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. Author manuscript; available in PMC: 2022 Dec 1.
Published in final edited form as: Appetite. 2021 Aug 11;167:105626. doi: 10.1016/j.appet.2021.105626

Hungry is Not Safe: A Mixed Methods Study to Explore Food Insecurity in Early Care and Education

Taren Swindle 1, Joshua Phelps 2, Britney Schrick 2, Susan Johnson 3
PMCID: PMC8434997  NIHMSID: NIHMS1733325  PMID: 34389375

Abstract

The early care and education (ECE) environment has the potential to affect both children and their families. Food insecurity in ECE and its management may be an important influence. Objectives of this mixed methods study were to (1) elicit prominent themes relating to teacher experiences with food insecurity (in the classroom) through qualitative interviews; (2) translate interview themes into survey items and analyze survey data to explore generalizability of the qualitative findings; and (3) provide preliminary data on properties of a new tool to study the influence of food insecurity in the ECE setting. An exploratory sequential mixed methods design (QUAL → quant) was used. Twenty-eight interviews about teacher experiences with food insecurity were followed by 781 surveys to assess generalizability of interview findings. Qualitative themes highlighted that ECE teachers are concerned about children’s food insecurity in their classroom; ECE teachers have developed their own set of strategies to manage their concern; and teachers often struggle with what to do. Quantitative results demonstrated many teachers had the same concerns and used the strategies described in the interviews. Further, in exploratory analyses, ECE teachers with Food Insecurity scored significantly higher on all scales (e.g., Food Insecurity Concerns, Struggle with Addressing Food Security) in both adjusted and unadjusted analyses. ECE teachers with Food Acquisition Stress had higher scores on Strategies to Address Food Insecurity with Families in adjusted analyses.

Introduction

In 2018, 11.1% of households (14.3 million) within the US reported experiencing food insecurity (FI), meaning “households were, at times, unable to acquire adequate food for one or more household members because they had insufficient money and other resources for food” (Coleman-Jensen, Rabbitt, Gregory, & Singh, 2019). In households with children, approximately 7.1% (2.7 million) experienced FI (Coleman-Jensen et al., 2019). Researchers have documented links between child FI and reduced fruit and vegetable intake (Bruening, Lucio, & Brennhofer, 2017; Lee, Kubik, & Fulkerson, 2019), increased consumption of sugar-sweetened beverages (Lee et al., 2019), and higher rates of eating past satiation and in the absence of hunger, all of which cause concern (Kral, Chittams, & Moore, 2017). Overall, poor diet quality during childhood may lead to development of chronic disease later in life (Landry et al., 2019).

Childhood FI is associated with numerous adverse outcomes. Adverse health outcomes include higher prevalence of asthma and anemia, poor dietary quality, oral health problems, increased hospitalization rates, and decreased overall health (Gundersen & Ziliak, 2015; Rocha, Milagres, Novaes, & Franceschini, 2015). Socio-emotional risks include behavior problems (Gundersen & Ziliak, 2015), trouble getting along with other children, higher suspension rates (Alaimo, Olson, & Frongillo, 2001), and trouble developing interpersonal relationships and self-control (Howard, 2011). Additional study of the impact of FI on children’s cognitive outcomes has documented a relation of FI with lower arithmetic scores and increased risk of repeating a grade (Alaimo, Olson, & Frongillo, 2001). Longitudinal studies bolster this connection with children experiencing FI showing both lower initial math scores and lower gains in math achievement over a single kindergarten school year (Winicki & Jemison, 2003) and from kindergarten to third grade (Jyoti, Frongillo, Jones, & Al, 2005). Thus, exposure to FI in childhood can have far-reaching impacts.

In addition to the direct influence of FI on children, indirect effects are possible through FI’s influence on their caregivers. For example, parents who are food insecure enact greater restrictive and controlling feeding practices, which in turn, have been found to be mediating factors of child BMI percentile within a food insecure household (Darling, Fahrenkamp, Ruzicka, & Sato, 2017). Severe psychological distress is also more likely in parents experiencing FI (Tseng, Park, Shearston, Lee, & Weitzman, 2017), which can affect children detrimentally. Thus, in homes, indirect effects of FI may be present even if adults protect the children from experiencing the household FI. Little research has explored how FI in caregivers outside the home (e.g., childcare) may result in indirect impacts on children. An important first step in this exploration is to examine the link between food security status of caregivers outside the home [e.g., teachers in early care and education (ECE) settings] with their practices and interactions with children in the classroom.

ECE teachers are one group of caregivers outside the home with the potential to impact children’s eating in a number of domains. Recent studies have documented the economic instability and poor health ECE teachers (i.e., childcare providers) often experience. Head Start teachers make only 58% of the mean female civilian wage and only 37% of the mean male civilian wage (Whitebook, Phillips, & Howes, 2014). These lower wages are associated with a number of outcomes for ECE teachers including worry about having enough food for their families (48%) and having enough money to pay their monthly bills (73%, Whitebook et al., 2014). In total, 46% of ECE teachers enrolled in public support programs (Whitebook et al., 2014), 21% more than the national average among all workers. The health of the ECE workforce is similarly concerning with rates of diagnosed depression and physical health conditions greater than the general population (Whitaker, Becker, Herman, & Gooze, 2013). Further, FI rates among ECE teachers exceed national averages with study estimates ranging between 28% (Song et al., 2016) and 34% (Swindle et al., 2018); some sub-groups demonstrate even higher rates (e.g., assistants teachers at 45%, Swindle et al., 2018). The impact of ECE teachers’ FI on classroom interactions has received some attention with qualitative work suggesting that teachers’ personal experiences with FI result in desires and actions to protect children from the experience of hunger (Swindle, Patterson, & Boden, 2017).

The combination of FI among ECE teachers and concerns about FI for children in their classrooms has the potential to amplify potential indirect effects of FI on children. Despite frequent encounters with hunger among children they serve (Sigman-Grant et al., 2008; Stuff et al., 2009), ECE centers’ efforts to address FI vary widely and often lack a systematic or resourced approach to supporting families (Gooze, Hughes, Finkelstein, & Whitaker, 2012; Sigman-Grant et al., 2008). As a result, ECE teachers are left to their own judgment about children’s experiences with FI (i.e., “children do not seem to be getting enough at home,” Gooze et al., 2012) and report feeling uncertain about the best way to handle it (Lumeng, Kaplan-Sanoff, Shuman, & Kannan, 2008). One study on this topic documented that responses among ECE teachers differ for children and their parents. The most frequent reactions involved ensuring children had enough healthy food at the center (98%); however, less than half inquired of parents whether they needed assistance with food (Sigman-Grant et al., 2008). A lack of research exists that explores ECE teachers’ responses to child FI and whether their responses differ based on their own personal experiences with FI.

Given that the ECE workforce in the U.S. exceeds 2 million adults (National Survey of Early Care and Education Project Team, 2013) and that each adult can impact many young children across his/her career, understanding the relationship between teachers’ FI, classroom practices, and child outcomes is essential. To date, studies have not explored how the personal experience of FI influences ECE teachers’ beliefs and interactions with children around food in their classroom. Objectives of this mixed methods study were to (1) elicit prominent themes relating to teacher experiences with FI (in the classroom) through qualitative interviews; (2) translate interview themes into survey items and analyze survey data to explore generalizability of the qualitative findings; and (3) provide preliminary data on properties of a new tool to study the influence of FI in the ECE setting.

Methods

Source of Qualitative Data

To date, our team has published two qualitative manuscripts and one quantitative manuscript from the overarching study. The qualitative studies focused on examining the application of theoretical models to better understand personal and contextual factors that influence ECE teachers’ feeding (Swindle et al., 2017; Swindle & Phelps, 2018). The quantitative study generated survey items and examined properties of these items for the construct of Food Acquisition Stress (Swindle et al., 2019). The focus of this study on identifying and measuring FI experiences in the classroom is distinct from prior publications.

An exploratory sequential mixed methods design (QUAL → quant, Creswell et al., 2011; Meissner et al., 2011) directed collection of data. Qualitative data were derived from the previous project investigating contextual factors influencing ECE mealtime and nutrition practices (Swindle & Phelps, 2018). Belsky’s Determinants of Parenting Model informed design of the interview guide which sought to elicit ECE teachers’ personal backgrounds, beliefs, and teaching interactions in the arena of child feeding and nutrition (Belsky, 1984). The final version reflected input from community stakeholders and a qualitative expert as well as three pilot interviews. Twenty-eight interviews were completed between February 2015 and May 2015. Recruitment was driven by a stratified, purposive sampling strategy, balancing across teaching role (lead vs. assistant) and agency type (Head Start vs. state-funded). Sites were stratified by these criteria, randomly selected using a random number generator, and sent materials to recruit teachers upon approval from administration. One ECE teacher per site was included in the study.

Following verbatim transcription of recorded interviews by research staff, transcripts were imported into QSR NVivo (Nvivo, 2012). Initially, two co-authors with graduate-level training in qualitative methods employed a directed thematic analysis (Bradley, Curry, & Devers, 2007; Fereday & Muir-Cochrane, 2006) with a start list (Crabtree & Miller, 1999) informed by a literature review and the PARiHS context construct (Rycroft-Malone, 2004) to code qualitative interviews. Initial analysis focused on understanding and describing organizational characteristics evident in narratives of ECE teachers and influencing mealtime and nutrition promotion practices. These results are reported elsewhere (Swindle & Phelps, 2018). FI was prevalent across constructs and worthy of further in-depth analysis. FI was viewed as an “overarching dimension of meaning,” or a meta-theme (Hagaman & Wutich, 2017) in that it had a “complexity of function in the unification of meaning”(DeSantis & Ugarriza, 2000). Thus, this manuscript focuses on analyzing ECE teacher narratives through a lens of FI.

Source of Quantitative Data

Quantitative data for this analysis represent a subset of data collected as part of a larger survey (Swindle et al., 2019). Between January 2017 and May 2017, 1203 ECE teachers attending professional development trainings voluntarily completed the hardcopy survey [~50% of those invited]. The survey included a cover sheet with study details and communicated participation was voluntary and not associated with the professional development training. A final page was detached and submitted separately from the survey if ECE teachers elected to enter a drawing for $75.

Survey items were generated based on qualitative themes, striving to use ECE teachers’ language when possible. The item bank was reviewed and discussed with an expert in the field [SJ]. Items were then pre-tested and revised through two cognitive interviews (Willis, 2004) with ECE teachers in the target population and reviewed for feedback by 65 extension agents who train and interact regularly with the target population. This process resulted in 28 items grouped into four constructs; one construct was conceived as having two sub-scales. Items from the USDA’s Household Food Security Survey Module (HFSSM, Economic Research Service, 2012) short form (N=10) were used to assess FI status; Food Acquisition Stress (FAS) was also measured (Swindle et al., 2019). Demographic questions (n = 16) were asked at the end of the survey (e.g., role at the center, years of experiences, race/ethnicity).

Study Ethics

This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the University of Arkansas for Medical Sciences (IRB # 204384). Written consent was waived by the institutional review board because it would have been the only document linking participants to the study. Verbal consent was obtained on the recordings for the interviews. The survey included an informational sheet informing participants of the purpose of the study and their participation as well as the anonymous and voluntary nature of the survey. They were informed there were no consequences for electing not to participate or for withdrawing at any time.

Data Analysis

Qualitative Data Analysis

The researchers used QSR NVivo 10 (Nvivo, 2012) for analysis. We followed a thematic analysis process (Vaismoradi, Turunen, & Bondas, 2013) in an effort to search for and identify “common threads that extend throughout an entire … set of interviews” (DeSantis & Ugarriza, 2000). Two researchers (TS & JP) trained in qualitative data analysis separately coded three interviews. Findings were discussed to establish consensus and build a coding process. From that point, one researcher (TS) coded the remaining interviews, which included notes to document the coding and thematic development process (Braun & Clarke, 2006). The two researchers engaged in regular meetings to discuss notes, and the coding and thematic development process. We talked about each individual interview and holistic impressions across interviews; we also discussed individual-level salient quotes, reviewing how the primary coder conceptualized codes and themes; and we resolved ambiguous codes. These meetings functioned as “reliability checks … to prevent coder drift” (Syed & Nelson, 2015).

Quantitative Data Analysis

Quantitative survey data were screened for careless responders based on Mahalanobis distance values, even-odd consistency indicators, and long string response patterns. After eliminating careless responders [i.e., participants with survey responses that indicated insufficient consideration (Meade & Craig, 2012), N = 32], the analyst computed descriptive statistics for items to assess for ceiling and floor effects and assess distribution across response options. Patterns of missingness were examined by item. Cronbach’s alpha was calculated to provide an index of internal consistency for items designed to measure the same construct. Scale scores were created by averaging across the means of the items in the scale and requiring response to the majority of items on the scale (66% or more). Responses from the HFSSM measure were categorized as food secure or food insecure across the last 12 months in accordance with scoring directions (Economic Research Service, 2012). FAS was also scored dichotomously in accordance with published scoring conventions (Swindle et al., 2019). Finally, in exploratory analyses, the analyst compared teachers with and without FI and FAS on the survey constructs in unadjusted t-test comparisons as well as adjusted ANOVA analyses controlling for race/ethnicity, years of experience in early education, and education level. Complete case analysis was used for t-tests and ANOVA analyses given the overall low level of missing in the data. These group comparisons were exploratory only as the focus of this paper is presentation of the conceptual development and preliminary testing of the tool and does not present a full psychometric examination.

Results

Qualitative Results

Teachers in the qualitative portion of the study (N=28) included 75% White, 14% Black, 7% Hispanic, and 4% Other ethnicities. Lead teachers comprised more than two-thirds of the sample (68%). A majority held college degrees (61%), followed by some college (32%), and 7% with a high school diploma or GED. The average years of teaching experience was 10.8, while the average age was 40.7 years. Slightly over half of sites were exclusively Head Start (54%); 39% of sites were exclusively state-funded; and 7% received both types of funding.

Analysis of ECE teachers’ narratives resulted in four themes (and two subthemes): (1) Teachers’ Concerns about Child Food Insecurity; (2) Teachers’ Assessment of Child Food Insecurity; (3) Teachers’ Strategies to Address Child Food Insecurity (Strategies in the Classroom, Strategies with the Families); and (4) Teachers’ Struggles with Addressing Food Insecurity. A detailed description of themes and sub-themes follows below.

Teachers’ Concerns about Child Food Insecurity.

Although the perception about the prevalence of FI in ECE teachers’ classrooms varied, nearly all accounts described that teachers had concerns for at least a few children in their class. ECE teachers worry that meals at the center might be the only meals children eat and expressed concerns about how child FI might affect children’s development. Several teachers mentioned physical health concerns [e.g., “blood sugar (ID 23),” ‘tired all the time (ID 24)” and undernourishment (ID 21)] including a recognition that “nutrition has a lot to do with brain development (ID 17)”. A few teachers also spoke about how FI affects children emotionally as illustrated by one participant who said, “If you’re hungry, you’re not feeling safe; you’re not feeling loved, ‘cause you’re concentrating on being hungry. I think if they have a good nutritious meal, you’re ready for the day (ID 19)”. However, the focus of their concerns was on cognitive impacts. Many teachers voiced concerns that children “are not going to learn (ID 4)” and they will be unable to “concentrate on anything (ID 14)” if they are hungry “because all they’re worried about is ‘what am I going to eat next (ID 14).’ ” Concentration and focus were mentioned frequently as a concern for children experiencing FI. These concerns may be heightened when teachers have experienced FI themselves as illustrated by a participant who said, “I guess that’s the reason my heart breaks whenever I see them going through that. Because if it hadn’t been for my granny and grandpa, I would have been in trouble (ID 20).”

Teachers’ Assessment of Child Food Insecurity.

ECE teachers described a range of signals they used to assess for FI in children in their classroom. Physical health signs including body size and grogginess were noted as indicators. Yet, most often this assessment was based on observations of child behavior including consistently high levels of hunger at breakfast, unusual hunger on Mondays, eating fast [i.e., gobbling it up (IDs 27, 2)], insatiable hunger at school, being protective of food, and crying when there weren’t second portions or the meal was over. These behaviors are noted as atypical compared to their general experience with children (e.g., “Most kids this age aren’t really like ‘I’ve got to eat everything.’ ID 22”). Teachers also used their background knowledge of the child and intuition to assess for FI [e.g., “I know the family (ID 10),” “pretty sure (IDs 15, 21)”].

Less frequently, ECE teachers noted comments from children or directly asked children and families about food. Teachers expressed that repetitive and unsolicited comments from children were those that raised concern. These included children’s questions about when meals were coming, statements that children had not eaten the night before, strong declarations of hunger, or comments about meals at home that were troubling (e.g., “ ‘I had chips for dinner last night, ID 14’ ”). Directed questions such as “Hey, what did you have to eat for dinner last night (ID 3)?” were used by teachers to explore their assumptions.

Teachers’ Strategies to Address Child Food Insecurity.

FI was suspected to impact between 2 and 5 children in a given classroom among teachers who provided comment on the prevalence of this issue. None of the teachers in this sample described an agency policy designed to systematically assess for and address FI. In fact, teachers described how they felt the rules and policies often failed to fit the needs of the children. In the absence of standard processes, teachers described a range of strategies to mitigate FI for children in their classrooms. Primarily, teacher strategies directed towards children focused on ways to offer children extra food at the center. Teachers also described strategies targeted directly at families with the goal of reducing FI for children.

Strategies in the Classroom.

Strategies at mealtimes were the primary way that teachers described attempts to mitigate perceived FI. A main thread was to do “whatever we’ve gotta do (ID 24)” to prevent children from being hungry and to “fatten them up before they go (ID 23).” Teachers described working around meal and snack policies in other ways to make sure children had enough food. For example, common strategies included offering more than the prescribed portion, offering seconds to children of concern first, sharing their personal meal, sneaking food between meals, and opening food at the center so children could take it home. Extra snacks, outside the planned meal pattern, were described similarly as a way to direct food to children perceived to be hungry as well as efforts to “beef up our snack, to make sure that…their bellies are full (ID 23).”

Another prominent strategy at meals was altering their feeding behaviors including their communications with children and their food offerings. That is, teachers said they would “try to encourage her [a food insecure child] to eat a lot (ID 21)” and “try to really, really get them to eat (ID 15).” Teachers described that getting children foods they liked most was a way they felt they could help. This strategy was applied by asking for extra portions from the cafeteria or trading foods between children.

Strategies with the Families.

Some teachers combined efforts with children at the center with strategies directed at the family. Few did these without also altering their practices with the children. A common step was to “go to the parents” and ask if they “need help with something” (ID 5). When parents indicated a need, teachers described efforts to connect them with local resources including churches, food banks, Women Infants and Children (WIC), and the Supplemental Nutrition Assistance Program (SNAP). For example, one ECE teacher said, “If they’re not getting enough to eat, if they’re having trouble with getting food, we can help them get applications for food stamps and send them to food banks (ID 17).” Teachers also described existing programs that their centers had in place to respond quickly to family needs including backpack programs and commodity sharing. Some teachers purchased food from their personal budget to send to families while others described finding ways to send “home an extra snack or two.”

Teachers Struggle with Addressing Food Insecurity.

Across the range of narratives, teachers often described a struggle in knowing the right approach to take with children experiencing FI. To some extent, ECE teachers described the tension between obesity prevention in the long-term and addressing immediate hunger. One teacher articulated, “Obesity, it’s rampant, but sometimes it is hard when there’s no more and they are wanting more… then if you’re almost certain that baby’s not eating again, you want to give them more (ID 21).” This tension created personal turmoil about altering portion sizes and deciding how many additional portions to allow, when to “cut him off (ID 29).” Often, teachers felt resolved that feeding to fullness was their priority as stated by a teacher who said, “Our cook has even questioned, ‘Do you think I should give them more?’ And I’m like ‘I’d feed them. If it was me, I’d feed them until they didn’t want anymore’ (ID 12).” Teacher narratives indicate perceived FI among children in the ECE setting and reveal the influence this perception has on teachers, as expressed in their actions when encountering children considered FI in their classrooms. Table 1 has additional exemplar quotes supporting themes and subthemes, as well as how themes contributed to development of quantitative survey items. Results of the quantitative portion of this sequential mixed methods study follow below.

Table 1.

Qualitative themes, exemplar quotes, and item examples.

Theme Exemplar Quotes Quantitative Item Examples
Teachers’ Concerns about Child Food Insecurity I think they need full tummies in order to learn and be a productive day. If they’re hungry, they’re not going to absorb what we’re trying to instill, you know. Makes me have a bad day when I don’t get something to eat in the mornings, so I would think they would be the same, you know. A hungry tummy’s not a happy brain. −9
That’s my concern the biggest is ya know, wondering if they are are being fed. Because ya know some children, I have noticed over these years that most of the time the children that eat fast are the children that hardly probably don’t get much food at home. So that’s my concern. −29
I have a couple of kids, or one in particular, that sometimes I feel the meal he gets here, the meals he eats here may be the only ones he’s getting, because he seems really hungry. − 19

  • Sometimes the meals at the center are the only meals the children eat.

  • When a child does not eat at school, I worry they will be hungry at home.
Teachers’ Assessment of Food Insecurity They would keep their food up really close to them. They would gobble it like they were worried about when they’d eat again. Their appearance, their eyes would be sunk in. They had no energy. They were very unkempt…they were very very small… And food was so primary to them at school those three meals, breakfast, snack and lunch; they centered around it. It’s just some of the comments they would make, they’d be like, ‘I’m so hungry. And I just didn’t eat very much’ or ‘I hardly ate anything.’ It’s really hard as you want everybody to eat… and they’ve been found putting food in their pockets. And they are like ‘I’m taking it home because I won’t eat again tonight. I won’t eat until tomorrow.” So that’s really hard. −21
And we have some that come in and say, I didn’t get to eat last night. Or they’ll want more, seconds. If we have seconds, you know, if we have seconds we give it to them and, um, we have one little girl in particular that she’ll come in sometimes on Mondays and she’ll eat three or four helpings of something. And we’re pretty sure, you know, she might not have ate a lot over the weekend −15
She cries when she finishes. Or he cries because another person has more food. Well the portions are the same but he thinks they have more food than her. She wants more, and we give it to her…she said that she had not eaten at her house. Then I went to sit her down and I told her that her food was there, [in a consoling tone] “You don’t have to cry, go wash your hands and then come to sit and eat. When you finish you can go with your friends at the carpet.” −18		 Over a normal week, how many children in your class will:

  • Tell you they didn’t eat the night or morning before school.

  • Cry if there are no seconds.
Teachers’ Strategies to Address Child Food Insecurity in the Classroom I mean, I will even give them what’s on my plate if they’re still hungry. I know we’re not supposed to do that, but if a child is still hungry, I’m going to make sure they eat…And I will even go to the kitchen and see if there’s any more fruits and vegetables. −16
We just try to make sure they eat here, you know, find… There have been times I’ve found stuff that they would eat to make sure they had something in their belly before they went home. −17
Those kids, you know, if they are hungry, you know, even after school, you know, and if they need something else we will give them something else because we don’t want them to be hungry… I mean the cafeteria is always really good about. They’ll have something, whether it’s just crackers or something to hold them older until it is lunch time or it is snack time or something like that. −24
Give them extra food. I mean if I find something that… they’re starving… if a kid’s not going to eat something, I know they’re not going to eat it or if I have an extra like we feed seventeen kids and only fifteen showed up, I’ll give the extra food to that child.– 23		 How do you address hunger with children in your class that may not have enough food at home. How often do you do the following:

  • Share food from my plate.

  • Buy food for the child/family using my own money.
Teachers’ Strategies to Address Child Food Insecurity with Families We have commodities that the center provides for families, …and sometimes we have went and bought food and took it to families that we knew were struggling. Or during the winter dad’s not working and mom’s on unemployment because we’re tourists town, and a lot of our parents don’t work in the winter time because tourist season’s over. We encourage them to go apply for SNAP benefits, you know, food stamps, and all of our kids almost are eligible for WIC. −15
I mean I’ve went and got just snack packs and little things that they can do themselves, because sometimes the family it’s really just a sad situation…I went and bought things that he can open on his own, because the mother was on drugs so bad that I don’t know that she would’ve fed him even if I would have bought something that she had to cook…so I would buy like puddings, things that were already pre-made that all he would have to do would be to open them. – 20
We have a backpack program right now through our main center that goes through the Rice Depot, but all I have to do is send a request into our main office and they send them back pack to me and I send it home with a child. Maybe over the weekend or something, and it has very easy things that if the child happened to have to fix by themselves they could, or if the parent wasn’t able to fix a lot they could fix for them. – 11		 How do you address hunger with childre0n in your class that may not have enough food at home. How often do you do the following:

  • Send food home with children who need it.

  • Connect parents with a food backpack program.
Teachers Struggle with Addressing Food Insecurity And it still brings up that inner struggle “fill their belly or expose them to new foods?” That’s like the biggest thing that stuck out with me now, because you want to fill their belly. And is it more important to feed them something healthy or make sure they go home with something in their stomach? −21
And, um, she was just, really kept telling me she was hungry and she was hungry, and so I brought her in and our snacks are stored here on site. .. And, um, I asked her, ‘What are you going to have for supper tonight?’ She was like, ‘I don’t know if I’ll get to eat.’ And I wish there was some way we could…and I know you can’t fix every family and every child, but for a 4-year-old to not know if they’re going to get to eat supper…– 10
I would like to see a little more, and sometimes it’s really hard when there’s because we have to meet the guidelines. And we want to keep these babies healthy, and we really don’t want to be overfeeding them. Obesity, you know that it’s rampant, but sometimes it is hard when there’s no more and they are wanting more. And you come back and there’s no more; Portion, portion control. We have to give them a certain amount, and then there’s not always more. Sometimes there is a little more and we do give them. Or it’s just really hard because, this year I have not seen it but in the past I’ve seen it, where I was almost certain that the child was not eating again after they left the center, so that’s hard, when there is no more. Because you know cost and portion control. And then if you’re almost certain that baby’s not eating again, you want to give them more…. I would try whenever there was any extra food if we did have, I would always try to give that child first. And make sure they did get some, especially that lunch meal. – 21		 How do you address hunger with children in your class that may not have enough food at home. How often do you do the following:

  • Struggle with what you should do.
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Quantitative Results

Sample.

Consistent with the focus of the study on exploring how FI is managed in the ECE classroom, the survey sub-sample was limited to survey participants who were providing care to toddlers or preschoolers; cooks, parents, office aids, and owners/directors who were not classroom teachers were excluded. After these exclusions, 781 cases remained (~65% of the original survey sample). Most participants (96%) were female. The majority of teachers were White (67%), followed by Black (25%), American Indian (2%), and other (6%). Participants were 39 years of age on average (SD = 15) with 10.7 years of experience in ECE settings (SD=10). Approximately 45% of the participants reported an annual household income less than $25,000; 29% made between $25,000 and $45,000 for their household annually; and the remaining 26% had an annual household income greater than $45,000. An approximate third of the sample had attained a high school education (35%); 36% had some college; 13% had completed an Associate’s degree; 10% had completed a Bachelor’s degree; and 3% held a Master’s degree or higher.

Assessing Teachers’ Perceived Concerns about Child Food Insecurity in the Classroom.

As illustrated in Table 1, all quantitative items were based on qualitative themes (sub-themes) from teacher interviews. Table 2 presents six survey items (scored as a scale) designed to assess perceived concerns teachers may have about experiences of FI among children in their classrooms. Cronbach’s alpha for the scale was 0.81, and all items were retained. The percentage of missing values was less than 2% for all items on this scale. Teachers most highly endorsed the item stating that “children have enough to eat at home,” with about half (49%) agreeing or strongly agreeing with that statement. This item was reverse coded for scale creation.

Table 2.

Items to Assess Teachers’ Concerns about Child Food Insecurity

How much do you agree with the following: Strongly Disagree (1) Disagree Neither Agree or Disagree Agree Strongly Agree (5) Item Mean (SD) Missing %
Sometimes the meals at the center are the only meals the children eat. 25.7% 26.3% 25.0% 18.4% 4.6% 2.5
(12)		 0.1
I have children in my classroom that don’t get to eat at home. 29.3% 31.0% 28.6% 9.9% 1.3% 2.2
(10)		 0
I know which families struggle with hunger. 16.7% 19.7% 36.8% 23.3% 3.5% 2.8
(11)		 1.7
Children have enough to eat at home. * 4.4% 11.8% 35.1% 33.0% 15.6% 3.4
(10)		 1.5
When a child does not eat at school, I worry they will be hungry at home. 17.2% 22.7% 22.2% 28.1% 9.8% 2.9
(13)		 0.1
I worry that children who are skinny are not getting enough to eat. 21.4% 31.1% 28.8% 15.1% 3.5% 2.5
(11)		 0.1
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*

Reverse coded for item analysis and scale creation

Assessing Frequency of Teacher Concern about Child Food Insecurity in the Classroom.

Table 3 presents six survey items (scored as a scale; internal consistency = 0.79) designed to address the frequency with which teachers encounter children about whom they have a FI concern. All items had less than 1.5% missing responses. About a third of the sample (29 %) stated that 50–75% of children “always ask for seconds.”

Table 3.

Items to Assess Frequency of Perceived Signals of Food Insecurity

Over a normal week, how many children in your class will: None A few children 25% of children 50% of children 75% of the children Item Mean (SD) Missing %
Always ask for seconds. 9.1% 31.8% 30.2% 16.6% 12.3% 2.9
(12)		 0.3
Cry if there are no seconds. 59.1% 24.0% 12.5% 2.7% 1.7% 1.6
(0.9)		 0.6
Gobble their food. 22.6% 35.7% 30.8% 9.0% 1.9% 2.3
(1.0)		 0.6
Arrive at school hungry. 26.6% 36.5% 24.5% 9.1% 3.4% 2.3
(11)		 1.0
Guard their food. 59.7% 20.4% 15.6% 2.6% 1.7% 1.7
(10)		 1.5
Tell you they did not eat the night or morning before school. 78.1% 12.6% 7.7% 1.3% 0.3% 1.3
(0.7)		 0.8
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Assessing Teachers’ Strategies to Address Child Food Insecurity.

Table 4 presents fifteen items (a scale) designed to assess teacher strategies to address child FI at the center and with families. Consistent with other constructs, item language reflects the narratives of teachers. In addition, three items (*) are included from the About Feeding Children Survey (Swindle et al., 2018). These items are designed to measure strategies used to address perceived FI among children in their classrooms. A global scale of Teachers’ Strategies to Address Child FI (all items in Table 4) demonstrated a Cronbach’s alpha of 0.88. Separating this scale into subscales of Strategies in the Classroom and Strategies with Families resulted in Cronbach’s alphas of 0.83 and 0.92, respectively. All items were retained. Items on the Strategies in the Classroom scale demonstrated higher missingness than other scales; 6 items had 5% missing or greater (max = 8.1%). The most frequently used strategy with children was “making sure the child gets all the food they want while they are at the center, which 65% of teachers agreed they did “often” or “always.” With families, few teachers reported using these strategies “often” or “always.” However, 27% said they “give information about the food bank to families” on a “sometimes” or more frequent basis. All items on the Strategies with Families scale had low missingness (max = 3.5%).

Table 4.

Items to Assess Teachers’ Strategies to Address Child Food Insecurity

When there are children in your class that may not have enough food at home, how often do you do the following: Never (1) Rarely Sometimes Often Always (5) Item Mean (SD) Missing %
Make sure the child gets all the food they want while they are at the center. * 8.7% 6.5% 19.7% 24.0% 41.1% 3.8
(13)		 3.8
Mention the child to my center director.* 26.6% 15.0% 22.0.% 10.1% 26.0% 2.9
(1.5)		 5.1
Offer the child extra food at meals. 12.2% 9.5% 28.2% 18.7% 31.4% 3.5
(13)		 4.2
Share food from my plate. 56.7% 11.1% 16.7% 7.0% 8.5% 2.0
(13)		 8.1
Trade foods between children so the hungry child can have more of what they like. 66.3% 11.6% 14.7% 4.4% 2.9% 1.7
(11)		 4.4
Buy food for the child/family using my own money. 69.0% 10.8% 13.3% 3.5% 3.4% 1.6
(11)		 5.0
Emphasize the importance of eating. 11.2% 5.9% 19.4% 25.9% 37.6% 3.7
(13)		 5.0
Serve more than a typical portion size. 26.9% 16.0% 32.7% 12.9% 11.4% 2.7
(13)		 5.8
Do things beyond my job duties to make children get enough food. 27.6% 15.4% 26.7% 12.8% 17.5% 2.8
(14)		 5.0
How often do you do the following: Never Rarely Sometimes Often Always Mean
Give information about the food bank to families. 61.5% 11.3% 14.9% 5.1% 7.2% 1.9
(13)		 3.5
Help families with SNAP or WIC applications. 69.7% 10.7% 10.9% 3.4% 5.2% 1.6
(11)		 2.9
Send food home with children who need it. 69.3% 12.2% 11.9% 3.7% 3.0% 1.6
(10)		 3.3
Ask parents if they need help getting more food.* 72.3% 10.2% 12.3% 2.2% 3.0% 1.5
(10)		 3.2
Connect parents with a food backpack program. 72.4% 8.7% 11.6% 3.3% 3.9% 1.6
(11)		 2.7
Complete a nutrition assessment with families. 75.0% 9.5% 8.9% 2.6% 4.1% 1.5
(1.0)		 3.3
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*

Items from the About Feeding Children Survey

Teachers Struggle with Addressing Food Insecurity.

One item assessed teachers’ struggle with addressing FI. Over 35% indicated they sometimes or more often struggle in this area (Table 5). Just under half (47%) stated they never struggle to know what to do when FI is present in the classroom. Missing data on this item was 4.1%.

Table 5.

Items to Assess Teachers’ Strategies to Address Child Food Insecurity

When there are children in your class that may not have enough food at home, how often do you do the following: Never Rarely Sometimes Often Always Item Mean (SD) Missing %
Struggle with what you should do. 46.6% 18.2% 22.4% 6.1% 6.7% 2.1
(1.2)		 4.1%
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Exploratory Analyses: Differences in FI Concerns and Strategies by Teacher FI and FAS status.

Approximately 40% of participants experienced marginal (19.7%), low (13.1%), or very low (8.2%) food security. Those with low or very low food security were labeled as Food Insecure for further analyses. Almost half (48.5%) experienced FAS.

Exploratory unadjusted mean comparisons using t-tests demonstrated that teachers with FI in the last 12 months differed from those without FI on all scales as well as the item on the perceived struggle of managing FI. Participants with FI scored significantly higher on each scale. Supplementary File 1 provides means, t-test values, and significance levels. Exploratory adjusted ANOVA analyses controlling for race/ethnicity, years of experience in early education, and education level replicated these findings in terms of group differences. In addition, race was a significant predictor of Food Insecurity Concern and Strategies to Address Food Insecurity with Families with Black ECE teachers demonstrating significantly higher means than White ECE teachers for both scales (FI Concern MBlack = 2.7, SD = 0.8; FI Concern MWhite = 2.5, SD = 0.8; FI Child Strategies MBlack = 2.6, SD = 1.8; FI Child Strategies MWhite = 2.0, SD = 1.5). Years of experience also predicted Strategies to Address Food Insecurity with Children with greater teaching experience corresponding to higher scores, F (1, 476) = 11.3, p = .001.

Additional exploratory unadjusted mean comparisons showed that those with FAS had significantly higher means on all constructs except Strategies to Address Food Insecurity with Children (See Supplementary File 1). In exploratory adjusted analyses, Strategies to Address Food Insecurity with Families had a significant overall F-test (F = 7.6). In the presence of other variables, both FAS status and race/ethnicity predicted scores on Strategies to Address Food Insecurity with Families. ECE teachers with higher FAS and ECE teachers who were Black had higher scores (Food Insecurity Family Strategies MBlack = 2.5, SD = 1.8; FI Family Strategies MWhite = 2.0, SD = 1.5).

Discussion

Prior work suggests FI is a primary driver of parent feeding practices of children in households experiencing FI (Bruening et al., 2017; Coleman-Jensen et al., 2019; Kral et al., 2017; Lee et al., 2019). Within the ECE setting, feeding programs have the dual responsibility of teaching eating behaviors and addressing hunger. Both our qualitative and exploratory quantitative findings suggest that ECE teachers alter their teaching of eating behaviors in light of their own FI experiences or concerns about FI children. Further, this study builds on previous work in the ECE setting (Sigman-Grant et al., 2008; Song et al., 2016; Swindle et al., 2018) by sharing teachers’ experiences with managing FI in the classroom, providing a tool for measuring attitudinal and behavioral constructs related to FI in the ECE setting, and exploring quantitatively the relationship revealed (qualitatively) between personal FI and these constructs. Qualitative and quantitative results reveal the influence of FI within the ECE setting. Quantitative items (scales) assessing the influence of felt and perceived FI on teachers’ classroom behaviors and strategies produced results amplifying themes derived from teachers’ narratives. Personal experience with FI, coupled with perceived FI experienced by children in the classroom, seemed to shape teachers’ reported behaviors and strategies used within the classroom.

FI in the ECE setting has received limited attention, as questions raised over 12 years ago are still waiting for answers today: “What should be done to support children who have limited access to food at home? Should they be allowed, or even encouraged, to compensate for additional food from their childcare center to relieve their hunger and support their growth? Should there be different guidance for children of normal weight than for overweight children who have the additional characteristic of hunger at the childcare center or the Head Start program? Should the Child and Adult Care Food Program (CACFP) at the national level make fiscal allowances to provide more food to children from food insecure households? (Sigman-Grant et al., 2008). As promoted by Sigman-Grant et al. in 2008 and Gooze et al. in 2012, ECE teachers “should consider systematically assessing household food security” (Gooze et al., 2012). Regarding assessment of FI in ECE settings, training in the assessment process (and who assesses, when and where), as well as outlets/inputs to address what the assessment may potentially reveal are areas that would need to be addressed. Toward addressing FI in the ECE setting, needs assessment of ECE participants (the families and children they serve), could drive policy development to facilitate meaningful practice.

Findings from this current study show the influence of FI beyond the household and into the classroom. ECE teachers struggle to address perceived FI among children in their classrooms. In 2015, the American Academy of Pediatrics (AAP, 2015) prioritized addressing FI in the clinical setting, releasing guidance on screening for FI in pediatric practice as well as tools to support screening (American Academy of Pediatrics; Food Research and Action Council, 2017). While the ECE setting is different from clinic settings, and clinicians and other health care workers have different sets of skills compared to teachers, this authoritative policy supported by resources is an example of action that could aid in addressing FI in the ECE context.

Qualitative data and our exploratory group comparisons highlight that concern about FI in the classroom led teachers to adapt their feeding and mealtime strategies in ways that may influence the entire classroom of children. Encouraging children perceived as FI to “eat a lot (21)” and trying “to really get them to eat (15)” involves altered communication between teachers and children. With no center or higher-level guidance on how to handle FI in the classroom (like the AAP’s example), teachers are faced with improvising strategies to encourage children to eat more food than they would otherwise consume on their own. Other strategies involved offering less healthy options to get children with perceived FI to eat, “is it more important to feed them something healthy or make sure they go home with something in their stomach? (21).” The extent of the strategies demonstrates the sense of personal responsibility felt by teachers, which is justified based on the expectations of their role as teachers; as noted by one teacher, “a hungry tummy’s not a happy brain (9).” As earlier research has revealed, it would be “useful to provide caregivers with information on options available to them in supporting families facing food insecurity”(Sigman-Grant et al., 2008); it would also be helpful to provide teachers with guidance and training to address FI among children in their classrooms. This current study provides the means for assessing the influence of FI in the classroom and direction for developing guidance and training to better prepare teachers for handling FI in their classrooms.

Song et al. reported approximately 47% of childcare providers experienced marginal (19.9%), low (16%), or very low (11.7%) food security. In this current sample, approximately 40% of participants experienced marginal (19.7%), low (13.1%), or very low (8.2%) food security, while nearly half (48.5%) experienced FAS. That ECE teachers experience FI and FAS demands attention. The connection between teacher feeding behaviors and child eating behaviors in the classroom is documented (Hendy, 1999; Hendy & Raudenbush, 2000; Ramsay et al., 2010). Our exploratory group comparisons suggest that FI among ECE teachers influenced concerns, perceptions, and feeding practices in the ECE setting and the strategies used to help families. FAS was associated with teachers’ strategies to address FI with families of children in their classrooms. ECE teachers earn poverty-level wages (McLean, Whitebook, & Roh, 2019). According to data from four counties across four states (CA, NY, MN, FL), 24–70% (54%, 50%, 24%, 70%, respectively) of ECE teachers worried about having enough food to feed their families on a monthly basis (McLean et al., 2019). Considering these numbers, it is not surprising to see the potential influence of FI and FAS inside the classroom when working with children and outside when dealing with parents. Regarding ECE teachers, Song et al. pointed out the need to “ensure their health and wellbeing,” as those areas may directly relate to the quality of care provided to children in their care. While influence of teachers’ FI on classroom interactions has received some attention, results of this current study suggest a need for further study of the potential of FI experiences to shape practice in ECE settings.

This mixed methods study has both limitations and strengths. First, this study sought to present the conceptual development of the tool, illustrating our process for moving between qualitative data, item development, and survey testing. Further work is needed to establish psychometric properties (e.g., test-retest reliability, predictive validity) and measurement invariance across key groups (e.g., food secure and insecure). For this reason, our group comparisons should be interpreted carefully. Another primary limitation is that the characteristics of this study sample may limit generalizability of our findings as our sample includes only one state in the Southern US. Educators in this state experienced high rates of FI and FAS; relationships between FI and FAS and the constructs we present may be different in other locations. Further, the experiences shared in the qualitative interviews, which drove the development of survey items, may not be as prevalent in other areas. Despite the concern of generalizability, the primary strength of our work is the representation of the voices of ECE teachers in the newly developed survey items, ensuring that item content is grounded in the lived experience of ECE teachers in the classroom. In addition, the quantitative portion of our study included an adequate sample size to provide reliable data on basic descriptive statistics for the newly formed items. The overarching result of the qualitative and quantitative approaches is a comprehensive understanding of ECE teachers’ concerns, perceived signals, strategies, and struggle to address FI in the classroom.

The current study lays the foundation for future work in several key areas. To begin, studies can use the tool presented here to examine how ECE teachers’ concerns, perceived signals, strategies, and struggles with FI predict behavior in the classrooms and if those behaviors, in turn, predict outcomes for children and families. For example, a teacher with higher concern about FI may pressure children to eat at mealtimes, which may lead to lower responsiveness to caloric density (Birch, McPheee, Shoba, Steinberg, & Krehbiel, 1987) and less liking of healthy foods (Batsell, Brown, Ansfield, & Paschall, 2002; Galloway, Fiorito, Francis, & Birch, 2006). A counter example to the positive may be that teachers with greater strategies to support families use less controlling feeding practices in the classroom. Both examples have important policy and practice implications. Specifically, individually-targeted interventions to reduce FI and organizational-level efforts to equip teachers to manage FI effectively may result in shifts in the constructs this tool presents. Such attitudinal shifts may, again, lead to feeding practices that are more responsive and less controlling, which are desirable patterns based on a review of the impact of parent feeding practices on children (Bergmeier, Skouteris, & Hetherington, 2015). These ideas can be explored and compared in diverse samples of teachers serving children across a range of contexts (e.g., programs with and without CACFP support).

A key product of this work is a multi-dimensional scale with strong indicators of internal consistency to measure attitudes (FI concerns, Perceived Signals, Struggle) and behaviors (Strategies with Children/Families) related to FI management in the early education environment. Hunger in childcare has been a concern for over a decade (Sigman-Grant et al., 2008); yet, there have been limited research efforts to understand teachers’ perspectives and reactions to this phenomena. The result has been negligible policy and/or resource allocation to support ECE teachers to address this situation, a key need identified by earlier studies (Gooze et al., 2012; Sigman-Grant et al., 2008). Our work provides a structured tool to measure concepts related to FI management discussed in prior work (i.e., caregiver and center strategies, Sigman-Grant et al., 2008) that were also present with ECE teachers in interviews in our state. Several studies have demonstrated a link between FI and parent feeding practices (Barlow, 2007; Feinberg, Kavanagh, Young, & Prudent, 2008; Kuyper, Smith, & Kaiser, 2009). However, feeding in childcare environments differs from parental feeding practices in key ways as the ECE teacher is responsible for practicing and promoting evidenced-based best-practices during mealtimes within the ECE setting, which are group (and individual) learning experiences that also function to address child hunger. Our tool, paired with other childcare-specific feeding instruments (e.g., Swindle et al., 2018; Tovar et al., 2019; Trost et al., 2009) can provide a unique opportunity to examine the association between FI and feeding practices for ECE teachers.

Examining the association between FI and feeding practices is meaningful for several reasons. At the ECE center level, it provides additional evidence to push for policy change toward adequately addressing FI in the ECE setting (among teachers, children, and families). At the teacher level, it provides direction for developing best-practice-based procedures and strategies toward working with children experiencing FI in their classrooms. At the child level, it enables development of healthy eating behaviors through the potential for improved communication and interaction with ECE teachers. In sum, a systems-level effort to assess and address FI in ECE settings could improve health for children and teachers.

Supplementary Material

1

Funding Acknowledgement:

The work was supported by the Translational Research Institute (TRI; UL1TR000039, KL2TR000063), grants through the NIH National Center for Research Resources, the National Center for Advancing Translational Sciences, the National Institutes of Diabetes and Digestive and Kidney Diseases (K01-DK110141), the National Institute of General Medical Sciences (P20GM109096), and the Arkansas Biosciences Institute (T.S.), the major research component of the Arkansas Tobacco Settlement Proceeds Act of 2000. TS also receives support from NIH R21CA237984 and NIH R03DK117197. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Declaration of Interests:

The authors have no financial interests to disclose.

Ethical Statement

This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the University of Arkansas for Medical Sciences (IRB # 204384). Written consent was waived by the institutional review board because it would have been the only document linking participants to the study. Verbal consent was obtained on the recordings for the interviews. The survey included an informational sheet informing participants of the purpose of the study and their participation as well as the anonymous and voluntary nature of the survey. They were informed there were no consequences for electing not to participate or for withdrawing at anytime.

Data and Code Availability:

The lead author has full access to the data reported in the manuscript.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

1
NIHMS1733325-supplement-1.docx (25.1KB, docx)

Data Availability Statement

The lead author has full access to the data reported in the manuscript.

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