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Childhood obesity has been recognized as a national problem of epidemic proportions. Child care represents an ideal venue in which to address this problem, as many young children spend a significant amount of time and consume the majority of their meals in this setting. Recognizing this opportunity, Delaware recently enacted reforms to statewide licensing regulations designed to improve the quality of the nutrition-, physical activity-, and screen viewing–related environments in child care settings.
To facilitate the translation of these regulations into practices, a series of broad-scale trainings was held throughout the state. Attendance was required for all Child & Adult Care Food Program (CACFP)-participating facilities, although child care providers from non-CACFP facilities also attended. Pre- and posttraining surveys were used to assess changes in providers' knowledge of the regulations and satisfaction with the training.
In total 1094 presurveys and 1076 postsurveys were received. Participants were highly satisfied with the training format and content, including the instructors, materials, and schedule. Data analysis demonstrates improved knowledge of all 26 regulation components from presurvey to postsurvey. Family child care providers, providers with more years of experience, CACFP-participating facilities, and facilities with food service personnel scored significantly higher than their center staff, less experienced and non-CACFP counterparts, as well as those without food service personnel.
Broad-scale, in-person training can effectively increase child care providers' knowledge of the regulations and is well received by this audience. Other states and jurisdictions seeking to improve nutrition, physical activity, and screen-viewing practices in child care settings should consider this model of quality improvement.
For more than a decade, childhood obesity has been recognized as a national problem of epidemic proportions.1–4 In 2009–2010, 31.8% of US children and adolescents aged 2–19 were either overweight or obese. Among children aged 2–5 years, the prevalence of overweight and obesity was 26.7%.5 Overweight and obese children are at increased risk for developing a range of chronic conditions, including type 2 diabetes, hypertension, sleep apnea, asthma, depression, and anxiety.6 Childhood obesity rates in Delaware are comparable to or even exceed those documented nationally; in 2008, the prevalence of overweight and obesity ranged from 40% to 46% across Delaware's three counties and was highest among nonwhite children (49%) compared with white children (37%).7
To make progress toward reducing childhood obesity, policy and environmental change interventions must be implemented in the settings in which children live, learn, and play. Child care settings represent an ideal venue for such interventions for several reasons. First, approximately 80% of preschool-aged children with employed mothers spend an average of nearly 40 hours a week in some form of nonparental care.8 Second, early childhood is a crucial period during which children develop the food habits and patterns of nutrient intake that will follow them into adolescence and beyond.9 Furthermore, while in full-time child care, young children typically consume half to three-quarters of their daily total calories.10,11 As such, child care is a highly opportune setting to promote healthful eating.
Recognizing child care as a critical setting for addressing childhood obesity, the state of Delaware recently enacted reforms to statewide child care licensing rules designed to improve the quality of the nutrition-, physical activity–, and screen viewing–related environment in child care settings (Table 1). Prior to these reforms, Delaware child care facilities were required to follow the meal patterns and rules set forth by the federal Child & Adult Care Food Program (CACFP). This program is administered by the USDA Food and Nutrition Service (FNS) and reimburses eligible child care facilities for approved meals and snacks served. The updated rules, known as the Delaware CACFP/Delacare Rules, go above and beyond federal standards in limiting sugar and fats from cereal, fried foods, and baked goods. They apply to all licensed child care centers, family child care homes, and large family child care homes, and have been enforced since January of 2011.
This article describes the results of the evaluation of a statewide training for child care providers on the revised rules—specifically, providers' satisfaction with the rules and knowledge change.
To facilitate the translation of the updated rules into practices, an intensive training of over half of licensed child care center staff and family child care home owners in the state was undertaken. At the time of training, Delaware had 540 licensed child care centers and 1062 family child care homes. Seven training sessions were offered in the spring of 2011, and attendance at one full-day training session was required for all centers and family child care homes participating in CACFP in the state (130 centers and 740 family child care homes). All facilities participating in CACFP (n=870) were sent letters by the Department of Education informing them of this mandatory training. Additional recruitment took place through the Office of Child Care Licensing, local CACFP-sponsoring organizations and child care newsletters.
The trainings were based on a series of implementation toolkits designed to convey practical, “how-to” information directly aligned with implementation of the new rules (the First Years in the First State toolkits are available online from the Nemours Health and Prevention Services website). Training covered key toolkit materials and included hands-on activities and opportunities for providers to practice newly acquired skills in groups. All training sessions were conducted by the same 4 individuals who were recognized as approved trainers by the Delaware Institute for Excellence in Early Childhood, Delaware's professional development body for child care providers. In addition, 3 of the 4 trainers were credentialed health educators and held advanced degrees in public health or health promotion.
The evaluation of this training used self-administered written pre- and postsurveys to gather participants' demographic information, assess their knowledge of the rules, and gauge satisfaction with the training. In total, 1115 child care providers attended the training. Among those who completed the presurvey (n=1094), 923 providers represented CACFP-participating facilities and 131 represented non-CACFP facilities (the remainder did not indicate CACFP affiliation on the presurvey). The pretraining survey had 38 questions (see Appendix A for excerpt), including 12 questions that solicited demographic information about the respondent and his/her facility (e.g., job function, CACFP status, number of staff in various categories).
The pretraining survey also included 26 multiple-choice questions covering the state's 24 updated nutrition, physical activity, and screen-viewing rules. Each item asked about one component of the rules and presented four possible answer choices, including the correct answer. Pretraining surveys were collected immediately upon completion, and identical questions pertaining to the rules were asked on the posttraining survey approximately 7 hours (and nine training modules) later. While the training was focused on implementing the rules, trainers did not review the correct answers to the pretraining questions at any point during the day. Thus, the act of completing the presurvey should have had no effect on knowledge change; instead, all knowledge change should have been the result of the training itself. The posttraining survey, composed of 30 total questions (see Appendix B for excerpt), also included four additional items assessing participant satisfaction with the training, perceived barriers and facilitators to implementation, and desired areas for professional development.
Surveys were reviewed by content experts and piloted with child care providers before being administered during full-scale training. Survey items were modeled after similar surveys (e.g., Nemours' Delaware Child Care Provider Survey) that had been successfully administered to Delaware child care providers in the past.
All data were analyzed using IBM SPSS Statistics, Release 19.0.0 (Chicago, IL, 2011). Basic descriptive tests were run to gain a better understanding of providers' knowledge of the rules. A total score was calculated by adding the number of correct answers for each provider with complete data. Student t-tests and analysis of variance (ANOVA) were used to compare demographic and facility-level characteristics with total score at baseline for binary and categorical covariates, respectively.
This evaluation was approved by the Nemours Institutional Review Board (IRB) and has been given an “exempt” research status.
In total, 1094 presurveys and 1076 postsurveys were received. The response rate for the pretraining survey was 98.1%, whereas the posttraining survey garnered a 96.5% response rate (21 participants declined to complete the presurvey, 28 declined to complete the postsurvey, and 11 left the training early due to family matters, an emergency at their child care facility, or other issues). Detailed information about respondents is presented in Table 2. Of note, the majority of the attendees represented centers or child care homes that participate in CACFP (84%). Regarding job function, the majority of training participants were family child care providers (62%) or teachers (9%). Providers reported having extensive experience in the early care and education field; 59% had more than 10 years of experience. Respondents also reported on their highest level of education: One-third (33%) of the providers had a college degree or higher, whereas the majority had either a high school diploma/GED (39%) or had completed some college credits (28%). It is important to note that several facilities, primarily large child care centers, sent multiple representatives to the training.
The postsurvey included questions about participant satisfaction with the training and the instructors. Overall, participants reported high levels of satisfaction with the training format and content, including the instructors, materials and schedule (Table 3). In particular, 97% of participants agreed or strongly agreed that the information was easy to understand, and 94% agreed or strongly agreed that they learned new ideas/skills that will help them to work with children.
Participants improved their knowledge of all 26 rule components from presurvey to postsurvey (Table 4). Before the training, the average number of rule components correctly identified was 17 of 26 (data not shown). After the training, the average number of components correctly identified was 23 of 26. The number of respondents who were correctly able to identify all 26 rule components increased from 10 (pretraining) to 175 (posttraining). After the training, over 85% of participants correctly identified the rules for infants pertaining to meats (fried/prefried meat and cheese), grains (servings of whole grains required and sugar limit for cereal), juice, combination foods (both type and the rule for desserts), and confining equipment. For the rules pertaining to children, over 85% of participants correctly identified the rules for meats (processed meat and cheese), grains (whole grain servings required and sugar limit for cereal), juice (both type and number of servings), milk, and TV/computer time allowed each day.
We examined the relationship between participant characteristics and knowledge of the rules from the pretraining survey only to identify subpopulations of providers that may be especially important to target for training due to low levels of knowledge of the rules. The total number of components correctly identified (score, out of 26) was used for these comparisons. Center staff scored significantly lower than family child care providers (14.7 versus 18, p<0.001). Participants with more years of experience scored significantly higher than those with less experience (ANOVA p<0.001), although there was no relationship between educational attainment and score. We also examined the relationship between facility characteristics and knowledge and found that facilities that did not participate in CACFP scored significantly lower (12.7 correct versus 17.2; p<0.001) than participating facilities, and that facilities without food service personnel on staff scored significantly lower (p<0.001) than those with food service personnel.
Analyzing child care providers' knowledge of the rules at baseline and pre/post knowledge change revealed interesting results. First, knowledge for several rules was very low at baseline. Less than half of training attendees were able to correctly identify the rules pertaining to fried or prefried and then baked fruits, vegetables, and meats for children; the amount of physical activity required for children; and the amount of time that infants are permitted to be in confining equipment. These questions are unique, however, in that several respondents chose an answer choice that was actually more restrictive than the rule. For example, Delaware requires that children be provided with the opportunity to engage in 20 minutes of moderate-to-vigorous physical activity (MVPA) for every 3 hours in child care. However, several attendees marked 30 minutes as their answer. Providing 30 minutes of MVPA is certainly a best practice, but for the purposes of this survey, it was technically an incorrect response. A similar trend was observed with fried and prefried and then baked fruits, vegetables, and meats for children. The rules state that these items can be served to children as long as no more than 35% of their total calories are from fat, but many providers selected the answer choice “cannot be served at all.”
A second interesting observation was that several rules did not exhibit a very large knowledge change. For example, the rules pertaining to cheese, whole grains, and juice for children only showed a 10% or less increase in knowledge. Knowledge of these rules, however, was very high at baseline—90%, 90%, and 97%, respectively. These high percentages did not allow much room for improvement.
Third, knowledge of select rules remained fairly low, even after the 7-hour training, with 75% or less of training attendees marking the correct answer choice. There are several possible explanations for this observation. First, it is possible that the rule is too complicated, as in the case of sweet grains. The Delaware CACFP/Delacare rules state that sweet grains can only be served to children once in a 2-week menu cycle as a snack. They cannot be served for breakfast, lunch, or supper, and they cannot be served to infants. This rule is complicated because it has multiple components—frequency and meal type—and because it requires determining whether a food is considered a sweet grain based on a fairly technical definition or lengthy list of items. This may explain why, even after the training, only 71% of attendees knew that sweet grains cannot be served to infants. The rule governing processed meats is also complicated; they can be served to children once in a 2-week menu cycle, but they cannot be served to infants. It is possible that training attendees confused the details of this rule, as only 75% of providers correctly identified the infant-specific component of this rule.
The last rule for which knowledge remained low even after the training was the amount of MVPA required for children during their time in child care. Knowledge of this rule started low (21%) and remained low (68%) posttraining compared to other rules, which demonstrated nearly 100% comprehension. However, the number of providers who were able to correctly identify this rule increased over three-fold after the training, a very sizeable increase. It is possible that knowledge of this rule remained relatively low for the reason described previously; namely, that attendees selected the answer choice that was actually above and beyond the rules and thus was scored as incorrect.
We also found that levels of variability in knowledge across provider groups was large, despite the fact that compliance was being actively enforced by the state of Delaware prior to the trainings being implemented. Specifically, results revealed that center staff and providers with fewer years of experience appeared to be less knowledgeable about the rules at baseline than family child care providers and those with more years of experience. These results are fairly intuitive, given that job duties vary substantially between center staff and family child care providers. Many child care centers, for example, have food service workers that plan menus and prepare meals. Because the directors and teachers at these centers are not directly involved in meal preparation, they may be less familiar with the state's nutrition rules. Family child care providers, on the other hand, are responsible for all aspects of their facilities' operation, including purchasing food, planning menus, and preparing food. As sole employees, they are required to be well-versed in all state regulations.
Results also revealed that representatives of CACFP-participating facilities were able to correctly identify more rule components than those from non-CACFP facilities. These results were also expected. Child care centers and family child care homes enrolled in CACFP are required to submit monthly menus to the Department of Education and local CACFP-sponsoring organizations, respectively. If review of these menus reveals a violation of the CACFP meal pattern, the meal in question is not reimbursed. In a tough economic climate, this loss of revenue can be detrimental to small business owners. Additionally, CACFP-participating family child care homes are supported by local CACFP-sponsoring organizations (i.e., liaisons) and can reach out to these organizations with questions. For these reasons, CACFP-participating facilities are likely to be more familiar with the rules.
Our experience suggests that broad-scale, in-person training can effectively increase child care providers' knowledge of the rules. This experience, however, also reveals areas where Delaware and other entities pursuing similar rules can modify their approach. First, it is very important to carefully consider the complexity and clarity of definitions when instituting rules applying to child care providers. Rules with multiple components and technical language are difficult to comprehend, and presumably also difficult to translate into practice. Accordingly, Delaware is actively looking for ways to refine and better communicate the definition of these rule components.
High levels of variability in knowledge across provider demographic groups, furthermore, suggests that simply changing licensing rules may not result in concomitant changes in knowledge, let alone practice, at the facility level. Even though Delaware began enforcing the updated rules in January of 2011, the pre/postsurvey results demonstrate that many providers were still unfamiliar with some rules. Accordingly, training should target the subgroups that appear to be less knowledgeable about the rules (i.e., child care center staff and providers with fewer years of experience in the field). Targeting center teachers is particularly important, because turnover rates tend to be high among this group. This strategy may prove particularly effective for entities that do not have the ability, due to financial or geographic constraints, to conduct statewide training as Delaware did. States and jurisdictions should continue to support these efforts, because child care represents such a pivotal setting for influencing children's dietary intake, activity levels, and weight status.
SECTION II: PRELEARNING EVALUATION
Please answer the following questions based on your knowledge of the DE CACFP and Delacare Rules pertaining to children in Delaware licensed child care centers and family child care homes.
FRUITS AND VEGETABLES
1.What is the rule regarding serving fried or pre-fried and then baked vegetables or fruits (e.g., French fries, tater tots, sweet potatoes) to children?
Cannot be served unless no more than 35% of their calories comes from fat. Cannot be served at all
Can be served only once per 2-week period Not sure
MEATS AND MEAT ALTERNATES
2.How often can processed meats be served (e.g., sausage, hot dogs, bologna) to children?
Once per 2-week period Never
Twice per 2-week period Not sure
PHYSICAL ACTIVITY AND SCREEN TIME
3.Each child should be provided with at least how many minutes of moderate-to-vigorous physical activity for every 3 hours of care?
10 minutes 30 minutes
20 minutes Not sure
4.TV/DVD/video watching must be limited to how many hours per day for children ages two and older?
1 hour 3 hours
2 hours Not sure
*Posttraining survey questions on the DE CACFP/Delacare Rules were identical to those on the pretraining survey (see Appendix A).
SECTION II: TRAINING EXPERIENCE
1.What do you think about this professional development experience?
2.What do you think about the instructor or instructors?
We wish to acknowledge the following individuals and organizations who contributed to this project: Gina Celano, Michelle Boyle, Gregory Benjamin, the associates and leadership of Nemours Health and Prevention Services, the Delaware Department of Education, the Delaware Office of Child Care Licensing, the Team Nutrition Advisory Board, and the many child care centers and family child care homes that provided input for materials development and training design. Finally, we would like to thank the USDA, who funded the implementation of this project, with a USDA Team Nutrition Training Grant awarded to the Delaware Department of Education, and the Robert Wood Johnson Foundation, who provided supplementary funds for evaluation activities under Grant ID #62078, “Evaluation of School and Child-Care Sector Strategies in Delaware.”
No competing financial interests exist.