1 INTRODUCTION

Food behaviours learned in the first 5 years of life have a lasting impact and are critical to growth, wellbeing, nutrition status, brain development and developmental trajectory.^{1, 2} The behaviours learned in these formative years also traverse into adulthood, impacting long-term weight status and future chronic disease risk.³ Decreased diet quality in childhood is associated with poorer educational outcomes which,⁴ in turn, impacts socio-economic outcomes in adulthood.⁵ Research investigating diet quality among Australian children identified that less than 5% of children consumed the recommended number of vegetables,⁶ while discretionary foods and drinks are among the top contributors to energy, added sugars, saturated fat and sodium.⁷ Diet is a significant risk factor for developmental outcomes² and chronic disease,⁸ highlighting the need for interventions to improve the quality of children's diets. In Australia, almost half (46%) of all children aged 6 weeks to 5 years attend an early childhood education and care (ECEC) service and spend an average of 25 hours per child per week at the service.⁹ It is generally accepted that at least 50% of the recommended dietary intake should be consumed while attending an ECEC service.¹⁰ Thus, ECEC settings are an ideal environment to optimise nutrition and positively influence children's food behaviours.

The Australian ECEC setting is comprised of centre based day care, family day care, and outside school hours care services.⁹ ECEC services comprising a range of organisation types, including private operators, and community and non-profit organisations, employ a workforce comprising educators (76%), early childhood teachers (6%) and centre directors (6%).¹¹ Australian ECEC services must adhere to the National Quality Framework (NQF); a system that regulates education and care by benchmarking against National Quality Standards (NQS).¹² Implementation of the NQF is guided by the Australian Children's Education and Care Quality Authority (ACECQA), while assessment and rating of ECEC services against the NQS is undertaken by the regulatory authority in each state and territory.¹² The NQS address nutrition in one element (out of 40) and requires services employ practices that promote a food environment that supports child health and wellbeing, for example, ensuring that policies and procedures relating to nutrition and dietary requirements are in place.¹² The intention of such centre-based policies and procedures is to inform staff and parents about how the ECEC service operates and intends to conduct its services.¹³ Practices that support the service to meet the standards, such as strategies to meet children's nutritional needs and delivery of educational experiences that facilitate children taking greater responsibility for their own health and wellbeing, may be outlined in the policies and procedures.¹² The NQS also require minimum staff ratios and qualifications (eg, 50% of staff must hold at least an approved qualification at the diploma level and centre director to hold an approved degree);¹² however, staff in Australian ECEC services have revealed that their qualifications included limited nutrition education.¹⁴

Despite a legislated standard for children's education and care in Australia since 2012,¹³ a national and coordinated approach to improving food environments in ECEC services is lacking. Several recent Australian studies have identified examples of unhealthy food environments in ECEC services.^15-19 For example, a New South Wales study that conducted detailed menu reviews for 69 ECEC services reported that none were compliant with recommendations for daily serves of vegetables, only one (1%) for meat/alternatives, 10 (14%) for fruit and vegetables, nine (13%) for breads and cereals, 24 (35%) for dairy and only three (4%) for discretionary foods.¹⁶ Similar results have been reported for lunchbox services.¹⁸ Another study evaluated the nutrition policy from a company that provided ECEC services at over 300 locations in Queensland, Australia, and found that the policy lacked information about the type, quality, and amount of food children should be given.¹⁹ In addition, mealtimes were observed in 10 ECEC services and revealed limited instances of role modelling, with no educators observed to consume an entire meal with the children.¹⁹ Strong and comprehensive nutrition policies support ECEC services to implement appropriate and consistent practice; a crucial strategy to establishing a healthy food environment.²⁰ Nutrition policies also guide educators in their approach to role-modelling and behaviours towards nutrition²¹ and children's dietary intake.²² However, application of nutrition policies in practice require ECEC staff to have the capacity and capability to understand, implement, and actively engage with the policy for intended benefits to be realised.²³

Evidence-based approaches to creating an effective health-promoting food environment, including nutrition education, food provision, and mealtime environments, should address the perceived place-based challenges and barriers of ECEC centre staff.²⁴ Challenges and barriers regarding the implementation of nutrition guidelines²⁵ and nutrition-focused interventions^{26, 27} in ECEC settings have previously been explored. Implementation of nutrition policy and practice, more broadly, has also been investigated; however, this study used theoretically derived factors.²² An open exploration of barriers and enablers to a health-promoting food environment in ECEC settings is notably absent. Centre directors are reported to be the ‘gatekeepers’ within ECEC services²⁸ and provide a unique and comprehensive perspective of barriers and enablers impacting the nutrition environment given their leadership and decision-making roles within ECEC services.²⁹ Therefore, the purpose of this study was to explore centre directors' perceptions of barriers and enablers to a health-promoting food environment, including nutrition policy, nutrition education, food provision, and mealtimes, within ECEC services operating in Nerang and surrounding areas in Queensland, Australia.

2 METHODS

3 RESULTS

ECEC directors completed a telephone interview between March and May 2021. The average duration of interviews was 23 minutes (range 12–37 minutes). Participant demographic information is outlined in Table 2. Three models for food provision were reported by directors: provided by a parent (parent-provided food; n = 5), provided by an external catering company (catering-provided food; n = 4), and prepared by a chef/cook at the service (service-provided food; n = 2). In this study, ‘parent’ included a parent, guardian, or grandparent who was responsible for the care of a child. Barriers and enablers were identified for each domain of interest (see Table 3). No additional themes beyond the four domains that were pre-defined were identified as outlined in (Table 3).

4 DISCUSSION

This study reports the perceived barriers and enablers to adopting a healthy food environment described by directors within a group of ECEC services in South-East Queensland, Australia. Understanding barriers and enablers from the perspective of ECEC service staff is necessary to inform the development of future initiatives that will support services to establish a health-promoting food environment. Overall, engagement with nutrition policies and education and support for educators, parents, and children, were identified as key barriers and focus areas for improvement.

Key barriers identified in the present study pertaining to the development and implementation of nutrition policies concerned the content of, and engagement with, the policy. Approved ECEC services are required by the Education and Care Services National Regulations to have policies and procedures relating to ‘nutrition, food and beverages, dietary requirements’ (p.167).³⁷ The focus of these regulations is to ensure services operate in a way that protects the health, safety, and wellbeing of children within their care.¹³ Universal requirements for nutrition policies in ECEC settings have been identified as an enabler to delivering a healthy food environment^{38, 39} but, beyond the regulations, there is limited guidance regarding the content of nutrition policies. Clear, strongly worded nutrition policies are essential to support staff to implement recommendations and communicate expectations to the ECEC community.⁴⁰ However, some directors in this study were hesitant to be sufficiently detailed, reporting concern for non-compliance with legal requirements. This suggests that ECEC directors appear to experience challenges when interpreting national and jurisdictional regulations³⁷ and operationalising them at a service level. There is an opportunity to support services to better understand legal obligations while also specifying universal requirements to inform the development and implementation of clear service-level nutrition policies.

Directors in the present study identified parental disengagement as another barrier to nutrition policy development and implementation; a barrier also reported in US ECEC services.³⁹ Evidence-based standards from the World Health Organization advocate for parental engagement in policy development and implementation and cite the positive impact this has on creating a healthy food environment.⁴¹ In the US, ECEC services addressed parental disengagement by discussing policy requirements during activities, such as a centre orientation or regular parent meetings.³⁹ Other strategies to engage parents, as identified in the NQS, include building strong partnerships with families to encourage parents to co-contribute to service decisions.¹² Such collaborative approaches provide parents the opportunity to influence the ‘what’ and ‘how’ of a health-promoting food environment, including how to communicate information to improve implementation of the nutrition policy.¹² However, further research is needed to explore parents' expectations regarding the food and nutrition environment in ECEC services, and how they wish to engage with the ECEC community (eg, using codesign methods) to shape that environment.

Several barriers to communication with parents were identified by directors in the present study, and included a lack of time and skill to converse with parents without them feeling judged. These barriers are not uncommon, with concerns about upsetting³⁹ or offending parents,⁴² and educators lacking confidence¹⁴ or time,⁴² previously reported. Strategies to overcome these barriers and improve communication with parents include building respectful partnerships,³⁹ providing training to support staff in communicating with parents,⁴² and engaging with a nutrition expert,^{14, 26} but these strategies clearly require access to greater resources and expert personnel. Regardless, it remains important to support educators to develop interpersonal and communication skills given the value placed on in-person communication (ie, workshops and family events at the centre) previously reported by parents.⁴³ Training for these skills is currently limited within the mandatory training for Australian ECEC educators (ie, Certificate III and IV),⁴⁴ highlighting that, despite the desire to engage with parents about children's nutrition (eg, the quality of packed lunches), a lack of skills and confidence may see staff avoid these important conversations. Thus, more needs to be done to support staff to develop interpersonal and communication skills and emotional judgement.^{44, 45}

Appropriate staff education was identified by directors in the present study as an important enabler to the implementation of policy requirements, such as positive feeding practices, but described a lack of ‘easy to use’ nutrition-focused resources for staff; a sentiment echoed in previous research conducted in Australia.¹⁴ In a study of 48 staff from Australian ECEC services, more than half of participants reported that they had searched for nutrition information on the internet; yet, 63% were not aware of the ‘Get Up & Grow’ resource collection—which are the key guidelines for childhood nutrition in ECEC—and only 12% had used them in practice.¹⁴ Mandatory training for Australian ECEC educators does not appear to equip providers with the necessary skills related to nutrition¹⁴ or feeding practices,⁴⁶ highlighting the importance of nutrition-focused professional development for staff. ECEC services require access to user-friendly and appropriate resources alongside staff professional development to enhance nutrition knowledge and implementation of nutrition policy. Opportunities to enhance formal professional education (ie, at the certificate or diploma level) for the ECEC workforce should also be explored.

Nutritional adequacy of food consumed by children while in care was impacted by the model of food provision employed within the ECEC service. Where parents provided food for their child, directors believed that a lack of financial resources was the reason some parents provided food that was unhealthy or inadequate in quantity. This is consistent with a previous review that identified cost as a key factor influencing parental decisions when packing lunchboxes for school-aged children⁴⁷ and emphasises the need for strategies that minimise the impact of financial constraints on parents' abilities to purchase healthy foods. In the ECEC setting, where it is relatively more common for services to provide food for children, previous research has identified financial resources as a barrier faced by ECEC services to the provision of nutritious food.^{40, 48} This is important given that previous Australian research identified a negative relationship between the nutritional adequacy of service menus and the daily cost of food per child.⁴⁹ While cost was not described as a barrier in the present study, further research is needed to understand how decisions about food provision are made by ECEC services, that is, the influence of cost and nutritional adequacy on choice of menu or catering provider. Reforming the nutrition environment to include universal high quality food provision for all children in ECEC services would promote food security and child development and reduce the burden on services.⁵⁰

Nutritional adequacy was also influenced by poor eating behaviours that directors believed children developed due to limited exposure to healthy foods in the family environment. In practice, this meant that some parents provided discretionary foods because they knew their child would eat it, while other children were resistant to eating food provided by the centre. Providers in a US study similarly perceived that children were unwilling to try new foods because they were not encouraged to consume a wide variety of nutritious foods in the home environment.³⁸ Parents in another US study wanted to learn from ECEC staff as they perceived them to be skilled in supporting children to form positive behaviours.⁴² Indeed, educators' role-modelling, encouragement, and positive reinforcement—all components of the mealtime environment – have been shown to positively influence children's intake of healthy foods.^{40, 51} This was echoed by directors in the present study, who described a positive mealtime environment as an enabler to supporting good nutritional behaviours in children. However, the lack of food for staff to consume was identified as a barrier to a positive mealtime environment in the present study. This mirrors recent results from another Australian study, which indicated that staff at each of 10 ECEC services monitored (on a single day of observation) only ate the same foods as children at 19.6% of mealtimes observed.¹⁹ This presents an opportunity for services to positively influence eating behaviours of children, but high quality food provision must still be addressed.⁵⁰ Universally provided meals for children and staff by ECEC services would expose children to a variety of nutritious foods and positive behaviours while providing an opportunity for educators to discuss and explore nutrition with parents.

Planned educational activities involving children have demonstrated effectiveness at promoting healthy food behaviours in ECEC settings.⁵¹ In the present study, directors expressed ‘lack of time’ as a barrier to incorporating formal nutrition education in an already over-crowded curriculum. Instead, nutrition education was included informally as part of everyday practice (eg, during mealtimes). This is not a unique experience, with a US study reporting that childcare providers perceived mealtime conversations as a feasible approach to delivering nutrition education to children.⁵² Strengthening nutrition education in mandatory training for educators should be prioritised and may enhance educator confidence to incorporate regular informal nutrition education within their daily practice. A systems approach that also invests in professional learning for educators would ensure the ECEC workforce have the capabilities to embed nutrition education within their current capacity.

5 CONCLUSION

The barriers and enablers described by directors in this study are important considerations for future initiatives that aim to improve the food environment in ECEC services. Exploring the perceived challenges and opportunities facing staff employed within ECEC services is a critical step towards informing evidence-based approaches that aim to improve the nutrition environment within these services. Research investigating strategies to address barriers to nutrition policy development and implementation, engagement, and education of staff, children and parents is needed.

AUTHOR CONTRIBUTIONS

Conception and design of the work: Amy Kirkegaard, Chris Irwin, and Lisa Vincze. Data collection: Lisa Vincze. Data analysis and interpretation: Amy Kirkegaard, Chris Irwin, and Lisa Vincze. All authors made substantial contributions to the writing of the manuscript and have approved the submitted version.

FUNDING INFORMATION

This research was supported by a Capacity Grant from Menzies Health Institute Queensland.

CONFLICT OF INTEREST STATEMENT

There are no conflicts of interest to declare.