Four pilot states—Arizona (AZ), Florida (FL), New York (NY), and Ohio (OH)—were selected for participation. Public health professionals within state health departments in each of the four states served as the points-of-contact to help carry out the survey in their respective states, with the support of Westat staff. These four states were selected to ensure a variety of state licensing structures and geographic locations, thus maximizing opportunities for learning during the pilot. To develop the sampling frame, each state health department point-of-contact obtained a list of legally operating ECE programs in each of the four pilot states, and research staff at Westat used these lists to create a stratified sampling frame. Systematic sampling was used to select a set number of ECE program sites within each state. Each state’s sample was proportionally allocated to strata, which were formed by program type or license status. Within strata, the sampling units were sorted by key frame variables (urbanicity, capacity, and, in OH, quality rating) and selected with equal probabilities. Selected ECE centers were recruited to participate in this voluntary, one-time survey and mailed a recruitment letter tailored to their state. The sample included only ECE centers serving children aged 0 to 5 years but not yet in kindergarten, and Head Start and preschool programs. This survey does not evaluate the Head Start program, but it does include assessments of centers in which Head Start is offered.

A consultative review process by ECE subject matter experts was used to develop the survey. The C-SAW instrument draws from various existing surveys and includes items in nine areas including program demographics (18 questions), nutrition (19 questions), PA (7 questions), staff training (3 questions), and other health and wellness topics (7 questions). The survey was to be completed by the ECE’s director, who would be knowledgeable about the ECE center’s policies and practices. The survey was pre-tested with the help of state health department points-of-contact, who identified nine ECE directors for pre-testing.

The study and its materials were approved by the Westat IRB and the Office of Management and Budget (OMB control #0920–1277). Data collection was scheduled to begin in March 2020; however, it was delayed due to the COVID-19 pandemic and eventually took place from April 15 to June 29, 2021.

A sample of 1,284 ECE centers within the four pilot states was recruited, comprised of 289 centers in AZ, 299 centers in FL, 400 centers in NY, and 296 centers in OH. Each center was mailed a letter introducing the survey, objectives, incentive for participation ($20 gift card), and instructions for completion via web-based survey. Three states (AZ, NY, OH) included endorsements from state agencies and other organizations that work with ECE programs in their state. Reminders were sent 2 weeks after initial communication, and nonrespondents were sent a letter and hardcopy of the survey 4 weeks later, allowing nonrespondents to fill out a paper copy if they preferred. Assistance was offered via email and a toll-free phone number.

Data were cleaned and analyzed using SAS (9.4, Cary, NC). Unweighted, pooled data were used to calculate descriptive statistics for key variables.

Of the responding ECE programs, 58% had children less than 1 year of age in their care, whereas nearly all cared for 3- to 5-year-olds (Table 1). Thirty-seven percent enrolled 50 or more children, and 53% were for-profit. Respondents reported various sources of federal funding including child care subsidies (72%), public pre-kindergarten (33%), and Head Start or Early Head Start (14%). Fifty-two percent reported participating in the Child and Adult Care Food Program or the National School Lunch Program.

National standards promote children’s active play and outdoor time while in ECE programs (American Academy of Pediatrics et al., 2019). Eighty-three percent of respondents met or exceeded the national standard for total PA time for toddlers (60–90 min per 8-hour day) and 57% met or exceeded the national standard for 3- to 5-year-olds (90–120 min per 8-hour day). Most respondents (84%) stated they take children outdoors twice a day or more.

Respondents were asked questions about several health and wellness topics. Eighty-one percent said they have a space for parents to breastfeed, whereas 32% said they see children who do not appear to be getting enough food at home “sometimes,” “often,” or “very often.” Fifty percent said they participate in farm to ECE activities, 73% report no screen time for children below 2 years, and 30% report no screen time for children 2 to 5 years. See Table 1 for other results related to use of developmental screening tools, experiences related to challenging child behavior, and trainings for staff.

In addition, respondents were asked if they had engaged in activities to improve nutrition or PA in the last 12 months. Activities included use of an assessment tool to review the programs’ nutrition and PA policies and practices (35%), earning a special recognition or designation for nutrition and PA practices (19%), and using a curriculum for healthy eating (46%) or PA (52%).

Finally, responses to nutrition questions were provided by 191 centers who reported providing meals and snacks for the children in their care (Table 2). Of these, 12% reported not serving fruits at all or not serving fruits every day in the last week, whereas 19% reported serving one time per day, 46% reported serving two times per day, and 23% reported serving three times per day or more. For vegetables, 21% reported not serving at all or not serving every day in the last week, 46% reported serving one time per day, 22% reported serving two times per day, and 11% reported serving three times per day or more. In addition, 51% reported serving no juice last week, whereas almost all reported not serving sugar sweetened beverages (97%) or flavored milk (91%).

C-SAW offers public health practitioners in states and communities the opportunity to use a survey developed by experts and piloted in four states to gather data on ECE nutrition and PA in their jurisdictions. Additional questions could be developed to gather data on topics such as lead testing, infectious disease, or state- or community-specific health priorities in states or localities. In an environment of public health resource constraints, both fiscal and human, C-SAW can save survey development costs as a free, public-access, cognitively-tested survey for public health practitioners in jurisdictions to independently administer. This tool can help states and communities to better understand ECE programs in their jurisdictions and to track and evaluate efforts to improve nutrition, PA, and breastfeeding over time.