevalence among Australian children (Jakobsen et al., 2023) and the influential role of ECEC services in shaping eating preferences (Walker & Littlewood, 2018), these findings highlight an urgent need to challenge professionals’ existing beliefs and practices regarding discretionary foods. As the cost of quality food provision is related to the use of discretionary foods at ECEC services (Sambell et al., 2020), financial support could help reduce food insecurity, while also improving child developmental outcomes (Thorpe et al., 2022). As Spence et al. (2020) suggest, policy changes may need to be promoted across organisational and governmental levels to help create enabling environments for healthier food practices, in addition to supporting services to develop and implement sound nutrition policy (Kirkegaard et al., 2024).

At your service

Overall, participant beliefs about establishing a healthy eating environment at their services scored positively. Only one statement, recommendations on healthy eating for children change so often, it is hard to know what to believe, showed a statistically significant difference between time and groups. This finding corroborates with a previous study (Devine et al., 2019) in which educators expressed similar concerns about recommendations being “changeable and hard to follow” (p. 10). Confusion could be attributed to the different ECEC nutrition guidelines present across Australian jurisdictions, which also creates challenges for service accreditation, resource provision and support (Spence et al., 2020). As such, nutrition experts have called for the harmonisation of nutrition guidelines to ensure consistent support and education is available across Australia. Implementing such changes would reduce confusion and encourage healthy eating environments, while enabling ECEC professionals to work across jurisdictions without the need for additional training.

Strengths and limitations

Participants were randomly allocated to either group, with outcomes measured, ensuring methodological rigour (Wagle, 2018). Recruitment based on participant interest in healthy eating minimised selection bias. However, there was potential for participant bias. For example, participants may have joined the study to improve their nutrition knowledge and, thus, were motivated to learn, while others with entrenched habits and paradigms may have opted not to participate, potentially influencing the results. The extent of self-selection bias and its impact on generalisability should be carefully considered when interpreting the findings, as well as the relatively small sample size compared to the sampling frame and power calculation.

In addition, there is variation in how food is provided at ECEC services across Australia (National Nutrition Network - Early Childhood Education and Care, 2022). For example, some services prepare food on the premises, while others request food from parents, potentially influencing participants’ responses. More recently, it has become increasingly common for services to source food from a commercial catering company, so researchers must consider the sources of food provided at services when designing studies. We did not collect data on how the food was sourced because commercial sources were uncommon at the time of this study.

While the online course included nutrition policy information in Module 1, this was brief, and we did not test participants’ knowledge of nutrition policy in the pre and post surveys. Given that Lum’s (2023) review found only 37% of 523 participating ECEC services reported fully implementing nutrition policies, and system-wide change is recommended (Love et al., 2020), future nutrition education interventions in ECEC settings should include learning activities about nutrition policy, measuring participants understanding and assessing their ability to apply policy across all aspects of their practice (Kirkgaarde et al., 2024), as per the Health Promoting Schools Framework (Figure 1).

Conclusion

This study followed recommended best practices (Matwiejczyk et al., 2018) by developing and testing a comprehensive online short course, called ‘SNACing_101’, specifically designed to help ECEC professionals promote healthy eating across all aspects of their service - curriculum, partnerships and environment (Gillies et al., 2011).

Our findings demonstrate that online training can be effective (just like face-to-face) as positive outcomes were seen for some aspects of participants’ nutrition knowledge, their confidence in making recommendations to parents and awareness of their responsibilities in child nutrition. However, participants’ variable knowledge regarding the specific nutrition content of foods/meals highlights that training should target potential misconceptions and preconceived ideas, in addition to providing specific details about nutrition content of commonly used foods/meals. We also raised the issue of incorporating nutrition policy into education and, subsequently, enforcing it in practice, preferably supported by a harmonsed national approach.

Considering the complexity of nutrition topics, it is not surprising that one three-hour course could not address all misconceptions and knowledge gaps. Thus, it is important to explore how comprehensive training can be delivered across all levels of ECEC and embedded across each professionals’ career as part of their ongoing development to ensure enduring improvements to knowledge and practice. While such training options may present challenges, especially in an overcrowded ECEC agenda (Kirkegaard et al., 2023), the substantial influence of nutrition on child growth, development and future outcomes necessitates prioritising such strategies as part of a broader solution. Integrating child nutrition into ECEC tertiary education is also essential, given its integral role in a whole-service-approach and evidence that isolated, one-off programs yield limited impact (Yoong et al., 2023). It is vital to keep the needs of ECEC firmly in the sights of government and to advocate for multi-level solutions to enhance professionals’ nutrition knowledge, role adequacy and legitimacy. By doing so, we can work toward ensuring healthier environments for young children and better overall future health outcomes.

Footnotes

Acknowledgements

Ainslie Sartori (Research Assistant).

Author contributions

Ruth Wallace: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – original draft; Ros Sambell: Conceptualization, Funding Acquisition, Methodology, Writing – review and editing; Shih Ching Fu: Formal analysis, Validation, Writing – review and editing; Johnny Lo: Formal analysis, Validation, Writing – review and editing; Elizabeth J. Cook: Visualisation, Writing – review and editing; Amanda Devine: Conceptualization, Funding Acquisition, Investigation, Methodology, Supervision, Writing – review and editing.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Edith Cowan University Early Career Researcher Grant G1003434 awarded to Dr. Ruth Wallace (lead author).

Ethical statement

ORCID iDs

Ruth Wallace

Ros Sambell

Shih Ching Fu

Johnny Lo

Elizabeth J Cook

Amanda Devine

References

Australian Children’s Education & Care Quality Authority . (2017). Guide to the national quality standard. Australian Children’s Education & Care Quality Authority. https://www.acecqa.gov.au/sites/default/files/acecqa/files/National-Quality-Framework-Resources-Kit/NQF-Resource-03-Guide-to-NQS.pdf

Australian Government, Department of Education . (2023). Child care in Australia report December quarter, 2023. Australian Government, Department of Education. https://www.education.gov.au/early-childhood/early-childhood-data-and-reports/quarterly-reports-usage-services-fees-and-subsidies/child-care-subsidy-data-report-december-quarter-2023

Australian Bureau of Statistics . (2018). National health survey: First results. Australian Bureau of Statistics. https://www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey-first-results/latest-release

Australian Children’s Education and Care Quality Authority . (2023). National registers. Australian Children’s Education and Care Quality Authority. https://www.acecqa.gov.au/resources/national-registers

Australian Institute of Health & Welfare . (2020). Overweight and obesity among Australian children and adolescents. Australian Institute of Health & Welfare. https://www.aihw.gov.au/reports/overweight-obesity/overweight-obesity-australian-children-adolescents/summary

Australian Institute of Health & Welfare . (2021). Inequalities in overweight and obesity and the social determinants of health. Australian Institute of Health & Welfare. https://www.aihw.gov.au/reports/overweight-obesity/inequalities-overweight-social-determinants-health/summary.

Bhawra

Kirkpatrick

Hall

Vanderlee

White

Hammond

(2023). Patterns and correlates of nutrition knowledge across five countries in the 2018 international food policy study. Nutrition Journal, 22(1), 19. https://doi.org/10.1186/s12937-023-00844-x

Boyd

(2015). The tensions between food choices and sustainable practices in early childhood centres. Australasian Journal of Early Childhood, 40(4), 58–65. https://doi.org/10.1177/183693911504000408

Branscum

Sharma

(2012). After-school based obesity prevention interventions: A comprehensive review of the literature. International Journal of Environmental Research and Public Health, 9(4), 1438–1457. https://www.mdpi.com/1660-4601/9/4/1438

10.

Byrne

Baxter

Irvine

Vidgen

Gallegos

Martin

Trost

(2022). Feeding practices in Australian early childhood education and care settings. Public Health Nutrition, 25(2), 303–311. https://doi.org/10.1017/S1368980021004055

11.

Commonwealth of Australia . (2022). The national obesity strategy 2022–2032. Health ministers meeting. Commonwealth of Australia. https://www.health.gov.au/sites/default/files/documents/2022/03/national-obesity-strategy-2022-2032_0.pdf

12.

Devine

Wallace

Miller

Sambell

Costello

Lombardi

Veurink

(2019). Online programs build confidence and improve healthy eating messages in Early Years services. Australasian Journal of Early Childhood, 44(2), 139–152. https://doi.org/10.1177/1836939119833244

13.

Forde

Costello

Devine

Sambell

Wallace

(2021). A multifaceted approach increased staff confidence to develop outside of school hours care as a health promoting setting. BMC Public Health, 21(1), 2286. https://doi.org/10.1186/s12889-021-12360-w

14.

Gillies

Dimitrijevich

Lambert

(2011). What is a health promoting school? WA Health Promoting Schools Association Inc. https://wahpsa.org.au/wp-content/uploads/2015/09/What-is-a-HPS-2011.pdf

15.

Jakobsen

Brader

Bruun

(2023). Association between food, beverages and overweight/obesity in children and adolescents: A systematic review and meta-analysis of observational studies. Nutrients, 15(3), 764. https://doi.org/10.3390/nu15030764

16.

Kang

(2016). Spaced repetition promotes efficient and effective learning: Policy implications for instruction. Policy Insights from the Behavioral and Brain Sciences, 3(1), 12–19. https://doi.org/10.1177/2372732215624708

17.

Kirkgaard

Anderson

Irwin

Vincze

(2024). Quality evaluation of nutrition policies in early childhood education and care services in Nerang, QLD. Health Promotion Journal of Australia, 1–6. https://doi.org/10.1002/hpja.862

18.

Kirkgaard

Irwin

Byrne

Sambell

Vincze

(2023). Barriers and enablers to a healthy food environment in Australian childcare services: Exploring director’s perspectives. Health Promotion Journal of Australia, 35(1), 122–133. https://doi.org/10.1002/hpja.722

19.

Love

Walsh

Campbell

(2020). Knowledge, attitudes and practices of Australian trainee childcare educators regarding their role in the feeding behaviours of young children. International Journal of Environmental Research and Public Health, 17(10), 3712–3719. https://doi.org/10.3390/ijerph17103712

20.

Luo

Chen

P. Y.

(2008). Sample size estimation for repeated measures analysis in randomized clinical trials with missing data. International Journal of Biostatistics, 4(1), 9. https://doi.org/10.2202/1557-4679.1098

21.

Lum

Grady

Wolfenden

Lecathelinais

Lin Yoong

(2023). Implementation of healthy eating and physical activity practices in Australian early childhood education and care services: A cross-sectional study. Preventive Medicine Reports, 36, 102455. https://doi.org/10.1016/j.pmedr.2023.102455

22.

Matwiejczyk

Mehta

Scott

Tonkin

Coveney

(2018). Characteristics of effective interventions promoting healthy eating for pre-schoolers in childcare settings: An umbrella review. Nutrients, 10(3), 293. https://doi.org/10.3390/nu10030293

23.

National Health and Medical Research Council . (2013). Australian dietary guidelines summary. National Health and Medical Research Council. https://www.eatforhealth.gov.au/sites/default/files/2022-09/n55a_australian_dietary_guidelines_summary_131014_1.pdf

24.

National Nutrition Network – Early Childhood Education and Care . (2022). Policy brief 2 - a case for mapping food provision across jurisdictions and ECEC services and settings: How one tick box can build and support the bigger picture in early childhood health and education development. National Nutrition Network – Early Childhood Education and Care. https://www.nationalnutritionnetwork.com.au/

25.

Qualtrics Labs Inc . (2023). Qualtrics survey software. Qualtrics Labs Inc.

26.

Ramia

People

Ridgway

Greaves

Jackson

Healey

(2023). Evidence use in early childhood education and care: National Snapshot 2021/2022. Australian Education Research Organisation. https://www.edresearch.edu.au/sites/default/files/2023-07/evidence-use-in-ecec-aa.pdf

27.

R Core Team . (2021). R: A language and environment for statistical computing. R Foundation for Statistical Computing. https://www.R-project.org/

28.

Sambell

Wallace

Costello

Devine

(2020). Increasing food expenditure in long day-care by an extra $0.50 per child/day would improve core food group provision. Nutrients, 12(4), 968. https://doi.org/10.3390/nu12040968

29.

Skinner

Roche

Freeman

Addy

(2009). Responding to alcohol and other drug issues: The effect of role adequacy and role legitimacy on motivation and satisfaction. Drugs: Education, Prevention & Policy, 12(6), 449–463. https://doi.org/10.1080/09687630500284281

30.

Spence

Love

Byrne

Wakem

Matwiejczyk

Devine

Golley

Sambell

(2020). Childcare food provision recommendations vary across Australia: Jurisdictional comparison and nutrition expert perspectives. International Journal of Environmental Research and Public Health, 17(18), 6793. https://doi.org/10.3390/ijerph17186793

31.

Thorpe

Potia

Searle

Van Halen

Lakeman

Oakes

Harris

Staton

(2022). Meal provision in early childhood education and care programs: Association with geographic disadvantage, social disadvantage, cost, and market competition in an Australian population. Social Science & Medicine, 312, 115317. https://doi.org/10.1016/j.socscimed.2022.115317

32.

Wagle

(2018). 20 differences between randomized control trial (RCT) and quasi-experimental study design. Public Health Notes. https://www.publichealthnotes.com/20-differences-between-randomized-controlled-trial-rct-and-quasi-experimental-study-design/

33.

Walker

Littlewood

(2018). Pragmatic implementation studies to improve nutrition practices and policies: Childcare during the first 1000 days as a contributor to long-term health. Public Health Nutrition, 21(7), 1209–1211. https://doi.org/10.1017/S1368980018000022

34.

Wallace

(2016). Supporting Nutrition for Australian Childcare (SNAC): The development, implementation and evaluation of an online nutrition education intervention. Edith Cowan University. https://ro.ecu.edu.au/theses/1771/

35.

Wallace

Costello

Devine

(2017a). Over-provision of discretionary foods at childcare dilutes the nutritional quality of diets for children. Australian & New Zealand Journal of Public Health, 41(4), 447. https://doi.org/10.1111/1753-6405.12658

36.

Wallace

Devine

Costello

(2017b). Determining educators needs to support healthy eating environments in early childhood settings. Australasian Journal of Early Childhood, 42(2), 20–28. https://doi.org/10.23965/AJEC.42.2.03

37.

Wallace

Mills

(2019). A study of the food environment at Australian Family Day Care. Nutrients, 11(10), 2395. https://doi.org/10.3390/nu11102395

38.

Wood

Blisset

Brunstrom

Carnell

Faith

Fisher

Hayman

Khalsa

Hughes

Miller

Momin

Welsh

Woo

Haycraft

(2020). Caregiver influences on eating behaviours in young children. Journal of the American Heart Association, 9(10), e014520. https://www.ahajournals.org/doi/full/10.1161/JAHA.119.014520.

39.

World Health Organization . (2016). Report of the commission on ending childhood obesity. WHO. https://apps.who.int/iris/bitstream/handle/10665/204176/9789241510066_eng.pdf

40.

World Health Organization . (2021a). Obesity and overweight. WHO. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

41.

World Health Organization . (2021b). Standards for healthy eating, physical activity, sedentary behaviour and sleep in early childhood education and care settings: A toolkit. WHO. https://www.who.int/publications/i/item/9789240032255

42.

Yoong

Lum

Wolfenden

Jackson

Barnes

Hall

McCrabb

Pearson

Lane

Jones

Dinour

McDonnell

Booth

Grady

(2023). Healthy eating interventions delivered in early childhood education and care settings for improving the diet of children aged six months to six years. Cochrane Database of Systematic Reviews, (6), CD013862. https://doi.org/10.1002/14651858.CD013862.pub2

43.

Yoong

Skelton

Jones

Wolfenden

(2014). Do childcare services provide foods in line with the 2013 Australian dietary guidelines? A cross-sectional study. Australian and New Zealand Journal of Public Health, 38(6), 595–596. https://doi.org/10.1111/1753-6405.12312

Enhancing nutrition information utilisation,confidence,and role legitimacy and adequacy among early childhood education professionals through evidence-based online training

Abstract

Keywords

Introduction

Methods

Results

Demographic data

Food foundations

Making good food choices

At your service

Discussion

Food foundations

Making good food choices

At your service

Strengths and limitations

Conclusion

Footnotes

Acknowledgements

Author contributions

Declaration of conflicting interests

Funding

Ethical statement

ORCID iDs

References