The Wellness Child Care Assessment Tool was designed to rate the strength and comprehensiveness of written nutrition and physical activity policies in child-care centers. Psychometric analyses demonstrate good range in subscale scores, suggesting that the tool overall is not vulnerable to floor or ceiling effects and can distinguish between low- and high-quality policies. As expected, several individual items were found rarely or never in the sample of policy documents reviewed. Nonetheless, these items remain in the tool because they represent important aspects of nutritional quality and are expected to show greater variability as child-care centers develop formal wellness policies in the future. Excellent inter-rater reliability was achieved for all subscales, suggesting that the tool produces replicable results. Internal consistency values were moderate overall. This may be because the data were drawn from multiple documents from each site, introducing substantial heterogeneity. Internal consistency is expected to improve when the tool is used to rate more structured, cohesive wellness policies. The observed differences between Head Start and non–Head Start centers provide strong evidence of construct validity, since it was predicted that Head Start preschools would have policies with stronger language and more breadth because of their regulatory status and institutional culture. It was also predicted that policies from National Association for the Education of Young Children-accredited programs would be stronger and more comprehensive than those from non–National Association for the Education of Young Children programs, and this was the case for some subscales. However, these differences were expected to be smaller than those observed for Head Start status, because National Association for the Education of Young Children guidelines are less comprehensive and not associated with as strong sanctions for noncompliance as are Head Start regulations (although accreditation is an important motivator).
There is growing interest in studying nutrition and physical activity policies in the child-care setting. Previous work has focused mostly on state regulations, and few studies have measured policies at the child-care center level. Dowda and colleagues used a structured interview with preschool administrators to assess the presence of physical activity policies and practices but did not review written policies (36
). Ward and colleagues developed the environment and policy assessment and observation instrument, which included a document review evaluating a mix of written policy and documentation of practices (eg, safety checks) pertaining to nutrition and physical activity (32
). The Wellness Child Care Assessment Tool provides a unique tool to researchers, because it is specific to written policies, evaluates both the scope and strength of policy language, and encompasses a wide range of content areas.
Written policies have the potential to improve child health, yet only one study has evaluated the relationship between written policies and outcomes in the child-care setting. A weak association was observed between presence of written physical activity policies and physical activity levels, but the scope of policies assessed was limited (37
). In the same study, the subscale most strongly associated with physical activity levels included observed provision of structured physical activity, outdoor play, and total minutes of active opportunity—most of which are addressed as policy items in the Wellness Child Care Assessment Tool. Another study evaluating how observed practices predict physical activity found that lower electronic media use, portable equipment on the playground, and larger playgrounds predicted higher physical activity levels and less sedentary time (38
). Because these are also practices that overlap with content areas of the Wellness Child Care Assessment Tool, it is possible that the Wellness Child Care Assessment Tool scores could predict physical activity and other outcomes to the extent that policies are followed.
Written program-level wellness policies are important not only because of the potential to affect practices, but also because written policies offer a way through which administrators and families can evaluate program performance. Recently, the White House Task Force on Childhood Obesity issued recommendations that states should be encouraged to strengthen licensing standards regarding nutrition, physical activity, and screen time and that the federal government should look for opportunities in programs such as CACFP and Head Start to base policies and practices on current scientific evidence (39
). In addition, the American Dietetic Association developed new benchmarks for nutrition in child care and suggested that these benchmarks be achieved through policy and regulation (40
). As state-licensing and federal program standards are strengthened, such standards are likely to be integrated into center-level policies. However, without a legal requirement for written wellness policies in the child-care setting, written policies may remain widely variable in detail and scope. Given that Head Start programs scored higher than non–Head Start programs on both comprehensiveness and strength, child-care administrators who would like to write wellness policies may consider using Head Start Program Performance Standards (10
), the current Dietary Guideline for Americans (33
), Position of the ADA: Benchmarks for Nutrition in Child Care (40
), and examples in the Wellness Child Care Assessment Tool as model policies.
The Wellness Child Care Assessment Tool may provide an important starting point for studying predictors of center policy quality and how such policies may relate to center practices and child health. There is preliminary evidence of adequate to excellent psychometric properties, and there is considerable overlap between content of the Wellness Child Care Assessment Tool and the new independently developed ADA benchmarks for nutrition in child care (40
). However, because the study of child-care nutrition and physical activity policy is in its infancy, items on the Wellness Child Care Assessment Tool should be interpreted as promising policy strategies. Future studies should seek to provide evidence of the relative importance of each policy item, and as empirical evidence accumulates, the Wellness Child Care Assessment Tool may benefit from further refinement.
The following limitations should be considered for future uses of the Wellness Child Care Assessment Tool. Policies rated were from child-care centers participating in CACFP from one state, and thus the results may have limited generalizability. In addition, policy documents collected from preschools and child-care centers varied greatly in the amount of information they contained, as they were not strictly wellness policies. Because the lack of a written policy may not necessarily indicate lack of a practice, the Wellness Child Care Assessment Tool should be used only to assess written policies and is not appropriate for the evaluation of overall program quality or practices. Also, this study was not able to assess predictive validity. Future research should test whether Wellness Child Care Assessment Tool scores predict the quality of the child-care wellness environment, nutrition and physical activity practices, and child nutrition and activity levels. Finally, policy raters for this study had previous policy rating experience, so the precise degree of training required to achieve high inter-rater reliability should be determined in future studies.