Implementation of Federal Waivers for Feeding Children in Early Care and Education During the COVID-19 Pandemic.

OBJECTIVE: To capture Child and Adult Care Food Program (CACFP) state directors' experiences implementing federal waivers for feeding children in early care and education (ECE) settings during coronavirus disease 2019.
DESIGN: Qualitative semistructured interviews.
SETTING: Virtual interviews with state CACFP directors. PARTICIPANTS: Child and Adult Care Food Program directors from 21 states from December 2020 to May 2021. PHENOMENON OF INTEREST: Implementation of state-level waivers. ANALYSIS: Qualitative thematic analysis.
RESULTS: State directors reported that the coronavirus disease 2019 waivers allowed ECE programs to continue feeding children despite being closed or having limited enrollment. The meal pattern, noncongregate feeding, parent/guardian meal pick-up, and monitoring waivers were most frequently used by states. Challenges included maintaining integrity to CACFP meal pattern requirements, addressing the limited capacity of ECE to produce and distribute noncongregate meals, and adapting technology for virtual reviews. Suggested improvements included streamlined communication from the US Department of Agriculture, standing waivers for emergencies, ongoing flexibilities for feeding children, and strategies to increase CACFP enrollment and reduce financial viability requirements for ECE. CONCLUSIONS AND IMPLICATIONS: Results indicate the need for the US Department of Agriculture to consider issuing and extending waivers, increasing ECE participation in CACFP, and ensuring timely communication and guidance on waiver tracking.

INTRODUCTION

The Child and Adult Care Food Program (CACFP) is a critical component of the federal nutrition safety net, ensuring access to healthful foods for income-eligible children participating in early care and education (ECE) programs. The CACFP reaches more than 4.2 million children daily through reimbursements to ECE programs to provide meals and snacks to children that meet meal pattern requirements. Research has shown that children enrolled in CACFP-participating ECE programs have improved access to nutritious foods compared with those enrolled in nonparticipating ECE programs2, 3, 4, 5 and compared with what is available to children at home. Furthermore, CACFP participation has economic implications; low-income households can reduce their food expenses, and ECE providers receive reimbursements for food purchases and free nutrition education and resources.

Early in the coronavirus disease 2019 (COVID-19) pandemic, many ECE programs closed, operated at limited capacity, or experienced reduced enrollment as parents opted to keep children home. These changes resulted in a 20% decrease in average daily attendance in CACFP-participating ECE programs and placed more than 900,000 children at risk of losing access to the healthful meals that CACFP-participating ECE programs provide. Program closures also increased families’ risk of food insecurity and children's risk of nutrition-related health conditions, such as obesity. Prompted partly by the widespread ECE closures, Congress passed the Families First Coronavirus Response (FFCR) Act that allowed the US Department of Agriculture (USDA) to provide waivers to states that enabled CACFP-participating ECE programs to continue distributing nutritious food to children.

Key waivers created by the FFCR Act that impacted CACFP-participating ECE programs included the meal times waiver, which allowed ECE programs to serve meals outside the standard mealtimes typically required by USDA; the noncongregate feeding waiver, which allowed ECE programs to serve meals outside of a group setting; the parent/guardian meal pick-up waiver, which allowed parents or guardians to pick up to-go meals without having their children present; the monitoring waiver, which relaxed state CACFP agencies’ requirements for in-person monitoring of ECE programs; and the meal pattern flexibility waiver, which allowed for reimbursement of meals that did not meet the meal pattern requirements. Although the federal waivers were available to all states, each state had to formally opt-in to use any or all of the waivers. Once states’ requests were approved, state CACFP agencies approved individual CACFP-participating ECE program's use of the waivers.

Despite the significant resources invested in creating these waivers and most states opting to use all the waivers, very little is known about the implementation of the waivers. Significant variation in waiver implementation among states may have resulted in diet-related inequities for children served by CACFP, underscoring a critical need to understand the state-level implementation of these waivers. Understanding how waivers were implemented has implications for improving CACFP by guiding the implementation components about the waivers that did not work, so these can be refined for the next emergency. Thus, we aimed to capture the experiences of CACFP directors on state-level waiver implementation to better inform future program and policy efforts for feeding young, low-income children during ECE program closures or interruptions such as those caused by COVID-19.

METHODS

Research Design

We followed a basic qualitative research approach wherein semistructured interviews were used to explore state CACFP directors’ perspectives and experiences regarding the challenges and facilitators of implementing waivers for CACFP-participating ECE programs during the COVID-19 pandemic. The University of Nebraska–Lincoln Institutional Review Board approved all procedures and deemed this research study exempt.

Participants and Recruitment

Individuals were eligible to participate in the study if they were a state-level CACFP director or another state employee who assisted in implementing CACFP waivers. Hereafter, all participants are considered state CACFP directors regardless of their official position title. Researchers obtained contact information for CACFP directors through searches of each state's CACFP website. State CACFP directors with contact information published on the state's CACFP website (n = 42 states) were sent an email and invited to participate in this study. If participants did not respond, 1 follow-up email was sent each week for 2 weeks following the initial invitation until researchers completed 3 attempts to connect. Participants were offered a $30 gift card. Twenty-four directors from 21 states agreed to participate, 8 declined, and 13 did not respond. All participants gave written, informed consent to participate.

Data Collection

Semistructured interview questions were developed by the coauthors and other members of the Nutrition and Obesity Policy Research and Evaluation Network Early Childhood COVID-19 Work Group. Questions were reviewed by an expert committee with backgrounds in CACFP policy, ECE nutrition, and/or qualitative methods (Table 1 ). Interviews were conducted via Zoom (Zoom Video Communications, Inc, 2021) by experienced qualitative researchers from December 2020 through May 2021. Interviewers did not have any previous relationships with participants. All interviews lasted between 45 and 75 minutes. Participants were sent the interview questions before the interviews, and the authors reiterated the goals of the study at the beginning of the interview. After each set of 2–3 interviews, the interviewers met to discuss major themes identified during the interviews. The interviews continued until the researchers determined that saturation was reached or no new information was revealed. All interviews were video and audio recorded.

Table 1

Interview Protocol to Capture State-level Child and Adult Care Food Program (CACFP) Waiver Implementation and Strategies in Early Care and Education (ECE) During the Coronavirus Disease 2019 (COVID-19) Pandemic

Protocol Steps
Introduction
Thank you again for taking the time to speak with me regarding how CACFP functioned in your state during COVID-19, including some of the challenges and facilitators that emerged. I expect the interview to take approximately 45 min. Feel free to let me know if you need to pause or take a break at any time. With your permission, I'd like to audio-record our conversation [get permission].Before we get started, do you have any questions for me?
Stakeholder information
• Could you verify your current title and position?
• How many years have you been in this position?
• What is your highest level of education or any training pertaining to the position?
Understanding context
• What role does the state agency play with regard to the administration and implementation of CACFP?
• How did COVID-19 impact child care in your state? Feel free to share how this has changed from the beginning of COVID-19 in March until now.
• As you know, CACFP nationally provides 4 million meals to low-income children. With COVID-19, how were children in child care who would normally be getting meals through CACFP impacted in your state?
Waivers: Use, benefits, challenges, and communication channels
• As you are aware, the US Department of Agriculture (USDA) provided waivers to make it easier for CACFP-participating providers to feed children during COVID-19, such as allowing grab-and-go. Can you discuss how these waivers were implemented in your state?  • Were they used?  • Which ones were mostly used?  • Has the use of waivers changed, and how?
• How did you communicate with sponsors and providers about the waivers?  • What are some challenges you faced in communicating the waivers to programs (eg, communication/clarity from     USDA, challenges in monitoring, paperwork, and training their staff)?  • What questions and concerns have sponsors/programs raised with regard to the waivers?  • How were they resolved?
• Beyond communication, what other barriers have sponsors or programs faced using the waivers?  • What solutions have sponsors/programs come up with to overcome challenges with regard to the waivers?     [another potential cue to ask for contact info if they mention a specific strategy from a program/sponsor]
• In your opinion, how helpful were the waivers in feeding young children attending ECE?  • Tell me about child care programs using waivers to feed children not attending child care? Give me some     examples of things they did?
• How did other resources, organizations, or entities help feed young children in your state?  • If you were asked to advise other states to begin such a partnership, where should they begin? What are some     key things to get started to make the partnership work?  • Are there any other barriers or facilitators you can think of?
• Tell me about your state's rollout of the pandemic electronic benefit transfer benefits to CACFP families? What has your experience been with this program? What are the challenges you're facing with this process?
Future steps
• What supports, resources, or professional development would help you continue? Would it help you or your staff   continue to support sponsors and programs during COVID?
• Thinking ahead and as COVID-19 evolves and waivers are extended, what other kinds of changes do you think you   will need to make to ensure young children continue to be fed?
• What have you learned that can help improve USDA and/or CACFP best practices or meal service now and beyond   COVID-19?
• What were some success stories?
• Who were your biggest partners, and what advice would you give other states to establish such partnerships?
• What are your biggest concerns for the long-term future in terms of meeting the needs of young children in your   district/area?

Data Analysis

Interview recordings were transcribed verbatim, checked for accuracy, and uploaded to NVivo (version 12, QSR International Pty, Ltd, 2020) for data analysis. In this study, thematic analysis followed the realist method, which reports experiences, meanings, and the reality of participants. Themes were identified using an inductive approach at the semantic level, meaning our themes were identified using the explicit meaning of the data, without looking beyond what the participants said during the interviews. Development of themes focused primarily on participants’ voices, and emergent themes were descriptive to capture the semantic meaning and summarize the range of participants’ experiences. Data were coded using the 6 steps of thematic analysis as follows. First, coders familiarized themselves with the data by thoroughly reading the transcripts from each state multiple times and identifying patterns of responses. Second, codes were developed inductively by identifying units of meaning derived from the transcripts, and a codebook was developed. Third, codes were generated and grouped into potential themes and subthemes. Coders discussed grouping and arranging codes and reached a verbal agreement for all potential themes and subthemes. Fourth, possible themes and subthemes were reviewed between authors. The themes were reviewed for consistency with the codes to ensure they represented the data. Fifth, themes were defined, named, and assessed to ensure the data supported them. Sixth, a final report included the themes, subthemes, and representative quotes. All authors reviewed the initial themes and the final report to ensure that the data supported all generated themes and subthemes. The authors discussed any inconsistencies until an agreement was reached. Throughout the process, strategies to promote trustworthiness were employed. These strategies included establishing credibility through peer debriefings with all authors present; establishing dependability through the use of audit trails , that documented all decision-making during data analysis and records of codebooks, raw data, field notes, and transcripts; and maintaining reflexivity throughout the process by monitoring our biases through peer consultations and frequent team meetings. ,

RESULTS

Participants were from 21 states representing the 7 USDA Food and Nutrition Services regions with 2 states representing the Mid-Atlantic Region, 4 states representing the Midwest Region, 5 states representing the Mountain Plains Region, 1 state representing the Northeast Region, 3 states representing the Southeast Region, 3 states representing the Southwest Region, and 3 states representing the Western Region. State CACFP-participating ECE programs had an average daily attendance ranging from 6,000 to 121,000 in 2020. Participants had been in their positions for an average of 7.2 ± 7.2 years. All participants had earned a bachelor's degree or higher. Table 2 summarizes the identified themes and subthemes and their representative quotes.

Table 2

Description of Themes, Subthemes, and Representative Quotes From State Child and Adult Care Food Program (CACFP) Directors on Waiver Implementation With Early Care and Education (ECE) Programs During the Coronavirus Disease 2019 (COVID-19) Pandemic

Theme	Representative Quote
Theme 1: Waivers were used to continue to feed children, address food shortages, and maintain connections
Waivers allowed child care programs to continue feeding children when children could not attend child care each day	“The waivers gave options for the child care to continue serving the meals, because there are [usually] a lot of the requirements that they have to stay within the mealtimes and serving the meals on site, and [allowed] that flexibility to be able to continue serving kids. And so, the ones not attending child care, they were able to do the grab and go meals and have parent pickup, but they also have the delivery option to some of the families that could not come out of their home. That was a good option that USDA provided.”
The meal pattern flexibility waiver was widely implemented in states with food supply shortages, especially at the beginning of the pandemic	“The waivers for the meal pattern were important because they couldn't get milk or they couldn't get whole grain rich items are so there was some food shortages in the beginning, not so much probably through fall and this era time. We are now experiencing milk shortage, so that waiver has been used in that way.”
The monitoring waiver granted flexibility so there could be dedicated staff for technical assistance, waiver implementation, troubleshooting, and safety.	“The sponsor monitoring waiver was really helpful for those agencies, especially some of the agencies that have school, or have child cares all across different towns because then they didn't have to go from one town to the next and potentially spread the virus if they're going from a community that has a really high rate right now, and then going somewhere else that maybe has a lower rate. That's the biggest thing we've heard. They have all really appreciated that waiver so that they could relax some of that monitoring.”
Theme 2: The meal pattern, noncongregate feeding, parent/guardian meal pick-up, and monitoring waivers were most commonly used by states and used in conjunction with each other, and state CACFP directors reported challenges and strategies regarding waiver implementation
Meal pattern flexibility waiver
Challenge: Preserving meal pattern integrity State CACFP directors preserved the integrity of meal pattern requirements by approving the waiver with adequate justification and providing resources for healthy substitutes for foods that were not available	“And so, with the CACFP meal pattern, one of the challenges was probably in some of the rural areas they were having a hard time finding whole grain products to meet the whole grain requirement. So, we did a lot of flexibility on that, but made sure that they had a grain. But we allowed waivers in the meal pattern with whole grain rich. Just to make sure that they were serving all the components and they had a grain.”“The one waiver that we did see utilized more in the beginning of the pandemic, not so much now, is the meal pattern waiver because it was a meal pattern waiver issued for CACFP. We approved to do it on a case-by-case basis, they had to tell us specifically what the issue was [before] we would grant waivers.”
Noncongregate feeding waiver
Challenge: Feeding families The utility of the noncongregate feeding waiver was limited because it only allowed child care programs to serve meals to children enrolled in child care and not all children in the family	“I think the summer feeding was absolutely critical or having some method outside of CACFP that could feed the complete family. Because that was one of the big issues we were struggling with was feeding that family as a whole. You know if they have three children and two are in school and one's in daycare we have to have a reasonable method of how we're going to feed all the children in the family.”
Challenge: Limited capacity It was challenging for child care providers to implement the noncongregate feeding waiver because they had limited capacity for staffing, packaging, delivery, and storage space	“With the non-congregate feeding waiver, one of the things that we got a questions on that was an issue for some of our providers was getting the paper products or to-go containers, and then also the added expense of that, met with also like a delivery expense that they didn't necessarily have before, just some extra expenses around that that isn't really covered in their normal reimbursement because they're probably doing fewer meals, and getting less reimbursement but also adding this additional service on to meet their participants where they are. That was a huge thing with gas and mileage and delivering, as well as those to-go containers because as we know, a lot of restaurants and other types of programs switched to a lot of to-go containers for their own services that they were offering so it was harder for them to find those things.”“Being able to do more than one day distribution was important because the staffing. It was difficult to have to staff up daily for those small number of meals.”
Overcoming challenges: Limited capacity Child care programs addressed challenges by preparing meals that were easy to pack, offering bulk products, and coordinating meal deliveries with the Department of Transportation.	“We did find that [child care programs] were much more likely to give out the cold meals, instead of hot meals. And so, in this case, they could prepare them in the morning, and instead of putting them in the fridge they could put them in a cooler, or something like that and maintain the temperature that way. They also were more likely to, first of all, for supply reasons, but also because it does take up a little bit less space, I think, they would give out more bulk quantities. Instead of giving out multiple, for those sites that could give out some bulk, instead of giving out like individual small cartons of milk, the family might get a gallon of milk and that might include all the breakfast and lunch milk quantity for the week, and then they wouldn't have to give out milk with every single meal.”“Most of our school districts developed what we call distribution routes, and parents could come to a particular school site, but also families could call in and they would be placed on a list, and the distribution routes would be the traditional bus routes. So they were going right to the kids home and for some areas of the community if we had a call from an apartment complex where not a lot of kids go, we may have had some younger kids, the school district would include them as a route or stop as well. And once we received that flexibility, that meal time waiver, that mealtime restriction flexibility that allowed us to kind of bundle meals, it helped to reduce transportation costs.”
Challenge: Food safety It was challenging to adapt noncongregate meals for pick up or delivery and meet food safety standards	“We did provide overarching food safety guidelines, but food safety. The actual authority in [our state] is county by county so each county might have slightly different requirements and so just making sure they were meeting the county requirements for food safety was always a concern.”
Overcoming challenges: Food safety As a strategy to ensure food safety, some state CACFP directors reported providing technical assistance and educational materials.	“We did a lot of technical assistance on how to provide a take home meal and what guidance to give them about storage and preparation or that sort of thing. We had not done any take home meals before, so making sure they held temperature and those sorts of things we had to provide a lot of education on.”
Parent/guardian meal pick-up waiver
Challenge: CACFP verification It was challenging for child care programs to verify CACFP participants during parent pick up	“The problem, you know, just being realistic, [parent pick-up is] a great thing and it's a very necessary thing, but it also does allow and cause some concerns as an administering agent because the rules are kind of loosey goosey. And, it does allow for people to maybe bend them in not the way they were intended or to add a couple meals here there because there really is no way. I mean people could pull up, the parents could even pull up so they can say, “We have five kids,” and they would give them 35 meals. And maybe they have no kids, and we didn't know that. You know, and in fact, not the intent of that, but I do think if you want to know that the constructs of a space, yes, I think when you are a state that really tries to keep your ducks in a row, this does make it a bit difficult to monitor and keep on track.”
Challenge: Duplication of meals It was challenging to prevent duplication of meals served between other child nutrition programs such as the Summer Food Service Program	“[The Department of Education] and [CACFP and SFSP] had to coordinate really close together to make sure a) we weren't overlapping in service and both serving the same thing and b) that the schools were picking a side, either they were going to stay with the school lunch or the same with summer, or they were going to go with our program. And so, we had to work together to make sure that we were picking the right waivers we were implementing everything and then we were also doing our administrative oversight to make sure there wasn't duplicate participation.”
Monitoring waiver
Challenge: Adoption of technology Adapting to technology for monitoring was challenging for child care programs	“Technology has been a big point of discussions specifically with our offsite reviews. I mentioned this before I'll mention it again though, there's a lot of very rural frontier areas in [our state] and with that comes the lack of a high bandwidth. So doing a Zoom call or a FaceTime or Skype would either break up or you wouldn't be able to get completely through a call, that's happened to me and it's also happened to sponsors while they're trying to conduct their monitoring reviews.”“The monitoring waiver to basically do desk reviews is great in certain circumstances, but what we're finding is it's taking us longer to get the review done and we're having more issues because those things that we would normally just observe or get when we're out there on site, then become a challenge because we're back and forth and back and forth saying you didn't send me this, or we're missing this particular piece, or I need you to take a picture of your notification that you have your justice for all poster posted, and I need to have you send your labels for your meal, take pictures of your labels. People struggle with that and that's a big burden on our sponsors.”
Overcoming challenges: Adoption of technology Using alternative strategies such as phone interviews, sending supporting documentation, and following best practices for virtual reviews	“[Child care programs] did the best they could with [technology], whereas our sponsors reported that you know there was a lot of pictures that were sent, there was a lot of telephone conversations.”“We used the best practices for monitoring document for state agencies as well for really streamlining how our virtual monitoring for our reviews, for how that would play out for this fiscal year because we were really just scrambling and being flexible, yet meeting our requirements once COVID hit. When we switch to doing our virtual reviews because that was not something that we had ever done either, so we worked through some of the challenges, but we were like happy to see the best practices document, and it helped us define what our protocols are for our reviews during COVID for this fiscal year.”
Theme 3: Implications for policy. Timely communication from USDA, standing waivers and continued flexibilities for feeding children, increasing CACFP enrollment, and reducing financial burden on child care are continued critical needs
Timely and clear communication from USDA: State CACFP directors reported the need for clear communication regarding waiver usage and tracking from USDA
Timelier and streamlined communication from USDA regarding waiver implementation, waiver extensions, and responding to questions	“I think that the thing that has been the most difficult for everybody throughout this is just like the lack of agility in terms of responding to something like this. So, I think that the USDA did the best that they could, given the circumstance. But, I mean, it wasn't fast enough. We were not hearing back on waiver requests. We weren't issuing them quickly enough.”“There was a lot of nationwide waivers that came out so it was getting very confusing on which waivers the sponsors needed to use, and which one was still effective, and which one had expired. So, that was very challenging to make sure that they understood which waiver was still effective.”
Challenges regarding tracking waiver usage and understanding what data to report back to USDA	“I think a lot of questions from our providers to our sponsors to us was, “What is my record keeping look like during COVID?” That was a huge question about what's required, especially during the non-congregate feeding, “What do we really need to keep because they're not really in attendance? Do we keep an attendance?”
Streamline waiver communication where USDA communicates about waivers with the state directors, who then communicate with sponsors and providers	“I will say one of the largest issues that we had with the waiver information is that the waivers were released, the sponsors understood them, or knew about them but maybe didn't understand how they were supposed to be used, so were asking to be able to utilize them before the state agency truly understood the purpose of the waiver and the intent of the waiver and to what extent it could be used. So I would say that was probably one of our largest hurdles is that the information was available to the public and. Yes we didn't get the guidance as timely as we could have. We had to tell a lot of our sponsors which fortunately we have a good working relationship with our sponsors and they understand that that can be an issue, that information gets publicized before we really know what's going on with it.”
Offer a wide variety of mechanisms for timely and effective waiver communication from state agencies to CACFP sponsors and child care programs	“So, we already had a broadcast email system to communicate with all the sponsors on. Anytime there's policy memos that come out, updates and such, we send out broadcast emails to all the sponsors. And so, we used that same system to communicate with them.”“Again, we were calling them every day, and we are still calling the sponsors every week, so it was conversational. Each of the staff was doing their own recommendations based upon that need so I can ask them if they had any suggestion, what the suggestions were and the problems, but I do not have anything in writing. That's because it was that one on one thing that we're doing.”“And then we did offer just one-on-one technical assistance…. We felt like it was better to communicate with them individually. And just address their questions and their assistance needed that way because technology, for the most part, can sometimes be challenging for those folks.”“We created some resources that we can give you links to. One of them is our “At a Glance” document that summarizes all of the currently available waivers, and what their deadlines are, and gives like a quick synopsis of what this is. We have a “Frequently Asked Questions” document that we just kind of collated all of our most frequently asked questions during COVID with their answers. We can give you a link to that, and then we also have our CACFP Training Calendar that we created at some point during COVID to help them know when we have our different trainings live that are available.”
Standing waivers and continued flexibility: State CACFP directors reported the need for standing waivers to implement during emergencies and continued flexibility to implement the meal pattern and monitoring waivers
Flexibility to transition between normal and emergency regulations moving forward	I have learned that when there are public emergencies such as a pandemic or now in the Midwest a big storm, that if there was an easy way to transition from current regulation to adjusted regulation without having to opt in or have a big formal process or formal, I mean yes we do need to provide a plan of how we're going to ensure program integrity. I just feel that it will be easier for our organizations to say “Okay well this happened, so we can automatically go back to our pandemic plan.”
Permanent waiver allowances for continuing to feed children during situations such as child care closures or isolation for illness, during evenings, weekends, and holidays	“I would love to see us to continue providing meals to our programs on weekends for children. I would like to see recognition of the fact that children are hungry on weekends and holidays, too, and I would like to see, with COVID again, it is brought this to the forefront, I think. We always knew that children we're hungry, people who work with it on weekends and holidays, but I would like to see CACFP have the ability to feed children, to give children food on weekends and holidays.”“There are a lot of advocacy groups out there that are pushing for these [waivers] to continue forever. You fed them, basically, we fed them free for a year. Clearly, we can continue to do that. There, I hear that on several calls in our State for advocacy groups and when we have our, our regional call with our USDA office, they, other States are saying the same thing. There's a huge push for universal free feeding on all programs. Because they feel like it's clear that we can do it because we've had to do it for a year, so let's just keep it up.”
Continued flexibility from USDA so states can adjust meal patterns and monitoring requirements to their specific needs	“I think, and I mentioned it earlier, I would like to see USDA allow the state to use waivers when needed. I'll give you an example. We realize the importance of whole grain products, but when you live in a rural area, and you have maybe one little tiny local mom and pop, little tiny, tiny store, it's hard to find whole grain and our provider sometimes have to travel 20 to 30 miles to find a loaf of true whole grain bread or products that have that are whole grain. I don't want to see, and I want to be able to use some waivers when they're necessary.”“The continued flexibility from USDA has been so helpful, and allowing us as a state agency to work with our sponsors for what works best for them, rather than USDA prescribing, “This is what you have to do.” They understand that every state is different and every region is different and so being able to have that flexibility to work with the sponsors as needed and having USDA be willing to grant flexibilities when needed, is really, really helpful.”
Increase CACFP enrollment and reduce financial burden on child care: CACFP directors suggested strategies such as changing financial viability standards for CACFP, lowering income eligibility requirements for for-profit centers and some states also reported state-funded grants and resources to increase CACFP participation and alleviate the financial burden on child care
Support child care providers to leverage funding through the state or other sources by developing a repository of funding sources for child care and supporting providers to apply for such funding	“I think our governor has done a pretty good job of providing grants to child care providers to stay open. I can't speak to all the grants. It's really hard to keep up with what's going on in our world and their world. We do receive their newsletter, but the grants are for their operation, and to help them stay open....I think the governor's focus on child cares staying open has prevented most of our centers and homes from closing. I know I've talked to our family child care home sponsors, and they're stable. They're holding steady with providers. They may have lost a couple, but if anything, they've probably added more because there's a hunger issue, and the providers are recognizing the value of programs like CACFP.”Well I also mentioned the Office of Childcare and Development which distributes our state funded reimbursements for families for child care. Our partnership with them was very important, they offered several grants throughout COVID to child care providers. Yeah they've offered grants that child cares could apply for and then those childcares could then credit families for their childcare fees even if they were not getting state assistance.
Change financial viability standards for CACFP participants because programs may no longer be eligible because of the financial effects of COVID-19	“I think that the, financial viability standards that are embedded within CACFP are limiting a lot of our smaller and sometimes our newer centers and organizations. …Of course we expected a, a downward trend this year, but so many of our organizations have not been able to meet that standard because of COVID. The pandemic has kind of put them back, push them back a couple of years maybe. And I think if the State agencies could have some flexibility when it comes to that particular performance standard. They, they they're willing to have that program accountability measure. They just don't have contingency funds. They have just enough money to pay the bills that they get. So if we could have a bit more flexibility when it comes to new organizations, even if it's probationary, but we have a lot of sponsoring organizations that are fearful of bringing on sites that aren't financially solvent. We don't mean those where the house is about to burn down, but if you're just making ends meet, this is really who we should be looking for because that's who really would benefit from the program.”
For-profit centers may need lower eligibility requirements to continue to participate in CACFP	“The other thing that was a really negative impact was on our for-profit centers, because they still had to show that they were 25% or above [low-income] in the children that they served, and when they were taking care of first responders, that skewed that number so then they weren't able to claim on CACFP because their income level for their children was about that 25%. We did ask for waiver from USDA and we have gotten no response. And so, for example, we have someone who called us who was at 24.5%, free or reduce, who still could not claim.”

USDA indicates US Department of Agriculture.

Theme 1. Waivers Were Used to Continue Feeding Children, Address Food Shortages, and Maintain Connections

State CACFP directors perceived that the waivers were critical to ensuring that young children were fed and families could avoid food insecurity early in the pandemic. As 1 state director said, “I think within our state, if we had not opted in and been granted those flexibilities [waivers], we would have had mass food insecurity in our state.” Specifically, the meal pattern flexibility waiver was widely used and essential in states in which food supply shortages occurred. See Table 2 for more representative quotes. Furthermore, state CACFP directors reported that the monitoring waiver, which reduced requirements for monitoring, granted flexibility and time for CACFP staff to provide technical assistance with waiver implementation. This allowed CACFP staff to maintain connections with CACFP-participating ECE programs even though routine monitoring was not occurring.

Theme 2. The Meal Pattern, Noncongregate Feeding, and Parent/Guardian Meal Pick-Up Waivers Were Used Most Often by States

State CACFP directors reported what waivers were most used in their respective states. State CACFP directors discussed how the waivers worked together. For example, directors described how ECE programs that wanted to use the parent/guardian pick-up waiver also had to apply for the noncongregate meals waiver and the mealtime waiver to remain in compliance with all CACFP guidelines and receive the necessary flexibilities. Further themes emerged specific to each waiver regarding limitations, challenges implementing the waivers as intended, and strategies states employed to overcome these challenges.

Meal pattern flexibility waiver

Subtheme: State CACFP directors felt the need to preserve the integrity of meal pattern requirements before approving its use. The meal pattern flexibility waiver allowed for reimbursement of meals that did not meet the meal pattern requirements. One of the biggest challenges with implementing the meal pattern flexibility waiver was maintaining integrity to the meal pattern. This was difficult because it required additional time and resources to work with each ECE program to determine the best options available and follow meal pattern requirements as closely as possible. For example, when ECE programs could not purchase whole grains, state agencies worked with them to still serve whole grain-rich food items by finding an alternative or encouraging ECE programs to at least offer some type of grain. One state CACFP director said,

We do ask folks who are operating, “What are you serving?” because we don't want them going from fresh fruits and vegetables, bananas, broccoli, and chicken breasts to honey buns, chocolate milk, and vanilla wafers. We are regulating, and they know that the Meal Pattern [Flexibility] Waiver is not a free-for-all. We do say, “If you can afford to stick with the meal pattern, of course, stick with the meal pattern.” [However] we understand there are going to be times when now that item might not even be available to you.

In addition, some state CACFP directors confirmed the need for this waiver before approving ECE programs to use them. For example, several states reported only authorizing ECE programs to use the meal pattern flexibility waiver after verifying a food shortage in their area. By following these strategies, state CACFP directors used the meal pattern flexibility waiver when necessary without compromising the CACFP meal pattern requirements.

Noncongregate feeding waiver

Subtheme: State directors perceived the utility of the noncongregate feeding waiver was limited because it only allowed child care programs to serve meals to children enrolled in child care and not all children in the family. The noncongregate feeding waiver allowed ECE programs to serve meals outside a group setting. Although the noncongregate feeding waiver was widely implemented across states, CACFP directors reported challenges related to inherent limitations with this waiver. Specifically, the first challenge was for families with school-aged children and children enrolled in ECE programs. For these families, ECE programs participating in CACFP could only provide meals for the children enrolled in the ECE program, meaning families had to find other sources of meals for their school-aged children.

Subtheme: It was challenging for child care providers to implement the noncongregate feeding waiver because they had limited capacity for staffing, packaging, delivery, and storage space. Early care and education programs did not always have the capacity or infrastructure to implement noncongregate meals. Before COVID-19, ECE programs that served children prepared meals on site or had meals delivered by vendors. As the noncongregate feeding waiver allowed ECE programs to distribute meals outside of the group setting, ECE programs were then required to develop or purchase meals that could be delivered to children elsewhere. Commonly, ECE programs did not have sufficient staff to produce, package, and distribute the to-go meals. In addition, several ECE programs did not have storage or refrigerator space for the to-go meals, nor did ECE programs have the resources to deliver meals to children whose parents could not pick-up meals. One state CACFP director said,

[ECE providers] would tell us, ‘Oh, I want to give out a week's worth of meals.’ And we had to say, ‘Okay, let's stop and think about this, because how are you going to do that? You don't have huge commercial refrigerators. Do you have the staff to be able to prepare all those meals at once and get them out?’

Subtheme: Child care programs addressed challenges by preparing meals that were easy to pack, offering bulk products, and coordinating meal deliveries. To overcome the challenges of packaging and delivering meals, CACFP directors reported working with ECE programs to develop menus with food items that were easy to package and encouraged programs to offer foods in bulk packaging (eg, milk, rice, and bread for the whole week). Prepackaging of foods allowed programs to meet needs for the entire week rather than 1 day of meals. Regarding delivering meals, 1 innovative strategy some state CACFP directors reported was partnering with the state's Department of Transportation to deliver meals to children's homes using school buses.

Subtheme: It was challenging to adapt noncongregate meals for pick up or delivery and meet food safety standards. Early care and education programs found it challenging to adapt noncongregate meals for parent pick up or delivery while maintaining food safety standards. Safely holding food at appropriate internal temperatures was a new challenge for several ECE programs that were used to prepare meals before serving them to children. State CACFP directors and their staff provided programs with technical assistance and educational materials to overcome food safety challenges.

Parent/guardian meal pick-up waiver

Subtheme: It was challenging for child care programs to verify CACFP participants during parent pick-up and prevent accidental duplication of meals with other child nutrition programs. The parent/guardian meal pick-up waiver allowed parents or guardians to pick-up to-go meals without having their children present. Given the waiver stipulation that CACFP can provide meals only to children enrolled in CACFP-participating ECE programs, state directors reported that it was challenging to verify if the parents were picking up meals for CACFP-participating children and, if so, how many. In addition, state CACFP directors reported challenges not duplicating meals served by other child nutrition programs such as the Summer Food Service Program (SFSP). For example, state directors reported that some SFSP sites also acted as CACFP sites, meaning they submitted claims for meals served to both programs. The CACFP and SFSP worked closely with these sites to ensure that meals were submitted appropriately for reimbursement. One strategy to overcome this challenge was for programs to delegate which meals would be claimed with each program. For example, breakfast and snacks were claimed through CACFP, and lunch was claimed through SFSP to ensure no accidental overlap in program reimbursements.

Monitoring waiver

Subtheme: Adapting to technology for monitoring was challenging for child care programs. The monitoring waiver relaxed state CACFP agencies’ requirements for in-person monitoring of ECE programs. State CACFP directors reported that this waiver granted them the flexibility and time to dedicate staff to technical assistance for programs implementing waivers and helped keep their staff safe because they no longer had to travel throughout the state to visit ECE programs. Despite the comprehensive implementation of the monitoring waiver, state CACFP directors reported that adapting to technology was challenging for ECE directors and providers. For example, state directors described how ECE directors and providers could not always email or scan the required monitoring documents during virtual monitoring. Furthermore, states with programs in rural areas reported challenges using video calls because of the lack of internet connection. To overcome these challenges, state CACFP directors reported using alternative strategies such as conducting phone interviews, allowing programs to send supporting documents by email after virtual monitoring sessions, and following best practices for virtual monitoring created by USDA.

Theme 3. Implications for Policy

State CACFP directors reported their current critical needs and implications for policy moving forward. Specific themes emerged around the timing of USDA communication, continued or permanent flexibilities for feeding children, and financial implications for ECE programs.

Timely and clear communication from USDA

Subtheme: Timelier and streamlined communication from USDA regarding waiver implementation, waiver extensions, and responding to questions is a critical need. State CACFP directors reported a need for more timely communication from USDA regarding waiver implementation, waiver extensions, and response to questions raised by state agencies. State CACFP directors reported that information about waiver allowances and extensions was often not approved or communicated fast enough, which made planning and communication with ECE programs more complicated. For example, ECE programs needed to know what waivers would be continued ahead of time to plan for preparation and distribution. However, directors reported that they often would not know if a waiver would be extended early enough to help their ECE programs make accurate plans.

Subtheme: Streamlined waiver communication was needed when the USDA communicates about waivers with the state directors, who then communicate with sponsors and providers. Streamlined communication from USDA to state agencies is needed to prevent confusion about waiver implementation. Directors reported that USDA would simultaneously release information on waivers to all states and CACFP-participating ECE programs. Early care and education programs would then call their state CACFP agency, asking questions before the state agency could review the waiver and understand its implications. A streamlined communication channel would allow state CACFP agencies to review the waivers and be prepared to answer questions before sharing the information with CACFP-participating ECE programs. One state CACFP director said,

I would say the guidance for [waivers] is extremely slow in coming out. And while we totally understand why that is, the timeframes for [waivers coming out] are relatively short. It does make it a bit difficult to implement these things on time and still know what the rules are.

Subtheme: Tracking waiver usage and understanding what data to report to USDA was challenging. State CACFP directors reported the need for additional guidance from USDA regarding what data states and CACFP programs needed to track and report back to USDA when implementing the waivers. One director said,

[The challenges were] interpreting the policy memos and walking through what an implementation plan at the institution level looks like and what the state is asking as far as the data that these folks are to collect and report to us so then we can report to FNS.

Standing waivers and continued flexibility

Subtheme: Permanent waiver allowances for continuing to feed children during emergencies and flexibility to transition between normal and emergency regulations are needed. State CACFP directors reported a critical need for permanent standing waivers and continued flexibility. Specifically, they wanted to make decisions to transition between standard regulations and emergency flexibilities moving forward to save time rather than waiting for communication from USDA. This would enable states to respond efficiently to natural disasters or other emergencies and allow CACFP programs to continue serving food to young children in need. Further, directors reported the need for permanent waiver allowances to enable programs to continue feeding children during ECE program closures, evenings, weekends, or holidays because of concerns about children not receiving enough food at home. Directors felt that they finally learned how to implement noncongregate meals efficiently, enabling them to feed children who could not attend.

Subtheme: Continued flexibility from USDA so states can adjust meal patterns and monitoring requirements to their specific needs. States also reported the need for continued flexibility from USDA to respond to and adjust requirements to meet each state's unique needs. For example, states with large rural populations are spending more time and incurring extra costs to drive to remote ECE programs for routine monitoring when the option of virtual monitoring could be just as efficient. Another state CACFP director explained,

I think the continued flexibility from USDA has been so helpful and allowing us as a state agency to work with our sponsors for what works best for them, rather than USDA prescribing what you have to do. They understand that every state is different, and every region is different, and being able to have that flexibility to work with the sponsors as needed and having USDA be willing to grant flexibilities when needed, is really, really helpful.

Increase CACFP enrollment and reduce the financial burden on child care

Subtheme: Support child care providers to leverage funding through the state or other sources and change the financial viability standards. Directors also reported a critical need to increase CACFP program enrollment and reduce the financial burden on ECE programs. Suggested strategies included having state CACFP agencies support ECE providers to leverage funding through the state or developing a repository of funding sources for ECE programs that could apply. Furthermore, states reported the need to change the financial viability standards, given the concern that several programs would fail to meet the current standards following the financial repercussions of the COVID-19 pandemic. To participate in CACFP, an ECE must demonstrate that

It has adequate financial resources to operate the CACFP on a daily basis, has adequate sources of funds to continue to pay employees and suppliers during periods of temporary interruptions in Program payments and/or to pay debts when fiscal claims have been assessed against the institution, and can document financial viability (for example, through audits, financial statements, etc).

State directors were concerned that ECE programs would not meet the financial viability standards given the reduced child enrollment and consequential loss of income. One state CACFP director said,

[Financial viability] is something that we anticipate as a future challenge because we're tasked with assessing their financial viability on an annual basis. We're really concerned that next year when we do that, their financials from this year period are not going to reflect viability.

Subtheme: For-profit centers may need lower eligibility requirements to continue to participate in CACFP. Finally, states reported that for-profit centers needed lower eligibility requirements. Several for-profit ECE programs were no longer eligible for CACFP because of closures, reduced enrollment, and state mandates limiting capacity. For example, state directors reported that several of their for-profit ECE programs experienced reduced enrollment of children. When children from low-income families were not attending the ECE program, it reduced the program's percentage of children that met the CACFP income eligibility guidelines. Consequentially, these ECE programs were no longer eligible for CACFP because they did not meet CACFP requirements for enrollment of children from low-income households.

Discussion

State CACFP directors reported that the waivers helped ECE programs continue feeding children during the COVID-19 pandemic. This is consistent with a previous study whereby ECE programs participating in CACFP in Arizona and Pennsylvania were more likely to offer noncongregate meals or meal delivery to families unable to attend during COVID-19 than non-CACFP sites, which was a key flexibility provided by the waivers. Although several waivers were available, directors mentioned that 4 specific waivers, the meal pattern, noncongregate feeding, parent/guardian meal pick-up, and monitoring waivers, were the most used and helpful in feeding children during the pandemic. Directors reported how several of these waivers had to be used in conjunction with others. Combining waivers, such as the noncongregate feeding and parent/guardian meal pick-up waivers, could help increase state CACFP directors’ efficiency in approving waivers. This solution could also reduce confusion and paperwork for both ECE programs and state agencies.

Overall, the CACFP state directors were consistent in their perspectives about waiver usage, benefits, challenges, and policy implications for USDA. Commonly reported challenges for waiver implementation included concern over meal pattern integrity and limited capacity in ECE programs to provide noncongregate meals while maintaining food safety. Other problems included verification of enrollment and preventing accidental duplication of services between child nutrition programs. A previous study conducted with food service staff, superintendents, and community partners of school-aged children reported similar challenges in ensuring that food delivered via noncongregate feeding was safe. These challenges indicate increased training and resources to develop and ensure safe food delivery systems across child nutrition programs.

Although directors reported several challenges with implementing the waivers, they also shared effective solutions that helped them overcome these challenges. For example, directors reported that ECE programs provided meals by offering products in bulk and using bus routes to deliver meals. In another emergency whereby children cannot congregate to receive meals, child nutrition programs can leverage existing infrastructure for meal deliveries and offer items in bulk.

State CACFP directors were also concerned about ensuring integrity to the CACFP meal patterns while implementing the meal pattern flexibility waiver. Research has established that participation in CACFP improves the nutritional quality of foods and beverages served in ECE settings and is associated with fewer barriers to serving healthy foods. A previous study conducted with ECE providers found that meeting the meal pattern requirement, especially at the beginning of the pandemic, was challenging given the food shortages. Because CACFP participation benefits nutritional quality, CACFP directors viewed adherence to the CACFP meal pattern as essential. Several factors impacted the ability of providers to follow the mealtime requirements, including food shortages of whole grains and dairy and the limited capacity for staffing, packaging, delivery, and storage space. However, there is a need to better understand the level of regulation and monitoring necessary for child care programs to adhere to the meal pattern requirements to ensure the healthfulness of foods.

State CACFP directors identified unique areas in which they perceived a critical need for more support or policy changes. Although the need for timely and streamlined communication from USDA regarding waiver availability and tracking was uniquely reported by the present research, director suggestions regarding more financial support for ECEs are also recommended by previous research. For example, Kuhns and Adams reported that ECE programs that remained open and ECE programs that closed but continued to receive funding through public programs or philanthropy could continue feeding children during COVID-19 through grab-and-go meals. Conversely, ECE programs that closed and did not receive external funding were less likely to provide meals for children. Early care and education program closures, whether because of state mandates or financial strains, leave a gap in service for families who rely on these programs for food. However, ensuring these programs have the funding and support to continue providing meals could help close the gap in food access. Funding and support for ECE programs could come from state or local governments.

In addition, directors reported that families with children of multiple ages were concerned about not getting enough food for all their children because they were only receiving meals for their children enrolled in ECE, whereas SFSP offered meals to all children aged < 18 years. Furthermore, neither of these programs provided meals to parents or guardians. Increased coordination and communication across various nutrition assistance programs and food resources could have helped families access these resources more efficiently, regardless of their child's age.

State CACFP directors also reported the need for more flexibility in the program, especially during times of emergency. The flexibility to swiftly transition between normal and emergency operations could be useful beyond a pandemic. For example, if a storm or other situation arose that prevented children from attending ECE programs or prevented ECE programs from serving meals that met all meal pattern requirements because of food shortages, having infrastructure and protocols in place that allowed individual states to determine if there were a need to use emergency waivers would allow states and CACFP-participating ECE programs to quickly respond and ensure there was no gap in meals for young children.

In addition, state CACFP directors reported the need for CACFP to provide meals for children outside of scheduled ECE program hours, such as evenings, weekends, and holidays. The extension of CACFP services could help children experiencing food insecurity receive a continuous supply of healthful foods between the ECE and home settings. Schools across the US have integrated weekend feeding or backpack programs that provide food to children over the weekends. Weekend feeding programs are often provided by nonprofit organizations and foodbanks and have implications for improving academic performance in school-age students. , Integrating such programs through CACFP in ECE settings could further support low-income children who do not have access to healthful meals when they cannot attend ECE.

This study had some limitations. First, this study included the perspectives of state-level CACFP directors for 21 US states, so the findings may not be transferable to other states. However, there was the representation of at least 1 state from each region of the US. Another limitation was the semistructured interview process, introducing social desirability bias from the state CACFP directors, whereby directors who felt their state had successfully provided meals to children may have been more likely to participate. Finally, state CACFP directors opted to participate, increasing the risk of self-selection bias.

Implications for Research and Practice

Child and Adult Care Food Program directors reported that the waivers were valuable for ensuring the continuity of healthy meals distributed to young children in ECE. Further research is required to explore whether increased coordination and communication across nutrition assistance programs could have helped families access food resources more efficiently. In addition, research is needed to better understand the regulation and monitoring of meal pattern requirement adherence during times of emergency to ensure that children continue to receive healthy foods. Additional research is needed to explore CACFP perspectives on effectively feeding children during emergencies at the federal, CACFP sponsor, program, and parent/guardian levels. Finally, research is needed to explore how state CACFP characteristics, such as rurality, racial demographics, or prevalence of low-income children attending ECE programs, impacted state CACFP programs’ ability to continue feeding children during the COVID-19 pandemic.

Although some state directors reported challenges in implementing waivers, others also suggested novel ways to work around them and considered their success stories in implementing the waivers. For future emergencies and to improve the CACFP program, USDA can consider including suggestions to overcome commonly reported challenges for successful waiver implementation. Specific considerations to continue feeding children in ECE settings include implementing standing waivers for use during emergencies, permanent waiver flexibilities to feed children when they cannot attend ECE programs, continued flexibility to adjust meal pattern requirements to meet specific state needs, and reducing financial viability standards for CACFP participation.

Taken together, the need for continued funding and support for ECE programs to operate during emergencies, increased coordination and communication across various nutrition assistance programs, and increased flexibility for state CACFP agencies to respond to emergencies and provide nutritious foods for children when they cannot attend ECE are strong implications for policy changes. Addressing these changes through a policy, such as Child Nutrition Reauthorization Act, can positively affect CACFP operations and improve access to nutritious foods for young children across the US. Future research is needed to examine the impact of this policy and programmatic recommendations for improving waiver implementation, increasing CACFP enrollment, and feeding young children in ECE.