Protocol section	Appraisal points	Appraisal points
Background and research question	Review and update background section, including supporting references to take account of any changes that may have occurred. This should include updating any new information and current policy debates on the topic.	The review update will not involve a change in research question or aim. The primary aim of the review is to examine the effectiveness of strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services. The background section of the review will be updated to include current statistics regarding the condition (obesity) and the intervention.
Inclusion criteria	• Review current PICO(s) and amend in light of new knowledge • Identify any changes in usual care standards • Check for standardised core outcome sets, such as those developed in collaboration with the core outcome measures in effectiveness trials (COMET) initiative (www.comet‐initiative.org) or by guideline groups since the original review • Check for any relevant patient‐reported outcomes to include subsequent to the original review • Consider any new studies with less risk of bias that might warrant a stricter study design inclusion criteria (where the older version, when there was a dearth of evidence, included observational or quasi‐randomised comparisons)	The PICO developed for the original review will be closely replicated for the review update. There will be no changes to the type of population group, interventions or comparison groups previously included in the original review. However, two adjustments will be made to the secondary outcomes measured. The original review included a secondary outcome describing the impact of strategies on childcare service staff skills, knowledge and attitude. This will be removed from the review update. The updated review will include a secondary outcome examining implementation acceptability, adoption, penetration, sustainability and appropriateness. As outlined by Proctor in the study, Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda, it is recommended that all implementation trials assess these implementation outcomes. For the review, these implementation outcomes will be operationally defined as follows: ‐ Acceptability: Defined as the perception among implementation stakeholders that a given treatment service, practice or innovation is agreeable, palatable or satisfactory. Measures of acceptability assessed at the individual or organisational level will be included such as surveys of staff or managers of childcare services regarding their experience of features of the intervention. ‐ Adoption: any measure of uptake, including intention, initial decision, or action to try and implement potentially effective interventions, programmes or services. These could include decisions by managers of childcare services to take up a potentially effective service, or individual staff interventions to deliver potentially effective services. ‐ Penetration: integration of a practice within a service setting or its sub‐settings. Include any measure of penetration at the individual or organisational level. For example, proportion of eligible individuals (or childcare services) that receive an intervention (or implement an intervention) of the total number eligible to do so. These could include the proportion of all childcare services eligible for an intervention that actually receive it. ‐ Sustainability: defined as the extent to which a newly implemented intervention, programme or service is maintained. Measures of sustainability must require successful implementation in part or in full, of an intervention, programme or service. Include any measure of ongoing sustainability of implementation of intervention elements assessed at least 6 months following a measure of successful implementation. This could include the proportion of childcare services maintaining implementation of all elements of a program 12 months following the provision of implementation support. ‐ Appropriateness: defined as the perceived fit, relevance of the compatibility of an innovation of evidence‐based practice for a given setting, provider or consumer, and/or perceived fit of the innovation to address a particular problem. Measures of appropriateness assessed at the individual of organisational level will be included, such as surveys of staff or managers of childcare services regarding their perception of the consistency of the implementation of a new intervention with their skill set or work expectations. The study design inclusion criteria will remain the same for the review update. Any study (randomised, including cluster‐randomised, or non‐randomised) with a parallel control group that compares an implementation strategy with no intervention or ‘usual’ practice; or two or more alternative strategies to improve implementation, will be considered and screened for eligibility.
Methods	• Appraise and update the methods pending relevant methodological advancements or developments. For example, if there are new tools for assessing the risk of bias of individual studies or appraising the quality of a body of evidence (e.g. GRADE) • Update or include a ‘Summary of findings’ table, which is recommended for all systematic reviews, because it improves the clarity, understanding, and interpretation of the findings of a systematic review, and rapidly reduces the amount of time readers require to find key information • Any new subanalysis needed • Any substantive change in the review structure	The updated review will include a minor refinement of the search strategy for electronic databases used in the previous review. This refinement aligns with feedback received from the Cochrane Editorial team regarding the search strategy used in another review by the same lead author. Due to the inclusion of an additional secondary outcome in the review update, studies included in the original review will be re‐examined to assess the new secondary outcome. Any data from studies in the original review that assessed the new secondary outcome will be extracted and included in the review update. Despite the addition of a new secondary outcome, the amended search will only be applied to the review update date range (27th June 2016 – present). As per the original review, the primary outcome of the review update is the implementation of policies, practices or programmes in centre‐based childcare services to promote healthy eating, physical activity or obesity prevention. Therefore, any eligible studies that assess the primary outcome will be included in the review. These studies will then be further examined to determine if any secondary outcomes were also evaluated, with relevant data then extracted. As per the original review, studies that do not assess the primary outcome, despite potentially assessing secondary outcomes, will be excluded from the review update. As per the original review, the review update will appraise the quality of evidence using the GRADE method and include a ‘Summary of findings’ table to increase clarity and understanding for the reader. We will, however, report a SOF table for RCTs separate from non‐RCTs in line with GRADE recommendations. The updated review will also include methodological analysis advancements utilised in the Cochrane review titled Audit and Feedback: effects on professional practice and healthcare outcomes (http://cochranelibrary‐wiley.com/doi/10.1002/14651858.CD000259.pub3/full). Authors of the review update intend to formally pool the trial using an adjusted median effect and conduct analyses in STATA, as described in the Audit and Feedback review. No substantive change in the review structure will occur in the update.