Recent studies demonstrate that young children in high-income countries like the United States (US) and the United Kingdom (UK) consume insufficient servings of fruits and vegetables [1
]. Children from low socioeconomic status families are particularly at risk for poor dietary intake [4
], and interventions to increase fruit and vegetable consumption could be tailored to reach this vulnerable population [7
]. Traditionally, the family has been the primary influence on young children’s dietary intake. Parent preferences and parents modeling healthy behaviors have been shown to be important determinants [8
]. However, a growing number of parents share caregiving and feeding responsibilities with early care and education (ECE) providers [9
], and these providers can impact children’s dietary intake [11
]. In high-income countries, nearly 80% of children ages 3–6 years and 25% of children ages 0–3 years spend time in some form of non-parental child care [12
]. Children may consume one-half to two-thirds of their daily calories in these settings [13
], including most of their carbohydrates and servings of fruit [14
There is ample evidence that young children consume inadequate amounts of fruits and vegetables in ECE. A previous study of children in the US found they consumed one-third of a serving of fruit and one-quarter of a serving of vegetables per day in ECE—far fewer than the recommended national guidelines [15
]. Moreover, nearly 50% of vegetables consumed in ECE were fried potatoes, and only 8% were the more nutrient-dense dark green or brightly colored vegetables [15
]. Other studies of young children in the US and the Netherlands have found similar results [14
]. In the UK, limited data suggest that children are also served insufficient quantities of fruits and vegetables. In one study in Northern England, about half of nurseries (one type of ECE setting) reported serving either a fruit or vegetable with lunch daily [19
]. In our prior work, we found that 92% of nurseries reported serving a fruit and 70% reported serving a vegetable to children each day [20
]. Although somewhat promising, this still falls below the recommended amount [21
Studies show that exposure to fruits and vegetables by age 5 years is vital to establishing habitual consumption later in life [22
]. Encouraging children to try and accept novel foods has been more effective in younger children than with older children, and repeated exposure has yielded positive results in ECE setting [23
]. Interventions that engage children in food preparation, encourage hands-on experiences, and include home-grown foods have increased child fruit and vegetable consumption beyond that of an intervention that merely increases availability [11
]. Thus, interventions that include growing fruits and vegetables, for example, have the potential to increase child intake, but only a handful have been conducted in ECE [36
]. The ECE setting is perhaps ideal because preschool-aged children may be more likely to try new foods like vegetables with both repeated exposure and eating in a group setting [25
Further, gardens may help offset costs associated with the purchasing of fruits and vegetables. School gardens in high-income countries have focused on promoting experiential learning and exposing children to fruits and vegetables to increase familiarity and consumption [38
]. An added benefit for ECE, however, is the potential to serve children what is grown. Generally, ECE programs tend to be smaller and there are often fewer children to feed, compared to schools. This may help offset food costs for fruits and vegetables served to children in ECE [41
], in addition to other benefits.
The aims of this study were to assess whether nurseries were interested in growing their own fruits and vegetables and perceived any barriers to doing so. We further assessed whether responses to these questions differed by socioeconomic status. We hypothesized that nurseries in the most deprived areas of England would be more interested in growing their own fruits and vegetables as a means to offset food costs, but would report cost to establishing the garden as the primary barrier.
A total of 851 of nurseries returned a completed survey, resulting in a 54% response rate after accounting for surveys returned undelivered and nurseries that had closed for business, did not care for children regularly, or did not provide meals and snacks to children. The response rate was similar across all deprivation tertiles. Of the 851 surveys returned, 846 provided complete data for this analysis (five were missing information required to geocode nurseries). Nurseries had been in operation for a mean and standard deviation (SD) of 17.1 (12.3) years and over half (58%) of nursery managers had a 2-year degree or higher (Table 1
). Nurseries were based in a workplace (43%), run by a non-profit (25%), or part of a corporate chain (33%). Nurseries had a mean (SD) of 49.9 (37.3) children enrolled (range 2−310); nearly all (97%) nursery managers were women.
Most nurseries (81%) were interested in growing their own fruits and vegetables (Table 2
). Seventeen nurseries did not respond to the question and were therefore not included as not interested or interested in Table 2
below. Of those interested, 40% of nurseries were already growing some fruits or vegetables. Among all nurseries, a small percentage (18%) were not interested in growing fruits or vegetables.
In adjusted analyses, interest in growing fruits and vegetables did not differ by deprivation tertile (interest was not associated with deprivation in the middle (OR 1.55; 95% CI 0.84, 2.87; p
= 0.16) or most deprived (OR 1.05; 95% CI 0.62, 1.78; p
= 0.87) tertile, compared to nurseries in the least deprived tertile). Nursery managers reported a number of perceived barriers to growing fruits and vegetables, including space (42%), expertise (26%), and time (16%). However, 24% reported no barriers. Nurseries already growing, compared to those who were interested but not yet growing, were significantly more likely to report no barriers (OR 2.90; CI 1.87, 4.50; p
≤ 0.001) and significantly less likely to report space (OR 0.36; CI 0.24, 0.55; p
≤ 0.001), expertise (OR 0.30; CI 0.19, 0.49; p
≤ 0.001), or time (OR 0.58; CI 0.34, 1.0; p
= 0.049) as a barrier. There were no significant differences between groups regarding likelihood of reporting cost, external threats, ownership/shared use, or seasonality/growing conditions as barriers. Of nurseries that were interested but not yet growing, those in the most deprived areas were more likely to report space as a barrier (OR 2.02; 95% CI 1.12, 3.66; p
= 0.02) (Table 3
). However, adjusting for urban location did not substantially change the results (OR 2.19; 95% CI 1.18, 4.06; p
= 0.01). There were no other differences in perceived barriers by deprivation tertile.
In this cross-sectional survey of nursery managers throughout England, we found that the majority were interested in growing their own fruits and vegetables and interest did not vary based on area deprivation level. This finding was contrary to our hypothesis. We expected nursery managers in the most deprived areas to be more interested in growing fruits and vegetables, in part to offset food costs. We also assessed barriers and hypothesized that costs associated with establishing gardens would be the primary barrier reported. Instead, very few nurseries reported cost as a barrier to growing fruits and vegetables and space was the most commonly reported barrier.
Most nursery managers in our study expressed interest in growing fruits and vegetables. Gardens in ECE may expose children to fruits and vegetables through experiential learning, which may ultimately encourage greater consumption. In a recent qualitative study in the US, ECE providers reported that the ECE environment had the potential to exert a strong influence over children and was an ideal setting for introducing less familiar foods [46
]. In another qualitative study in the Netherlands, managers believed it was vital to encourage healthy eating for the children in their care [47
]. Managers emphasized the importance of making healthy foods, like fruits and vegetables, readily available in the ECE environment [47
Moreover, child care providers in the US believed that fruit and vegetable gardens could help increase children’s willingness to try new foods [46
]. A handful of prior gardening interventions have been conducted in ECE settings [48
]. One observed a modest increase in vegetable but not fruit intake in children [48
], another found the intervention itself to be well received but did not measure dietary intake [51
], and a third did not find any improvement in child fruit and vegetable intake [49
]. These prior studies were limited, however, by a small sample size, lack of a control or comparison group, or self-reported outcomes [32
]. Larger intervention studies with more robust study designs and rigorous outcome measures are needed to fully assess the potential impact of fruit and vegetable gardens in ECE. Our study provides some justification for a future garden-based intervention in ECE in England, although we focused on perceived barriers rather than motivators to start a garden.
We also found that space was the most common barrier reported among nurseries. Although this was not what we expected, this finding provides information that can be used to tailor a future gardening intervention. While having enough space to grow sufficient amounts of produce can be challenging, there are solutions to help overcome this challenge. In our prior study where we established gardens in ECE programs in the US [49
], we used creative solutions to establish gardens in small spaces. There are numerous resources available for gardening in small or restricted areas that can apply to nurseries with insufficient space (e.g., hanging tomatoes pots) to address this barrier.
We expected nurseries to report cost as a primary barrier to establishing gardens. In a review of gardening interventions with older children, schools reported financial challenges as a substantial impediment to growing fruits and vegetables [53
]. To overcome this barrier, schools solicited donations from local businesses, held fundraising events, and applied for small grants to offset costs [53
]. In a prior qualitative study in ECE, providers expressed concern about having adequate financial resources to grow fruits and vegetables sufficient to feed children [16
]. Despite these prior findings, most nursery managers in our study did not express concern about costs associated with establishing fruit and vegetable gardens.
Food costs have been reported as a barrier to serving more fruits and vegetables during meals and snacks in previous studies in ECE. Growing fruit and vegetables as a way to reduce food costs may be a viable option for some ECE programs. Monsivais et al. found that increasing food expenditures in ECE settings would increase the total servings of fruits and vegetables available to children [41
]. A recent intervention in US-based Head Start centers established a fruit and vegetable delivery program with local farms to provide additional low-cost fruits and vegetables to children [54
]. Head Start serves mainly low-income children, and this study highlights the need to help offset costs associated with fruits and vegetables in this setting.
However, in order to reduce food costs, gardens need to yield sufficient produce to help feed all children in care. In our prior ECE garden study, we planned for one additional serving of fruits and vegetables per week for each child [49
]. Although this may not have a large impact on food costs, it could make a meaningful difference, especially over the long term if gardens are sustained. However, most of the prior gardening interventions designed for children 5 years and younger required only a modest amount of growing (e.g., seedlings in small paper cups) and did not result in full-scale gardens that would produce enough servings of fruits and vegetables for child consumption [52
]. Thus, the majority of the existing gardening programs aimed to expose children to growing fruits and vegetables but were not designed to provide enough to help offset food costs. If a goal is to decrease costs associated with purchasing fruits and vegetables, then it is important to establish gardens that will yield sufficient produce to feed rather than just expose children.
There are some limitations to this study. First, we obtained nursery manager opinions only, although we did encourage managers to speak with teachers at the nursery prior to completing the survey. However, interest in and perceived barriers to growing fruits and vegetables are likely reflective of the nursery manager and not the entire nursery staff. Responses may have differed if we had surveyed teachers (perhaps the ones more likely to care for the gardens) rather than managers. Generalizability is also limited by the response rate, even though responses were similar across deprivation tertiles in our sample. Despite this, our results may not be generalizable to other nurseries in England. However, our response rate is nearly identical to that of a similar survey of 211 ECE programs in New Zealand (54% versus 55%) [56
]. Further, we used surveys rather than qualitative interviews or focus groups because we were interested in assessing a wide range of nurseries across England and quantitatively exploring associations rather than the range of perceptions present. However, while IMD provides information on the area where the nursery is located, it does not necessarily reflect the socioeconomic status of the children in care (i.e., some children may not live close to the nursery). Therefore, the deprivation results apply to nurseries as a business located in their specific geographic area, but not necessarily to the children within the nurseries. Finally, we asked nursery managers if they were interested in growing fruits and vegetables at the nursery. However, we did not assess motivators to starting a garden. Also, the question of interest was not specific enough to assess interest in growing sufficient amounts of fruits and vegetables to help offset food costs at the nursery.