Delaware was the first state to implement comprehensive guidelines and standards for nutrition and physical activity in child care settings. These standards were developed as part of a larger state strategy for the prevention of childhood obesity by promoting healthy eating and physical activity behaviors early in childhood. The state’s standards have been implemented through both the state Child and Adult Care Food Program (CACFP) and its child care licensing body, Delaware’s Office of Child Care Licensing (OCCL). They apply to child care centers as well as child care homes.
During the summer and fall of 2009, Altarum undertook a focus group study with child care center directors, child care home providers*, and parents of children in child care centers across the state of Delaware. This study, conducted in partnership with Nemours Health and Prevention Services and the Delaware CACFP and OCCL, was designed for two purposes. The primary purpose was to learn how child care providers and parents are responding to Delaware’s comprehensive nutrition and physical activity standards for child care facilities. The secondary purpose was to understand what child care providers need to comply with nutrition and physical activity standards and develop a set of recommendations to address these needs. The focus groups were designed to answer the following questions about the implementation of Delaware’s nutrition, physical activity, and screen time standards for child care:
- What are providers’ and parents’ attitudes and perceptions of Delaware’s new CACFP guidelines and child care regulations?
- What challenges do providers face as they try to comply with enhanced nutrition and physical activity standards?
- What strategies are some providers using to address the challenges?
- How are providers communicating with parents about these policies, and what help do they need in communicating the new standards to parents?
- What kinds of information, tools, training, and other supports are needed to help providers implement enhanced nutrition and physical activity standards?
Overall, 83 individuals participated in these focus groups. Seven groups were conducted with child care providers from a total of 32 child care centers and 27 child care homes. Three groups were conducted with parents of children in child care centers.
The experiences of advocates, program administrators, child care providers, and parents in Delaware can inform other states’ efforts to address childhood obesity in early learning and care settings. This report details the findings of the provider and parent focus groups, and presents recommendations based on those findings and ongoing research into related policy and program development in Delaware and elsewhere.
Focus Group Findings
Providers and parents generally understand and embrace the guidelines
The focus group findings clearly indicate that both child care providers and parents in Delaware have responded positively to the goals of the state’s nutrition and physical activity standards for child care. They have also welcomed most of the content of these policies. The fact that providers and parents have embraced the overall goal of Delaware’s healthy eating and physical activity guidelines is obviously critical for successful implementation of these health promoting policies.
While the rationale for the majority of the guidelines are well understood, many providers and parents still reportedly do not understand enough about the need for some of the state’s nutrition guidelines. The standard on milk in particular, which requires that children over age 2 be served only 1% or fat-free milk, was noted as a concern among many providers and parents.
Providers are developing innovative strategies to address the standards
The lengths to which child care center and home providers are going in order to come into compliance with the new policies are highly encouraging. Many providers have already taken innovative steps toward adopting new practices. Successful efforts to overcome new challenges demonstrate a children-come-first approach being taken by providers. These are detailed in the report and reflected in its recommendations.
Implementation challenges are frequently related to limited available resources (e.g., money, time, relevant expertise) and staff motivation
Food service and food cost issues were the most frequently cited challenges for providers in complying with the nutrition standards. These included challenges in paying their food costs on a very limited budget, developing menus, incorporating variety, and cooking child-friendly meals that meet the standards. Other food service barriers cited were difficulties in modifying existing recipes and scaling up recipes that are designed to comply with the new standards, challenges in reading and interpreting food labels, and increased time now required for food shopping. Other types of challenges noted by providers were limited resources and experience in nutrition and physical activity and a need for ideas and resources to help children try new foods and engage in increased physical activity. Providers also experienced difficulties overcoming staff and parent resistance and engaging them positively in implementation of the changes.
Providers need additional training, tools, and other supports
Many providers reported that they need more help and support to fully implement the nutrition and physical activity standards. Feedback on past trainings was very positive, but providers voiced a need for expanded access to trainings for directors and staff. They had many suggestions for the format of future trainings. Providers also expressed a desire for state and child care sponsoring agencies to establish forums to help them obtain up-to-date resources and information, and to share information and resources with one another.
A few center providers noted that their training priorities and center-level policies are driven in part by Delaware Stars for Early Success, the state’s Quality Rating and Improvement System (QRIS). Providers in several focus groups suggested that the state QRIS incorporate nutrition and physical activity standards in its ratings to give providers a stronger incentive to focus their training and practices to meet these standards.
Clearly and consistently communicate the rationale for nutrition and physical activity standards in child care
Present and explain the rationale for the new nutrition and physical activity standards in all communications, informational materials, and trainings. Clear, consistent, and frequent explanations will allow providers and parents to be even more effective supporters of the policies. They will be better equipped to communicate effective messages to their colleagues, the children, and parents, and perhaps more likely to support changes in the foods that they prepare and serve to children.
Offer supports to help providers address the challenges of meal planning, food preparation, and food purchasing
The following suggested actions build on the promising strategies that providers reported during the focus groups and their recommendations for state action:
- Develop sample menus with recipes that are child friendly, are tested with providers, and can be scaled up for large child care facilities.
- Provide lists of commonly used allowable foods.
- Create a cookbook with recipes and hints from local providers and parents.
- Build partnerships with food retailers and institutional food suppliers to educate them on the standards and encourage them to develop tools for providers, such as recipes tied to shopping lists.
- Consider meal subsidies for providers where the costs for compliance are excessive.
- Offer subsidies or other incentives to local growers to lower the cost of produce, similar to the U.S. Department of Agriculture’s Fresh Fruit and Vegetables program that brings fresh produce to schools.
- Work with food banks and pantries to obtain information about available food donations that meet the state’s nutrition guidelines.
Develop new and expand on existing resources to help providers educate and engage preschool children in healthy eating habits and increased physical activity
Recommended types of materials include:
- Educational displays targeted to children such as bulletin boards and posters;
- Games, songs, and rhymes that staff can use to reinforce healthy habits;
- Step-by-step guides for activities to engage the children in trying new foods;
- Sample daily lesson plans that integrate indoor and outdoor physical activity opportunities;
- Sample staff-led physical activity lessons that require limited or no equipment;
- Information on sources of play equipment that are available at no or low cost; and
- Lending libraries where providers can borrow equipment to promote physical activity.
Help providers implement strategies to successfully engage staff and parents
State agencies and their partners, including child care-sponsoring agencies and organizations such as Nemours in Delaware, should consider developing some of the following materials and tools to assist providers in engaging these audiences:
- A step-by-step guide for organizing meetings and events for families;
- Informational materials directed to parents and guardians;
- Sample policies that centers can incorporate into parent handbooks; and
- Written materials and other resources for directors to use as part of staff in-service training.
Expand and improve training and technical assistance for child care directors and staff
Based on their past experience, Delaware providers had many suggestions for training providers like themselves on these standards. They stressed the need for trainings that address the rationale of the guidelines and have a how-to focus. Training could reportedly be most effective if it includes hands-on guidance in group settings and opportunities for information sharing among peer providers; exchange of promising practices; and, in some cases, follow-up, one-on-one technical assistance. They also recommended offering trainings at a variety of locations and different days and times, as well as providing incentives and continuing education credits to encourage more participants to attend.
Develop and implement mechanisms for improved peer-to-peer information sharing
Child care providers overwhelmingly expressed a need to share information and to learn from one another as they overcome obstacles in implementing the new standards. Recommended mechanisms to facilitate peer-to-peer exchange include newsletters and a website that provides access to free materials and opportunities for sharing of resources and strategies, and having discussions among providers.
Align state child care QRIS with enhanced nutrition and physical activity standards
Child care providers indicated that the state child care QRIS provides a positive incentive for child care centers to improve their quality of care. States can consider many ways to incorporate nutrition and physical activity standards into their QRIS. For example, higher ratings in QRIS can include a requirement for centers to document teacher-led physical activity in their lesson plans and a requirement for specified amounts of staff training in nutrition and physical activity.
As partners across Delaware and in other parts of the country work to develop and implement nutrition and physical activity standards for child care facilities, the continued acceptance of providers and parents of these policies needs to be reinforced. Implementation plans should take into account providers’ and parents’ expressed needs, and the challenges child care providers in Delaware face in stretching limited resources to comply with policy changes. While the study was based in Delaware, the findings and recommendations may apply more broadly across the country as many states, communities, and the federal government work toward the development and implementation of effective early obesity prevention policies for child care settings.
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*Note: For the purposes of this study, the term “provider” is defined as the child care administrator or staff person responsible for the meal planning and overseeing the provision of care at the center. For child care homes, the provider is the person responsible for all aspects of the children’s care, including meal quality and physical activity opportunities.