Facility-level Interventions

sp-facilityFacility-level interventions are programs or initiatives that encompass a defined set of activities that take place directly within ECE facilities. They may seek to alter policies and practices within the facility or to support behavior change in children directly. They may specifically target one aspect of obesity prevention, such as breastfeeding support, or may be comprehensive to include nutrition, breastfeeding, physical activity, and screen time.

Interventions can entail a single component, such as a curriculum, or have multiple components that are mutually reinforcing. For example, a multicomponent intervention might entail the adoption of a policy for all children to be physically activity for 120 minutes per 8-hour day, the adoption of a particular curriculum that incorporates several physical activity segments as part of the lesson plan, and training for providers. Statewide support for, or implementation of, facility-level interventions in ECE is often undertaken with the help of partnering organizations such as a state health department, Child Care Resource and Referral agency, or university.

Numerous facility-level interventions, especially curricula, are available to promote nutrition, breastfeeding, and physical activity and to limit screen time in ECE; five are described here. Some of these interventions have been evaluated for effectiveness, while others have simply been tested for acceptability to ECE providers and families.

Nutrition and Physical Activity Self-Assessment for Child Care

NAP SACC1 is an environmental intervention to enhance policies and practices in ECE for children 2 to 5 years by improving the nutritional quality of food served, the amount and quality of physical activity, staff-child interactions, nutrition and physical activity policies and practices, and related environmental characteristics of the center. The key steps of NAP SACC include:

  • Self-assessment to identify strengths and needs for improvement;
  • Goal setting and action planning to map out strategies for change;
  • Training for ECE providers to improve knowledge and increase self-efficacy;
  • Technical assistance and consultation to provide centers with motivation and resources;
  • Follow-up and reinforcement to assess progress and address barriers; and
  • Repeat self-assessment to identify areas of improvement and set new goals for change.

It is important to note that NAP SACC is not a curriculum, although selecting and implementing a specific curriculum might be a key item on a facility’s action plan developed through NAP SACC. The NAP SACC intervention helps centers assess and make changes to their nutrition and physical activity environments and is a tool to promote continuous quality improvement. NAP SACC is designed to facilitate change in areas where a center feels ready and able, with the help of a local, trained health professional.  Training and materials NAP SACC are available at no cost online.

Eat Well Play Hard in Child Care Settings

EWPHCCS is a multicomponent intervention that focuses on improving nutrition and physical activity practices in ECE and improving the nutrition and physical activity behaviors of preschool-age children and their parents and caregivers. EWPHCCS combines the NAP SACC intervention with a nutrition and physical activity curriculum developed by the New York State Department of Health. EWPHCCS uses educational strategies and skill-building activities to enhance self-efficacy for targeted behavior change in both the parent and the child. The intervention also builds social support within the ECE environment by including ECE providers in lessons and encouraging positive role-modeling and classroom reinforcement of nutrition and physical activity messages. Some of the lessons include Food Mood, Vary Your Veggies, Flavorful Fruit, Dairylicious, Choose Your Fun, Cooking with Children, Smart Snacking, Fitness Is Fun, Awesome Appetites, and Growing Goodness.

Key steps of EWPHCCS include:

  • Implementation of NAP SACC (self-assessment, goal setting and action planning, continuing education for ECE providers, technical assistance and consultation, and follow-up and reinforcement);
  • A 10-lesson curriculum that provides age-appropriate lessons for children in ECE and corresponding lessons for parents; and
  • Parent handouts available in six languages (English, Spanish, Chinese, Russian, Arabic, and French).

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Color Me Healthy

 CMH  is a practice-tested curriculum developed by North Carolina Cooperative Extension and the North Carolina Division of Public Health. CMH is designed to improve fruit and vegetable intake and increase physical activity among 4- and 5-year-old children in ECE. CMH uses color, music, dance, and imaginary play to provide opportunities for physical activity and to teach children about fruits and vegetables. The intervention uses a train-the-trainer approach to support implementation of the program. The CMH toolkit includes 12 lessons, picture cards, a music CD, posters, and parent newsletters. CMH materials and information on training are available at a moderate cost online.

Grow it, Try it, Like it! Preschool Fun with Fruits and Vegetables

Developed by the USDA, GITILI is a garden-themed nutrition education program that is centered on an activity kit. The kit includes an overview of gardening, plus booklets focusing on three fruits and three vegetables. The curriculum encourages hands-on exploration of gardening, fun activities, and recipes for families to encourage consumption of fruits and vegetables in ECE settings and in the home.

Action Guide for Child Care Nutrition and Physical Activity Policies

The Connecticut State Department of Education (CSDE) developed an action guide to help ECE facilities establish and implement policies and practices that promote healthy eating and physical activity in young children. The guide promotes clear and consistent messages that explain and reinforce healthy eating and physical activity habits, developmentally appropriate and culturally relevant nutrition education, quality physical education and daily opportunities for developmentally appropriate physical activity, and ideas for engaging and supporting families in promoting healthy habits. In May, 2010 the CSDE distributed 5,850 copies of the guide to Head Start, CACFP, Afterschool, and other ECE programs and conducted a statewide training series for all CACFP sponsors through six regional workshops. These trainings reached nearly 300 ECE stakeholders, representing 128 CACFP programs and 17 other organizations. The guide can be downloaded here.

State Example: North Carolina NAP SACC

North Carolina (NC) implemented NAP SACC in ECE facilities in many of the 100 counties in the state.

How It Came About

The NC Partnership for Children (www.smartstart.org) became interested in statewide dissemination of NAP SACC based on pilot test results. The Partnership operates the Smart Start program, NC’s early childhood infrastructure. The Smart Start program is implemented at the local level, and these agencies serve as a statewide system of ECE resources. Through a collaboration, including the Partnership, the NC Division of Public Health and UNC-Chapel Hill NAP SACC was implemented across much of the state.


In NC, NAP SACC relies on trained health consultants (i.e., child care health consultants, nurses, health educators, nutritionists, and other health professional) familiar with ECE facilities, to implement the intervention. Consultants working with the facilities completed four-hours of web-based training on implementation of the intervention, nutrition, physical activity and healthy weight in young children. Consultants helped recruit ECE centers to participate in the statewide program by letter, phone, or in-person.

In 2011, NAP SACC became part of a state initiative called “Shape NC: Healthy Starts for Young Children” to help prevent obesity in ECE centers. The first cohort of centers began the program in May 2011, and project funding concluded in December 2013.  Through funding from The Blue Cross and Blue Shield of North Carolina Foundation, the NC Partnership for Children is implementing a comprehensive intervention to create early childhood wellness champions among ECE professionals. The overall goal of Shape NC is to ensure that children attending ECE facilities are served nutritious foods, engage in physical activity, have naturalized outdoor learning environments and have teachers modeling healthy behaviors.  The Shape NC program was implemented in 20 counties over the three years of the grant.  ECE centers in each of these counties received intensive technical assistance to become a model center and demonstration site for centers in the surrounding area.

Lessons Learned

  • Incentives for ECE facilities in the form of small items that support organizational change (gift cards for classroom supplies, balls or hula hoops, activity or nutrition books for children) can be provided periodically.
  • Some ECE facilities may need lots of support and encouragement, while others may be able to accomplish change on their own, so tailoring technical assistance to the needs of the facility is suggested.
  • Training is highly recommended to increase the skills, knowledge, and confidence of the consultants and to promote implementation of the core elements of the intervention.
  • Continuing education credits from the state agency that oversees ECE can provide an additional incentive for participation in the NAP SACC intervention. Often, ECE providers are required by the state licensing agency to complete continuing education each year. Offering continuing education credits was a significant incentive for providers to participate in the NAP SACC workshops.
  • It is essential to tailor the NAP SACC self-assessment to ensure that responses on the tool are consistent with or even exceed state licensing requirements (see www.nrckids.org for information on your state licensing and administrative regulations).



  1. Ammerman AS, Ward DS, Benjamin SE, Ball SC, Sommers JS, Molloy M, Dodds JM. An intervention to promote healthy weight: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) theory and design. Prev Chronic Dis [serial online] 2007;4(3). Available from http://www.cdc.gov/pcd/issues/2007/jul/06_0115.htm.