Preschoolers’ parent and teacher/director perceptions of returning to early childcare education during the COVID-19 pandemic

Preschool-aged children, especially those in underserved communities, have experienced increased deficits in learning opportunities due to COVID-19 [1‐3]. In addition to literacy, numeracy and other academic skills, early childhood is a period of intense motor development and nutritional needs, and many families from underserved populations rely on early care and education (ECE, i.e., preschool) to help meet these developmental needs [4, 5]. The pandemic caused schools and ECE sites throughout the US to shift to emergency remote learning, which typically reduces learning opportunities and engagement [6]. Most children have spent more time online [7]. With ECE site closures, children’s physical activity has decreased, while screen time has increased, for both education and recreation purposes [7‐9], worsening already too low amounts of physical activity, potentially impeding motor development [8, 10]. Adults have reported more unhealthy eating behaviors during the pandemic [11]. Avoiding dine in restaurants has sent many to drive through fast food take out windows, and higher fast food consumption has been associated with poverty and obesity [12], contributing to poor nutrition for young developing brains and bodies. As the pandemic has persisted, more information is needed to understand how the pandemic has impacted lifestyle behaviors, particularly among those with young children who have attended ECE sites previously.

In some places, including Arizona, many ECE sites serving low-income and underserved students were closed through 2021, further limiting young children’s access to education. As these sites have reopened, children and staff (e.g., teachers) at ECE sites are increasingly affected by COVID-19 infection. At the onset of the pandemic, it was unclear how young children could contract or spread COVID-19. However, recent data from ECE settings shows that children can not only contract SARS-CoV-2 in ECE environments, but also spread it to others, even when they are asymptomatic [13‐16]. ECE staff also pose high risk of virus transmission within the ECE environment [14], possibly because adults have been found to carry higher viral loads than children, leading to an increased incidence of transmission [14]. Research is needed to better understand how to best mitigate COVID-19 in ECE environments, where the COVID-19 mitigation strategies are different due to the developmental stage of the children (e.g., possible difficulty wearing face masks, understanding of infectious disease).

The Centers for Disease Control and Prevention (CDC) promotes a layered prevention approach against COVID-19 for ECE sites: vaccination for eligible individuals, masking, and social distancing [17‐20], as well as, use of adequate indoor ventilation and outdoor learning. Social distancing is presently known as an effective COVID-19 prevention measure [21], and public masking in Arizona schools showed a significant decrease in transmission of COVID-19 [19]. Until Fall 2022, positive cases were being reported frequently in ECE sites across the US [1, 22, 23]. Thus, these established mitigation strategies may be more effective when combined with testing school staff and children for COVID-19 infection periodically, perhaps as part of back-to-school readiness, in order to greatly reduce transmission risk [24, 25]. It is unclear how COVID-19 mitigation strategies, including onsite testing, would be perceived by those working in ECE sites and the parents of children attending the sites. Understanding perceptions as they relate to testing would help to better understand risk for COVID-19 for children at ECE sites.

Persistent disparities in infection and subsequent morbidity and mortality have affected underserved populations (low-income and communities of color [26, 27]), especially in Arizona [28]. Specifically, people in Arizona who are American Indian, Hispanic, or Black have higher rates of COVID-19 cases, hospitalization, and deaths compared to people who are White [28]. Despite these documented disparities, there has been little focus on young children. This study aimed to identify and understand the best practices of ECE sites that were operating and how to best support these practices to help keep children from underserved populations safely in school as the pandemic continues to help close education deficits. The aim of the present study was to explore ECE teacher/director perceptions COVID-19 mitigation strategies and a secondary aim was to understand parents’ perceptions of ECE sites during the pandemic as well as self-reported preschool children and their families’ nutrition and physical activity behaviors and practices during the pandemic.

We conducted a concurrent mixed methods study to explore parent and teacher/director perceptions of COVID-19 mitigation strategies and the impact on ECE children and sites. In the Spring of 2021, we administered a survey to parents of ECE children who had previously participated in our NIH-funded gardening intervention, Sustainability via Active Garden Education (SAGE) [29], at ECE sites serving low-income families in the Phoenix metropolitan (NCT03261492). A total of 363 parents were called, of these, 29 (9.0%) refused, 22 (6%) were no longer in service, 249 (69%) did not respond, and (16%) 59 were reached, with 55 that had complete information for analysis.

As sites began to reopen, in the summer of 2021, we conducted focus groups over Zoom with teachers and directors at ECE sites serving underserved populations throughout Arizona, in preparation for an upcoming trial, Back to Early Care and Education Safely with Sustainability via Active Garden Education; BE SAGE; (NCT05178290). A purposive sampling approach was used in which teachers/directors at ECE sites were recruited for the focus groups, using listserv messages, personal invitations, and word of mouth. Inclusion criteria included working at an ECE site in Arizona prior to the pandemic and participating the Child Adult Food Program. As such, all types of centers (e.g., Head Start Programs, home-operated centers) were included in the study. In order to get a broad understanding of experiences, participants came from ECE sites that had already reopened as well as sites that were still closed. To minimize spread of COVID and to increase reach to potential participants, focus groups were conducted and recorded on Zoom. All participants provided written informed consent. Parents were thanked for their time. Teachers/directors received a $50 gift card for their time. All protocols were approved by the Arizona State University Institutional Review Board (protocol ID: 00,003,761).

The dual purpose of this mixed-methods study was to explore perceptions of how to return young children safely to ECE and understand how family health behaviors may have changed during the COVID-19 pandemic. Given that COVID-19 vaccines only became available for preschool children in June 2022, and COVID-19 variants are impacting young children at an increasing rate [1, 22, 23], this study offers a better understanding of testing and mitigation strategies to encourage enrollment and ongoing attendance in ECE sites is needed. Teachers reported high support for non-invasive saliva COVID-19 testing and thought ECE sites would be ideal for implementation of the testing. For those who had taught in the 2020–2021 school year, teachers reported schools and children adapting to COVID-19 mitigation strategies relatively easily; although, some had concerns about the developmental implications for the children and the extra time it took to implement the strategies. Teachers enthusiastically supported outdoor gardening as a COVID-19 mitigation strategy for preschool children. Parents reported high value in their children attending ECE sites, but strong hesitation in returning their children to ECE sites before 2022.

Mitigation of COVID-19 is ever-evolving as new strains of the virus influence the infectiousness of the disease, and as vaccines roll out to younger populations. Beyond vaccinations, evidence consistently shows that good ventilation, social distancing, proper mask wearing, regular handwashing, and staying home when sick are helpful in decreasing risk of exposure to COVID-19 for all populations [24]. The teachers in this study reported that mask wearing and handwashing with young children has gone relatively well, especially when incorporated into the routine of the day. The teachers/directors also indicated that the children and their parents would enjoy outdoor gardening education and that it would be well accepted by parents, which is supported by our previous work [29, 30]. More research is needed to examine how effective gardening education is for mitigating COVID-19 among preschool children.

Currently, there are no saliva-based COVID-19 tests that are readily available for young children. Saliva tests are FDA approved for children under 5 years old, but, to our knowledge, no group in the US has implemented wide-scale testing of this population, but researchers in Germany successfully tested this approach [31]. We have begun to examine the acceptability and feasibility of implementing population-based saliva testing. The ECE teachers/directors in this study indicated enthusiasm for saliva testing, as saliva tests are relatively non-invasive compared to nasal swabs. According to our findings, consideration must be made on a site-by-site basis to accommodate site-level logistical constrains and onsite support (e.g., school nurses). Given the concerns about positive cases and parents potentially missing work due to sick children as indicated by the teachers in this study, it would be helpful if state or federal support was in place for paid leave for families missing work due to COVID-19. Care must be taken when implementing any COVID-19 testing with underserved populations (e.g., people of color, low-income families) given historical misuse of data [32, 33]. Based on the limited concerns highlighted in this study, clear, straightforward assurances of data protection and privacy laws need to be reiterated with families.

Consistent with other studies [34, 35], in the midst of COVID-19, parents in the current study reported ECE sites being a source of social, developmental growth for their children. Interestingly, just more than half of the parents (58%) reported being comfortable sending their child back to their ECE site before 2022. The same parents reported that a key benefit to having their children in ECE sites provides parents time to go to work. Nationally, multiple reports indicate that people, especially low-income women, are leaving the workforce and that the lack of safe childcare during the COVID-19 pandemic was a driver for some to stay out of the workforce [36, 37]. Roughly 45% of parents surveyed in this study reported having less work or no work at all as a result of the pandemic. This is consistent with reports that low-wage workers lost their jobs at five times the rate of middle-wage workers during the first year of the pandemic [24]. Many of these workers were parents of young children [25, 26], limiting access to ECE resources for their children and causing deficits in learning opportunities. At the same time, many ECE sites serving underserved communities in Arizona were closed for more than one year, and this closure likely impacted parents’ ability to return to the workforce. Future research is needed on how perceptions of safe ECE is linked to leaving the workforce, as well as how it relates to the health and development of children over time.

In the current study, parents reported a decrease in physical activity as a result of the pandemic for both themselves and their children, which is consistent with other COVID-related studies [7]. Parents also noted seeing an increase in the amount of television and movies their children were watching as well as the amount of time they spent playing games on various electronic devices. Long-term effects of decreased physical activity and increased exposure to screen time can be detrimental, and both are associated with overweight and obesity in children, an ongoing concern in the US and other countries [38, 39]. The contribution of COVID-19 to these factors further underscores the importance of safely returning children to school as the pandemic continues. Interestingly, the parents in the current study reported improved healthy eating and relatively low levels of fast food consumption. These results are contrary to the limited literature on eating during the pandemic [11, 12], and provides a first glance at how underserved households with young children are managing in these rapidly changing times. Despite these findings, more research is needed on how the pandemic has impacted health behaviors overtime for families and preschoolers.

Together, the survey results and focus group findings aligned and support the reality that ECE sites are critical venues to supporting underserved families with preschoolers with COVID-19 mitigation. Parents highlighted the need to continue to send their children to school; while teachers were eager to serve as a resource and model for families. Gray literature indicates that the pandemic exacerbated shortages in staffing for ECE sites [40, 41], likely affecting enrollment at sites serving low-income and underserved children. Many ECE sites serving underserved communities in Arizona were closed for more than one year. Study findings suggest that ECE site closures likely impacted physical activity and screen time, which in turn could impede motor skills development for many children. We anticipate that the closure impacted parents’ ability to return to the workforce, and study findings suggested more meals at home, perhaps reflecting preferences for staying safer at home or containing costs with home cooked meals. Future research should follow how these combined ECE and home environment and behavior changes impact the health and development of children over time. Additionally, as the pandemic progresses, more research is needed on the role of ECE in supporting changing factors related to COVID-19 mitigation including changes in masking, testing, and vaccination.

Although the sample of teachers/directors was purposeful, we did not collect demographic data, and therefore findings may not be generalizable to all teachers/directors in Arizona. In addition, the recruitment was open to all centers participating in the Child and Adult Care Food Program, but we did not assess from which type of center focus group participants represented. Anecdotally, teachers mentioned that they were representing home centers, Head Start sites, sites housed in elementary schools, and large multi-center ECE operations. The sample of parents participating in the survey was a convenience sample, and may not be representative of all parents of underserved children in Arizona. These were parents of preschool age children at the start of the pandemic, and by the time that the survey was conducted, their children may have moved to kindergarten. We did not collect data on the current age of participants’ children; thus, inferences are limited to parents whose children were in preschool at the start of the pandemic. As the pandemic has rapidly changed over time, the findings are likely limited to the experiences at the moment in the pandemic in which the data were collected.

COVID-19 is a global pandemic that has had far-reaching consequences for everyone, but especially young children and their families. According to ECE teachers, saliva COVID-19 testing seems to be an acceptable approach to screen for COVID-19 at ECE sites. Outdoor gardening is a COVID-19 mitigation approach that needs to be explored further. While parents see the benefits of ECE sites, strategies are needed to help families from underserved populations transition back to ECE sites safely. Many young children from underserved populations may not be achieving sufficient physical activity to provide adequate stimulation to meet motor development milestones. More research is needed to improve safe back-to-school approaches for preschool children and families and ECE sites teachers and staff.