How Does Context Relate to Nutrition Promotion and Mealtime Practice in Early Care and Education Settings? A Qualitative Exploration

Quality evaluation of nutrition policies in early childhood education and care services in Nerang, QLD

ISSUE ADDRESSED

Food environments in early childhood, such as early childhood education and care services, influence the development of dietary patterns and behaviours that traverse into adulthood, where they affect health and longevity. Nutrition policies are mandatory in early childhood education and care services in Australia and can positively or negatively shape the food environment. However, the quality of such nutrition policies is unknown. This study aimed to evaluate the comprehensiveness and strength of nutrition policies of early childhood education and care services among services participating in a university-community alliance in South East Queensland.

METHODS

Early childhood education and care services (n = 12) in Nerang, Queensland, Australia, participated in a cross-sectional study evaluating the comprehensiveness and strength of nutrition policies across four domains (Nutrition Education, Nutrition Standards, Promoting Healthy Eating and Communication and Evaluation) of the Wellness in Child Care Assessment Tool.

RESULTS

Nutrition policies evaluated in this study had median total comprehensiveness scores of 55 (out of 100) and median total strength scores of 19 (out of 100). 'Nutrition Education' had the highest median scores for comprehensiveness (67 out of 100) and strength (33 out of 100), while 'Nutrition Standards' had the lowest comprehensiveness score (41 out of 100), and 'Communication and Evaluation' had the lowest strength score (0 out of 100).

CONCLUSIONS

All services have a nutrition policy, but there are opportunities to enhance both the content and linguistic strength of statements within policies related to nutrition domains. SO WHAT?: There is a clear need to improve the comprehensiveness and strength of written statements in nutrition policies across all four domains, particularly 'Nutrition Standards' and 'Communication and Evaluation'.

Integration of Food-based Learning With Science in the Preschool Classroom: Implementation Gaps and Opportunities

OBJECTIVE

To explore Head Start teachers' use and integration of food-based learning (FBL) with science learning in the Head Start classroom.

DESIGN

Phenomenological approach using in-depth semistructured telephone interviews.

SETTING

North Carolina Head Start preschools.

PARTICIPANTS

Thirty-five Head Start lead and assistant teachers.

PHENOMENON OF INTEREST

All interviews were transcribed verbatim. Authors coded interview data for emergent themes.

ANALYSIS

Eleven primary themes were identified during analysis and inductively organized using the Systems Thinking Iceberg Model.

RESULTS

Teachers described most frequently using FBL during mealtimes. Teachers stated they felt successful when children were engaged and willing to try a new food. However, they struggled to connect food to science concepts. Teachers reported several motivators (eg, improving health) and barriers (eg, food waste) to integrating FBL. Teachers prioritized preparing children for kindergarten, but most teachers did not see how FBL could help them achieve this goal.

CONCLUSIONS AND IMPLICATIONS

Head Start teacher professional development programs could impact all 4 levels of the Systems Thinking Model to improve teachers' perceptions, underlying structures, and mental models regarding integrative FBL. Additional research is warranted to investigate the adoption, implementation, and potential impact of FBL on academic outcomes.

Informing State-Wide Coalition Efforts to Implement and Integrate Nutrition Best Practices in Early Care and Education: Focus Group Insights from Child Care Providers

A healthy diet in early childhood is an important contributor to ensuring lifelong health and in reducing risk for obesity. The child care environment is critical to supporting nutrition as a majority of young children less than 5 years of age are enrolled in out-of-home care. In order to better understand barriers to implementing and integrating nutrition best practices, we conduced focus groups with child care providers (n = 25) in Illinois. Providers from low-income communities, rural communities, and communities of color were prioritized. Focus group participants reported several challenges including the high cost of nutritious food, picky eating, and their perception that parents did not set good examples at home. Many providers identified the Child and Adult Care Food Program (CACFP) as a critical resource in helping them implement best practices. Providers discussed needing and wanting more training, more money for food, and more parental support. These results indicate support for additional resources and sustained training and technical assistance to address perceived challenges. The evidence of the importance of CACFP in helping providers engage in nutrition best practices indicates support for expansion and strengthening of the program.

Ecological Approach to Family-Style, Multilevel Child Care Intervention: Formative Evaluation Using RE-AIM Framework

OBJECTIVE

Conduct formative evaluation of Ecological Approach to Family-Style Dining (EAT) Intervention.

DESIGN

Qualitative semistructured interviews and demographic surveys.

SETTING

Early care and education (ECE) centers in Nebraska.

PARTICIPANTS

Cooperative Extension coaches (n = 9), ECE administrators (n = 8), and teachers (n = 17) caring for children aged 3-5 years.

INTERVENTION

The EAT intervention (a 16-week, 7-lesson, evidence-based online responsive feeding ECE model) uses a multilevel improvement system of 5 implementation strategies. Early care and education administrators and teachers completed 1 lesson/wk followed by a coaching session.

MAIN OUTCOME MEASURES

The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework includes 5 evaluative dimensions.

ANALYSIS

Thematic analysis.

RESULTS

Overall, 77% of children aged 3-5 years (n = 216) participated from targeted Child and Adult Care Food Program ECEs (Reach). All perceived EAT improved children's nutritional and developmental outcomes and encouraged a positive mealtime environment (Effectiveness). Coaches found professional development incentives important, whereas administrators/teachers valued inservice hours (Adoption). Teachers reported successful implementation of responsive feeding, and administrators supported the teachers (Implementation). All reported they intended to continue using EAT, and administrators and teachers discussed incorporating EAT practices into the handbook/school policy (Maintenance).

CONCLUSION AND IMPLICATIONS

The EAT was valued by all stakeholders for its perceived effectiveness to positively impact children's nutritional outcomes. Furthermore, stakeholders valued the provided incentives and multilevel design with coaching, ECE administrators, and teachers. Future research is needed on how to use Extension coaches in ECE interventions.

De-Implementation of Detrimental Feeding Practices in Childcare: Mixed Methods Evaluation of Community Partner Selected Strategies

This pilot evaluated strategies to decrease detrimental feeding practices in early care and education, which are hypothesized to compete with evidence-based feeding and obesity prevention practices. This study made two key comparisons: (1) a between-site comparison of sites receiving (a) no implementation or de-implementation strategies (i.e., Basic Support; B), (b) implementation strategies only (i.e., Enhanced Support; E), and (c) implementation and de-implementation strategies (i.e., De-implementation + Enhanced Support; D + E) and (2) a within-site pre-post comparison among sites with D + E. At nutrition lessons, the D + E group had more Positive Comments (Hedege’s g = 0.60) and higher Role Model fidelity (Hedege’s g = 1.34) compared to the E group. At meals, assistant teachers in the D + E group had higher Positive Comments than in the B group (g = 0.72). For within-group comparisons, the D + E group decreased Negative Comments (t(19) = 2.842, p = 0.01), increased Positive Comments (t(20) = 2.314, p = 0.031), and improved use of the program mascot at nutrition lessons (t(21) = 3.899, p = 0.001). At meals, lead teachers’ Negative Comments decreased (t(22) = 2.73, p = 0.01). Qualitative data identified strengths and opportunities for iteration. Despite a COVID interruption, mid-point comparisons and qualitative feedback suggest promise of the de-implementation strategy package.

Implementation fidelity, attitudes, and influence: a novel approach to classifying implementer behavior

Background

The current study sought to (1) describe a new classification approach for types of implementer behavior and (2) explore the implementer behavior change in response to tailored implementation facilitation based on the classifications.

Methods

A small-scale, cluster-randomized hybrid type III implementation trial was conducted in 38 early care and education classrooms that were part of the Together, We Inspire Smart Eating (WISE) program. WISE focuses on 4 evidence-based practices (EBPs), which are implemented by teachers to promote nutrition. External facilitators (N = 3) used a modified Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) to complete immersion (i.e., observations) and thematic content analyses of interviews to identify the characteristics of teachers’ behavior at varying levels of implementation fidelity. Three key factors—attitudes toward the innovation, fidelity/adaptations, and influence—were identified that the research team used to classify teachers’ implementation behavior. This process resulted in a novel classification approach. To assess the reliability of applying the classification approach, we assessed the percent agreement between the facilitators. Based on the teachers’ classification, the research team developed a tailored facilitation response. To explore behavior change related to the tailored facilitation, change in fidelity and classification across the school year were evaluated.

Results

The classifications include (1) enthusiastic adopters (positive attitude, meeting fidelity targets, active influence), (2) over-adapting adopters (positive attitude, not meeting fidelity targets, active influence), (3) passive non-adopters (negative attitude, not meeting fidelity targets, passive influence), and (4) active non-adopters (negative attitudes, not meeting fidelity targets, active influence). The average percent agreement among the three facilitators for classification was 75%. Qualitative data support distinct patterns of perceptions across the classifications. A positive shift in classification was observed for 67% of cases between the mid-point and final classification. Finally, we generated an expanded classification approach to consider additional combinations of the three factors beyond those observed in this study.

Conclusions

Data from this study support the ability to apply the classification approach with moderate to high reliability and to use the approach to tailor facilitation toward improved implementation. Findings suggest the potential of our approach for wider application and potential to improve tailoring of implementation strategies such as facilitation.

Associations between food provision and feeding practices in socially disadvantaged childcare centres

Preschool children consume a large proportion of their daily food intake in their childcare settings. These settings, therefore, provide important opportunities for children to experience food socialisation, and related positive nutrition. Yet, the extent to which these opportunities are taken, particularly in socioeconomically disadvantaged areas where risk of poor nutrition is high, is not well documented. This study focused on 10 childcare centres in socially disadvantaged locations and examined daily feeding practices via direct in-situ observation (n = 189 children observed). Centres were randomly selected based on type of food provision: centre-provided (n = 5 centres) or family-provided (n = 5 centres). Analyses showed that where food was family-provided, educators were significantly more likely to use controlling feeding practices, including pressuring children to eat, restricting food choices and rushing children into finishing meals. These practices were particularly evident during mid-morning meals, where pressuring children to eat healthy foods first, was more often observed. Further research and interventions that target feeding practices in childcare are indicated and should consider how source of food provision impacts upon these practices.

Hungry is not safe: A mixed methods study to explore food insecurity in early care and education

The early care and education (ECE) environment has the potential to affect both children and their families. Food insecurity in ECE and its management may be an important influence. Objectives of this mixed methods study were to (1) elicit prominent themes relating to teacher experiences with food insecurity (in the classroom) through qualitative interviews; (2) translate interview themes into survey items and analyze survey data to explore generalizability of the qualitative findings; and (3) provide preliminary data on properties of a new tool to study the influence of food insecurity in the ECE setting. An exploratory sequential mixed methods design (QUAL → quant) was used. Twenty-eight interviews about teacher experiences with food insecurity were followed by 781 surveys to assess generalizability of interview findings. Qualitative themes highlighted that ECE teachers are concerned about children's food insecurity in their classroom; ECE teachers have developed their own set of strategies to manage their concern; and teachers often struggle with what to do. Quantitative results demonstrated many teachers had the same concerns and used the strategies described in the interviews. Further, in exploratory analyses, ECE teachers with Food Insecurity scored significantly higher on all scales (e.g., Food Insecurity Concerns, Struggle with Addressing Food Security) in both adjusted and unadjusted analyses. ECE teachers with Food Acquisition Stress had higher scores on Strategies to Address Food Insecurity with Families in adjusted analyses.

Table Talk: revision of an observational tool to characterize the feeding environment in early care and education settings

Objective

The Table Talk tool is an observational assessment of early care and education teacher (ECET) mealtime practices. The Table Talk Revised (TT-R) tool incorporates new constructs that emerged from qualitative research and teases apart existing categories to improve nuance of data capture. The objective of this study was to evaluate the TT-R, document interrater reliability for the TT-R, and report on ECET feeding communications in broader settings than previously studied (i.e., beyond a single Lunch and Head Start only).

Methods

Trained observers conducted mealtime observations in classrooms (N_classroms = 63, 10 sites) during Breakfast and two Lunches for both Lead and Assistant ECETs (N = 126). Classrooms were spread across Head Start in an urban area (60%), Head Starts in a rural area (24%), and a state-funded preschool (16%).

Results

On average, there were 22.17 (SD = 10.92) total verbal feeding communications at Breakfast, 37.72 (SD = 15.83) at Lunch₁, and 34.39 (SD = 15.05) at Lunch₂ with meals averaging 25 min. The most commonly observed supportive statement category was Exploring Foods for Lead (Breakfast = 1.61, Lunch₁ = 3.23, Lunch₂ = 2.70) and Assistant ECETs (Breakfast = .89, Lunch₁ = 2.03) except for Lunch₂ which was Encourages Trying in a Positive Way (Lunch₂ = 1.30). The most commonly observed unsupportive statement category was Firm Behavioral Control for both Lead (Breakfast = 3.61, Lunch₁ = 5.84, Lunch₂ = 5.51) and Assistants ECETs (Breakfast = 3.11, Lunch₁ = 6.38, Lunch₂ = 4.32). The majority of Interclass Correlation Coefficients indicating interrater reliability were in the excellent range (64%) for commonly occurring statement categories, and 14 of the 19 low frequency statement categories had > 80% agreement.

Conclusions and implications

Overall, items added to the Table Talk tool performed well, and interrater reliability was favorable. Our study also documented differences between Lead and Assistant teachers in mealtime practices and illustrated differing patterns of interaction between lunches and breakfast, important findings to inform future research and practice. The TT-R may be a useful measurement tool for monitoring and evaluating ECET practices in mealtime environments as well as informing intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10087-8.

De-implementation of detrimental feeding practices: a pilot protocol

BACKGROUND

Early childhood educators (ECEs) often use detrimental feeding practices and are slow to implement positive feeding practices. Nevertheless, few studies have aimed to understand and change ECEs' feeding practices. This gap needs to be addressed because implementation (i.e., adding new, evidence-based practices) and de-implementation (i.e., stopping low-value or harmful practices) are distinct processes that require unique strategies.

METHODS

We will develop a de-implementation strategy for detrimental feeding practices using evidence-based quality improvement (EBQI) sessions to engage stakeholders and draw on the Niven process model for de-implementation. Then, we will investigate the effects of the de-implementation strategy in a proof-of-principle study. The de-implementation strategy will be evaluated in 2 partnering childcare agencies using a pre-post, within-site design. For our primary outcome, we will interview educators throughout the school year to assess the feasibility and acceptability of the intervention and survey them with standard measures for assessing feasibility and acceptability. For secondary outcomes, we will investigate its effects on the use of detrimental and evidence-based feeding practices by teachers and impacts on child BMI and diet.

DISCUSSION

The current study will establish the feasibility and acceptability of our de-implementation approach and will provide preliminary data toward 3 predicted secondary outcomes: (1) decreased detrimental feeding practices by ECEs, (2) increased adoption of and fidelity to nutrition promotion practices, and (3) improved child dietary outcomes. These results are expected to contribute to the uptake and sustainability of mealtime interventions to improve the diets of young children. Results will also apply to the field of implementation science by informing processes for developing de-implementation approaches in a community setting.

Eastern North Carolina Head Start Teachers' personal and professional experiences with healthy eating and physical activity: a qualitative exploration

OBJECTIVE

Explore the interrelationship between teachers' personal and professional socio-ecological structures while examining Head Start (HS) teachers' experiences with (1) trying to eat healthy and engage in physical activity (PA) and (2) promote healthy eating and PA in their classrooms.

DESIGN

In-depth semi-structured interviews were collected from March through June 2017. Researchers designed the data collection and analysis methods using a phenomenological approach. All interviews were recorded using digital audio and transcribed verbatim.

SETTING

Seven HS centres in two rural eastern North Carolina counties.

PARTICIPANTS

Teachers (n 15) who had recently participated in a healthy eating and physical activity intervention. Participants were 100 % female, an average age of 43 years (sd 9·6) and primarily Black/African American (93·3 %).

RESULTS

Eighteen primary themes were identified providing unique insight into individual, social and environmental determinants that may influence teachers' personal health behaviours and professional health promotion practices. Findings indicated that teachers want to improve health behaviours personally (individual/family health) and professionally (children/families served); however, barriers exist at all levels impacting their ability to improve their own health and facilitate positive behaviours among the children/families they serve. Many teachers observed connections between their personal and professional experiences, but not beyond the individual level.

CONCLUSIONS

Study findings highlight the importance of considering and emphasising the potential relationship between personal and professional determinants of health when working with early childhood teachers. Findings from this study may be useful for informing the development, implementation and evaluation of future health promotion interventions using teachers as implementers.

Knowledge, Attitudes and Practices of Australian Trainee Childcare Educators Regarding Their Role in the Feeding Behaviours of Young Children

Background: Early childhood (2-5 years) is acknowledged as a critical time for the establishment of healthy behaviours. The increasing number of children and amount of time spent in childcare provides strong rationale to explore the important role that childcare services and childcare educators play in influencing healthy eating behaviours of young children in their care. Methods: This study used a qualitative exploratory approach to describe the knowledge, attitudes and practices of Australian childcare trainee educators' regarding their role in the feeding of young children. Results: All participants agreed that feeding of young children was an important part of their role, but described challenges to the promotion of healthy eating and the adoption of responsive child feeding practices. These included personal beliefs and experiences with food, the bi-directional nature of child feeding, conflicting parental requests and/or unsupportive centre-based policies and procedures. Conclusion: Training about responsive child feeding practices within the childcare sector should include all childcare staff; aim to enhance relational efficacy and communication skills with parents; and empower childcare staff to lead organisational change. To support this, childcare centres need to provide coherent centre-based healthy eating policies inclusive of healthy food provision and desirable feeding practices.

Sharing is Caring: A Study of Food-Sharing Practices in Australian Early Childhood Education and Care Services

Food connects people, and can significantly impact the physical, social and emotional development of young children. Food sharing and family-style mealtimes can support healthy eating practices and psychological well-being among young children, and carersother than family members, such as Early Childhood Education and Care staff, play an important role in the provision of these practices. Despite increasing numbers of Australian children attending Early Childhood Education and Care services, there is often reluctance among staff to promote such mealtime practices, to the detriment of children's social and emotional development. The aim of this paper was to focus on the potential role of Early Childhood Education and Care services in facilitating food sharing and family-style mealtime practices in the earliest stages of the lifespan. A qualitative, netnographic approach was used, and data was collected as part of the broader 'Supporting Nutrition for Australian Childcare' (SNAC) study, via online conversation threads, observations and qualitative interviews. Findings demonstrated that whilst many Early Childhood Education and Care services are committed to supporting food sharing and family-style mealtime practices, a number of barriers were reported. These included the perception that babies and toddlers could not participate in these practices, concerns about food hygiene and cross contamination of allergens, and negative parental influences on food sharing. In conclusion, this paper supports the practice of food sharing in Early Childhood Education and Care settings and calls for them to become embedded in everyday operations to support the physical, social and emotional development of Australia's future generations.

Identifying a Fine Line between Food Insecurity and Food Acquisition Stress: A Mixed Methods Exploration

This study introduces the concept of Food Acquisition Stress (FAS), stress associated with food acquisition among those who do not necessarily screen positive for food insecurity.. This study used an exploratory sequential mixed methods approach among a sample of predominantly early childhood educators to develop a 7-item tool for measuring current and retrospective FAS. Using this tool, we identified that 61% of individuals who had FAS did not meet criteria for food insecurity. Capturing FAS, even among those categorized as food secure, has the potential to identify individuals who may need supportive interventions. Future research can explore how FAS is related to health behaviors.

A Mixed-Methods Exploration of Barriers and Facilitators to Evidence-Based Practices for Obesity Prevention in Head Start

OBJECTIVE

To identify positive and negative deviant cases using quantitative fidelity data from a previous implementation of a nutrition intervention, Together, We Inspire Smart Eating (WISE), and to determine barriers and facilitators to fidelity by conducting qualitative interviews with deviant cases.

DESIGN

Explanatory sequential mixed methods.

SETTING

Head Start Program agencies in 2 southern US states.

PARTICIPANTS

Quantitative fidelity data were collected in 42 Head Start classrooms. Recruitment for qualitative interviews prioritized those who were positive or negative deviants across fidelity components (African American, n = 21; white, n = 19; and Hispanic, n = 3).

INTERVENTION

WISE introduces children to fruits and vegetables using evidence-based practices of role modeling, positive feeding, mascot use, and hands-on exposure.

ANALYSIS

A directed content analysis approach informed by the integrated Promoting Action on Research Implementation in Health Service framework.

PHENOMENON OF INTEREST

Barriers and facilitators to WISE evidence-based practices implementation.

RESULTS

Qualitative analyses identified themes of culture, leadership support, and mechanisms for embedding change as key contextual factors. Key findings related to recipient characteristics were beliefs about what works, personalized strategies to use WISE, and classroom management. Primary themes for the innovation construct were time and preparation, degree of fit, and WISE advantage. Finally, findings relative to the construct of facilitation included trainer support and desire for additional training.

CONCLUSIONS AND IMPLICATIONS

The study of cases at the extreme ends of the fidelity spectrum can provide unique perspectives on barriers and facilitators to implementation of interventions.