1 CACFP Roundtable ConferenceOctober 19, 2016

2 Early Childhood Obesity Prevention Initiative (ECOPI) – General OverviewProject duration: July 2012 – June 2017 Funding: $41.2 million from First 5 Los Angeles Target groups: children ages 0-5 and their families Collaborations: County departments, community-based organizations, child care agencies, research and evaluation, and many others Strategies: education, skills-building, policy, systems and environmental change efforts to promote improved nutrition, increase physical activity, and reduced obesity *CHLACC program implementation was from July 2012-June 2016; remainder of time dedicated to data analysis and program evaluation

3 ECOPI Overview - ProgramsEarly Childhood Obesity Prevention Initiative (ECOPI) Choose Health LA Kids Choose Health LA Child Care Choose Health LA Moms

4 Why Focus on Child Care Settings?40% of 0-5 children in LAC (350,000) spend most of their day in child care. Among the PHFE WIC population, 19% of 3 and 4 year olds in LA County are overweight. Observational study by PHFE-WIC and CFPA (2008)1 demonstrated significant need for improvement in nutrition policies and practices in licensed child care in LA County. Children are taking in a significant portion of their daily calories in child care – therefore child care settings present an opportune environment to establish health eating habits and attitudes early in life as a way to prevent obesity. The WIC Report noted that there is unanimous consent that child care providers need support, encouragement, resources and incentives to facilitate improving food, beverage and physical activity practices in all child care settings. Due to the de‐centralized system of child care in Los Angeles County, thousands of independent and unconnected caregivers, centers and programs, and the busy lives providers lead, multiple, overlapping strategies are critical to improve nutrition and activity policies and practices in child care. Over the past several years significant efforts have been made to improve nutrition and PA in child care environments that I’ll briefly share with you. 1: WIC report available at:

5 Child Care Nutrition - California LegislationAB 2084 – Healthy beverages in child care (Chaptered 2010) Standards for beverages in CCC. Maximum of 4 – 6 ounces of 100% fruit juice served. Only low fat milk served. No natural or artificially sweetened beverages. Water accessibility at all times. AB 290 – Nutrition Training for Providers (Chaptered 2013) Requires child care providers to complete one hour of nutrition training as a component of licensing. The new CACFP food program will also assist us. AB 627 In 2009, AB 627 would have established basic nutrition and PA requirements as a condition of licensure. It was vetoed by Governor Schwarzenegger due to concerns about cost and feasibility of implementation by child care providers. Would have required water to be available throughout the day, allowed only low-fat or non-fat milk to be served to children two years or older, and provided at least one serving of a vegetable at lunch or dinner, unless exempted in writing by a physician.

6 Choose Health LA Child CareProgram Framework: Partnership with the county network of Resource and Referral (R&R) agencies R&Rs provide training, tools and technical assistance to: Child care centers Licensed child care homes License-exempt providers

7 Choose Health LA Child Care - Key StrategiesConduct nutrition and physical activity workshops for child care providers that includes a policy component. Incentivize training participation, offer swag and Cert. of Completion through Gateways to EducationTM program. Offer on site coaching to reinforce provider learning and evaluate use of training information. Evaluate trainings, and coaching through surveys and observational assessments Conduct events for families to promote and encourage healthy nutrition and physical activity habits.

8 What We Hoped to AccomplishImproved nutrition and PA practices in child care. Creation and adoption of nutrition and PA policies in child care. Providers communicate nutrition and PA policies with parents via newsletters or other venues. Identified barriers and concerns that child care providers face in efforts to promote good nutrition and active play. Promotion of, and the benefits of participation in, CACFP. Reduced prevalence of overweight & obesity among children in child care. Above all we hope to reduce prevalence of overweight and obesity among children in child care However, through implementation of the LA ROCCS Project SOW we anticipate accomplishing the outcomes described in the slide. Other Considerations Project may inform future advocacy efforts such as: Enhanced licensing regulations with improved Nutrition and Physical Activity standards at the State level Ways to improve participation in the Child and Adult Care Food Program (CACFP) While it is not in the current project budget we hope the outcome of this project will influence the development of state standards for nutrition and PA in child care.

9 Curriculum for Child Care ProvidersTalk about the curriculum development

10 Program Accomplishments

11 Program AccomplishmentsTrained over 5,800 ECE providers Coached over 2,300 ECE providers Goal: 5,500 by June 30, 2016 Types of providers trained: Centers: 68% Licensed Homes (FCC): 22% License-Exempt: 10% Goal: 2,200 by June 30, 2016 Additional 753 second visits given Coaching This includes follow up 1 visits; there were an additional 753 follow up 2 visits Goal is to coach 2,300 child care providers by June 30, 2016 which is approximately, 40% of providers trained A large portion of providers continue to ask for help with ideas for structured physical activity or gardening. Many are also interested in serving meals family style. Coaches provide a variety of physical activity ideas culled from sources like Head Start Body Start, PE Central, and ideas from Jennifer Romack's "On the mmMove" program at Cal State University Northridge.

12 Training & Coaching IncentivesNewsletter Calendar Handouts Posters Re-usable grocery bags Portioned dining sets Coaching: PA kit Yoga cards Recipe cards Healthy eating kit Apron Seeds Books

13 Most Common Coaching RequestsImprove Food/Beverages Menu plan improvements/recipe ideas Developing new menus for new providers Assistance with joining the Child and Adult Care Food Program (CACFP) Healthy cooking activity ideas Increase Physical Activity Expanding physical activity ideas Incorporating more structured play into curriculum Reduce Screen Time Doing physical activity instead of screen time Others Creating “Healthy Policies” Starting a garden at child care sites Developing ideas for classroom container gardening Family engagement and support

14 Making Healthy ChangesSmall steps to big changes Gardening Structured physical activity VS Using gardening as a way to learn about science and nutrition Choosing healthier food options; introducing kids AND providers to new foods Using PA kits

15 Program AccomplishmentsReached over 16,500 parents through events Over 34,500 parents given print information Goal: 7,400 by June 30, 2016 Families participated in activities and given print information Goal: 20,211 by June 30, 2016 Materials disseminated: Nutrition and PA handouts CHLA CC Newsletters

16 Programmatic Changes Along the WayCreated a 1-hour version of the workshop for centers, tailored for Head Start and School District sites. Scheduled center trainings during staff development time. Marketed the workshops specifically for license-exempt providers who may want to become licensed. Continued to create new and exciting giveaways. Outreach strategies constantly evolved.

17 Program Evaluation

18 Evaluation Methods Training and Coaching Satisfaction SurveysFocus Groups Observational Assessments Policies and Practices Self-Assessment Questionnaire Mixed methods evaluation employing different data collection methods (quantitative and qualitative and self-reported and observational) Training and Coaching Satisfaction surveys Focus groups Observational assessments Baseline and 6 month assessments conducted in a sample of child care facilities to measure objectively how nutrition and/or physical activity policies, practices, and environments are impacted as a result of the program. Policies and Practices Self-Assessment Questionnaire preliminary results from the baseline and follow up measure the impact of training and coaching. Policies and Practices Survey They key purpose of this evaluation tool is to determine if policies and practices at child care sites are changed as a result of CHLA CC. Both groups of providers who received only training and those who received both training and coaching are included. The questionnaire does not ask for names, as to encourage honest responses, though the paper is coded with the Gateways ID number so that we may analyze the results based on various differences. This questionnaire is mailed to providers at their work address after attendance at a CHLA CC workshop using a reflective baseline method. A $10 gift card to Target is offered as incentive for completing the questionnaire. If completed, a second “post” questionnaire is mailed 4-6 months later. Preliminary results will be available in the next month or so. On-Site Observations To complement the policies and practices survey with a more objective measure we are conducting on-site observations of child care sites (centers and FCCs) to determine the effectiveness of the project. As funds are limited, on-site observations will only be conducted for sites receiving both training and coaching to limit the number of variables in the evaluation. Sites were recruited for full participation before attending a CHLA CC training to allow for a true baseline observation. The goal for year 3 was 45 sites with another 30 sites in year 4. Recruitment is being handled by the Child Care Alliance office and DPH.

19 Training and Coaching Satisfaction SurveysTraining Satisfaction survey given to every participant at the end of each workshop Coaching Satisfaction survey given at the end of last coaching session Data from every 4th survey was entered and analyzed at the end of each fiscal year Training: (n=415) (n= 553) (n=367) TOTAL: n= 1,335, out of 5,800 trained (23%) Coaching: N for =101 N for =149 N for =174 Total N: 424 out of 2,323 coached (18%)

20 Training Satisfaction Survey ResultsTypes of Providers Reached, by Program Year Child Care Center Family Child Care Center License-Exempt (inc. Family, Friend, Neighbor) Other (students, serving in support role, no response)

21 Training Satisfaction Survey ResultsAges of Children Served, by Program Year Participants were also asked about the ages of children they care for, and are asked to select all that apply. Many family child care providers care for children that are a variety of ages; therefore, it was very common to see providers select multiple categories, and sometimes all three. The higher percentage of children served who are under 3 years and over 6 years of age in Year 4 ( ) is most likely due to a greater number of FCC’s reached compared to the number of centers reached during that year (see Figure 1).

22 Training Satisfaction Survey ResultsProviders who Agree or Strongly Agree with Following Statements, by Program Year: Providers who Agree or Strongly Agree with Following Statements: Because of training, I plan to do new things with the children I serve The training has increased my knowledge about the topic presented The training was informative The training presented helpful ideas I’ll be able to use

23 Coaching Satisfaction Survey ResultsMain Goal Area for Coaching, by Program Year Main goal area consistently PA. Across all 3 years is the breakdown of all participants receiving coaching, not only the ones who completed a survey. In , Participants were allowed to select multiple goals, hence the % adding up to over 100. Years and 15-16, participants selected a main goal to work on. the large number of “unknown” in year 3 represents participants who selected multiple goals (usually PA and food/beverage).

24 Coaching Satisfaction Survey SummaryParticipants reporting a need for more resources to make changes in their programs Program Year Need Additional Resources? (Yes) More Printed Materials More Coaching Sessions More Equipment Other 52.5% 56.7% 22.6% 62.3% 17.0% 66.2% 44.1% 35.5% 56.9% 11.8% 49.4% 52.9% 28.7% 64.4% 12.6% All 3 Years 56.0% 50.1% 30.2% 60.8% 13.2% 56% of participants across all 3 years of the program indicated they needed additional resources to make changes in their programs. Consistently, the most requested resource were equipment and more printed materials.

25 Training Satisfaction Survey – CommentsThe best thing about this training was… “New activities to do in the classroom – and for my own family.” “The encouragement to develop a successful child care.” “The DANCING! I’ve never danced.”

26 Coaching Satisfaction Survey – CommentsThe best thing about this program was… “I have done so many things with my daycare. We planted a big garden, we do art, we cook together, we play all kinds of physical activities. We sit down all together and talk about the things they like and don’t like. It’s so much more fun now.” “The music and movement box she gave us helps our children with our mini Olympics in June and also with our DRDPs.”

27 Focus Groups BackgroundPurpose Impact Successes and challenges Resources Engaging parents and providers Methods & Participants: Eligibility (English/Spanish, Choose Health LA Child Care training and coaching, serve children 0-5) 7 focus groups (6-10 each) 4 English; 3 Spanish 54 participants (Female, Latino, 5+ years in business) $40 gift card & light meal

28 Focus Groups Results Prominent themes Example commentsParticipating increased knowledge and changed own health behavior I’m more aware. I read the labels when I get something. Modeling helped change children’s health Our children have become more physical because the staff has now started doing more movement with them and engaging with them in the yard. Children’s health improved [Child name] is a child who didn’t like fruit. Now he eats bananas, and he eats peaches…that’s a success. Hard to change some families eating habits We’ve got a healthy breakfast ready and waiting. Dad will come in and go, “He just had all of this doughnuts. All he needs is a little swig of milk.” Inclement weather as barriers to physical activity Sometimes I hear teachers saying, “Oh, it’s too cold” when we have the rain during the winter season. Or, “it’s too windy or too hot.”

29 Focus Groups Results Prominent themes Example commentsResources helped open dialogue with families We have a parent newsletter [incorporated training information] where they get to read. I focus in on a particular food and how parents can help at home in having kids eat certain foods. Written policies reinforced health message/s As part of our policy that if, say for instance, we have celebration and the parents want to do a birthday party or something, as long as it’s healthy foods. Multiple strategies to incorporate nutritious foods in meals/snacks Our curriculum introduces new food all the time. They are experimenting, they are doing actual projects involving food and that really helps them. Provide complimentary training and coaching for parents I would like to have a workshop where the parents get involved so they can see what it is we’re doing and why we do policies around certain things. More and regular coaching and networking opportunities desired Provide different options for folks depending on their time commitment.

30 Observational Assessments BackgroundPurpose Changes in nutrition and/or physical activity Barriers and facilitators to promoting healthful changes Assessment Focus Foods served Staff behavior Physical activity opportunities Methods & Participants Purposive sampling & Pretest-Posttest design Eligible providers (not Head Start, serves lunch, serves 3-5 year old) 65 matched pairs (31 centers; 34 homes) – owners or administrators $100 gift card

31 Observational Assessments ResultsFood environment: No change – water access No change – nutrition materials *Significant increase – produce growing area Staff behavior during lunch: No change – most sat with children *Significant increase – times encouraged new/healthy foods No change – modelled eating same food *p<0.05

32 Observational Assessments ResultsChildren’s behavior during lunch: No change – lunch time No change – clean plate *Significant increase – family style + children serve Foods offered: No change – most served unsweetened fruit and non-fried vegetables *Significant increase – dark colored vegetables *Significant increase – grains No change – except 1 at follow-up, no pre-packaged foods or sweets *p<0.05

33 Observational Assessments ResultsPhysical activity environment: No change – most physical activity outdoors *Significant increase – physical activity materials No change – except 1 at follow-up, no screen use during physical activity Staff behavior during physical activity: *Significant increase – participate in structured physical activity *Significant decrease – participate in unstructured physical activity *Significant increase – prompts to increase physical activity *p<0.05

34 Observational Assessments ResultsChildren’s behavior during physical activity: *Significant increase – structured physical activity *Significant decrease – optional structured physical activity *Significant decrease – unstructured physical activity minutes Challenges: Parent motivation – need training/resources for parents Limited resources for staff (money, time, information, equipment, space) Keeping children engaged in structured activity *p<0.05

35 Observational Assessments ResultsRecommendations: Increase capacity of providers to engage staff and parents More and regular coaching and networking opportunities desired More interactive and skill-based learning opportunities

36 Policies and Practices Survey BackgroundSelf-assessment based on the C.H.O.I.C.E. Toolkit, Self-Assessment Questionnaire, and NAP SACC Participants were mailed a baseline and follow-up survey Received 602 matched pairs CHOICE – developed by the Contra Costa Child Care Council and NAP SACC, created by the University of North Carolina t Chapel Hill. Baseline survey was sent about 40 days after the training and follow-up after then. The follow-up survey had to have been received between 4-6 months after the participant attended a training to be included in the analyses. Because the license-exempt group was so small, it was not included in the analyses.

37 Policies and Practices Survey BackgroundSurveys analyzed: Type of Providers Center % Family Child Care % Primary Language English % Spanish % Coaching Yes % No – 45%

38 Policies and Practices ResultsBroad impact vs. deep impact Ceiling effect 85% of participants indicated coaching was helpful 73% reported parents have responded generally positively to rules or guidelines about healthy practices 35% of providers saw increase in demand for their business Broad – goal to reach the greatest amount of people, deep- provide greater depth, more intensive services to smaller group; Goal of public health is to make greatest impact possible reaching many providers and impacting many children and families. Ceiling effect – many providers may have started in the program with a high level of knowledge; therefore, when testing for changes between pre- and post- detecting differences more difficult if knowledge or practices were already high. 73% is of those who indicated they have shared rules or guidelines about healthy practices with parents.

39 Policies and Practices ResultsBreastfeeding: Spanish-speaking participants more prepared to make changes than English-speaking participants Screen time: English-speakers more prepared than Spanish speakers to make changes around screen time; note that quality of screen time is not assessed Parent engagement: 67% of providers reported more materials for parents would be helpful for creating healthy practices and guidelines How to engage parents, how to involve them, provide them with resources for activities to do at home was a theme that came across all components of the evaluation (training survey, coaching satisfaction survey, focus groups, policies and practices survey)

40 Policies and Practices ResultsPhysical Activity (PA): Significant increases in: Parents receive written physical activity policy upon enrollment Children have at least 60 minutes structured or teacher-led physical activity time Information is provided to parents about their child’s physical activity while in child care Staff participate in physical activities with children Parents are provided information that encourages physical activity at home There were differences between centers and fccs at baseline on 6 items: However, at follow-up there no differences in 4 of those areas. 2 areas still showed fccs doing less of: ensuring children with special needs have their needs met, meals and snacks are served at routine times.

41 Policies and Practices ResultsNutrition: Significant increases in: Parents receive written nutrition policies upon enrollment Parents are given information about what their children are eating Parents are given information about what their children are offered (menus) Children decide which foods they will eat from the foods offered Children serve themselves from serving dishes at meal time Foods are served that reflect the ethnicity and cultures of the children in the centers/home Special occasions and holidays are celebrated with healthy foods or with non-food treats Parents are provided information on child nutrition and healthy eating FCCs more likely to serve snacks and dinner than CCCs Serving flavored milk showed the greatest positive change: This question asked participants to report how often they serve flavored or sweetened milk- 1 time a day or more, 2-3 times per week, 1 time per week or less, Never. Of those who had room for growth, that is, those who were serving flavored or sweetened milk with any frequency (except never), 62% made a positive change. 62% served less flavored or sweetened milk at follow-up than they did at baseline. This was a significant change.

42 Policies and Practices ResultsCACFP participation: Over 70% of providers surveyed participate Self-efficacy (preparedness): 90% of providers feel prepared to make changes in food and beverage practices 94.4% of providers feel prepared in doing teacher-led physical activity Providers feel least prepared to address breastfeeding Self-efficacy – 53.8% feel prepared to make changes in Breast feeding practices

43 Policies and Practices ResultsChallenges: Most frequently cited: Lack of support from parents Not enough resources to make changes Providers who received coaching reported more challenges at baseline and follow-up than those who did not Center-based providers reported more challenges at follow-up than family child care providers Challenges: 34.7% reported lack of support from parents; 33.4% not enough resources to make changes Coached experienced more challenges – Those who were experiencing more challenges in taking steps towards creating healthy practices or routines and in creating written rules or guidelines may self-select into the coaching group. It’s possible that those who were facing more challenges felt they needed more support and were more likely to want to receive coaching than those who experienced less challenges. Center-based more challenges: selected from factors that may be less of a challenge for fccs: e.g. lack of support from management/leadership staff, lack of support from other child care staff. There may not have been a difference at baseline because they didn’t start experiencing these challenges until they started trying to make changes at follow-up.

44 Lessons Learned from Program Implementation and EvaluationProviders need more resources for their sites for parents Providers need & want more training, especially around family engagement, as well as training for parents FCC’s are fertile ground for making healthy changes Further intervention regarding breastfeeding practices needed Need LE-specific trainings Across all evaluation methods, providers reported needing more resources and wanted to learn ways to engage parents. Evaluation also found that FCC’s are fertile ground for making healthy changes as they are typically more autonomous in decision-making, and many serve more meals and snacks than centers. [continue…] Our target was that out of all providers trained, 10% would be license-exempt providers. They don't really consider themselves providers (more like neighbors or grandmas or friends) and could benefit from having training that is tailored specifically for them. When LEs did attend our training, we then sent them the CHLA Kids flyer for 6-week healthy parenting workshop – as of last month, 400 LEs had attended (identified themselves as “caring for one or more children in addition to their own at least 3 days a week.”

45 What We DID Accomplish Improved nutrition and PA practices in child care. Creation and adoption of nutrition and PA policies in child care. Providers communicate nutrition and PA policies with parents via newsletters or other venues. Identified barriers and concerns that child care providers face in efforts to promote good nutrition and active play. Promotion of, and the benefits of participation in, CACFP. Reduced prevalence of overweight & obesity among children in child care. In addition, we have created partnerships locally, statewide and nationally, and have set a precedent for Public Health to work with child care professionals. We are also working with our partner, Child Care Resource Center, to put our entire curriculum online as videos that LAC providers can watch for credit. Look for this in We will also have provider highlight videos coming out at the end of this year. Finally, we built momentum. Our work is not done but at least agencies are talking about these issues and perhaps more parents are demanding certain standards. ?

46 Narrative from the FieldThis program has changed my life. Through the program I learned about portions, family-style eating, and physical activity – lessons I took home to my family too. My son has struggled with his weight for a long time and was unhappy and never wanted to go out. But since making changes at home, he lost 15 pounds, seems much happier, and displays greater self-confidence. Thank you. – CHLA CC participant* “[CHLA CC] helped me attain my dream job, and I don't think anyone enjoyed this program as much as I did. It gave me the opportunity to inspire, motivate, create, and learn to become an efficient public speaker…I feel it was very positive for the children and families it reached, and that it provided more awareness about what we can all do to raise healthier children. I also feel it was a wonderful way of reaching out to providers, by giving them support and motivation, as they give so much of themselves for the children and families they serve.” – CHLA CC coach *Edited for length and clarity

47 Special Thanks! Choose Health LA Child Care Coaches:Mariah Johnson – CCRC Sharlout Golbari – Connections Adriana Sanchez – Crystal Stairs Sophia Gonzalez – MAOF Armida Rosario – Options Maria Ponce – Pathways Dell Harris & Martha Arreguin – Pomona Holiday photo!

48 Contact Information Helen O’Connor, MPH Health Program Analyst Los Angeles County Department of Public Health (213) Jeremiah Garza, PhD, MPH, MA Associate Sarah Samuels Center for Public Health Research & Evaluation (510)