Implementation Challenges With the Child and Adult Care Food Program in Family Childcare Homes: A Qualitative Study

Abstract

Background

The Child and Adult Care Food Program (CACFP) reimburses childcare programs for serving nutritious foods to young children and has potential as a strategy to improve young children’s dietary quality. However, it is underutilized.

Objectives

Using the Consolidated Framework for Implementation Research (CFIR), identify the systemic challenges family childcare home (FCH) providers face when implementing CACFP.

Methods

In this descriptive qualitative study, we conducted interviews with 33 English- or Spanish-speaking FCH providers operating in Massachusetts, including current, former, and never participants in CACFP. We elicited their perspectives on barriers and facilitators to implementing CACFP using a semistructured interview protocol with open-ended questions informed by CFIR. Interviews were transcribed and analyzed using a pragmatic thematic analysis approach.

Results

Four main themes were identified from the interviews: 1) frustration and fatigue across multiple implementation activities; 2) perception that CACFP’s implementation requirements do not consider FCH providers’ unique needs; 3) providers’ commitment to reducing families’ burdens; and 4) providers’ discontinuing or avoiding participation when they perceive the burdens of participation to outweigh benefits.

Conclusions

The range of activities required for FCH providers to implement CACFP results in their taking on roles and responsibilities that are outside of their main professional role, creating fatigue and conflict. More implementation support, in the form of food service infrastructure or increased flexibility for program operations, could help FCH providers participate in CACFP.

Introduction

Ensuring young children have access to nutritious food is essential for a healthy growth trajectory [1,2]. However, current estimates suggest that, on average, children are not meeting science-based recommendations for dietary quality [3,4], and children from households with low incomes, which face enormous challenges in accessing adequate nutritious foods [3,5], are at heightened risk for poorer dietary quality. Because of the critical importance of proper nutrition in early childhood, several public health policies focus particularly on supporting young children’s access to healthful food. The Child and Adult Care Food Program (CACFP), a federal nutrition assistance program that reimburses childcare programs for providing meals and snacks to children that meet a set of nutritional standards [6], is one such program. CACFP reaches ∼4 million children attending early care and education (ECE) on a given day and partially reimburses providers for ≤3 meals and/or snacks a day [6,7]. For ECE programs, both childcare centers and family childcare homes (FCHs)—smaller programs that are operated by a single caregiver, sometimes with an assistant, out of the caregiver’s own home—can participate, and both can access support from sponsors, organizations that help CACFP-participating ECE programs complete administrative paperwork, access their reimbursements, and check that programs are adhering to program requirements. Although centers can operate independently from sponsors, FCHs are required to go through a sponsor to participate in CACFP [8]. Evidence suggests that children from households with lower incomes who receive CACFP meals and snacks have reduced risk of food insecurity and better overall health compared with children from lower income households who receive parent-provided meals and snacks at childcare [9], and CACFP participation is associated with childcare programs having more healthful food environments [10].

However, despite its benefits, CACFP is substantially underutilized; it is estimated that, nationally, between 58% and 61% of eligible centers and about two-thirds of FCHs participate [11,12]. Given CACFP’s potential for supporting food security and nutrition for young children [9], as well as partially alleviating the high operating costs faced by ECE providers, which have put enormous strain on the childcare system in the United States [13], understanding potential reasons for underutilization is critical.

Several qualitative studies have identified individual challenges with the program, including: onerous paperwork; insufficient reimbursement rates; a lack of adequate staff capacity for planning, purchasing, and preparing meals on top of regular childcare duties; and even a lack of awareness of the program’s existence in the first place [[14], [15], [16], [17], [18], [19]]. These important findings suggest individual, piecemeal challenges, but taken together, they also suggest that this array of challenges may be interrelated and may be driven at a systems level. Yet, studies have not yet investigated these challenges from a holistic framework that would allow for the consideration of their relative importance, interrelationships, and impacts on providers’ actual implementation activities. Thus, building on existing prior research, this study aims to deepen understanding of providers’ experiences with CACFP participation by examining these experiences systematically from an implementation science lens. Using conceptual frameworks from implementation science [[20], [21], [22], [23]], we conceive of CACFP as a program that is being implemented and ECE providers as the actors who implement it. We thus sought to investigate the interrelated challenges ECE providers face as implementors, particularly related to administrative burden [24], as well as the conflicting demands that their roles as implementors, care providers, business owners, and educators may place on them. We focus on FCHs specifically, given that FCH participation in CACFP has dropped sharply over time [25], and FCHs may face unique challenges in implementing CACFP [14,17], even with the support of sponsoring organizations.

Methods

Study design and sample

In this qualitative study, individuals were eligible to participate if they ran an FCH in Massachusetts and spoke English or Spanish. Our goal was also to purposively sample individuals with varying experiences with CACFP participation (current participants, former participants, and never participants) to better understand diverse experiences with the program. To recruit study participants, we used a combined convenience and snowball sampling approach, first reaching out to FCH providers already known to the study team from a previous study of nutrition in FCHs [26] and asking for support in contacting fellow FCH providers; several gave suggestions and provided contact information (phone or e-mail) for FCH colleagues that we could invite to participate in the current study. One of these FCH providers also shared our research team’s recruitment flyer about the study, which explained that the purpose of the study was to understand FCH providers’ perspectives about CACFP, on a private Facebook group only accessible by other FCH providers. Providers who were interested could then contact us to participate in the study. We screened a total of 38 interested individuals, of which 33 were eligible and participated in the interview from January 2023 through August 2023. This sample size is justified based on our broad study aims (general experience with CACFP) that is combined with applied theory (the Consolidated Framework for Implementation Research 2.0, or CFIR [22]), allowing us to rigorously answer our research question with a small to medium sample size for qualitative research (30–35 interviews) [27].

Data collection

We developed a semistructured interview protocol that explored FCHs’ experiences with CACFP (Supplemental File 2). The protocol was organized using the CFIR [22] and also built upon prior findings about barriers and facilitators to accessing CACFP [16,17,19,26], as well as a pilot qualitative study about implementing CACFP nutrition standards that had been conducted earlier by the research team among Boston-area FCHs (unpublished). The protocol focused on: exploring providers’ perspectives on CACFP itself (CFIR domain: innovation; subdomains: relative advantage, complexity, design, cost); the influence of the external resources (CFIR domain: outer setting; subdomains: partnerships and connections, financing); aspects of ECE programs that influence implementation (CFIR domain: inner setting; subdomains: relational connections, communications, access to knowledge and information, mission alignment, available resources); aspects of the providers’ characteristics themselves that influenced their role [CFIR domain: individuals; subdomains: role (innovation deliverers), motivation, need, capability]; and experiences with the implementation process (CFIR domains: implementation process). The interview protocol was also modular, such that all study participants responded to a core group of questions, but some questions were worded differently according to whether the participant currently participated in CACFP, had never participated, or used to participate in CACFP and, at the time of interview, no longer participated. Content experts reviewed the interview protocol.

Our team consisted of 4 research assistants and 1 principal investigator; together, we brought diverse and complementary lived experiences, professional training, and subject matter expertise to inform and shape the data collection and analysis process (Supplemental File 1). We also asked the participants descriptive demographic questions (age, race/ethnicity, and years of operation). Trained researchers (KK, ACG, EK), with prior experience conducting qualitative research, conducted interviews in either Spanish or English via phone or Zoom call, which, on average, lasted 30 min. Interviews were conducted in a semistructured manner to allow for additional probes and increased flow of conversation. As compensation, participants received a $25 e-gift card. All interviews were recorded and transcribed in the interview language (English or Spanish) through Sonix, an external artificial intelligence service, and reviewed for accuracy by research team members involved in coding the data, who also corrected any transcription errors.

Data analysis

We used a pragmatic thematic analysis approach [28], informed by the CFIR [22,23] and aided by the qualitative analysis software Dedoose. We first familiarized ourselves with the data by reading through each transcript. We then developed a deductive codebook informed from the interview protocol and CFIR domains and constructs utilizing a hierarchical coding structure (Supplemental File 3). To refine the codebook, we selected 3 transcripts for the initial coding set, and 4 members of the study team (KKE, ACG, JI, and MZ) used the codebook to code each transcript individually. The team then met to discuss and review the coding process to further refine the codebook in alignment with the study aims and dataset. The transcripts were then recoded based on codebook revisions. We repeated this process with 3 additional transcripts as a method to build familiarity with the coding process within the research team and further iterate on the codebook. For the remainder of the data, each transcript was double coded to ensure that each research analyst was applying codes to the data in a consistent manner. Coders met to discuss differences and reach consensus with codes applied for each transcript. Throughout the entirety of the coding process, the team met to discuss challenges with the codes for further iteration on the codebook and to discuss analytic insights. Transcripts were coded in their original language (English or Spanish).

Once the coding process was complete, we further organized each data excerpt within a code by whether the participant was expressing a positive, negative, or neutral sentiment. We also noted each participant’s CACFP participation status for each code. Each team member then developed summaries for select codes by nature of expression and CACFP participation status. Collectively as a team using individual memoing, discussion, and analytic mapping, we examined patterns within and across code summaries to identify key themes, with particular emphasis on comparing patterns for providers who still participate compared with those who never have or no longer participate in CACFP. The themes were thus synthesized across the domains and subdomains of CFIR covered in the interview protocol. We continued to iteratively refine the themes until each theme was distinct, clearly defined, accounted for deviant experiences, and in alignment with study aims.

The study was approved by the Harvard T.H. Chan School of Public Health Institutional Review Board. We obtained informed consent from all interview participants; consent forms were sent to participants electronically and consent was verbally recorded at the beginning of the interview. Interviews were conducted over our university’s secure Zoom platform, and all data were stored on password-protected servers to maintain participant confidentiality.

Results

Of the 33 interviews, we conducted 5 in Spanish and 28 in English. All participants were female, most identified as White (83.9%), and 23.3% identified as being Latina (Table 1). Most participants (76%, n = 26) were currently participating in CACFP, 12% (n = 4) had previously participated, and 9% (n = 3) had never participated.

TABLE 1.

Sociodemographic and work history characteristics of Massachusetts family childcare home providers participating in the study (n = 33)

Characteristics	n	%
Preferred language spoken
Spanish	5	15
English	28	85
Race
White	28	85
Black/African American	1	3
Asian	1	3
Mixed race	3	9
Ethnicity
Hispanic	6	18
Non-Hispanic	27	82
CACFP participation status
Participated at time of study	26	79
Had never participated	3	9
Formerly participated	4	12
Years of experience working in childcare
0–5	6	18
6–10	6	18
11–15	5	15
16–20	3	9
20+	17	52

Abbreviation: CACFP, Child and Adult Care Food Program.

We identified 4 main themes on how FCH providers experience implementing CACFP (Table 2). Although the design of the interview guide and codebook was informed by CFIR, the thematic analysis approach yielded themes that often were cross-cutting across the CFIR constructs. Thus, each theme can span multiple constructs (Table 2).

TABLE 2.

Summary of themes and representative illustrative quotations among family childcare providers regarding the implementation process of CACFP among 33 Massachusetts family childcare home providers

Theme	Subtheme	Representative quotations
Providers experience fatigue and frustration related to time burdens, feasibility challenges, and limited flexibility. Relevant CFIR domains/subdomains: •Innovation/complexity and costs •Individuals/capability	Time burdens and feasibility challenges	“Yeah, it would be like asking your child’s third grade teacher to cook lunch for them in the middle of math class.” – Provider 104, previous participant. “So I have my husband, [he] is also a licensed assistant and so he helps me at lunch every day pretty much. I have everything else under control, but it’s nice to have an extra set of hands at lunch. And I have another person that comes in during the summer to help out in school vacations.” – Provider 150, current participant. “Already a lot of work to run a family child care center and now this is extra work” – Provider 108, current participant.
	Limited flexibility with requirements and nutrition standards	“[I] feel like I am an ant under their thumb lately and they’ve gotten so particular about every little thing.” – Provider 135, current participant. “Yeah, I don’t think their standards are difficult by any stretch. Well I guess by saying that, it’s easy if you want to serve them food from boxes. So I guess my complaint is I think they should allow you to have more whole foods, check my recipes, and approve them.” – Provider 133, current participant. “And I just feel like it’s just gotten more strict and overwhelming and it takes me a lot longer to do things.” – Provider 142, current participant. “Because, you know, during the pandemic, yeah, they [monitors/auditors] didn’t show up. And you could, you know, probably get away with things and be like, yeah, you know what, they’re not going to show up. So I can do it this way, right? Because to be completely frank, [children] have fed more vegetables to the floor than they have to themselves. And it’s just like, you know what, my floor is not hungry.” – Provider 133, current participant.
Perception that needs and complexities of operating FCH programs are not considered Relevant CFIR domains/subdomains: •Inner setting/relational connections, mission alignment, available resources •Implementation process •Individuals/role	Financial pressure	“It’s definitely a lot of work just keeping track...And I mean, I do keep up with it every day, but I mean, we are already so busy with these kids and we’re making little to no money anyway and again, spending our own money to be doing it. It’s really kind of something nice that we’re doing for the kids in the family, but we get penalized with our time and our money, which makes no sense. Like any other job, they would not be doing that.” – Provider 145, current participant.
	Compliance and training	“Sorry, you know, but [monitors] are so insulting to your intelligence. I’m like, Is this a joke?” – Provider 106, previous participant. “There are monitors that come out. It’s fine. I have no problem with that other than sometimes the length of stay. It’s very disruptive to the kids. Like, I mean, I don’t feel like an hour and a half to 2 h is necessary.” – Provider 147, current participant. “[The monitors] were good until their visits got so ridiculously long. I just couldn’t do it because they drop in and just stay so long. And they had always seemed to have problems with their technology when they were here. And she would have to enter things. And I’m like, I just can’t. Kids are chomping at the bit to go outdoors. And it was just too, too disruptive.” – Provider 138, previous participant. “Uh, it’s been kind of mixed. We had a really wonderful monitor for many years, and then we had a couple of really difficult visits where the person was intrusive. One time they walked into the daycare during nap time and shouted at people and scared all the children. We’ve had folks come and just stay for hours, which is very disruptive. But I think we’re back on track. I think we have someone now who’s really good. I haven’t been there. The other teachers have been, and I’ve heard them say that it’s gone really smoothly. Um.” – Provider 112, current participant.
	Need for additional resources to ease the process	“As far as I know, absolutely no help at all from the USDA. Not that I’m aware of. I have never gotten an e-mail. I have never gotten a piece of regular mail, a phone call, nothing from them. In fact, I want to write a letter about the two-tier system, and I don’t even know who to write it to. Yeah, because I have no idea who they are. From the state, nothing either” – Provider 132, current participant. “We have a Facebook page that the providers keep asking for their questions and stuff, and sometimes people ask questions about the food programs and, you know, or they’ll ask about menu choices and, you know, things like that.” – Provider 140, current participant “I think in general, knowing the why behind all of the different regulations would be very useful. And if there are certain things that like would be recommended or even if like, I don't know, if there was a resource available for helping make the menu, because like offering creative solutions to the specific problems of the daycare because obviously we have all of these dietary restrictions.” – Provider 114, current participant.
CACFP is still seen by many as essential for children’s nutrition and for lowering families’ financial and workload burden. Relevant CFIR domains/subdomains: •Innovation/relative advantage, cost •Inner setting/mission alignment, available resources •Individuals/motivation, need	Commitment to children’s nutrition	“I guess like back to the basics. If they’re well fed, then they can have the capacity to learn better and learn more because their nutritional needs are being met just like they’re getting sleep that they need. They’re getting the food that they need. They can have a more successful day.” – Provider 143, current participant. “Um, and also again learning strategies for ensuring that the children that I’m caring for are getting well balanced meals, even though they might have different habits at home. You know, they might not be the same. But thankfully when children are together with other kids, the peer pressure is helpful. Yes, of course, when everyone is eating the same thing, it’s really helpful.” – Provider 134, current participant. “I like the fact that there’s guidelines on what should be served for children at certain times. I found even in the past I’ve had new parents going… ‘I have no idea like what I should be serving them, especially as an infant when they're getting off the bottle.’ And I was able to share, ‘Well, this is what the food program requires. So this is a good way to go.’ I like that there’s guidelines to follow because I think for some people, if they don’t know what to do, [CACFP] can kind of have a direction.” – Provider 147, current participant.
	Lessening the burden on families	“Because they’re at work all day, you know. And they don’t want to have to worry about what am I going to pack for my kid lunch.” – Provider 108, current participant. “I think they are absolutely thrilled and relieved that they they’ve got enough to do in the morning, so they don't need to worry about feeding their child breakfast” – Provider 132, current participant. “Overall, the program has been good and helpful, so I don’t have to go up on my prices for my current families.” – Provider 105, current participant.
Providers stop or avoid participation in CACFP when they find or perceive the burdens outweigh the benefits. Relevant CFIR domains/subdomains: •Innovation/relative advantage, complexity •Inner setting/mission alignment •Individuals/role, motivation		“[Some families are] from a different culture and they don’t believe that their kid should be drinking cow’s milk every day. They don’t believe in, you know, certain foods. They believe in these other things. So I’m respectful. And now, not being on the food program, I don’t have to worry about that.” – Provider 106, previous participant. “But through covid… I just think the rules were just a little over the top. And I think that’s when they lost a lot of their providers... I stayed on the food program for a little bit during Covid, but then I stopped. It just got to be too much. [COVID’s] impact was more of the regulations and prepackaged and spread the kids apart and do this and do that.” – Provider 106, previous participant. “It’s easier when all the kids come with their little lunch bags and their freezer pack. We can just grab it and I can spend far more time outside and less time on food prep.” – Provider 138, previous participant.

Abbreviations: CACFP, Child and Adult Care Food Program; CFIR, Consolidated Framework for Implementation Research.

Theme 1: Providers experience fatigue and frustration related to time burdens, feasibility challenges, and limited flexibility

Influence on time

Providers expressed how the time required to complete tasks required for CACFP, including daily meal preparation and reporting on attendance and meal provision—which are necessary to ensure compliance with meal standards and to validate reimbursement rates—interfered with their main responsibilities as childcare providers. One participant said: “[it’s] already a lot of work to run a family childcare center, and now this is extra work [Provider 108, current participant].” Although many providers reported that, after getting used to it, paperwork was not necessarily difficult to complete, most participants reported that it was still burdensome because some paperwork had to be done daily or even multiple times a day (e.g., meal counts must be completed by the end of each meal). Regardless of the time required, providers consistently felt frustrated when they had to step away from the children, especially because most providers operated their programs without an assistant. In fact, this was a large motivating factor for opting out of CACFP reported by nonparticipating providers, with some providers feeling that they had been neglecting the children because of the work they had to do to comply with CACFP requirements at times. In contrast, providers who maintained participation reported relying on close friends and relatives to help, especially during mealtimes. For example, one provider noted, “So I have my husband, [he] is also a licensed assistant and so he helps me at lunch every day pretty much. I have everything else under control, but it’s nice to have an extra set of hands at lunch [Provider 150, current participant].”

Limited flexibility

Many providers also shared a feeling of frustration with limited flexibility and grace for errors with the reporting requirements and nutrition standards. Providers shared that if they accidentally included errors in the paperwork, there was an inability to correct it, which would lead to a lower rate of meal/snack reimbursement, creating a resentful attitude toward the program and administrators. One provider described feeling “like I am an ant under their thumb lately and they've gotten so particular about every little thing [Provider 135, current participant].” This lack of flexibility, combined with the paperwork demands that conflicted with providers’ need to care for children as described above, made providers feel misunderstood and underappreciated for all that they do in their role as a childcare provider. One said, “I just feel like it’s just gotten more strict and overwhelming and it takes me a lot longer to do things [Provider 142, current participant].”

Although there was a general appreciation from providers of the CACFP nutrition standards to guide meal planning to ensure nutritious snacks/meals for the children in their care, providers particularly felt the CACFP nutrition standards lacked flexibility, leading to higher costs, more waste, and less consumption. One provider shared “To be completely frank, [children have] fed more vegetables to the floor than they have to themselves. And it’s just like, you know what, my floor is not hungry. [Provider 133, current participant].” Another said, “You know, it’s just more of the problems of not being allowed to serve things to kids that the kids have been eating at home for years. (#106, previous participant).” Many mentioned that they were required to provide specific types of foods/beverages to children who would not consume it because of allergies, dietary preference, or pickiness, leading to high amounts of food waste. Cow milk was often reported as producing high amounts of waste in particular. Providers described how they either offer alternative options or serve larger amounts of foods/beverages the children will consume, even if these cannot be reimbursed and thus are at extra cost. Providers also felt that the standards limited their creativity and ability to accommodate children’s cultural backgrounds or dietary restrictions, such as vegetarian diets. Providers also felt the nutrition standards were easier to satisfy with packaged, highly processed foods than with scratch-cooked foods because of the challenge in getting scratch recipes approved; one provider said, “I don't think their standards are difficult by any stretch. Well I guess by saying that, it’s easy if you want to serve them food from boxes. So I guess my complaint is I think they should allow you to have more whole foods, check my recipes, and approve them [Provider 133, current participant].” All study participants who had left CACFP described their relief at having more flexibility since leaving the program.

Theme 2: Perception that needs and complexities of operating FCH programs are not considered

Financial pressure

Providers expressed an immense amount of financial pressure in operating their business, especially during and after the COVID-19 pandemic. Although CACFP’s meal reimbursements help financially, providers shared that these often only cover bare-minimum food costs. Some providers expressed that even though the reimbursement did not cover all the costs of meal/snack provision, it was still better than nothing. Some providers felt that, even if they did not participate in CACFP, they would continue buying the same types of foods, whereas others felt that their grocery bills would decrease substantially if they did not have to meet CACFP nutrition standards. Many providers noted that they continue to participate in CACFP because it would otherwise be infeasible to continue feeding the children without raising tuition.

CACFP’s 2-tiered reimbursement system for FCH providers was described unanimously as something that exacerbated financial pressures. This system is designed so that FCH providers in areas with lower median income, and/or FCH providers demonstrating they have low incomes themselves, can receive higher reimbursements, under the assumption that providers in lower income areas are more likely to be serving children with higher needs. Providers noted that, in reality, however, many children live in different geographic areas than the FCH, which has led to a mismatch of the economic need of the children attending the FCH and the FCH providers’ reimbursement tier. They also described how, during the COVID-19 pandemic, the tiering policy was changed so that all providers received the higher reimbursement rate, resulting in substantial financial relief. One provider noted that when they received the higher rate, this covered 75% of costs compared with 30% of costs when receiving the lower tier reimbursement rate. As a result, several providers whom we interviewed before the expiration of the relaxed tiering reimbursement system suggested that they would not be able to continue participating in CACFP if the tiering system returned.

Compliance

State CACFP agencies monitor FCHs, partly through auditor visits, to ensure compliance with the program. Some providers described monitors as easy, flexible to work with, helpful, and kind. Other providers, however, described negative experiences, characterizing them as quite harsh and lacking respect for FCH providers. This group of providers described such individuals as being “nitpicky,” “strict,” and “inflexible.” Providers also described a sense of mismatch between monitors’ actions and the needs of the children in their care; one noted, “I have no problem with [monitor visits] other than sometimes the length of stay. It’s very disruptive to the kids. Like, I mean, I don't feel like an hour and a half to 2 h is necessary [Provider 147, current participant].” Some providers felt that these auditors went out of their way to try to find errors, which could lead to denial of the provider’s reimbursement claims. Some providers reported feeling that auditors often seemed to forget that a FCH operates from the provider’s own home and seemed to forget basic manners for visiting another’s house. One provider summed up their experience as follows: “We had a really wonderful monitor for many years, and then we had a couple of really difficult visits where the person was intrusive. One time they walked into the daycare during nap time and shouted at people and scared all the children. We’ve had folks come and just stay for hours, which is very disruptive. But I think we’re back on track. I think we have someone now who’s really good [Provider 112, current participant].” Among participants who had formerly participated in CACFP, one of the main reasons they reported for leaving was experiencing auditors that they described as “too disruptive” or “rude.” For example, one provider said the monitors “were good until their visits got so ridiculously long. I just couldn't do it because they drop in and just stay so long. And they had always seemed to have problems with their technology when they were here. And she would have to enter things. And I'm like, I just can't. Kids are chomping at the bit to go outdoors. And it was just too, too disruptive [Provider 138, previous participant].”

Additional resources to support implementation

Providers also expressed receiving minimal other support with implementing CACFP. Most participants described relying on informal information-gathering systems for support. They often reached out to other FCH providers with questions or relied on Facebook support groups for FCH providers.

To ease the implementation process, providers suggested additional technical assistance (e.g., resources for meal planning, additional training on meal preparation for children with food allergies) combined with less tedious paperwork, material supports (e.g., equipment and paper products to serve foods and cleaning products to support clean up because these items add significantly to the costs of meal/snack provision), and a higher reimbursement overall to cover the cost of the entire food bill. One provider said, “I think in general, knowing the why behind all of the different regulations would be very useful. And if there are certain things that like would be recommended or even if like, I don't know, if there was a resource available for helping make the menu, because like offering creative solutions to the specific problems of the daycare because obviously we have all of these dietary restrictions [Provider 114, current participant].”

Theme 3: CACFP is still seen by many as essential for children’s nutrition and for lowering families’ financial and workload burden

The motivations to participate in CACFP were overwhelmingly similar among study participants, and they were primarily altruistic. Key motivators included being able to help families and children, feed children healthy meals, and reduce families’ financial and workload burden. Providers pointed out that for some families, particularly those who may not have the resources or time to prepare nutritious meals, childcare might be the only opportunity children have to eat healthy foods. Therefore, the importance of providing a variety of healthy foods was a clear motivator for providers to participate. Although all providers voiced their desire to feed healthy food to the children under their care, most mentioned it would be difficult or impossible to do so without CACFP’s reimbursements, even if these only partially covered costs. One participant described how participating in CACFP made it possible to serve healthy foods in the face of high costs: “I have a lot of families that weren't bringing healthy things. I would have a lot of kids that would bring something like, you know, Doritos and a cupcake and that’s all they'd be eating all day. So I just started, you know, providing the food and it was just getting super, super expensive. Especially with the cost of food. [Provider 145, current participant].”

Some providers felt an additional benefit of participating was the opportunity to offer parents a reliable nutritional guide that they could use at home with their children to promote healthy eating. One provider noted, “I like the fact that there’s guidelines on what should be served for children at certain times. I found even in the past I've had new parents going… ‘I have no idea like what I should be serving them, especially as an infant when they're getting off the bottle.’ And I was able to share, ‘Well, this is what the food program requires. So this is a good way to go.’ [Provider 147, current participant].” Providers also reported that participating led to children being willing to try new foods, gaining experiential learning by participating in meal preparation with the providers, and consuming healthy meals that support growth and development. Some providers also shared that participating resulted in personal benefits to the provider, such as a sense of fulfillment and an overall positive impact on the caregiving experience. One provider mentioned that participating in CACFP gave her an advantage compared with other FCH businesses, by having a higher likelihood to enroll families because she was providing meals.

Theme 4. Providers stop or avoid participation in CACFP when they find or perceive the burdens outweigh the benefits

Study participants who no longer participated in CACFP expressed that this decision allowed them to operate their FCH more easily without the burden and stress of fulfilling CACFP’s operational requirements. One provider described it thus: “It’s easier when all the kids come with their little lunch bags and their freezer pack. We can just grab it and I can spend far more time outside and less time on food prep [Provider 138, previous participant].” Providers also reported that not participating in CACFP added flexibility during meal/snack times, reduced food waste, and allowed them to spend more time with the children. One never-participating provider shared, “I also hear there’s a lot of waste and that’s not anything that I’m willing to take on [Provider 154, never participant].” These providers still valued nutritious meals and fair prices for families, but felt that not participating did not interfere with maintaining fair prices for their families and serving nutritious meals. One provider who no longer participates in CACFP described how she thinks a meal she recently served to her children would not have met CACFP nutrition standards: “Like our lunch today. I'm not sure if that would have passed the food program, but I could be wrong [Provider 104, previous participant].”

When comparing participating providers with formerly participating providers, those who left described feeling an unsustainable level of burden for accommodating dietary preferences of the children under their care while navigating CACFP nutrition standards. This was particularly problematic when children and/or their families had dietary restrictions or preferences that FCH providers perceived as difficult to honor, practically speaking, with CACFP; providers facing this situation reported switching to parent-provided meals/snacks. Several formerly participating providers specifically noted that they discontinued CACFP participation because they felt that more onerous state-level rules around food safety and cleaning were introduced during the COVID-19 pandemic, which they felt increased the participation burden so much that it was no longer worthwhile.

Discussion

In this qualitative study of FCH providers in Massachusetts, study participants described how the entire process of implementing CACFP—planning and preparing meals that meet rigid nutrition standards and maintaining required paperwork in particular—is a challenge for their unique context. While expressing their appreciation for the program and alignment with CACFP’s values (i.e., promoting healthy eating and supporting food security for young children), the FCH providers in this study also expressed how difficult it is to take on the administrative and meal preparation tasks required while simultaneously caring for children and running their business, even with the support of sponsors. They also expressed that they feel this conflict is not adequately acknowledged or supported by CACFP administrative agencies. When coupled with a sense of inadequate financial support and inflexibility, the challenges FCH providers faced in balancing the demands of implementation with the demands of caring for young children contributed to a sense among some that participation was not worth the trouble. Among those who maintained participation, a strong commitment to helping families and a sense that it would not be possible to serve meals without CACFP was enough to overcome these challenges, but providers still reported fatigue and frustration.

Inadequate finances, burdensome paperwork, and lack of implementation support have also been found in prior studies to be implicated in FCH’s providers’ nonparticipation in CACFP [[14], [15], [16], [17], [18], [19]]. Our results clarify, however, these alone are not necessarily the reasons why FCH programs may opt out of participating. In terms of CFIR [22], our results suggest that there is instead often a conflict related to the inner setting in terms of mission alignment and available resources. Providers in our study were willing to put up with paperwork and less financial support than would ideally cover their costs; exhibiting a substantial level of altruism, they are willing to do a lot of things to provide better services for their families and to support children’s growth. For the providers in this study, particularly those who either had stopped participating or were contemplating it, the issue was not the workload of implementing CACFP itself, but rather how the workload actively threatened their ability to do the most essential part of their job—caring for children. This conflicted with one of their foundational roles of providing responsive caregiving [29,30]. Thus, using a CFIR frame, without adequate mission alignment and resources to support their role, adoption of CACFP became untenable.

Modifying this pressure on providers’ sense of mission alignment and available resources in the inner setting by better linkage to outer context resources, per CFIR [22], could be beneficial. Although CACFP sponsors support FCH providers and some childcare centers with CACFP compliance and can help providers plan menus and compile paperwork [31], their capacity to help providers with the day-to-day implementation of CACFP is ultimately limited. This is in stark contrast to the United States’ nutrition assistance program for primary and secondary schools, the National School Lunch and Breakfast Programs [32,33], in which implementation is supported by school food authorities composed of staff members dedicated to planning, preparing, and serving meals and ensuring compliance [34], leaving educators to their roles as teachers. Although developing a CACFP implementation infrastructure that more closely resembles school food infrastructure, that is, taking some of the day-to-day burden of meal preparation and paperwork off of the providers themselves, may not be feasible, especially given the relatively fractured and underfunded landscape of childcare in the United States [13], our results, along with previous research among sponsors themselves [15], do suggest that providing more outer context resources and implementation support to FCH providers may be critical for ensuring continued CACFP participation.

Our results, interpreted through a CFIR lens, also suggest the importance of considering FCH providers’ perceptions of complexity. Absent the development of more supportive food service infrastructure for childcare programs, another solution to the challenge of underutilization could be for policymakers to allow more flexibility for childcare programs and recognition of the unique operating challenges they face. Policies allowing for more substitutions that support diets that are restricted by food allergies, cultural preferences, and/or vegetarian/vegan choices—or, possibly, clarifying to FCH providers in which there already is flexibility and clarifying in which they can make changes now—and eliminating paperwork barriers to use such substitutions could be an important step toward reducing complexity, as could standards that hold weekly, rather than daily, nutritional requirements to allow for more day-to-day variability in what is served. Absent these types of changes, our results suggest that even the simple act of program administrators’ training CACFP agency staff to recognize and sympathize with the challenges FCH providers face and to acknowledge in which FCH providers have expertise in caring for the children in their programs could go a long way toward improving providers’ experiences with the program.

Strengths of the study include the use of an implementation science framework to develop and guide the interviews, ensuring that the researchers systematically asked participants to consider multiple aspects of the implementation process. The inclusion of both current and former participants in the study sample, as well as the inclusion of a diverse group of FCH providers across the state of Massachusetts, also allowed for new understandings of why utilization of CACFP may be low and what the implementation challenges are for FCH providers participating in CACFP. Limitations of the study include the nongeneralizable sample—as with most qualitative studies, which prioritize detail and depth for transferability over representativeness, the sample was geographically limited and was recruited via convenience sampling methods, so the results herein may not generalize to all FCH populations. The use of snowball sampling approaches in particular may have resulted in our hearing perspectives only from those who were connected to our initial FCH provider contacts, although we note that we did see a diversity of sometimes differing perspectives in our data. Additionally, we were unable to reach as many former CACFP participants as current participants. This limits our ability to rigorously compare current with former participants and requires that the results related to former CACFP participants be interpreted with caution given the extremely small sample size.

In conclusions, FCH providers face challenges in implementing CACFP to provide healthful meals to children in their care because the process essentially requires taking on another professional role—even with the support of sponsors—yet most continue to participate in CACFP despite the challenges because of their valuing of young children’s nutrition and their commitment to supporting child health. Developing more supportive food service and administrative compliance infrastructure for childcare, potentially through leveraging the existing sponsorship system, could be an important strategy for addressing the constellation of implementation challenges FCH providers face, thus improving utilization and ensuring that children are provided with nutritionally optimal meals. Research should continue to explore how best to support CACFP sponsors and ECE providers so that, in turn, they are best able to provide needed nutritious foods for the children they serve.

Author contributions

The authors’ responsibilities were as follows – KKE, ELK: designed research; AC-G, KKE, ELK: conducted the interviews; KKE, JI, AC-G, MZ: analyzed data; ELK, KKE: wrote the paper; MZ, JI, AC-G: edited the paper; ELK: had primary responsibility for final content; and all authors: read and approved the final manuscript.

Data availability

Data described in the manuscript, code book, and analytic code will not be made available because of the inability to fully deidentify data and sensitive information. For additional information, see our website at https://jn.nutrition.org/content/authorinfo.

Declaration of Generative AI and AI-assisted Technologies in the Writing Process

The authors declare that no generative AI or AI-assisted technologies were used in the writing of this manuscript.

Funding

This work was supported by a National Institute for Diabetes and Digestive and Kidney Diseases Career Development Award (K01DK125278) and the Centers for Disease Control and Prevention (U48DP006785). The funders had no role in the study design; collection, analysis, and interpretation of data; writing of the report; and were not involved in publication.

Conflict of interest

The authors report no conflicts of interest.

Appendix A. Supplementary data

The following is the Supplementary data to this article: