The NAP SACC program contains a number of components, including a self-assessment instrument, continuing education workshops, collaborative action planning and technical assistance materials, and an extensive resource manual that includes copy-ready materials. Development of each of these components, including the conceptual model, is described below.
Influencing the nutrition and physical activity behaviors of children necessitates an intervention approach that considers individual behaviors as well as the environments in which behaviors take place. Physical activity is heavily affected by the social environment, where children can learn behaviors through observing the teacher or other adults in the center. Similarly, dietary choices are influenced by the physical environment through food availability and adult role modeling. This inherent relationship between environments and behaviors, coupled with strong support from intervention research, suggested the utility of using Social Cognitive Theory (SCT) as the theoretical basis for the NAP SACC nutrition and physical activity environmental intervention (35
). SCT identifies several crucial factors that influence behavior change, including expectancies, observational learning, self-efficacy, behavioral capability, environment, situation, reinforcement, and reciprocal determinism. The NAP SACC intervention was designed to reflect these key constructs.
The NAP SACC intervention was designed for implementation through an existing infrastructure of public health professionals, typically registered nurses and health educators who are trained as NAP SACC consultants. Key steps in the intervention included the following:
- Child care center directors and related staff complete the self-assessment instrument to assess center nutrition and physical activity policies, practices, and overall environment.
- NAP SACC consultants work with centers to develop an action plan to improve at least three target areas of concern identified from the self-assessment instrument. Center directors select their areas of interest to facilitate the most fitting and lasting environmental changes.
- NAP SACC consultants deliver to center staff three NAP SACC continuing education workshops on 1) childhood overweight, 2) healthy eating for children, and 3) physical activity for children.
- NAP SACC consultants provide ongoing targeted technical assistance, through in-person visits and telephone follow-up, to support implementation of planned policy, practice, and environmental changes.
- Centers use a follow-up self-assessment instrument to evaluate changes made to the center during the 6-month intervention period.
Development of the self-assessment instrument and workshops
Although other instruments to improve child care quality (e.g., ECERS and ITERS rating scales) provided some guidance when developing this instrument, we decided to take a self-assessment approach to improving child care environments, similar to that of the School Health Index (36
). Our formative work suggested that a self-assessment approach would help target areas for attention and provide more sustainable improvements through voluntary participation and self-initiated change. Center-directed assessment allows child care settings to evaluate their nutrition and physical activity environments without repercussion from regulatory or licensing groups. Thus, no outside rater is needed. In addition, completion of the self-assessment instrument is quick and easy. The instrument is designed to allow the child care center director to answer questions, with assistance from key center staff (e.g., lead teacher, cook), about the center environment.
The initial instrument included 44 questions from nine nutrition and six physical activity areas that had either a demonstrated (evidence-based) or perceived (expert-based) relationship to childhood overweight based on the review of standards and research findings. Key areas, along with references from standards, recommendations, and research are presented in . Each of the 44 questions had three possible response categories, with 1, 2, or 3 points assigned for each response (1 = minimum standard, 2 = good, 3 = best practice). The total score range for the instrument was 44 to 132 points.
Key Areas on the NAP SACC Self-Assessment Instrument, North Carolina, 2001–2006
Once the instrument was developed, it was reviewed by eight NC experts in the fields of child development, child care, nutrition for young children, and physical activity for young children. These experts included physicians, registered dietitians, and physical activity and child development researchers. A number of improvements were suggested, and changes were incorporated. In addition, the advisory group evaluated the self-assessment instrument before conducting the pilot study.
As the program moved from the development to implementation stage, the advisory group provided a number of suggestions that led to crucial modifications to the intervention. The three workshops, which were at first designed to provide training to interested child care center staff, became a more prominent step in the intervention. The advisory group suggested we seek state licensing agency approval for continuing education (CE) credits for each of the workshops to help ensure greater participation from center staff and to increase support for the intervention. We subsequently learned that obtaining adequate CE credits is a significant challenge for many center staff, and providing credits for NAP SACC workshops was a substantial incentive for workshop participants.
On the basis of formative data and guidance from our advisory group, we developed a tool kit of technical assistance and background materials to facilitate effective intervention implementation by the NAP SACC consultants. The NAP SACC tool kit was designed by local health professionals and researchers from the University of North Carolina. It consists of several components designed to provide the consultant with additional materials and handouts for use during the center workshops and the general intervention process. The tool kit consists of the NAP SACC notebook, copies of educational materials (paper and CD-ROM) for the three NAP SACC workshops, and handouts for centers and parents linked to each of the 15 key areas in NAP SACC.
Although the NAP SACC consultants were thoroughly trained by research staff to implement the NAP SACC intervention, we felt that they may have additional questions on nutrition and physical activity extending beyond the scope of the training. This was the rationale behind the development of the NAP SACC resource manual. The resource manual is divided into four sections: 1) self-assessment, 2) nutrition, 3) physical activity, and 4) resources. Both the nutrition and physical activity sections are further divided according to the NAP SACC key areas and include a rationale for each best practice along with potential challenges for implementing the practice and tips to help child care providers address these challenges. depicts a sample best practice guideline along with likely implementation challenges and tips to circumvent them. With this manual, NAP SACC consultants have technical assistance materials to support the center in implementing the intervention.
NAP SACC Resource Manual, Sample Best Practice Guideline, North Carolina, 2001–2006
The resource section of the NAP SACC manual was compiled from information on child nutrition, meal preparation, outdoor activity and safety, indoor activity and safety, and physical activity. It was designed to give NAP SACC consultants and centers ideas for improvement and to provide additional background knowledge relative to child nutrition and physical activity. Additionally, it provides a broad selection of recipes for center use.
Workshop materials are provided as both paper copies and PowerPoint presentations on a CD-ROM in order to accommodate the needs of the NAP SACC consultants. A separate folder for each workshop is included in the tool kit with everything needed to conduct the workshops at the child care centers. The center handouts were created from the NAP SACC resource manual and emphasize best practices, tips, and suggestions for working with parents. A handout for each NAP SACC key area provides additional guidance for child care staff.
Pilot testing and revision
The NAP SACC program was pilot tested for feasibility and acceptability in a convenience sample of 19 child care centers from eight counties in NC. The program was delivered by Child Care Health Consultants, who volunteered to be trained as NAP SACC consultants for this pilot. Results from the pilot study are reported elsewhere (37
On the basis of feedback from the pilot study, additional revisions were made to the self-assessment instrument. A number of questions were reworded to improve clarity, and some of the response categories were modified to reflect typical practice. Upon completion of this process, the self-assessment instrument was once again sent out for expert review. Ten national experts in the fields of child development, child care, nutrition for young children, and physical activity for young children were asked to review the instrument. As a result, the response categories were expanded from three to four categories, 11 questions were added to the instrument, and one question was removed. Reliability and validity testing of the self-assessment instrument is under way in a sample of child care centers.