Policies,Practices,and Environmental Characteristics Among Family Child Care Homes in South Carolina

Abstract

Background:

Child care program requirements have adopted nutrition and physical activity standards to address childhood obesity, but few studies have examined the effects of these standards in family child care homes (FCCHs).

Methods:

In a cross-sectional study (2017–2019), the Childcare Home Eating and Exercise study examined self-reported provider characteristics and observed policies and practices related to physical activity and nutrition in FCCHs in South Carolina. Two-sample t-tests were used to compare observed nutrition and physical activity policy, practice, and environment scores in child care homes that participated in versus did not participate in the state's ABC Quality program, which is designed to improve child care and includes policies and practices intended to increase physical activity levels and improve diet quality.

Results:

Environment and Policy Assessment and Observation results for nutrition and physical activity were 7.5 out of 21 and 11.8 out of 30, respectively, indicating much room for improvement in nutrition and physical activity policies, practices, and environment in South Carolina FCCHs. The study found one difference between FCCHs that did and did not participate in the ABC Quality program; non-ABC homes provided more time for physical activity.

Conclusions:

Future research should develop ways to strengthen the guidelines and improve the implementation of obesity prevention standards in FCCHs.

Introduction

Childhood obesity rates have increased dramatically in the United States for the past 30 years,¹ and children in racial and ethnic minority groups have been disproportionately affected.² Obesity in childhood is associated with an increased risk of multiple negative health outcomes, including cardiovascular and liver disease, sleep apnea, insulin resistance, and a weakened immune response.^3,4 Among 2- to 5-year-old children, the prevalence of obesity during the past 30 years has nearly doubled, from 7.2% to 13.4%.¹

This suggests that obesity prevention efforts should target children as early as possible.⁵ Accordingly, a number of authoritative organizations have advocated for policies and programs designed to promote healthy eating and physical activity in preschool-age children.⁶

Parents can choose to enroll their children in a wide range of child care settings. These include child care centers, where multiple staff members provide services to multiple children in a nonresidential facility, and family child care homes (FCCHs), where a single staff member provides care to children in their residence.⁷ In the state of South Carolina, child care centers typically care for ≥13 children in nonresidential commercial buildings, and usually operate ≥4 hours per day and ≥2 days a week.^8,9

FCCHs typically include one staff member who cares for ≤6 children in a residential building.^8,9 Approximately 60% of children under the age of 5 years attend a nonparental child care arrangement at least one time per week.¹⁰ Much of the research assessing childhood obesity and the child care environment has focused on larger child care centers, and less is known about the role FCCHs play in efforts to prevent childhood obesity.¹¹ A positive association exists between nonparental child care and the risk of overweight and obesity among infants and younger children—especially in the less formal FCCH setting.¹²

Most US states have created standards for evaluating the quality of child care settings,¹³ including obesity prevention standards, which vary by state. In 2019, the South Carolina Department of Social Services implemented the voluntary ABC Quality program,¹⁴ which applies to all licensed or registered child care centers and FCCHs in the state.

Licensed FCCHs that participate in this program are inspected, monitored, and rated by ABC Quality staff, who evaluate FCCHs based on their performance on five elements: Program Administration and Structure; Staff Education and Professional Development; Child Well-being; Family Communication, Engagement, and Cultural Competence; and Intentional Teaching Practices. To address concerns related to childhood obesity, the program requirements include several nutrition and physical activity standards. However, the effects of these standards on nutrition and physical activity policies, practices, and environmental characteristics in FCCHs in South Carolina have not been examined.

Accordingly, this study included both FCCHs in South Carolina that were either enrolled in the ABC Quality program or were not. The study was designed to (1) describe policies, practices, and environmental characteristics among FCCHs located in South Carolina, and (2) to compare policies, practices, and environmental characteristics between FCCHs that were enrolled in ABC Quality and those that were not.

Materials and Methods

Study Design, Recruitment, and Participants

The Childcare Home Eating and Exercise (CHEER) study examined FCCHs and the children attending them in South Carolina; the cross-sectional data reported here were collected in 2017–2019. FCCHs without any open cases of neglect or abuse with the state licensing agency, and that received state subsidies for providing care to low-income children through a statewide program, were eligible to participate in the study. The sample was drawn from the population of all FCCHs in South Carolina. The study was approved by the Institutional Review Board at the University of South Carolina.

The South Carolina Child Care Resource and Referral Network helped connect the research team with FCCH providers by mailing a packet with study information to all members throughout the state. In addition, the research team made recruitment calls to 1088 FCCH providers. Furthermore, members of the research team attended four regional conferences of the South Carolina Child Care Resource and Referral Network, held in larger metropolitan areas of the state, to connect directly with providers and regional leaders. They also networked with Child and Adult Care Food Program Child Care Home Sponsors. A total of 77 FCCH providers provided written informed consent to participation in the study (25 ABC providers and 52 non-ABC providers).

Measures

Provider characteristics

Surveys assessed the age, race, ethnicity, gender, and highest level of education of FCCH providers. These surveys also provided data regarding the number of years the FCCH had been in operation, and whether it was accredited by the National Association for Family Child Care (NAFCC). FCCH status as an ABC Quality participant was determined by using information from the scchildcare.org website listing.

FCCH policies and practices

The FCCH environment was measured using the Environment and Policy Assessment and Observation (EPAO),¹⁵ which was modified for the FCCH setting.¹⁶ The EPAO was administered through direct observation by trained data collectors during a full-day visit to each FCCH. Data collectors were blinded to ABC/non-ABC status. This instrument assigned each FCCH a score on the physical activity and nutrition environments.

Higher scores on each subscale and on the overall physical activity and nutrition scales indicated healthier physical activity and nutrition environments. The nutrition score ranged from 0 to 21 and was based on the sum of seven subscales that all ranged from 0 to 3. Subscales assessed the foods and beverages that were provided, the behaviors of providers during mealtimes, the nutrition education that providers offered to children and parents, and the professional nutrition education that providers completed.

The physical activity (PA) EPAO score was calculated by summing scores from 10 subscales, each of which ranged from 0 to 3. The total EPAO PA score ranged from 0 to 30. Subscales measured indoor and outdoor play time and resources, screen time policies and practices, the physical activity education that providers offered to children and parents, and the professional PA education that providers completed.

Statistical Analysis

Descriptive statistics, including means, standard deviations (SD), and percentages, were used to summarize provider and FCCH characteristics, overall and by ABC participation. Two-sample t-tests were used to compare EPAO overall nutrition and physical activity scores by ABC status. Hypothesis tests were two-sided and performed at the alpha = 0.05 significance level. Analyses were performed in Stata/SE version 16.0 (StataCorp., 2019).

Results

Provider Characteristics

Data were collected from 68 of the 77 consenting FCCHs (23 ABC providers and 45 non-ABC providers; Table 1). The FCCHs in the sample had been in operation for an average of 8.7 (SD = 10.1) years and had an average of 5.9 (SD = 2.2) children in their care. A majority (75.3%) were not NAFCC accredited. Providers had spent an average of 15.1 (SD = 11.4) years in the child care profession, a majority had an education of college or above, and half were between the ages of 35–54 years. A majority of providers were non-Hispanic Black (61%), followed by non-Hispanic White (35.1%).

Table 1.

Baseline Characteristics of Family Child Care Home Providers in the Childcare Home Eating and Exercise Study, 2017–2019 (n = 68)

Characteristic	Overall (n = 68)	ABC (n = 23)	Non-ABC (n = 45)
Years of operation, mean (SD)	8.7 (10.1)	10.1 (8.2)	8.0 (11.0)
NAFCC accredited, %	18	22	17
Children enrolled, mean (SD)	5.9 (2.2)	6.0 (2.8)	5.8 (1.9)
Years employed in child care, mean (SD)	15.1 (11.4)	15.7 (11.1)	14.8 (11.6)
Provider education, %
Some or all high school	12	8.0	14
Some or all college or more	88	92	86
Provider race and ethnicity, %
Non-Hispanic Black	62	88	49
Non-Hispanic White	36	12	47
Hispanic/Latino(a)	1	0	2
Other	1	0	2.
Provider age category, years, %
18–34	24	16	27
35–54	50	48	51
55+	26	36	22

ABC, ABC Quality program; NAFCC, National Association for Family Child Care; SD, standard deviation.

FCCH Policies and Practices

Nutrition

FCCHs in the study had an average overall EPAO nutrition score of 7.5 (SD = 2.0) out of a total possible score of 21. The nutrition subscale with the highest score was Foods Provided (M = 2.0, SD = 0.4), and the nutrition subscales tied for the lowest score were Nutrition Education and Professional Development (M = 0.4, SD = 0.4) and Nutrition Policy (M = 0.4, SD = 0.8). There were no significant differences between ABC and non-ABC FCCHs for the nutrition subscores of the EPAO (Table 2).

Table 2.

Environment and Policy Assessment and Observation of Family Child Care Home Nutrition and Physical Activity Policies, Practices, and Physical Environment

Characteristic	Overall (n = 68)	ABC (n = 23)	No ABC (n = 45)	p ^a
EPAO scores, mean (SD)
EPAO nutrition subscore	7.5 (2.0)	8.0 (2.1)	7.2 (2.0)	0.10
Foods provided	2.0 (0.4)	2.1 (0.3)	2.0 (0.4)	0.09
Beverages provided	1.3 (0.3)	1.3 (0.4)	1.3 (0.3)	0.71
Feeding environment	1.4 (0.4)	1.4 (0.3)	1.4 (0.4)	0.40
Feeding practices	1.5 (0.3)	1.5 (0.2)	1.5 (0.3)	0.62
Menus and variety	0.7 (1.1)	0.8 (1.2)	0.7 (1.1)	0.83
Nutrition education and professional development	0.4 (0.4)	0.5 (0.4)	0.4 (0.4)	0.27
Nutrition policy	0.4 (0.8)	0.6 (0.8)	0.3 (0.8)	0.14
EPAO physical activity subscore	11.8 (3.0)	11.9 (2.9)	11.7 (3.0)	0.78
Time provided for PA	1.0 (0.6)	0.8 (0.6)	1.1 (0.6)	0.04
Indoor play equipment	0.7 (0.5)	0.7 (0.4)	0.6 (0.5)	0.54
Daily PA practices	1.4 (0.4)	1.5 (0.3)	1.4 (0.4)	0.16
PA education and professional development	0.6 (0.6)	0.8 (0.6)	0.6 (0.5)	0.09
PA policy	2.5 (1.1)	2.3 (1.1)	2.5 (1.1)	0.45
Screen time	1.2 (0.5)	1.2 (0.6)	1.3 (0.4)	0.57
Daily screen time practices	2.3 (0.7)	2.2 (0.7)	2.4 (0.7)	0.37
Screen time policy	0.4 (1.0)	0.7 (1.3)	0.2 (0.7)	0.06
Outdoor playtime	0.6 (0.7)	0.5 (0.6)	0.7 (0.8)	0.18
Outdoor play environment	1.1 (0.6)	1.2 (0.6)	1.1 (0.6)	0.33

Welch two sample t-test; Fisher's exact test.

EPAO, Environment and Policy Assessment and Observation; PA, physical activity.

Physical activity

FCCHs had an average EPAO physical activity score of 11.8 (SD = 3.0) out of a total possible score of 30. The physical activity subscales with the highest scores were PA Policy (M = 2.5, SD = 1.1) and Daily Screen Time Practice (M = 2.3, SD = 0.7). The physical activity subscales with the lowest scores were Screen Time Policy (M = 0.4, SD = 1.0), PA Education and Professional Development (M = 0.6, SD = 0.6), Outdoor Playtime (M = 0.6, SD = 0.7), and Indoor Play Equipment (M = 0.7, SD = 0.5). ABC and non-ABC FCCHs differed in scores for time provided for physical activity (M = 0.8, SD = 0.6 for ABC vs. M = 1.1, SD = 0.6 for non-ABC FCCH; p = 0.04). There were no other significant differences between ABC and non-ABC FCCHs for the PA scores (Table 2).

Discussion

Nutrition

The overall nutrition score and subscores were lower than in other similar studies in FCCHs.^17–19 One study, Keys to Healthy Family Child Care Homes (KEYS), conducted the EPAO in 166 FCCHs in North Carolina and reported an overall nutrition baseline score of 9.1,¹⁷ compared with 7.5 in this study. Given the close geographic proximity of the two study sites (North Carolina and South Carolina), this difference is somewhat surprising. However, the KEYS study was conducted from 2013 to 2016, whereas our study took place several years later (from 2017 to 2019), so secular trends related to diet could account for the differences.

Similar to KEYS, a study of 134 FCCHs in Mississippi reported a baseline score of 9.4 from 2014 to 2016.¹⁸ Another study among 51 FCCHs in Oklahoma conducted from 2017 to 2018 reported a baseline score of 11.7.¹⁹ However, the studies in Oklahoma and Mississippi altered portions of the EPAO scoring method to meet study-specific needs and, therefore, may not be directly comparable with our study. They were also conducted before our study in South Carolina.

Still, it is important to note that overall nutrition scores in FCCHs were low across all studies, including this one, at less than half of the total possible score. Our findings add to the growing consensus that there is substantial room to improve the nutrition environment in FCCHs. The finding of no differences between ABC Quality participants and nonparticipants further suggests the need to strengthen efforts to support compliance with ABC Quality nutrition standards.

Findings from our study, as well as prior similar studies,^17–19 also suggest a need to improve nutrition education in FCCHs, as well as improve the variety of menus in these settings. In our study and in prior similar studies,^17–19 FCCHs scored lowest on Nutrition Education, Nutrition Policies, and Menus/Variety, and highest on the Foods Provided. This indicates that improving the nutrition environment in FCCHs should focus not only on what foods and beverages are provided, but also on how children and providers learn about healthy eating.

Physical Activity

As previously reported, the average overall physical activity score on the EPAO was 11.8 out of a possible score of 30, which, as in other similar studies,^20,21 indicates considerable room for improvement (Table 2). Providers scored highest on physical activity policies and daily screen time practices, with scores between 2.0 and 2.5 of 3.0. The lowest scores were on screen time policy, outdoor playtime, and indoor play equipment, with scores <1.0.

It appears that policies for promoting physical activity may not translate to providing staff development in physical activity, physical activity opportunities, and optimal environments to promote child physical activity in FCCH settings. Time provided for physical activity was the only EPAO item that differed significantly between ABC and non-ABC FCCH providers, with non-ABC providers providing more time for physical activity.

This suggests the need to strengthen efforts to support compliance with the physical activity standards in the ABC Quality program. Mazzucca et al. hypothesized that underutilization of resources contributed to low EPAO PA scores, and that staff development may be particularly important.²² Policies and interventions designed to improve the physical activity environment in the FCCH setting should educate providers on how to utilize the resources that are already available in their home or immediate environment, as well as on the different ways providers can adapt their residence to be more physical activity friendly. Private agencies or government entities should consider providing additional funds to aid in these changes.

Limitations of this study include the cross-sectional design, which precludes an assessment of causal relationships; inclusion of a small sample FCCHs in only one state in the United States, which limits generalizability; and potential selection bias due to the low participation rate among FCCHs. The EPAO is limited to 1 day of observation, although it has been validated for use in this setting.¹⁶

Few studies have examined policies, practices, and environmental characteristics among FCCHs and compared characteristics between FCCHs that were enrolled in a quality improvement program and those that opted not to enroll. We acknowledge that the emphasis on provider education and enforcement/compliance may be a challenge for many FCCH providers with limited resources.

Conclusions

An objective assessment of FCCHs in South Carolina through the EPAO indicates much room for improvement in policies and practices related to healthy eating and physical activity. Furthermore, the study found essentially no differences between FCCHs participating and not participating in the ABC Quality program in terms of healthy eating and physical activity policies and practices. Future research should develop ways to strengthen the guidelines and improve the implementation of obesity prevention standards in FCCHs.

Impact Statement

The CHEER study revealed that FCCHs in South Carolina need to improve their implementation of policies and practices related to physical activity and nutrition to more effectively address childhood obesity.

Footnotes

Acknowledgment

The authors thank Gaye Groover Christmus, MPH, for editorial assistance in the preparation of the article.

Authors' Contributions

Conceptualization, methodology, funding acquisition, project administration, writing, and editing by R.R.P. and S.E.B.-N. Data curation and formal analysis, review, and editing by D.A.Z. and T.L. Formal analysis, review, and editing by B.N. Data curation and writing by A.B.

Funding Information

This study was funded by NIH grant R01HD093784 to Sara E. Benjamin-Neelon and Russell R. Pate. Daniel A. Zaltz is partially supported by a grant from the National Institutes of Health T32DK062707. The funders had no role in selection of study topic, research design, analysis, or interpretation of findings.

Author Disclosure Statement

No competing financial interests exist.

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