Abstract
Introduction:
To date, gaps exist in our understanding of how child care provider participation in various support programs is associated with the reported implementation of nutrition and physical activity best practices by child care providers. Thus, the purpose of the current study was to compare implementation of nutrition and physical activity best practices among child care providers engaged in the Child and Adult Food Care Program (CACFP), Parent AWARE, and other training opportunities, to implementation among providers who do not participate in each of these opportunities.
Methods:
Cross-sectional analysis of survey data collected from a stratified-random sample of licensed family-home and center-based child care settings (Family-homes n=394; Centers n= 224) in XXX from Month-Month 20XX. Descriptive statistics and multiple regression models were used to characterize differences in adherence to best practices based on program participation (CACFP, Parent AWARE, training) and type of child care setting (center versus family-home). Surveys measured self-reported engagement in nutrition and PA best practices as well as participation in CACFP, Parent Aware, and training opportunities.
Results:
Center-based child care providers participating in CACFP adhered to more nutrition and PA best practices than those not involved in CACFP. Further, with one exception, participating in Parent AWARE and engagement in training were positively associated with adherence to nutrition practices in center and family-home setting, and with adherence to PA practices in family homes.
Conclusions:
Child care providers should be encouraged to participate in available support programs; advocates should work to identify and remove barriers to support program participation.
Keywords: Child care, Child and Adult Care Food Program, Nutrition best practices, Physical activity best practices, Child care training, Quality rating improvement syste
1. Introduction
More than two thirds of US children under age five are enrolled in a licensed child care program, including centers and family child care homes. (National Academies of Sciences, 2016) Child care settings offer numerous opportunities for interventions aimed at improving dietary intake and physical activity (PA) patterns in preschoolers, (Birch, Parker, Burns, et al., 2011; Kaphingst, French, & Story, 2006; Neelon & Briley, 2011; Nicklas et al., 2001; Pediatrics AA of, 2002) as children spend a significant amount of their waking hours and routinely consume 1–2 meals and snacks in these settings.(National Academies of Sciences, 2016) The knowledge that child care settings are uniquely positioned to impact children’s eating and physical patterns (Kaphingst et al., 2006) has led to the development of recommended nutrition and PA best practices. (Education NRC for H and S in CC and E. Caring for Our Children, 2011; McGuire, 2012; National Academies of Sciences, 2016; Neelon & Briley, 2011; Pratt, Stevens, & Daniels, 2008) However, a lack of federal and only minimal state regulations means that compliance with best practices is optional and any burden associated with compliance is assumed by child care providers themselves.
A multitude of programs have been developed to provide nutrition and PA related guidance and assistance to child care providers. For example, the United States Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP), a federal nutrition assistance program that provides re-imbursement for meals and snacks for children in participating child care programs, makes a pointed effort to promote healthy behaviors within child care environments. (Murphy, Yaktine, Suitor, & Moats, 2012) For programs to qualify for reimbursement through CACFP, the foods they serve for meals and snacks must comply with a number of nutrition standards; these standards were recently updated in 2017 to require a greater variety of vegetables and fruit, more whole grains, and less added sugar and saturated fat. CACFP also offers its’ participants various educational and training opportunities, as well as resources (e.g. recipes, tip sheets) all focused on promoting nutrition and physical activity best practices. Childcare providers from sites participating in CACFP are required to complete one CACFP compliance training annually; additional educational and training opportunities are made available to all CACFP participants, but participation is not required. CACFP participation has been associated with increased compliance with nutrition best practices, including offering whole grain foods daily and providers modeling healthy food intake, as well as greater consumption of milk, vegetables, and reduced consumption of sweets (Korenman, Abner, Kaestner, & Gordon, 2013; Liu, Graffagino, Leser, Trombetta, & Pirie, 2016; Monsivais, Kirkpatrick, & Johnson, 2011; Murphy et al., 2012; Ritchie, Boyle, Chandran, et al., 2012). Beginning with the introduction of the national Healthy, Hunger Free Kids Act of 2010, CACFP sites across the country have also been encouraged to offer daily opportunities for PA and to limit children’s exposure to screen time; despite the introduction of these focused efforts to increase opportunities for physical activity and reduce child screen time at CACFP sites, no CACFP specific physical activity or screen time requirements have been introduced, nor are physical activity and screen time behaviors assessed as a part of program compliance. Less is known about adherence to PA best practices among CACFP versus non-CACFP sites, as the call for CACFP sites to focus more on encouraging PA among children is fairly recent. However, one 2016 study of 350 child care centers in the Midwest found no significant differences between CACFP and non-CACFP child care settings in adherence to PA best practices.(Liu et al., 2016)
Parent AWARE is Minnesota’s Quality Rating and Improvement System (QRIS), a state-run program, as a part of the federal Child Care Aware of America program funded by the Department of Health and Human Services that aims to connect families with quality child care programs by making high quality child care programs easy to identify. States can use a QRIS to set standards that define high-quality care and award child care providers with a quality rating designation based on how well they meet these standards. More than three-quarters of states (n=38) have a child care QRIS program; however, program standards and associated support services vary from state to state. In Minnesota, licensed child care programs can volunteer to be rated by the Parent AWARE program, which assesses programs based on their participation in and commitment to ongoing training, adherence to a range of child care best practices, and commitment to maintaining daily activities and routines that help children learn and grow appropriately. During the Parent Aware assessment, providers are specifically evaluated on what their program’s nutrition and physical activity environment currently looks like and encouraged to work with their evaluator to set goals to improve this environment; there are no Parent Aware specific nutrition and physical activity best practices that programs are required to follow. Providers who engage in the Parent AWARE evaluation process are connected with free education, coaching and training opportunities as well as scholarship opportunities. (Tout, Starr, Albertson-Junkans, Soli, & Quinn, 2011) To our knowledge, the impact of Parent AWARE or other QRIS programs on nutrition and PA practices has not been thoroughly evaluated.
Government and privately run child care training programs have also become prevalent over the past decade; overall, these various local, state, and national training programs aim to deliver knowledge, skill-based lessons, and practical tips to providers related to improving the nutrition and PA environment in their child care setting. Recommended best practices suggest that providers participate in one nutrition- and one PA-focused training annually, but regular training is not required for licensing.(Pediatrics AA of, 2002) The widespread availability of child care training programs focused on nutrition and physical activity is helpful, in that it makes it easier for providers interested in meeting best practices by attending a nutrition or physical activity training to do so; at the same time, there is no oversight with regard to the content included in privately run trainings, which means that the type and quality of content included could vary widely from training to training. While individual training programs are often evaluated for effectiveness, information on how participation in training impacts provider compliance with recommended nutrition and PA best practices is scarce.
To date, gaps exist in our understanding of how participation in various support programs is associated with the reported implementation of nutrition and PA best practices by providers. Thus, the purpose of the current study was to compare implementation of nutrition and PA best practices among providers engaged in CACFP, Parent AWARE, and other training opportunities to adherence among providers who do not participate in each of these opportunities.
2. Methods
2.1. Study advisory board
An active advisory board of child care experts and key stakeholders were relied on to guide all aspects of the current study, including assistance with recruiting participants, development of the survey instrument, interpretation of study findings, and dissemination of the results to key decision makers. The advisory board included individuals representing state agencies like the State Departments of Health (e.g., Early Care and Education Specialist, Nutrition) and Education (e.g., Child and Adult Care Food Program [CACFP] program staff), local public health (Bloomington Public Health, Statewide Health Improvement Program), nonprofit advocacy organizations (Public Health Law Center, Hunger Impact Partners), association representatives (e.g., West Central Initiative, Association of Family Home Providers, State Head Start Director), licensure regulators (Minnesota Department of Health Services child care licensing), a CACFP sponsoring organization, and a handful of ECE providers. Members of the advisory board were not allowed to participate in the study.
2.2. Study design and procedures
In 2016, the University of Minnesota conducted a survey of licensed Minnesota child care providers in collaboration with the Center for Prevention at Blue Cross and Blue Shield of Minnesota (“Healthy Start, Healthy State” study). This survey was a follow-up to a 2010 survey of providers in Minnesota and Wisconsin. A stratified random sampling procedure was used in 2010 to select a representative sample of licensed child care centers and licensed family home providers. (Korenman et al., 2013) One provider from all child care sites that participated in 2010, and were still open, was invited again to participate again in 2016 (cohort sample n=215). Additionally, a new sample of providers was recruited in 2016 using a stratified random sampling technique (2016 random sample n=175); a random sample of licensed child care providers stratified by provider type (center and family home) were invited to participate with the goal of surveying a sample of licensed child care providers that represented providers from different types of care settings. Providers were mailed a packet that included the study description, a unique link to a site to take the survey online, a paper copy of the survey, and a postage paid return envelope in which to return a completed paper survey. Providers were given a $30 gift card for their participation in the study. Additionally, surveys were completed by an open, convenience-based sample of providers (convenience sample n=228); members of the advisory board were provided with an email that included a study description and link to the online survey and invited to pass along this invitation to any potential participants. Only the online survey option was available and no monetary incentive was provided. The University of Minnesota Institutional Review Board approved all study procedures.
Survey responses for all three samples (cohort sample from 2010, random sample from 2016, and convenience sample) were maintained in separate databases to ensure that no one provider participated in the 2016 survey twice and to allow for comparison between participants recruited in each of these distinct ways on key study variables (e.g. nutrition and physical activity practices, license type). No meaningful differences in adherence to nutrition and physical activity best practices were found between participants recruited using the three methods. However, meaningful differences in license type were found between participants recruited using these three methods; more providers representing Child Care Centers were recruited from the original cohort sample, whereas more providers representing Family Homes were recruited within the 2016 random sample and the 2016 open sample. Thus, for the current analysis, data collected from these three separate recruitment techniques were combined, but all analyses were stratified by license type. Only data collected from the surveys completed in 2016 was used for the current analysis (Overall N=618; Centers N=224; Family Home N=394); data collected from surveys completed in 2010 was not used. Details on provider respondent characteristics are included in Table 1.
Table 1.
Provider responder characteristics, by license type.
| Overall | Centers | Family home | |
|---|---|---|---|
| N = 618 | N = 224 | N = 394 | |
| Provider characteristics | |||
| Age, mean (SD) | 46.2 (10.9) | 45.4 (11.4) | 46.6 (10.6) |
| Non-Hispanic White, N (%) | 561 (96%) | 204 (96%) | 357 (96%) |
| Education, N (%) | |||
| Some high school or high school graduate | 95 (16%) | 2 (1.0%) | 93 (25%) |
| Trade school or some college | 237 (40%) | 45 (21%) | 192 (51%) |
| Bachelors or graduate | 262 (44%) | 169 (78%) | 93 (25%) |
| Years of ECE experience, Mean (SD) | 18.7 (10.3) | 18.7 (10.0) | 18.8 (10.4) |
| Program/site characteristics Head start, N (%) | 21 (3%) | 21 (9%) | 0 (0%) |
| Total number of children on a typical day | |||
| Median (interquartile range) | 10 (8 – 36) | 50 (32 – 78) | 8 (7 – 10) |
| Serve at least one meal, N (%) | 563 (92%) | 173 (77%) | 390 (100%) |
| Serve meal or snack, N (%) | 613 (99.8%) | 223 (99.6%) | 390 (100%) |
| Do not serve meals/snacks, N (%) | 1 (0.2%) | 1 (0.5%) | 0 (0%) |
| Location, N(%) | |||
| Urban | 386 (62%) | 163 (73%) | 223 (57%) |
| Rural | 232 (38%) | 61 (27%) | 171 (43%) |
| Characteristics of families served Average annual family income, N (%) | |||
| < $25,000 | 48 (8%) | 35 (16%) | 13 (3%) |
| $25,000 – $59,999 | 213 (34%) | 70 (31%) | 143 (36%) |
| > = $60,000 | 208 (34%) | 76 (34%) | 132 (34%) |
| I do not know/missing | 149 (24%) | 43 (19%) | 106 (27%) |
| Currently have children with assistance/scholarships, N (%) | |||
| Yes | 250 (43%) | 145 (70%) | 105 (28%) |
| No | 112 (19%) | 21 (10%) | 91 (24%) |
| We are willing to accept subsidies, but we currently do not have families who participate in the program. | 225 (38%) | 41 (20%) | 184 (48%) |
| Another language (besides English) spoken at home, N (%) | 146 (24%) | 106 (47%) | 40 (10%) |
Data are from providers in the cohort (n = 215), random sample (n = 175) and eligible providers in the open sample (n = 228).
Number totals differ slightly within some cells due to missing responses on participant surveys.
2.2.1. Measures
A 115-item survey was adapted from the 2010 survey with heavy input from the stakeholder advisory board and was pilot tested with nine providers. A complete copy of the survey is available at the project website z.umn.edu/healthystarthealthystate.
2.2.2. Nutrition and PA best practices
Nutrition best practices included 18 questions within two categories assessing whether providers: 1) serve healthy meals, snacks, and beverages (n=12) and 2) encourage and model healthy eating habits (n=6). PA best practices included six questions within two categories assessing whether providers: 1) meet frequency and time standards for providing PA opportunities, including for special needs children (n=3) and 2) limit inactive/sedentary time (n=3). Individual nutrition and PA items are detailed within Tables 2 (nutrition) and 3 (PA).
Table 2.
Participation in support programs: overall and by type of child care program.
| Support program participationa | All sites | Centers | Family homes |
|---|---|---|---|
| N = 608b | N = 220 | N = 388 | |
| N (%) | N (%) | N (%) | |
| All 3 support programs | 93 (15.3) | 36 (16.4) | 57 (14.7) |
| Two support programs | 229 (37.7) | 82 (37.3) | 147 (37.9) |
| One support program | 221 (36.4) | 54 (24.6) | 167 (43.0) |
| No support programs | 65 (10.7) | 48 (21.8) | 17 (4.4) |
Participants were asked to indicate (yes/no) if their child care site participated in each of three support programs (CACFP, Parent AWARE, and other training). This table provides information on total number of support programs participated in, overall and by type of child care program.
All program participation data is missing for 10 of the 618 sites (4 Centers and 6 Family homes).
Six response options allowed participants to indicate either 1) how difficult it would be to comply with each best practice, (using a 5-item Likert scale: “very difficult,” “difficult” “somewhat difficult,” “not difficult” “not at all difficult”, or 2) to indicate that they “already do this”. Summated scales were constructed by summing the number of nutrition-related best practices already implemented (n= 18) (range 0 – 18; Cronbach’s Alpha for All Programs: 0.86;); and the number of PA-related best practices already implemented (n= 6) (range 0 – 6; Cronbach’s Alpha for All Programs: 0.74;).
2.2.3. Support program participation
All information on support program participation was gathered via survey. Study instructions that accompanied the survey indicated that the survey was to be completed by the person (provider, director or teacher) most knowledgeable about nutrition and physical activity issues within the child care facility. Providers self-reported their program’s participation (yes/no) in the Child and Adult Care Food Program (CACFP) program. Providers also self-reported if their program was currently Parent AWARE rated (yes/no) and if anyone at their program (themselves or another provider or staff member) had participated in any Nutrition and/or PA Training opportunities in the past year (yes/no). No information on specific Parent AWARE Star Rating was gathered, nor were participants asked to report the specific type (physical activity or nutrition or combo) or amount of training received.
2.2.4. Analysis
Descriptive statistics were calculated to determine the number and percent of the sample that participated in three, two, one or none of the available support programs (CACFP, Parent AWARE, additional training); these calculations were done for all sites, as well as stratified by type of site (Center versus Family Home). A chi-square test was run to evaluate differences in support program number distribution between centers and family homes. Two sample t-tests were used to evaluate differences in mean nutrition and PA best practice scores by current CACFP participation (yes/no); Parent AWARE participation (yes/no); and whether providers participation in training (yes/no). Chi-square tests were used to evaluate associations between individual best practices and participation in each of the three support programs (CACFP, Parent AWARE, training). Due to a priori hypothesis that observed associations might be different between center and family-home based providers, findings are reported separately by type of provider. Finally, because significant associations were observed between support program participation (CACFP, Parent AWARE, training) and nutrition and PA best practice scores, separate multiple regression models were run to examine associations between each type of support program and best practice score, adjusted for the other types of support programs and type of child care. Variables for interaction between child care types were run. SAS version 9.4 was used for all statistical analysis (SAS Institute Inc., Cary, NC, US).
3. Results
3.1. Support program participation
Approximately 15% (n=93, 15.3%) of all participating sites reported being engaged in all three support programs, 37.7% reported being engaged in two support programs, 36.4% reported being engaged in one support program, and 10.7% of sites indicated that they did not participate in any of the three support programs assessed. Differences in overall engagement in support programs across site type (center versus family home) were observed; for example, child care centers were more likely to report that they did not engage in any of the three support programs (21.8%) as compared to family homes (4.4%). Additional details on overall engagement in support programs, as well as engagement in support programs by site type are presented in Table 2.
With regard to participation in specific types of support programs, participation in CACFP was much higher in family-homes (92.9%) than in child care centers (50.7%). Almost two thirds of child care centers (62.8%) were Parent AWARE rated, compared to just under half (45.6%) of family homes. Around 40% of family-homes (41.6%) and child care centers (37.3%) reported participating in nutrition training; 46.0% of family-homes and 43.8% of child care centers reported participating in physical activity or gross motor training. Additional details can be found in Tables 3 and 4.
Table 3.
Engagement in nutrition best practices by participation in CACFP, parent AWARE, and nutrition training.
| CACFP participant | Parent AWARE participant | Nutrition training participant | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Centers | Family homes | Centers | Family homes | Centers | Family homes | |||||||||||||
| N =217 | N = 386 | N = 215 | N = 382 | N = 217 | N = 387 | |||||||||||||
| Overall nutrition best practices scorea | Yes | No | P-Value | Yes | No | P-Value | Yes | No | P-Value | Yes | No | P-Value | Yes | No | P-Value | Yes | No | P-Value |
| % (N) | 50.7 (110) | 49.3 (107) | — | 92.8 (358) | 7.2 (28) | — | 62.8 (135) | 37.2 (80) | — | 29.6(113) | 70.4 (269) | — | 37.3 (81) | 62.7 (136) | — | 41.6 (161) | 58.4 (226) | — |
| Mean (SD) | 11.5 (4.1) | 9.5 (4.5) | < 0.01 | 10.0 (4.4) | 9.6 (5.2) | 0.62 | 11.4 (4.4) | 9.2 (4.1) | < 0.01 | 11.1 (4.4) | 9.5 (4.5) | < 0.01 | 11.6 (4.8) | 10.0 (4.0) | < 0.01 | 10.8 (4.4) | 9.4 (4.5) | < 0.01 |
| Nutrition Best Practices % (N) High fat foods less than once a week | 51.8 (57) | 48.6 (52) | 0.64 | 48.9 (175) | 42.9 (12) | 0.54 | 49.6 (67) | 50.0 (40) | 0.96 | 55.8 (63) | 45.0 (121) | 0.05 | 53.1 (43) | 47.8 (65) | 0.45 | 51.6 (83) | 46.0 (104) | 0.28 |
| Only lean meat, nuts, beans, lentils, and tofu for protein sourcesb | 21.8 (24) | 18.7 (20) | 0.57 | 23.7 (85) | 14.3 (4) | 0.25 | 24.4 (33) | 15.0 (12) | 0.10 | 27.4 (31) | 20.5 (55) | 0.14 | 28.4 (23) | 15.4 (21) | 0.02 | 31.7 (51) | 16.8 (38) | < 0.01 |
| Processed meats less than once per weekb | 44.6 (49) | 39.3 (42) | 0.43 | 49.2 (176) | 50.0 (14) | 0.93 | 45.2 (61) | 35.0 (28) | 0.14 | 54.0 (610 | 46.5 (125) | 0.18 | 49.4 (40) | 38.2 (52) | 0.11 | 49.1 (79) | 49.1 (111) | 0.99 |
| High sugar foods less than once per week | 51.8 (57) | 48.6 (52) | 0.64 | 46.7 (167) | 53.6 (15) | 0.48 | 54.8 (74) | 43.8 (35) | 0.12 | 52.2 (59) | 44.6 (120) | 0.17 | 56.8 (46) | 47.8 (65) | 0.20 | 54.7 (88) | 41.6 (94) | 0.01 |
| Low sodium meals or snacks everyday | 29.1 (32) | 28.0 (30) | 0.86 | 27.7 (99) | 21.4 (6) | 0.48 | 34.1 (46) | 21.3 (17) | 0.05 | 30.1 (34) | 25.3 (68) | 0.33 | 40.7 (33) | 21.3 (29) | < 0.01 | 33.5 (54) | 22.6 (51) | 0.02 |
| Whole grain or at least 1 whole grain dailyb | 57.3 (63) | 29.0 (31) | < 0.01 | 45.5 (163) | 50.0 (14) | 0.65 | 53.3 (72) | 27.5 (22) | < 0.01 | 46.9 (53) | 44.2 (119) | 0.63 | 53.1 (43) | 37.5 (51) | 0.03 | 50.3 (81) | 42.5 (96) | 0.13 |
| At least one fruit/non-fried vegetable at every meal or snackb | 64.6 (71) | 48.6 (52) | 0.02 | 64.0 (229) | 60.7 (17) | 0.73 | 65.9 (89) | 43.8 (35) | < 0.01 | 64.6 (73) | 62.5 (168) | 0.69 | 66.7 (54) | 50.7 (69) | 0.02 | 70.8 (114) | 58.4 (132) | 0.01 |
| Serve only unflavored milk and water | 47.3 (52) | 53.3 (57) | 0.38 | 55.3 (198) | 67.9 (19) | 0.20 | 55.6 (75) | 45.0 (36) | 0.13 | 63.7 (72) | 53.5 (144) | 0.07 | 50.6 (41) | 50.0 (68) | 0.93 | 60.9 (98) | 52.7 (119) | 0.11 |
| Only unflavored whole milk for children 12–23 monthsb | 79.1 (87) | 43.9 (47) | < 0.01 | 74.3 (266) | 71.4 (20) | 0.74 | 68.2 (92) | 52.5 (42) | 0.02 | 83.2 (94) | 69.5 (187) | < 0.01 | 65.4 (53) | 59.6 (81) | 0.39 | 77.6 (125) | 70.8 (160) | 0.13 |
| Only unflavored lowfat milk to children two and olderb | 85.5 (94) | 58.9 (63) | < 0.01 | 84.1 (301) | 64.3 (18) | < 0.01 | 79.3 (107) | 61.3 (49) | < 0.01 | 87.6 (99) | 80.3 (216) | 0.09 | 79.0 (64) | 69.1 (94) | 0.11 | 87.0 (140) | 79.2 (179) | 0.05 |
| Never serve sugar sweetened beveragesb | 87.3 (96) | 72.0 (77) | < 0.01 | 75.4 (270) | 53.6 (15) | 0.01 | 83.0 (112) | 73.8 (59) | 0.11 | 82.3 (93) | 70.3 (189) | 0.01 | 82.7 (67) | 78.7 (107) | 0.47 | 76.4 (123) | 71.7 (162) | 0.30 |
| Drinking water is available to children throughout operating hoursc | 92.7 (102) | 81.3 (87) | 0.01 | 89.7 (321) | 78.6 (22) | 0.07 | 89.6 (121) | 83.8 (67) | 0.21 | 94.7 (107) | 86.3 (232) | 0.02 | 87.7 (71) | 87.5 (119) | 0.97 | 93.2 (150) | 85.4 (193) | 0.02 |
| Include healthy foods and non-food items at celebrations | 48.2 (53) | 50.5 (54) | 0.74 | 46.7 (167) | 50.0 (14) | 0.73 | 50.4 (68) | 47.5 (38) | 0.68 | 59.3 (67) | 42.4 (114) | <0.01 | 58.0 (47) | 45.6 (62) | 0.08 | 57.8 (93) | 39.8 (90) | < 0.01 |
| Refrain from using food for reward or punishment | 86.4 (95) | 81.3 (87) | 0.31 | 76.5 (274) | 64.3 (18) | 0.15 | 88.2 (119) | 76.3 (61) | 0.02 | 85.8 (97) | 72.1 (194) | < 0.01 | 84.0 (68) | 85.3 (116) | 0.79 | 78.9 (127) | 73.5 (166) | 0.22 |
| At least one adult sits at table and eats with children | 81.8 (90) | 70.1 (75) | 0.04 | 37.4 (134) | 53.6 (15) | 0.09 | 79.3 (107) | 70.0 (56) | 0.13 | 38.9 (44) | 37.6 (101) | 0.80 | 80.3 (65) | 73.5 (100) | 0.26 | 37.9 (61) | 38.9 (88) | 0.83 |
| Model healthy eating behaviors during meal and snack time | 78.2 (86) | 71.0 (76) | 0.23 | 61.7 (221) | 67.9 (19) | 0.52 | 77.8 (105) | 68.8 (55) | 0.14 | 68.1 (77) | 59.5 (160) | 0.11 | 82.7 (67) | 70.6 (96) | 0.05 | 65.8 (106) | 59.3 (134) | 0.19 |
| Allow children to decide when they are full during meal and snack time | 87.3 (96) | 80.4 (86) | 0.17 | 72.9 (261) | 60.7 (17) | 0.17 | 86.7 (117) | 78.8 (63) | 0.13 | 77.0 (87) | 69.5 (187) | 0.14 | 82.7 (67) | 84.6 (115) | 0.72 | 73.3 (118) | 70.4 (159) | 0.53 |
| Meals are served family-style | 58.2 (64) | 29.9 (32) | <0.01 | 25.1 (90) | 35.7 (10) | 0.22 | 54.8 (74) | 26.3 (21) | <0.01 | 37.2 (42) | 20.8 (56) | <0.01 | 59.3 (48) | 36.0 (49) | <0.01 | 31.1 (50) | 22. 1 (50) | 0.05 |
Notes: Difference between participants and non-participants was considered statistically significant at p<0.05.
N’s vary slightly across analyses due to missing data for some programs.
Bolding indicates a significant difference in adherence to best practice by engagement in support program.
Nutrition Best Practices: Scale Range 1–18 (higher score = more best practices); Cronbach’s Alpha: Centers=0.86; Family homes=0.86.
These best practices are required to meet CACFP meal patterns and/or are CACFP specific best practices.
Making drinking water available to children throughout operating hours is required by Minnesota State Law.
Table 4.
Physical Activity (PA) Best Practices by Participation in CACFP, Parent Aware, and Gross Motor / PA Training
| CACFP participant | Parent aware participant | Gross motor/PA training participant | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Centers | Family homes | Centers | Family homes | Centers | Family homes | |||||||||||||
| N = 217 | N = 386 | N = 215 | N = 382 | N = 217 | N = 387 | |||||||||||||
| Overall PA best practices scorea | Yes | No | P-value | Yes | No | P-value | Yes | No | P-value | Yes | No | P-value | Yes | No | P-value | Yes | No | P-value |
| % (N) | 50.7 (110) | 49.3 (107) | — | 92.8 (358) | 7.2 (28) | — | 62.8 (135) | 37.2 (80) | — | 29.6 (113) | 70.4 (269) | — | 43.8 (95) | 56.2 (122) | — | 46.0 (178) | 54.0 (209) | — |
| Mean (SD) | 4.9 (1.4) | 4.0 (1.7) | < 0.01 | 3.5 (1.8) | 3.8 (2.0) | 0.53 | 4.8 (1.5) | 3.9 (1.7) | < 0.01 | 3.9 (1.8) | 3.4 (1.8) | 0.02 | 4.55 (1.7) | 4.46 (1.6) | 0.69 | 3.9 (1.8) | 3.2 (1.8) | < 0.01 |
| PA best practices % (N) Opportunities for MVPA for at least 60 minutes per day | 81.8 (90) | 72.9 (78) | 0.12 | 71.8 (257) | 78.6 (22) | 0.44 | 83.7 (113) | 67.5 (54) | < 0.01 | 73.5 (83) | 71.4 (192 | 0.68 | 81.1 (77) | 76.2 (93) | 0.39 | 82.0 (146) | 64.1 (134) | < 0.01 |
| Outdoor PA at least two times a day | 77.3 (85) | 64.5 (69) | 0.04 | 57.0 (204) | 71.4 (20) | 0.14 | 78.5 (106) | 60.0 (48) | < 0.01 | 57.5 (65) | 58.4 (157) | 0.88 | 68.4 (65) | 74.6 (91) | 0.32 | 68.0 (121) | 49.8 (104) | < 0.01 |
| Large motor PA opportunities for children with special needs | 79.1 (87) | 49.5 (53) | <0.01 | 36.6 (131) | 50.0 (14) | 0.16 | 73.3 (99) | 51.3 (41) | < 0.01 | 46.0 (52) | 34.2 (92) | 0.03 | 67.4 (64) | 63.1 (77) | 0.51 | 48.3 (86) | 28.2 (59) | <0.01 |
| Limit inactive time to no more than 30 minutes | 81.8 (90) | 72.0 (77) | 0.08 | 64.3 (230) | 57.1 (16) | 0.45 | 78.5 (106) | 73.8 (59) | 0.42 | 71.7 (81) | 60.2 (162) | 0.03 | 80.0 (76) | 76.2 (93) | 0.51 | 70.8 (126) | 57.4 (120) | < 0.01 |
| For preschoolers, limit screen time to no more than 60 minutes per day | 93.6 (103) | 89.7 (96) | 0.30 | 77.1 (276) | 71.4 (20) | 0.49 | 91.1 (123) | 92.5 (74) | 0.72 | 85.0 (96) | 72.9 (196) | 0.01 | 88.4 (84) | 95.1 (116) | 0.07 | 78.7 (140) | 74.6 (156) | 0.35 |
| No screen time for children less than 2 years old | 75.5 (83) | 51.4 (55) | < 0.01 | 45.8 (164) | 46.4 (13) | 0.95 | 74.1 (100) | 48.8 (39) | < 0.01 | 53.1 (60) | 42.0 (113) | 0.05 | 69.5 (66) | 60.7 (74) | 0.18 | 44.4 (79) | 46.4 (97) | 0.69 |
Notes: Difference between participants and non-participants was considered statistically significant at p<0.05.
N’s vary slightly across analyses due to missing data for some programs.
Bolding indicates a significant difference in adherence to best practice by engagement in support program.
PA Best Practices: Scale Range 1–6 (higher score=more best practices); Cronbach’s Alpha: Centers=0.75; Family homes=0.72.
3.2. CACFP participation and use of best practices
Child care center Nutrition and PA Best Practices scores were higher among centers that participated in CACFP [Mean Nutrition Score (SD) = 11.5 (4.1); Mean PA Score (SD) = 4.9 (1.4)] as compared to non-participating centers [Mean Nutrition score (SD) = 9.5 (4.5); Mean PA Score (SD) = 4.0 (1.7)]. The observed differences were statistically significant for nutrition (p < 0.01) and PA (p≤0.01) scores.
Among family home-based care facilities, no significant difference in mean Nutrition or PA Best Practice scores was observed by participation in CACFP (Nutrition p=0.62; PA p=0.53). Additional details on adherence to individual Nutrition and PA Best Practices by participation in CACFP and other support programs can be found in Tables 1 and 2.
3.3. Parent AWARE participation and use of best practices
Child care centers that were Parent AWARE participants had significantly higher mean Nutrition and PA Best Practices scores [Mean Nutrition Score (SD) = 11.4 (4.4); Mean PA Score (SD) = 4.8 (1.5)] as compared to child care centers that did not participate in Parent AWARE [Mean Nutrition score (SD) = 9.2 (4.2); Mean PA Score (SD) = 3.9 (1.7)] (both p < 0.01).
Similarly, home-based programs that were Parent AWARE participants had significantly higher mean Nutrition and PA Best Practices scores [Mean Nutrition Score (SD) = 11.1 (4.4); Mean PA Score (SD) = 3.9 (1.8)] as compared to family-home based programs that did not participate in Parent AWARE [Mean Nutrition score (SD) = 9.5 (4.5); Mean PA Score (SD) = 3.4 (1.8)] (Nutrition p < 0.01; PA p=0.02).
3.4. Nutrition and PA training participation and use of best practices
Child care centers that participated in Nutrition Training had a significantly higher mean Nutrition Best Practice score [Mean Nutrition Score (SD) = 11.6 (4.8)] as compared to child care centers that did not participate in Nutrition Training [Mean Nutrition score (SD) = 10.0 (4.0)] (p < 0.01). No significant difference in PA Best Practice Score was observed between child care centers that participated in PA Training as compared to those that did not (p=0.69).
Home-based providers that participated in Nutrition Training had a significantly higher mean Nutrition Best Practice score [Mean Nutrition Score (SD) = 10.8 (4.4)] as compared to family home-based providers that did not participate in Nutrition Training [Mean Nutrition score (SD) = 9.4 (4.5)] (p < 0.01). Similarly, home-based programs that participated in PA Training had a significantly higher mean PA Best Practices score [Mean PA Score (SD) =3.9 (1.8)] as compared to family home-based programs that did not participate in PA Training [PA Score (SD) = 3.2 (1.8)] (p < 0.01).
3.5. Participation in multiple programs and adjusted best practice scores
There was no significant association between child care type and nutrition best practices score after adjusting for the support program impacts; thus analysis focused on the impact of participation in multiple support programs on overall nutrition best practice score was not stratified by child care type. Adjusted for other support program participation, there was a mean (SE) increase of 1.09 (0.51) points in mean nutrition best practice score for those who participated in CACFP compared to those who did not (p=0.03); a mean (SE) increase of 1.37 (0.40) points for those who participate in Parent AWARE compared to those who do not (p < 0.01); and a mean (SE) increase of 1.15 (0.37) points for those who completed child nutrition training in the past year compared to those who did not (p < 0.01).
Child care type was independently association with PA best practices; thus the analysis exploring the impact of participation in multiple support programs on PA best practices was stratified by child care type. In center based child care, CACFP participation (Mean increase (SE) =0.78(0.22); p < 0.01) and Parent AWARE participation [Mean increase= 0.62; SE (0.23); p < 0.01) were both significantly associated with higher mean physical activity best practice scores after adjustment for participation in other support programs. For home-based providers, participation in Parent AWARE was associated with a mean (SE) increase in physical activity best practice score of 0.40(0.20); p=0.05 and participation in Physical Activity Training was associated with a mean (SE) increase of 0.68 (0.18) (p < 0.01) after adjustment for participation in other support programs. CACFP participation was not significantly associated with physical activity best practice score after adjustment for participation in other support programs among home-based providers.
4. Discussion
The overarching goal of the current descriptive study was to compare adherence to nutrition and PA best practices in child care settings that were and were not engaged in different types of supportive programming (CACFP, Parent AWARE, and additional training). Center-based child care providers who were engaged in CACFP adhered to more nutrition and PA best practices as compared to those not engaged in CACFP. Further, with one exception, center and family-home based providers that reported participating in Parent AWARE and engagement in available training opportunities adhered to more nutrition and PA best practices compared to those providers who did not participate in these support programs.
The financial reimbursement provided by CACFP, as well as associated requirements to meet certain nutrition standards, contribute to improved child care nutrition quality, as suggested by this study and other studies on the topic.(Korenman et al., 2013; Liu et al., 2016; Monsivais et al., 2011; Ritchie et al., 2012) Providers in this study who do not (N=117), or no longer (N=18) participate in CACFP were asked to provide reasons for their lack of participation status. Burdensome paperwork was the top barrier for both groups, outside of not qualifying for the program among those who have never participated. Among those who no longer participate in CACFP, 28% reported the reimbursement rate as being too low to cover cost of the foods the program required. Eligibility for CACFP participation is complicated, especially for family home providers which require sponsorship by an organization “that assumes responsibility for ensuring compliance with Federal and State regulations and that acts as a conduit for meal reimbursements”. (Hamilton, 2002) Advocates interested in increasing participation in CACFP with the goal of realizing the potential benefits outlined in this study and others, should consider avenues for simplifying paperwork and advocating for sustainable reimbursement rates.
Findings suggest that participation in Parent AWARE as well as additional training also have significant, positive impacts on the child care nutrition and PA environment. Further, these associations remain after adjustment for participation in CACFP, suggesting that efforts to increase participation in Parent AWARE and/or additional training could result in improved healthy nutrition and physical activity environments independent of CACFP participation.
It is notable that many of the individual best practices examined in this study were significantly associated with participation in training, but not with CACFP or Parent AWARE participation. This suggests that there are important topics being covered within nutrition and physical activity trainings that are not necessarily being addressed by CACFP or Parent AWARE related trainings or educational resources. Thus, while it is important to support and encouraged providers to participate in CACFP and Parent AWARE, increasing availability and support to attend available trainings for all provider, regardless of participation in CACFP or Parent AWARE, may be of importance.
The use of a large, semi-random sample of both center- and family home-based child care providers to explore differences in adherence to nutrition and PA best practices by participation in available support programs represents an important addition to the extant literature. However, study findings represent the experience of licensed child providers serving 2 to 5 year olds in Minnesota and may not be generalizable to providers in other states or serving other age groups. This study was also limited by a number of missing and/or imprecise predictor variables and study findings should be interpreted with these limitations in mind. For example, participants reported whether or not they were currently participating in CACFP or Parent AWARE, but not how long they had participated. Further, participants indicated if they had participated (yes/no) in a nutrition or physical activity training in the past year, but it is unknown if some providers participated in more than one training or the specific content of trainings attended. Finally, data on potential confounders (e.g., how long a site had been in business, a program’s financial resources) were not available. In sum, the current study was intended to provide a description of differences in adherence to nutrition and physical activity best practices across participation in various support programs; findings should not be interpreted as causal.
5. Conclusions
Overall, study findings indicate that child care settings that are engaged with support programs, including CACFP, Parent AWARE, and nutrition/PA training, are more likely to report adhering to nutrition and PA best practices as compared to child care settings not engaged in these support programs. Child care providers should be encouraged to participate in available support programs and advocates for child care providers should work to identify and remove barriers to program participation. Further, this study lends support to the potential benefit of including greater specification in licensing requirements regarding nutrition and PA training for child care providers.
Acknowledgements
Members of the stakeholder group contributed significantly to the survey development and interpretation of the findings: Minnesota Department of Education, Minnesota Department of Health, Minnesota Department of Human Services, ECE Licensing, Minnesota Licensed Family Child Care Association, Minnesota Child Care Resource and Referral Network, West Central Initiative, Minnesota Extension/SNAP-Ed, Public Health Law Center, Hunger Impact Partners, Parent Aware, Bloomington Public Health, Renewing the Countryside, Partners in Nutrition, Center for Prevention, Head Start, Child and Adult Food Program Sponsors (e.g. Providers Choice). The authors would like to acknowledge the contributions of Natasha Frost and Anna Ayers Looby of the Public Health Law Center for their ECE law and regulatory expertise and syntheses of best practices across multiple entities. Additional University of Minnesota staff and student support included Susan Lowry and Annette Nicolai for providing data management and quality control checks and Brittany Stotmeister and Carly Griffiths for recruitment and data collection. This study was made possible by Marilyn “Susie” Nanney, a pioneer in child nutrition and obesity research and a strong advocate for policy and training support for educators across all child care and school environments. Susie died tragically in the summer of 2018, she is sorely missed by all her colleagues and collaborators.
Funding statement
The original Healthy Start, Healthy State study (2010) was funded by the University of Minnesota and University of Wisconsin Clinical and Translational Science Institutes (Co-PIs: Nanney, MS and LaRowe, T). Through a cooperative agreement, the Center for Prevention at Blue Cross and Blue Shield provided funding ($76,000) for the current Healthy Start, Healthy State Study (2016) (PI: Nanney, MS). Additional unspecified funds were provided by Minnesota Hunger Impact Partners and used to increase the provider incentive ($2,500).
Footnotes
Ethical standards disclosure
This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects/patients were approved by the University of Minnesota Institutional Review Board. Written informed consent was obtained from all subjects.
None of the authors of this manuscript have any conflicts of interest to disclose.
Declaration of Competing Interest
The University of Minnesota authors have no conflicts of interest to report.
References
- Birch LL, Parker L, Burns A, et al. (2011). Early childhood obesity prevention policies. National Academies Press; https://books.google.com/books?hl=en&lr=&id=4l5sUweFg7AC&oi=fnd&pg=PR1&dq=daycare+recommendations+meal+service+family-style+AMA&ots=eLUzyk3Jyg&sig=IAMUK3GZGbje6Ahz6XIB5Pyfuno Accessed June 1, 2016. [Google Scholar]
- Education NRC for H and S in CC and E (2011). Caring for our children (3rd ed.). . [Google Scholar]
- Hamilton WL (2002). Family child care home participation in the CACFP–effects of reimbursement tiering [electronic resource] [Google Scholar]
- Kaphingst KM, French S, & Story M (2006). The role of child care settings in obesity prevention. The Future of Children, 16(1), 143–168. [DOI] [PubMed] [Google Scholar]
- Korenman S, Abner KS, Kaestner R, & Gordon RA (2013). The child and adult care food program and the nutrition of preschoolers. Early Childhood Research Quarterly, 28(2), 325–336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Liu ST, Graffagino CL, Leser KA, Trombetta AL, & Pirie PL (2016). Obesity prevention practices and policies in child care settings enrolled and not enrolled in the child and adult care food program. Maternal and Child Health Journal, 20(9), 1933–1939. [DOI] [PubMed] [Google Scholar]
- McGuire S (2012). Institute of medicine (IOM) early childhood obesity prevention policies. Washington, DC: The National Academies Press; Oxford University Press. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Monsivais P, Kirkpatrick S, & Johnson DB (2011). More nutritious food is served in child-care homes receiving higher federal food subsidies. Journal of the American Dietetic Association, 111(5), 721–726. [DOI] [PubMed] [Google Scholar]
- Murphy SP, Yaktine AL, Suitor CW, & Moats S (2012. Apr 16). Child and adult care food program: aligning dietary guidance for all Committee to review child and adult care food program meal requirements. Food and Nutrition Board2011; Available Httpwww Nap Educ Php. [Google Scholar]
- National Academies of Sciences, Medicine (2016). Obesity in the early childhood years: State of the science and implementation of promising solutions. Workshop SummaryNational Academies Press. [PubMed] [Google Scholar]
- Neelon SEB, & Briley ME (2011). Position of the American Dietetic Association: Benchmarks for nutrition in child care. Journal of the American Dietetic Association, 111(4), 607–615. [DOI] [PubMed] [Google Scholar]
- Nicklas TA, Baranowski T, Baranowski JC, Cullen K, Rittenberry L, & Olvera N (2001). Family and child-care provider influences on preschool children’s fruit, juice, and vegetable consumption. Nutrition Reviews, 59(7), 224–235. [DOI] [PubMed] [Google Scholar]
- Pediatrics AA of, Health NRC for, (US) S in CC, Association APH, Maternal US, Bureau CH (2002). Caring for our children: national health and safety performance standards: Guidelines for out-of-home child care. Amer Academy of Pediatrics. [Google Scholar]
- Pratt CA, Stevens J, & Daniels S (2008). Childhood obesity prevention and treatment recommendations for future research. American Journal of Preventive Medicine, 35(3), 249–252. 10.1016/j.amepre.2008.05.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ritchie LD, Boyle M, Chandran K, et al. (2012). Participation in the child and adult care food program is associated with more nutritious foods and beverages in child care. Childhood Obesity, 8(3), 224–229. [DOI] [PubMed] [Google Scholar]
- Tout K, Starr R, Albertson-Junkans L, Soli M, & Quinn K (2011. May). Evaluation of parent aware: minnesota’s quality rating system pilot: Final evaluation report. Minneap MN Child Trends. 19, 2014. [Google Scholar]