What is the level of effectiveness of a training package in empowering preschool teachers to engage preschool children and their mothers to promote healthy food habits and reallocate household expenditure of ultra processed food to nutritious and healthy food in a selected Medical Officer of Health area in Gampaha District.

Study Design: A cluster randomized control trial. Participatory processes of this trial will be embedded in the intervention process thus integrating the principles of Participatory action research and Community-based participatory research(CBPR)

Study Setting: Early Childhood Care and Development Centers (ECCD) in Ragama Medical Officer of Health (MOH) area, Gampaha District Sri Lanka

Study Population:Teachers in ECCD centers in selected MOH areas

Randomization Unit of randomization is the MOH area. First, depending on Phase I results MOH areas were paired with similar characteristics. One pair was randomly selected using simple randomization (via Computer generated random numbers) From the selected pair, One MOH area was allocated to intervention (Ragama) One MOH area was allocated to control (Attanagalla) No further randomization was done at preschool or individual level. Fixed 1:1 allocation at MOH level via single random number generation (1 -10) on pre specified rule. odd number Ragama = Intervention Attanagalla= Control If even number Attanagalla = Intervention Ragama = Control

Among two selected MOH areas, an independent statistician generated single random number between 1 and 10 and applied prespecified rule.

Intervention: There will be three components of this trial

Component 1 : Pre evaluation Component 1A This will be conducted to assess the existing maternal knowledge, attitudes and practices on children’s food habits in selected ECCD centers. The food environment and dietary behaviors of children at ECCD centers will also be assessed during this phase. Component 1 B This will be conducted to assess the knowledge and attitudes of teachers on children’s food habits in selected ECCD centers. The food environment and dietary behaviors of children at ECCD centers will also be assessed during this phase.

Component 2 : Intervention Step 1: Inviting at least one teacher from the consenting ECCD Centers at the pre-intervention evaluation Step 2: Session 1 – Initiation of the training with an introduction to concepts of healthy food habits and engaging preschool children and their parents in promoting healthy food habits and reducing Ultra processed food (UPF) consumption. Step 3: Teachers initiate processes to promote healthy food habits and reduction of UPF consumption in their preschool communities Step 4: Establishing a WhatsApp chat group to initiate discussions and give distal inputs to improve processes. The group chat will continue till the end of the intervention and beyond, upon their consent Step 5: Session 2 (two weeks after the session 1) – Teachers report back with their experiences and their processes are discussed and improved, further actions and monitoring mechanisms identified. Step 6: Monitoring visit (one month after the session 1) – ECCD centers will be visited and direct inputs given to improve processes and outcomes Step 7: Monthly Zoom meetings to assess progress and provide technical input will be held from third month onwards Step 8: Evaluation visit (4 months after session 1) – Process evaluation and the Post evaluation (Phase III)

Component 3 : Post Evaluation Same protocols will be used during the pre-evaluation phase.

No training package will be used at Control MOH area. Usual practices only. (Allowing teachers to continue the usual practices on child nutrition at their ECCD centers as per their curriculum). Control arm receives same pre- and post-evaluation assessments.

Both arms continue to receive routine guidance and care from Early Childhood Development Officers with monthly meetings. Care and support given by the Public Health Midwife as a routine in measuring child weight and height will continue normally. Neither arm is deprived of usual services.

All teachers who are permanent employees of the ECCD Centers in the selected MOH areas Assistant/ trainee teachers working at the ECCD centers in the selected MOH area Teachers who are nominated by the preschool upon the request of the researchers. Age over 18 Both male and female

• Teachers who have experience of less than three months at the ECCD center
• Assistant/trainee teachers who have experience less than one year at an ECCD center
  
• Teachers who will not be available for entire four months of the intervention ( who plan to get retired or vacate the job during intervention period)