The scaled and customized policy- and practice-based interventions promoted healthy eating and physical activity among children in early care and education settings.
Keywords: Early care and education, Nutrition and physical activity policy, Nutrition and physical activity self-assessment for child care, Childhood obesity prevention
Abstract
The National Early Care and Education Learning Collaboratives Project (ECELC) was a multistate intervention that was highly effective in implementing best practices for healthy eating physical activity (HEPA) in early care and education (ECE) programs across the USA. The ECELC included didactic in-person learning sessions, technical assistance, and self-assessment-guided action planning. This study aimed to describe the effectiveness of adaptions to the self-assessments, learning sessions, and overall support, and also aimed to compare the effectiveness of each to the Original ECELC Model, when applicable. This study utilized a pre-poststudy design using data collected via the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) instrument for ECE programs that adapted the Original ECELC Model. Adaptations to the Original ECELC Model were found to promote best practices and policies with regard to Breastfeeding & Infant Feeding, Child Nutrition, Infant & Child Physical Activity, Outdoor Play & Learning, and/or Screen Time as demonstrated by the NAP SACC (p < .05), with some exceptions of nonstatistically significant increases. Improvements were found to be statistically similar to improvements made among participants of the Original ECELC Model. Partner-driven, scalable, and customizable policy- and practice-based interventions to promote HEPA among children in ECE settings may serve as a key strategy to work toward reducing risk for childhood obesity.
Implications.
Practice: Early Care and Education settings are viable for reaching children aged 0–5 years, improving their healthy eating and physical activity environments, and ultimately decreasing their risk for obesity.
Policy: Effective healthy eating and physical activity-based policies and practices must consider access to and availability of resources, program characteristics, and initiative leadership (e.g., community- or state-level implementation partners) in order to promote scale and customization of program improvement strategies in ECE settings.
Research: Future research is needed to examine specific program-level practices and policies that result in changes to child behaviors (e.g., eating and activity patterns) and health outcomes (e.g., body mass index).
BACKGROUND
More than one in eight children (14%) aged 2–5 years had obesity in 2016 [1,2] warranting establishment of healthier diet and physical activity behaviors in early childhood [3]. A growing body of evidence has demonstrated that program-level healthy eating and physical activity (HEPA) interventions can promote best practices and policies in early care and education (ECE) settings [4–6] which may directly influence children enrolled in these programs [7]. Results from previous work in this arena have shown programs and interventions involving self-assessment and action planning enabled change in ECE program-level practices [8–10]. Thus, ECE is a key setting to implement strategies to improve policies and practices that may impact the nearly 13 million children aged 5 years and younger who spend some portion of their week in an ECE program [11]. Further, strategies in ECE may contribute concurrently with other cross-sector childhood obesity prevention efforts in the USA [12].
In an effort to integrate strategies to promote HEPA in ECE, Nemours National Office of Policy and Prevention (Nemours) collaborated with the Centers for Disease Control and Prevention (CDC) to implement the National Early Care and Education Learning Collaboratives (ECELC) Project from 2013 to 2017. The project instituted learning collaboratives (learning system that brings together teams to seek improvement in a focused topic area [13]) over a 10-month period for ECE program staff (e.g., child care center directors, food service directors, family child care owners, other staff, etc.) in order to promote HEPA environments, policies, and practices within ECE settings. The ECELC project recently ended its sixth and final year of implementation, reaching a total of 2,573 ECE programs across ten states (Alabama, Arizona, California, Florida, Indiana, Kansas, Kentucky, Missouri, New Jersey, and Virginia). Preassessment and postassessment data collected via the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) have indicated that the ECELC has been highly effective in implementing best practices for breastfeeding, nutrition, physical activity, and sedentary behaviors in ECE programs [14]. This evidence supports the continued implementation of the ECELC in order to ultimately reach more children aged 5 years and younger, however, the ECELC (hereinafter referred to as the Original ECELC Model) was relatively resource-intensive (i.e., inputs included a national team, state partners, program materials, $500 monetary incentives to ECE programs, ECE program staff time to attend in-person trainings, etc.) which may create a barrier to spreading and scaling the intervention.
In the final years of the project, Nemours supported the development of cost-effective adaptations to the delivery of the Original ECELC Model in order to facilitate the adoption, support, and sustainability of the model in additional states, communities, and ECE programs . These modifications were a deliberate effort to broaden the reach of the ECELC [15]. The purpose of this study was to determine the feasibility of three adaptations to the Original ECELC Model by examining the efficacy of each. More specifically, this study aimed to assess the effectiveness of each adaptation by using preassessment and postassessment data collected via the NAP SACC instrument for ECE programs that participated in each adaptation, and determine how changes in scores compared to the Original ECELC Model in similar locations, when applicable.
METHODS
ECE programs were recruited for each respective adaption of the ECELC by state project coordinators through a variety of informal methods, including personal telephone calls, online recruitment, and connections with groups such as Head Start/Early Head Start. This study utilized a pre-postdesign to examine the effectiveness of each of the three adaptations to the Original ECELC Model. Primary outcome data were collected via the NAP SACC instrument [9], which was typically administered after the first didactic in-person learning session and then approximately 10 months later towards the end of the intervention. The NAP SACC instrument is part of a larger Go NAPSACC intervention that aims to improve the health of young children through ECE-based practices, policies, and environments, and has demonstrated moderate agreement for test-retest reliability, inter-rater reliability, and validity when tested against the Environment and Policy Assessment and Observation (κ ≥ 0.20) [16].The NAP SACC consisted of five topic areas: Breastfeeding & Infant Feeding (23 items), Child Nutrition (44 items), Infant & Child Physical Activity (22 items), Outdoor Play & Learning (20 items), and Screen Time (12 items). Each item presented four response options, ranging from noncompliance to total compliance with a particular best practice. For the purpose of determining the number of best practices met, when the response option representing total compliance was selected, it was considered the best practice was being met (best practice met = 1). All other responses were considered to mean the best practice was not fully being met (best practice not met = 0).
Original ECELC model
The Original ECELC Model’s learning collaborative design was developed out of the Institute for Healthcare Improvement’s Breakthrough Series Model [13]. The Original ECELC Model involved a statewide organization as the implementing partner relying on their staff to coordinate the project and facilitate project strategies. Strategies to promote change within ECE settings included a self-assessment-guided Action Plan, didactic in-person learning sessions, and ongoing support via technical assistance (TA). ECE programs developed a goal(s) with corresponding objectives (referred to as their Action Plan) based on their self-determined need (using what they learned from their preassessment NAP SACC as a guide), interest, and capacity to reach the goal(s). ECE program directors and/or lead teachers participated in five didactic in-person learning sessions, which were led by state-based trainers and included presentations on content, interactive activities, and peer sharing and support. Individualized TA at varying levels of intensity, type, and frequency supported ECE programs in their Action Plan implementation. Each strategy is described in more detail elsewhere (placeholder for manuscript in review).
Self-assessment adaptation
The first adaptation examined in this study was to the self-assessment guided action planning, as ECE programs in Virginia utilized the Online Go NAP SACC instead of the paper version typically used in the Original ECELC Model. Virginia ECE program staff accessed the online assessment through a computer, tablet, or phone via the Go NAP SACC website (https://gonapsacc.org/) during one-on-one TA visits and/or on their own before their first TA visit. The Online Go NAP SACC generated immediate feedback that ECE programs were able to use to inform their action planning and provided online resources addressing HEPA topics. Like in the Original ECELC Model, one ECE program staff member from each program completed the Online Go NAP SACC as a preassessment and postassessment.
Learning session adaptation
For the second adaptation examined in this study, ECE program staff in Alabama and Florida received a hybrid of in-person and online-learning sessions (via the Better Kid Care on demand distance education system online modules [Better Kid Care Online Modules]) instead of the in-person-only learning sessions in the Original ECELC Model. The Better Kid Care Online Modules, developed by Penn State Extension, provided an online professional development tool that includes video tutorials, activity pages, resources, and online quizzes to gauge retention of lessons [17]. Like in the Original ECELC Model, one ECE program staff member from each program completed the pen-and-paper NAP SACC instrument after the first didactic in-person learning session and then again as a postassessment.
Overall support adaptation
The third and final adaptation was a stand-alone ECE Learning Collaboratives Implementation Toolkit (Toolkit) tested in Arkansas. The Toolkit was designed to replace (when applicable) the support (e.g., trained staff to conduct in-person learning sessions) and TA typically available to state organizational partners from Nemours and was made available in PDF form online (https://healthykidshealthyfuture.org/about-ecelc/national-project/resources/). It was also designed to support states and communities to implement the ECELC approach in the absence of large grant support. One ECE program staff member from each program completed the pen-and-paper NAP SACC instrument as a preassessment and again as a postassessment.
Analysis
SAS (version 9.4 SAS Institute Inc., Cary, NC) was used for all statistical analyses. Analysis included ECE programs that participated in one of the three adaptations (2017–2018) or in the Original ECELC Model in the same state during the previous implementation cycle (2016–2017), who cared for infants, toddlers, and preschoolers (with the exception of ECE programs in Arkansas), and who also responded to at least one item at preassessment and postassessment per each topic area of the NAP SACC. The number of best practices being met at preassessment and postassessment per NAP SACC topic area was summed for each program resulting in a score. A change score was calculated by subtracting the preassessment score from the postassessment score. Primary comparisons of NAP SACC change scores between ECE programs that underwent the adaptation and programs that underwent the Original ECELC Model were conducted utilizing a Longitudinal Linear Mixed Model where the outcome variables were the five NAP SACC topic area scores measured for each ECE program at preassessment and postassessment, controlling for NAP SACC preassessment scores. All statistical significance was set at a two-sided alpha level of p < .05.
RESULTS
Self-assessment adaptation
Thirty-one ECE programs in Virginia that participated in the Online Go NAP SACC and 63–74 ECE programs (depending on the topic area) that participated in the Original ECELC Model during the previous implementation cycle (2016–2017) were included in this study (Table 1). Significant improvements occurred across each of the five topic areas for both models and ranged from 1.8 (Online Go NAP SACC) or 2.4 (Original ECELC Model) more best practices in Screen Time to 7.4 (Online Go NAP SACC) or 10.5 (Original ECELC Model) more best practices in Child Nutrition (p < .001). When comparing improvements between the two models, there were no statistically significant differences in change score, indicating they improved at similar rates.
Table 1.
| Differences in NAP SACC Change Scores among ECE Programs in Virginia that participated in the Original ECELC Model in 2016–2017 compared to those that participated in the Online Go NAP SACC Model in 2017–2018
| NAP SACC scores | |||||
|---|---|---|---|---|---|
| NAP SACC topic | n | Pre | Post | Change scorea | Difference in change score P valueb |
| Breastfeeding and infant feeding | |||||
| Original ECELC Model | 63 | 9.3 | 14.1 | 4.8*** | .1182 |
| Online Go NAP SACC | 31 | 7.7 | 14.7 | 7.1*** | |
| Child Nutrition | |||||
| Original ECELC Model | 74 | 24.4 | 31.9 | 7.4*** | .1934 |
| Online Go NAP SACC | 31 | 21.8 | 32.3 | 10.5*** | |
| Infant and Child Physical Activity | |||||
| Original ECELC Model | 74 | 8.7 | 13.7 | 5.0*** | .0519 |
| Online Go NAP SACC | 31 | 8.3 | 14.2 | 5.9*** | |
| Outdoor Play and Learning | |||||
| Original ECELC Model | 74 | 4.8 | 8.7 | 3.9*** | .4201 |
| Online Go NAP SACC | 31 | 5.1 | 10.3 | 5.2*** | |
| Screen Time | |||||
| Original ECELC Model | 74 | 4.9 | 7.3 | 2.4*** | .0910 |
| Online Go NAP SACC | 31 | 4.3 | 6.1 | 1.8*** | |
Analysis included ECE programs that served infants, toddlers, and preschoolers and responded to at least one item per each topic area of the NAP SACC at preassessment and at least one item in postassessment.
aChange Scores were calculated by subtracting from preassessment from postassessment. Statistically significant changes from preassessment to postassessment, after adjusting for NAP SACC preassessment score, are denoted with *p < .05, **p < .01, or ***p < .001.
b p-values shown were for model-estimated differences in change scores per intervention type (original vs. adaptation), after adjusting for NAP SACC preassessment scores.
Learning session adaptations
Twenty-nine to 44 ECE programs in Alabama and 15 to 59 ECE programs in Florida, depending on the model (i.e., original vs. adaptation) and NAP SACC topic area, were included in Table 2. Improvements occurred in all NAP SACC topic areas, though improvements were not statistically significant for ECE programs that participated in the Better Kid Care Model in Florida for the topic areas of Infant & Child Physical Activity, Outdoor Play & Learning, and Screen Time. There were no statistically significant differences in change scores between the two models for either state.
Table 2.
| Differences in NAP SACC Change Scores among ECE Programs in Alabama and Florida that participated in the Original ECELC Model in 2016–2017 compared to ECE Programs who participated in the Better Kid Care Online Modules in 2017–2018
| Alabama | Florida | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| NAP SACC scores | NAP SACC scores | |||||||||
| NAP SACC topic | n | Pre | Post | Change Scorea | Difference in change score p valueb |
n | Pre | Post | Change scorea | Difference in change score p valueb |
| Breastfeeding and Infant Feeding | ||||||||||
| Original ECELC Model | 27 | 9.9 | 12.7 | 2.9*** | .0762 | 26 | 8.8 | 12.6 | 3.7*** | .8412 |
| Better Kid Care Online Modules | 29 | 11.7 | 15.9 | 4.2*** | 15 | 9.1 | 13.0 | 3.9** | ||
| Child Nutrition | ||||||||||
| Original ECELC Model | 35 | 22.6 | 27.6 | 4.9*** | .2453 | 59 | 21.9 | 28.5 | 6.6*** | .6823 |
| Better Kid Care Online Modules | 29 | 26.3 | 32.0 | 5.7*** | 15 | 25.6 | 30.3 | 4.7** | ||
| Infant and Child Physical Activity | ||||||||||
| Original ECELC Model | 34 | 7.3 | 11.4 | 4.1*** | .1392 | 57 | 7.1 | 11.8 | 4.7*** | .3597 |
| Better Kid Care Online Modules | 29 | 10.6 | 14.6 | 4.1*** | 15 | 10.2 | 11.9 | 1.7 | ||
| Outdoor Play and Learning | ||||||||||
| Original ECELC Model | 34 | 5.1 | 7.9 | 2.7*** | .3374 | 57 | 4.5 | 8.1 | 3.6*** | .1453 |
| Better Kid Care Online Modules | 29 | 6.6 | 9.2 | 2.6*** | 15 | 6.4 | 7.6 | 1.2 | ||
| Screen Time | ||||||||||
| Original ECELC Model | 34 | 4.6 | 6.4 | 1.8*** | .2641 | 59 | 4.5 | 6.3 | 1.9*** | .0762 |
| Better Kid Care Online Modules | 44 | 5.8 | 7.8 | 2.1*** | 15 | 4.9 | 5.5 | 0.5 | ||
Analysis included ECE programs that served infants, toddlers, and preschoolers and responded to at least one item per each topic area of the NAP SACC at preassessment and at least one item in postassessment.
aChange Scores were calculated by subtracting from preassessment from postassessment. Statistically significant changes from preassessment to postassessment, after adjusting for NAP SACC preassessment score, are denoted with *p < .05, **p < .01, or ***p < .001.
b p-values shown were for model-estimated differences in change scores per intervention type (original vs. adaptation), after adjusting for NAP SACC preassessment scores.
Overall support adaptation
Twenty-three ECE programs in Arkansas participated in the Toolkit and were included in this study. As shown in Table 3, the number of best practices met for Breastfeeding & Infant Feeding, Child Nutrition, Outdoor Play & Learning, and Screen Time significantly increased from pre- to postassessment (ranging from 1.7 to 9.0 best practices; p < .05). While Infant & Child Physical Activity did not experience a statistically significant increase, the positive change suggested that a larger sample may have led to a statistically significant increase. The Original ECELC Model was not implemented in Arkansas; therefore, there were no comparison programs included.
Table 3.
| NAP SACC change scores among ECE programs who participated in the Toolkit Model in Arkansas
| NAP SACC scores | ||||||
|---|---|---|---|---|---|---|
| NAP SACC topic | n | Pre | Post | Change Scorea | ||
| Breastfeeding and Infant Feeding | 23 | 9.0 | 14.4 | 5.4** | ||
| Child Nutrition | 23 | 22.5 | 31.5 | 9.0** | ||
| Infant and Child Physical Activity | 23 | 9.0 | 12.2 | 3.2 | ||
| Outdoor Play and Learning | 23 | 4.3 | 6.4 | 2.1* | ||
| Screen Time | 23 | 5.3 | 6.9 | 1.7* |
Analysis included ECE programs that served infants, toddlers, and preschoolers and responded to at least one item per each topic area of the NAP SACC at preassessment and at least one item in postassessment.
aChange Scores were calculated by subtracting from preassessment from postassessment. Statistically significant changes from preassessment to postassessment, after adjusting for NAP SACC preassessment score, are denoted with *p < .05, **p < .01, or ***p < .001.
DISCUSSION
This study focused on three adaptations of the Original ECELC Model as they have been implemented in natural, “real-world” settings in an effort to describe the outcomes as measured using the NAP SACC instrument. The majority of ECE programs described in this study have undergone the Original ECELC Model, which was highly supported via funding (average of $4,325 per facility) and staff support. A study conducted in Ohio determined that financial stability was crucial to quality in ECE settings, and that the majority of programs in that study that were considered high-quality had supplemental revenue streams [18]. Another recent study that assessed factors associated with the implementation of HEPA policies and practices in ECE programs found that perceived availability of external support was associated with implementation [19], further supporting the need for the supplemental revenue streams to support initiatives to improve HEPA policy in ECE settings. However, because future funding priorities may limit dissemination of the Original ECELC Model, exploring the feasibility and effectiveness of less-resource intensive is crucial for sustainability [20,21]. This study found the three adaptations to be feasible and appropriate deliveries of the intervention in that the adaptations performed relatively similarly with regard to NAP SACC change scores when assessed against ECE programs in the same state, suggesting the adaptations may be effective in fostering changes that may lead to a greater public health impact [15]. However, for the Toolkit in Arkansas and the Better Kid Care Online Modules in Alabama, some improvements were not statistically significant among ECE programs that participated in the adapted models. The largely significant improvements reported through the NAP SACC measurement in this current study, along with previous studies, suggest that participation in the Original ECELC Model may help facilitate important changes to policies and practices among ECE programs with regard to Breastfeeding & Infant Feeding, Child Nutrition, Infant & Child Physical Activity, Outdoor Play & Learning, and Screen Time [22,23].
Adaptation to self-assessments
Staff members employed by the Virginia State Implementing Partner participated in interviews regarding their experiences with the Online Go NAP SACC assessment and cited that the Online Go NAP SACC reduced user errors, that assessments were generally less time consuming to complete, and less difficult to collect from ECE programs compared to the paper version [24]. In the current study, when examining ECE programs in Virginia who utilized the Online Go NAP SACC assessments instead of the paper version, all topic areas saw statistically significant improvements, ranging from a 42% increase (Screen Time for Online Go NAP SACC) to a 102% increase (Outdoor Play & Learning for Online Go NAP SACC). These findings suggest that, despite resources being heavily devoted to assisting ECE programs through the online platform [24], using the Online Go NAP SACC contributed to effective promotion of best practices and policies for Breastfeeding & Infant Feeding, Child Nutrition, Infant & Child Physical Activity, Screen Time, and Outdoor Play & Learning in ECE programs.
Further, ECE programs that participated in the Online Go NAP SACC Model improved at the same rate as those in Virginia that participated in the Original ECELC Model for all topic areas. In interviews, state-level ECELC staff expressed seeing value in the online platform in that it made administration of the NAP SACC easier [24]. They appreciated the platform in being able to collect data and provide immediate feedback for the provider, contributing to an ECE program’s ability to set a goal(s) to work on during their time in the ECELC. When examining psychosocial predictors of dietary behavior, a previous study found that both internal and external factors are related to behavior, though internal factors such as self-efficacy and goal setting are more impactful that external factors [25,26]. However, in a later study that explored how the Social Cognitive Theory, specifically goal setting, related to healthy eating practices; it was found that goal setting alone was not a significant predictor of change in practices [25]. In the ECELC, project staff support ECE programs via TA as they work toward their goals during action periods. These findings suggest that using the Online Go NAP SACC was an effective and feasible adaptation to the paper version typically used in the Original ECELC Model, though it may be most useful in situations where the State Implementing Partner is unable to provide substantial TA, or when TA is carefully allocated to both assisting with navigating the online platform and HEPA content. Bearing in mind, also, that ECE programs that are proficient in program improvement processes may find technology to be a sufficient level of support for making changes.
Adaptation to learning sessions
One of the key strategies of the Original ECELC Model was to provide in-person, peer learning sessions on content coupled with group activities, and peer sharing and support. One study of early childhood professionals found that it is best to be responsive to a variety of learning styles and anticipate barriers to training delivery methods [27]. For example, while some respond well to peer-learning, others appreciate the option of self-paced learning, and some ECE staff may experience barriers to attending in-person sessions, such as scheduling conflicts, which can be alleviated with online-learning options [27]. When examining ECE programs from Florida and Alabama that utilized the Better Kid Care Online Modules, improvements were relatively similar to the full sample of ECE programs that participated in the Original ECELC Model in that almost all topic areas saw statistically significant improvements. Improvements in Alabama ranged from a 22% improvement (Child Nutrition for both models) to a 56% improvement (Infant & Child Physical Activity for the Original ECELC Model) and improvements in Florida (among those that saw statistically significant improvements) ranged from 18% (Child Nutrition for the Better Kid Care Model) to 80% (Outdoor Play & Learning for the Original ECELC Model). ECE programs were interviewed previously about their experiences with the Better Kid Care Online Modules, and they expressed satisfaction with the combination of online and in-person training [24]. While online modules were considered to be convenient, and a cost and time saver, interviewees described that they did not provide the same valuable experience (peer-to-peer, efficacy building) as in-person sessions [24]. The Better Kid Care Online Modules were a generally effective alternative to the in-person learning sessions in contributing to the promotion of best practices and policies Breastfeeding & Infant Feeding, Child Nutrition, Infant & Child Physical Activity, Screen Time, and Outdoor Play & Learning in ECE programs. However, improvements varied across states and NAP SACC topic area, underscoring that access to and availability of resources, ECE program characteristics, and sources of intervention leadership (e.g., community- or state-level implementation partners) should be considered when promoting scale and customization of strategies to implementation.
Adaptation to overall support
While implementation of evidence-based policies and practices is important, perhaps equally important is the opportunity for community- or even ECE program-level customization of an intervention. For illustrative purposes, one study from a single county in Ohio demonstrated variability among ECE programs with regard to physical activity environments and weather-related outdoor play policies [28]. Toolkits have been implemented widely in the public health landscape in order to provide a framework and guidance to implementers in the field. A recent process evaluation in California demonstrated that the use of a toolkit (in addition to the NAP SACC and trainings) had high fidelity and was potentially replicable for implementation in ECE settings among Hispanic/Latino communities [29]. Prior to this study, the Toolkit was tested for applicability by staff of the pilot implementing partner and they reported a generally positive experience, though areas of improvement were identified [30]. In this case through, it should be noted that the implementing partner had a robust organizational structure that supported the implementation of a learning collaborative, as well as the previous experience, lending to expertise in facilitating Learning Sessions and provide TA [30]. Future implementation by other, possibly less equipped partner organizations who may also be experiencing competing priorities, budget constraints, fluctuating degrees of readiness to change, and variations in existing frameworks and structures, should be taken in account. The Toolkit was revised according to the pilot evaluation and implemented in Arkansas, and programs that underwent changes guided by only the Toolkit saw improvements in all areas of the NAP SACC, though improvements in Infant & Child Physical Activity were not statistically significant. Despite this, these overall improvements suggest that participation in the ECELC via the Toolkit may lead to important changes to policies and practices in ECE programs with regard to Breastfeeding & Infant Feeding, Child Nutrition, Screen Time, and Outdoor Play & Learning. The Toolkit can help promote implementation of the full learning collaborative model across many partner organizations and the Toolkit adaptation to the overall support of the Original ECELC Model enabled and facilitated important changes to policies and practices in the ECE programs within a flexible delivery structure.
Evidence suggests that the Original ECELC Model was highly effective and should be considered the standard model for implementing best practices for HEPA in ECE programs across the USA. However, when faced with resource constraints (e.g., funding or staff), geographical challenges (e.g., ECE programs in rural areas), and/or lack of intervention leadership (e.g., TA providers or trainers), scaled adaptations may be the vehicle to promote HEPA policies and practices. Using the Online Go NAP SACC is recommended when the users (ECE program staff) are technologically proficient but one-on-one TA is limited. The Better Kid Care Online Modules are recommended for ECE programs that experience travel as a barrier (e.g., those in rural communities or family child care providers who are the sole staff person) and who can implement new practices and policies sans peer-to-peer interface. The Toolkit is recommended for support states and communities in which a strong implementing partner is eager to implement the project in the absence of large grant support.
Limitations
This study has limitations to report. First, the sample sizes were relatively small in some analyses (e.g., ECE programs in Florida that participated in the Better Kid Care Online Modules). While the generally significant improvements demonstrated within those programs suggest there was enough power to detect change for most NAP SACC topic areas, nonsignificant improvements suggest that ECE programs chose to not work on certain topic areas, respective trainings were relatively ineffective at promoting change in certain topic areas, and/or a larger sample size may have been necessary to examine whether the intervention was effective or not. Second, the adaptations were pilot implementations within the respective states, and subject to the recruitment methods of each state’s implementing partner, so the samples may not be representative and therefore findings lack generalizability. Accordingly, participation rates were unavailable for reporting. Third, data were self-reported and may be subject to bias. Fourth, due to length limitations, we were unable to include characteristics of ECE programs in this manuscript, though the ECE programs that participated in the Original ECELC Model are described in detail elsewhere (placeholder for manuscript in press). Further, data analysis did not control for any variation in ECE characteristics. Despite these limitations, this study has many strengths; the first being that it allowed for the exploration of adaptations of the Original ECELC in their respective natural, “real-world” settings. Next, all models utilized the NAP SACC tool as the main outcome measure, which has been widely used in many studies with ECE programs across multiple locations [4,6,29,31]. Lastly, all three adaptations described were available online for use by states, communities, and ECE programs, contributing to the spread of the Original ECELC Model.
CONCLUSIONS
ECE settings are viable for reaching children aged 5 years and younger to improve their HEPA environments. Effective policies and practices must consider access to and availability of resources, ECE program characteristics, and sources of intervention leadership (e.g., community- or state-level implementation partners) in order to promote scale and customization of strategy implementation. Future research is needed to test each adaptation in additional settings (e.g., with state implementing partners who are less-resourced or experienced) and to examine specific program-level practices and policies that result in changes to child behaviors (e.g., eating and activity patterns) and health outcomes (e.g., body mass index). Partner-driven, scalable, and customizable policy- and practice-based interventions may serve as a key strategy to work toward reducing risk for childhood obesity.
Funding: Nemours was funded by CDC under a 6-year cooperative agreement (no. 1U58DP004102), 2012–2018, to support states/localities in launching ECE learning collaboratives focused on childhood obesity prevention. The views expressed in written materials or publications or by speakers and moderators do not necessarily reflect the official policies of the US Department of Health and Human Services, nor does the mention of trade names, commercial practices, or organizations imply endorsement by the US government. No copyrighted materials were used in this research.
Compliance with Ethical Standards
Conflict of Interest: There are no conflicts of interest to report.
Authors’ Contributions: T.G., J.S., C.P., and A.Y. contributed to the design and implementation of the research. T.G. and L.W.M.B. conducted to the analysis of the results. All authors contributed to the writing of the manuscript.
Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Study activities were approved by the Nemours Children’s Health System Institutional Review Board..
Informed Consent: Informed consent was obtained from all individual participants included in the study.
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