Family Child Care Providers’ Experience With the Child and Adult Care Food Program During the COVID-19 Pandemic

Addressing children’s nutritional health in child care settings is important, because 60% of all children under age 5 years spend a significant portion of their waking hours in nonparental care.¹ Meals and snacks eaten in these settings often provide most of a young child’s daily food and nutrient intake.² The nutritional quality of these meals is important, as adequate nutrition is critical to healthy development in early childhood.³ There is abundant evidence that low-income children are at a greater risk for poor nutrition.⁴

The Child and Adult Care Food Program (CACFP), a federally funded program designed to support young children’s equitable access to nutrition and healthy development,⁵ subsidizes nutritious meals and snacks for low-income children in center- and family-based child care. The program is administered by state agencies through sponsoring organizations (henceforth, sponsors).⁶ Early child care programs participating in CACFP have been shown to serve healthier food than nonparticipating child care centers and homes,⁷ and emerging evidence indicates that children who receive CACFP-funded meals are less likely to experience food insecurity.⁸

Family child care providers are an important access point for CACFP.^3,9 Millions of children in the United States receive care in family child care settings,¹⁰ which are estimated to represent more than 70% of all child care providers.¹¹ Children from low-income, racial and ethnic minority households are more likely to be enrolled in family child care than higher-income and majority race/ethnicity children,¹² and many family child care providers are low-income themselves, with higher documented rates of food insecurity than in the general public.¹³

There is evidence that the COVID-19 pandemic exacerbated inequities in food access,¹⁴ particularly for low-income families and families of color.^15,16 The pandemic also affected child care in unprecedented ways. One of the most significant impacts was widespread child care closures, which prevented children from accessing nutritious CACFP-funded food through their child care provider.¹⁷ Nationwide, the number of CACFP meals claimed by child care providers dropped dramatically in the first three months of the pandemic.¹⁸

The federal government took several steps to mitigate the impact of the pandemic on child care and children’s feeding programs.¹⁹ In response to unprecedented pandemic-related program operation challenges, the Food and Nutrition Service of the US Department of Agriculture (USDA) authorized temporary waivers to core policy elements of CACFP as authorized by the Families First Coronavirus Response Act.²⁰ One waiver allowed providers to serve meals outside of standard mealtimes, another allowed parents to take food home even when the children were not present, and another permitted flexibility regarding the specific foods that providers served to children to meet CACFP meal pattern requirements.²¹ Providers were eligible to use any or all of the waivers. Implementation of waivers varied among states, and little is known about how the waivers were operationalized in the field, particularly in the child care setting.²²

Here, we summarize insights on child care providers’ experiences participating in CACFP during the COVID-19 pandemic, obtained through surveys with a convenience sample of family child care providers conducted in early fall 2021 (method described in the Appendix, available as a supplement to the online version of this article at http://www.ajph.org). Providers gave voice to the problems they experienced utilizing the temporary programmatic waivers, difficulties they had providing nutritious food to children, and obstacles they faced in operating their family child care. Rural–urban differences were also of interest. Access to CACFP is more limited in rural areas because of the ways the geographic concentration of poverty affects CACFP benefit levels²³ and the documented barriers for rural areas in accessing healthy food.²⁴

KNOWLEDGE OF AND EXPERIENCE WITH WAIVERS

Prior evidence has shown that COVID-19 relief funds were effective in providing critical short-term support for child care programs.²⁵ However, there is uneven evidence of the contribution of CACFP programmatic waivers for child care providers, particularly family-based child care.²⁶ Previously identified barriers to using programmatic waivers included limited program capacity due to issues such as staffing, storage, and transportation.²⁶ Importantly, we found that many of the licensed family child care providers that we surveyed had little knowledge of CACFP program waivers. For instance, 40.6% of providers reported they had not heard of the waivers at all, and 44.1% had no knowledge of at least one of the waivers. Those who had heard about the waivers most commonly learned about them from their CACFP sponsor or monitor (32.9%), their child care resources and referral agency (10.5%), or the statewide network of such agencies (9.8%).

The overwhelming majority of our sample (85.9%) reported that they never used a waiver. One provider even noted, “Wish I would’ve known about the waivers because it would have helped my families.” Several providers who were aware of the waivers, but did not use them, indicated they did not understand the waivers. Among providers who used one or more of the waivers, few reported problems associated with their use. One provider mentioned that the mealtime flexibility waiver helped with school-age students’ online learning schedules, and others talked about the waivers helping support the families of the children in their care whom they perceived needing food support: “The children were able to still get nutritious meals when program attendance wasn’t allowed. Many families needed those meals.” Providers indicated reasons they had stopped using the waivers, which included that their child care program had reopened and they were serving meals in person; that there was no longer interest from the families in taking meals home; and that grocery availability had improved.

Providers’ lack of awareness is surprising, given that CACFP connects every family child care provider to a sponsor who should have provided them with information about the waivers. A prior study found that child care providers who participated in CACFP were more likely to connect families in their care with food resources than non-CACFP-participating providers.¹⁷ Communication challenges (e.g., confusing program guidance) have been identified as barriers to CACFP participation²⁷ and to the implementation of healthy eating standards.²⁸ A study of state CACFP administrators found that they experienced difficulty receiving timely and clear communication from the USDA, which translated into downstream communication challenges for program participants.²⁶ CACFP sponsoring organizations and participating child care centers also reported confusion that was due to changing and inconsistent rules and guidance for COVID-19.^29,30 These communication-related challenges resulted in diminished access to nutritious meals for children and families who were already likely to face nutrition inequities.¹⁶

Family child care providers who participate in CACFP are an important focus of policy efforts to support children’s nutritional health and equitable access to nutritional meals. Few providers used or were aware of CACFP programmatic waivers during the COVID-19 pandemic, which was a missed opportunity for children’s nutrition, particularly as providers that used waivers found them beneficial. Identifying effective ways to directly communicate to providers in a timely and clear manner is critical for current programmatic needs as well as for future public health crises.

CHALLENGES DURING THE PANDEMIC

During the pandemic, family child care providers struggled to purchase food for their business. Almost all of the providers (95.8%) we surveyed said they noticed higher food prices since March 2020, with a majority reporting difficulty at times purchasing the food they needed for their child care. The most frequent reasons that providers gave were that food prices had increased during COVID-19, that grocery stores had trouble keeping the items they wanted or needed in stock, and that they didn’t have enough money to buy the food they needed for their day care. We also sought to understand if providers in rural areas had more food-related challenges than those in urban areas. In our sample, providers in rural areas did not report more difficulty purchasing food than providers in urban areas.

Our survey results indicated that providers were currently experiencing more difficulty, both in making meals and snacks that children wanted to eat and in purchasing food that complied with CACFP menu requirements, than they were before March 2020. Providers mentioned that grocery shortages required additional travel and time to find certain foods and that they sometimes had to make trips to multiple stores. Difficulty finding items created additional complications, such as needing to rearrange CACFP menus (for themes and illustrative quotes from open-ended questions, see Table A, available as a supplement to the online version of this article at http://www.ajph.org). Other providers mentioned the poor quality and short shelf life of available foods, particularly fruits and vegetables. Others pointed out that certain items required by meal patterns were hard to find (e.g., whole grain items). One provider mentioned that reduced enrollment had affected their economy of scale. Many providers also mentioned that children’s picky eating was challenging. Some suggested that these behaviors had gotten worse since COVID-19, whereas others saw them as ongoing. However, despite these challenges, many said they felt that their participation in CACFP supported the healthy eating habits of children in their care.

Our study also found that providers reported higher food costs, significantly more difficulty finding the food they needed, and more difficulty making CACFP-compliant meals and snacks in fall 2021 than before the pandemic. Because CACFP reimbursement does not cover the full cost of meals, providers must pay the difference out of pocket. Our findings reinforce other studies that have also identified the ways that meeting CACFP meal patterns is challenged by limited food availability and high food costs.³¹ Contrary to our expectations, there were few rural–urban differences.

An important priority should be helping providers address financial hardships such as rising food prices. Identifying cross-sector and system-level opportunities to leverage connections, information, and support for providers is critical.^32,33 Sponsors could help connect providers with food assistance programs (e.g., the Supplemental Nutrition Assistance Program, or SNAP) and charitable food assistance (e.g., food pantries), and provide information about budgeting and stretching resources.

ADDITIONAL COVID-19– RELATED CONCERNS

Overall, providers were worried about their personal financial situation, the sustainability and future of their child care business, and purchasing food compliant with CACFP menu requirements (Table 1). Many providers reported difficulty finding protective equipment and cleaning supplies and an increase in the cost of supplies. A few mentioned that COVID-19–related cleaning was burdensome and took time away from interacting with children. The toll of added worry and stress that the pandemic created on the physical and mental health of the providers themselves was mentioned frequently. Providers voiced concern about the impact on their immediate family, and some commented that they felt the children in their care experienced greater stress and anxiety than before the pandemic. A majority reported they were somewhat or very worried about the future health and safety of children after the pandemic.

TABLE 1—

Illinois Family Child Care Providers’ Concerns About Child Care Program During and After COVID-19 Pandemic

When It Comes to the Current and Future Sustainability of Your Child Care Program, How Much Do You Worry About—	Very Much, %	Somewhat, %	Undecided, Not Much, or Not at All, %
Paying myself	50.0	28.9	21.1
Making rent or mortgage payments	37.3	34.5	28.2
Making utility payments	38.0	35.9	26.1
Paying for health insurance and other benefits	41.8	26.2	32.0
Finding and paying for protective equipment and cleaning supplies	27.5	39.4	42.5
Whether families will come back after the pandemic is over	31.9	25.5	42.6
Purchasing food that meets the CACFP menu requirements	24.6	38.7	36.7
Health and safety of children after the pandemic is over	48.3	29.4	22.3

Note. CACFP = Child and Adult Care Food Program. The response options “undecided,” “not much,” and “not at all” were collapsed. Sample size was n = 143.

IMPACT OF COVID-19 ON CHILD CARE OPERATION

Providers’ concern about their financial situation was not surprising, given that over 75% of providers reported financial loss due to COVID-19, with another 7.7% reporting they had not yet experienced a financial loss but expected to in the future. One contributing factor was that many providers were still operating under capacity. One quarter of providers reported that they were operating at under 50% of their capacity, 23.8% at between 51% and 75% of their capacity, and 50.3% at 76% or more of their capacity. Comparable pre-COVID-19 capacity information is not available. These results are critical, as fewer children enrolled in care means that fewer children can access the benefits of healthy food through the CACFP program. Responses about additional COVID-19 impacts illuminated some reasons that providers were operating under capacity. These included parents working from home, parents wanting different schedules, families losing employment, and exposure-related closings. Providers also mentioned not being able to find reliable assistants and the inability to employ assistants due to reduced capacity. We also sought to understand if providers in rural areas faced more financial hardships than those in urban areas. Our results indicated that although providers in rural areas did not report more financial loss than providers in urban areas, they were more likely to report operating under capacity.

Many providers in our study reported that they experienced a financial loss, had reduced enrollment, were operating under capacity, and had difficulty finding and paying assistants. These challenges have been documented for family child care providers statewide, with 48.2% of all Illinois child care providers reporting they considered quitting because of economic stress from COVID-19.³⁴ Even before the pandemic, numbers of family child care providers were declining.³⁵ Such declines reduce children’s access to nutritional supports through CACFP, particularly among lower-income and non-White families, who are more likely to use family child care.³⁶ Our finding that rural providers were more likely to report operating under capacity is of note. Future research should seek to understand the drivers of this relationship and whether it has continued after the pandemic.

Providers’ significant worries about the financial sustainability of their child care operation are not surprising, given that child care providers overall are low-income earners.¹² Thirty-eight percent of our sample fell below the federal poverty level (according to the US Department of Health and Human Services; https://bit.ly/3SQxX6q). Food insecurity among child care providers is higher than in the general public,³⁷ and providers’ food security status influences their feeding practices with children.¹² Providers’ physical and mental health are also predictors of quality in family child care.³⁸ Providing nutritional support to providers, who play a critical role in the child-serving ecosystem, can further support the health and well-being of children.³²

COVID-19 disrupted the food safety net, and the government responded with speed and great flexibility. However, we have presented evidence that communication to providers was poor, and lack of knowledge overwhelmingly prevented the providers in our sample from taking advantage of COVID-19 waivers that would have helped children. These are issues that were also evident in the CACFP program before the pandemic. An important question dramatically highlighted by COVID-19 is how to improve communication of CACFP policies to families, providers, and state agencies. Given the recent USDA focus on advancing nutrition security and equity,³⁹ family child care providers and their participation in CACFP are essential to consider if we are to meet the goal of connecting all Americans with healthy, safe, affordable foods and to ensure equitable access to nutrition for all children.