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Assessing the Health Promotion Policies and Practices at Dutch Early Childhood Education and Care (ECEC) Locations: A Quantitative Study among ECEC Staff

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Title: Assessing the Health Promotion Policies and Practices at Dutch Early Childhood Education and Care (ECEC) Locations: A Quantitative Study among ECEC Staff
Language: English
Authors: Sid Penders (ORCID 0000-0003-1002-9512), Mandy M. N. Stijnen (ORCID 0000-0003-2672-3437), Stef P. J. Kremers (ORCID 0000-0002-7406-2779), Jessica S. Gubbels (ORCID 0000-0002-9284-1725)
Source: Child Care in Practice. 2026 32(2):125-144.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 20
Publication Date: 2026
Document Type: Journal Articles
Reports - Research
Tests/Questionnaires
Education Level: Early Childhood Education
Descriptors: Early Childhood Education, Child Care, Health Promotion, Educational Policy, Educational Practices, Nutrition, Physical Activity Level, Computer Use, Conservation (Environment), Foreign Countries
Geographic Terms: Netherlands
DOI: 10.1080/13575279.2025.2488854
ISSN: 1357-5279
1476-489X
Abstract: The early childhood environment plays a pivotal role in a child's health, development, and opportunities in the later stages of their lives. Therefore, the early childhood education and care (ECEC) setting could be essential to health promotion interventions. This study explored the current health promotion policies and practices within the Dutch ECEC setting, as well as the differences in policies and practices over time. A quantitative study was conducted in South Limburg, a region in southern Netherlands, with survey data collected in 2020 and 2022 among pedagogical staff members. The online questionnaire evaluated health promotion policies and practices related to nutrition, physical activity, media use and green environments, and was filled in by staff from 123 ECEC locations in 2020 and 141 ECEC locations in 2022. Descriptive statistics were calculated and Pearson Chi-Square tests were performed to assess the differences between 2020 and 2022. Results showed that policies and practices within the ECEC setting mainly focused on nutrition and physical activity, while media use and green environment received less attention. Notably, there was a significant increase over time in the implementation of various nutrition and physical activity practices. This change may be attributed to the enhanced adoption of health promotion and obesity prevention interventions in ECEC settings within the region. More research is needed on the use and implementation of policies, practices and interventions regarding other health promotion topics within the Dutch ECEC setting.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1503324
Database: ERIC
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  Value: <anid>AN0193123849;j2301apr.26;2026Apr22.06:44;v2.2.500</anid> <title id="AN0193123849-1">Assessing the Health Promotion Policies and Practices at Dutch Early Childhood Education and Care (ECEC) Locations: A Quantitative Study among ECEC Staff </title> <p>The early childhood environment plays a pivotal role in a child's health, development, and opportunities in the later stages of their lives. Therefore, the early childhood education and care (ECEC) setting could be essential to health promotion interventions. This study explored the current health promotion policies and practices within the Dutch ECEC setting, as well as the differences in policies and practices over time. A quantitative study was conducted in South Limburg, a region in southern Netherlands, with survey data collected in 2020 and 2022 among pedagogical staff members. The online questionnaire evaluated health promotion policies and practices related to nutrition, physical activity, media use and green environments, and was filled in by staff from 123 ECEC locations in 2020 and 141 ECEC locations in 2022. Descriptive statistics were calculated and Pearson Chi-Square tests were performed to assess the differences between 2020 and 2022. Results showed that policies and practices within the ECEC setting mainly focused on nutrition and physical activity, while media use and green environment received less attention. Notably, there was a significant increase over time in the implementation of various nutrition and physical activity practices. This change may be attributed to the enhanced adoption of health promotion and obesity prevention interventions in ECEC settings within the region. More research is needed on the use and implementation of policies, practices and interventions regarding other health promotion topics within the Dutch ECEC setting.</p> <p>Keywords: Early childhood education and care (ECEC); nutrition; physical activity; policies; practices; childcare</p> <hd id="AN0193123849-2">Introduction</hd> <p>The early childhood environment in which a child grows up has a major impact on the child's health, development, and opportunities at later stages of life (Carson et al., [<reflink idref="bib3" id="ref1">3</reflink>]; Schiariti et al., [<reflink idref="bib28" id="ref2">28</reflink>]). Research shows that healthy behaviour and habits are predominantly determined by nurture and experiences during childhood (Craigie et al., [<reflink idref="bib4" id="ref3">4</reflink>]; Sleddens et al., [<reflink idref="bib32" id="ref4">32</reflink>]). Early childhood education and care (ECEC) could therefore be a key public health setting for health promotion interventions, as many children attend ECEC for a prolonged period of time (Wolfenden et al., [<reflink idref="bib50" id="ref5">50</reflink>]). In 2021, formal ECEC was provided to approximately 36% of all children under the age of 3 years and 83% of children between age 3 and compulsory school age in Europe (Eurostat, [<reflink idref="bib10" id="ref6">10</reflink>]). Among the European countries, the Netherlands had the highest share of children receiving formal ECEC per week (74.2%), followed by Denmark (69.1%) (Eurostat, [<reflink idref="bib10" id="ref7">10</reflink>]).</p> <p>ECEC health policies can act as a foundation for effective health promotion interventions and encourage the development of healthy behaviors (van de Kolk et al., [<reflink idref="bib44" id="ref8">44</reflink>]). Written policies help ECEC organisations to communicate their priorities and support childcare staff in their practices by providing consistent and unambiguous information to both childcare staff and parents (Jackson et al., [<reflink idref="bib17" id="ref9">17</reflink>]; van de Kolk et al., [<reflink idref="bib43" id="ref10">43</reflink>]). Research shows that written policies focusing on health topics such as physical activity (PA), sedentary behaviour, nutrition, and screen time can have a positive effect on children's health status in terms of obesity prevention (Jackson et al., [<reflink idref="bib17" id="ref11">17</reflink>]; Larson et al., [<reflink idref="bib19" id="ref12">19</reflink>]; Lyn et al., [<reflink idref="bib20" id="ref13">20</reflink>]; Staiano et al., [<reflink idref="bib34" id="ref14">34</reflink>]). In recent years, health promotion efforts related to obesity prevention have become more prominent within the ECEC setting (Matwiejczyk et al., [<reflink idref="bib21" id="ref15">21</reflink>]). The use of theory- and evidence-based health promotion interventions are advocated, as such interventions are more likely to positively affect children's health and weight status (Matwiejczyk et al., [<reflink idref="bib21" id="ref16">21</reflink>]; Ward et al., [<reflink idref="bib47" id="ref17">47</reflink>]). Contextual factors such as staff behaviour, education, encouragement and turnover, availability of outdoor play areas, and parental engagement may facilitate or hamper the implementation of health promotion interventions (Kenney et al., [<reflink idref="bib18" id="ref18">18</reflink>]; McConnell-Nzunga et al., [<reflink idref="bib22" id="ref19">22</reflink>]; Trost et al., [<reflink idref="bib38" id="ref20">38</reflink>]; Tugault-Lafleur et al., [<reflink idref="bib39" id="ref21">39</reflink>]; Wenden et al., [<reflink idref="bib49" id="ref22">49</reflink>]; Wolfenden et al., [<reflink idref="bib51" id="ref23">51</reflink>]). Written policies can help to sustain these health promotion interventions despite the influence of such contextual factors (Shoesmith et al., [<reflink idref="bib29" id="ref24">29</reflink>]).</p> <p>To achieve optimal results, health promotion policies in ECEC organisations need to be translated into the practices of ECEC staff, as such staff practices play a vital role in promoting healthy behaviours and habits among children (Gubbels et al., [<reflink idref="bib13" id="ref25">13</reflink>]). For example, with regard to nutrition, observational studies show that food practices of ECEC staff, such involving children in food preparation, providing explanations to children regarding what staff are doing when preparing food, and a high level of staff encouragement to eat healthy foods were associated with a higher fruit intake and reduced consumption of sweet snacks (Gubbels et al., [<reflink idref="bib13" id="ref26">13</reflink>]; Sisson et al., [<reflink idref="bib30" id="ref27">30</reflink>]). In general, ECEC staff who have adequate skills and knowledge are more likely to adopt desirable healthy practices (Matwiejczyk et al., [<reflink idref="bib21" id="ref28">21</reflink>]; Ward et al., [<reflink idref="bib47" id="ref29">47</reflink>]). Concurrently, comprehensive ECEC policies should support ECEC staff in adopting and implementing healthy practices (Gubbels et al., [<reflink idref="bib14" id="ref30">14</reflink>]; Sisson et al., [<reflink idref="bib30" id="ref31">30</reflink>]; Wolfenden et al., [<reflink idref="bib52" id="ref32">52</reflink>]).</p> <p>To date, research concerning health promotion policies in the ECEC setting has mainly been conducted in the United States and Australia (Jackson et al., [<reflink idref="bib17" id="ref33">17</reflink>]). Research concerning health promotion practices is more prevalent in the European context (De Craemer et al., [<reflink idref="bib7" id="ref34">7</reflink>]; Gubbels et al., [<reflink idref="bib13" id="ref35">13</reflink>]; Ray et al., [<reflink idref="bib27" id="ref36">27</reflink>]). However, research regarding both policies and practices has primarily focused on nutrition and physical activity thus far (Jackson et al., [<reflink idref="bib17" id="ref37">17</reflink>]), although these behaviours are strongly related to other health behaviours (Herrington & Brussoni, [<reflink idref="bib15" id="ref38">15</reflink>]). For example, less is known about ECEC written policies and daily practices regarding the use of green environments, yet outdoor play spaces consisting of natural elements and higher exposure to nature are shown to have positive effects on both physical and social well-being (Gubbels et al., [<reflink idref="bib14" id="ref39">14</reflink>]; Herrington & Brussoni, [<reflink idref="bib15" id="ref40">15</reflink>]; Herrington & Lesmeister, [<reflink idref="bib16" id="ref41">16</reflink>]; Spencer et al., [<reflink idref="bib33" id="ref42">33</reflink>]). While screen time is linked to lower physical activity levels and higher sedentary behavior (Vanderloo, [<reflink idref="bib46" id="ref43">46</reflink>]), there is limited knowledge about the policies and practices of early childhood education and care (ECEC) regarding screen use.</p> <p>This study examined health policies and practices regarding the health topics of nutrition, physical activity, media use and green environment as reported by ECEC staff working at ECEC locations in the southern region of the Netherlands in 2020 and 2022. We hypothesise that with increasing attention to health promotion in the ECEC setting in the Netherlands, more ECEC locations will eventually begin to pay attention to health topics in both policy and daily practices. In addition, we hypothesised that healthy practices by ECEC staff are more prevalent at ECEC locations working with a theory- or evidence-based health promotion intervention. This led us to address two sub-questions: (i) To what extent has implementation of policies and daily practices at ECEC locations regarding health topics changed over time (between 2020 and 2022)? and (ii) To what extent do healthy practices used by ECEC staff differ between the ECEC locations that work with a theory- or evidence-based health promotion intervention and the ECEC locations that do not?</p> <hd id="AN0193123849-3">Methods</hd> <p></p> <hd id="AN0193123849-4">Study design and setting</hd> <p>This quantitative study included data from 2020 and 2022 of a recurring monitoring of the Public Health Service South Limburg (in Dutch: GGD Zuid Limburg) regarding "Healthy Childcare", distributed among all ECEC locations in South Limburg. All ECEC locations are part of an ECEC organisation, and the sizes of these organisations range from 1 to 79 locations.</p> <p>South Limburg is a region in the Southeast part of the Netherlands. In general, people living in this region have a deprived health status compared to the national figures, which contributes to persistent health inequalities and disadvantages in comparison with other parts of the Netherlands (Meisters et al., [<reflink idref="bib23" id="ref44">23</reflink>]).</p> <p>All ECEC organisations that provide formal, centre-based childcare for children aged 0–4 years (day-care centre) and/or 2–4 years (preschool) in South Limburg were eligible for inclusion. In the Netherlands, children who grow up in a socially unfavourable home situation (based on e.g. low parental educational levels) are eligible for an Early Childhood Education Intervention Programme ("VVE") to alleviate language and social-emotional delays (Driessen, [<reflink idref="bib9" id="ref45">9</reflink>]). The programme provides funding for children to attend ECEC organisations that offer the programme, for multiple days a week. As such, the ECEC locations care for a variety of children from different socio-economic backgrounds, rather than merely children of working parents.</p> <p>This study was reviewed and approved by the Faculty of Health, Medicine and Life Sciences Review Ethics Committee of Maastricht University (Approval number: FHML-REC/2022/093).</p> <hd id="AN0193123849-5">Study procedures and participants</hd> <p>A health promotion professional of the Public Health Service was responsible for approaching all ECEC organisations in South Limburg (in 2020, <emph>N</emph> = 251 locations; in 2022, <emph>N</emph> = 254 locations). An email that included an information letter was sent to the contact person of each ECEC organisation, who was often a policy-maker or director. This information letter contained a link to the online questionnaire. Each contact person was asked to forward the information letter to the childcare locations that are part of the specific ECEC organisation. One staff member per location was asked to complete the survey. Each ECEC location was free to choose which staff member filled in the survey.</p> <p>The survey took 20–25 minutes on average to complete. ECEC locations had four weeks to complete the survey, and two reminder emails were sent by the respective contact person. Those filling in the survey provided informed consent by affirmatively answering the first question of the survey, namely, "I have read the information mail about this research and I agree to participate in the current study". ECEC locations that did not consent to participate were excluded.</p> <hd id="AN0193123849-6">Materials</hd> <p>The "Healthy Childcare" survey of the Public Health Service South Limburg consisted of an online questionnaire with 63 questions, including open-ended and closed questions. Initially, questions were asked about the characteristics of ECEC locations, such as whether the type was preschool or daycare, as well as the municipality in which each specific ECEC was situated. Subsequently, questions were posed that addressed the ECEC location's policies, practices and interventions concerning the following topics: nutrition, physical activity, media use (e.g. use of screens or screen time) and green environment. All interventions that were included in the questionnaire were formally acknowledged as a theory- or evidence-based intervention according to the Dutch National Institute for Public Health and the Environment (National Institute for Public Health and the Environment, [<reflink idref="bib25" id="ref46">25</reflink>]) and all interventions targeted physical activity and/or nutrition. An example question related to a health promotion policy was "Does the organisation you work for have a policy regarding which beverages are served to the children?" The following is an example of a question related to a health promotion practice: "Does the ECEC location you work for make use of tools or activities that stimulate short exercise breaks?" Finally, the following question was related to the use of a theory- or evidence-based intervention "Does the ECEC location you work for make use of a theory- or evidence-based health promotion intervention?" (See Appendix 1, for an overview of the survey questions addressed in this study and their answer options.)</p> <hd id="AN0193123849-7">Data analysis</hd> <p>The number of missing values was separately assessed for each of the overarching health topics (nutrition, physical activity, media use and green environment) included in the questionnaire. An ECEC location was excluded from analysis of that specific health topic if one or more answers were missing for that topic. Therefore the number of units of analysis (<emph>n</emph>) differed for health topics. Descriptive statistics (frequencies and percentages) were calculated for all items using SPSS version 27. Pearson Chi-Square tests were performed to examine the differences between 2020 and 2022. <emph>P</emph>-values < 0.05 were considered statistically significant in all analyses. Pearson Chi-square tests were performed to assess the association between health promotion policies and practices of ECEC locations regarding nutrition and physical activity and the use of a theory- or evidence-based intervention at the ECEC location. ECEC locations were categorised based on (i) whether or not they used a theory- or evidence-based health promotion intervention that included a nutritional component and (ii) whether or not they used a theory- or evidence-based health promotion intervention that included a physical activity component. We were not able to test this association for the use of theory- or evidence-based health promotion interventions regarding media use and green environment, as only a few ECEC locations used interventions regarding these topics.</p> <hd id="AN0193123849-8">Results</hd> <p>Overall, 123 (49%) and 141 (56%) ECEC locations participated in this survey in 2020 and 2022, respectively. The characteristics of the participating ECEC locations are shown in Table 1. In 2022, somewhat larger ECEC organisations (i.e. those with ≥10 locations) and more ECEC locations located in high SES municipalities participated than in 2020 (39.7% versus 30.9%, respectively).</p> <p>Table 1. Study characteristics of the ECEC locations participating in 2020 and 2022.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td><p>Characteristics</p></td><td><p>2020 (<italic>n</italic> = 123)</p></td><td><p>2022 (<italic>n</italic> = 141)</p></td></tr></thead><tbody><tr><td><p>Type of formal ECEC</p></td><td char="("><p><italic>n</italic> (%)</p></td><td char="("><p><italic>n</italic> (%)</p></td></tr><tr><td><p> Preschool</p></td><td char="("><p>79 (64.2)</p></td><td char="("><p>88 (62.4)</p></td></tr><tr><td><p> Day-care</p></td><td char="("><p>44 (35.8)</p></td><td char="("><p>53 (37.6)</p></td></tr><tr><td><p>Size of ECEC organisation</p></td><td char="(" /><td char="(" /></tr><tr><td><p> <10 locations</p></td><td char="("><p>34 (27.6)</p></td><td char="("><p>30 (21.3)</p></td></tr><tr><td><p> ≥10 locations</p></td><td char="("><p>89 (72.4)</p></td><td char="("><p>111 (78.7)</p></td></tr><tr><td><p>Socio-economic status<xref ref-type="table-fn" rid="tfn1">a</xref></p></td><td char="(" /><td char="(" /></tr><tr><td><p> Low SES < 0</p></td><td char="("><p>85 (69.1)</p></td><td char="("><p>85 (60.3)</p></td></tr><tr><td><p> High SES ≥ 0</p></td><td char="("><p>38 (30.9)</p></td><td char="("><p>56 (39.7)</p></td></tr></tbody></table> </ephtml> </p> <p>1 The socio-economic status was assessed using a standardised composed score based on the following indicators: financial welfare, educational level and employment history (SES-WOA-score). This score was based on the municipality where each ECEC was located. Municipalities with a score below zero were classified as a low SES municipalities, and municipalities with a score above zero were classified as a high SES municipalities (Statistics Netherlands (CBS), [<reflink idref="bib35" id="ref47">35</reflink>]).</p> <hd id="AN0193123849-9">Health promotion policies</hd> <p>Results regarding the written health promotion policies that were in place at ECEC locations in 2020 and 2022 are depicted in Table 2. In general, the majority of the ECEC locations had healthy nutrition policies for each of the nutrition sub-themes (beverages, snacks and treats at children's birthdays) (see Appendix 1 for the operationalisation of all questionnaire items) in place, both in 2020 (>85%) and in 2022 (>91%). In both years, having a healthy snack policy was the most prevalent nutritional policy, with 94.5% in 2022 and 98.5% in 2022. ECEC locations had policies on nutrition and physical activity more often that they had policies on media use and green environment. In both 2020 and 2022, large differences were visible for policy on green environment: whereas more than 90% of the ECEC locations had a policy for playing outdoors during rain, only less than half of the ECEC locations had a policy about creating spaces to stimulate experience with nature and a policy to finance nature facilities structurally. Also, the prevalence of having a policy regarding media has increased between 2020 (57.6%) and 2022 (69.2%) among ECEC organisations, although not significant.</p> <p>Table 2. Prevalence of ECEC locations that had written health promotion policies in place in 2020 and 2022.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td><p>ECEC organisations' policies</p></td><td><p>2020 <italic>n</italic> (%)<xref ref-type="table-fn" rid="tfn3">a</xref></p></td><td><p>2022 <italic>n</italic> (%)<xref ref-type="table-fn" rid="tfn3">a</xref></p></td><td><p><italic>p</italic>-value for difference</p></td></tr></thead><tbody><tr><td><p><italic>Nutrition</italic></p></td><td><p><italic>n</italic> = 109</p></td><td><p><italic>n</italic> = 133</p></td><td char="." /></tr><tr><td><p>1. ECEC organisation has a written healthy beverage policy</p></td><td char="("><p>99 (90.8)</p></td><td char="("><p>125 (94.0)</p></td><td char="."><p>0.351</p></td></tr><tr><td><p>2. ECEC organisation has a written healthy snack policy</p></td><td char="("><p>103 (94.5)</p></td><td char="("><p>131 (98.5)</p></td><td char="."><p>0.083</p></td></tr><tr><td><p>3. ECEC organisation has a written healthy birthday treat policy</p></td><td char="("><p>93 (85.3)</p></td><td char="("><p>121 (91.0)</p></td><td char="."><p>0.171</p></td></tr><tr><td><p><italic>Physical activity</italic></p></td><td><p><italic>n</italic> = 101</p></td><td><p><italic>n</italic> = 130</p></td><td char="." /></tr><tr><td><p>4. ECEC organisation has a written policy on playing outdoors</p></td><td char="("><p>90 (93.8)</p></td><td char="("><p>107 (93.0)</p></td><td char="."><p>0.837</p></td></tr><tr><td><p>5. ECEC organisation has a written policy on movement skills</p></td><td char="("><p>64 (82.1)</p></td><td char="("><p>89 (85.6)</p></td><td char="."><p>0.520</p></td></tr><tr><td><p>6. ECEC organisation has a written policy on little PA exercises during the day</p></td><td char="("><p>55 (73.3)</p></td><td char="("><p>80 (76.2)</p></td><td char="."><p>0.663</p></td></tr><tr><td><p><italic>Media use</italic></p></td><td><p><italic>n</italic> = 100</p></td><td><p><italic>n</italic> = 129</p></td><td char="." /></tr><tr><td><p>7. ECEC organisation has a written policy on the use of media/screens</p></td><td char="("><p>38 (57.6)</p></td><td char="("><p>54 (69.2)</p></td><td char="."><p>0.147</p></td></tr><tr><td><p><italic>Green environment</italic></p></td><td><p><italic>n</italic> = 99</p></td><td><p><italic>n</italic> = 126</p></td><td char="." /></tr><tr><td><p>8. ECEC organisation has a written policy on playing outdoors during rain</p></td><td char="("><p>94 (97.9)</p></td><td char="("><p>106 (91.4)</p></td><td char="."><p>0.040*</p></td></tr><tr><td><p>9. ECEC organisation has a written policy on providing education about nature experiences and use of green</p></td><td char="("><p>52 (64.2)</p></td><td char="("><p>73 (73.3)</p></td><td char="."><p>0.167</p></td></tr><tr><td><p>10. ECEC organisation has a written policy on creating indoor/outdoor spaces to stimulate nature experiences</p></td><td char="("><p>26 (36.1)</p></td><td char="("><p>37 (43.5)</p></td><td char="."><p>0.345</p></td></tr><tr><td><p>11. ECEC organisation has a written policy to structurally finance nature facilities</p></td><td char="("><p>33 (44.6)</p></td><td char="("><p>40 (46.0)</p></td><td char="."><p>0.861</p></td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 *Significant at <emph>p</emph>-value < 0.05.</item> <item>3 The number of units of analysis (<emph>n</emph>) may differ per health topic, as responses were excluded if not all questions related to a specific health topic were filled in.</item> </ulist> <p>Chi-square tests were used to assess the differences between 2020 and 2022 (see Table 2). A significant difference was found for having a written policy on playing outdoors during rain (<emph>p</emph>-value = 0.040), indicating that in 2022, fewer ECEC locations had such a policy in place (91.4%) compared to 2020 (97.9%). For all other written policies, no significant differences were found between 2020 and 2022.</p> <hd id="AN0193123849-10">Health promotion practices</hd> <p>Results concerning the health promotion practices in 2020 and 2022 are shown in Table 3. Healthy nutrition and physical activity were the most common practices at ECEC locations in both 2020 and 2022 (>75% for all practices), with the exception of using a theory- or evidence-based PA intervention (59.2% in 2020 and 66.4% 2022). ECEC staff were least likely to adopt practices regarding green environment (all practices <40%) in both 2020 and 2022. Regarding media use, over half of the ECEC locations (51.2%) made use of electronic devices. These were mostly used as supportive devices by ECEC staff for educational purposes (72.7%) and to stimulate physical activity (77.3%).</p> <p>Table 3. Prevalence of ECEC locations that had health promotion practices in place in 2020 and 2022.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td><p>ECEC locations' practices</p></td><td><p>2020<bold /><italic>n</italic> (%)<xref ref-type="table-fn" rid="tfn5">a</xref></p></td><td><p>2022<bold /><italic>n</italic> (%)<xref ref-type="table-fn" rid="tfn5">a</xref></p></td><td><p><italic>p</italic>-value for difference</p></td></tr></thead><tbody><tr><td><p><italic>Nutrition</italic></p></td><td><p><italic>n</italic> = 108</p></td><td><p><italic>n</italic> = 133</p></td><td char="." /></tr><tr><td><p>1. ECEC locations make use of a theory- or evidence-based<xref ref-type="table-fn" rid="tfn6">b</xref> intervention with a nutrition component</p></td><td char="("><p>51 (46.8)</p></td><td char="("><p>108 (81.2)</p></td><td char="."><p><0.001*</p></td></tr><tr><td><p>2. Healthy drinks provided by ECEC location</p></td><td char="("><p>92 (85.2)</p></td><td char="("><p>125 (94.0)</p></td><td char="."><p>0.023*</p></td></tr><tr><td><p>3. Healthy snacks provided by ECEC location</p></td><td char="("><p>73 (78.5)</p></td><td char="("><p>115 (86.5)</p></td><td char="."><p>0.115</p></td></tr><tr><td><p><italic>Physical activity</italic></p></td><td><p><italic>n</italic> = 100</p></td><td><p><italic>n</italic> = 130</p></td><td char="." /></tr><tr><td><p>4. ECEC location makes use of a theory- or evidence-based<xref ref-type="table-fn" rid="tfn6">b</xref> intervention with a PA component</p></td><td char="("><p>63 (63.0)</p></td><td char="("><p>104 (80.0)</p></td><td char="."><p>0.004*</p></td></tr><tr><td><p>5. ECEC location makes use of short exercise breaks</p></td><td char="("><p>80 (84.9)</p></td><td char="("><p>112 (93.3)</p></td><td char="."><p>0.076</p></td></tr><tr><td><p><italic>Media use</italic></p></td><td><p><italic>n</italic> = 100</p></td><td><p><italic>n</italic> = 129</p></td><td char="." /></tr><tr><td><p>6. Does the ECEC location make use of media or electronic device(s) (e.g. television, PC, laptop, tablet, telephone, smartboard)?</p></td><td char="("><p>44 (44.4)</p></td><td char="("><p>66 (51.2)</p></td><td char="."><p>0.314</p></td></tr><tr><td><p>7. Main application of media tools:</p></td><td char="(" /><td char="(" /><td char="." /></tr><tr><td><p> Education</p></td><td char="("><p>29 (67.4)</p></td><td char="("><p>48 (72.7)</p></td><td char="."><p>0.554</p></td></tr><tr><td><p> Leisure</p></td><td char="("><p>18 (41.9)</p></td><td char="("><p>34 (51.5)</p></td><td char="."><p>0.324</p></td></tr><tr><td><p> Stimulate PA</p></td><td char="("><p>29 (67.4)</p></td><td char="("><p>51 (77.3)</p></td><td char="."><p>0.256</p></td></tr><tr><td><p><italic>Green environment</italic></p></td><td><p><italic>n</italic> = 99</p></td><td><p><italic>n</italic> = 126</p></td><td char="." /></tr><tr><td><p>8. Activities provided to stimulate nature experiences:</p></td><td char="(" /><td char="(" /><td char="." /></tr><tr><td><p> Use of rain boots and rain coats, to play outdoors during rain</p></td><td char="("><p>37 (37.4)</p></td><td char="("><p>44 (34.9)</p></td><td char="."><p>0.704</p></td></tr><tr><td><p> Children receive education about nature</p></td><td char="("><p>38 (38.4)</p></td><td char="("><p>38 (30.2)</p></td><td char="."><p>0.195</p></td></tr><tr><td><p> ECEC location has a vegetable garden</p></td><td char="("><p>18 (18.2)</p></td><td char="("><p>29 (23.0)</p></td><td char="."><p>0.376</p></td></tr><tr><td><p> ECEC location has green schoolyard, or a schoolyard that stimulates a nature experience</p></td><td char="("><p>32 (32.3)</p></td><td char="("><p>44 (34.9)</p></td><td char="."><p>0.683</p></td></tr></tbody></table> </ephtml> </p> <ulist> <item>4 *Significant at <emph>p</emph>-value < 0.05.</item> <item>5 The number of units of analysis (<emph>n</emph>) may differ per health topic, as responses were excluded if not all questions related to a specific health topic were filled in.</item> <item>6 This indicates that a health promotion intervention is included in the Dutch database loketgezondleven, which is part of the Dutch Health Ministry. These interventions are assessed by the National Institute of Public Health and the Environment (RIVM) and relevant partners. The interventions in this database are theory- or evidence-based (National Institute for Public Health and the Environment, [<reflink idref="bib25" id="ref48">25</reflink>]).</item> </ulist> <p>Chi-square tests were used to assess the differences in the implementation of health promotion practices between 2020 and 2022 (see Table 3). For nutritional practices, significant differences were found between 2020 and 2022 regarding both the provision of healthy beverages and healthy snacks, both showing higher adoption of these practices in 2022 (<emph>p</emph> = 0.013) than in 2020 (<emph>p</emph> = 0.039). For all other health promotion practices, no significant differences were found between 2020 and 2022.</p> <p>When comparing the implementation of policies (Table 2) and practices (Table 3), the percentage of ECEC organisations that had a written policy in place regarding aspects of green environment (range: 36.1%–97.9% in 2020 and range: 43.5%–91.4% in 2022) was notably higher than the percentage of ECEC locations that adopted practices to stimulate green environments (range: 18.2%–38.4% in 2020 and range: 23.0%–34.9% in 2022). This difference between having policies and the adoption of practices was smaller for the other health promotion subjects in both 2020 and 2022.</p> <hd id="AN0193123849-11">Health promotion interventions</hd> <p>A total of 107 (80.5%) ECEC locations made use of at least one theory- or evidence-based intervention in 2022. Chi-square tests were used to assess the differences between 2020 and 2022 concerning the implementation of a theory- or evidence-based intervention. In 2022, more ECEC locations implemented an intervention with a nutrition and/or physical activity component than in 2020 (<emph>p</emph> < 0.001 and <emph>p</emph> = 0.004, respectively).</p> <p>Table 4 shows the relationship between healthy daily practices of ECEC locations regarding nutrition and physical activity and working with a theory- or evidence-based health promotion intervention. ECEC locations that worked with a theory- or evidence-based nutrition intervention were significantly more likely to have a healthy beverage policy in place than locations that did not use a theory or evidence-based intervention (96.2% vs 85.2%, respectively; <emph>p</emph>-value <0.031). Healthy drinks were more often provided at ECEC locations that worked with a theory- or evidence-based nutrition intervention (99.0%) than ECEC locations that did not (83.3%; <emph>p</emph>-value <0.001). Moreover, ECEC locations that had a physical activity intervention in place were more likely to make use of short exercise breaks (95.8%), than ECEC locations that did not have such an intervention in place (83.3%; <emph>p</emph>-value = 0.028).</p> <p>Table 4. Association between healthy daily practices of ECEC locations regarding nutrition and physical activity and working with an acknowledged health promotion intervention in 2022 (<emph>n</emph> = 133).</p> <p> <ephtml> <table><thead valign="bottom"><tr><td><p>ECEC location practices</p></td><td><p><italic>n</italic> (%)<xref ref-type="table-fn" rid="tfn8">a</xref></p></td><td><p><italic>n</italic> (%)<xref ref-type="table-fn" rid="tfn8">a</xref></p></td><td><p><italic>p</italic>-value for difference</p></td></tr></thead><tbody><tr><td><p><italic>Nutrition</italic></p></td><td><p>No theory- or evidence-based<xref ref-type="table-fn" rid="tfn9">b</xref> intervention with nutrition component <italic>n</italic> = 27</p></td><td><p>Theory- or evidence-based<xref ref-type="table-fn" rid="tfn9">b</xref> intervention with nutrition component <italic>n</italic> = 106</p></td><td char="." /></tr><tr><td><p><italic>Policies</italic></p></td><td char="(" /><td char="(" /><td char="." /></tr><tr><td><p>1. ECEC location has a healthy beverage policy in place</p></td><td char="("><p>23 (85.2)</p></td><td char="("><p>102 (96.2)</p></td><td char="."><p>0.031*</p></td></tr><tr><td><p>2. ECEC location has a healthy snack policy in place</p></td><td char="("><p>26 (96.3)</p></td><td char="("><p>105 (99.1)</p></td><td char="."><p>0.293</p></td></tr><tr><td><p>3. ECEC location has a healthy treat policy in place</p></td><td char="("><p>23 (85.2%)</p></td><td char="("><p>98 (92.5)</p></td><td char="."><p>0.229</p></td></tr><tr><td><p><italic>Practices</italic></p></td><td char="(" /><td char="(" /><td char="." /></tr><tr><td><p>4. ECEC location provides healthy drinks</p></td><td char="("><p>21 (77.8)</p></td><td char="("><p>104 (98.1)</p></td><td char="."><p><0.001*</p></td></tr><tr><td><p>5. ECEC location provides healthy snacks</p></td><td char="("><p>22 (81.5)</p></td><td char="("><p>89 (84.0)</p></td><td char="."><p>0.772</p></td></tr><tr><td><p><italic>Physical activity</italic></p></td><td><p>No theory- or evidence-based<xref ref-type="table-fn" rid="tfn9">b</xref> intervention with PA component <italic>n</italic> = 27</p></td><td><p>Theory- or evidence-based<xref ref-type="table-fn" rid="tfn9">b</xref> intervention with PA component <italic>n</italic> = 94</p></td><td char="." /></tr><tr><td><p><italic>Policies</italic></p></td><td char="(" /><td char="(" /><td char="." /></tr><tr><td><p>6. ECEC location has a policy regarding outdoor play in place</p></td><td char="("><p>24 (88.9)</p></td><td char="("><p>83 (88.3)</p></td><td char="."><p>0.933</p></td></tr><tr><td><p>7. ECEC location has a policy regarding exercise skills in place</p></td><td char="("><p>20 (80.0)</p></td><td char="("><p>69 (73.4)</p></td><td char="."><p>0.792</p></td></tr><tr><td><p>8. ECEC location has a policy regarding short exercise breaks in place</p></td><td char="("><p>14 (51.9)</p></td><td char="("><p>66 (70.2)</p></td><td char="."><p>0.076</p></td></tr><tr><td><p><italic>Practices</italic></p></td><td char="(" /><td char="(" /><td char="." /></tr><tr><td><p>9. ECEC location makes use of short exercise breaks</p></td><td char="("><p>20 (83.3)</p></td><td char="("><p>92 (95.8)</p></td><td char="."><p>0.028*</p></td></tr></tbody></table> </ephtml> </p> <ulist> <item>7 *Significant at <emph>p</emph>-value < 0.05.</item> <item>8 The number of units of analysis (<emph>n</emph>) may differed per health topic as responses were excluded if not all questions related to a specific health topic were filled in.</item> <item>9 This indicates that a health promotion intervention is included in the Dutch database loketgezondleven, which is part of the Dutch Health Ministry. These are interventions are assessed by the National Institute of Public Health and the Environment (RIVM) and relevant partners. The interventions in this database are theory- or evidence-based (National Institute for Public Health and the Environment, [<reflink idref="bib25" id="ref49">25</reflink>]).</item> </ulist> <hd id="AN0193123849-12">Discussion</hd> <p>This paper explored health promotion policies and practices from the perspective of early childhood education and care (ECEC) staff working at ECEC organisations in the Southern Netherlands. This study found that the percentages of almost all health promotion policies and practices have increased in a positive direction between 2020 and 2022, but these increases were often not significant. This may be due to the already high percentages in 2020, leaving less room for improvement in 2022. This so-called "ceiling effect" (Uttl, [<reflink idref="bib40" id="ref50">40</reflink>]) was mainly visible for the nutrition and physical activity policies and practices. Nonetheless, the adoption of nutrition practices has increased significantly. An Australian study found similarly high percentages of nutrition policies and practices (Yoong et al., [<reflink idref="bib54" id="ref51">54</reflink>]). For example, 95% of the ECEC locations in the study of Yoong and colleagues provided only non-sweetened drinks in 2013 (Yoong et al., [<reflink idref="bib54" id="ref52">54</reflink>]), which is similar to our findings (94.7%). Moreover, our study shows that a high percentage of ECEC locations have implemented a nutrition policy regarding beverages, snacks or birthday treats, varying between 98.5% and 91.0%. Another study showed similar high percentages for having a written nutrition policy in place (Finch et al., [<reflink idref="bib11" id="ref53">11</reflink>]). For physical activity, our study showed that at least 93.0% of the ECEC organisation had a written policy related to physical activity. This is in contrast with previous studies that reported lower percentages, ranging from 41.0% to 79.0%, depending on the type of ECEC (Finch et al., [<reflink idref="bib11" id="ref54">11</reflink>]; Wolfenden et al., [<reflink idref="bib52" id="ref55">52</reflink>]). In addition, a study conducted in a similar geographical context as our study indicated that ECEC staff and managers have a positive attitude towards healthy nutrition and physical activity behaviours (van de Kolk et al., [<reflink idref="bib43" id="ref56">43</reflink>]), implying that ECEC organisations and locations might feel a responsibility to address nutrition and physical activity in both their policies and practices, which could also explain the high implementation of both nutrition and physical activity policies and practices.</p> <p>With regard to media use, our study shows that the use of electronic devices for education, leisure or physical activity purposes in the ECEC setting has increased between 2020 and 2022, varying from around 5% to 10%. A study by Green et al. (2020) similarly found increases over time in screen time among pre-schoolers from 3 to 5 years of age receiving ECEC. Green et al. argue that this could be attributed to an increase of available electronic devices and their possible application for educational purposes (Green et al., [<reflink idref="bib12" id="ref57">12</reflink>]). Recently, the Dutch Health Council has published Dutch recommendations regarding screen time for children between 0 and 4 years of age (The Health Council of the Netherlands, [<reflink idref="bib36" id="ref58">36</reflink>]). These guidelines recommend that children under 2 years should not have any sedentary screen time and that screen time for children between 2 and 4 years of age should be limited to an hour per day. These recommendations are in line with international guidelines (Okely et al., [<reflink idref="bib26" id="ref59">26</reflink>]; Tremblay et al., [<reflink idref="bib37" id="ref60">37</reflink>]). Other studies found that for some pre-schoolers, screen-viewing time was used during light levels of physical activity (Brown et al., [<reflink idref="bib2" id="ref61">2</reflink>]; Dowda et al., [<reflink idref="bib8" id="ref62">8</reflink>]). In line with this, the current results indicate that when electronic devices were used, 77.3% of the ECEC locations used them to stimulate physical activity. Although the of use screen time to stimulate physical activity could be an alternative to reduce inactive screen-viewing time (Vanderloo, [<reflink idref="bib46" id="ref63">46</reflink>]), as yet it is recommended to limit any screen time for children in this age group (World Health Organization, [<reflink idref="bib53" id="ref64">53</reflink>]). It is necessary to further explore the role, application and appropriateness of media and electronic devices within the ECEC setting.</p> <p>Research regarding green environment has shown that nature play, vegetation and edible gardens have positive effects on physical activity levels, fruit and vegetable intake and the socioemotional development of preschool-aged children, indicating the importance of integrating green environment into existing health promotion interventions (Davis & Brann, [<reflink idref="bib5" id="ref65">5</reflink>]; Dawson et al., [<reflink idref="bib6" id="ref66">6</reflink>]; Mygind et al., [<reflink idref="bib24" id="ref67">24</reflink>]). The current study found a larger discrepancy between written policies and implemented practices regarding green environment, compared to the other topics. Recent research in the Netherlands (van Dijk-Wesselius et al., 2019) identified several barriers that hamper nature-based teaching among primary school teachers, such as a lack of time, maintenance of the green space and weather conditions. A lack of confidence in their own outdoor teaching-skills was also mentioned as a possible barrier, as teachers expressed that they were worried about guaranteeing the safety of the children (van Dijk-Wesselius et al., [<reflink idref="bib45" id="ref68">45</reflink>]). Other studies found similar barriers regarding the implementation of edible gardens or gardening programs, such as a lack of funding, knowledge, space, time and staff support (Davis & Brann, [<reflink idref="bib5" id="ref69">5</reflink>]; Dawson et al., [<reflink idref="bib6" id="ref70">6</reflink>]). It is important to note that implementation is not self-evident, and more attention should be paid to effective implementation strategies such as involving relevant stakeholders, establishing boundaries in which to operate and ensuring long-term commitment (van de Kolk et al., [<reflink idref="bib42" id="ref71">42</reflink>]). Greater insight is needed into the factors that promote or hinder the translation of policies into practical implementations for ECEC staff regarding a green environment.</p> <p>Finally, significant increase in the use of theory- or evidence-based interventions with either a nutrition or physical activity component was observed between 2020 and 2022 in the current study, which may contribute to high percentage of nutrition and physical activity policies and practices found in this study. A review by Sisson and colleagues (2016) found that most obesity prevention interventions are effective in improving nutrition and physical activity behaviours among children and staff within the ECEC setting (Sisson et al., [<reflink idref="bib31" id="ref72">31</reflink>]). In particular, more comprehensive, multi-component interventions that target, for example, nutrition, physical activity and screen time are more likely to yield positive effects on the weight status of the children compared to interventions that only target one component (Ward et al., [<reflink idref="bib48" id="ref73">48</reflink>]). In the study region (South Limburg, the Netherlands), several of such multi-component interventions focusing on improving the lifestyle practices of children between 0 and 4 years of age were implemented during the study period (e.g. "Healthy Start" (Abrahamse & Balledux, [<reflink idref="bib1" id="ref74">1</reflink>]) and "SuperFIT" (van de Kolk et al., [<reflink idref="bib41" id="ref75">41</reflink>]). A core component of these interventions was to improve the healthy practices of ECEC staff (Abrahamse & Balledux, [<reflink idref="bib1" id="ref76">1</reflink>]; van de Kolk et al., [<reflink idref="bib41" id="ref77">41</reflink>]), which can have a positive influence on the health practices of staff and ultimately on the health behaviour of the children attending ECEC (Gubbels et al., [<reflink idref="bib13" id="ref78">13</reflink>]; Sisson et al., [<reflink idref="bib30" id="ref79">30</reflink>]). These theory- or evidence-based interventions provide tangible tools to support ECEC organisations and locations in adopting and implementing health promotion policies and practices regarding nutrition and physical activity in a structural way, as they provide information and support for ECEC staff (e.g. on-the-job coaching) (van de Kolk et al., [<reflink idref="bib41" id="ref80">41</reflink>]). At the same time, it is important to consider that the increased focus on nutrition and physical activity policies and practices may have led to the increased use of theory- or evidence-based intervention, suggesting that the direction of the association may also be the other way around.</p> <p>Media use and green environment are relatively new themes within the ECEC setting and have not received as much attention yet as nutrition and physical activity. Furthermore, there is a lack of theory- or evidence-based interventions in the Netherlands or policy guidelines regarding media use and green environment in the ECEC setting, making it more difficult for ECEC locations to embed these topics into their policies and practices. Therefore, future research should focus on how a broader range of health promotion topics can be integrated into new or existing health promotion interventions to support ECEC staff in the adoption and implementation of these practices and to unlock the potential synergistic effects of integrated interventions targeted at multiple health behaviours (Ward et al., [<reflink idref="bib48" id="ref81">48</reflink>]).</p> <p>The current findings should be interpreted in light of the study's strengths and limitations. A strength of the present study is that the study design included data at two time points, making it possible to see which health promotion topics received the most attention at ECEC locations and whether this changed over time. Also, it helped to advise and support ECEC locations regarding topics that are currently receiving less attention. Nonetheless, the follow-up duration was limited, with two years between both time points. Hence, it would be interesting to examine changes over a longer time period. The sample included ECEC locations with different characteristics, including the type of formal ECEC provided, the size of the ECEC organisation and the socio-economic background of the ECEC locations, thus improving the generalisability of the findings. It is important to note that this study was conducted in South Limburg, which means the results may not be applicable to other regions of the Netherlands.</p> <p>A limitation of the current study is that the sample of participating ECEC locations differed between 2020 and 2022. Although some ECEC locations participated in both measurements, some participated only in 2020 or in 2022, and it was not possible to link locations between 2020 and 2022. This precluded the possibility of analysing whether a specific ECEC location had made any improvements over time.</p> <p>Another limitation of this study is that we used a self-reported questionnaire that was filled out by ECEC staff. Although the questionnaire could be completed anonymously, socially desirable responses cannot be completely ruled out. Furthermore, only one staff member per ECEC location was requested to fill in the questionnaire. Staff members not included in this study might have other perceptions regarding the health promotion practices and policies at their ECEC location or might use different practices. Lastly, only ECEC locations that completed all questions regarding a certain health promotion topic were included in the analysis for that specific topic. As a result, the units of analysis differed per health topic, which may have affected the outcomes.</p> <hd id="AN0193123849-13">Conclusion</hd> <p>In conclusion, this study showed that health promotion policies and practices within the ECEC setting found that nutrition and physical activity were the most commonly addressed topics, while media use and green environment received less attention. An increase over time was observed for the use of some nutrition and physical activity practices, which could be related to the significant increased implementation of theory- or evidence-based health promotion interventions targeting nutrition and physical activity in the region. As ECEC locations using a theory- or evidence-based intervention had better outcomes on almost all nutrition and physical activity policies and practices than ECEC location not using a theory- or evidence-based intervention. Therefore, theory- or evidence-based interventions should be further disseminated within and beyond the region. To improve the topics media use and green environment, we recommend that future research explores how these topics could be further integrated into the ECEC setting, as well as how implementation strategies can overcome barriers perceived by ECEC staff.</p> <hd id="AN0193123849-14">Acknowledgements</hd> <p>We would like to thank all ECEC locations that participated in this study, as well as the health promotion professionals of the Public Health Services who recruited these locations. We thank Dr. Jessie Meis for her role in the coordination and data collection of 2020.</p> <hd id="AN0193123849-15">Disclosure statement</hd> <p>No potential conflict of interest was reported by the author(s).</p> <hd id="AN0193123849-16">Data availability statement</hd> <p>Data presented in this paper are available at the Open Science Framework: https://osf.io/837pz.</p> <hd id="AN0193123849-17">Appendix</hd> <p> <bold>Appendix 1.</bold> Overview of all items from the "Healthy Childcare" monitor of ECEC policies and practices regarding physical activity, nutrition, media use and green environment included for analysis.</p> <p></p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Items questionnaire</td><td>Answer options</td><td>Categorisation of answer options as used for analysis</td></tr></thead><tbody><tr><td><italic>Topic: Nutrition (policies)</italic></td></tr><tr><td>"Does the organisation you work for have a policy regarding which beverages are served to the children?"</td><td>1. Yes, only water, tea without sugar or milk is consumed 2. Yes, parents give their own drinks and there are no (healthy) guidelines available 3. Yes, we have other agreements about drinking, namely: 4. We do not have a policy/agreements about which beverages are consumed within our organisation 5. I do not know if we have policies/agreements about beverages</td><td>Healthy policy<xref ref-type="table-fn" rid="tfn10">a</xref> in place = Answer option 1 Unhealthy or no policy in place = Answer options 2 + 4 Answer option 3 is categorised based on the open answer that was provided by the respondent Answer option "I do not know"<xref ref-type="table-fn" rid="tfn11">b</xref> was not included due to being unable to classify the answer option into health or unhealthy</td></tr><tr><td>"Does the organisation you work for have a policy regarding which snacks are served to the children?"</td><td>1. Yes, only fruit and vegetables or a small healthy snack (e.g. whole grain cracker) are consumed 2. Yes, parents give a snack and there are NO (healthy) guidelines available 3. Yes, we have other agreements about snacks, namely: 4. No, we do not have a policy/agreements about which snacks are consumed within our organisation 5. I do not know if we have policies/agreements about snacks</td><td>Healthy policy in place = Answer option 1 Unhealthy or no policy in place = Answer options 2 + 4 Answer option 3 is categorised based on the open answer that was provided by the respondent</td></tr><tr><td>"Does the organisation you work for have a policy regarding treats at birthdays?"</td><td>1. At our ECEC location we provide no treats by birthdays (the birthday is celebrated in a different way) 2. At our ECEC treats are provided by the parents, and this must be healthy or non-edible 3. At our ECEC treats are provided by the parents, and there are no (healthy) guidelines available 4. At our ECEC treats are provided by the ECEC location itself, and this must be healthy or non-edible 5. At our ECEC treats are provided by the ECEC location itself, and there are no (healthy) guidelines available 6. Other, namely: 7. I don't know if we have agreements about treats at birthdays</td><td>Healthy/no treat by birthdays = Answer options 1 + 2 + 4 Unhealthy treat policy = Answer options 3 + 5 Answer option 6 is categorised based on the open answer that was provided by the respondent</td></tr><tr><td><italic>Topic: Nutrition (practices)</italic></td></tr><tr><td>"What types of beverages are consumed by children (aged 0–4) at the ECEC location you work for?"<xref ref-type="table-fn" rid="tfn12">c</xref></td><td>1. Tea (without sugar) 2. Tea (with sugar) 3. Water 4. Milk 5. Optimel 6. Sweet milk/yogurt drinks (chocolate milk, fristi) 7. Fruit juices (orange juice, apple juice) 8. Ranja (lemonade with water) 9. Wicky, Capri-Sonne, Ice tea, etc. 10. Something else 11. I do not know</td><td>Healthy = Answer options 1 + 3 + 4 Unhealthy = Answer options 2 + 5 + 6 + 7 + 8 + 9 Answer option 10 was not included, because it was not possible to categorise this answer option into healthy or unhealthy</td></tr><tr><td>"What types of snacks are consumed by children (aged 0–4) at the ECEC location you work for?"<xref ref-type="table-fn" rid="tfn12">c</xref></td><td>1. Fruit 2. Vegetables 3. Small cookie (biscuit) 4. Packed cakes/bars (gingerbread, milk biscuit, granola bar) 5. Corn waffle, rice waffle, breadstick 6. Whole wheat sandwich, whole wheat cracker, whole wheat bun 7. White sandwich, white crackers, white bun 8. Sweet snacks such as chocolate, sweets or sweet cakes 9. Salty snacks such as chips or popcorn 10. Something else 11. I do not know</td><td>Healthy = Answer options 1 + 2 + 5 + 6. Unhealthy = Answer options 3 + 4 + 7 + 8 + 9 Answer option 10 was not included, because it was not possible to categorise into healthy or unhealthy</td></tr><tr><td><italic>Topic: Physical Activity (policies)</italic></td></tr><tr><td>"Does the organisation you work for have a policy regarding playing outdoors?"</td><td>1. Yes 2. No 3. Not applicable 4. I do not know</td><td>Policy exists = Answer option 1 Policy does not exist = Answer options 2 + 3</td></tr><tr><td>"Does the organisation you work for have a policy regarding movement skills?"</td><td>1. Yes 2. No 3. Not applicable 4. I do not know</td><td>Policy exists = Answer option 1 Policy does not exist = Answer options 2 + 3</td></tr><tr><td>"Does the organisation you work for have a policy regarding short exercise breaks?"</td><td>1. Yes 2. No 3. Not applicable 4. I do not know</td><td>Policy exists = Answer option 1 Policy does not exist = Answer options 2 + 3</td></tr><tr><td><italic>Topic: Physical Activity (practices)</italic></td></tr><tr><td>"Does the ECEC location you work for make use of a PA intervention?"</td><td>1. Nijntje Beweegdiploma 2. Van Gelder 3. Beweegkriebels 4. Something else, namely: 5. Our ECEC location does not make use of PA intervention 6. I do not know</td><td>Use of PA intervention = Answer options 1 + 2 + 3 + 4 No use of PA intervention = Answer option 5</td></tr><tr><td>"Does the ECEC location you work for make use of tools or activities that stimulate short exercise breaks?"</td><td>1. Beweegkriebels 2. Toddler exercise box JOGG Heuvelland/Maastricht 3. Daily Mile 4. Exercise cards SuperFIT 5. Beweegvloer 6. Other tool, namely: 7. Self-made ideas of ECEC staff, namely: 8. Our ECEC location does not use tools or activities to stimulate short exercise breaks? 9. I do not know</td><td>Use of tools/activities = Answer options 1 + 2 + 3 + 4 No use of tools/activities = Answer option 5</td></tr><tr><td><italic>Topic: Media use (policies)</italic></td></tr><tr><td>"Does the organisation you work for have a policy regarding the use of media and electronic devices?"</td><td>1. Yes 2. No 3. I do not know</td><td>Policy exists = Answer option 1 Policy does not exist = Answer option 2</td></tr><tr><td><italic>Topic: Media use (practices)</italic></td></tr><tr><td>"Which types of media and electronic devices are used by the children at the ECEC you are working for?"</td><td>1. None 2. Television 3. PC/laptop 4. Tablet 5. GSM 6. Smartboard 7. Something else, namely:</td><td>No use of media or electronic devices = Answer option 1 Children make use of media or electronic devices = Answer options 2–7</td></tr><tr><td>"For which applications are these media and electronic devices used?"</td><td>1. Education 2. Leisure 3. To stimulate exercise</td><td>Same categorisation as answer options</td></tr><tr><td><italic>Topic: Green environment (policies)</italic></td></tr><tr><td>"Does the organisation you work for have a policy regarding playing outside during rain?"</td><td>1. Yes 2. No 3. I do not know</td><td>Policy exists = Answer option 1 Policy does not exist = Answer option 2</td></tr><tr><td>"Does the organisation you work for have a policy regarding providing education about nature experience and use of green?"</td><td>1. Yes 2. No 3. I do not know</td><td>Policy exists = Answer option 1 Policy does not exist = Answer option 2</td></tr><tr><td>"Does the organisation you work for have a policy regarding creating indoor/outdoor spaces to stimulate nature experiences?"</td><td>1. Yes 2. No 3. I do not know</td><td>Policy exists = Answer option 1 Policy does not exist = Answer option 2</td></tr><tr><td>"Does the organisation you work for have a policy regarding structural financing nature facilities?"</td><td>1. Yes 2. No 3. I do not know</td><td>Policy exists = Answer option 1 Policy does not exist = Answer option 2</td></tr><tr><td><italic>Topic: Green environments (practices)</italic></td></tr><tr><td>"Which types of activities are provided by the ECEC location you work for in order to stimulate a nature experience?"</td><td>1. The children regularly play outside 2. We use rain boots/rain gear so that the children can still go outside when it rains 3. We make trips into nature, e.g. to the forest or the (children's) farm 4. We give the children education about greenery/nature/environment 5. We have a vegetable garden 6. We have a water pump 7. We have a "green" coach 8. We work together with the CNME (Centre for Nature and Environmental Education) 9. We have a green playground/nature playground/playground with nature experience 10. Other, namely: 11. None 12. I do not know</td><td>Providing activities in nature = Answer options 1–11 Not providing activities in nature = Answer option 12 + 13</td></tr><tr><td><italic>Topic: Health promotion interventions</italic></td></tr><tr><td>"Does the ECEC location you work for make use of a theory- or evidence-based health promotion intervention?"</td><td>1. A healthy start 2. Smakelijke Moestuinen 3. Eetplezier en Beweegkriebels ouderworkshop 4. Smakelijke Eters 5. B-Fit 6. Lekker Fit! Kinderdagverblijf 7. Nijntje Beweegdiploma 8. Beweegkriebels 9. Beweeg Wijs 10. SuperFIT 11. Tigers op Recept 12. Communicatie en interactie is meer dan samen praten en spelen 13. Poetsbus 14. De Zonnetjesweek 15. None of the interventions mentioned above 16. I do not know</td><td>Use of intervention = Answer options 1–14 No use of intervention = Answer option 15 ECEC locations were divided based on whether they worked with acknowledged nutrition or PA intervention with regards to the specific nutrition or PA practices</td></tr></tbody></table> </ephtml> </p> <ulist> <item>10 Classification was based on whether the beverage or food was healthy or unhealthy according to the guidelines of the Dutch Nutrition Centre.</item> <item>11 Answer option "I do not know" was not included in the classification of the answer options and excluded for the analysis.</item> <item>12 Multiple answers were possible. When an ECEC location provided both healthy and unhealthy beverages and foods, it was classified as unhealthy.</item> </ulist> <ref id="AN0193123849-18"> <title> References </title> <blist> <bibl id="bib1" idref="ref74" type="bt">1</bibl> <bibtext> Abrahamse, S., & Balledux, M. (2017). 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Journal of Paediatrics and Child Health, 52 (7), 765 – 770. https://doi.org/10.1111/jpc.13252</bibtext> </blist> </ref> <aug> <p>By Sid Penders; Mandy M.N. Stijnen; Stef P.J. Kremers and Jessica S. Gubbels</p> <p>Reported by Author; Author; Author; Author</p> <p></p> <p>Sid Penders is a PhD candidate in the field of health promotion at Maastricht University. His research focuses primarily on the interprofessional collaboration between early childhood education and care organisations and the implementation of health promotion policies, practices and interventions within the early childhood education and care setting.</p> <p>Mandy Stijnen is a senior researcher/epidemiologist at the Public Health Service South Limburg and is affiliated with the Department of Social Medicine at Maastricht University. She is a program coordinator of the Living Lab Public Health Limburg. She has expertise in practice-based research, implementation and quantitative and qualitative research methods. She leads research projects and supervises PhD students on a broad range of public health topics focused on prevention, health promotion and integrated health policy (e.g. youth, interprofessional collaboration, health in deprived neighbourhoods, healthy living environment, mental health).</p> <p>Stef Kremers is a professor in health promotion and conducts most of his studies in the field of prevention of overweight and obesity. His research focuses on the determinants of dietary behaviour and physical activity and the evaluation of comprehensive interventions regarding these behaviours for various target groups (e.g. children, adolescents, young adults and those with diabetes or pre-diabetes).</p> <p>Jessica Gubbels is an associate professor at the Department of Health Promotion at Maastricht University. Her research focuses on the health behaviour of children and their families, with a special interest in the influence of parents and the early childhood education and care (ECEC) setting. She is involved in the development, implementation and evaluation of various health promoting interventions.</p> </aug> <nolink nlid="nl1" bibid="bib28" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib32" firstref="ref4"></nolink> <nolink nlid="nl3" bibid="bib50" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib10" firstref="ref6"></nolink> <nolink nlid="nl5" bibid="bib44" firstref="ref8"></nolink> <nolink nlid="nl6" bibid="bib17" firstref="ref9"></nolink> <nolink nlid="nl7" bibid="bib43" firstref="ref10"></nolink> <nolink nlid="nl8" bibid="bib19" firstref="ref12"></nolink> <nolink nlid="nl9" bibid="bib20" firstref="ref13"></nolink> <nolink nlid="nl10" bibid="bib34" firstref="ref14"></nolink> <nolink nlid="nl11" bibid="bib21" firstref="ref15"></nolink> <nolink nlid="nl12" bibid="bib47" firstref="ref17"></nolink> <nolink nlid="nl13" bibid="bib18" firstref="ref18"></nolink> <nolink nlid="nl14" bibid="bib22" firstref="ref19"></nolink> <nolink nlid="nl15" bibid="bib38" firstref="ref20"></nolink> <nolink nlid="nl16" bibid="bib39" firstref="ref21"></nolink> <nolink nlid="nl17" bibid="bib49" firstref="ref22"></nolink> <nolink nlid="nl18" bibid="bib51" firstref="ref23"></nolink> <nolink nlid="nl19" bibid="bib29" firstref="ref24"></nolink> <nolink nlid="nl20" bibid="bib13" firstref="ref25"></nolink> <nolink nlid="nl21" bibid="bib30" firstref="ref27"></nolink> <nolink nlid="nl22" bibid="bib14" firstref="ref30"></nolink> <nolink nlid="nl23" bibid="bib52" firstref="ref32"></nolink> <nolink nlid="nl24" bibid="bib27" firstref="ref36"></nolink> <nolink nlid="nl25" bibid="bib15" firstref="ref38"></nolink> <nolink nlid="nl26" bibid="bib16" firstref="ref41"></nolink> <nolink nlid="nl27" bibid="bib33" firstref="ref42"></nolink> <nolink nlid="nl28" bibid="bib46" firstref="ref43"></nolink> <nolink nlid="nl29" bibid="bib23" firstref="ref44"></nolink> <nolink nlid="nl30" bibid="bib25" firstref="ref46"></nolink> <nolink nlid="nl31" bibid="bib35" firstref="ref47"></nolink> <nolink nlid="nl32" bibid="bib40" firstref="ref50"></nolink> <nolink nlid="nl33" bibid="bib54" firstref="ref51"></nolink> <nolink nlid="nl34" bibid="bib11" firstref="ref53"></nolink> <nolink nlid="nl35" bibid="bib12" firstref="ref57"></nolink> <nolink nlid="nl36" bibid="bib36" firstref="ref58"></nolink> <nolink nlid="nl37" bibid="bib26" firstref="ref59"></nolink> <nolink nlid="nl38" bibid="bib37" firstref="ref60"></nolink> <nolink nlid="nl39" bibid="bib53" firstref="ref64"></nolink> <nolink nlid="nl40" bibid="bib24" firstref="ref67"></nolink> <nolink nlid="nl41" bibid="bib45" firstref="ref68"></nolink> <nolink nlid="nl42" bibid="bib42" firstref="ref71"></nolink> <nolink nlid="nl43" bibid="bib31" firstref="ref72"></nolink> <nolink nlid="nl44" bibid="bib48" firstref="ref73"></nolink> <nolink nlid="nl45" bibid="bib41" firstref="ref75"></nolink>
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  Group: Ti
  Data: Assessing the Health Promotion Policies and Practices at Dutch Early Childhood Education and Care (ECEC) Locations: A Quantitative Study among ECEC Staff
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  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Sid+Penders%22">Sid Penders</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-1002-9512">0000-0003-1002-9512</externalLink>)<br /><searchLink fieldCode="AR" term="%22Mandy+M%2E+N%2E+Stijnen%22">Mandy M. N. Stijnen</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-2672-3437">0000-0003-2672-3437</externalLink>)<br /><searchLink fieldCode="AR" term="%22Stef+P%2E+J%2E+Kremers%22">Stef P. J. Kremers</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-7406-2779">0000-0002-7406-2779</externalLink>)<br /><searchLink fieldCode="AR" term="%22Jessica+S%2E+Gubbels%22">Jessica S. Gubbels</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-9284-1725">0000-0002-9284-1725</externalLink>)
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  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Child+Care+in+Practice%22"><i>Child Care in Practice</i></searchLink>. 2026 32(2):125-144.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Data: Y
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  Label: Page Count
  Group: Src
  Data: 20
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  Label: Publication Date
  Group: Date
  Data: 2026
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  Group: TypDoc
  Data: Journal Articles<br />Reports - Research<br />Tests/Questionnaires
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  Label: Education Level
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  Data: <searchLink fieldCode="EL" term="%22Early+Childhood+Education%22">Early Childhood Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Early+Childhood+Education%22">Early Childhood Education</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Care%22">Child Care</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Promotion%22">Health Promotion</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Policy%22">Educational Policy</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Practices%22">Educational Practices</searchLink><br /><searchLink fieldCode="DE" term="%22Nutrition%22">Nutrition</searchLink><br /><searchLink fieldCode="DE" term="%22Physical+Activity+Level%22">Physical Activity Level</searchLink><br /><searchLink fieldCode="DE" term="%22Computer+Use%22">Computer Use</searchLink><br /><searchLink fieldCode="DE" term="%22Conservation+%28Environment%29%22">Conservation (Environment)</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Netherlands%22">Netherlands</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/13575279.2025.2488854
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  Group: ISSN
  Data: 1357-5279<br />1476-489X
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: The early childhood environment plays a pivotal role in a child's health, development, and opportunities in the later stages of their lives. Therefore, the early childhood education and care (ECEC) setting could be essential to health promotion interventions. This study explored the current health promotion policies and practices within the Dutch ECEC setting, as well as the differences in policies and practices over time. A quantitative study was conducted in South Limburg, a region in southern Netherlands, with survey data collected in 2020 and 2022 among pedagogical staff members. The online questionnaire evaluated health promotion policies and practices related to nutrition, physical activity, media use and green environments, and was filled in by staff from 123 ECEC locations in 2020 and 141 ECEC locations in 2022. Descriptive statistics were calculated and Pearson Chi-Square tests were performed to assess the differences between 2020 and 2022. Results showed that policies and practices within the ECEC setting mainly focused on nutrition and physical activity, while media use and green environment received less attention. Notably, there was a significant increase over time in the implementation of various nutrition and physical activity practices. This change may be attributed to the enhanced adoption of health promotion and obesity prevention interventions in ECEC settings within the region. More research is needed on the use and implementation of policies, practices and interventions regarding other health promotion topics within the Dutch ECEC setting.
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  Data: 2026
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  Label: Accession Number
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  Data: EJ1503324
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        Value: 10.1080/13575279.2025.2488854
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      – Text: English
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        PageCount: 20
        StartPage: 125
    Subjects:
      – SubjectFull: Early Childhood Education
        Type: general
      – SubjectFull: Child Care
        Type: general
      – SubjectFull: Health Promotion
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      – SubjectFull: Educational Policy
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      – SubjectFull: Educational Practices
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      – SubjectFull: Nutrition
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      – SubjectFull: Conservation (Environment)
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      – SubjectFull: Foreign Countries
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      – SubjectFull: Netherlands
        Type: general
    Titles:
      – TitleFull: Assessing the Health Promotion Policies and Practices at Dutch Early Childhood Education and Care (ECEC) Locations: A Quantitative Study among ECEC Staff
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