3

Barriers and Facilitators to Providing Meals and Snacks that Align with the Current Dietary Guidance

Recommended revisions to the Child and Adult Care Food Program (CACFP) meal requirements laid out in the CACFP report were designed to come as close as possible to the Dietary Guidelines (USDA and HHS, 2010), while still being practical for the CACFP setting (IOM, 2011). Likewise, the Healthy, Hunger-Free Kids Act of 2010 (P.L. 111-296) requires for the first time that CACFP meal patterns align with current dietary guidance. Workshop participants considered how to measure factors that serve as barriers and facilitators to implementing a new CACFP meal pattern in alignment with current dietary guidelines.

Data on the barriers and facilitators to changing meal requirements in a child care setting, CACFP or otherwise, are even sparser than data on food group and nutrient intake in the same setting(s). In fact, as presenter Lorrene Ritchie pointed out, data on barriers and facilitators to any kind of change in the meal and food environment in a child care setting are lacking. Ritchie reviewed the few methodologies that have been used to evaluate changes in the meal and food environment in child care centers and, to a lesser extent, in day care homes, with the expectation that one or more might be useful for systematically studying barriers and facilitators to meal pattern compliance in CACFP at a national level.

Acknowledging that day care home providers differ significantly from child care center staff in the way that they plan menus and purchase, prepare, and serve meals, with much more limited data available for day care homes, presenter Angela Odoms-Young suggested that studies of the home meal and food environment might be a reasonable proxy for studying food



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3 Barriers and Facilitators to Providing Meals and Snacks that Align with the Current Dietary Guidance R ecommended revisions to the Child and Adult Care Food Program (CACFP) meal requirements laid out in the CACFP report were de- signed to come as close as possible to the Dietary Guidelines (USDA and HHS, 2010), while still being practical for the CACFP setting (IOM, 2011). Likewise, the Healthy, Hunger-Free Kids Act of 2010 (P.L. 111-296) requires for the first time that CACFP meal patterns align with current di- etary guidance. Workshop participants considered how to measure factors that serve as barriers and facilitators to implementing a new CACFP meal pattern in alignment with current dietary guidelines. Data on the barriers and facilitators to changing meal requirements in a child care setting, CACFP or otherwise, are even sparser than data on food group and nutrient intake in the same setting(s). In fact, as presenter Lorrene Ritchie pointed out, data on barriers and facilitators to any kind of change in the meal and food environment in a child care setting are lacking. Ritchie reviewed the few methodologies that have been used to evaluate changes in the meal and food environment in child care centers and, to a lesser extent, in day care homes, with the expectation that one or more might be useful for systematically studying barriers and facilitators to meal pattern compliance in CACFP at a national level. Acknowledging that day care home providers differ significantly from child care center staff in the way that they plan menus and purchase, pre- pare, and serve meals, with much more limited data available for day care homes, presenter Angela Odoms-Young suggested that studies of the home meal and food environment might be a reasonable proxy for studying food 35

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36 RESEARCH METHODS TO ASSESS DIETARY INTAKE and mealtime practices in family day care settings. She reviewed several methodologies for assessing barriers and facilitators in both the home food “microenvironment” (i.e., the environment inside the home) and the “mac- roenvironment” (i.e., the social and environmental context of the home itself). The same methodologies could be adapted for use in identifying factors that operate as barriers or facilitators to implementing the CACFP meal requirement changes. EVALUATING BARRIERS AND FACILITATORS TO CHANGE IN CHILD CARE CENTERS1 Lorrene Ritchie identified two major elements of organizational change: factors external to the organization (e.g., how the change is communicated, external resources available to an organization to implement the change, and perceived value of the change) and factors internal to the organization (e.g., existing factors that influence reaction to the change or willingness to change, steps for putting the change into practice, and how the change is made permanent). Both external and internal change are part of the “Model of Diffusion of Innovations in Organizations” (Greenhalgh et al., 2004; Olstad et al., 2011), which Ritchie pointed to as a good theoretical framework for building research questions on barriers and facilitators to organizational change in child care settings. In her opinion, having a theo- retical framework in hand is helpful, as researchers have only just begun to touch the surface of this topic in child care settings. There are many ques- tions that have not even been asked yet. Ritchie highlighted three types of child care sites where more studies are especially needed: sites with younger children, family child care homes, and license-exempt care sites (a child care home that can operate legally without a license; e.g., a provider who cares only for his or her relatives may be exempt). Ritchie identified four “to whom” types of barriers and facilitators, that is, “to whom” the factor is a barrier or facilitator: (1) centers (e.g., costs, ac- cess, staffing, facilities, policy, and experience); (2) providers (e.g., time, train- ing, support, priorities, and health concerns); (3) children (e.g., preferences and knowledge); and (4) parents (e.g., preferences, support, and knowledge). The methodologies she discussed addressed a mix of “to whom” types of barriers and facilitators. 1 This section summarizes the presentation of Lorrene Ritchie from the University of Cali- fornia, Berkeley.

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37 BARRIERS AND FACILITATORS TO PROVIDING MEALS AND SNACKS Measuring Barriers to Change in Child Care Settings Most of the methodologies that Ritchie identified for use in measuring barriers to change in child care settings were built upon the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) question- naire (Benjamin et al., 2007).2 Although NAP SACC itself did not contain any barrier questions, researchers have adapted the questionnaire for use in measuring barriers. For example, in ongoing work, Dianne Ward and colleagues added self-efficacy questions aimed at understanding individual behavior change within the context of organization behavior change (e.g., How confident do you feel about improving the quality of food that you serve? How confident do you feel about making menu changes?) (Personal communication, D. Stanton Ward, University of North Carolina at Chapel Hill, January 2012). The Yale Rudd Center also used a NAP SACC–like questionnaire in its Child Care Nutrition & Physical Activity Assessment survey (Henderson et al., 2011). The survey included a checklist of barriers to promoting a healthy environment (e.g., lack of support, sale of unhealthy foods at fundraisers, serving unhealthy foods at social events, insufficient funds, inadequate food preparation or storage facilities, limitations of food service providers or vendors, lack of policies, and lack of training for food service staff). As yet another example of a NAP SACC–like tool being used to assess barriers to change in child care, the Survey of Healthy Activity and Eating Practices in Environments in Head Start (SHAPES) includes a question on challenges to providing healthier foods in child care (Whitaker et al., 2009). Ritchie noted that the questions are more theoretical than those on the Yale Rudd Center’s Child Care Nutrition & Physical Activity Assessment survey. Rather than asking the provider about current challenges, the tool asks the provider about anticipated challenges if they were to serve healthier foods. The tool acknowledges some of the same challenges as the Yale Rudd Cen- ter survey (e.g., funds, control over food service provider, and knowledge) but also includes some additional challenges (e.g., time, child preferences, and parent support). Finally, the Statewide Assessment of California tool administered by Ritchie and colleagues (2012) also included some barrier questions. Based on results of the survey, major challenges to providing healthier foods among both CACFP and non-CACFP providers were no CACFP reim- bursement (4 percent), parents not wanting healthier foods (7 percent), not enough information (8 percent), not enough room for food preparation or 2 NAP SACC is an intervention designed to improve the nutrition and physical activity en- vironment, policies, and practices of child care centers through self-assessment and technical assistance. For more information, visit http://www.napsacc.org.

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38 RESEARCH METHODS TO ASSESS DIETARY INTAKE storage (15 percent), lack of control over food provider (18 percent), chil- dren not liking (48 percent), and high food costs (57 percent). Cost as a Potential Barrier With respect to measuring food costs as a barrier, rather than asking if food costs were a barrier, Monsivais and Johnson (2012) attempted to quantify food costs by matching menus and grocery receipts. Assessing Facilitators to Change in Child Care Gathering information on facilitators is more difficult than gathering information on barriers, according to Ritchie. Many people are unable to articulate why things are “easy.” When asked, a typical response is, “I don’t know. I just do it.” So rather than asking why certain things are easy or not, Ritchie suggested that a more useful approach is to ask about characteristics of the organization or population being served that researchers think might contribute to making something “easy.” As an example of using indirect questioning to gather facilitator in- formation, in a study of Head Start, state preschools, and other CACFP centers, Hecht et al. (2009) asked, “Where is food prepared?” The survey showed that food for Head Start programs is typically prepared in a cen- tral kitchen, while State Preschools typically obtain food from school food service, and other CACFP centers prepare food on site. These are very dif- ferent situations, with variations in provider control over food preparation, relationships providers have with their food preparers, and other similar factors. Any of these factors could be facilitators to change, depending on the situation. In the same study, another question was, “Who does the menu planning?” Again, the responses varied, with some menu planning being done by the caregivers themselves, some by the director or supervisor, some by the cook or chef, and some by a dietitian. Access to a dietitian would presumably be a facilitator to making certain changes, in Ritchie’s opinion. If that is the case, Head Start would have a “leg up” on making some of the suggested changes recommended in the CACFP report (IOM, 2011), given that, according to the Hecht et al. (2009) study, 62 percent of Head Starts have a dietitian available for menu planning (compared to 19 percent of state preschools, 7 percent of CACFP centers, and 0 percent of family child care homes). Finally, providers were asked about major factors used when considering what foods to offer children. The number one factor across all types of providers was nutritional content (81 percent), followed by cost (20 percent), child preferences (14 percent), availability (13 percent), and convenience (9 percent). Thus, the indirect questioning used in the Hecht

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39 BARRIERS AND FACILITATORS TO PROVIDING MEALS AND SNACKS et al. (2009) survey led to the nutritional content of healthy foods being identified as yet another facilitator to change. Implementing Enhanced Nutrition Standards in Delaware: Lessons Learned In a focus group study on child care providers’ and parents’ perception of Delaware’s enhanced nutrition standards, Gabor et al. (2010) found that the potential for promoting health was definitely a facilitator to adopting the new nutrition standards. Ritchie suggested that providers with less exposure to policies to promote healthy foods would likely face a steeper learning curve when the new CACFP guidelines are implemented. Gabor et al. (2010) also identified some negative perceptions that might act as bar- riers to changes associated with the new CACFP guidelines (e.g., concerns about children not getting enough fat or whole milk after age 2 years when low-fat or nonfat milk is recommended, children not eating nutritious foods and therefore going hungry, and meals served being inconsistent with school meal standards). With respect to meal planning and food preparation, Ga- bor et al. (2010) identified the challenge of making meals appealing and providing variety as the greatest concerns among providers. Cooking from scratch and modifying recipes were also barriers. With respect to facilitators, Gabor et al. (2010) identified several fac- tors related to meal planning and food preparation changes: advanced menu planning, advanced meal preparation, providing kid-friendly foods, making the transition to healthier foods and beverages gradually, and shar- ing menus and recipes among providers. Ritchie noted that one of the interesting features of the Gabor et al. (2010) study on barriers and facilitators to implementing new enhanced nutrition standards in Delaware was its reliance on focus groups, a meth- odology that no other speakers during the workshop addressed. What Are the Best Methods for Assessment of Barriers and Facilitators to Organizational Change? To assess child care nutrition and physical activity in child care settings, the previously mentioned Yale Rudd Center Validity Study (Henderson et al., 2011) compared interview, observation, and self-report methodologies and evaluated the strengths and limitations of each in terms of cost, feasi- bility, and data quality. They concluded that the best method depends on what one wants to know. Interviews are very good for assessing compli- cated factors, such as staff training (e.g., Who is being trained? How often? On what topics?), and for very sensitive questions (e.g., information that people may not want to share, such as whether a provider is really doing

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40 RESEARCH METHODS TO ASSESS DIETARY INTAKE what is best for the children). Interviews during which the interviewer is able to develop a rapport with the provider may generate more accurate information than other methods. Observation is good for assessing routine child feeding practices. Surveys are good for assessing most other types of measures, including policies. EVALUATING BARRIERS AND FACILITATORS TO MAKING HEALTHY FOOD CHOICES IN THE HOME ENVIRONMENT3 Information on barriers and facilitators to change is especially lacking for family child care homes. Because family child care homes operate more like a home environment than a child care center, with providers operat- ing more like parents than child care center staff, Angela Odoms-Young suggested that research on barriers and facilitators in the home food envi- ronment provides a framework for understanding barriers and facilitators to change in CACFP day care homes. The findings—and methodologies employed—may be adaptable to a study of CACFP day care homes. The home food environment is complex. Several studies have shown that the social and environmental context of family settings, both inside the home (the microenvironment) and outside the home (the macroenvi- ronment), impacts provision of food, intake of food, and the link between intake and health outcomes. For example, with respect to the microenviron- ment, women living in food-insecure households are more likely to consume high-calorie but nutritionally poor food to avoid feelings of hunger; to eat irregular meals; to skip breakfast; and to consume less milk and fewer fruits and vegetables (Martin and Lippert, 2012). Other studies have shown that short sleep duration is a risk factor for consumption of energy-dense foods; television viewing is associated with increased caloric consumption; and stress increases energy intake for energy-dense foods and shifts food choices from lower- to higher-fat foods. The Chicago Family Food Survey As an example of relevant research on the home food environment, Odoms-Young highlighted the Chicago Family Food Survey (CFFS) (Kong et al., in press; Odoms-Young et al., unpublished). CFFS is a study of about 300 participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) between the ages of 2 and 3 years and their parents and/or primary caregivers. Parents or caregivers were surveyed both before the new food package was introduced and then 6, 12, and 18 3 This section is based on the presentation of Angela Odoms-Young from the University of Illinois, Chicago.

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41 BARRIERS AND FACILITATORS TO PROVIDING MEALS AND SNACKS BOX 3-1 Measures Used in the Chicago Family Food Survey • C hild Feeding Questionnaire (CFQ) (Birch et al., 2001) • F ood Availability/Accessibility Measure (Cullen et al., 2003) SDA Short Household Food Security Surveya • U • E nvironmental Confusion in Household (CHAOS) (Matheny et al., 1995) • C ontemporary Life Stressors (CRISYS) (Shalowitz et al., 1998) • P erceived Neighborhood Availability (Moore et al., 2008) • S outhwest Chicago Food Store Audit Instrument (Zenk et al., 2006) awww.ers.usda.gov/briefing/foodsecurity/surveytools.htm. months afterward.4 The survey assessed several microenvironmental factors that could potentially influence what foods are provided, which foods are consumed, and how nutrient intake impacts health outcome(s). These fac- tors include child feeding practices, parent or caregiver nutrition knowledge and food preferences, shopping patterns, home food availability, household food security or insecurity, children’s sleeping routines, television viewing and computer use, level of stability within the home, and stressful life events. The researchers explored aspects of the macroenvironment as well, including perceived availability of healthy versus unhealthy food options and cost of healthy versus unhealthy food. Odoms-Young indicated that measures used in CFFS may be relevant when identifying contextual factors and child care provider practices that influence children’s dietary intake in child care homes (see Box 3-1). For example, to assess child feeding practices, the survey utilized the Child Feeding Questionnaire (CFQ). The CFQ was originally designed to assess parents’ perceptions and concerns regarding childhood obesity, as well as parents’ child-feeding attitudes and practices (Birch et al., 2001). Specifi- cally, in the Chicago survey, it was used to assess • Measures of parental perception of child and parent weight and concern about weight: o Responsibility (e.g., “When your child is at home, how often are you responsible for feeding her/him?”); 4 In2009 the U.S. Department of Agriculture (USDA) made major revisions to food packages provided by WIC. For more information on the new food packages, visit http://www.fns.usda. gov/wic/benefitsandservices/foodpkg.htm.

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42 RESEARCH METHODS TO ASSESS DIETARY INTAKE o Parent weight status (parents who have heard a lot about obesity may change their feeding based on perceived weight status of either themselves or their children); and o Child weight status; and parents’ concerns about child weight (e.g., “How concerned are you about your child becoming overweight?”). • Measures of parents’ attitudes and practices regarding their use of controlled child-feeding practices included o monitoring (e.g., “How much do you keep track of the high-fat foods that your child eats?”); o restriction (e.g., “I intentionally keep some food out of my child’s reach”); and o pressure to eat (e.g., “My child should always eat the food on her plate”). Odoms-Young remarked that some of these same questions would be appropriate to ask of child care providers as well. In addition, CFFS measures used to assess parent or primary caregiver perceptions of the macroenvironment may be particularly relevant for CACFP given that child care homes may be located in residential communities where limited avail- ability or high cost of healthy food options, particularly in Latino, African American, and rural communities, may shape what is provided. Additionally, the researchers added questions about child-feeding prac- tices that were not included in the CFQ. Specifically, they asked how often children eat while watching television, videos, or DVDs; how often children eat meals at a regular time; how often children share their food with adults or eat food from their parents’ plates; and how often children eat food from a fast food restaurant. To assess shopping patterns, the researchers asked respondents to pro- vide the names and addresses of two stores where the main shopper in the household normally purchases food (e.g., supermarkets, grocery stores, corner or convenience stores, dollar stores, drug stores, liquor stores, gas stations), and how often the person in charge of groceries and food shops at those stores. Later, the researchers assessed those stores. To assess home food availability, the researchers used a measure de- veloped by Cullen et al. (2003) to assess availability (in the home in the last 7 days) and accessibility of fruit, juice, and vegetables (fresh, frozen, or canned), as well as availability (in the home in the last 7 days) and ac- cessibility of low- and high-fat dairy products and grain products. All of these measures were self-report measures. To account for cultural modi- fications, the survey added some foods that are traditionally available in the Latino culture (e.g., mangoes, avocados, nopales/nopalitos [cactus], jicamas).

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43 BARRIERS AND FACILITATORS TO PROVIDING MEALS AND SNACKS To assess household food security or insecurity, the researchers used the USDA Short Household Food Security Survey.5 Items included the follow- ing: “The food that we bought just didn’t last, and we didn’t have money to get more,” “We couldn’t afford to eat balanced meals,” “Did you or other adults in your household ever cut the size of your meals or skip meals because there wasn’t enough money for food?,” “Did you ever eat less than you felt you should because there wasn’t enough money for food?,” and “Were you ever hungry but didn’t eat because there wasn’t enough money for food?” To assess the level of stability within the home, the researchers used the Environmental Confusion in Household (CHAOS) measure (Matheny et al., 1995). Items included the following: “There is very little commotion in our home,” “We can usually find things when we need them,” “We almost always seem to be rushed,” “We are usually able to stay on top of things,” “No matter how hard we try, we always seem to be running late,” “It’s a real zoo in our home,” “At home we can talk to each other without being interrupted,” “There is often a fuss going on at our home,” “No matter what our family plans, it usually doesn’t seem to work out,” “You can’t hear yourself think in our home,” “I often get drawn into other people’s arguments at home,” “Our home is a good place to relax,” “The telephone takes up a lot of our time at home,” “The atmosphere in our home is calm,” and “First thing in the day, we have a regular routine at home.” To assess stressful life events, the researchers used the Contemporary Life Stressors (CRISYS) measure (Shalowitz et al., 1998). CRISYS measures 63 items pertaining to potentially stressful life events during the past 6 months. Items include • Financial issues (e.g., “Did you go deeply in debt?,” “Did your income decrease by a lot?,” “Did you miss a rent or mortgage payment because you couldn’t pay for it?,” “Was your telephone, electricity, or gas turned off?”) • Legal issues (e.g., “Did anyone in your family get arrested?”) • Career issues (e.g., “Did you begin a new job or get promoted?,” “Did you get laid off?”) • Relationships (e.g., “Did you get a divorce or break up with a partner?,” “Did your regular child care arrangements change in any way?”) • Safety in the home (e.g., “Did you feel emotionally or physically abused?”) • Safety in the community (e.g., “Did you hear violence outside your home?,” “Did you see drug dealing in your building or neighbor- 5 For details, see www.ers.usda.gov/briefing/foodsecurity/surveytools.htm.

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44 RESEARCH METHODS TO ASSESS DIETARY INTAKE hood?,” “Were you a victim of a crime while you were outside or away from your home?”) • Medical issues (e.g., “Did you/your partner have a baby?,” “Did you become ill or did you have a flare-up of a chronic illness?,” “Did your children become ill or did your children have a flare-up of a chronic illness?,” “Did another family member become ill?”) • Home issues (e.g., “Did a relative or friend move into your home?”, “Did you move?,” “Did rats, mice, or insects bother you in your home?”) • Authority issues (e.g., “Did you have trouble with social ser- vice agencies?,” “Did you have trouble with medical or health professionals?”) • Prejudice (e.g., “Did someone treat you unfairly because of your race?,” “Did someone treat you unfairly because you didn’t have a lot of money?”) • Other items (e.g., “Did you ever use alcohol or drugs to get through a day?,” “Did you have trouble reading or understanding some- thing that was important to you?”) Odoms-Young suggested that stressors and financial strains experi- enced by family day care providers could potentially impact their ability to plan and purchase healthy meals and, consequently, to implement the new CACFP guidelines. Finally, the CFFS used two macroenvironmental measures: (1) per- ceived neighborhood availability (e.g., “a large selection of fresh fruits and vegetables is available in my neighborhood”) (Moore et al., 2008) and (2) availability, selection, and cost at specific stores where the respondents said they shopped, using the Southwest Chicago Food Store Audit instrument (Zenk et al., 2006). DISCUSSION Following Ritchie and Odoms-Young’s presentations, workshop par- ticipants engaged in an open discussion on methodologies for assessing barriers and facilitators to implementing the recommended CACFP meal pattern requirements. Major topics of discussion were state-level “prelimi- nary” data, cost as a potential barrier, food insecurity as a potential barrier, and other macroenvironmental barriers. Each of these is discussed in more detail below.

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45 BARRIERS AND FACILITATORS TO PROVIDING MEALS AND SNACKS State-Level “Preliminary” Data There were several comments about the possibility of preliminary data on barriers and facilitators being collected in states that have been imple- menting new state nutrition guidelines for child care (e.g., California, Delaware, New York, and West Virginia). States often have a wealth of raw data but insufficient resources to analyze those data. If such data ex- ist, they could help frame questions for a nationally representative study of child care. For example, one audience member remarked that, in New York, registered dietitians are entering homes to assist providers with implement- ing new state guidelines and there might be data available in the future on the ease, or difficulty, of making the required changes. Ritchie noted that the California state legislature passed a law regulating beverages in all child care centers and homes and that a statewide survey which is about to be launched will be providing data not just on how well the facilities conform to the new standards but also on barriers and facilitators to making the necessary changes. She said, “Some of those natural experiments and the lessons that we have learned from them will be very informative” and will “help frame how we ask questions for the national study.” Cost as a Potential Barrier Cost is often perceived as a significant barrier to implementing change in child care settings, yet many unanswered questions remain. A few audi- ence members listed some of those questions. For example, what does it mean when providers say that certain foods cost “too much”? What are provider expectations around cost? How much do providers in family day care homes think about what food costs should be? Odoms-Young agreed that these are important questions to consider and suggested that some providers may be experiencing economic constraints similar to what the children’s families are experiencing. Fred Glantz emphasized the importance of looking at the entire cost of an operation, not just the cost of the actual purchased food; for example, the cost of labor should be considered as well. If a home or center buys more prepared foods, the food cost will be higher than for a site that relies on raw ingredients because the cost of the processed food embodies the labor that went into the product(s). However, the total cost (food plus labor to prepare the food) for a home or center that buys raw ingredients may be similar. Quantitative data on cost are especially lacking. This raises the ques- tion, how can cost data be collected in a family day care setting? If families are shopping for foods for their child day care programs while shopping for household foods, how are the costs separated? Ritchie identified two

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46 RESEARCH METHODS TO ASSESS DIETARY INTAKE studies that have quantified costs in family child care homes (Monsivais and Johnson, 2012; Monsivais et al., 2011). Glantz noted that there is some very early research on family child care cost that could be useful. In 1976, Abt Associates was contracted by the Administration for Children and Families to do a national survey of family child care. Part of that study was an intensive examination of what it costs to run a family child care home, as opposed to a center. It was a very detailed study. While outdated, he said that it has the best data currently available and that the methodol- ogy is relevant. The Impact of Food Insecurity on Implementing Organizational Change Previous CACFP research done by Madeleine Sigman-Grant and col- leagues (2006) has shown that staff in CACFP sites respond differently to children from food-insecure households. It was suggested that this would be an interesting issue to explore further. For example, do providers serve more of some things? Do they refer parents to another resource? How often do they face this situation? Food insecurity may also influence parents’ ex- pectations of what their children are going to be served. While some parents may be more concerned with nutrition, others may be more concerned with whether their children are getting enough of any food. Again, this would be an interesting issue to explore further. For example, are parents satisfied with what their children are being served? Other Macroenvironmental Barriers It was suggested that variation in licensing exemption standards is another “external” factor that may impact how providers practice. Exemp- tion rules vary across states, as do requirements for licensing. One audi- ence member observed that license-exempt providers typically have fewer resources at their disposal and are often less skilled in preparing foods than other types of child care settings. Finally, several participants agreed that another important measure to consider is where home day care providers purchase their foods. Glantz re- marked that in some places, like New Mexico, where the population density is not great enough to support many child care centers, most child care fa- cilities are family day care homes. Many of those homes are located in rural food deserts where the choices for food purchasing are highly restricted. In some places, the only source for food is the local gas station. Another participant pointed out that food deserts exist in urban areas as well.

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