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Formative evaluation of a parental involvement program for obesity prevention with low-income elementary school children

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FORMATIVE EVALUATION OF A PARENTAL INVOLVEMENT PROGRAM FOR
OBESITY PREVENTION WITH LOW-INCOME ELEMENTARY
SCHOOL CHILDREN
by
GEORGE G LEREW, BA
APPROVED:
CHERYL L PERRY, PHD
MELISSA H STIGLER, PHD
Copyright
by
George G Lerew, BA
2010
FORMATIVE EVALUATION OF A PARENTAL INVOLVEMENT PROGRAM FOR
OBESITY PREVENTION WITH LOW-INCOME ELEMENTARY
SCHOOL CHILDREN
by
GEORGE G LEREW, BA
Presented to the Faculty of The University of Texas
School of Public Health
in Partial Fulfillment
of the Requirements
for the Degree of
MASTER OF PUBLIC HEALTH
THE UNIVERSITY OF TEXAS
SCHOOL OF PUBLIC HEALTH
Houston, Texas
May, 2010
UMI Number: 1474799
All rights reserved
INFORMATION TO ALL USERS
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a note will indicate the deletion.
UMI 1474799
Copyright 2010 by ProQuest LLC.
All rights reserved. This edition of the work is protected against
unauthorized copying under Title 17, United States Code.
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FORMATIVE EVALUATION OF A PARENTAL INVOLVEMENT PROGRAM FOR
OBESITY PREVENTION WITH LOW-INCOME ELEMENTARY
SCHOOL CHILDREN
George G Lerew, MPH, BA
The University of Texas
School of Public Health, 2010
Thesis Chair: Cheryl Perry, PhD
This study addresses the responses to a postcard campaign with health messages
targeting the parents of children in a sample of low-income elementary schools and assesses
the feasibility and areas of possible improvements in such a project. The campaign was
implemented in Spring 2009 with 4th grade students (n=1070) in fifteen economically
disadvantaged elementary schools in Travis County, Texas. Postcards were sent home with
children, and parents filled out a feedback card that the children returned to school. Response
data, in the form of self-administered feedback cards (n=2665) and one-on-one teacher
interviews (n=8), were qualitatively analyzed using NVivo 8 software. Postcard reception
and points of improvement were then identified from the significant themes that emerged
including health, cessation or reduction of unhealthy behaviors, motivation, family, and the
comprehension of abstract health concepts.
Responses to the postcard campaign were almost completely positive, with less than
1% of responses reporting some sort of dislike, and many parents reported a modification of
their behavior. However, possible improvements that could be made to the campaign are:
increased focus of the postcards on the parents as the target population, increased information
about serving size, greater emphasis on the link between obesity and health, alteration of
certain skin tones used in the graphical depiction of people on the cards, and smaller but
more frequent incentives to return the feedback cards for the students. The program appears
to be an effective method of communicating health messages to the parents of 4th grade
children.
TABLE OF CONTENTS
List of Figures ............................................................................................................................ i
List of Appendices .................................................................................................................... ii
BACKGROUND .......................................................................................................................1
Childhood Obesity as a Public Health Problem ...................................................................1
Epidemiology of Obesity .....................................................................................................2
Behavioral Etiology of Childhood Obesity..........................................................................4
Parental Influence on Childhood Obesity ..........................................................................10
Parent-Focused Interventions.............................................................................................12
Need for More Parental Involvement ................................................................................13
METHODS ..............................................................................................................................14
Study Design ......................................................................................................................15
Analysis Methods...............................................................................................................16
Postcard Campaign ............................................................................................................17
Measures ............................................................................................................................19
Human Subjects .................................................................................................................19
RESULTS ................................................................................................................................19
General Health ...................................................................................................................20
Cessation or Reduction of Unhealthy Behaviors ...............................................................21
Motivation ..........................................................................................................................22
Family 22
Concept of Energy Balance ...............................................................................................23
Barriers ...............................................................................................................................24
Negative Reactions ............................................................................................................25
Logistical Issues .................................................................................................................25
DISCUSSION ..........................................................................................................................27
Parents’ Reactions ..............................................................................................................27
Postcard Improvements ......................................................................................................30
Logistic Improvements ......................................................................................................32
CONCLUSION ........................................................................................................................34
STRENGTHS AND LIMITATIONS ......................................................................................35
Appendices ...............................................................................................................................36
Research Services Center .............................................................................. 38
References ................................................................................................................................40
LIST OF FIGURES
Figure 1: Prevalence of Obesity Among US Children and Adolescents ...................................3
i
LIST OF APPENDICES
Appendix A: 10 Top Tips for Healthy Kids Postcards ...........................................................36
Appendix B: approval Letter ...................................................................................................38
ii
BACKGROUND
Childhood Obesity as a Public Health Problem
The current childhood obesity epidemic is perhaps the largest threat to public health
in the United States. The negative health problems that are correlated with childhood obesity
are myriad and significant. Among the most notable and well-documented is type II diabetes.
Obesity is associated with glucose metabolism abnormalities like impaired glucose
tolerance1, 2 and has repeatedly been linked to insulin resistance2-4 and prediabetes4, the
subsequent type II diabetes4-8, and diabetes mellitus9 as well. Obesity predisposes one to
these endocrine disorders and all the negative cardiovascular sequelae that accompany them
such as heart attack, peripheral neuropathy, poor wound-healing, blindness, fetal anomalies,
and even amputation of extremities.
Childhood obesity is also correlated with a higher risk of heart disease independent of
a diagnosis of diabetes1, 8, 10. Logically, this also increases the risk of morbidity and mortality
among the obese1, 5, 11. Other chronic illnesses have been associated with childhood
overweight and obesity including metabolic syndrome4, 7, polycystic ovarian syndrome4, 8,
hypertension1, 5, 7-9, arteriosclerosis7, obstructive sleep apnea7-9, dyslipidemia8, 9,
hyperlipidemia, pseudotumor cerebri, and Blount’s disease1 which all significantly contribute
to increased morbidity. Another major correlate of obesity is non-alcoholic fatty liver
disease2, 4, 7, 9 which can also be so severe that even the modest consumption of alcohol can
substantially increase the risk of obesity-related diseases of the liver12. The physical
detriment carried with obesity is so considerable that it is plausibly hypothesized that the
epidemic increase in overweight and obesity in the United States will subsequently halt the
1
modern trend of the steady and consistent increase in average life expectancy, and might
actually reverse this trend7, 13.
In addition to the physiological consequences, childhood obesity also incurs
psychological harm as well. Obesity has been shown to carry with it a heavy “social burden”
that negatively affects self-esteem5, 14-17, body image, and even economic mobility5. Obesity
has a pronounced social stigma, especially in childhood and adolescence15, and overweight
and obese children have been shown to score higher on measures of sadness, loneliness, and
nervousness, as well as having an increase in high-risk behaviors like smoking and the use of
alcohol14. The social marginalization of obese children has been observed and documented.
Overweight and obese children score higher on scales of body dissatisfaction18 and healthrelated quality of life (HRQOL)19-21. They experience more psychological distress than their
peers who have typical Body Mass Index’ (BMIs)22.
Childhood obesity is also an excellent predictor of obesity in adulthood23, 24, even
when examined irrespective of parental obesity24. BMI has been shown to positively
correlate with later adult levels of adiposity in the Bogalusa Heart Study25, and children or
adolescents with higher BMIs have also been shown to be more likely to be overweight or
obese as adults compared to children with lower BMIs26.
Epidemiology of Obesity
The well-known increase in the prevalence and degree of childhood overweight and
obesity compounds the threat to public health even further. That childhood obesity has taken
on epidemic proportions is broadly accepted, as is the opinion that, while obesity may not be
as acute as HIV/AIDS or H1N1 in decreasing health, obesity should be regarded just as
2
gravely23, 27. Overweight is now the most common disorder among children and adolescents
in the US1, 28, 29. In 1998, the US population of overweight adults increased to 150% of what
it was in 1986, with an accompanying increase in childhood obesity as well29. However,
during the period between 1999-2004, the level of at-risk for overweight children had risen to
a prevalence of 30%, while 15% were already overweight30, 31. In 2006, childhood
overweight and obesity levels were only slightly higher at 31.9% and 16.3%, respectively32.
Figure 1 demonstrates the meteoric rise in childhood obesity levels in the last forty years.
Figure 1: Prevalence of Obesity Among US Children and Adolescents33
Data from NHANES demonstrates the unequal distribution of obesity among
minorities and people with low socioeconomic status (SES) being more at risk for
overweight. The most recent data show non-Hispanic whites as having the lowest prevalence
of obesity, 28.2%, compared to that of African Americans, 35.4%, and Mexican Americans,
3
39.9%. An inverse relationship between SES and obesity prevalence is observed in young
non-Hispanic white boys, but not in their Hispanic or African American counterparts; girls’
obesity prevalence difference between races are much smaller. However, in adolescence,
males do not exhibit the inverse relationship between SES and obesity prevalence observed
at younger ages. Female adolescents with lower SES had a higher prevalence of obesity, but
this was mainly due to the very strong inverse relationship between SES and overweight
among white females. African American female adolescents with higher SES had an
increased risk of overweight and obesity compared to those with lower SES34.
While the increasing level of overweight and obesity seems to be slowing relative to
the previous decades’ rates, this pattern only maintains the current subnormal level of health
in children who will most likely retain their overweight or obesity status in adulthood, and
consequently suffer their entire lives from the negative health effects. The poor health states
that accompany childhood obesity are well-established and clearly significant. Their cost,
both financial and in terms of quality of life, necessitate action at all levels of public health.
Not only does being overweight or obese as a child affect the health of the individual and the
population at that particular time, but the harm may persist into adulthood, even if the
increased weight does not.
Behavioral Etiology of Childhood Obesity
The most immediate cause of overweight or obesity is the imbalance between energy
taken into the body through food, and the energy expended by the body through the activities
of daily living. Simply reducing the etiology to this level though is myopic. Both eating and
living are human behaviors, and consequently, dealing with them is quite complicated, and
4
the factors that influence them are both numerous and complex. Many studies have examined
various behaviors or qualities and their association with obesity in an attempt to better
elucidate the intricate manner in which overweight and obesity manifest themselves in the
US population of children and adolescents.
Among the most-documented risk factors for overweight and obesity is parental
weight. Parental overweight has been positively associated with children’s overweight
repeatedly35-52, but the exact mechanism of the relationship that this association reveals is
still poorly understood because of the inevitable confounding of genetics. Some individuals
have a genetic predisposition to gain and retain excess body weight36, 53, 54, and this genetic
susceptibility must necessarily be possessed by one or both parents. However, as the
biological parents are usually the caregivers of the child as well, they create the environment
in which the child learns eating behaviors, habits of physical activity, etc. Therefore,
disentangling one risk factor from another and determining the amount of variation in obesity
caused by each, becomes very difficult. Still, the nature of genes alleviates any dilemma of
decision from the view of public health as no sufficient knowledge and technology exist to
successfully modify one’s genes to avoid obesity, and hypothetical interventions to attempt
to do so would surely involve ethical issues. The environment of the home and family
though, is highly modifiable and provides a promising arena in which to employ obesity
prevention/reduction interventions.
Another highly researched risk factor for childhood obesity is the average level of
physical activity that a child performs each day. Physical activity is negatively correlated
with overweight and obesity41, 42, 46, 55-59 via the obvious mechanism of increased energy
5
expenditure which would reduce any deficit in energy balance. Correspondingly, sedentary
behavior is positively correlated with overweight and obesity directly36, 60, as demonstrated
by “poor aerobic capacity”38, and by observing the effective reduction of weight indices in
obese populations through interventions aimed at reducing sedentary behavior61. Again,
increased energy expenditure is the assumed operating force behind this relationship. The
amount of physical activity is also largely modifiable and should be a focus of interventions.
Closely related to the concept of physical activity with regard to energy expenditure
is the specific concept of sedentary behavior in terms of amount of TV watched. This is
another influential factor in childhood obesity that has been well-researched. The amount of
time spent in front of the television, including video games, is very strongly positively
correlated with childhood obesity42, 46-48, 50, 54, 56, 58, 62, 63. It seems logical that this would be
simply a specific instance of one kind of sedentary behavior that adds little new information
regarding the etiology of obesity. However, it has been shown that physical activity does not
necessarily mediate the relationship between obesity and the amount of time spent watching
television. The likely explanation for this being an increase in food consumption63. This
example demonstrates the level of complexity that is inherent in discerning what the actual
causes of weight gain are in children and how they affect their energy balance. From one
perspective, television’s effect on obesity is through the reduction of energy expenditure,
while from another point of view, the cause seems to be affecting the other side of the
equation through energy intake. Either way, a reduction in time spent watching television can
realistically by expected to reduce or prevent obesity, although it is acknowledged that
6
further research is needed to address the causal nature and directionality of the relationship
between television and obesity.
Specific elements of diet are also correlated with childhood obesity. Eating fruit less
than once per day is positively associated with obesity37, while the consumption of fruits and
vegetables is associated with having a healthy weight in adolescents64. Fruit and vegetable
consumption has also been shown to be an essential component of some weight management
strategies65. Conversely, sugar-sweetened beverages (SSBs), such as soda, are associated
with weight gain and obesity66, so much so that the effect of individual servings per day exert
an observable effect. Each additional serving of SSB carries with it an increase in BMI and
the frequency of obesity in school-aged children67. Preschool children who drank 1-3 SSBs
per day were twice as likely to become or remain overweight than those who had less than
one SSB per day68. Simply the energy being in the form a liquid may also negatively affect
weight status in children. Liquid carbohydrates cause a weak dietary reaction relative to solid
equivalents and can promote positive energy balance69 due to a lack of satiety experienced.
This, then, can lead to weight gain and obesity, especially in children in adolescent who may
not possess the necessary self-regulating skills.
It also appears that not only the “what” of diet is important, but also the “when.”
Consuming less energy at breakfast and more at dinner increases the risk overweight in
childhood70, and regular breakfast consumption may be a protective factor against adolescent
obesity71. However, it may just be that breakfast consumption co-varies with a healthier
distribution of energy consumption throughout the day. High meal frequency has been shown
to be inversely associated with obesity even when regular breakfast consumption is
7
controlled for72. Whatever the specifics, the timing of energy intake appears to affect the risk
of becoming overweight or obese in childhood or adolescence.
There are other various behaviors and characteristics associated with childhood
obesity, though their relation to the development of obesity is more complicated and
mechanistically removed than physical activity and sedentary behavior. Low inhibitory
control73 and persistent child tantrums about food35 are linked to childhood obesity,
suggesting that the relative lack of ability to control one’s urges translates to a lack of control
over what and how often one eats. Another behavior that is linked to being at-risk for
overweight is eating in the absence of hunger (EAH). EAH levels of at-risk for overweight
boys were twice those of low-risk boys53. Having a high number of meals throughout the day
has been shown to be negatively correlated with childhood obesity50, 72, 74. The frequency
with which one eats outside the home58, the number of sugar-sweetened beverages
consumed46, 70, eating less than one serving of fruit a day37, and weight-loss dieting all
increase the risk for being overweight.
Another interesting risk factor for childhood obesity is weight status in very early life.
Babies with higher birth weights have been shown to be at increased risk for overweight or
obesity47, 49, 51, 75. It is not known whether this is due to genetics, parenting behaviors, or both.
The rate of weight gain has also been positively correlated with BMI and weight indices.
Those in the highest quintile of weight from 0 to 5 months have double the odds of being
overweight at 4.5 years39, and obesity at 1 and 2.5 years can predict obesity at 544. Rapid
weight gain within the first year of life has been to shown to predict obesity at 2 to 3 years76
and childhood49. These findings could be interpreted in many ways. Again, they could be the
8
result of the home environment, but they could also be early signs of an inherited “thrifty”
genome that predisposes them to gaining weight. In either case, it useful to be able identify
those infants and children who are more at-risk for obesity later in life, as we can better
understand how to time interventions.
While the risk factors discussed above have the most evidence to support them, there
remains evidence for other risk factors even farther removed from the ultimate behaviors of
energy intake and expenditure. Many behaviors and interpersonal factors of parents are
suggested to exert an effect on the weight levels of their children. Low concern for the
weight of one’s children has been shown to be inversely associated with obesity levels35,
while high levels of food restriction in feeding by parents is positively associated with
obesity. If one assumes a high level of concern about weight to accompany highly restrictive
feeding practices, another complicated facet of childhood obesity is revealed by the apparent
failure of both extremes to have a protective effect on overweight and obesity.
Other parent-specific behaviors that increase the risk for obesity include
overfeeding45, 77, smoking in the home35, and smoking while pregnant39, 42, 50. Breastfeeding
seems to confer some protection against overweight and obesity because of the inverse
relationship observed42, 48, 70, 78, 79. The alternative feeding practice of using baby formula has
been shown to positively correlate with weight status49, 50. Interestingly, one randomized trial
study suggests that a lower protein formula 80 resulted in weights more similar to those of
breast-fed infants. This has exciting implications for interventions aimed at increased
breastfeeding because they would be able to provide two alternatives to normal formula
feeding that could reduce the levels of overweight and obese.
9
There are still more features of parents that seem to affect children’s weight. Different
attitudes or states of mood are correlated with weight status: parental depression81, parental
stress82, and poor family affective response38 are all positively associated with childhood
obesity. Parents can also affect childhood obesity in the way that they facilitate how the
family performs certain activities; childhood obesity is positively associated with fewer
family meals together62. The great influence that the families, and specifically the parents,
have in a child’s weight and the development of overweight and obesity is unmistakable and
can be reasonably surmised by the documented risk factors. However, a more thorough
review of parental influence is necessary to better judge a parent’s role in the development
and prevention of obesity in children.
Parental Influence on Childhood Obesity
In addition to the linked behaviors and weight statuses of children and parents, the
direct study of parental influence further supports the recognition of parents as a model of
childhood obesity. How parents eat influences how their children eat83. Non-eating
behaviors of parents also influence children’s eating behaviors. In addition to the media,
parents are integral in the development of adolescents’ concerns about weight and weight
control methods84. Mothers in particular strongly influence weight concerns, while fathers
influence via the imposing of feeding practices85 and the fact that acceptance of weight status
by the father appears to be important86. One study showed that the eating behaviors of obese
children differed from normal weight children only when the mother was physically in the
lab87.
10
How a parent feeds their child logically exerts an enormous effect on weight status
and the development of eating behaviors. What, when, and how a parent chooses to feed a
child can function to modify the relatively simple and innate food preferences and behaviors
of intake regulation88 with a vast range of results, as evidenced by the variance in cuisine and
eating behaviors between different cultures. The feeding behavior of parents that do not
correspond to proper nutritional and health principles can result in many nutritional deficits
and surpluses, and also promote eating behavior that contribute to the gaining of excess
weight89. Parental feeding practices have been shown to account for 22.2-26.9% of the
variance in food consumption of children90. For example, using food as a reward or as a tool
to placate an upset child can increase a child’s risk for obesity by impairing the ability to
self-regulate with regard to food91.
Additionally, the influence of parents does not simply affect the ultimate behavioral
result of the amount of food intake. Parents can also influence children’s attitudes toward
foods through their own behaviors. Parental levels of physical activity have been shown to
predict the physical activity level of their children92 as well as the risk for overweight in
girls93. Already mentioned is the association between lack of parental concern about
children’s weight status and childhood obesity. However, higher parental concern seems to
carry with it the potential to result in unwanted weight gain, somewhat counter-intuitively, if
this concern culminates in restrictive feeding practices94. Although the intended goal is
reduced calorie intake, high levels of food restriction and limitation can increase the risk for
overweight and obesity45, 95. The mechanism through which the well-meaning actions of
parents actually enhance the targeted, unwanted outcome is certainly complex, but it is
11
hypothesized that the hyper-controlling of a child’s food environment may interact with
various genetic and behavioral predispositions to produce unhealthy styles of eating95.
The almost overwhelming influence that parents have over children with regard to
eating behavior and food attitudes makes parents a prime target in childhood obesity
interventions. Reaching children through their parents via role modeling has been suggested
as a method superior to communicating health messages directly to children96. In fact, there
is evidence that eliminating the child entirely from health programs may improve outcomes9799
.
Parent-Focused Interventions
Many intervention studies have been performed with the family or parents as one
component to varying degrees, most providing evidence that the inclusion of the parents adds
to the effectiveness of the intervention100. Reviews and meta-analyses of the majority of
obesity interventions concur that the inclusion of a family or parental element is feasible and
beneficial101-106. More specifically, recent individual studies that have the family or parents as
a main focus have been conducted. Family-centered programs have sometimes demonstrated
almost twice the effectiveness of traditional programs107, including significantly reducing fat
intake while increasing health knowledge108. Home-based interventions have also
demonstrated an ability to produce measurable, significant changes in health behavior109, 110
such as increased fruit and vegetable (FV) servings110. Programs have also been implemented
that specifically focus on the inclusion of parents as opposed to simply a home or family
context. Having a parental component as one of several in obesity interventions has been
shown to be beneficial with regard to various elements in the development of childhood
12
obesity such as physical acitvity111, weight reduction104, an increase in offering of water, and
opportunities for physical activity112. While the same outcomes may be observed from
traditional interventions that do not necessarily have as much of a focus on parents, studies
designed to compare the two types directly show that the involvement of the family provided
better outcomes against school-based programs113 and those that focus only on the children9799
. It has also been shown that parents who have the ability to change their children’s
behavior114, have high self-efficacy to do so115, and are receptive to health messages that help
them114.
The efficacy of including parents in interventions seems clear, and it seems just as
clear that this is due to the documented influence that parents have over their children and
their environment. While it is entirely possible that the reason parent-focused strategies are
the most effective is simply that they are very effective tools of change with regard to their
children. It might also be that these strategies are the most effective because the parents are
the component of the issue that needs the most improvement.. Evidence to support this
perspective is found when examining parental attitudes and beliefs about obesity and their
children.
Need for More Parental Involvement
Besides the obvious point that current attempts at reducing childhood obesity levels in
America are not working30-32, there is additional evidence that suggests that one of the
changes that needs to be made to obesity prevention and reduction efforts is more parental
involvement in childhood obesity interventions. The evidence comes mainly in the form of
the enormous amount of data that suggest that the parents of overweight or obese children
13
simply do not recognize the weight status of the children. Study after study yields the same
conclusion: parents of overweight or obese children do not recognize them as such116-125.
Most studies do not show more than half of parents realizing that their children are
overweight117, 118, 122, 123. The misperception appears to be especially more likely to be had by
parents who are overweight themselves119, and made more about male children118.
A possible explanation for this is the lack of the use of clinical definitions for weight
status. Some mothers do not use height or weight measurements to make decisions about
their children’s weight but instead rely on other signs such as the children being teased about
their weight or physical limitations due to weight, and see behaviors like having a good
appetite as signs that the child is nevertheless healthy126. Focus group data also suggest that
many parents do not factor in weight into their conception of health status at all127.
Regardless of the reasons why parental involvement works so well or why parents
have misperceptions about their children’s weight status, it is clear that more needs to be
done, both in realizing actual high BMI reduction or healthy BMI maintenance, and in
improving parental knowledge and the consequent ability to improve their children’s eating
behaviors and food environment. This claim is supported by the sustained high levels of
childhood obesity and the fact that most parents do not even know their children are at
unhealthy weights.
METHODS
This study aims to address the following questions relative to the 10 Top Tips for
Healthy Kids parent postcard campaign: 1) what are the reactions of parents to such
postcards; 2) what improvement can be made to the program based on the qualitative data
14
from the pilot program of 10 Top Tips for Healthy Kids; and 3) is the attempt to
communicate health messages to parents through this postcard mechanism a feasible strategy
for increasing parental involvement in obesity preventions?
Study Design
We assessed the utility of postcards sent home with students to reach parents as well
as any improvements that could be made to the campaign to make it a better potential
addition to the CATCH project in Travis County. The cross-sectional sample with which the
campaign was conducted in Spring 2009 consisted of the parents of the 4th grade students
(n=1070) in fifteen economically disadvantaged schools in Travis County, Texas. In the
2007-2008 school year, gender was equally distributed among the 4th graders in these
schools. Also, 69% were Hispanic and 14% were African-American. Among all students,
89% were considered economically disadvantaged, and 45.6% used Spanish as the primary
language to communicate with their parents.
The postcard campaign was implemented in the schools (n=15) throughout the spring
semester of 2009 and was formatively evaluated at its conclusion using feedback card return
rates and a parent survey. A further qualitative evaluation was begun in the fall of 2009 using
feedback card written data from parents from all 15 schools and teacher interviews from a
sample of the participating schools (n=4).
Feedback cards solicited the relatively immediate reaction of parents upon receiving
each individual postcard. The feedback cards asked the parents to comment on each card by
answering the following three questions: 1) What did you like or dislike about the postcard?;
2) Did you display the postcard or magnet anywhere in your house (and if so, where)?; 3)
15
What actions, if any, did you tale as a result of receiving the postcard? One-on-one teacher
interviews (n=8) were conducted during the 2009-2010 school year with teachers that had
been involved in the postcard campaign in the spring of 2009. The teacher interviews focused
on mainly logistical aspects of the campaign, including the delivery mechanism, incentives,
and possible classroom interventions such as a classroom curriculum component.
Analysis Methods
Feedback card and survey return rates were previously used as a gauge to measure the
actual “reach” of the postcards. In this study, the content of the feedback cards were
analyzed to see how the parents reacted to the postcards (Aim 1). Teacher interviews were
used to evaluate the implementation of the program and identify possible areas of
improvement, along with some of the data from the feedback cards (Aim 2). The overall
qualitative analysis was used to determine if this intervention is a practical method of
increasing parental involvement (Aim 3).
All teacher interviews were taped, and transcribed. Feedback cards were translated
by an outside agency. The data from both the feedback cards and teacher interviews were
entered into NVivo 8128, a well-recognized qualitative software analyses program, as source
material. The data were then coded independently by two coders using a coding scheme
based upon the attitudes and behaviors presented in the data and various patterns that
emerged. Inter-rater reliability was determined by running a coding comparison query. Any
discrepancy between coders was discussed until a consensus was reached.
The resulting network of themed “nodes,” consisting of all source material similarly
coded to each theme or node, was then thoroughly examined for qualitative features such as
16
motivation, attitudes, beliefs, and reactions. This qualitative analysis was used to generate a
model of how parents responded to the postcards in addition to further identifying aspects of
the campaign that needed improvement.
Postcard Campaign
The “10 Top Tips for Healthy Kids” campaign was developed as an extension of the
Coordinated Approach to Child Health (CATCH), a school-based program designed to
promote healthy behaviors and prevent tobacco. CATCH is used in more than7,500 schools
in grades pre-K-8th. CATCH combines classroom curricula and modification of the school
environment relating to food intake and physical activity. The 10 Top Tips for Healthy Kids
was developed with the intent to increase parental involvement in the program by educating
and promoting obesity-preventing actions and changes to the home environment they could
perform within their households.
The selection of the ten messages in the postcard campaign was based on the IOM
report of key behaviors that are related to childhood obesity129 and that corresponded to the
primary CATCH behavioral objectives: eating at least 5-9 servings of vegetables per day,
drinking water or fat-free milk, reducing soda consumption, eating low-fat, low-sugar, high
fiber foods and snacks, eating whole grains, eating breakfast, walking or riding a bike to
school, getting one hour of moderate-to-vigorous physical activity a day, and reducing
“screen time” to less than one hour per day. Also taken into consideration were the behaviors
that parents would be able to influence.
With the help of a graphic design artist, ten oversized postcards were developed with
images accompanying the messages with the intent of making the postcards more visually
17
appealing, youth-oriented, and memorable (see Appendix A). On the back of each postcard
was additional information to reinforce the main message as well as provide tips and
strategies to realize healthier lifestyles and eating behaviors. These included ways to
motivate family members to eat healthier foods and suggestions for fun activities that would
increase physical activity.
“Add sparkling water to fruit and make your own fun drinks.”
“Replace the candy dish with a fruit bowl.”
“10 minutes of physical activity gives you more energy than a candy bar.”
The main message, or slogan, of each postcard was printed in English on the front of
each card with a Spanish translation just below. The information on the reverse side was only
in English due to space constraints, but an insert that had a Spanish version of the back of the
postcard always accompanied the main postcard.
The postcard, Spanish language insert, feedback cards, and small magnets that
depicted the front of the postcard were inserted into a single envelope and delivered to the
schools every one to two weeks. Feedback cards were collected on each subsequent delivery.
At the end of the semester a parent survey was delivered in the same manner as the postcards.
Incentives were provided in the form of pin-on buttons and T-shirts using graphics from the
campaign. Any student returning at least one completed feedback card received one 10 Top
Tips button. Any student returning a completed parent survey received two 10 Top Tips Tshirts-one for his/her parents, and one of their own. The t-shirt had the graphics from one of
the postcards on the front and all postcard slogans on the back. Teachers also received gift
cards for their participation in the program.
18
Measures
The feedback cards provided data such as the date, student’s name, and school. They
also asked for the following information: whether or not the parents liked the postcard and
why; if they took any actions as a result of reading the postcard and if so, what; and any
additional comments the parents had about the postcards.
While teachers were asked about their overall impression of the program, the major
portion of interviews focused on campaign execution instead of content. Teachers were asked
what they thought about how the postcards were delivered to the classes and the frequency of
postcard delivery. They were also asked what, if any, actions they took to encourage students
to return the feedback cards, and what they thought would be good incentives for the children
and parents. Interviews also covered potential reaction of teachers to a scaled incentive
program for them based on feedback card return rates and the possibility of brief classroom
lessons to accompany each card. Eight teacher interviews were conducted in four Travis
county schools. Interview length ranged from approximately ten minutes to 45 minutes in
length.
Human Subjects
This thesis was exempt from review by the University of Texas Health Science
Center at Houston Committee for the Protection of Human Subjects (see Appendix B). All
feedback was given voluntarily, and the dataset was de-identified before analysis.
RESULTS
According to the returned feedback cards, the postcards were very well-received by
both parents and students, including their design, layout, and health messages. As the
19
feedback cards were analyzed, several particular themes emerged that appeared to be highly
important to this population of parents with regard to how they think about health and what
actions they take toward health as a goal for themselves and their families. The most
significant and common of these themes are: general health, the cessation or reduction of
unhealthy behaviors, motivation, the concept of the family, and parents’ comprehension of
the more abstract health messages such as energy balance. In addition to the themes above,
which provide useful insight into how the health messages might be modified or enhanced,
other themes emerged that can be used to improve the concrete or logistical aspects of the
intervention including the postcards’ use of colors and incentives.
General Health
Parents very often liked the postcards’ utility in teaching themselves and their
children ways to be healthier in their everyday lives.
"I like the facts on postcard because it makes our children more healthconscious."
"I am enjoying all tips given and feel like they help to teach my children to
eat better."
Specific things that parents were glad to learn were appropriate serving sizes and how
exercise will not only reduce overweight but also result in better cardiovascular health, etc.
They very much liked the lists of activities on the backs of the cards that showed various
options for them to become more active or to make their diet healthier. Generally, parents
seemed to highly value their own health and their children's, but it seems like they place a
higher priority on their children's health, almost as if their own health was set. It seemed that
most parents viewed the health messages as aimed exclusively at their children, and not
20
theirselves. Despite this apparent high value of health, only 18 feedback cards (0.6%) had
any mention about the issue of being overweight or being "fat."
Cessation or Reduction of Unhealthy Behaviors
Most parents agreed with the postcard campaign's recommendations about ceasing or
reducing some unhealthy behaviors related to weight gain, including time spent watching TV
or playing video games (some parents even reportedly "took my kids’ TVs out of their
bedrooms”), portion size, including reducing serving sizes and “avoiding buffets" and
adopting strategies, like serving dressing on the side and not placing serving dishes on the
table where they're eating or eating from bags of chips, etc. However, some clearly did not
understand what proper servings are or what an appropriate amount of food to eat at one meal
is.
"We eat healthy. For example when we go to a buffet our kid's plate #1 has
one or two meats and three veggies, plate #2 can have one slice of pizza and
then whatever else they want, and for dessert they get one choice."
With fast food reduction, parents clearly agreed that fast food was unhealthy, but
varied in the amount that they planned to reduce its consumption in their households. Some
reported intent to reduce fast food to once per week while others reported once per every one
to two months. Parents' reluctance to eliminate fast food entirely from their family’s diet
may be due to its temporal convenience and how pleasing it is to children. Reducing the
amount that a car was used for simple transportation was less enthusiastically received,
primarily due to urban physical barriers to walking such as busy streets and a lack of
pedestrian walkways.
21
Motivation
The cards appear to have served as effective motivational tools for parents. "It made
me want to get up and move a bit; I take the stairs instead of the elevator." Parents also
reported a motivational effect on their children, "It encourages my child to keep making
healthier food choices." The magnet was an essential part of the continuing presence of the
postcards’ messages as they could be easily kept on the refrigerator. This provided two key
functions: 1) a more permanent presence of the health messages in the home and 2) a
convenient way for the parents to keep the cards on the refrigerator, reminding parents and
children of the postcards' messages right at a main source of food in the home, so the health
message is very proximal, both physically and temporally, to where they will be making a
significant portion of their eating choices.
"The cards have helped me a lot; when I see the refrigerator I take into
account what the cards say."
"I liked the magnet because it is a constant reminder on the fridge."
"I like how this works because my kids always pay attention to what's on
the fridge."
"I love it because when my children will open the fridge for soda, they will
imagine themselves in the postcard."
Family
The subject of family was a huge topic that was commented on in the feedback cards.
This population of parents seems to value the concept of family very highly, as well as
complimentary concepts like togetherness, parental duty to children in raising them well and
providing for them, and parent-child communication. The tips and strategies on the cards
were seen not only as ways to improve health but also to improve the level of family
22
togetherness, whether it was eating or exercising together. One parent wrote that: "We're
pleased to have information about activities we can do to keep the family close." The parents
seemed to take their responsibility with regard to their children's health very seriously.
"Any parent who really cares about their children should take action.”
"This thing about the cards is good because it's support for us parents who
don't know what we have to do."
"It's very good what you say because in this way children grow up healthier,
and we as parents must help them get ahead."
Parents also reported that they used the postcards as topics of conversation and
"springboards" into conversation about health with their family: "Thanks for the information;
great reminders and good conversation openers with child."
It is notable that numerous times, in response to the feedback card questioning what
actions they took after receiving a postcard, in addition to actually performing the healthy
behaviors, parents reported that they sat down and discussed the postcard and the topic of
being healthy with their children.
Concept of Energy Balance
Some parents seemed to understand the concept of excessive energy intake, that they
should "not give them a lot of food---only what is needed," and the energy balance between
caloric intake and caloric expenditure, "like more calories/more exercise and fewer
servings/less exercise." However, other parents did not seem to completely understand these
messages. Some seemed to think that physical activity had a direct causal relationship with
energy levels, as evidenced by statements like, "the importance of being active and having a
lot of energy." It was almost as if some parents thought that being active gives the body
23
energy instead of using it up. Also, most of the comments that were made about the energy
balance card were one-sided, speaking about three disparate behavioral patterns like 1) eating
healthy in conjunction with exercising, 2) simply reducing energy intake, or 3) increasing
energy expenditure, but not many that really touched on the key concept of the balancing
one’s energy, specifically the more one eats, the more one should exercise. It was rare that a
parent’s comment elicited the understanding that an increased level of calorie intake
necessitated an increased level of behavior that consumed calories.
Another point of confusion might be with the popular concept of a balanced diet.
Some quotes from parents such as, “It gives us idea [sic] of balance diet” and, “Now I think
more about eating a diet where all the food is balanced” could be perceived as a sign of
effective health promotion. However, when viewed in the context of other parental comments
like, “these balance exercises help the children with their skills in the pool,” it suggests that
some parents understand messages about energy balance as messages about literal balance
and not the consequent issues regarding weight gain.
Barriers
There were several barriers to following the advice of the postcards, mostly relating
to time constraints and finances. Not surprisingly, time was the most common difficulty
encountered by families when attempting to adopt the suggested food and physical activity
behaviors. Things like work, too many children in the family, and busy schedules took up
time to the detriment of the postcards’ effect on the family’s behavior. Direct citation of
24
economic barriers was not as frequent as the downstream indicators of such barriers like not
having enough chairs to seat everyone or even owning a table with which to dine as a family.
Negative Reactions
Although negative comments about the cards were in the extreme minority (<1%),
they were present. It is difficult to classify any “main” complaint as the very small number of
complaints would enable simple chance to skew the results. Nevertheless, the most common
complaints were about the characters’ skin tones and the frequency of the postcards’ delivery
to the parents. The main reason that the parents liked the colors used on the postcards so
much seems to be that they were bright and perceived as “eye-catching” which was seen as a
positive in getting the attention of children and parents. However, some parents felt the skin
tones of some the characters to be “strange,” “unnatural,” or “gross.” These were mostly in
response to card #2, which depicted a family that had a blue-green skin color.
Additionally, some parents complained of having to fill out the feedback cards every
week. It was not the actual postcards that were tiring to the parents, as they did not complain
about receiving them too often. The specific duty of having to fill out the same feedback
cards weekly was seen as bothersome after a few weeks.
Logistical Issues
The data regarding logistical aspects of the project such as schedule, delivery
mechanism, and incentives was primarily obtained from the one-on-one teacher interviews as
the teachers were the ultimate deliverer of the project materials and collector of feedback.
Overall, teachers thought the weekly delivery of the postcards was a good schedule, but that
it needed to not extend so late into the spring semester, as the teachers’ and students’
25
schedules become more hectic due to the Texas Assessment of Knowledge and Skills test
(TAKS). Preferred method of delivery to the teacher varied by individual, with some
preferring to receive them directly in their classroom, some via their office mailbox, and
some through that grade’s lead teacher. The preference in method of feedback card collection
also varied in this manner.
Teachers found the identical appearance of the feedback cards a source of difficulty
because they could not identify specific postcard to which each feedback card corresponded.
It was also suggested that the content of the feedback cards be modified to make it more
convenient for parents to fill out, such as having different boxes that could be checked off as
opposed to having to write out responses. Teachers approved of the incentives that were used
but did volunteer some alternative prizes that could be awarded to further increase parental
participation through increased student interest. Such alternatives included small,
inexpensive items like coupons to healthy restaurants, erasers, pencils, etc. It was also
recommended that the incentives should be given out with more frequency to better maintain
the level of student interest. Another method of maintaining student interest that was brought
up by more than one teacher was to employ some sort of visual aid, like an oversized poster,
that would aid the teachers in keeping track of each student’s feedback return rate as well as
communicating to each student how many more cards they had to return to get the incentives.
Teachers were generally not receptive to the possible implementation of a scaled
incentive plan which would increase their cash incentives as the return rates of their students
increased. Perceived negative reactions to this type of incentive included the consequent
punishing of students for failure to return sufficient cards, the possibility of conflict between
26
teachers, a sense of unfairness because of the teacher’s lack of control, and even the potential
for cheating by teachers which would result in erroneous data. Incentives that teachers
would like in addition to the existing gift cards were mainly things that could be used in their
classroom, like class equipment or school supplies that the teachers personally supply, so as
not to have to rely on the already taxed resources of the school and school districts.
Teachers liked the idea of brief lessons that could accompany each postcard, but were
concerned about successfully incorporating them into their demanding curricula. Time was
the only barrier to teaching these lessons. Some teachers were optimistic about their ability to
fit very informal lessons into small intervals between their major lessons or activities, while
others suggested that the lesson take place in physical education class. TAKS was a major
factor in this perception: “It’s all about TAKS.” There was also some speculation that having
an accompanying lesson with a homework assignment in the form of an activity done with
the parents would actually decrease participation as it would be perceived as more
inconvenient to parents who might disregard the project entirely, or that parents will falsely
report completion of the activity.
DISCUSSION
Parents’ Reactions
Parents seemed to value their own health as well as their children’s, but did not
necessarily associate this with weight status. Parents positively responded to messages and
pictures about the family and very much liked the tips about spending time together as a
family. Parents were also ready to cease or reduce unhealthy behaviors but seemed less able
27
to do so with regard to food serving sizes due to a lack of knowledge, or less willing to do so
when it came to sacrificing convenience by avoiding fast food. It would seem that parents
perceive the value of the health gained by reducing fast food consumption as less than the
value of either the time saved by using fast food or the satisfaction of their children. Time
and money were the major barriers for families following the advice on the postcards
However, the fact that parents often viewed this advice as solely focused on their
children, and not on themselves or the family as a whole, is not ideal. Parents’ written
reactions to the postcards suggested the perspective of a passive spectator. Such selfelimination from the complexity that is related to the home and parental environment,
represents a significant obstacle in this type of prevention program, and should be addressed.
While it is true that this perception by the parents is not immediately problematic for the aim
of implementing childhood obesity prevention via the parents, it is a promising place for
improvement in the project, given the previously presented data about how important the
home environment is, as well as the parents’ health status and health attitudes.
It is also interesting that, while parents reported a great concern about their own
health, and even more about their children’s, they rarely mentioned overweight or obesity.
This concept was centrally related to every postcard’s message, and this lack of reaction from
the parents’ suggests that the postcards’ obesity prevention messages may not be direct
enough. Alternatively, this might reflect a general lack of concern about this issue with this
parent population, or some sort of disconnect between how these concerns were identified in
the data set and how the parents were communicating them in the feedback cards.
28
While parents did report increased motivation as a result of the postcards, the magnets
seem to be the main cause of a significant and sustainable motivational effect in the home,
even prompting parents and children to initiate conversation about the postcards’ health
messages and the issues relating to them. This demonstrates the ability of the postcards to
not only change the home environment, but maybe initiate a child's health education through
their parents, or bolster the already existing health knowledge base the child has.
It was not demonstrated that the overall study population had full comprehension
about the concept of caloric energy balance, and some degree of confusion or
misunderstanding was evident in the comments from the feedback cards. This could
represent a key miscommunication or misunderstanding about the most fundamental aspect
of weight gain, energy imbalance. However positively the parents react toward the health
messages that are provided, it mutes the effectiveness of the project if they do not understand
them and cannot then make the appropriate changes in behavior.
While the colors of the postcards were most often a source of positive comments by
the parents, the green skin tones used on some of the postcards were not well-received by
some, being seen as “unnatural.” Requiring the parents to fill out the same feedback cards
every week became bothersome and a source of complaint toward the end of the project.
Overall, the data reflect a very favorable reception of the postcards by the teachers,
students, and parents, and the majority of feedback cards reported at least a temporary
adoption of some of the advice on the postcards. The messages of improved health strategies
genuinely resonated with parents, reflecting a sincere concern for their children’s health.
29
These reactions represent the postcards’ quality of communication, not only in superficial
appeal, but also in appropriateness and cultural competence for the target population.
Postcard Improvements
The overwhelmingly positive reception from the parents’ suggests that the majority of
the postcards’ design should be maintained, but there are definitely areas where they could be
improved. It would be worthwhile to modify the cards’ messages to more clearly state that
these health messages were intended for the children and the parents. However, this might
prove to be difficult, as these postcards are coming from the school and delivered to the
home by the children. One way of doing this could be to include more parental figures in the
visuals of the postcards which had adult figures on just two postcards. Of course, this does
carry with it the risk of confusing the message for the children. Forthcoming data from focus
groups will be better able to guide the project further as materials are revised.
The significant lack of knowledge regarding serving size must also be addressed.
While one card was entirely devoted to proper portions sizes, it might be beneficial to
reinforce this message by including appropriate serving size information across multiple
postcards using everyday approximations as were used on postcard #7. Parents’ main reason
for not reducing fast food consumption as much as they reportedly wanted to was time.
Postcard #5 addressed this issue and included ways to avoid fast food, and methods of
obtaining healthier options from such venues. An improvement that could be made to this
card would be to address the barrier of time. The postcard advises parents to eat at home but
does not elaborate any further on how parents might do so easily. Information should be
provided on the postcard that educates parents how to quickly and easily prepare healthy
30
meals at home in an economic fashion. This information will allow parents to overcome the
most commonly cited difficulty in reducing their family’s fast food consumption.
While parents repeatedly reported concern for their children’s health, they rarely
mentioned the specific issue of weight status. This lack of a response could result from
several causes including: 1) the project’s inability to identify this concern although it is
present or 2) this population of parents being unaware of the close ties between weight status
and health. These two causes are not mutually exclusive and should both be addressed with
changes to the project. If there is a parental concern about children’s weight that the project
is not identifying, one strategy of accurately assessing it is with feedback cards that ask more
specific questions. The possibility of feedback cards tailored to each postcard is discussed in
the logistical section below. If parents are simply unaware of the relationship between
weight and health, the postcards need to make this explicit. Weight as a risk factor for
disease is cursorily addressed, but it’s incredibly negative effects on health should be
presented in a more salient way. This modification, too, will be difficult to do while
maintaining the postcards’ original design qualities of positivity and while avoiding offense.
As evidence by the confusing statements in the feedback cards, the concept of energy
balance, which is somewhat abstract to this study population, needs to be made clear. The
text on postcard #9 states:
“Think of food as fuel for your body. If you don’t use that fuel, it will slosh
around your middle. That’s what we mean by energy balance. Ideally, your
energy in-the calories in the food you eat-balances with your energy outyour physical activity. If it doesn’t, you gain weight. To improve your
health, work on both ends of the equation.”
31
The text rates a 5.2 on the Flesch-Kincaid Grade Level (as determined by Microsoft
Word 2007 software), so it would not seem that simplifying the language any more would
increase the comprehensibility of the postcard very much. It may be beneficial to include
additional imperative statements that emphasize the necessities that caloric consumption and
physical activity impose on each other, specifically defining increased physical activity as e
necessary step in order to get rid of the excess food previously consumed i.e., “Eating more
food means that you must get more exercise.” Again, focus group data will better inform the
project on how to make parents understand the nature of this relationship.
The skin tones that were perceived as strange or unnatural clearly need to be changed.
Fortunately, this is a simple enough adjustment of substituting the offensive skin tones with
another from the postcards that, while still being technically unnatural, will be received well
by the target population while still maintaining their universal appearance instead of being
classified as any one race or ethnicity.
Logistic Improvements
Judging from the teacher interviews, it is not recommended that the project employ
any set method of delivering the cards to the schools and teachers. Since teachers did not
agree on their preferred method, program staff need to specialize their delivery and collection
methods for each individual teacher. Circumstances are different at each school and with
each teacher, and it is a mistake to generalize preferences from one teacher to another, even
within one school. Scheduling of the deliveries needs to be planned in advance with
cooperation from the teachers, with special consideration given to the spring semesters when
TAKS occupies a majority of their workload and schedule.
32
Feedback cards need to be specialized for each card. A label system that numbers the
feedback cards, or allows the respondents to label the feedback themselves. Question content
needs to be tailored to elicit more specific feedback from parents about that postcard’s
message to gather richer data. Both these measures will aid teachers and project staff in
correctly categorizing feedback information. Incentives need to be more numerous and
frequently distributed to the students to maintain their level of interest. This should not be
subject to financial restraints as teachers confirmed that inexpensive items like erasers and
pencils are perfectly effective in motivating the students. In addition to the new type and
scheduling of incentives, some sort of chart should be given to each classroom that allows the
children and the teacher to see their progress. Teachers reported that this would not only
help them keep track of their students’ return rates, but also motivate the students much
more. The chart could also be designed as to keep the postcards that have been distributed on
constant display within the classroom, establishing a permanent presence akin to the very
effective refrigerator magnets.
It is not recommended that the project implement a scaled incentive program to
motivate teachers to take a more active role in promoting the postcards. This was mostly met
with skepticism and negative reaction and may be counter-productive. However, it is still
necessary to sufficiently motivate the teachers given the varying degrees to which the
teachers involved themselves with the campaign. Incentives should be given at benchmark
feedback card return rates, and these incentives should include monetary gifts and equipment
specifically for their classroom.
33
While classroom lessons that could accompany each postcard will
undoubtedly be well-received by the teachers for their content, the time they will take up
from the teachers schedules will make them unpopular. The only way to successfully
implement these is to develop coordination with existing CATCH curriculum employed in
Travis County schools or to make them informal or easy enough to teach in a way that they
take up minimal time. Both solutions are difficult; the former requires added planning and a
reworking of the existing CATCH curriculum while the latter may be possible, but the
resulting lessons may be of no practical value since they will be so brief or informal.
CONCLUSION
Parents’ reactions to the 10 Top Tips for Healthy Kids parent postcard campaign
were, overall, very positive and appreciative. Less than 1% of feedback cards reported any
negative reaction whatsoever. According the feedback data from the pilot program of 10 Top
Tips for Healthy Kids, improvements that can be made to the cards deal with better reach to
parents as targets of the campaign, additional education with specific issues such as serving
size and strategies to overcome time barriers, an increased emphasis on the link between
health and obesity, and the changing of the “unnatural” skin tones of some cards’ figures.
Improvements to how the program could be better implemented include feedback cards that
are specific to each postcard for improved feedback and better organization, highly
specialized and coordinated schedules with teachers, more frequent, if lesser, incentives, and
the resolution of time as the major obstacle to implementing classroom lessons with each
postcard. Such a solution will require further collaboration with school and project staff.
Sending home postcards with children appears to be an effective method of reaching the
34
parents of 4th grade children and communicating to them health messages about the home
environment and their children’s health.
STRENGTHS AND LIMITATIONS
This study’s major strengths include its fair degree of novelty and the amount of
qualitative data that was collected. The method employed to reach parents is unorthodox and
represents a real and promising possibility in bringing obesity interventions into the home
environment. The large number of feedback cards enabled the analysis to work with a very
sizeable amount of data, and consequently, helped to discern the themes described above.
Limitations of the study include its cross-sectional observation, which limits our ability to
measure actual change in the target population, and the self-administering of the feedback
cards undoubtedly resulted in selection bias among respondents. Also, the predominant
Hispanic ethnicity and economically disadvantaged state of a majority of the target
population prevents the results to be generalized broadly across other populations that have
different characteristics. However, these limitations do not affect the validity and
implications of the study within the context of the studied target population.
35
APPENDICES
APPENDIX A: 10 TOP TIPS FOR HEALTHY KIDS POSTCARDS
36
37
APPENDIX B: APPROVAL LETTER
Research Services Center
Phone 713.500.9055
Fax 713.500.9145
MEMORANDUM
TO:
George Geoffrey Lerew
FROM:
Laura Mitchell, PhD
Associate Dean for Research
RE:
Thesis Proposal
DATE:
March 12, 2010
TITLE:
Formative Evaluation of a Parental Involvement Program for Obesity
Prevention with Low-Income Elementary School Children
Your proposal has been reviewed and approved by the UT School of Public Health Research
Services Center. Your proposal is exempt from review by the University of Texas Health
Science Center at Houston Committee for the Protection of Human Subjects. You may proceed
with your research.
CC:
Dr. Cheryl Perry
Sema Spigner, Student Affairs
Note: Other committee member(s) include Dr. Melissa Stigler
38
39
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