Counce's Blog: March 2009

Family Involvement in School-Based Health Promotion:
Bringing Nutrition Information Home
Jessica Blom-Hoffman, Kaila R. Wilcox, and Liam Dunn
Northeastern University
Stephen S. Leff and Thomas J. Power
The Children’s Hospital of Philadelphia and University of Pennsylvania School
of Medicine
Abstract. Family–school collaboration related to children’s physical development
has become increasingly important as childhood obesity rates continue to rise.
The present study described the development and implementation of a literacybased,
family component of a school-based health education program and investigated
its viability, acceptability, and effectiveness. Interactive children’s books
were the mechanism by which students, parents, and teachers received consistent
messages at home and school regarding nutrition information. The home–school
intervention served to bridge home and school cultures in an urban population.
Preliminary process evaluation results indicated that the interactive children’s
books were feasible to implement in the school context. Parents, children, and
teachers had positive perceptions of the books. Parents who received the books
demonstrated increased knowledge of “5 a Day,” which highlights the importance
of eating fruits and vegetables. Although not statistically significant, after the first
and second years of intervention, parents in the experimental group reported that
their children were eating 0.54 and 0.36 additional servings of fruit and vegetables
per day compared with children in the control group. The program did not seem
to influence the availability and accessibility of fruits and vegetables at home.
This project was supported by Grant Number K23HD047480 from the National Institute of Child Health and Human
Development. The content of this article is solely the responsibility of the authors and does not necessarily represent
the official views of the National Institute of Child Health and Human Development and the National Institutes of
Health. The authors are deeply appreciative of the children, parents, school staff, and public health professionals, who
participated in the development, dissemination, and evaluation of the interactive children’s books. Finally, the authors
are indebted to the support of the Center for Study of Sport in Society at Northeastern University.
Correspondence regarding this article should be addressed to Jessica Blom-Hoffman, Department of Counseling
and Applied Educational Psychology, 203 Lake Hall, Northeastern University, Boston, MA 02115; E-mail:
j.blom-hoffman@neu.edu
Copyright 2008 by the National Association of School Psychologists (ISSN 0279–6015), which has nonexclusive
ownership in compliance with Division G, Title II, Section 218 of PL 110–161 and NIH Public Access
Policy (NIHMSID# 67401).
School Psychology Review,
2008, Volume 37, No. 4, pp. 567–577
567
To date, much of the focus of family–
school collaboration in the educational literature
is related to promoting children’s academic
and social development (e.g., Christenson,
2004). Home–school collaboration
focused on promoting children’s physical
health has received less attention, yet may be
just as important. The present study addresses
this gap by focusing on home–school collaboration
related to the promotion of healthy
eating, an important topic for families and
schools given that proper nutrition is important
for cognitive and physical development
(Nutrition-Cognition National Advisory Committee,
1998). This topic is relevant for school
psychologists (Harrison, Cummings, Dawson,
Short, Gorin, & Palomares, 2004; Ysseldyke
et al., 2006), who can play important roles in
the design, implementation, and evaluation of
school-based health promotion programs
(Power, DuPaul, Shapiro, & Kazak, 2003).
Given the current obesity epidemic
(U.S. Department of Health and Human Services,
2001), it is now more important than
ever for families and schools to collaborate in
obesity prevention. Both home and school settings
influence children’s eating and physical
activity, so consistent messages across these
settings are important. This is particularly relevant
for young children who rely on their
caregivers and school to procure and prepare
their food.
Because of the importance of children’s
healthy eating and the suitability of the school
environment for nutrition education, many
school-based nutrition education programs
have been developed and evaluated. Schoolbased
programs frequently include family
components. The authors conducted a systematic
review of 58 school-based, nutrition education
programs implemented in preschools
and elementary schools.1 Thirty-eight programs
(65.5%) mentioned the inclusion of a
family component. Of the 38 programs that
mentioned a family component, 8 (21.1%) included
activities that were based at school or
in the community only (e.g., family activity
nights), 20 (52.6%) described activities that
were based at home only (e.g., newsletters;
homework), 8 (21.1%) described family activities
that were based both at school and at
home, and 2 (5.2%) were unclear. That many
school-based nutrition programs send information
home is important because parents frequently
find it difficult to attend school events.
Engaging, time-efficient, enjoyable activities
that can be completed at home can meet the
needs of large numbers of families. Two published
studies incorporated home-based activities
assigned for homework at the elementary
school level. Gordon and Haynes (1982) developed
a series of parent pamphlets that outlined
information students learned in school
over a 3-week period. Luepker, Perry, Murray,
and Mullis (1988) designed family games and
a 5-week correspondence course that was sent
home in packets. Luepker et al. reported an
86% participation rate by families. These
types of approaches are desirable to reach the
maximum number of families. Although both
approaches were evaluated in controlled studies,
neither study reported the degree to which
activities were implemented in the homes or
parent- and child-reported acceptability. Information
regarding the degree to which homebased
activities are completed and found to be
acceptable is important when considering issues
of program feasibility and sustainability.
This article describes the development,
implementation, and process evaluation of the
family component of a school-based nutrition
program that also used an interactive, homebased
approach to family–school involvement.
The family component involved a literacybased
approach with shared book reading. It
was intended that parents would read the
books to their children. Books were designed
to provide multiple opportunities for children
to respond through active engagement (Greenwood,
Delquadri, & Hall, 1984). They reinforced
messages that students learned at
school in an engaging, interactive format and
communicated consistent, informative messages
to parents. Book activities provided a
context for children and parents to have a
conversation about the health information. Assigning
the books as homework may have
increased the likelihood they would be read.
Another advantage of this approach was that it
was an efficient way to promote shared book
School Psychology Review, 2008, Volume 37, No. 4
568
reading within the comfort of the families’
own home. This study is innovative in that it
represents the first time interactive, shared
book reading, assigned as homework and used
to communicate school-based nutrition information
with families, has been evaluated. The
main purpose of this article was to describe the
development, implementation, and preliminary
evaluation of this approach. The following
research questions were addressed:
1. Did the children complete the activities
in the books with the assistance of family
members? In this study, the completed
activities served as permanent
products documenting that children
read the books with an adult.
2. Was this type of home–school transmission
of health information acceptable to
parents, children, and teachers?
3. Did parents learn the “5 a Day” message
(i.e., the importance of eating at
least five servings of fruits and vegetables
[F&V] per day), and report
changes in their children’s F&V consumption
and the availability/accessibility
of F&V at home?
Method
Participants and Setting
The study took place in four elementary
schools in a large, urban, public school district.
The schools represented a sample of convenience
as the first author’s university already
had a relationship with them. Two
schools were randomly assigned to receive the
Fruit and Vegetable Promotion Program
(F&VPP), a school-based, multiyear, multicomponent
program designed to increase children’s
F&V consumption (Blom-Hoffman,
2008), and two were randomly assigned to
serve as comparison schools. All schools were
already participating in a physical activity promotion
program called Athletes in Service.
Schools in the experimental group received
the F&VPP plus Athletes in Service. Schools
in the control group received Athletes in Service
only. A total of 297 parents provided
written consent for their kindergarten or firstgrade
child to participate in the evaluation
(56% participation rate). Demographic information
is displayed in Table 1. Participating
school staff included kindergarten, first, and
second grade, computer and art teachers (n
24). Most teachers had been teaching for 10 or
more years (80%), and almost all were women
(95%).
Materials
Interactive children’s books. Five interactive
children’s books were developed
over a 2-year period with a partnership between
the first author, public health professionals,
and parents. The books were designed
to communicate a simple health message that
the students already learned at school, contained
a variety of activities designed for children
to complete with adult assistance, and
were written on a third- through seventh-grade
reading level. A brief questionnaire was included
at the end of each book for parents and
children. The books were available in English,
Spanish, and Vietnamese, the primary languages
spoken by the families. See Table 2 for
titles and descriptions.
Teacher acceptability. Teachers completed
a modified version of the Intervention
Rating Profile (Martens & Witt, 1982) to report
acceptability of the F&VPP in the spring
of 2006 and 2007. The questionnaire was
modified so items were directly related to the
F&VPP. For this study, the primary item of
interest was: “The children’s health books are
an acceptable way to encourage students to eat
more fruits and vegetables during school
lunch.” Teachers used a 6-point Likert-type
scale to rate this item.
Parent questionnaire. Parents were
interviewed by phone in their native language
by a native speaker, who used a structured
questionnaire in the summer 2005 (pretreatment),
summer 2006 (post-Year 1) after the
first three books were distributed, and summer
2007 (post-Year 2) after all books were distributed.
Parents provided demographic information,
knowledge of the 5 a Day message,
information regarding F&V availability (i.e.,
Family Involvement
569
the degree to which foods are present) and
accessibility (i.e., the extent to which foods
are prepared, presented, or maintained in a
way that makes them easy to eat) in the home
(F&V Availability/Accessibility Scale; Hearn
et al., 1998), and the number of F&V servings
their child eats per day.
Procedure
The books were developed over a 2-year
period in an iterative process with feedback
from parents and public health professionals.
A parent focus group was held to review the
first three books. Feedback included shortening
the books’ length, adding more game-like
activities, and making the books narrative in
structure. The final book was co-developed by
a community coalition of public health professionals,
and was illustrated by children because
culturally relevant clip art was unavailable.
All books followed the same format.
Each included a short letter to parents, activities
requiring adult assistance, a simple health
message, and a brief questionnaire at the end
of the book for parents and children. Books
were translated into Spanish and Vietnamese
by native speakers working at a professional
translation company. Participant recruitment
procedures are described in detail elsewhere
(Blom-Hoffman, Leff, Franko, Weinstein,
Table 1
Participant Demographic Characteristics
Variable
Group
Experimental
(N 149)
Control
(N 148)
Gender (% male; N 297) 51% 50.7%
Age (in years) at baseline (N 297) 6.22 6.21
Student weight status at baseline (N 293)a
Overweight 17.6% 19.3%
Obese 22.3% 26.2%
Percentage of students receiving free or reduced price lunch (N 192)b 93.9% 88.3%
Parent-reported child race and ethnicity (N 190)b
African American 29.3% 36.3%
Asian 24.2% 0%
Hispanic 41.4% 50.5%
White 3% 4.4%
Other 2% 8.8%
English only spoken at home (N 196)b 29.7% 51.6%
Maternal education (N 191)b
High school degree or less 60.8% 72.3%
More than high school 39.2% 27.7%
Paternal education (N 175)b
High school degree or less 79.8% 82.6%
More than high school 20.2% 17.4%
aChildren removed their shoes and sweaters before being measured. Weight was measured to 0.1 kg (Seca digital
electronic scale, Creative Health Products, Plymouth, Michigan). Standing height was measured to 0.1 cm with a
portable stadiometer (Shorr Productions, Olney, Maryland). Weight status of children determined using gender-specific
Centers for Disease Control and Prevention growth reference charts (Ogden et al., 2002). Overweight 85th percentile
and 95th percentile; obese 95th percentile.
bParents provided demographic information as part of a structured phone interview conducted in Summer 2005. Almost
all phone interviews were conducted in the parents’ native language by a native speaker. A total of 196 parents (66%)
were able to be reached for the first phone interview.
School Psychology Review, 2008, Volume 37, No. 4
570
Table 2
Titles and Descriptions of the Interactive Children’s Books
Title
———’s 5 a Day Book
Smart Shopping &
Great Goals Color Your Plate
———’s Physical
Activity Book Delicious Drinks
Key Message(s) 5 a Day goal; different
ways to reach the
goal.
5 a Day; self-monitoring
F&V eating
behaviors.
Eating a variety of F&V
in different colors.
Being physically active
every day;
minimizing
sedentary activity.
Promoting non-sugar
sweetened
beverages.
Flesch-Kincaid grade levela 5.2 4.6 7.8 5.4 3.9
Illustrations Clip art Clip art Clip art Clip art Children’s artwork
Activities Drawing Drawing Drawing Drawing Drawing
Coloring Coloring Coloring Circling Circling
Self-monitoring Self-monitoring Coloring Coloring
Shopping List
Note. F&V fruit and vegetables.
aThe Flesch-Kincaid grade level was calculated using Microsoft’s Word Readability Statistics (http://unf.edu/ccavanau/readabilitystats.pdf).
Family Involvement
571
Beakley, & Power, in press). The study was
approved by the Institutional Review Board at
Northeastern University and the school district’s
research office. Although signed consent
was required for study participation, all
students in the target grades received the
books. Students received the books over a
16-month period (Winter 2006 to Spring
2007). Teachers sent them home as homework
in an envelope, and asked parents to return
them within a week. When families spoke
either Vietnamese or Spanish at home, teachers
provided the book in both English and the
native language. Research assistants collected
the books from teachers to review the completed
activities and the parent and child questionnaire
responses. Because participation in
the F&VPP was voluntary, no negative consequences
were imposed if students did not
return the books. Only those students whose
parents provided written permission to participate
in the study were included in the data
analyses. All books were returned to students.
Results
The first research question was to understand
the extent to which the books would be
returned and completed. As shown in Table 3,
77% of students returned the first book; subsequent
books were returned at a lower rate
(range 43%–59%). Table 3 shows that the
majority of activities were completed (range
51%–85%), indicating that children read
the books with an adult.
The second question asked if parents,
children, and teachers would find the books
acceptable. Table 3 shows their perceptions.
When asked how much they enjoyed reading
the book together with their child, parents
responses across the books on the 3-point
scale ranged from 2.84 to 2.91 (1 not at all
acceptable, 2 a little acceptable, and 3 a
lot/very acceptable). When asked how much
they enjoyed reading each book, children’s
responses across the books ranged from 2.86
to 2.90. When asked how much they learned
from each book, parents’ responses across the
books ranged from 2.82 to 2.91, and children’s
responses across the books ranged from 2.89
to 2.91. The final two books also asked parents
to report behavioral intentions to make
changes suggested in the book. As shown in
Table 3, parents’ responses indicted they were
considering or were very likely to make
changes after reading the book. Teachers also
believed the books were an acceptable way to
encourage students to develop the target behaviors
(Year 1 M 5.36; SD 0.93; Year 2
M 5.29; SD 0.91; on a 6-point scale
anchored by 1 strongly disagree and 6
strongly agree).
The final question asked if parents
would learn the 5 a Day message and report
changes in children’s consumption and home
availability/accessibility of F&V. Eighty parents
(27% of the sample) participated in all
three phone interviews: Summer 2005 (pretreatment),
Summer 2006 (post-Year 1), and
Summer 2007 (post-Year 2). As shown in
Table 4, parents in the experimental group
were more likely to know about the 5 a Day
message at the second and third time points
compared with pretreatment (Time 1–2:
2
Yates [1, n 37] 3.91, p .05; Time 1–3:
2
Yates [1, n 37] 13.88, p .001) and
compared with parents of children who did not
receive the books (Time 2: 2
Yates [n 80]
3.98, p .05; Time 3: 2
Yates [1, n 80]
12.81, p 0.001). As shown in Table 4, there
were no significant differences with regard to
parent-reported child F&V consumption (F[2,
77] 2.02, p ns), parent-reported F&V
availability at home (F[2, 77] 0.86, p ns),
and parent-reported F&V accessibility in the
home (F[2, 77] 0.68, p ns).
Discussion
The interactive children’s books were
feasible to implement in the school context.
Many books were returned, and of those books
the majority of activities were completed. Parent
and child questionnaires indicated the
books were perceived as beneficial and enjoyable.
Teachers also reported that the books
were acceptable; however, teacher acceptability
of the books was limited in that it was
assessed from a single item that was part of a
broad acceptability questionnaire reported
School Psychology Review, 2008, Volume 37, No. 4
572
Table 3
Titles, Descriptions, and Parent and Child Perceptions of the Children’s Books
Title
———’s 5 a Day Book
Smart Shopping &
Great Goals Color Your Plate
———’s Physical
Activity Book Delicious Drinks
Percentage Returneda 77% 59% 47% 53% 43%
Percentage Activities completedb 79%–85% 71%–83% 74% 51%–71% 67%–83%
Parent acceptabilityc
Book was enjoyable 2.89 (0.35) 2.89 (0.36) 2.91 (0.29) 2.86 (0.35) 2.84 (0.42)
Book was informative 2.84 (0.40) 2.82 (0.47) 2.87 (0.34) 2.84 (0.42) 2.91 (0.29)
Likely to make behavioral changesd,e NA NA NA 2.73 (0.45) 2.35 (1.23)
Child acceptabilityc
Book was enjoyable 2.89 (0.35) 2.88 (0.32) 2.87 (0.40) 2.90 (0.31) 2.86 (0.35)
Book was informative 2.89 (0.32) NA 2.91 (0.29) 2.86 (0.35) 2.91 (0.29)
aAlthough all children in the classrooms received and were asked to return the books, this percentage refers only to children whose parents provided written permission for their children
to participate in the outcome evaluation.
bBecause each book contained several activities, the ranges refer to the percent of activities completed within each book.
cMean (SD) parent- and child-rated acceptability. The following 3-point scale was used: 1 not at all; 2 a little; 3 a lot.
dThese items were only asked at the end of ———’s Physical Activity Book and Delicious Drinks. The items asked parents how likely they were to help their child (a) be more physically
active after reading the book and (b) make healthy drink choices after reading the book. Response items included: 1 not likely at all; 2 may be; 3 very likely; or my child is
already physically active for at least 1 hour/day or we already make healthy drink choices.
eNA not asked.
Family Involvement
573
Table 4
Parental Awareness of the 5 a Day Message, Report of Children’s F&V Eating Behaviors, and Availability/Accessibility
of Fruits and Vegetables at Home by Group
Variable
Pretreatment Post-Year 1 Post-Year 2 Group
Time
Experimental Control Experimental Control Experimental Control Interaction
Parent 5 a Day Knowledge
(percentage correct) 10.8% 7.0% 32.4%* 11.6%* 54.1%** 14.0%**
F&V servings children eat each
day; M (SD) 2.46 (.99) 2.44 (1.10) 2.89 (.97) 2.35 (1.20) 2.76 (.90) 2.40 (1.10) ns
F&V home availabilitya M (SD) 17.51 (3.85) 17.76 (5.22) 18.78 (4.04) 19.67 (5.33) 19.00 (3.84) 18.90 (5.26) ns
F&V home accessibilityb M (SD) 2.65 (.58) 2.58 (.63) 2.81 (.46) 2.60 (.48) 2.76 (.56) 2.54 (.53) ns
Note. F&V fruit and vegetables; ns not significant. n 80 (Experimental n 37; Control n 43).
aParents were asked if they had 48 different types of fruits or vegetables in the home in the past 7 days. The foods could have been in fresh, frozen, or canned forms. This questionnaire
was based on the Fruit and Vegetable Availability/Accessibility Scale (Hearn et al., 1998). It was modified to include additional fruits and vegetables common in Central and South
American, and Vietnamese diets.
bParents used the following scale to respond to seven F&V accessibility items on a modified version of the Fruit and Vegetable Availability/Accessibility Scale: 1 Never; 2 Once
in a While; 3 Most of the Time; 4 All of the Time.
*Experimental Control, p .05
**Experimental Control, p .001
School Psychology Review, 2008, Volume 37, No. 4
574
elsewhere (Blom-Hoffman, 2008). Parents in
the experimental group were significantly
more likely to demonstrate awareness of the 5
a Day message relative to pretreatment and
relative to parents in the comparison group.
Parents estimated the number of F&V
servings their children ate per day. Although
the group by time interaction did not reach
statistical significance, an examination of the
mean changes in child consumption showed
the changes were in the expected direction.
Whereas control group children’s F&V consumption
remained stable across all three time
periods, F&V consumption of children in the
experimental group increased. Parents in the
experimental group reported a 0.43 serving
per day increase between pretreatment and
post-Year 1 and a 0.30 serving per day increase
between pretreatment and post-Year 2.
Also, after Years 1 and 2 of program implementation,
parents in the experimental group
reported that their children were eating 0.54
and 0.36 more servings of F&V per day compared
with children in the control group. Although
not statistically significant, the magnitude
of these changes is consistent with those
reported in the school-based F&V promotion
literature (Howerton, Bell, Dodd, Berrigan,
Stozenberg-Solomon, & Nebeling, 2007;
Knai, Pomerleau, Lock, & McKee, 2006). A
power analysis (using an alpha level of .05 and
an effect size of .5 based on data from this
study) indicated that we only had 54% power
for the group by time interaction; to have 80%
power to test the group by time interaction
with a repeated-measures analysis of variance,
we would have needed 70 participants per
group. In addition, it is important to interpret
our preliminary findings regarding child F&V
consumption with caution because of the parent
report methodology used, which did not
include training on portion size estimation.
However, parent reports of small changes in
children’s F&V consumption are consistent
with our research team’s own direct assessment
of children’s eating behaviors in the
school cafeteria (Blom-Hoffman, Franko,
Power, Stallings, Dai, & Thompson, 2007).
The books were read by a large group of
parents and were disseminated in an efficient
manner. Costs associated with the books included
time spent writing and formatting the
book, translating, and printing. Once completed,
very few resources were spent disseminating
the books. Each book cost approximately
$3.38, including translation and printing
expenses. Relative to other modes of
family involvement in school-based initiatives,
the books enabled large numbers of families
to participate and served to provide consistent
health messages between home and
school environments. In contrast, other forms
of family involvement in school-based nutrition
education initiatives have considerable
limitations. In-school events often require sufficient
resources to organize and host, and
sometimes are met with extremely poor parent
attendance. Newsletters cost little to develop
and disseminate, but it is unclear how many
parents actually read and discuss them with
their children. The interactive books assigned
as homework address these limitations by engaging
families around health information.
This study suggests that the use of interactive
books has promise as a mechanism of
conveying knowledge. The program did not
change home F&V availability/accessibility.
This finding is consistent with other health
education research (e.g., Blom-Hoffman &
DuPaul, 2003) indicating the provision of
knowledge is not sufficient for behavior
change. To improve F&V availability and accessibility,
particularly in under-resourced
communities, major environmental changes
are likely required (e.g., supermarket availability;
food pricing).
There were a number of limitations in
this preliminary study that should be addressed
in future research. First, this study
compared a group of parents who received a
multilevel program that included the family
component described in this study to a control
group. Therefore, it is unclear if the parent
knowledge change resulted from the books
alone or the books in combination with knowledge
that the children brought home from
school. Future research efforts can explore the
individual and combined effects of the
F&VPP components. Second, book return
rates declined across time. Classwide ap-
Family Involvement
575
proaches (e.g., interdependent group contingencies)
can be established to increase the
number of books returned. Third, because of
practical reasons, schools as opposed to participants
were assigned to study condition;
therefore, children and parents were nested
within schools. Fourth, three books in this
study promoted the 5 a Day message. In 2007,
5 a Day was replaced by Fruits and Veggies—
More Matters (Produce for Better Health
Foundation, 2007), a campaign promoting individualized
recommendations based on gender,
age, and physical activity level, and communicated
in cups instead of servings (http://
www.fruitsandveggiesmatter.gov/). As such,
these books should be revised to reflect the
new message. Fifth, children’s F&V consumption
was assessed via parent report. Future
research should use more rigorous dietary assessment
methods (e.g., 24-hour recalls; Lytle
et al., 1993). Finally, the selection of anchor
points for the parent and child acceptability
measures may have had an influence on ratings.
Respondents may have been reluctant to
use the lowest anchor point (i.e., “never”; S.
McConaughy, personal communication, January
22, 2008). Nevertheless, the majority of
parents and children reported liking the books
“a lot,” and learning “a lot” from them, suggesting
that the level of acceptability was at
least moderately high. Finding ways to create
effective, acceptable, feasible mechanisms to
promote home–school collaboration related to
healthy eating is important. This pilot study
illustrates one such effort.

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