Outcomes From Healthy Eating and Physical Activity Recognition Programs in Early Child Care and Education: A Scoping Review

Abstract

Objective:

Recognition programs are designed to incentivize early care and education (ECE) settings to implement childhood obesity prevention standards, yet little is known regarding their efficacy. This scoping review details characteristics, methodologies, and criteria used to evaluate recognition programs, identifies gaps in evaluation, and synthesizes existing evidence.

Data Source:

A public health librarian created the search strategies for six databases: Ovid MEDLINE, AGRICOLA, CAB Abstracts, PAIS Index, ERIC, and Scopus.

Study Inclusion and Exclusion Criteria:

Inclusion criteria include recognition program, ECE setting, nutrition or physical activity, and qualitative or quantitative outcomes. Exclusion criteria include programming without recognition component, no ECE setting, no nutrition or physical activity outcome, case studies, or not written in English.

Data Extraction:

Three researchers independently extracted and complied data into an Excel spreadsheet.

Data Synthesis:

Tables were created describing location, recognition program criteria, award incentive, study design, study sample, risk of bias, and outcomes (e.g., menu nutrition) evaluated in each study.

Results:

Three unique recognition programs (described in 7 studies) provided technical assistance, incentives, and training. While outcome measures and study designs varied across programs, it is clear that recognition programs are well accepted and feasible, and one study demonstrated beneficial weight outcomes.

Conclusion:

Although additional evaluation is needed, recognition programs may be a promising strategy to improve obesity prevention practices in ECE.

Objective

Obesity prevention strategies are needed for young children, as one in four children aged 2–5 years have overweight or obesity.¹ Roughly 80% of children with working parents spend up to 40 hours per week in non-parental care, and 41% of these children attend an early care and education center (ECE). As such, ECE centers are important targets for child obesity prevention.^1–3

Obesity prevention efforts in ECE settings are guided by national health and safety standards.⁴ The Centers for Disease Control and Prevention created the Spectrum of Opportunities framework in 2012 to guide states on how to embed obesity prevention standards into existing ECE systems.¹ Following the introduction of this framework, the 2016 Early Care and Education State Indicator Report identified recognition programs as a promising obesity prevention strategy.¹ Recognition programs are voluntary programs managed by a state agency or non-profit organization that incentivize ECE programs to meet healthy eating and physical activity standards. Programs meeting set criteria are issued recognition or designation (e.g. “Healthy Child Care Center”) for a specified period of time.¹ Criteria for recognition usually meet or exceed general licensing and accreditation requirements.¹ Recognition criteria and components vary by program, but most require ECE providers to implement wellness policies, offer healthy menus, complete staff training, and conduct regular self-assessments of healthy eating and physical activity policies and practices.⁵

Many countries have government-supported health and safety standards for ECE settings, including the United States, Canada,⁶ New Zealand,⁷ the United Kingdom, Sweden, and Australia.⁸ While many of these countries provide educational materials to assist with the implementation of standards, it is unclear how many utilize recognition programs as a strategy to promote adherence to standards. Further, even in nations in which the presence of active recognition programs has been identified (e.g., 13 states in the United States have active recognition programs⁵), program outcomes have yet to be synthesized, leaving the potential of recognition programs as a tool for obesity prevention underexplored.^8–10 This scoping review (1) conducted a systematic search of literature evaluating recognition programs, (2) mapped out the characteristics, methodologies, and criteria used to evaluate recognition programs, (3) identified gaps in evaluation outcomes, and (4) synthesized existing evidence to provide recommendations for professionals interested in using recognition systems to improve obesity prevention efforts in ECE settings.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines for Scoping Reviews (PRISMA-ScR), a checklist of twenty essential reporting items, was followed to conduct the review and analysis.¹¹ The scoping review protocol, developed a priori to describes the rationale, hypothesis, and planned methods of the review, was registered with Open Science Framework.¹² The purpose of prospective registration is to increase transparency and reduce bias in the conduct and reporting of reviews.

Data Sources

A public health librarian (SH) created the search strategies for six databases based on their disciplinary relevance to the research question: Ovid MEDLINE (medicine, public health), AGRICOLA (nutrition), CAB Abstracts (nutrition), PAIS Index (policy), ERIC (education), and Scopus (interdisciplinary). An interdisciplinary database was included to catch rare studies published outside these disciplines. All final searches were executed March 7, 2021.

Supplementary Appendix A details the full electronic search strategies. The original search was built in MEDLINE via Ovid and utilized controlled vocabulary as well as free text. Terminology focused on three concepts: designation programs, nutrition or physical activity, and early childhood education. The search prioritized sensitivity over specificity and captured literature from any time period. Additionally, the names of previously identified designation programs⁵ were specifically added to the search strategy as a separate concept. The search was then translated to the other five databases.

After the records discovered via databases were fully screened, researchers performed a forward and backward search. A forward search identifies articles that cite an original work after it had been published. SH used the “cited by” feature in Scopus to find all records that cited the included articles. A backward search identifies articles by examining the references in an article. MP collected all works cited by the included articles.

Study Selection

The following inclusion criteria were determined a priori: (1) describe a state, county, or city-level recognition or designation process, (2) focus on early child care and education settings, (3) relate to the topic of nutrition or physical activity, and (4) describe qualitative or quantitative outcomes (e.g., process based outcomes, feasibility/acceptability outcomes, provider implementation of practices or policy changes, child-level physical activity or nutrition behaviors). Studies were excluded if they (1) described implementation or outcomes of nutrition programming that was not related to state, county, or city-level recognition or designation indicators (e.g., SNAP, WIC), (2) were not in an early child care or education setting (i.e., licensed child care center or family child care home), (3) did not measure nutrition or physical activity outcomes, and instead measured other outcomes assessed by recognition or designation programs (e.g., breastfeeding), (4) were case studies, (5) were not original studies published in full (e.g., letters to the editor, commentaries, abstracts), or (6) were reported in a language other than English.

Duplicate references were removed and items were uploaded to Rayyan¹³ for independent title/abstract screening. In a pilot round, 20 records were reviewed for inter-rater reliability by two faculty (KA, JS) and two public health students (MP, GW), reaching 100% agreement. Each remaining title/abstract record was then screened by two reviewers, and disagreements were resolved through discussion. Full text records (PDFs) were gathered for studies that were included in the first round of screening and again evaluated for alignment with inclusion/exclusion criteria. Each record was screened by three reviewers (KA, MP, GW), and disagreements settled through discussion.

The forward search results were screened for title/abstract and then full text in a separate Rayyan project using the same methods described above. Backward search results were compiled in an Excel spreadsheet and then KA, MP, and GW independently screened for inclusion/exclusion. The study selection flow and reasons for exclusion are reported in Figure 1.

Figure 1.

Flow diagram of study selection.

Risk of Bias Assessment

While not required for a scoping review, a risk of bias of included studies was performed with the hopes of better informing future research in this area. The Joanna Briggs Institute Critical Appraisal Tools were used for the assessment.^14,15 KA, MP, and LG independently assessed each study using the appropriate appraisal tool for each study design. Then, KA, MP, and LG made a spreadsheet to compile results of the individual assessments. Disagreements regarding sources of bias (e.g., identification of confounders, measurement of exposure and outcome variables, etc.) were settled through discussion.

Data Extraction

Included studies were independently coded by KA, MP, and GW. The following information was extracted from included studies and entered into an Excel spreadsheet: authors, year of publication, study location, setting (e.g. child care center or family child care home), sample size, study design, participant characteristics, name of recognition program as provided by study authors, recognition program rationale/theory/goal, recognition program criteria, recognition program length, criteria/methodologies used to evaluate program, and reported outcomes (classified as acceptability/feasibility outcomes, process outcomes, effectiveness outcomes at the provider level, effectiveness outcomes at the child level).

Data Synthesis

After the researchers independently extracted the data, data were compiled into an Excel spreadsheet. Data analysis was performed through researcher discussion examining the similarities and differences of each of the individual studies. Two different tables were created to map out the characteristics, range of methodologies, and criteria used to evaluate recognition programs: one table focused on the characteristics of each child care designation program and the other table focused on the outcomes evaluated in each study.

Results

Results of the Search

Figure 1 outlines the search process including the number of articles found via databases, forward and backward search screening, and publication alert (n = 3246); screened for eligibility in title/abstract round (n = 2554), screened for eligibility in the full text round (n = 11), and included for review (n = 7). Reasons for full text exclusion were not an original study published in full (n = 1), case studies (n = 2), and duplicate article (n = 1).

Characteristics of Included Studies

Three unique child care recognition programs were identified: Start Right Eat Right in Southern and Western Australia, the Empower Program in Arizona, and the Healthy Apple Program in San Francisco, CA (Table 1). The criteria to achieve recognition, length of recognition, and recognition award type differed across programs.

Table 1.

Characteristics of Recognition Programs.

Program name	Location	Recognition program criteria	Recognition award length	Award incentive
Start Right Eat Right (SRER)16–18,21,22	Southern and Western Australia	To receive the SRER award, directors and cooks attend six to nine hours of training on general child nutrition, importance of the eating environment, menu modification, and developing or improving their nutrition policy. The SRER award recognizes centers that have: (i) a menu that provides at least 50% of children’s daily nutrition requirements (as recommended by Australian state health departments) and a current nutrition policy; (ii) all staff trained in food hygiene with appropriate food safety and hygiene practices in place; and (iii) a supportive eating environment for children.	1 year, with annual renewal process after resubmitting menus, award checklist, continued training and random site visit	Participation in the award is promoted as giving relative advantage to centers through: Gains in management efficiency, quality of service, and staff development achieved. by workforce training Greater eligibility for center accreditation. Award is a tool for gaining a market edge in a competitive environment. (Advertisements listing the names of current award recipients run twice yearly in the statewide newspaper.)
Empower Program19	Arizona, USA	ECE settings must meet ten standards, including 5 obesity prevention related criteria: physical activity and screen time, breastfeeding, fruit juice and water, family-style meals, and staff training	Not reported	Participating facilities receive discounted licensing fees.
Healthy Apple Program20	San Francisco, California, USA	ECE settings must complete self-assessments, goal setting, receive technical assistance materials, attend workshops, and improve best practices.	1 year, renewal requires yearly self-assessment	Local recognition ceremony for receiving award; $25 incentive paid to child care providers to participate in program

The Start Right Eat Right (SRER) award scheme, operating in Southern and Western Australia, was designed to encourage long day care centers (LDDC) to meet quality standards set forth by Australian state government licensing systems.¹⁶ Centers are awarded if their menu provides ≥50% of children’s daily nutrition requirements as recommended by Australian state health departments, if they have a current nutrition policy, all staff trained in food hygiene, appropriate food safety and hygiene practices in place, and a supportive eating environment for children.¹⁷ Achievement of criteria is determined through self-checklists and site visits from a SRER dietitian to evaluate compliance and provide feedback.¹⁸ The award lasts for one year, with renewal pending continued adherence to program requirements. Recognized centers are advertised in local publications that promote the child care center to parents and the child care industry.¹⁶ The award was promoted by highlighting potential gains in management efficiency, quality of service, staff development through workforce training, greater eligibility for center accreditation, and use of the award as a tool for gaining a marketing edge in a competitive environment.¹⁶

The Empower Program, implemented in 2010 in Arizona, is based on national health and safety performance standards designed for early child care education programs.¹⁹ Participating licensed child care facilities were asked to commit to ten standards to promote healthy environments. Five of the ten standards relate to obesity prevention: (1) physical activity and screen time, (2) breastfeeding, (3) fruit juice and water, (4) family-style meals, and (5) staff training.¹⁹ Except for staff training, which contains one component, each standard contains multiple components representing discrete, actionable steps as part of achieving the standard.¹⁹ Once the facility commits to meeting the ten Empower standards, they receive toolkit containing a guidebook and additional resources.¹⁹ Facilities that adhere to the standards are granted discounted licensing fees. While the overall program length was not reported, the Arizona Department of Health Services inspects licensed child care facilities annually for adherence to these standards.¹⁹

The Healthy Apple Program, based in San Francisco, California, is an award incentive for child care facilities to adopt best practices outlined by the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program.²⁰ The NAP SACC program is an evidence-based program that aims to engage child care providers in an iterative quality improvement process. The Healthy Apple Program adapted the physical activity and nutrition resources and program processes of the NAP SACC program.²⁰ Self-assessment, goal setting, followed by further self-assessment are key components of this program.²⁰ In addition, the Healthy Apple Program intends to provide a connection between child care providers and local resources, tailored support, and technical assistance through existing public health nursing services offered by the San Francisco Department of Public Health Child Care Health Program.²⁰ One representative per child care facility received a $25 gift card for participating in the pilot.²⁰ Child care centers that complete program requirements are awarded the Healthy Apple Program certification in a ceremony.²⁰ The recognition’s length is one year and can be renewed if centers continue with adherence to NAP SACC best practices.²⁰

Table 2 provides an outline of the included studies with corresponding methodologies and outcomes. One study included a randomized, experimental design and the remaining studies employed an observational design to evaluate the program.²⁰ Four studies evaluated outcomes pre- and post-program implementation with no comparison group.^16–19 Three studies included comparison groups^18,20,21 comprised of centers trained in award criteria and non-awarded centers. A variety of survey measures were used, including modified versions of validated measures,^20,21 surveys based on state or national guidelines,²² surveys established by the award program,^17,18,20,21 and non-validated self-report surveys created for the study outcomes of interest.^16,17,19 Table 3 describes the bias assessment completed on each study. In addition to differences in survey methods, studies varied by whether baseline data were collected, if statistical inference was performed, and by ability to control for confounding factors. The heterogeneity of study design, level of bias, and methodology limits the ability for comparison across studies.

Table 2.

Characteristics and Outcomes From Included Studies.

Study	Program name	Sample	Study design	Methodologies	Outcomes
Golley et al (2012)22	Start Right Eat Right	184 staff from 184 long day care centers (106 community, 78 private) Centers were classified as being SRER engaged (trained and awarded, or trained and not awarded), or SRER non-engaged (not trained or awarded).	Observational-survey comparing outcomes between SRER-engaged and non-engaged centers on mealtime environment and communication with families	A 16-item survey was developed for this study and informed by state and national guidelines. The survey was pilot tested but not validated and contained open and close-ended questions.	152 centers were classified as SRER engaged (110 centers were trained and awarded SRER, 42 centers were trained, but not awarded) and 32 centers were classified as non-SRER engaged (not trained or awarded). Survey respondents were more likely to be directors of the LDCC, female, and 72% reported they were involved with supervision of children at meals. Compared to SRER non-engaged centers, SRER engaged centers were significantly more likely to offer snacks at regular and predictable intervals, ensure that staff sit down with the children at meal and snack times, role-model eating, and encourage children to taste all foods offered. SRER-engaged centers were also more likely to use a nutrition policy, engage in verbal communication with parents, allow children more control of the amount of food they eat, and discuss the child’s fussy eating with parents to help manage the child while in care
Tysoe et al (2010)21	Start Right Eat Right	103 parents (95% mothers) 72 parents attending SRER centers 31 parents attending non-SRER centers	Observational- survey comparing outcomes between SRER-engaged and non-SRER engaged centers	A modified family food environment measure (validation status not indicated) and food frequency questionnaire (validated) were completed by parents. Demographic data were obtained from parents. The SES of child care centers was assessed through postal code. Two weeks of menus were collected by all but one child care center and were scored using the SRER program nutrition checklist. Validity of group assignment (SRER vs non-SRER center) was confirmed by comparing menus between child care centers that were accredited and those that were not.	SRER parents were significantly older and of higher SES than non-SRER parents. SRER child care centers had significantly healthier menus than non-SRER centers. Children attending SRER centers consumed significantly fewer savory snacks compared to non-SRER children. Analysis of family food environment was not stratified by SRER status.
Bell et al (2015)18	Start Right Eat Right	20 long day care centers 216 children at baseline 221 children at follow-up 14% of children contributed data to both points	Observational - pre-post program evaluation (no control group)	Each LDCC was assessed for policy, menu, food safety training, and eating environment at baseline (prior to SRER training) and follow up (after SRER training) using SRER evaluation materials. Children’s food intake was assessed through one pre-program and one post-program dietary plate waste study.	80% of centers were fully compliant with the SRER award criteria. 90% of centers met targets for all food groups following implementation of SRER. Statistically significant improvements in provision and consumption of Ca, K, Mg, P, Zn, riboflavin, niacin, folate, and reduced Na were observed from pre-SRER implementation to post-implementation.
Matwiejczyk et al (2007)17	Start Right Eat Right	50 sites were included 44 attended the training 25 centers achieved SRER, of which, a sample of 10 centers were included for qualitative component 47 cooks 40 directors	Observational – Cross-sectional survey data was collected	Nutritional value of menus was assessed through the SRER menu checklist, food hygiene and safety practices were audited against the 18 essential SRER criteria, comprehensiveness of food policies were assessed through a validated food policy checklist, and staff capacity to strengthen nutrition policies was assessed through qualitative phone feedback.	88% of the sample attended SRER training; 50% achieved award at 30 months. 50% of centers attended food safety/hygiene training. All SRER centers that attended training reported having to change menus to meet SRER guidelines. After implementing the SRER award scheme, 289 staff from 25 child care centers received food hygiene and safety practices training. Auditing of food policies demonstrated an improvement in scores from 8.4 before SRER implementation to 17.1 after implementation. Barriers reported by centers that did not complete SRER included financial constraints, time constraints, and competing commitments.
Pollard et al (2001)16	Start Right Eat Right	Uptake of award was monitored among 330 centers and 44 centers completed a qualitative component.	Observational – Several surveys were administered over set time periods	Participation in the award scheme was evaluated at 6 weeks, 3 months, 9 months, 1 year, and 2 years from program launch. Qualitative feedback regarding benefits, barriers, and changes in menus were obtained from registered centers who had not earned the award and centers who had achieved the award. Details on the survey measure used were not reported.	66 of the 72 (92%) of centers registered at 9 months made changes to their menus. 25 out of 76 registered (33%) of centers registered for the award were awarded within 9 months of registering. Of those awarded and participating in the survey (21 of 25 awarded), 8 made menu changes, 5 reported increased awareness of food, nutrition, hygiene, and health issues, and 5 reported changes to nutrition policies. Uptake of the award increased over time. People interested in employment with a center enroll in the training to enter the field.
Papa et al (2017)19	Empower Program	1850 facilities providing care to 182,602 children All facilities were licensed and enrolled in the empower program from July 1, 2013 to June 30, 2015.	Observational – Cross-sectional survey data	A self-assessment survey, known as the “Empower Survey,” was designed for this study and was not validated or pretested. The survey asked about implementation of each component of the five empower standards related to obesity prevention.	46.7% of facilities reported lacking materials associated with the program, such as the guidebook. 20% of programs needed clarification on terminology used in the guidebook. Staff training was met by 77.4% of facilities (more than any other standard). 46.3% of facilities reported full implementation of the physical activity and screen time standard. 21.7% of the facilities reported full implementation of the standards; the remaining facilities reported partial implementation. Nearly all facilities reported offering water as the first thirst offer and having water available all day. High implementation of staff involvement at meals, not using food as a punishment or reward, using kid friendly serving utensils, and allowing children to pick how much and what they eat was reported. The least implemented component across standards was communication with families.
Stookey et al (2017)20	Healthy Apple Program	43 child care centers 19 treatment group (CCHP + HAP) 24 control group (CCHP + HAP delayed) Children aged 2–5 years enrolled at eligible centers	Cluster RCT pilot study treating child care centers as clusters Child care centers were randomly assigned to receive usual treatment plus HAP (CCHP + HAP) or to receive routine services plus HAP after a 1 year delay (CCHP + HAP delayed).	San Francisco Department of Public Health Child Care Health Program (CCHP) staff collected child BMI data in Autumn and Spring, documented nutrition and physical activity resources visible during a site visit, and interviewed child care facilities about needs. CCHP staff assessed 3 index practices through yes/no questions- “use of a physical activity curriculum,” “staff usually join in physically active play with children,” and “pitchers of drinking water visible in the classroom” to determine a child’s relative odds of exposure to these practices. San Francisco Children’s counsel HAP coordinator monitored child care facilities for completion of HAP award criteria (established by NAP SACC) and centers that received awards.	After randomization, intervention and treatment groups differed significantly by age and prevalence of overweight/obesity. Of the 19 centers randomized to CCHP + HAP, 10 centers received all resources as allocated. Significant reductions in BMI change from year to year were observed after groups received HAP resources. Incidence of overweight/obesity also reduced in child care centers after receiving HAP resources. 9/19 centers received the HAP award. 10/19 centers randomized to CCHP + HAP made a total of 210 practice and policy improvements. Two-thirds of children attending CCHP+HAP centers were exposed to the HAP process.

Table 3.

Results of Bias Assessment.

Observational study bias criteria	Bell et al 2015	Matwiejczyk et al 2007	Pollard et al 2001	Golley et al 2012	Papa et al 2017	Tysoe et al 2010	RCT bias criteria	Stookey et al 2017
Clear inclusion criteria?	Y	Y	Y	Y	Y	Y	True randomization used?	Y
Study subjects and setting described in detail?	Y	Y	Y	Y	Y	Y	Was allocation to treatment groups concealed?	Y
Exposure measured in a reliable/valid way?	Y	Y	Y	Y	Y	Y	Treatment groups similar at baseline	N
Objective criteria used for measurement of condition?	Y	N	N	Y	Y	Y	Participants blind to assignments?	N
Confounding factors identified?	N	N	N	N	N	Y	Were those delivering treatment blind to assignment?	N
Strategies to deal with confounding stated?	N	N	N	N	N	N	Were outcome assessors blind to assignment?	U
Outcomes measured in a valid and reliable way?	Y	N	N	N	N	Y	Were treatment groups treated identically outside of the intervention?	Y
Appropriate statistical analyses used?	Y	N	U	Y	Y	N	Was follow up complete? If not, were differences between groups analyzed?	Y
							Were participants analyzed in the groups they were randomized?	Y
							Were outcomes measured the same way for treatment groups?	Y
							Were outcomes measured in a reliable way?	Y
							Appropriate statistical analyses used?	Y

Y=yes; N=no; U=unclear.

Feasibility and Acceptability of Recognition Programs

Centers self-reported a high degree of participation and compliance with award criteria across programs.^16,19,20,22 Specifically, 80% of a sample of SRER centers in Southern Australia were fully compliant with award criteria,¹⁸ 47% of centers randomized to the Healthy Apple Program intervention training arm received the award,²⁰ and all centers participating in the Empower Program had at least partially implemented the program’s standards, with 20% of centers self-reporting full compliance.¹⁹ SRER centers reported high satisfaction with the award and its benefits, such as accreditation, improving parental perception of the center, and improving cooperation between foodservice staff and the center administration.¹⁶ Center satisfaction with the Healthy Apple Program was not measured in the pilot intervention.²⁰ A survey of child care facilities participating in the Empower Program also did not report on center satisfaction with the program, but found that the 77.4% of the facilities surveyed completed the staff training standard of the program.¹⁹

Policy and Food Environment Outcomes

Outcomes of interest varied across studies and included changes to menu and policy,^{16–18,20,22} increases in staff training,^17,19 impact on child food intake,^18,21 and impact on the eating environment.^17,21,22 Most centers participating in SRER reported changing their menu to meet award criteria,^16,17 resulting in increased provision of all major food groups.¹⁸ Of the 25 SRER awarded centers, the number of staff who received food safety and hygiene practices training increased 17-fold.¹⁷ In child care centers randomized to receive the Healthy Apple Program intervention, 47% of centers received technical assistance and 47% set at least one best practice goal, compared to 12% of centers and 4% of centers in the Healthy Apple Program delayed arm, respectively.²⁰ Both SRER-engaged and Empower program centers self-reported increases in child autonomy in the amount of food they ate (e.g. allowed children to self-serve food and drink, provided kid-friendly serving utensils) related to program participation.^19,22 Centers enrolled in the Empower Program self-reported high levels of staff role modeling at meals and not using food as a punishment or reward, however, information on practices in non-Empower centers was not available.¹⁹

Dietary Consumption and Weight Outcomes

Only the SRER program was evaluated for changes in child dietary intake.^18,21 Tysoe and Wilson (2010) found that children attending SRER awarded centers consumed significantly fewer savory snacks per week compared to non-SRER centers.²¹ In a pre-post program evaluation of SRER, Bell, Hendrie, Hartley, and Golley (2015) found that after receiving SRER training, centers made menu changes resulting in increased consumption of all food groups except for vegetables and increased overall energy intake among children aged 2–4 years old.¹⁸ Improvements in intakes of eleven of the nineteen nutrients evaluated were reported, determined through one pre- and one post- SRER training plate waste study.¹⁸

One study, The Healthy Apple Program pilot intervention, examined child weight outcomes.²⁰ Compared to centers receiving usual programming, significant reductions in zBMI and incident overweight and obesity were observed among children attending centers randomized to receive the Healthy Apple program.²⁰

Conclusions

Early child care settings contribute to the establishment of health-promoting behaviors in young children and recognition programs may incentivize centers to engage in best practices. This scoping review systematically searched peer-reviewed literature to assess the evidence base regarding recognition programs in early child care settings. Our findings indicate that empirical evaluation of recognition programs is limited, with only two out of thirteen existing programs in the United States having a published evaluation of their program.^5,19,20 Synthesis of this limited evidence is complicated by varying assessment methodologies, study designs, and outcome measures. However, existing data is promising that obesity prevention strategies can feasibly be implemented through recognition programs in ECE settings.

Common features among the recognition programs were training and technical assistance, which distinguish recognition programs from the obesity prevention standards embedded into Quality Rating and Improvement Systems (QRIS).¹ Technical assistance targets the individual needs of ECE centers to provide optimized support,^23,24 yet whether training and technical assistance benefit ECE programs is not well understood. For example, initial research indicates that technical assistance provided by the National Early Care and Education Learning Collaborative to ECE settings was inversely related to implementation of best practices.²⁵ In contrast, increased training and technical assistance offered by the New York City Department of Health and Mental Hygiene resulted in improved compliance with meeting physical activity standards in ECE settings.²⁶ While the recognition programs included in this review discussed the benefits and acceptability of training and technical assistance, data on potential long-term costs were not reported.^17,19,20 As technical assistance, ongoing training, and incentives provided by recognition programs require continuous funding, cost-benefit analyses will be important for future evaluation to better understand the sustainability of recognition programs. Further, survey results from one program that provided only limited technical assistance (provision of materials vs. trainings and personal technical assistance as provided by other programs) indicated a need for additional support and clarification regarding the training materials provided.¹⁹ This finding demonstrates that ongoing resources and technical assistance to support centers should be considered prior to recognition program implementation.

Despite a shared focus on training, technical assistance, and incentives, criteria for recognition differed. Recognition criteria ranged from passing menu reviews, establishing policies, using local resources, and a focus on food safety. Due to the observational nature of the current literature in this area, it is unknown which features and criteria maximize potential benefits to ECE health environments and child behaviors. Further, outcomes of interest varied between studies, and included program implementation, process outcomes, child behavior, and health outcomes. While these outcomes provide the groundwork of our understanding of ECE recognition programs, they do not capture whether the strategy of a recognition program is beneficial from the ECE center perspective. Indicators like the financial standing of centers, child enrollment, and employee retention and hiring, would provide greater evidence for recognition programs as a sustainable strategy to promote healthy environments. Notably, multiple of these outcomes might need to be assessed to gain a more complete picture. For example, depending on factors such as geographic location and child age, demand for child care can be high, resulting in centers having waitlists.^27,28 In this context, child enrollment may not be a relevant indicator of the benefit of the recognition program. Similarly, when demand for centers is very high, recognition as a healthy center may not be a large enough incentive for the center to participate in the program. In Australia, SRER awarded centers viewed their accreditation/award as a way to advertise to parents,¹⁶ but it is unclear if centers in the United States consider recognition awards an important marketing tool. Other incentives such as discounted licensing fees could be considered.

Future work is needed to understand the type of incentive most likely to work and longer-term impacts of the program on both the benefit to centers and to child health. Business-related outcomes are critical to evaluate to better understand the sustainability of recognition programs. For example, qualitative evaluation of the SRER program, the longest standing recognition program reviewed, indicated that the required trainings for staff were changing the labor market with those interested in working in ECE settings proactively completing the required training prior to applying for positions within ECE settings.¹⁶ Rigorous, validated measures are needed to assess all outcomes. Consistent assessment tools and experimental designs will aid comparison across programs, help understand how recognition programs compare to other intervention strategies and policy changes, and improve understanding of cumulative impacts of recognition program policies on top of other intervention strategies for ECE settings.²⁹ Use of experimental or quasi-experimental designs with appropriate statistical inference will further our understanding of how to implement these programs into ECE systems. Considering the heterogeneity of ECE settings (e.g., geographic location, characteristics of population served, public vs private, family vs commercially owned, etc.), randomized control trials should consider matching ECE settings with similar characteristics during study design. Future research may benefit from focusing on the outcome measures most relevant to the specific ECE settings in their study sample. For ECE settings in under-resourced communities, feasibility of and sustainability of adhering to recognition programs may be an important initial outcome measure beyond child health outcomes, which may require longer-term adherence to program standards and additional follow-up to observe.

Despite the clear need for future research, the limited evidence surrounding recognition programs is promising that this approach may facilitate uptake of best practices for child health in ECE settings. For example, the Healthy Apple Program found a reduction in children’s BMI and incident overweight/obesity in child care centers who received program materials.²⁰ SRER-engaged centers and Empower Program centers reported practices that foster appropriate child autonomy at meals and snacks, avoiding using food as a punishment or reward, and encouraging family style meals.^19,22 Recognition programs were acceptable to center staff. Acceptability by ECE centers is critical when considering the long-term sustainability of recognition programs. These encouraging findings demonstrate the potential of recognition programs to improve the health behaviors of children in ECE settings and inform future interventions and policy changes for this age group.

This review is not void of limitations. The search strategy was limited to peer-reviewed literature. There may be some grey literature around various recognition programs, such as poster sessions, program websites, informal meeting notes, additional non-peer reviewed literature, or international publications inaccessible to our research team that describes recognition programs outcomes and evaluation strategies, but we only focused on published studies that fit the search strategy. One strength of this review includes following a rigorous and highly detailed research protocol with several researchers that was pre-registered at the Open Science Framework prior to execution.¹²

Current recognition programs are encouraged to publish programmatic outcomes of all types to help assess the value of recognition programming and share information for expansion to other states. Early findings, such as improvements in menu offerings, mealtime environment, staff training, and improvements in weight outcomes demonstrate the potential benefit of recognition programming. The impact of recognition programs on child growth, nutrition, physical activity, and sustainability of programs requires future research, particularly as a policy strategy. While current evidence on recognition programs in ECE settings is formative and exploratory in nature, findings suggest that recognition programs could be a feasible mechanism to improve the health environments of ECE settings.

So What?

What is already known on this topic?

Recognition programs for early care and education (ECE) centers are voluntary programs that incentivize centers to meet nutrition and physical activity standards. While the presence of recognition programs is well-documented, outcomes are less established and have yet to be synthesized.

What does this article add?

Current evidence examining the impacts of recognition programs is limited and program sustainability is not addressed. However, existing evidence suggests that ECE recognition programs have the potential to improve food and nutrition environments.

What are the implications for health promotion practice or research?

Recognition programs should consider plans for evaluation of the effects of the program on child health outcomes using consistent and validated measures when partnering with ECE settings. Experimental designs are needed to understand the impact of recognition programs on childhood obesity.