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Service Delivery Innovation Profile

Tools, Education, and Technical Assistance Encourage Child Care Sites to Adopt Strategies That Promote Healthy Eating and Physical Activity in Young Children


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Snapshot

Summary

Let’s Go! is a multilevel, multisector initiative in Maine that promotes physical activity and healthy eating in an effort to increase the proportion of children at a healthy weight. The program, which began as a demonstration project in greater Portland and now operates throughout Maine, consists of complementary interventions in six sectors (schools, after-school programs, primary care practices, child care centers, work sites, communities). The program recommends adoption of nine key strategies to increase physical activity and improve eating habits in child care settings, and supports providers in adopting these strategies through toolkits, education, online training, and telephone-based and onsite technical assistance. The program also advocates for policies that promote healthy eating and physical activity in local and state child care contracts, regulations, and standards. The program has contributed to widespread implementation of targeted strategies by child care sites, and to incorporation of related messages and strategies into local contracts and standards related to child care.

Evidence Rating (What is this?)

Suggestive: The evidence consists of a post-implementation assessment of the degree to which child care sites adopted targeted strategies, along with examples of key program messages that have been integrated into local child care standards and contracts.
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Developing Organizations

Let's Go!
Let’s Go!’s seven founding partners include Hannaford, Anthem Blue Cross and Blue Shield, Unum, TD Bank, Maine Medical Center, MaineHealth, and The United Way of Greater Portland. Harvard Pilgrim Health Care Foundation became a major partner soon after project initiation. Nearly 30 organizations throughout the state now serve as partners in Let’s Go!, which is housed at the Kids CO-OP at the Barbara Bush Children's Hospital at Maine Medical Center.end do

Date First Implemented

2009
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Patient Population

Vulnerable Populations > Children; Age > Preschooler (2-5 years)end pp

Problem Addressed

Childhood overweight/obesity is a widespread, growing public health problem with devastating consequences. Much of the problem stems from the failure of children and adolescents to eat healthfully and engage in adequate levels of physical activity. Child care providers can play an important role in modeling—and providing opportunities to engage in—healthy behaviors that reduce the risk of overweight/obesity. However, child care providers face competing priorities that make it difficult to play this role effectively without outside support.
  • A growing epidemic: The prevalence of obesity (defined as having a body mass index, or BMI, at or above the 95th percentile) among children and adolescents has grown significantly over the last several decades, both nationally and in Maine:
    • Nationwide: Between the 1976–1980 and 2007–2008 time periods, the prevalence of obesity rose from 5.0 to 19.4 percent in 2- to 5-year-olds, from 6.5 to 19.6 percent in 6- to 11-year-olds, and from 5.0 to 18.1 percent in 12- to 19-year-olds.1
    • Maine: Maine has not been immune from the overweight/obesity epidemic. Data from the National Conference of State Legislatures show that approximately 28 percent of Maine children age 10 to 17 were overweight or obese in 2007, more than double the 12.7 percent rate in 2003.2 A 2006 review of 3,000 charts representing roughly 50,000 Maine patients between the ages of 3 and 18 produced similar findings, with roughly a third (32.8 percent) being overweight or obese.3
  • Driven by poor health-related behaviors: High rates of overweight/obesity stem in large part from poor health-related behaviors, including unhealthy diets and lack of physical activity:
    • Poor diet: Although data specific to preschoolers are not available, children in Maine generally do not adhere to recommended guidelines for healthy eating. For example, according to the 2009 Maine Integrated Youth Risk Survey, only 14.9 percent of high school students and 18.4 percent of children in grades 7 and 8 ate at least five servings of fruits and vegetables a day during the week before the survey.4
    • Lack of physical activity: The same survey found that less than half of Maine children met national physical activity guidelines during the prior week, while roughly a third watched 3 or more hours of television on the average school day.4
  • Leading to severe health consequences: A critical public health issue, overweight and obesity put children at current and future risk of many serious health problems, including cardiovascular disease, type 2 diabetes, and mental health conditions such as anxiety and depression.5 Approximately 60 percent of obese children between the ages of 5 and 10 have at least one risk factor for cardiovascular disease, such as elevated total cholesterol, triglycerides, insulin, or blood pressure, while 25 percent have two or more such risk factors.6
  • Failure to support child care system in doing its part: Nearly 74 percent of children between the ages of 3 and 6 (representing nearly 12 million children nationwide) are in some form of nonparental care, with over half being in center-based child care.7 Child care providers can play a critical role in modeling and promoting life-long behaviors that reduce the risk of overweight/obesity. Yet child care providers face many competing demands and priorities on a daily basis, and consequently need guidance and support to play this role effectively.

What They Did

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Description of the Innovative Activity

Through its 5-2-1-0 Goes to Child Care program, Let’s Go! promotes nine key strategies to increase physical activity and improve eating habits in child care settings, and supports providers in adopting these strategies through toolkits, education, online training, and telephone-based and onsite technical assistance. The program also advocates for the embedding of policies that promote healthy eating and physical activity in local and state child care contracts, regulations, and standards. At present, Let’s Go! supports 163 child care sites (out of 2,200 licensed sites in Maine) that collectively care for more than 5,000 young children. Key program elements include the following:
  • Targeted strategies: Let’s Go! outlines nine key strategies that can be embedded individually or collectively in child care site policies and practices to promote healthy behaviors. Based on recommendations from the Centers for Disease Control and Prevention and the Institute of Medicine, these strategies relate to specific nutrition and physical activity goals and to environmental changes, as outlined below:
    • Encourage healthy choices for snacks and celebrations.
    • Participate in local, state, and/or national initiatives that promote physical activity and healthy eating.
    • Include community organizations in wellness promotion.
    • Involve and educate families in initiatives that promote physical activity and healthy eating.
    • Encourage consumption of water and low-fat milk instead of sugar-sweetened drinks.
    • Discourage the use of food as a reward; instead, use physical activity as a reward.
    • Incorporate physical activity into the day.
    • Develop a staff wellness program consistent with the messages in the Let’s Go! “5-2-1-0” social marketing campaign. (For details about the 5-2-1-0 message, which focuses on fruit and vegetable consumption, recreational screen time, physical activity, and avoidance of sugary drinks, see the related profile.)
    • Implement or strengthen a wellness policy that supports the 5-2-1-0 messages and strategies.
  • Toolkit for child care providers: This toolkit includes resources and materials for child care providers and parents that facilitate implementation of the targeted strategies in child care settings. Examples of specific materials include:
    • A resource binder for use by program champions within child care sites to facilitate implementation of targeted strategies and related activities.
    • Tips for getting started and strategies for success.
    • A laminated “grab-and go activities” ring with directions for quick, easy-to-implement physical activities appropriate for various age groups.
    • Parent handouts related to healthy behaviors, such as strategies for consuming five servings of fruits and vegetables daily, how to make homemade baby food, use of nonfood rewards at home, healthy snacks, appropriate portion size, family mealtime, beverage consumption, breakfast consumption, limiting screen time, and age-appropriate physical play.
    • Information about community resources related to nutrition and physical activity.
  • Education and technical support: Let’s Go! sponsors several educational programs and offers telephone-based and onsite technical assistance, as outlined below:
    • Staff training and conferences: Let’s Go! holds periodic training sessions and conferences for child care providers. Speakers cover a range of topics related to physical activity and nutrition in child care settings.
    • Online education: Child care sites just getting started with Let’s Go! that have identified a program champion receive training through an online presentation called “The Role of the Child Care Provider in the Obesity Epidemic.” This presentation covers the importance of the multisector model, the role of the child care setting in combating obesity, and the need to connect with others in the community.
    • Onsite technical assistance: Child care sites that that have full support from their administrative leaders and that want to “ramp up” implementation of the recommended strategies receive two onsite visits annually (in the fall and spring) from trained dissemination partners (see bullet below on train-the-trainer education). These sessions focus on helping child care center representatives identify and implement strategies that directly relate to their needs. To that end, the trained partner and center staff collaboratively review the toolkit; discuss whether the center has already implemented any of the targeted strategies; review how the center can use the tools to build on existing activities and/or implement new strategies; outline staff and funding requirements, and brainstorm strategies for making connections with key stakeholders in the community.
    • Telephone-based technical assistance: Child care sites that have previously received on-site technical assistance and sites that require minimal support because they have well-established programs can access ongoing technical assistance on an as-needed from Let’s Go! staff via e-mail or telephone.
    • Train-the-trainer program: Let’s Go! offers a “train-the-trainer” program that teaches staff within partner organizations how to solicit interest in Let’s Go! and provide technical assistance to those that adopt it. To date, participants have included representatives of Healthy Maine Partnerships (a community-based organization serving Maine’s public health infrastructure), Head Start, and others who work directly with child care providers.
  • Special program for home-based caregivers of young children: Let’s Go! is piloting the 5-2-1-0 In the Early Years program, which offers tools that tailor 5-2-1-0 messages to those caring for children age 2 and under. The program is being tested as a new component of Maine’s Healthy Families Program, which provides a free home visit to any Maine family with prenatal care needs and/or children age 5 and younger. (Families need only request such a visit.) As part of the pilot, home visitors incorporate 5-2-1-0 messages into interactions with and recommendations to families.
  • Advocacy efforts: Let’s Go! staff advocate for the embedding of 5-2-1-0 messages and strategies in local and state child care contracts, regulations, and standards. For example, staff have worked with key stakeholders involved with the Maine Department of Health and Human Services’ quality rating system (known as Maine Roads to Quality), child care licensing regulations, early childhood education curricula at state universities and community colleges, and contracts between child care facilities and local charitable organizations, such as the United Way of Greater Portland.

For information about other aspects of the larger Let’s Go initiative, see the related profile. For information about program-related activities in other sectors, see the related profiles on primary care and schools.

Context of the Innovation

Development of Let’s Go! started with tools and other resources created by the Maine Youth Overweight Collaborative, a program that provided education and practical tools (e.g., BMI assessment, an obesity management algorithm, motivational interviewing techniques, and a counseling tool) to support pediatric practices in assessing and managing overweight and obesity in their patient populations. (See related profile.) Given their concern about the continuing obesity problem among Maine youth, business leaders in the greater Portland area (a multicultural area with 230,000 residents, including many immigrants and low-income families) created Let’s Go! in an effort to expand the fight against obesity to nonmedical settings that can have a significant impact on youth. Recognizing the importance of child care sites in influencing the behavior and health of Maine’s children, Let’s Go! leaders decided to make supporting policy and practice changes in these sites a major priority (along with the five other targeted sites). For more information on the overall Let’s Go! initiative, see the related profile.

Did It Work?

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Results

The program has contributed to widespread implementation of targeted strategies by child care sites and the incorporation of 5-2-1-0 messages and strategies into local contracts and standards related to child care.
  • Widespread implementation of key strategies: By the end of the 2009–2010 school year, all participating child care sites had implemented at least two of the targeted strategies. Because program leaders do not have data on use of these strategies before implementation, they cannot be sure that in all cases implementation occurred as a result of Let’s Go! support.
  • Adoption of 5-2-1-0 messages in local contracts and standards: Due in part to Let’s Go! advocacy activities, the United Way of Greater Portland now requires that 5-2-1-0 messages and strategies be included in the contracts of all child care facilities funded by the organization. In addition, the Maine Roads to Quality initiative incorporated 5-2-1-0 messages into one of its program modules in August 2009.
The overall initiative raised public awareness of desired behaviors and encouraged Maine youth to adopt such behaviors, which in turn has helped to halt the increase in childhood overweight/obesity in the state; for details, see the related profile.

Evidence Rating (What is this?)

Suggestive: The evidence consists of a post-implementation assessment of the degree to which child care sites adopted targeted strategies, along with examples of key program messages that have been integrated into local child care standards and contracts.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Pilot testing the program: Let’s Go! staff and early childhood experts adapted the “5-2-1-0 Goes to School” toolkit for a younger population and tested the revised toolkit in 10 child care sites in the Greater Portland area. Pilot sites included large centers (those serving 200 or more children) and centers funded by the United Way of Greater Portland (which serve a high proportion of low-income families). Following the 6-month pilot, Let’s Go! staff held focus groups with participating child care providers to understand their needs and challenges and to identify opportunities to better support them. This information led to the development of the program components.
  • Hiring staff: Let’s Go! hired a program manager and part-time coordinator to oversee implementation in child care settings.
  • Creating learning opportunities: Let’s Go! staff developed the train-the-trainer program and a presentation entitled “Role of the Child Care Provider in the Obesity Epidemic.” They also former partnerships with community-based organizations (such as Healthy Maine Partnerships) that could provide onsite presentations and coaching to child care providers interested in implementing the toolkit.
  • Soliciting interest: Let’s Go! promotes the program to child care sites around the state, mainly through word of mouth but also via local and state child care organizations.
  • Developing and testing tools for very young children: Because the scientific evidence for 5-2-1-0 messages is based on children age 2 to 18, Let’s Go! convened a workgroup of early childhood experts to refine the tools for use with very young children, and then pilot tested these tools in collaboration with the Healthy Families Program.

Resources Used and Skills Needed

  • Staffing: Activities specific to child care settings are overseen by a part-time project manager (who spends 4 days a week on the program) and part-time coordinator (24 hours a week). The Let’s Go! project director and a data coordinator also devote part of their time to program-related activities in this setting.
  • Costs: Data on the costs of child care-related activities are not available. For information on total program costs, see the related profile.
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Funding Sources

Let's Go!
Let’s Go! is funded by local business and health care partners in the greater Portland, Maine area. Major financial partners include the American Academy of Pediatrics/Healthy Active Living, the Maine Department of Health and Human Services, the Anthem/WellPoint Foundation, the Francis Hollis Brain Foundation, Hannaford, the Harvard Pilgrim Health Care Foundation (the program’s Platinum Supporter), Maine Medical Center, MaineHealth, the New Balance Foundation, the Rite Aid Foundation, TD Bank, the Bingham Program, the Mattina R. Proctor Foundation, the United Way of Greater Portland, UNUM, and the Walmart Foundation.end fs

Tools and Other Resources

More information about this program, along with sector-specific toolkits and resources, can be found at: http://www.letsgo.org.

Adoption Considerations

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Getting Started with This Innovation

  • Support both policy and practice-based changes: Success with this type of population-based initiative depends on changes at the policy level (via guidelines, regulations, and/or legislation) and ground-level support (e.g., toolkits and training) for organizations and individuals involved in implementation.
  • Develop and reinforce consistent message: A social marketing campaign can ensure a clear, consistent message for all program elements, conveying an action-oriented prescription for health that can influence the population as a whole. This message is embedded in the child care toolkit and all program-related communications to and within child care sites.
  • Highlight benefits of participation: Busy child care providers must be convinced of the merits of participating in such a program. For example, Let’s Go! staff emphasize that participation can facilitate compliance with regulatory mandates.
  • Define goals and associated metrics: Clearly defined goals and measures (e.g., whether a provider meets mandated requirements) can help program developers design focused activities and ensure that child care providers can track and improve their performance.
  • Create strong partnerships: Identify stakeholders with a similar mission who can help create tools and assist child care centers in adopting them. To facilitate dissemination, identify partner organizations that already serve child care providers, such as the United Way.
  • Avoid mandates when possible: Child care sites face competing demands and budget constraints that can impede implementation. Because child care providers may resist mandates, position the development and adoption of health-promoting activities as recommendations, and then work to convince providers of their value.
  • Identify champion in each center: Child care providers who are passionate about reducing childhood overweight/obesity can help disseminate information and tools, and can build enthusiasm for new initiatives within each site.

Sustaining This Innovation

  • Continually advocate for policy change: Regulations and laws obviously play a key role in supporting practice changes in child care settings.
  • Keep support programs in place, building on current community capacity: Ongoing support is critical to helping child care providers maintain success. For example, group seminars can help providers sustain improvements and learn about innovative practices from colleagues.
  • Develop and maintain strong dissemination model: Partner with organizations that can take ownership of dissemination activities. Partners can work with child care site representatives in their local areas to spread the message and provide guidance on toolkit adoption.
  • Monitor progress, refine program as needed: Program developers should collect key data from child care providers on an ongoing basis, periodically analyze the data to gauge program impact and provider-specific performance, and regularly ask center leaders for feedback about the results. These steps help maintain enthusiasm and ensure prompt responses to any problems or concerns that emerge.
  • Be opportunistic: External events may present an opportunity to create or expand policies and programs targeted at key stakeholders. For example, Let’s Go! can use updates to Maine child care regulations and policies as an opportunity to advocate for a greater focus on promoting healthy behaviors, and can then set up implementation support to help child care providers comply with the updates.
  • Expect expansion to take time: With so many licensed child care providers in most areas, it takes time to spread the initiative to all of them.

More Information

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Contact the Innovator

Victoria Rogers, MD
Director, The Kids CO-OP and Let's Go!
Barbara Bush Children's Hospital at Maine Medical Center
22 Bramhall Street
Portland, ME 04102
Phone: (207) 662-3747
E-mail: rogerv@mmc.org

Innovator Disclosures

Dr. Rogers has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Let's Go! program Web site: http://www.letsgo.org.

Footnotes

1 Ogden C, Carroll M. Prevalence of Obesity Among Children and Adolescents: United States, Trends 1963–1965 Through 2007-2008. June 4, 2010. Available at: http://www.cdc.gov/obesity/childhood/data.html
2 National Conference of State Legislatures. Childhood Overweight and Obesity Trends. Available at: http://www.ncsl.org/?tabid=13877#2003_50-State_Chart
3 Let’s Go! Annual Report Year Four. Fall, 2010. Available at: http://www.letsgo.org/wp-content/uploads/LGAnnualReportYear4.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
4 2009 Maine Integrated Youth Risk Survey. Highlights—2009 State of Maine. Available at: http://www.maine.gov/youthhealthsurvey/fact_sheets.shtml
5 Koplan J, Liverman C, Kraak V (eds). Preventing childhood obesity: health in the balance. Washington, DC: National Academies Press; 2005.
6 Institute of Medicine of the National Academies. Childhood Obesity in the United States, Facts and Figures. September 2004. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2004/Preventing-Childhood-Obesity-Health-in-the-Balance
/FINALfactsandfigures2.pdf
7 Federal Interagency Forum on Child and Family Statistics: America’s Children: Key National Indicators of Well Being, 2002. Washington, D.C.: U.S. Government Printing Office, 2002.
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Original publication: August 03, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: October 23, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.