Intervention Implementation Guide

NAP SACC Intervention Implementation Guide: This guide outlines the 5 steps of the NAP SACC intervention along with potential barriers and keys to success for implementing the program in child care facilities.

Developed by the NAP SACC program, Center for Health Promotion and Disease Prevention, The University of North Carolina, Chapel Hill, NC

NAP SACC Implementation Guide The Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program is an obesity prevention intervention that aims to improve the nutrition and physical activity environment, policies and practices of child care facilities. NAP SACC is implemented through a trained NAP SACC Consultant. This Guide is a follow-up to the training to provide you with step-by-step instructions for implementing the NAP SACC program with child care centers or family child care homes in your area.

Recruiting a Child Care Facility to Participate Getting a facility committed and excited to participate is critical to a successful NAP SACC implementation. Strong, sustainable nutrition and physical activity environmental improvements begin with an interested, excited and motivated provider. Get started by sharing the NAP SACC Recruitment Letter with child care providers in your area. This explains the importance of NAP SACC along with the steps of the program and the expectations for a provider’s participation.

Overview Upon recruiting an excited, ready and willing facility to participate, you are ready to begin implementing the 5 steps of the NAP SACC program. Remember—these steps can be completed multiple times until a provider is satisfied with their nutrition and physical activity environment. On average, working through these steps will take 6 months, but the length of the program really depends on both you and your participating child care provider.

NAP SACC Program Steps 1. Self-Assessment 2. Action Planning . Workshop Delivery 4. Technical Assistance 5. Evaluate, Revise, and Repeat



Step One: Self-Assessment What is the NAP SACC Self-Assessment Instrument? The NAP SACC self-assessment instrument is an intervention tool that allows child care facilities to freely assess their own environment, policies, and practices. It is an intervention tool, in that it will suggest key areas for improvement. The self-assessment consists of both nutrition and physical activity sections. Within each section there are multiple “key areas” each containing questions that relate to that area. Each question has four possible answers, representing a continuum of practice, from minimal standard on the far left, through best practice on the far right. The NAP SACC Best Practices have been developed from existing national child care standards and recommendations, as well as from research literature and expert opinion.

Figure 1. NAP SACC Key Areas

Nutrition KEY AREAS • • • • • • • • •

Fruits and Vegetables Meats, Fats, and Grains Beverages Menus and Variety Feeding Practices Foods Outside of Meals and Snacks Supporting Healthy Eating Nutrition Education

Physical Activity KEY AREAS •

Active Play and Inactive Time

• •

Play Environment

• •

Physical Activity Education

Supporting Physical Activity Physical Activity Policy

Nutrition Policy



Figure 2. NAP SACC Best Practices

Key Area

Best Practices

Nutrition: N1. Fruits and Vegetables

• Offer fruit (not juice) at least 2x a day. • Serve fruit canned in its own juice (not syrup), fresh, or frozen all of the time.

• Offer vegetables (not fried) at least 2x a day. • Offer vegetables, other than potatoes, corn or green beans 1 or more times per day.

• Prepare cooked vegetables without added meat fat, margarine or butter.

N2. Meats, Fats, and Grains

• Offer fried or pre-fried potatoes less than once a week or never.

• Offer fried or pre-fried meats or fish less than once a week or never.

• • • •

N3. Beverages

Offer beans or lean meats at least once a day. Offer high fiber, whole grain foods at least 2x a day. Offer sweets or salty foods less than once a week or never.

• Make drinking water easily visible and available for self-serve both indoors and outdoors.

• • • •

N4. Menus and Variety

Offer high-fat meats less than once a week or never.

Offer 100% fruit juice 2x a week or less. Offer sugary drinks rarely or never. Serve skim or 1% milk to children over 2 years. Locate soda and other vending machines off-site.

• Use a cycle menu of 3 weeks or greater that changes with the seasons.

• Include a combination of new and familiar foods on weekly menus.

• Include foods from a variety of cultures on weekly menus.



N5. Feeding Practices

• Staff should help children determine if they are full before removing their plate.

• Staff should help children determine if they are still hungry before serving additional food.

• Staff should gently and positively encourage children to try a new or less favorite food.

• Do not use food to encourage positive behavior.

N6. Foods Offered Outside of Regular Meals and Snacks

• Provide and enforce written guidelines for healthier food brought in and served for holidays and celebrations.

• Celebrate holidays with mostly healthy foods and non-food treats.

• Fundraising should consist of selling non-food items only.

N7. Supporting Healthy Eating

• Staff should join children at the table for meals and consume the same food and drinks.

• Always serve meals family style. • Staff should rarely or never eat less healthy foods in front of the children.

• Staff should talk with children about trying and enjoying healthy foods.

• Provide visible support for healthy eating in 2 to 5 year old classrooms and common areas through use of posters, pictures, and displayed books.

N8. Nutrition Education

• Provide training opportunities on nutrition (other than food safety and food program guidelines) for staff 2x per year or more.

• Provide nutrition education for children through a standardized curriculum 1x per week or more.

• Offer nutrition education opportunities to parents 2x per year or more.

N9. Nutrition Policy

• Create a written policy on nutrition and food service that is available and followed. It may include items from the previous 8 nutrition key areas.



Key Area

Best Practices

Physical Activity PA1. Active Play and Inactive Time

• Provide children with at least 120 minutes of active play time each day.

• Provide teacher-led physical activity to children 2 or more times per day.

• Provide outdoor active play time 2 or more times per day. • Active play time should never be withheld for children who

misbehave and additional active play time should be given for good behavior.

• Ensure that children are not seated for periods of more than 30 minutes.

• Rarely or never show television or videos.

PA2. Play Environment

• Make a wide variety of fixed play equipment available that accommodate the needs of all children.

• Make a large variety of portable play equipment available for children to use at the same time.

• Make outdoor portable play equipment freely available to all children at all times.

• Outdoor play space should include open, grassy areas and a track/path for wheeled toys.

• Make indoor play space available for all activities, including running.



PA3. Supporting Physical Activity

• Encourage children to be active and join children in active play.

• Provide visible support for

physical activity in 2 to 5 year old classrooms and common areas through use of posters, pictures, and displayed books.

PA4. Physical Activity Education

• Provide training opportunities on physical

activity (not including playground safety) for staff 2x per year or more.

• Provide physical activity education for children through a standardized curriculum 1x per week or more.

• Offer physical activity education opportunities to parents 2x per year or more.

PA5. Physical Activity Policy

• Create a written policy on physical activity that is available and followed. It may include items from the previous 4 physical activity key areas.



Working with the provider Give the child care director the NAP SACC self-assessment instrument and instruction guide. The instruction guide includes a term glossary and provides additional clarity for certain questions. Instruct the director to set aside a period of uninterrupted time to complete this with key personnel such as the cook, a lead teacher, or a program coordinator. As well, encourage the director to have ready appropriate materials to assist them in answering questions. These may include the parent and staff handbooks, written policies, monthly menus and classroom lesson plans. Remind the director to be honest and reflect on the current environment. Your role in the self-assessment process is now complete; step back, and let the provider complete the instrument.

Potential Barriers • • • •

Time Minimal knowledge of current policies and practices Lack of motivation to get started Fear of retribution regarding current practices

Keys to Success • Let child care providers complete this independently without your help. • Encourage self-reflection and honestly and be sure to stress that answers will in no way reflect poorly on the facility or get them into trouble. It is just to be used as a starting point for the intervention.

• Encourage providers to set aside at least 30 minutes of uninterrupted time to successfully complete the assessment and to include appropriate personnel and materials.

• At this time, set a date for an in-person meeting to discuss the self-assessment results and start action planning. This should be approximately 2-3 weeks in the future so that (s)he doesn’t feel rushed, but completes it within an appropriate time period.

• Provide a small incentive for completing the self-assessment instrument on time.

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Step Two: Action Planning What is Action Planning? Action planning begins after completion of the self-assessment. This is when the child care director chooses key areas for improvement, creates goals, and brainstorms which action items are needed to meet these goals. The Action Planning Document is designed to help in this process.

Working with the provider Once the director has completed the self-assessment, it is time to review and discuss it and look for areas in need of improvement. It is best to set aside 1 to 2 hours for this meeting. Thoroughly review answers to the self-assessment and discuss possible key areas for improvement. Ask providers what they are interested in improving. Some will have very clear ideas, while others will need more guidance from you. Illicit suggestions and ideas from the provider but encourage him/her to choose 3 key areas and create 2-3 overall goals to improve each of these key areas. We suggest choosing at least 1 nutrition and 1 physical activity key area. Once the goals have been selected, map out action items, which are specific strategies, to help meet each particular goal. This will break potentially large goals into small, attainable steps. Finally, set an overall target date for evaluation (the date to complete the self-assessment again to see if and where changes have been made), as well as dates for completing each goal and action item.

Potential Barriers • • • •

Unattainable, hard to reach goals Unrealistic timelines Lack of ideas and suggestions Unmotivated provider

Keys to Success • Keep goals, action items, and completion dates realistic and attainable. Set providers up for success (no matter how small), not failure.

• Try to schedule a block of uninterrupted time to review the completed self-assessment and complete the Action Planning Document.

• Make sure the provider is prepared and has completed the selfassessment before the action planning meeting.

• Challenge providers to make good, long lasting improvements. • Keep changes “cost-neutral” if possible. • Give providers incentives for each goal attained.

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Step Three: Workshop Delivery What are the NAP SACC Staff Workshops? The NAP SACC staff workshops are designed to inform staff about healthy nutrition and physical activity environments and practices and why they are so important. The workshops are also helpful to the director, who is facilitating most of the improvements, by increasing staff buy-in as to why these issues are so important. There are 5 staff workshops, each designed to be delivered by NAP SACC consultants, including: 1) Childhood Obesity; 2) Nutrition for Young Children; 3) Physical Activity for Young Children; 4) Personal Health and Wellness for Staff, and 5) Working with Families to Promote Healthy Weight Behaviors. A brief description of each has been provided below. In North Carolina, the workshops have been approved for continuing education credits by the Division of Child Development. Providers seem to appreciate this opportunity, so you may want to consider applying for credits in your area as an extra incentive to get staff involved.

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Working with the provider During the action planning meeting, set aside time to schedule all the workshops. Ideally, workshops should be completed 1 to 2 months after the Action Plan has been developed. At this point, decide, with input from the director, how best to present the workshop material to staff. The workshops are designed to be delivered in a number of ways. PowerPoint presentations, with facilitator notes, as well as workshop outlines have been developed. This allows presentation to a large group in a “lecture-like” format or presentation to small groups or one-on-one in a discussion format. Additionally, the workshops can be presented separately, with each workshop lasting anywhere between 30 and 60 minutes, or all together in one longer workshop. Asking for the director’s input is especially critical if you have never worked with this facility before. The workshops can be presented in any order, but it is helpful to deliver the Childhood Obesity workshop first. This provides the background to staff as to why healthy eating and physical activity during the child care day are so important.

Potential Barriers • • • •

Time Scheduling Uninterested staff Limited participation

Keys to Success • Set the dates for the workshops before leaving the action planning meeting. • Be flexible with the facility as much as possible. While presenting the workshops to the staff during

naptime might be ideal for some, for others it is impossible without additional staff to take over child care responsibilities. Consider evening or weekend workshops so all staff will be able to attend.

• Consider your audience and the facility before presenting the workshops. Is the space conducive to

PowerPoint or would it be better to hold a round table discussion? Are the staff quiet or more highly engaged?

• Use icebreakers to start off the workshop series. This will get the group laughing and break tension. This may make the group more comfortable and willing to participate.

• Child care staff love door prizes! If you have small items such as recipe books, pedometers, or coupons or the ability to purchase some, use them as a way to encourage participation.

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Table 3. List of NAP SACC Workshops

Workshop

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Description Supersizing our Children: Childhood Obesity

Introduces the problem of obesity in 2 to 5 year old children and the consequences of being overweight/ obese. Also, describes the role of child care staff in helping to prevent this problem.

Eat Right, Grow Strong: Nutrition for Young Children

Overviews not only what should be offered to children, but how and why those foods should be offered. Also, describes the role of child care staff in helping shape children’s eating behaviors.

Moving Children to Good Health: Physical Activity for Young Children

Discusses the importance of physical activity for young children in child care settings and how activity can be integrated into all parts of a preschool day.

Stepping Toward a Healthy Lifestyle: Personal Health and Wellness

Provides information to staff about their own healthy eating and physical activity behaviors. It describes barriers to making these important lifestyle changes and provides an opportunity to brainstorm some solutions to these problems.

Growing Healthy Kids Together: Working with Healthy Families to Promote Healthy Weight Behaviors

Describes how child care providers can communicate healthy weight behavior messages to parents so that children are receiving the same messages at home as they are during their time in the child care setting. It also provides strategies to best communicate these messages.

Step Four: Provision of Technical Assistance What is technical assistance? NAP SACC consultants provide technical assistance to facilities in support of their chosen improvements. This step of the NAP SACC program tends to be the most overlooked and may be the most important. Providers need technical assistance, not only to as a reminder to work on their goals, but for additional knowledge and support in achieving these goals.

Working with the provider Once the director has completed the action plan, it is important to set up regular meetings to provide assistance where needed and keep the director on task and motivated. While monthly follow-up is recommended, consultants know their providers and can best determine how often they should check in. Methods of technical assistance can be through in-person meetings, scheduled telephone calls or emails. A combination of these methods may work best.

Potential Barriers • Time • Lack of motivation

Keys to Success • Schedule meetings in advance and send reminders close to the day. To save time, schedule a quick follow-up meeting prior to or after delivering a workshop.

• Be flexible. If a director says they just do not have the time to devote to the project, encourage them to focus on just 1 or 2 small goals on their action plan.

• Provide resources and help when necessary. Use incentives to help providers move through their action items to reach proposed goals.

• Encourage and

support providers. It is important to keep them motivated and encouraged throughout the process.

• Discuss the barriers the

director may need to overcome in order to meet his/her goals, or revise the goals to make them a more simple and attainable.

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Step Five: Evaluate, Revise, and Repeat What is evaluate, revise, and repeat? This activity provides a much needed opportunity for providers to celebrate accomplishments, reflect upon barriers, and think about how to move forward. Providers do not have to accomplish everything in their first NAP SACC effort. The idea is to see continual change over time, even if changes are small, and repeat the process where necessary. We would love to see facilities meet all the best practice guidelines; however, this may not be a possibility for some.

Working with the provider Once the action plan completion date has arrived, have providers evaluate their progress by repeating the self-assessment, looking for positive changes. Some will have improved their environment by leaps and bounds while others will have made small, steady steps in the right direction. Encourage providers to revise their current action plan or create a new one if they accomplished everything.

Potential Barriers • Feeling of failure • No interest in continuing

Keys to Success • Celebrate all accomplishments, no matter how small, and assure providers that they can revisit goals when they have more time to devote to the program.

• Don’t force additional improvements upon a director or facility. They may not want to continue at this time, but may regain interest. Keep in contact with providers to gauge future interest.

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NAP SACC Toolkit Components Intervention Materials 1. Self-Assessment • The NAP SACC self-assessment instrument is an intervention tool that allows child care

facilities to freely assess their own environment, policies, and practices. The self-assessment consists of both nutrition and physical activity sections and will suggest areas for possible improvement.

2. Sample Self-Assessment • An example of what the self-assessment will look like once the provider has completed it.

3. Self-Assessment Instruction Sheet • The self-assessment instruction guide is provided for the director when filling out the self-

assessment. It includes a term glossary and provides additional clarity for certain questions.

4. Action Planning Document • The Action Planning Document is used to help choose key areas for improvement, create goals, and action items.

5. Sample Action Planning Document • An example of what the Action Planning Document will look like once completed.

6. Five NAP SACC Workshops with Activities • The workshops are designed to inform the staff about nutrition and physical activity and help them understand why these topics are so important.

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Technical Assistance Materials 1. Intervention Implementation Guide • The intervention implementation guide briefly outlines the 5 steps of the NAP SACC project along with potential barriers and keys to success for each NAP SACC step.

2. Consultant Technical Assistance Manual • The technical assistance manual provides in-depth information

related to each question on the self-assessment instrument. In addition, this manual provides additional resources related to each key area, as well as, references that support each best practice.

3. Facility Key Area Handouts • There are 11 facility handouts, one for each key area on the self-

assessment. Distribute the appropriate handouts to the director depending upon the key areas chosen for improvement.

4. Parent Handouts for Providers • There are 5 parent handouts, related to nutrition and physical activity, that facilities can use with their parents.

5. Sample Nutrition and Physical Activity Policy • The sample nutrition and physical activity policy is provided for use with facilities that would like to make policy changes.

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Informational Materials 1. Recruitment Letter for Providers • The recruitment letter is used to explain what NAP SACC is

and what the child care facility can expect if they choose to participate in the NAP SACC program.

2. NAP SACC Informational Brochure for Parents • This brochure can be used by facilities to inform parents of the

facility’s participation in NAP SACC. It also gives parents suggestions of things they can do at home to improve their own nutrition and physical activity environment and practices.

3. Best Practice Recommendations • This is a list of the NAP SACC best practices related to all the questions on the self-assessment.

4. Certificate of Completion for Providers • This is a certificate to present to the facility once they have completed the NAP SACC program.

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