Engaging Parents to Promote Children's Nutrition and Health

Evaluating a Mobile App Supporting Evidence-Based Parenting Skills: Thematic Analysis of Parent Experience

Background

Disruptive behavior disorders are among the most common disorders of childhood, and evidence-based parenting programs are the first-line treatment. Digital microinterventions have been proposed as one possible means of supporting parenting style change by giving parents in-the-moment advice about how to respond to challenging behavior. Until now, no digital microintervention supporting evidence-based parenting skills programs has been evaluated.

Objective

The aim of this study is to evaluate the subjective experience of parents using a digital microintervention to support evidence-based parenting skills, with particular attention to acceptability, usability, family relationships, and parents' values.

Methods

We conducted serial interviews with 11 parents of 33 children before and after spending 3 weeks using an app including 3 digital microinterventions. Parents were recruited via local authorities in the Midlands region of the United Kingdom. Previous participation in a parenting program was an inclusion criterion. Interviews explored family composition; child behavior problems; and experience of using the mobile app, including barriers to use. Thematic analysis was conducted from a user-centered design perspective, and illustrative case vignettes were produced.

Results

Many parents used the app in ways that helped them rather than strictly following the instructions they were given. Parents described a range of barriers to using the app including practical problems and failure to change child behavior. Parents and children responded in a variety of ways to the use of the phone, with many wholeheartedly embracing the convenience of technology. Case vignettes illustrate the uniqueness of each family's experience.

Conclusions

Parents' use of a mobile app supporting evidence-based parenting skills is difficult to predict due to the unique challenges each family encounters. Many parents found it an acceptable and helpful addition to family life, but increased personalization is likely to be key to supporting parents. Future digital microintervention developers should keep in mind that parents are likely to use the app pragmatically rather than following instructions, may struggle to use a complex app under pressure, and are likely to hold complex feelings about parenting with an app.

Implementing a nutrition education intervention in Eastern Norwegian Kindergartens: barriers and facilitators

BACKGROUND

Implementations to improve healthy eating in kindergartens may play a pivotal role in shaping children's dietary behaviors. There is limited research on the implementation and key implementation determinants (barriers and facilitators) of interventions in kindergarten settings. The aim of this study was to explore kindergarten staff members' experiences with the implementation of a nutrition education intervention to identify implementation barriers and facilitators.

METHODS

We interviewed 12 employees from five different kindergartens in an Eastern Norwegian municipality between 2019 until 2020. The individual interviews were guided by the consolidated framework for implementation research. The interviews were recorded, transcribed verbatim, and analyzed inductively, inspired by Braun and Clarke's reflexive thematic analysis.

RESULTS

Implementation facilitators were satisfactory planning and presentation execution, including tailoring to kindergarten and staff needs, food and meals being a kindergarten/staff priority, and confidence-building of staff. Barriers included unsatisfactory planning and presentation execution, the presentation as a one-time event, non-tailoring to kindergarten and staff needs, and kindergartens/staff not prioritizing food and meals.

CONCLUSIONS

When developing and implementing similar kindergarten interventions, the following should be considered: a participatory approach, active engagement of staff, the physical learning environment, and the frequency of opportunities to revisit topics.

Lipid Profile, Eating Habit, and Physical Activity in Children with Down Syndrome: A Prospective Study

Children with Down Syndrome (DS) frequently undergo health challenges, including a higher prevalence of overweight and obesity. We aimed to evaluate the impact of dietary and physical advice provided by a specialized pediatrician over two years. In this prospective study, 44 children with DS, aged 2 to 17, underwent outpatient follow-up visits every six months between December 2020 and May 2023. Dietary habits, physical activities, anthropometric data, and laboratory results were recorded at baseline and 2-year follow-up. Adherence to the Mediterranean diet and physical activity were investigated using the 'KIDMED' and 'Godin-Shepard Leisure-Time' questionnaires, respectively, completed by the parents of the children. Venous blood samples were taken to determine the lipid profile. A significant reduction in BMI z-scores (p = 0.006) and an improvement in Godin-Shepard questionnaire scores (p = 0.0004) were observed. On the other hand, the lipid profile worsened, with an increase in LDL-c (p = 0.04) and a decrease in HDL-c (p = 0.03). Children with DS may benefit from an educational program on nutrition and physical activity to optimize weight control. Different interventions should target the lipid profile. Preventive intervention and follow-up by the pediatrician are essential for DS, which should continue into adulthood.

Barriers and enablers to a healthy food environment in Australian childcare services: Exploring directors' perspectives

ISSUE ADDRESSED

Early childhood education and care (ECEC) settings are ideal environments to optimise nutrition and positively influence children's food behaviours. However, recent research has identified the need to improve nutrition policies, food provision, and mealtime environments in Australian ECEC settings. This study explored the perceptions of ECEC directors regarding barriers and enablers to a health-promoting food environment within ECEC services.

METHODS

Eleven directors from ECEC services in Nerang, Queensland, and surrounding areas, participated in qualitative interviews between March and May 2021. Transcripts were analysed using qualitative content analysis that followed a deductive-inductive approach employing nutrition-related domains from the Wellness Child Care Assessment Tool, these being: (i) nutrition policy; (ii) nutrition education; (iii) food provision; and (iv) mealtimes. Transcripts were coded independently by two researchers in NVivo and consensus for barriers and enablers was achieved through discussion.

RESULTS

Barriers and enablers were reported across four domains (nutrition policy, nutrition education, food provision, and mealtimes). Comprehensive nutrition-related policies were an enabler to a healthy nutrition environment but were sometimes described as lacking detail or customisation to the service. Nutrition education for children was described as competing with other activities for time and resources in an already-crowded curriculum. Financial and time pressures faced by families were a barrier to healthy food provision in services where families provided food for children. The ability of staff to sit with children and engage in conversation during mealtimes was an enabler; however, competing demands on time and the unavailability of food for staff were cited as barriers to health-promoting mealtimes.

CONCLUSIONS

Directors in ECEC services report both barriers and enablers to a healthy food environment. Nutrition policies were an enabler when comprehensive and relevant but a barrier when vague and not tailored to the service environment. ECEC services should be supported to develop and implement service-specific nutrition policies and practices by engaging with parents and staff. SO WHAT?: The barriers and enablers reported in this study should be considered when designing and implementing future evidence-based interventions to improve the nutrition environment in ECEC services.

Effect and process evaluation of a preschool-based intervention to promote an early childhood education and care teacher-parent partnership about healthy behaviours in children: Study protocol for the cluster randomised controlled trial CO-HEALTHY

BACKGROUND

Early Childhood Education and Care (ECEC) teachers at urban preschools are potential key figures to promote healthy behaviours in disadvantaged young children and to engage parents in lifestyle-related topics. An ECEC teacher-parent partnership regarding healthy behaviours may support parents and stimulate their children's development. However, it is not an easy task to establish such a collaboration and ECEC teachers need tools to communicate with parents about lifestyle-related topics. This paper describes the study protocol of a preschool-based intervention (CO-HEALTHY) to promote an ECEC teacher-parent partnership regarding healthy eating, physical (in)activity and sleeping behaviours in young children.

METHODS

A cluster randomised controlled trial will be performed at preschools in Amsterdam, the Netherlands. Preschools will be randomly allocated to an intervention or control group. The intervention consists of a toolkit with 10 parent-child activities and associated training for ECEC teachers. The activities were composed using the Intervention Mapping protocol. At intervention preschools, ECEC teachers will carry out the activities during standard contact moments. Parents will receive associated intervention materials and will be encouraged to perform similar parent-child activities at home. At control preschools, the toolkit and training will not be implemented. The primary outcome will be the teacher- and parent-reported partnership regarding healthy eating, physical (in)activity and sleeping behaviours in young children. The perceived partnership will be assessed by a questionnaire at baseline and at 6 months. In addition, short interviews with ECEC teachers will be held. Secondary outcomes include the knowledge, attitude, food- and activity-related practices of ECEC teachers and parents. Furthermore, children's eating, physical (in)activity and sleeping behaviours, and weight development will be assessed. A process evaluation of the intervention will be made.

DISCUSSION

The intervention aims to provide a practical tool for ECEC teachers at urban preschools to promote an ECEC teacher-parent partnership regarding a healthy lifestyle in young children.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NL8883. Date registered: September 8, 2020.

How involved are parents in their child's early years setting's food decisions and practices?

As childhood obesity and poor nutrition rates in England continue to rise, parents and childcare practitioners have key partnership roles in ensuring young children have healthy balanced diets. Yet little is known about parents' understanding and involvement in their childcare settings' food decisions and practices, and how this might be strengthened. Semi-structured interviews were carried out with a purposive sample of 59 parents with one or more children attending early years settings in England. Framework analysis was used to explore the interviews. Epstein's model of parental partnerships was adapted as a reflective lens for the findings, and their implication for early years' policy and practice. Parents reported a lack of two-way communication on food, and of opportunities for active, meaningful engagement around food and healthy eating outside of one-to-one discussions of their child's specific needs and requirements. Some parents reported a lack of trust in the food related information provided by their childcare setting. As young children spend more time in formal childcare, it is increasingly important that trusting collaborative relationships are built between parents and childcare practitioners to ensure that children have the best start in life. This study adds to the limited literature on parental involvement in early years settings. Findings suggest that more policy work and development is needed in the early years sector, particularly in ensuring clear and accessible guidelines on food in early years settings are readily available, and that practitioners and parents have more clarity about their mutual roles and responsibilities in this.

Communicating With Head Start Families About Children's Weight Status: A Phenomenological Approach

BACKGROUND

To support the early identification of childhood obesity, Head Start (HS) implemented a body mass index screening program. This program provides opportunities for HS to communicate with families about children's weight status. Limited research is available describing the methods used to communicate this information.

OBJECTIVE

Explore common experiences of HS health/nutrition managers (HNM) when communicating information to families about children's weight status.

STUDY DESIGN, SETTINGS, AND PARTICIPANTS

Twenty-eight in-depth telephone interviews with HNM across North Carolina (n = 15) and Ohio (n = 13).

STUDY DESIGN/ANALYSIS

Phenomenology guided the study design and analysis. The themes focused on HNM's lived experiences with their body mass index screening program. Interviews were recorded and transcribed verbatim.

RESULTS

Four emergent themes identified: (1) strategies for communicating weight status to families; (2) family response to communication strategies; (3) educational, staff support, and counseling opportunities for families; and (4) challenges engaging families in childhood obesity prevention efforts.

CONCLUSIONS AND IMPLICATIONS

Head Start programs acknowledged the importance of communicating children's weight status; however, there are inconsistencies in methods used and information communicated across programs. Head Start programs have community partners who support obesity prevention efforts; however, these partnerships may be underused. More research is needed to explore effective and sensitive communication methods for HS families regarding children's weight status.

Mothers as advocates for healthier lifestyle behaviour environments for their children: results from INFANT 3.5-year follow-up

BACKGROUND

The amount of time children spend outside of their home environment has increased over the past decades. Therefore, the quality of the health behaviour environments where young children spend time is likely to impact their health behaviour opportunities. The aim of this study was to describe the proportion of mothers who consider it possible to make changes in their local communities to increase opportunities for children to eat healthily, be physically active, and limit screen time exposure, as well as the proportion who have attempted to do so. The characteristics of mothers with differing advocacy beliefs and intentions were explored.

METHODS

Cross-sectional data collected using questionnaires from 307 mothers who participated in the 3.5-year follow-up of the INFANT cluster-randomized controlled trial were used. Frequencies were used to assess the number of mothers who thought it possible to bring about change in their local communities and for the those who had attempted to do so. Binary logistic regression analyses were used to compare sociodemographic characteristics of mothers with differing responses.

RESULTS

Most mothers thought it was possible to bring about change in their local community with regards to providing more opportunities for their child to eat healthily (83.7%), be physically active (90.9%) as well as limit exposure to screen time (63.5%). However, less than 19% and 11% of mothers have thought about or tried to bring about change in their child's childcare centre or local community, respectively. No sociodemographic differences were found between the mothers who thought it was possible to bring about actioning change (p-values > 0.1) or for those that have thought about change (p-values > 0.1).

CONCLUSION

As children are continuously being exposed to obesogenic environments future quantitative and qualitative studies are needed to describe how to promote parental advocacy and engagement, in order to provide children with environments that support healthy lifestyle behaviours.

Responsive Feeding Environments in Childcare Settings: A Scoping Review of the Factors Influencing Implementation and Sustainability

Children benefit from responsive feeding environments, where their internal signals of hunger and satiety are recognized and met with prompt, emotionally supportive and developmentally appropriate responses. Although there is existing research on responsive feeding environments in childcare, there is little synthesized literature on the implementation practices using a behavior change framework. This scoping review sought to explore the factors influencing the implementation and sustainability of responsive feeding interventions in the childcare environment, using the behavior change wheel (BCW). A total of 3197 articles were independently reviewed and 39 met the inclusion criteria. A thematic analysis identified the factors influencing the implementation and sustainability of responsive feeding, including the following: (1) pre-existing nutrition policies, (2) education and training, (3) provider beliefs and confidence, (4) partnership development and stakeholder engagement and (5) resource availability. The most common BCW intervention functions were education (n = 39), training (n = 38), environmental restructuring (n = 38) and enablement (n = 36). The most common policy categories included guidelines (n = 39), service provision (n = 38) and environmental/social planning (n = 38). The current literature suggests that broader policies are important for responsive feeding, along with local partnerships, training and resources, to increase confidence and efficacy among educators. Future research should consider how the use of a BCW framework may help to address the barriers to implementation and sustainability.

Parents’ Communication with Teachers about Food and Nutrition Issues of Primary School Students

Parents and teachers have a major influence in the formation of primary school children’s eating behaviours. Although the cooperation of parents and teachers has frequently been recommended in the promotion of healthy eating habits among primary school children, little is known about the communication between these two groups regarding food- and nutrition-related issues. This paper reports findings from semi-structured interviews with primary school parents (n = 19) and primary teachers (n = 17), as well as findings from a survey of 787 parents in Australia. Audio-recorded interviews were analysed using NVivo and descriptive statistics were calculated for the survey questions. The results indicated that their communications involved various topics, including allergies, lunchbox content, and supervision requests, through diverse communication channels. The risk of offending each other and time scarcity were reported as communication barriers. Parents mainly expected teachers to ensure that their children were given enough time to eat their lunch, teach healthy eating, and be good role models of healthy eating. This study highlights the need to overcome communication barriers between parents and teachers and support teachers in their multifaceted professional roles.

An mHealth Intervention to Reduce the Packing of Discretionary Foods in Children's Lunch Boxes in Early Childhood Education and Care Services: Cluster Randomized Controlled Trial

Background

Interventions in early childhood education and care (ECEC) services have the potential to improve children’s diet at the population level.

Objective

This study aims to test the efficacy of a mobile health intervention in ECEC services to reduce parent packing of foods high in saturated fat, sugar, and sodium (discretionary foods) in children’s (aged 3-6 years) lunch boxes.

Methods

A cluster randomized controlled trial was undertaken with 355 parent and child dyads recruited by phone and in person from 17 ECEC services (8 [47%] intervention and 9 [53%] control services). Parents in the intervention group received a 10-week fully automated program targeting barriers to packing healthy lunch boxes delivered via an existing service communication app. The program included weekly push notifications, within-app messages, and links to further resources, including websites and videos. The control group did not receive any intervention. The primary outcomes were kilojoules from discretionary foods and associated nutrients (saturated fat, free sugars, and sodium) packed in children’s lunch boxes. Secondary outcomes included consumption of kilojoules from discretionary foods and related nutrients and the packing and consumption of serves of discretionary foods and core food groups. Photography and weights of foods in children’s lunch boxes were recorded by trained researchers before and after the trial to assess primary and secondary outcomes. Outcome assessors were blinded to service allocation. Feasibility, appropriateness, and acceptability were assessed via an ECEC service manager survey and a parent web-based survey. Use of the app was assessed via app analytics.

Results

Data on packed lunch box contents were collected for 88.8% (355/400) of consenting children at baseline and 84.3% (337/400) of children after the intervention. There was no significant difference between groups in kilojoule from discretionary foods packed (77.84 kJ, 95% CI −163.49 to 319.18; P=.53) or the other primary or secondary outcomes. The per-protocol analysis, including only data from children of parents who downloaded the app, also did not find any statistically significant change in primary (−1.98 kJ, 95% CI −343.87 to 339.90; P=.86) or secondary outcomes. Approximately 61.8% (102/165) of parents in the intervention group downloaded the app, and the mean service viewing rate of weekly within-app messages was 26% (SD 14.9). Parents who responded to the survey and participating services agreed that it was appropriate to receive lunch box information via the app (40/50, 80% and 6/8, 75%, respectively).

Conclusions

The intervention was unable to demonstrate an impact on kilojoules or associated nutrients from discretionary foods packed in children’s lunch boxes. Low app downloads and program message views indicate a need to explore how to improve factors related to implementation before further testing similar mobile health interventions in this setting.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000133235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374379

Exploring a theory of change: Are increases in parental empowerment associated with healthier weight-related parenting practices?

INTRODUCTION

Parent health-related empowerment is defined as the process by which parents realize control over their life situation and take action to promote a healthier lifestyle. For decades, researchers have described the theoretical potential of empowerment in health promotion efforts, though few have empirically examined this hypothesized relationship. This study is one of the first to examine the relationship between parental empowerment and healthy weight parenting practices (i.e., food, physical activity, sleep, and media parenting), as a mechanism for early childhood health promotion in community settings.

METHODS

Low-income parents of preschool-aged children attending Head Start in Greater Boston between fall 2017 and spring 2019 were invited to complete a survey in the fall and spring of each academic school year (n = 578 with two surveys and n = 45 with four). Parental empowerment and healthy weight parenting practices were assessed using validated surveys. We used a multilevel difference-in-difference approach to estimate changes in healthy weight parenting practices score by changes in parental empowerment score.

RESULTS

Out of a possible score of four, the unadjusted mean (SD) score in fall was 3.20 (0.40) for empowerment and 3.01 (0.40) for parenting. An increase in parental empowerment was associated with an increase in healthier parenting practices (b = 0.14; 95% CI = 0.08, 0.20; p < 0.0001).

CONCLUSIONS

Parent empowerment may be an important target in interventions to prevent obesity in low-income children.

A qualitative comparison of parent and childcare provider perceptions of communication and family engagement in children's healthy eating and physical activity

BACKGROUND

Parents and childcare providers play a substantial role in the development of health behaviours among the children they care for. In order to ensure the optimal growth and development of children, communication and family engagement in childcare is critical. Previous studies examining parent or provider perceptions about healthy eating or physical activity have explored these concepts individually and/or have only included only parents or providers. Therefore, the purpose of this study was to compare childcare provider and parent perceptions of communication regarding healthy eating and physical activity as well as use of best practice strategies on family engagement for these topics.

METHODS

Childcare providers (n = 12) in childcare centres or a family childcare home and a parent (n = 12) of a child they provide care for participated in a semi-structured interview guided by the Social Ecological Model. Interviews were transcribed verbatim and uploaded to NVivo for data analysis. Data were analysed using a directed content analysis. Three trained qualitative researchers developed a codebook and then compared responses between parents and providers.

RESULTS

Similarities in provider and parent responses included agreement on healthy eating; influences on child development; parents being the most influential on children's healthy eating; how they identified physical activity opportunities; and the use of family engagement principles. Differences that arose included parents' roles in promoting children's physical activity; challenges for parents in promoting healthy eating and physical activity; and providers' encouragement of physical activity. Importantly, few parents mentioned providers were top influences on their child's healthy eating or physical activity. Providers also mentioned having difficult conversations with parents was challenging.

CONCLUSIONS

Future efforts are needed to (1) help parents understand the providers' role in the development of their child's health behaviours and (2) strengthen efforts to engage families in healthy behaviours outside of childcare facilities.

Feasibility of a Web-Based Implementation Intervention to Improve Child Dietary Intake in Early Childhood Education and Care: Pilot Randomized Controlled Trial

Background

Internationally, the implementation of evidence-based healthy eating policies and practices within early childhood education and care (ECEC) settings that encourage children’s healthy diet is recommended. Despite the existence of evidence-based healthy eating practices, research indicates that current implementation rates are inadequate. Web-based approaches provide a potentially effective and less costly approach to support ECEC staff with implementing nutrition policies and practices.

Objective

The broad aim of this pilot randomized controlled trial is to assess the feasibility of assessing the impact of a web-based program together with health promotion officer (HPO) support on ECEC center implementation of healthy eating policies and practices. Specifically, we seek to describe the completion rate of study evaluation processes (participant consent and data collection rates); examine ECEC center uptake, acceptability, and appropriateness of the intervention and implementation strategies; understand the potential cost of delivering and receiving implementation support strategies; and describe the potential impact of the web-based intervention on the implementation of targeted healthy eating practices among centers in the intervention group.

Methods

A 6-month pilot implementation trial using a cluster-randomized controlled trial design was conducted in 22 ECEC centers within the Hunter New England region of New South Wales, Australia. Potentially eligible centers were distributed a recruitment package and telephoned by the research team to assess eligibility and obtain consent. Centers randomly allocated to the intervention group received access to a web-based program, together with HPO support (eg, educational outreach visit and local technical assistance) to implement 5 healthy eating practices. The web-based program incorporated audit with feedback, development of formal implementation blueprints, and educational materials to facilitate improvement in implementation. The centers allocated to the control group received the usual care.

Results

Of the 57 centers approached for the study, 22 (47%) provided consent to participate. Data collection components were completed by 100% (22/22) of the centers. High uptake for implementation strategies provided by HPOs (10/11, 91% to 11/11, 100%) and the web-based program (11/11, 100%) was observed. At follow-up, intervention centers had logged on to the program at an average of 5.18 (SD 2.52) times. The web-based program and implementation support strategies were highly acceptable (10/11, 91% to 11/11, 100%). Implementation of 4 healthy eating practices improved in the intervention group, ranging from 19% (2/11) to 64% (7/11).

Conclusions

This study provides promising pilot data to warrant the conduct of a fully powered implementation trial to assess the impact of the program on ECEC healthy eating practice implementation.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619001158156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378099

International Registered Report Identifier (IRRID)

RR2-10.1186/s40814-020-00707-w

Connecting Families to Food Resources amid the COVID-19 Pandemic: A Cross-Sectional Survey of Early Care and Education Providers in Two U.S. States

Early care and education (ECE) settings are important avenues for reaching young children and their families with food and nutrition resources, including through the U.S. federally funded Child and Adult Care Food Program (CACFP). Researchers conducted a cross-sectional survey of ECE providers in two U.S. states in November 2020 to identify approaches used to connect families with food and nutrition resources amid the COVID-19 pandemic. Logistic regression models were used to estimate odds of sites reporting no approaches and adjusted Poisson models were used to estimate the incidence rate ratio of the mean number of approaches, comparing sites that participate in CACFP to those that did not. A total of 589 ECE sites provided responses. Of those, 43% (n = 255) participated in CACFP. CACFP participating sites were more likely to report using any approaches to connecting families to food resources and significantly more likely to report offering "grab and go" meals, providing meal delivery, distributing food boxes to families, and recommending community food resources than non-CACFP sites. This study suggests that CACFP sites may have greater capacity to connect families to food resources amid emergencies than non-CACFP participating sites.

Understanding the process of implementing nutrition and physical activity policies in a large national child care organization: a mixed-methods study

Learning Care Group made a three-year commitment with the Partnership for a Healthier America to implement several evidence-based nutrition and physical activity policies in over 900 child care centers. New practices included serving more fruits and vegetables; eliminating sugary drinks and juice; family-style dining; healthier celebrations; limiting screen time; increasing outdoor play time; and supporting breastfeeding. A sequential convergent mixed-methods design was used to describe changes in center practices over time; organizational support for changes; and center director perceptions of the implementation process. Data were collected through an interview with organizational leadership; document review; and online center director surveys at 6, 18, and 36 months. The final center director survey included open-ended questions about policy implementation. Written responses were coded and overall themes were extracted by integrating the qualitative and quantitative data. The five overall themes were to: take a comprehensive approach; build the initiative over time; provide structural supports; replace old practices with new ones; and communicate thoroughly. Center leaders reported primarily positive reactions to healthier menus, juice removal, and increased physical activity. The most controversial policy concerned healthier celebrations. Center directors reported that the staff and children adapted quickly to changes, while some families required more assistance. The experience of this large child care organization can inform other efforts to implement early care and education wellness policies.

A Qualitative Study: Perceived Barriers and Facilitators to Nutrition Standard Adherence by In-home Childcare Providers

BACKGROUND

The Child and Adult Care Food Program (CACFP) nutrition standards may present food purchasing, preparation, and feeding challenges for caregivers of young children.

OBJECTIVE

To elucidate perceived barriers and facilitators faced by in-home childcare providers to following the CACFP food and beverage nutrition standards.

DESIGN

Virtual, semistructured individual interviews elicited perceptions from a cross section of low-income, in-home childcare providers in Michigan.

PARTICIPANTS/SETTINGS

Twenty childcare providers of various races, ethnicity, urban and rural residence, and licensure status.

ANALYSIS

Thematic coding analysis with NVivo (ver12.0) to organize and interpret data.

RESULTS

Four primary barriers to adhering to the CACFP nutrition standards emerged including (1) noncompliant food preferences of children and providers; (2) higher cost and lower availability of CACFP-approved items; (3) celebrations and food rewards; (4) excessive time and effort needed to prepare foods and beverages, especially with dietary restrictions for some children. Ten perceived facilitators included (1) using nutrition education available through community organizations; (2) finding convenient and easy ways to prepare foods and beverages; (3) using CACFP and Special Supplemental Nutrition Program for Women, Infants, and Children guidelines and funding; (4) increasing variety of foods and beverages by using a menu or recalling items recently served; (5) modeling eating healthful foods and encouraging sampling of new foods and beverages; (6) mixing preferred foods/beverages with less preferred; (7) using nutrition information available from social media and from peers; (8) allowing children to choose foods and beverages; (9) serving the same eligible food and beverages to all children; and (10) provider concern about impact of foods and beverages on children's health and behavior.

CONCLUSIONS

Results from this study can inform nutrition education from community organizations that occurs in tandem with CACFP sponsor organizations. In addition, they can be utilized to address state-level licensure regulations and quality improvement rating systems that include nutrition standards childcare providers are encouraged or required to follow.

Paediatric teams in front of childhood obesity: A qualitative study within the STOP project

INTRODUCTION

Understanding the underlying factors that influence the approach to overweight and obesity in children is basic to best support families searching a solution to this important public health problem.

OBJECTIVE

To assess attitudes and feelings of paediatric staff in addressing overweight and childhood obesity to parents, exploring perceived barriers and facilitators, for an effective care.

PARTICIPANTS AND METHOD

Qualitative study by means of individual semi-structured questionnaires of paediatric staff (paediatricians and paediatrician nurses; n = 57; 68% female) of primary health care centres and hospitals in Mallorca. Thematic analysis was done.

RESULTS

Three themes emerged from the data: "Parents' attitude in childhood obesity" (sub-themes "The conscience of parents", "The parents ask for help"), "Paediatric staff and childhood obesity" (sub-themes "Approaching to the problem: The interview with parents", "Looking together for the solution"), and "System barriers" (sub-themes "Improving teamwork and health policy", "Family participation in addressing childhood obesity").

CONCLUSIONS

Paediatric staffs know how to treat childhood obesity, but demand training on motivation. Effectivity on therapy of childhood obesity will be obtained after parents/carers recognize the problem and establish a trustful relationship with paediatric staff. The health system is still a barrier to the activity of paediatric personnel.

Parent Website Engagement and Health Equity Implications in a Child Care-Based Wellness Intervention

OBJECTIVE

To evaluate demographic differences in parent website engagement in a child care-based wellness intervention.

DESIGN

Parent-reported demographic characteristics and observed website engagement were averaged by child care centers participating in the web-based intervention arm of a cluster randomized controlled trial of wellness interventions.

SETTING AND PARTICIPANTS

Parents of preschoolers in 17 Maryland child care centers.

MAIN OUTCOME MEASURES

Website engagement: (1) webpage views, (2) average time on webpage, and (3) intervention activity completion.

INTERVENTION

Parents received access to a website containing content on wellness-promoting topics (eg, parenting, nutrition, physical activity) and their child care center's activities.

ANALYSIS

Cross-sectional differences in website engagement by demographic characteristics were assessed using ANOVA.

RESULTS

Centers with a high proportion of parents who identified as other than non-Hispanic White and had less than a bachelor's degree had significantly fewer webpage views, and completed significantly fewer intervention activities compared with centers with parents who were predominantly non-Hispanic White and had more than a bachelor's degree.

CONCLUSIONS AND IMPLICATIONS

Demographic differences in parents' child care center website engagement represent disparities that could contribute to health inequities in parents' access to wellness-promoting material. Future efforts could identify factors that eliminate demographic disparities in parent engagement in web-based interventions.

Conducting a psychosocial and lifestyle assessment as part of an integrated care approach for childhood obesity: experiences, needs and wishes of Dutch healthcare professionals

BACKGROUND

The causes and consequences of childhood obesity are complex and multifaceted. Therefore, an integrated care approach is required to address weight-related issues and improve children's health, societal participation and quality of life. Conducting a psychosocial and lifestyle assessment is an essential part of an integrated care approach. The aim of this study was to explore the experiences, needs and wishes of healthcare professionals with respect to carrying out a psychosocial and lifestyle assessment of childhood obesity.

METHODS

Fourteen semi-structured interviews were conducted with Dutch healthcare professionals, who are responsible for coordinating the support and care for children with obesity (coordinating professionals, 'CPs'). The following topics were addressed in our interviews with these professionals: CPs' experiences of both using childhood obesity assessment tools and their content, and CPs' needs and wishes related to content, circumstances and required competences. The interviews comprised open-ended questions and were recorded and transcribed verbatim. The data was analysed using template analyses and complemented with open coding in MAXQDA.

RESULTS

Most CPs experienced both developing a trusting relationship with the children and their parents, as well as establishing the right tone when engaging in weight-related conversations as important. CPs indicated that visual materials were helpful in such conversations. All CPs used a supporting assessment tool to conduct the psychosocial and lifestyle assessment but they also indicated that a more optimal tool was desirable. They recognized the need for specific attributes that helped them to carry out these assessments, namely: sufficient knowledge about the complexity of obesity; having an affinity with obesity-related issues; their experience as a CP; using conversational techniques, such as solution-focused counselling and motivational interviewing; peer-to-peer coaching; and finally, maintaining an open-minded, non-stigmatizing stance and harmonizing their attitude with that of the child and their parents.

CONCLUSIONS

Alongside the need for a suitable tool for conducting a psychosocial and lifestyle assessment, CPs expressed the need for requisite knowledge, skills and attitudes. Further developing a supporting assessment tool is necessary in order to facilitate CPs and thereby improve the support and care for children with obesity and their families.

Fidelity and factors influencing implementation of Healthy Me, Healthy: process evaluation of a social marketing campaign for diet and physical activity behaviors of children in childcare

The effectiveness of interventions targeting children's eating and physical activity behaviors through childcare settings is inconsistent. To enhance public health impact, it is imperative to evaluate fidelity of implementing complex interventions in real-world settings. This study evaluated fidelity and contextual factors influencing implementation of Healthy Me, Healthy We (HMHW). HMHW was an 8-month social marketing campaign delivered through childcare to support children's healthy eating and physical activity. HMHW required two levels of implementation support (research team and childcare providers) and two levels of campaign delivery (childcare providers and parents). Process evaluation was conducted among childcare centers in the intervention group (n=48) of the cluster-randomized control trial. Measures included attendance logs, self-report surveys, observation checklists, field notes, and semi-structured interviews. A 35-item fidelity index was created to assess fidelity of implementation support and campaign delivery. The fidelity with which HMHW was implemented by childcare providers and parents was low (mean 17.4 out of 35) and decreased between childcare providers and parents. Childcare providers had high acceptability of the program and individual components (80 - 93%). Only half of parents felt intervention components were acceptable. Frequently cited barriers to implementation by childcare providers included time constraints, parent engagement, staff turnover, and restrictive policies. The lack of observable effect of HMHW on children's dietary or physical activity behaviors may be due to inadequate implementation at multiple levels. Different or additional strategies are necessary to support implementation of multilevel interventions, particularly when individuals are expected to deliver intervention components and support others in doing so.

Exploring Feeding Practices and Food Literacy in Parents with Young Children from Disadvantaged Areas

Early childhood provides an opportunity to optimize growth and development and parents play a fundamental role in forming healthy eating habits in their children. A healthy diet improves quality of life and wellbeing and reduces the risk of chronic disease. The aim of this research was to explore parents' experiences of feeding 0-5-year-old children and food literacy behaviors. This qualitative study employed a general inductive inquiry approach. Participants were recruited through community-based parenting organizations in disadvantaged areas. Eight focus groups were conducted with 67 parents (92.5% female) living in socially disadvantaged areas within metropolitan Perth of Western Australia. Ten themes emerged from the preliminary analysis and were aligned with domains of relatedness, autonomy, and competence within the self-determination theory. Themes included relatedness (1) feeding is emotional, (2) variations in routine and feeding structures, (3) external influences, autonomy (4) power struggles, (5) it must be quick and easy, (6) lack of strategies for feeding autonomy, competency (7) whatever works, (8) healthy is important but for some unattainable, (9) improvements in food literacy skills, and (10) conflicting information overload. This research informed the development of a food literacy program for parents. Parents faced many challenges when trying to provide healthy food. This research has shown parents would benefit from support to achieve healthy eating practices for their families.

[Paediatric teams in front of childhood obesity: a qualitative study within the STOP project]

INTRODUCTION

Understanding the underlying factors that influence the approach to overweight and obesity in children is basic to best support families searching a solution to this important public health problem.

OBJECTIVE

To assess attitudes and feelings of paediatric staff in addressing overweight and childhood obesity to parents, exploring perceived barriers and facilitators, for an effective care.

PARTICIPANTS AND METHOD

Qualitative study by means of individual semi-structured questionnaires of paediatric staff (paediatricians and paediatrician nurses; n=57; 68% female) of primary health care centres and hospitals in Mallorca. Thematic analysis was done.

RESULTS

Three themes emerged from the data: «Parents' attitude in childhood obesity» (sub-themes «The conscience of parents», «The parents ask for help»), «Paediatric staff and childhood obesity» (sub-themes «Approaching to the problem: The interview with parents», «Looking together for the solution»), and «System barriers» (sub-themes «Improving teamwork and health policy», «Family participation in addressing childhood obesity»).

CONCLUSIONS

Paediatric staffs know how to treat childhood obesity, but demand training on motivation. Effectivity on therapy of childhood obesity will be obtained after parents/carers recognize the problem and establish a trustful relationship with paediatric staff. The health system is still a barrier to the activity of paediatric personnel.

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.

Alignment of State Regulations With Breastfeeding and Beverage Best Practices for Childcare Centers and Family Childcare Homes, United States

OBJECTIVES

Childcare is an important setting for nutrition; nearly half of young children in the United States participate in licensed childcare, where they consume up to two-thirds of their daily dietary intake. We compared state regulations for childcare with best practices to support breastfeeding and healthy beverage provision.

METHODS

We reviewed regulations for childcare centers (centers) and family childcare homes (homes) in effect May-July 2016 and rated all 50 states for inclusion (1 = not included, 2 = partially included, 3 = fully included) of 12 breastfeeding and beverage best practices. We calculated average ratings for 6 practices specific to infants aged 0-11 months, 6 practices specific to children aged 1-6 years, and all 12 practices, by state and across all states. We assessed significant differences between centers and homes for each best practice by using McNemar-Bowker tests for symmetry, and we assessed differences across states by using paired student t tests.

RESULTS

States included best practices in regulations for centers more often than for homes. Average ratings (standard deviations) in regulations across all states were significantly higher in centers than in homes for infant best practices (2.1 [0.5] vs 1.8 [0.5], P < .001), child best practices (2.1 [0.6] vs 1.8 [0.6], P = .002), and all 12 best practices combined (2.1 [0.5] vs 1.8 [0.6], P < .001).

CONCLUSIONS

Although best practices were more consistently included in regulations for centers than for homes, many state childcare regulations did not include best practices to support breastfeeding and the provision of healthy beverages. Findings can be used to inform efforts to improve regulations and to reduce differences between centers and homes.

Provider-Selected Training Needs and Associations With Related Practices in Childcare Settings in Minnesota and Wisconsin

BACKGROUND

Early care and education settings (ECE) are potential venues for young children to develop healthy lifestyle habits. The study assesses training needs and associations with relevant practices of licensed ECE providers across Minnesota and Wisconsin.

METHODS

A random sample of 823 providers completed a 97-item survey assessing nutrition and physical activity (PA) practices and training needs. Logistic regression, adjusted for program type (center- and family home-based), and location (urban/rural) examined associations between the top 3 selected training needs and provider practices.

RESULTS

Top training needs: (1) ways to effectively engage parents about healthy eating and PA, (2) low-cost ways to serve healthy foods, and (3) fun and easy nutrition education curricula. Providers who reported being not happy/somewhat happy vs happy/very happy with parent communication were more likely to need training to engage parents. Among providers who prepared food on-site, shopping at Farmer's Market had lower odds of needing training for serving healthy meals on a budget. Not having completed nutrition training in the past year providers were more likely to need training for fun and easy nutrition education curricula.

CONCLUSIONS

Providers need additional training to improve communication with parents, healthy food shopping practices, and nutrition-related games.

A pilot randomised controlled trial of a web-based implementation intervention to increase child intake of fruit and vegetables within childcare centres

Background

As dietary behaviours developed during early childhood are known to track into adulthood, interventions that aim to improve child nutrition at a population level are recommended. Whilst early childhood education and care (ECEC) is a promising setting for interventions targeting children’s nutrition behaviours, previous interventions have largely used high intensity, face-to-face approaches, limiting their reach, implementation and potential impact at a population level. Web-based modalities represent a promising means of supporting the delivery of childcare-based interventions whilst overcoming challenges of previous approaches; however, the feasibility of using such modalities to support implementation is largely unknown. As such, this study sought to collect feasibility and pilot data to inform the design of a web-based intervention together with health promotion officer support within childcare centres. Child dietary intake will also be assessed to provide an estimate of the impact of the implementation intervention.

Methods

A superiority cluster randomised controlled trial with repeat cross-sectional data collection employing an effectiveness-implementation type-II hybrid design will be conducted with childcare centres within the Hunter New England region of New South Wales, Australia. Type-II hybrid designs provide the opportunity to assess intervention efficacy whilst piloting the feasibility of the implementation strategies. Centres allocated to the intervention group will receive access to a web-based program together with health promotion officer support to implement targeted healthy eating practices to improve child diet in care. A number of outcomes will be assessed to inform the feasibility to conduct a larger trial, including childcare centre and parent recruitment and consent rates for each component of data collection, uptake of the implementation strategies, acceptability of the intervention and implementation strategies, appropriateness of the implementation strategies and the contextual factors influencing implementation.

Discussion

This study will provide high-quality evidence regarding the potential feasibility of a web-based intervention and the impact of healthy eating practices on child diet in care. Web-based modalities provide a promising approach for population-wide implementation support to childcare centres given their potential reach and consistency with existing infrastructure.

Trial registration

Prospectively registered with Australian New Zealand Clinical Trial Registry (ACTRN12619001158156).

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s40814-020-00707-w.

Participation in the Child and Adult Care Food Program is associated with fewer barriers to serving healthier foods in early care and education

BACKGROUND

Early care and education (ECE) is an important setting for influencing young children's dietary intake. There are several factors associated with barriers to healthy eating in ECE, and recent evidence suggests that participation in the Child and Adult Care Food Program (CACFP), the primary national food assistance program in ECE, may be associated with fewer barriers to serving healthier foods. However, no prior studies have examined differences between CACFP participants and non-participants across a large, multi-state sample. This is the first study to examine the association between CACFP participation and barriers to serving healthier foods in ECE using a random sample of directors from two regions across the country.

METHODS

We conducted a cross-sectional survey among a random sample of child care center directors from four states (Massachusetts, North Carolina, Rhode Island, and South Carolina). We conducted logistic and Poisson regression to calculate the odds and incidence rate ratios of reporting 1) no barriers, 2) specific barriers (e.g., cost), and 3) the total number of barriers, by CACFP status, adjusting for covariates of interest.

RESULTS

We received 713 surveys (36% response rate). About half (55%) of centers participated in CACFP. The most prevalent reported barriers to serving healthier foods were cost (42%) and children's food preferences (19%). Directors from CACFP centers were twice as likely to report no barriers, compared to directors from non-CACFP centers (OR 2.03; 95% CI [1.36, 3.04]; p < 0.01). Directors from CACFP centers were less likely to report cost as a barrier (OR = 0.46; 95% [CI 0.31, 0.67]; p < 0.001), and reported fewer barriers overall (IRR = 0.77; 95% CI [0.64, 0.92]; p < 0.01), compared to directors from non-CACFP centers.

CONCLUSIONS

CACFP directors reported fewer barriers to serving healthier foods in child care centers. Still, cost and children's food preferences are persistent barriers to serving healthier foods in ECE. Future research should evaluate characteristics of CACFP participation that may alleviate these barriers, and whether barriers emerge or persist following 2017 rule changes to CACFP nutrition standards.

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.

Implementation of Revised Nutrition Standards in US Department of Agriculture's Child and Adult Care Food Program

OBJECTIVE

In October 2017, substantial changes were made to improve the nutritional quality of meals served in the Child and Adult Care Food Program (CACFP). This study describes the experience of child care providers and sponsors during the first year of implementation.

METHODS

A 1-time survey was administered to CACFP sponsors in Delaware 1 year after implementation of the changes. Data analysis included frequencies and chi-square tests of independence.

RESULTS

Among respondents (n = 137), 21% faced moderate or significant challenges. Food cost (53.1%) and communicating with parents about changes (44.6%) were the most common challenges faced. The majority reported that parents supported the changes and that children and teachers generally ate the new food.

CONCLUSIONS AND IMPLICATIONS

A minority of providers in Delaware faced significant challenges, suggesting that broad changes to CACFP may be feasibly implemented across settings. Training focused on food cost and parent communication may be warranted.

Barriers and facilitators to obesity prevention dissemination and implementation efforts in the childcare centre setting from the provider perspective

BACKGROUND

It has been established that the childcare centre (CCC) is a setting suitable for healthy weight promotion efforts. As the field advances, it is important to understand the barriers and facilitators to early childhood obesity prevention implementation and dissemination efforts from the CCC providers' perspective. This is especially true among those who serve low-income and diverse populations to maximize scalability success.

METHODS

Focus groups were held in English or Spanish with CCC providers across six CCCs who implemented healthy caregivers-healthy children (HC2), an early childhood healthy weight promotion programme targeting 2- to 5-year-olds from low-resource backgrounds. Centres represented both rural and urban environments. Focus groups were audio recorded, transcribed, and coded. A thematic analysis that combined a deductive and inductive approach was conducted. Codes were analysed using Dedoose to identify general themes and subthemes.

RESULTS

CCC providers stated that (a) children understood the nutritional benefits of healthy foods; (b) improved cognitive development as a result of HC2; (c) parents were barriers to HC2 implementation efforts, particularly in terms of cooperative healthy lifestyle efforts; and (d) modelling healthy eating and making healthy CCC environmental changes facilitated HC2 implementation. Overall, HC2 was well received by CCC teachers, and they shared creative classroom HC2 adaptions and improvements.

CONCLUSIONS

CCC providers can provide valuable insight to guide early childhood healthy weight promotion programme dissemination and implementation efforts. Although they value the implementation of HC2 programme in their classroom settings, they perceive parents as somewhat obstructive. This information is critical to informing future healthy weight promotion efforts in this setting, especially among low-resource families. It is important to continue to include the CCC provider viewpoint in future obesity prevention efforts to maximize scalability and sustainability efforts.

Provider reported implementation of nutrition-related practices in childcare centers and family childcare homes in rural and urban Nebraska

Approximately 15 million children under age 6 are in childcare settings, offering childcare providers an opportunity to influence children's dietary intake. Childcare settings vary in organizational structure - childcare centers (CCCs) vs. family childcare homes (FCCHs) - and in geographical location - urban vs. rural. Research on the nutrition-related best practices across these childcare settings is scarce. The objective of this study is to compare nutrition-related best practices of CCCs and FCCHs that participate in the Child and Adult Care Food Program (CACFP) in rural and urban Nebraska. Nebraska providers (urban n = 591; rural n = 579) reported implementation level, implementation difficulty and barriers to implementing evidence-informed food served and mealtime practices. Chi-square tests comparing CCCs and FCCHs in urban Nebraska and CCCs and FCCHs in rural Nebraska showed sub-optimal implementation for some practices across all groups, including limiting fried meats and high sugar/ high fat foods, using healthier foods or non-food treats for celebrations and serving meals family style. Significant differences (p < .05) between CCCs and FCCHs also emerged, especially with regard to perceived barriers to implementing best practices. For example, CCCs reported not having enough money to cover the cost of meals for providers, lack of control over foods served and storage problems, whereas FCCHs reported lack of time to prepare healthier foods and sit with children during mealtimes. Findings suggest that policy and public health interventions may need to be targeted to address the unique challenges of implementing evidence-informed practices within different organizational structures and geographic locations.

Planting a seed - child health care nurses' perceptions of speaking to parents about overweight and obesity: a qualitative study within the STOP project

BACKGROUND

Nurses in child health care (CHC) centers in Sweden play a key role in the early detection and management of childhood overweight/obesity, through meeting families early, regularly and over many years. However, research focusing on CHC nurses' perceptions of their role in childhood overweight/obesity management is scarce. As part of the EU-funded project "Science and Technology in childhood Obesity Policy" (STOP), this study examines CHC nurses' perceptions of speaking to parents about children's overweight/obesity and of their role in referring children to treatment for overweight/obesity.

METHODS

All registered CHC nurses in Stockholm County (n = 442) received an email invitation letter explaining the study. Individual face-to-face visits (n = 15) in selected centers, and phone calls (n = 24) to nurses working in these centres were also conducted. In total, 17 CHC nurses (all female, average work experience 6.7 years (SD ± 4.9 years)) from 10 municipalities (including four of the top five municipalities with the highest prevalence of overweight and obesity) in Stockholm County were interviewed. The interviews were conducted by phone, transcribed and analyzed using thematic analysis.

RESULTS

Two main themes were developed through the analysis: 1) The relationship between the nurse and the parent and 2) Glitch in the system. Under the first theme, nurses reported that weight-related discussions were facilitated by building and maintaining trust with parents. However, nurses also said they were reluctant to address children's weights if this could compromise parents' trust. Under the second theme, nurses highlighted several organizational barriers to addressing a child's weight with parents, including insufficient cooperation with other healthcare providers and limited time for visits. Nurses also identified lack of sufficient knowledge about what to offer the family and lack of confidence in their communication skills as additional barriers.

CONCLUSIONS

We found that pediatric nurses perceive relational and organizational factors as barriers to address childhood obesity with parents. To improve care, it is necessary to provide nurses with continuing education about obesity and communication skills and organizational support to improve communication within the healthcare system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03800823; 11 Jan 2019, prospectively registered.

Together, We Inspire Smart Eating (WISE): An Examination of Implementation of a WISE Curriculum for Obesity Prevention in Children 3 to 7 Years

This study examined the implementation of a school-based, obesity prevention curriculum, Together, We Inspire Smart Eating (WISE), targeting 3- to 7-year-old low-income children. Survey data from a convenience sample were collected from educators and parents (N = 73, N = 188, respectively) at the beginning and end of a school year in which WISE was implemented. Educators also reported on lessons weekly. Measures to evaluate the success of the implementation were conceptually distinct implementation outcomes (Educators: Perceived Barriers, Appropriateness, Acceptability, Feasibility, Fidelity; Parents: Adoption, Appropriateness). WISE was successfully implemented in 33 target classrooms representing 7 preschool centers and 2 elementary schools. Based on educator report, perceived barriers were reduced. Educators rated Appropriateness, Acceptability, and Feasibility high. Evidence of Fidelity was mixed. Parents reported indicators of Adoption and Appropriateness high. The study provided support for WISE in preschools and elementary schools serving young children from low-resource homes.

Understanding Parental Ethnotheories and Practices About Healthy Eating: Exploring the Developmental Niche of Preschoolers

PURPOSE

To understand parental ethnotheories (ie, belief systems) and practices about preschoolers' healthy eating guided by the developmental niche framework.

DESIGN

Qualitative hermeneutic phenomenology.

SETTING

Home.

PARTICIPANTS

Participants were 20 parents of preschool-age children ages 3 to 5 years, recruited from a quantitative investigation. A majority of the participants were white, female, married, well educated, and working full time.

METHODS

Participants who completed the quantitative survey were asked to provide their contact information if they were willing to be interviewed. From the pool of participants who expressed their willingness to participate in the interviews, 20 participants were selected using a random number generator. In-person semistructured interviews were conducted until data saturation (n = 20). Thematic analysis was performed.

RESULTS

Three themes and 6 subthemes emerged: theme 1-parental ethnotheories about healthy eating included subthemes of knowledge about healthy eating, motivations to promote healthy child development through healthy eating, and sources of knowledge about healthy eating (eg, doctors, social media, government guidelines, positive family-of-origin experiences); theme 2-parental ethnotheories that supported organization of children's physical and social settings included structured mealtime routines and food socialization influences (eg, grandparents, siblings, and childcare programs); and theme 3-parental ethnotheories that supported children's learning about healthy eating included parent-child engagement, communication, and encouragement in food-related activities (eg, meal preparation, visiting farmer's market, grocery shopping, gardening, cooking, baking).

CONCLUSION

Findings advance the literature on parental practices about healthy eating. Parental ethnotheories (eg, beliefs, motivations, knowledge, and skills) matter. Developmental niche of preschoolers (ie, physical and social settings, childrearing practices, and parental ethnotheories) constitutes an interactive system in which ethnotheories serve as guides to parental practices. Fostering nutrition education and parent-child engagement, communication, and encouragement in food-related activities are recommended to promote children's healthy eating in daily routines.

Predictors of Parent Engagement Based on Child Care Providers' Perspectives

OBJECTIVE

Determine the predictors of child care providers' parent engagement regarding child nutrition in child care centers (CCCs) and family child care homes (FCCHs).

DESIGN

Cross-sectional.

SETTING

Child care centers and FCCHs.

PARTICIPANTS

Child care center directors (n = 337) and FCCH providers (n = 1,153) completed a self-administered survey.

MAIN OUTCOME MEASURES

Fifteen variables were examined as predictors for parent engagement: providers' perceived barriers to communication, participation in Go Nutrition and Physical Self- Assessment in Child Care, National Association for the Education of Young Children accreditation, participation in Quality Ratings and Improvement Systems, feeding practices, and professional development.

ANALYSIS

Structural equation modeling examined the relation between variables for CCCs and for FCCHs.

RESULTS

For CCCs, NAEYC accreditation, providers' perceived barriers regarding parents' cultural beliefs about food, parents not liking the taste of healthy foods, and parents prioritizing other food-related topics over healthy eating significantly predicted parent engagement. For FCCHs, participation in Go Nutrition and Physical Self- Assessment in Child Care, perceiving parents to be busy, not wanting to offend parents, and practicing family-style dining were significantly related to parent engagement. For both CCCs and FCCHs, professional development regarding child nutrition was related to parent engagement.

CONCLUSIONS AND IMPLICATIONS

Focusing professional development on child care contexts and addressing providers' perceived barriers may improve parent engagement.

Energy balance-related parenting and child-care practices: The importance of meso-system consistency

Background

Our knowledge of the role of parental and child-care staff behavior in the development and prevention of obesity is rapidly increasing. Potential interaction between both settings in so-called meso-systems, as hypothesized by the ecological systems perspective, is however often ignored. Specifically, inconsistency between home and child-care is hypothesized to have negative effects on child outcomes.

Methods

Participants were recruited through 23 child-care centers in the Netherlands. Data regarding 161 child-parent-child-care staff triads were available. Parenting and child care practices were assessed using validated questionnaires for parents (Child Feeding Practices Questionnaire, Preschooler Physical Activity Parenting Practices instrument) and child-care staff (Child-care Food and Activity Practices Questionnaire), using similar items in both settings. Absolute difference scores between parents and child-care staff were calculated for each triad as a measure of meso-system consistency. Child outcomes were physical activity (as assessed by accelerometry), dietary intake (from the parental questionnaire), and measured BMI z-scores. Paired t-tests were used to examine consistency between practices in both settings. Linear regression analyses were used to explore the association of parenting practices, child-care practices and difference scores on the one hand, and child outcomes on the other.

Results

Significant differences between settings were found for almost all practices, and in most cases child-care staff scores more favorable on the practices than parents. Inconsistencies were mostly associated with unhealthy dietary intake and lower physical activity levels, but not with BMI.

Conclusion

The current study showed that inconsistencies in parenting and child-care practices exist, and that these inconsistencies seem to be associated with unhealthy behavior in children. The results underline the importance of studying meso-system influences on behavior in general, and children’s energy balance-related behavior specifically.

Compliance with the New 2017 Child and Adult Care Food Program Standards for Infants and Children before Implementation

BACKGROUND

Nationally, child care providers serve nutritious food to over 4.5 million children each day as part of the federal Child and Adult Care Food Program (CACFP). As implementation of the first major revisions to the CACFP standards occurs in 2017, understanding how to support compliance is critical.

METHODS

In 2016, surveys were sent to a randomly selected sample of 2400 licensed California child care centers and homes. Compliance with the new CACFP standards and best practices for infants under 1 year and children 1-5 years of age was assessed. Also, compliance was compared by CACFP participation, and between centers and homes. Interviews were conducted with 16 CACFP stakeholders to further understand barriers to and facilitators of compliance.

RESULTS

Analysis of 680 survey responses revealed that compliance with most individual CACFP standards and best practices examined was high (>60% of sites). However, compliance with all new standards was low (<23% of sites). Compliance was lowest for timing of introduction of solids to infants, not serving sweet grains, serving yogurt low in sugar, and serving appropriate milk types to children. When different, compliance was higher for sites participating in CACFP versus nonparticipants, and for centers versus homes. Although providers indicated few barriers, stakeholders identified the need for incremental and easily accessible trainings that provide practical tips on implementation.

CONCLUSION

Training on a number of topics is needed to achieve full implementation of the new CACFP standards to ensure that young children in child care have access to healthier meals and snacks.

Developing Healthy Food Preferences in Preschool Children Through Taste Exposure, Sensory Learning, and Nutrition Education

PURPOSE OF REVIEW

The present review was undertaken in order to summarize and evaluate recent research investigating taste exposure, sensory learning, and nutrition education interventions for promoting vegetable intake in preschool children.

RECENT FINDINGS

Overall, taste exposure interventions yielded the best outcomes for increasing vegetable intake in early childhood. Evidence from sensory learning strategies such as visual exposure and experiential learning also show some success. While nutrition education remains the most common approach used in preschool settings, additional elements are needed to strengthen the educational program for increasing vegetable intake. There is a substantial gap in the evidence base to promote vegetable intake in food fussy children. The present review reveals the relative importance of different intervention strategies for promoting vegetable intake. To strengthen intervention effects for improving vegetable intake in preschool children, future research could consider integrating taste exposure and sensory learning strategies with nutrition education within the preschool curriculum.

Pre-school nutrition-related behaviours at home and early childhood education services: findings from the Growing Up in New Zealand longitudinal study

OBJECTIVE

Pre-school nutrition-related behaviours influence diet and development of lifelong eating habits. We examined the prevalence and congruence of recommended nutrition-related behaviours (RNB) in home and early childhood education (ECE) services, exploring differences by child and ECE characteristics.

DESIGN

Telephone interviews with mothers. Online survey of ECE managers/head teachers.

SETTING

New Zealand.

SUBJECTS

Children (n 1181) aged 45 months in the Growing Up in New Zealand longitudinal study.

RESULTS

A mean 5·3 of 8 RNB were followed at home, with statistical differences by gender and ethnic group, but not socio-economic position. ECE services followed a mean 4·8 of 8 RNB, with differences by type of service and health-promotion programme participation. No congruence between adherence at home and in ECE services was found; half of children with high adherence at home attended a service with low adherence. A greater proportion of children in deprived communities attended a service with high adherence, compared with children living in the least deprived communities (20 and 12 %, respectively).

CONCLUSIONS

Children, across all socio-economic positions, may not experience RNB at home. ECE settings provide an opportunity to improve or support behaviours learned at home. Targeting of health-promotion programmes in high-deprivation areas has resulted in higher adherence to RNB at these ECE services. The lack of congruence between home and ECE behaviours suggests health-promotion messages may not be effectively communicated to parents/family. Greater support is required across the ECE sector to adhere to RNB and promote wider change that can reach into homes.