The Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) is one such intervention that can be used to address healthy weight behaviors in child care settings (Ammerman et al., 2007). It consists of a self-assessment performed by child care center directors to evaluate the nutrition and physical activity environment. The NAP SACC has been endorsed by the Center for Excellence in Training and Research Translation and the White House Task Force on Childhood Obesity as a tool to combat childhood obesity (Go NAP SACC). The NAP SACC program includes four steps: 1) The completion of a self-assessment questionnaire by the child care

center Epigenetics inhibitor director; 2) Goal setting; 3) Participation in workshops focused on nutrition and physical activity guidelines as well as strategies to implement center-level change; and 4) Reassessment by the child care center director (Ammerman et al., 2004). Information from the NAP SACC results provides the center with areas in need of improvement.

Reliability and validity has been reported on NAP SACC with rest–retest kappa statistics ranging from 0.07 to 1.00 and percent agreement of 34.29–100.00 and validity kappa statistics of − 0.01 to 0.79 and percent agreement Bcl-2 phosphorylation of 0.00–93.65. However, the authors also noted over half of the validity weighted kappa statistics indicated moderate agreement and suggest the instrument is relatively stable and accurate but also encourage caution to its use as an indication of impact (Benjamin et al., 2007b). More studies have begun to investigate the child care center environment using the NAP SACC. However, child care centers can vary widely in their organization. For example, some child care centers are affiliated with school districts and must adhere not only to state and federal guidelines but also to district Bumetanide policies and procedures; other child care centers may be privately owned and operated, and rely on other sources of funding, but also must adhere to state and federal guidelines.

Centers unaffiliated with school districts include family and private child care centers and non-profit and for-profit centers. The small number of studies that have investigated the child care center environment have either not differentiated between the type of center (Ward et al., 2008) or only focused on one type, such as family child care centers (Trost et al., 2009). Therefore, we sought to determine if (1) rural area child care centers provided children with environments that supported and met evidence-based recommendations for good nutrition and adequate physical activity (2) a focus on policies and practices related to nutrition and physical activity improve the overall center environment and (3) there are differences between types of child care centers (affiliated versus unaffiliated with school districts).