Early Childhood Education and Care (ECEC) settings are important food environments in high-income countries, given high attendance rates(1–Reference Wasser, Thompson and Siega-Riz3), long hours of attendance and substantial contributions to a child’s daily nutritional intake(Reference Benjamin-Neelon4). In Australia, approximately 860 000 children attend ECEC, for an average of 31 h per week – similar to other high-income countries(1,2) . To meet nutritional needs, it is recommended that children receive 50–67 % of their daily dietary intake when attending a full day in ECEC(Reference Benjamin-Neelon4) equating to about half a tonne of food/day in Australia.
Food is important for both human health and planetary health(Reference Willett, Rockström and Loken5). The WHO and FAO of the UN have created guiding principles for diets that are both healthy and sustainable(6). The Sustainable Development Goals include recommendations for the halving of food waste by 2030, as one component of more sustainable diets(7). Given the large volumes of food procured, prepared and served in ECEC settings, there is potential to influence both human and planetary health at scale through adoption of some of the strategies set out by these guiding principles and recommendations(Reference Willett, Rockström and Loken5). In Australia, current national guidelines(8) provide support and guidance to ECEC services on planning and preparing healthy meals in line with current nutrition guidelines. These guidelines, however, do not include a focus on procurement and preparation of more environmentally sustainable foods, nor a focus on food waste reduction/management.
There is limited research on sustainability of ECEC food provision, with studies suggesting that approximately 30 % of food prepared in ECEC is wasted(Reference Silvennoinen, Nisonen and Pietiläinen9,Reference Nicklas, Liu and Stuff10) equating to about 168 000 kg food waste/day in Australia. Our research in Victoria, Australia, explored sustainable healthy food provision and food costs in ECEC centres with a purpose-developed survey based on the FAO Sustainable Healthy Diets guiding principles(6) and weighed food waste audits(Reference Elford, Spence and Wakem11). Surveys reported that centres did not regularly engage in practices such as purchasing foods with less packaging or food waste management strategies such as composting. Survey responses also indicated that previous food waste audits lead to changes in food waste management practices, such as menu changes or adding a compost bin. Less than half (43 %) of staff responsible for preparing food had received any training in nutrition, and centres were operating on low food budgets, with average food costs/child/day being AUD3.80, and 27 % of centres having budgets of ≤ $2·50/child/day(Reference Elford, Spence and Wakem11). Weighed food waste audits found that centres that had previously conducted food waste audits had lower plate waste, indicating a level of awareness of food waste in their centre(Reference Elford, Spence and Wakem11). Research in other countries in ECEC, school and university settings also report an association between food waste awareness and significantly lower food waste, with food services changing their practices based on food waste audit outcomes(Reference Elford, Spence and Wakem11–Reference Malefors, Sundin and Tromp13). This suggests that food waste awareness activities (e.g. a food waste audit) could be an effective strategy to catalyse a change in practice leading to reduced food waste; however, the practicalities of undertaking such activities in the ECEC setting require further research. Furthermore, research suggests that strategies to improve sustainable healthy food provision practices should take food costs into consideration(Reference Elford, Spence and Wakem11).
Given the current absence of ECEC-specific guidance for food provision that considers both human and planetary health, and our previous research in Victoria that described low levels of nutrition training in ECEC staff (therefore low knowledge), low food waste awareness, and low food budgets, there is a need to develop feasible strategies to support ECEC staff towards sustainable, healthy and affordable food provision. To enable practical and feasible support strategy development, a co-design process was chosen to support stakeholders to collaboratively participate in the development of solutions(Reference Slattery, Saeri and Bragge14). This method has the potential to reduce misalignment between researcher aims and end user needs through deeper understanding of the requirements for the end user by the end user(Reference Slattery, Saeri and Bragge14). The aim of this study was therefore to co-design support strategies to enable sustainable, healthy and affordable food provision in the ECEC setting.
Methods
Sustainable healthy food provision in Early Childhood Education and Care
In the absence of ECEC-specific guidance for sustainable healthy food provision, this study utilised the FAO Sustainable Healthy Diets guiding principles to inform interview and focus group questions and solution development(6). Table 1 outlines the Sustainable Healthy Diets guiding principles that are transferrable to food provision in the ECEC setting.
Sustainable Healthy Diets guiding principles(6) transferrable to ECEC food provision
ECEC, Early Childhood Education and Care.
*Guideline 1 was not included in this research which focused on children aged 2–5 years. The green-shaded guidelines are considered transferrable to guide food provision in ECEC. Guideline 7 is covered by country or state ECEC-specific guidelines which are developed to reduce risk of diet-related disease. Guidelines 9–11 relate to agricultural practices. Guideline 16 refers to gender impacts of food, unrelated to food provision in ECEC.
Theoretical underpinnings
This study was underpinned by co-design, a method of developing solutions with the end users in mind, described as a research design that brings stakeholders together to participate collaboratively in policy and service design(15). Our study applied co-design between (i) the research team (research nutritionists and dietitians); (ii) ECEC centre staff (cooks, educators and directors) and (iii) the Healthy Eating Advisory Service (HEAS), a Victorian Government-funded programme delivered by Nutrition Australia.
The IDEAS framework is a co-design process for the design of online/digital health behaviour interventions(Reference Mummah, Robinson and King16). This framework was selected due to the embedding of behaviour change theory, indicated as an important factor in intervention design(Reference Wolfenden, Barnes and Jones17). Second, it was chosen as we aimed to co-design strategies based on end user feedback that could be disseminated in a scalable manner through online/digital means. The framework comprises ten phases (empathise, specify, ground, ideate, prototype, gather, build, pilot, evaluate and share), grouped into four overarching stages (Integrate, Design, Assess and Share)(Reference Mummah, Robinson and King16). Our study focused on the first two overarching stages of ‘Integrate’ and ‘Design’ in line with our aims to co-design support strategies.
The Theoretical Domains Framework (TDF) was used to inform interview question development and data analysis as a theory-informed approach(Reference French, Green and O’Connor18) to understanding barriers and facilitators to behaviour change and identification of appropriate intervention strategies(Reference Cane, O’Connor and Michie19). The TDF comprises fourteen domains, namely, knowledge, skills, professional role, beliefs about consequences, memory/attention/decision, goals, optimism, intentions, social influences, beliefs about capabilities, emotions, reinforcement, behavioural regulation (self-monitoring/action planning) and environmental context. See online supplementary material, Supplemental file 1, for application of the TDF in this study.
Recruitment and consent
This study built on our previous research and included the same consenting participants (reported in detail elsewhere(Reference Elford, Spence and Wakem11)). All centre-based ECEC centres in the state of Victoria, Australia, were invited via publicly listed email(20) to participate in the research. Written consent was given via email to participate in Phase 1 only (surveys), or Phase I and Phase II (surveys, weighed food served and wasted audits, interviews and focus groups). Centre directors distributed survey links to relevant staff, who provided individual consent prior to participating in surveys, interviews and/or focus groups. The quantitative results (surveys and audits) are reported elsewhere(Reference Elford, Spence and Wakem11). This study reports on interview and focus group results. Eligible centres operated at least 8 h per d, 48 weeks per annum, and prepared and served food onsite. Purposive sampling occurred for Phase II to capture varied locations (metropolitan/regional), centre management type (for-profit/not-for-profit) and socio-economic position of centre (low, medium and high). In addition to written consent, verbal consent was obtained at the commencement of each interview and focus group. The programme director of Nutrition Australia’s HEAS, a public health Dietitian with extensive experience in supporting and leading support programmes to ECEC in various locations and from various demographics, was invited to participate in the co-design and provided verbal consent.
Data collection
Data collection comprised interviews, workshops and focus groups. Figure 1 outlines the data collection points and how they relate to each phase of the IDEAS framework. To promote participation from diverse geographical areas, data collection was conducted via the teleconference platform Zoom™. Videoconferencing as a data collection method in interviewing has gained popularity due to practical reasons and has been found to be a viable approach due to its ability to pick up on both verbal and non-verbal cues(Reference Archibald, Ambagtsheer and Casey21,Reference Irani22) . It has also been successfully used in the facilitation of focus groups, provided the practicalities are well managed(Reference Greenspan, Gordon and Whitcomb23).
The IDEAS framework and data collection related to each phase. The IDEAS framework(Reference Mummah, Robinson and King16) stages are in the first line, the phases in the second line and corresponding data collection in the third line. TDF was used as a theory approach(Reference Cane, O’Connor and Michie19). *The participants in this co-design previously participated in surveys and audits that was reported in another study(Reference Elford, Spence and Wakem11). Findings from that study formed a basis of the first steps of this co-design. TDF, Theoretical Domains Framework.
Interviews (Early Childhood Education and Care staff)
Online supplementary material, Supplemental file 2, outlines the semi-structured interview guide, which focused on perceptions of sustainable healthy food provision practices and barriers/enablers to such practices. Information on participant role in the ECEC centre, length of time in the role and highest educational attainment was obtained during the interview. Interviews were recorded and transcribed.
Workshops (Nutrition Australia)
Nine workshops with the programme director of Nutrition Australia’s HEAS and the researchers were held at 3-weekly intervals during interview and focus group data collection and analysis. The workshops aimed (i) to understand and interpret current needs and suggested support outlined by interviews with centre staff, (ii) to adjust interview questions where needed to explore emerging patterns and (iii) to workshop practical support strategies to feed back to centre staff via subsequent interviews and focus groups. Nutrition Australia offered their perspective as both a user of the research and as a co-investigator through providing real-world insights from, and application, to all users. For example, emerging patterns were considered from a logistics/location perspective to determine a more scalable and accessible approach, which was fed back to centre staff and refined through further interviews and focus groups.
Focus groups (Early Childhood Education and Care staff)
Focus groups further explored themes constructed from interviews and workshops to develop feasible support strategies. Discussion included confirmation of themes and solutions to ensure all participants felt that what they had said in interviews were understood. It then focused on solutions and further refining of support strategies. Preparation for the focus groups included a detailed time management plan and visual slides at the start of the focus group outlining the aims and structure of the focus group. Each focus group had a facilitator with the role of active engagement and encouragement of participants, and a note taker, adding verbal feedback iteratively to Padlet, an online programme allowing all participants to share content through a visual bulletin board(24). This ensured participants could see the discussion being visually recorded in real time, providing an opportunity to interact verbally and/or directly onto the bulletin board. Throughout the focus group, the facilitator checked with all participants to ensure the solutions were acceptable and practical and accurately addressing their needs. Focus groups were recorded for reference if needed but were not transcribed, as refined strategies were displayed and clarified in real time using annotation on Padlet.
Data analysis
Interview and workshop data were transcribed using NVivo transcription software(25) and cross-checked by AE for accuracy of transcription. Themes were coded using inductively (not using the TDF framework) and then deductively (using the TDF framework). PL checked 10 % of coding for agreement, with any differences discussed in a subsequent meeting with the research team (AE, PL, AS and KC). Interview quotes and coding/themes were discussed by the research team and Nutrition Australia (AE, PL, AS, KC and MR) during workshops to identify strategies to take to subsequent interviews and the focus groups for refining. Workshop discussions with Nutrition Australia were iterative to ensure that the final ‘prototype’ resources were not the result of only highly engaged centres but would be practical, with minimum cost and low burden, for centres to adopt. Strategies identified in the interviews and workshop discussions were taken to the focus groups for further refinement resulting in development of ‘prototype’ resources.
Results
Due to the iterative nature of the co-design process, with themes from interviews discussed in focus groups and workshops and strategy development evolving over time, all results are presented together using the IDEAS framework.
Participant characteristics
Seventeen ECEC staff from twelve centres participated in interviews and eight ECEC staff from five centres participated across two focus groups. Table 2 outlines the individual and centre characteristics of interview and focus group participants, purposively sampled to ensure that co-designed strategies have had input from representatives across different centre locations, management types and socio-economic position. Centres who participated in interviews (n 12) were mostly ‘for-profit’ (n 8) and medium socio-economic status (n 7). Regional and metropolitan centres were represented equally (n 6 each). For those who continued to the focus groups (n 8 staff from n 5 centres), most operated as ‘for-profit’ (n 3), were in metropolitan areas (n 3) and medium SEIFA (n 4). There is currently no publicly available data in Australia regarding the number of ECEC centres with onsite food provision; therefore, it is not possible to make comparisons of participating centres to nationally representative data. Whilst generalisability cannot be reported here, input for this co-design included all centre types, locations and socio-economic statuses.
Interview and focus group participant characteristics
* Centre socio-economic position was determined by the relative disadvantage in the area using the Socioeconomic Economic Indexes for Areas (SEIFA)(40), based on centre postcode.
Stage 1: Integrate
This part of the co-design related to phases 1–3 of the IDEAS framework (empathise, specify target behaviour and ground in behaviour theory). During the phase of empathise, the Nutrition Australia Representative did not provide much input but rather listened to understand and empathise from the ECEC staff’s perspectives. As interviews and workshops occurred iteratively, themes are discussed as they appeared with interview and workshop themes presented together. Detailed descriptions and coding can be found in online supplementary material, Supplemental File 3.
The main themes, coded to the TDF were as follows:
1. Knowledge and awareness: There was a lack of knowledge and awareness of what sustainable healthy food provision entails.
2. Skills and role: For sustainable healthy food provision to take place, cooks and educators would need to have the appropriate skills, and these practices would need to be made part of their role.
3. Environmental context: Successful implementation of environmental sustainability practices needs to be part of the ECEC centre culture and communication. An important part of this culture was the involvement of children.
Knowledge and awareness
During the interviews, all participants indicated some understanding of what is involved in healthy food provision, but most were unsure about the meaning of sustainable healthy food provision. These participants perceived that they would need more information and resources on the topic.
Director_centre_7: ‘We need some more information on the sustainability [of food provision], so we have a clear idea of what this is’.
Being aware of food waste was considered to be important, as it may influence decision-making processes.
Cook_centre_8 ‘So it made me realize that often we’re serving too much food. I guess because I was doing this [food waste audit]. So, I did learn something from it. I don’t need to give them as much’.
These findings confirm quantitative research reported in the same centres elsewhere(Reference Elford, Spence and Wakem11) which found lower food waste in centres who had previously conducted a food waste audit and were therefore more aware of their food waste. NA’s scalability and feasibility lens to this information suggested a focus on low-intensity solutions as a starting point.
Nutrition Australia Representative: ‘We need to help centres identify a feasible starting point. Not just overload them with things they could do such that they end up enacting none’.
Skills and role
Participants discussed the need to have the skills to plan, prepare, purchase and serve sustainable healthy food, which was also considered to be cost-saving.
Director_centre_4: ‘by being more considerate and cautious about what you are purchasing, you’re not necessarily buying excess therefore saving money’.
For ECEC cooks, a key factor was purchasing the right foods and the right amounts of these foods. After purchasing, and on the day of preparation, it was perceived that there was a need to be responsive to attendance numbers and cooking accordingly, especially with regard to food waste.
Cook_centre_8: We are quite responsive because we cook on the day. We see the numbers by nine o’ clock, and then we cook accordingly’.
Previous quantitative research on the same centres found less than 50 % of staff who prepare and plan meals had any training in nutrition(Reference Elford, Spence and Wakem11) which suggests that training/education to enable skills is needed.
Role modelling (sitting with the children at mealtimes and encouraging repeated exposure to food options) was considered by a key ECEC educator role, with this being perceived as leading to reduced food waste by increasing acceptance of healthy sustainable foods.
Director_centre_1: ‘And if there is an educator who doesn’t like the fish, you know, its guaranteed that that meal won’t get eaten as much as what it should be ate, and that’s influencing the children’.
Cook_centre_11: Oh, absolutely. I know straight off the top of my head [why we sometimes have less food waste and sometimes more]. It’s the staff in the room – so sometimes you get staff that are willing to take their time with the children and assist them. On those days we have less waste’.
Educator Centre 3: ‘Even though we make healthy food, kids don’t like it every time. So, we need to encourage them at every time. For example, yeah, the chickpea curry, they didn’t like it the first time, but now they love it. So, yeah, we get to practice introducing more than ten times. So, this is very important and sometimes teaching-heavy. But I think it’s our role’.
Environmental context
Some of the centres in this co-design indicated a passion for environmental sustainability and deemed this essential for successful sustainable healthy food provision. The centres without such a culture agreed that if the culture of the centre did not support environmental sustainability, it would be a barrier.
Director_centre_2: ‘So I would say it’s a culture. It’s a culture that needs to be adopted and instilled – with passion too’.
From a food waste management perspective, participants felt that there needed to be some waste management practices in place for consistent implementation. Where these organisational practices were not in place, food waste ended in landfill bins. This indicates the importance of embedding organisational practices that promote food waste management and sustainable healthy food provision.
Educator_centre_2: ‘So all of the rooms have three buckets, one for the worm farm, one for the compost, one for the Bokashi’.
Cook_centre_8: ‘Plate waste goes to the chickens and then my dogs get the meat scraps’.
Educator_centre_5: ‘Our local council does not allow compost in the greens bin, and our composting thing we have in the garden. I can’t even turn it anymore [so the food waste in this centre goes into the regular bin]’.
Nutrition Australia Representative: ‘lots of local governments are now offering food waste collection which might facilitate this. It would be good if they could do both [composting and worm farms] as worm farms form part of the curriculum. But we do hope they would reduce their food loss in the first place through good menu planning and practice’.
Participants viewed the involvement of children as important, both as part of organisational culture, and in the development of solutions for sustainable healthy food.
Director_centre_1:‘So what happens here is that when a menu is created for lunch. we sit down with the children, and we ask them what they’d like to have for lunch. [We tell them] we are doing a new menu. What would you like to have? It’s about getting everyone involved [in developing the menu]’.
Director centre_2: ‘I think educating [children] is important, because … if we can coordinate some sort of activities with the kids so that they can adopt this themselves, it’s a good option’.
Nutrition Australia Representative: ‘Could we build something that is also an educational tool and involves the children? If so, we need to investigate [in the focus groups] what teachers [educators] would need to support this’.
During this stage, some discussion points that arose in interviews were not prioritised after the workshop with the Nutrition Australia Representative due to strategies being labour-intensive or high-involvement strategies. An example (quotes below) is growing a centre garden as a source of sustainable food. Nutrition Australia and some centres viewed this strategy as a labour-intensive strategy; therefore, it is not practical for all centres. It was decided that, given the low knowledge and awareness of sustainable healthy food, this would be the initial starting point for all centres, regardless of available space and resources.
Director centre_10: ‘you need to find someone that really likes to garden that is going to help maintain [the vegetable/fruit/herb garden]’.
Nutrition Australia Representative: ‘we need to be cautious of how and where we propose high involvement/ high motivation strategies. These might be great for keen centres, but might be off putting for a centre where there is no clear champion or vegetable garden feasibility. Ideally our messaging should be that everyone can do something and start somewhere’.
Stage 2: Design
This part of the co-design related phases 4–7 of the IDEAS framework (Ideate, Prototype, Gather and Build), developing support strategies informed by stage 1 to enhance awareness and knowledge, build skills to apply this knowledge and embed practices into the organisational culture. Support strategies were developed and designed through iterative workshops with Nutrition Australia and focus groups with ECEC staff.
The format of the support strategies
Participants were supportive of a visual representation of sustainable healthy food provision that aimed to improve understanding and could be accessed online. A visual representation/infographic (Fig. 2), based on FAO Sustainable Healthy Diets guiding principles(6), was developed, acknowledging that the infographic would need a companion resource (Fig. 3) to explain each of these elements to make these more practical and usable for the end user. It was deemed important that these were visually appealing and easy to follow; therefore, picture/photo examples of these type of foods would need be included. The possibility of a ‘rating tool’ to assess current practices against sustainable healthy food provision practices was discussed, and whilst participants thought this was a good idea, they felt this would most likely only be used by the ECEC directors. Participants stressed the importance of having a printable version that can be placed in the kitchen (potentially laminated) as an easy-to-use resource for the ECEC cooks, who often cannot access online resources.
Visual representation (infographic) of sustainable healthy food provision for ECEC. *Co-designed with Nutrition Australia and based on FAO Sustainable Healthy Diets guiding principles(6).
Companion resource to infographic (prototype, to be graphically designed to be visually appealing). *Links can be adjusted to be area-/country-specific. The example links are Australian Resources, current government resources or resources utilised by the co-design participants and can be adjusted for by location. 1Tips were discussed during focus groups and were based on practices relating to each sustainable healthy diets guiding principle that was deemed practical and feasible in the setting.
A whole-of-centre approach (including children)
In the focus groups, the participants stressed that the resources needed to target all ECEC staff – directors, cooks, educators – and the children. The resources would therefore need to incorporate support and tips for each staff member and include children in the solutions. The developed solutions for each staff member are included in Fig. 4.
A whole-of-centre approach to sustainable healthy food provision. *This resource can be made part of an awareness week or month and is a starting point for a whole-of-centre approach deemed important for success. Children are part of the solutions and activities. The resources will need to be graphically designed to make it visually appealing, and whilst these resources are Australia-specific, they can be adjusted by country/region.
Feasible and practical tips
Each of the Sustainable Healthy Diet principles (Table 1) were workshopped regarding how these could be practically applied in the ECEC setting. Participants suggested including links to suitable existing resources, such as menu planning guidelines to assist cooks with preparing the recommended quantities of foods. The links included in the prototype resources (Figs 3 and 4) are Australia-specific examples but could be adjusted for application in other high-income countries using links to local resources with similar themes. Some ideas were deemed impractical – for example, purchasing local (from local producers) ethical food (for example, organic and ethically farmed) was seen as something that was likely expensive, whilst purchasing food seasonally was deemed practical with the inclusion of a seasonal food chart (region-specific) seen as useful.
A food waste awareness activity for the children
Participants co-designed a food waste awareness activity that would be easy and quick to implement, use equipment already available in the centre (avoiding extra costs) and able to be incorporated into the daily curriculum. The activity is included in Fig. 4. An important feature of this activity was that it would involve the children in discussing solutions with the educator which could then be relayed to the director and cook.
Discussion
Our study aimed to develop scalable support strategies to guide Australian ECEC centres towards sustainable, healthy and affordable food provision. A co-design framework was utilised which included steps to understand the aims and requirements of the stakeholders (ECEC staff and Nutrition Australia) and thus to develop strategies that are potentially more practical and desirable for the target end users.
Our findings suggest that there is low awareness/knowledge on the topic of sustainable healthy food provision and a need for information and education within the ECEC setting. These findings are similar to those in an Irish qualitative study on the development of sustainable food strategies in schools, hospitals and workplaces (n 21), which indicated that lack of knowledge and education regarding sustainable food provision were perceived barriers to sustainable food provision(Reference Goggins26). Research in Canadian and Australian ECEC settings also indicated a lack of knowledge to be a major barrier to compliance with healthy food provision (menu planning) guidelines(Reference Gerritsen27,Reference Lanigan28) .
In our study, ECEC staff expressed the need for resources to guide their practices as there are currently no clear guidelines regarding the environmental sustainability of food provision in the ECEC setting. Previous Australian research in this setting indicated that staff responsible for planning and preparing meals rely on resources and training for guidance(Reference Matwiejczyk, Mehta and Coveney29,Reference Elford, Spence and Wakem30) . A recent quantitative study in Australia found ECEC centres that accessed freely available Victorian Government nutrition resources had higher perceived knowledge and skills for preparing healthy meals in ECEC, and access to these resources was associated with higher quality menus(Reference Elford, Spence and Wakem30). The availability and uptake of resources such as those co-designed in this study may therefore create awareness and increase knowledge of sustainable healthy food provision in ECEC and resultant changes in practices.
Interestingly, whilst our study aimed to develop strategies to be delivered via digital platforms, the provision of both digital and printable versions of content was perceived as important due to the concern of lower computer literacy and/or access by ECEC staff. This finding is similar to those in an Australian qualitative study, where ECEC cooks expressed disinterest in accessing online resources due to low computer literacy skills(Reference Matwiejczyk, Mehta and Coveney29). The use of printed materials particularly for ECEC cooks may therefore be a more user-friendly solution to encourage uptake. This was demonstrated in an Australian intervention study that aimed to examine the impact of printed educational materials on the intentions of ECEC cooks to use nutrition guidelines and serve more fruit and vegetables(Reference Yoong, Jones and Marshall31). The study found that 59 % of cooks who received the materials utilised them, with the remaining 41 % intending to use it in the future(Reference Yoong, Jones and Marshall31).
A key strategy highlighted through our co-design process was the focus on a whole-centre approach, rather than targeting individual staff members only. Our participants believed that for the successful implementation of sustainable healthy food provision practices, there needed to be a ‘culture’ to foster these practices that actively included staff members. This might catalyse longer-term sustainment of practices in a centre. A systematic review aiming to understand the barriers and facilitators to the sustainment of health behaviour interventions in ECEC and schools found that factors such as team cohesion and continued leadership were facilitators of sustaining interventions without external support(Reference Shoesmith, Hall and Wolfenden32). The authors of the systematic review made two recommendations specific to the ECEC sector; first, strong executive and administrative support and engagement, and second, facilitation of resources and materials to support sustained delivery. Our co-designed whole-centre resource includes guidance for the ECEC director which aligns with the recommendations as per the systematic review. This adds strength to the use of co-design methodology in the development of support as it highlights the value of including end users who have a clear understanding of what their needs are and what might work in their setting(Reference Slattery, Saeri and Bragge14,Reference Mummah, Robinson and King16) .
The whole-centre approach in our study also includes consideration of the role of children and the development of co-designed sustainability knowledge and awareness activities. Children’s involvement in ECEC food preparation has been associated with healthier food consumption in a Dutch study involving 398 children (aged 1–5 years)(Reference Gubbels, Gerards and Kremers33). This study found that when ECEC staff spoke to the children about what they were doing during meal preparation, this was positively associated with healthy food consumption(Reference Gubbels, Gerards and Kremers33). Our study’s co-designed child activity recommends that ECEC educators talk to children about sustainable healthy food and food waste during and after the meal service. Future research is needed to confirm whether these practices can lead to increased knowledge and awareness and changes in food waste behaviours in children. Another recommendation in our co-designed child activity is to involve the children in the development of solutions regarding food waste. Qualitative research in primary school children (aged 4–9 years) in the United Kingdom indicated that children were keen problem-solvers in regard to school food waste, focused on self-regulation and could act as agents of change regarding the reduction of food waste(Reference Yen, Cappellini and Dovey34). This was taken a step further in an Irish study that found that when primary school aged children were involved in sustainability education and activities at school, this prompted reinforcement of these behaviours at home, where they tried to influence their parents in adopting the same sustainable behaviours through positive ‘pester power’(Reference O’Neill and Buckley35). This may indicate that when children have agency of sustainable food practices, it may not only change their own behaviours but also potentially lead to positive changes in their home, having impacts more broadly. Targeting these behaviours in ECEC therefore has potential long-term impacts through habits that track into adulthood.
Our study participants perceived the cost of purchasing local foods as a barrier to healthy sustainable food provision. This was also found in the US Farm to ECEC report, where food costs were considered a major barrier to local food purchasing(36). Due to this, our study resource focused on including ‘some’ locally sourced foods, which was a practice deemed practical and affordable by our participants, and aligned with moving ‘towards’ more sustainable healthy food provision.
Next steps and future considerations
Recommended next steps include producing a graphically designed resource toolkit, pilot-testing of the resources for acceptability and feasibility, and a larger intervention study to explore effectiveness of the resources to create awareness, enhance knowledge and catalyse changes in healthy sustainable food provision practices. These steps will make up the final two stages of the IDEAS framework (Assess and Share)(Reference Mummah, Robinson and King16). An important consideration in any pilot or intervention research pertaining to these resources would be to investigate any unintended negative consequences related to their implementation. For example, that a focus on food waste does not result in a menu that only provides foods that children prefer to eat, as best practice guidelines for child feeding advise that food should continue to be offered even when refused the first time, to ensure repeated exposure to a variety of foods(Reference Benjamin-Neelon4,Reference Anzman-Frasca, Savage and Marini37) . Another example would be to ensure that children receive adequate quantities of food and that food portions are not reduced in order to mitigate food waste(Reference Ellison and Prescott38).
Future evaluation should include any impacts food waste reductions have on food costs as a result of implementing the resource toolkit. Food costs have been identified as a major barrier to food provision in this setting(36,Reference Zaltz, Pate and O’Neill39) . This was also raised by our study participants, with the topic of food costs incorporated into some of the tips and recommendations of our co-designed resources.
Applicability of this research to countries other than Australia
This is the first study to the authors’ knowledge that utilised co-design methodology to involve ECEC stakeholders from the outset of planning new ECEC nutrition resources while facilitating inclusion of geographically diverse ECEC centres and involve key stakeholders (end users from ECEC as well as a government-funded organisation that supports ECEC). This suggests that co-design of support resources is possible in the ECEC setting, and methodological approaches in this study could be applicable to ECEC co-design research in other high-income countries. Whilst our co-designed resources were developed for the Australian ECEC setting, we identified similar findings to other high-income countries, as presented throughout the discussion. It is therefore possible that the co-designed resources developed in this study may be adapted to other high-income countries; however, this will require future evaluation.
Strengths and limitations
Unique to our co-design approach was the involvement of two important end user groups involved in the ECEC setting, namely ECEC centre staff and the HEAS delivered by Nutrition Australia and funded by the Victorian Government. A previous study on the nutrition resources provided by HEAS found that access to their suite of nutrition resources was associated with higher perceived knowledge, awareness and skills, and higher-quality menus(Reference Elford, Spence and Wakem30). Given that the main areas of need identified in our current study were knowledge, awareness and skills, resources provided through such an agency may therefore improve these domains, and needs to be confirmed in future studies. The involvement of Nutrition Australia as both practitioner/expert and end user of the co-designed resources likely makes the resources practical and a scalable option with dissemination across Australia through current infrastructure and support to ECEC centres. The involvement of ECEC staff in the design of resources increases the likelihood that the support strategies are achievable and practical for the setting. Our purposive sampling also aimed for strategies to be co-designed by and for centres with different management types (for-profit and not-for-profit), socio-economic positions (low, medium and high) and from varying locations (regional and metropolitan). However, this was less balanced in the focus groups with greater representation of medium socio-economic position. Due to research taking place during COVID-19, participation rates were lower than expected, and there was a relatively small sample size in the co-design process, particularly the focus groups. It is also possible that the ECEC centres that participated in the co-design process had a keen interest in the topics discussed; therefore, selection bias may have skewed the resources to be applicable to ECEC centres highly interested in the topic of healthy and sustainable diets. These factors reiterate the importance of pilot-testing the co-designed resources. Lastly, the co-design methodology did not facilitate direct discussions between ECEC staff and Nutrition Australia, and facilitating direct conversations may have resulted in variations in the discussions and findings. This can be considered in future research.
Conclusions
ECEC centres procure and prepare large amounts of food for hundreds of thousands of children in high-income countries. A shift to food provision in this setting that is more aligned with healthy and environmentally sustainable diet principles can have impacts on both human and planetary health at scale. The co-designed resource content and guiding practices developed in this study aim to improve awareness and knowledge of healthy and sustainable food provision for the ECEC setting with food costs in mind and suggest a whole-centre approach, involving children in the development of solutions. The inclusion in the co-design process of a government-funded agency that supports ECEC centres to provide healthy food likely enhanced the practical application of resource content. This collaboration also took into consideration scalable and long-term dissemination through existing infrastructure and support approaches. The co-designed resources could provide feasible strategies for the adoption of healthy, environmentally sustainable and affordable food provision practices in the ECEC setting.
Supplementary material
For supplementary material accompanying this paper visit https://doi.org/10.1017/S1368980024002477
Authorship
A.E., A.C.S., K.J.C., M.R. and P.L. conceptualised the study, and all authors contributed to the design of the work. A.E. managed recruitment and data collection (interviews and focus groups) and analysed the qualitative data. P.L. cross-checked qualitative themes. All authors contributed to the interpretation of the data and the co-design process. AE drafted the initial manuscripts, and A.E., K.J.C., A.C.S., M.R. and P.L. revised the manuscript at multiple time points. All authors read and revised the final manuscript. All authors have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.
Financial support
During this work, Audrey Elford was a funded scholarship PhD student at Deakin University’s School of Exercise and Nutrition Sciences. Margaret Rozman is an employee of Nutrition Australia’s Healthy Eating Advisory Service, which is funded by the Victorian Department of Health.
Competing interests
There are no conflicts of interest.
Ethics of human subject participation
This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Deakin University Ethics committee. Written and verbal informed consent was obtained from all subjects. Verbal consent was witnessed and formally recorded.
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