Setting: Early Care and Education & Out-of-School Time

Strategy Profile: Creating Healthier Early Care and Education Environments

Posted on September 22, 2023

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

Improving nutrition, physical activity, & screen time policies & practices for children ages 3-5 by incorporating the Nutrition & Physical Activity Self-Assessment for Child Care (NAP SACC) Program into state’s Quality Rating and Improvement Systems (QRIS) for early care and education programs.

What population benefits?

Children ages 3-5 attending licensed early care and education programs that participate in their state’s Quality Rating and Improvement Systems (QRIS).

What are the estimated benefits?

Relative to not implementing the strategy
Promote healthy child weight.

What activities and resources are needed?

Activities	Resources	Who Leads?
Train early care and education health professionals to work with early care and education programs	• Time of state training consultant to train early care and education health professionals • Time of early care and education health professionals to be trained	State QRIS administrators
Provide consultation to early care and education program directors and staff for conducting self-assessments of program policies and practices, completing action plans, and implementing changes to improve nutrition, physical activity, and screen time environments in programs	• Time of early care and education health professionals to provide consultation to early care and education programs • Time of early care and education program directors and staff to participate in consultation	Early care and education health professionals
Provide materials and equipment for implementing NAP SACC program	• Cost for GO NAP SACC online license • Physical activity equipment costs	State QRIS administrators
Implement changes in early care and education programs to improve nutrition, physical activity, and screen time environments	• Time of early care and education program directors to implement changes	Early care and education program directors
Improve nutritional quality of meals served in early care and education programs	• Food costs for improving nutritional quality of meals	Early care and education program directors
Monitor compliance with NAP SACC program	• Time of state-level QRIS Administrators to monitor compliance	State QRIS administrators

Strategy Modification

In states where NAP SACC is already being implemented, the strategy could be modified to focus on increasing the number of early care and education programs that participate in NAP SACC. With this modification, the cost for the GO NAP SACC online license would not be needed, since it is a fixed annual cost paid per state (i.e., it does not depend on the number of participating programs). With this modification, the impact on health is expected to be similar, and the impact on reach and cost would vary according to the number of programs reached.

FOR ADDITIONAL INFORMATION

Gortmaker SL, Wang YC, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC, Cradock AL. Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Aff (Millwood). 2015 Nov;34(11):1932-9. doi: 10.1377/hlthaff.2015.0631. Supplemental Appendix with strategy details available at: https://www.healthaffairs.org/doi/suppl/10.1377/hlthaff.2015.0631/ suppl_file/2015-0631_gortmaker_appendix.pdf

Selected CHOICES research brief including cost-effectiveness metrics:

Adams B, Sutphin B, Betancourt K, Balamurugan A, Kim H, Bolton A, Barrett J, Reiner J, Cradock AL. Arkansas: Creating Healthier Child Care Environments: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) in the Quality Rating Improvement System (QRIS) {Issue Brief}. Arkansas Department of Health, Little Rock, AR, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2021. Available at: https://choicesproject.org/publications/brief-napsacc-arkansas

Kenney EL, Giles CM, Flax CN, Gortmaker SL, Cradock AL, Ward ZJ, Foster S, Hammond W. New Hampshire: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention {Issue Brief}. New Hampshire Department of Health and Human Services, Concord, NH, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2017. Available at: https:// choicesproject.org/publications/brief-napsacc-intervention-new-hampshire

Browse more CHOICES research briefs & reports in the CHOICES Resource Library.
Explore and compare this strategy with other strategies on the CHOICES National Action Kit.

Suggested Citation

CHOICES Strategy Profile: Creating Healthier Early Care and Education Environments. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; September 2023.

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

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Strategy Profile: More Movement in Early Care and Education Settings

Posted on September 15, 2023

Policy to promote physical activity among children ages 3-5 in licensed early care and education (ECE) programs by requiring training for early care educators in the provision of structured physical activity opportunities using an evidence-based curriculum.

What population benefits?

Children ages 3-5 who attend licensed early care and education programs.

What are the estimated benefits?

Relative to not implementing the strategy
Increase children’s moderate-to-vigorous physical activity levels and, in turn, promote healthy child weight.

What activities and resources are needed?

Activities	Resources	Who Leads?
Train early care and education program directors and staff on evidence-based strategies and curricula (Hip Hop to Health Jr.) to provide physical activity instruction	• Time for State Early Care and Education Agency Training Consultant to prepare for and lead training • Time for early care and education program directors and staff to attend training • Travel costs	State early care and education training consultant
Provide materials and equipment for promoting physical activity (such as CDs with activity-promoting music and templates for parent newsletters)	• Cost of materials and equipment	Early care and education programs (or local government)
Assess compliance with new policy to provide training and physical activity opportunities	• Time for state licensor to assess compliance with policy during monitoring visit	State early care and education agency monitoring and compliance staff

FOR ADDITIONAL INFORMATION

Cradock AL, Barrett JL, Kenney EL, Giles CM, Ward ZJ, Long MW, Resch SC, Pipito AA, Wei ER, Gortmaker SL. Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood. Prev Med. 2017 Feb;95 Suppl: S17-S27. doi: 10.1016/j.ypmed.2016.10.017. Supplemental Appendix with strategy details available at: https://ars.els-cdn.com/ content/image/1-s2.0-S0091743516303395-mmc1.docx

Browse more CHOICES research briefs & reports in the CHOICES Resource Library.
Explore and compare this strategy with other strategies on the CHOICES National Action Kit.

Suggested Citation

CHOICES Strategy Profile: More Movement in Early Care and Education Settings. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; September 2023.

Funding

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

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Brief: Creating Healthier Afterschool Environments (OSNAP) in Boston, MA

Posted on July 28, 2023

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining the implementation of the Out of School Nutrition and Physical Activity (OSNAP) initiative that helps afterschool programs improve practices and policies that increase physical activity and consumption of healthy snacks.

The Issue

Every child should have opportunities to grow up healthy. Regular physical activity, healthy eating, and adequate hydration can help children maintain a healthy weight. Over 6,000 students in kindergarten to fifth grade participate in afterschool programs in Boston.¹ These educational settings can provide essential opportunities for children to learn healthy eating habits and promote physical activity and wellness. However, not all programs offer the same opportunities for healthy eating and physical activity.² Helping more afterschool programs adopt policies and practices that incorporate more physical activity, healthier snacks, and improved water access during program time can help ensure that all children in Boston’s afterschool programs have opportunities to grow up healthy.

About Creating Healthier Afterschool Environments

OSNAP is a proven initiative implemented in multiple communities that helps afterschool programs create environments that promote increased physical activity and consumption of healthy snacks.^3-6 Creating healthier afterschool environments can contribute to higher quality afterschool programming. To implement this initiative, the Boston Public Health Commission would provide professional development opportunities for afterschool program leaders serving students in grades K-5. Afterschool staff leaders would participate in three learning collaborative sessions and receive technical assistance to assess⁷ and modify their programs’ practices and policies³ to meet the OSNAP nutrition and physical activity goals. The Boston Public Health Commission would supply program leaders with materials to support implementation and offer continuing education units for their participation.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2029) of implementing the OSNAP program with the costs and outcomes associated with not implementing the program.

Creating healthier afterschool environments is an investment in the future. By the end of 2029:

Conclusions and Implications

Opportunities for physical activity and access to healthy foods in afterschool programs are important to parents² and can help enhance the quality of afterschool programing. Over 10 years, this strategy could train more than 600 afterschool teachers and directors. By equipping afterschool leaders with these skills and resources, afterschool programs could adopt healthier practices and policies and we project that 10,800 children would benefit from more physical activity and improved diet. We project that 37 cases of obesity would be prevented and $34,100 in healthcare costs related to excess weight would be saved in 2029. We expect this strategy would cost $18.30 per child per year to implement in Boston and is projected to be cost-effective at commonly accepted thresholds⁸ based on net population health improvement related to excess weight ($72,100 per quality-adjusted life year gained).

In addition to promoting healthy weight, this strategy may also support children’s health in other ways. Regular physical activity, healthy eating, and adequate hydration can improve children’s mental and emotional well-being and their heart, lung, and bone health.⁹ These healthy behaviors can also strengthen students’ attention, memory,^10,11 and cognitive functioning,¹⁰ all important components for learning and academic performance. Incorporating physical activity and healthy snacks in afterschool programs can help children nurture healthy habits and lay a strong foundation for overall health and well-being.

This strategy builds upon Boston Public Health Commission’s demonstrated success where, in 2015, more than 120 programs took steps to improve their screen time, physical activity, and nutrition practices through OSNAP, creating higher quality afterschool programs across Boston.¹¹ Broader implementation could reach all afterschool programs in Boston, improving practices and policies that promote increased physical activity and consumption of healthy snacks, furthering the Boston Public Health Commission’s goal of creating policy and systems changes in childcare to promote the health of all Boston residents.

References

Boston AfterSchool & Beyond. SY 21-22 Programs. In. Boston, MA: Boston AfterSchool & Beyond; 2021.
Kids on the Move: Afterschool Programs Promoting Healthy Eating and Physical Activity. Washington, D.C.: America After 3pm, Afterschool Alliance; 2015.
Kenney EL, Giles CM, deBlois ME, Gortmaker SL, Chinfatt S, Cradock AL. Improving nutrition and physical activity policies in afterschool programs: results from a group-randomized controlled trial. Prev Med. 2014;66:159-166. doi:10.1016/j.ypmed.2014.06.011
Cradock AL, Barrett JL, Giles CM, et al. Promoting Physical Activity With the Out of School Nutrition and Physical Activity (OSNAP) Initiative: A Cluster-Randomized Controlled Trial. JAMA Pediatr. 2016;170(2):155-162.
Lee RM, Giles CM, Cradock AL, Emmons KM, Okechukwu C, Kenney EL, Thayer J, Gortmaker SL. Impact of the Out-of-School Nutrition and Physical Activity (OSNAP) Group Randomized Controlled Trial on Children’s Food, Beverage, and Calorie Consumption among Snacks Served. J Acad Nutr Diet. 2018 Aug;118(8):1425-1437. doi: 10.1016/j.jand.2018.04.011.
Lee RM, Barrett JL, Daly JG, Mozaffarian RS, Giles CM, Cradock AL, Gortmaker SL. Assessing the effectiveness of training models for national scale-up of an evidence-based nutrition and physical activity intervention: a group randomized trial. BMC Public Health. 2019 Nov 28;19(1):1587. doi: 10.1186/s12889-019-7902-y.
Lee RM, Emmons KM, Okechukwu CA, Barrett JL, Kenney EL, Cradock AL, Giles CM, deBlois ME, Gortmaker SL. Validity of a practitioner-administered observational tool to measure physical activity, nutrition, and screen time in school-age programs. Int J Behav Nutr Phys Act. 2014 Nov 28;11:145. doi: 10.1186/s12966-014-0145-5.
Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. DOI: 10.1056/NEJMp1405158. PMID: 25162885.
Health Benefits of Physical Activity for Children. Centers for Disease Control and Prevention. https://www.cdc.gov/physicalactivity/basics/adults/health-benefits-of-physical-activity-for-children.html. Published Jan 12, 2022. Updated 2022-01-12T05:06:09Z. Accessed Dec 7, 2022.
Childhood Nutrition Facts. Centers for Disease Control and Prevention. https://www.cdc.gov/healthyschools/nutrition/facts.htm. Published 2022. Updated 2022-08-05T03:49:26Z. Accessed Dec 12, 2022.
Blanding N. Afterschool Programs in Boston, MA, Expand Opportunties for Obesity Prevention. Centers for Disease Control and Prevention; 2016. http://nccd.cdc.gov/nccdsuccessstories

Suggested Citation:

Carter S, Bovenzi M, Clarke J, Bolton AA, Reiner JF, Barrett JL, Cradock AL, Gortmaker SL. Boston, MA: Creating Healthier Afterschool Environments (OSNAP) {Issue Brief}. Boston Public Health Commission, Massachusetts, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; July 2023.

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Boston Public Health Commission through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

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Strategy Profile: Creating Healthier Afterschool Environments

Posted on October 6, 2022

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

Creating healthier afterschool environments is a strategy to improve nutrition and physical activity policies & practices through the Out of School Nutrition and Physical Activity (OSNAP) initiative for children in grades K-5 attending state-administered 21^st Century Learning afterschool programs.

What population benefits?

Children in grades K-5 attending state-administered 21^st Century Learning afterschool programs.

What are the estimated benefits?

Relative to not implementing the strategy
Increase vigorous physical activity and improve nutritional quality of snacks and beverages offered in afterschool programs, and, in turn, promote healthy child weight.

What activities and resources are needed?

Activities	Resources	Who Leads?
Issue regulations to improve nutrition and physical activity policies and practices in afterschool programs	• Time to issue and communicate regulations	State government
Provide training and technical assistance to regional Healthy Afterschool trainers on how to lead learning collaborative sessions	• Time for state Healthy Afterschool coordinator to lead trainings • Time for regional Healthy Afterschool trainers to be trained and receive technical assistance • Travel costs • Training material costs	State healthy afterschool coordinator
Conduct regional learning collaboratives with afterschool program staff including training and technical assistance on goals and implementation activities	• Time for regional Healthy Afterschool trainers to lead learning collaboratives and provide technical assistance • Time for afterschool program staff to attend learning collaboratives and receive technical assistance • Training material costs • Travel costs	Regional healthy afterschool trainer
Assess and implement actions to change program practices to meet Healthy Afterschool standards	• Time for afterschool program staff to conduct program practice self-assessments and implement changes at their program • Increase in food costs to provide snacks in compliance with nutrition standards to children attending Healthy Afterschool programs	Afterschool program director
Develop CEU-accredited course for local program staff	• Cost to create a CEU-accredited course	State healthy afterschool coordinator
Provide educational materials and incentives to local program staff	• Material and incentive costs	State government
Monitor compliance to ensure afterschool programs are following programmatic requirements	• Time for state monitoring and compliance staff to monitor compliance • Travel costs	State government monitoring and compliance staff
Establish a Healthy Afterschool recognition and monitoring website	• Time to create and maintain website	State government website developer

Strategy Modification

This strategy could be modified to benefit children who participate in out-of-school programs administered by other organizations (e.g., YMCA or Boys and Girls Club of America). With this modification, the activities necessary to carry out the voluntary recognition program may not be included (e.g., issuing regulations, creating a healthy afterschool nutrition website, and monitoring compliance). With this modification, the impact on health is expected to be similar, and the impact on reach and cost may vary.

FOR ADDITIONAL INFORMATION

Browse more CHOICES research briefs & reports in the CHOICES Resource Library.
Explore and compare this strategy with other strategies on the CHOICES National Action Kit.

Suggested Citation

CHOICES Strategy Profile: Creating Healthier Afterschool Environments. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2023.

Funding

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

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Brief: More Movement Program in Early Child Care Settings in Boston, MA

Posted on September 20, 2021

The information in this brief is intended only to provide educational information.

Versions of this brief were published in September 2021 and January 2023. The January 2023 update was to reflect revised projections for Boston’s population. This brief was updated again in October 2023 to more accurately represent the model period.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining the More Movement program in early child care settings in Boston. This strategy provides training opportunities and resources for early child care educators to implement actions in their programs to encourage physical activity.

The Issue

Every child should have opportunities to grow up at a healthy weight. Early child care programs are key settings that can provide physical activity opportunities that support child development and lay the foundation for a healthy lifestyle. National guidelines recommend preschool-aged children engage daily in 60 to 90 minutes of moderate-to-vigorous physical activity while in early child care settings.¹ However, many children do not meet these recommended levels of activity.²

In 2017, about three in 10 first graders in Boston had overweight or obesity.³ If trends continue, over half of today’s children will have obesity as adults.⁴ Increasing physical activity in child care settings is a national health priority.⁵ Therefore, identifying strategies that help young children move more is important for ensuring children develop healthy habits and grow up at a healthy weight.

About the More Movement Program in Early Child Care Settings

The More Movement program could support Boston’s efforts to improve early child care quality through the Boston Healthy Child Care Initiative. It would include training opportunities for early child care educators in physical activity curricula, provide resources and instructional materials, and support technical assistance opportunities that may lead to higher physical activity levels among young children.^6,7 Helping educators implement practices shown to be effective in increasing physical activity can help the children in Boston’s early education and care settings to move more.

NOTE: The data that informed these estimates were collected after the program closures prompted by the COVID-19 pandemic. As programs reopen and demand continues to increase, this strategy could reach more children.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of implementing the More Movement program in Boston early child care settings with the costs and outcomes associated with not implementing the strategy over 10 years (2020-2029).

Implementing the More Movement program in early child care settings is an investment in the future. By the end of 2029:

Conclusions and Implications

If the More Movement program were implemented, we project that over 10 years, 18,200 children ages 3-5 would attend early child care programs that promote and encourage more physical activity (based on the number of programs open during the COVID-19 pandemic). This strategy would prevent 94 cases of obesity in 2029 alone, saving $104,000 in obesity-related health care costs over 10 years. The average annual cost to implement these activities would be $293 per program, or $30 per child.

Expanding training opportunities for early child care educators will also help support quality care. Ensuring access to quality care is essential for families and employers.⁸ In the initial training series, the More Movement program would provide additional skills training and professional development for 1,380 educators and more physical activity promotion opportunities in 570 (100%) child care programs serving 3-5 year olds.

Besides promoting a healthy weight, engaging in physical activity benefits children in other ways. Increased physical activity is linked to improved bone and muscular health and better gross motor skills in young children.^9-11 We estimate that, on average, each child attending a More Movement program would increase daily moderate-to-vigorous physical activity by seven minutes. This can help to form a strong foundation for overall health and well-being.

The More Movement program is a strategy for training and providing technical assistance in early child care. As programs reopen post-pandemic and demand for child care continues to increase, the strategy could reach even more children. The More Movement program would enable early child care programs in Boston to support healthy growth because every child deserves a healthy start.

References

American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for our Children: National Health and Safety Performance Standards Guidelines for Early Care and Education Programs. 2019. https://nrckids.org/files/CFOC4%20pdf-%20FINAL.pdf
Tassitano RM, Weaver RG, Tenório MCM, Brazendale K, Beets MW. Physical activity and sedentary time of youth in structured settings: a systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity. 2020;17(1):160. Published 2020 Dec 4. doi:10.1186/s12966-020-01054-y
School Health Services, Dept of Public Health. Results from the Body Mass Index Screening in Massachusetts Public School Districts, 2017. School Health Services, Dept of Public Health; 2020. Accessed July 23, 2021. https://www.mass.gov/doc/the-status-of-childhood-weight-in-massachusetts-2017
Ward Z, Long M, Resch S, Giles C, Cradock A, Gortmaker S. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. New England Journal of Medicine. 2017; 377(22): 2145-2153.
Healthy People 2030. Increase the proportion of child care centers where children aged 3 to 5 years do at least 60 minutes of physical activity a day — PA-R01. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health. Accessed Nov 16, 2020. https://health.gov/healthypeople/objectives-and-data/browse-objectives/physical-activity/increase-proportion-child-care-centers-where-children-aged-3-5-years-do-least-60-minutes-physical-activity-day-pa-r01
Fitzgibbon ML, Stolley MR, Schiffer LA, et al. Hip-Hop to Health Jr. Obesity Prevention Effectiveness Trial: Postintervention Results. Obesity (Silver Spring). 2011;19(5):994-1003.
Kong A, Buscemi J, Stolley MR, Schiffer LA, Kim Y, Braunschweig CL, Gomez-Perez SL, Blumstein LB, Van Horn L, Dyer AR, Fitzgibbon ML. Hip-Hop to Health Jr. Randomized Effectiveness Trial: 1-Year Follow-up Results. American Journal of Preventive Medicine. 2016 Feb;50(2):136-44.
Campbell F, Patil P, McSwain K. Boston’s Child-Care Supply Crisis: What a Pandemic Reveals. Boston Opportunity Agenda; 2020. Accessed July 23, 2021. https://www.bostonopportunityagenda.org/-/media/boa/early-ed-census-2020-pt-1-202011.pdf
U.S. Dept of Health and Human Services. Physical Activity Guidelines for Americans, 2^nd edition. U.S. Dept of Health and Human Services; 2018. Accessed Jul 23, 2021. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
Pate RR, Hillman CH, Janz KF, et al. Physical Activity and Health in Children Younger than 6 Years: A Systematic Review. Medicine & Science in Sports & Exercise. 06 2019;51(6):1282-1291.
Timmons BW, Leblanc AG, Carson V, et al. Systematic review of physical activity and health in the early years (aged 0-4 years). Applied Physiology, Nutrition, and Metabolism. Aug 2012;37(4):773-92.

Suggested Citation:

Bovenzi M, Carter S, Sabir M, Bolton AA, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Boston, MA: More Movement Program in Early Child Care Settings {Issue Brief}. Boston Public Health Commission and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2023. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

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Brief: Reducing Screen Time in Early Child Care Settings in Boston, MA

Posted on September 20, 2021

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy to reduce screen time in early child care settings in Boston. This strategy provides voluntary training to early child care educators and resources to families to limit noneducational television time at child care and home.

The Issue

Every child should have opportunities to grow up at a healthy weight. Too much screen time in early childhood is linked to overweight and obesity, as it reduces opportunities for children to be active and advertisement exposure can lead children to eat and drink more unhealthy foods.¹ The American Academy of Pediatrics recommends limiting screen time to one hour of quality programming per day in child care and at home for children over 2 years old.² Less than half of children ages 2-5 met this guideline.³

Limiting screen time at child care and home would support children’s healthy growth. In 2017, about three in 10 first graders in Boston had overweight or obesity.⁴ Reducing young children’s screen time will ensure more children grow up at a healthy weight and enter school ready to learn.

About the Strategy to Reduce Screen Time in Early Child Care Settings

This strategy could support Boston’s efforts to improve early child care quality through the Boston Healthy Child Care Initiative. It would include training opportunities for early child care educators, offering ongoing support and technical assistance, and providing parents with educational materials that may lead to reducing screen time in young children.^5,6Helping educators to implement practices shown to be effective in reducing television time can help the children in Boston’s early education and care settings engage in fewer minutes of screen time.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of implementing a strategy to reduce screen time in Boston early child care settings with the costs and outcomes associated with not implementing the strategy over 10 years (2020-2029).

Implementing a strategy to reduce screen time in early child care settings is an investment in the future. By the end of 2029:

Conclusions and Implications

If the strategy were implemented, we estimate that over 10 years, 18,200 children ages 3-5 would attend programs that support reducing screen time (based on the number of programs open during the COVID-19 pandemic). This strategy would prevent 125 cases of obesity in 2029 alone, saving $138,000 in obesity-related health care costs over 10 years. The average annual cost to implement this strategy would be $161 per program, or $16 per child.

Expanding training opportunities for early child care educators will also help support quality care. Ensuring access to quality care is essential for families and employers.⁷ In the initial training series, this strategy would provide additional skills training and professional development for 1,380 educators and more opportunities to reduce screen time in 570 (100%) child care programs serving 3-5 year olds.

Besides promoting a healthy weight, viewing less screen time benefits children in other ways. Too much screen use is associated with less sleep and can negatively impact social well-being.¹ We estimate that, on average, each child attending a program implementing the strategy would view 33 fewer minutes of screen time per day. This allows more time for developmentally appropriate play activities, helping to form a strong foundation for overall well-being.

This strategy would train and provide technical assistance to early childhood educators on reducing screen time. As programs reopen post-pandemic and demand for child care continues to increase, the strategy could reach even more children. This strategy would enable early child care programs in Boston to support healthy growth because every child deserves a healthy start.

References

Li C, Cheng G, Sha T, Cheng W, Yan Y. The Relationships between Screen Use and Health Indicators among Infants, Toddlers, and Preschoolers: A Meta-Analysis and Systematic Review. International Journal of Environmental Research and Public Health. 2020;17(19):7324.
COUNCIL ON COMMUNICATIONS AND MEDIA. Media and Young Minds. Pediatrics. 2016;138(5):e20162591.
Healthy People 2030. Increase the proportion of children aged 2 to 5 who get no more than 1 hour of screen time a day – PA-13. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. Accessed July 20, 2021. https://health.gov/healthypeople/objectives-and-data/browse-objectives/physical-activity/increase-proportion-children-aged-2-5-years-who-get-no-more-1-hour-screen-time-day-pa-13/data
School Health Services, Dept of Public Health. Results from the Body Mass Index Screening in Massachusetts Public School Districts, 2017. School Health Services, Dept of Public Health; 2020. Accessed July 23, 2021. https://www.mass.gov/doc/the-status-of-childhood-weight-in-massachusetts-2017
Mendoza JA, Baranowski T, Jaramillo S, et al. Fit 5 Kids TV Reduction Program for Latino Preschoolers: A Cluster Randomized Controlled Trial. American Journal of Preventive Medicine. 2016;50(5):584-592.
Dennison BA, Russo TJ, Burdick PA, Jenkins PL. An intervention to reduce television viewing by preschool children. Archives of Pediatrics and Adolescent Medicine. 2004;158(2):170-176.
Campbell F, Patil P, McSwain K. Boston’s Child-Care Supply Crisis: What a Pandemic Reveals. November 2020. https://www.bostonopportunityagenda.org/-/media/boa/early-ed-census-2020-pt-1-202011.pdf

Suggested Citation:

Bovenzi M, Carter S, Sabir M, Bolton AA, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Boston, MA: Reducing Screen Time in Early Child Care Settings {Issue Brief}. Boston Public Health Commission and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2023. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

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Stories from the Field: Allegheny County Strengthens Partnerships to Make Progress Toward Local Impact

Posted on June 24, 2021

The information in this Story from the Field is intended only to provide educational information.

In this Story from the Field, partners in Allegheny County, Pennsylvania, used the CHOICES framework and tools to engage partners in identifying and prioritizing strategic opportunities for action to promote healthy weight for children in their community.

Identifying Priorities in Allegheny County, PA

The Allegheny County Health Department (ACHD) engaged community members and public health partners through the Mobilization for Action through Planning and Partnerships (MAPP) process to help prioritize their planning efforts. The ACHD identified reducing obesity among school-aged children as a key objective to improve chronic disease risk factors – a priority area identified in their Community Health Improvement Plan.

Strategic Alignment to Promote Child Health

The ACHD leveraged funds to support capacity building and infrastructure to establish the Healthy Kids Allegheny Task Force. This task force brought together partners with a multi-sectoral, collaborative focus on children’s health and wellness.

The task force looked to identify strategies to effectively reduce childhood obesity and to ensure their resources were being invested responsibly. They also were looking for ways to advance the strategic priorities of Live Well Allegheny – a county-wide campaign to improve the overall health and wellness of Allegheny County residents.

Engaging Partners to Create Evidence for Action

The ACHD teamed up with the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Project through its Learning Collaborative Partnership program. In this program, the CHOICES Project works with health agencies to create new, local evidence to inform decision-making. The ACHD team saw an opportunity to identify strategies to promote child health and learned how to use local data and apply cost-effectiveness analysis methods to prioritize effective strategies to reduce childhood obesity in Allegheny County. To identify relevant strategies, the ACHD team assembled a group of key partners:

• the Healthy Kids Allegheny Task Force
• Allegheny Partners for Out-of-School Time
• Healthy Out-of-School Time
• the United Way of Southwestern Pennsylvania
• Children’s Hospital of Pittsburgh
• Live Well Allegheny Schools and Community Partners

Evaluating Opportunities to Address Key Priorities

ACHD identified partners early in the process. This facilitated engagement in the selection of school and afterschool settings as key areas for collaboration. The ACHD CHOICES team opted to focus on Active Physical Education in schools and a Healthy Snack Policy in afterschool programs from the CHOICES menu of strategies with strong evidence for impact on health and data on cost-effectiveness.

Then, the team used CHOICES tools to identify the activities and resources needed to put these strategies into action, considered the interests of partners, and discussed what would be feasible to implement. These tools helped the team answer several key questions for planning:

1. What is the strategy?
2. Where is it implemented?
3. Which populations are impacted?
4. Who will be involved in implementing the strategy?
5. What is the status of this strategy in your state, county, or city?

Lessons Learned

The ACHD CHOICES team engaged partners to establish what would need to happen to implement their chosen strategies, who would need to be involved, and what impact these strategies would have in their community. These efforts enabled them to identify feasible implementation plans that are projected to make an impact on health. Using CHOICES tools and resources, the ACHD CHOICES team and partners developed evidence they could use to make a case for investing in these efforts to promote a healthy weight.

Active Physical Education in Schools

A policy requiring provision of 50% moderate-to-vigorous physical activity in physical education classes.

See what would happen if Active PE was implemented in schools in Allegheny County

Healthy Snack Policy in Afterschool Programs

A policy that sets nutrition standards to ensure that all food and beverages available in programs meet national standards to support good nutrition.

See what would happen if a healthy snack policy was implemented in afterschool programs in Allegheny County

“Partnering with the CHOICES Team equipped the ACHD Team with a clear understanding of what it would take to implement the strategies that we modeled, and a very specific guide for doing so. Strategic alignment of our partners and the evidence from this work with CHOICES helped us to have more informed conversations with decision-makers.” – Hannah E. Hardy, Director, Chronic Disease & Injury Prevention Program, Allegheny County Health Department

Suggested Citation:

CHOICES Stories from the Field: Allegheny County Strengthens Partnerships to Make Progress Toward Local Impact. Allegheny County Health Department, Pittsburgh, PA, and the CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; June 2021. For more information, please visit www.choicesproject.org

Funding

This work has been supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). This story from the field is intended for education use only. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention, or other funders.

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Brief: Creating Healthier Child Care Environments: NAPSACC in the Quality Rating Improvement System in Arkansas

Posted on May 17, 2021

Young kids playing in an early care setting

The information in this brief is intended only to provide educational information.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy incorporating the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) assessment tools into Better Beginnings, Arkansas’ Quality Rating and Improvement System, to support quality early child care program opportunities and promote child health.

The Issue

In Arkansas, three out of 10 kindergarteners entering school in 2018 had overweight or obesity.¹ The majority of today’s children will have obesity at age 35 if we don’t act.² Making sure children are growing up at a healthy weight from their very first days is a critical way to prevent obesity and future risk for obesity-related diseases like diabetes as adults. Conditions linked to obesity, previously only seen in adults, are appearing in Arkansas’ Medicaid-enrolled children.³ Early child care programs that support healthy nutrition and physical activity habits show great promise in promoting healthy weight.⁴

In Arkansas, more than half of children ages 2-5 attend a licensed child care program.⁵ Providing licensed child care programs with training opportunities and resources through Better Beginnings may be an effective strategy to improve the quality of child care programs and to ensure that the majority of children in Arkansas are off to a healthy start.

About NAP SACC

NAP SACC is an evidence-based, trusted strategy enabling child care centers to attain best practices regarding nutrition, active play, and screen time.⁴ To date, NAP SACC shows the best evidence for reducing childhood obesity risk in children under age 5.⁶ Early education program directors and staff complete self-assessments and receive training and technical assistance to implement practices, policies, and changes supporting healthy outcomes. Better Beginnings is designed to improve child care environments to support child health and development. Integrating NAP SACC into Better Beginnings can improve the quality of child care programs and ensure more children grow up healthy in Arkansas.

Comparing Costs and Outcomes

A CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2030) of implementing NAP SACC with the costs and outcomes of not implementing the program.

Implementing NAP SACC into Better Beginnings in Arkansas is an investment in child health. By the end of 2030:

Conclusions and Implications

Every child should have opportunities for a healthy start. A state-level initiative integrating NAP SACC into training and quality improvement through Better Beginnings could create healthier nutrition and physical activity environments in child care programs for 116,000 children over 10 years. This strategy would benefit 1,320 early care directors and staff with training and technical assistance to support using nutrition, active play, and screen time best practices at 659 child care programs. Over 10 years, children in Arkansas would have 8,720 more years lived at a healthy weight and 1,130 fewer children would have obesity in 2030 alone.

Many prevention strategies targeting children require an upfront investment because costly obesity-related health conditions generally present later in adulthood.⁷ While we project this strategy would cost $18 per child per year, shortchanging early prevention efforts may lead to costly and complicated treatment in the future. Already, the total annual costs of having obesity are estimated to be $6 million for the 30,000 25- to 29-year-olds enrolled in Medicaid—inclusive of Arkansas’ expansion population. This represents an excess annual cost of $200 per person due to obesity.³

Early child care programs also play a critical role in supporting healthy child development and children’s academic readiness.⁸ Investing in a strategy for quality improvement that provides the necessary training, technical assistance, and resources supports early educators in providing high-quality child care that nurtures healthy habits. Enabling early education leaders in Arkansas to use the best available evidence to prevent excess weight gain in children will support children’s healthy growth and development.

References

ACHI. (2019). Assessment of Childhood and Adolescent Obesity in Arkansas: Year 16 (Fall 2018–Spring 2019). Arkansas Center for Health Improvement. Little Rock, AR.
Ward Z, Long M, Resch S, Giles C, Cradock A, Gortmaker S. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. New England Journal of Medicine. 2017; 377(22): 2145-2153.
ACHI, Arkansas Medicaid. Comorbid Conditions and Medicaid Costs Associated with Childhood Obesity in Arkansas. 2019.
Alkon A, Crowley AA, Neelon SE, Hill S, Pan Y, Nguyen V, Rose R, Savage E, Forestieri N, Shipman L, Kotch JB. Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health. 2014;14:215.
Arkansas Department of Human Services, Division of Child Care and Early Childhood Education, Child Care Facilities Database. Unpublished data. 2020.
Kenney E, Cradock A, Resch S, Giles C, Gortmaker S. The Cost-Effectiveness of Interventions for Reducing Obesity among Young Children through Healthy Eating, Physical Activity, and Screen Time. Durham, NC: Healthy Eating Research; 2019. Available at: http://healthyeatingresearch.org
Gortmaker SL, Wang YC, Long MW, Giles CM, Ward ZJ, Barrett JL, …Cradock, AL. Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Affairs. 2015; 34(11), 1932–1939.
Morrisey T. The Effects of Early Care And Education on Children’s Health. Health Affairs Health Policy Brief. 2019

Suggested Citation:

Adams B, Sutphin B, Betancourt K, Balamurugan A, Kim H, Bolton A, Barrett J, Reiner J, Cradock AL. Arkansas: Creating Healthier Child Care Environments: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) in the Quality Rating Improvement System (QRIS) {Issue Brief}. Arkansas Department of Health, Little Rock, AR, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2021. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Arkansas Department of Health through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

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Making CHOICES in a Health Department: Case 2 (Advanced)

Posted on May 13, 2021

In this advanced teaching case, which builds on Case 1, a fictional health department continues to work with the CHOICES Project’s Learning Collaborative Partnership to determine how to implement an evidence-based strategy that requires substantial investment, but they face a variety of additional challenges such as state politics and the complexities of health policy.

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Making CHOICES in a Health Department: Case 1 (Introductory)

Posted on May 13, 2021

In this introductory teaching case, a fictional health department engages with the CHOICES Project’s Learning Collaborative Partnership to help them narrow down a list of potential strategies to reduce childhood obesity in their county through a cost-effectiveness lens.

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