Training Child Care Inspectors to Deliver Health Messaging: A Quality Improvement Pilot Project

Abstract

Early childhood obesity is at epidemic proportions. Early child care providers have a unique opportunity to instill healthy eating and active living behaviors in children that can foster lifelong health. Academic–community partnerships that involve collaborations between child care centers, local public health departments, and universities provide one avenue to strengthening healthy eating and active living–related knowledge and skills among early child care providers. This quality improvement pilot intervention, titled Healthy Child Care Makes a Healthy Start, is one example of this type of collaboration. This quality improvement pilot project consisted of two complementary intervention components. Inspectors were trained to cofacilitate a strategic planning process with university researchers to help providers implement healthy eating and active living–related policy, system, and environment changes in their child care homes and centers. An average of five changes were implemented in participating child care locations. Inspectors also received training on health-related best practices and delivered 1-minute health messages to child care providers during routine inspection visits. This type of innovative partnership has the potential to leverage a currently existing relationship between child care providers and licensing and regulation inspectors and shift the relationship to include dissemination and implementation of health messaging in child care center and home settings.

Keywords

obesity chronic disease community intervention environmental and systems change health promotion

The national prevalence of obesity in preschool children aged 2 to 5 years of age is currently 9.4% (Ogden et al., 2016), with low-income and non-Hispanic Black and Hispanic children experiencing disproportionately higher rates of overweight and obesity compared to higher income and non-Hispanic White children (Pan, 2016; Wang & Beydoun, 2007). It is well documented that dietary and physical activity behaviors established in early childhood lay the foundation for mitigating health risks and chronic disease later in life (Shonkoff, 2010). Child care centers and homes are largely untapped settings that could offer obesity prevention interventions (Kaphingst & Story, 2009). It is estimated that 75% of children spend time in child care, for an average of 35 hours per week (Laughlin, 2010). Early child care providers have a unique opportunity to instill healthy eating and active living (HEAL) behaviors in children that can decrease risk for overweight and obesity into adulthood.

Colorado is one of three states that experienced a rise in early childhood obesity rates between 2008 and 2011 with the highest increases among low-income populations (Centers for Disease Control and Prevention, 2013). In 2013, 52% of 3- and 4-year-olds were enrolled in child care centers and homes in Colorado (U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2013). As such, promoting the adoption of HEAL-related best practices in child care settings in Colorado, particularly those serving low-income children, is essential.

Background

Multiple HEAL-related best practices contribute to a healthy weight among preschoolers (Brown et al., 2009; Duffey & Popkin, 2007; Kant & Graubard, 2004). HEAL-related policies (e.g., not withholding play for poor behavior), systems (e.g., teachers facilitating structured play during outdoor time), and aspects of the built environment (e.g., having access to a school garden) play important roles in promoting healthy eating and physical activity behaviors (Sallis, Owen, & Fisher, 2008). These best practices are defined as interventions that have been shown to produce desirable outcomes in improving health in real-life settings and are suitable for adaptation by other communities (Ng & de Colombani, 2015). Implementing policy, system, and environment (PSE) best practice changes in child care settings can promote HEAL behaviors that last into adulthood. However, novel ways of translating PSEs into child care settings are needed.

Formation of a community–academic partnership to implement PSE changes into child care centers is one unique way to improve health behaviors (Korfmacher, Pettibone, Gray, & Newman, 2016). One example of a successful community–academic partnership that targeted obesity prevention with local public health agencies resulted in development of a capacity evaluation plan, the synthesis of HEAL-related best practices, and an increase in perceptions of trust among community partners (Zoellner et al., 2017).

In Colorado, the state’s department of public health and environment contracts with the City and County of Denver’s Department of Environmental Health (DEH), the local health department, to enforce child care licensing and conduct routine health inspections in over 550 child care settings across the city reaching approximately 37,900 children. Inspectors have an ongoing relationship with child care providers and have tremendous potential to positively affect the attitudes and practices of the child care community. DEH and the Rocky Mountain Prevention Research Center within the Colorado School of Public Health partnered to develop a quality improvement pilot intervention, titled Healthy Child Care Makes a Healthy Start (HCMHS). The educational messaging and intervention used for the pilot study was based on the evidence-based Culture of Wellness in Preschools (COWP) program, a comprehensive early childhood obesity prevention program in Colorado, which aims to promote a “culture of wellness” in preschool settings by increasing fruit and vegetable consumption and physical activity among students, parents, and staff. One component of the COWP program, the Assess, Identify, Make It Happen for Preschools (AIM-P) process, is a strategic planning tool that leads to the implementation of PSE changes in child care center environments (Farewell, Puma, Powers, & Belansky, 2018). The AIM-P process was the primary component that was adapted for the HCMHS study.

The HCMHS study used a socioecological theoretical perspective; the first component focused on making systems-level changes to the preschool environment while the second component targeted the knowledge and attitudes toward health-related best practices of individual providers. The goals of the HCMHS study were to (1) test the feasibility of training inspectors in the facilitation of the AIM-P strategic planning process to make health-promoting PSE changes in participating child care centers and homes and (2) test the feasibility of training inspectors to deliver HEAL messaging during routine licensing inspection visits. Our hypothesis was that inspectors could be successfully trained on both HEAL interventions, resulting in dissemination and implementation of PSE best practices in child care settings.

Method

Project Setting and Participants

For the first component of this intervention, a low-income city council district in Denver, Colorado, was selected for implementation of the HCMHS QI pilot study. The council district was served by 36 licensed child care homes and centers. To qualify for participation in the AIM-P process, child care providers had to be located within this council district, be willing to meet with DEH staff for up to six 1-hour meetings over a 5-month period, and complete all data collection activities. Head Start centers were excluded from the sample because they had already received the COWP program.

Recruitment letters from DEH were sent to the directors of the 36 child care centers or homes inviting them to participate in the pilot. DEH staff followed up with a telephone call to explain the project and invite their participation. Child care settings were offered several incentives for participating, including continuing education credits, a $1,000 stipend to purchase educational supplies, a certificate from Be Healthy Denver (a DEH initiative related to Denver’s community health improvement plan), and an invitation to participate in a celebration event with local policy makers. A total of 36 child care homes and centers were eligible to participate in the first component of the HCMHS QI pilot study.

For the second component of the intervention, six DEH inspectors (five inspectors and one supervisor) were trained on HEAL key messages and best practices. All child care homes and centers throughout Denver County were eligible to receive HEAL messaging during route inspection visits.

Intervention Components

Approval for the study was obtained from the Colorado Multiple Institutional Review Board. The two components of the HCMHS QI pilot study are displayed in Figure 1.

Figure 1

Two Components of the HCMHS QI Pilot Study

Component 1: Cofacilitation of the AIM-P Process

AIM-P is based on the AIM for Elementary Schools process, which has been successful in implementing PSE changes in elementary school settings (Belansky et al., 2013). AIM is aligned with community-based participatory research principles. Academic partners bring the latest evidence-based practices and program evaluation expertise to the community. The community partners bring experiential knowledge about the school culture, policies, and procedures. AIM is also an adaptation of intervention mapping, a planning process based on the socioecological model and the use of best practices in the development of interventions (Bartholomew, Parcel, Kok, & Gottlieb, 2001). Intervention mapping and AIM represent an iterative theoretical and evidence-based process. The six primary steps of intervention mapping are used throughout the AIM process. Specifically, Assessing current best practices, Identifying PSE changes, and Making it happen by planning for adoption, implementation, and sustainability, result in PSE changes within early childhood education centers (Bartholomew et al., 2001; Belansky et al., 2013). Site-specific Wellness Policy posters are developed that highlight old and new PSE changes related to healthy eating and physical activity. Posters were printed English and Spanish to underscore the new PSE changes implemented through the AIM-P process. Table 1 displays the purpose and agenda items that comprise the AIM-P process.

Table 1

HCMHS QI Pilot Study Component 1: The Modified AIM-P Process

Meeting	Purpose	Agenda Items
1	Learning the Process, Analyzing strengths and needs	■ Increase wellness team members understanding of AIM-P ■ Conduct strengths and needs assessment ■ Review best practices ■ Identify possible PSE changes
2	Choosing Healthy Eating and Physical Activity PSE Changes	■ Rate changes based on importance and feasibility ■ Select and finalize PSE changes
3-4^a	Planning for Action and Developing Strategies	■ Develop action steps and action plans for each change ■ Identify resources necessary to complete each action step ■ Discuss evaluation
4-6^a	Updating Action Plans and Writing a Wellness Policy	■ Update on action step progress ■ Discuss purpose of wellness policy ■ Finish writing Wellness Policy ■ Discuss Dissemination and Sustainability ■ Congratulate

NOTE: HCMHS = Healthy Child Care Makes a Healthy Start; QI = quality improvement; AIM-P = Assess, Identify, Make It Happen for Preschools; PSE = policy, system, and environment.

The AIM-P process ranges from 4 to 6 meetings depending on the productivity and needs of the wellness team.

Child care homes, when compared to child care centers, pose unique challenges such as not having staff capacity (substitutes for child care) to participate in regular meetings, individual provider attitudes, perceived costs, and facility constraints (Rosenthal, Crowley, & Curry, 2013). Therefore, the AIM-P process was modified for child care home environments. The menu of best practices used as a resource during the AIM-P process was adapted to include PSEs that influence health behaviors of children age birth to 5 years old. Child care home providers were interested in making HEAL-related changes that positively affected all children enrolled in their care. Another modification was that only the lead child care provider participated in the AIM-P process in child care home settings. Although research suggests an interdisciplinary team is necessary for PSEs to be effectively translated into practice (Glasgow & Emmons, 2007), the unique challenges faced by child care homes mentioned above resulted in this modification to the composition of the wellness team.

A COWP researcher (Author 1) who has been trained in AIM and has 6 years of experience implementing AIM-P in child care settings trained the inspector on external facilitation of the AIM-P process. The COWP researcher and inspector cofacilitated monthly meetings with the wellness teams at each child care center, or provider at each child care home, to lead the provider/s through the AIM-P process. The expected outcome was that providers would make at least two nutrition- and two physical activity–related PSE changes within each child care setting over the course of the pilot study.

Component 2: HEAL Training for All Child Care Inspectors

Component 2 aimed to increase the knowledge and awareness of HEAL strategies among local inspectors, who could, in turn, increase the knowledge and awareness of HEAL strategies with early child care providers. To accomplish this goal, five inspectors and one supervisor took part in four 2-hour interactive HEAL trainings (a total of 8 hours). The trainings focused on HEAL-related key messages displayed in Table 2 related to the following subjects: Helping Children Be Good Eaters, Meal Planning Around Fruits and Vegetables at Meals and Snacks, Selecting Better Beverages, and Helping Children Be Physically Active. A content expert and trained COWP facilitator (Author 4) presented each topic to inspectors using hands-on demonstrations. Emphasis was placed on “1-minute messages” that could be shared and combined with HEAL topic areas already being reviewed during the inspections. Inspectors were encouraged to implement the messaging and distribute educational materials during routine visits throughout the duration of the study period.

Table 2

HCMHS QI Pilot Study Component 2: HEAL Messages and Health Inspection Core Indicators Comparison

Culture of Wellness Key Topics	Health Inspector Core Indicators	Caring for Our Children: National Health and Safety Performance Standards Guidelines for Early Care and Education, 3rd Edition (National Resource Center for Health and Safety in Child Care and Early Education, 2011)
Helping Children Be Good Eaters Meal Planning Around Fruits and Vegetables at Meals and Snacks Selecting Better Beverages	● Nutritious meals and snacks served at sustainable intervals ● Meals and snack menus are prepared in advance and posted ● Meals provided meet 1/3 child’s nutritional needs ● Encourage children to eat/engage in conversation/independence ● Meals, snacks menu, and food allergy accommodation^a ● Nutritious meals and snacks^a ● Milk and juice must be pasteurized^a ● Juice once a day, sweets no more than 2 times/week^a ● Water available and not substituted for milk at meals^a	Categories of food (4.2.0.4) Standards for meals and snacks (4.2.0.5) Availability of drinking water (4.2.0.6)
Helping Children Be Good Eaters Meal Planning around Fruits and Vegetables at Meals and Snacks	● Discipline not associated with food ● Behavior guidance and appropriate discipline^a	Caregivers/teachers should not force or bribe children to eat or use food as a reward or punishment (4.5.0.11)
Helping Children Be Physically Active	● Outdoor play provided each day ● Outdoor play area adjacent to or safely accessible ● 30 square feet of indoor play space per preschool-age child ● Daily outdoor play unless severe weather^a ● Provider must supervise children’s activity^a ● Daily outdoor play unless severe weather^a	Staff health education (2.4.2)
Helping Children Be Physically Active	● Parent is advised of television and video policy	Total media time (2.2.0.3)
Helping Children Be Physically Active	● Variety of play equipment and materials include large muscle equipment, games	Facilities should have a policy on the use and maintenance of play areas . . . (9.2.6.1)

NOTE: HCMHS = Healthy Child Care Makes a Healthy Start; QI = quality improvement; HEAL = healthy eating and active living.

Indicators that are only included in home-based child care settings.

Data Collection

To assess the outcomes of the AIM-P process, the university researcher reported the number of PSE changes implemented by each wellness team. The total number of PSE changes were aggregated after completion of all wellness team meetings. These data were captured in Excel, and a report was generated depicting the breakdown of PSE changes and cumulative number of changes across all six implementing child care settings. Semistructured interviews were conducted with providers who participated in the wellness team meetings. These were conducted by a DEH evaluator with qualitative research expertise (Author 2). Interview questions focused around three primary categories to inform feasibility of the QI study: Participation Interest (e.g., What motivated you to participate in this pilot study), Project Utility (e.g., Were the intervention and related materials useful), and Perceived Project Impacts (e.g., How did this pilot study affect you and your child care setting). To ensure there was no bias or conflict of interest, the DEH staff member did not take part in other aspects of the study intervention.

To evaluate the success of the second component of this intervention, inspectors tracked the total number of child care homes and centers that were visited and received the 1-minute HEAL messaging and materials over the course of the intervention. Additionally, in-depth semistructured interviews lasting about 60- minutes were conducted with inspectors after the intervention by the DEH staff member (Author 2).

Data Analysis

All interviews were digitally recorded and then transcribed verbatim. Handwritten notes were also taken during the interviews and were transcribed after each interview. The transcriptions were then uploaded into Atlas.ti (Seale, 2000), a commonly used qualitative data analysis software program, and coded. The emergent themes helped illuminate the feasibility of the intervention, its strengths and challenges, and the lessons learned in both intervention components.

Results

Component 1: Cofacilitation of the AIM-P process

From January to May 2015, three centers and three home care providers participated in the AIM-P process (16.7%). These six child care settings are in a low-income district where one in three residents identified as Hispanic. Additionally, 21% of the children (2-17 years) who attended public schools in this district are obese (5% higher than the overall rate of child obesity rates in Denver; City and County of Denver, n.d.).

Quantitative Findings

The number and type of PSE changes that were implemented after cofacilitation of the AIM-P process in each child care setting were documented and are presented in Table 3. A total of 30 health-promoting changes were selected from the menu of PSE best practices across all participating sites, which is an average of five changes per child care center or home. Sixteen PSE changes were healthy eating focused (53%) and 14 PSE changes were physical activity focused (47%).

Table 3

PSE Changes Implemented by Child Care Settings Through the AIM-P Process (n = 6)

HEAL-Related Best Practice PSE Changes by Child Care Setting
Location	Healthy Eating Changes	Physical Activity Changes
Center 1	1 A variety of fruits/vegetables are served.	1. A variety of portable play equipment is available during outdoor play.
	2. Meals are served family style.	2. Transition activities incorporate varied movements throughout the school day.
	3. The center has a school garden.	3. Teachers do not restrict outdoor play for poor behavior.
Center 2	1. Teachers do cooking activities with the children.	1. A variety of portable play equipment is available during outdoor play.
Center 2	2. The center has a school garden.	2. Teachers lead structured activities during outdoor time.
Center 3	1. Healthy eating messaging and activities are incorporated into monthly meetings.	1. Teachers lead structured activities during outdoor time.
	2. Healthy eating messaging is displayed around the center.	2. Music and movement activities are led throughout the school day.
	3. Celebrations are celebrated with healthy foods.	3. Natural environment features are in the outdoor environment.
Home 1	1. The home has a school garden.	1. Teachers lead structured activities during outdoor time.
	2. Meals are served family style.	2. A variety of portable play equipment is available.
	3. The provider sits with the children during meal time.	3. Music and movement activities are led throughout the school day.
Home 2	1 A variety of fruits/vegetables are served.	1. A variety of portable play equipment is available.
	2. The center has a school garden.
	3. Teachers do cooking activities in home.
Home 3	1. No processed foods are served.	1. A variety of portable play equipment is available.
Home 3	2. Provider sits with children during meals.	2. Parents are required to bring appropriate clothing

NOTE: PSE = policy, system, and environment; AIM-P = Assess, Identify, Make It Happen for Preschools; HEAL = healthy eating and active living.

Qualitative Findings

Interviews were conducted with the providers of three home settings and two centers after the intervention was completed; one center declined. Themes were grouped into three categories: Participation Interest, Project Utility, and Perceived Project Impact.

Participation interest

All the directors stated that they wanted their home or center to participate in the AIM-P process because they were personally or professionally interested in improving health and wellness within their preschool settings. One provider said,

Eating and healthy food is important to me, especially when working with kids at younger ages. That’s a lot of what you are doing, feeding and encouraging them to try different foods. This is the base, the beginning for these kids.

Project utility

Early child care providers valued the HEAL-related menu of best practices and resources that were provided during the AIM-P process. They reported that the tools were helpful when talking with parents and when motivating staff to prioritize HEAL-related PSE changes: “The program gave me a way to talk about healthy eating with parents in a light, yet professional way. It gave me a language to speak with parents without stepping on their toes.”

Perceived project impacts

Providers shared that the AIM-P process increased their knowledge of HEAL-related PSE changes. They reported feeling more confident implementing PSE changes. One provider said, “The program provided a way to plan and prioritize short and long term changes.” Another provider commented that participation in the AIM-P process “solidified my understanding of the science behind each recommendation.”

Component 2: HEAL Training for All Child Care Inspectors

From February 2015 to May 2015, 179 routine inspections were conducted throughout the city of Denver with dissemination of HEAL-related talking points and materials. Key informant interviews were completed with inspectors. Inspectors reported that the educational flyers and key messages were easily integrated into their routine site visits with child care providers. Inspectors stated, “By initially asking questions, it helped to engage the provider. Then I could provide advice on additional things they could do.” Inspectors also said, “I definitely felt more confident when talking about core indicators because it was helpful to give examples . . . it was easier to have a conversation and give some resources than just getting yes or no responses.”

Discussion

The environmental context of child care settings may be an independent risk factor for obesity (Sigman-Grant et al., 2011; Story, Kaphingst, & French, 2006). Although there are recommendations and regulations for nutrition and physical activity in child care settings, Colorado licensing requirements do not reflect all PSE best practices that have been shown to increase the adoption of healthy behaviors in early childhood. The HCMHS QI pilot study represents a novel community–academic partnership that resulted in implementation of HEAL-related PSE changes and dissemination of 1-minute health messages in a large number of early child care settings.

To our knowledge, this is the first intervention that leveraged the role of inspectors to provide direct HEAL-related technical assistance to early child care providers. Intensive training and cofacilitation of the AIM-P process resulted in an average of five PSE changes across all six child care settings. This component increased both the uptake and utilization of HEAL-related PSE changes in diverse child care settings. The qualitative findings provided information related to participation interest, project utility, and perceived project impacts of the HCMHS study. Providers were most likely to participate in this type of intervention if they are personally interested in health and wellness. Providers also reported that the project materials were helpful and facilitated conversations with families about healthy eating– and physical activity–related best practices. Finally, participation in the AIM-P process improved provider knowledge and awareness related to the science behind best practices and fostered confidence in implementing PSE changes in their child care settings. These findings suggest that the gap between research and practice can be bridged using this type of dissemination and implementation framework (Wandersman et al., 2008).

The second component of the pilot study resulted in the dissemination of 1-minute HEAL-related messages during routine visits at child care settings. The inspectors felt that the trainings and educational materials were valuable tools. They were better able to discuss core indicators as well as create a dialogue, versus a unidirectional type of communication, with early child care providers. Inspectors can effectively function as channels of new information and advocates for health for child care providers (Kendall, Aronson, Goldberg, & Smith, 1986). These findings imply that the integration of HEAL messaging into inspector training programs may increase provider knowledge of HEAL-related best practices and dissemination of 1-minute health messages.

Challenges related to implementation of the AIM-P process were noted, particularly in child care home settings. Home providers felt that participation in the AIM-P process was challenging due to distractions and competing responsibilities in the home. Past studies have found a wide variability among child care settings (Burchinal, Howes, & Kontos, 2002; Rosenthal et al., 2013). The uptake of HEAL messages and PSE changes in home child care settings poses unique challenges including limited staffing, resulting in increased workloads and less time for inspectors to devote to the educational aspects of their inspection and permitting visits. Additionally, child care homes may be less likely to participate in state or local quality regulation programs (Burchinal et al., 2002; Fuller, Kagan, Loeb, & Chang, 2004). As such, providers at child care centers may be more motivated to implement PSE changes in order to meet quality regulation requirements. Facilitation of the AIM-P strategic planning process to implement HEAL-related PSE changes may be a more effective tool in child care center settings versus home settings.

Limitations

There were several limitations to this pilot study. First, a small convenience sample of self-selected child care centers and homes from a purposefully selected council district was used for the study, and thus the findings are not generalizable. However, the success of the AIM-P process in over 100 child care settings to date suggests that this tool leads to implementation of PSE changes in diverse child care settings. Second, this study did not include a control group, so it is uncertain how the participating centers and homes might differ from those that chose not to participate. Finally, follow-up data from providers who participated in only the first component of the pilot study was not collected. As such, the sustainability and long-term impact of HEAL messages in child care settings are unclear.

Conclusions

Implementation of the HCMHS QI pilot study used the currently existing infrastructure of public health and augmented the inspector role to include more education and dialogue into their contacts with child care settings. The provision of an intensive technical assistance model by an inspector trained in the AIM-P process represents an innovative way to bridge the gap between research and practice in order to combat early childhood obesity. Providing topic-specific training to inspectors and integrating HEAL talking points in core quality indicators checklists helped facilitate a dialogue between inspectors and child care providers.

Practical recommendations for expansion of this pilot study include the following: creating HEAL webinars and professional development opportunities (including networking and information sharing) as part of ongoing inspector trainings throughout the year, integration of HEAL talking points into inspectors core indicator checklists, developing a more flexible version of AIM-P for child care home settings, and incorporating innovative and practical ways to engage and educate providers and parents of children on HEAL-related best practices in early child care settings. The HCMHS study represents a unique partnership that fostered collaboration between university researchers, a local public health department, and early child care providers to disseminate HEAL messaging and implement PSE changes in child care settings to decrease rates of early childhood obesity.

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