Using Causative Methods to Determine System-Level Factors Driving the Uptake and Use of Evidence-Based Practices in a Public Early Intervention System.

Part C Early Intervention (EI) systems are an entry point to services for autistic toddlers and can be leveraged to facilitate access to autism evidence-based practices (EBPs). However, EI systems are complex and limited research has examined how an EI system's infrastructure (i.e. system-level factors) impacts the adoption and implementation of EBPs. To address this gap, 36 EI providers and 9 EI administrators completed a semi-structured interview or focus group about factors impacting the implementation of autism EBPs. Qualitative analysis included a combination of grounded theory and causative coding. Analyses were refined by input from providers, administrators, and family stakeholders in the form of round tables and presentations at the state's interagency coordinating council. Primary themes centered on: (1) the costs associated with independent contracting structures; (2) operational demands; (3) workforce stability; (4) communication consistency; and (5) implementation supports for EBP implementation. Causative coding helped to demonstrate the perceived relationships between these factors and underscored the important role of incentivization structures, collaboration opportunities, and championing in supporting the use of EBPs within a system that primarily uses independent contracting structures. The current study extends previous research by demonstrating how several system-level factors are perceived to play a role in the adoption and implementation of EBPs by independently contracted EI providers. These findings underscore the need for implementation strategies, such as incentivization strategies and social network building, to increase providers' implementation of autism EBPs within EI systems.

"The Early Years are Like a Foundation for the Future" Perspectives, Facilitators, and Challenges of Anganwadi Workers in Supporting Early Child Development Interventions in Hyderabad, India: Qualitative Findings from a Scalable Program Incorporating Early Child Development Interventions.

BACKGROUND: Integrated Child Development Services (ICDS) scheme, a large public health program, addresses the needs of young children with Anganwadi Workers (AWWs) as frontline agents of delivery. A scalable program incorporating early child development interventions (ASPIRE) has been developed to complement the program and address some of its gaps. OBJECTIVES: This paper describes formative work done with AWWs, as part of ASPIRE to assess their understanding of early childhood development (ECD) and acceptability of a novel ECD intervention using digital technology. MATERIALS AND METHODS: Six focus group discussions (FGDs) were conducted with 31 AWWs, using a semi-structured guide. RESULTS: Framework analysis of their responses from FGDs led to the identification of three themes: (1) time use, (2) understanding of ECD, and (3) delivering messages using videos. The findings suggest that AWWs tight schedules often leave them feeling overburdened with work. They are aware of factors that can aid as well as hinder child growth and development, but their understanding of play is limited to games played by older children. They expressed acceptability in using a video intervention, specifying features that would increase relevance for families. CONCLUSION: Integration of novel ECD interventions delivered by frontline workers needs to take into account their existing work schedules and associated challenges. Training on ECD interventions will need to broaden AWWs understanding of the critical foundational experiences which responsive caregiving and early child stimulation can provide.

Developmental Service Referrals and Utilization Among Young Children in Protective Custody.

Children in foster care are at high risk for developmental delay. In this retrospective cohort study of young children presenting to a foster care clinic, 77% were not receiving developmental services and 75% failed developmental screening. Of those potentially eligible, 60% were not referred for developmental services.

How early intervention practitioners describe family-centred practice: A collective broadening of the definition.

BACKGROUND: Given the importance of families in supporting the health and developmental outcomes of young children, current recommended practices for early intervention services advocate for a family-centred practice (FCP) approach that recognizes the importance of children's family systems. Though there is consensus in the field on the importance of this approach, there often remains a disconnection between these values and the everyday practice of early intervention practitioners. This study focuses on understanding the ways in which practitioners define FCP as this can provide valuable insight into why these belief-practice disconnections may exist. METHODS: Early intervention practitioners (n = 203; e.g., special education or child development teachers, therapists, audiologists, etc) were surveyed at a statewide early intervention conference. Qualitative content analyses procedures were used to analyse participants' open-ended responses. RESULTS: Three themes emerged in the analysis, including the following: (a) FCP is a distinct approach to providing early intervention services; (b) there are specific practices for best implementing FCP; and (b) there are provider qualities that are essential in order to use FCP. CONCLUSIONS: Practitioners' definitions of FCP were primarily in line with recommended practices; however, they extend beyond the current definition of FCP in the early intervention literature, suggesting that the way this approach is conceptualized may be collectively broadening within the field. Opportunities, difficulties, and practical implications of this broadening definition are discussed.

Family-centred care in early intervention: Examining caregiver perceptions of family-centred care and early intervention service use intensity.

BACKGROUND: Family-centred care (FCC) is an approach to paediatric rehabilitation service delivery endorsing shared decision making and effective communication with families. There is great need to understand how early intervention (EI) programmes implement these processes, how EI caregivers perceive them, and how they relate to EI service use. Therefore, the purpose of this study is to examine (a) parent and provider perceptions about EI FCC processes and (b) the association between FCC perceptions and EI service intensity. METHODS: In this cross-sectional study, parent perceptions of EI FCC were measured using the electronically administered Measures of Processes of Care (MPOC-56 and MPOC-SP; using 7-point scales). Participants included EI parents (n = 29) and providers (n = 9) from one urban EI programme (1/1/18-6/1/18). We linked survey responses with child characteristics and service use ascertained through EI records. We estimated parent-provider MPOC score correlations and the association between EI service intensity (hr/month) and parent MPOC scores using adjusted linear regression accounting for child characteristics. RESULTS: Parents (M = 4.2, SD = 1.1) and providers (M = 5.8, SD = 1.3) reported low involvement related to general information exchange. Parent and provider subscale scores were not correlated except that parent-reported receipt of specific information was inversely associated with provider-reported provision of general information (r = -0.4, P < .05). In adjusted models, parent perceptions related to respectful and supportive (b = 1.57, SE = 0.56) and enabling (b = 1.42, SE = 0.67) care were positively associated with EI intensity, whereas specific information exchange and general information exchange were not associated with intensity. CONCLUSION: We found that EI parents and providers reported high levels of investment in the family centredness of their EI care, with the exception of information sharing. Greater EI service intensity was associated with higher perception of involvement with some metrics of family centredness.

[Program offer for the integral development of early childhood in Chile: Scoping review]. / Oferta de programas para el desarrollo integral de la primera infancia en Chile: Revisión exploratoria.

OBJECTIVE: To describe the program offering designed to promote comprehensive early childhood de velopment in Chile. METHOD: A scoping review was carried out following the Joanna Briggs Institute's methodological framework. A researcher conducted the review considering as inclusion criteria go vernment programs aimed at the comprehensive development of children under 5 years of age in Chile. The data were organized and synthesized to describe the characteristics of the program and the service(s) it provides. RESULTS: The search identified 2.060 documents and 72 met the inclusion crite ria. 59 current programs are covering early childhood, which are mainly managed by the Ministries of Justice, Education, Health, and Social Development. Most of the programs are aimed at promotion and intervention, focusing on vulnerable populations, are cross-sectoral, and use different strategies for their implementation. CONCLUSION: The program offering in Chile for early childhood has charac teristics suggested as effective to promote child development.

Targeting Youth to Prevent Later Substance Use Disorder: An Underutilized Response to the US Opioid Crisis.

The evolving US opioid crisis is complex and requires myriad different interventions. These include reducing opioid overprescribing and curtailing the supply of illicit opioids, overdose rescue interventions, and treatment and recovery support services for those with opioid use disorders. To date, more distal primary prevention strategies that have an evidence base are underutilized. Yet, the impact of early environments on later substance use disorder risk is increasingly well understood, including knowledge of the mechanistic linkages between brain development and subsequent risk behaviors. Applying this developmental framework to prevention shows promise, and some middle-school interventions have demonstrated significant reductions in prescription opioid misuse. Reducing these risks of initial misuse of opioids may be the "ounce of prevention" that makes a substantial difference in a society now reeling from the worst drug crisis our country has seen. The challenge is to continue to develop and test promising distal interventions and to support implementation fidelity through frameworks that ensure their cultural appropriateness and sustainability. In addition, research is needed to develop new prevention strategies for adults, including patients with pain at risk for transitioning from prescription to illicit opioids.

Evaluating the implementation of a multicomponent asthma education program for Head Start staff.

OBJECTIVE: Asthma disproportionately affects minority groups, low income populations, and young children under 5. Head Start (HS) programs predominantly serve this high-risk population, yet staff are not trained on asthma management. The objective of this study was to assess a 5-year, multicomponent HS staff asthma education program in Baltimore City HS programs. METHODS: All HS programs were offered annual staff asthma education by a medical research team that included didactic lectures and hands-on training. Attendees received continuing education credits. HS staff were anonymously surveyed on asthma knowledge and skills and asthma medication management practices in Year 1 (preimplementation) and Year 5. RESULTS: There was an estimated response rate of 94% for Year 1 and 82% for Year 5. Compared to staff in Year 1, Year 5 staff were significantly more likely to report they had very good knowledge and skills related to asthma [odds ratio (OR) 1.63; p < 0.05] and were engaged in asthma care activities (OR 2.02; p < 0.05). Self-reported presence of asthma action plans for all children with asthma was 82% at Year 1 and increased to 89% in Year 5 (p = 0.064). CONCLUSIONS: Year 5 HS staff reported higher self-assessed knowledge and skills, self-reports of asthma medication management practices, and self-reports of asthma activities compared to Year 1 staff. HS serves high-risk children with asthma, and a multicomponent program can adequately prepare staff to manage asthma in the child care setting. Our results indicate the feasibility of providing efficacious health skill education into child care provider training to reduce asthma knowledge gaps.

Pass the parcel: Service provider views on bridging gaps for youth with dual diagnosis of intellectual disability and mental health disorders in regional areas.

AIM: Youth with both intellectual disability (ID) and mental health (MH) disorders (dual diagnosis) have complex physical and MH needs that can make providing integrated care for this complex group challenging. We conducted a mixed methods needs assessment to identify gaps and challenges in care delivery, identify bridges for these and identify what works well in existing services. METHODS: Our research team recruited service providers (n = 126) caring for youth aged 14-24 years with a dual diagnosis in the Illawarra Shoalhaven region of New South Wales, Australia, to participate in focus group interviews. Data were transcribed and analysed thematically. RESULTS: We identified six themes related to caring for youth with dual diagnosis in regional areas: access to services and information about services, communication between service providers and with clients and carers, the divide between MH and ID, early intervention and health promotion, capacity building of service providers and capacity building of clients and carers. Across these themes, service providers highlighted the transition from child to adult services as a particularly challenging time for clients, families and carers. CONCLUSIONS: Our data suggest several approaches to break down silos and to facilitate collaboration between current services for youth with a dual diagnosis, including increasing specialised ID/MH services and building the capacity of current disability and MH service providers. Our results provide important information to provide quality and integrated care for youth with complex health needs.

The development of a South African Early Learning Outcomes Measure: A South African instrument for measuring early learning program outcomes.

BACKGROUND: Assessment of early childhood development programme effectiveness in South Africa is hampered by a lack of suitable measures that account for variations in cultural and socio-economic backgrounds and can be administered by non-professionals. This contribution reports the standardisation of the South African Early Learning Outcomes Measure (ELOM), an instrument designed for population level monitoring of the developmental status of children aged 50-69 months and for evaluation of early learning programmes. METHODS: The development of the ELOM was informed by South Africa's National Curriculum Framework from Birth to Four and its National Early Learning and Development Standards. ELOM items were drawn from reliable and valid instruments, particularly those used in Africa and other developing regions and were clustered in five domains: gross motor development, fine motor coordination and visual motor integration, emergent numeracy and mathematics, cognition and executive functioning, emergent literacy and language. The ELOM was standardised on a sample of 1,331 children aged 50-69 months, from five South African official languages and five socio-economic strata. Item Response Theory techniques were used to establish reliability, validity, and differential item functioning. RESULTS: Confirmatory Factor Analysis established that ELOM domains are unidimensional and internally consistent. Items discriminate reliably between more and less able children and do not discriminate unfairly between children of the same ability from different language backgrounds. Socio-economic gradients were evident in children's performance. South African Early Learning Development Standards (ELDS) based on standard scores were developed and set at the 60th percentile of the sample standard score distribution. CONCLUSIONS: This research produced the first South African, age-validated population-level standardised instrument that can be administered relatively cheaply by trained non-professionals. This will facilitate the assessment of the efficacy of early learning programmes in enabling children to reach ELDS prior to entering Grade R and track progress toward Sustainable Development Goal 4.2.

Who Gets What? Describing the Non-supervisory Training and Supports Received by Home Visiting Staff Members and its Relationship with Turnover.

The early childhood home visiting field lacks a basic understanding of home visiting program staff members' receipt of on-the-job training from experts outside of their programs who are not their immediate colleagues or supervisors. To address this gap, we created a unique dataset by asking program leaders to log the external technical assistance (TA) that staff members received, and we collected a survey from 288 of the same staff members. We performed descriptive analyses to learn how many hours of TA staff members were receiving, what topics the TA most commonly addressed, and what formats (e.g., in-person or virtual/remote, individual, or group) the TA was most commonly provided in. We then associated characteristics of the TA received with staff and program characteristics, as well as with staff members' turnover. Multilevel analyses showed the TA supports that home visiting staff members received differed by role (home visitor or supervisor) and program characteristics, including home visiting model-Nurse Family Partnership (NFP) or Parents as Teachers (PAT)-program size, and maturity. About 23% of the home visiting staff members left their programs over the course of 18 months. PAT staff members were more likely to leave their programs than NFP staff members. We did not find that characteristics of TA received were predictive of staff members' turnover. Implications and the need for further research are discussed.

Does Efficacy Equal Lasting Impact? A Study of Intervention Short Term Gains, Impact on Diagnostic Status, and Association with Background Variables.

OBJECTIVE: This article examines the efficacy of language intervention services for monolingual and immigrant children in a public clinic in Montreal, Canada. Intervention is provided in French for a preset number of sessions regardless of intervention needs. The study assessed immediate gains after intervention, their maintenance over 2 months, and their effect on diagnostic status at both time points. METHODS: Participants included 15 children (57.7 months SD 7.8) diagnosed with developmental language disorder: 3 monolinguals and 12 bilingual immigrants. Intervention targeted vocabulary and syntax. Assessment of intervention targets and standardized testing was conducted before, after, and 2 months after treatment. Diagnostic status and severity level were assessed at each time point. RESULTS: Intervention was highly efficacious with large effect sizes for intervention targets. However, for diagnostic status, efficacy was more questionable. Seven children improved their diagnostic status from pre- to posttest; but many dropped back at maintenance point. For 3 children, all test time showed scores within the non-impaired range, indicating misdiagnosis or change in status while waiting for treatment. Amount of pain was not correlated with any background variable. CONCLUSIONS: Results suggest that intervention could be more efficacious by giving more therapy sessions and conducting evaluation and treatment closer in time.

Early Intervention and Postural Adjustments During Reaching in Infants at Risk of Cerebral Palsy.

PURPOSE: To investigate postural effects of the family-centered program, COPing with and CAring for infants with special needs (COPCA), applied at 3 to 6 months' corrected age in infants at high risk of cerebral palsy. Previously, we reported postural differences between the infants at risk of CP in the control group of the current study and a group of infants developing typically. Now we focus on differences between 2 intervention groups. METHODS: We explored postural adjustments during reaching in seated infants at 4, 6, and 18 months using surface electromyography of arm, neck, and trunk muscles. Infants randomly received the family-centered program or another infant physical therapy. Using videotaped intervention sessions, we investigated correlations between time spent on specific physical therapeutic actions and direction specificity, recruitment order, and anticipatory activation at 18 months. RESULTS: Postural adjustments in both groups were similar, but development of direction specificity and anticipatory activation in COPCA infants better mimicked typical development. These 2 parameters were associated with COPCA-type physical therapeutic actions. CONCLUSIONS: Postural control was similar after both interventions. Positive outcomes were associated with fewer intervening actions of the therapist and greater allowance of spontaneous movements.

CARING: The Impact of a Parent-Child, Play-Based Intervention to Promote Latino Head Start Children's Social-Emotional Development.

CARING is a preventive, play-based, parent-child intervention designed to promote preschoolers' social-emotional development by strengthening their bonds with their parents. We describe the qualitative impact of the CARING Preschool program on Latino preschool children and their parents. One hundred and eleven Latino families participated in a larger study of the efficacy of the CARING preschool program. Of these families, 40 participated in this qualitative study. We invited families to participate in a focus group after completing the intervention. We used an inductive approach based on grounded theory to identify thematic categories. Parents reported substantial changes in themselves, their children and the quality of their relationships with their children as a result of their participation in CARING. Parents also reported an increased understanding of their children's needs, their ability to use at home the skills learned during the intervention, and improved parent-child communication. In addition, parents reported the social skills and self-regulation abilities of their children improved. These findings highlight the promise of preventive, low-cost interventions for families facing socioeconomic and psychosocial adversity, and their potential role in strengthening parent-child relationships. Results highlight cultural parenting practices and implications for intervention with Latino families.

Investing in the foundation of sustainable development: pathways to scale up for early childhood development.

Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.

Assessing retention in care after 12 months of the Pediatric Development Clinic implementation in rural Rwanda: a retrospective cohort study.

BACKGROUND: In Africa, a high proportion of children are at risk for developmental delay. Early interventions are known to improve outcomes, but they are not routinely available. The Rwandan Ministry of Health with Partners In Health/Inshuti Mu Buzima created the Pediatric Development Clinic (PDC) model for providing interdisciplinary developmental care for high-risk infants in rural settings. As retention for chronic care has proven challenging in many settings, this study assesses factors related to retention to care after 12 months of clinic enrollment. METHODS: This study describes a retrospective cohort of children enrolled for 12 months in the PDC program in Southern Kayonza district between April 2014-March 2015. We reviewed routinely collected data from electronic medical records and patient charts. We described patient characteristics and the proportion of patients retained, died, transferred out or lost to follow up (LTFU) at 12 months. We used Fisher's exact test and multivariable logistic regression to identify factors associated with retention in care. RESULTS: 228 children enrolled in PDC from 1 April 2014-31 March 2015, with prematurity/low birth weight (62.2%) and hypoxic ischemic encephalopathy (34.5%) as the most frequent referral diagnoses. 64.5% of children were retained in care and 32.5% were LTFU after 12 months. In the unadjusted analysis, we found male sex (p = 0.189), having more children at home (p = 0.027), health facility of first visit (p = 0.006), having a PDC in the nearest health facility (p = 0.136), referral in second six months of PDC operation (p = 0.006), and social support to be associated (100%, p < 0.001) with retention after 12 months. In adjusted analysis, referral in second six months of PDC operation (Odds Ratio (OR) 2.56, 95% CI 1.36, 4.80) was associated with increased retention, and being diagnosed with more complex conditions (trisomy 21, cleft lip/palate, hydrocephalus, other developmental delay) was associated with LTFU (OR 0.34, 95% CI 0.15, 0.76). As 100% of those receiving social support were retained in care, this was not able to be assessed in adjusted analysis. CONCLUSIONS: PDC retention in care is encouraging. Provision of social assistance and decentralization of the program are major components of the delivery of services related to retention in care.

Rates of early intervention services in children born extremely preterm/extremely low birthweight.

AIM: To determine the rates of early intervention (EI) service use in extremely preterm (EP, <28 weeks' gestation) or extremely low birthweight (ELBW, <1000 g) infants between 1991 and 2013, and identify biological or socio-economic factors associated with receiving EI. METHODS: Participants comprised consecutive EP or ELBW survivors born in 1991-1992, 1997 or 2005 in Victoria, Australia, and randomly selected, matched term-born controls. The main outcome measure was parent-reported EI participation up to 8 years of age. Neurodevelopmental outcomes and socio-economic risk factors were compared with EI participation to identify associations among the preterm groups. RESULTS: The rates of EI were higher in the preterm groups than the control groups overall (odds ratio 4.29, 95% confidence interval 3.28, 5.59, P < 0.001), and the rates of EI rose significantly over time - from 42% in the 1991-1992 preterm cohort to 64% in the 2005 preterm cohort. Among the preterm groups, post-natal corticosteroid therapy, cystic periventricular leukomalacia and surgery in the newborn period were all independently associated with increased odds of receiving EI. Increased severity of disability was associated with higher rates of EI. The majority (95%) of preterm children with a physical impairment received EI, compared with only 73% of children with a cognitive impairment alone. EI participation rates were independent of social risk. CONCLUSION: EI participation is high in the EP population, and rates of EI use have increased over time. Contrary to previous reports, social risk factors were not found to be associated with EI use.

Care for Child Development: an intervention in support of responsive caregiving and early child development.

BACKGROUND: An estimated 43% of children younger than 5 years of age are at elevated risk of failing to achieve their human potential. In response, the World Health Organization and UNICEF developed Care for Child Development (CCD), based on the science of child development, to improve sensitive and responsive caregiving and promote the psychosocial development of young children. METHODS: In 2015, the World Health Organization and UNICEF identified sites where CCD has been implemented and sustained. The sites were surveyed, and responses were followed up by phone interviews. Project reports provided information on additional sites, and a review of published studies was undertaken to document the effectiveness of CCD for improving child and family outcomes, as well as its feasibility for implementation in resource-constrained communities. RESULTS: The inventory found that CCD had been integrated into existing services in diverse sectors in 19 countries and 23 sites, including child survival, health, nutrition, infant day care, early education, family and child protection and services for children with disabilities. Published and unpublished evaluations have found that CCD interventions can improve child development, growth and health, as well as responsive caregiving. It has also been reported to reduce maternal depression, a known risk factor for poor pregnancy outcomes and poor child health, growth and development. Although CCD has expanded beyond initial implementation sites, only three countries reported having national policy support for integrating CCD into health or other services. CONCLUSIONS: Strong interest exists in many countries to move beyond child survival to protect and support optimal child development. The United Nations Sustainable Development Goals depend on children realizing their potential to build healthy and emotionally, cognitively and socially competent future generations. More studies are needed to guide the integration of the CCD approach under different conditions. Nevertheless, the time is right to provide for the scale-up of CCD as part of services for families and children.

WIDENING THE SCOPE OF SOCIAL SUPPORT: THE FLORIDA MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAM.

The Florida Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program is designed to support pregnant women and families in developing skills and utilizing resources necessary to promote their children's physical, social, and emotional development. Little evaluation attention has focused on large-scale, public policy driven home-visiting programs. Social support provision is a critical component of a successful home-visiting program; therefore, there is a need to better understand participants' perceptions of social support provided to them in this context. Forty-five home-visiting participants from five Florida MIECHV programs completed semistructured telephone interviews. Participants discussed their experiences with the MIECHV program, including descriptions of their interactions with home visitors. Content analysis revealed that participants experienced multilayered social support from home-visiting staff. Families needed and received substantial emotional, instrumental, informational, and appraisal support at the individual level. This support was embedded within and strengthened by the strategies and activities of the home-visiting model of service provision. Results highlight the powerful opportunity home visiting offers as a method of service delivery within the larger system of care to increase social support in families experiencing high risk for negative maternal and child health outcomes. Implications for policy and practice are discussed.

Behavioral and Psychosocial Characteristics Among Head Start Childcare Providers.

The aim of the study was twofold: (a) describe behavioral and psychosocial characteristics of Head Start childcare providers including technology use, physical activity, nutrition, depression, and quality of life and (b) examine associations among these characteristics. Using a cross-sectional design, a nonrandom sample of 80 Head Start childcare providers completed an online survey via SurveyMonkey. About 80.1% were overweight or obese. Nearly all had a computer or smartphone. About 55% met the national physical activity recommendation of 150 min/week. Approximately 56.2% did not know the recommended daily servings of fruits and vegetables, and 26.3% had ≥3 servings of vegetables per day. About 38.8% had major depression or dysthymia, and 31.3% had depressive symptoms. The top two perceived health needs were weight loss and stress management. Providing a health promotion and stress management program to childcare providers may benefit both providers and children, considering the strong influence of teachers on children.