The main components in the development of the ABC Grow Healthy Standards are:
- Decision to integrate nutrition and physical activity standards into system with existing reimbursement protocol (financial incentive for participation). Once enrolled in the ABC Quality system, centers can opt to participate in the ABC Child Care Voucher System to serve families receiving child care vouchers. Families who meet income qualifications based on gross family income and who are working, in school, or in training may choose a child care provider enrolled in the ABC Child Care Voucher System. For entrance to the program, the income criteria are no more than 150% of the federal poverty level. Once enrolled, when the gross family income exceeds 175% of the federal poverty level, the family is no longer eligible for a child care voucher. Child care providers are reimbursed for ABC children they serve based on the center's actual weekly rate not to exceed the established maximum amount for the quality level the provider is enrolled. Providers at Level B or above also receive a quality incentive award per week per ABC child enrolled. The incentive award ranges from $5 per week per child for Level B centers to $20 per week per child for Level A+ centers. No change was made to the reimbursement system with the addition of the ABC Grow Healthy Standards.
- Review existing standards for healthy eating, physical activity, and screen time, and develop final list of standards for each level of ABC Grow Healthy. DHEC and DSS contracted with the University of South Carolina Arnold School of Public Health (USC) to create a crosswalk of national recommendations and state level requirements for both nutrition and physical activity in the child care setting. Based on their expert opinion, USC recommended standards the ABC Quality system should consider for adoption. Upon conclusion of the evaluation pilot (see Evidence Summary section for more on the pilot evaluation), the standards were further refined by the ABC Grow Healthy team and adopted by the ABC Quality system for implementation across the quality levels. The crosswalk and the final standards are available in the Intervention Materials section.
- Conduct presentations and share information about the adoption of nutrition and physical activity standards with key stakeholders (e.g, child care center directors, child care technical assistance providers, other early care and education partners). To create awareness of forthcoming standards, DHEC and DSS staff presented at early childhood professional conferences, communicated with child care center directors, and shared information with early care and education partners from the onset of the initiative. The goal of this process was to build familiarity with the intent to introduce new standards and lay the groundwork for a successful implementation.
Levels A+ and A: South Carolina uses the Environmental Rating Scales (ERS) tool applicable for the age group(s) the provider serves. The ERS tools are recognized internationally as reliable and valid classroom observation instruments. Completing the tool requires approximately 3 hours of observation per classroom. There are three tools, used for different age groups:
- Infant/Toddler Environment Rating Scale (ITERS)
- Early Childhood Environment Rating Scale (ECERS)
- School-age Care Environment Rating Scale (SACERS)
A sample of 1/3 of the classrooms in the center per age group is chosen randomly for review. Additionally, these centers are reviewed for compliance to South Carolina-specific standards, which were expanded to include the mandatory ABC Grow Healthy standards. The ERS tools are not available as part of this intervention package, but the South Carolina developed tool is available in Intervention Materials.
Levels B+ and B: South Carolina uses a state-developed tool that includes all ABC Child Care standards for Level B, including the Grow Healthy standards. The advantage of using the state-developed tool for this group of centers is that this tool does not require the observer to be in the classroom for 3 hours (as the ERS tools mentioned above do), thereby allowing the observer to see a larger sample of classrooms to be more reflective of quality differences across classrooms. The ABC Grow Healthy standards for Level B are embedded into the mandatory standards as well as classroom observation standards.
Level C: At this level, South Carolina uses a state-developed tool that includes the mandatory ABC Child Care standards and Grow Healthy standards. This tool is formatted similarly to the Level B tool but it addresses basic health and safety standards based on child care licensing only.
- Train the ABC Quality assessors to reliably use the assessment tools with the embedded ABC Grow Healthy standards. The assessors are staff of ABC Quality in the Division of Early Care and Education, housed within DSS. The assessors received training on how to complete sections added to the monitoring tools specific to ABC Grow Healthy. For example:
- Sessions were held with the assessors to talk through the meaning and intent of each standard and to create a common understanding.
- Staff collectively discussed measurability of each standard and created examples of compliant actions.
- CACFP staff provided training to familiarize the assessors with CACFP requirements.
- During meetings, assessors participated in activities to informally assess inter-rater reliability. For example, assessors were given a sample center menu and asked to assess compliance ABC Grow Healthy standards.
- Monthly staff meetings provide an ongoing opportunity for ABC assessors to address questions raised by child care center staff, as well as learn how other assessors are measuring compliance with specific standards.
Achieving inter-rater reliability is an ongoing challenge, and discrepancies continue to be addressed as they arise.
- Communicate the revised ABC Quality Standards for child care centers at all quality levels. Information sessions were held across the state to introduce the new standards and allow child care providers the opportunity to ask questions. All enrolled centers were notified in writing that the new standards had been embedded in the existing ABC Quality levels. All materials, standards, website information, and information sheets were revised accordingly in preparation for the date of compliance.
- Child care centers implement standards. The child care centers developed their own center-level physical activity and nutrition policies and implemented the standards through those policies. Technical assistance, such as menu review, assistance re-arranging classrooms to promote movement among infants, etc., was made available from the ABC Quality assessors, DHEC staff, and other ABC Quality partners including the South Carolina Child Care Resource and Referral Network and the South Carolina Program for Infant Toddler Care Specialist Network.
- Assess enrolled centers for implementation and compliance with standards. With the new nutrition and physical activity standards embedded in the existing ABC Quality system, unannounced site visits were conducted to assess compliance. In the first year of implementation, only Level B centers were assessed due to the very small number Level A centers and the few new standards for Level C centers.
- Provide a grace period to allow providers the opportunity to take corrective action for non-compliance prior to financial sanctions. As the nutrition and physical activity standards were embedded into the existing ABC Quality standards and levels, there was no change in reimbursement policy. However, since provider performance and payment were impacted by non-compliance with mandatory standards, providers were given the opportunity to take corrective action with no financial consequence within a limited time frame if they did not meet the new nutrition and physical activity mandatory standards on the date of their unannounced review.
Keys to Success
- Conducting a pilot implementation and evaluation period uncovers discrepancies, inconsistencies, and/or misunderstandings about the standards and improves clarity and implementation.
- Hiring a position in the public health agency dedicated to coordinating obesity prevention efforts and supporting partners in the early care and education setting.
- Listening carefully to feedback from early implementers can frame key issues and "selling points" for other providers.
- Reviewing pilot feedback on the proposed standards in the context of cost, feasibility, and impact on children results in compelling discussions about the rationale for adopting the standards.
- Incorporating a communications period helps to get the word out about the new standards before they are fully rolled out, which allows centers to begin planning for how to meet the new standards.
- Providing a financial incentive (i.e., higher reimbursement than normal for qualifying children, implementation grants) for center participation in the ABC Quality system, which includes nutrition and physical activity standards, may improve adoption and reach. The financial incentive also provides the potential for this policy to reach children with the highest need.
- Reaching out to health-related groups and other partners within the early childhood community for support and using common messaging expands the reach of the intervention and creates shared ownership.
Barriers to Implementation
- The assessors with early childhood backgrounds who appraise compliance and implementation at the child care sites need significant training to reliably monitor implementation and compliance of nutrition and physical activity standards. Even with training, achieving reliability is challenging. Without reliable monitoring, it is challenging to assess the public health impact.
- Development and availability of sufficient number of training opportunities to meet staff training requirements.
- Centers may see participation in this voluntary program as cumbersome, expensive, and/or resource-intensive; whether their perceptions are true or not, this might be a barrier to participation/adoption.
- Technical assistance: Assessors need to be responsive to provider concerns to ensure that applicable technical assistance is made available promptly. In most cases, the provider concerns result from misunderstandings about the assessment item(s) in question.
- Cost: Some providers may express concerns about the cost of implementing the nutrition standards. Centers are encouraged to explore enrolling in CACFP, which has similar nutrition standards. CACFP participation can provide another source of funds to offset food costs.
- Interpretation of the standards was an issue revealed in the pilot evaluation, which could still be an issue now that the standards are finalized and integrated into the ABC Quality system.
- Change to daily practices, habits, and cultural traditions is challenging. Continuing national media attention on childhood obesity has been positive in reinforcing the nutrition and physical activity standards.