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Volume
3:
No. 2, April 2006
COMMUNITY CASE STUDY
Design and Implementation of a Nutrition and Physical Activity
Curriculum for Child Care Settings
Carolyn Dunn, PhD, Cathy Thomas, MAEd, Dianne Ward, EdD,
Leslie Pegram, Kelly Webber, MS, Courtney Cullitan, MPH, RD
Suggested citation for this article: Dunn C, Thomas C,
Ward D, Pegram L, Webber K, Cullitan C. Design and implementation
of a nutrition and physical activity curriculum for child
care settings. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Available from: URL:
http://www.cdc.gov/pcd/issues/2006/
apr/05_0039.htm.
PEER REVIEWED
Abstract
Background
Childhood overweight continues to increase in the United States. Children should begin establishing healthy
eating and physical activity behaviors at a young age.
Context
Many children spend a large part of their day in child care
settings, whether in preschools or home day care settings. Child
care providers in these settings have an opportunity to establish
and reinforce habits that promote good health. However, the
providers need training and creative educational materials to
teach children about healthy eating and physical activity. Color Me Healthy is an educational program focusing on
nutrition and physical activity that was developed for children
aged 4 and 5 years by three of the authors (C.D., C.T., and L.P.).
Methods
In 2001 and
2002, the program was implemented in 47 North Carolina counties and the North
Carolina Cherokee reservation. In December 2001, we used an
information-dissemination model called Train the Trainer during a session to
teach county teams comprising local public health professionals
and cooperative extension employees how to teach child care
providers in their communities to use the curriculum. The child care providers
were then trained between March and August 2002. Follow-up
evaluation forms were given to trained child care providers 8
weeks after the training.
Consequences
Of the providers who completed the evaluations (n = 486), 92.0%
indicated that using the Color Me Healthy curriculum
increased the physical activity of their students, and 91.8%
indicated that it increased the children’s knowledge about
movement. In addition, 93.0% of providers also indicated
that using Color Me Healthy had increased the
children’s knowledge about healthy eating.
Interpretation
Child care providers need educational materials on healthy
eating and physical activity and should be trained to use them. The Train the Trainer model is an effective way to
teach public health professionals to train child care providers
on the Color Me Healthy curriculum materials about
healthy eating and physical activity.
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Background
Childhood overweight is increasing in the United States.
Currently, one in five children is overweight or at risk of
becoming overweight (1). In the United States, the prevalence of
childhood overweight tripled between 1980 and 2000 (2).
Specifically, 10.4% of children aged 2 to 5 years are overweight
(≥95th percentile body mass index [BMI] for age), and 20.6% are at risk
of overweight (85th to < 95th percentile BMI for age) (3). The
prevalence of overweight in this age group is even higher among
Mexican Americans, with 11.1% being overweight and 22.7% being at risk of
overweight (3). The epidemic of childhood overweight is a
complex problem with many contributing factors. Lack of adequate
physical activity and unhealthy eating habits are widely
recognized issues; however, very few children have healthy eating
and physical activity habits that would decrease their risk of overweight (4,5).
Many children’s eating patterns are not consistent with
current recommendations for a healthy diet (4,5). Children consume too
much fat and sugar-sweetened beverages and too little fiber,
fruit, and vegetables (2,6). In addition, lack of physical
activity is associated with higher weights in children. It is
recommended that children participate in at least 60 minutes of
physical activity per day, but many children do not meet this
recommendation (5,7).
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Context
Every day, more than 13 million preschool-age (3 to 5 years) children are in
child care settings such as preschools or home day care settings,
which could present excellent opportunities for the child care
providers to reinforce healthy eating and physical activity
habits. It is imperative that at a young age, children are taught
about healthy eating and the benefits of physical activity (8).
Furthermore, children may then be able to influence the health
behaviors of their own families (9,10).
Involving caregivers in educating and inspiring children about
healthy eating and physical activity is an important way adults
can help children develop behaviors that can prevent overweight.
However, many child care providers lack training in nutrition and
physical activity education.
The purpose of this article is to describe the development and
initial implementation of Color Me Healthy, a healthy eating and physical activity
program for children aged 4 and 5 years in child care settings.
Health promotion should include multiple strategies including
education, advocacy, organizational change, policy change, and
environmental change, emphasizing a complete approach involving
the individual, family, and community. Color Me Healthy is
a curriculum that was developed based on this philosophy (11,12).
Social cognitive theory (13) and the socioecological model (12)
were used to guide program development. Social cognitive theory
explains the way people acquire and maintain their behavior
patterns and provides the basis for intervention strategies;
changing behavior involves the environment, people, and the
behavior itself. The socioecological model is also used as a
framework for designing and implementing health education
programs and is based on the idea that five levels of influence
on health and health behavior exist: individual, interpersonal,
organizational, community, and society. The model suggests that
humans are shaped by their environments, which comprise many
settings. According to the socioecological model, interventions
are more effective if they address all five levels of influence;
therefore, the Color Me Healthy curriculum components
address all five levels (Table
1).
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Methods
Curriculum development and components
Color Me Healthy was
developed by three of the authors (C.D., C.T.,
and L.P.) and is a program designed to increase physical
activity and promote healthy eating among children aged 4 and 5 years.
An advisory committee of subject matter experts, child
development professionals, and child care professionals reviewed all of the curriculum materials.
Color Me Healthy incorporates color, music, and the senses to
teach children that healthy food and physical activity are fun.
All materials needed to implement the Color Me Healthy
program are provided in the curriculum kit, which includes the
following:
1. Teacher’s guide: The Color Me Healthy
teacher’s guide contains 12 Circle Time lesson plans. Each
lesson contains the purpose of the lesson, a list of materials
needed, and specific steps to carry out the lesson.
The guide also contains the Color You Active section, which includes descriptions
of six trips that allow the children to use their imagination to
“travel” to different places and events. The teacher reads a
story about visiting a destination, and the children act out
events along the way. The Color Your Classroom section of the
guide provides bulletin board and display suggestions. Because
teachers are role models for children, the guide also includes
Color You Healthy, a section that provides strategies for ways
teachers can eat healthy and stay active.
2. Picture cards: The Color Me Healthy kit includes
four sets of picture cards that are used in many of the Circle
Time lessons. Colors of Foods includes eight cards with a color on one side and
fruits and vegetables of the same color on the other side. Where the Foods Grow
includes 15 cards with a single fruit or
vegetable on one side and a description of where it grows on the
other side. Places to Be Active has five cards with pictures of either a
park, a backyard, the beach, the mountains, or a swimming pool on
one side and activities children can do in these settings on the
other side. The Dairy Foods card shows children all the foods that
come from milk.
3. Classroom posters: Posters are used as educational
tools in many of the Circle Time lessons. Three classroom posters
are included in the kit: the Color Me Healthy logo poster,
the Colors of Foods poster, and the Pretend
You Are a . . . poster, which uses the alphabet to
encourage children to be physically active.
4. Music: Music is used in many of the Circle Time
lessons. Seven original songs were written to convey healthy
eating and physical activity messages. Songs include the Color
Me Healthy Theme Song, Heartbeat Beat, Try New Foods, Play
Outside, Taste the Colors, The Picnic Song, and the Color
Me Healthy Dance Mix.
5. Hand stamp: A self-inking hand stamp is included and
can be used as a reward for participation.
6. Parent component: The kit includes a series of 14
reproducible newsletters that reinforce messages the children are
learning in the classroom. In addition, two posters for parents
are included that convey a basic message about healthy eating and
physical activity that is similar to what the children are
learning in the classroom. The parent posters are displayed in
the child care setting in areas where parents typically collect
information about their children.
Train the Trainer model
In December 2001, Color Me Healthy county teams comprising family and
statewide representatives from the North Carolina Cooperative Extension and representatives
from the North Carolina Division of Public Health attended a 1-day Train the
Trainer workshop to learn how to teach child care providers in
their community about the program. During the workshop, teams
received information on nutrition and physical activity for young
children as well as materials needed to implement the program
locally.
The training for county teams involved promotional strategies,
such as visual displays of material, music, and singing, to
promote interest and motivate the attendees. Team members modeled
lessons and practiced techniques they could use to train child
care providers. Each county team received a training manual that
included a PowerPoint presentation, evaluation instruments,
sample training agendas, and marketing materials. County teams
received instructions on how to conduct local training
sessions as well as all the educational materials needed to help
promote consistency among all local training sessions.
Teams were instructed to develop a county Color Me
Healthy dissemination plan for 2002. Training
formats (4 hour, 1 day, or 2 day) and timing (typically nights or
weekends) were selected based on local needs and preferences.
Teams were encouraged to model their county-level child care provider trainings on the
statewide training design and to use the sample agendas provided
in their training manual. Child care providers received the
Color Me Healthy kit after completing the training.
Evaluation by child care
providers
Child care providers who attended training during the first 6
months after the December 2001 Train the Trainer event (53 trainings with a
total of 1338 participants) were given training evaluation forms
immediately after their training session ended. Providers were
asked to rate how effectively the training prepared them to
implement the Color Me Healthy curriculum (with 94.4%
reporting excellent or very good effectiveness) and to rate the
Color Me Healthy materials (with 97.0% rating the materials
as excellent or very good). In addition, providers were given an
opportunity to give the trainers feedback on how to improve the
training in the future. At the training session, child care
providers were asked if they would be willing to provide a
follow-up evaluation in 8 weeks.
The 38-item 8-week follow-up evaluation was designed and reviewed by subject matter specialists and education
professionals and tested for readability by a small group of
child care providers. Of the child care providers who attended
training, 76.4% (1023) agreed to provide an 8-week follow-up
evaluation. Participants were not asked to provide a reason for
nonparticipation in the follow-up survey; however, many were not willing to provide their
addresses or indicated that they would have to check with the
owner of the child care center before agreeing to participate.
Participants had the option of receiving their 8-week follow-up
survey through the regular mail (899 participants) or e-mail (124
participants). Participants who did not respond to the 8-week
follow-up evaluation received another evaluation 11 weeks after
the training. Of the participants who initially agreed to
complete the follow-up evaluation, 48.0% (486) participants
completed and returned the survey, which was 36.3% of all
individuals trained during the first 6 months of the program.
(None of the surveys provided via e-mail were returned, indicating that
e-mail may be an ineffective communication method for child care
providers.)
Participants who completed the evaluation worked in child care
centers (48.0%), home day care settings (34.7%), Head Start
programs (7.9%), and other settings (9.5%); 74.0% participated in
the Child and Adult Care Food Program. Six of the seven
components provided in the Color Me Healthy curriculum
were used by more than 85.0% of the respondents; 66.7% of
respondents used the parent newsletters (Table 2).
Of the participating providers, 92.0% indicated that using
Color Me Healthy increased the physical activity of the
children in their care, and 91.8% indicated that it increased the
children’s knowledge about movement. In addition, 93.0% of
providers indicated that using Color Me Healthy increased
the children’s knowledge about healthy eating. Of
participating providers, 79.0% indicated that the children were
more willing to try new foods, and 82.0% reported that the
curriculum had improved fruit and vegetable recognition. The
providers’ responses were used to assess an increase in
knowledge and behavior changes in the children. We hoped to
assess the providers’ perception of the curriculum’s
effectiveness because we knew it would affect future
implementation.
Many providers (92.3%) indicated that using Color Me
Healthy had helped them realize the importance of teaching
children about nutrition. Most child care providers rated
Color Me Healthy to be excellent (73.5%) or very good
(23.6%); only 2.9% rated the program as good, and none rated it
as fair or poor. Almost all the child care providers (99.8%)
indicated they would use Color Me Healthy in the
future.
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Consequences
Providing children with experiential learning in a fun
environment has been recognized as a developmentally appropriate strategy for
educating preschool children (14). Color Me Healthy is a preschool
curriculum that addresses physical activity and healthy eating; it is designed
to be teacher friendly, upbeat, and fun. Overall, the Color Me Healthy
curriculum was positively received by child care providers, and
they were using all the provided materials. We attribute the
positive response to several factors.
First, the Color Me Healthy kit contains all the
materials needed to implement the program. The kits were produced
with the preschool classroom in mind and include a sturdy
plastic case, laminated picture cards, a durable spiral-bound
teacher’s guide, and full-color materials.
Second, training sessions were provided for the trainers, who
were then prepared to teach the child care providers. The Train
the Trainer model is an effective way to disseminate educational
programs (15). It allowed many counties to implement the Color
Me Healthy program using existing county extension and public
health personnel. In addition, the Color Me Healthy Train
the Trainer workshops included hands-on learning experiences such
as modeling Circle Time activities. The training motivated the
county teams and prepared them to train child care providers in
their communities. Because the teams received a training manual
for use in provider training sessions, they were not required to
develop any additional materials.
Child care providers received training from the county teams.
Child care providers have limited time to prepare lesson
plans; the trainings gave them the opportunity to become
familiar with the curriculum materials and participate in
lessons. In addition, the trainings encouraged child care
providers to teach children about physical activity and healthy
eating. Providing training to child care providers was essential
for the implementation of the program in the classroom. Providers
often lack formal training in nutrition and physical activity.
Training for child care providers has been shown to be an
effective method for improving the quality of care children
receive and increasing their exposure to educational
opportunities (16,17). Furthermore, using hands-on experiential
methods during training is an effective method of ensuring that
methods taught during training are implemented in the classroom
(18).
Finally, the power of the state and county partnerships played
a role. The partnership between cooperative extensions and
the state division of public health provided a model for the counties. The state partnership benefited from combined
financial and human resources, which ensured consistent physical
activity and nutrition messages for the target population. In addition,
the county teams had an existing relationship with child care
providers and a history of training them. Working
together as a team maximized the use of human resources
without duplication of services. The use of county teams instead
of single trainers provided program continuity even during county team staff
turnover.
Of all the kit components, the parent newsletters were the
least used. Parent newsletters were provided as paper documents that could be
copied for distribution. The newsletter was the only component of the
curriculum that the child care provider had to duplicate for
distribution. Even though the cost would have been minimal,
providers may not have had the resources, time, or motivation to
copy the forms. If this were true, it would reinforce the
importance of providing all needed components for the curriculum
to increase the likelihood of use.
The training evaluation and 8-week follow-up evaluation were
designed to accommodate providers with limited written
communication skills and a low reading ability. Thus, the
evaluation instruments did not ask for detailed or lengthy
explanations. Feedback on the use and viability of the Color
Me Healthy curriculum were provided by 486 (approximately
36%) of the child care providers who attended training in the
first 6 months of the program. Of this group, an overwhelming
number indicated that the materials were useful in educating the
children about physical activity and healthy eating. It is not
known whether the participants who were unwilling to participate
in the 8-week follow-up evaluation (or who agreed to do so but
did not complete the evaluation) had a similar opinion.
Unfortunately, child care providers have little extra time during
their day to complete evaluations, and job turnover is high.
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Interpretation
Color Me Healthy is a response to a need for nutrition
and physical activity education materials in preschool settings.
Child care providers need fun, innovative curriculum materials to
address physical activity and healthy eating, but they often lack
the formal training needed to use these materials without
assistance. Using the Train the Trainer model is an effective way
to train people to provide child care providers with information
and curriculum materials on physical activity and healthy
eating.
Partnerships between agencies at the state and county levels
provide a rich infrastructure for the implementation and
dissemination of successful programs. The county teams were able
to successfully train child care providers in using the Color
Me Healthy curriculum because of the training and materials
they received at a statewide workshop. This allowed for
consistency in training and messages delivered to child care
providers across the state.
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Acknowledgments
The authors thank the Family and Consumer
Science Agents with the North Carolina Cooperative Extension,
the North Carolina Division of Public Health professionals, and other county team
members; Huong Nguyen for inputting evaluation data; and all the
supporters of Color Me Healthy, including the North
Carolina Cooperative Extension, the North Carolina Division of
Public Health, and the Dannon Institute.
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Author Information
Corresponding Author: Carolyn Dunn, PhD, Associate Professor
and Nutrition Specialist, North Carolina State University,
Department of Family and Consumer Sciences, North Carolina
Cooperative Extension, Box 7605, North Carolina State University, Raleigh, NC
27695. Telephone: 919-515-9142. E-mail: Carolyn_Dunn@ncsu.edu.
Author Affiliations: Cathy Thomas, MAEd, Branch Head, Physical
Activity and Nutrition, North Carolina Division of Public Health, Raleigh, NC;
Dianne Ward, EdD, Professor, Kelly Webber, MS, graduate student, Courtney Cullitan, MPH, RD, former graduate
student, Department of Nutrition, University of North Carolina at
Chapel Hill, Chapel Hill, NC; Leslie Pegram, former Color Me Healthy
Coordinator, North Carolina Cooperative Extension, Raleigh, NC. Ms Cullitan is now a Child Nutrition Manager with East Coast
Migrant Head Start, Raleigh, NC.
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