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Alyssa Cofano NUTR 485 April 20, 2012 Research Paper Critique Chosen article: Slusser, W.

, Prelip, M., Kinsler, J., Erausquin, J. T., Thai, C., & Neumann, C. (2011). Challenges to parent nutrition education: a qualitative study of parents of urban children attending low-income schools. Public Health Nutrition, 14(11), 1833-1841. 1. The nature and significance of the research problem was identified in the beginning

section of the research paper before the methods section. The reason why this paper is significant is because childhood obesity is a growing problem not only in the United States but worldwide as well. Parents have an influence on their childrens eating behaviors and this could relate to the rise in childhood obesity. Its believed that if parents are educated on what foods are healthy and are role models for their children that it would help lower childhood obesity rates. However, previous studies show that guiding parents with nutrition education alone will not improve the weight status of their children and will not promote healthy eating behavior either. The parents motivation to make healthy food choices are blocked by barriers such as lack of money, lack of time, lack of desirability of healthy foods, and lack of knowledge about healthy foods. It was found in one previous study that was mentioned that parents blamed their children for the unhealthy eating habits in their households. Their reasons for blaming their children ranged from picky eating habits to preferring fast foods and junk foods. Another challenge that a previous study found was that parents werent receptive to interventions that encouraged healthy eating. Overall, it can be challenging to engage low-income parents with children to eat healthier because of time constraints, lack of money, and lack of transportation.

The research problems were addressed in the aims of the paper which were laid out as objectives within the introduction section. The research looked at parents of children from the Los Angeles Unified School District (LAUSD). The first objective of the study was to learn more about LAUSD parents knowledge about healthy foods, factors associated with food purchasing and preparation, and current nutrition education resources. The second objective was to learn more about the parents barriers to and promoters for establishing healthy eating habits with their children and family. The third and final objective was to learn about the parents interest in participating in nutrition interventions. These objectives all targeted low-income families that were of ethnic minority populations such as Hispanics/Latinos and AfricanAmericans. Focus group interviews were conducted by the Public Health Nutrition Friendly Team of the University of California at Los Angeles to address the stated objectives of this qualitative research study. This research study was initiated by the Network for a Healthy California-Los Angeles Unified School District to assess the need for nutrition interventions that target low-income parents. 2. This study looked at low-income and minority populations to explore the relationship

between obesity among adults and children in this population. Their goal was to learn more about parents knowledge about healthy foods, factors associated with food purchasing and preparation, current nutrition education resources, any barriers to and promoters for establishing healthy eating habits with their children and family, and to learn about the parents interest in participating in nutrition interventions. Based upon the objectives for this research study, the study design was descriptive qualitative and used focus group interviews. Descriptive research was applicable to this study because the researchers were not trying to manipulate their variables. They were trying to gain insight on how much nutrition knowledge the parents have in the

selected population based off of the interviews conducted. The study was not conducted in a controlled condition; it was conducted in natural settings, which in this case were the schools in the LAUSD. The responses from the interviews provided data that could be used for content analysis to identify themes within the responses. Once the themes were identified, the researchers compared the themes to see how they related to the objectives of the research. 3. The sampling design that was used was discussed in the methods section of the paper.

The sampling criterion was that the LAUSD schools that were allowed to participate in the research had to be part of the Network schools. This meant that they had to be a Title 1 school that had over 50% of their students eligible for the free or reduced lunch program. The parents eligible for the study had to be parents of children who attended the Network schools. Both of these criteria are inclusion criteria, which meant that they must be met in order to be included in the study. The study used non-probability sampling so not everyone within the population group would be included in the population sample used for the study. The type of non-probability sampling used in the study was a combination of convenience and purposive sampling. It was convenience sampling because only five of the thirteen schools asked to participate in the study responded and agreed to participate. This means that the parents of children at the schools that agreed to participate were included in the sample based off the availability of the school to participate. The reason why the sample is also purposive is because the researchers made it so that only parents of children in Network schools were allowed to participate and not parents of low-income, ethnic minorities in other non-Network schools. Its important to note here that at the end of the methods section there was a paragraph stating that this study had been approved by the LAUSD Program Evaluation and Research Branch and the UCLA Institutional Review

Board. This is important because it adds credibility to this study and clarifies ethical standards and guidelines for research were followed during the study. The sampling design for this research study was adequately described within the methods section. To get parents to participate in the study, flyers that were in both English and Spanish were sent home with all the students at each of the five participating elementary schools. The flyers contained the details of the study and the incentives for participating. If parents were interested in enrolling in the focus groups for the study, they had to phone UCLA to let them know and also indicate their preferred language. The sample size for this study was determined based off of the number of parents willing to participate in the focus groups. Sixty-four parents voluntarily participated and were broken down into nine focus groups. Two of these groups were conducted in English and the remaining seven groups were conducted in Spanish. The focus groups conducted in English were composed of eight subjects per group and the Spanish focus groups were composed of six to eight subjects per group. A potential error that could have resulted from the sampling design is subject error. Subject error could have been introduced in this study because of the difference between parents who volunteered to participate in the focus groups versus those parents who did not want to volunteer or didnt have the time to volunteer for the study. This subject error could be caused by both the difference in those who volunteer and those who dont as well as response bias. Response bias would relate to some sort of systematic error in the sampling process. For example, response bias could occur if parents couldnt attend because they didnt have transportation to the focus group or the flyers that were sent home with the children never made it home. Another source of response bias could be if some of the families didnt have telephones than they were unable to express their interest in participation in the study.

4.

There were three main qualitative tools that were adequately described for this study

which consisted of a pre-interview questionnaire, an interview guide, and an audio recorder. The procedures section of the paper discussed how the focus groups were conducted and how the tools were used. The brief pre-interview questionnaire took ten to fifteen minutes to complete and was administered to gather information regarding the subjects demographics as well as their use of the Network nutrition program. Both the questionnaire and the guide were based off of previous literature, research aims for the study, knowledge about the population of interest, and other nutrition education related information. The Health Belief Model was used to help develop the loosely structured interviews and address the three main objectives of the study. The focus group interviews were conducted for 45 minutes and the facilitator of the focus group made sure to ask more questions to clarify responses from the parents. The above tools for the focus groups were developed by the UCLA School of Public Health research team and the Network. All of the nine focus group interviews were recorded using an audio recorder and transcribed verbatim so they could be used for content analysis. Recordings that were from the focus groups conducted in Spanish were converted to English for analysis purposes. 5. Steps that were taken to minimize subject error in the study were providing the

questionnaire in Spanish and English as well as conducting the focus groups in both of these languages. This allowed for more parents to be able to participate in the study and to minimize bias caused by language barriers. Another source of error could have been investigator error which could have been introduced consciously or unconsciously during the focus group interviews. To reduce investigator error there was one bilingual doctoral student who was in charge of facilitating the focus group interviews. The doctoral student was experienced with working with the selected population of interest and was trained about the research objectives,

protocol, and interview guide. By having only one person conducting the interviews and standardizing the interview process it helped to reduce investigator error by keeping the process more consistent. Measurement error could have been introduced via the pre-interview questionnaire. For example if the wording on the questionnaire was misleading or implied that a certain response was expected this could affect the answers to the questionnaire. Furthermore, bias could have occurred from the questionnaires that the subjects answered since they were selfreported responses. Underreporting also could have contributed error to the study because the subjects included in the sample consisted mostly of women and parents who came from low-income households. This is relevant because underreporting is most commonly noted in women and subjects who are undereducated. It was not evident that there were steps taken to prevent underreporting in the information provided within the paper. 6. The research paper adequately described the subjects who participated in the study. As

stated in the sample section of the results, the final sample size for the study was 64 parents who participated for the entire duration of the study and no attrition occurred. Attrition is what happens when study participants drop out in the middle of the study for various reasons. All of the 64 parents participated in both the pre-interview questionnaire and the focus group interviews. Table 2 in the research paper showed the demographic information regarding the 64 parents who participated in the study. The demographics that are provided in the table include gender, race/ethnicity, mean age, and language. Of the 64 parents who participated, 93% of them were female and 84% of them were of Hispanic/Latino descent. The subjects in this study are not representative of the population because a convenience sample was used which means that subjects were chosen selectively and not randomly. In addition, qualitative research cannot

be generalized to a whole population because it is not typically randomized. The purpose behind qualitative research is to explore and identify themes or categories within the data gathered from the study. 7. The purpose of this research study was to learn from parents of low-income, minority

status regarding the three main objectives of 1) their knowledge of food purchasing and preparation, 2) their barriers to and promoters for healthy family eating behaviors, and 3) their interest in participating in nutrition interventions. These objectives were addressed by using a questionnaire and focus group interviews which resulted in data that was used for content analysis. The process for data analysis was discussed at the end of the methods section. Based off of the transcribed interviews, univariate analyses were used to assess the parents demographic characteristics and involvement in nutrition education activities. There were three reviewers who independently looked over the data to find themes that were recurring in the data. There were two main themes that emerged from the data analysis. The first was about the balance between the positives and the negatives of healthy eating. The paper gave an example for this first theme by saying that some parents would weigh their options on whether it was worth buying healthy food if they had a child that was a picky eater. The second theme that emerged from the content analysis was about the important role that the family plays in motivating both the child and the rest of the family to make healthy choices about food. The results of the analysis were clearly presented in the results section and organized by discussing each objective consecutively. The first objective focused on learning more about the parents knowledge of healthy foods, food purchasing and preparation, and their current nutrition education resources. What the study found was that the majority of parents were able to identify the major food groups that are important in a healthy diet such as fruits, vegetables, and beans.

They even mentioned categories such as low sodium, low saturated fat, and low-fat milk as important factors as well. There were a few parents that noted the importance of how food is prepared and how it affects nutrition. However, it was also discovered that some parents didnt know what healthier food options were and didnt know what they could do to make their food healthier. When it came to purchasing healthy foods, children had an influence on what foods were purchased. Some of the parents would buy more expensive healthy foods if they knew their children would like them even if it meant paying more. Some less common factors that influenced some of the parents food purchasing choices were caused by limited time, limited ways to store healthy food, living in neighborhoods that lacked markets with healthy food, and not knowing how to read a nutrition label. Lack of time and lack of availability and/or accessibility to healthy foods was identified as a sub-theme of the main themes from the results. The last topic addressed in the first objective was about nutrition education. Some of the parents said that they were self taught and many of the parents gained their nutrition knowledge from various sources such as TV, radio, newspapers, and magazines. Some of the people also mentioned that relatives, physicians, and food markets were their sources of information as well. When parents were asked who their most trusted source of nutrition information was, they responded that is was their physician. The results of the second objective followed the results of the first objective. The second objective was about learning what the parents considered barriers to and promoters for healthy eating for both their children and families. What the researchers found was that most of the parents wanted their families to eat healthier foods. There were three main barriers for buying healthy food that parents mentioned which were the cost, their childrens food preferences, and lack of time to prepare healthy meals. The lack of time to prepare healthy meals often led most

of the parents to resort to taking their families to eat at fast food restaurants. A challenge that many of the parents in the study faced was that their children didnt like the taste of healthy foods and so it made it hard for them to convince their children to eat healthier. Many of the parents mentioned how their children love junk food and fast food. With the wide abundance of fast food restaurants in cities now, its a struggle for parents to get their children to eat healthy food when an easier, more desirable food is in closer reach that is less time consuming and more wallet friendly. The results of the third objective were discussed in the last section before the discussion. The third objective addressed gaining more insight on parents interests in participating in nutrition interventions if given the opportunity to do so. What was discovered from the study was that most of the parents were willing to take part in group nutrition education and wanted a hands-on way to learn about nutrition education. The parents wanted to learn not only just how to cook, but also how to cook healthier meals at home. They added that they wanted more information regarding ways to make healthy foods taste better and healthy substitutions for cooking too. Education on how to teach their children about healthy foods was also another topic of interest. One of the major themes that came from the third objective was that the parents wanted the nutrition education classes to include the whole family. When asked what times they would want the classes offered they indicated before or after school. This request reflected their desire to make it accessible for the whole family to attend. Since the subjects mainly consisted of women, there was a strong desire for fathers to be more involved in nutrition education and healthier eating behaviors of the family. Topics that were suggested for these nutrition education classes ranged from basic cooking techniques to learning about more ways fit exercise into their lifestyle. The parents offered that a good incentive to get parents involved and to attend the

classes would be if they were given food vouchers, gift certificates, or other prizes such as food and kitchen items. 8. The discussion section of the paper compared the results of the study to the previous

research. The discussion section was laid out similarly to the results section so that each of the objectives of the study was discussed consecutively. In the first objective of the discussion section it mentioned that the study findings regarding parents desire for more nutrition interventions needed to be family oriented. This was similar to the findings of previous research done by Hart et al. that emphasized the entire family to be responsible for healthy eating and exercise behaviors. The results of the second objective found that the parents most common barriers to healthy eating were cost, children who were picky eaters, and lack of time to prepare healthy food was similar to previous findings of Goh et al. In the work done by Goh and colleagues, they found that unhealthy food, such as fast food, was easier for parents to access than healthier foods because they were cheap and convenient for the whole family. Another study by Hesketh et al. had similar findings in their research as well. Parents in their study reported that with the increasing amount of fast food restaurants becoming available that it was an obstacle to healthy eating for their families. However, despite the above mentioned barriers, parents in the current study were still willing to weigh the pros and the cons of foods when it came to buying healthy food for their children. The study found that parents knew which foods were healthy for their children and this was a promoter for healthy eating behavior that outweighed the cost of having to pay a little more. The findings that related to the third objective reflected previous research as well. The main theme that emerged from the results in the third objective addressed the importance of

including the entire family when it came to eating healthier and attending nutrition classes. The paper noted that there are expert work groups that recommend that the family as a whole be included in interventions that address childhood obesity treatment and prevention. Having the whole family involved provides more support and stability for the family to reach their nutritional goals. When it came to disparities in the findings of the research compared to previous research there was one disparity. The paper said that previous studies had found that parents were not interested in nutrition interventions that focused on dietary behavior and were only interested if it involved the family as a whole. However, the findings in the third objective contradict this. The current study found in the results of the third objective that parents were open to nutrition interventions and that including the family as a whole would be an added benefit to the nutrition interventions. The study findings did not mention anything about the parents not being interested in nutrition interventions if the whole family wasnt involved. 9. Limitations to this study were discussed towards the end of the discussion section of the

paper. The first limitation identified by the authors said that because focus group interviews were used, that individual perspectives may be over-represented and so the study does not equally reflect any specific concerns of every subject who participated. Furthermore, another limitation was that their sampling design used convenience sampling so this created selection bias. Because of this, the findings of this study are not generalizable to every LAUSD parent. Another limitation that occurred during this study was that detailed demographic information about the subjects who participated in the focus groups was not obtained because of time constraints. Because of this, there is no data regarding the number of children the parents had, how many people lived in each household, and other demographics that were of interest. Also,

one last limitation that was not discussed in the paper was that there were incentives offered to the parents who participated in the study. This could potentially have an effect on the results of the study and created bias as well. 10. An implication for further research was mentioned in the discussion part of the paper

under the section that addressed the first objective. It mentioned here that future nutrition interventions should look at providing parents with the skills necessary to talk with their physicians about any questions or concerns they have regarding their childrens health. The reason why this implication was presented was because during the study it was found that many of the parents didnt talk with their physicians regarding their childrens health and so their physicians didnt provide them with nutrition information. In addition to this implication, the findings from the focus groups are a hopeful indication that parents will be receptive to nutrition interventions that address healthy eating behaviors for both the children and the family. Overall, this study offered more insight and made a contribution to the small amount of existing literature regarding low-income, Hispanic/Latino parents. Because of the results from the focus groups in this study, parent nutrition education programs were developed and implemented in LAUSD schools for the 2008-2009 school year.