Overweight and obesity are increasing in preschool children in the US. Policy, systems, and environmental change interventions in childcare settings can improve obesity-related behaviors. The aim of this study was to develop and pilot an intervention to train childcare providers to promote physical activity (PA) in childcare classrooms. An evidence scan, key informant (
Overweight/obesity has become a critical public health concern in the United States [
In Northwest Florida (NWFL), the local health department implemented
In addition to the
While there is a growing body of research related to the physical activity needs of preschool children [
A review of the evidence of related materials for childcare centered-focused curricula promoting physical activity was completed in Fall 2014. Programs and studies were identified through a database search that included PubMed/Medline and Google Internet search. The PubMed search, which was not meant to serve as an exhaustive systematic review of the literature, included only articles that had been published in peer-reviewed/academic journals. The Google search included websites and linked toolkits, reports, and flyers. Search terms related to the population of interest included
For the PubMed/Medline search, titles and abstracts were reviewed to determine whether the abstract or full reference met the search criteria listed below. Abstracts selected for further review were identified and evaluated to determine whether review of the full article would occur. Selected full papers, including several previously published systematic reviews of the literature, were reviewed to make a final determination of whether the studies/programs would be recommended for potential use. For each Google search, hit titles were reviewed to determine whether they met the search criteria. Due to a large number of Google hits, they were only reviewed through page five of the Google searches. Hits from unreliable sources, such as personal blogs, were excluded.
Any study/program designs were eligible for inclusion in this review including international studies. Inclusion criteria also covered studies/programs that focused on children of ages five and under and on increasing physical activity and/or reducing sedentary behavior. We also included programs focused on other outcomes (e.g. nutrition) if they described a separate physical activity curriculum. Studies/programs that focused on kindergarten students 5 years or older were excluded. We excluded studies/programs that provided no information regarding how the activities linked to early childhood learning objectives and studies/programs that did not provide a full physical activity curriculum available online free of charge or free via a request from the creators at no charge. A full curriculum was defined as including all physical activity program materials and instructions/guidelines for instructors. Because of noted funding constraints by early childhood education teachers, popular programs that were only available for a cost (e.g., SPARK, CATCH Early Childhood) were not included.
Participants in key informant and focus group interviews were recruited through the Early Learning Coalition (ELC) in Northwest Florida, whose purpose is to support children and families for lifetime success by preparing children to enter school ready to learn and helping families achieve economic self-sufficiency. Purposeful sampling techniques were used to identify childcare directors, staff, and teachers to participate in discussions. Key informants included childcare center directors (
An initial round of key informant and focus group interviews took place in December 2014. Questions were developed based on the results of the evidence scan. Questions assessed typical daily routines in the childcare setting for children and staff, how lessons are typically taught, staff perceptions of the importance of teaching children about nutrition and physical activity, perceptions of how staff behaviors influence children’s behaviors, and suggestions from teachers about the format of a training program and training materials for teachers and student curriculum content. A trained project team member reviewed each recording, summarized question responses, and noted general themes. Themes from the entire document were reviewed as a whole to determine similarities or contradictions across responses. Two additional project team members reviewed the recordings and summaries and provided input regarding agreement with themes. Discussion occurred until final agreement on themes and implications was reached within the team. Implications and themes were incorporated into teacher training materials and the student curriculum.
A representative from each center that participated in the interviews or focus groups completed a self-assessment questionnaire to assess environments and policies related to physical activity at their respective childcare center. The questionnaire was selected by the local health department since it was a part of Maine’s
Findings from the evidence scan, key informant and focus group interviews, and the physical activity self-assessment were used to create a draft set of teacher workshop topics, training overview, and training materials to be provided to teachers (Figure
Flow diagram for curriculum development.
The pilot teacher training workshop,
From the 2,058 records identified in PubMed, only 23 matched the search criteria and warranted a review of the full articles. Upon further inspection, only one of the 23 articles reported on a program that focused on preschool children, included a full physical activity curriculum free of charge and available online, and reinforced learning objectives in the classroom. That program had two names: MOVE, for children ages 0–3 years, and HOP for children ages 3–5 years. From the 218,788,900 hits on Google, only 13 hits from the first five pages matched the search criteria and warranted a full review of the program. After further review, only three programs met the final search criteria and were recommended. A total of four programs met the inclusion/exclusion criteria for the evidence scan (Table
Low-cost physical activity curricula accessible through the Internet.
Curricula | Sponsoring agency | URL |
---|---|---|
Go smart | National Head Start Association | |
Hop |
Decoda Literacy Solutions, British Columbia | |
Keystone kids go active | Pennsylvania Department of Human Services, PA Nutrition Education Network | |
Move |
Decoda Literacy Solutions, British Columbia |
|
Sesame street we have the moves: physical activity resource | US Department of Health & Human Services and the National Association for Family Child Care |
|
A total of 54 childcare staff participated in the initial key informant and focus group interviews in December 2014. This represents a convenience sample of referrals identified by the ELC. Participant demographics are included in Table
Demographic characteristics of key informant and focus group participants.
December 2014 |
March 2015 |
|
---|---|---|
|
|
|
0–5 years (entry level) | 8 (14.8) | 4 (22.2) |
>5–10 years (mid-career) | 9 (16.7) | 0 |
>10–20 years (experienced I) | 19 (35.2) | 6 (33.3) |
>20–30 years (experienced II) | 14 (25.9) | 7 (38.9) |
>30 years (late career) | 4 (7.4) | 1 (5.6) |
|
||
|
||
Family childcare home | 20 (37.0) | 7 (38.9) |
Small center | 8 (14.8) | 3 (16.7) |
Medium center | 15 (27.8) | 3 (16.7) |
Large center | 2 (3.7) | 0 |
Coalition | 6 (11.1) | 4 (22.2) |
Missing data | 3 (5.6) | 1 (5.6) |
|
||
|
||
<1 year | 3 (5.6) | 1 (5.6) |
1 to <2 years | 2 (3.7) | 2 (11.1) |
2 to <5 years | 15 (27.8) | 6 (33.6) |
5 to <10 years | 13 (24.1) | 1 (5.6) |
10 to <15 years | 12 (22.2) | 3 (16.7) |
15 to <20 years | 3 (5.6) | 3 (16.7) |
20 years or more | 5 (9.3) | 2 (11.1) |
Missing data | 1 (1.9) | |
|
||
|
||
Owner | 23 (42.6) | 8 (44.4) |
Director | 17 (31.5) | 3 (16.7) |
Teacher | 10 (18.5) | 1 (5.6) |
Assistant director | 1 (1.9) | 2 (11.1) |
Provider assessment and training | 3 (5.6) | 4 (22.2) |
|
||
|
||
High school graduate | 15 (27.8) | 5 (27.8) |
GED | 2 (3.7) | 0 |
Some post-high school education | 7 (13.0) | 1 (5.6) |
Associate degree | 11 (20.4) | 3 (16.7) |
BA or BS degree | 8 (14.8) | 6 (33.3) |
Post BA or BS degree | 5 (9.3) | 2 (11.1) |
Certificate program | 5 (9.3) | 1 (5.6) |
Other | 1 (1.9) | 0 |
|
||
|
||
21 to 29 years | 7 (13.0) | 1 (5.6) |
30 to 39 years | 9 (16.7) | 2 (11.1) |
40 to 49 years | 15 (27.8) | 4 (22.2) |
50 to 59 years | 17 (31.5) | 6 (33.3) |
60 years or older | 4 (7.4) | 4 (22.2) |
Missing data | 2 (3.7) | 1 (5.6) |
|
||
|
||
Male | 2 (3.7) | 1 (5.6) |
Female | 50 (92.6) | 16 (88.9) |
Missing data | 2 (3.7) | 1 (5.6) |
|
||
|
||
African American/black | 32 (59.3) | 9 (50.0) |
Asian American/Pacific Islander | 1 (1.9) | 0 |
Caucasian/white | 17 (31.5) | 6 (33.3) |
Native American | 0 | 2 (11.1) |
Hispanic/Latino | 2 (3.7) | 0 |
Missing data | 2 (3.7) | 1 (5.6) |
Home care providers identified additional specific factors that were not raised by center staff including the wide age ranges of children at home care facilities since they provide before and after school care, as well as birth to age five child care, and the need for activities that can be adapted for a wide range of ages. Home care staff were frequently cited as being considered “extended family” for children and families, often providing basic lessons on child rearing, cooking, and homemaking for younger parents. Home center providers also cautioned against providing physical activities that required extensive space or equipment, since space is limited in home-based centers.
In March 2015, 18 individuals participated in the follow-up key informant and focus group interviews to review and provide feedback on the planned training curriculum and student intervention materials and to offer additional suggestions (see demographics in Table
Respondents suggested a two- to three-hour training time frame and preferred training that included staff from other childcare centers so new perspectives and ideas could be shared. The consensus was that Saturday was the best day for a long training, particularly since parents were often late picking children up at the end of the day and after clean up and closing a center, attending a weekday evening training would be challenging. Respondents were highly supportive of having continuing education credits and felt that would impact their willingness to attend training. Overall, respondents felt it would be important for researchers to reach out several times following the training to be sure the student curriculum was being used and to assess further support if needed.
ELC staff participated in a specific focus group for their team and provided suggestions for the teacher training materials and student intervention curriculum based on their previous experiences with providing training for early childcare educators. They suggested providing teachers with 50 to 250 activity cards, preferably laminated for durability and made easily available to teachers. ELC staff volunteered to review activity cards to assist researchers with matching activities to early learning standards. ELC staff also supported the idea of providing some equipment for implementing activities during teacher training, with additional equipment provided at technical assistance visits following training, once it was clear that childcare staff were implementing lessons learned during training. All of the recommendations from the childcare providers and ELC staff were incorporated into the final teacher training workshop curriculum.
Twenty-two directors from childcare centers completed the physical activity self-assessment questionnaire. All of these centers reported serving children of ages one to five years with 77% also providing care for children under one and 95% also caring for children five years and older. Ninety-five percent of the centers were full day programs and most centers offered Florida’s Voluntary Prekindergarten (VPK) program. Additionally, 91% of programs required continuing education (CE) for certification or licensure; however, only 27% of the centers offered CE.
With regard to physical activity, 77% of the centers provide active play for more than 45 minutes daily, and all centers reported providing outdoor active play time with 54% of the centers reporting one or more times for a total of 30–45 minutes. Only six centers (27%) reported two or more play times daily with a total outdoor activity time of 60 minutes or more. Most centers reported that children were expected to be seated for long periods of time. For example, 64% reported this expectation for more than 30 minutes at a time or 15–30 minutes on three or more occasions. Ninety-one percent of the centers stated that active play time is often or sometimes withheld for misbehavior. Finally, respondents indicated limited existing training opportunities for physical activity for childcare providers and parents.
Most (77%) of respondents reported having ample indoor space available to accommodate active play and 73% reported having multiple outdoor play areas and open space for running and/or a path for wheeled toys; however, only 22.7% indicated having sufficient variety of and equipment for multiple children to use at the same time. Most centers (76.2%) reported limiting television/DVD viewing during meals or snack times and reported limiting screen time as a reward for good behavior. Most centers (71.4%) stated that computer time is limited to 15 minutes per day per child and that providers typically watch children during screen time activities. Centers reported that they had not received training on screen time reduction or media literacy for preschool children for staff and/or parents. Fifty-nine percent of directors stated that their center had not participated in programs supporting healthy eating and active living within the past year. Only 14% of center directors reported having programs that support healthy eating and active living. Twenty-one of 22 centers (95%) have policies that require that all children have opportunities for physical activity every day, which is usually enforced. Approximately 91% of the centers had policies that require that recreational screen time be limited for all children, and the policy is usually enforced at the centers.
Summary of physical activity environmental self-assessment completed by child care center directors (
Assessment item is physical activity: With regard to active play time, 77% of centers provide active play time for more than 45 minutes daily:
15 centers (68%) provide 46–90 minutes and 2 (9%) centers provide 91–120 minutes. No centers provide more than 120 minutes; 5 centers (23%) provide 45 minutes or less (which could include 0). All centers report providing outdoor active play time:
12 centers (54%) report 1 or more times for a total of 30–45 minutes. Six centers (27%) report 2 or more times daily for a total of 60 minutes or more. Most centers reported that children are expected to be seated for long periods of time:
14 centers (64%) reported this expectation for more than 30 minutes at a time or 15–30 minutes on 3 or more occasions. 20 schools (91%) reported that active play time is often or sometimes withheld for misbehavior. Current training opportunities for physical activity for preschool children are limited for providers and parents:
12 providers (55%) indicated opportunities were provided one time per year or less. 15 schools (68%) reported offering such education to parents one time per year or less.
Assessment item is childcare environment: With regard to indoor gross motor play areas, 17 centers (77%) reported having ample space for some or all active play. 16 centers (73%) reported having multiple outdoor play areas and open space for running and/or a track/path for wheeled toys. Only 5 centers (22.7%) indicated having sufficient variety and amount of equipment for children to use at the same time. Most centers (76.2%) report limiting television/DVD viewing during meals or snack times or as a reward. Most centers (71.4%) report that computer time is limited to 15 minutes per day per child and is only available during a set time of day. Most centers (81%) report that providers are supervising and watching children during screen time activities all or most of the time. Center staff report no training on screen time reduction and/or media literacy for preschool children for staff or for parents. Within the past year with regard to programs supporting healthy eating/active living,
13 centers (59%) participated in no programs, 3 centers (14%) reported program-wide programs. 16 centers (73%) do not have a staff wellness policy. 21 centers (95%) have policies that require that all children have opportunities for physical activity every day and the policy is usually enforced in the program, and the director has verified it. 20 centers (91%) have policies that require that recreational screen time is limited for all children and the policy is usually enforced in the program, and the director has verified it.
As mentioned, the evidence scan, key informant and focus group interviews, and physical activity environmental self-assessments were used to create the final two-hour teacher training workshop curriculum. Workshop topics and timing are listed in Table
Final training workshop topics.
Topic | Timing |
---|---|
Welcome & introductions | 10 minutes |
5-2-1-0 Let’s Go, Escambia! | 10 minutes |
Physical activity in the early learning setting | 10 minutes |
Finding and selecting quality activities | 10 minutes |
Round Robin, trying out a number of activities | 40 minutes |
How to weave physical activity into your weekly plans | 5 minutes |
Activity, match early learning standards & activities | 15 minutes |
Engaging parents | 5 minutes |
Practicing over the next 4 weeks & CEUs | 5 minutes |
Q&A | 5 minutes |
Postquestionnaire | 5 minutes |
Research staff delivered the teacher training workshop with support from local university student volunteers. Sixteen (16) staff from six childcare facilities participated in the two-hour training, including 11 full-time (35+ hours per week) and 5 part-time (<35 hours per week) staff. Most attendees were more experienced providers compared to the representative population, with 43.75% having greater than 20 years working in childcare, 25% with 10–20 years of experience, and 31.25% participants under ten years. Six attendees reported working primarily with preschoolers (3–5 years), 3 worked with children ≤2 years, 1 worked primarily with school aged children (≥6 years), and 5 worked with all age groups; 1 attendee did not provide a response to this question. Most centers (
Teacher training workshop participants completed a course summary evaluation following the workshop (Table
Overall course evaluation.
Please rate the quality of the following | Poor |
Fair |
Good |
Very good |
Excellent |
---|---|---|---|---|---|
Mean | |||||
Overall content of course | 4.81 | ||||
PowerPoint slides | 4.63 | ||||
Participant manual | 4.63 | ||||
Presentation of material by trainers | 4.73 | ||||
Participant/group activities | 4.81 | ||||
Facilitation of activities by trainers | 4.81 |
Self-assessment of knowledge and skills.
1 = no knowledge/skills; 3 = some knowledge/skills; 5 = a lot of knowledge/skills | ||
---|---|---|
Before-training |
After-training | |
Benefits of physical activity (PA) for children | 3.31 | 4.75 |
Developmental milestones for children | 3.69 | 4.69 |
Makeup of childcare centers in county | 3.00 | 4.19 |
Day-to-day activities in childcare centers in county | 3.38 | 4.69 |
5-2-1-0 Let’s Go! campaign | 2.81 | 4.75 |
Age appropriate PA for preschoolers | 3.50 | 4.81 |
Strategies for incorporating PA in childcare | 3.50 | 4.88 |
Age appropriate PA adaptation strategies | 3.19 | 4.81 |
Ability appropriate PA adaptation strategies | 3.19 | 4.75 |
There is a void in the literature related to evidence-based interventions involving physical activity and nutrition curricula that focus on preschool children, are easily accessible (e.g., available online), and free of charge and that reinforce learning objectives in the classroom. The current study suggests that childcare providers understand the importance of health-related behaviors in young children and are cognizant of their role in teaching about and demonstrating healthy behaviors for children. When given the opportunity, teachers are willing to learn about strategies for incorporating physical activity into daily classroom activities.
Cost, access, and emphasis on early learning standards are three critical components that increase the likelihood that materials will be incorporated into standard practices in childcare settings. These findings are based on our insights from childcare providers and the ELC who provided technical assistance for childcare providers and are in line with other studies that have assessed factors that improve intervention fidelity among teachers [
Participation of and input from childcare leadership and staff in key informant interviews and focus groups was critical for understanding nuances within center childcare environments and the most effective strategies for intervening on children’s physical activity in classroom settings. Input from childcare staff was also helpful for understanding how to structure training and the types of intervention materials that would be most likely utilized by childcare staff. Their input changed the researchers’ planned materials and activities in ways that enhanced the workshops and training materials (e.g., offering training on Saturday, providing hands-on activities and continuing education, having regular follow-up visits, and providing activities on large laminated cards that are easy to read and clean if spills occurred). In our and other recent reviews of the literature, we did not identify any published studies that described extensive input from childcare staff in developing and shaping training materials and interventions to promote physical activity in childcare settings. A recent paper described protocol fidelity among teachers in an intervention designed to increase physical activity during play time [
The current study tested the feasibility and acceptability of training teachers to incorporate student intervention curriculum materials in classroom-based activities rather than during outdoor play. Data suggests that the influence of parents/adults has been negatively associated with outdoor physical activity in children [
The trainings offered insight about the additional support that may be needed during and following the workshops. Contrary to our expectations teachers wanted more, rather than less, follow-up and check-ins with research staff for advice on how to use the curriculum. Teachers stated that knowing someone would be checking in with them would motivate them to use the curriculum and equipment. Teachers also wanted to begin using the curriculum and materials and then have the opportunity to interact with research staff in case they had questions. As mentioned, teachers also desired additional training on strategies for engaging parents in physical activity with their children and strategies for intervening on nutrition.
There are some limitations for the current study that should be noted. Childcare providers who participated in focus groups and interviews and provided feedback on the teacher training curriculum were invited by the ELC. The ELC does not work with all childcare providers in the county, and providers not served by the ELC could have had different perspectives. It is also possible that providers who volunteered to participate in the discussion groups and in the teacher training were more interested in promoting physical activity than providers who chose not to participate. Finally, data were collected only from childcare providers in Escambia County, Florida, and it is possible that providers in other regions of the country have different insights. The current study also had several strengths including the sample of childcare providers whose demographics were representative of childcare providers in the area. The combination of the evidence scan and discussion groups with childcare providers allowed the project team to create a training curriculum that directly addressed needs and concerns of childcare providers. Additional review of the curriculum by childcare providers prior to pilot testing ensured that teacher’s needs were incorporated into the curriculum.
Findings from the current study highlight the feasibility and acceptability of working with childcare staff to develop relevant training and materials that can be used to incorporate physical activity into policies, systems, and environments in early childcare settings. Childcare administrators and teachers were engaged in the development of a training curriculum and provided feedback for future training workshops and continuing education opportunities. Next steps include evaluating the implementation of the student curriculum in childcare settings, understanding the protocol implementation fidelity, and assessing the impact of the training on physical activity levels in children. Additionally, more insight is needed on the benefits of individual coaching for childcare teachers to promote sustainability of physical activity within the classroom setting.
The authors declare that they have no competing interests.
Funding for this project was provided by the Florida Department of Health Escambia County (FDOHEC). Publication of this paper was funded in part by the University of West Florida Libraries’ Open Access Publication Fund. The authors gratefully acknowledge Versilla Turner of the FDOHEC, Vicki Pugh, and the staff at the Early Learning Coalition of Escambia County, the childcare center directors, teachers, and staff, and the University of West Florida students who participated in this project. They also thank Dr. J. Nelson-Weaver for her contributions to the evidence scan process.