Needs assessment of child care centres in the former city of Toronto

Jane Ying, MHSc, CPHI(C),1 Joann Braithwaite, RN, CPHI(C), CIC,2 Rise Kogon, CPHI(C)3

ABSTRACT

In 1994 the City of Toronto Public Health Department conducted a needs assessment in the 235 child care centres (CCCs) in the former Toronto area. The purposes of the study were to construct a profile of Toronto's CCCs, to acquire a better understanding of these centres' operations and administration, and to assess their levels of compliance with current public health standards and regulatory requirements. During the study period, five certified environmental health officers audited the 235 centres and interviewed their supervisors using a standardized questionnaire to record self-reported and observational data. The study identified five priorities for public health intervention: written policy regarding monitoring and management of ill children, handling body substances, environmental sanitization procedures and frequencies, water-play table, and injury prevention. The results clearly call for expanding the conventional inspection focus (i.e., primarily food safety) to include other aspects of disease and injury prevention, and for strengthening the onthe-job training programs for CCC caregivers.

ABREGE

En 1994, le service de sante publique de la ville de Toronto procedait a l'evaluation des besoins des 235 garderies de l'ancienne region de Toronto. L'etude visait a elaborer un profil des garderies torontoises, pour mieux en comprendre le fonctionnement et l'administration, et A evaluer la mesure dans laquelle elles respectaient les normes et les exigences reglementaires de sante publique en vigueur. Au cours de l'etude, cinq agents diplomes en hygiene du milieu ont mene des verifications dans les 235 garderies et en ont interroge les surveillants au moyen d'un questionnaire type que ces derniers ont rempli eux-memes en y inscrivant leurs observations. L'etude a cerne cinq priorites d'intervention en sante publique: l'adoption de politiques ecrites sur le controle et la gestion des enfants malades, les precautions a prendre avec le materiel biologique humain, les mesures d'assainissement du milieu et leur frequence, l'usage des tables de jeu que 1 on remplit d'eau, ainsi que la prevention des blessures. Les resultats obtenus montrent clairement qu'il faut elargir la portee conventionnelle des inspections (surtout axees sur la salubrite des aliments) pour inclure d'autres aspects de la prevention des maladies et des blessures et pour renforcer les programmes de formation en milieu de travail a l'intention des intervenants des services de garde.

Whether due to economic necessity or cultural shifts, a growing number of mothers with young children have been joining the labour force in the past two decades. In Canada, 68% of mothers with young children were employed in 1991, up sharply from 52% in 1981.1 The number of licensed child care spaces in Canada has also increased from 17,000.in 1971 to 321,000 in 1990.2 As more families need to seek non-parental child care services, the demand for licensed child care spaces in Canada is likely to continue to rise.

Compared to those cared for at home, children attending child care centres (CCCs) experience a higher incidence of infectious diseases, in particular respiratory and gastrointestinal infections.3,4 Young children's poor personal hygiene and immature immunity to diseases, as well as their close proximity to other children of the same age group, are thought to be the contributing factors.3,4 Other public health issues such as safety, allergy awareness, nutrition, and prevention of long-term diseases also affect the quality of care provided in CCCs.

Child care centres in Ontario are licensed under the provincial Day Nurseries Act (1990) and Regulation 262, which require any premises that provide temporary care to more than five children under ten years of age to be licensed. Routine inspection of CCCs for control of communicable diseases is usually the responsibility of municipal public health units/departments, and the conventional focus of the inspection is on food safety, due to the health units' responsibility to enforce the Food Premises Regulation. In 1992 the Canadian Paediatric Society released the resource manual Well Beings. A Guide to Promote the Physical Health, Safety and Emotional Well-Being of Children in Child Care Centres and Family Day Care Homes,5 and its ten-part strategy for infection control was subsequently recommended by the Ontario Ministry of Health for health units to adopt as minimum standards.

Prompted by the release of Well Beings, and the Ministry's recommendation, the former City of Toronto Department of Public Health planned to expand its CCC inspection program to address a wider range of public health issues. A needs assessment of CCCs was undertaken by the Department in 1994 to aid in the design of the revised inspection program. The purposes of the needs assessment were to construct a profile of Toronto's child care centres, to acquire a better understanding of their operations and administration, and to assess how well the Well Beings' recommendations and the legislative requirements were being met in the CCCs. This article reports the findings from the needs assessment and identifies priorities in need of public health interventions.

METHOD

The needs assessment was conducted between May and September 1994 and it included all licensed child care centres in the former City of Toronto area. Using a standardized questionnaire, five certified environmental health officers (EHOs) audited the CCCs and interviewed the supervisors* or directors during the fivemonth study period. Training was provided to the EHOs prior to the commencement of the assessment.

The needs assessment questionnaire was developed based on the Ontario Day Nurseries Act and Well Beings, and it includes both self-reported and observational data. A total of 82 questions are contained in the questionnaire addressing: type of centre, age groups of children, management of ill children, sun safety measures, animal keeping, diaper changing, water-play table, food preparation, toy cleaning, injury prevention and security, and staff training and experience. The questionnaire was reviewed by three CCC supervisors and several infection control experts within the Department for content validity and comprehensiveness.

Due to the length of the questionnaire, each needs assessment was pre-arranged with the centre's supervisor. After a brief introduction about the purpose of the assessment, the EHO started by interviewing the supervisor about the centre's administration and health-related policies, followed by a "walk through" of the centre, usually accompanied by the supervisor. At each operational site specified in the questionnaire (e.g., diaper change table, waterplay table, kitchen), the EHO would observe the ongoing practices and ask questions about the operation. Any departure from the legislative requirements or Well Beings' recommendations was discussed with the supervisor, and when necessary, subsequent visits were made to follow up on the issues identified.

RESULTS

General profile

All 235 CCCs in the City were assessed between May and September 1994. An average of two hours was needed in each centre for the EHO to complete the questionnaire and to discuss with supervisors any issues needing attention. In five centres the supervisors were not available and a child care staff member was interviewed instead.

The 235 centres provide a wide variety of programs including "full-day", "halfday", "before/after school", "fewer than five days a week", and "any of the five 2hour periods within a day". The full-day program is however the most common arrangement (76%). Thirty-two (14%) of the 235 CCCs are operated for profit, and the remaining are run by non-profit organizations. Nine CCCs (4%) provide services to children with special needs, and 19 (8%) centres are parent co-operatives where the parents participate in the daily child care operations.

Of the 10,849 children (including fulltime and part-time) attending CCCs in the City, the majority (85%) were pre-schoolers or of school age, and only 15% were infants or toddlers. In fact, 134 (57%) CCCs did not have any infants or toddlers attending their centres during the study period.

A total of 1,666 caregivers were employed in the 235 CCCs in the City during the study period. The turnover rates of caregivers are shown in Table I. In approximately 15% of the 227 centres, more than one third of their current staff had been working in the centres for less than a year.

In terms of caregivers' professional training, Regulation 262 requires that all CCC supervisors must hold a diploma in early childhood education or have equivalent academic qualification, and have a minimum of two years experience in the profession. The Regulation also specifies that at least one caregiver for each age-group of children^ shall hold a diploma in early childhood education or have equivalent academic qualification. However, there is no requirement for a minimum level of education or professional training for all caregivers.

Under these stipulations, a mean of 14 years of experience, ranging from 2 to 36 (normal distribution), in the child care profession was found among the 230 supervisors/directors interviewed (five centres with missing data). Seventeen centres (7%) in the City were found to have at least one caregiver who did not complete secondary school.

Policies and operations

Table II summarizes the needs assessment findings pertaining to 13 administrative and operational aspects in CCCs, and outlines the relevant requirements and recommendations from Regulation 262 and Well Beings respectively for comparison.

DISCUSSION

While this was an assessment of CCCs within the former City of Toronto area, the administration and operation of CCCs elsewhere in the province or in the country are probably vulnerable to similar flaws and failures. The responsibility to enforce the Provincial Food Premises Regulation, and the lack of health-specific requirements in the Day Nurseries Act and Regulation 262, have until recently made food safety almost the sole focus of CCC inspection programs in Ontario. The findings of this needs assessment clearly call for an expansion of the inspection focus to include other aspects of disease and injury prevention.

The study identified five administrative and operational priorities for public health intervention:

1)Written policy regarding monitoring and management of illness

Caregivers of CCCs are faced with the issue of managing ill children on a daily basis, and most CCCs (91%) in the City have a written exclusion/re-admittance policy even though this is not required by any legislation. But a high percentage (24%) of them do not record the health reason when a child is too ill to attend or needs to be sent home. This again is not legally required, but it is important for early detection of outbreaks and control of disease transmission. A three-year longitudinal study conducted by Bartlett et al. found that continuous surveillance can effectively decrease the risk of diarrheal infections in CCCs.6 Daily surveillance can be easily incorporated into the children's daily attendance form using a "D" to denote absence due to diarrheal illnesses, "R" for respiratory illnesses, and "A" for other health reasons. A number of centres in the City adopted this practice after the needs assessment.

2) Handling body substance

Less than two thirds of CCCs have adequate procedures and equipment to handle spills of body substances. This is alarming, considering the widespread public health concerns with HIV and hepatitis infections. The low percentage (62%) of supervisors with an accurate understanding of body substance or universal precautions further attests to the need for education and training in this area.

3)Environmental sanitization procedures and frequencies

It is evident from examining the cleaning and sanitizing routines for diaper change areas, toys, and water-play tables, that many centres' current practices were inadequate. The wide range of sanitizers available in the market can be confusing to some CCC supervisors, and many of them were found to be using a costly but ineffective product for equipment sanitizing. While a number of sanitizers (e.g., quaternary ammonium products) are acceptable for use in CCCs, the Department recommends a chlorine-based sanitizer such as bleach for use at the diaper change area. Chlorine is inexpensive and effective in controlling both bacterial and viral agents. The latter is important for CCCs as viral infections such as rotavirus infection are particularly prevalent among young children attending CCCs.

Although many centres were able to meet Well Beings' recommended frequencies for equipment cleaning and sanitizing (i.e., weekly cleaning and sanitizing of toys and daily sanitizing of water tables), some centres found them unattainable. Staff shortage was often the reason cited, and this difficulty is fully acknowledged by the Department. Alternative means such as limiting the number of toys for each day, or integrating certain sanitizing procedures into the daily cleaning routine may help alleviate the workload.

4)Water-play table

In Ontario, "water-play table" is one of the required play activities for toddlers and older children in CCCs, and over 90% of the centres in the City use water-play tables at least on a monthly basis. Environmental surveys have identified both bacterial and viral contaminations in water-play tables, and one study even found up to 8,000 faecal coliform in some play-tables.78 Steps such as increasing supervision, thoroughly washing children's hands before and after the activity, frequent changing of the water, and when possible providing individual play basins and separate toys for each child, are measures that can help reduce the risk of disease transmission.

5) Injury prevention

Since injury prevention is a very broad subject, 20 specific indoor and outdoor safety checkpoints in Well Beings were selected for the needs assessment as a means of maintaining consistency and minimizing differences between the five assessors (Table III). It is very likely that a more extensive safety audit would have identified more potential safety hazards.

Well Beings provides three sample safety checklists for use on a weekly, monthly, and yearly basis. Only five centres at the time of the needs assessment used these safety audit forms regularly. While most centres do have some form of daily informal safety checks (e.g., check for foreign objects in sandbox), CCC supervisors should be encouraged to conduct a systematic safety check on a regular basis.

The overall study findings also indicate the need for improving CCC caregivers' awareness and understanding of infection control and injury prevention. Despite most CCC supervisors having many years of professional experience, the high staff turnover rate and the lack of any legislative requirement for all caregivers to possess a minimum level of child care training, suggest that on-the- job training for CCC caregivers should be a priority for both public health workers and the CCC supervisors. Krilov et al. showed that a comprehensive educational and infection control program could effectively reduce the rates of infections among children attending a specialized child care facility.9 Equally important is the incorporation of infection control principles and training into the early childhood education curriculum, and this requires a joint effort from provincial and municipal governments, and the educational institutions.

Although whenever possible, precise assessment criteria were incorporated into the questionnaire to reduce variation between assessors, a certain degree of professional judgement and personal interpretation was inevitable. During the study period, the team of EHOs met with the study organizers regularly to discuss concerns and to clarify the assessment criteria. Another limitation of the study is the lack of observational data regarding actual practices in CCCs (such as how caregivers washed their hands and how they changed the diapers). EHOs were unable to observe these practices in many centres during the short time of the visits. It should therefore be pointed out that many of the study findings refer to the centre's policies or are based on information reported by the supervisors as opposed to practices actually observed by the assessors.

CONCLUSION

The role of public health workers in CCCs should go beyond ensuring compliance with legislation. Through routine monitoring, education, and consultation, public health workers can help ensure the quality of care provided to children attending child care centres. By presenting objective details of administrative and operational problems in CCCs within a large urban area, this needs assessment may assist health professionals in Canada to design and provide a more effective inspection and education program for CCCs.

ACKNOWLEDGEMENTS

This study is a result of the commitment to more effective services by the former City of Toronto Department of Public Health. The authors wish to thank the infection control team members for their dedication to this project, the staff of the Metro Community Services Department and the Ministry of Community and Social Services for their support and assistance, and Dr. Tim Sly of Ryerson Polytechnic University for reviewing the manuscript.

[Reference]

REFERENCES

[Reference]

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3. Thacker SB, Addiss DG, Goodman RA, et al. Infectious diseases and injuries in child day care. JAMA 1992;268(13):1720-26.

4. Holmes SJ, Morrow AL, Pickering LK. Childcare practices: Effects of social change on the epidemiology of infectious diseases and antibiotic resistance. Epidemiol Rev 1996;18(1):10-28.

5. Canadian Paediatric Society. Well Beings: A Guide to Promote the Physical Health, Safety and Emotional Well-Being of Children in Child Care Centres and Family Day Care Homes. Toronto: Creative Premises Ltd, 1992.

6. Bartlett AV, Jarvis BA, Ross V, et al. Diarrheal illness among infants and toddlers in day care centres: Effects of active surveillance and staff training without subsequent monitoring. Am J Epidemiol 1988;127(4):808-17.

7. Butz AM, Fosarelli P, Dick J, et al. Prevalence of rotavirus on high-risk fomites in day-care facilities. Pediatrics 1993;92(2):202-5.

8. Fok N, Zazulak E, Mak T. Water Play-Tables in Child Care Centres: Vehicle for Disease Transmission and Control Strategy. Edmonton Board of Health, 1993.

9. Krilov LR, Barone SR, Mandel FS, et al. Impact of an infection control program in a specialized preschool. Am J Infect Control 1996;24:167-73.

Received: September 15, 1997

Accepted: February 13, 1998

[Author Affiliation]

1. Health Promotion and Advocacy Services, Toronto Public Health

2. Communicable Disease and Epidemiology Services, Toronto Public Health

3. Environmental Health Services, Toronto Public Health

Correspondence: Jane Ying, Program Consultant, Health Promotion and Advocacy Services, Toronto Public Health, Toronto Office, 277 Victoria Street, 3rd Floor, Toronto, ON, M5B IWI, Tel: 416-3927685, Fax: 416-392-1482, E-mail: jying@city.toronto.on.ca