The adaptation and translation of the PEACH™ RCT intervention: the process and outcomes of the PEACH™ in the community trial

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Original Research

The adaptation and translation of the PEACH™ RCT intervention: the process and outcomes of the PEACH™ in the community trial R.A. Perry a,*, R.K. Golley b, J. Hartley a, A.M. Magarey a a

Nutrition and Dietetics, School of Health Sciences, Flinders University, Adelaide, South Australia, Australia Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia

b

article info

abstract

Article history:

Objective: To describe the process and report selected outcomes of translating an effective

Received 3 April 2017

child weight management initiative (PEACH™) from a randomised controlled trial inter-

Received in revised form

vention to a community health programme.

18 July 2017

Study design and methods: Pre-post study design utilising the reach, effectiveness, adoption,

Accepted 21 August 2017

implementation and maintenance (RE-AIM) evaluation framework. Adaptation of PEACH™

Available online 26 October 2017

required significant promotional activity and consideration of legal, ethical and financial issues. PEACH™ components were revised and an evaluation design based on the RE-AIM

Keywords:

framework was developed. Facilitator training workshops were made available to South

Children

Australian health or education professionals initially, then opened up to new graduates,

Weight management

interstate dietitians and others interested in professional development. Facilitators

Translation

completed pretraining and post-training questionnaires and a third questionnaire

RCT

following programme delivery. Data were collected from families by facilitators and

Community

returned to university staff for assessment of change (baseline to programme end) in body mass index (BMI) and waist circumference (WC) z-scores. Results: Changes to organisational and political environments prevented maximum programme reach and adoption. Nonetheless, data indicated that PEACH™ was effective at improving facilitators' confidence (P < 0.05) and children's (n ¼ 37) BMI z-score (0.17, 95% confidence interval [CI]: 0.03:0.30, P ¼ 0.016), WC z-score (0.14, 95% CI: 0.02:0.30, P ¼ 0.09) and lifestyle behaviours. Collection of maintenance data was prevented due to time and financial constraints. Conclusions: Translational research needs to develop ways to effectively and efficiently bridge the gap between behavioural research and practice to improve the adoption of

Abbreviations: BMI, body mass index; BMIz, BMI z-score; CHP, community health programme; CPG, clinical practice guidelines; PEACH™, Parenting Eating and Activity for Child Health; PEACH™ IC, PEACH™ in the Community; RCT, randomised controlled trial; WC, waist circumference; WCz, waist circumference z-score. * Corresponding author. Nutrition and Dietetics, School of Health Sciences, Flinders University South Australia, GPO Box 2100, Adelaide, South Australia 5000, Australia. Tel.: þ61 8 8201 7739. E-mail address: [email protected] (R.A. Perry). http://dx.doi.org/10.1016/j.puhe.2017.08.009 0033-3506/© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

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evidence-based approaches to child weight management. Nutrition educators and researchers can drive these nutrition-focussed translational research efforts forward. Funding bodies and health service organisations are encouraged to provide financial and structural support for such activity. © 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction

Methods

Childhood obesity continues to be a major global public health issue1 which requires the early application of evidence-based practice to its prevention and management. Such evidence exists in the form of a Cochrane Review2 and various national practice guidelines3,4 which recognise the cornerstones of management to be diet and activity changes through behaviour modification with parental involvement and support. One of the several child weight management studies showing promising results is the Parenting, Eating and Activity for Child Health Programme (PEACH™). In 2004, the Australian National Health and Medical Research Council (NHMRC) funded a single blinded randomised controlled trial (RCT) to test the effectiveness of incorporating parenting skills training in the management of overweight in 5- to 9-year olds (ACTR: 00001104).5 The trial demonstrated a 10% reduction in relative adiposity (child body mass index z-score [BMIz] and waist circumference z-score [WCz]) at intervention end (6 months), which was maintained in the following 18 months without further programme contact.5 While the initial change in adiposity is similar to that reported in other child weight management trials,2,6 the long-term maintenance is better than published adult outcomes.3,7 Furthermore children's eating and activity behaviours improved,8 indicating that the programme led to enhanced lifestyle behaviours contributing to healthy growth. These anthropometric and behavioural outcomes, combined with the positive participant feedback, limited availability of evidence-based child weight management services9 and reported low levels of practitioner confidence to practice in this area,10 provided the impetus to disseminate PEACH™ and provide a practical model for its transition from efficacyto-effectiveness.11 Dissemination, or translational research, describes a continuum which integrates basic, patient-oriented and population-based research, with the aim of improving public health.12,13 In the behavioural sciences, translational research focusses on the delivery of recommendations, new treatments and research knowledge to individuals or groups within communities.14 There are few reports of dissemination, or translation, of health behaviour interventions2,11 such as PEACH™. This paper therefore aims to report the process and selected outcomes of translating an effective child weight management initiative (PEACH™) from an RCT to a community health programme (CHP).

Preliminary work Support for the adaptation of the PEACH™ RCT intervention into a CHP required significant promotional work, including dissemination of the RCT findings at conferences (local/international), in peer-reviewed journals, government departmental briefings and via the media. Relationships were developed with government departments, clinicians and managers within service provider organisations. As a result, funding for translation to a CHP was secured from a state government health department ($200,000 over 3 years) and a car manufacturing company ($85,000). In-house legal discussions were held regarding licencing, intellectual property and maintaining programme integrity. Ethical approvals were obtained from four committees (see Author statements section for details). In 2008, adaption of the PEACH™ RCT intervention (conducted in the hospital out-patient setting) into a non-research setting CHP, titled ‘PEACH™ in the Community’ (PEACH™ IC) commenced. The revision and evolution of programme components are detailed below.

Revision of programme eligibility criteria The PEACH™ RCT upper BMIz cut-off eligibility criteria of >4.0 was removed following observations from the analysis of the RCT data that BMIz above this point was unlikely to be associated with secondary health conditions. The age range criterion was expanded from 5e9 years of age to 4e10 years which enabled the recruitment of children through a newly introduced statewide 4-year-old health check-up, to the upper middle primary school years (when children are aged 10 years). Eligible siblings could enrol regardless of their weight status.

Programme content and supporting resources Modifications to the PEACH™ RCT intervention were informed by feedback from RCT participants (Table 1). A key modification was to weave parenting skills relevant to promoting healthy lifestyle behaviours through the healthy lifestyle sessions, rather than deliver the generic parenting programme as an initial stand-alone component. For example, the generic parenting programme included in the RCT had a

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Table 1 e Summary of modifications made to programme content and delivery format of the PEACH™ programme when translated from an RCT to a CHP. Programme segment Parent Sessions

Healthy lifestyle information (dietary and activity behaviour recommendations) Parent follow-up phone calls Length of contact with parents (no change) Parent handbook

PEACH™ RCT

PEACH™ in the Community

Four weekly parenting sessions þ eight healthy lifestyle (HL) or eight HL only HL held fortnightly (5) then monthly (3) Unchanged

10 face-to-face fortnightly healthy lifestyle sessions incorporating parenting skills

Three individual phone calls held monthly between the last three sessions 6 months

Three individual phone calls conducted after completion of the parent sessions 6 months

Photocopied A4 booklet

96 page spiral bound colour book

CHP, community health programme; RCT, randomised control trial.

focus on managing problem behaviour and as such, included strategies such as ‘Time Out’. Parents found such strategies irrelevant to promoting healthy lifestyle behaviours, so they were removed and instead strategies such as establishing expectations, setting rules and rewarding desirable behaviour remained. There were no changes to the content with respect to dietary and activity behaviours. The PEACH™ Facilitator Manual and PEACH™ Parent Workbook were modified in line with content and sequencing changes. A graphic designer produced a more commercial looking PEACH™ Parent Workbook which was piloted with paediatric dietitians prior to professional colour printing (ISBN 9780730897798).15 A free two-day facilitator training course was developed to provide trainees with the knowledge, skills and confidence to implement and evaluate PEACH™ IC. Trainees were provided with training and resources regarding preprogramme and postprogramme data collection, session delivery and record keeping to maximise programme fidelity and evaluation. A communications plan and password-protected website portal were developed to permit information sharing and support between university staff, facilitators, families and funders. The website provided mechanisms for practitioner registration for training, family referral into PEACH™ IC and access to university project staff by facilitators at all stages of programme implementation.

Study and evaluation framework design This programme utilised a pre-post study design incorporating the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) evaluation framework. The RE-AIM framework16 was selected to report evaluation of the translation of the PEACH™ programme, as it has been used widely to a) evaluate effectiveness of general health behaviour interventions,17 b) enable and assess the impact of dissemination efforts18 and c) guide the reporting of research team activities to enhance both programme implementation and evaluation.19 RE-AIM is an acronym for reach (individual-level measure of patient participation and representativeness), effectiveness (programme success at an individual level), adoption (programme acceptance/uptake at organisational level),

implementation (programme fidelity to the original RCT intervention, measured at organisational level) and maintenance (long term effects at individual and organisational level).16 Table 2 briefly defines RE-AIM framework components and associated data collected in the PEACH™ IC trial.

PEACH™ IC trial delivery Promotion of facilitator training workshops commenced in April 2009 via professional networks. At that time, workshops were available only to health or education professionals employed by the South Australian government and from a workplace that would potentially support implementation of PEACH™ e.g. dietetic departments in public hospitals, or community health centres in metropolitan and regional South Australia. These eligibility limitations made it difficult to recruit sufficient numbers to achieve a critical mass at training workshops for effective group processes. Therefore in mid2010 training was made available to newly graduated dietitians, interstate dietitians and other health or education professionals interested in professional development in the area of family-focussed child weight management. These trainees were recruited via organisational and professional body communication channels and word of mouth. Although not essential, a working knowledge of the Australian Dietary Guidelines and prior experience working with children and running groups were considered desirable. The workshop format modelled the PEACH™ problem solving approach to management, using a combination of information sharing and role-modelling of PEACH™ activities and role-playing activities. All participants received a PEACH™ Facilitator Manual. Facilitators completed pretraining and post-training questionnaires and a third questionnaire following programme delivery. Trainees who had not implemented the programme within 6 months of training completed an alternative third questionnaire exploring reasons behind poor implementation rates. Recruitment of families and data collection were a facilitator responsibility (including parent consent and child assent) using university provided materials (Table 2). Deidentified data were returned to university staff for data entry and analysis including assessment of BMI and WC z-score change from baseline to programme end.

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Table 2 e Dimensions of the RE-AIM framework, their definition17 and relevant evaluation data collected for the PEACH™ IC trial. RE-AIM dimension definition17 Reach: proportion of the target population that participated in the intervention Efficacy/Effectiveness: success rate if implemented as in guidelines; defined as positive outcomes minus negative outcomes

Adoption: proportion of settings, practices, and plans that will adopt this intervention Implementation: extent to which the intervention is implemented as intended in the real world Maintenance: extent to which a programme is sustained over time

Level (source) of data

Data collected

Tool used

Administrator

Individual (Family)

No. families enrolled Family demographics

Purpose-developed database Questionnaire

Data collected by facilitators and managed by the research team

Individual (Facilitator)

Changes in knowledge, skills and confidence (0e6 m) Satisfaction with programme resources

Data collected and managed by the research team Change assessed using Chi-squared test

Individual (Family)

Child measures (anthropometrics, parentreported diet and activity behaviours) Unintended negative consequences (child-reported body size satisfaction) Attendance rates Satisfaction with programme and materials No. facilitators trained Demographics (facilitators and services) No. health services/other organisations engaged No. facilitators who delivered groups and how many Adherence to programme protocol and session outlines

Self-rated on a Likert scale for the practice areas of familyfocussed weight management, lifestyle support and behaviour modification Purpose-developed questionnaire Measured weight, height and waist circumference Children's Dietary Questionnaire31 Children's Body Image Scale22 Purpose-developed database Purpose-developed questionnaire

Purpose-developed database and questionnaire

Data collected and managed by the research team

Purpose-developed database Purpose-developed questionnaire and session monitoring forms

Data collected and managed by the research team

Unable to be measured due to discontinuation of funding

Unable to be measured due to discontinuation of funding

Organisation (Facilitator)

Organisation (Facilitator)

Organization (Facilitator) Individual (Family)

Workforce capacity change Funding committed Long-term family impact

Results Selected data are presented according to the domains of the RE-AIM framework.

Reach Families only The potential beneficiaries of participating in the PEACH™ programme were families with an overweight primary-school aged child, living in an area where the programme was provided. As these were across the metropolitan area approximately 20% of families with a child in the age range were eligible. Overall, 62 families and 78 children enrolled in the programme, across eight different groups in metropolitan Adelaide, South Australia. At baseline anthropometric and behaviour data were available for 69 children, 59 of whom were classified as overweight.20 The majority of families (n ¼ 54e61) provided demographic data. Nine families indicated that care of child(ren) was split between mother and father and 25 reported receiving a government pension or

Data collected by facilitators and managed by research team Change assessed using paired ttest (anthropometric measures) and Wilcoxon signed-ranked test (dietary questionnaire)

benefit. Nineteen of 56 respondents were university educated and eight reported a family income of greater than $100,000 pa. The majority of parents were born in Australia (52/59) and 5/59 identified themselves as Aboriginal or Torres Strait Islander. A majority (53/56) indicated that people in the home were supportive of PEACH™.

Effectiveness Facilitators Trainees ranked their pretraining and post-training levels of knowledge, skills and confidence in three key areas of child weight management (1. family-focussed weight management, 2. lifestyle support, 3. behaviour modification) (Fig. 1). There were increases in the proportion of respondents self-rating themselves as moderately high/high in all areas, and these increases were significant for confidence (1. P ¼ 0.02, 2. P ¼ 0.02, 3. P ¼ 0.03, Fig. 1).

Families Due to several issues of compliance with data collection protocol, usable outcome data were available for 47/69 children

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70 60 50 40 30 20 10 0

* *

*

Family focussed weight management

Lifestyle support

Pre-training

Confidence

Skills

Knowledge

Confidence

Skills

Knowledge

Confidence

Skills

Knowledge

Post-training

Behaviour modificaƟon

Fig. 1 e Number of workshop participants rating their knowledge, skills and confidence in each of the three areas as high or medium-high pretraining and post-training (n ¼ 54). *Denotes a statistically significant improvement in pretraining and post-training scores (P < 0.05).

who provided baseline data. Presented data are from 37 of these 47 children who were overweight, the primary target of this programme, at baseline. Overweight children for whom follow-up data were not available (n ¼ 22) compared with

those providing follow-up data were similar in age (8.5 years vs 8.6 years) and sex (1/22  3/37 male) but more likely to be obese (19/22 vs 26/37). Data in Table 3 demonstrate a 0.17 (95% confidence interval [CI]: 0.03:0.30) decrease in BMIz from baseline to programme end (P ¼ 0.016) and a 0.14 (95% CI: 0.02:0.30) decrease in WCz (P ¼ 0.09). These reductions are less than those reported in the PEACH™ RCT.5 Baseline and follow-up food and activity behaviour data were available for a maximum of 33 children. There were significant improvements in three of the five Children's Dietary Questionnaire21 scores (fruit and vegetable intake, extras intake and food behaviours, all P < 0.001). There was a significant reduction in small screen time, and a significant increase in activity score. Although there were increases in the numbers achieving the target scores for both food and activity behaviours, there remained considerable room for improvement (Table 3). The Children's Body Image Scale assessed changes in body image for children aged more than 5 years at baseline.22 Of the 34 overweight children of this age, 16 exhibited a decrease in body dissatisfaction at 6 months compared with baseline, for 13 there was no change and for five

Table 3 e Outcome data for the sample of children who were overweight at baseline (n ¼ 37) and for whom complete data were available at follow-up (n values differ by variable). Variable

Baseline

Anthropometry (n ¼ 37) Sex Age (years) Height z-scorea Weight z-scorea BMIza WCza Weight categoryb Food behaviours

Recommended scorec

Fruit and vegetables (n ¼ 31)

16

Sweetened beverages (n ¼ 32)

<1

Fat in dairy products (n ¼ 24)

<0.28

Extra foods (discretionary) (n ¼ 31)

2

Food-related behaviours (n ¼ 32)

30

Activity behaviours

Recommended score

Total small screen timed (n ¼ 33)

<4

Activity scoree (n ¼ 33)

28

20 male 8.6 (1.8) 0.88 (1.19) 2.47 (0.84) 2.75 (0.74) 3.20 (0.72) 0/11/26

6 months

9.2 (1.9) 1.09 (1.16) 2.42 (0.83) 2.58 (0.72) 3.06 (0.76) 1/13/23

Median (IQR) Number meeting recommendation 12.9 (9.9:14.6) 14.3 (12.4:18.3)** 1 12 0.8 (0:1.4) 0.1 (0.0:1.1) 17 20 2.2 (1.3:3.0) 1.4 (1.0:3.3) 3 5 2.7 (1.1:3.4) 1.1 (0.7:1.9)** 25 11 24 (19:27) 29 (24:31)** 4 13 Median (IQR) Number meeting recommendation 7.0 (6.1:8.4) 6.0 (5.4:7.1)** 1 0 27 (23:32) 32 (29:34)** 26 13

BMIz, body mass index z-score; WCz, waist circumference z-score. *P < 0.05 for comparison with baseline. **P  0.001 for comparison between baseline and 6 months (Wilcoxon signed-rank test). a Based on UK reference data calculated using the LMSgrowth add-in in Excel.39,40 b Based on international obesity taskforce cut-points20 and presented as acceptable/overweight/obese. c Target recommended scores based on dietary guidelines and described elsewhere.23 d A score of 3 is an approximation between one and 2 h per day. e Recommended activity score was determined as use of walking and or cycling to and from school 3e4 times per week, spending recess and lunchtime running around playing sports and games three or more times a week, and being active 2e3 times per week in three different ways e.g. organised sporting activities, out of school hours care, etc.

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children there was an increase (four by one point only and one by three points). Participant attendance and withdrawal data were available for only two groups (n ¼ 28 families). Parents attended an average of 7/10 sessions. Reasons for withdrawing, provided by 4/5 families, were custody issues, parent started a new job, travel issues and child too young. Overall, participants were satisfied with the programme, with 38 and 37 parents assigning ‘programme quality’ and ‘satisfaction with help received’ a score of at least five on a 7point Likert scale (n ¼ 38 responders) In addition, 36 responders indicated ‘yes’ when asked if PEACH™ ‘provided the help they were wanting’, ‘helped to change their parenting style’ and ‘helped to make positive changes to their child's eating and activity behaviors’. Thirty-seven parents would recommend the programme to others. Lack of time, work and family commitments were the three most common reasons given for not implementing the PEACH™ IC materials at home (reported by 15, 13 and 11 of 37 respondents, respectively). Similar factors were identified as limiting attendance at sessions. These were all cited as major barriers to implementation and attendance in the RCT.23 Parents reported having made many different changes to their family's eating and activity behaviours, such as:  ‘Try to include more vegetarian in main mealsdeven if hidden. Switched to wholemeal/brown breads, low fat milk and multigrain/low fat crispbreads for biscuits. As a family we try to do more activities’.  ‘We are eating meals together at the table except weekends. Only minimum television time allowed, encouraged to play outside more. Being aware of serving portions’.

Adoption Facilitators Between April 2009 and October 2011, eight training workshops were delivered to 54 participants (47 female, 30 worked full-time). Forty worked in metropolitan Adelaide and 10 were from four states and territories outside South Australia. Due to the untargeted nature of facilitator recruitment, it was not possible to undertake a setting-level assessment of facilitator adoption of the programme. While professionals from many disciplines were represented (e.g. social worker, nurse, psychologist and personal trainer), 35 were dietitians and 11 were primary healthcare workers. Twenty-two attendees had graduated from their tertiary course in the last 3 years and 14 had graduated more than 10 years previously. Thirty-five attendees had less than 3 years' experience in child weight management.

Implementation Facilitators Of the 54 trained facilitators, 11 delivered PEACH™ IC to six groups which commenced with eight or less families. A twelfth facilitator (J.H.) was a Flinders University employee and had undertaken PEACH™ programme training prior to this project. She delivered two groups: n ¼ 13 and 15 families. Reasons for 43 facilitators not implementing the programme

159

were workplace related (e.g. weight management not in job description, programme not supported by management) or personal (e.g. maternity leave, left position). Facilitator satisfaction with the programme resources, parent resources and support provided by the university was high, with eight, eight and nine of the 11 trained facilitators respectively being satisfied or very satisfied with these aspects. Facilitators reported some difficulties with the programme, including recruitment of participants, taking measurements and completing/collecting data. In response to an open-ended question, 6/11 facilitators reported the parenting approach as a PEACH™ strength and seven facilitators reported the family focus as a strength.

Maintenance Funding for PEACH™ IC was for a 3-year period from late 2008. It was predicted that programme maintenance would be assessed during that period, however less than anticipated adoption and implementation of the programme (specifically poor facilitator recruitment, workplace support and recruitment of families) prevented this. In addition, significant restructuring of the South Australian health department in 2012 resulted in cessation of funding to many primary healthcare programmes, including PEACH™ IC.24 This prevented collection of long-term maintenance data beyond the life of PEACH™ IC. Strategies to overcome this in future efforts are suggested below.

Discussion To the authors' knowledge, this is one of only two papers to report on the experiences of translating a child weight management intervention from the research setting to practice25 and the first to apply the RE-AIM framework. The funding for this project commenced in 2008 and at the time the researchers were guided by the reporting requirements of the funding body. Following the decision to publish our findings, a thorough search of the literature resulted in the selection of the RE-AIM framework as a suitable reporting framework. As such, the constructs of the RE-AIM framework were not taken into consideration at the time of designing and implementing the project. Future activities regarding the translation of the PEACH™ programme will define dissemination goals prior to project design and implementation. Given the emerging phase of this type of work, reporting of such experiences is crucial. As asserted by Serrano et al., nutrition educators and researchers have a unique skill set and work in settings that provide opportunities for translating effective research findings into programmes with wider reach.26 In doing so, the current gap between the evidencebase informing practice and the delivery of child weight management services may be reduced. The translation of PEACH™ provides workforce development for dietitians and other health workers and increases accessibility to a child weight management programme for families. Surveys conducted with dietitians have found that many feel ill-prepared to manage obese clients, particularly children.10 Our findings show PEACH™ IC was effective in

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increasing practitioner knowledge, skills and confidence and important aspects of workforce development in the area of best practice of child weight management. Despite the less than anticipated uptake, the programme resulted in positive effects, particularly changes in children's dietary and activity behaviours. Changes in these outcomes are easier to detect in the short term and arguably if a longer follow-up period was possible there may have been a greater change in anthropometric outcomes. Importantly, as for the original RCT, no harm was caused by the programme in terms of children's perceptions of their body size. The limited reach, adoption and implementation of PEACH™ IC are disappointing as the potential appeared great. The State Health Department upper management support and ‘priority health programme’ status, allowed health services to access funding for staff training and programme implementation. However, the ‘priority health programme’ initiative was revoked as part of a broader State Health Department restructure and change management process. This shift in the political landscape was not anticipated. Such possibilities and their impact on the translation potential of programmes must be recognised by both health researchers and practitioners. Lang and Rayner argue that public health advocacy ‘requires a political savvy not reflected in the mantras of evidence-based policy’,27 suggesting that public health researchers need skills to align evidence-based programmes with policy to avoid the fate experienced by PEACH™ IC. A stronger advocacy approach that ensures funders a fully appreciated programme value and benefits and thus commits to continued funding is recommended. This could be achieved via opportunistic ‘voluntary’ progress reports, testimonials from participants and the sharing of unintended benefits of the programme. Researchers should consider utilising professionals such as knowledge brokers to assist with strategising, performing risk assessments, building effective partnerships, managing the political landscape and taking a business-minded approach to implementing evidence.28 The limited programme implementation by facilitators may be explained also by additional logistical and administrative factors. For example, a significant paradigm shift was required of facilitators regarding their approach to child weight management from one-to-one counselling, often directed to the overweight child, to the PEACH™ approach and best practice guidelines that recommend a family-centred approach that targets parents as the primary agents of change.3 Furthermore, individual practitioners working within an organisation require support at the workplace level to change practice. In hindsight, despite securing uppermanagement support, there was insufficient middlemanagement support for the implementation of the PEACH™ approach at the health service sites targeted. To improve programme fit we recommend assessment of worksites' readiness to change and willingness to adopt a new approach to service delivery.29 In retrospect, focussing our activities in geographically/structurally defined areas rather than making the programme available state-wide may have delivered a concentrated programme ‘dose’. Health workers trained as programme facilitators had difficulty recruiting enough families to provide a viable group size that allowed for absentees (six of eight groups

commenced with less than eight families). Greater investment in engaging with families prior to programme commencement may support improved attendance30 and efforts are required to increase the flexibility of programme delivery31 to maximise retention, e.g. offering sessions out of business hours and trialing the online delivery of programmes. Securing adequate numbers was dependent on ‘active recruitment’ via promotional activities through schools and local media. This was in contrast to the normal practice of ‘passive referral’ and required a change to practice that was not sufficiently adopted. Ideally a marketing and communications officer would be responsible for this activity and such positions may need to be budgeted for in future programmes. Furthermore resources such as those offered on the recently established Centres for Disease Control and Prevention ‘Gateway to Health Communication and Social Marketing Practice’ website should be promoted and their use encouraged.32 The requirement of facilitators to collect evaluation data conflicted with the ‘service delivery’ focus of many community-based health services, as reported by facilitators. Reliance on health workers to collect measurements contributed to a high rate of missing or unusable data contributing to the 37% of missing data at follow-up and overall small sample size. While the small sample was less than desired, the within person design permits P-values <0.05 to be interpreted with confidence. Despite this, findings are not generalisable and the assessment of overall effectiveness is limited. We acknowledge that practitioners do not have the flexibility or time to undertake the activities associated with conducting an RCT, e.g. recruit participants, collect data, deliver programmes at flexible times and make numerous follow-up phone calls (following study protocol). This compromises the ability to implement translation research evaluation plans. A number of strategies were available to support facilitators (e.g. email and website portal to enable debrief communication between university staff and other facilitators; online and hard copy session summary template to support reflective practice), however these were rarely used. Future iterations of the PEACH™ program need to promote these strategies in order to maximise data collection for evaluation purposes. In the real-life application of PEACH™ IC, families were permitted to enrol in the programme without meeting the strict inclusion criteria of the RCT, e.g. healthy weight children could enrol. Parents in this situation had identified that while their child was not presently overweight, there was a strong future likelihood of this due to behavioural, environmental and genetic risks.33 This relaxation of inclusion criteria demonstrates the flexibility required when transitioning from efficacy to effectiveness trials.11 Similarly at the point of service-delivery, some facilitators adapted certain aspects of PEACH™ to better suit their organisation/audience. It is crucial that researchers recognise that programme adaption (e.g. content or session frequency) by service providers is inevitable.11 It is highly recommended that researchers determine any ‘non-negotiables’ (e.g. programme duration) and importantly have a process for monitoring changes to ensure maintenance of

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programme fidelity.34 For PEACH™ these are facilitator led, minimum of 6 months contact with families, recognition of parents as the focus of the programme and their parenting role as crucial to its effectiveness, acknowledgement of the environmental context of lifestyle behaviours (permitting the removal of weight and age-based inclusion criteria applied in the RCT5), and where possible, a minimum starting group size of 10. As mentioned, meaningful changes in anthropometric outcomes and adoption at an organisational level require time. This is difficult in the defined funding periods within which most health promotion programs operate. Ideally ongoing revenue generation would sustain the process of translation until adoption and long-term implementation of the desired practice is achieved. Such challenges have been experienced by numerous programs targeting other public health issues, described elsewhere.18 Translational research needs to develop ways to effectively and efficiently bridge the research to practice gap and improve the adoption of evidence-based child weight management practices. As stated by Brownson and Jones, ‘effective academic-practice-policy maker partnerships (are) the most effective strategies to bridge (this) gap,’35 and we aim to continue working to achieve this. Agencies such as the Canadian Institutes of Health Research36 and the more recent Australian Government's National Health and Medical Research Council Research Translation Faculty37 have the potential to assist with the development of such partnerships. In 2008, the National Partnership Agreement on Preventive Health was announced by the federal Australian government to provide funds to the states and territories to deliver a range of population-based health initiatives. Under this agreement, delivery of PEACH™ throughout the Australian state of Queensland commenced in 2013. Following a change of federal government, this funding was withdrawn in 2014, however the Queensland government assumed full responsibility for the delivery of PEACH™ to up to 1400 children by end-2016. Ongoing delivery of the programme at this stage relies on the continuation of this funding so lessons learnt from the PEACH™ IC trial are now being applied to this next iteration of PEACH™. Given the increasing awareness of translational research amongst health funders and policy makers38 and increased need due to dwindling health budgets and escalating burden of chronic diseases, nutrition educators and researchers have the opportunity to advance nutrition-focussed translational research. It is hoped the learnings reported in this paper can be applied to future efforts in the PEACH™ translational journey.

Author statements Ethical approval The ethical approvals for this study were obtained from four committees; Flinders University Social and Behavioural Ethics Committee (SBREC), Children, Youth and Women's Health Service Human Research Ethics Committee (CYWHS HREC), South Australian Department of Health Human Research

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Ethics Committee (DoH HREC) and the Central Northern Adelaide Health Service Ethics of Human Research Committee (CNAHS EHREC).

Funding The funding was provided by SA Health (2008e2011) to implement the PEACH™ program in a practice setting, with additional support (2008) from the Mazda Foundation (via Flinders Foundation).

Competing interests None declared.

Author contributions R.A.P. led the modification of the PEACH™ RCT intervention to the PEACH™ IC trial with input from A.M.M. and R.K.G. J.H. delivered the PEACH™ IC facilitator training and co-ordinated the PEACH™ IC translation process. A.M.M. oversaw the PEACH™ IC translation project with input to the evaluation plan and data collection tools by R.K.G. All authors were involved in writing the paper and had final approval of the submitted and published versions.

references

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