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
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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).
METHOD
Participants
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).
Procedure
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).
Data Analysis
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).
RESULTS
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.
Positive Strategies
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.
Negative Strategies
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."
DISCUSSION
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.
CONCLUSIONS
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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DOI: 10.1080/02568543.2011.632069
Meghan Lynch
University of Toronto, Toronto, Canada
Malek Batal
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: meghan.lynch@utoronto.ca
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