Our results, the first from a study that examined child care center exclusions in a state that endorses AAP/APHA guidelines, showed continued high rates of unnecessary director exclusion decisions. Contrary to our hypothesis, our average director-reported unnecessary exclusion rate of 57% for children with mild illness in a state that actively endorses child care guidelines was essentially equivalent to the 59% inappropriate exclusion rate found by Copeland et al13,20
in a state that had not endorsed AAP/APHA guidelines. With almost one-third of the directors in the “high” unnecessary exclusion group, our study shows that a significant disconnect remains between state endorsement of national guidelines and child care director–reported exclusion decisions. We were also able to discover characteristics that were associated with exclusion practices at the director, center, and neighborhood levels.
Directors with greater child care experience make fewer unnecessary exclusion decisions than directors with less experience. Experienced directors are potentially more comfortable keeping children with mild illness in child care compared with their colleagues with less experience. Previous studies suggested that child care directors are overly conservative with respect to exclusion of ill children; this may be particularly true for directors with less experience. 11
Our study did not find director education level to be associated with exclusion practices. One study found that directors without college degrees were more likely to use incorrect temperature thresholds for defining fever15
; however, in our cohort, the overwhelming majority (86%) of directors had college experience; therefore, there may not have been sufficient variability in our sample to reach statistical significance. Our study suggests that inexperienced directors (<10 years of experience) would be a potential focus for future interventions because inexperienced directors seem to make more inappropriate exclusion decisions and are more likely to report being unfamiliar with AAP/APHA guidelines.
Center size is associated with exclusion practices. Previous studies have clearly shown that the risk for illnesses increases in large child care settings25–28
; however, our study is the first to show that children who attend larger child care centers are excluded less for the same symptoms of mild illness. One reason for this difference may be that larger centers are more likely to have greater availability of resources, such as separate sick or isolation rooms and extra child care staff available to care for and monitor children with mild illness as compared with smaller child care centers and therefore may be less likely to send children home29
; however, our study defined large center size on the basis of number of children and did not use actual child care building size, number of classrooms, children per classroom, or availability of sick or isolation rooms.
Directors of centers with a smaller percentage of their children on state-assisted tuition had higher inappropriate exclusion rates compared with centers with a larger percentage of children on state-assisted tuition. One reason for this may be that in Wisconsin, some children who are on state assistance are authorized to attend child care on an attendance-based fee. In contrast to enrollment-based fees, the center does not receive payment if the child is absent for any reason, including illness. (J. Bates, Department of Children and Families, Bureau of Childhood Education [jim.bates/at/wisconsin.gov
], written communication, July 31, 2009). Directors of centers with a higher proportion of children on attendance-based state subsidies may be less inclined to exclude children for mild illness. In addition, a higher percentage of children on state-assisted tuition may reflect the neighborhood’s lower socioeconomic status. These neighborhoods also seem to be in federally designated Health Professional Shortage Areas, with a severe shortage of primary care physicians.30
Directors may take into account the lack of health care access when making exclusion decisions.
Centers that were located in areas with a higher proportion of female heads of household had fewer exclusions. These areas also have fewer child care options and resources because percentage of female heads of household is a marker for the single mother or grandmother who is the sole income provider. These female heads of household are often faced with the decision of either staying home without pay or scrambling to find alternative child care.31
Directors of centers in these areas may be less inclined to exclude children because single parents are less able to find alternative child care or lack sick leave to care for their child.
Wisconsin does not provide directors with any formal education of child care health guidelines. Despite some barriers, previous studies have shown that active training of child care providers improves quality of child care and knowledge and compliance with child care health-related measures.32–34
Given the complete lack of any formal training regarding exclusion guidelines, we believe that the state could offer initial and ongoing state-accredited training classes.
Another potential intervention is the use of telemedicine as reported by McConnochie et al.35
Urban child care centers that use telemedicine reported a 63% decrease in absence from child care as a result of illness, and >90% of parents reported being able to stay at work. Additional studies need to be performed to assess large-scale feasibility of child care telemedicine.
Our study has several potential limitations. The study used English-speaking child care center directors and may not be representative of Spanish-speaking directors or family-based child care. With regard to the population, our sample mirrors national demographics but may not be representative of Wisconsin; however, with almost 50% of child care centers in Wisconsin located in the areas that we surveyed, we do not believe that the percentages would change significantly. In addition, our results were obtained from vignettes and may not reflect actual exclusion practices.36
Although directors could have excluded children because they could not participate comfortably in normal activities or be cared for without jeopardizing the health or safety of other children, none of our scenarios described any children who could not participate in normal activities, and all had symptoms of mild illness. Directors may have also felt the need to vary their responses, thus excluding unnecessarily. In addition, we did not determine whether directors made unsafe inclusion decisions. Directors may have answered vignettes differently depending on the interviewer (physician versus research assistant); however, a comparison of interviews conducted by the physician and the nonphysician showed no patterns of increased or decreased exclusion rates. Data regarding time of initial center licensing were unavailable; therefore, we cannot determine whether more recently licensed centers (<10 years) are more familiar with guidelines.