PARENT TESTED…PARENT APPROVED? LESSONS LEARNED FROM THE HEALTHY ACTIVE LIVING FOR FAMILIES FOCUS GROUPS

PARENT TESTED…PARENT APPROVED? LESSONS LEARNED FROM THE HEALTHY ACTIVE LIVING FOR FAMILIES FOCUS GROUPS

Linda Radecki, Alison Baker, Jeanne Lindros, Amy Pirretti and Amy KephartLinda Radecki, Alison Baker, Jeanne Lindros, Amy Pirretti and Amy Kephart

American Academy of Pediatrics, Elk Grove Village IL

Background: Childhood obesity is a health concern that touches even the youngest children. Early childhood has been identified as a critical period for obesity prevention. As a frequent point of contact in the health care of young children, pediatricians are positioned to provide guidance on early obesity prevention but report gaps in preparedness to address these issues. The Healthy Active Living for Families…Right from the Start (HALF) project was created out of this need to 1) develop, test and disseminate family-focused messages for families with infants, toddlers, and preschoolers and 2) provide supporting materials to parents and pediatricians for use in the clinical setting. The HALF project, parent-driven and designed to “meet families where they are” conducted a series of formative focus groups in Fall 2010 to better understand parents’ concerns, challenges and successes surrounding food, feeding and activities. Results were used to develop a series of messages incorporating elements of the 5,2,1,0 health promotion model plus breastfeeding and general obesity prevention. Messages were tested in Spring 2011 in a series of evaluative focus groups. This report presents findings from the evaluative groups. Objectives: Obtain parent feedback on a series of healthy active living/obesity prevention messages for families with young children and explore parent preferences for information dissemination. Methodology: 18 evaluative focus groups with diverse groups of parents. At each primary site, we conducted 2 groups based on child age (Parents of Infants [birth-11 mos] and Parents of Toddlers/Preschoolers [12-59 mos]). Sessions lasted 90 minutes; parents completed questionnaires and reviewed draft messages. Messages were assessed for specific wording and content and action strategies were obtained. Parent preferences for dissemination were also explored. Results: Participants included 113 parents. The sample over-represented at risk families. Messaging surrounding obesity prevention, breastfeeding and 5,2,1,0 elements were not uniformly endorsed by parents. Parents of infants rejected use of the word “obesity” and preferred a focus on healthy habits vs obesity prevention. Breastfeeding was valued but a majority of mothers were unlikely to breastfeed longer out of concern for child’s future weight. Parent struggled with the “why” surrounding messages related to fruit/vegetable and sugar sweetened beverage consumption. Messages to limit screen time did not resonate, regardless of obesity prevention implications. Parents often reported that television is educational for young children and provides a break for parents. In general, parents rejected standard handouts, requesting more durable (eg, posters, magnets) or individualized materials.

Conclusions: Findings from a series of focus groups suggest that parent perceptions and behaviors are often incongruous with expert guidelines and standard anticipatory guidance. Obtaining the parent perspective is critical in developing messages and materials that resonate with families of young children.

OBJECTIVESABSTRACT RESULTS (con’t)

LIMITATIONS

BACKGROUND

• Results from a series of focus groups with parents of young children suggest that parent perceptions and actions may often be incongruent with expert guidelines and guidance.

• Obesity prevention messages promoting behavior change based on future consequences did not resonate with families in our focus groups.

• Additional action strategies – positive, tried and true suggestions – to foster implementation of new behaviors are needed. Parents in our focus groups valued “how to“ and “what works” ideas from other parents.

• Rethinking traditional methods of information delivery may be necessary to reach young families in ways that are meaningful and support change. Focus group participants requested materials that are durable and serve as frequent reminders that promote healthy habits and decision making (eg, magnets, posters). Parents also value information that can be individualized to meet their unique needs.

• Understanding parent perspectives is critical in meeting young families where they are regarding obesity prevention/healthy active living messaging.

• 113 parents (92% mothers; <1/3 first time parents) participated across 18 groups

• Race/ethnicity African American = 37% Hispanic = 24% White = 45%

• >70% of children were publicly insured

• Questionnaire data addressed various components of healthy practices and obesity prevention efforts (see Table 1)

• Obtain parent feedback on a series of healthy active living/obesity prevention messages for families with young children

• Explore preferences for information dissemination

• Childhood obesity is a health concern that touches even the youngest children. According to the Institute of Medicine’s newly released report, Early Childhood Obesity Prevention Policies, almost 10% of infants and toddlers have high weight for length; over 20% of children 2-5 years are overweight or obese.

• Early childhood has been identified as a critical period for obesity prevention. Early childhood provides opportunities to establish healthy eating practices, good physical activity habits and optimal sleep routines before unhealthy patterns are engrained.

• A frequent point of contact in the health care of young children, pediatricians are positioned to provide guidance on early obesity prevention but a 2009 AAP needs assessment of pediatricians identified gaps in preparedness to address such issues.

• In response to this need, the AAP initiated the Healthy Active Living for Families…Right from the Start (HALF) project to 1) develop, test, and implement a series of positive, family focused obesity prevention messages for families with infants, toddlers, and preschoolers, and 2) provide supporting materials for parent distribution and use at pediatric well visits to foster dialogue between families and health professionals. A hallmark of the HALF project is the commitment to a parent driven approach, with messaging and materials designed to “meet parents where they are.”

• To that end, a series of focus groups were conducted – formative groups to inform message development and evaluative groups to provide critical review of the messages created. This poster reports results from the evaluative groups.

CONCLUSIONS

ACKNOWLEDGEMENTS

• Special thanks to our parent focus group participants who shared their ideas and experiences

• HALF Project Editorial Board: Co-Chairs Sandra G. Hassink, MD, FAAP and Paula Duncan, MD, FAAP; members Nwando Anyaoku, MD, MPH, FAAP, Kim Avila Edwards, MD, FAAP, Jon Korfmacher, PhD, Tamela Milan, and Elsie Tavaras, MD, MPH, FAAP

Funding for the HALF project is generously provided by a grant from the Nestlé Nutrition Institute

• Focus group participants were self-selected and may not be representative of all parents with young childrenTable 1. Parent-Reported Behaviors and Lifestyle Surrounding

Healthy Active Living and Early Childhood Obesity Prevention

% yes

Child ever breastfed 65 Child eats breakfast everyday 91

Child eats ≥5 fruits and vegetables each day 52 Child drinks ≥1 soda, juice or sugar sweetened drink each day

36

Family eats dinner together every day in a typical week

51

TV in child’s bedroom 45 Child in child care at least 1 hr per day 69

Pediatrician is child’s usual provider of well child care

90

METHODOLOGY• 18 focus groups were conducted with parents in NM, IL, LA, AL, NY &

PA. At each site, at least 2 groups were held based on child age [Parents of Infants (ages birth-11 mos) & Parents of Toddlers and Preschoolers (ages 1-5 years)].

• Parents were recruited through flyers and word of mouth. Groups were held in locations familiar to families (eg, libraries, health centers).

• Sessions lasted 90 minutes; parents completed questionnaires and reviewed draft messages. To determine whether messages resonated with parents, we obtained feedback on specific wording and content (eg, Did the message provide new information? Would the message promote changes in knowledge, attitude, or behavior?) and action strategies to facilitate implementation. Preferences for information delivery were also obtained.

• The project was approved by the AAP’s Institutional Review Board.

RESULTSNEXT STEPS

• Revision of parent messages is underway based on evaluative group feedback

• Physician implementation guide in development

• First point of care material released at 2011 AAP NCE (“Start Today” poster)

• Upon completion, all Healthy Active Living for Families project materials will be housed on the AAP website and its consumer site, healthychildren.org

Obesity Prevention – message focused on starting obesity prevention and healthy habits early

• Challenges – 1) perceptions of weight, especially re: infants, may be inaccurate, 2) limited awareness of obesity prevention at the earliest ages, 3) parents of infants reject the term “obesity.”

Breastfeeding – message highlighted link between breastfeeding and likelihood of weight problems as child grows.

• Challenges - most mothers acknowledged that they would be unlikely to continue breastfeeding based on concern for child’s future weight, often citing difficulties with pumping, especially upon return to work.

I love my baby but I’m really busy and I work full time. I have other kids. It’s just a lot of work…I breastfed for the time I’m off work but trying to go back to work and pump and then it gets raw and I’m at work and I’m like oh, forget it!

They’re supposed to be chubby babies…once they start crawling and walking they start thinning out…

I don’t think I’m buying into obesity at under a year…from 0-1 they’re gonna stop eating when they don’t

want any more…

5+ Fruits & Vegetables/Day – message presented in the context of solid food introduction (infants) and picky eaters

(toddlers/preschoolers)

• Challenges – Parents struggled with various recommendations, particularly around repeated exposure. Action strategies needed.

I’m thinking about being a busy mom…I did not have time to

introduce peas 15 times. It was ‘well, he didn’t like it, let’s move on

to something else…’

I don’t get mad at my baby because I didn’t eat vegetables. I didn’t like

vegetables. I was forced to eat ‘em when I was young so now as I get older, I don’t eat vegetables at all.

Zero Sugary Beverages/Day – message promoted limiting/eliminating sugar sweetened beverages

• Challenges – Misconceptions abound, particularly surrounding 100% fruit juice. Many parents were puzzled by this recommendation, arguing that WIC provides juice. Parents were more receptive to limiting sugar sweetened beverages based on oral health concerns rather than as an obesity prevention strategy.

I give my son WIC and they always give me juice so I feel like they don’t give ‘em anything else unhealthy, why would they give ‘em juices?

1 Hr Active Play; < 2 hrs Screen Time/Day – messages encouraged active play; discouraged

screen time

• Challenges – Parents lacked ideas for ways to promote active play with infants. Messages regarding screen time limits did not resonate, regardless of obesity implications. Participants often reported that television is educational for young children and provides a break for parents.

How do you teach a baby to be active? That’s very

hard!

It’s like preschool on TV. I don’t feel bad…it gets me the time that I need to do

stuff…