Use of the Environment and Policy Evaluation and Observation as a Self-Report Instrument (EPAO-SR) to measure nutrition and physical activity environments in child care settings: validity and reliability evidence.

BACKGROUND: Early care and education (ECE) centers are important settings influencing young children's diet and physical activity (PA) behaviors. To better understand their impact on diet and PA behaviors as well as to evaluate public health programs aimed at ECE settings, we developed and tested the Environment and Policy Assessment and Observation - Self-Report (EPAO-SR), a self-administered version of the previously validated, researcher-administered EPAO. METHODS: Development of the EPAO-SR instrument included modification of items from the EPAO, community advisory group and expert review, and cognitive interviews with center directors and classroom teachers. Reliability and validity data were collected across 4 days in 3-5 year old classrooms in 50 ECE centers in North Carolina. Center teachers and directors completed relevant portions of the EPAO-SR on multiple days according to a standardized protocol, and trained data collectors completed the EPAO for 4 days in the centers. Reliability and validity statistics calculated included percent agreement, kappa, correlation coefficients, coefficients of variation, deviations, mean differences, and intraclass correlation coefficients (ICC), depending on the response option of the item. RESULTS: Data demonstrated a range of reliability and validity evidence for the EPAO-SR instrument. Reporting from directors and classroom teachers was consistent and similar to the observational data. Items that produced strongest reliability and validity estimates included beverages served, outside time, and physical activity equipment, while items such as whole grains served and amount of teacher-led PA had lower reliability (observation and self-report) and validity estimates. To overcome lower reliability and validity estimates, some items need administration on multiple days. CONCLUSIONS: This study demonstrated appropriate reliability and validity evidence for use of the EPAO-SR in the field. The self-administered EPAO-SR is an advancement of the measurement of ECE settings and can be used by researchers and practitioners to assess the nutrition and physical activity environments of ECE settings.

Development of HomeSTEAD's physical activity and screen time physical environment inventory.

BACKGROUND: The home environment has a significant influence on children's physical activity, sedentary behavior, dietary intake, and risk for obesity and chronic disease. Our understanding of the most influential factors and how they interact and impact child behavior is limited by current measurement tools, specifically the lack of a comprehensive instrument. HomeSTEAD (the Home Self-administered Tool for Environmental assessment of Activity and Diet) was designed to address this gap. This new tool contains four sections: home physical activity and media equipment inventory, family physical activity and screen time practices, home food inventory, and family food practices. This paper will describe HomeSTEAD's development and present reliability and validity evidence for the first section. METHODS: The ANGELO framework guided instrument development, and systematic literature reviews helped identify existing items or scales for possible inclusion. Refinement of items was based on expert review and cognitive interviews. Parents of children ages 3-12 years (n = 125) completed the HomeSTEAD survey on three separate occasions over 12-18 days (Time 1, 2, and 3). The Time 1 survey also collected demographic information and parent report of child behaviors. Between Time 1 and 2, staff conducted an in-home observation and measured parent and child BMI. Kappa and intra-class correlations were used to examine reliability (test-retest) and validity (criterion and construct). RESULTS: Reliability and validity was strong for most items (97% having ICC > 0.60 and 72% having r > 0.50, respectively). Items with lower reliability generally had low variation between people. Lower validity estimates (r < 0.30) were more common for items that assessed usability and accessibility, with observers generally rating usability and accessibility lower than parents. Small to moderate, but meaningful, correlations between physical environment factors and BMI, outside time, and screen time were observed (e.g., amount of child portable play equipment in good condition and easy to access was significantly associated with child BMI: r = -0.23), providing evidence of construct validity. CONCLUSIONS: The HomeSTEAD instrument represents a clear advancement in the measurement of factors in the home environment related to child weight and weight-related behaviors. HomeSTEAD, in its entirety, represents a useful tool for researchers from which they can draw particular scales of greatest interest and highest relevance to their research questions.

Nutrition practices and mealtime environments of North Carolina child care centers.

BACKGROUND: The majority of children in the United States attend out-of-home child care. However, little is known about the nutritional quality of foods served and the mealtime environments. METHODS: We assessed 96 child care centers over one full day using a researcher-administered structured observation and document review. We focused on eight nutrition domains: (1) fruits and vegetables, (2) whole grains, (3) high-sugar, high-salt, and high-fat foods, (4) beverages, (5) food availability and service, (6) staff behaviors, (7) training and education, and (8) policies. We computed daily means and frequencies for each domain. RESULTS: Seventy-five percent of centers participated in the Child and Adult Care Food Program, indicating they served low-income children. Centers enrolled 66 children on average; 60% were white, 28% were black, 4% were Native American, and 8% identified as mixed race. On the day of observation, seven centers did not serve a fruit and 15 did not serve a vegetable. Eighty centers served a high-sugar or high-salt food and 84 did not serve any whole grains. Five centers did not provide water indoors to children, 22 served juice twice, and 50 served whole milk. Seventeen centers had a vending machine on site visible to parents and children. Overall, children were served excessive juice, high-sugar and high-salt snack foods, and too much whole milk. CONCLUSIONS: Centers had room for improvement and could strive to serve more nutritious foods and create healthier mealtime environments for children.

Nutrition policies at child-care centers and impact on role modeling of healthy eating behaviors of caregivers.

Studies suggest that caregivers influence children's dietary behaviors through role modeling in child-care environments. However, few studies have examined role modeling by caregivers and child-care center policies. This cross-sectional study evaluated the associations between child-care center policies about staff eating practices and caregivers' eating behaviors during mealtime interactions with children. Data were collected in 2008-2009 at 50 North Carolina child-care centers. Caregivers (n=124) reported about modeling healthy eating behaviors to children, trained research staff observed caregivers' (n=112) eating behaviors in classrooms, and directors reported about the presence/absence of center policies on staff eating practices. About 90% of caregivers reported modeling healthy eating behaviors to children. At 80% of centers, caregivers were observed modeling healthy dietary behaviors (eg, sitting with or eating same foods as children), but at fewer centers they were observed consuming unhealthy foods (eg, fast foods, salty snacks: 25%; and sugar-sweetened beverages: 50%). Although no substantial associations were observed between caregiver behaviors and center policies, effect size estimates suggest differences that may be of clinical significance. For example, caregivers were observed modeling healthy dietary behaviors more frequently at centers that had written policies about staff discouraging unhealthy foods for meals/snacks and having informal nutrition talks with children at meals. However, caregivers were observed consuming unhealthy foods and sugar-sweetened beverages more often at centers with policies that promoted healthier foods for meals/snacks. Future research should build on this study by using larger samples to understand why healthy food policies in child-care centers may not translate to eating practices among caregivers.

Best-practice guidelines for physical activity at child care.

Research has indicated that the child care center is a very strong predictor of preschool-aged children's physical activity levels, making this an important setting to help young children obtain physical activity that is appropriate for their health and development. However, some evidence suggests that organized child care may not adequately support children's physical activity needs. Although many organizations provide recommendations, guidelines, or standards for motor skill development and physical activity opportunities, no set of guidelines exist that directly target the overall physical activity environment at child care. Because of the lack of comprehensive recommendations, the Nutrition and Physical Activity Self-assessment for Child Care best-practice guidelines for healthy weight development were created on the basis of an extensive review of existing guidelines, research evidence, and expert review. The purpose of this article is to present these physical activity best-practice guidelines and provide data on how these guidelines compare to current practice in a large sample (N = 96) of child care centers in North Carolina. These best-practice guidelines include recommendations for 8 unique components of the child care environment, including active opportunities, fixed play environment, portable play environment, sedentary opportunities, sedentary environment, staff behavior, staff training/education, and physical activity policies. Our results showed that only a few of the best-practice guidelines were achieved by a majority of the 96 North Carolina child care centers that participated in this study. Establishing comprehensive guidelines for physical activity at child care could result in higher activity levels and healthier children, but more research is needed.