- Email: [email protected]
Parents’ Perceptions of 5210 Nutrition Messaging and Child Weight Status
Research Brief Parents’ Perceptions of 5210 Nutrition Messaging and Child Weight Status Stephanie Nicely, EdD, RN1; M. Elizabeth Miller, PhD, RD2; Marisol del-Teso Craviotto, PhD3 ABSTRACT Objective: To explore parent perceptions of child weight status and 5210 nutrition messaging recommendations, including daily consumption of 5 fruits and vegetables, limiting child screen time to ≤2 hours, incorporating 1 hour of daily physical activity, and no consumption of sugary, sweetened beverages. Methods: Using the Convergence Model of Communication as a framework, qualitative focus groups (n = 5) were conducted at 4 Head Start sites across 1 Ohio County. Twenty-eight parents aged 20−60 years comprised the groups. A deductive analysis technique with respondent validation was used. Results: Parents have limited understanding of 5210 messages delivered by the program. Parent food preferences, family finances, and children’s picky eating were identified as barriers to integrating healthy eating habits at home. Parents prefer practical strategies regarding how to integrate healthy eating habits into the home environment. Participants expressed concern about children’s psychological health and happiness vs weight status. Conclusions and Implications: Understanding parental perceptions of 5210 messaging and programreported weight status may assist Head Start programs in addressing childhood obesity through focused parent education and support. Key Words: childhood obesity, Head Start, low-income, nutrition messaging, preschoolers (J Nutr Educ Behav. 2019; 51:629−635.) Accepted January 27, 2019. Published online February 26, 2019.
INTRODUCTION Childhood obesity rates among lowincome, preschool-age children remain a national concern.1 Overweight is defined as a body mass index (BMI) ≥ 85th percentile and < 95th percentile for children of the same age and sex, whereas obesity is defined as a BMI ≥ 95th percentile.2 Children aged 2 −19 years from socioeconomically disadvantaged families are disproportionately affected by overweight and obesity;3 the national prevalence of childhood obesity among the lowestincome groups (<100% of federal poverty guidelines) is at 18.9%.2 Data collected in 2014 from the Special Supplemental Nutrition Program for
Women, Infants, and Children4 (WIC) showed that 14.5% of participants aged 2−4 years had obesity. The prevalence within this group varied by state from 8.2% to 20%. Ohio Head Start surveillance data revealed that approximately 35.7% of Head Start students were classified as either overweight or obese, and 7.7% of all Head Start students were classified as severely obese (BMI ≥ 99th percentile).5 The Institute of Medicine6 identified preschool environments as a critical location to address childhood obesity. Head Start, a US federally funded preschool program for lowincome families, serves more than 1,000,000 families each year.7 Head Start promotes school readiness for
1
Department of Nursing, Miami University, Hamilton, OH Department of Kinesiology and Health, Miami University, Hamilton, OH 3 Department of Spanish and Portuguese, Miami University, Hamilton, OH Conflict of Interest Disclosure: The authors have not stated any conflicts of interest. Address for correspondence: Stephanie Nicely, EdD, RN, Department of Nursing, Miami University, 1601 University Blvd, Hamilton, OH 45011; E-mail: [email protected] Ó 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jneb.2019.01.023 2
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children aged <5 years through education, nutrition, health, and social services.7 Current Head Start Program Performance Standards reflect Head Start’s commitment to supporting children in healthy weight and active lifestyle maintenance8 and provide families with nutrition education in addition to offering healthy food selections during an enrolled child’s daily schooling experience. Because of this commitment, the healthy eating, active living 5210 messaging has been 1 strategy used in many Head Start programs to expose families and children to simple, consistent health messages with the goal of modeling these behaviors at home. The 5210 messaging reinforces daily consumption of ≥5 servings of fruits and vegetables, limitation of recreational screen time to ≤2 hours, engagement of ≥1 hours of daily physical activity, and no consumption of sweetened beverages.9 Studies examining the effectiveness of general nutrition messaging, including 5210 messages, on child behaviors and subsequent weight status have been limited10−17 and focused mostly on school-age
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Table 1. Focus Group Questions Within Convergence Theory Constructs Convergence Theory Construct
Focus Group Question As a preschool parent, describe the types of things you would like to know related to your child’s nutrition. What type of nutrition messages do you think are important to give to parents of preschool-age children? Tell me about the 5210 nutrition messaging you receive from your child’s preschool. How do you feel about this messaging? Describe your understanding of the 5210 nutrition messaging recommendations used by Head Start. What changes are you being asked to make related to the 5210 nutrition messaging information? What are barriers to making behavior changes regarding the 5210 nutrition messages? What are your thoughts about the weight status notification sent by Head Start? Describe to me the best way Head Start might communicate health concerns related to your child that would motivate you to do something. For instance, if Head Start identifies your child as falling into the overweight or underweight category, how would that message best be shared with families for them to act on it? What are specific strategies that would assist you in making changes regarding the 5210 messages?
children11−14 and adolescents.10,13,15 Results from a 5-year multisite 5210 project in Maine revealed that coordinated consistent 5210 messaging was associated with statistically higher levels of parental knowledge of child health behaviors necessary to prevent childhood obesity, with more limited improvement in the actual practice of the 5210 behaviors.12 Children’s adherence to 2 of the 4 5210 healthy behaviors significantly improved, including children’s adherence to daily consumption of ≥5 servings of fruits and vegetables and limited consumption of sugary drinks.12 Results from the Maine project highlighted the need to examine parental perceptions of the 5210 nutrition messaging. The purpose of the current research study was to explore parental perceptions of Head Start 5210 messaging and children’s weight status in 1 county program in which weekly written information was given to families in both English and Spanish and posters were displayed throughout hallways and classrooms during an entire academic year. This study attempts to fill a gap in the literature, because there is limited research examining parental perception and understanding of nutrition messaging, including 5210 nutrition messages,
especially as it relates to the preschoolage population. The Convergence Model of Communication18 recognizes communication as a process in which ≥2 individuals or groups share information to reach a mutual understanding and agreement to take action.18 The model acknowledges that an individual’s perception and interpretation of a message drastically alter one’s understanding and subsequent reaction or action to that message. As such, this model was used for this study as a means to examine parental perceptions and interpretations of the 5210 messaging shared by the Head Start organization.
METHODS Study Design and Participants The researchers conducted qualitative focus groups with parents of preschool-age children (3−5 years) enrolled in 1 Ohio county Head Start preschool program. Five focus groups were conducted with 28 parents between October, 2016 and February, 2017. Four sites across the program’s funded service area were identified and selected as focus group locations; they represented the diverse composition of
Information Information Perception Understanding Interpretation Perception Believing Action
Action
the county. All parents who had children enrolled at the identified sites were invited to participate, totaling approximately 200 families. Focus group questions (Table 1) were designed based on constructs within the Convergence Model of Communication and developed in conjunction with Head Start following results of a parent survey19 indicating that 83% of parents thought that the nutrition information received from Head Start was moderately to very important, 84% that the nutrition information was somewhat or highly valued, and 48% that they never or rarely incorporated 5210 behaviors at home. The questions were reviewed by Head Start’s nutrition services team and pretested with the parent advisory council, which was composed of both Englishand Spanish-speaking parents. Four 60-minute focus groups were conducted in English and 1 was hosted in Spanish by a native Spanish-speaking researcher trained in qualitative methods. The focus group hosted in Spanish was held at a Head Start site that predominantly serves preschool children who are native Spanish speakers. The research was conducted with reference to the consolidated criteria for reporting qualitative research20 and was exempt from institutional review
Journal of Nutrition Education and Behavior Volume 51, Number 5, 2019 board review by the Miami University Research Compliance Office. Table 1 presents focus group questions.
Focus Group Questions Within Convergence Theory Constructs The researchers employed purposive sampling methods to maximize the demographic variability of participants. Parents of enrolled Head Start students were recruited via flyers, which were available in both English and Spanish, and were disseminated to families at the selected sites. Participants were offered a $10 gift card for participating in the focus group. All interested participants were included in the study. No participants were excluded or rejected from the study.
Data Collection and Analysis Informed consent was obtained before the research commenced. A brief demographic questionnaire was collected and 2 members of the research team who were trained in interviewing and qualitative research conducted the focus groups following Krueger and Casey’s21 guide. The researchers gave each participant an opportunity to respond to prompts; input was garnered from all participants during each focus group. At the end of each focus group, notes taken by the research team were reviewed as a method of member checking to ensure respondent validation. Interviews were audio-recorded and transcribed verbatim for analysis. The Hispanic focus group recording was transcribed into English by a bilingual researcher trained in linguistics and qualitative methods. Data were analyzed using a deductive analysis technique. The researchers independently coded data and then compared codes. Data analysis began with the independent assignment of initial codes by 2 researchers to each line or segment of the transcript for the first 3 focus groups. Concurrent coding occurred after the third focus group. No analysis was conducted to validate consistency of coding. As a means of organizing the data within the theoretical framework, the initial codes were organized into categories from the theoretical
framework. All codes were entered into a codebook by category and used for subsequent interpretation. Once all coding was completed, they were collectively grouped into themes. Theme generation was guided by the constructs of the theory. Each theme was defined and supported with quotations from the transcripts. Data saturation was reached once no new themes or categories emerged from the data, at which time no new focus groups were scheduled. Respondent validation was used to enhance the
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internal validity of the findings. Participants verified the accuracy of transcripts and drafts of interpretive reports of results and themes. Demographic data were analyzed using SPSS statistical software (version 23.0, SPSS Statistics for Macintosh, IBM Corporation, Armonk, NY, 2015).
RESULTS Table 2 outlines the participant characteristics for each focus group.
Table 2. Characteristics of Participants in Head Start Nutrition Messaging Focus Groups (n = 28) Variable Age, y 18−34 35−49 ≥50 Sex Male Female Head Start location 1 2 (Hispanic) 2 (non-Hispanic) 3 4 Ethnicity Non-Hispanic Hispanic Race White All others Education level Some high school High school diploma/General Equivalency Diploma Some college or associate’s degree Bachelor’s degree or higher Annual household income level (dollars) <15,000 15,000−23,999 24,000−29,999 30,000−39,999 40,000−49,999 Marital status Single Married Divorced/separated Single/living with partner Relationship to child Mother Father Custodial grandparent
n
%
19 7 2
68 25 7
1 27
4 96
4 10 5 3 6
14 36 18 11 21
17 11
61 39
26 2
93 7
9 14 4 1
32 50 14 4
12 10 0 3 2
43 36 0 11 7
5 10 2 11
18 36 7 39
24 1 3
86 4 11
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Theme 1: Limited Parent Understanding of Nutrition Messaging Focus group participants were asked about the 5210 messaging received from the Head Start program and their understanding of such information. Participants reported that the nutrition messaging was limited to written information provided on monthly menus distributed by nutrition services staff. Parents reported viewing information when it was received but could recall little of the content presented. When asked about their understanding and perceptions of the 5210 healthy eating, active living message, participant knowledge and understanding were limited. One participant stated, “It’s something about a bunch of numbers and you’re supposed to eat fruits and vegetables. That’s the gist of it” (Location [Loc] 4, Mother, English). Another participant stated, “I’ve read it. Don’t remember it, but I’ve read it” (Loc 3, Mother, English). Yet another participant stated, We get papers about it in a backpack, but most of the time I don’t read it or other times, I don’t understand even when it is in Spanish. I prefer in person messages. (Loc 2, Mother, Spanish) The majority of participants had heard the term 5210 but could not articulate the significance and meaning of the numbering within the message itself.
Theme 2: Parental Perception of Children’s Weight Status While discussing the types of nutrition messages received from Head Start, parents focused on the child weight status notification letters provided by nutrition services. Parents reported that these letters were provided to parents 1−2 times each school year, after the school’s weight status screening. The letters identified the child’s current weight status as normal weight, overweight, underweight, or obese.2 If the child’s weight was within the overweight/obese category, a recommendation was made to follow up with the child’s
Journal of Nutrition Education and Behavior Volume 51, Number 5, 2019 pediatrician. Follow-up appointments often demonstrated inconsistencies between the school’s BMI readings and those of the pediatrician’s office. Participants also discussed the discordance between the school’s measurements and that of the WIC office. One participant questioned how measurements and subsequent weight status could be so varied between agencies: “Why are 2 different government-funded places getting 2 different answers?” (Loc 4, Mother, English). Participants voiced frustration about the inconsistencies in weight status among the various entities: “Head Start could say your child’s obese and the pediatrician could be, like, ‘No, they’re perfectly fine.’ You’re like, ‘Which one’s right?’ It’s so frustrating” (Loc 2, Grandparent, English). Many participants reported that despite their child’s weight status, they focused on their child’s psychological health and happiness. Participants acknowledged that even when the pediatrician had identified their child as overweight or obese, they did not often see the connection between childhood obesity and overall health or future health. One parent stated, “As far as her weight and height and all that goes, like I said, she’s happy and healthy, so that doesn’t matter” (Loc 4, Mother, English). Another parent similarly reflected on the child’s weight status: “If their weight’s not affecting their health, this shouldn’t be that big of a deal” (Loc 4, Mother, English). Parents’ comments demonstrated a lack of understanding about the impact of early obesity on their children’s current and future health. One parent stated, I guess, unless it’s something severe and dramatic, I just don’t think it’s very important. Like I said, my daughter, she doesn’t look huge or anything. She is happy and healthy. (Loc 2, Mother, English)
Theme 3: Perceived Barriers to Integrating Healthy Eating Habits Parents cited multiple barriers to family engagement in healthy eating practices. Three subthemes were
identified: parental food preferences, family finances, and picky eaters. Parental food preferences. Many of the parents disclosed issues with their own weight management and healthy food intake, also acknowledging that they were role models for their child’s food intake habits. Several participants discussed how food recommendations provided by the school and WIC often conflicted with family practices, such as the recommendation for children’s milk consumption to be 1% milk and the family practice of drinking whole or 2% milk. Parents acknowledged that their personal eating and cooking practices affected their child’s food selections: My mistake was with the fruits and vegetables, because I don’t like them very much. I tend not to offer them because I don’t eat them, so when we’re cooking, you know what I mean? I think that’s my biggest problem. She probably would eat more. (Loc 4, Mother, English) Family finances. Family income was identified as a major barrier to healthy eating among interviewed program participants. Families reported receiving $6 to $8/mo allocated for fresh fruits and vegetables from the WIC program. The majority of the participants were receiving WIC and Supplemental Nutrition Assistance Program benefits, and as such had limited funding available for fresh fruits and vegetables. One parent stated, You could get a small amount for that budget. For something that’s probably not as healthy for you, you could get a lot more. That’s what a lot of people look at nowadays, because it’s hard times. (Loc 1, Mother, English) Parents acknowledged that with limited money allotted for fruits and vegetables, their availability became more limited as funds dwindled throughout the month. Participants reported being more apt to have fresh fruits and vegetables available at the beginning of the month, when financial resources were more plentiful: “I can get a bag of apples and maybe a package of carrots. That’s not going
Journal of Nutrition Education and Behavior Volume 51, Number 5, 2019 to last very long at our house” (Loc 4, Mother, English). Picky eaters. Each focus group discussion elicited parent challenges with picky-eating behaviors. Parents reported many issues with expanding their child’s food preferences because of a child’s dislike or unwillingness to try certain foods. Parents expressed interest in specific strategies for dealing with picky eating and ideas for how to expand their child’s food repertoire and incorporating healthy food options. During the focus groups, parents began to share ideas among themselves; they reported that this was a significant challenge and that they needed additional information by professionals.
Theme 4: Actions to Increase Healthy Eating Use of technology to reinforce ideas and strategies. When parents were asked about the methods and strategies Head Start used to communicate 5210 information, the majority of parents cited written information disseminated via flyers and handouts. Flyers and educational handouts were placed in the enrolled child’s backpack throughout the academic year. The majority of participants reported that they viewed the information sent home in the child’s backpack, but often merely glanced at the materials before discarding them: “I mean, like, yeah, I did skim this. I doubt I’ll read every single word on this page, to be honest with you. There’s a lot of writing down here” (Loc 3, Mother, English). Another parent stated, “The problem isn’t information, the problem is carrying out the advice” (Loc 2, Mother, Spanish). When parents were asked about the most effective methods for communicating 5210 information to program participants, participants suggested the use of various technologies to add in transmitting the information. Facebook and Pinterest were cited as 2 main technological resources the school could use to disseminate and share nutrition information and resources: The [school] website, or the Facebook page, that would be amazing
to post, maybe not every day, like on a weekly, but post like a nutritional dinner. I think something I would like to see on Pinterest would be maybe stuff that wouldn’t be good for them. Ideas of what not to give and why . . . fun ideas of ways to make fruit fun for them to eat. (Loc 1, Mother, English) Participants also cited using pictures and images as a more effective means of communication as opposed to solely written information. This finding was consistent among all focus groups except for Hispanic parents, who reported that technological resources were not frequently used and that they preferred information to be given face-to-face by a trusted individual within the school community. Participants cited the program’s bilingual site-based social worker as a primary source of health and nutrition information. Parent−child engagement activities. TaggedPParticipants discussed use of parent− child activities, including cooking and meal preparation, as a strategy for increasing healthy eating behaviors. One parent stated, “I have noticed with my kids, when I engage them in the activity of cooking or being part of making, they usually tend to eat it better than if they aren’t” (Loc 4, Mother, English). Another parent stated, When they are engaged in the activity of creating with me, then they’re more apt to eat what they’re making, I guess because they feel that they’re a big boy and big girl. (Loc 4, Mother, English) One parent identified that cooking together could be an opportunity to spend quality time and bond with the child: “I get the one-on-one with my daughter. You’re teaching how to cook healthy things. . . . It would be bonding for them all, too” (Loc 2, Mother, English). Supportive structures. During focus group discussions, participants identified supportive structures that could be established to improve family’s and children’s eating habits. All
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focus group participants expressed high levels of interest in parent groups that would offer social and educational support to parents. Participants suggested a parent support group format, facilitated by a professional, that would promote idea sharing, recipe development, and handson practice in making recipes that suited a low-income budget. A parent stated, “I’d be interested in some kind of couponing, how to save money and feed your kids nutritionally” (Loc 2, Mother, English). Participants also expressed interest in strategies for dealing with picky eating and ways to present fruits and vegetables in an appealing manner: “One thing that would be helpful is presentation. A fun way to get your kids to eat their fruits and vegetables: ideas of how you can” (Loc 4, Mother, English).
DISCUSSION Findings suggest that parents have limited understanding of the current nutrition messaging strategies used by the Head Start program. Current 5210 and nutrition messages are provided in predominantly written format, which resulted in low levels of participant recall. Use of social media platforms, visual images, and parent cooking classes were identified as potential means of increasing families’ understanding and incorporating 5210 and general healthy eating messages. Preference was given to written materials only if messaging was concise, easy to read, and visually stimulating. Previous research22 supported that visualizations and infographics were useful in supporting the understanding and comprehension of messaging among lowliteracy individuals. Findings from this study were consistent with other research, which demonstrates that information should be made available across multiple formats; this is further supported by health behavior research23 demonstrating that providing multiple opportunities for individuals to engage with material designed to change knowledge and behavior improves the chances that the intended changes will take place.
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Participants suggested that 5210 recommendations given to parents include specific strategies for how this practice could be integrated into the family’s daily routine, acknowledging that this might result in higher levels of compliance. Practical strategies are needed to increase fruit and vegetable consumption while considering the barriers of family income and picky eaters. These findings were consistent with previous research suggesting that health and nutrition communications incorporate how-to knowledge to support behavior change.24 These findings also highlighted the role poverty might have in adopting healthy eating behaviors. Family finances were consistently cited as a barrier to healthy eating and adherence to the 5210 guidelines, which further emphasized the importance of practical ways in which families might meet the fruit and vegetable requirements on a budget. Head Start parent −child cooking classes were cited as an intervention to increase family understanding of healthy, affordable meal ideas that incorporate the 5210 recommendations. Parent−child cooking classes were shown to increase the implementation of sustainable food practices and healthy nutrition behaviors by educating families about how to involve their children in positive mealtime practices.25 This study included a focus group that specifically targeted the Hispanic community. Themes within this focus group were consistent with those of other focus groups in the study, except for the use of social media platforms for 5210 and general nutrition messaging dissemination. Participants in the Hispanic focus group acknowledged that they preferred face-to-face communication with a trusted member of the Head Start community, compared with electronic forms of communication such as Facebook and Pinterest. This finding was consistent with other research26 conducted with Hispanic parents of Head Start preschoolers, which found that networks of support, including friends and family members, were used as main sources of health and nutrition information within the community. Data from this study also highlighted the importance of accurately measuring and categorizing the
Journal of Nutrition Education and Behavior Volume 51, Number 5, 2019 weight of enrolled children before notifying parents of children’s weight status. This was consistent with other research27−29 acknowledging that parents were likely to support BMI screening programs when deliberate attention was given to standardized conduction of screenings and the parent notification process, and the way in which results were used to support a healthy school environment. Parents in this study expressed a certain level of distrust in BMI measurement reporting from Head Start owing to its inconsistency compared with other health providers, namely the pediatrician and WIC. Previous research28,29 confirmed that parents desired height and weight measurements to be performed in a standardized manner by trained health professionals and wanted BMI information to be presented to parents in a neutral manner, avoiding weight labeling, including information about strategies for improving overall family nutrition and health. Communication models are useful for exploring individuals’ perceptions, beliefs, and actions related to nutrition messages. However, how individuals interpret information may radically alter their understanding.18 As such, it is important for Head Start to create clear and engaging messages that are understood, believed, and then acted upon by families enrolled in the program. The results of this study were consistent with other research25,26,30 indicating that low-income parents were interested in acquiring practical information about nutrition, recipes, and parenting in a supportive setting that encouraged parental interaction and facilitated change. Parents across all focus groups expressed interest in nutrition education sessions hosted at the school, with specific interest in cooking classes that provided hands-on instruction on how to prepare healthy meals on a limited budget. Although these findings provide insight into factors to consider when developing nutrition education messages, materials, and programming for low-income families, the results of this study may not transfer to other parent groups without further
exploration. Because Head Start sites in this study were selected based on higher parental involvement, it is unknown whether parents’ responses would be similar at sites with lower levels of parental engagement. In addition, because focus groups were conducted during the school day, results may not reflect the opinions of parents who work traditional daytime hours. Only 1 focus group was conducted in Spanish with Spanishspeaking families. Furthermore, a potential loss of meaning might have occurred when translating from Spanish to English, which needs to be considered. No calculation of coder agreement was included in this study. Finally, the Convergence Model of Communication does not take into consideration the role of power in the communication process and was not been used in Head Start. The way in which parents receive nutrition messages could potentially be influenced by this power dynamic and was not explored in this study. The majority of participants also reported being benefit recipients of WIC and/or Supplemental Nutrition Assistance Program. The messages that participants receive from these entities may have had the potential to influence the results of this study.
IMPLICATIONS FOR RESEARCH AND PRACTICE The results of this study provide insight into the perceptions of lowincome parents as they relate to nutrition messaging and education. Head Start programs are uniquely positioned to address childhood obesity through parental education and support, especially because this is an integral component of the existing program. Future research could examine the effectiveness of implementing the interventions suggested by study participants on actual behavior change and adherence to healthy living messaging, such as 5210, in the home environment. It could also explore factors that influence the perceived value of nutrition information among Head Start families. Finally, research could explore the role of perceived power in the nutrition education communication process. Results
Journal of Nutrition Education and Behavior Volume 51, Number 5, 2019 of this study might provide a framework for designing interventions focused on communication and practical strategies for ensuring understanding and adherence to 5210 among Head Start families.
ACKNOWLEDGMENTS The authors acknowledge the Miami University Office for the Advancement of Research and Scholarship.
REFERENCES 1. Childhood obesity facts: prevalence of childhood obesity in the United States. Center for Disease Control and Prevention. https://www.cdc.gov/obesity/ data/childhood.html. Accessed July 2, 2018. 2. Defining childhood obesity: BMI for children and teens. Center for Disease Control and Prevention. https://www. cdc.gov/obesity/childhood/defining. html. Accessed November 21, 2018. 3. Ogden CL, Carroll MD, Fakhouri TH, et al. Prevalence of obesity among youths by household income and education level of head of household, United States 2011−2014. MMWR. 2018;67:186-189. 4. Pan L, Freedman DS, Sharma AJ, et al. Trends in obesity among participants aged 2−4 years in the Special Supplemental Nutrition Program for Women, Infant, and Children—United States, 2000− 2014. MMWR. 2016;65:1256-1260. 5. Oppenheim E, Scarpitti H, Hornbeck C. Early childhood overweight and obesity, Ohio 2016. Ohio Department of Health. https://odh.ohio.gov/wps/ wcm/connect/gov/3e5bd040-c1474dcd-a411-6d772d86d92a/2016+Early +Childhood+Data+Brief.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSPACE. Z18_M1HGGIK0N0JO00QO9DDDDM3000-3e5bd040-c1474dcd-a411-6d772d86d92a-ml38Z.w. Accessed July 1, 2018. 6. Early childhood obesity prevention policies: goals, recommendations, and potential action. Institute of Medicine. http://www.nationalacademies.org/ hmd/~/media/Files/Report%20Files/ 2011/Early-Childhood-Obesity-Prevention-Policies/Young%20Child% 20Obesity%202011%20Recommendations.pdf. Accessed November 27, 2018.
7. Head Start programs. Office of Head Start. https://www.acf.hhs.gov/ohs/about/ head-start. Accessed November 27, 2018. 8. Head Start program performance standards. US Department of Health and Human Services Administration for Children and Families: Office of Head Start. https://eclkc.ohs.acf.hhs.gov/ sites/default/files/pdf/hspps-appendix. pdf. Accessed July 2, 2018. 9. Rogers V, Motyka E. 5-2-1-0 goes to school: a pilot project testing the feasibility of schools adopting and delivering healthy messages during the school day. Pediatrics. 2009;123(suppl 5):S272-S276. 10. Foltz JL, Cook SR, Szilagyl PG, et al. US adolescent nutrition, exercise and screen time baseline levels prior to national recommendations. Clin Pediatr. 2011;50:424-433. 11. Kunin-Batson AS, Seburg EM, Crain EL, et al. Household factors, family behavior patterns, and adherence to dietary and physical activity guidelines among children at risk for obesity. J Nutr Educ Behav. 2015;47:206-215. 12. Rogers VW, Hart PH, Motyka E, et al. Impact of Let’s Go! 5-2-1-0: A community-based, multisetting childhood obesity prevention program. J Pediatr Psychol. 2013;38:1010-1020. 13. Haughton CF, Wang ML, Lemon SC. Racial/ethnic disparities in meeting 52-1-0 recommendations among children and adolescents in the United States. J Pediatr. 2016;175:188-194. 14. Gonzalez M, Feinstein R, Iezzi C, et al. Nutrition intake and physical activity in a middle school in New York City. Int J Adolesc Med Health. 2015;27:335-340. 15. Iannotti RJ, Wang J. Trends in physical activity, sedentary behavior, diet, and BMI among US adolescents, 2001− 2009. Pediatrics. 2013;132:606-614. 16. Briefel RR, Deming DM, Reidy KC. Parents’ perceptions and adherence to children’s diet and activity recommendations: 2008 feeding infants and toddlers study. Prev Chronic Dis. 2015;12: E159. 17. Turer CB, Stroo M, Brouwer RJ, et al. Do high risk preschoolers or overweight mothers meet AAP-recommended behavioral goals for reducing obesity? Acad Pediatr. 2013;13:243-250. 18. Kincaid DL. The Convergence Model of Communication. Honolulu, HI: EastWest Communication Institute; 1979. 19. Administration for Children and Families. Evaluation of I Am Moving, I Am Learning implementation [internal
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report]. Washington, DC: US Department of Health and Human Services; 2017. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19: 349-357. Krueger RA, Casey MA. Focus Groups: A Practical Guide for Applied Research. 4th ed. Thousand Oaks, CA: Sage; 2009. Houts PS, Doak CC, Daok LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006;61:173-190. Hart LM, Damiano SR, Cornell C, Paxton SJ. What parents know and want to learn about healthy eating and body image in preschool children: a triangulated qualitative study with parents and Early Childhood Professionals. BMC Public Health. 2015;15:596. Snyder LB. Health communication campaign and their impact on behavior. J Nutr Educ Behav. 2007;39(suppl 2): S32-S40. Miller ME, Kaesberg JL, Thompson VB, Wyand RA. What’s cooking? Qualitative evaluation of a Head Start parent−child pilot cooking program. Health Promot Pract. 2017;18:854-856. Miller ME, Nicely S, Del-Teso Cravioto M, Timler G. Understanding cultural factors contributing to obesity in Head Start Hispanic preschoolers: perceptions from one county Head Start. NHSA Dialog. 2017;20:29-47. Thompson H, Linchey J, Madsen K. Critical elements of a school report to parents on body mass index. Prev Chronic Dis. 2015;12:E136. Soto C, White JH. School health initiatives and childhood obesity: BMI screening and reporting. Policy Polit Nurs Pract. 2010;11:108-114. Kubik MY, Story M, Rieland G. Developing school-based BMI screening and parent notification programs: findings from focus groups with parents of elementary school students. Health Educ Behav. 2007;34:622-633. Birkett D, Johnson D, Thompson JR, Oberg D. Reaching low-income families: focus group results provide direction for a behavioral approach to WIC services. J Am Diet Assoc. 2004;104: 1277-1280.
INTRODUCTION Childhood obesity rates among lowincome, preschool-age children remain a national concern.1 Overweight is defined as a body mass index (BMI) ≥ 85th percentile and < 95th percentile for children of the same age and sex, whereas obesity is defined as a BMI ≥ 95th percentile.2 Children aged 2 −19 years from socioeconomically disadvantaged families are disproportionately affected by overweight and obesity;3 the national prevalence of childhood obesity among the lowestincome groups (<100% of federal poverty guidelines) is at 18.9%.2 Data collected in 2014 from the Special Supplemental Nutrition Program for
Women, Infants, and Children4 (WIC) showed that 14.5% of participants aged 2−4 years had obesity. The prevalence within this group varied by state from 8.2% to 20%. Ohio Head Start surveillance data revealed that approximately 35.7% of Head Start students were classified as either overweight or obese, and 7.7% of all Head Start students were classified as severely obese (BMI ≥ 99th percentile).5 The Institute of Medicine6 identified preschool environments as a critical location to address childhood obesity. Head Start, a US federally funded preschool program for lowincome families, serves more than 1,000,000 families each year.7 Head Start promotes school readiness for
1
Department of Nursing, Miami University, Hamilton, OH Department of Kinesiology and Health, Miami University, Hamilton, OH 3 Department of Spanish and Portuguese, Miami University, Hamilton, OH Conflict of Interest Disclosure: The authors have not stated any conflicts of interest. Address for correspondence: Stephanie Nicely, EdD, RN, Department of Nursing, Miami University, 1601 University Blvd, Hamilton, OH 45011; E-mail: [email protected] Ó 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jneb.2019.01.023 2
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children aged <5 years through education, nutrition, health, and social services.7 Current Head Start Program Performance Standards reflect Head Start’s commitment to supporting children in healthy weight and active lifestyle maintenance8 and provide families with nutrition education in addition to offering healthy food selections during an enrolled child’s daily schooling experience. Because of this commitment, the healthy eating, active living 5210 messaging has been 1 strategy used in many Head Start programs to expose families and children to simple, consistent health messages with the goal of modeling these behaviors at home. The 5210 messaging reinforces daily consumption of ≥5 servings of fruits and vegetables, limitation of recreational screen time to ≤2 hours, engagement of ≥1 hours of daily physical activity, and no consumption of sweetened beverages.9 Studies examining the effectiveness of general nutrition messaging, including 5210 messages, on child behaviors and subsequent weight status have been limited10−17 and focused mostly on school-age
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Table 1. Focus Group Questions Within Convergence Theory Constructs Convergence Theory Construct
Focus Group Question As a preschool parent, describe the types of things you would like to know related to your child’s nutrition. What type of nutrition messages do you think are important to give to parents of preschool-age children? Tell me about the 5210 nutrition messaging you receive from your child’s preschool. How do you feel about this messaging? Describe your understanding of the 5210 nutrition messaging recommendations used by Head Start. What changes are you being asked to make related to the 5210 nutrition messaging information? What are barriers to making behavior changes regarding the 5210 nutrition messages? What are your thoughts about the weight status notification sent by Head Start? Describe to me the best way Head Start might communicate health concerns related to your child that would motivate you to do something. For instance, if Head Start identifies your child as falling into the overweight or underweight category, how would that message best be shared with families for them to act on it? What are specific strategies that would assist you in making changes regarding the 5210 messages?
children11−14 and adolescents.10,13,15 Results from a 5-year multisite 5210 project in Maine revealed that coordinated consistent 5210 messaging was associated with statistically higher levels of parental knowledge of child health behaviors necessary to prevent childhood obesity, with more limited improvement in the actual practice of the 5210 behaviors.12 Children’s adherence to 2 of the 4 5210 healthy behaviors significantly improved, including children’s adherence to daily consumption of ≥5 servings of fruits and vegetables and limited consumption of sugary drinks.12 Results from the Maine project highlighted the need to examine parental perceptions of the 5210 nutrition messaging. The purpose of the current research study was to explore parental perceptions of Head Start 5210 messaging and children’s weight status in 1 county program in which weekly written information was given to families in both English and Spanish and posters were displayed throughout hallways and classrooms during an entire academic year. This study attempts to fill a gap in the literature, because there is limited research examining parental perception and understanding of nutrition messaging, including 5210 nutrition messages,
especially as it relates to the preschoolage population. The Convergence Model of Communication18 recognizes communication as a process in which ≥2 individuals or groups share information to reach a mutual understanding and agreement to take action.18 The model acknowledges that an individual’s perception and interpretation of a message drastically alter one’s understanding and subsequent reaction or action to that message. As such, this model was used for this study as a means to examine parental perceptions and interpretations of the 5210 messaging shared by the Head Start organization.
METHODS Study Design and Participants The researchers conducted qualitative focus groups with parents of preschool-age children (3−5 years) enrolled in 1 Ohio county Head Start preschool program. Five focus groups were conducted with 28 parents between October, 2016 and February, 2017. Four sites across the program’s funded service area were identified and selected as focus group locations; they represented the diverse composition of
Information Information Perception Understanding Interpretation Perception Believing Action
Action
the county. All parents who had children enrolled at the identified sites were invited to participate, totaling approximately 200 families. Focus group questions (Table 1) were designed based on constructs within the Convergence Model of Communication and developed in conjunction with Head Start following results of a parent survey19 indicating that 83% of parents thought that the nutrition information received from Head Start was moderately to very important, 84% that the nutrition information was somewhat or highly valued, and 48% that they never or rarely incorporated 5210 behaviors at home. The questions were reviewed by Head Start’s nutrition services team and pretested with the parent advisory council, which was composed of both Englishand Spanish-speaking parents. Four 60-minute focus groups were conducted in English and 1 was hosted in Spanish by a native Spanish-speaking researcher trained in qualitative methods. The focus group hosted in Spanish was held at a Head Start site that predominantly serves preschool children who are native Spanish speakers. The research was conducted with reference to the consolidated criteria for reporting qualitative research20 and was exempt from institutional review
Journal of Nutrition Education and Behavior Volume 51, Number 5, 2019 board review by the Miami University Research Compliance Office. Table 1 presents focus group questions.
Focus Group Questions Within Convergence Theory Constructs The researchers employed purposive sampling methods to maximize the demographic variability of participants. Parents of enrolled Head Start students were recruited via flyers, which were available in both English and Spanish, and were disseminated to families at the selected sites. Participants were offered a $10 gift card for participating in the focus group. All interested participants were included in the study. No participants were excluded or rejected from the study.
Data Collection and Analysis Informed consent was obtained before the research commenced. A brief demographic questionnaire was collected and 2 members of the research team who were trained in interviewing and qualitative research conducted the focus groups following Krueger and Casey’s21 guide. The researchers gave each participant an opportunity to respond to prompts; input was garnered from all participants during each focus group. At the end of each focus group, notes taken by the research team were reviewed as a method of member checking to ensure respondent validation. Interviews were audio-recorded and transcribed verbatim for analysis. The Hispanic focus group recording was transcribed into English by a bilingual researcher trained in linguistics and qualitative methods. Data were analyzed using a deductive analysis technique. The researchers independently coded data and then compared codes. Data analysis began with the independent assignment of initial codes by 2 researchers to each line or segment of the transcript for the first 3 focus groups. Concurrent coding occurred after the third focus group. No analysis was conducted to validate consistency of coding. As a means of organizing the data within the theoretical framework, the initial codes were organized into categories from the theoretical
framework. All codes were entered into a codebook by category and used for subsequent interpretation. Once all coding was completed, they were collectively grouped into themes. Theme generation was guided by the constructs of the theory. Each theme was defined and supported with quotations from the transcripts. Data saturation was reached once no new themes or categories emerged from the data, at which time no new focus groups were scheduled. Respondent validation was used to enhance the
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internal validity of the findings. Participants verified the accuracy of transcripts and drafts of interpretive reports of results and themes. Demographic data were analyzed using SPSS statistical software (version 23.0, SPSS Statistics for Macintosh, IBM Corporation, Armonk, NY, 2015).
RESULTS Table 2 outlines the participant characteristics for each focus group.
Table 2. Characteristics of Participants in Head Start Nutrition Messaging Focus Groups (n = 28) Variable Age, y 18−34 35−49 ≥50 Sex Male Female Head Start location 1 2 (Hispanic) 2 (non-Hispanic) 3 4 Ethnicity Non-Hispanic Hispanic Race White All others Education level Some high school High school diploma/General Equivalency Diploma Some college or associate’s degree Bachelor’s degree or higher Annual household income level (dollars) <15,000 15,000−23,999 24,000−29,999 30,000−39,999 40,000−49,999 Marital status Single Married Divorced/separated Single/living with partner Relationship to child Mother Father Custodial grandparent
n
%
19 7 2
68 25 7
1 27
4 96
4 10 5 3 6
14 36 18 11 21
17 11
61 39
26 2
93 7
9 14 4 1
32 50 14 4
12 10 0 3 2
43 36 0 11 7
5 10 2 11
18 36 7 39
24 1 3
86 4 11
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Theme 1: Limited Parent Understanding of Nutrition Messaging Focus group participants were asked about the 5210 messaging received from the Head Start program and their understanding of such information. Participants reported that the nutrition messaging was limited to written information provided on monthly menus distributed by nutrition services staff. Parents reported viewing information when it was received but could recall little of the content presented. When asked about their understanding and perceptions of the 5210 healthy eating, active living message, participant knowledge and understanding were limited. One participant stated, “It’s something about a bunch of numbers and you’re supposed to eat fruits and vegetables. That’s the gist of it” (Location [Loc] 4, Mother, English). Another participant stated, “I’ve read it. Don’t remember it, but I’ve read it” (Loc 3, Mother, English). Yet another participant stated, We get papers about it in a backpack, but most of the time I don’t read it or other times, I don’t understand even when it is in Spanish. I prefer in person messages. (Loc 2, Mother, Spanish) The majority of participants had heard the term 5210 but could not articulate the significance and meaning of the numbering within the message itself.
Theme 2: Parental Perception of Children’s Weight Status While discussing the types of nutrition messages received from Head Start, parents focused on the child weight status notification letters provided by nutrition services. Parents reported that these letters were provided to parents 1−2 times each school year, after the school’s weight status screening. The letters identified the child’s current weight status as normal weight, overweight, underweight, or obese.2 If the child’s weight was within the overweight/obese category, a recommendation was made to follow up with the child’s
Journal of Nutrition Education and Behavior Volume 51, Number 5, 2019 pediatrician. Follow-up appointments often demonstrated inconsistencies between the school’s BMI readings and those of the pediatrician’s office. Participants also discussed the discordance between the school’s measurements and that of the WIC office. One participant questioned how measurements and subsequent weight status could be so varied between agencies: “Why are 2 different government-funded places getting 2 different answers?” (Loc 4, Mother, English). Participants voiced frustration about the inconsistencies in weight status among the various entities: “Head Start could say your child’s obese and the pediatrician could be, like, ‘No, they’re perfectly fine.’ You’re like, ‘Which one’s right?’ It’s so frustrating” (Loc 2, Grandparent, English). Many participants reported that despite their child’s weight status, they focused on their child’s psychological health and happiness. Participants acknowledged that even when the pediatrician had identified their child as overweight or obese, they did not often see the connection between childhood obesity and overall health or future health. One parent stated, “As far as her weight and height and all that goes, like I said, she’s happy and healthy, so that doesn’t matter” (Loc 4, Mother, English). Another parent similarly reflected on the child’s weight status: “If their weight’s not affecting their health, this shouldn’t be that big of a deal” (Loc 4, Mother, English). Parents’ comments demonstrated a lack of understanding about the impact of early obesity on their children’s current and future health. One parent stated, I guess, unless it’s something severe and dramatic, I just don’t think it’s very important. Like I said, my daughter, she doesn’t look huge or anything. She is happy and healthy. (Loc 2, Mother, English)
Theme 3: Perceived Barriers to Integrating Healthy Eating Habits Parents cited multiple barriers to family engagement in healthy eating practices. Three subthemes were
identified: parental food preferences, family finances, and picky eaters. Parental food preferences. Many of the parents disclosed issues with their own weight management and healthy food intake, also acknowledging that they were role models for their child’s food intake habits. Several participants discussed how food recommendations provided by the school and WIC often conflicted with family practices, such as the recommendation for children’s milk consumption to be 1% milk and the family practice of drinking whole or 2% milk. Parents acknowledged that their personal eating and cooking practices affected their child’s food selections: My mistake was with the fruits and vegetables, because I don’t like them very much. I tend not to offer them because I don’t eat them, so when we’re cooking, you know what I mean? I think that’s my biggest problem. She probably would eat more. (Loc 4, Mother, English) Family finances. Family income was identified as a major barrier to healthy eating among interviewed program participants. Families reported receiving $6 to $8/mo allocated for fresh fruits and vegetables from the WIC program. The majority of the participants were receiving WIC and Supplemental Nutrition Assistance Program benefits, and as such had limited funding available for fresh fruits and vegetables. One parent stated, You could get a small amount for that budget. For something that’s probably not as healthy for you, you could get a lot more. That’s what a lot of people look at nowadays, because it’s hard times. (Loc 1, Mother, English) Parents acknowledged that with limited money allotted for fruits and vegetables, their availability became more limited as funds dwindled throughout the month. Participants reported being more apt to have fresh fruits and vegetables available at the beginning of the month, when financial resources were more plentiful: “I can get a bag of apples and maybe a package of carrots. That’s not going
Journal of Nutrition Education and Behavior Volume 51, Number 5, 2019 to last very long at our house” (Loc 4, Mother, English). Picky eaters. Each focus group discussion elicited parent challenges with picky-eating behaviors. Parents reported many issues with expanding their child’s food preferences because of a child’s dislike or unwillingness to try certain foods. Parents expressed interest in specific strategies for dealing with picky eating and ideas for how to expand their child’s food repertoire and incorporating healthy food options. During the focus groups, parents began to share ideas among themselves; they reported that this was a significant challenge and that they needed additional information by professionals.
Theme 4: Actions to Increase Healthy Eating Use of technology to reinforce ideas and strategies. When parents were asked about the methods and strategies Head Start used to communicate 5210 information, the majority of parents cited written information disseminated via flyers and handouts. Flyers and educational handouts were placed in the enrolled child’s backpack throughout the academic year. The majority of participants reported that they viewed the information sent home in the child’s backpack, but often merely glanced at the materials before discarding them: “I mean, like, yeah, I did skim this. I doubt I’ll read every single word on this page, to be honest with you. There’s a lot of writing down here” (Loc 3, Mother, English). Another parent stated, “The problem isn’t information, the problem is carrying out the advice” (Loc 2, Mother, Spanish). When parents were asked about the most effective methods for communicating 5210 information to program participants, participants suggested the use of various technologies to add in transmitting the information. Facebook and Pinterest were cited as 2 main technological resources the school could use to disseminate and share nutrition information and resources: The [school] website, or the Facebook page, that would be amazing
to post, maybe not every day, like on a weekly, but post like a nutritional dinner. I think something I would like to see on Pinterest would be maybe stuff that wouldn’t be good for them. Ideas of what not to give and why . . . fun ideas of ways to make fruit fun for them to eat. (Loc 1, Mother, English) Participants also cited using pictures and images as a more effective means of communication as opposed to solely written information. This finding was consistent among all focus groups except for Hispanic parents, who reported that technological resources were not frequently used and that they preferred information to be given face-to-face by a trusted individual within the school community. Participants cited the program’s bilingual site-based social worker as a primary source of health and nutrition information. Parent−child engagement activities. TaggedPParticipants discussed use of parent− child activities, including cooking and meal preparation, as a strategy for increasing healthy eating behaviors. One parent stated, “I have noticed with my kids, when I engage them in the activity of cooking or being part of making, they usually tend to eat it better than if they aren’t” (Loc 4, Mother, English). Another parent stated, When they are engaged in the activity of creating with me, then they’re more apt to eat what they’re making, I guess because they feel that they’re a big boy and big girl. (Loc 4, Mother, English) One parent identified that cooking together could be an opportunity to spend quality time and bond with the child: “I get the one-on-one with my daughter. You’re teaching how to cook healthy things. . . . It would be bonding for them all, too” (Loc 2, Mother, English). Supportive structures. During focus group discussions, participants identified supportive structures that could be established to improve family’s and children’s eating habits. All
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focus group participants expressed high levels of interest in parent groups that would offer social and educational support to parents. Participants suggested a parent support group format, facilitated by a professional, that would promote idea sharing, recipe development, and handson practice in making recipes that suited a low-income budget. A parent stated, “I’d be interested in some kind of couponing, how to save money and feed your kids nutritionally” (Loc 2, Mother, English). Participants also expressed interest in strategies for dealing with picky eating and ways to present fruits and vegetables in an appealing manner: “One thing that would be helpful is presentation. A fun way to get your kids to eat their fruits and vegetables: ideas of how you can” (Loc 4, Mother, English).
DISCUSSION Findings suggest that parents have limited understanding of the current nutrition messaging strategies used by the Head Start program. Current 5210 and nutrition messages are provided in predominantly written format, which resulted in low levels of participant recall. Use of social media platforms, visual images, and parent cooking classes were identified as potential means of increasing families’ understanding and incorporating 5210 and general healthy eating messages. Preference was given to written materials only if messaging was concise, easy to read, and visually stimulating. Previous research22 supported that visualizations and infographics were useful in supporting the understanding and comprehension of messaging among lowliteracy individuals. Findings from this study were consistent with other research, which demonstrates that information should be made available across multiple formats; this is further supported by health behavior research23 demonstrating that providing multiple opportunities for individuals to engage with material designed to change knowledge and behavior improves the chances that the intended changes will take place.
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Participants suggested that 5210 recommendations given to parents include specific strategies for how this practice could be integrated into the family’s daily routine, acknowledging that this might result in higher levels of compliance. Practical strategies are needed to increase fruit and vegetable consumption while considering the barriers of family income and picky eaters. These findings were consistent with previous research suggesting that health and nutrition communications incorporate how-to knowledge to support behavior change.24 These findings also highlighted the role poverty might have in adopting healthy eating behaviors. Family finances were consistently cited as a barrier to healthy eating and adherence to the 5210 guidelines, which further emphasized the importance of practical ways in which families might meet the fruit and vegetable requirements on a budget. Head Start parent −child cooking classes were cited as an intervention to increase family understanding of healthy, affordable meal ideas that incorporate the 5210 recommendations. Parent−child cooking classes were shown to increase the implementation of sustainable food practices and healthy nutrition behaviors by educating families about how to involve their children in positive mealtime practices.25 This study included a focus group that specifically targeted the Hispanic community. Themes within this focus group were consistent with those of other focus groups in the study, except for the use of social media platforms for 5210 and general nutrition messaging dissemination. Participants in the Hispanic focus group acknowledged that they preferred face-to-face communication with a trusted member of the Head Start community, compared with electronic forms of communication such as Facebook and Pinterest. This finding was consistent with other research26 conducted with Hispanic parents of Head Start preschoolers, which found that networks of support, including friends and family members, were used as main sources of health and nutrition information within the community. Data from this study also highlighted the importance of accurately measuring and categorizing the
Journal of Nutrition Education and Behavior Volume 51, Number 5, 2019 weight of enrolled children before notifying parents of children’s weight status. This was consistent with other research27−29 acknowledging that parents were likely to support BMI screening programs when deliberate attention was given to standardized conduction of screenings and the parent notification process, and the way in which results were used to support a healthy school environment. Parents in this study expressed a certain level of distrust in BMI measurement reporting from Head Start owing to its inconsistency compared with other health providers, namely the pediatrician and WIC. Previous research28,29 confirmed that parents desired height and weight measurements to be performed in a standardized manner by trained health professionals and wanted BMI information to be presented to parents in a neutral manner, avoiding weight labeling, including information about strategies for improving overall family nutrition and health. Communication models are useful for exploring individuals’ perceptions, beliefs, and actions related to nutrition messages. However, how individuals interpret information may radically alter their understanding.18 As such, it is important for Head Start to create clear and engaging messages that are understood, believed, and then acted upon by families enrolled in the program. The results of this study were consistent with other research25,26,30 indicating that low-income parents were interested in acquiring practical information about nutrition, recipes, and parenting in a supportive setting that encouraged parental interaction and facilitated change. Parents across all focus groups expressed interest in nutrition education sessions hosted at the school, with specific interest in cooking classes that provided hands-on instruction on how to prepare healthy meals on a limited budget. Although these findings provide insight into factors to consider when developing nutrition education messages, materials, and programming for low-income families, the results of this study may not transfer to other parent groups without further
exploration. Because Head Start sites in this study were selected based on higher parental involvement, it is unknown whether parents’ responses would be similar at sites with lower levels of parental engagement. In addition, because focus groups were conducted during the school day, results may not reflect the opinions of parents who work traditional daytime hours. Only 1 focus group was conducted in Spanish with Spanishspeaking families. Furthermore, a potential loss of meaning might have occurred when translating from Spanish to English, which needs to be considered. No calculation of coder agreement was included in this study. Finally, the Convergence Model of Communication does not take into consideration the role of power in the communication process and was not been used in Head Start. The way in which parents receive nutrition messages could potentially be influenced by this power dynamic and was not explored in this study. The majority of participants also reported being benefit recipients of WIC and/or Supplemental Nutrition Assistance Program. The messages that participants receive from these entities may have had the potential to influence the results of this study.
IMPLICATIONS FOR RESEARCH AND PRACTICE The results of this study provide insight into the perceptions of lowincome parents as they relate to nutrition messaging and education. Head Start programs are uniquely positioned to address childhood obesity through parental education and support, especially because this is an integral component of the existing program. Future research could examine the effectiveness of implementing the interventions suggested by study participants on actual behavior change and adherence to healthy living messaging, such as 5210, in the home environment. It could also explore factors that influence the perceived value of nutrition information among Head Start families. Finally, research could explore the role of perceived power in the nutrition education communication process. Results
Journal of Nutrition Education and Behavior Volume 51, Number 5, 2019 of this study might provide a framework for designing interventions focused on communication and practical strategies for ensuring understanding and adherence to 5210 among Head Start families.
ACKNOWLEDGMENTS The authors acknowledge the Miami University Office for the Advancement of Research and Scholarship.
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