Child Care Providers' Strategies for Supporting Healthy Eating: A Qualitative Approach
Lynch, Meghan, Batal, Malek, Journal of Research in Childhood Education
Recent research has revealed child care settings and providers to be important influences on children's developing behaviors. Yet most research on children's nutritional development has focused on home settings and parents. Thus, through semistructured interviews with child care providers, this study aimed to develop a better understanding of the strategies they perceive to encourage healthy eating in child care settings. Results revealed that providers employ a range of strategies, many of which focus on short-term goals that do not promote the development of healthy long-term nutritional behaviors. By using a social ecological lens, the authors found providers use these strategies due to a combination of pressures from the personal and societal levels of influence. Furthermore, the method of semistructured interviewing allowed for a better understanding of child care settings not achieved through quantitative research. These findings can be used to improve nutritional information sources aimed at providers by considering the challenges specific to child care settings.
Keywords: child care staff, qualitative research, social aspects, child development
Research has revealed Canadian children's diets to be lacking in fruits and vegetables but plentiful in candy, chocolate bars, and soft drinks (Taylor, Evers, & McKenna, 2005). Such dietary behaviors should be concerning, as healthy diets have been linked with healthy weight status, improved cognitive function, physical performance levels, and psychosocial health (O'Dea, 2003). Early childhood experiences are pivotal in developing children's food preferences, which is significant because it is believed that all food preferences and nutritional behaviors are learned (Hendy, 1999; Liem & Menella, 2002). How children actually learn these behaviors is not well understood (Cashdan, 1994; Hendy, 1999; Paquette, 2005). What has been well established is the social environment's paramount role in shaping children's nutritional behaviors, particularly in the development of self-regulation of food intake. Young children are capable of self-regulating the amount of food they require based on their physiological needs (Johnson, 2000). To foster children's development of self-regulation, research recommends that parents employ such strategies as allowing children to eat when they are hungry and allowing children to serve themselves (Birch, 1998; Birch & Davidson, 2001; R. S. Strauss & Knight, 1999). Conversely, when children, especially those between ages 3 to 5 years, are socialized to ignore their internal hunger and satiety cues and instead rely on external cues, such as adults controlling the amount of food they eat, they may lose their capacity to self-regulate (Birch & Davidson, 2001; Birch, McPhee, Shoba, Pirok, & Steinberg, 1987).
Still, to date, the majority of research examining the impact of the social environment on nutritional behavior development has centered on parents (Moore et al., 2005; Story, Kaphingst, & French, 2006). Considering the impact of other significant social influences in the lives of young children is crucial to gaining a fuller understanding of how healthy dietary behaviors are shaped (Lumeng, Kaplan-Sanoff, Shuman, & Kannan, 2008; Lytle, 2005; Moore et al., 2005; Needham, Dwyer, Randall-Simpson, & Heeney, 2007; Story et al., 2006). Further, a qualitative research approach has been recommended to develop a more well-rounded understanding of how people perceive food and nutrition (Matheson, Spranger, & Saxe, 2002; Taylor et al., 2005).
Over the past decade, the number of Canadian children in child care has risen significantly, and thus child care providers have become important influences in the lives of many children. More than one half of Canadian children between ages 6 months to 5 years, regardless of their demographic background, typically spend more than 27 hours per week in child care (Statistics Canada, 2005). This increasing dependence on child care providers reinforces the need for more research to investigate these individuals' behavior in relation to food and, subsequently, their shaping of young children's nutritional behaviors during this very impressionable and formative period (Birch & Fisher, 1998; Paquette, 2005; Taylor et al., 2005).
Research conducted with child care providers has yielded several positive findings regarding their perspectives on children's nutrition in child care settings. Providers view themselves as playing essential roles in developing healthy eating behaviors in children, including the social and health aspects of eating (Moore et al., 2005; Pagnini, Wilkenfeld, Ling, Booth, & Booth, 2007). Providers report arranging the child care settings to ensure that everyone can eat together around a table (Moore et al., 2005). A study of a large sample of child care providers (Trost, Messner, Fitzgerald, & Roths, 2009) found providers report serving the recommended servings of fruits and vegetables and lesser amounts of unhealthy foods. However, due to the large sample sizes involved, these studies are unable to explore the motivations behind providers' attitudes and behaviors. These studies are also limited to focusing on how individual-level factors, such as nutritional knowledge, affect providers. As such, more research that examines the variety of factors that influence the behaviors of providers in child care settings is needed. Considering the importance of the social environment during early childhood on lifelong nutritional behaviors, and due to the amount of time that many young children spend in child care settings (Statistics Canada, 2005), these findings all illustrate the need for more in-depth explorations of the nutritional environment of child care settings with providers.
Through semistructured interviews, this study examined the strategies that child care providers perceive as encouraging healthy eating behaviors. These findings were then compared to current research-recommended strategies for developing children's healthy nutritional behaviors. Importantly, the objective of this study was to develop an understanding of providers' perspectives, and not to observe from an outsider's perspective what was occurring in the child care settings. The research questions were (1) What strategies do child care providers report using to support the development of healthy dietary behaviors in children? and (2) What influences providers to use these strategies?
SOCIAL ECOLOGICAL THEORY
To develop a well-rounded understanding of why providers use certain strategies to encourage healthy eating, it was essential to use a theoretical framework that enabled a broad understanding of the variety of factors at play in their lives (Davidson & Birch, 2001; Lytle, 2005). Using an interview guide that was based on social ecological theory (Bronfenbrenner, 1979, 2005; Davidson & Birch, 2001; Gregson et al., 2001) and past research with child care providers (Lumeng et al., 2008; Lytle, 2005; Moore et al., 2005; Needham et al., 2007; Story et al., 2006), the providers were asked about the different levels of influence, as described briefly below.
The first level of influence is the most immediate and involves individual characteristics of the providers, such as nutritional knowledge, as well as interpersonal factors, such as providers' interactions in the immediate environment. Examples of individual characteristics include providers' attitudes and their relationships with parents. Studies focused on understanding the provider-parent relationship have reported less-than-encouraging findings. Child care providers frequently speak negatively about the feeding practices and types of foods offered by parents (Needham et al., 2007) and have noted that children's diets at the child care facility are rarely discussed with parents (Fees, Trost, Bopp, & Dzewaltowski, 2009; Lumeng et al., 2008; Moore et al., 2005).
Nevertheless, though individual-level factors are often considered in studies with providers, to better understand their decisions and attitudes, it is essential to delve into the wide range of social influences by also asking questions regarding community factors (Bronfenbrenner, 1979, 2005). As such, the second level of influence that was examined focused on the social support perceived by providers and available on community resources.
Last, the third level was societal and covered such factors as societal pressures and government involvement by inquiring whether providers had ever received nutritional information from the government. The perceived usefulness of this information also was examined. This is important, as research has typically focused on how child care providers can improve recipe and menu quality or food safety practices, with less consideration for how information is perceived by providers (Fees et al., 2009; Mooney, Boddy, Stratham, & Warwick, 2008; Moore et al., 2005; Romaine, Mann, Kienapple, & Conrad, 2007). For example, Romaine et al. (2007) interviewed those in charge of planning the menus at child care centers and found that though most reported using Canada's Food Guide (Health Canada, 2009), whether the guide's information was perceived as helpful was not explored. Interestingly, a similar study by Moore et al. (2005) that did consider providers' perceptions revealed that government-supplied nutritional information for the child care setting was perceived as offering nothing more than "common sense" (p. 205). These studies highlight the need for research to further explore not only if providers receive nutritional materials, but also if they are suited to the providers' needs (Moore et al., 2005; Needham et al., 2007).
The participants in this study consisted of 13 formal, licensed child care providers (eight center-based and five home-based) from the Ottawa region. In this article, child care refers to the care of a child by someone other than the parent or guardian. The center-based child care providers worked with multiple providers caring for the children in a center, whereas the home-based providers worked alone out of their homes. Although the different challenges faced by home-and center-based child care providers are recognized by the authors, both types of child care providers are involved in feeding the children and are believed to exercise some influence on the children's developing nutritional behaviors. Table 1 shows the characteristics of the participants. All providers were female and between ages 32 and 64, although the majority were in their midforties to midfifties. All except two had a postsecondary degree. Providers' years of experience ranged between 7 and 28 years, but the majority had at least 20 years of experience working in child care. Theoretical sampling was employed; that is, the data were analyzed throughout the process, with the number of interviews conducted being based on when interviews were no longer revealing new information (Cousin, 2009).
The Research Ethics Board at the University of Ottawa provided ethics approval for this study, and all participants provided voluntary informed written consent. Sampling of formal, licensed center-based and home-based child cares from the Ottawa region was conducted by random selection from a list composed of licensed providers found through telephone book and Internet searches, as well as from the online database of licensed child care providers provided by the city (City of Ottawa, 2001). Providers were contacted by telephone and provided with information on the study and asked to participate in a one-on-one interview. Only one provider was interviewed per child care setting. To determine the number of providers included in the study, the concept of saturation was employed (Bowen, 2008; Cousin, 2009). Interviews were held either at the home of the child care provider or in the child care setting and lasted, on average, 41 minutes. Each interview was conducted by the same researcher to ensure consistency.
Semistructured interviewing was selected because it allowed for questioning into unexpected responses through the use of follow-up questions (Cousin, 2009; Smith & Osborn, 2008). A semistructured interview guide was created to ensure consistency while also allowing for flexibility to discuss topics raised by the providers themselves. A review of the literature pertaining to similar studies conducted with parents and providers assisted in the development of the interview guide. Providers were initially asked questions regarding the nutritional environment of the child care setting, such as how they encourage eating in the child care setting and what is done if a child refuses to eat the food offered or is hungry outside of a meal- or snacktime. Next, providers were asked to describe how and why they made such decisions and were prompted with questions pertaining to personal, community, and societal influences. The methods and sampling are described in greater detail elsewhere (Lynch & Batal, 2011).
Interviews were digitally recorded and transcribed verbatim. The interview data were then analyzed by both researchers separately, using an approach of constant comparison that entailed summarizing and classifying the data and then relating it to previous literature (Pope, Ziebland, & Mays, 2000; A. Strauss & Corbin, 1998), followed by both researchers comparing findings and resolving discrepancies. To allow for emerging themes to influence subsequent transcript analysis, transcript reading and preliminary analysis were conducted sequentially. First, transcripts were read line by line and coded under either anticipated themes (identified by previous research, such as "interactions with parents") or emergent themes (such as "use of condiments to encourage vegetable consumption"). Initial codes were applied to later data, new codes developed as new themes emerged, and some initial codes were revised. Related codes were then grouped together under the main themes of positive strategies, negative strategies, and influences for the development of healthy eating behaviors in children. The main themes of the data resulting from this analysis are presented below. Examples and quotations were selected because they are typical of the themes identified (A. Strauss & Corbin, 1998).
The first two sections below cover the study's first focus on the strategies reported by child care providers to encourage healthy eating. These strategies are presented as being either "positive" or "negative" in accordance with the literature on children's nutritional behavior development. The third section covers the study's second focus, that of identifying the range of factors influencing providers to use such strategies. As this study did not aim to specifically investigate differences between home-based and center-based providers, they have not been presented separately. However, issues that seemed more applicable to each group are noted throughout.
Providers reported employing a variety of strategies considered effective in encouraging the development of healthy nutritional behaviors in children (Aldridge, Dovey, & Halford, 2009; Birch, 1998; Schwartz & Puhl, 2003). To encourage children to try new foods, snack- and mealtimes were typically described as needing to occur in a pleasant environment, with all providers and children eating together. This pleasant setting was achieved through not pressuring children to eat any certain food; one provider described her philosophy toward feeding children as, "I provide healthy choices and you decide what to eat--or not eat." Other providers spoke of the importance of "not making meals a power struggle" and how an undemanding approach encourages the children to try new foods. Virtually all providers spoke of how their own behavior affected the children's mealtime experience. One provider explained the most successful way to get children to try new foods was "the way you look and talk about it and if you eat it yourself." Encouraging the children verbally was a widespread strategy; many spoke of encouraging the children to try "just one bite," or even to simply smell the unfamiliar food.
The caregivers acknowledged that giving children the opportunity to exert some choice in what they eat for snacks was important: "If the child feels they have [sic] some control, then they are more willing to try new things." One provider similarly encouraged children to exert some control by allowing them to pour their own juice. Another provider explained, "Serving themselves is a big point. So if you have a plate of apples on the table, for them to be able to choose what apple piece is, for them, at this age, a big deal."
Consistently offering new foods also was described as being a key strategy for encouraging children to try new foods, especially new fruits and vegetables. Providers reported presentation as equally important; foods need to be served in small portions, to avoid overwhelming the children. Similarly, providers described how certain foods require specific presentations, due to children being sensitive to the textures and visual appeal of foods; one stated that "colors and textures are important at this age; smells are important too." For instance, many providers stressed the necessity of cutting up fruits and vegetables and leaving the peel or skin on fruits to ensure they remained looking "fresh."
Interestingly, the home-based child care providers spoke more frequently of spending mealtimes educating the children about the importance of eating healthy foods and teaching children about different aspects of cooking: "I find the more they do in the kitchen, the more interested they are in learning stuff." A smaller number of providers spoke of the strategy of introducing new foods "as a fun activity ... we try and do a cooking activity once a month with them." Another home-based provider described how she found it helped to involve the children in all the aspects of mealtime, including making a grocery list, going grocery shopping, and setting the table.
Although all of the providers described their intentions to encourage the development of children's healthy nutritional behaviors, relating their strategies to the literature revealed many strategies to be less than ideal for developing children's healthy nutritional behaviors (Birch & Davidson, 2001; Birch & Fisher, 1998; Johnson, 2000; Orrell-Valente et al., 2007).
Providers employed many strategies that focused only on the goal of children consuming healthy foods. A strategy common to home- and center-based providers involved serving vegetables with ketchup, cheese, dips, and salad dressing, and was perceived as a necessary step, because "if we could put salad dressing with anything they would eat it." Another provider explained, "I find this generation is all about ketchup; they'll put ketchup on anything." Likewise, providers described a strategy of disguising healthy or unfamiliar foods in unhealthy foods "so you don't feel you have to add a vegetable to that meal that they're not going to eat. You can put applesauce or pureed prunes into brownies and nobody would know." This strategy was described by many providers as being ideal to "get the healthy stuff into them" or even how it was often "the only way that you're going to be able to get vegetables into them." Contrasting with their descriptions of familiarizing children with foods, providers simultaneously described how unfamiliar foods need to be well blended because "if they can see it they won't eat it." Similarly, juice was frequently diluted with water, chocolate milk was watered down with plain milk, and white bread that "has the benefits of whole wheat" were commonly cited ways for getting children to eat healthfully. Importantly, the success of this strategy of disguising foods was shared with parents. One provider described how "I just discovered quinoa and what a good source of protein it is. I just kind of stuck it in the pasta--she never even knew it was there. So I said to her mom, 'You might want to try some of that because she seemed to accept it.'"
With the ultimate objective of having the children eat healthy foods, another widespread strategy was using less nutritious foods as rewards for eating nutritious foods. Providers described using desserts as rewards for eating healthy meals. For instance, children were told they could "get the cookies after we've had the vegetables," or warned that "Remember, you lost your snack because you didn't eat the healthy stuff." Again, one provider spoke of sharing this strategy with parents, and how she advises parents to warn their children that "if you only eat a little bit of dinner, you're only getting a little bit of ice cream, but if you eat your whole dinner, then you'll get a bowl of ice cream."
Providers' descriptions of the child care's mealtime scheduling were found to encourage children to focus on external rather than internal cues for hunger, a finding particularly evident among the home-based providers. Many providers spoke of the strategy of having the children eating on a set schedule, and how it takes the children a few weeks to learn they need to eat everything served to them at lunch. When the children are hungry afterward, providers remind them, "This is why you should eat all your food at lunch." Or they might add that snacktime is "not for a few more hours; this is why you should eat all your food at lunchtime, so you won't be starving." Providers further discussed how it is necessary to have all the children eat only during designated times and how the children must learn the schedule, by instructing them:
"You have to wait until the girls get up from their nap and then you can have your snack. If you ate better at lunch then you would have enough to keep you ..." Yeah, they learn the schedule. And then it's like, "OK, I better eat all my lunch, because it's going to be like three hours until before I get something else."
All of the providers also spoke of restricting the consumption of unhealthy foods to certain times--serving healthy foods the majority of the time and reserving less nutritious food for parties, special occasions, and Fridays. When asked about typical foods served to the children, providers spoke of fruits, vegetables, and whole grains and stated they only had cookies, cupcakes, and cake to celebrate birthdays or other holidays. Many providers spoke of baking cookies with the children to celebrate holidays, such as Christmas, Mother's Day, Valentine's Day, and so on. One provider described how a special day each month is celebrated with treat foods: "We'll have PJ and Movie day so we'll have popcorn and M&Ms." Likewise, providers spoke of serving different foods on Fridays compared to the rest of the week; several served treat foods, such as cookies, only on Fridays: "On Friday, we have a big treat, like you get a Rice Crispy square or maybe a cookie."
Factors Influencing Use of Strategies
To develop a better understanding of why providers use these strategies, the authors asked questions based on the social ecological understanding of how individual, community, and societal influences all have on people's decisions. The most important factors perceived by providers were found to originate from the individual and societal levels: their beliefs, experiences in the child care setting and with their families, interactions with parents, and pressures from societal sources, most commonly, Canada's Food Guide (Health Canada, 2009). Community-level factors were not described by providers to have as great an influence and, due to the space limitations of this article, will not be discussed.
Individual-level factors were described as being influential on many strategies, particularly in determining the snack- and mealtime schedule and serving of food. Many described needing to portion out and serve the food to decrease the spread of viruses and germs, a concern that was particularly evident among the center-based providers. One provider described her belief in a "huge difference" in the spread of viruses when her center-based child care switched from allowing the children to choose their own snacks from a common platter, compared to having staff hand out the food. Another center-based provider described the time-consuming task of ensuring that all of the children washed their hands and all of the tables had been disinfected before anyone was allowed to eat any food. A home-based provider gave further insights: "You run into so many allergies; you've got dairy allergies, nut allergies, and peanut allergies. And it's not just anymore where you could just have them at another table; it's environmental and you can't have them around anybody that's had some of these." Another provider described the range of food constraints that can be found in one group of children: "A gluten-free diet or they're very strict about the peanut-free diet ... the other one is a child who has religious issues with food and then we have another child that has PKU [phenylketonuria], so she's on a special diet." Similarly, having the providers eat at the same time as the children was described as being a positive, but unrealistic, strategy for many child care settings. Snack- and mealtimes were described as being the best times for providers to prepare for activities later in the day, as well as being a time when they are busy preparing or cleaning up food. As one center-based provider detailed, "Teachers are allowed to sit with them once--I don't want to say once their duties are done--but we have to have beds put out, right? Obviously the best time to do it is when they are all sitting at the lunch table." Not surprisingly, this challenge was especially noted by the home-based child care providers, as one home-based provider explained, "One person, five kids? There's usually not time to sit."
Individual-level factors, such as beliefs and attitudes about how children should eat, as well as providers' experiences with their own families, also affected providers' use of strategies in the child care setting. Children were commonly perceived as being healthy if they ate a lot; they were depicted as being "good eaters" or they "ate very well" if they ate all of the food offered to them during snack or mealtimes. Children who were described as eating a lot in the morning but still ate a "ton" at lunch were characterized as being "just good eaters." Similarly, when asked to describe children who ate healthfully in the child care setting, providers typically depicted them physically as having "round cheeks" and a "full tummy." Children who ate larger amounts of food were additionally perceived to behave differently, acting happier and more energetic: "Those who eat well have more energy" and are "more vibrant" than those who ate less, and those who don't eat well are "usually cranky and irritable."
Providers' experiences with their own families also influenced many of their decisions. One provider described how she chose to use the strategy of blending vegetables to hide them in sauces in the child care because "it worked at my house really well ... no one ever tasted it [the healthy food] or realized it until anybody saw me making it." Family experiences also influenced some providers to believe that children have genetic predispositions to food preferences that are unalterable; as one provider stated, "I think there's a genetic component to it. I can see it in my own family; my husband won't eat onions and two of my kids will not touch onions. They were absolutely and completely against onions fight from the start."
Interactions between providers and parents were found to play an influential role in determining the strategies used by home- and center-based providers. Providers reported rarely speaking with parents about food and eating in the child care settings. A few providers reported relaying nutritional information through newsletters to parents; more commonly, however, providers described feeling uncomfortable discussing nutrition and children's eating habits in child care with parents. The majority stated that they discussed food and nutrition only "if we're asked." Importantly, the exception to this lack of communication was when parents believed their child wasn't eating enough. One provider explained: "Sometimes the parents are worried about their lunches ... even though we do sit with them during lunchtime and we do encourage them to eat. I've also had parents complain that they [the children] aren't drinking enough, so we try and get them to drink." Another said, "Some of the parents say to us, 'Oh, he needs to have snack.' Then we'll make a point of saying, 'Well, you really should just come and have something.' But if it doesn't bother their parents and it doesn't bother them, then we don't insist that they have snack." When discussing parents, providers frequently commented on how shocked parents were to learn what their children are eating at the child cares, as children "eat stuff at my house that they won't eat at their house ... and they'll eat more at my house than they will at home." One provider explained how she even videotaped one young girl eating peas for lunch, in response to her mother's skepticism. However, when asked if how the children eat at the child care improves their habits at home, providers disagreed, offering such insights as, "No, they have two different sets of rules--mine and the parents', and they know who's who."
Pressures from society to ensure the children were eating healthily also proved influential, especially for the center-based providers. Center-based providers typically described the importance of following Canada's Food Guide (Health Canada, 2009) in the child care setting: "We have to follow the Canada Food Guide, with serving proportions and everything. We have to provide the right amount of number of fruit and vegetable[s] ... we have to provide protein versus carbohydrate, so each snack and lunchtime menu will be according to the number" or "we try and stick to Canada's Food Guide." Another common reference was to "the Ministry." For example, "We're supposed to go by the Ministry requirements, so they require so much milk a day and so much fruit a day and that stuff." Yet, when asked how helpful sources of information were in their daily lives in child care, the majority of center- and home-based providers said they did not typically use them, because feeding young children is "common sense."
The findings from this study provide necessary descriptions of how healthy eating is perceived and encouraged by a sample of child care providers. In agreement with past research (Moore et al., 2005), providers described employing many strategies that are consistent with research on developing children's healthy eating behaviors (Aldridge et al., 2009; Birch, 1998; Schwartz & Puhl, 2003). Nevertheless, regarding what can be gleaned from this study to aid providers in supporting children's healthy nutritional behaviors, of particular interest were providers' inabilities to implement research-recommended strategies and their use of negative strategies. By developing an interview guide based on a social ecological perspective, it was possible to gain an understanding of the interconnections among the many factors acting on providers, as well as the complexity of creating child care environments that are supportive of healthy eating. In particular, personal beliefs, interactions with parents, and societal influences were found to factor into providers' use of control strategies that limited children's opportunities to develop self-regulation over food intake. The findings further revealed the importance that qualitative research affords for developing a more well-rounded understanding of nutrition in the child care setting.
For developing healthy and long-term nutritional behaviors in children, certain strategies are recommended, such as having children and adults eat the same meals together, allowing children to eat when they are hungry, allowing children to serve themselves portions of food, and involving children in cooking and preparing foods (Birch, 1998; Birch & Davidson, 2001; Lytle et al., 1997; R. S. Strauss & Knight, 1999; Young, Anderson, Beckstrom, Bellows, & Johnson, 2003). However, providers described factors that interacted to create real child care situations that were incompatible with such research-recommended strategies. Allowing children to serve themselves or eat whenever they are hungry was described as impractical, due to providers' concerns of children spreading germs and colds. The high number of children on special diets presented providers with additional fears that required the provider to control the foods served. Likewise, providers described how careful they need to be when allowing the children to eat, due to fears over contamination of foods that would be dangerous for children with allergies. Furthermore, providers described the impracticality of eating at the same time as the children and the amount of time involved in preparing for mealtimes. The inability of providers to implement recommended strategies concurs with past research. Trost et al. (2009) found that only 23% of providers served food "family-style" (allowing children to choose their own portions from a communal plate) to children in their care. Lumeng et al. (2008) also found that teachers in a preschool program describing mealtimes as being overwhelming when they attempted to implement a family-style mealtime approach. These findings deserve significant attention because, as described earlier, children between ages 3 to 5 years can lose their capacity to self-regulate when they are socialized to rely on others to determine the amount of food to eat (Birch & Davidson, 2001; Birch et al., 1987).
Providers were found to use negative strategies to achieve the short-term goal of ensuring children eat healthy foods. Such strategies as concealing healthy foods in unhealthy foods, using unhealthy foods as rewards, serving foods with high-sugar or high-salt condiments, and limiting children's access to certain foods were classified as "negative" in this study because they were contradictory to what research has found is needed to develop children's food preferences for healthy foods (Aldridge et al., 2009; Birch, 1999; Cooke, 2007). For example, although concealing fruits in baked goods may be an effective short-term solution for increasing children's fruit intake, this practice does not enable children to become familiarized with the fruit, and, consequently, does not encourage the development of lifelong healthy food preferences for fruits in the long run (Birch, 1999; Cooke, 2007; Johnson, 2000).
Echoing the findings of past research with providers (Lumeng et al., 2008), providers reported rarely discussing nutrition and food with parents and felt unqualified to raise any nutritional concerns. A possible consequence of this lack of communication between providers and parents could be seen in how providers spoke of children eating differently (in terms of variety and quantity) in the child care setting, compared to the home setting. Providers perceived the children as eating more healthfully at the child care setting as a positive point, describing how children know they have to respect the "rules" of mealtimes at the child cares. However, research on the long-term development of behavior emphasizes that to build healthy behaviors, such behaviors must be promoted and practiced in a variety of settings (Bronfenbrenner, 1979, 2005; Lytle, 2005; Lytle et al., 1997). Importantly, however, providers described discussions with parents about fears that their children are not eating enough, discussions that resulted in providers encouraging the children to eat more during mealtimes at the child care settings. Providers seemed to share in this belief of children needing to eat more to be healthier, as they described children appearing healthier and behaving better if they ate large amounts of food. Providers also described their beliefs in needing to control when certain foods could be served by limiting unhealthy foods for celebrations. Additionally, providers spoke of personal experiences with their families and their own positive childhood experiences of birthday and holiday celebrations involving treats. Unfortunately, although well-intended, controlling strategies such as these have been found to promote the development of obesity by limiting children's opportunities to develop self-control (Birch, 1999; Costanzo & Woody, 1985).
Providers note that Canada's Food Guide (Health Canada, 2009) emphasizes the necessity of young children eating adequate servings from each of the food groups but does not focus on long-term behavior development. These findings echo conclusions drawn from research with parents showing that nutritional information sources must go beyond stressing consumption of certain food groups to address the importance of developing children's long-term healthful nutritional behaviors (Benton, 2003; Schwartz & Puhl, 2003).
These findings--that different influences combine to pressure providers to encourage children to eat in the absence of hunger and ignore internal cues for satiety--are significant, as these strategies have been found to disrupt children's ability to self-regulate, which has been linked to obesity (Birch et al., 1987). Although these findings are new for child care providers, similar findings have been noted with parents. Orrell-Valente et al. (2007) found that 85% of parents tried to get their children to eat more during mealtimes, ignoring the children's self-regulation of intake. Consequently, though providers perceived limiting unhealthy foods as a way to foster healthy eating habits, this practice has been found to instead encourage children to eat when these limited foods are served, whether they are hungry or not. As a result, the presence of food, and not hunger, initiates eating (Birch & Davidson, 2001). Developing strategies to help providers deal with these concerns is crucial, as limiting children's control over their food intake at a young age results in long-term consequences on their weight and nutritional behaviors (Birch, 1998).
Finally, a number of strategies that providers described in this study contrast to past research with providers and illustrate the importance of a qualitative research approach for developing a fuller understanding of providers' behaviors in child care settings. For instance, providers spoke of serving the children unhealthy or dessert foods only after they had eaten the healthier food, or of refusing them the snack later in the day if they did not eat their lunches. These practices differ greatly from quantitative research by Trost et al. (2009), who reported that nearly 100% of providers do not employ any such strategies, such as not serving vegetables with butter--a finding that could also be made of the providers in this sample--resulting in the conclusion that providers are serving children healthy meals. However, providers from the current study reported frequently serving vegetables with high-sugar and high-fat condiments, such as ketchup and salad dressing--a fact that would not have been revealed through a closed-ended questionnaire.
Study Limitations and Future Research
This study provided information on the healthy eating strategies used by a sample of providers in Ottawa working on home-based and center-based child cares as well as on the complex social context--involving pressures from parents, children, and nutrition education materials--in which they are delivered. The generalizability of the results is limited by the small sample size, as well as the use of convenience sampling within the region of one city. Additionally, the method of semistructured interviewing resulted in providers having more control over the interview topics covered, resulting in variability among the interviews. Finally, as this study relied upon one method of data collection, interviews combined with observations could have produced richer findings, and should be considered for future research with child care providers. Nonetheless, with the study goal being to better understand providers' perceptions of strategies to support healthy eating, the results provide a foundation for future research and provide practical insights into the variety of factors that influence child care providers.
Future research needs to replicate this study with diverse samples of providers to better understand the strategies that providers perceive as supporting healthy eating habits. Using research techniques that go beyond questionnaires has been recommended for better understanding social influences on childhood eating behaviors (Benjamin et al., 2009; Towns & D'Auria, 2009) and was highlighted in the findings. Through semistructured interviews, providers revealed a number of unanticipated strategies and the challenges that providers face, making many recommendations incompatible with the reality of day-to-day life for these providers not previously identified in quantitative studies.
These findings regarding the challenges providers are facing, particularly those who run home-based child cares, are especially important to address in light of research by Benjamin et al. (2009), who found a correlation between the number of hours children spend in child care and higher body mass indexes at ages 1 and 3. Importantly, this correlation was only noted if the child was in a home child care and not a center-based child care or in his or her own home with a nonparent. Differences between the center-based and home-based child care providers noted in the current study included center-based providers describing better access to courses on child development and information on food and nutrition. Home-based providers were the only ones to mention using the Internet as a source of information on nutrition and as a virtual social support network with other home-based providers. Additionally, home-based child care providers were the only ones to discuss serving the children reheated meals from their family's dinners (whereas center-based child cares have meals cooked specifically for the children), indicating that the children's meals in home-based child cares were dependent on the family's food preferences. Finally, it is possible that many of the unfavorable factors influencing providers could be intensified in home-based child cares. There, with only one adult present, the isolation could heighten the provider's need to control the food situation because of germs/colds/cross-contamination; such individual responsibility also could make the provider less willing to engage in educational food-related activities with children (such as baking). And in contrast to the center-based child care, where there are several teachers modeling healthy behaviors, in home child care there is only one adult to model healthy eating habits.
The findings of this study are important with regard to developing nutrition education materials for child care providers. There is a need to develop materials for and with providers, as opposed to supplying them with materials that do not address the range of social ecological factors influencing child care settings. For instance, there is a need to describe how providers can aid children in developing healthy dietary habits, especially by being less focused on the immediate goal of fruit and vegetable consumption and more on establishing long-term healthy nutritional behaviors. Schwartz and Puhl (2003) similarly stressed how little is taught to parents about children's nutritional development, despite evidence of the long-term effects that result from these early behaviors. Benton (2003) agreed, concluding that teaching more about child development should be used to develop healthy food preferences in children. The current study also identified a need for providing educational materials to encourage partnerships between parents and child care providers in developing healthy dietary approaches. The strained relationships between providers and parents present a finding that is not exclusive to the current study (Briley, Jastow, Vickers, & Roberts-Gray, 1999; Mooney et al., 2008; Moore et al., 2005). Yet researchers frequently recommend that providers act as liaisons for teaching healthy eating behaviors to parents, a recommendation that ignores the realities of the provider-parent relationship. Thus, future researchers and policymakers should consider these sensitive relationships, and understand that it is unrealistic simply to recommend that providers "educate" parents about such a highly personal topic. Still, echoing the findings by Pagnini et al. (2007), providers in this study expressed an openness to improving relations with parents; many wanted educational materials to focus on how they can best discuss nutrition with parents as well as information they could pass on to parents. Moreover, these findings also illustrated the need to develop these materials in conjunction with providers by knowing more about the variety of factors that influence providers, as opposed to merely prescribing food and nutrition guidelines that are not specific to the child care setting (Lytle, 2005). As the influences raised by providers illustrated, it is essential to develop nutritional resources with providers to best recognize the impact of different factors influencing providers' mealtime and food decisions, beyond a narrow focus on nutritional knowledge.
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University of Toronto, Toronto, Canada
University of Ottawa, Ottawa, Canada
Submitted November 27, 2010; accepted February 15, 2011.
Address correspondence to Meghan Lynch, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON M5T 3M7, Canada. E-mail: email@example.com
TABLE 1 Characteristics of Participants Age Setting Education Years of Experience 64 Home Postsecondary 25 54 Center Postsecondary 28 54 Home Postsecondary 15 52 Center Postsecondary 24 51 Center Postsecondary 19 48 Home Some postsecondary 21 48 Home High School 9 44 Center Postsecondary 26 44 Center Postsecondary 25 40 Center Postsecondary 24 40 Center Postsecondary 20 38 Center Postsecondary 15 32 Home Postsecondary 7…
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Publication information: Article title: Child Care Providers' Strategies for Supporting Healthy Eating: A Qualitative Approach. Contributors: Lynch, Meghan - Author, Batal, Malek - Author. Journal title: Journal of Research in Childhood Education. Volume: 26. Issue: 1 Publication date: January-March 2012. Page number: 107+. © 2009 Association for Childhood Education International. COPYRIGHT 2012 Gale Group.
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