Dialog, 18(2), 92-97 Copyright © 2015, ISSN: 1930-9325 This project was made possible with generous funding from Boston Children’s Hospital and Northeastern University. The authors thank the Head Start staff and parents who participated in this project. Correspondence concerning this article should be addressed to Jessica Hoffman, PhD, Department of Applied Psychology, Northeastern University, 360 Huntington Ave., Boston, MA 02115. E-mail: j.hoffman@neu.edu RESEARCH-TO-PRACTICE SUMMARY Engaging Head Start Families in Childhood Obesity Prevention: School- Home Communication about Children’s Height and Weight Screenings Jessica A. Hoffman, Catherine Wirth, Sarah Johnson Northeastern University Sonia Carter Action for Boston Community Development, Inc. Head Start and Children’s Services Matthew DuBois, Colin Cox, and Carmen Castaneda-Sceppa Northeastern University Head Start provides children with healthy, nutritious meals, physical activity opportunities, and health screenings, all of which are important components of combatting early childhood obesity. Communicating health screening information about a child’s weight status to parents is one way to engage families in childhood obesity prevention efforts. This article describes a process that was used to develop and evaluate strategies for communicating with Head Start parents about their child’s Body Mass Index. Keywords: obesity, Head Start, body mass index, health screening Nationally, 22.8% of preschoolers are overweight or obese (Ogden, Carroll, Kit, & Flegal, 2014) and there is a higher prevalence among children from low-income families and some racial and ethnic groups (Cunningham, Kramer, & Narayn, 2014; Ogden et al., 2014; Whitaker & Orzol, 2006). With its comprehensive focus on children’s healthy physical, cognitive, and emotional development, Head Start is well positioned to engage in early childhood obesity prevention. Height and weight screenings are potentially effective practices that Head Start programs can implement to promote healthy weight in early childhood (Davison, Jurkowski, Li, Kranz, & Lawson, 2013). Head Start screenings provide an opportunity to collect information that can be shared with parents about their child’s weight status, which can range from underweight to obese. Communicating with parents of young children about their child’s weight status is important because many parents of overweight and obese preschool children consider their COMMUNICATING WITH HEAD START PARENTS 93 children to be at a healthy weight (Baughcum, Chamberlin, Deeks, Powers, & Whitaker, 2000; Carnell, Edwards, Croker, Boniface, & Wardle, 2005; Hudson, Cherry, Ratcliffe, McClellan, 2009). Parental reactions to learning from school professionals that their child is overweight or obese vary. Bennett Johnson, Pilkington, Lamp, He, and Deeb (2009) found that most parents (and ethnic-minority parents in particular) viewed school-based Body Mass Index (BMI) screening programs favorably and reported taking action in response to a BMI result that was outside of the normal range. Chomitz, Collins, Kim, Kramer, and McGowan (2003) found that a BMI report card was associated with increased parental awareness of the weight status of obese children and that most parents who read the materials requested annual screening information. In contrast, Grimmett, Croker, Carnell, and Wardle (2008) found mixed results regarding parents’ reactions. Although many parents viewed the information as helpful, some parents found it distressing, which highlights the importance of delivering this information in a sensitive manner, particularly for families with overweight children. Kubik, Fulkerson, Story, and Rieland (2006) found that parents of overweight children were more likely to report discomfort with weight status reporting than parents of children who were not overweight. Although there is evidence for parental support and appreciation for learning about their child’s weight status from their child’s school, this information is not always well-received. OUR STUDY Our study was conducted through a university-Head Start partnership. Its aim was to revise a school-home communication tool that would be used to inform parents about children’s BMI screening information in a format this is understandable and acceptable (see Appendix). Nutrition Services staff at Action for Boston Community Development (ABCD), Inc. Head Start and Children’s Services measure children’s height and weight twice a year. Following these measurements, a BMI letter is sent home to notify parents about their child’s height, weight, BMI percentile, and weight status. To improve the agency’s efforts to address childhood obesity, including communicating with parents about their child’s BMI screening results, an internal quality improvement working group was formed. The group identified several challenges with the existing BMI communication system and the role of the letter in conveying BMI information to parents, which included: (a) Nutrition Services staff numbers and time are limited and staff have limited time is not able to follow-up with parents individually about the contents of the BMI letter; (b) parents may not understand the BMI letter and may have added difficulty understanding it because of the emotions it can elicit; (c) parents may receive conflicting information from health professionals and Head Start staff about how concerned they should actually be if their child is identified as overweight or obese in the BMI letter and may be told that their child will “grow out of it” or that “it’s not a big deal”; and (d) competing demands related to other issues the family is facing may make it challenging for parents to prioritize their child’s overweight or obesity as a key health issue to address. Given the challenges identified by the working group, Head Start staff made a first round of revisions to an existing BMI letter to make it easier for parents to clearly and easily identify their child’s BMI and weight status, to understand what BMI is and how their child’s BMI and weight status were determined, and to encourage them to follow-up with Head Start Nutrition Services staff if their child’s weight status was not in the healthy range. 94 HOFFMAN ET AL. In this study, we conducted a series of four parent focus groups with 27 Head Start parents to obtain feedback on a draft of the revised BMI letter. Focus group feedback was used to further revise the letters, which were then sent out to 1,913 Head Start parents. Information about the final letters was then obtained via an anonymous annual parent survey administered by ABCD Head Start that 887 parents completed. Four questions about the BMI letters were incorporated into the annual survey. Parents were asked: (1) to recall what the BMI letter they received indicated about their child’s weight status, (2) whether they shared the information in the letter with other individuals; (3) to report how helpful they thought the letter was overall; and (4) to how helpful it was to receive information about their child’s weight status. Important Focus Group Findings/Relevance to Practice The bullet points below summarize key findings from the focus groups:  The focus groups revealed a range of reactions (positive, negative, and mixed) among the parents when discussing the letter as a whole. Some parents mentioned that the letter was helpful because it shared key information about a child’s weight status, allowing parents to determine if they should be concerned about their child’s weight. Although there were fewer negative reactions to the letter as a whole, some parents noted that receiving weight status information through the mail is difficult to understand and that they are aware of their child’s weight status but do not know how to change it.  Parents suggested adding the child’s name to personalize the letter, making it more likely to stand out among the many papers children bring home from school to be read by parents.  Parents had a mostly negative reaction to the idea of including a growth chart in the letter. Parents said that the growth chart was difficult to understand, even after reading a set of instructions about how to interpret it and reviewing the chart as a group. Parents said they preferred a simpler visual representation of their child’s weight status. They preferred a clear message that focused on whether their child was at a healthy weight, and if not, what they could do about it.  Parents reported a range of reactions when asked how they would feel if they learned (hypothetically) that their child was overweight or obese. Of the parents who indicated they would have negative reactions, two noted that they would be motivated to help their child achieve a healthy weight, despite it being hard to hear that their child was currently at an unhealthy weight.  Some parents in the focus groups reported that there was nothing they could do to change their child’s weight status, either because they believed their child’s weight was biologically pre-determined or because they felt they did not have agency in shaping their child’s eating habits (e.g., other family members controlled meals). These findings present an area of opportunity for Head Start, as promoting parent education around these issues could be beneficial. Parent feedback from the focus groups was used to revise the BMI letters a second time. Revisions included adding the child’s name, removing the growth chart, adding more COMMUNICATING WITH HEAD START PARENTS 95 information about what to do if the child was identified as not being at a healthy weight, and adding a Frequently Asked Questions (FAQ) section. FAQs were derived from information that arose during the parent focus groups and included basic information about BMI, a note emphasizing the positive role that parents can play in helping their child achieve a healthy weight, and a warning about avoiding dieting in children. Important Survey Findings/Relevance to Practice The bullet points below describe key findings regarding the BMI letter questions on the anonymous annual parent survey:  Most parents reported that receiving specific information about their child’s weight status was helpful: 59.2% reported it was very helpful and 22% reported it was somewhat helpful.  Most parents reported sharing the information in the letter about their child’s weight status with someone else: a family member (30.7%), their child’s Head Start teacher (20%), their child’s pediatrician or nurse (18.9%), a WIC nutritionist (17.7%), their child’s Head Start nutritionist (13.7%), a friend (12.4%), their child’s Head Start family advocate (8.4%), someone else (5.3%), and someone else at Head Start (4.1%). Only 23.3% reported that they did not share information in the letter with anyone.  One in five parents reported sharing information with their child’s Head Start teacher, which underscores the critical role of teachers as agents in the BMI communication process. Teacher “buy in” about the importance of healthy weight in preschoolers and teacher comfort and preparedness to respond to parents’ questions and concerns about the weight status screening information when it is sent home are critical to consider when delivering this information to families.  Only 10% of parents reported that the BMI letter they received indicated that their child was overweight or obese. This figure is much lower than the agency- wide screening data indicating that 34% of Head Start children in the agency were overweight or obese during the school year when the survey was administered. Although parental underreporting has been widely documented, we expected better awareness because the parents we surveyed had received the BMI communication letter. CONCLUSION Communicating health screening information to parents about their child’s weight status is one way to engage families in childhood obesity prevention efforts. This article provides an example of a BMI communication letter that was developed in a multi-phase process using feedback from Head Start staff and parents at every step of the way. This systematic approach to communication with parents is an ongoing process that must occur each year, as new children enroll in programs and existing students grow. There is much more to be done in the area of childhood overweight/obesity prevention, however, to make significant and lasting changes in 96 HOFFMAN ET AL. parents’ beliefs and understanding about childhood overweight/obesity as an important health issue. REFERENCES Baughcum, A. F., Chamberlin, L. A., Deeks, C. M., Powers, S. W., & Whitaker, R. C. (2000). Maternal perceptions of over-weight preschool children. Pediatrics, 106, 1380-1386. doi: 10.1542/peds.106.6.1380 Bennett Johnson, S., Pilkington, L. L., Lamp, C., He, J., & Deeb, L. C. (2009). Parent reactions to a school-based body mass index screening program. Journal of School Health, 79, 216-223. doi: 10.1111/j.1746 1561.2009.00401.x Carnell, S., Edwards, C., Croker, H., Boniface, D., & Wardle, J. (2005). Parental perceptions of overweight in 3-5 year olds. International Journal of Obesity, 29, 353-355. doi:10.1038/sj.ijo.0802889 Chomitz, V. R., Collins, J., Kim, J., Kramer, E., & McGowan, R. (2003). Promoting healthy weight among elementary school children via a health report card approach. Archives of Pediatric and Adolescent Medicine, 157, 765-772. doi: 10.1001/archpedi.157.8.765 Cunningham, S., Kramer, M., & Narayn, K. V. (2014). Incidence of childhood obesity in the United States. 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Journal of School Health, 76, 496-501. doi: 10.1111/j.1746-1561.2006.00147.x Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014). Prevalence of childhood and adult obesity in the United States, 2011-2012. Journal of the American Medical Association, 311, 806-814. doi:10.1001/jama.2014.732 Whitaker, R. C., & Orzol, S. M. (2006). Obesity among US urban preschool children: relationships to race, ethnicity, and socioeconomic status. Archives of Pediatric & Adolescent Medicine, 160, 578-584. doi:10.1001/archpedi.160.6.578 COMMUNICATING WITH HEAD START PARENTS 97 Appendix Final BMI Letter