Majority of the participants were white, with a mean age of 42 (±) y, 45(±) y for ECE administrators, and 35 (±) y (for coaches, ECE administrators and teachers, respectively. Almost 90% coaches had at least an MA degree, 62% of ECE administrators had BA degree, and 47% of teachers had some college experience. Most coaches and ECE administrators had > 15 years of experience working in ECE programs, whereas 35% of teachers had 1–2 years. Complete participant demographic information is outlined in Table 3.
Table 3
Dimension
|
Definition (49)
|
Concepts Addressed and Example Interview Questions
|
Reach
|
How many and what proportion of the target population participated in the program?
|
Describes variation in reach: number of participants enrolled and decline rate
What are participants’ reasons for not participating?
|
Effectiveness
|
What outcomes are of value to what stakeholders, and how did the intervention fare on these factors?
What was the impact of the program / intervention on important outcomes? What was the most important benefits achieved?
|
Identify outcomes valuable to stakeholders, and the impact of the program on these outcomes.
How did EAT Family Style impact children’s mealtime behavior (e.g. serving themselves, engagement)?
Did you observe children's behavior in response to the program? How do you think some of the children responded to some of the strategies?
|
Adoption
|
Why organizations (and staff and members in each organization) choose to participate or not in the intervention?
|
Factors influencing decision to participate or not for implementation support team (coaches), organization (ECE administrators), and staff (ECE teachers).
What made you participate?
Which program incentive was most valuable to you?
|
Implementation
|
How are the different components of the program delivered?
|
Program delivery through EAT Family Style implementation strategies.
How are the lessons applied?
How did the goal sheets and technology work for you? (e.g., Chromebook, Zoom, video recordings)
What things did not work for you? How were they addressed in real time?
What aspects in the program did you like? What made you say so?
|
Maintenance
|
Why the organizations delivering the intervention decides to continue or discontinue the intervention for future program design?
|
Motivations for intending to continue using program practices and strategies.
What kind of changes do you plan to continue in your program?
What are some incentives we can give to (participants) that will encourage them to continue implementing this program?
|
Demographic characteristics of Ecological Approach To (EAT) Family Style multilevel intervention participants |
Reach assesses whether EAT Family Style is addressing its target population. To measure this, we included the number and percentage of eligible 3-5-year-old children enrolled in EAT Family Style sites, compared to those who were eligible but decided not to participate. Across EAT Family Style targeted sites, a total of 282 children were eligible to participate in the program. Out of this, 251 3-5-year-old children initially participated with a 14% attrition rate. Reasons for non-participation and decline in number of participants include children on special diet, parents not providing consent for their children to be video recorded, and ECEs dropping out in the program. Overall, 77% of 3-5-year-old children (n = 216) from our targeted CACFP ECEs in Nebraska participated in EAT Family Style intervention in 2018.
Effectiveness identifies how the program influenced positive children’s outcome and the overall mealtime context as highlighted by the descriptions that coaches, ECE administrators and teachers provided.
Child-level. EAT Family Style responsive feeding practices improved children’s dietary outcomes.
Teachers described how their use of EAT Family Style responsive feeding practices improved children’s eating behaviors at mealtimes, such as trying new foods and increased intake of healthier foods. For example, they mentioned that practicing food-based sensory exploration with children encouraged them to eat vegetables, while role modeling encouraged children to try new foods. Teachers also reported that since using EAT Family style responsive feeding practices at mealtimes, children feel less intimidated to taste food they do not like. Specifically, peer modeling raised children’s willingness to try different fruits and vegetables especially picky eaters. Many of them also shared that several of their picky eaters benefit from watching their peers eat the served food and are now slowly trying variety of foods at mealtimes:
“I have a couple of children that can be picky eaters. And I think because they were listening to the other kids say that the food was good because it tasted sweet or they started playing a game where they pick up a piece of fruit, put it on their fork and hold it up and they'd say, “Whoever has cantaloupe, hold it up,” and then they all take a bite together. And so that kind of got some of them involved doing that with fruits and vegetables too.”
Similarly, ECE administrators and coaches noticed children learning to cue feelings of fullness by using sensory words like “full bucket” or “water filled to the brim of cup.” In addition, they also observed children decide what food to eat and consume more of the food offered since they started using different EAT Family Style responsive feeding strategies in the classroom.
Child-level. EAT Family Style responsive feeding practices supported children’s healthful development (i.e. skills for communication, socialization, and autonomy).
Stakeholders described different ways responsive feeding EBPs supported children’s developing communication and social skills. They also reported how responsive feeding EBPs helped children become more engaged in their mealtime interactions with peers, and improved skills for serving themselves. For instance, one teacher shared that practicing EAT Family Style during lunch helped her students become more independent and notably improved their fine motor skills in pouring liquids or scooping food. In addition, teachers also observed changes in students’ mealtime interactions - with children having more interesting and pleasant conversations with their peers. They also mentioned that they observed children talking more about the food served and relating them to concepts they learned in class (e.g. tortilla cut in half). Similarly, teachers also noticed improvements in children’s communication skills especially their use of polite words during mealtimes. Many of the teachers gave examples how children are getting better expressing themselves politely when refusing the food offered.
They are more polite saying ‘No, thank you,’ instead of ‘Ewww, no, that's gross’ which I think is very helpful because before when they would say ‘That's gross,’ and then everyone would say‘ Ewww, no.’ And now they're just like, ‘No, thank you, I don't like that.’ So, it's a lot more polite. They’ll say thank you. So we're working on that, they do have pretty good manners.
Child-level. EAT Family Style responsive feeding practices promote positive mealtime environment in the classroom.
Stakeholders agreed that using EAT Family Style feeding practices with the children has remarkably improved the overall mealtime environment. Specifically, teachers mentioned how their mealtimes positively changed since practicing EAT Family Style in the classroom. For example, one of the teachers shared that mealtimes with children used to be chaotic but remarkably shifted to a much calmer lunchtime after the EAT Family Style program.
“I just feel like it goes a lot smoother than it was before. Before it was really crazy. I honestly feel like it goes a lot smoother now and it takes, it takes more time. And so we actually use our entire lunch period and I'm not constantly having to tell everyone to sit back down, or stay at the table because I did that a lot before, but now they stay at the table until everybody's done eating and then we all help clean up and then by that time, our whole lunch hour’s over and it wasn't as terrible as it used to be.”
In addition, teachers also mentioned how EAT Family Style helped younger children practice self-regulation especially those students who used to be restless during mealtimes. They noticed how children learned to slow down and patiently waited for their turn by watching their peers serve themselves. Teachers also related EAT Family Style feeding practices in the classroom with increased children’s intake of healthy food, and noted decrease in food wastage during mealtimes. ECE administrators and coaches also noted the change in the classroom’s overall mealtime environment by highlighting how EAT Family Style encouraged cooperation and positive conversations among children. They also described mealtimes in the classrooms to be calmer and less messy, with children looking more relaxed and engaged.
Adoption focuses on specific components of the program that stakeholders deemed to be essential in their decision to adopt EAT Family Style in their centers. This section describes factors that influenced participants’ decisions to participate in EAT Family Style intervention.
Coach-level. Coaches adopted EAT Family Style because it aligned with their professional beliefs and goals, and promoted opportunities to improve their coaching skills for professional development.
Program coaches reported that they were convinced by the positive outcomes of responsive feeding from previous research, and emphasized that being in the forefront of a quality intervention program such as EAT Family Style primarily motivated them to join. In addition, coaches greatly valued how EAT Family Style provided them the opportunity to grow professionally. They shared that serving as a program coach for both administrators and teachers helped them hone their coaching skills by reflecting on their individual practices.
I'm trying to refine and hone these coaching skills because this is something that I'm really passionate about, and something that I am going to pursue as I move forward with my academic career in grad school. I have really identified coaching as the next step in my career path. So this was just something that really seemed like the right fit for me. Something I have been really interested in, and it really allowed me to understand more of what I needed to work on. EAT Family Style gave me the opportunity to really reflect on some of my biases and how I interact with [teachers] and really just learn more about how to be an effective coach.
Administrator-level. ECE administrators valued that EAT Family Style intervention overlapped with other existing ECE programs, supported their beliefs and professional goals, and provided incentives that cover in-service hours and mini grants.
ECE administrators reported that they were primarily encouraged to participate in the intervention because of its resemblance to programs they were previously involved in such as Head Start and Go NAP SACC. In addition, they were also motivated to do responsive feeding EBPs of in their schools because it aligned with their beliefs and goals for their respective organization which include (but not limited to) children’s healthy eating behaviors and positive mealtime context.
One reason why I wanted to do it was to make sure that we're teaching children that it is important to sit down eat like a family, that there are things you can talk about while you're sitting and eating and not just, you know, running around with food in your mouth and going from there.
ECE administrators valued incentives that support ongoing professional development among ECE educators and practitioners. Hence, they found it greatly important that their participation in EAT Family Style intervention covered the required hours for licensing and training. ECE administrators also shared that it was helpful they were provided with mini grants to buy the required materials and supplies for family style meal services in the classroom. For many ECE administrators, being able to purchase and use the recommended materials to do the program helped them commit in doing responsive feeding EBPs in their centers.
Teacher-level. Teachers perceived EAT Family Style intervention’s relevance to children's healthful development, and valued the program incentives designed to address their needs.
EAT Family Style intervention’s overarching goal of supporting children’s healthful development was a strong influence on teachers’ decision to participate. Specifically, teachers emphasized that they find it important that children gain information about health and nutrition early to guide future eating behaviors.
I do feel like the healthy eating is a good choice for kids. I feel like they do need to learn it at a younger age so they can just grow up knowing what they should and shouldn't eat, what is healthy and what isn’t.
Like the administrators, the program incentives offered by EAT Family Style are crucial in teachers’ involvement in the intervention. Specifically, teachers mentioned that the free one-on-one coaching, the coverage of the required in-service hours, and the free continuing professional development were highly motivating for many of them. In addition, teachers also identified the mini grants useful for obtaining the recommended equipment for doing family style meal services since many of the centers have limited capacity and resources to purchase the necessary materials. Aside from the mini grants, teachers also expressed their appreciation for the gift cards which they can use for their personal purchases.
Implementation describes coaches,’ ECE administrators’, and teachers’ use of key components of the programs, including adaptations and implementation strategies.
Coach-level. Coaches support ECE administrators and teachers’ implementation of responsive feeding EBPs in schools through monitoring and feedback, and EAT Family Style program resources.
Coaches supported administrators and teachers through their regular coaching sessions where they encouraged participants to talk about their successes and challenges in using EAT Family Style. Coaches used this approach to better understand what the teachers/administrators needed, and then come up with strategies and support tailored to each participant’s needs (e.g. those who had difficulty letting go non-responsive feeding practices that they consistently used in the past). They also used the coaching session to reinforce the use of EAT Family Style resources and materials in teachers’ classroom practice. Consistent with this, teachers identified coaching as an important component of the program. Many of them shared that the coaching sessions provided them both practical and emotional support, and helped them become more mindful in meeting their lesson goals. These experiences were also shared by ECE administrators and added the importance of coaching for clarifying aspects of the lessons and the weekly goals before using them in their classrooms.
Coaches used different program materials such as binders and individual online folders to track individual progress. They also referred to the teacher’s goal sheets and mealtime recordings during their one-on-one coaching sessions to develop constructive feedback and coaching agenda.
I personally liked mealtime video recordings because then I had a lot more to talk to them and give like lots of positive feedback on. I think that really helped my relationship, especially with the one that was kind of, I could say, well, you know, I really saw that you were doing this and I saw that you even carried over you know, from the last lessons.
However, coaches reported that they were initially overwhelmed by the scope of the materials that they need to use for coaching. Coaches also mentioned their challenges in letting go coaching strategies they used in past programs that were not aligned with EAT Family Style strategies such as prescribing participants solutions to challenges, or simply giving out instructions.
Administrator-level. ECE administrators support teachers’ implementation of responsive feeding EBPs in the classroom through administrative support.
To support their teachers, ECE administrators integrated school policies in their activities and events related to healthy celebrations and children’s nutrition. In addition, they also developed scheduling arrangements and utilized “floating” staff to help teachers complete the EAT Family Style online lessons. They also mentioned that the parent handouts were useful not only in providing parents information about responsive feeding practices and family style meal services, but also as a visual tool for them to talk about simple tips that parents can use with their children at home. However, ECE administrators mentioned that finding the time to video record children’s mealtime was sometimes difficult to do because of competing priorities in the classroom. ECE administrators also suggested that their teachers need additional time to familiarize themselves with the technology that they will be using for the program (e.g. video conferencing), and more flexible schedules to complete and practice the lessons before meeting with their coaches.
Give them enough time; time to get familiar with the technology with some practicing, practice Zooming. I would have my [teacher] do the lesson and then I would do my lesson and then we’d Zoom with the coach and then we’d record and then we’d start all over and I think I found myself a little stressed.
Teacher-level. Teachers implemented responsive feeding EBPs in the classrooms and used EAT Family Style program materials and resources.
Overall, teachers mentioned that they enjoyed using EAT Family Style responsive feeding with their students. For many of them, using different sensory activities for children to use and try were helpful in guiding students relate concepts learned in class with real objects (e.g. color of the food served). In addition, teachers also shared that they use EAT Family Style to help children explore different types of food, as well as encourage children to try the food served by watching their peers during mealtime. Similarly, teachers perceived EAT Family Style responsive feeding practices helpful in managing the class. For instance, one teacher shared that she noticed her students became more engaged in class when she started using “star chart” and stickers as rewards. Aside from the use of non-food rewards, teachers also described how they became more involved in their students’ mealtime experiences. They shared that teaching children how to serve themselves helped them “bond” with their students.
I could do hand over hand, I could do, like, hold the glass. And I really liked that because I thought that particular thing got teachers involved instead of just having that for the kids. I think it was a bonding thing for the kids. And I liked the way that, you know, the materials encouraged the teachers to be a part of the dining experience with the kids because lot of times, somebody’ll sit back with a Whopper in a bag, and not have much to do with the kids.
Teachers reported that EAT Family Style resources which include the online lessons, workbooks, handouts, and technology were informative and convenient to use. Specifically, they found examples of EAT Family Style strategies in the videos helpful for their classroom practice, while they use workbooks as supplementary materials to the online lessons. In addition, teachers also shared that having EAT Family Style Chromebooks allowed them to complete the online lessons during their most convenient time. However, they also talked about their challenges in using selected program materials and procedures initially (e.g. order of activities in the online lessons), and commented about how some of them can be time consuming, lengthy, and redundant (e.g. videos in the online lessons were too long and repetitive).
Maintenance identifies ECE centers’ motivations for using practices and strategies from EAT Family Style, and the changes they plan to continue in their schools. This section focuses on the extent to which EAT Family Style is intended to be integrated in the ECE centers’ practices and policies, as well as the professional routines of the coaches who served in the program.
Coach-level. Coaches intend to continue participating in EAT Family Style to build their professional skills and community partnerships.
Coaches plan to continue their involvement in EAT Family Style intervention because they feel that their efforts and skills as coaches were valued and appreciated. Similarly, coaches shared that they are motivated to continue partnering with EAT Family Style program because of the program incentives (e.g. classes, training hours) that cover their professional development activities free of charge.
Coaches also see the value of meeting other program coaches in expanding their professional network. They mentioned that simply knowing who to tap or contact for concerns could help them develop partnerships with fellow Extension practitioners.
I enjoyed that initial training that we had out of the Extension Center solely for the fact of like, networking with other coaches out there because if you encounter somebody that you maybe haven't worked with previously or haven't come across the goals or maybe challenges that they're encountering. It was nice to know like, oh, you know, Linda would be somebody that I could contact and so that networking really helped and just I'm somebody that I like to bounce ideas off other people so that in person training was really valuable.”
Administrator-level. ECE administrators intend to integrate healthy eating practices in the parent handbook and school policy.
ECE administrators emphasized that continuing the use of EAT Family Style strategies in their classrooms supports children’s developing autonomy, growing vocabulary, and positive mealtime environment. To do this, they plan to integrate healthy celebrations and non-food rewards in their center policies. Specifically, ECE administrators mentioned that they plan to include non-food items in their parent handbook to substitute sweet foods typically offered to children during special celebrations.
But there are other ways to celebrate it, which I learned from that last lesson is there are [other] ways. So that is going into our policies and procedures and our handbook that instead of cake, bring bubbles or pencils or tattoos or stickers.
Teacher-level. Teachers intend to do more nutrition discussions with parents, and continue practicing different responsive feeding EBPs in the classrooms.
Teachers value the role of parents in shaping children’s healthy eating behaviors. Thus, they plan to engage more in discussions with parents about children’s nutrition and EAT Family Style dining to help parents understand mealtime practices that they use in their classrooms. Aside from engaging parents, teachers also intend to continue practicing responsive feeding EBPs by incorporating more sensory exploration activities in the classroom, and use of praise, peer and role modeling to encourage children to eat healthy foods at mealtimes. They also shared that they plan to continue mealtime discussion about the food served, include a sensory table for introducing different types of food, and keep encouraging children to try new foods especially those they do not like.
“Having more food items, just in the classroom or like sensory stuff in a sensory table. I guess talking about food in ways, I mean, I always have kids that don't eat anything green. I don't know why, but if it's green, they won't touch it. And so, just encouraging them, not forcing them to eat it, but encouraging them and describing that food and learning more about that food. I would really like to do all that in the future as well.”
Table 4
provides descriptions of themes, subthemes, and representative quotes across all stakeholder levels, organized around the five RE-AIM dimensions.
|
Coaches
(n = 9)
%
|
ECE Administrators
(n = 8)
%
|
ECE Teachers
(n = 17)
%
|
Age Mean
|
42
|
45
|
35
|
Racial Background
|
|
|
|
American Indian or Alaskan Native
|
11
|
0
|
0
|
White or Caucasian
|
89
|
100
|
100
|
Educational Background
|
|
|
|
High School Diploma / GED
|
0
|
0
|
11.8
|
Some College
|
0
|
12.5
|
47
|
Associates Degree
|
0
|
12.5
|
17.7
|
Bachelor’s Degree
|
11
|
62.5
|
23.5
|
Graduate Degree
|
89
|
12.5
|
0
|
Years of Experience Working in Early Childhood
|
|
|
|
Less than 1 year
|
22.2
|
|
5.9
|
1–2 years
|
22.22
|
|
35.3
|
3–5 years
|
0
|
|
17.6
|
6–10 years
|
0
|
12.5
|
17.6
|
11–15
|
22.22
|
25
|
11.8
|
More than 15 years
|
33.34
|
62.5
|
11.8
|
Description of RE-AIM themes and subthemes across key stakeholders of Ecological Approach To (EAT) Family Style Multilevel Intervention including coaches, Early Care and Education (ECE) administrators and teachers. |