Appetite 90 (2015) 37–44

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Research report

An explanatory framework of teachers’ perceptions of a positive mealtime environment in a preschool setting ☆ Satoko C. Mita a, Samuel A. Gray b, L. Suzanne Goodell a,,* a b

Department of Food, Bioprocessing, and Nutrition Sciences, North Carolina State University, Raleigh, NC, USA Department of Biological Sciences, North Carolina State University, Raleigh, NC, USA

A R T I C L E

I N F O

Article history: Received 27 June 2014 Received in revised form 20 February 2015 Accepted 21 February 2015 Available online 26 February 2015 Keywords: Preschool teachers Mealtime environment Healthy eating Grounded theory Qualitative research

A B S T R A C T

Attending a preschool center may help preschoolers with growth and development that encourage a healthy lifestyle, including sound eating behaviors. Providing a positive mealtime environment (PME) may be one of the keys to fostering a child’s healthy eating habits in the classroom. However, a specific definition of a PME, the components of a PME, or directions on how to create one have not been established. The purpose of this study, therefore, was to explore Head Start teachers’ perceptions related to a PME and create a conceptual framework representing these perceptions. To achieve this purpose, researchers conducted 65 in-depth phone interviews with Head Start teachers around the US. Applying principles of grounded theory, researchers developed a conceptual framework depicting teachers’ perceptions of PME, consisting of five key components: (1) the people (i.e., teachers, kitchen staff, parent volunteers, and children), (2) positive emotional tone (e.g., relaxed and happy), (3) rules, expectations, and routines (e.g., family-style mealtime), (4) operations of a PME (i.e., eating, socialization, and learning), and (5) both short- and long-term outcomes of a PME. With this PME framework, researchers may be able to enhance the effectiveness of nutrition interventions related to a PME, focusing on the factors in the conceptual framework as well as barriers associated with achieving these factors. © 2015 Elsevier Ltd. All rights reserved.

Introduction More than half of preschoolers, who are aged 3 to 6 years and not enrolled in kindergarten, receive some type of care at centerbased programs (Federal Interagency Forum on Child and Family Statistics, 2013). Because early childhood programs, including Head Start (i.e., the federally-funded program for children from lowincome families), have focused their services not only on education, but also on health and nutrition (Office of Head Start, n.d.), attending a preschool center may help preschoolers with growth and development that encourage a healthy lifestyle, including sound eating behaviors. To identify how preschool centers help preschoolers develop sound nutrition habits, researchers are focusing on many aspects of preschool life, such as the practices preschool teachers use to support their students’ development of healthy eating habits (Freedman & Alvarez, 2010; Goodell, Goh, Hughes, & Nicklas, 2010; Mita, Li, & Goodell, 2013; Ramsay et al., 2010). Of the many contributing factors included within preschool teachers’ practices at mealtimes, providing a pleasant mealtime atmosphere

☆ Acknowledgements: We would like to thank North Carolina State University Undergraduate Research Grant for financial support for the work. This manuscript will be included as a part of Satoko Mita’s dissertation at North Carolina State University. * Corresponding author. E-mail address: [email protected] (L.S. Goodell).

http://dx.doi.org/10.1016/j.appet.2015.02.031 0195-6663/© 2015 Elsevier Ltd. All rights reserved.

throughout the meal may be one of the keys to developing a child’s sound eating behaviors as reflected in the Dietary Guidelines for Americans (US Department of Agriculture and US Department of Health and Human Services, 2010). Theoretically, if children spend time in a positive mealtime environment, they will establish positive associations with foods served during the mealtime and will thus develop preferences for those foods. These positive eating experiences could be a predictor of healthy eating habits later in life. For example, adults who reported enjoying meals in childhood are more likely to consume a balanced diet and include vegetables in their meals (Ainuki, Akamatsu, Hayashi, & Takemi, 2013). In contrast, individuals who have memories of being forced to eat particular foods in childhood are more likely to avoid the foods in adulthood (Batsell, Brown, Ansfield, & Paschall, 2002). In preschool mealtime studies, researchers have referred to what we (the authors) would call a positive mealtime environment in varying terms, including pleasant mealtime environments (Johnson, Ramsay, Shultz, Branen, & Fletcher, 2013), a supportive feeding environment (Sigman-Grant et al., 2011), and a positive mealtime environment (Benjamin Neelon & Briley, 2011). No matter the term used for this type of mealtime, its underlying components are similar. Examples of recommended mealtime practices include: a clean and safe mealtime environment (American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education, 2011; Benjamin Neelon & Briley, 2011; National Association for the Education of

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Young Children, 2014; US Department of Agriculture. Child and Adult Care Food Program, n.d.; US Department of Health and Human Services, 2006), age-appropriate equipment (e.g., chairs) and utensils (Fletcher, Branen, Price, & Matthews, 2005; Hagan, Shaw, & Duncan, 2008), and allowing the child to serve him/herself (Benjamin Neelon & Briley, 2011; National Association for the Education of Young Children, 2014). Among effective practices to support children’s development, adults are recommended to sit with children (National Association for the Education of Young Children, 2014; US Department of Health and Human Services, 2006), be a positive role model by eating the same food with children (American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education, 2011; Benjamin Neelon & Briley, 2011), and provide verbal encouragement (“Mmm! I love mangos!”) (Hendy & Raudenbush, 2000) while helping recognize children’s internal cues (Ramsay et al., 2010). While the creation of a positive mealtime environment can positively influence healthy eating habits in children, of the existing childcare-related guidelines from different early childhood professionals (American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education, 2011; Benjamin Neelon & Briley, 2011; National Association for the Education of Young Children, 2014; US Department of Health and Human Services, 2006), only the Academy of Nutrition and Dietetics (the Academy) has acknowledged the importance of the preschool teachers’ role in creating a positive mealtime environment (PME), stating: “[c]hild-care providers should be knowledgeable about. . .strategies for creating a positive mealtime environment. . .” (Benjamin Neelon & Briley, 2011). However, neither the Academy nor the existing literature provides a specific definition of a PME, the components of a PME, or directions on how to create it. Thus, the term “PME” remains ambiguous, and this lack of clear PME-related guidelines at many levels, as well as the lack of training opportunities that allow teachers to consistently contextualize mealtime-related guidelines/policy (Sigman-Grant et al., 2011), may be one of the factors that could lead to undesirable mealtime practices in the preschool setting. As a result, teachers may use unsupportive practices at mealtimes (Benjamin Neelon, Vaughn, Ball, McWilliams, & Ward, 2012; Sigman-Grant et al., 2011); for example, childcare staff may serve seconds without asking whether children were still hungry (Benjamin Neelon et al., 2012). Furthermore, despite the existence of mealtime-related quantitative studies, the focus of those studies was more on teachers’ practices, quality of food served at mealtimes (Benjamin Neelon et al., 2012), and mealtime routines (Sigman-Grant, Christiansen, Branen, Fletcher, & Johnson, 2008). Additionally, though in the quantitative work by Sigman-Grant et al. (2011) the authors defined key mealtime factors that should be emphasized to support a child’s healthy eating habits, little is known about how each component is interrelated to create a PME and how preschool teachers perceive a PME. The purpose of this study, therefore, was to qualitatively elucidate Head Start teachers’ perceptions related to a PME and to create a conceptual framework representing these perceptions, thus conceptualizing the complexity of mealtimes at preschools and illustrating the factors that influence a PME. Because their perceptions of a PME can positively or negatively impact their mealtime practices and thus their students’ eating, assessing teacher perceptions around creating a PME is important. To accomplish this goal, researchers interviewed Head Start teachers across the US, asking them to define a PME in a preschool setting and to identify the factors that influence the creation of a PME. In the future, researchers may be able to use our conceptual framework as a foundation to identify the gaps between what teachers perceive as important and what observational evidence suggests for promoting a PME. If such gaps

exist, educators can then create educational curricula to assist preschool teachers in effectively establishing a classroom PME. Materials and methods Research design Applying principles of grounded theory (Charmaz, 2006; Creswell, 2012) to explore Head Start teachers’ perceptions of a PME, researchers conducted 65 in-depth phone interviews with Head Start teachers in the US between March 2012 and February 2013. While recognizing the importance of conducting the present study with all preschool teachers regardless of who they serve, researchers targeted teachers at Head Start (i.e., the federally-funded preschool program for children from low-income families) because these teachers work with low-income children who are at greater risk for obesity (Ogden, Lamb, Carroll, & Flegal, 2010) and low intake of some of the essential nutrients (Bucholz, Desai, & Rosenthal, 2011). North Carolina State University’s Institutional Review Board approved the methods included in this study. Sampling and recruitment Head Start preschool teachers in the US were recruited from centers serving different proportions of ethnic groups (e.g., African American, Caucasian, Hispanic, Asian, and Native American). To be included in the study, participants were required to be either Head Start preschool teachers or teacher assistants, be over the age of 18, work with three- to five-year-olds, and be present with preschool children in a classroom (not in a cafeteria) during mealtimes. Investigators combined a nationwide sampling technique with snowball sampling (Marshall, 1996) for recruitment. First, using the guidance of Census Regions and Divisions of US (US Department of Commerce, n.d.), researchers aimed to recruit 20 study participants per region (i.e., West, Midwest, Northeast, and South). Researchers used the Head Start Locator tool (US Department of Health and Human Services, n.d.) to obtain contact information for Head Start center directors and administrators. Then, investigators asked administrators and center directors to forward a recruitment email to teachers and/or to aid in identification of teachers who might be willing to participate in the project. Additionally, to aid in recruitment, at the end of each interview researchers asked study participants to help recruit other teachers they knew might be interested in participating in the study. Interviewers and researchers had no established relationships with participants or their centers prior to data collection. Administrators and center directors were not told which of their teachers, if any, participated in the study; the research confidentiality plan, along with other parts of the consent form, was explained to participants before verbal consent was given. Per IRB protocol and as described to the participant, the interviewer then wrote a study participant’s name and the date on the interviewer’s copy of the consent form. This indicated that the teacher had given his/her verbal consent to participate. The interviewer also signed and dated the form. After the interview, researchers sent study participants a copy of the final consent form. Measurement instruments To insure consistency in data collection, interviewers used a standardized interview guide, which included open-ended major questions and probes, in all the interview sessions. The interview questions were preceded by a series of warm-up questions designed to help teachers feel more comfortable speaking with the interviewer. The questions then became more focused as the interview progressed, eliciting Head Start teachers’ perceptions related

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Table 1 Key questions in the Head Start teachers’ interview guide.a Definition Facilitators

Motivators a

How do you define a positive mealtime environment? Who is involved in creating a positive mealtime environment? What is your role as a teacher in creating a positive mealtime environment? What do you do to create a positive mealtime environment? What is your co-teacher’s role in creating a positive mealtime environment? What are the children’s roles in creating a positive mealtime environment? What are some reasons, if any, why you or other teachers would want to create a positive mealtime environment?

Questions in the guide were not asked in this order.

to a PME. The lead author drafted the guide, and the research team critically reviewed the interview guide questions to improve the clarity and appropriateness of the language for the target audience. Table 1 summarizes the main questions in the guide. To improve the credibility of the data (Krefting, 1991), interviewers received extensive training prior to data collection, including training in ethics related to research with human subjects; how to remain open, unbiased, and non-judgmental during the interview process; and how to summarize the participant statements at the end of the interview. Before data collection, each interviewer pilottested the guide with at least one person from the research team and one non-Head Start preschool teacher. After each pilot, the interviewer received constructive criticism about his or her interviewing skills from the lead author. Data collection procedures Five trained research assistants (4 female and 1 male) conducted phone interviews with 65 Head Start teachers. The interviewers encouraged potential study participants to find a quiet, secluded place to sit during the interview. Prior to starting the interview, interviewers reviewed the previously e-mailed consent form with potential participants and provided participants the opportunity to ask questions concerning the interview process. After obtaining verbal informed consent, the interviewers asked participants demographic questions, ice-breaker questions, and then a series of questions in five categories related to a PME, including: definition, facilitators, motivators, barriers, and needs assessment. To increase overall trustworthiness of the data (Krefting, 1991), interviewers summarized participant answers at the conclusion of the interview. The interviewer then requested feedback from the participants to increase the accuracy of the interviewers’ interpretation, as well as to give interviewees an opportunity to add anything that the interviewers may have missed. Each phone interview lasted an average of 50 minutes (range: 31–109 minutes). After each interview, interviewers wrote a summary of participant answers and recorded field notes about the teacher’s demeanor (e.g., How open was the teacher about the topics discussed?). All interview sessions were digitally audio-recorded and transcribed verbatim.

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selective coding (Charmaz, 2006; Creswell, 2012). During the open coding phase, the lead author read all 65 transcripts and reflected on the data by adopting a memoing technique (Creswell, 2012). Then, the lead author developed a coding manual by critically reviewing the notes from initial analyses, preliminary findings, and memos recorded during the open coding phase. During weekly meetings, five data analysts, including the lead author and one interviewer, edited the coding manual to clarify the definitions for each code. An expert in qualitative research with a background in community nutrition critically reviewed the coding manual, and researchers used her feedback to finalize the manual. Next, to improve the coding process by establishing that each data analyst understood the operational definitions for each code in the same manner as all of the other analysts, all five data analysts coded one transcript together. To further establish consistency in coding, all five data analysts coded another transcript independently and then met as a group to compare codes and discuss discrepancies. After the data analysts had coded two transcripts and the lead author believed consistency in independent coding had been established, full consensus coding began. The remaining 63 transcripts were divided between four of the analysts for independent coding. The lead author coded all of the transcripts independently and then met with each analyst separately to compare transcript codes. During this meeting, the lead author determined whether the analyst coded the transcript in the same way as she did through verbal consensus (Creswell, 2012). When discrepancies arose in this process, the two analysts discussed whether or not a particular code should be assigned to a quote. In cases when the two analysts could not agree on a code for a quote, these discrepancies were presented in a group meeting, and the five analysts determined the final code as a group. Once coding was complete, the lead author transitioned to axial coding: inductively and deductively finding relationships among the codes identified in open coding. The goal in this phase was to determine causal conditions, strategies, contextual and intervening conditions, and consequences (Creswell, 2012; Strauss & Corbin, 1990) associated with the central phenomenon (PME). In the last phase of data analysis, selective coding, researchers selected a core category (i.e., central phenomenon: PME) and then developed a theoretical framework from the core category (Creswell, 2012; Strauss & Corbin, 1990). In this phase, an initial conceptual framework consisting of five major elements (central phenomenon, causal conditions, strategies, conditions and context, and consequences) was then revised through an iterative process; the lead author condensed and modified the conceptual framework multiple times based on the feedback from the four data analysts and discussions with the qualitative research expert. Expressed as “a tentative theory” (Maxwell, 2013), a conceptual framework is a visually or narratively presented phenomenon of interest that consists of key components and shows how they are related to each other (Miles & Huberman, 1994). Thus, as opposed to a statistical model in quantitative research wherein hypotheses are proposed and are then tested, a conceptual framework in qualitative research is used to conceptualize the answer to a research question which may or may not be developed into testable hypotheses in future research.

Analysis Researchers entered all the transcripts into QSR NVivo to manage the data (QSR International Pty Ltd, 2010). While collecting the data, the lead author conducted an initial analysis of the interviews to determine when researchers had reached theoretical saturation (Morse, 1995). This analysis was based upon discussions from weekly research meetings, transcripts of the interviews, and interview notes. Once saturation was reached, data collection was terminated. Following a grounded theory approach, data analysis included the following phases: (1) open coding, (2) axial coding, and (3)

Results Among the 65 Head Start teachers from 28 states representing all regions in the US, the average length of working experience with preschool children was 14.4 ± 9.8 years, and the average age was 40.7 ± 12.1 years. Almost all of our study participants were female (97%) and predominately Caucasian (66%) or African American (22%). The majority (95%) had at least an associate degree from a technical school or college.

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Fig. 1. Conceptual framework of Head Start preschool teachers’ definition of a positive mealtime environment.

A conceptual framework for positive mealtime environment

Positive emotional tone

Grounded in teachers’ perceptions, a PME is a place where everyone is enjoying him or herself and has positive feelings (e.g., happy, relaxed) that are fostered through interactions around the food provided and consumed. As shown in the conceptual framework (Fig. 1), a PME includes learning, socializing, and eating and is considered to be the foundation for children’s healthy growth and development to nourish their minds, bodies, and spirits. Of note, the conceptual framework provided in Fig. 1 is a description and a summary of the findings; causal relationships remain unclear. Therefore, the proposed framework should not be used to predict outcomes. Examples of what might be in each construct are in Table 2. The following sections cover components of a PME in Fig. 1: (1) the people, (2) positive emotional tone, (3) rules, expectations, and routines, (4) operations of a PME, and (5) outcomes of a PME.

According to teachers, the children and adults involved in mealtimes can both positively and negatively influence the creation of a PME through setting the emotional tone. One teacher in our study described the importance of emotional tone and its impact

The people According to our participants, two important groups of people help to create a PME at preschool: adults and children. Adults include teachers, kitchen staff, and parent volunteers, and their main roles are to help children eat and practice their social skills (Fig. 1). As the main facilitator, teachers lead and are always present at mealtimes. Kitchen staff and parent volunteers are not always present at mealtimes, but when they are, they can play a critical role in supporting teachers in creating a PME. Children are to participate in the mealtime by eating, socializing with adults and peers, and learning (Fig. 1).

Table 2 Examples of each construct in the conceptual framework.a Construct in the framework

Examples

Rules, expectations, and routines Positive emotional tone Socialization

Family-style mealtimes; singing songs while waiting for meal; giving children responsibilities; reminding children to be polite at mealtimes Relaxed, happy, enjoyable, fun, calm, smooth, safe, no stress, comfortable

Eating

Learning

Short-term outcomes Long-term outcomes

Asking questions (e.g., about the day); sharing about home, what they learned in the day, something about the meal Everybody is eating, enjoying the food, getting healthy food, getting nutrients, focusing on eating, eating healthy foods; children are open to new foods; role modeling Skills (e.g., motor skills, self-help skills), new foods, shapes, color, food groups, nutrition, independence, manners, language Positive feeling after mealtimes; set the tone for a day; looking forward to the mealtime Positive relationship with foods; healthy eating habits

a This table is not an exhaustive list of examples in the framework, and each teacher may include different examples for each construct.

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on mealtime: “If you think about it as an adult, if your waiter gives you bad service, or you hear someone yelling, or someone yells at you, you don’t really want to eat, and it’s definitely the same with the kids.” Participants stated that a PME includes a positive emotional tone (Fig. 1), a collective of emotions that makes an entire mealtime atmosphere positive, wherein adults and children feel relaxed, happy, safe, comfortable, and calm. Under certain rules, expectations, and routines (Fig. 1), adults facilitate setting a positive emotional tone through their positive behavior (e.g., tone of voice, positive reinforcement, and enthusiasm). As a result, three operations (eating, socialization, and learning) in Fig. 1 function favorably, leading to positive feelings in both adults and children and then establishing a positive emotional tone. One teacher summarized the effect of a positive emotional tone, saying that in a PME everyone is “. . . very relaxed. And when I mean relaxed, I mean one where the children are engaging in conversation with each other and the teachers, where the children are trying new food, experiencing new things.” Rules, expectations, and routines In a PME, teachers and other adults in the classroom set certain rules, expectations, and routines, helping children anticipate and prepare for the interactions that are to take place before, during, and after the meal. One teacher said, “The children know what’s going to happen before meal time, during meal time, and after meal time. . .the children think of it as security, in that everything is the same [each meal] and I think that’s really important.” These rules, expectations, and routines differed from classroom to classroom; however, teachers often emphasized one commonly utilized and rather important routine: family-style mealtime.1 One teacher said family-style mealtime is important because it embodied all of the components of a PME: “. . .carrying on a lot of rich conversation with open ended questions and encouraging children to try new foods, modeling, trying new foods. . .Our big thing is family-style.” Teachers discussed that the rules, expectations, and routines help set a positive emotional tone, mitigating negative outbursts from the children and facilitating the three key operations of a PME (eating, socialization, and learning) (Fig. 1). Operations of a positive mealtime environment According to the teachers, there are three main operations of a PME: eating, socialization, and learning (Fig. 1). Each operation has inherent outcomes attached to it (not shown in Fig. 1). These inherent outcomes are immediate outcomes, expected to be achieved during mealtimes. The first operation of a PME is eating. As shown in Fig. 1, both adults and children are expected to eat in a PME. According to the teachers, adults should eat the same food as children to give their students a role model. One teacher said, “[My eating] serves as a role model, so that if the children see me drinking milk and eating carrots, they’ll be more likely to try it themselves.” Teachers also expressed the importance of children eating in a PME so that they can receive nutrients required for that day. Teachers said their students should eat at school because preschoolers with whom they are working may not receive adequate nutrition at home. One teacher said, “You never know which child eats at home. You don’t know when was the child’s last meal. You don’t know whether it’s the first meal. So, you want to encourage healthy eating habits number one, because they possibly don’t have the best environment [at home].” Teachers also expressed that their students should try new foods in a PME because

1 At family-style mealtime, food is served from common food service containers on the table, encouraging children to feed themselves. Cafeteria-style service is not considered as family-style mealtime (US Department of Agriculture. Food and Nutrition Service, n.d.).

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they may not be exposed to a variety of foods at home: “. . .introducing them to new foods and allowing them to try different things that they might not get at home, which is important I think.” As a result, eating helps make a child’s body and mind happy (inherent outcomes) as one teacher commented: “. . .when kids are full and their tummies are satisfied then they are more happy children.” The second operation within a PME is socialization. As defined by the teachers, socialization is the interaction among the people present at a PME and can be facilitated by both adults and children through basic sharing or asking questions. Teachers said they discussed many topics during a PME, ranging from questions about the children’s daily lives (e.g., “What did you do last night?”) to foodrelated conversation (e.g., shape, color, smell). One teacher said, “. . .a positive mealtime environment includes talking. We have conversation while we’re eating, whether it be about what we’re eating, the different fruits and vegetables, our food. . .what they did at home, sometimes it’s good to talk and enjoy the meal as a group. . .” Our participants indicated that this socialization provides an important time for strengthening relationships between adults and children, as well as among children (inherent outcomes): “As we build the bond with the children, we become a mini classroom family. . ..” Finally, the third operation of a PME is learning. As defined by our participants, learning is when a child gains skills or knowledge as a result of setting rules, expectations, and routines and/or through eating and socialization in a PME. Teachers discussed four different yet overlapping categories of skills and knowledge gained while learning in a PME: language, social, motor, and cognitive skills. In addition to these skills, a PME provides opportunities for children to learn about various subjects, according to teachers. One of our study participants described this as a cross curricular environment: “. . .[children are] learning about colors of food. . .textures of food, they’re learning vocabulary, social skills, math, I could just could go on and on. . .mealtime is like cross curricular activity, because it goes across all the curriculum.” Another teacher perceived a PME as one of the most important learning opportunities in a day: “Some of the best learning time is when you’re sitting at the table, eating lunch with the children or breakfast. There’s a wide variety of things you can discuss with [children].” Of note, the three operations described above contain overlap. For example, one teacher commented “Most of the time, our cooks are just in the kitchen, but when they do come out, they do interact with the children and talk to [the children] and get to know [the children] and encourage [the children] to try new things. Sometimes [cooks] talk to the kids about how [they] prepared their food and what different things are in [the food].” In this example, the kitchen staff interact and discuss with children the meals the staff made that day (socialization) while children are eating (eating), resulting in increased knowledge of the food they eat (learning).

Outcomes of a positive mealtime environment As a consequence of a PME, teachers believed that positive changes occur in children over both short and long periods of time. These outcomes are different from inherent outcomes attached to the operations of a PME in that these short- and long-term outcomes are likely to occur outside of mealtimes. The most commonly discussed short-term outcome from establishing a PME was “a better day” (Fig. 1). A teacher expressed this as “. . . [children] learn better when their stomachs are full. . . they’re better at social skills. Your day goes so much more smoothly because your meal plans are so calm and positive. . .the rest of the day just flows with it.” Another teacher also commented that creating a PME is important “. . .because it’s how the tone of the rest of your day would go.. . . [children] start out really happy, and then interact in a positive way with [children’s] friends and then with the teachers.”

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Teachers also reported that a PME helps children develop longterm healthy eating habits (Fig. 1) by increasing their knowledge of healthy eating and openness to trying new foods. One teacher said, “[A] child will [gain] good nutrition from here. It’s a lifelong skill. . . Sometimes I ask kids, what do you remember the most, and they’ll say, I remember being the lunch helper and I remember you told me to try the green beans and I liked them.” As this teacher described, teachers in our study believed in the importance of establishing a PME at preschool so that children can create positive relationships with food for their later life. As explained earlier, providing a PME is significant because some children may not receive one at home: “[Children] need to eat for nourishment because it is a lot of hurried lives. [Children] are thrown in front of a TV and fast food, and we try to create an environment where [children] can all sit down and eat like a family.” In summary, according to our study participants, each component in Fig. 1 is crucial for creating a PME. Of the multiple factors in Fig. 1, adults are key to facilitating a PME by setting a positive emotional tone in an environment where rules, expectations, and routines are embedded. Through interactions (eating and socialization) among the people (i.e., adults and children), children learn cross-curricular content. According to the teachers, this complexity not only makes the mealtime environment positive, but also leads to positive outcomes in children outside mealtimes, impacting both their day and their long-term eating habits. Discussion In a preschool, teachers play the principal role in leading a mealtime. In this qualitative study, researchers targeted Head Start teachers around the US to gain insight into their perceptions of a PME and developed a conceptual framework. Because their views of a PME can positively or negatively influence their PME-related practices and their students’ eating, assessing teacher perceptions around creating a PME is essential. According to our study participants, a PME is a place where everyone is enjoying himself or herself and has positive feelings (e.g., happy, relaxed) that are fostered through interactions around the food provided and consumed. Grounded in teachers’ perceptions, our conceptual framework shows the factors teachers perceived as important when they are trying to create a PME and depicts the complexity of how each component is interrelated. The results suggest that teachers believe creating a PME leads to positive outcomes in children. The conceptual framework in this study does not present hypotheses to test but, rather, is a summary of concepts that can potentially be used to construct future hypotheses to predict outcomes. Additionally, teachers’ PME-related perceptions and/or their actual practices may not be ideal. Thus, the relationships between a PME and positive outcomes in children (e.g., development of healthy eating habits) and teachers’ perceived definition of healthy eating habits are unknown. Therefore, our conceptual framework should be investigated further by exploring how a PME can impact teachers’ reported desired outcomes. Overall, preschool teachers discussed some of the mealtime practices that are recommended by childcare-related guidelines and previous research. Our study participants expressed three key operations for creating a PME at preschool: eating, socialization, and learning. Our findings are supported by guidelines and previous studies emphasizing the importance of performing these operations at mealtimes for a child’s growth and development. For example, in terms of learning, both guidelines and our results indicate that mealtimes can be used as opportunities for learning through foods (e.g., color, shape, temperature of food) (American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education, 2011). Additionally, when focusing on the eating

operational definition, both our findings and guidelines suggest that children’s roles at mealtimes are to try new foods (American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education, 2011) and eat nutritious foods (American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education, 2011; Benjamin Neelon & Briley, 2011; US Department of Health and Human Services, 2006). While recognizing the existence of these established guidelines and evidence related to the operations, previous studies have shown that teachers’ practices at mealtimes are not always supportive of fostering a child’s healthy eating habits (Benjamin Neelon et al., 2012; Sigman-Grant et al., 2011). Teachers may use these undesirable feeding practices because they lack constructive mealtime training (Sigman-Grant et al., 2011) on how to consistently implement mealtime-related guidelines/policy. Of note, our findings do not explain whether teachers’ perceptions of a PME align with their actual practices or whether teachers recognized the importance of their feeding practices to promoting healthy eating in preschoolers (e.g., supporting preschooler’s ability to self-regulate). Therefore, to improve teachers’ use of these mealtime practices, future researchers should investigate teachers’ actual practices (e.g., observational study) as well as their perceived barriers associated with these key operations. In addition, future interventions (e.g., training) should be provided to help teachers contextualize ideal PME-related practices for consistent interpretation and implication between the people at mealtimes, administrators, and researchers. Rules, expectations, and routines set by the adults present at the meal are the core of a PME, according to our study participants. When teachers were asked their PME-related perceptions, a majority of teachers expressed that a family-style mealtime is an important routine in a PME as supported by the existing guidelines (Benjamin Neelon & Briley, 2011; US Department of Agriculture. Child and Adult Care Food Program, n.d.; US Department of Health and Human Services, 2006). However, investigators are unsure if our study participants recognized positive aspects of a family-style mealtime such as helping children develop skills (e.g., self-feeding skills), control the type and amount of foods they eat, and try new foods (National Food Service Management Institute, 2011). Additionally, a familystyle mealtime was a commonly discussed routine, but rules, expectations, and routines – a common language at mealtimes – are different from state to state (Benjamin, Cradock, Walker, Slining, & Gillman, 2008) and from classroom to classroom (Gable & Lutz, 2001). Though our study participants did not specify details about who created mealtime rules, expectations, and routines, as previously discussed, these rules might have been established based on inadequate knowledge of more desirable feeding practices. In the future, this research team will investigate the consistencies of mealtime rules, expectations, and routines between preschool teachers, other staff, classroom volunteers, and preschool administrators. Head Start teachers in our study said the people in the classroom strongly influenced the mealtime environment. Previous guidelines (American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education, 2011; Benjamin Neelon & Briley, 2011; National Association for the Education of Young Children, 2014; US Department of Agriculture. Child and Adult Care Food Program, n.d.; US Department of Health and Human Services, 2006) identified both teachers and children as key players during mealtimes; however, we found that teachers believe that classroom volunteers and other staff members also play an important role in creating a PME. While these volunteers and staff members are believed to influence a PME, few have focused research efforts on these groups (Sigman-Grant et al., 2008, 2011). Thus, future research should more closely

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investigate volunteers and other staff members’ practices at mealtimes, particularly their practices related to eating, socializing, and helping a child’s learning, determining how these outside adults impact PME and child eating outcomes. While teachers seemed to recognize the importance of many recommended practices at mealtimes, the existing literature indicates other practices that teachers did not discuss should be employed at preschool mealtimes to support a child’s eating behaviors. These practices include: children should use age-appropriate equipment (e.g., utensils, tables) (Fletcher et al., 2005; Hagan et al., 2008), a mealtime environment should provide physical comfort (e.g., space, auditory sense, and olfactory sense) (Fletcher et al., 2005), and adults should support children to help recognize their internal cues (Fletcher et al., 2005; Ramsay et al., 2010). Future research should explore professionals’ (experts in feeding practices and child development) perceived definition of a PME. Then, our findings should be compared and contrasted with the experts’ views and the existing literature to determine a comprehensive definition of a PME and develop tools for training teachers how to create a PME in their classrooms. Limitations The present study has limitations that should be acknowledged. First, our qualitative study may not be generalizable to nonHead Start teachers or other Head Start teachers who did not participate in this study. Additionally, because of a lack of information related to the ethnic diversity breakdown of Head Start teachers in the US, our sample may not reflect demographic diversity of the Head Start teacher population in the US. Because of the way we recruited teachers (i.e., asking teachers who were interested in talking to us about mealtimes at their preschool), our study participants may have had differing opinions from those who did not participate in this study. Researchers tried to minimize these limitations by recruiting geographically diverse study participants around the US. Second, social desirability bias – participants’ tendency to respond in a favorable way to others – may have impacted our results due to the nature of the qualitative methodology. Therefore, teachers’ responses may have been positively biased toward a PME. To limit this bias, each interviewer was trained to remain open, unbiased, and non-judgmental during an interview session, encouraging participants to share their thoughts and feelings (e.g., “You are the expert on this subject.”). Lastly, five interviewers were involved in this study, which could have led to difficulty in maintaining consistency throughout the data collection. However, we attempted to increase the trustworthiness of our findings by providing interviewers with intensive training on qualitative interviews with recurring feedback from the lead author and an expert in qualitative research throughout the data collection. Conclusions The findings of the present study fill a gap in the literature related to preschool mealtime environment by conceptualizing the complexity of preschool mealtimes and providing a framework to understand the factors that preschool teachers believe influence the creation of a PME. Along with the existing and future research, our PME framework may be used to enhance the effectiveness of interventions related to a PME by allowing educators to focus on the factors in the conceptual framework as well as through identifying barriers associated with acting on the factors. Researchers may also use the proposed conceptual framework to develop reliable and validated tools to evaluate a preschool mealtime environment by focusing on the key constructs identified in the conceptual framework. Our PME framework is one step toward a better understanding of a preschool mealtime. Future research should

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include qualitatively assessing a variety of participants’ (e.g., administrators, volunteers) perceptions related to a PME, followed by quantitatively comparing and contrasting perceptions of a PME among the different groups. Researchers should also conduct a longitudinal study by exploring how a PME, or a lack thereof, impacts a child’s eating habits. References Ainuki, T., Akamatsu, R., Hayashi, F., & Takemi, Y. (2013). Association of enjoyable childhood mealtimes with adult eating behaviors and subjective diet-related quality of life. Journal of Nutrition Education and Behavior, 45(3), 274–278. American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education (2011). Caring for our children. National health and safety performance standards; Guidelines for early care and education programs (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics. 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