We will use a stakeholder-driven process called evidence-based quality improvement (EBQI) [3739, 6366] to ensure that our sustainability strategy reflects cultural needs and preferences. EBQI has been used frequently to develop strategies and adapt interventions in primary care, outpatient care, and pharmacy practice [38, 64, 67, 68]. Consistent with the DSF [40], we expect that engaging stakeholders will contribute to the most effective strategies. EBQI panels will operate according to principles of community-based participatory research [69] and best-practices for engaging stakeholders in implementation [70]. Childcare directors and educators will contribute the local knowledge needed to select and tailor strategies; the research team will provide expertise on implementation approaches.

The EBQI process will (1) leverage strategies that worked for high sustainability sites from aim 1, (2) prioritize barriers and facilitators to sustainability reported from sites and external stakeholders from aim 1, (3) identify theoretically informed sustainability strategies that match priorities/needs, and (4) tailor sustainability strategies to the early childhood context. The EBQI panel will include 8 to 12 stakeholders combining FF and WISE users, and the diversity of the panel will reflect the diversity of the target populations.

EBQI is a flexible process conducted across a series of meetings with topic-driven agendas; each session will last 2 h. In EBQI session 1, the research team will present a summary of aim 1 findings, conduct a “member checking” exercise to assess validity of the findings, reach consensus on prioritized barriers and facilitators to inform the sustainment strategies, and vet sustainment strategies identified in aim 1. In session 2, we will present potential sustainment strategies mapped by the research team to the ERIC [42] taxonomy of implementation strategies, incorporating knowledge on strategies that worked in high sustainability sites and predictors of sustainability (from aim 1). To reach a consensus on sustainment strategies, we will use techniques outlined by Powell et al. [71], including concept mapping with virtual polling. This method provides quantifiable information and promotes the efficient collection of input in real time. Our existing relationships with Extension offices and regional medical facilities will facilitate virtual meetings in all counties. In session 3, we will present the draft strategies/tools, collect feedback for revisions, and receive final approval. In sessions 4 and 5, we will present our plan for a future pilot test of the sustainability strategy to assess acceptability and adoption. Stakeholders will receive $50 per session. By applying the EBQI process to the study of sustainability rather than implementation, our findings may be broadly applicable to the field of implementation science.

We will engage key community stakeholders to serve on our EBQI panel and provide input on the development of a sustainment strategy. This process will review the existing scientific evidence and data from aim 1 with the EBQI panel to solicit stakeholder input on how best to sustain nutrition/PA programs in childcare. EBQI sessions will be audio-recorded so that we can review the content covered in each session and rapidly code the reactions of the EBQI panel. These data will be collected anonymously. Panel members may also be asked to complete survey instruments to provide quantitative input on proposed strategies. The identity of EBQI members will not be included in reports or manuscripts. We expect to engage up to 12 stakeholders for the panel. The EBQI panel will meet 5 times virtually.

For aim 2, stakeholders and pilot participants will be recruited through IRB approved procedures, focusing on agencies with which we have continued partnerships. We expect these activities to include site visits, emails, contacts at early childhood conferences, and phone calls. Stakeholder recruitment will reflect the demographics of early-childhood educators in each state as published by the state departments of education. External stakeholders will be recruited through established relationships with governing, funding, and administrative bodies in each respective state.

We will use an online platform and database server to collect and store the EBQI panel’s perceptions of feasibility and importance of potential sustainment strategies. Then, we can query the database [72] in real time to plot potential strategies by their rated importance (x-axis) and feasibility (y-axis), consistent with a concept mapping approach [71]. Strategies above the mean for both criteria will be considered for inclusion in the sustainability strategy. After each EBQI session, research team members will document what they observed and heard, what was resolved, and what remains undecided. These meeting minutes will guide subsequent EBQI sessions. The research team will also assimilate panel feedback, translate it to actionable plans, and develop the next iteration of materials for panel input. Qualitative information from meeting minutes and audio recordings will be analyzed using directed content analysis [61] relative to the main goals of the EBQI process (e.g., matching barriers/facilitators to sustainability strategies). After data from the final EQBI meeting are analyzed and incorporated into the design, the sustainability approach will be fully specified.

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