The Target: Wellbeing Preschool Nutrition Project · 2018-04-04 · Target: Wellbeing Preschool Nutrition Project 2010 2009-2 | P a g e Evaluation by the University of Chester Awarded

The Target: Wellbeing Preschool Nutrition Project Evaluation Report

May 2010 Georgie Charnley and Dr Basma Ellahi Public Health Nutrition Department of Biological Sciences University of Chester Parkgate Road Chester CH1 4BJ [email protected] Tel: 01244-513125

mailto:[email protected]

Target: Wellbeing Preschool Nutrition Project 2009-2010

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Evaluation by the University of Chester

Awarded by successful tender and commissioned by the Heart of Mersey

Acknowledgements

The authors would like to thank the following individuals and organisations for their assistance in

creating this report: Ashley Walker, BSc Nutrition and Dietetics student for data analysis, Angela

Craney for her administrative assistance, Colin Sinclair for statistical analysis guidance, Knowsley

Community College, all of the participating nurseries and pre-schools and their staff and children.


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Contents

Chapter 1: Background of the project.....................................................................................10-15

Chapter 2: The Heart of Mersey.............................................................................................16-17

Chapter 3: Methods & design................................................................................................ 18-22

Chapter 4: General findings.................................................................................................. 23-35

Chapter 5: Changes in practitioner‟s confidence, knowledge & attitudes..............................36-39

Chapter 6: Impact & satisfaction with the training course.....................................................40-43

Chapter 7: Discussion of the staff training results................................................................ 44-51

Chapter 8: Recommendations & conclusion........................................................................ 52-53

Annex 1: Nursery observations

Annex 2: Child led interviews

Annex 3: Food sticker diaries

Annex 4: Sample menus (pre-training)

References............................................................................................................................68

Appendices...........................................................................................................................71


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List of figures page number

Figure 1 – Nursery size 23

Figure 2 – Money spent on food per child per day 14

Figure 3 - Has your nursery received nutritional guidance in the past? 25

Figure 4 – Changes in milk provision 30

Figure 5 – Changes in daily snack provision 31

Figure 6 – Changes in the frequency of serving dried fruit 31

Figure 7 – Changes in oily fish provision 32

Figure 8 – Changes in ingredients used potentially high in salt 33

Figure 9 – Changes in sandwich fillings used 34

Figure 10 – Changes in descriptions of nursery food 34

Figure 11 - Cutlery used

55

Figure 12 - Pre-plated or self service 56

Figure 13 - Number of children that could name a selection of fruits 59

Figure 14 - Number of children who could name a selection of vegetables 59

Figure 15 - Reported likes and dislikes of fruit 60

Figure 16 - Reported likes and dislikes of vegetables 60

Figure 17 - Food diary fruit preferences 61

Figure 18 - Food diary vegetable preferences 61

Figure 19: Food diary meal preferences 62

Figure 20 - Food diary snack preferences 62

Figure 21 - Food diaries pudding preferences 63


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List of tables Page number

Table 1 – Type of guidance received 25

Table 2 – Main changes that have/or are being made 26

Table 3 – Most beneficial/important things learnt on the course 27

Table 4 – Do the staff eat with the children? 28

Table 5 – Does your nursery have a food/nutrition policy?

Table 5b – Changes in type of policy post-training

28

29

Table 6 – Changes in average confidence levels pre and post-training 36

Table 7 – Improvement in nutritional knowledge 36

Table 8 – Changes in attitudes 37

Table 9 – Significant values pre-training 37

Table 10 – Minced beef/lamb/pork provision pre-training 39

Table 11 – Changes in pre and post-training confidence levels 39

Table 12 - Comparison of pre- and post-training confidence scores using a Wilcoxon

Signed Rank Test

40

Table 13 - Comparison of pre and post-training confidence scores between phase 1 and

phase 2

40

Table 14 - Comparison of post-training confidence scores based on staff type 41

Table 15 - Mean responses using PSAT 42

Table 16 - Lunch-time observations 54

Table 17 - Lunch-time interactions 55

Table 18 - Meal served 56

Table 19 - Vegetables 57

Table 20 - Amount eaten 57

Table 21 - Nursery atmosphere 58

Table 22 - Tidying-up routine 58


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Table 23 - Fruit and vegetables served daily 64

Table 24 - Variety of fruit served per week 64

Table 25 - Number of meals with vegetables in the recipe 65

Table 26 - Number of meals with fish per week 65

Table 27 - Number of meals with oily fish per week 66

Table 28 - Number of home-made meals per week 66

Table 29 - Number of meals on the menu containing processed foods/ingredients

67


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The Target: Wellbeing Preschool Nutrition Project Evaluation

Executive Summary

Introduction

The Pre-School Nutrition Project was created when Heart of Mersey identified a gap in the availability of nutrition

training & guidance for early years staff working in nurseries.

The Pre-School Nutrition Project is part of the Knowsley Target: Wellbeing portfolio of programmes. The project

is managed by Heart of Mersey and was funded for two years by BIG Lottery, Knowsley Health and Wellbeing

Partnership and Heart of Mersey.

This report details the project and the evaluation of the project as undertaken by the University of Chester.

Background

There has been growing concern in the UK that children‟s diets contain too much sugar, salt, saturated fat and

too few fruits and vegetables.1 2In the last five years there have been many changes to the way food is provided

in our schools; however food fed to younger and more vulnerable children has been left behind3. In England

there are currently no nutrient based standards for food provided to children in day care, as there are for children

in schools4. Children in full day care can spend up to ten hours a day in a nursery and as such the setting will

provide the majority of the food the child consumes each day. With this in mind those who provide childcare are

in a unique position to have a positive influence not only on the nutritional intake of these children but also the

knowledge and attitudes the children have towards food and healthy lifestyle5.

Aims

The project aims to develop, pilot and evaluate a nutrition training course and programme of support for early

years caterers and staff, which in turn will benefit children and parents who attend the early years settings.

Objectives:

Development and production of a nutrition training course for early years staff


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Evaluation of the effects of the training on knowledge/practices

Development of a Early Years Nutrition model to encompass staff, parents and children

Improved nutritional knowledge, practices, intakes among children

To train and utilise local volunteers

Key Outcomes

Accredited Nutrition Training Programme for early years staff

Training of local volunteers

Guidance for healthy early years catering

An evaluation of effectiveness

Results

Nineteen nurseries took part in the project & 37 participants attended the Diet and Nutrition in a Pre-School

Setting training course.

Key results include

Increased general nutritional knowledge for all pre-school staff

Participants were statistically more confident about key areas of early years nutrition post-

training

The reported number of high sugar snacks and drinks has decreased

Food preparation methods have improved

Two additional nurseries are now providing semi-skimmed milk for children age 2 and over

Some changes to current food provision have been observed and many planned changes have

been reported

New menus are being planned and implemented


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Catering staff are now reporting reading the fat/salt content on food labels

Participant attitudes changing to realise the importance of good nutrition

Increase in the number of staff eating with the children.

Post-training all nurseries had ceased adding salt during or after cooking.

Conclusions

The Pre-School Nutrition project has had a beneficial impact on all settings that took part, however the

full extent of this impact is not reflected at this stage as many changes were in the planning stages

when data was collected. Increases in confidence and perceived “ability to do” have been seen for all

participants, reflecting that the course was accessible for all attendees. Excellent partnerships have

been established between agencies in Knowsley which will continue to support early years settings and

staff.

Future recommendations

Offer the accredited training to all nurseries and early years staff in knowsley

Establish regular up-dates, on-going training and examples of best practice

Continue the partnership working between agencies involved in the project

Encourage the pre-school “networking” observed throughout the training programme to

continue

Continued support to settings, particularly resources for menu planning

Support for the call for national compulsory regulations for pre-school nutritional guidelines

Nutritional knowledge to be included in early years/foundation stage practitioners training.

1. National Diet and nutrition survey: Children aged 1½ to 4½ years. 1995. Ministry of Agriculture, Fisheries and Food and

Department of Health. 1995. London: HMSO 2. Food Standards Agency and Department of Health. 2000. National Diet and Nutrition Survey: Young people aged 4-18 years.

London: HMSO 3. A guide to introducing the Government‟s food-based and nutrient-based standards for school lunches.2008. School Food Trust 4. Georgie Porgie Pudding and Pie, Exposing the truth about nursery food. 2008. Soil Association 5. Eating Well for Under 5‟s in Child Care. 2006. Caroline Walker Trust


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The Target: Wellbeing Preschool Nutrition Project

“I found the course very enjoyable and informative. It reinforced the things I knew and gave me

the confidence to try the things I wasn’t too sure about. Thank you.” – Cook, nursery 18

Chapter 1: Background of the project

Background & Rationale

Over the last decade there has been a governmental move to improve the nutrition standards in

primary and secondary schools, with the introduction of Healthy Schools, which currently 97% of

schools nationally are involved in (Department for Children, Schools and Families, 2009). The

intervention has four themes including healthy eating, physical activity and emotional wellbeing. The

healthy eating theme aims to equip young people with the knowledge and confidence to make healthy

food choices alongside ensuring healthy, nutritious food is available across the school day, including

controlling the amount of processed and high fat foods available (Department for Children, Schools and

Families, 2009).

However at present none of these directives exist for the under 5s age group. The Caroline Walker

Trust have published guidelines for the nutritional intake for under 5s and are urging for mandatory

dietary regulations to be put in place for the over 60,000 children who currently attend childcare settings

in England and Wales (Fookes, 2008). The Caroline Walker Trust “Eating well for under 5‟s” report

found evidence that children under 5 in Britain are likely to have diets that are too low in vitamins A and

C as well as low intakes of both iron and zinc. These children also consume high levels of non milk

extrinsic sugars associated with tooth decay and high levels of salt (Crawley, 2006).

The 2008 Soil Association/Organix report into nursery food has identified several areas of concern in

food provision in childcare settings including:


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No nutrient based standards to guide nurseries on what they should be serving.

No restriction or exclusions for less healthy foods such as crisps, chips, processed meats

(which are mandatory in schools).

No standards for portion sizes or minimum amount of fruit and vegetables per child.

No regulation concerning snacks.

(Source: Fookes, 2008)

These trends are concerning as the Foresight report forecasts that by 2025 14% of girls between the

ages of 6 and 10 years and 21% of boys between these ages will be obese using the International

Obesity Task Force criteria (GOfS, Foresight, 2007). Poor eating habits, learned from a young age can

be adopted into later life although parent‟s BMI can indicate risk of obesity, not only through genotype,

but by family eating habits and activity levels (Tounian, 2007, cited in Maurage, 2008). One of the long

term aims of the Heart of Mersey Early Years Nutrition Training Programme is to involve parents in

nursery food policies and cascade the healthy eating knowledge. It is now known that even in

childhood overweight and obesity can cause significant health complaints and lead to diseases such as

type 2 diabetes, hypertension and psycho-social stress and overweight children are more likely to

become overweight and obese adults (Benjamin, Ammerman, Sommers, Dodds, Neelon & Ward,

2007).

Early nutrition from during pregnancy to infancy to pre-school can have a significant influence on the

development and eating habits of the child and can have implications for health in later life. Studies

have been carried out using animal models, investigating the effects of over and under nutrition and the

mechanisms and processes involved, during critical periods of development in fetal and infant life. This

research has demonstrated characteristics equivalent to human disease in the animals including:

cardiovascular and renal dysfunction, glucose intolerance, insulin resistance, altered stress responses

and a preference for foods with higher fat and sugar content in the offspring (BMA, 2009). Numerous


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other studies have shown positive connections between weight gain in children under 3 years and

overweight and obesity in later life (Owen et al, cited in Maurage, 2008). This is currently being

investigated further in the Early Years Nutrition Programming Project (EARNEST) which has followed

990 infants on breast milk and high and low protein formula milk (within EU protein limits) exploring the

hypothesis that increased protein would lead to increased growth and subsequently increased insulin

secretion leading to a predisposition to obesity in later life (EARNEST, n.d.). The infants fed the higher

protein formula showed higher serum concentrations of insulin like growth factor, agreeing with the first

part of the hypothesis (EARNEST, n.d.).

Preschools and nurseries are ideally situated to positively influence how children feel about food and

set healthy habits, young. Research has shown young children can exhibit “noephobia” or the fear of

novel foods (Ogden, 2007). It has been observed that children need to be presented with a new food

between 8 and 10 times before their preferences change significantly to accept the food (Birch & Marlin

1982, cited in Ogden). Social learning is a vital element in children‟s development and food choices. In

a nursery setting this can be achieved through staff eating with children and creating opportunities for

children to sample a wide range of foods before they reach 18 months, at which point neophobia

(possibly a preventative condition to prevent children eating poisonous foods) is more likely to develop

(Fookes, 2008). The evaluation of the Preschool Nutrition Training Project will aim to identify common

features in the “eating environment” in the preschools and nurseries (such as whether staff eat with the

children) to assess whether these routines change post training programme.

However there has been little research into the experiences and knowledge of childcare setting

practitioners, although the government is encouraging increased quality of settings and parental uptake

of affordable and accessible childcare, there is limited reference to dietary recommendations (Alderton

& Campbell-Barr, 2005). A recent pilot study in Kent investigating food provision in nurseries found that

common barriers preventing the preparation and cooking of fresh food on site were; insufficient time,


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worries about health and safety and hygiene rules, lack of staff and no kitchen facilities, whilst only 4%

of respondents admitted lack of knowledge or experience was a main problem (Alderton & Campbell-

Barr, 2005). The study also highlighted worries and lack of understanding about cultural special dietary

requirements and the practitioners‟ priority was food the children would eat, rather than how healthy the

food provided was (Alderton & Campbell-Bar, 2005). The practitioner‟s were also asked what they

perceived to be the main barriers preventing children choosing food. 31% of the providers felt that the

children would choose unhealthy foods, suggesting a lack of knowledge of the adults around them to

pass on knowledge, combined with the possibility that the children are not given access to healthy

options at home and are unfamiliar with them (Alderton & Campbell-Bar, 2005).

The majority of these results were presented as percentages, as data collected was done so by using

self-completed survey questionnaires by the participants (Alderton & Campbell-Bar, 2005). This method

will be employed in the HoM evaluation as a large amount of the data gathered will be nominal and

ordinal. However the authors used an index system to test several hypothesises and found that the

larger childcare providers were more likely to have food and nutrition policies (0.05 level was used as

significant, although p values were not stated in the paper), the study also found that providers in more

deprived areas scored better on the nutrition index rating, possibly indicating that these providers saw it

as their responsibility to provide high quality food as the children may be less likely to receive it at home

(Alderton & Campbell-Bar, 2005). Overall the study suggests that there does tend to be a lack of

knowledge around food and nutrition among early years providers, which can lead to less effective

practice in the quality of food provided (Alderton & Campbell-Bar, 2005).

An American study identifying the sources of energy and major nutrients in the diets infants and

toddlers aged between 4 and 24 months discovered that juices and fruit-flavoured drinks were the

second and third most important sources of energy for toddlers, with milk providing most of the energy

and nutrients. The nurseries in the evaluation will be asked about the drinks provided at break times


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and with meals to see if there is a similar trend appearing in Merseyside. Again this study is limited by

self-reported data, meaning over and under-reporting may influence the findings and results are given

as percentages. The study reports that health professionals should educate care providers about the

importance of food and not just nutrients, to move away from the trend of relying on fortified foods and

supplements and encourage toddlers to try a wide range of fruits, vegetables and wholegrains (Fox,

Reidy, Novak & Ziegler, 2006). These suggestions for good practice compliment the ethos of

introducing new foods to toddlers to reduce neophobia and the identified need to develop preschool

and nursery practitioners‟ knowledge and confidence in providing the children in their care with healthy

and nutritious foods.

A recent study in North Carolina reported on the feasibility and impact of a nutrition and physical activity

intervention aimed at childcare settings. The success of the intervention was determined by the

comparison of pre and post intervention self- assessment. The aim of the NAP SACC programme was

to improve policies and practices in preschool settings in relation to tackling overweight and obesity in

young children (Benjamin, et al, 2007). The self-assessment tool used included 29 nutrition questions

and 15 physical activity questions (each answer had 3 response categories, that were awarded 1, 2 or

3 points) the childcare centres taking part were then awarded and overall score, and a separate

nutrition and physical activity score that were compared pre and post intervention (Benjamin, et al,

2007). The sample size in the study was small allowing for no statistical analysis of the control groups‟

pre and post self-assessment scores, however the intervention groups‟ self assessment score

increased on average by 7.75 points (p < .005). A common reported effect of the intervention was to

swap children aged 2 and above to 1% milk rather than whole milk as well as serving more fruit and

vegetables. The questionnaire that will be employed to evaluate the Preschool Nutrition Training

Project includes a section on milk provision and age ranges as children under 2 should be given whole

milk and under 5s should not be given skimmed milk (Crawley, 2006). The increase in fruit and


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vegetable provision and reduction in sugary foods/snacks indicates that interventions aimed at

improving childcare providers‟ knowledge and skills can directly affect the quality of food provision

given (Benjamin, et al, 2007).

As already mentioned the Healthy Schools initiative has been successfully adopted by the majority of

schools and is making positive improvements to the dietary quality and nutritional knowledge of school

aged children. It has now been recognised that a similar improvement is required in pre-schools

settings. This study aims to evaluate the impact of a nutrition training programme for nursery staff and

volunteers, by analysing both improvement in knowledge and practice of the pre-school practitioners

and its impact on the food provision in these settings.


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Chapter 2: The Heart of Mersey

“Enjoyed the course very much, in particular networking with other settings and discussing

ideas to exchange. I feel more knowledgeable about what to serve the children and how to cook

it.” – Manager, nursery 15

The Heart of Mersey Target: Wellbeing Preschool Nutrition Training Programme aims to improve the

quality of food provision in pre-schools in the Knowsley area by providing a nutrition training course to

nursery staff in collaboration with Knowsley Community College.

In 2006 the Heart of Mersey (HoM) conducted a questionnaire survey to 29 nurseries across Cheshire

and Merseyside to access current food provision, policies and practices. This was deemed necessary

as nationally children‟s diets were being shown to be high in saturated fat, sugar and salt, and 45% of 5

year olds in Cheshire and Merseyside have experienced tooth decay compared to the national average

of 39% (Mwatsama, 2006).

The key findings of the survey revealed that current pre-school food policies on healthy eating were

weak and reflected vagueness in the national guidance, with only 3 out of 14 of the policies provided,

making reference to the need to reduce fat, sugar and salt levels. Healthy diet training for catering staff

was uncommon and was not considered a priority for pre-school staff. The survey demonstrated that

there was a general lack of awareness/action to reduce saturated fat intakes, exacerbated by the

ambiguity in national guidelines for suitable milk provision for young children, resulting in most nurseries

providing whole milk daily for all age groups. The survey also identified concerns around providing

adequate calories for the children by caterers, which was commonly overcome by providing full fat dairy

products and high fat and sugar puddings and desserts. More positively the survey has shown that

chopped fruit and vegetables was the most common snack reported in the questionnaire and the

majority of caterers did not add salt during cooking (Mwatsama, 2006).


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The findings from the survey led to the production of a list of recommendations including the need for

an accredited training course on healthier catering methods for pre-school catering staff. The Heart of

Mersey alongside Knowsley College have developed this training programme which began training

nursery staff in August 2009. The University of Chester has been commissioned to carry out an

evaluation of the training programme, focusing on improvement in nutritional knowledge and resulting

improvements to pre-school menus.

Objectives of the project:

1. Development and delivery of a nutrition training course for early years staff

2. Evaluation of the effects of the training on knowledge/practices

3. Development of an early years nutrition model to encompass staff, parents and children

4. Improved nutritional knowledge, practices and intakes among children

5. To train and utilise local volunteers

Aims of the evaluation

To evaluate the effectiveness in terms of improved nutritional knowledge and changes in practice of a

pre-school nutrition training programme, covering objectives 1 and 2 of the HoM project.

Objectives 3-5 will be reported on in the complete project report compiled by Heart of Mersey, which

can be accessed at www.heartofmersey.org.uk


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Chapter 3: Methods & design

A thoroughly enjoyable, informative training course...Great opportunity to share current

knowledge and practice and learn new ways of doing things!” - Manager, nursery 13

The evaluation was quasi-experimental in design and collected pre and post intervention data from two

cohorts of nursery practitioners (managers and catering staff) enrolled in the training programme. The

first cohort (phase 1 nurseries) took part in the training across the summer 2009 and the second cohort

(phase 2) attended the training course over the autumn/winter 2009.

The data collected was mostly quantitative (ordinal and nominal data) although the nature of the

questionnaire allowed for some qualitative statements relating to how participants found the training

programme overall.

Population

The study does not require a sample size calculation as it will be evaluating pre-recruited childcare

settings (n=20) by the Heart of Mersey.

The target was for HoM to recruit 20 nurseries/pre-schools from the Knowsley area, however the end

population was 19 nurseries due to 1 nursery being unable to take part at the last minute. The nurseries

received participant information sheets from HoM and enrolled for the training programme. The project

aimed to provide nutritional training to between 20 and 40 pre-school staff, 7 volunteers and to

indirectly affect 500 young people and engage 300 parents.

In total 37 participants took part in the training programme (30 nursery staff (15 managers, 5 who

fulfilled the role of both caterer and manager & 10 caterers), 4 volunteers and 3 school meals service

managers), over 700 children registered at the participating nurseries had potential to indirectly benefit


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from the project due to changes made to the food provided at the nurseries as a result of taking part.

As the nurseries usually involve parents in changes that occur within the nurseries it is hoped that an

estimated 300 parents with children at those settings will indirectly benefit. Project participants were

aged between 18-70 years old, 1 of these was male.

The training programme was split into 2 phases with the nurseries and pre-schools divided into two

groups. Phase 1 nurseries (n=10) attended the first training course (commencing August 2009) and 9

attended phase 2 (commencing October 2009).

Inclusion criteria: The pre-school/nursery is to provide at least one “proper” meal (ie cooked lunch) and

one snack a day. Nurseries recruited will be state maintained, private and Sure Start to gain a good

representative sample. All nurseries were willing to allow 1 or 2 members of staff (where possible

manager and catering staff) to attend the full 30 hours (over 10 weeks) Diet and Nutrition in a Preschool

Setting training course.

Procedures

Recruitment: The recruited nurseries received a Participant Information Sheet about the programme

from HoM. As part of the training programme they verbally consented to taking part in the evaluation.

A combination of pre and post intervention nutritional knowledge and nursery practice questionnaires

and confidence scales were used to assess the impact of the training programme.

The questionnaire: The pre and post-training questionnaires were designed using the learning

objectives from the nutrition training programme, alongside questions taken from the HoM Nursery food

provision, policy and practice across Cheshire and Merseyside survey (2006), as these have been pre-

tested and provided a high level of response, the Soil Association and Organix nursery food provision


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questionnaire (used to produce the Georgie Porgie Pudding and Pie exposing the truth about nursery

food report, 2008) and the validated Parmenter and Wardle General nutrition knowledge questionnaire

for adults (Parmenter & Wardle, 1999). The pre-training questionnaire (see appendix 1) was

administered by the research assistant while accompanied by a member of the Heart of Mersey. The

questionnaire was completed by the nursery manager and the catering staff in each nursery with either

the research assistant or HoM team member available to assist where appropriate. After the Pre-school

staff had completed the accredited nutrition programme a post-training questionnaire (see appendix 2)

was administered in the same format, to identify changes in nursery practices and nutritional

knowledge. Both questionnaires took approximately 30 minutes to complete.

The pre-training questionnaire was piloted at two nurseries with verbal consent from the managers and

participating staff. The pilot highlighted several areas of the questionnaire that would need altering

before the general administration and use in the evaluation. The main changes required included

adding an “age range” column to the food and drink provision questions (15 & 16), adding a

“sometimes” choice to question 11, after in the two nurseries where the questionnaire was piloted

reported that staff ate with the children for special occasions (i.e. Christmas dinner). A question asking

how long the children were given to eat meals (ie. 20, 30, 45, 60 minutes) was removed, as in both the

pilot nurseries and in the pre-school food policies that HoM had already collected, it was reported that

there was no set time for meals, the children were given as long as the needed. The questionnaires on

average took 20 minutes to complete, and for the purpose of the final questionnaires completion was

estimated to take between 20-30 minutes maximum.


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Confidence questions: One of the criteria of the evaluation was to assess changes in confidence levels

in the participating nursery practitioners from T0 (pre-training programme) and T2 (post-training

programme) to evaluate the accessibility of the training course. Six questions have been chosen to

score confidence levels for attending the training and “being able to do” the learning outcomes of the

training course (appendix 1). These 6 questions were re-administered after the participants had

completed the training combined with the Participant Satisfactions Assessment Tool (PSAT) Heyliger,

(2001) (appendix 2). The researcher has registered to use the assessment tool with the Browne Centre

at the University of New Hampshire. The PSAT was employed to monitor how well the training course

met the expectations of the participants and how accessible the course content and method of delivery

were perceived. The pre and post confidence question sheets were administered on the first and last

day of the training course.

Data handling/analysis

The questionnaire data collected from both pre and post training was entered into a database to allow

statistical analysis using SPSS software where appropriate.

Questionnaires: The pre and post-training course questionnaires collect a mixture of nominal and

ordinal scale data due to the combination of yes/no answer questions and Likert scale based questions.

Statistical analysis will predominately be in the form of frequencies and percentages, due to the level of

data and the small population size (although this is expected to represent 100% of the population

enrolled on the training course). Where possible the Wilcoxon Signed Ranks Test will be employed to

compare changes in the answers between T0 (pre-training course) and T2 (post-training course) and

separately between phase 1 and phase 2 nurseries. This test will be used to convert the participants‟

scores into ranks that can be compared at T1 and T2. Due to the small population size (40 expected

participants, 20 in the intervention group and 20 in the control group) the statistical tests will have less

power than usually employed, where a significance level of equal or less than 0.05 is considered


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statistically significant (Pallant, 2007). This method is very similar to those used in other studies

(Alderton & Campbell-Bar, 2005, Benjamin, et al, 2007) were results and findings are presented

predominantly as frequencies due to the type of data collected.


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Chapter 4: General findings

“I found the course both enjoyable and informative, and as a result I am more aware of the

dietary needs of the under 5’s and how to plan a weekly menu.” – Manager, nursery 11

The nurseries

Out of the original 20 nurseries recruited to take part in the Preschool Nutrition Project, 19 enrolled on

the course and complete data was collected for 18 of the nurseries. 15 of the nurseries were privately

run and 3 were voluntary.

Figure 1: Nursery size

As many children rely on the nursery to provide at least one of their meals a day we asked for opening

hours and number meals served.

Most of the nurseries (14 or 77.8%) were open for between 8 and 10 hours with 3 further

nurseries open for more than 10 hours a day.


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17 out of the 19 nurseries reported the number of children that attend the nursery. From this

data at least 773 children have the potential to benefit from changes to food provision that may

have been made as a result of nursery staff attending the Preschool training Course.

Figure 2: Money spent on food per child per day

17 out of the 19 nurseries reported the number of children that attend the nursery. From this data we

know at least 773 children have the potential to benefit from changes to food provision that may have

been made as a result of nursery staff attending the Heart of Mersey Training Course.

The information gathered on money spent per child per day was quite encouraging when compared to

the National Survey conducted by the Soil Association and Organix (2008). The nurseries in Knowsley

appear to spend considerably more money on food per child, 75% of the nurseries in Knowsley

reported spending £1.01 or more per child. Specifically out of 487 nurseries in the above mentioned

survey, 21% of private nurseries spent between £1 and £2 per child per day, 9 percent of state-

maintained nurseries spent between £1 and £2 per child per day, while 17% of state-maintained

nurseries spent 50p or less per day and only 7% of the private nurseries reported spending less than

50p per child per day


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Figure 3: Has your nursery received nutritional guidance in the past?

Table 1: Type opf guidance received

Nursery code Nutritional guidance received

1 Healthy eating guidelines

2 SureStart training

3 nutritionist brought in privately

4 none

5 Community cook

6 Dental health nurse

7 healthy eating courses

8 none

9 none

10 brochure from SureStart

11 healthy eating and nutrition - 3 hours training

12 Knowsley training course 1/2 day

13 school healthy eating policy

14 not mentioned

15 none

16 Internet/Surestart/PCT

17 none

18


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Changes planned/made in practice

All nurseries (that completed the full questionnaire n=18) responded that they agreed (23.5%)

or strongly agreed (76.5%) that the training course had increased their nutritional knowledge.

All nurseries agreed (41.2%) or strongly agreed (58.8%) that the training course has changed

practices in the nursery.

Table 2: Main changes that nurseries state have been, or are being made as a result of attending the training:

Nursery code

Changes made/planned

1 Lower fat, salt and sugar in general when planning menus.

2 Products bought for breakfast and snack have been changed to healthier options. ie. olive oil

spread rather than sunflower spread.

3 Have implemented a new menu, updated policies, introduced a new parents‟ forum to aid

consultation and evaluation

4 We gave already started to change the menu, although we already used fresh fruit and

vegetables, I am now more aware of what I am adding ie salt, sugar etc.

5 We now do continuous snack morning and afternoon and we have a healthy eating policy in

place.

6 I feel that our menus were very good in the first place, but it has just increased my awareness

about salt, sugar and fat.

7 To make more nutritional lunches during the school holidays as we usually receive our lunches

via the school.

8 We will adopt new menus to reflect the importance of the Eatwell plate.

9 Juices, less salt, alternative foods.

10 I am currently doing questionnaires for parents regarding food given to the children. I will

assess the outcome with the training I have received - will redo the menu on offer at the

nursery.

11 Using different recipes gained whilst doing the course.

12 Check all labels for salt & sugar & fats, more oily fish.

13 Planning to change aspects of our menus, involve parents and consult with children.

14 We have implemented an afternoon healthy snack eg. cucumber & carrot sticks with dips.

15 To use less salt & sugar, we use only olive oil in cooking, make a lot more from scratch and a

lot less processed foods are now used.

16 I have already made changes to the menu and intend to do more. I have added more fruit and

veg into savoury dishes. I have increased the amount of fish on the menu.

17 Checking all the foods ingredients that we buy, making our own sauces.

18 To look at changing menus and displays for parents with information.


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All of the nurseries responded positively that what they learnt on the training course is

important to help them to provide high quality food in the nursery. 35.3% agreed this was the

case, and 64.7% strongly agreed with this statement.

Table 3: Most beneficial/important things learnt of the course

Nursery code

Most beneficial/important things learnt on the training course

1 Learning about vitamins and what they are for and where to find them.

2 Salt & sugar intakes for children & vitamins.

3 The content increased knowledge in all areas and was a useful tool to connect with

the cook and parent volunteers. It has allowed for reflection and exploration of ideas

collectively.

4 How to provide a good all round nutritional meal and healthy snacks.

5 I have a greater understanding of what is in the food we give the children.

6 Salt, sugar and fats.

7 The salt, sugar and fat contents hidden in foods.

8 The amount of salt, vitamins and minerals that are needed.

9 Healthy alternatives, portions & nutrition guidance.

10 Just to look at fat/sugar etc contents in food & what is in each particular thing we give

to the children.

11 How to read a label more effectively and the daily amounts for children.

12 Hidden salts & sugars ie. in baby meals.

13 Understanding food labels, salt content in everyday products.

14

15 To be more aware of the everyday food items used in nursery to check the labels and

make more healthy choices.

16

17 About the salt and fat content.

18

Your nursery routine

As nurseries have been shown to help foster children‟s emotional and social development (Bellisle,

2008), HoM was keen to discover the eating environments in the nurseries involved in the training

course.


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Both pre and post training 16 out the 18 nurseries reported that the children ate within their

nursery rooms and did not have a designated dining room as might be expected in a primary

school environment.

Pre training 16 of the nurseries reported that they teach the children about food and where it

comes from. One nursery reported that this was not the case, and one nursery did not answer

this question.

Post-training all 18 nurseries reported that the children learnt about food and where it comes

from.

All of the nurseries reported that the children did cooking or food related activities.

Common activities: messy play (pasta/beans/jelly), making snack, baking cakes, making smoothies/fruit

salads.

Table 4: Do the staff eat with the children?

Pre-training Post-training Improvement

Yes 27.8% (n=5) 55.5% (n= 10) 27.7%

No 22.2% (n=4) 11.1% (n=2) 11.1%

Sometimes 50% (n=9) 33.3% (n=6) 16.7%

Table 4 shows that as a result of the training more nurseries are now having staff eat with the children

forming an important opportunity for role modelling and social learning as encouraged as best practice

by both the Caroline Walker Trust Guidelines and the Georgie Porgie Pudding and Pie report (2008).

Changes in nursery practices and food provision

Table 5a: Does your nursery have a food/nutrition policy?

Pre-training Post-training

Yes 94.4% 88.2%

No 5.6% 11.8%


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Table 5a shows that post training the number of nurseries reporting they had a food policy had actually

dropped. One possible explanation for this is that nurseries reported that post-training food policies and

menus were being reviewed.

Table 5b: Changes in type of policy post-training

Type of policy Pre-training Post-training Change

Own policy 57.1% 37.5% 20% drop in own policy

Knowsley Healthy

eating guidelines

28.6% 12.5% 16% drop in Knowsley policy

Mixture of own &

Knowsley

0 31.3% 31.3% combined policy

Other policy (ie

Caroline Walker)

14.3% 18.8% 4.5% increase

Table 5b shows that post-training there has been a considerable change in the types of food policies

employed by the nurseries. As shown post training 31.3% of nurseries have produced a policy which is

a combination of their own policy and that of the Knowsley Healthy Eating Guidelines. This shift in

policy type reflects the impact the training course has had and that positively nurseries have reviewed

their original food/nutrition policy and incorporated elements of the Knowsley Guidelines which are now

possibly more relevant or better understood than pre-training.

All the nurseries reported telling parents what food was served during the day.


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Drinks provision

Figure 4: Changes in milk provision

Two new nurseries (11.1%) are now serving semi-skimmed milk daily to children over the age of 2

years.

After the training the nurseries have made small changes to their general drinks provision.

The use of diluted squash has fallen, although 1 nursery (4) is still serving it on a daily

basis. The use of sugar-free squash has also declined post-training.

Diluted fruit juice provision has remained similar although frequency of serving has

increased as 2 nurseries report serving it 2-3 times a week post-training, compared with

no nurseries pre-training. Giving fruit juice as a drink with meals is a positive step as

vitamin C increases the absorption of iron.


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Snack provision

The nurseries displayed some differences in snack provision post-training. Areas of interest were

snacks high in salt, sugar and saturated fat, as recognised in previous studies (crawley, 2006,

Mwatsama, 2006).

Figure 5: Changes in daily snack provision

Post-training toast and chopped fruit and vegetable provision has increased and dried fruit

(high in natural sugar) and sandwiches have decreased.

Figure 6: Changes in the frequency of serving of dried fruit


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General food provision

Differences in meal provision can be seen pre and post the training programme.

Fruit and vegetables are served daily in all nurseries.

Fish

It is important for children to obtain adequate amounts of Omega 3 fatty acids in their diets to aid brain

development, it has been recognised that low levels of DHA can impair cognitive development and

behaviour performance (Innis, 2007). The beneficial circulatory affects of oily fish in the diet (reducing

LDL cholesterol and increasing HDL) is well known for adult health. Encouraging children to eat fish is

in the early years, may help continue this behaviour into adulthood.

Figure 7: Changes in oily fish provision

Pre-training one nursery reported serving oily fish daily and this has ceased post training.

The current government recommendations for fish consumption are 2 portions a week,

one of which to be oily. Over-consumption of oily fish is not recommended due to the

build-up of pollutants found in oily fish such as dioxins and PCBs (polychlorinated

biphenyls)[FSA, n.d].


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General fish consumption has also risen with an improvement of 2 nurseries now serving

“other fish/fish pie” less than once a week and no nurseries reporting “never” serving

other fish post-training.

Salt

Nurseries were asked whether they added salt during or after cooking.

Pre-training 4 nurseries reported adding salt (3 “to taste” and 1 as “habitual custom”).

Post-training all nurseries had ceased adding salt during or after cooking

Figure 8: Changes in ingredients used potentially high in salt

Encouragingly post-training there has been an overall increase in the number of nurseries

reporting “never” using ingredients that can be high in hidden salt.


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Figure 9: Changes in sandwich fillings used

Post-training there has been an increase in the addition of tomatoes and cucumbers used in

sandwiches. Post-training 4 new nurseries (2,5,6,&18) are now serving both tomatoes and

cumbers in sandwiches although 3 nurseries(3,8 & 9) who originally reported serving tomatoes

pre-training and 2 who served cucumbers stated this was not the case post-training (nurseries

3&8).

3 nurseries now use smoked mackerel as a filling compared with no nurseries pre-training.

Peanut better is no longer used as an ingredient.

Figure 10: Changes in descriptions of nursery food


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The number of nurseries who chose the option of “food freshly prepared from scratch, with very

few sugary puddings or unhealthy snacks” increased from 41.2% pre-training to 72% post-

training.


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Chapter 5: Changes in practitioner’s confidence, knowledge and attitudes

Table 6: Changes in average confidence levels pre and post-training

Questions 31-35 No confidence Extremely at all confident

1 2 3 4 5 6 7

How confident do you feel about your own

healthy eating knowledge?

4.4 6.1

How confident do you feel about being able to

provide healthy, nutritious meals for the

children in your nursery?

5.0 6.2

Would you be able to name the 5 food groups

on the Eatwell plate model?

4.2 6.3

Would you feel confident providing drinks and

meals for a child who is lactose intolerant?

4.8 6.0

How confident would you be at identifying

foods containing high levels of saturated fats?

4.3 6.1

Pre-training mean scores (blue) Post-training mean scores (pink).

All of the nurseries have shown an increase in mean confidence for all assessment questions.

Table 7: Improvement in nutritional knowledge

Question Pre-training Post-training

How many portions of oily fish does the government recommend you aim to eat each week?

22.2% correct 22.2% correct

No improvement

A glass of unsweetened fresh fruit juice counts as a portion of fruit?

77.7% correct 94.4% correct

16.7% improvement

Carbohydrates are a good source of what?

88.8% correct 100% correct

11.2% improvement


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Table 8: Changes in attitudes

Statement Pre-training Post-training

Disagree Neither agree nor disagree

Agree Strongly Agree

Agree Strongly Agree

Eating a healthy diet is important to me

0 0 50% 50% 27.8% 72.2%

I feel confident choosing healthy options for myself and my family

5.6% 5.6% 66.7% 22.2% 33.3% 66.7%

I would like to learn more about healthy eating and nutrition

0 5.6% 38.9% 55.6% 61.1% 38.9%

I feel by completing the HoM Early Years Nutrition programme my ability to provide high quality food for my nursery will improve

0 0 27.8% 72.2% 22.2% 77.8%

Statistically significant changes in food provision and behaviour

It has been shown that the reported food provision has altered between the pre and post training

survey. Some statistically significant changes were found.

Nursery size

Q. Is there a difference in pre-training food provision by nursery size?

Table 9: Significant values pre-training

Kruskal-Wallis Minced beef/lamb/pork

Significance .014


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A statistically significant difference was found between the serving frequency of minced beef/lamb/pork

and nursery size. The large nurseries (60+ children) served minced meat less often than nurseries with

30-44 children. Additionally nurseries with less than 30 children also served minced meat less often

than nurseries with 30-44 children.

Table 10: Minced beef/lamb/pork provision pre-training

Nursery size Kruskal-Wallis Rank Mann-Whitney (Bonferonni adjustment)

Less than 30 children 12.25 .019

30-44 children 5.17

45-60 children 6.33

More than 60 children 13.50 .019

Table 10 shows that in this study, nurseries sized between 30 and 60 children served minced meat

more often than the larger and smallest nurseries. As a Bonferonni adjustment was employed 0.025 is

considered significant.

Q. Is there a difference in post-training food provision by nursery size?

No – no significant differences were found in food provision post-training by nursery size.

Attitudes - Statistically significant changes in attitudes were noticed for question 2: “I feel confident

choosing healthy options for myself and my family” where there was a significant change towards the

statement “agree” and “strongly agree” p = .008.

This outcome alongside some of the anecdotal evidence implies that the participants have gained an

understanding of the importance of good nutrition for themselves and their families, not just the target

group of under 5‟s in day care settings.


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Confidence levels

Q. Is there any difference between pre and post training confidence levels for all nurseries?

Table 11: Changes in pre and post-training confidence levels

Wilcoxon Signed Rank

Own healthy eating knowledge

Providing healthy nutritious meals

Naming 5 food groups on the Eatwell plate

Providing for a lactose intolerant child

Identifying foods high in saturated fats

Mean confidence score pre-training

4.4 5.0 4.2 4.8 4.3

Mean confidence score post-training

6.1 6.2 6.3 6.0 6.1

Significance

.002 .011 .002 .052 .006

A. Yes - nurseries showed significant improvement in own healthy eating Knowsley, naming the 5

groups on the Eatwell plate and indentifying foods high in saturated fats. However, overall

whilst showing a trend towards significance nurseries were less confident in Providing healthy

nutritious meals; and Providing for a lactose intolerant child

This finding satisfies research question 1: Do participant‟s nutritional confidence and knowledge scores

(Section D of questionnaire) improve after completion of the HoM training programme? - Yes nutritional

confidence levels have improved after completion of the training programme.


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Chapter 6: Impact and satisfaction with the training course

“I enjoyed the course and both my nursery and family have reaped the benefits of my

knowledge gained.” – Cook, nursery 11

Pre and post-training “ability to do” confidence levels were analysed for increased confidence post-

training and differences between phase of training and staff member.

Table 12: Comparison of pre- and post-training confidence scores using a Wilcoxon Signed Rank Test

Question Confidence Menu

Planning

Foods High

in Sugar

Cook From

Scratch

Identify

Allergens

Good Fats

vs. Bad Fats

Significance

level

0.000 0.000 0.000 0.000 0.000 0.000

Table 18 shows that when the impact of the training was measured in “ability to do” the confidence

levels for all 6 assessment questions (see appendix) has significantly improved, indicating a positive

impact from the training course.

Table 13: Comparison of pre and post-training confidence scores between phase 1 and phase 2


Planning

Foods High

in Sugar

Cook From

Scratch

Identify

Allergens

Good Fats

vs. Bad Fats

Phase 1 Sig.

value

0.013 0.004 0.004 0.003 0.004 0.001

Phase 2 sig.

value

0.004 0.004 0.007 0.010 0.003 0.003

Table 19 shows that there were no significant differences between the two phases of training, indicating

that the course was equally accessible to both cohorts, which were defined by the nurseries own

preference for training times.


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Table 14: Comparison of post-training confidence scores based on staff type


Planning

Foods High

in Sugar

Cook From

Scratch

Identify

Allergens

Good Fats

vs. Bad Fats

Chi-

Squared

1.448 1.221 1.180 1.141 2.353 1.219

Significance

value

0.458 0.543 0.554 0.565 0.308 0.544

Comparison of the pre-training confidence scores with the post-training confidence scores via a

Wilcoxon signed rank test showed that participants were significantly more confident in their knowledge

and skills after completing the training (p=0.000).

The results remain significant when the population is split into the two phase groups.

There was no significant difference found between pre- and post-training confidence scores of different

types of staff when compared with a Chi-squared test, which suggest that the course content was both

accessible and applicable to all participants.


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Programme Satisfaction Assessment Tool

Table 15: Mean responses using PSAT

PSAT Question Mean response Code

Overall the training programme met the stated

goals/learning objectives. 1.28 1=Strongly agree

The trainers presented the material and activities in a

clear, concise manner. 1.09 1=Strongly agree

Activities chosen by the trainers were appropriate for our

nursery. 1.09 1=Strongly agree

Discussions and/or presentations were applicable to our

goals. 1.14 1=Strongly agree

Trainers actively engaged all participants in activities

and discussions. 1.09 1=Strongly agree

Programme content accurately reflected our nurseries

goals. 1.19 1=Strongly agree

Trainers were knowledgeable about the subjects and

topics. 1.04 1=Strongly agree

The programme length was appropriate for achieving

our goals. 1.23 1=Strongly agree

The programme was too short 4.14 4=Disagree

The programme was too long 4.09 4=Disagree

As a result of attending the training programme we

achieved our goals. 1.28 1=Strongly agree


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Summary of the impact of the training course



training

The reported number of high sugar snacks and drinks (diluted squash) has decreased


2 additional nurseries are now providing semi-skimmed milk for children age 2 and over

Some changes to current food provision have been observed and many planned changes

have been reported



Participant attitudes changing from 22% to 72% “strongly agreeing” with the statement

that “eating a healthy diet is important to me”


Comments

“The course has provided all attendees with the knowledge needed to help maintain a healthy balanced

diet in the nursery setting. It also made people more aware of the amounts of fats, salt and sugar that

we put into our diet without realising this. This course has also made me look at my own diet.” –

Volunteer, nursery 2

“Enjoyed the course very much in particular networking with other settings and discussing ideas to

exchange. Feel more knowledgeable about what to serve the children and how to cook it.” – Manager,

nursery 15


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Chapter 7: Discussion of staff training results

“I thoroughly enjoyed the course and the practicals were particularly informative about taste

etc. The group I was in all enjoyed everything about the course and we all seemed to gel really

well as a group” – Manager, nursery 6

The Preschool Nutrition Training Project has had a significant impact on the nurseries enrolled on the

scheme. 18 nurseries (94%) completed the full training course and both pre and post-training

questionnaires, although 20 nurseries were recruited, 19 of these attended the programme.

Research Question 1: Do participant‟s nutritional confidence and knowledge scores (Section D of

questionnaire) improve after completion of the Preschool training project?

Statistically both general nutritional knowledge confidence and “ability to do” of the staff has increased

post-training in line with the first research question that scores would increase after the training

programme (Question 1 p =.002, question 2 p = .011, question 3 p = .002, question 4 p = .052, question

5 p = .006). Queston 4 (providing for a lactose intolerent child) not significant but shows a trend towards

significance.

Research Question 2: Do the participating childcare setting‟s food provision and practices (Sections B

and C of the questionnaire) improve after completion of the Preschool training project?

Some differences have been noticed in food provision and nursery practices. One area of interest was

the number of high sugar snacks served to children due to the North West‟s high levels of tooth decay

seen in 5 year olds (Mwatsama, 2006). Post training the number of nurseries frequently serving dried

fruit as a snack and diluted squash has decreased. This is encouraging as Carolline Walker Trust


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guidelines are for sugary foods to be given as part of a meal, rather than a snack to reduce the overal

time children‟s teeth are in contact with the sugars as well as the total sugar content of the diet

(Crawley, 2006).

General food provision had not changed substantially when the post-training questionnaire was

administered although the nurseries reported important planned changes and a higher level of

awareness of under 5‟s nutritional needs. Staff now report reading food labels for amounts of sugar, fat

and salt, (areas identified as a concern by the Caroline Walker Trust [Crawley, 2006]), basing new

menus on the Eatwell Plate, and one nursery reported starting a Parent‟s Forum, for imput into the

children‟s meals.

64.7% of the nurseries also “stronlgly agreed” that what they had learnt on the training would help them

provide high quality food in their settings.

Important changes have been noted in preparation methods, the number of nurseries describing their

meals as “food freshly prepared from scratch” rose by 30% post-training, and 52.9% of nurseries now

have staff eating with the children (in line with “Better Nursery Food Now” guidelines, 2008) compared

with 27.8% pre-training.

Mixed results were reported for the implementation and development of food/nutrition policies in the

preschools. Pre-training 94% of nurseries reported having a food policy in place. However post training

this fell to 88.2%. One possible reason for this could be that the the settings were re-evaluating their

current guidelines. Changes were recorded for the type of policy. Nurseries using their own policy fell

by 20% and 31.3% of nurseries reported using a combination of their own policy and the Knowsley

Healthy Eating Guidelines, which were not recorded at all pre-training. There was also a 4.5% rise in

the use of “other” policies such as Caroline Walker Trust.


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When considered as a whole both the annecdotal and quanitative evidence implies that the Early Years

Nutrition Training Programme has had a positive impact on food provision in the nurseries. The overall

impact at this point is unclear, but from current indications, if a follow-up questionnaire was re-submitted

(concentrating on food provsion and awareness) 6 months post-training,it is possible that further

improvements to food provision would be observed.

Research Question 3: Do participant‟s confidence in their perceived ability “to do” common early years

nutrition tasks (pre & post training confidence assessment) improve after completion of the Preschool

training project?

Encouraging results were seen in terms of perceived “ability to do” and a clear and significant

improvement was noted for all staff (managers, catering staff & volunteers) post-training. Six questions

were employed to measure confidence (attending and completing the course, planning a menu,

identifying foods high in sugar, cooking meals from scratch, identifying common allergens on a food

label and knowing the difference between good and bad fats).

Statistically significant improvements were seen from all 6 questions, even when analysed by phase of

training and nursery size, indicating that neither had any effect on the accessibility of the training course

objectives (see chapter 6).

Research Question 4: Do the participating childcare setting‟s nutritional quality of their menus improve

after completion of the Preschool training project?

Full analysis of the nutritional quality of the nurseries‟ food provision was outside the scope of this

project. However pre-training sample menus were provided by some of the nurseries and basic

analysis was carried out on those (see Annex 4). To thoroughly investigate changes in nutritional

quality sample menus, with recipes and portion sizes would be necessary. Post-training all nurseries


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have reported planned changes to their current food provision and redesigning menus in line with the

objectives of the training programme.

Overall the training course has brought about important changes to the nurseries enrolled and has had

a positive effect on participants‟ knowledge and understanding of pre-school children‟s nutritional

needs. Certain aspects have been identified as areas for improvement if the training course is re-

administered to further nurseries, particularly oily fish provision, which has been recognised as an area

for confusion in this study.

Findings of the children’s evaluation

The children‟s evaluation was originally planned to run as another full method of impact assessment of

the training course. However due to time constraints and participant burden this “full” pre and post-

training evaluation was not possible within the scope of this project. However as ethical approval

(University of Chester) had been granted, it was possible to observe lunch-time routine in 6 of the

nurseries enrolled on the programme.

As part of the project children‟s food sticker diaries were utilised as a novel way of exploring young

children‟s food preferences within nursery. The nurseries were provided with a range of food stickers

that the children could stick in the diaries themselves. Nursery staff were asked to help the children

record in this manner which foods during the nursery day children had liked, disliked or not tasted. 5

nurseries and 44 children took part in this activity. Using pictures and photographs has been

documented as a child friendly method of recording data Cremin & Slatter (2004).

Child led interviews were also administered to use alongside the sticker diaries to record the children‟s

recognition and identification of fruits and vegetables using flashcards. The interviews were voice


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recorded (all children taking part had parental permission and the children were asked on the day

whether they wished to join in) these results are displayed in the annexes.

Observations

The children‟s assessments and observations have shown that nursery practices are changing.

Allowing the children to serve themselves was almost as common as pre-plated meals in the nurseries

visited.

Importantly all children were free to eat as much or as little as they liked and lunch-time ran for as long

as necessary in all nurseries. Alternatives or afternoon snack were available in all nurseries observed

for children who did not eat lunch.

In all but one nursery (which was short staffed on the day visited) staff sat with the children. Making

meal times sociable has been identified as important in children‟s development (Soil Association,

2008). Good practice is now seen as staff sitting with, and where possible, eating the same foods as

the children (Crawley, 2006).

Post-training there has been a 27% (n=5) increase in the number of nurseries reporting that

practitioners now eat with the children, resulting in over half of the nurseries adhering to this guideline.

Children‟s interviews

All of the preschool children interviewed (27) had a good recognition of common fruits and vegetables.

Kiwi fruit, melon and pepper were least well recognised.


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Gapes and bananas were reported as the most popular fruits by the children, with oranges, pineapple

and kiwi being the least popular. Peas, carrots and broccoli were reported as the most popular

vegetables, tomatoes and pepper were the least popular.

Food sticker diaries

Importantly and in line with findings from Cremin & Slatter (2004) that young children can competently

express their opinions, the level of reported “likes” and “dislikes” in the interviews did coincide with

foods liked, disliked and not tried in nursery. Bananas and grapes alongside apples were happily eaten

by the children. Interestingly oranges were “liked” by 9 children and only disliked by 2, possibly

reflecting the influence of social learning and role models in the nursery setting (Bellisle, 2008). Out of

10 children offered kiwi fruit, 5 children reported not liking it and 1 child did not taste it.

10 children were served tomatoes whilst keeping the diaries and in line with the reports from the

interviews, 7 children “disliked” tomatoes.

7 children were served fish pie, noticeably none of the children reported “disliking” the meal although 3

children did not taste it at all possibly displaying behavioural neophobia (Reverdy, Chesnel, Schlich,

Kőster & Lange, 2008).

These findings were in line with previous research where behavioural neophobia based on the child‟s

acceptance of familiar foods may be tackled by changing what Dr Pilner (speaking at a symposium as a

satellite to the FENS 2007 Congress) describes as schemas. These represent organised knowledge

about particular foods, and effect expectations about known and novel foods. When presented with a

new food, children will often have the cognitive schema that the food will not taste good. Dr Pilner

suggests that convincing the child that this food is an exception to this schema, could facilitate the


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child‟s willingness to taste the food (Bellisle, 2008). Observations have shown that role models, or

children witnessing significant others enjoying a food unknown to the child can increase willingness to

try. Changing the children‟s perceptions about new foods is challenging and little research has been

carried out but it is believed that by introducing children to good-tasting novel foods and early exposure

to a broad range of foods can reduce neophobia and create positive schemas about novel foods

(Bellisle, 2008).

A major element in achieving these positive schemas is presenting healthy foods in a child friendly

approach. It has been shown that children are more likely to consume more energy dense, high fat and

sugar foods than lower energy, more nutritious foods and their preference is for sweet tasting food and

to dislike those which are sour or bitter (Birch, 1999, cited in Cooke & Wardle). To improve acceptance

and liking of vegetables (intake is low in young people as their sensory characteristics do not appeal to

children) pairing the vegetable with a more highly palatable food (sensory-sensory learning) and social

learning could improve willingness to eat these foods (Bellisle, 2008). Dr Hans Brug cited in Bellise,

proposes that parents and care givers could be given advice to improve the preparation and cooking of

vegetables to present them more favourably.

Encouragingly the children in the Heart of Mersey study nurseries have reported a positive response to

many fruit and vegetables in observations, interviews and food diaries. It is perceived that the training

course has led to a 25.1% increase in the number of nurseries that have practitioners eating with the

children.


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Limitations

The study was reliant on self reported data and so open to bias, with the possibility of participant‟s

reporting what they believe the trainers/researcher wants to hear, as well as the chance that the most

interested/motivated nurseries will take part in this type of intervention (Crombie, 2007). However the

overall impact of the training course has been expressed as a very positive experience for the pre-

school practitioners. The training programme was designed for both the nursery manager and catering

staff and where possible volunteers allowing a varied range of participants, and hopefully reducing bias

in self reported data.

The training programme aimed to reduce the ambiguity around the current guideline for early years

nutrition offered by The Early Years Foundation Stage (EYFS) that: „Where children are provided with

meals, snacks and drinks, these must be healthy, balanced and nutritious.‟

Post-training the confidence of all the pre-schools had shown a statistically significant increase in their

confidence and perceived “ability to do” in relation to implementing changes. It has been found in other

countrywide studies that nurseries are keen to attend training and have more “user friendly” guidance (Soil

Association 2008, LACORS survey 2010).

The main and children‟s evaluations were also limited by time constrictions. To accurately reflect the full

impact of the study on food provision, nurseries would need to be follow-up some 6-12 months post-training.

In a more in-depth study full nutritional analysis of menus could be carried out to assess changes on the

nutritional values (energy, salt, fat, sugar) and vitamin status of the meals served.


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Chapter 8: conclusion & recommendations

“I feel I have learnt a lot from the course and would recommend it to other nurseries.”

– nursery 1

The Target: Wellbeing Preschool Nutrition Project has had a beneficial impact on all settings that took

part. Importantly increases in confidence and perceived “ability to do” have been seen for all nurseries

and all participants (managers, catering staff and volunteers), reflecting that the course was accessible

for all attendees.

The overall impact on the preschool children is yet to be determined, although the reported increases in

staff eating with the children alone can improve social learning and set healthy eating habits, which will

hopefully be adopted into later life (Bellisle 2008, Crawley 2006).

The project has demonstrated that given the opportunity, early years staff are keen to access training

and to provide the best nutriton that they can for the children in their care. However prior to the

Preschool Nutrition Project there was little comprehensive training and support available to them. With

the lack of national guidance for them to follow it is left to their own good will to make changes to food

provision.

Summary of the impact of the training course



training

The reported number of high sugar snacks and drinks (diluted squash) has decreased


2 additional nurseries are now providing semi-skimmed milk for children age 2 and over


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Some changes to current food provision have been observed and many planned changes

have been reported



Participant attitudes changing from 22% to 72% “strongly agreeing” with the statement

that “eating a healthy diet is important to me”


Future recommendations:

Offer the accredited training to all nurseries and early years staff in knowsley

Etablish regular up-dates and on-going training and examples of best practice

Continue the partnership working between agenices involved in the project

Encourage the pre-school “networking” observed throughout the training programme to

continue

Continued support to settings particularly resources for menu planning ie. CWT

Nationally:

Support for the call for national compulsory regulations for pre-school nutritional guidelines

(CWT, Soil Association)

Nutritional knowledge to be included in early years/foundation stage practitioners training.


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Annex 1: Nursery observations

Lunch-time observations

By observing usual practice within the nurseries the children‟s eating environment could be assessed.

Six nurseries were visited during the training programme and the following observations were made:

Five out of the 6 nurseries all served meals within the children‟s room within nursery.

5 out of 6 of the nurseries had pictures of food on the walls.

Table 22: Lunch-time observations

Nursery Tablecloths, placemats, plates used. Do the children help lay the table?

4 Blue & pink plastic plates – no table cloths No

11 Plastic table cloth and colourful bowls. Yes- help with tablecloth.

13 Colourful tablecloths, colourful bowls. No

14 Spotty tablecloths, colourful plastic cups and

dinosaur patterned plates.

Yes – selected “helpers” put the

cups on the tables.

16 No tablecloth – white plates, metal cutlery, bright

plastic cups.

No

17 Individual placemats with the children‟s names,

picture, and any allergy information on them.

Plates and bowls with images on them.

Yes – one child gave out the spoons.

19 Plastic tablecloths, plastic coloured plates and

cups.

No

Making meal times fun and sociable is important for childrens‟development. Recommendations from the

Soil Association include using bright tablecloths and real crockery with elder children and encouraging

chidlren to help lay the table and to have designated waiters and waitresses for the day (Soil

Association, 2008).


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Figure 11: Cutlery used

The majority of the children (3-4 year olds) were eating with spoons, importantly some nurseries were

encouraging the children to use knives and forks.

Table 17: Lunch-time interactions

Nursery Do the staff talk to the

children about the food?

Do the staff eat the same

food as the children?

Do the staff sit with the

children whilst they are

eating?

4 No No Short staffed – staff moving

between tables.

11 Yes No Yes

13 Yes Yes Yes

14 Yes No Yes

16 Yes No Yes

17 Yes No Yes

19 Yes No Yes


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Table 18: Meal served

Nursery What is being served?

Mains Pudding

4 Corned beef hash and baked beans with salad Vanilla blamange

11 Quorn chicken and sweet potato curry with rice Banana & custard or a yoghurt

13 Chicken and vegetable casserole with bread Yoghurt

14 Sardines and tomato pasta Mandarin flan

16 Beef and vegetable casserole with roast potatoes Fruit puree – peach & orange

17 Beef casserole and brown bread Sliced fruit – tangerines, banana & apple

19 Bolognese pasta bake Orange sugar-free jelly

Figure 12: Pre-plated or self service


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Table 19: Vegetables

Nursery On their own Part of the ingredients

4 Side salad – children can help themselves No

11 No Yes (curry)

13 No Yes (casserole)

14 No Yes (peas & sweetcorn in pasta)

16 Yes (sprouts served at the side) Yes (onion, mushroom, carrots in casserole)

17 No Yes

19 No Yes

Table 20: Amount eaten

Nursery Are the children free to eat as

much or as little as they like?

Are children offered an alternative if they refuse food?

4 Yes If the child is due to go home at 1pm – then No

If the child is staying all day – they can have a sandwich later.

11 Yes Child would be offered a sandwich later on in the afternoon –

although encouraged to sit with other children while they eat

their food.

13 Yes Plate of sliced fruit

14 Yes Given plain pasta

16 Yes No – but substantial afternoon snack provided

17 Yes Fruit

19 Yes Sandwich


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Table 21: Nursery atmosphere

Nursery What is the atmosphere

like?

Are the children allowed to

talk during the meal?

How long does lunch last?

4 Noisy until the children get

settled.

Yes Approx. 40 minutes

11 Relaxed, staff offer the

children help with cutting etc.


13 Relaxed – staff eat with

children.

Yes Approx. 20-25 minutes

14 Relaxed- children help

themselves to how much or

little they want.


16 Happy, encouraging Yes As long as needed

17 Calm Yes No set time

19 Yes No set time

Table 22: Tidying-up routine

Nursery Do the children help tidy-up after lunch?

4 Some of the children brought their bowls back. Staff clean the table

11 Children pass dishes to the staff

13 Children scrape leftovers into the bin and put

their bowls/plates back on the trolley

14 No Staff clean up

16 No – but they wipe their own faces

17 No

19 Designated helper collects cups 7 washes them.

Also brings pudding bowls back to staff.


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Annex 2: Child led interviews

Children’s recognition of fruits and vegetables

Figure 13: Number of children that could name a selection of fruits

Figure 14: Number of children who could name a selection of vegetables


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Figure 15: Reported likes and dislikes of fruit

Figure 16: Reported likes and dislikes of vegetables


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Annex 3: Food sticker diaries

Food sticker diaries

Food sticker diaries were used as a way for the children to record which foods they liked, disliked and

did not taste whilst in nursery. 44 children took part in this activity from 5 nurseries.

Figure 17: Food diary fruit preferences

Figure 18: Food diary vegetable preferences


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Figure 19: Food diary meal preferences

Figure 20: Food diary snack preferences


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Figure 21: Food diaries pudding preferences


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Annex 4: Sample menus (pre-training)

Menu analysis

8 nurseries provided samples of their menus prior to commencing the training programme. The

majority were in phase 2.

Fruit and vegetables

Table 23: Fruit and vegetables served daily

Nursery code

Fruit served daily Vegetables served daily

Yes Yes Yes No

4

10

12

13

14

16

19

Table 24: Variety of fruit served per week

Nursery code Variety of fruit served per week

Not stipulated on menu

3-4 different fruits

5 or more different fruits

4

10

12

13

14

16

19


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Table 25: Number of meals with vegetables in the recipe

Nursery code Number of meals per week with fruit or vegetables in the recipe

1-2 different meals

3-4 different meals

4

10

12

13

14

16

19

Table 26: Number of meals with fish per week

Nursery code Number of meals per week with fish as a

main ingredient

None 1 meal 2 meals

4

10*

12

13**

14

16

19

*Nursery 10 served 2 meals with fish in week 1 out of a sample 3 week rolling menu.

**Nursery 13 served fish in week 3 only out of a 3 week rolling menu.


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Table 27: Number of meals with oily fish per week

Nursery code Number of meals per week with oily fish as a

main ingredient

Not stipulated

on menu

None 1 meal

4

10

12

13

14

16

19

Home-made meals

Table 28: Number of home-made meals per week

Nursery code Number of home-made meals per week

Not stipulated

on menu

1 meal 2 meals

4

10

12

13

14

16

19


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Table 29: Number of meals on the menu containing processed foods/ingredients

Nursery code Number of processed meals/ingredients served per week

Not stipulated

on menu

1 meal containing

processed food

2 meals containing

processed food

3 meals containing

processed food

4

10

12

13

14

16

19


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Appendies

Appendix 1: Pre-training questionnaire & pre-training confidence assessment

Appendix 2: Post-training questionnaire & post-training confidence assessment

Documents

The Target: Wellbeing Preschool Nutrition Project · 2018-04-04 · Target: Wellbeing Preschool Nutrition Project 2010 2009-2 | P a g e Evaluation by the University of Chester Awarded