CONNECTING KINDERGARTEN READINESS AND FOOD-BASED LEARNING IN THE HEAD START PRESCHOOL CLASSROOM by Jocelyn Dixon May, 2023 Director of Thesis: Virginia C. Stage, PhD, RDN Major Department: Nutrition Science ABSTRACT While food-based learning (FBL) has been cited as the most effective way to increase children’s preference and consumption of vegetables in the preschool classroom, teachers face barriers such as limited time or competing priorities. Integration of FBL with other learning domains is one promising solution; however, research is needed to understand teachers’ use and perception of integrative FBL experiences. The purpose of this phenomenological qualitative study was to explore common experiences of Head Start (HS) teachers’ use and integration of FBL with science learning in the HS classroom. Thirty-five in-depth semi-structured telephone interviews were conducted with HS teachers from 16 counties across the three regions of North Carolina. Participants were 94% female, 40.8 years (SD 10.06), and predominantly white (52.9%) or Black/African American (44.1%) and of non-Hispanic (97.1%) ethnicity. All interviews were audio recorded and transcribed verbatim. Researchers identified significant statements through open coding which were grouped into themes. Researchers identified 11 primary themes which were inductively organized into the Systems Thinking Iceberg Model. Teachers described most frequently utilizing FBL during mealtimes. Teachers stated they felt successful when children were engaged and willing to try a new food. However, teachers struggled to connect food to academic concepts (e.g., science, mathematics, literacy). Teachers reported several motivators (e.g., improving health) and barriers (e.g., food waste) to integrating FBL. A few teachers saw a connection between FBL and kindergarten readiness but the majority of teachers = did not. Implications for teacher professional development and resources to improve FBL integration in ways that promote kindergarten readiness are discussed. CONNECTING KINDERGARTEN READINESS AND FOOD-BASED LEARNING IN THE HEAD START PRESCHOOL CLASSROOM A Thesis Presented to the Faculty of the Department of Nutrition Science East Carolina University In Partial Fulfillment of the Requirements for the Degree Master of Science in Nutrition Science By Jocelyn Dixon May, 2023 © Jocelyn Dixon, 2023 CONNECTING KINDERGARTEN READINESS AND FOOD-BASED LEARNING IN THE HEAD START PRESCHOOL CLASSROOM by Jocelyn Dixon APPROVED BY: DIRECTOR OF THESIS: _________________________________________________ Virginia C. Stage, PhD, RDN COMMITTEE MEMBER: _________________________________________________ Nicole Arnold, PhD COMMITTEE MEMBER: _________________________________________________ Archana Hegde, PhD CHAIR OF THE DEPARTMENT OF NUTRITION SCIENCE: _____________________ Michael Wheeler, PhD INTERIM DEAN OF THE GRADUATE SCHOOL: ______________________________________ Kathleen Cox, PhD ACKNOWLEDGEMENTS I would like to thank my advisor Dr. Virginia Stage for her guidance during my master’s and the completion of this thesis. Her mentorship and support have been invaluable in my development both personally and professionally. I also thank the other members of my committee, Dr. Archana Hegde and Dr. Nicole Arnold, and external reviewers, Dr. Suzie Goodell and Dr. Taren Swindle, for their expertise and feedback. I would also like to thank Narmin Zeidan and Zachary Paramore for their assistance collecting and analyzing the data. Additionally, I am grateful to all the participants who gave of their time to be a part of my first major study. Lastly, I give my deepest appreciation to my family, especially to my husband, Holden. I couldn’t have done this without your unwavering love and support. TABLE OF CONTENTS LIST OF TABLES .............................................................................................................................. viii LIST OF FIGURES ........................................................................................................................... ix CHAPTER 1: INTRODUCTION ......................................................................................................... 1 Statement of problem ........................................................................................................... 4 Statement of purpose ........................................................................................................... 4 References ........................................................................................................................... 5 CHAPTER 2: LITERATURE REVIEW ............................................................................................... 9 Dietary Quality Among Preschool Children in the United States ................................... 9 Determinants of Fruit and Vegetable ............................................................................ 9 Biological ....................................................................................................... 9 Relational – Parents ...................................................................................... 10 Relational – Early Childhood Teachers ......................................................... 11 Environmental ................................................................................................ 12 Methods for Improving Vegetable Intake ....................................................................... 12 Repeated Exposure ....................................................................................... 13 Mealtime ........................................................................................................ 13 Outside the Mealtime ..................................................................................... 14 The “What” and “Why” of Food-based Learning ............................................................ 14 Benefits of FBL .............................................................................................. 14 Prior FBL Interventions & Outcomes ............................................................. 15 FBL Best Practices ........................................................................................ 16 Incorporate Healthy Foods ................................................................... 16 Multiple exposures ............................................................................... 17 Engage the Senses .............................................................................. 17 Do Not “Play” with Food ....................................................................... 18 Role Model and Respect ...................................................................... 18 Family Engagement ............................................................................. 18 Barriers to FBL ............................................................................................... 18 Resources ............................................................................................ 18 Influence of Policy ................................................................................ 19 Other Challenges ................................................................................. 20 COVID-19 ............................................................................................ 20 Gaps in Research .......................................................................................... 21 References ........................................................................................................................... 22 CHAPTER 3: METHODS .................................................................................................................. 33 Research Design .................................................................................................................. 33 The Larger NIH SEPA Study ................................................................................................ 33 Subject Population and Eligibility ......................................................................................... 33 Recruitment .......................................................................................................................... 33 Data Collection and Tools .................................................................................................... 35 Data Collector Training ......................................................................................................... 36 Procedure for Data Collection .............................................................................................. 37 Procedure for Data Analysis ................................................................................................. 38 Validity and Reliability ......................................................................................................... 39 Potential Risks and Benefits ................................................................................................. 40 Ethical Considerations .......................................................................................................... 41 Bias and Assumptions .......................................................................................................... 41 Potential Limitations ............................................................................................................. 41 Expected Outcomes ............................................................................................................. 42 References ........................................................................................................................... 42 CHAPTER 4: CONNECTING KINDERGARTEN READINESS AND FOOD-BASED LEARNING IN THE HEAD START PRESCHOOL CLASSROOM .................................................................................... 44 Introduction ........................................................................................................................... 43 Methods ................................................................................................................................ 46 Study Design ........................................................................................................... 46 Participants and Recruitment .................................................................................. 47 Data Collection ........................................................................................................ 47 Measures ................................................................................................................. 48 Data Analysis ........................................................................................................... 50 Results ................................................................................................................................. 51 FBL Events in the Preschool Classroom ................................................................. 53 FBL Inside the Mealtime Environment ........................................................ 53 FBL Outside the Mealtime Environment ..................................................... 54 Pattens and Trends of FBL in the Preschool Classroom ........................................ 54 Teachers’ Use of Unhealthy Foods Outside Mealtime Environment ......... 55 Uncertainty on how to Integrate FBL into Other Learning Domains ........... 55 Feelings of Helplessness Related to FBL in the Classroom ....................... 55 Underlying Structures Affecting FBL ....................................................................... 56 Food Waste ................................................................................................ 56 Policy Environment ..................................................................................... 56 COVID-19 ................................................................................................... 57 Teachers’ Mental Models for FBL ............................................................................ 58 Motivators for FBL ...................................................................................... 58 Perceptions of Successful FBL ................................................................... 59 Kindergarten Readiness ............................................................................. 60 Discussion ............................................................................................................................ 62 Conclusions and Implications ............................................................................................... 66 References ........................................................................................................................... 67 APPENDIX A: INSTITUTIONAL REVIEW BOARD APPROVAL ...................................................... 76 APPENDIX B. HEAD START RECRUITMENT SCRIPT ................................................................... 79 APPENDIX C. HEAD START INTERVIEW RECRUITMENT FLYER ............................................... 82 APPENDIX D. STATEWIDE INTERVIEW CONSENT FORM .......................................................... 83 APPENDIX E. QUALITATIVE INTERVIEW GUIDE .......................................................................... 87 LIST OF TABLES 1. Teacher Semi-Structured Qualitative Interview Questions 2. Teacher Semi-Structured Qualitative Interview Questions, Including Probes (n=35) 3. Supportive HS Teacher Quotations for Themes Aligned with the Systems Thinking Iceberg Model (n = 35) LIST OF FIGURES 1. 2-Stage model of the development of children’s vegetable preferences and consumption as presented by Johnson (2016) 2. Head Start Grantees Across North Carolina 3. Phenomenology Theory Procedures: Data Collection and Analysis 4. Teachers from North Carolina Counties Participating in Semi-Structured Qualitative Interviews (n=35) 5. Theoretical model presenting relationship between HS teachers’ (n = 35) experiences with FBL at 4 different levels CHAPTER 1: INTRODUCTION Childhood obesity is a widely recognized national problem (Birch, 2009) with local impacts. In the United States (US), approximately 30% of preschool-aged (3-5 years) children are considered overweight or obese (Ogden et al., 2014). Similar statistics have been observed locally, with counties in Eastern North Carolina (NC) often experiencing higher rates than the rest of the State (North Carolina Pediatric Nutrition and Epidemiology Surveillance System, 2019). Rates of overweight and obesity in young children are alarming because the habits established during the preschool years (3-5 years old) are suggested to impact long-term health status (De Cosmi et al., 2017; Ventura & Worobey 2013; Harris, 2008; Birch, 1999). Preschool children in the US spend the vast majority of their day and consume half or more of their daily dietary intake in preschool (Frisvold & Lumeng, 2011). Thus, for many children the first influence on their health occurs outside of the home in childcare (Swindle et al., 2017). During the preschool years, children are continually learning from their environment and the people they are with (Birch, 1999), placing early childhood teachers in a critical position to promote positive dietary behaviors for children (Davison & Birch, 2001; Ritchie et al., 2005; Wolfenden et al., 2001). Positive health experiences that preschool children have with early childhood teachers can have drastic health implications such as placing them at lower risk for later diseases including obesity, hypertension, type II diabetes, cancer, and cardiovascular disease (Dietz, 1998; Raychaudhuri & Sanyal, 2012). The importance of positive health experiences with healthy foods such as fruits and vegetables (FV) are even higher for children from low-income families who are at an increased risk for childhood obesity than the general population (Kaphingst & Story, 2009; Hughes et al., 2010). Furthermore, children from low- income households spend 30+ hours a week in childcare (Burstein & Layzer, 2007) where they consume between 50-75% of their daily dietary intake (Frisvold & Lumeng, 2011). Thus, preschool is an ideal setting, and teachers an important partner, to expose children to positive experiences with healthy foods (Burstein & Layzer, 2007; Li et al., 2010). Exposing children to healthy foods occurs any time the food is presented to children in any form (mealtime, science experiment, book, photographs etc.) Head Start (HS) is a federally funded preschool program that serves low-income children and their families in the US (Office of Head Start, 2016). Each year, HS strives to meet the emotional, social, health, nutritional and psychological needs of the one million low-income preschoolers (3–5-year-old’s) they serve nationwide (Office of Head Start, 2016). HS began in in 1965 on the basis of the “war against poverty” and is housed under the US Department of Health and Human Services (Currie & Thomas, 1995). To be qualified for HS, a family’s household income must be less than 100% of the federal poverty level that is determined by number of people living in a household (Office of Head Start, 2016). HS’s central goals include preparing children for kindergarten through education, health, and social services (Office of Head Start, 2016). To address school readiness concerns, HS’s Early Learning Outcomes Framework (ELOF) provides an overview of the skills, behaviors and knowledge that programs should teach children prior to kindergarten. The framework is organized into five elements: domains, sub-domains, goals, developmental progress, and indicators. Each element is informed by comprehensive bodies of research in the early childhood development field. The domains are broad areas of early learning and development that HS considers essential for kindergarten readiness. In total, there are five domains: 1) Approaches to Learning; 2) Social and Emotional Development; 3) Language and Literacy; 4) Cognition, and 5) Perceptual, Motor, and Physical Development (Head Start Early Learning Outcomes Framework, 2020). While the services and education that HS provides are essential to establish positive academic and health behaviors in young preschool-age children, approximately one in every three children in HS are categorized as overweight or obese with a BMI at or above 85th percentile (Hughes et al., 2010). One explanation is that fruit and vegetable (FV) consumption among preschool aged children is lower than the daily recommended five servings (Swindle et al., 2018). However, children from low-income families may have even lower access to healthy foods, such as FV, and consume more refined, highly processed, calorically dense, foods (Swindle et al., 2018). To combat childhood obesity and poor eating habits, classroom-based methods that increase familiarity and create positive experiences with healthy foods can result in increased willingness to taste healthy foods and improve overall dietary intake among preschoolers (Batties-Fries et al., 2017; Dazeley, Houston-Price & Hill, 2012; Perez-Rodrigo & Aranceta, 2001). Classroom-based methods to improve children’s willingness to try and consume healthy foods include incorporating healthy foods into the mealtime (Bayles et al., 2020; Whiteside-Mansell et al., 2019), creating a positive mealtime environment (Dev et al., 2019), or exposing children to healthy foods outside the mealtime through activities such as 2 gardening, books, and science experiments (Cooke, 2007; Sullivan & Birch, 1990). While many teachers consider mealtime as an opportune time to talk about food because foods are naturally present, some teachers find mealtime environments chaotic and are often preoccupied with other tasks, making nutrition education difficult (Dev et al., 2017). For this reason, exposing children to healthy foods outside the mealtime through activities such as gardening, science experiments, and other hands-on experiences has been suggested to be the most effective way to increase children’s’ exposures, or experiences with, healthy foods (Contento et al., 1995). Using food as a teaching tool in the classroom, outside of the mealtime environment, has been termed food-based learning (FBL) (Carraway-Stage et al., 2015). When children are allowed to explore FV outside the mealtime, the development of children’s healthy eating behaviors are supported by exposing children to healthy foods and expanding their food preferences and consumption (Bayles et al., 2020; Johnson et al., 2019; Sandell et al., 2016; Whiteside-Mansell et al., 2019). For example, over the course of a week a teacher could read a book about how carrots grow, design a classroom experiment to watch carrots grow roots in water, use a ruler to measure and document how long a carrot is and then have children engage their senses by touching, feeling, smelling, listening to and tasting carrots. These FBL activities would provide children with continuous exposures to carrots using a multitude of learning domains such as science, mathematics, literacy and language outside of the mealtime environment. While FBL is considered the most effective way to increase children’s preference and consumption of vegetables (Contento et al., 1995; Whiteside-Mansell, Swindle, Davenport, 2019), teachers face barriers when implementing FBL in the classroom such as time and competing priorities, making the integration of FBL with other learning domains a promising solution (Carraway-Stage et al., 2014). While integrating FBL with other learning domains has been cited as a method to overcome teacher barriers, only two studies have examined dietary outcomes of FBL but neither study examined FBL’s impact on academic outcomes (e.g., science, mathematics, literacy) (Bayles et al., 2020; Johnson et al., 2019), leaving a critical gap in the understanding of its potential. Additionally, both aforementioned studies employed quantitative methodologies, thus lacking qualitative perspective. Furthermore, FBL was previously a requirement in HS, but has recently been changed from a requirement to a suggestion. 3 Therefore, to the authors’ knowledge no studies have since explored how FBL is currently being integrated with other learning domains, such as cognition or language, in the HS classroom. The cognition learning domain, which encompasses preschool scientific reasoning, is, in particular, a key area for integration as engaging children in early science learning is indicative of future academic achievements (Cabell et al., 2013; Straits, 2018). Science learning provides a natural foundation for hands-on, science learning related to living things (e.g., humans, animals, and plants), their relationships with one another, and how to care for our bodies and other living things (e.g., healthy eating, animal/plant life cycle). The science environment has the ability to improve children’s language, literacy, and mathematics skills (Gelman et al., 2009), while also serving as a platform to expose children to healthy foods through experimentation and exploration (Bayles et al., 2020). Additionally, as preschoolers cognitively mature, the skills developed through high-quality science learning will enable them to use acquired science knowledge to make positive choices about their personal health and living things in their environment (Nayfeld, Brenneman, Gelman, 2011; Sigman-Grant et al., 2014; Carruth et al., 2000). Further exploration of the characteristics and use of FBL (e.g., quality of activities), and their integration with other learning domains, such as cognition and language, will move the field of nutrition forward by gaining understanding of the critical components of effective FBL that will reduce teacher barriers, improve teacher practices, and promote positive academic and health outcomes for children. Statement of Problem The preschool years (3 to 5 years old) are critical to establish healthy dietary behaviors that carry children through adulthood; however, HS teachers frequently face barriers limiting their ability to expose children to healthy foods in the classroom (e.g., limited time, limited resources, lack of support, conflicting priorities). Integrating FBL into other school readiness domains, such as science, has been cited as a method to address these barriers and promote future academic success. To fill this gap, this study will investigate teachers’ experiences with the current general use (post policy change removing FBL as a requirement) and integration of FBL with other learning domains, such as cognition and language, in HS classrooms across NC using a qualitative approach. Statement of Purpose 4 In this study, NC HS teachers’ experiences using and integrating FBL in their classroom will be studied. A qualitative method design will be used to guide the study. The in-depth, semi-structured interviews will explore the phenomenology, or common lived experience, of HS teachers’ use and integration of FBL in their classrooms. The purpose of this phenomenological study is to explore HS teachers’ experience using food as a teaching tool in the classroom and integrating food into other learning domains, such as cognition and language, in the classroom. A qualitative design will be utilized for the present study. Qualitative research provides detailed perspectives of participants and is told from their viewpoint. Phenomenology allows for understanding of the what and how of teachers’ experiences (Bowen, 2008; Moustakas, 1994; Creswell, 2012; Creswell, 2013). References Battjes-Fries, M.C.E., Haveman-Nies, A., Zeinstra, G.G., van Dongen, E.J.I., Meester, H.J., van den Top- Pullen, R., van’t Veer, P., & de Graaf, K. (2017). 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Cabell, S.Q., DeCoster, J., LoCasale-Crouch, J., Hamre, B.K., & Pianta, R.C. (2013). Variation in the effectiveness of instructional interactions across preschool classroom settings and learning activities. Early Childhood Research Quarterly, 28(4) 820-830. 5 Carraway-Stage, V., Henson, S.R., Dipper, A., Spangler, H., Ash, S.L., & Goodell, L.S. (2014). Understanding the State of Nutrition Education in the Head Start Classroom: A Qualitative Approach. American Journal of Health Education, 45, 52-62. Carraway-Stage, V., Hovland, J., Ochab, C., Diaz, S., & Duffrin, M.W. (2015). Food-based Science Curriculum Yields Gains in Nutrition Knowledge. Journal of School Health, 85, 231-240.DOI: 10.1111/josh.12243 Carruth, B.R., Skinner, J.D., Moran, J.D., Coletta, F. (2000). Preschoolers food product choices at a simulated point of purchase and mother’s consumer practices. J Nutr Educ. 32:146-151. Contento IR, Balch GI, Bronner YL et al. 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Barriers to obesity prevention in Head Start. Health Affairs, 29(3), 454-461. Johnson, S.L., Ryan, S.M., Kroehl, M., Moding, K.J., Boles, R.E., & Bellows, L.L. (2019). A longitudinal intervention to improve young children’s liking and consumption of new foods: Findings from the Colorado LEAP study. International Journal of Behavioral Nutrition and Physical Activity, 16, 49. Kaphingst, K.M., Story, M. (2009). Childcare as an untapped setting for obesity prevention: state child care licensing regulations related to nutrition, physical activity, and media use for preschool aged children in the United States. Preventative Chronic Disease, 6(1), A11. Li, J., Hooker, N.H. (2010). Childhood obesity and schools: evidence from the national survey of children’s health. J Sch Health, 80(2):96-103. Nayfeld, I., Brenneman, K., & Gelman, R. (2011). Science in the classroom: Finding a balance between autonomous exploration and teacher-led instruction in preschool settings. Early Education and Development, 22, 970–988. doi:10.1080/10409289. 2010.507496. Office of Head Start, Administration for Children and Families, US Department of Health and Human Services. http://www.acf.hhs.gov/programs/ohs/about. Accessed April 21, 2020. Ogden, C., Carroll, M.D., & Lawman, H.G. (2016). Trends in Obesity Prevalence Among Children and Adolescents in the United States, 1988-1994 Through 2013-2014. JAMA, 315(21), 2292-2299. Perez-Rodrigo & Aranceta (2001). School-based nutrition education: lessons learned and new perspectives. Public Health Nutrition, 4(1A), 131-139. Raychaudhuri, M., & Sanyal, D. (2012). Childhood obesity: Determinants, evaluation, and prevention. Indian Journal of Endocrinology and Metabolism, 16(Suppl 2), S192. 7 Ritchie, L.D., Welk, G., Styne, D., Gerstein, D.E., & Crawford, P.B. (2005). Family environment and pediatric overweight: What is a parent to do? Journal of the American Dietetic Association, 105(5 Suppl), s70-90. Sandell, M., Mikkelsen, B.E., Lyytikainen, A., Ojansivu, P., Hoppu, U., Hillgren, A., & Lagstrom, H. (2016). Future for Food Education of Children. Futures, 83, 15-23. Sigman-Grant et al., 2014 Straits, W. (2018). A Head Start on Life Science: Encouraging a Sense of Wonder. National Science Teachers Association Press. Sullivan, S.A., Birch, L.L. (1990). Pass the Sugar, Pass the Salt: Experience Dictates Preference. Dev Psychol. 26:546-551. Swindle, T. & Phelps, J. (2018). How Does Context Relate to Nutrition Promotion and Mealtime Practice in Early Care and Education Settings? A Qualitative Exploration. Academy of Nutrition & Dietetics, 118(11), 2081-2093. Swindle, T., Rutledge, J.M., Dix, B., & Whiteside-Mansell, L. (2017). Table Talk: Development of an observational tool to assess verbal feeding communication in early care and education settings. Public Health Nutrition, 20(16), 2869-2877. Ventura, A.K., & Worobey, J. (2013). Early influences on the development of food preferences. Current Biology, 23(9), R401-R8. Whiteside-Mansell, L., Swindle, T., Davenport, K. (2019). Evaluation of “Together, We Inspire Smart Eating” (WISE) nutrition intervention for young children: assessment of fruit and vegetable consumption with parent reports and measurements of skin carotenoids as biomarkers. J Hunger Environ Nutr. doi: 10.1080/19320248.2019.1652127 Wolfenden, I., Wyse, R.J., Britton, B.I., Campbell, K.J., Hodder, R.K., Stacey, F.G., McElduff, P., James, E.L. (2012). Interventions for increasing fruit and vegetable consumption in children aged 5 years and under. Cochrane Database Systematic Reviews, 11, CD008552. 8 CHAPTER 2: LITERATURE REVIEW Dietary Quality Among Preschool Children in the United States Preschool aged children’s dietary consumption is of concern with between 25-30% of children not consuming vegetables daily (Johnson, 2016). Additionally, vegetables that are commonly consumed are not vegetables rich in nutrient sources, such as dark leafy greens, rather potatoes (Fox et al., 2010). In fact, children’s consumption of vegetables throughout the first five years of life are lowest during the preschool years (Grimm et al., 2014). Children from low-income families are even more vulnerable to have low FV intake (Darmon & Drewnowski, 2008; Hughes et al., 2010). Low FV intake in childhood is correlated with increased risk for disease later in life (Boeing et al., 2012). The preschool years are therefore critical for establishing positive health behaviors because although children do not decide what food is available to them, they are beginning to learn how to make their own health decisions (Gripshover et al., 2013; Sigman-Grant et al., 2014) and recognize what constitutes as healthy choices (Sigman-Grant et al., 2014; Carruth et al., 2000; Lanigan et al., 2011). These health experiences matter as the habits children establish at this age will impact their health status into adulthood (Cashdan, 1994; Dwyer, Suitor & Hendricks, 2004; Skinner et al., 2002). Determinants of Fruit and Vegetable Consumption Biological Many factors, at a variety of different levels, including interpersonal, intrapersonal and environmental, interact to impact vegetable intake in young children (Figure 1) (Johnson, 2016). Children begin developing food preferences as early as in utero and continue developing experiences and preferences during breast feeding, long before introduction to solid food (Beauchamp & Mennella, 2009). Long-term breast feeding has been suggested to increase FV consumption later in infancy (Deming, Briefel & Reidy, 2014; de Lauzon-Guillain et al., 2013). As children begin to consume food, both timing and variety can impact their acceptance; however, future research is needed to understand optimal conditions for FV acceptance in young infants and toddlers (Coulthard, Harris & Emmet, 2010; Shim, Kim & Mathai, 2011; Nicklaus, 2009). Regardless of these early experiences, once children reach preschool years (3-5 years old), encouraging them to try new foods can be difficult for parents and early childhood teachers because neophobia, or “fear of the new”, is heightened during preschool years (Dovey et al., 2008). At this age, children prefer and consume more energy dense foods that tend to be sweet or salty (Cooke, Wardle & Gibson, 2003). When encouraging preschool children to consume FV, children have a natural predisposition to favor fruits since they have natural sweetness (Birch, 1999), compared to vegetables that often have a bitter taste profile (Skinner et al., 1999; Nickalus et al., 2005). Relational - Parents In addition to biological development of preferences, children’s’ relationship with adults, albeit parents or early childhood teachers, also influence their FV consumption. Since young children do not dictate what foods are available to them at school and home, adults serve as role models for eating behaviors that children emulate (Larson & Story, 2009). Prior research suggests that parents who model healthy eating themselves can improve their children’s’ consumption of FV (Galloway et al., 2005; Larson & Story, 2009; Busick et al., 2008). Having an adult role model helps children feel supported in their learning of new experiences (Bustamante et al., 2017). Prior research also suggests that the presence of a trusted adult role model who enthusiastically tries a new food, improves the chance that the child will also try it (Harper & Sanders, 1975). Parents and caregivers may become frustrated with the preschool children’s neophobic behaviors (e.g. continual refusal of food) and respond by offering healthy foods less often and/or use pressuring strategies to try and coerce the child to consume vegetables which may negatively impact FV consumption (Galloway et al.2005; Kaar, Buti & Johnson, 2014; Gregory, Paxton & Brozovic, 2011). 10 Figure 1. 2-Stage model of the development of children’s vegetable preferences and consumption as presented by Johnson (2016). Relational – Early Childhood Teachers Effective role modeling and strategies related to FBL are equally important for early childhood teachers as children consume the majority of their daily meals/snacks at preschool (Frisvold & Lumeng, 2011). At HS, meals are served “family style”, foods are passed around the table and children serve themselves with guidance from teachers (Office of Head Start, 2014). Per HS policy, children and teachers sit at the same table and eat the same foods in an effort to promote positive adult role modeling and increase children’s vegetable intake (Kharofa et al., 2016; Blaine et al., 2015). A prior qualitative study seeking to understand HS teachers’ attitudes towards mealtimes and portion sizes found that teachers modeled healthy eating behaviors and encouraged children to try new foods by explaining how much they liked the healthy food (Goodell et al., 2010). These strategies, such as enthusiastic teacher modeling and verbal praise, have been shown to increase children’s food acceptance (Hendy & Raudenbush, 2000). However, other studies have found less beneficial food-related practices in the HS classroom. For example, a longitudinal study consisting of 75 childcare providers found that teachers often lacked knowledge about healthy practices regarding foods in the classroom, that led teachers to pressure 11 children to eat while failing to role model properly (Lanigan, 2011). Another study by Swindle and colleagues (2017) identified 3 factors that impacted teachers’ food-related behaviors in the classroom: Rules and Routines, Leave a Health Legacy, and Food Insecurity. Early childhood teacher’s prior history with food experiences (e.g. how meals were done as they were growing up) dictated the rules and routines that they tried to instill in their students during mealtime. Teachers desired to see children establish better dietary habits than they did as children inspiring them to “Leave a health legacy” through the food-related experiences they provided. Lastly, teachers worried about children’s food security, often encouraging children to eat when not hungry and/or offering them increased amounts of food due to perceived food insecurity in the child’s home. Other studies have also indicated that HS teachers’ fears of child food insecurity impacts their behaviors during mealtime (Sigman-Grant et al, 2008; Gooze, 2012). One study found that 56% of ECE knew they had children in their classes who were hungry, leading them to give them extra food while at school (Sigman-Grant et al, 2008) or “clean their plate” (Gooze 2012). Environmental Teachers’ fears of children’s food insecurity are not unmerited as children from low-income households may have decreased access to food in their homes (Gooze 2012). It has been estimated that one-third of children entering HS come food insecure households (Nord et al., 2010). In such households, there may be decreased access specifically to vegetables since vegetables may be perceived as costly and require preparation techniques that low-income families may be unfamiliar with (Cullen et al., 2003). However, although children are not guaranteed access to vegetables in the home, they do have guaranteed access to FV at school. As a federally funded program, HS centers are required to follow federal performance standards and use funds from the US Department of Agriculture (USDA) to purchase meals and snacks via the Child and Adult Care food Program (CACFP). Provded centers follow CACFP nutrition guidelines for nutrients and portion sizes, such as the provision of vegetables at meals and snacks, CACFP will reimburse programs for food (Child and Adult Care Food Program, 2017). Impacting children’s health behaviors regarding vegetable preference and consumption is vital so that when healthy foods, such as vegetables, are available in the school environment, they are accepted and consumed by preschool children (Bayles et al., 2020). Methods for Improving Vegetable Intake 12 Repeated Exposure There is a saying that children “like what they know and eat what they like” (Cooke, 2007). While this statement is true, one way to get children to “know” new foods is through repeated exposure (Sullivan & Birch, 1990). Repeated exposure consists of providing children with the opportunity to experience healthful foods, multiple times, in multiple different forms, to increase familiarity of a food. Although other methods for improving vegetable consumption in children have been studied such as flavor-flavor learning (Heath, Houston-Price, & Kennedy, 2011), flavor-nutrient learning, (Heath, Houston-Price, & Kennedy, 2011), manipulation of portion size (Krall & Hetherington, 2015), and rewards (Heath, Houston- Price, & Kennedy, 2011; Krall & Hetherington, 2015), repeated exposure is suggested to be the most effective method for impacting both preference and consumption is repeated exposure (Sullivan & Birch, 1990). Specifically, children need 8-15 exposures to increase liking of a new food (Sullivan & Birch, 1990; Johnson et al., 2007). Further, it is recommended that exposures should occur both inside and outside the mealtime environment (Whiteside-Mansell, Swindle, Davenport, 2019). Mealtime Children are exposed to healthy foods during mealtimes. Teachers can create a positive mealtime environment by role modeling healthy eating (Hendy & Raundebush, 2000), encouraging children to explore food using their five senses (Hoppu et al., 2015), and providing verbal praise (Cooke et al., 2011). For example, teachers should positively describe their experience eating healthy foods and encourage children to share their thoughts with each other as well (Dev et al., 2019). Teachers can also improve children’s consumption of healthful foods by engaging in responsive feeding that encourages children’s innate self-regulation (Blaine et al., 2015). These feeding practices encourage children to have autonomy in their food experiences and encourage consumption of healthful foods (Dev et al., 2019). While these feeding practices are ideal to impact FV consumption in preschool children, teachers are often distracted during mealtimes (Ramsay et al., 2010; Lumeng et al., 2008; Dev et al., 2017), decreasing the quality of feeding practices and positive food experiences (Gable et al., 2001; Ramsay et al., 2010). Additionally, food exposures during the mealtime are often chaotic and children may feel heightened pressure to taste the food, rather than explore it with their other senses, which is often even discouraged during mealtimes as “poor table manners” (Carruth & Skinner, 2000; Orrell-Valente et al., 13 2007). Lastly, teachers have been observed applying coercion and pressure to encourage children to eat healthy foods. These practices generally result in the opposite behavior and have been associated with negative child health outcomes such as childhood obesity (Dev et al., 2013; Ventura & Birch, 2008). Outside the Mealtime For these reasons hands-on learning, outside of the mealtime, that engages children’s’ natural curiosity, is an ideal way to increase children’s’ exposure to healthful foods. When children are encouraged to explore foods through hands-on learning, the development of children’s healthy eating behaviors are supported by exposing them to unfamiliar foods and ultimately expanding their food preferences (Sandell et al., 2016). Classroom-based methods that increase familiarity and create positive experiences with healthy foods can result in increased willingness to taste healthy foods and overall improved dietary intake among preschoolers (Batties-Fries et al., 2017; Perez-Rodrigo & Aranceta, 2001). Specifically, FBL or the use of food as a teaching tool in the classroom (Carraway-Stage et al., 2015), has been theorized as an effective method for improving children’s eating behaviors through positive exposures with healthy foods (Bayles et al., 2020; Johnson et al., 2019; Swindle et al 2017). HS has identified FBL as a common educational approach. Prior research has cited cooking, ranging from basic food preparation (e.g., ants on a log) to actual cooking (e.g., soup), (Hersh et al., 2014; Carraway-Stage et al., 2014; Dev et al., 2018) and gardening (Heim, Stang & Ireland, 2009; Robsinon-O’brien et al., 2009) as common FBL strategies. Additionally, by garnering hands-on learning outside of the mealtime, children are free to engage in multisensory learning without the stress of needing to taste the vegetable (Nekitsing et al., 2018). The “What” and “Why” of Food-based Learning Benefits of FBL The benefits of FBL include providing exposure to healthy foods in a less stressful environment (Nekitsing et al., 2018) while encouraging children to use their five senses to explore foods (Whiteside- Mansell & Swindle, 2018) which may not be encouraged during mealtime (Carruth & Skinner, 2000; Orell- Valente et al., 2007). Integrating FBL with other learning domains such as cognition and language is a unique opportunity for preschool teachers to engage children across multiple school readiness domains while exposing children to new foods and nutrition education (Bayles et al., 2020; Johnson et al., 2019). 14 Additionally, integrating FBL with learning domains has been cited as a method to reduce identified barriers that HS teachers face, such as time constraints and competing priorities, which often impact the quantity and quality of nutrition education provided (Carraway-Stage et al., 2014). Integrating FBL with these school readiness domains as a way to teach foundational academic concepts has been cited by HS teachers as a way to reduce such barriers (Carraway-Stage et al., 2014; Dev et al., 2017). Science in particular is an ideal subject to integrate with FBL since children’s attitudes about science and their confidence in their ability to “do” science is established at an early age (Early STEM Matters, 2018). With HS’s mission of kindergarten readiness, and research suggesting early science learning can be indicative of future academic success (Duncan et al., 2007; Straits, 2018), the integration of science and FBL is promising. Additionally, FBL has the potential for possible co-benefits such as reinforcing young children’s fine/gross motor skills (Bellows, Davies, Anderson & Kennedy, 2013; Story et al., 2008) and promoting early literacy (Droog, Buijzen, & Valkenburg, 2014; Heath, Houston-Price, Kennedy, 2011). Prior FBL Interventions & Outcomes Prior interventions that expose preschool children to healthy foods in the classroom through the use and integration of FBL have shown promise in increasing FV consumption (Bayles et al., 2020; Whiteside-Mansell et al., 2019) and impacting the environment (Whiteside-Mansell, Swindle, Davenport, 2019). A few of these studies are described below. Integrative FBL intervention, Together, We Inspire Smart Eating (WISE) is an 8-month nutrition education curriculum designed to increase children’s exposure to FV through weekly hands-on exposures using foods that are readily available in the school and home environments (Whiteside Mansell., 2019). The WISE curriculum encourages children to use their senses to explore FV and includes recipes that children can help prepare. The curriculum was created to be integrated during regular classroom activities (e.g., circle time). An example of an integrative FBL WISE activity is creating skewers using spinach, tomatoes, and mozzarella cheese to create predetermined patterns, a common mathematical concept. Outcomes of the WISE study indicated a significant increase in vegetable consumption among children in the intervention (M=3.44, SD=1.23) at post-test as reported by parent-reported food frequency questionnaires. Additionally, the study used resonance Raman spectroscopy (RRS) which measures the levels of carotenoids in the blood, indicative of FV consumption, to measure children’s FV consumption 15 (Ermakov, 2001). Children in the intervention had significantly higher RRS scores at post-test compared to baseline (t(263)=-.08 p<.039) (Whiteside Mansell, 2019). Bayles et al. (2020) also observed positive outcomes for FV consumption as a result of hands-on FBL activities in preschool classrooms. Their intervention consisted of 7 hands-on Science, Technology, Engineering, Arts and Mathematics (STEAM) FBL activities implemented over the course of 4 months. The intervention featured 9 target vegetables (broccoli, cauliflower, sweet potato, cucumber, tomato, carrot and pea pod) chosen based on prior exposure as determined by parent report, and/or the potential of the food to influence skin carotenoid status. The activities were 15-20 minutes and included circle time (group discussion) and a hands-on activity integrated with a science, mathematics, and/or language concept. Children were given the opportunity to taste the featured target vegetable at the end of each lesson and were encouraged to continue to explore the food with their other senses. An example integrative FBL from this program includes exploring chlorophyll that makes broccoli green by steaming broccoli. Outcomes of the intervention revealed children in the intervention group consumed significantly more carotenoid rich FV than the control (F 1,77=3.98; p=.02, r=.10) (Bayles et al., 2020). FBL Best Practices The following section outlines best practices for using FBL in the preschool classroom. Previous papers have attempted to discuss FBL best practices but have mainly emphasized exploring food with the senses (Netkitsing et al., 2018) or the mealtime environment (Dev et al., 2019). No papers to the authors knowledge have specifically described the full range of best practices for FBL; this is an area for future study. Incorporate Healthy Foods Engaging children in integrated FBL has the potential to prepare children for kindergarten, while also promoting healthy consumption of FV (Whiteside-Mansell & Swindle, 2018; Johnson et al., 2019; Shilts, Lamp, Horowitz & Townsend, 2009). When providing food experiences in the classroom, the inclusion of FV is ideal, compared to other foods, because preschool children do not consume the recommended amount of daily FV (Grimm et al., 2014; Vernarelli et al., 2011). Instead, preschool children consume high-calorie food with little nutritional benefits such as sugary foods and snacks (Lorson, Melgar-Quinonez & Taylor, 2009). FV provided should also be culturally appropriate to the demographics 16 of preschool children (Office of Head Start, 2015). Additionally, prior research suggests that teachers use unhealthy foods during activities in the classroom, further emphasizing the need to incorporate healthy foods instead (Swindle & Phelps, 2018). Multiple Exposures Providing children with multiple exposures in an environment where children are not pressured to eat the food, such as outside the mealtime, are necessary to improve liking and consumption of FV (Johnson et al., 2007; Sullivan & Birch, 1990). Prior research suggest 8-15 exposures are needed for a new food (Johnson et al., 2007; Sullivan & Birch, 1990). However, there is limited research for the necessary exposures for a familiar vegetable that a child has already had exposures to. In a prior study, it was hypothesized that improving children’s’ liking for a new vegetable may be easier since children do not have a predisposed disliking (Birch, 1998). For this reason, teachers should not be discouraged after children reject a given vegetable since it takes persistence and repeated exposure to overcome these neophobic barriers (Carruth & Skinner, 2000; Maier et al., 2007). Teachers’ dedication to providing continued exposures to healthy foods in the school environment is especially important since parents may be less persistent in offering previously rejected foods at home (Carruth & Skinner, 2000; Maier et al., 2007). Engage the Senses Instead of pressuring children to eat the food which has been shown to have negative outcomes (Osborne & Forestell, 2012), teachers should encourage children to explore the food with their other senses (Hoppu et al., 2015). This can lead to future acceptance of that food (Nekitsing et al., 2018). Prior interventions aimed at multisensory FBL experiences, have observed increases in children’s FV acceptance (Dazeley & Houston-Price, 2015; Hoppu et al., 2015). Additionally, prior interventions specifically targeting visual exposures to FV via books and posters have been observed to increase preference and consumption of FV (Heath, Houston-Price & Kennedy, 2011; Osborne & Forestell, 2012). While teachers encourage children to explore foods with their senses, tasting should not be over- emphasized. Teachers should avoid using rewards as contingencies to get children to try vegetables (e.g., “You can have a cookie only if you finish your peas”). This feeding practice has been suggested to lower vegetable consumption in children (Blissett, 2011; Kiefner-Burmesiter et al., 2014). Other studies 17 suggest that using bribery and rewards may in the short-term improve consumption, but it will not improve long-term liking of the vegetable (Birch, Birch, Marlin & Kramer, 1982; Birch, Marlin, & Rotter, 1984). Do Not “Play” with Food One-third of children entering HS come from food insecure households (Nord et al., 2010). Teachers are often aware of this fact and may have concerns about using food for learning activities (Sigman-Grant et al, 2008; Gooze, 2012). For this reason, food presented in the classroom as a learning tool, such as during FBL, should always be available to be consumed after the learning activity has ended (Office of Head Start, 2015). For this reason, using food in the sensory table and/or food materials as construction to the point that they are no longer suitable for consumption should be avoided (Office of Head Start, 2015). Role Model and Respect On the other hand, when food is provided for tastings, teachers should respect children’s decision about whether or not they desire to eat the food. (McBride & Dev, 2014). Encouraging children to eat food when they have stated they are no longer hungry teaches children to ignore their innate internal cues of hunger and fullness (McBride & Dev, 2014). Teachers can be good role models of acknowledging personal signs of hunger and fullness by verbalizing their feelings when with children (e.g., “My tummy is full now, I am going to stop eating now!”) (Dev et al., 2019). Family Engagement Additionally, teachers should look for ways to engage families. Parents who model healthy eating themselves can improve their children’s’ consumption of FV (Galloway et al., 2005; Larson & Story, 2009; Busick et al., 2008). Prior research suggests that while children do not purchase the food available in the home, they can advocate for change based on their experiences at school (e.g., “We had carrots at school today, they were yummy, can we get carrots from the store?”) (Stage et al., 2020). Families and the community help to bridge the gap between school and the outside world. Their engagement promotes learning and encourages children to make discoveries and healthy choices on their own (Straits, 2018). Barriers to FBL Resources 18 Providing preschool children with the proper classroom environment is key to promote exploration. Classrooms area should include materials that children can independently explore (Harper- Whalen & Spiegle-Mariska, 1991; Kostelnik et al., 2004). It is recommended to have FBL materials handy such as measuring cups, pots/pans, cutting boards, strainers (Tu, 2006). However, it is important to note that FBL can be integrated into any learning domain (e.g. mathematics, literacy, science) and so materials are not exclusive. Prior research suggests that teachers do not feel they have adequate resources, both material and financial, for FBL which limit their ability to use food in the classroom as a teaching tool (Carraway-Stage et al., 2014). Stage et al. (2014) also describe that teachers faced barriers such as limited funding as a reflection of low priority for FBL in the classroom and cited funding for nutrition-related activities as their area of highest need. Other studies have also found that funding is a significant barrier to health education (Gupta et al., 2005; Hughes et al., 2010). Influence of Policy Engaging children in food experiences, during mealtimes and outside of mealtimes, are subject to HS policy. HS programs are regulated by federal performance standards (Office of Head Start, 2015). These standards outline expectations for children’s development cognitively, socially and physically. Regarding nutrition-related policies, the Performance Standards (1304.23) outline practices for appropriate child feeding practices, nutrition education, and provision of meals and snacks (Office of Head Start, 2015). To provide healthy foods to their children, HS programs participate in CACFP or the National School Breakfast Program (Office of Head Start, 2015). While federal performance standards require HS programs to use FBL in the classroom help young children develop positive eating habits (Briley & Mcallaster, 2011; Lumeng, 2008; Maher, 2008), research suggests that such policies in the food environment have led to excessive administration burden on teachers and staff as well as general uncertainty (Carraway-Stage et al., 2014; Kaphingst & Story, 2009; Peterson et al., 2017). More specifically, the overwhelming number of policies surrounding FBL, and their subsequent lack of clarity, has been suggested to cause confusion for teachers and inhibit the likelihood and quality of FBL in the classroom (Peterson et al., 2017). In one instance, state sanitation policies regarding FBL through cooking in the classroom have been misinterpreted by local centers to prohibit such FBL activities. Other Policies like “no outside food”, intended to prohibit unhealthy food from entering the classroom, have 19 been interpreted to prohibit all food, inhibiting FBL such as taste testing novel FV. These misinterpretations cause infrequent FBL activities and lower teacher efficacy, which hinders food experiences children can have in the classroom and ultimately their long-term dietary quality (Peterson et al., 2017). Other Challenges In addition to challenges regarding food-related policy, HS teachers face other challenges when trying to implement FBL in their classrooms. Prior research suggests teachers may feel they are not well- equipped to teach the subject matter and/or lack professional development (Cotugna & Vickeryn, 2012). Further, time constraints and pressure to complete all necessary materials often left teachers feeling they did not have time for FBL or nutrition education (Stage et al 2014). Therefore, teachers may need assistance in learning to integrate nutrition materials into the daily classroom and kindergarten readiness topics such as Science, Technology, Engineering, and Mathematics (STEM) (Scherr, 2011). The time and means to attend professional development opportunities may be key to overcome these cited barriers (Carraway-Stage et al., 2014). COVID-19 Lastly, the severe acute respiratory syndrome, coronavirus disease (COVID-19), has become a significant barrier to FBL in the preschool classroom. COVID-19 first appeared in Wuhan, China at the end of 2019 (Holshue et al., 2020; Zhu et al., 2021). The highly infectious disease can be transmitted person-to-person and its first recorded case in the US occurred on January 20, 2020 (Harcourt et al., 2020). To date, over 21 million and 578,000 people in the US and NC have contracted COVID-19, respectively (World Health Organization, 2020). Additionally, over the course of a 3-week period in March 2020, more than 16 million people filed for unemployment (Blustein et al., 2020). Beyond the vast economic implications of the disease, in NC, on March 16, 2020 schools state-wide were ordered to closure for the academic year to reduce the COVID-19 spread (Education Week, 2020). The unprecedented closure of schools statewide, including HS preschool centers, have created greater stress for children and families. Low-income children, such as those enrolled in HS, have been disproportionately affected by the closure of childcare centers as many of these children rely heavily on 20 school services for nutritional, physical and mental needs (Masonbrink, 2020). As such, there has been widespread concern for low-income children’s food insecurity (Masonbrink, 2020). Responses to food-insecurity have included increased access to nutrition programs such as Supplemental Nutrition Assistance Program (SNAP), emergency allotments and Pandemic-Electronic Benefit Transfer, grocery vouchers, and “to-go” meals from educational centers. However, it is estimated that only 11% of newly unemployed, low-income families reported access to such “grab-and-go” meals (Ananat, 2020). Prior research in April of 2020 found that 35% of households with children under the age of 18 are now food insecure, which is double the rates found in 2018 (Wozniack, 2020). Academically, it is estimated that COVID-19 closures and changes within the early childhood environment will lead to lower test scores, lower educational attainment, and decreased earning potentials (Psacharopoulos, 2020). As HS centers begin to reopen during the COVID-19 pandemic, new measures such as daily health checks, personal protective equipment, cleaning, sanitizing and disinfecting, and group size and ratio measures have been put into place (Centers for Disease Control, 2020). However, lack of understanding on the incubation and transmission of COVID-19 among young children, as well as the financial strain that implementing all recommended steps for childcare, has made reopening difficult and in some cases impossible. For centers that are reopened, additional concerns about the transmission of COVID-19 via food and/or concerns about food sharing are barriers in the FBL environment (Pressman & Clemmons, 2020). More research is needed to understand both the short and long-term impacts of COVID-19 on childcare centers such as HS and the children and families they serve (Hashikawa er al., 2020). Gaps in Research FBL in the classroom has been theorized as an effective method for improving children’s eating behaviors through positive exposures with healthy foods. However, FBL in the classroom has often been underutilized due to barriers such as time and competing priorities (Carraway-Stage et al., 2014). While integrating FBL with other learning domains has been cited as a method to overcome teacher barriers, only two studies to the authors knowledge have examined this impact (Bayles et al., 2020; Johnson et al., 2019), leaving a critical gap in our understanding of its potential. Science in particular is an ideal subject 21 to integrate with FBL since children’s attitudes about science and their confidence in their ability to “do” science is established at an early age (Early STEM Matters, 2018). Further, prior research suggests that early science learning can be indicative of future academic success (Duncan et al., 2007; Straits, 2018). To date, only three studies have partially described teacher-led FBL in the preschool classroom as reported through broader research questions related to nutrition education (Carraway-Stage et al., 2014; Dev et al., 2018; Swindle & Phelps, 2018). However, these studies were conducted qualitatively and lacked quantitative context. Additionally, to the authors knowledge, none of these studies have explored how FBL is being integrated with other learning domains, such as science. 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J Hunger Environ Nutr. doi: 10.1080/19320248.2019.1652127. 31 Whiteside-Mansell, L., Swindle, T.M. (2018). Together, We Inspire Smart Eating (WISE): Preschool fruit and vegetable consumption. Health Education Research, 34(1), 62-71. World Health Organization. (2020). Coronavirus disease 2019 (COVID-19) situation report— 106. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200505covid-19- sitrep-106.pdf?sfvrsn=47090f63_2. Wozniak, A., Willey, J., Benz, J., Hart, N. (2020). COVID Impact Survey. Chicago, IL: National Opinion Research Center. Zou, H., Yang, Y., Dai, H., Xiong, Y., Wang, J. Q., Lin, L., & Chen, Z. S. (2021). Recent updates in experimental research and clinical evaluation on drugs for COVID-19 treatment. Frontiers in Pharmacology, 12 32 CHAPTER 3: METHODS Research Design This study will explore NC HS teachers’ experiences using and integrating FBL in their classrooms. A qualitative method design will be used to explore the phenomenology, or common lived experiences, that NC teachers have with FBL. Prior to the start of data collection, East Carolina University’s Institutional Review Board will review and approve all study protocols and instruments. The Larger NIH SEPA Study The present study is a part of a larger needs assessment study being conducted at the state-level to assess the specific needs, assets, and resources of partner HS programs to inform the development of teacher professional development resources for the Preschool Education in Applied Science (PEAS) Institute for Early Childhood Teachers. PEAS is a five-year grant funded by a National Institutes of Health (NIH) National Institute of General Medical Sciences (NIGMS) Science Education Partnership Award (SEPA). The overall aim of PEAS is to create a teacher professional development intervention that aims to (1) build teachers’ science teaching efficacy and pedagogical knowledge and skills; and (2) improve children’s science knowledge, development of scientific language, and dietary quality. The needs assessment study at large will help to provide context for program needs, inform program and behavioral theories that will guide curriculum development, identify existing resources and infrastructure in HS across the state and identify key stakeholders and gain momentum for intervention, evaluation, and sustainability. The proposed study will represent a subset of the larger needs assessment data. Subject Population and Eligibility Eligible study participants will be current employees of a HS-funded organization in NC. All participants must be 18 years of age or older and currently serving in the role of a Teacher (Lead or Assistant). Recruitment Teachers will be recruited from HS organizations throughout the state of NC. To recruit teachers, researchers will use a comprehensive list of HS funded organizations and their affiliated centers as the sampling frame (see Figure 3). The research team will contact all organizations to ensure representation by location and organization type. There are 354 centers within 52 funded HS organizations in NC (Head Start NC, 2021). Researchers will contact the education manager of each HS grantee via phone or email to obtain permission prior to communicating with HS teachers (Appendix A). HS Program Directors may also be contacted and asked to post details about the study on their internal webpage and/or Facebook page (Appendix B). However, HS Directors will be unaware of which individuals in their organization ultimately volunteer to participate in the study. Once permission is obtained, HS Teachers within each organization will be recruited by email (Appendix C). Teachers who agree to participate will provide electronic consent (Appendix D) and complete a brief demographic questionnaire online. At completion of the survey, teachers will be asked if they are interested in scheduling an individual interview with the research team to further discuss their experiences with food in the classroom. Interviews will only be conducted with teachers who have expressed interest in participating. Researchers will confirm completion of the survey and consent prior to conducting the interview. Using the recruitment technique of snowballing, participating teachers will be asked to recommend and/or forward information to other potential study participants (Valerio, 2016). The estimated sample size is approximately 30 or until saturation is reached (Bowen, 2008). A minimum sample size of 10 is considered appropriate for qualitative research (Creswell, 2013). Saturation occurs when collection of new data does not yield novel information about the phenomenon being studied (Bowen, 2008). 34 Figure 2. Head Start Grantees Across North Carolina Data Collection and Tools Interviews were chosen as the ideal form of data collection because they will comfortably engage HS teachers to share their personal experiences in their classroom. The interview guide will be designed to address the primary research questions using an iterative process which is a non-linear, reflexive process that consists of multiple rounds of revisiting data and collection materials to develop insight and meaning (Srivastava & Hopwood, 2009). Questions will be developed in collaboration with an experienced research team consisting of three Nutrition Science faculty/Registered Dietitians and three Nutrition Science graduate students who are informed by personal experience and observation of the problem in the field. Multiple revisions of the guide, led through group discussions, will be completed to prevent leading questions and to keep the guide focused on the subject matter. The interview guide will also be piloted by at least three preschool teachers prior to data collection. If a recruited teacher is currently employed by an NC-based HS program, this individual will not be considered part of the official sample size. Overall, the interview guide will be designed to include major questions intended to facilitate open ended discussion, in addition to specific probes to clarify participant responses and gain depth on interview topics. The interview guide examines teachers’ current classroom practices related to the use and integration of FBL in the classroom (Table 1). As the interview guide progresses, questions become 35 more focused to examine teachers’ opinions and motivations toward teaching science and integrating food experiences with preschool-age children, as well as teachers’ perception of needed changes (Appendix F). Since the proposed study is a part of a larger study, interview questions that will be analyzed for the present study pertain only to FBL and the integration of FBL into other learning domains (e.g., science). All interviews will be conducted over the phone. The interviews will be recorded using the Rev App call recorder using university-owned electronic devices (e.g., iPad). Rev will also be used to transcribe audio recordings verbatim for data analysis. Findings from interviews will be analyzed to identify key themes regarding food experiences in the science learning and classroom environment (Bound, 2011). Table 1. Teacher Semi-Structured Qualitative Interview Questions Main Interview Questions (Pilot Tested) Can you describe some lessons or activities that you have used in the last year, prior to COVID-19, to teach children about science using food? Remember, nutrition is a science too so be sure to think about all the science topics you teach with food. * Can you list things that have helped or supported you when you have incorporated food experiences in your classroom prior to COVID-19? This can be people, places or things. * Can you list some challenges you faced when incorporating food experiences in your classroom prior to COVID-19? This can be people, places, or things. * In your opinion, what are some reasons you should use food experiences to teach science to preschool children? * Additionally, cognitive interviews will be held with at least two HS teachers who will be asked to provide feedback. Cognitive interviews are a set of techniques that allow researchers to analyze how respondents understand survey/interview questions and are considered best practice in research studies (Ryan, Gannon-Slater & Culbertson, 2012; Carbone, Campbell & Honess-Morreale, 2002) Anticipated revisions include expanding or revising response options or wording. Data Collector Training Data collectors will complete training in human ethics and qualitative methods before conducting interviews with HS teachers. The 5-Step Goodell method will be used (Goodell, Stage & Cooke, 2016). This method begins with a review of basic ethical standards of research concerning human subjects. Data collectors will be trained on the topics of obtaining informed consent from participants, participant confidentiality, and the need for research data collectors to reduce any social, psychological, or physical 36 risk for the participants. Secondly, data collectors will review qualitative research methods and data collection procedures to familiarize themselves with the methodologies and purpose of qualitative research. During this phase, data collectors will learn note taking and summarization skills that are imperative during the interview process. Data collectors will practice keeping interviews conversational as well as responding appropriately to a variety of different types of possible interviewee responses. Next, data collectors will listen to a previously recorded interview to independently practice note taking and will be given constructive feedback. In the final two steps, the data collectors will conduct two mock telephone interviews, one with a fellow data collector within the research team acting as a participant, and the second with a local preschool teacher that falls within a similar participant population. These interviews will not be used in the data analysis; however, the interviewee feedback will be used to provide data collectors with feedback on questions and interviewing techniques. Researchers will modify the interview guide based on feedback to improve clarity and flow of the guide. During the fourth and fifth steps, data collectors will be evaluated to identify common pitfalls such as counseling, teaching, overly positive feedback, leading probes and prompts, and the tendency of the interviewer to present their own perspective (Goodell, Stage & Cooke, 2016). Procedure for Data Collection Participants will be contacted through email to participate in the brief online statewide teacher survey. Participants will be asked to provide electronic consent prior to beginning the survey (Appendix D). Following completion of the survey, teachers will be asked if they would like to participate in a phone interview. If the participant expresses interest, they will be contacted via email or phone to set up a convenient time for an in-depth interview. All in-depth interviews will be conducted via telephone. During the interview, participants will be encouraged to find a quiet, secluded room where they can sit for the duration of the interview. The interviews will be collected using the Rev App call recorder using university-owned electronic devices (e.g. iPad). Recordings will then be uploaded to ECU’s Pirate Drive and be password protected with only access given to the PI. This data will be transcribed verbatim into a word document for analysis by a third-party transcription company. At least one researcher will conduct random spot checks of the test along with the interview recordings to ensure accuracy of transcriptions. 37 The consent process will occur throughout the life of the research study. Prior to the scheduled interview, researchers will confirm completion of the survey and consent. As part of the consenting process, the participants will be informed that their relationship with their worksite, East Carolina University, NC State University, University of NC Greensboro or NC A&T State University will not be negatively affected by their decision to not participant in this research study. Confidentiality will be maintained at all times during and after the study. Any social, psychological, or physical risk will be minimized as much as possible for all participants. Nevertheless, participants will be allowed to de-participate at any time. If a participant declines to participate before or during an interview, the interviewer will thank them and will not continue data collection with participant. Teachers partaking in individual interviews and completing the survey will be provided a $30 gift card as compensation for their time. Procedure for Data Analysis All interviews will be transcribed, de-identified and summarized. Interview questions and their responses will be analyzed by the research team. Researchers will use a phenomenological approach, a qualitative method that strives to understand the common lived experience of individuals, to guide data analysis following Moustakas’s structured method for inductive data analysis (Moustakas 1994; Creswell, 2012). This method was selected for this study because multiple shared experiences of individuals have to be understood in order to make a determination of the best practices and policies relative to the phenomenon. The researchers will describe an essential, invariant structure, or essence, of the common experience by combining textural and structural descriptions of experiences of the participants (Creswell, 2013). Textural descriptions are the “what”’ behind participants experiences and structural descriptions are the “how” behind the participants experience of the phenomenon in a specific context and situations (Creswell, 2013). Researchers will follow four steps for the in-depth analysis: codes, themes, categories and narrative. At the end of the analysis, researchers hope to generate a descriptive narrative that captures the overall experience of participants with science education and food experiences in the classroom. During step 1, three independent coders will read transcribed interviews to identify shared themes and perceptions related to the topic. Coders will read all interviews multiple times to catch subtleties. Phrases 38 that appear to be significant will be marked by each coder and discussed until 100% consensus is met amongst coders (Creswell, 2013). A preliminary detailed coding manual will be organized to aid in continual analyses of common perceptions among data to construct clusters of meaning (Creswell, 2013). In step 2, researchers will discuss and eliminate statements that do not represent details necessary for understanding the participants’ experiences. Thirdly, researchers will begin to condense the manual into overall categories, themes, and subthemes based on patters in the data. Themes will describe “what” was experienced and “how” it was experienced. The team will use caution to ensure that essential components of participants’ views remain intact. Finally, categories will be compared to identify interrelationships among themes to construct the overall “essence” of teachers’ experiences (Moustakas 1994, Creswell 2012) (Figure 4). Figure 3. Phenomenology Theory Procedures: Data Collection and Analysis Validity and Reliability Trustworthiness in qualitative research refers to four criteria that reflect the validity and reliability of data: credibility, transferability, dependability, confirmability. Researchers will enact several techniques to address each of the four criteria of trustworthiness. To address credibility, researchers will closely review existing literature to frame methods, procedures and findings relevant to the study. Frequent debriefing sessions between researchers will identify flaws and function as a sounding board to test ideas 39 and interpretations. Peer scrutiny, or feedback, will be encouraged as well. Researchers will document bracketing procedures before data collection begins, a process of becoming more cognizant of personal biases about the target population and subject. Throughout the study, researchers will be encouraged to practice reflective commentary to record researcher’s initial impressions of each data collection session, emerging patters or theories. This will also help researchers to become more aware of their own constructions. Lastly, triangulation will be implemented as final themes will be sent to each participating teacher for review. Teachers will be asked to review and reflect on the accuracy of the summary of their individual interview and major identified themes (Shenton, 2004). To address transferability, sufficient background data and account of the phenomenon will be provided for future comparisons’ accuracy. Additional details regarding the research design, implementation, data collection and appraisal will be provided to ensure dependability, such that the study could be repeated in the future. Lastly, for confirmability, researchers will convey their assumptions and potential biases, as well as limitations of the study and their possible effect on the results. Potential Risks and Benefits There are no perceived risks pertaining to this study. Any risks that may occur with this research are no more than what the participants would experience in everyday life. However, due to the unique nature of this project, HS partners may see the responses of teachers participating in the study. To protect the identity and confidentiality of teachers and the information they share throughout the course of the study, all data shared with partners will be de-identified. Additionally, teachers could experience anxiety while being asked questions that may yield answers in non-compliance with organization, state, or federal-level priorities and/or policies. To minimize these fears, participants will be reassured that organization directors will not be informed of their participation or responses to the survey or interview. Additionally, participants will use a pseudonym to refer to themselves and any colleagues during interviews. Teachers will receive a $30 gift card to Walmart, Target, or Amazon for participating in both the survey and interview. The results of this study will inform professional development on science education and food experiences and in turn create stronger early STEM environments to prepare children for kindergarten and beyond 40 Ethical Considerations There are no vulnerable populations for this study. An informed consent (Appendix D) will be provided to each participant and must be signed electronically by the participant before an interview takes place. Graduate assistants will undergo IRB training prior to engaging in any part of the study. The three trained graduate research assistants will be the ones to obtain consent from participants. HS Partners will not participate in the recruiting or consenting process to ensure undue influence and coercion is not involved during consenting. Specific responses will not be shared with anyone, including respective employers or other government agencies, nor will these parties be informed of a participant’s participation or non-participation in the study. If participant divulges personal or sensitive information, it will be deleted from transcripts. Bias and Assumptions Biases will be important to avoid as much as possible to ensure validity of this study’s results. The interview guide and survey questions will be continually examined. Researchers will ensure that no leading questions are asked in the interview guide. The online survey and interview guide will also be edited to limit academic speech to reduce potential confusion among participants. The interview guide will revised based on feedback received from research team, experts and experiences with participants throughout the duration of the study. Potential Limitations Participants volunteering for the qualitative interview may participate because they are more interested in the subject matter which could lead to bias. There are also limitations inherent in the interview process. Phenomenology, as a subjective research method, could cause participants to have difficulty expressing themselves or fabricate some or all of their responses (Alase, 2017). Another challenge will be teachers who do not provide sufficient detail to their experiences. However, purposeful probing will be used to encourage detailed responses. Additionally, researchers will be trained to remain open to teachers’ perspectives by staying unbiased and nonjudgmental. Telephone interviews will limit interviewers’ ability to watch the interviewee’s body language in response to questions. In particular, certain questions could come off as an attempt of assessing the teacher’s adherence to HS protocol. This could lead the interviewee to give manufactured answers for fear of retribution from program staff. To 41 address this issue, interview questions will be examined closely by the research team to remove language that an interviewee may interpret as an assessment of following protocol. Further, researches may revise wording of questions and/or clarifying meanings when needed during the interview when necessarily. Lastly, results and interpretation of the study are not generalizable to other HS. Expected Outcomes Outcomes from this project will result in a better understanding of the essence of HS teachers’ experiences using and integrating FBL in their classroom. Literature shows that preschool children generally consume under the daily recommended amount of FV and that the dietary behaviors children establish in the preschool years will affect long-term health status. Additionally, literature shows that foundational science learning that occurs in preschool can have long-term impacts on academic success. Since FBL has been suggested to improve FV consumption, and science learning suggested to improve kindergarten readiness, and integration of the FBL and other learning domains such as science suggested to overcome teacher barriers, this study will shed light on the what, and the how of NC HSteachers’ experiences with FBL. Expanding benefit to the local partners and the larger HS community in NC, this study aims to identify program needs, resources, and infrastructure across HS to guide the development of professional development resources that teachers can use to improve their use and integration of FBL in their classroom. References Alase, A. (2017). The interpretative phenomenological analysis (IPA): A guide to a good qualitative research approach. International Journal of Education and Literacy Studies, 5(2), 9-19. Bound, M. G. (2011). Qualitative Method of Research: Phenomenological. Nova Southeastern University. Bowen, GA. (2008). Naturalistic inquiry and the saturation concept: a research note. Qual Res., 8: 132– 152. Carbone, E. T., Campbell, M. K., & Honess-Morreale, L. (2002). Use of cognitive interview techniques in the development of nutrition surveys and interactive nutrition messages for low-income populations. Journal of the American Dietetic Association, 102(5), 690-696. 42 Creswell, J.W. (2012). Educational research: planning, conducting, and evaluating quantitative and qualitative research. 4th ed. Boston: Pearson. Creswell, J.W. (2013). Qualitative Inquiry & Research Design: Choosing Among Five Approaches. (3rd ed.). Thousand Oaks, CA: Sage. Goodell, L. S., Stage, V. C., & Cooke, N. K. (2016). Practical Qualitative Research Strategies: Training Interviewers and Coders. Journal of Nutrition Education and Behavior, 48(8). doi:10.1016/j.jneb.2016.06.001. Head Start NC Programs. Retrieved from https://headstartnc.org/agency-locator/ on May 17, 2021. Moustakas C. (1994). Phenomenological research methods. Thousand Oaks: Sage. Ryan, K., Gannon-Slater, N., & Culbertson, M. J. (2012). Improving survey methods with cognitive interviews in small-and medium-scale evaluations. American Journal of Evaluation, 33(3), 414- 430. Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22(2), 63-75. doi:10.3233/efi-2004-22201. Srivastava, P., & Hopwood, N. (2009). A practical iterative framework for qualitative data analysis. International journal of qualitative methods, 8(1), 76-84. Valerio, M. A., Rodriguez, N., Winkler, P., Lopez, J., Dennison, M., Liang, Y., & Turner, B. J. (2016). Comparing two sampling methods to engage hard-to-reach communities in research priority setting. BMC medical research methodology, 16(1), 1-11. 43 CHAPTER 4: CONNECTING KINDERGARTEN READINESS AND FOOD-BASED LEARNING IN THE HEAD START PRESCHOOL CLASSROOM Introduction Integrative FBL is a unique opportunity for teachers to engage children in learning domains (e.g., science, mathematics, literacy) while simultaneously exposing children to healthy foods (Bayles et al., 2020; Whiteside-Mansell, Swindle & Davenport, 2019). The integration of FBL with other learning domains may be a solution to overcome frequently cited teacher barriers for FBL such as limited time and competing priorities in both primary (Follong et al., 2021) and preschool (Carraway-Stage et al., 2014; Swindle & Phelps, 2018) environments. Prior literature defines FBL as classroom-based methods to improve children’s willingness to try and consume healthy foods by introducing healthy foods in the classroom (Whiteside-Mansell, Swindle & Davenport, 2019). FBL occurs through methods during the mealtime such as creating a positive mealtime environment (Dev et al., 2019), or outside the mealtime through activities such as gardening, books, and science experiments (Bayles et al., 2020; Whiteside- Mansell, Swindle & Davenport, 2019; Cooke, 2007; Sullivan & Birch, 1990). FBL is beneficial as it allows children to be exposed to healthy foods in a less stressful environment (e.g., outside the mealtime) that encourages children’s’ exploration of foods using their five senses, which may not be encouraged during mealtime (Nekitsing et al., 2018; Carruth & Skinner, 2000; Orell-Valente et al., 2007). Repeated exposure to healthy foods is suggested to be the most effective method for impacting both preference and consumption (Sullivan & Birch, 1990). Impacting young children’s preference and consumption for healthy foods is critical as it is estimated that 30% of preschool-aged (3-5 years) children are considered overweight or obese (Ogden et al., 2014) and less than 20% of preschool children consume the daily recommended servings of vegetables (Grimm et al., 2014). Research suggests that the habits established during the preschool years are suggested to impact long-term health status into adulthood, augmenting the importance of early FBL experiences for children (De Cosmi et al., 2017; Ventura & Worobey 2013; Harris, 2008; Birch, 1999). In addition to impacting health outcomes, FBL may also reinforce children’s fine/gross motor skills (Bellows et al., 2013; Story et al., 2008) and promote learning such as literacy (Droog, Buijzen, & Valkenburg, 2014; Heath, Houston-Price, Kennedy, 2014). Prior interventions using integrative FBL have shown promise in increasing FV consumption and academic outcomes of primary school children (Follong et al., 2021). A recent systematic review details the integration of nutrition topics within core school subjects (Follong et al., 2021). Of the 39 studies included in the review, all but one study reported improvements in children’s nutrition knowledge (Follong et al., 2021). However, only two programs, the Food Math, and Science Teaching Enhancement Resource (FoodMASTER) program and the EatFit program, measured children’s academic outcomes (Follong et al., 2021; Hovland et al., 2013; Roseno et al., 2015; Roseno, Duffrin & Stage, 2017; Shilts et al., 2009). While there is literature on the integration of FBL in the primary school environment, to the authors knowledge, only two studies have integrated FBL in the preschool classroom and no studies have measured academic outcomes related to integrative FBL (Bayles et al., 2020; Whiteside-Mansell, Swindle & Davenport, 2019). The first study conducted by Bayles and colleagues engaged children in seven integrative FBL activities (e.g., science, mathematics, literacy) over 4 months in HS classrooms (2020). Outcomes of the intervention revealed children in the intervention group consumed significantly more carotenoid rich FV than the control (F 1,77=3.98; p=.02, r=.10). The second study explored the effects of Together, We Inspire Smart Eating (WISE), an 8-month nutrition education curriculum that exposed children to FV through weekly hands-on FBL activities (Whiteside Mansell, 2019). WISE provided teachers with integrative FBL activities such as learning patterns through the organization of tomatoes, spinach and cheese (e.g., mathematics) (Whiteside Mansell, Swindle & Davenport, 2019). Children in the intervention had significantly higher FV intake at post-test compared to baseline (t(263)=-.08 p<.039) (Whiteside Mansell, 2019). To the authors knowledge, these are the only two studies that have explored the use of integrative FBL in the preschool classroom (Bayles et al., 2020; Whiteside-Mansell, Swindle & Davenport, 2019). Without data on academic outcomes, the effect of FBL on academic knowledge such as science, mathematics and language in the preschool environment is still unclear. The integration of FBL in the preschool environment is critical since positive FBL experiences that preschool children have in the classroom can lower risk for the development of diet-related diseases in adulthood such as obesity, hypertension, type II diabetes, cancer, and cardiovascular disease (Dietz, 1998; Raychaudhuri & Sanyal, 2012). Specifically, the integration of FBL in HS (HS), the federally funded 45 preschool program serving one million low-income preschools nationwide, is of concern as children from low-income families are at greater risk for diet-related diseases compared to the general population (Swindle & Phelps, 2018; Office of HS, 2016). Additionally, children from low-income families may not have access to FV in the home, limiting the number of exposures children have to healthy foods which is critical to impact preference/consumption (Gooze et al., 2012). However, children do have guaranteed access to FV while at HS via the Child and Adult Care food Program (CACFP) (Child and Adult Care Food Program, 2017). FBL’s ability to impact children’s FV preference and consumption is vital so that when FV are available in the HS environment, they are accepted and consumed by preschool children (Smith et al., 2019; Bayles et al., 2020). HS previously recognized the benefits of FBL and required FBL in HS classrooms. However, the 2016 Performance Standards removed FBL as a requirement (Office of Head Start, 2016). To the authors knowledge, no studies have since explored how FBL is currently being implemented in the HS classroom or how FBL is currently being integrated with other learning domains in the HS classroom. Understanding the current integration of FBL in HS learning domains is key since HS’s ultimate goal is to help children possess the skills, knowledge, and attitudes necessary for kindergarten readiness. Additionally, no studies have qualitatively explored FBL from a teacher’s perspective. Therefore, the purpose of this phenomenological study was to explore HS teachers’ experiences using FBL in the classroom. Teachers were then probed on the integration of FBL into other learning domains because of its potential to address previously cited barriers in the preschool classroom. For the purposes of this study, authors have defined FBL, or food-based sensory exploration, as the use of healthy food as a teaching tool with the intention of 1) providing repeated exposure to healthy foods for improving children’s dietary behaviors; and 2) improving academic learning related to knowledge (e.g., science, mathematics, literacy) and skills (e.g., gross motor, fine, physical) in mealtime or classroom learning environments. Such experiences can be intentionally designed to introduce healthy foods to children to engage their senses while avoiding the use of food for art and food wastage. Methods Study Design 46 Researchers used a qualitative transcendental phenomenological approach to examine NC HS teachers’ shared experiences with the use and integration of FBL with science learning activities in the preschool classroom (Moustakas, 1994; Husserl, 1999). Researchers collected qualitative data via in- depth, semi-structured interviews. Researchers chose semi-structured interviews because participants’ open-ended responses can provide in-depth details of teachers’ experiences using and integrating FBL in the classroom. This study was part of a larger mixed methods cross sectional study conducted across NC. The goal of the larger study was to assess specific needs, assets, and resources of partner HS programs to inform the development of teacher professional development resources for the Preschool Education in Applied Science (PEAS) Institute for Early Childhood Teachers (More PEAS Please, 2021). The Institutional Review Board at East Carolina University reviewed and approved all study protocols and materials (UMCIRB 18-002749). Participants and Recruitment Researchers identified 54 funded HS organizations in NC fall 2020. One center serving primarily migrant families was excluded since it was only open during the summer and fall months. Researchers initiated contact with education managers or program directors via phone. At times, specific programs were contacted to ensure representation by geographical location and organization size. After establishing contact, researchers provided information about the study and asked for permission to communicate with HS teachers via email. Purposive sampling was utilized such that HS teachers were asked if they were interested in scheduling an individual interview to further discuss their experiences with FBL in the classroom. A member of the research team followed up with interested teachers via email to schedule the phone interview. Of the teachers who participated in the larger study, 16% (n=35) completed a qualitative interview. Thirty-five centers never responded to the initial communication potentially because HS programs were closed or providing virtual education to children making it difficult to communicate program administrators and staff (Bauer et al., 2021). This hypothesis is supported by the fact that many HS centers follow with their public-school counterparts’ calendars and many public schools were closed (Education Week, 2020). Data Collection 47 Three trained graduate student, two female (JD and NZ) and one male (ZP), with no prior relationship to participants, conducted interviews between October 2020 and March 2021. Telephone interviews were conducted one-on-one between data collectors and participants. While the interviews occurred during the COVID-19 pandemic, teachers were asked specifically about their experiences pre- COVID-19 (Table 1). Teachers were reminded with a prompt at the start of each question to think of their experiences prior to COVID-19. At the end of the interview, teachers were given an opportunity to share their experiences considering COVID-19. Data collection for qualitative interviews ended when saturation was reached. Saturation was defined as the point which collection of additional data yielded no new insights, themes or issues (Glaser & Strauss, 1967; Strauss & Cordbin, 1990; Bowen, 2008). Researchers verified saturation by creating a saturation grid with codes on the vertical axis and interviews conducted on the horizontal axis (Brod, Tesler & Christiansen, 2009). As interviews progressed, a visual tapering of new codes created was observed. Saturation was achieved when no new codes were developed with the collection of new interview data. Prior to data collection, data collectors completed training in human ethics and qualitative methods using the 5-phase Goodell protocol (Goodell et al., 2016). As part of the training process, data collectors completed 2 pilot interviews using the semi-structured interview guide, first with a fellow data collector and secondly with a local preschool teacher who resembled the participant population. Pilot interviews were not used in data analysis; instead, interviewees were asked for feedback to improve data collectors interviewing techniques. Pilot interviews also served to improve clarity and flow of the interview guide (Goodell, Stage & Cooke, 2016). For example, after feedback from pilot interviews the interview guide was reorganized into two distinct sections and five interview questions were removed and/or condensed into other questions to reduce redundancy. Measures Being more conversational in nature, researchers chose semi-structured interviews to allow teachers to comfortably engage with data collectors to share their personal experiences (Peterson et al., 2017). Interviews lasted 45-60 minutes and were conducted over the phone. Researchers designed the interview guide to address primary research questions using an iterative process over multiple rounds 48 (Srivastava & Hopwood, 2009). The interview guide consisted of a verbal script, interview questions, and required and optional probes (Table 1). At the start of the interview, the interviewer informed the participant about the researcher’s interest in the research topic and read the consent form to the participant to obtain verbal consent. During the interview, data collectors kept notes of participants responses to each question. At the end of the interview, the interviewer summarized the participant’s response to each question and asked the participant to confirm, modify, or disconfirm their response (member checking) (Shenton, 2004). Interviews were audio-recorded using the Rev App recorder on university-owned iPads, and transcribed verbatim. In addition to detailed notes, audio-recording and member checking, other strategies employed to ensure trustworthiness included: 1) bracketing to identify researchers’ potential biases prior to the start of data collection; 2) bi-weekly debriefing sessions between data collectors to discuss codes, emergent themes, and address potential biases; 3) reflective commentary; and 4) triangulation of data with HS participants (Lincoln & Guba, 1985; Bowen, 2008). Triangulation occurred by sending participants a summary of their individual interview via email which they were asked to confirm, revise, or disconfirm (Shenton, 2004). All teachers responded to the request. Interviews continued until saturation was achieved, or the collection of new data did not yield novel information about the phenomenon being studied (Bowen, 2008; Creswell, 2012). Table 2. Teacher Semi-Structured Qualitative Interview Questions, Including Probes (n=35) Interview Questions Required Probes (Pilot Tested) Can you describe some a. If activity described appears to be preplanned ask: Can you give me lessons or activities an example of a time you use food as a teaching tool that was not that you have used in preplanned? the last year, prior to COVID-19, to teach If activity appears to be unplanned ask: Can you give me an example children about science of a time you used food as a teaching tool that was planned? using food? Remember, nutrition is b. What are some things that have influenced your ability to use food a science too so be experiences as a teaching tool in the classroom? sure to think about all the science topics you c. How did you know when you were doing a good job of incorporating teach with food. food experiences? d. How did you know when you were struggling to do a good job incorporating food experiences? e. How did your standard of determining if you were doing a good job or struggling compare to what your supervisor expected of you? 49 Can you list things that a. I heard you list [say what they listed as supports] are there any have helped or others you would like to add? supported you when you have incorporated b. Which of these supports you’ve listed do you think helped the most? food experiences in your classroom prior to c. How did having this help or support influence which activities or COVID-19? This can lessons you did in the classroom? be people, places or things. d. Can you give me a detailed example, like a story, about how [list what they said was most helpful] has helped incorporate food experiences in your classroom prior to COVID-19? Can you list some a. I heard you list [say what they listed as challenges], are there any challenges you faced others you would like to add? when incorporating food experiences in b. Which of these challenges you’ve listed do you think is the biggest? your classroom prior to COVID-19? This can c. How did this challenge affect which science activities and lessons you be people, places, or did in the classroom prior to COVID-19? things. d. Can you give me a detailed example, like a story, about how [list what they said was most challenging] has been a challenge for you while you incorporated food experiences with children prior to COVID-19? In your opinion, what a. On the contrary, what do you think are some reasons you should not are some reasons you incorporate food experiences to teach science to preschool children? should use food experiences to teach science to preschool children? In what ways has a. How might COVID-19 impact your use of food experiences? COVID-19 already impacted your current b. How else might COVID-19 impact your classroom as a whole? science classroom? Data Analysis Researchers used Moustakas’s structured method for inductive data analysis in this phenomenological study (Moustakas 1994; Creswell, 2012). Researchers followed four steps for the in- depth analysis: 1) Horizontalization; 2) Reduction of Statements; 3) Categorizing or “Clustering”; and 4) Final Identification and Narrative of Themes. The study’s first author (JD) and a second analyst (NZ), who were trained in coding, served as the primary coders (Goodell et al., 2016). Prior to analysis, coders immersed themselves in the data by reading all manuscripts twice. Coders re-read transcripts a third time to record preliminary memos and highlight key concepts (Moustakas, 1994). Coders then began the first step of analysis, horizontalization, by independently reading transcripts, giving equal value and importance to each statement, and coding statements with a descriptive label (Moustakas, 1994). In step 2, coders eliminated statements that were not a horizon of the experience being studied and therefore did 50 not represent details necessary for understanding the participants’ experiences. Research meetings occurred 3 times weekly between the coders. At each meeting, coders collectively read each transcript comparing codes until 100% verbal consensus was met (Creswell, 2013). When necessary, a third author (VS) served as a tie breaker. Coders organized a preliminary coding manual where codes were identified and defined to aid in analyses of common perceptions among data to construct clusters of meaning (Creswell, 2013). Additionally, throughout the analysis process, coders maintained memos which consisted of emergent codes, categories, theoretical connections, themes, and theoretical questions (Creswell, 2013; Saldaña, 2009) which were also discussed during research meetings. Memos served as documentation of how coding evolved throughout the analysis (Saldaña, 2009). Thirdly, researchers condensed codes into overall categories or “clusters” and assigned each category a thematic label. This step was repeated to collapse all codes into subsequent categories. Lastly, coders derived final themes from the data and confirmed themes by rereading transcripts to ensure that themes and codes were consistent with teachers’ expressed words. Final themes described the “what” (textural descriptions) and “how” (structural descriptions) of participants’ experiences, which together represent the overall essence of the phenomenon (Creswell, 2013; Moustakas 1994, Creswell 2012). Results A total of 35 teachers from 16 counties spanning each geographical region of NC (Mountains, Piedmont, and Coastal Plain) were included in the final sample (Figure 1). Participants were 94% female and were an average age of 40.8 ± 10.06 years at the time of the interview. Teachers’ races were predominantly White (52.9%) and Black/African American (44.1%). Teachers’ ethnicities were predominantly non-Hispanic (97.1%) followed by Hispanic (2.9%). Many teachers held a bachelor’s degree (54.2%), 8.6% of teachers had completed a master’s degree, 20% had an associate degree, and 5.7% had taken some college courses. Most teachers (82.9%) had experience working in other preschool settings outside of HS. 51 ! ! "#!#$%&'(!)*+,!-./0!-1$&2!3&'2456278!9*::!;<;