- Email: [email protected]
Parents’ Perceptions of Childhood Obesity and Support of the School Wellness Policy
Research Brief Parents’ Perceptions of Childhood Obesity and Support of the School Wellness Policy Deana A. Hildebrand, PhD, RD, LD; Nancy M. Betts, PhD, RD; Gail E. Gates, PhD, RD, FAND ABSTRACT Objective: Investigate differences in familiarity of parents of school-aged children with school wellness polices (SWP) and perceptions of the problem of childhood obesity related to support for the SWP and school’s role in providing a healthy environment. Methods: Descriptive, cross-sectional study using telephone surveys conducted in spring, 2016. T test statistics compared differences between parents with high vs low SWP familiarity and agreement vs disagreement of childhood obesity as problematic. Results: Nearly half of parents (49.5%) had low familiarity with SWP. Overall, fewer parents agreed that obesity was a local school problem compared with a statewide problem (P < .001). Differences in agreement about childhood obesity explained some differences in SWP support. Conclusions and Implications: Greater awareness is needed among parents of schoolchildren regarding the SWP as well as the prevalence of childhood obesity. This could be achieved through increased development, implementation, and evaluation of communication efforts between schools and families regarding health-promoting environments. Key Words: childhood obesity, elementary schools, parents, school wellness policy (J Nutr Educ Behav. 2019; 51:498−504.) Accepted December 17, 2018. Published online February 6, 2019.
INTRODUCTION School activity and food environments are critically important for addressing child overweight and obesity.1 Congress recognized the vital role that schools have in promoting healthy lifestyles for students when they passed the Child Nutrition and Women, Infants, and Children Reauthorization Act of 2004.2 This act mandated that by the start of the 2006−2007 school year, all school districts participating in US Department of Agriculture meal programs were required to establish school wellness policies (SWPs). In 2010, the Healthy, Hunger-Free Kids Act further strengthened the SWP requirements by expanding the scope of the wellness policies to promote health
and prevent childhood obesity and increase the accountability and transparency of policies.3 Critical review of the research suggested that use of local SWP was associated with increased consumption of healthier food items and superior health-promoting practices in the school setting, such as regular physical activity.4 Students who are well-nourished and physically active are better equipped to meet their full academic potential and display positive behaviors in the classroom.5 Studies measured the extent of school adherence to wellness policies and evaluated implementation of such policies, but literature is limited examining the involvement of parents.6 Parents provide a significant influence on child behaviors and can reinforce at home the health-promoting behaviors
Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK Conflict of Interest Disclosure: The authors have not stated any conflicts of interest. Address for correspondence: Deana A. Hildebrand, PhD, RD, LD, Department of Nutritional Sciences, Oklahoma State University, 301 Human Sciences, Stillwater, OK 74078; E-mail: [email protected] Ó 2018 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jneb.2018.12.009
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children learn at school.6 Hung et al7 conducted a systematic review of factors that enhance implementation of health-promoting policies in schools and found that support from parents was an important component of successful implementation. However, none of the articles included in the review directly assessed parents’ perceptions about the SWP. Agron et al8 evaluated the perceptions of school board members regarding barriers to implementation of SWP; a key barrier identified was lack of support from parents. Two small studies interviewed parents about their perceptions of SWPs shortly after the policies were required to be adopted by schools.9,10 At that time, few parents interviewed were knowledgeable about SWP and they identified a number of barriers to parent participation in the policies, including lack of effective communication from the schools. There is little question that the rates of childhood obesity are a public health concern.11 However, although parents agree that childhood obesity is a problem,12 they often fail to recognize obesity in their own children or perceive it as problematic.13 Because
Journal of Nutrition Education and Behavior Volume 51, Number 4, 2019
Journal of Nutrition Education and Behavior Volume 51, Number 4, 2019 little is known about parents’ knowledge and perception of the SWP and because of their failure to recognize weight issues in their own children, the primary objective of this study was to investigate parents’ knowledge of and familiarity with SWP, perceptions of childhood obesity as being a problem, and their belief that schools have a responsibility for obesity prevention. The researchers hypothesized that (1) parents with higher familiarity with the SWP would have higher support for the policy, and (2) parents’ support of the SWP would be different based on their perception of childhood obesity as a problem.
METHODS Participants Participants in this study were parents and guardians, collectively referred to here as parents, of children enrolled in a public school district and residing in Oklahoma. They were required to have at least 1 child currently or recently enrolled in an elementary school. No incentives were used to recruit potential participants.
Instrumentation With input from the director of the University of Oklahoma Public Opinion Learning Lab, Oklahoma State University researchers developed a telephone interview survey. Interview items were based on relevant literature with 3 focus areas: (1) parents’ knowledge of and familiarity with SWP, (2) parents’ opinions about the feasibility of implementing SWP, and (3) parents’ opinions about the school’s role in promoting the reduction of obesogenic behaviors. Interviews started with providing parents with a brief definition of the SWP and asking, To the best of your knowledge, does the school your child attends have a SWP? Familiarity with the SWP was determined by asking, How familiar are you with the content of the SWP in your child’s school? Responses were based on a scale from 0 (not at all familiar) to 10 (completely familiar). Two items were used to assess the feasibility of implementing SWP: How feasible is it for the school to (1) change foods served to meet nutrition guidelines for health promotion and
obesity prevention, and (2) increase physical activity for all students? Responses were based on a scale of 0 (not at all feasible) to 10 (completely feasible). To guide development of items assessing parents’ perceptions of the school’s role and support of policy strategies, the researchers referenced WellSAT-2 (version 2, Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, CT; 2014), an evaluation tool used to measure the quality of SWPs.14 It is composed of 6 areas, each of which is assessed using a series of best practices. Areas include nutrition education, meal standards, nutrition standards for competitive foods, physical activity and physical education, wellness promotion, and implementation and evaluation.14 For this study, researchers focused on nutrition education (4 items), meal standards (10 items), nutrition standards for competitive foods (8 items), and physical activity and physical education (13 items). For each item, parents responded using a 5-point Likert-type scale from 1 = strongly disagree to 5 = strongly agree. In addition, researchers explored parents’ opinions about the prevalence of obesity in their child’s school and in the state, using a scale of 1 = strongly disagree to 5 = strongly agree. Family-level demographic information was obtained from the parent, including sex, race, educational level attained, number of children and school grade, and household income.
Procedure Researchers conducted the cross-sectional study from March, 2016 through June, 2016. The polling lab purchased zip codes and telephone numbers of households that were likely to include school-aged children. Trained staff employed by the polling center conducted the interviews following a detailed interview guideline and using a structured protocol to record responses. Interviewers were able to contact 1,026 eligible households; 470 completed the survey (45% response). Interviewers informed potential participants about the study’s purpose and the voluntary and confidential nature of the interview, and that they could opt out of the study at any time. The Oklahoma State
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University and University of Oklahoma Institutional Review Boards reviewed and classified the study as exempt.
Data Analysis All analyses were conducted using SPSS (version 21, IBM Corp, Armonk, NY; 2012). Significance was set at P ≤ .05. Researchers used frequency analysis to examine the demographic characteristics of households. Frequencies for each closed response item were tabulated and calculated as a percentage of the total. Student t test examined mean differences among continuous variables; the researchers calculated Cohen’s d to determine the effect size. Principal components analysis was conducted using 35 items assessing parents’ support of recommended components for SWPs, which resulted in 6 scales (Table 1): (1) increasing physical activity (n = 12), (2) providing healthy school food (n = 9), (3) providing nutrition information (n = 4), (4) improving food service (n = 5), (5) offering free meals (n = 3), and (6) requiring physical education certification for teachers (n = 2). Higher scores on the scales indicated greater agreement with the statements. Reliability coefficients for the scales ranged from 0.74 to 0.90 (Table 1).
RESULTS The majority of the sample was female (67.9%), white/Caucasian (80.2%), and had at least some college or higher education (72.6%) (Table 2). The average household income was $103,344. Slightly over 80% of participants had 1 or 2 children in elementary school in prekindergarten through fifth grade, with a mode of fifth grade (n = 139); 59.3% of respondents had children in higher school grades: sixth through 12th, with a mode of sixth grade (n = 103). Almost two-thirds of parents (62.6%) were aware that their child’s school operated under an SWP, but familiarity with policy content was low (mean = 4.4 § 0.2). Half of the parents (49.5%) reported low familiarity with policy content; of those, 38.5% reported they were not at all familiar with the content. Compared with parents who reported familiarity,
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Table 1. Factor Loadings and Reliability Coefficients for Scales Indicating Agreement With Recommended Components of School Wellness Policies
Scales Increasing physical activity To promote physical activity, schools should . . . regulate staff involvement in physical activity opportunities provide classroom physical activity breaks regulate recess programs provide joint or shared-use agreements to promote physical activity opportunities for members of the community promote family and community engagement in physical activity opportunities regulate the student to teacher ratio in physical education classes provide before and after-school physical activity programs provide physical activity training for all teachers to engage students in active learning classrooms provide active transport programs such as walking school buses regulate the amount of time per week that is set aside for physical education instruction regulate the use of physical education waivers, substitution rules, and exception requirements Standards for USDA school breakfast and lunch programs should require recess to be scheduled before lunch in elementary schools. Providing healthy school food Competitive and other foods and beverages sold to students should be required to comply with minimum USDA nutrition standards . . . during the extended school day during the school day if served to students attending before and after-care programs on school grounds if they contain nonnutritive artificial sweeteners if they contain caffeine if served to students during classroom parties and celebrations on school grounds if sold during fund-raising activities if such activities are affiliated with a school program Standards for USDA school breakfast and lunch programs should . . . be more stringent than what is currently required for other programs run by the USDA prevent students from leaving schools during lunch periods Providing nutrition information Nutrition information should be provided to all . . . students in schools parents with children in school teachers and administrators in schools Standards for USDA school breakfast and lunch programs should require that nutrition information for all school meals be provided to students and parents. Improving food service Standards for USDA school breakfast and lunch programs should . . . ensure that students have adequate time to eat require providing a clean and pleasant environment during school meals require training for food and nutrition services staff require free drinking water to be available during meals Schools should be required to make free drinking water available to students throughout the school
Factor Loading
Cronbach a .90
.705 .694 .685 .629 .627 .610 .585 .585 .563 .517 .474 .468 .89
.830 .784 .755 .701 .697 .691 .664
.464 .417 .85 .810 .798 .778 .625 .74 .743 .663 .658 .595 .515 (continued)
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Table 1. (Continued)
Scales Offering universal free meals Standards for USDA school breakfast and lunch programs should . . . require providing universal free breakfasts to students in schools require providing universal free lunches to students in schools require schools to develop strategies to increase participation in school meal programs, such as breakfast in the classroom Requiring physical education certification To promote physical activity, schools should . . . provide appropriate training for physical education teachers require physical education teachers to be certified
Factor Loading
Cronbach a .84
.881 .864 .570 .76 .850 .814
USDA indicates the US Department of Agriculture. 14 Notes: WellSAT-2 was used to identify recommended components of school wellness policies. Respondents were asked to indicate their level of agreement with each statement using a 5-point Likert-type scale from strongly disagree to strongly agree.
Table 2. Demographic Characteristics of Parents Demographic Variables Age, y (mean) Household income (mean) Gender, n (%) Female Male Education, n (%) Less than high school High school/General Equivalency Diploma 2-y degree Some college Bachelor’s degree Graduate degree Race, n (%) American Indian Asian/Asian American Black/African American White/Caucasian Something else Ethnicity, n (%) Hispanic Children in elementary school. n (%) 0a 1 2 3 ≥4 Children in secondary school, n (%) 0b 1 2 3 4
Total (n = 470) 42.2 § 0.37 $103,344 § $5,103 319 (67.9) 151 (32.1) 8 (1.7) 54 (11.5) 65 (13.8) 67 (14.3) 179 (38.1) 95 (20.2) 31 (6.6) 5 (1.1) 22 (4.7) 377 (80.2) 19 (4.0) 29 (6.2) 60 (12.8) 238 (50.6) 139 (29.6) 28 (6.0) 3 (0.8) 191 (40.6) 173 (36.8) 87 (18.5) 17 (3.6) 2 (0.4)
a All parents without children in elementary school had children in other grades; bAll parents without children in secondary grades had children in elementary school.
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Table 3. Comparison Between Parents Who Disagreed That Obesity Is a Problem at Their Child’s School and Those Who Agreed About Responsibility for, Feasibility of, and Agreement With Recommended Components of School Wellness Policies, Using t Test Obesity Is a Problem in Child’s Schoola Mean § SE Selected Variables
Disagreed (n = 157)
Agreed (n = 119)
P
Cohen’s dd
5.4 § 0.25
6.4 § 0.25
.01
.37
4.1 § 0.25
5.4 § 0.27
< .001
.46
7.3 § 0.24
8.1 § 0.23
.02
.33
5.0 § 0.27 5.3 § 0.27
6.2 § 0.27 6.3 § 0.27
.002 .01
.42 .33
6.5 § 0.25
6.9 § 0.25
.23
.39
7.6 § 0.20
6.9 § 0.20
.24
.16
41.7 § 1.00 25.5 § 0.81 16.3 § 0.37 23.5 § 0.23 9.8 § 0.35 8.6 § 0.17
45.0 § 0.81 30.1 § 0.88 17.8 § 0.26 23.6 § 0.21 10.2 § 0.36 9.2 § 0.13
.02 < .001 .002 .70 .45 .02
.33 .49 .51 .05 .09 .39
b
Level of responsibility school has for: providing specific foods and limiting others to promote health and reduce obesity requiring all school-sponsored events to provide only healthy food items requiring all students to participate in physical activity for obesity prevention requiring teachers to model eating healthy food requiring teachers to exercise with the children to model health behavior Level of feasibilityb for school to: change the foods served to meet nutrition guidelines for health promotion and obesity prevention increase physical activity for all students Scales indicating agreement with recommended components of school wellness policiesc Increasing physical activity (scale = 12−60) Providing healthy food (scale = 9−45) Providing nutrition information (scale = 4−20) Improving food service (scale = 5−25) Offering universal free meals (scale = 3−15) Requiring physical education certification (scale = 2−10) a
Agreement with the statement Childhood obesity is a problem in my child’ s elementary school was rated on a 5-point Likert scale from 1 = strongly disagree to 5 = strongly agree. For this analysis, parents with neutral responses were omitted; bResponsibility and feasibility were rated on a scale of 0 = no responsibility/not feasible to 10 = full responsibility/completely feasible; c Scales were calculated from ratings of related items identified by factor analysis (Table 1). Higher values indicated greater level of agreement; dCohen’s d effect size: 0.2 = small; 0.5 = medium; 0.8 = large; and 1.3 = very large.
those who reported low familiarity rated school responsibility as less important for providing foods to promote health and reduce obesity (P = .04), requiring all students to participate in physical activity (P = .01), requiring teachers to model healthy food behavior (P < .01), and requiring teachers to exercise with the children (P = .01). Parents with lower familiarity had lower agreement with policy components requiring provision of nutrition information (P = .05) for foods sold in the schools and providing universal free meals (P = .02). The practical significance of these differences was small (Cohen’s d range, .19−.28), with the exception of parents’ perceptions of the school’s responsibility for
requiring teachers to model healthy food behaviors (Cohen’s d = .41). Across the sample, parents had a higher level of agreement that obesity was a problem in the state (70.7%), as opposed to obesity being a problem in their child’s school (25.3%; P < .01). To examine further parents’ perceptions about the SWP, researchers compared the responses of parents who disagreed that obesity was a problem in their child’s school (n = 157) with those who agreed (n = 119) (Table 3). Parents who disagreed had significantly lower mean ratings for the school’s responsibility to provide specific food to reduce obesity (P = .01), require healthy event food (P < .001), require all
students to be physically active (P = .02), require the teachers to model healthy eating (P = .002), and require teachers to exercise with the children (P = .01). In addition, parents who disagreed that obesity was a problem had lower agreement with SWP components related to increased physical activity (P = .02), provision of healthy food (P < .001), and provision of nutrition information (P < .002), and required physical education teacher certification (P = .02). In this comparison, the degree to which the phenomenon was present in a broader population increased (Cohen’s d range, .33−.51), allowing for guarded generalized implications and recommendations.
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DISCUSSION This article describes the perceptions of parents, a key stakeholder group in schools, related to their familiarity with and support of SWPs. The current body of SWP literature reported progress in schools’ adoption of policies, compliance with federal requirements, implementation of the policy, and the support of stakeholders within the school setting, such as administrators and teachers.15 The findings of this study have potential to move policy forward, in that previous research identified parental support as a missing element in the successful implementation of SWP.7,8 A key finding in this study was that parents’ perception of childhood obesity as problematic explained differences in their perceptions of the school’s responsibility to provide obesity preventive environments and their agreement with recommended SWP components. Three of every 4 parents interviewed described child obesity as a problem statewide, which agreed with recent data indicating that 18.1% of children aged 10−17 years were obese in 2016.11 This was consistent with a 2014 national poll reporting that 80% of parents were concerned about the state of children’s health and 74% were concerned about the prevalence of child obesity.12 In contrast, only 1 in 4 parents in this study believed that child obesity was a problem locally. The lack of congruence between the perceived problem statewide vs locally may reflect the fact that a majority of parents were unable to recognize obesity in their own children.13 Likewise, low perception of obesity as a local problem may be associated with lower support for school efforts that protect against child obesity. As such, parents have a vague awareness of the need for local school wellness and child obesity prevention efforts.16 For example, parents who did not perceive child obesity to be a local problem were less likely to believe the school had responsibility for promoting wellness. This finding differs from the Pew Charitable Trusts’12 national poll, which reported that most parents supported nutrition standards for school meals and snacks. In this study, parents were more likely to agree with or
support efforts related to physical activity rather than those addressing food. Despite requirements that schools engage parents in developing and communicating components of the SWP to the public, a second finding of this study was that most parents knew their child’s school had an SWP but reported little or no familiarity with the SWP content. In 2015 and 2016, the researchers conducted a review of 354 school wellness policies (65% of the Oklahoma school districts) using the WellSAT 2.0.14 The results revealed that the majority of the policies did not include requirements for communicating policy content and progress with the public (88%) or school community (76%).17 These findings are consistent with previous research that identified inadequate communication with stakeholders as a barrier to effective SWP implementation.10,18 Strengths of this study were using the WellSAT-2 policy elements to identify parents’ support of SWP and the internal consistency of the scale items. These strengths address the lack of construct and face validity of the survey items, which could have created response bias. A second limitation was that the sample of study respondents was not representative of the state in terms of household income and education,19 which limits the generalization of their responses.
IMPLICATIONS FOR RESEARCH AND PRACTICE A unique contribution of this research is that it brings attention to parents’ low familiarity with and support of the SWP and their perceptions related to childhood obesity as being problematic at the local level. The Healthy, Hunger-Free Kids Act, 2010 requires schools to include input from parents and community stakeholders when developing or updating SWPs.3 Focusing on policy elements that elevate parental knowledge and familiarity with the SWP, practices that increase parents’ perceptions of childhood obesity as being problematic, and the role the schools have in providing healthy environments that protect against obesity would be beneficial in moving policy forward.4,7 This may be achieved when school districts include not only
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school personnel but also parents and community members in developing, implementing, and evaluating the SWP.15 Although engaging parents in SWP is consistently reported as a barrier, further research is needed to test interventions to engage parents in school wellness efforts.9,10,20 To ensure policies are implemented, schools are tasked with identifying a school official with monitoring implementation and reporting the school’s progress to school and community stakeholders. To facilitate this process, policy elements might identify specific and measurable outcomes including time lines, and how communication with parents will be conducted. This is further facilitated by designating individuals at the school site and district levels who will be responsible for implementing and evaluating progress of the policy. Local school or statewide efforts to measure students’ fitness levels have the potential to increase parental awareness of the issue of child obesity.18,20 By including a requirement for fitness testing and reporting in SWP, schools could track student progress in fitness across grade levels and report to parents with nonjudgmental messages. Funding allocations at the state and federal government levels would be particularly beneficial, especially for schools with limited resources. As successful efforts and communication increase, it is likely that parents will begin to perceive the school setting not only as an education setting but as a place where students and parents can learn and practice health-promoting behaviors to reduce obesity, thus increasing readiness to support strong policy implementation.16
ACKNOWLEDGMENTS The authors would like to acknowledge the Oklahoma State University Vice President for Research and Technology for funding the project.
REFERENCES 1. Clarke J, Fletcher B, Lancashire E, Pallan, Adab P. The views of stakeholders on the role of the primary school in preventing childhood obesity: a qualitative systematic review. Obes Rev. 2013;14:975-988.
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2. Schwartz MB, Lund AE, Grow HM, et al. A comprehensive coding system to measure the quality of school wellness policies. J Am Diet Assoc. 2009;109:12561262. 3. Welker E, Lott M, Story M. The school food environment and obesity prevention: progress over the last decade. Curr Obes Rep. 2016;5:145-155. 4. Hammerschmidt P, Tackett W, Golzynski M, Golzynski D. Barriers to and facilitators of healthful eating and physical activity in low-income schools. J Nutr Educ Behav. 2011;43:63-68. 5. Edwards JU, Mauch L, Winkelman MR. Relationship of nutrition and physical activity behaviors and fitness measures to academic performance for sixth graders in a midwest city school district. J Sch Health. 2011;81:65-73. 6. Brissette I, Wales K, O’Connell M. Evaluating the wellness school assessment tool for use in public health practice to improve school nutrition and physical education policies in New York. J Sch Health. 2013;83:757-762. 7. Hung TTM, Chiang VCL, Dawson A, Lee RLT. Understanding of factors that enable health promoters in implementing health-promoting schools: a systematic review and narrative synthesis of qualitative evidence. PLOS One. 2014;9:e108284. 8. Agron P, Berends V, Ellis K, Gonzales M. School wellness policies: perceptions,
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barriers, and needs among school leaders and wellness advocates. J Sch Health. 2010;80:527-535. Agron P, Berends V, Cole N, Gooley J, Hawksworth K, Martinez N. Engaging parents in stakeholders in school wellness: formative research report (California Project LEAN [Leaders Encouraging Activity, and Nutrition]. http://www.californiaprojectlean.org/docuserfiles/Parent%20 Formative%20Research%20Report.pdf. Accessed November 15, 2018. MacLellan D, Holland A, Taylor J, McKenna M, Hernandez K. Implementing school nutrition policy: student and parent perspectives. Can J Diet Pract Res. 2010;71:172-177. Robert Wood Johnson Foundation Trust for America’s Health. The state of obesity: better policies for better health. https://stateofobesity.org/wp-content/ uploads/2018/09/stateofobesity2018. pdf. Accessed November 15, 2018. Pew Charitable Trusts. Parents support healthier school food standards. http:// www.pewtrusts.org/en/multimedia/ data-visualizations/2014/parents-support-healthier-school-food-standards. Accessed November 15, 2018. Parry LL, Gopalakrishnan N, Parry J, Saxena S. A systematic review of parental perception of overweight status in children. J Ambul Care Manage. 2008;31:253-268. Rudd Center for Food Policy and Obesity. WellSAT:2.0 Wellness School
15.
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Assessment Tool. http://www.wellsat. org/upload/docs/WellSAT%202.0.pdf. Accessed November 15, 2018. Chriqui JF, Resnick EA, Schneider L, et al. School District Wellness Policies: Evaluating Progress and Potential for Improving Children’s Health Five Years After the Federal Mandate. School Years 2006-07 Through 2010-11, Vol 3. Chicago, IL: Bridging the Gap Program, Healthy Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago; 2013. Oetting ER, Plested BA, Edwards RW, Thurman PJ, Kelly KJ, Bequvais F. Community Readiness for Community Change. 2nd ed. Fort Collins, CO: Tri-Ethnic Center for Prevention Research, Colorado State University; 2014. Komakech JJ. School Wellness Policy Quality May Not Reflect the Presence of Health Promotion Programs [master’s thesis]. Stillwater, OK: Oklahoma State University; 2018. Metos J, Murtaugh M. Are school district wellness policies implemented? A systematic review of the literature. Child Obes. 2011;7:90-100. US Census. Quick facts: Oklahoma. https://www.census.gov/quickfacts/ fact/table/Oklahoma,US/INC110216. Accessed November 15, 2018. Soto C, White JH. School health initiatives and childhood obesity: BMI screening and reporting. Policy Polit Nurs Pract. 2010;11:106-114.
INTRODUCTION School activity and food environments are critically important for addressing child overweight and obesity.1 Congress recognized the vital role that schools have in promoting healthy lifestyles for students when they passed the Child Nutrition and Women, Infants, and Children Reauthorization Act of 2004.2 This act mandated that by the start of the 2006−2007 school year, all school districts participating in US Department of Agriculture meal programs were required to establish school wellness policies (SWPs). In 2010, the Healthy, Hunger-Free Kids Act further strengthened the SWP requirements by expanding the scope of the wellness policies to promote health
and prevent childhood obesity and increase the accountability and transparency of policies.3 Critical review of the research suggested that use of local SWP was associated with increased consumption of healthier food items and superior health-promoting practices in the school setting, such as regular physical activity.4 Students who are well-nourished and physically active are better equipped to meet their full academic potential and display positive behaviors in the classroom.5 Studies measured the extent of school adherence to wellness policies and evaluated implementation of such policies, but literature is limited examining the involvement of parents.6 Parents provide a significant influence on child behaviors and can reinforce at home the health-promoting behaviors
Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK Conflict of Interest Disclosure: The authors have not stated any conflicts of interest. Address for correspondence: Deana A. Hildebrand, PhD, RD, LD, Department of Nutritional Sciences, Oklahoma State University, 301 Human Sciences, Stillwater, OK 74078; E-mail: [email protected] Ó 2018 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jneb.2018.12.009
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children learn at school.6 Hung et al7 conducted a systematic review of factors that enhance implementation of health-promoting policies in schools and found that support from parents was an important component of successful implementation. However, none of the articles included in the review directly assessed parents’ perceptions about the SWP. Agron et al8 evaluated the perceptions of school board members regarding barriers to implementation of SWP; a key barrier identified was lack of support from parents. Two small studies interviewed parents about their perceptions of SWPs shortly after the policies were required to be adopted by schools.9,10 At that time, few parents interviewed were knowledgeable about SWP and they identified a number of barriers to parent participation in the policies, including lack of effective communication from the schools. There is little question that the rates of childhood obesity are a public health concern.11 However, although parents agree that childhood obesity is a problem,12 they often fail to recognize obesity in their own children or perceive it as problematic.13 Because
Journal of Nutrition Education and Behavior Volume 51, Number 4, 2019
Journal of Nutrition Education and Behavior Volume 51, Number 4, 2019 little is known about parents’ knowledge and perception of the SWP and because of their failure to recognize weight issues in their own children, the primary objective of this study was to investigate parents’ knowledge of and familiarity with SWP, perceptions of childhood obesity as being a problem, and their belief that schools have a responsibility for obesity prevention. The researchers hypothesized that (1) parents with higher familiarity with the SWP would have higher support for the policy, and (2) parents’ support of the SWP would be different based on their perception of childhood obesity as a problem.
METHODS Participants Participants in this study were parents and guardians, collectively referred to here as parents, of children enrolled in a public school district and residing in Oklahoma. They were required to have at least 1 child currently or recently enrolled in an elementary school. No incentives were used to recruit potential participants.
Instrumentation With input from the director of the University of Oklahoma Public Opinion Learning Lab, Oklahoma State University researchers developed a telephone interview survey. Interview items were based on relevant literature with 3 focus areas: (1) parents’ knowledge of and familiarity with SWP, (2) parents’ opinions about the feasibility of implementing SWP, and (3) parents’ opinions about the school’s role in promoting the reduction of obesogenic behaviors. Interviews started with providing parents with a brief definition of the SWP and asking, To the best of your knowledge, does the school your child attends have a SWP? Familiarity with the SWP was determined by asking, How familiar are you with the content of the SWP in your child’s school? Responses were based on a scale from 0 (not at all familiar) to 10 (completely familiar). Two items were used to assess the feasibility of implementing SWP: How feasible is it for the school to (1) change foods served to meet nutrition guidelines for health promotion and
obesity prevention, and (2) increase physical activity for all students? Responses were based on a scale of 0 (not at all feasible) to 10 (completely feasible). To guide development of items assessing parents’ perceptions of the school’s role and support of policy strategies, the researchers referenced WellSAT-2 (version 2, Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, CT; 2014), an evaluation tool used to measure the quality of SWPs.14 It is composed of 6 areas, each of which is assessed using a series of best practices. Areas include nutrition education, meal standards, nutrition standards for competitive foods, physical activity and physical education, wellness promotion, and implementation and evaluation.14 For this study, researchers focused on nutrition education (4 items), meal standards (10 items), nutrition standards for competitive foods (8 items), and physical activity and physical education (13 items). For each item, parents responded using a 5-point Likert-type scale from 1 = strongly disagree to 5 = strongly agree. In addition, researchers explored parents’ opinions about the prevalence of obesity in their child’s school and in the state, using a scale of 1 = strongly disagree to 5 = strongly agree. Family-level demographic information was obtained from the parent, including sex, race, educational level attained, number of children and school grade, and household income.
Procedure Researchers conducted the cross-sectional study from March, 2016 through June, 2016. The polling lab purchased zip codes and telephone numbers of households that were likely to include school-aged children. Trained staff employed by the polling center conducted the interviews following a detailed interview guideline and using a structured protocol to record responses. Interviewers were able to contact 1,026 eligible households; 470 completed the survey (45% response). Interviewers informed potential participants about the study’s purpose and the voluntary and confidential nature of the interview, and that they could opt out of the study at any time. The Oklahoma State
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University and University of Oklahoma Institutional Review Boards reviewed and classified the study as exempt.
Data Analysis All analyses were conducted using SPSS (version 21, IBM Corp, Armonk, NY; 2012). Significance was set at P ≤ .05. Researchers used frequency analysis to examine the demographic characteristics of households. Frequencies for each closed response item were tabulated and calculated as a percentage of the total. Student t test examined mean differences among continuous variables; the researchers calculated Cohen’s d to determine the effect size. Principal components analysis was conducted using 35 items assessing parents’ support of recommended components for SWPs, which resulted in 6 scales (Table 1): (1) increasing physical activity (n = 12), (2) providing healthy school food (n = 9), (3) providing nutrition information (n = 4), (4) improving food service (n = 5), (5) offering free meals (n = 3), and (6) requiring physical education certification for teachers (n = 2). Higher scores on the scales indicated greater agreement with the statements. Reliability coefficients for the scales ranged from 0.74 to 0.90 (Table 1).
RESULTS The majority of the sample was female (67.9%), white/Caucasian (80.2%), and had at least some college or higher education (72.6%) (Table 2). The average household income was $103,344. Slightly over 80% of participants had 1 or 2 children in elementary school in prekindergarten through fifth grade, with a mode of fifth grade (n = 139); 59.3% of respondents had children in higher school grades: sixth through 12th, with a mode of sixth grade (n = 103). Almost two-thirds of parents (62.6%) were aware that their child’s school operated under an SWP, but familiarity with policy content was low (mean = 4.4 § 0.2). Half of the parents (49.5%) reported low familiarity with policy content; of those, 38.5% reported they were not at all familiar with the content. Compared with parents who reported familiarity,
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Table 1. Factor Loadings and Reliability Coefficients for Scales Indicating Agreement With Recommended Components of School Wellness Policies
Scales Increasing physical activity To promote physical activity, schools should . . . regulate staff involvement in physical activity opportunities provide classroom physical activity breaks regulate recess programs provide joint or shared-use agreements to promote physical activity opportunities for members of the community promote family and community engagement in physical activity opportunities regulate the student to teacher ratio in physical education classes provide before and after-school physical activity programs provide physical activity training for all teachers to engage students in active learning classrooms provide active transport programs such as walking school buses regulate the amount of time per week that is set aside for physical education instruction regulate the use of physical education waivers, substitution rules, and exception requirements Standards for USDA school breakfast and lunch programs should require recess to be scheduled before lunch in elementary schools. Providing healthy school food Competitive and other foods and beverages sold to students should be required to comply with minimum USDA nutrition standards . . . during the extended school day during the school day if served to students attending before and after-care programs on school grounds if they contain nonnutritive artificial sweeteners if they contain caffeine if served to students during classroom parties and celebrations on school grounds if sold during fund-raising activities if such activities are affiliated with a school program Standards for USDA school breakfast and lunch programs should . . . be more stringent than what is currently required for other programs run by the USDA prevent students from leaving schools during lunch periods Providing nutrition information Nutrition information should be provided to all . . . students in schools parents with children in school teachers and administrators in schools Standards for USDA school breakfast and lunch programs should require that nutrition information for all school meals be provided to students and parents. Improving food service Standards for USDA school breakfast and lunch programs should . . . ensure that students have adequate time to eat require providing a clean and pleasant environment during school meals require training for food and nutrition services staff require free drinking water to be available during meals Schools should be required to make free drinking water available to students throughout the school
Factor Loading
Cronbach a .90
.705 .694 .685 .629 .627 .610 .585 .585 .563 .517 .474 .468 .89
.830 .784 .755 .701 .697 .691 .664
.464 .417 .85 .810 .798 .778 .625 .74 .743 .663 .658 .595 .515 (continued)
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Table 1. (Continued)
Scales Offering universal free meals Standards for USDA school breakfast and lunch programs should . . . require providing universal free breakfasts to students in schools require providing universal free lunches to students in schools require schools to develop strategies to increase participation in school meal programs, such as breakfast in the classroom Requiring physical education certification To promote physical activity, schools should . . . provide appropriate training for physical education teachers require physical education teachers to be certified
Factor Loading
Cronbach a .84
.881 .864 .570 .76 .850 .814
USDA indicates the US Department of Agriculture. 14 Notes: WellSAT-2 was used to identify recommended components of school wellness policies. Respondents were asked to indicate their level of agreement with each statement using a 5-point Likert-type scale from strongly disagree to strongly agree.
Table 2. Demographic Characteristics of Parents Demographic Variables Age, y (mean) Household income (mean) Gender, n (%) Female Male Education, n (%) Less than high school High school/General Equivalency Diploma 2-y degree Some college Bachelor’s degree Graduate degree Race, n (%) American Indian Asian/Asian American Black/African American White/Caucasian Something else Ethnicity, n (%) Hispanic Children in elementary school. n (%) 0a 1 2 3 ≥4 Children in secondary school, n (%) 0b 1 2 3 4
Total (n = 470) 42.2 § 0.37 $103,344 § $5,103 319 (67.9) 151 (32.1) 8 (1.7) 54 (11.5) 65 (13.8) 67 (14.3) 179 (38.1) 95 (20.2) 31 (6.6) 5 (1.1) 22 (4.7) 377 (80.2) 19 (4.0) 29 (6.2) 60 (12.8) 238 (50.6) 139 (29.6) 28 (6.0) 3 (0.8) 191 (40.6) 173 (36.8) 87 (18.5) 17 (3.6) 2 (0.4)
a All parents without children in elementary school had children in other grades; bAll parents without children in secondary grades had children in elementary school.
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Table 3. Comparison Between Parents Who Disagreed That Obesity Is a Problem at Their Child’s School and Those Who Agreed About Responsibility for, Feasibility of, and Agreement With Recommended Components of School Wellness Policies, Using t Test Obesity Is a Problem in Child’s Schoola Mean § SE Selected Variables
Disagreed (n = 157)
Agreed (n = 119)
P
Cohen’s dd
5.4 § 0.25
6.4 § 0.25
.01
.37
4.1 § 0.25
5.4 § 0.27
< .001
.46
7.3 § 0.24
8.1 § 0.23
.02
.33
5.0 § 0.27 5.3 § 0.27
6.2 § 0.27 6.3 § 0.27
.002 .01
.42 .33
6.5 § 0.25
6.9 § 0.25
.23
.39
7.6 § 0.20
6.9 § 0.20
.24
.16
41.7 § 1.00 25.5 § 0.81 16.3 § 0.37 23.5 § 0.23 9.8 § 0.35 8.6 § 0.17
45.0 § 0.81 30.1 § 0.88 17.8 § 0.26 23.6 § 0.21 10.2 § 0.36 9.2 § 0.13
.02 < .001 .002 .70 .45 .02
.33 .49 .51 .05 .09 .39
b
Level of responsibility school has for: providing specific foods and limiting others to promote health and reduce obesity requiring all school-sponsored events to provide only healthy food items requiring all students to participate in physical activity for obesity prevention requiring teachers to model eating healthy food requiring teachers to exercise with the children to model health behavior Level of feasibilityb for school to: change the foods served to meet nutrition guidelines for health promotion and obesity prevention increase physical activity for all students Scales indicating agreement with recommended components of school wellness policiesc Increasing physical activity (scale = 12−60) Providing healthy food (scale = 9−45) Providing nutrition information (scale = 4−20) Improving food service (scale = 5−25) Offering universal free meals (scale = 3−15) Requiring physical education certification (scale = 2−10) a
Agreement with the statement Childhood obesity is a problem in my child’ s elementary school was rated on a 5-point Likert scale from 1 = strongly disagree to 5 = strongly agree. For this analysis, parents with neutral responses were omitted; bResponsibility and feasibility were rated on a scale of 0 = no responsibility/not feasible to 10 = full responsibility/completely feasible; c Scales were calculated from ratings of related items identified by factor analysis (Table 1). Higher values indicated greater level of agreement; dCohen’s d effect size: 0.2 = small; 0.5 = medium; 0.8 = large; and 1.3 = very large.
those who reported low familiarity rated school responsibility as less important for providing foods to promote health and reduce obesity (P = .04), requiring all students to participate in physical activity (P = .01), requiring teachers to model healthy food behavior (P < .01), and requiring teachers to exercise with the children (P = .01). Parents with lower familiarity had lower agreement with policy components requiring provision of nutrition information (P = .05) for foods sold in the schools and providing universal free meals (P = .02). The practical significance of these differences was small (Cohen’s d range, .19−.28), with the exception of parents’ perceptions of the school’s responsibility for
requiring teachers to model healthy food behaviors (Cohen’s d = .41). Across the sample, parents had a higher level of agreement that obesity was a problem in the state (70.7%), as opposed to obesity being a problem in their child’s school (25.3%; P < .01). To examine further parents’ perceptions about the SWP, researchers compared the responses of parents who disagreed that obesity was a problem in their child’s school (n = 157) with those who agreed (n = 119) (Table 3). Parents who disagreed had significantly lower mean ratings for the school’s responsibility to provide specific food to reduce obesity (P = .01), require healthy event food (P < .001), require all
students to be physically active (P = .02), require the teachers to model healthy eating (P = .002), and require teachers to exercise with the children (P = .01). In addition, parents who disagreed that obesity was a problem had lower agreement with SWP components related to increased physical activity (P = .02), provision of healthy food (P < .001), and provision of nutrition information (P < .002), and required physical education teacher certification (P = .02). In this comparison, the degree to which the phenomenon was present in a broader population increased (Cohen’s d range, .33−.51), allowing for guarded generalized implications and recommendations.
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DISCUSSION This article describes the perceptions of parents, a key stakeholder group in schools, related to their familiarity with and support of SWPs. The current body of SWP literature reported progress in schools’ adoption of policies, compliance with federal requirements, implementation of the policy, and the support of stakeholders within the school setting, such as administrators and teachers.15 The findings of this study have potential to move policy forward, in that previous research identified parental support as a missing element in the successful implementation of SWP.7,8 A key finding in this study was that parents’ perception of childhood obesity as problematic explained differences in their perceptions of the school’s responsibility to provide obesity preventive environments and their agreement with recommended SWP components. Three of every 4 parents interviewed described child obesity as a problem statewide, which agreed with recent data indicating that 18.1% of children aged 10−17 years were obese in 2016.11 This was consistent with a 2014 national poll reporting that 80% of parents were concerned about the state of children’s health and 74% were concerned about the prevalence of child obesity.12 In contrast, only 1 in 4 parents in this study believed that child obesity was a problem locally. The lack of congruence between the perceived problem statewide vs locally may reflect the fact that a majority of parents were unable to recognize obesity in their own children.13 Likewise, low perception of obesity as a local problem may be associated with lower support for school efforts that protect against child obesity. As such, parents have a vague awareness of the need for local school wellness and child obesity prevention efforts.16 For example, parents who did not perceive child obesity to be a local problem were less likely to believe the school had responsibility for promoting wellness. This finding differs from the Pew Charitable Trusts’12 national poll, which reported that most parents supported nutrition standards for school meals and snacks. In this study, parents were more likely to agree with or
support efforts related to physical activity rather than those addressing food. Despite requirements that schools engage parents in developing and communicating components of the SWP to the public, a second finding of this study was that most parents knew their child’s school had an SWP but reported little or no familiarity with the SWP content. In 2015 and 2016, the researchers conducted a review of 354 school wellness policies (65% of the Oklahoma school districts) using the WellSAT 2.0.14 The results revealed that the majority of the policies did not include requirements for communicating policy content and progress with the public (88%) or school community (76%).17 These findings are consistent with previous research that identified inadequate communication with stakeholders as a barrier to effective SWP implementation.10,18 Strengths of this study were using the WellSAT-2 policy elements to identify parents’ support of SWP and the internal consistency of the scale items. These strengths address the lack of construct and face validity of the survey items, which could have created response bias. A second limitation was that the sample of study respondents was not representative of the state in terms of household income and education,19 which limits the generalization of their responses.
IMPLICATIONS FOR RESEARCH AND PRACTICE A unique contribution of this research is that it brings attention to parents’ low familiarity with and support of the SWP and their perceptions related to childhood obesity as being problematic at the local level. The Healthy, Hunger-Free Kids Act, 2010 requires schools to include input from parents and community stakeholders when developing or updating SWPs.3 Focusing on policy elements that elevate parental knowledge and familiarity with the SWP, practices that increase parents’ perceptions of childhood obesity as being problematic, and the role the schools have in providing healthy environments that protect against obesity would be beneficial in moving policy forward.4,7 This may be achieved when school districts include not only
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school personnel but also parents and community members in developing, implementing, and evaluating the SWP.15 Although engaging parents in SWP is consistently reported as a barrier, further research is needed to test interventions to engage parents in school wellness efforts.9,10,20 To ensure policies are implemented, schools are tasked with identifying a school official with monitoring implementation and reporting the school’s progress to school and community stakeholders. To facilitate this process, policy elements might identify specific and measurable outcomes including time lines, and how communication with parents will be conducted. This is further facilitated by designating individuals at the school site and district levels who will be responsible for implementing and evaluating progress of the policy. Local school or statewide efforts to measure students’ fitness levels have the potential to increase parental awareness of the issue of child obesity.18,20 By including a requirement for fitness testing and reporting in SWP, schools could track student progress in fitness across grade levels and report to parents with nonjudgmental messages. Funding allocations at the state and federal government levels would be particularly beneficial, especially for schools with limited resources. As successful efforts and communication increase, it is likely that parents will begin to perceive the school setting not only as an education setting but as a place where students and parents can learn and practice health-promoting behaviors to reduce obesity, thus increasing readiness to support strong policy implementation.16
ACKNOWLEDGMENTS The authors would like to acknowledge the Oklahoma State University Vice President for Research and Technology for funding the project.
REFERENCES 1. Clarke J, Fletcher B, Lancashire E, Pallan, Adab P. The views of stakeholders on the role of the primary school in preventing childhood obesity: a qualitative systematic review. Obes Rev. 2013;14:975-988.
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2. Schwartz MB, Lund AE, Grow HM, et al. A comprehensive coding system to measure the quality of school wellness policies. J Am Diet Assoc. 2009;109:12561262. 3. Welker E, Lott M, Story M. The school food environment and obesity prevention: progress over the last decade. Curr Obes Rep. 2016;5:145-155. 4. Hammerschmidt P, Tackett W, Golzynski M, Golzynski D. Barriers to and facilitators of healthful eating and physical activity in low-income schools. J Nutr Educ Behav. 2011;43:63-68. 5. Edwards JU, Mauch L, Winkelman MR. Relationship of nutrition and physical activity behaviors and fitness measures to academic performance for sixth graders in a midwest city school district. J Sch Health. 2011;81:65-73. 6. Brissette I, Wales K, O’Connell M. Evaluating the wellness school assessment tool for use in public health practice to improve school nutrition and physical education policies in New York. J Sch Health. 2013;83:757-762. 7. Hung TTM, Chiang VCL, Dawson A, Lee RLT. Understanding of factors that enable health promoters in implementing health-promoting schools: a systematic review and narrative synthesis of qualitative evidence. PLOS One. 2014;9:e108284. 8. Agron P, Berends V, Ellis K, Gonzales M. School wellness policies: perceptions,
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Assessment Tool. http://www.wellsat. org/upload/docs/WellSAT%202.0.pdf. Accessed November 15, 2018. Chriqui JF, Resnick EA, Schneider L, et al. School District Wellness Policies: Evaluating Progress and Potential for Improving Children’s Health Five Years After the Federal Mandate. School Years 2006-07 Through 2010-11, Vol 3. Chicago, IL: Bridging the Gap Program, Healthy Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago; 2013. Oetting ER, Plested BA, Edwards RW, Thurman PJ, Kelly KJ, Bequvais F. Community Readiness for Community Change. 2nd ed. Fort Collins, CO: Tri-Ethnic Center for Prevention Research, Colorado State University; 2014. Komakech JJ. School Wellness Policy Quality May Not Reflect the Presence of Health Promotion Programs [master’s thesis]. Stillwater, OK: Oklahoma State University; 2018. Metos J, Murtaugh M. Are school district wellness policies implemented? A systematic review of the literature. Child Obes. 2011;7:90-100. US Census. Quick facts: Oklahoma. https://www.census.gov/quickfacts/ fact/table/Oklahoma,US/INC110216. Accessed November 15, 2018. Soto C, White JH. School health initiatives and childhood obesity: BMI screening and reporting. Policy Polit Nurs Pract. 2010;11:106-114.