Keys to Healthy Family Child Care Homes

Childhood obesity is a major public health problem and an important predictor of obesity
later in life. Although early childhood is a formative period for dietary and activity
habits, little research targeting this young age group has been conducted. Child care
facilities are a prime setting for interventions targeting young children, given the number
of families using some form of out-of-home care. Family child care homes (FCCH) are a
particular type of child care facility in which the provider cares for children out of
his/her own residence. FCCHs are generally less regulated than child care centers, and a
significant percentage do not meet established recommendations for physical activity and
nutrition practices. While there is a great need to intervene in these settings, there has
been only one other published obesity prevention intervention in FCCHs to date.
Interventions targeting FCCH providers could help promote healthy child weight by creating
child care environments that provide and support active play opportunities and healthy food
choices, while helping providers become role models for healthy lifestyles (physical
activity and diet). However, the child care industry is faced with many challenges,
including limited profitability. By incorporating strategies for overcoming some of these
economic challenges, interventions may be able to more easily address barriers to
implementing and sustaining the changes needed to promote regular physical activity and
healthy dietary intakes in children.

This project will use a cluster-randomized controlled trial (RCT) to test the efficacy of
the 9-month intervention, Keys to Healthy Family Child Care Homes, which targets FCCHs. Keys
will be delivered in three modules which are designed to promote (1) provider health and
providers as healthy role models, (2) physical activity- and nutrition-supportive
environments at the FCCH, and (3) healthy business practices. Each module will be delivered
via group workshops, on-site visits and phone contacts using Motivational
Interviewing-inspired coaching and educational toolkits. By combining these components, the
ultimate objective is to create healthy and stable FCCHs that promote healthy physical
activity and eating behaviors in children.

The project will recruit and randomize 165 FCCHs (83 per arm). At each FCCH, subjects will
include one child care provider and 3 children (we are targeting children between the ages
of 1.5 and 4 years old, but one to two additional children who are younger than 18 months
may also take part in height and weight measurements only). These 165 FCCHs and 825 children
(495 children ages 1.5-4.9 years old and 330 children ages younger than 18 months) will be
recruited in five waves over the course of 3 years, each wave enrolling 30 or more FCCHs
(half assigned to each study arm). For recruitment, we will target areas with lower income
households and with higher prevalence of child overweight/obesity within a 100 mile radius
of the University of North Carolina at Chapel Hill (UNC) and Duke University. For each wave,
potential FCCHs will be identified through the online database of licensed programs provided
by the North Carolina Division of Child Development and Early Education
(http://ncchildcaresearch.dhhs.state.nc.us/search.asp). Trained project staff will contact
potential FCCH providers by mail/email (informational flyer/packets), telephone, and
promotion at local professional meetings and community events. Informed consent will be
obtained from providers and parents of participating children. Data collection will occur
before and after the 9-month intervention, and each participating child care provider will
receive up to $200 for completion of measures at both time points. At follow-up, we will
also recruit newly enrolled children between the ages of 1.5 and 5 years old (one or two per
home, thus about 210 additional children) to take part in all measures to allow additional
cross-sectional analysis.

Increased child physical activity and improved quality of child diet while at the FCCH will
be the primary outcomes used to assess the impact of this innovative, theory-driven
intervention. Secondary outcomes and mediators include child body mass index, provider body
mass index, provider weight-related behaviors (dietary intake and physical activity),
provider motivation, self-efficacy and social support, and obesogenic (nutrition- and
physical activity-related) environmental characteristics of the FCCH (including policies,
practices and communication between providers and parents). Primary analyses for primary
aims will involve testing each of these hypotheses under the intent-to-treat principle using
Generalized Linear Mixed Models (GLMM) that will account for the correlation induced by the
clustering of children within FCCHs. Statistical analysis will employ Statistical Analysis
System (SAS).

Inclusion Criteria:

- FCCH must have at least 2 children between the ages of 1.5 and 4 years currently
enrolled. * At least 2 children/families must agree to take part for the FCCH to
remain eligible. (Note: Children ages 0-17 months may take part in height and weight
measurements only)

- FCCH must have been in business for at least 2 years.

- FCCH must have a working telephone number.

- Provider must be able to read and speak English.

Exclusion Criteria:

- FCCHs cannot serve exclusively special needs children.

- FCCHs cannot close down during the summer months.