Results of caring and reaching for health (CARE): a cluster-randomized controlled trial assessing a worksite wellness intervention for child care staff.

BACKGROUND: Child care workers are among the lowest paid US workers and experience a wide array of health concerns. The physical and mental demands of their job and the lack of employer-provided health-insurance increase health risks. The Caring and Reaching for Health (CARE) study evaluated a 6-month Healthy Lifestyles intervention targeting child care workers' physical activity (primary outcome), other health behaviors, and their workplace health environment. METHODS: Eligible child care centers, defined as being in operation for at least 2 years and employing at least four staff, were enrolled into CARE's cluster-randomized trial. Centers and their child care staff were randomly assigned to either the Healthy Lifestyles (HL) intervention arm or the Healthy Finances (HF) attention control arm using a block randomization approach. Intervention components were delivered through in-person workshops, center-level displays, informational magazines, director coaching, electronic messaging, and an interactive website. Outcome measures were collected during center visits at baseline and immediately post-intervention by trained data collectors blinded to center arm assignment. Workers' physical activity was assessed with accelerometers, worn for 7 days. Secondary outcome measures included biometric assessments of health and fitness, web-based surveys about health behaviors, and an environmental audit of workplace supports for health. Multi-level linear mixed models assessed worker- and center-level changes in these outcomes. RESULTS: Participants included 553 child care workers representing 56 centers (HL = 250 staff/28 centers, HF = 303 staff/28 centers). At 6 months, moderate-to-vigorous physical activity declined slightly in both arms (- 1.3 min/day, 95% CI: - 3.0, 0.3 in HL; - 1.9 min/day, 95% CI: - 3.3, - 0.5 in HF), but there was no significant group by time interaction. Several secondary outcomes for other health behaviors and workplace health environment showed improvements in favor of the intervention arm, yet differences did not remain statistically significant after adjustment for multiple comparisons. CONCLUSIONS: While the Healthy Lifestyles intervention did not improve health behaviors or the workplace health environment, results confirmed the pressing need to focus on the health of child care workers. Future interventions should focus on prevalent health issues (e.g., weight, stress), include both high-tech and high-touch intervention strategies, and address work conditions or other social determinants of health (e.g. wages) as a means of improving the health of these essential workers. TRIAL REGISTRATION: Care2BWell: Worksite Wellness for Child Care (NCT02381938).

Keys to healthy family child care homes: Results from a cluster randomized trial.

Early care and education settings, such as family child care homes (FCCHs), are important venues for children's health promotion. Keys to Healthy Family Child Care Homes evaluated a FCCH-based intervention's impact on children's diet and physical activity. This study enrolled 496 children aged 1.5-4 years and 166 FCCH providers into a cluster-randomized control trial (intervention = 242 children/83 FCCHs, control = 254 children/83 FCCHs) conducted during 2013-2016. The 9-month intervention addressed provider health, health of the FCCH environment, and business practices, and was delivered through three workshops, three home visits, and nine phone calls. The attention control arm received a business-focused intervention. Primary outcomes were children's diet quality (2 days of observed intakes summarized into Healthy Eating Index scores) and moderate to vigorous physical activity (3 days of accelerometry) at the FCCH. Secondary outcomes were child body mass index (BMI), FCCH provider health behaviors, and FCCH nutrition and physical activity environments and business practices. Repeated measures analysis, using an intent-to-treat approach, accounting for clustering of children within FCCHs and adjusting for child age, sex, and BMI, was used to evaluate change (completed in 2018). Compared to controls, intervention children significantly improved their diet quality (5.39, p = .0002, CI = 2.53, 8.26) but not MVPA (0.31, p = .195, CI = -0.16, 0.79). Intervention FCCH providers significantly improved their diet quality and several components of their FCCH environment (i.e., time provided for physical activity, use of supportive physical activity practices, and engagement in nutrition and physical activity education/professional development). FCCHs are malleable settings for health promotion, especially diet quality. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.govNCT01814215.

Development of a Workplace Intervention for Child Care Staff: Caring and Reaching for Health's (CARE) Healthy Lifestyles Intervention.

Child care staff are among the lowest wage workers, a group at increased risk for a wide array of chronic diseases. To date, the health of child care staff has been largely ignored, and there have been very few interventions designed for child care staff. This article describes the development of the Caring and Reaching for Health (CARE) Healthy Lifestyles intervention, a workplace intervention aimed at improving physical activity and health behaviors among child care staff. Theory and evidence-based behavior change techniques informed the development of intervention components with targets at multiple social ecological levels. Final intervention components included an educational workshop held at a kick-off event, followed by three 8-week campaigns. Intervention components within each campaign included (1) an informational magazine, (2) goal setting and weekly behavior self-monitoring, (3) weekly tailored feedback, (4) e-mail/text prompts, (5) center-level displays that encouraged team-based goals and activities, and (6) coaching for center directors. This multilevel, theory-driven intervention is currently being evaluated as part of a larger randomized controlled trial. Process evaluation efforts will assess the extent to which child care staff participated in, engaged with, and were satisfied with the intervention. Lessons learned will guide future intervention research engaging child care workers.

Modifying the Environment and Policy Assessment and Observation (EPAO) to better capture feeding practices of family childcare home providers.

OBJECTIVE: To describe the modification and validation of an existing instrument, the Environment and Policy Assessment and Observation (EPAO), to better capture provider feeding practices. DESIGN: Modifications to the EPAO were made, validity assessed through expert review, pilot tested and then used to collect follow-up data during a two-day home visit from an ongoing cluster-randomized trial. Exploratory factor analysis investigated the underlying factor structure of the feeding practices. To test predictive validity of the factors, multilevel mixed models examined associations between factors and child's diet quality as captured by the Healthy Eating Index-2010 (HEI-2010) score (measured via the Dietary Observation in Childcare Protocol). SETTING: Family childcare homes (FCCH) in Rhode Island and North Carolina, USA.ParticipantsThe modified EPAO was pilot tested with fifty-three FCCH and then used to collect data in 133 FCCH. RESULTS: The final three-factor solution ('coercive control and indulgent feeding practices', 'autonomy support practices', 'negative role modelling') captured 43 % of total variance. In multilevel mixed models adjusted for covariates, 'autonomy support practices' was positively associated with children's diet quality. A 1-unit increase in the use of 'autonomy support practices' was associated with a 9·4-unit increase in child HEI-2010 score (P=0·001). CONCLUSIONS: Similar to the parenting literature, constructs which describe coercive controlling practices and those which describe autonomy-supportive practices emerged. Given that diets of pre-schoolers in the USA remain suboptimal, teaching childcare providers about supportive feeding practices may help improve children's diet quality.

The quality of nutrition and physical activity environments of child-care centers across three states in the southern U.S.

This cross-sectional study assessed the quality of nutrition and physical activity environments of child-care centers in three southern states and examined differences by rural versus urban location, participation in the Child and Adult Care Food Program, and Head Start status. The sample included 354 centers that enroll children aged 2-5: 154 centers from Georgia, 103 from Kentucky, and 97 centers from Mississippi. Directors and 1-2 teachers per center completed the Environment and Policy Assessment and Observation Self-Report (EPAO-SR) tool that assesses nutrition and physical activity environments of child-care centers. The EPAO-SR items were scored to capture six nutrition domains and six physical activity domains that were averaged and then summed to create a combined nutrition and physical activity environment score (range = 0-36); higher scores indicated that centers met more best practices, which translated to higher-quality environments. Overall, the centers had an average combined nutrition and physical activity environment score of 20.2 out of 36. The scores did not differ between rural and urban centers (mean = 20.3 versus 20.2, p = 0.98). Centers in the Child and Adult Care Food Program had higher combined nutrition and physical activity environment scores than non-participating centers (mean = 20.6 versus 19.1, p < 0.01). Head Start centers also had higher combined environment scores than non-Head Start centers (mean = 22.3 versus 19.6, p < 0.01). Findings highlight the vital role of federal programs in supporting healthy child-care environments. Providing technical assistance and training to centers that are not enrolled in well-regulated, federally-funded programs might help to enhance the quality of their nutrition and physical activity environments.

What matters most - what parents model or what parents eat?

PURPOSE: Parents have a strong influence on their children's eating habits; however, researchers struggle to identify which food parenting practices to recommend. This study examined the influence of parents modeling of healthy eating ("parent role modeling") and parents' actual food intake ("parent dietary intake") on child diet quality, and explored whether these practices work together to influence children's diets. METHODS: Baseline data from a larger intervention trial were used for this analysis. The sample included parents of preschool-age children from households with at least one overweight parent. The Comprehensive Feeding Practices Questionnaire was used to assess parent modeling of healthy eating ("healthy modeling"). Three days of dietary recalls were used to collect parents' report of their own intake and their children's intake (excluding food at child care). Associations between parent healthy modeling and parent intake of healthy and unhealthy foods were explored using Pearson correlations. Associations between parent healthy modeling and parent Healthy Eating Index (HEI) score on child HEI score were examined with linear regression. Additionally, the interaction between parent healthy modeling and HEI score on child HEI score was tested. RESULTS: Parent healthy modeling was significantly correlated with parent intake of healthy foodsLinear regression showed a significant association between parent modeling and child HEI score, even after controlling for parent diet (ß = 3.08, SE = 0.87, p < 0.001). Children whose parents had high parent healthy modeling scores had higher HEI scores (mean = 61.5 ±â€¯10.4) regardless of parent HEI score. We did not find evidence that parent healthy modeling and diet quality interact to influence child diet quality. CONCLUSIONS: Parents' healthy modeling is an important practice in influencing children's diet quality, possibly more so than the quality of parents' diets.

The family child care home environment and children's diet quality.

BACKGROUND: Developing healthy eating behaviors and food preferences in early childhood may help establish future healthy diets. Large numbers of children spend time in child care, but little research has assessed the nutritional quality of meals and snacks in family child care homes. Therefore, it is important to assess foods and beverages provided, policies related to nutrition and feeding children, and interactions between providers and children during mealtimes. We examined associations between the nutrition environments of family child care homes and children's diet quality. METHODS: We assessed the nutrition environments of 166 family child care homes using the Environment and Policy Assessment and Observation (EPAO) (scores range: 0-21). We also recorded foods and beverages consumed by 496 children in care and calculated healthy eating index (HEI) (scores range: 0-100). We used a mixed effects linear regression model to examine the association between the EPAO nutrition environment (and EPAO sub-scales) and child HEI, controlling for potential confounders. RESULTS: Family child care homes had a mean (standard deviation, SD) of 7.2 (3.6) children in care, 74.1% of providers were black or African American, and children had a mean (SD) age of 35.7 (11.4) months. In adjusted multivariable models, higher EPAO nutrition score was associated with increased child HEI score (1.16; 95% CI: 0.34, 1.98; p = 0.006). Higher scores on EPAO sub-scales for foods provided (8.98; 95% CI: 3.94, 14.01; p = 0.0006), nutrition education (5.37; 95% CI: 0.80, 9.94; p = 0.02), and nutrition policy (2.36; 95% CI: 0.23, 4.49; p = 0.03) were all associated with greater child HEI score. CONCLUSIONS: Foods and beverages served, in addition to nutrition education and nutrition policies in family child care homes, may be promising intervention targets for improving child diet quality.

Physical Activity and Sedentary Behaviors of Children in Family Child Care Homes: Are There Opportunities for Improvement?

PURPOSE: Many children attend family child care homes (FCCHs), an important setting to influence children's physical activity (PA) and sedentary behavior (SB). This study assessed children's PA and SB while in FCCHs, characteristics of the FCCH PA environment, and relationships between the environment and child PA and SB. METHOD: Children ages 1.5-4.0 years (n = 495) were recruited from 165 FCCHs in North Carolina. Children's moderate to vigorous PA and SB were measured via accelerometry for 3 days. FCCH PA environments were assessed over 2 days using the Environment and Policy Assessment and Observation for FCCHs. Ten subscores and an overall PA environment score (possible range: 0-30) were calculated; higher scores indicate better quality. RESULTS: Children accumulated 30 (13) minutes of moderate to vigorous PA and 143 (42) minutes of SB in FCCHs daily. FCCHs scored low on the Environment and Policy Assessment and Observation for FCCHs, with an average overall score of 13 (2). FCCHs scored highest on screen time and screen time practices subscores, and lowest on PA education/professional development and PA policy subscores. Although no statistically significant associations were observed, some large Cohen d effect sizes were noted (eg, outdoor playtime subscore and moderate to vigorous PA). CONCLUSIONS: This study highlights opportunities to improve FCCHs and increase children's behaviors (eg, providing adequate time and outdoor play spaces).

Cumulative Risk Exposure and Waist Circumference in Preschool-Aged Children: the Mediating Role of Television and Moderating Role of Sex.

BACKGROUND: Children exposed to multiple stressors are more likely to be overweight, but little is known about the mechanisms explaining this association. PURPOSE: This cross-sectional study examined whether children exposed to multiple stressors had higher waist circumference, and whether this association was mediated through children's television time. METHODS: Participants were 319 parent-child dyads. Children were 2-5 years old and had at least one overweight parent (BMI ≥ 25 kg/m2). Data were collected at baseline of a larger childhood obesity prevention study and included information on psychosocial stressors (e.g., parenting stress), demographic stressors (e.g., low income), children's television time, and children's waist circumference. Two cumulative risk scores were created by summing stressors in each domain (demographic and psychosocial). Mediation and moderated mediation analyses were conducted. RESULTS: Indirect effects of both cumulative risk scores on waist circumference through television time were not significant; however, moderated mediation analyses found significant moderation by gender. The indirect effects of both risk scores on waist circumference through television time were significant and positive for girls, but near-zero for boys. CONCLUSIONS: Reducing television time should be explored as a strategy for buffering against the negative health effects of exposure to multiple stressors among girls. Longitudinal and intervention research is needed to confirm these results and to identify mediating factors between cumulative risk and body weight among boys.

Food parenting practices for 5 to 12 year old children: a concept map analysis of parenting and nutrition experts input.

BACKGROUND: Parents are an important influence on children's dietary intake and eating behaviors. However, the lack of a conceptual framework and inconsistent assessment of food parenting practices limits our understanding of which food parenting practices are most influential on children. The aim of this study was to develop a food parenting practice conceptual framework using systematic approaches of literature reviews and expert input. METHOD: A previously completed systematic review of food parenting practice instruments and a qualitative study of parents informed the development of a food parenting practice item bank consisting of 3632 food parenting practice items. The original item bank was further reduced to 110 key food parenting concepts using binning and winnowing techniques. A panel of 32 experts in parenting and nutrition were invited to sort the food parenting practice concepts into categories that reflected their perceptions of a food parenting practice conceptual framework. Multi-dimensional scaling produced a point map of the sorted concepts and hierarchical cluster analysis identified potential solutions. Subjective modifications were used to identify two potential solutions, with additional feedback from the expert panel requested. RESULTS: The experts came from 8 countries and 25 participated in the sorting and 23 provided additional feedback. A parsimonious and a comprehensive concept map were developed based on the clustering of the food parenting practice constructs. The parsimonious concept map contained 7 constructs, while the comprehensive concept map contained 17 constructs and was informed by a previously published content map for food parenting practices. Most of the experts (52%) preferred the comprehensive concept map, while 35% preferred to present both solutions. CONCLUSION: The comprehensive food parenting practice conceptual map will provide the basis for developing a calibrated Item Response Modeling (IRM) item bank that can be used with computerized adaptive testing. Such an item bank will allow for more consistency in measuring food parenting practices across studies to better assess the impact of food parenting practices on child outcomes and the effect of interventions that target parents as agents of change.

Translating a child care based intervention for online delivery: development and randomized pilot study of Go NAPSACC.

BACKGROUND: As part of childhood obesity prevention initiatives, Early Care and Education (ECE) programs are being asked to implement evidence-based strategies that promote healthier eating and physical activity habits in children. Translation of evidence-based interventions into real world ECE settings often encounter barriers, including time constraints, lack of easy-to-use tools, and inflexible intervention content. This study describes translation of an evidence-based program (NAPSACC) into an online format (Go NAPSACC) and a randomized pilot study evaluating its impact on centers' nutrition environments. METHODS: Go NAPSACC retained core elements and implementation strategies from the original program, but translated tools into an online, self-directed format using extensive input from the ECE community. For the pilot, local technical assistance (TA) agencies facilitated recruitment of 33 centers, which were randomized to immediate (intervention, n = 18) or delayed (control, n = 15) access groups. Center directors were oriented on Go NAPSACC tools by their local TA providers (after being trained by researchers), after which they implemented Go NAPSACC independently with minimal TA support. The Environment and Policy Assessment and Observation instrument (self-report), collected prior to and following the 4-month intervention period, was used to assess impact on centers' nutrition environments. Process data were also collected from a sample of directors and all TA providers to evaluate program usability and implementation. RESULTS: Demographic characteristics of intervention and control centers were similar. Two centers did not complete follow-up measures, leaving 17 intervention and 14 control centers in the analytic sample. Between baseline and follow-up, intervention centers improved overall nutrition scores (Cohen's d effect size = 0.73, p = 0.15), as well as scores for foods (effect size = 0.74, p = 0.16), beverages (effect size = 0.54, p = 0.06), and menus (effect size = 0.73, p = 0.08), but changes were not statistically significant. CONCLUSIONS: Core elements of NAPSACC were effectively translated into online tools and successfully implemented by center directors. Results suggest that the online program may have retained its ability to drive change in centers' nutrition environments using a streamlined, self-directed, and flexible implementation approach. Results need to be confirmed in a larger more definitive trial. TRIAL REGISTRATION: NCT02889198 (retrospectively registered).

Assessment of nutrition and physical activity environments in family child care homes: modification and psychometric testing of the Environment and Policy Assessment and Observation.

BACKGROUND: Early care and education (ECE) settings play an important role in shaping the nutrition and physical activity habits of young children. Increasing research attention is being directed toward family child care homes (FCCHs) specifically. However, existing measures of child care nutrition and physical activity environments are limited in that they have been created for use with center-based programs and require modification for studies involving FCCHs. This paper describes the modification of the Environment and Policy Assessment and Observation (EPAO) for use in FCCHs. METHODS: The EPAO underwent a through modification process that incorporated an updated format for the data collection instrument, assessment of emerging best practices, tailoring to the FCCH environment, and creation of a new scoring rubric. The new instrument was implemented as part of a larger randomized control trial. To assess inter-rater reliability, observations on 61 different days were performed independently by two data collectors. To assess construct validity, associations between EPAO scores and measures of children's dietary intake (Healthy Eating Index (HEI) score) and physical activity (accelerometer-measured minutes per hour of moderate to vigorous physical activity, MVPA) were examined. RESULTS: The modified EPAO assesses 38 nutrition and 27 physical activity best practices, which can be summarized into 7 nutrition-related and 10 physical activity-related environmental sub- scores as well as overall nutrition and overall physical activity scores. There was generally good agreement between data collectors (ICC > 0.60). Reliability was slightly lower for feeding practices and physical activity education and professional development (ICC = 0.56 and 0.22, respectively). Child HEI was significantly correlated with the overall nutrition score (r = 0.23), foods provided (r = 0.28), beverages provided (r = 0.15), nutrition education and professional development (r = 0.21), and nutrition policy (r = 0.18). Child MVPA was significantly associated with overall time provided for activity (r = 0.18) and outdoor playtime (r = 0.20). There was also an unexpected negative association between child MVPA and screen time (-0.16) and screen time practices (r = -0.21). CONCLUSIONS: The EPAO for the FCCH instrument is a useful tool for researchers working with this unique type of ECE setting. It has undergone rigorous development and testing and appears to have good psychometric properties. TRIAL REGISTRATION: NCT01814215 , March 15, 2013.

Providers' response to child eating behaviors: A direct observation study.

Child care providers play an important role in feeding young children, yet little is known about children's influence on providers' feeding practices. This qualitative study examines provider and child (18 months -4 years) feeding interactions. Trained data collectors observed 200 eating occasions in 48 family child care homes and recorded providers' responses to children's meal and snack time behaviors. Child behaviors initiating provider feeding practices were identified and practices were coded according to higher order constructs identified in a recent feeding practices content map. Analysis examined the most common feeding practices providers used to respond to each child behavior. Providers were predominately female (100%), African-American (75%), and obese (77%) and a third of children were overweight/obese (33%). Commonly observed child behaviors were: verbal and non-verbal refusals, verbal and non-verbal acceptance, being "all done", attempts for praise/attention, and asking for seconds. Children's acceptance of food elicited more autonomy supportive practices vs. coercive controlling. Requests for seconds was the most common behavior, resulting in coercive controlling practices (e.g., insisting child eat certain food or clean plate). Future interventions should train providers on responding to children's behaviors and helping children become more aware of internal satiety and hunger cues.

Parenting around child snacking: development of a theoretically-guided, empirically informed conceptual model.

BACKGROUND: Snacking contributes to excessive energy intakes in children. Yet factors shaping child snacking are virtually unstudied. This study examines food parenting practices specific to child snacking among low-income caregivers. METHODS: Semi-structured interviews were conducted in English or Spanish with 60 low-income caregivers of preschool-aged children (18 non-Hispanic white, 22 African American/Black, 20 Hispanic; 92% mothers). A structured interview guide was used to solicit caregivers' definitions of snacking and strategies they use to decide what, when and how much snack their child eats. Interviews were audio-recorded, transcribed verbatim and analyzed using an iterative theory-based and grounded approach. A conceptual model of food parenting specific to child snacking was developed to summarize the findings and inform future research. RESULTS: Caregivers' descriptions of food parenting practices specific to child snacking were consistent with previous models of food parenting developed based on expert opinion [1, 2]. A few noteworthy differences however emerged. More than half of participants mentioned permissive feeding approaches (e.g., my child is the boss when it comes to snacks). As a result, permissive feeding was included as a higher order feeding dimension in the resulting model. In addition, a number of novel feeding approaches specific to child snacking emerged including child-centered provision of snacks (i.e., responding to a child's hunger cues when making decisions about snacks), parent unilateral decision making (i.e., making decisions about a child's snacks without any input from the child), and excessive monitoring of snacks (i.e., monitoring all snacks provided to and consumed by the child). The resulting conceptual model includes four higher order feeding dimensions including autonomy support, coercive control, structure and permissiveness and 20 sub-dimensions. CONCLUSIONS: This study formulates a language around food parenting practices specific to child snacking, identifies dominant constructs, and proposes a conceptual framework to guide future research.

Application of the Intervention Mapping protocol to develop Keys, a family child care home intervention to prevent early childhood obesity.

BACKGROUND: Many families rely on child care outside the home, making these settings important influences on child development. Nearly 1.5 million children in the U.S. spend time in family child care homes (FCCHs), where providers care for children in their own residences. There is some evidence that children in FCCHs are heavier than those cared for in centers. However, few interventions have targeted FCCHs for obesity prevention. This paper will describe the application of the Intervention Mapping (IM) framework to the development of a childhood obesity prevention intervention for FCCHs METHODS: Following the IM protocol, six steps were completed in the planning and development of an intervention targeting FCCHs: needs assessment, formulation of change objectives matrices, selection of theory-based methods and strategies, creation of intervention components and materials, adoption and implementation planning, and evaluation planning RESULTS: Application of the IM process resulted in the creation of the Keys to Healthy Family Child Care Homes program (Keys), which includes three modules: Healthy You, Healthy Home, and Healthy Business. Delivery of each module includes a workshop, educational binder and tool-kit resources, and four coaching contacts. Social Cognitive Theory and Self-Determination Theory helped guide development of change objective matrices, selection of behavior change strategies, and identification of outcome measures. The Keys program is currently being evaluated through a cluster-randomized controlled trial CONCLUSIONS: The IM process, while time-consuming, enabled rigorous and systematic development of intervention components that are directly tied to behavior change theory and may increase the potential for behavior change within the FCCHs.

A cross-sectional study of demographic, environmental and parental barriers to active school travel among children in the United States.

BACKGROUND: Promoting daily routine physical activities, such as active travel to school, may have important health implications. Practitioners and policy makers must understand the variety of factors that influence whether or not a child uses active school travel. Several reviews have identified both inhibitors and promoters of active school travel, but few studies have combined these putative characteristics in one analysis. The purpose of this study is to examine associations between elementary school children's active school travel and variables hypothesized as correlates (demographics, physical environment, perceived barriers and norms). METHODS: The current project uses the dataset from the National Evaluation of Walk to School (WTS) Project, which includes data from 4th and 5th grade children and their parents from 18 schools across the US. Measures included monthly child report of mode of school travel during the previous week (n = 10,809) and perceived barriers and social norms around active school travel by parents (n = 1,007) and children (n = 1,219). Generalized linear mixed models (GLMM) with log-link functions were used to assess bivariate and multivariate associations between hypothesized correlates and frequency of active school travel, assuming random school effect and controlling for the distance to school. RESULTS: The final model showed that the most relevant significant predictors of active school travel were parent's perceived barriers, specifically child resistance (Estimate = -0.438, p < 0.0001) and safety and weather (Estimate = -0.0245, p < 0.001), as well as the school's percentage of Hispanic students (Estimate = 0.0059, p < 0.001), after adjusting for distance and including time within school cluster as a random effect. CONCLUSIONS: Parental concerns may be impacting children's use of active school travel, and therefore, future interventions to promote active school travel should more actively engage parents and address these concerns. Programs like the Walk to School program, which are organized by the schools and can engage community resources such as public safety officials, could help overcome many of these perceived barriers to active transport.

Measuring parent food practices: a systematic review of existing measures and examination of instruments.

During the last decade, there has been a rapid increase in development of instruments to measure parent food practices. Because these instruments often measure different constructs, or define common constructs differently, an evaluation of these instruments is needed. A systematic review of the literature was conducted to identify existing measures of parent food practices and to assess the quality of their development. The initial search used terms capturing home environment, parenting behaviors, feeding practices and eating behaviors, and was performed in October of 2009 using PubMed/Medline, PsychInfo, Web of knowledge (ISI), and ERIC, and updated in July of 2012. A review of titles and abstracts was used to narrow results, after which full articles were retrieved and reviewed. Only articles describing development of measures of parenting food practices designed for families with children 2-12 years old were retained for the current review. For each article, two reviewers extracted data and appraised the quality of processes used for instrument development and evaluation. The initial search yielded 28,378 unique titles; review of titles and abstracts narrowed the pool to 1,352 articles; from which 57 unique instruments were identified. The review update yielded 1,772 new titles from which14 additional instruments were identified. The extraction and appraisal process found that 49% of instruments clearly identified and defined concepts to be measured, and 46% used theory to guide instrument development. Most instruments (80%) had some reliability testing, with internal consistency being the most common (79%). Test-retest or inter-rater reliability was reported for less than half the instruments. Some form of validity evidence was reported for 84% of instruments. Construct validity was most commonly presented (86%), usually with analysis of associations with child diet or weight/BMI. While many measures of food parenting practices have emerged, particularly in recent years, few have demonstrated solid development methods. Substantial variation in items across different scales/constructs makes comparison between instruments extremely difficult. Future efforts should be directed toward consensus development of food parenting practices constructs and measures.

Development of HomeSTEAD's physical activity and screen time physical environment inventory.

BACKGROUND: The home environment has a significant influence on children's physical activity, sedentary behavior, dietary intake, and risk for obesity and chronic disease. Our understanding of the most influential factors and how they interact and impact child behavior is limited by current measurement tools, specifically the lack of a comprehensive instrument. HomeSTEAD (the Home Self-administered Tool for Environmental assessment of Activity and Diet) was designed to address this gap. This new tool contains four sections: home physical activity and media equipment inventory, family physical activity and screen time practices, home food inventory, and family food practices. This paper will describe HomeSTEAD's development and present reliability and validity evidence for the first section. METHODS: The ANGELO framework guided instrument development, and systematic literature reviews helped identify existing items or scales for possible inclusion. Refinement of items was based on expert review and cognitive interviews. Parents of children ages 3-12 years (n = 125) completed the HomeSTEAD survey on three separate occasions over 12-18 days (Time 1, 2, and 3). The Time 1 survey also collected demographic information and parent report of child behaviors. Between Time 1 and 2, staff conducted an in-home observation and measured parent and child BMI. Kappa and intra-class correlations were used to examine reliability (test-retest) and validity (criterion and construct). RESULTS: Reliability and validity was strong for most items (97% having ICC > 0.60 and 72% having r > 0.50, respectively). Items with lower reliability generally had low variation between people. Lower validity estimates (r < 0.30) were more common for items that assessed usability and accessibility, with observers generally rating usability and accessibility lower than parents. Small to moderate, but meaningful, correlations between physical environment factors and BMI, outside time, and screen time were observed (e.g., amount of child portable play equipment in good condition and easy to access was significantly associated with child BMI: r = -0.23), providing evidence of construct validity. CONCLUSIONS: The HomeSTEAD instrument represents a clear advancement in the measurement of factors in the home environment related to child weight and weight-related behaviors. HomeSTEAD, in its entirety, represents a useful tool for researchers from which they can draw particular scales of greatest interest and highest relevance to their research questions.

Food Outlet Density, Distance, and Food Quality Offered to Preschool-Aged Children at Family Child Care Homes.

OBJECTIVE: To examine how food environments around family child care homes (FCCHs) are associated with the healthfulness of foods served to children. DESIGN: Cross-sectional data from a mail survey of FCCH providers, InfoUSA. PARTICIPANTS: The study included 132 Mississippi FCCHs (26% response). MAIN OUTCOME MEASURES: Dependent: compliance with nutrition best practices for 9 food categories; composite healthfulness score. Independent: counts of supermarkets, small-medium grocery stores, produce stores, convenience stores within 5 miles; distance to supermarket. ANALYSIS: Logistic regression estimated associations between best-practice compliance and food environment. Linear regression estimated associations between composite food healthfulness and food environment. Models stratified by rural/urban location. RESULTS: Rural FCCHs with higher counts of supermarkets, convenience stores, and produce stores had lower compliance with selected best practices (fried/prefried potatoes, high-sugar/high-fat foods). Urban FCCHs with more supermarkets had higher compliance with fruit not canned in syrup; those with more small-medium grocery stores and convenience stores had lower compliance with selected best practices (fried/prefried potatoes, vegetables, low-fat meats). CONCLUSIONS AND IMPLICATIONS: Food environment measures were associated with some nutrition best practices, though not consistently in the expected direction. Future research could examine food quality at stores near rural FCCHs. Programs that improve local food environments may improve foods served at FCCHs.

Characterization of Colorado residents and radon reduction behaviors through latent class analysis and path models.

Radon is a naturally occurring radioactive gas that enters homes through cracks in the foundation where accumulated levels can cause lung cancer. Within the United States (U.S.), state level radon reduction strategies rely on education and outreach to motivate people to test and mitigate their home. Only about 5% of the housing units in Colorado, U.S. have been tested for radon. This study looks at the 2012 Behavioral Risk Factors Surveillance System (BRFSS) in Colorado to identify distinct groups of people using Latent Class Analysis, and compares radon awareness, testing, and mitigation to understand underlying differences of radon reduction behaviors using path models. Five classes were identified: 1) Wealthy Young Families, 2) Older Singles, 3) Empty Nesters, 4) Smokers, and 5) Struggling Young Families. Significant differences in responses to radon survey questions existed across groups in which Struggling Young Families were the least likely to be aware of radon, have tested their home for radon, and have their home mitigated. Average radon awareness, testing, and mitigation appeared to be influenced by financial stress. Results from this study can be used to tailor future radon interventions and policy initiatives to enhance equity of radon reduction behaviors including legal framework to ensure radon mitigation takes place in rental properties.