Abstract
Many children in Head Start programs do not meet physical activity (PA) and dietary intake recommendations and have increased risk for obesity. The purpose of this pilot study was to formatively assess a multi-level intervention, exploring strategies to encourage PA and healthy eating among north Texas Head Start families. In year 1, 5 Head Start sites with 217 children began the Head Start to Healthy Lifestyles (HSHL) project. Direct and indirect education strategies began in the last 2 months of the school year. Surveys were used to evaluate child and caregiver PA, healthy eating behaviors, and interagency collaboration. Strategies and barriers to adopting healthy lifestyles were assessed via grant partner discussions. Of 217 children enrolled, 109 caregivers consented to participate in research, of which 35 completed baseline surveys and 10 also submitted post surveys. The number of fruits eaten by Head Start caregivers improved (P < .05). Perceived level of collaboration among grant partners was high. Strategies appreciated by Head Start site partners included PA support in the classrooms, take-home gardens, and reading food group books. Additional needed support included tasting and on-site cooking classes. Barriers to participation included few face-to-face meetings with parents, staffing shortages post-COVID, and difficulty engaging families.
“Promising practices included provision of materials impacting the school PA and nutrition environment.”
Introduction
Most children in the United States (U.S.) do not consume enough healthy foods such as fruits, vegetables, and whole grains, nor do they engage in the recommended level of daily physical activity (PA).1,2 Obesity prevalence is more than 1 in 8 (13.4%) among children aged 2 to 5 in the U.S. 3 A major contributor to childhood obesity is an imbalance between energy intake and energy expenditure. 4 Eating and exercise habits are formed early and typically persist over time. 5 Low-income, young children are more likely to have low food security, and with this often comes lower dietary quality, with especially low intake of fruits and vegetables and excessive intake of sugar-sweetened beverages.1,6 Poor dietary quality, insufficient PA, and high levels of sedentary behavior and screen time influence overall health among preschoolers and are significant risk factors for obesity and other chronic diseases.
Head Start is a U.S. government-funded program which provides free, high-quality early education to income-eligible 3-5 year olds. Most children enrolled in Head Start do not meet the recommendations for PA and dietary intake and have higher risk for overweight and obesity compared to U.S. children of higher income households.7,8 Although several studies using family or community-based approaches have demonstrated some improvements in PA and dietary quality in similar populations, children enrolled in Head Start still have high rates of overweight and obesity.9-11 Empirical research supports that interventions designed to improve the PA and healthy eating of preschoolers are needed to prevent and control childhood obesity.12,13 However, a systematic review on prevention of early childhood obesity 14 and another on preventive policies, practices, and interventions in childcare centers 15 both reported limited success in improving PA level and dietary behavior.
Young children’s PA and dietary behaviors are influenced not only by personal and parental factors but also by their school and home environments, including interactions with their peers, parents, and teachers. 16 To date, several studies have provided evidence to support educational interventions that have provided nutritional education and encouraged PA in childcare settings.17-20 However, because poor dietary intake and PA levels remain a problem in these settings, multi-level interventions, which impact individual, environmental, community, and cultural/societal factors, constructs of the social ecological model (SEM), 21 have greater potential for producing changes in lifestyles. In Head Start settings, interventions should address individual knowledge and behaviors (child and caregiver), interpersonal factors (support for behavior change), as well as supporting a healthy school environment and a healthy home environment. 22
The purpose of this pilot study was to formatively evaluate the implementation of the first year of Head Start to Healthy Lifestyles (HSHL), supported by SNAP-Ed, a 5-year, multi-level SEM-based intervention to promote PA and healthy eating among Head Start families and children to reduce risk for childhood overweight and obesity. The objectives of this study were to investigate (1) whether the short-term intervention improved PA and dietary intake in children or caregivers, (2) how deep the level of collaboration was among grant partners, and what steps could be taken to improve collaboration, (3) which strategies are helpful to encourage PA and healthy eating among Head Start families, and (4) which barriers impede communication and interaction to promote PA and healthy eating with Head Start families.
Methods
Study Design
This formative evaluation involved pre- and post-comparisons of caregivers’ survey responses about their and their children’s PA and dietary behaviors and intake, grant partner’s perceptions of the level of collaboration, as well as views of grant partners regarding what worked well and what did not. The University of Texas Health Science Center of Houston’s Committee for the Protection of Human Subjects determined the evaluation of SNAP-Ed programs, such as Head Start to Healthy Lifestyles, is not research with human subjects (Reference Number: 213697).
Participants and Setting
Five Head Start sites in Tarrant County, Texas, agreed to participate in the HSHL project. This project planned to begin services in January 2022; however, due to COVID-19 pandemic–related teacher shortages and demands on teachers’ and administrators’ time, the project was not able to begin until the last 2 months of the 2021-2022 academic year (late March to mid-May). Two-hundred seventeen children from the 5 sites received direct physical activity and nutrition education. All Head Start sites were managed by Child Care Associates (CCA) of Fort Worth, but 4 sites were in Crowley Independent School District (CISD) elementary schools. No control sites were used.
Direct education was delivered to all Head Start children at all sites and to families that participated in extra-curricular interventions. All participants were asked to complete pre- and post-surveys to provide formative feedback for the project.
HSHL Interventions
The UNT and TWU, together with community partner, Tarrant Area Food Bank (TAFB) delivered direct and indirect education to children and families in CCA, including CISD. A diagram of the interventions by category is provided in Figure 1. Head Start to Healthy Lifestyles (HSHL) year 1 interventions by type.
Direct Education to Preschoolers
The HSHL project included direct PA education in the classroom using the Coordinated Approach to Child Health (CATCH) physical activity curriculum. 23 CATCH was implemented weekly for 30-minute classroom sessions for the last 6-8 weeks of the school year (excluding weeks the elementary-school Head Start classrooms were inaccessible due to state testing). All PA sessions, which were created using a skill theme approach, aimed to engage children in physical activities to increase movement and develop physical, social, and psychological skills. The PA education sessions were delivered by trained Kinesiology faculty and students with a focus on movement and flexibility as well as muscle and skill development.
In addition, preschoolers were read 5 books on MyPlate food groups (eg, protein, vegetables, fruits, grains, and dairy) on a weekly basis for 20 minutes per reading session for 6-8 weeks. The books were developed by a nutrition PhD student and Registered Dietitian Nutritionist (RDN) with pediatric nutrition expertise, together with her faculty advisor and tested in childcare settings previously (unpublished data). They describe each of the food groups, highlighting where food comes from, and the benefits of eating foods from each group. Each book contained a QR code, that when clicked on with a smartphone or other device would open the book virtually and read to the classroom.
Indirect Education to Families
HSHL implemented a Walking for Heart program for families of the Head Start students. Pedometers were sent home for caregivers and preschoolers, along with instructions about using them at home. A family weekly log was also provided to promote PA self-monitoring. A monthly PA calendar with ideas for home PA for each day of the month was developed and sent home with the preschoolers. A family challenge program with small gifts was created to encourage participation.
Families were encouraged to sign up to receive text messages promoting family physical activity and healthy eating including consumption of fruits and vegetables, whole grains, high quality proteins, water in place of sugar-sweetened beverages, and dairy foods. In addition, messages related to food resource use, healthy feeding and eating, and promoting positive attitudes toward food were shared. One physical activity and one nutrition text message were shared each week using a system called Mosio (Seattle, WA). Some messages were derived from Text2BeHealthy 24 and others from Text4HealthyTots. 25 Others were written for this population to address eating and physical activity behaviors.
Caregivers were encouraged to follow a public Instagram page promoting the same PA and healthy eating outcomes and to join a closed Facebook group promoting similar behaviors. The Facebook group was also intended to provide opportunities to provide social/cultural/home support for healthy lifestyles and allow participants to share success stories as well as favorite recipes and fun physical activities and events.
Environmental Interventions
Head Start families received a three-level container garden, a bag of soil, and 4 types of seeds in March and another set of 4 seeds right before summer (late May). The gardens were provided with instructions for planting and a parent newsletter was provided (indirect education) based on the Harvest for Healthy Kids curriculum. 26 Materials were provided in English and Spanish, as needed. Gardens were intended to provide parental/child support for growing and consuming fruits and vegetables and provide some actual access to produce grown with the garden.
Physical activity equipment and supplies were provided to the centers to use when staff were not on-site to deliver the CATCH program. These included the CATCH curriculum, balls, cones, hula hoops, nets, games, etc. These were intended to promote activity when HSHL were not on site.
In addition, HSHL provided MyPlate food group books for Head Start teachers to read to children and discuss in the classroom to facilitate familiarity and acceptance of nutritious foods. Allowing children access to the books outside reading time provided resources to promote literacy and nutrition. Finally, sites were provided with cooking kits, including bowls, utensils, colanders, induction cooking burners and pots, measuring utensils, knives, and cutting boards so that teachers could provide food preparation activities with children.
Assessments
Child and parent nutrition and PA were assessed pre- and post-intervention using surveys. Collaboration perception among the partners was also assessed using pre- and post-intervention survey. Perception of strengths and weaknesses of the first-year intervention was assessed via formative feedback (email, in-person) and group discussion.
The University of Texas Health (UT Health), which was contracted with the grant agency to provide assessment for Supplemental Nutrition Assistance Program Education (SNAP-Ed), produced a customized survey for HSHL to use to evaluate PA engagement and dietary intake and behaviors among caregivers and their children. It was a 45-question survey, including validated questions (Email communication with UT Health). The survey’s key outcome variables assessed healthy eating intake and behaviors, of both parents and children in Head Start, including intake of fruits and vegetables, and intake of sugar-sweetened beverages. It also assessed whether parents routinely used MyPlate and food labels, compared unit prices, or used a grocery list when shopping, as well as parent and child PA level, screen use, and sedentary behavior. Finally, it inquired about demographic details such as parent/caregiver gender, age, ethnicity, race, and education level.
To evaluate partner collaboration, HSHL sent out an on-line survey to grant partners at the beginning and end of the project (late April and late September). The Levels of Collaboration Survey is a validated survey that was customized for the sites. 27 It was sent to 21 individuals at UNT, TWU, TAFB, CCA, and CISD at the start of the project (pre) and 14 individuals still at each site from the same agencies at the end of September 2022 (post). The Levels of Collaboration Survey employs a 5-point scale that ranges from Networking (1) to Collaboration (5) to describe the different partners on the grant as perceived by other partners. Information about perceived usefulness of strategies and barriers to communication and interaction were gathered via discussions with grant partners, including teachers, family engagement advocates, center directors, and community agencies. This information was informally gathered and shared via email, in person meetings, and personal interactions.
Statistical Analyses
Statistical analyses were conducted with the use of SPSS version 29 (IBM). Mean, standard deviations (SDs), and frequencies were assessed for all demographic data and other variables of interest based on the pre- and post-data. Then, the Wilcoxon signed-rank test was applied to compare nonparametric variables’ baseline and follow-up scores for the UT Health survey questions related to parent and child nutrition and PA. Descriptive statistics for the Levels of Collaboration Survey were gathered; pre- and post-means were compared using an independent samples t test because it was not possible to pair responses of individuals using identifiers.
Results
Demographic Characteristics of Head Start Caregivers/Parents Participating in the UT Health Baseline Survey (n = 35).
Baseline Child Eating Intake: Foods Eaten the Day Before (n = 35).
Baseline Parent/Caregiver Fruit and Vegetable Intake; Food Resource/Literacy Behaviors (n = 35).
Baseline Child and Parent/Caregiver Physical Activity (PA) and Sedentary Behavior (n = 35).
Changes in Healthy Eating, Nutrition Related, and Physical Activity (PA) and Sedentary Behaviors Among Head Start Parents/Caregivers (n = 10).
The Levels of Collaboration Survey was completed by ten partners (48% response rate) at the start of the project. Nine partners (64% response rate) submitted the survey at the end of the project. The pre-survey responses included 3 from UNT, 4 from TWU, 1 from CISD, and 2 from CCA; none from TAFB. Only one teacher responded to both the pre- and post-survey. Collaboration with the CCA teachers was rated a mean of 4.1 (Coalition: share ideas, resources) on the pre-survey and 3.6 (Coordination: share information and resources) on the post-survey. Collaboration with UNT researchers was rated a 4.1 on the pre-survey and 4.67 on the post-survey (Coalition: share ideas, resources) Collaboration with TWU researchers was rated a 4.6 on the pre-survey and 4.67 on the post-survey (Coalition: share ideas, resources). Collaboration with community partner TAFB was rated a mean of 3.5 on the pre-survey and 3.56 on the post-survey (Coordination: share information and resources). There were no significant differences in mean level of collaboration for any group between the pre- and post-surveys.
In informal discussions with Head Start teachers, family engagement advocates, and center directors and during a meeting in the beginning of year 2, the following positive aspects of the project were mentioned: children and teachers enjoyed direct PA delivery in the classroom; children enjoyed reading food group books. In addition, teachers reported the students loved their take-home gardens and sent pictures of kids with their gardens to HSHL staff. A key aspect needing improvement included streamlining communication. School staff requested less frequent and more organized communication from UNT, TWU, and TAFB staff. They also suggested additional needed support included more interactive sessions with food, including tasting food after reading food-group books and offering on-site cooking classes. Barriers to getting good parent participation included few face-to-face meetings with parents, staffing shortages post-COVID, and difficulty engaging families. In addition, TAFB was understaffed in year 1 and was not able to implement direct education to parents through Cooking Matters in year 1. Cooking Matters EXTRA for Center-based Childcare Professionals was offered to food service staff at the end of year 1, but this was technically difficult during the summer, which is an off period for Head Start centers.
Discussion
This pilot study aimed to conduct a formative evaluation of a multi-level intervention and assess strategies and barriers for encouraging PA and healthy eating behaviors among Head Start families and children. In the first year, HSHL made progress toward implementing health promotion activities to help Head Start families establish healthy eating habits and active lifestyles. Although there was a significant increase in the number of fruits consumed by caregivers (P < .05), caregivers self-reported higher fruit and vegetables consumption than expected among both them and their children at baseline. It should be noted that one center had a population that consisted almost entirely of recent immigrants, whom it seemed in discussions with the children were very used to eating fruits and vegetables. The other 4 centers had a primarily Black, non-Hispanic, non-immigrant population, whom it seemed anecdotally were less accustomed to eating fruits and vegetables. The majority of the survey responses came from the center with a high population of recent immigrants, which may account for the above average intake of fruits and vegetables at baseline compared to a more typical U.S. population. 1
Due to delays in getting agreements signed, the project had a delayed start and short duration of only 6-8 weeks, depending on site. While implementation of several parts of the multi-level intervention was achieved, including implementation of center-based direct education (PA and food group book reading), there were barriers to achieving others (eg, no on-site cooking/nutrition classes for parents), with low access to caregivers. Few parents signed up for text messaging (less than 30). Few signed up for the closed Facebook groups (less than 20), and few followed the Instagram page (less than 30). Because TAFB was also not able to implement Cooking Matters, this meant the intended multi-level intervention mostly provided direct education to the children and some environmental support/indirect education through home gardens, newsletters sent home, and a book/digital book provided to each child at the end of the school year. It was unclear if the monthly PA calendar used on a regular basis to foster movement at home. Thus, it is not surprising that the survey data showed no significant improvement in PA and healthy eating in the first year except for intake of fruit among caregivers. Overall, neither Head Start caregivers/parents nor children’s PA and sedentary behaviors were significantly different between baseline and post-intervention in the first year of implementation. This finding is consistent with previous studies in preschool-aged children17,28 that Head Start center- and family-based interventions to prevent obesity did not result in outcomes that were significantly different from those in a comparison group. It is almost certain that the family intervention’s level of intensity and duration was insufficient to produce major change. 29 Indeed, due to the COVID-19 pandemic, which resulted in teacher shortages and many demands on teachers’ and administrators’ time, this project had a limited intervention period and lack of implementation of interventions for caregivers and educators in the first year of project implementation.
A according to previous study, addressing diet and PA behavior changes among mothers of children between the ages of 1 and 3 years led to an increase in PA among both the mothers and their children. 30 Health-related habits of preschool-aged children are greatly influenced by their parents and caregivers, especially in the areas of diet, PA, and screen time. 31 Therefore, with more focus on family involvement and with more intervention time, children’s healthy eating and PA behaviors may improve as more aspects of the multi-level project are implemented and maintained.
There were several strengths of this multi-level, SEM-based intervention. These included the implementation of research and practice-based PA and nutrition curricula in the classroom at least once a week for 6-8 weeks, provision of parent newsletters on vegetables as well as gardens and seeds, and digital food group books to parents at the end of the school year. In addition, developing a closed Facebook group, public Instagram page, and research and practice-based text messaging helped provide reinforcing messages to change the culture of health at home. The Walking for Heart program including pedometers for preschoolers and families, the weekly steps challenge, and the monthly activity calendars are promising practices and will be implemented over a longer period in the future. The current study also involved meetings and discussions of the project’s stakeholders to receive collaborative suggestions for how to implement these activities.
As indicated above, community partners (eg, TAFB personnel, CCA and CISD teachers, and administrators) and research partners of this project (eg, researchers, post-docs, and graduate students) were also polled as part of the evaluation of collaboration to determine the level of collaboration using the Levels of Collaboration Survey. It is hard to draw strong conclusions about the Levels of Collaboration Survey results as some of the players changed between the timing of the pre- and post-surveys due to the change in school years, but in general, perceptions of collaboration seem to be improving. TAFB and Head Start teacher collaboration need the most work. This finding suggests that there is a need to plan to provide more teacher professional development and active communication and effectively collaborate with partners in programs such as HSHL.
A weakness of the implementation of this project included the short duration (a small part of the school year) due to the COVID-19 pandemic, teacher shortages, and various levels of parental comfort with return to school procedures. Additional weaknesses included the lack of parents receiving reinforcing text messages or participating/following the Facebook and Instagram pages, uncertainty of materials such as calendars and pedometers reaching the home, and the lack of on-site cooking/nutrition classes due to understaffing with the TAFB community partner. In this way, this project had challenges similar to Hornby and Lafaele’s, in which barriers included limited caregiver/parent involvement at home-based interventions. 32 In addition, getting more caregivers to complete surveys would strengthen the research rigor of the project, as well as adding delayed intervention, control sites.
Promising practices, based on conversations with partners, included provision of materials impacting the school PA and nutrition environment such as play and cooking equipment and supplies for classroom. More specifically, some Head Start sites encouraged participation in PA by using the PA equipment and supplies on a daily basis. In addition, all sites appreciated the direct provision of PA and nutrition education to children in the classroom, as well as having gardens sent home for families.
Future implementation of this multi-level project must include multiple meetings throughout the academic year with teachers, administrators, family advocates, nurses, and families to better understand their needs and to improve both communication and interventions. This will include meetings with various center staff during the summer, as well as attendance of HSHL staff at back-to-school and registration events to improve communication with families. To improve participation with text messaging and social media, sign-up for these needs to occur during the period in which they consent and complete the survey. Decreasing the length of the survey may help with completion and response rate. Also, further studies will necessitate efforts to provide training sessions to teachers and staff in an integrated way to strengthen relationships and the skills of all staff working with Head Start children and families. Finally, more meaningful interaction with families is needed to promote and sustain healthy lifestyle adoption. One way to promote this includes providing more education to parents at mandatory Head Start parent training sessions and encouraging attendance at cooking classes as another way to meet the parental in-kind training requirement for Head Start. In addition, parents may be encouraged to join the Facebook groups if they learn more about what is happening with HSHL in schools and engage more with Instagram with more video and recipe-type content, which parents informally mentioned wanting.
Footnotes
Acknowledgments
We wish to thank the teachers, family education advocates, and administrators for Child Care Associates, Crowley Independent School District, and our community partners at Tarrant Area Food Bank.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Texas Health and Human Services Commission (USDA FNS) (HHS001018600004) and USDA SNAP Ed provided funding for this study.
Correction (November 2024):
Article was updated to clarify the approval on Study Design under Methods section.
