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Exploring the effects of BMI health report card letters among 6th grade students and parents

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Title:
Exploring the effects of BMI health report card letters among 6th grade students and parents an application of the social cognitive theory
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Book
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English
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Kaczmarski, Jenna M
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University of South Florida
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Tampa, Fla
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Subjects / Keywords:
Body Mass Index   ( mesh )
Obesity   ( mesh )
Overweight   ( mesh )
Child   ( mesh )
Parents   ( mesh )
School Health Services   ( mesh )
Health Promotion   ( mesh )
Models, Psychological   ( mesh )
Questionnaires   ( mesh )
Adolescent
Obesity
Nutrition
Physical activity
Parent modeling
Dissertations, Academic -- Community and Family Health -- Masters -- USF   ( lcsh )
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non-fiction   ( marcgt )

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Summary:
ABSTRACT: In response to the growing child and adolescent obesity epidemic, some states and local school authorities are mandating the measurement of Body Mass Index (BMI). However, there is limited research addressing whether schools are an appropriate setting and the intended as well as unintended effects of sharing this information with parents. Furthermore, there is yet to be conclusive evidence that shows that BMI screening in the school setting is an effective way to improve student BMI status. Therefore, the purpose of this research study was to explore the effects of BMI Health Report Card Letters among 6th grade students and their parents by applying a Social Cognitive Theory conceptual framework. A non-experimental, post - test only study design involving child/parent dyads was employed to answer the proposed research questions. Quantitative data were gathered from students and parents using separate theory based questionnaires.Key results include a statistically significant difference between delivery methods (mail vs. backpack) for the number parents who confirmed receiving the BMI letter (p = .001) and reading the BMI letter (p = .005). Additionally, there were statistically significant differences between parents based on child BMI categories. Specifically, a greater number of parents of children "at risk of overweight" or "overweight" took one or more action to control their child's weight associated with food restriction (p = .005) and physical activity (p<.001) and reported greater parental concern about child's weight (p = .001) and parental modeling of negative talk /behaviors (p = .019). Parents of children of "normal weight" reported greater perceived importance of child nutrition behaviors (p = .026). Results indicate the importance of mailing BMI Health Report Card Letters as well as the occurrence of unintended negative consequences.Implications include the need for tailored BMI letters, based on child weight status, which include information and resources to increase parent's capacity to share BMI information with their child as well as make healthy changes in the home.
Thesis:
Thesis (M.S.P.H.)--University of South Florida, 2009.
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Includes bibliographical references.
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by Jenna M. Kaczmarski.
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Title from PDF of title page.
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Document formatted into pages; contains 137 pages.

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aleph - 002063802
oclc - 557402295
usfldc doi - E14-SFE0003198
usfldc handle - e14.3198
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Exploring the Effects of BMI Health Report Card Letters Among 6 th Grade Students and Parents: An Application of the Social Cognitive Theory by Jenna M. Kaczmarski A thesis submitted in partial fulfillment of the requirements for the deg ree of Master of Science in Public Health Department of Community and Family Health College of Public Health University of South Florida Major Professor: Rita Debate, Ph.D. Ellen M. Daley, Ph.D. Stephanie Marhefka, Ph.D. Date of Approval: November 12, 2009 Keywords: Adolescent, Obesity, Nutrition, Physical Activity, Parent Modeling Copyright 2009, Jenna M. Kaczmarski

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i Table of Contents List of Tables iii List of Figures v Abstract vi Chapter I Introduction 1 Statement of t he Problem 1 Review of the Literature 1 Prevalence of Childhood and Ado lescent Overweight and Obesity 2 Determinants of Childhood and Adolescent Overweight and Obesity 4 Intrapersonal Factors 5 Sociocultural Factors 7 Built Environment 9 Policies 10 BM I Surveillance and Screening 12 Organizational and Expert Recommendations pertaining to BMI Screening 13 Purpose of Research Study 16 Chapter II Conceptual and Theoretical Framework and Research Questions 17 Social Cognitive Theory 17 Research Ques tions 2 0 Chapter III Methods 2 2 Study Design 2 2 Research Setting 2 2 BMI He alth Report Card Intervention 2 2 Participan ts 2 3 Participant Recruitment 2 3 Parent 2 3 Student 23 Procedures 2 4 Parent 2 4 Student 2 4 Instruments 2 5 Parent Survey 2 5 Student Survey 29 Analysis 3 2

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ii Chapter IV Results 3 5 Participants 3 5 Descripti ve Data 3 6 Research Questions 3 7 Chapter V Discussion 5 6 Limitations 6 3 Conclusion 6 4 Future Research Directions 6 7 Summary 6 7 References 69 Appendices 7 4 Appendix A: Non Results Tab les 7 5 Appendix B: BMI Healt h Report Card Letter 9 0 Appendix C: Parent Survey Cover Letter 9 2 Appendix D: P arent Survey Informed Consent 9 3 Appendi x E: Parent Permission Letter 9 6 Appendix F: Parent Survey Reminder Letter 9 7 Appendix G: Teache r Instructions / Student Assent 9 8 Appendix H: Par ent Survey 99 Appendix I: Student Survey 10 8 Appendix J: Results Tables 1 19

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iii List of Tables Table 1 BMI Categories with Recommen ded and Previous Terminology 7 5 Table 2 Par ent Survey Questions related to Social Cognitive Theory Constructs 7 6 Table 3 Social Cognitive Theory Constructs, Themes and Scoring for Parent Survey 7 8 Table 4 Survey Questions Related to C hild Report of Modeling 8 3 Behaviors, Home Environ ment and Child Behaviors Table 5 Social Cognitive Theory Constructs, Themes and Scoring for Student Survey 8 6 Table 6 Characteri stics of Parent Participants 1 19 Table 7 Data Rel ated to Student Participants 12 1 Table 8 Frequencies of Selected Partic ipant Responses 12 2 Table 9 Post L et ter Weight Control Actions 12 3 Table 10 12 5 Table 11 Differences i n Psychosocial Determinants of Behavior Scores among Parents who Read the Letter and Did Not Read the Letter 12 6 Table 12 Differences in Environmental Determinants of Behavior Scores among Parents who Read and Letter and Did Not Read the Letter 12 7 T able 13 Differences in Modeling Behaviors among Parents who Read the Letter and Did not Read the Letter 12 8 Table 14 Modeling of Physical Activity among Parents who Read the Letter and Did Not Read the Letter 1 29 Table 15 Differences in Psychosocial Determinants of Behavior Scores 13 0 Table 16 Differences in Environmental Determinants of Behavior Scores Risk of 13 1

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iv Table 17 Differences in Modeling Behaviors among Parents of Children 13 2 Table 18 Modeling of Physical Activity among Parents of Children of 13 3 Table 19 Relationship between Psychosocial Determinants of Behavior and Modeling Behaviors and Environmental Determinants of Behavior 13 4 Table 20 Differences in Report of Modeling Behavior s between Parent and Child 13 5 Table 21 Differences in Report of Home Environment between Parent and Child 13 6 Table 22 Relationship between Parent Reported Environmental Determinants of Behaviors and Modeling Behaviors and Child Reported Behaviors 13 7

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v List of Figures Figure 1 Logic Model: BMI Health Repo rt Card Letters and Their 18 Association with Social Cognitive Theory

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vi Exploring the Effects of BMI Health Report Card Letters Among 6 th Grade Students and Par ents: An Application of the Social Cognitive Theory Jenna M. Kaczmarski ABSTRACT In response to the growing child and adolescent obesity epidemic, some states and local school authorities are mandating the measurement of Body Mass Index (BMI). However, there is limited research addressing whether schools are an appropriate setting and the intended as well as unintended effects of sharing this information with parents Furthermore, there is yet to be conclusive evidence that shows that BMI screening in t he school setting is an effective way to improve student BMI status. Therefore, the purpose of this research study was to explore the effects of BMI Health Report Card Letters among 6 th grade students and their parents by applying a Social Cognitive Theory conceptual framework. A non experimental, post test only study design involving child/parent dyads was employed to answer the proposed research questions. Quantitative data were gathered from students and parents using separate theory based questionnaires Key results include a statistically significant difference between delivery methods (mail vs. backpack) for the number parents who confirmed receiving the BMI letter (p = .001) and reading the BMI letter (p = .005). Additionally, there were s tatistically significant difference s between parents based on child BMI categories. restriction ( p = .005) and physical activity (p <.001) and reported greater parental

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vii importance of c hild nutrition behaviors (p = .026). Results indicate the importance of mailing BMI Health Report Card Letters as well as the occurrence of unintended negative consequences. Implications include the need for tailored BMI letters, based on child weight stat capacity to share BMI information with their child as well as make healthy changes in the home.

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1 Chapter I Introduction Statement of the Problem Child and adolescent obesity rema ins one of the top public health issues worldwide. Obese children and adolescents have increased incidence of type 2 diabetes, high cholesterol, high blood pressure, sleep apnea, orthopedic problems, liver disease and asthma (Torgan, 2002). Additionally, o verweight and obese children have a higher probability of being overweight or obese adults (Krebs, et al., 2007 & Torgan, 2002). In 2007, Larson and Story stated that in order to reverse the obesity trend, global interventions and policy initiatives were n eeded. States and local school districts across the US have mandated Body Mass I ndex (BMI) measurement programs. BMI is a measure of weight status by adjusting weight for height, which correlates with body fat and related health risks. (Barlow, et al., 200 7). Because the only measurements needed to calculate BMI are weight and height, it is a relatively easy to measure and useful indicator of weight status (Barlow, et al.). However, current research is unclear with regard to the intended and u nintended effe cts of measuring BMI in the school setting as well as sharing the information with students and their parents. Furthermore, long term research is needed to determine whether or not it is an effective means to prevent and/or reduce further increases in chi ldhood and adolescent overweight and obesity. Review of the Literature The Expert Committee on Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity ( Henceforth, Expert Committee) is a collaborative

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2 initiative among the Ame rican Medical Association, the Health Resources and Service Administration and the Centers for Disease Control & Prevention The Expert Committee convened in 2005 to update 1997 recommendations on the evaluation and treatment of child and youth obesity (B arlow, et al., 2007). Three writing groups focused on prevention, assessment, and treatment. They found that science continues to lag behind the obesity epidemic, which creates gaps in evidence based recommendations. As a result, the committee used evid ence based literature where available and filled in the gaps with clinical knowledge to provide practical guidance to clinicians and recommendations in all areas of obesity care, not excluding those that lack the best possible evidence (Barlow, et al.). A s a result, the Expert Committee recommended the use of BMI to assess weight status of children and suggest that clinicians use BMI as a screening tool to determine the need for further assessment (Barlow, et al., 2007). They further recommend that BMI sc reening is most effectively used in conjunction with an entire health assessment (Barlow, et al.). Childhood overweight and obesity can be defined using age and gender specific BMI normative values. The 2005 Expert Committee recommended new terminology fo r the uppermost categories, suggesting that children with a BMI percentile of 85% to 94% be classified as overweight (previous terminology was at risk for overweight) and children with a BMI percentile greater than or equal to 95% be classified as obese (p revious terminology was overweight) (Barlow, et al., 2007). Recommended 2005 terminology for BMI categories and previous terminology are shown in Appendix D, Table 1. Prevalence of Childhood and Adolescent Overweight and Obesity Ogden, Carroll, and Flega l (2008) reviewed the most recent data on prevalence of high BMI (at or above the 85th percentile) among children and adolescents. They

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3 and compared results using statis Nutrition Examination Survey (NHANES) data. In their assessment they found that in 2005 2006, 30.1% of children and adolescents aged 2 to 19 years were at or above the 85th percentile (above normal we ight). More specifically, 14.6% fell between the 85th and 94th percentile (classified as overweight) and 4.6% fell between the 95th and 96th percentile (classified as obese). Possibly most alarming are the 10.9% that are at or above the 97th percentile a t the highest end of the obese category. Whereas the data appeared to represent a decrease from 2003 2004, this decrease was not found to be statistically significant (Ogden, et al.). Future data may help to further examine the trend as well as the pos sibility that the prevalence of overweight and obesity among children and adolescents is beginning to plateau. NHANES data depicts an overall increase in child and adolescent overweight over many years. However, clear racial/ethnic disparity is seen beginn ing at very young ages with non Hispanic White children and adolescents having the lowest prevalence of overweight when compared to non Hispanic Black Americans and Hispanic Americans. While national data comparing girls and boys is similar, gender differe nces are apparent when broken down by racial/ethnic groups. Greater gender differences are seen among non Hispanic Black American and Hispanic American children and adolescen ts than among non Hispanic White Americans Among girls, non Hispanic Black Americ ans have the highest prevalence, whereas among boys, Hispanic Americans have the highest prevalence (Wang & Beydoun, 2007). Beyond racial/ethnic differences, socioeconomic disparity is less clear according to Wang and Beydoun (2007). Based on NHANES data f rom 1999 2002, Wang and Beydoun found that Socioeconomic Status (SES) was inversely related to prevalence of

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4 overweight among White American children and adolescents, but not among non Hispanic Black or Hispanics. At younger ages SES seems to have more o f an impact on boys than girls, with high SES boys having the lowest prevalence of overweight Among adolescents, Wang and Beydoun found the reverse to be true. No consistent association was seen between SES and overweight for boys, whereas low SES girls had a much higher prevalence of overweight However, high SES non Hispanic Black adolescent girls had much higher prevalence when compared with their lower SES counterparts (Wang & Beydoun). Determinants of Childhood and Adolescent Overweight and Obes ity Over the past ten years, the body of knowledge related to the risk factors, co morbidities and treatment of childhood overweight and obesity has grown dramatically (Barlow, et al., 2007). Barlow et al. posit that the increased prevalence has happened t oo quickly to be explained by genetic factors alone, in that there must be influences from changes in dietary and physical activity behaviors. Furthermore, Blass (2003) who lack exercise opportunities and often, owing to parental concern about street safety, The nature of c hildhood and adolescent overweight and obesity is complex and multi factorial. Therefore, the determi nants may be best described from a socioecological perspective, which provides an overview of the various intrapersonal factors, sociocultural factors, built environment and policies that can influence this complex hea lth issue (Butterfoss, Kegler & Francisco, 2008). As such, t he following presents an overview of the determinants of childhood overweight and obesity including intrapersonal factors, socio cultural factors, built environment, and policy.

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5 Intrapersonal fact ors Factors at this level include personal behaviors as well as genetics and biology (Budd & Hayman, 2006). Perhaps the most recognized behaviors contributing to the problem include increased dietary energy intake and insufficient physical activity (Colap into, Fitzgerald, Taper, & Veugelers, 2007). According to the Robert Wood Johnson Foundation (2006), US children are consuming more calories than they need to maintain energy balance and avoid unhealthy weight gain and the trend accelerates into adolescen ce. Food behaviors and preferences are developed often at an early age from a combination of influences of the Neumark Sztainer, & French, 2002). Dietary habits includin g eating fast foods as opposed to meals at home as well as larger portion sizes have been linked to excess calorie intake and increased body weight (Colapinto, et al., 2007). Interestingly, a group of researchers found that children who are allowed to serv e themselves at a meal actually consume smaller portion sizes (Colapinto, et al.) It also appears that the mechanism to stop eating when full can be overridden when children are served too much food repeatedly. Researchers observed that three year olds wo uld stop eating when full regardless of the portion size served, whereas five year olds ate more of the same entre as the portion size served increased (Colapinto, et al.). Colapinto, et al. demonstrated that children have a preference for large portions of high energy, low nutrient foods such as french fries, meats and potato chips, and smaller portions of nutrient dense vegetables. In fact, according to the Committee on Food Marketing and Diets of Children and Youth (2006), one third of calories consumed by children and adolescents come from less healthy food sources. They report that there has been a 30 year increase in the consumption of sugar sweetened beverages, high fat and high

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6 sugar snacks, meals and desserts (Committee on Food Marketing and Diets of Children and Youth, 2006). When asked about vending snack choices, adolescents rated taste as the number one motivator followed by hunger and price (Story, et al., 2002). In fact, one group of researchers used focus groups to determine that among adol escent girls, eating junk food was considered normal and was associated with pleasure, being with friends, weight gain, independence, guilt, affordability and convenience (Story, et al.). The presence of both negative and positive associations shows the c omplicated mix of influences on adolescent food choices. Data from the Youth Risk Behavior Survey (YRBS) show a decline in the amount of physical activity over the past decade among adolescents (Davis, et al., 2007). However, Davis, et al. point out the difficulty measuring physical activity among youth due to their limited ability to understand and recall concepts of time, duration and intensity of past activity. Girls in particular seem to be less active than boys in this age group possibly due to diffe rences in attitudes, beliefs, and motivations about physical activity as well as barriers that are different for girls than boys (Davis, et al). There is evidence that limiting sedentary behaviors such as TV viewing and playing video/computer games helps p revent obesity (Colapinto, et al., 2007 & Davis, et al.) and engaging in moderate and/or vigorous physical activity daily can improve BMI (Davis, et al.). There are, however, certain biological and genetic factors at play as well. Blass (2003) warns that looking at eating behaviors from a purely social standpoint ignores the physiologic factors that also contribute to overeating. In fact, he points out that humans have overcompensated for early food shortages with a situation of exploited food abundances, leading to overeating and the consumption of high caloric, low nutrient and

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7 often artificial foods. We teach our bodies to override and eventually diminish satiety signals, leading to weight gain (Blass). Blass state a feeding system that is opportunistic; it capitalizes on short term opportunities by ignoring hepatic, gastric and hormonal signals that determine how we eat during periods s that affect appetite regulation, satiety and fat distribution, some of which are established during fetal development (Barlow, et al., 2007 & Budd & Hayman, 2006). This is complicated by the fact that adolescence is a time of rapid growth, during which t here are increased needs for energy and nutrients (Story, et al. 2002). In fact, researchers found that al.). Adolescents need more energy and nutrients during this period of growth, but as discussed previously the increase in poor food choices is contributing to the obesity problem. Sociocultural factors Many behavioral determinants are impacted by sociocu ltural factors, which include family, social and community influences. Food choices are largely influenced by family, peers, availability, marketing and cost (Budd & Hayman, 2006 & Boutelle, Lytle, Murray, Birnbaum, & Story, 2001). The family is considered the provider of food and provides influences on food attitudes, preferences and values, which have lifelong impact on eating behaviors (Story, et al 2002). Weight status and physical activity behaviors in school aged children can be linked to parental BMI as well as parental eating and physical activity behaviors (Davis, et al., 2007). Parents of young children often use feeding strategies that can actually have a negative effect One example is requiring a child to finish an undesirable food, often times vegetables, which actually can lead to the food being more devalued than before (Blass, 2003). Overall, Blass warns that using a controlling approach with young children

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8 can lead to the child ignoring inter nal natural feeding cues During early adolescenc e, p arental influence is critical as a majority of food consumption still occurs at home (Story, et al., 2002). C urrent research suggests th at children and adolescents who eat meals with their family have healthier eating behaviors (Boutelle, et al., 2001) Story, et al. found that adolescents considered eating healthful food an oddity and associated it with family, meals and being at home. Moreover, Fulkerson, et al. (2006) found a strong positive association between the frequency of family meals and famil y support, positive family communication, parental involvement in school, and family boundaries. It has also been shown that children and adolescents look to their parents as a source of nutritional information (Boutelle, et al., 2001) making it important for adults to model positive nutrition behaviors in the home. Affection, consistent discipline and supervision are three ways that parents provide a positive influence towards healthy behaviors (Fulkerson, et al.). In fact, a 1997 survey showed that adol escents ranked eating dinner at home as one of the top rated activities they liked to do with their parents (Story, et al.). Unfortunately, parents must work against peer and media influence. Peers have a major influence on adolescent behavior (Story, et al., 2002). Eating is part of socialization and recreation and as stated previously adolescents associate eating junk food with spending time with their friends (Story, et al.). In addition, food and beverage marketing strongly influences the preferences and purchase requests of children and adolescents (Committee on Food Marketing and the Diets of Children and Youth, 2006). The majority of products introduced and marketed to children and adolescents are high in total calories, sugars, salt and fat, not to mention low in healthful nutrients (Committee on Food Marketing and the Diets of Children and Youth, 2006). Corporations understand the buying power and size of the adolescent market segment. Adolescents represent a

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9 captive audience and corporations seek to build brand loyalty at this young, impressionable age (Story, et al.). Built environment. A growing area of r esearch examines the role of the built environment in childhood overweight and obesity built environment incl uding the home as well as areas outside the home can influence both dietary and physical activity behaviors. Particularly in the home, parents strongly influence food availability and exposure (Boutelle, et al., 2001). Furthermore, availability of foods in the home is strongly correlated with child and adolescent food intake patterns (Pearson, Biddle & Gorely, 2008 & Hanson, Neumark Sztainer, Eisenberg, Story & Wall, 2004). According to Hanson et al., multiple qualitative research studies have identified the availability of less healthful food choices at home as a key barrier to choosing fruits, vegetables and dairy foods. As part of Project EAT (Eating Among Tee ns), Hanson et al., found that intake of fruits, vegetables and dairy foods was higher among ad olescents whose parents reported that these foods were more frequently available in the home. Fast food restaurants represent one third of the food that is eaten away from the home among adolescents, who visit them a little over two times per week (Story, et al., 2002). Fast food restaurants are a prevalent socially acceptable place to spend time with friend s that offer a fast, low cost meal (Story, et al.). Not surprisingly, when compared to food eaten at home, food eaten by adolescents at fast food restaurants is higher in fat, saturated fat and sodium as well as lower in fiber, iron and calcium (Story, et al.). In addition to fast food restaurants, adolescents look to vending machines and convenience stores as a fast option for food when outside of the home. The majority of foods purchased are unhealthful options such as carbonated beverages, candy, salt y snacks and bakery items (Story, et al.).

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10 Residents who have access to resources such as parks, sidewalks, bike paths, gyms, quality street layout and businesses in walking distance have greater opportunity to be physically active (Davis, et al., 2007). M ore specifically, neighborhood safety as well as community design impacts the amount of physical activity children and adolescents engage in (Budd & Hayman, 2006). For example, children are often un able to walk to school due to factors such as the school b eing too far away, too much traffic, no safe route, fear of abduction and neighborhood crime (Budd & Hayman). Policies. National and state level policies can have both negative and positive impacts on our overall health environment including the potential to influence childhood overweight and obesity. Following are examples of policy that specifically involve the school environment related to health. In schools, increasing competition and mandates on classroom time has left physical education (PE) as a sec ondary priority (Davis, et al., 2007). Daily physical education is becoming more and more uncommon and the amount of time spent being physically active during PE has also decreased (Davis, et al.). Food in schools is also regulated by national and state po licy. The United States Department of Agriculture (USDA) sets standards for the National School Lunch and School Breakfast programs, based on the Dietary Guidelines for Americans (USDA 2009a, 2009b). Meals served must meet standards for calories, key nut rients as well as total and saturated fat. However, on the other hand, USDA does little to control or limit the types of foods that can be sold at schools outside the school meals program (USDA, 2009a, 2009b). This leaves the responsibility with state and local school authorities to regulate these types of foods. As an example, in Hillsborough County Florida, 69% of middle and high schools students could purchase carbonated beverages or fruit drinks based on the school health profile (United States Depar tment of Health and Human Services 2006 ). Fifty one

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11 percent could purchase salty, high fat snacks such as regular potato chips and approximately 30% could purchase chocolate or other types of candy. In contrast, only 39% of students could purchase fruits or vegetables. A large percentage of middle and high schools (71%) do however prohibit the sale of these foods during actual lunch periods (United States Department of Health and Human Services). Additionally, i n response to the obesity epidemic, some states have developed policy requiring the measurement of BMI in schools. Within some states and l ocal school districts BMI data is being used as a surveillance and/or screening tool As descried by Nihiser, et al. (2007) those who use the data as survei llance obtain the BMI of the student population for the purpose of identifying and tracking the percentage of students who are potentially at risk for weight related health problems. In most cases the BMI measurements are kept anonymous and are not linked to individual students. On the other hand, those who use the data as a method of screening obtain the body mass index of individual students for the purpose of identifying which students are potentially at risk for weight related health problems (Nihiser et al.). In most cases this information is then shared with the parents with hopes that they will then take appropriate action. In summary, e xamining child and adolescent overweight and obesity from a socio ecological perspective provides a framework fo r understanding the complicated web of inter related influences and multi level factors. More specifically, as noted above, child and adolescent dietary and physical activity behaviors are influenced by the family environment, the built environment of the school and community, and various local, state, and national policies. Consequently, all of these factors should be considered together when implementing or researching interventions. Of particular interest are interventions implemented in the school sett ing to combat childhood and adolescent obesity. As stated previously, some states have developed policy mandating school

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12 based BMI measurement programs. As such, the following is a review of the literature specifically pertaining to BMI measurement in the school setting. BMI Surveillance and Screening Based on data collected by the National Association of School Board Educators (NASBE, 2009), 13 states have some type of state policy that provides for th e measurement of BMI in schools at least to some degre e. Of particular note are the four states, Arkansas, Maine, New York and Tennessee that require BMI measu rement in the form of screening, which includes the dissemination of results to parents following measurement Florida, Michigan and Maine have policy for optional and/or recommended screening. The remaining six states require or recommend the measurement of BMI to be used for surveill ance purposes and do not mandate providing results to parents. The decision to assess BMI in schools does cause conc ern. There are fears of the potential harm of labeling a child with a condition that is a target of prejudice (Barlow, et al., 2007). Ikeda, Crawford, and Woodward Lopez (2006) outline the potential harm in identifying a child as overweight. They discuss the following factors and provide recommendations for schools. The idea of childhood and adolescent overweight and obesity is very complex. A health professional in a clinical setting takes into account their eating and physical activity behaviors before making a diagnosis about their weight status (Ikeda, et al.). Schools current BMI, to assess weight status. C ommunicating this information to parents only complicates the process. There is fear that parents will initiate harmful or inappropriate dieting practices in efforts to get their child to lose weight (Ikeda, et al.). Chomitz, et al. (2003) found that afte r receiving information that their child was overweight, a significant

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13 amount of parents acted by placing their child on a calorie restricted diet. Beginning these inappropriate behaviors at a young age may place the children at risk for a dangerous cycle of dieting. There is some evidence that teens who self report dieting as a means to lose weight have an increased risk of overweight and obesity, possibly linked to a cycle of over restriction followed by binge eating (Ikeda, et al.). In fact, Ikeda, et a l. caution that being labeled as overweight or obese during childhood and adolescence could also increase motivation to develop disordered eating habits, which is already a major public health concern. They further discuss the increased stigmatization that esteem and body satisfaction. Based on a review of the literature, Ikeda, et al. believe children are aware at an early age that having a fat body is socially unacceptable in our culture, which is causing a fear of becoming fat as apposed to being fearful of the health risks. Furthermore, self esteem Lumeng, et. al. (2003) reported that children labeled as overweig ht are at greater risk for lowered self esteem, depression and social isolation. Lastly, Ikeda, et al. examined the literature of body dissatisfaction and fear that BMI screening may increase the social pressure to achieve the perfect body and contribute t o increased body dissatisfaction. Gibbs, et al. (2007) warn that research as well as interventions that fail to address body image can actually increase the likelihood of unhealthy weight status by generating body image dissatisfaction, poor self esteem, unhealthy eating behaviors and even reduced physical activity. Organizational and Expert Recommendations pertaining to BMI screening Barlow, et al. (2007) point out that schools and communities can either support or impede obesity prevention behaviors. Ho wever, the Expert Committee does not specifically recommend that schools measure or screen BMI of students (Barlow, et al.).

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14 In fact it is implied that these screenings are best suited in the clinical environment, in which the weight related condition is f ramed as a health problem (Barlow, et al.). While research in this area is growing, Nihiser, et. al. (2007) point out that there is still limited knowledge about the outcomes of BMI surveillance and screening programs. Ikeda, et al. (2006) recommend evalua ting the readiness to begin a new school based screening program by answering the following questions: 1) What difficulties are possible by not detecting the problem; 2) What is the effectiveness of the therapy available; 3) How efficient is the proposed s creening procedure; 4) How efficient is it to use schools as the screening location; 5) Are there adequate follow up resources available to students and their families when necessary; and 6) What is the cost of the screening program? They acknowledge the v alue of using BMI for surveillance purposes in schools to track the overall prevalence of overweight and obesity over time within the school or district in order to evaluate the success of school based interventions. However, they point out ey strategies to promote physical activity and healthy eating in children and adolescents do not include recommendations to send BMI reports to parents (Ikeda, et al.). If a school does choose to send this information to parents, the US Maternal and Child Health guidelines for contacting parent s about a health issue recommend that communications should be respectful in tone and written in a language and reading level that is easily understood (Ikeda, et al., 2006). In addition, the schools should provide o pportunities for parents with questions or concerns to meet with school staff at times that are convenient, such as evenings. Gibbs, et al. (2007) recommend utilizing a socio environmental positive health promoting approach when implementing a weight scree ning program in order to address possible negative body dissatisfaction consequences. The method involves promoting health and wellbeing for all children,

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15 rather than a program that focuses on targeting at risk or already overweight students only. Arkansa s is perhaps the best example of large scale implementation of this intervention approach Act 1220 is described as a comprehensive and coordinated approach to combat childhood obesity. The law includes a range of health related components including BMI s creening with dissemination of results to parents, formation of health related advisory committees and school based nutrition restrictions. Positive results were seen three years following the implementation of Act 1220 (Year Three Evaluation, 2006). Like any new program, over time they are seeing improvements in certain aspects of the program, specifically the efficiency of the BMI data collection system. An additional encouraging finding is that both parents and schools continue to be increasingly accepti ng of the BMI screening process. Moreover, no evidence of increased teasing, unhealthy diet behaviors or excessive concern about weight among students was found during their evaluation. Following the first year of implementation, 9% of parents reported pu tting their child on a diet, which decreased to 6% following year three. Students reporting starting a diet also declined somewhat from 29% in year one to 26% in year three. Unfortunately, they did not see significant changes in family nutrition behaviors or physical activity patterns at home (Year Three Evaluation). Florida state law requires height and weight measurement in schools as part of the growth and development screening for students in 1st, 3rd, 6th and optionally, 9th grades. It is recommended that BMI be used as a tool to assess growth and development, but is not explicitly required. It is also recommended but not required that the information be provided to parents (NASBE). More specifically, in Hillsborough County Florida, BMI measurements are conducted for students in K, 1st, 3rd, 6th and 7th grades. School Board policy states that results are to be mailed to parents of every

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16 child. However, due to budgetary constraints, there are some schools that mail the results only to parents of stu dents classified as overweight or at risk for becoming overweight. The results are sent home in the form of a letter and include a Health weight category (See Appendix B ). In ad dition, included on the back of the letter is information explaining BMI and the associated weight categories based on BMI for age percentiles. Basic recommendations are given for each weight category. Health risks associated with underweight and overwei ght are also explained. Schools can choose to mail the letter to the parents or send them home with the child in their backpack. Purpose of the Study Current literature points towards the plausibility of BMI measurement utilized as a surveillance tool in schools, to track overall weight status of their students and measure success of health and wellness programs. However, as described above, current research is lacking with regards to the intended and unintended effects of sharing the information with stu dents and their parents. Continued research is needed to determine the best method for providing the information to parents and whether or not it is an effective means to prevent and/or reduce further increases in childhood and adolescent overweight and o besity. Therefore, the purpose of this study is to explore the ps ychosocial and behavioral effects of BMI Health Report Card Letters among 6th grade students and their parents in one Hillsborough County middle school.

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17 Chapter II Conceptual and Theo retical Framework and Research Questions Social Cognitive Theory Social Cognitive Theory (SCT) wa s the theoretical framework used to guide the current study. SCT was applied to explore the effects of BMI Health Report Card Letters among 6 th grade students and their parents. SCT describes human behavior as the product of a dynamic interplay of personal, behavioral and environmental influences. Reciprocal determinism the key construct of Social Cognitive Theory refers to the interaction between the person, their behavior and their environment Furthermore, the t affects behavior is important; however, equally critical is the idea that people mold and change their environment to suit their purpose. In addition to reciprocal determ inism, the remaining concepts of SCT can be grouped into five categories: psychosocial determinants of behavior ; environmental determinants of behavior ; observational learning; self regulation ; and moral disengagement (McAlister, Perry and Parcel, 2008). S elf regulation and moral disengagement are not applicable to the current study. As such, as depicted in the logic model presented in Figure 1, the BMI Health Report Card Letter psychosocial determinants of behavior, environmental determinants of behavior and activity behaviors.

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18 Figure 1. Logic Model: BMI Health Report Card Letters and their association with Social Cognitive Theory

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19 With regard to psychosocial determinants, outcome expectation refers to a s knowledge as well as beliefs regarding the outcomes and/or consequences associated with a particular behavior. In addition, outcome expectancies refer to the values this person places on these outcomes and/or consequences (McAlister, et al.). With regar d to th e current study, outcome expectations after receiving and reading the BMI health report card letter may include increased parental knowledge regarding their parent believe s and values that their child is susceptible to the risk factors of being overweight, they may also believe that healthy lifestyle behaviors can positively influence weig ht. Moreover, this may set into motion certain modeling behaviors and changes in the home environment. As depicted in Figure 1, SCT suggests that changes made by the parent ultimately impact the child, their environment and their behavior. Environmental d eterminants of behavior involve the facilitation of behavior change through the provision of resources, thus making the desired behavior (McAlister, et al.). With regard to the current study, parents can facilitate h ealthy child behaviors (i.e. nutrition and physical activity) by making the home environment more conducive to this lifestyle. Additionally, parents can model healthy nutrition and physical activity behaviors. The concept of observational learning centers on the idea that the learning of behaviors is a result of exposure to a model of the behavior, such as media displays or interpersonal displays, particularly family and peer modeling (McAlister, et al.). Children can learn healthy lifestyle behaviors as a re sult of seeing these behaviors modeled in the home by parents and other family members.

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20 Lastly, reciprocal determinism is the dynamic interaction between people, their environment and their behaviors. In other words, the behaviors of a person or a group of people are shaped at least partly by their environment. However, people and/or groups can also influence or change their environment to make it conducive to their desired behaviors (M cAlister, et al., 2008). In th e current study as depicted in Figure 1, the per son refers to the parent, the environment is the home and the behaviors of interest are healthy lifestyle behaviors, such as nutrition and physical activity, as well as negative behaviors that the parent is modeling to the child. Research Questions Based upon the SCT based conceptual framework of the BMI Health Report Card intervention, the research questions for the current study are as follows: Re search Question 1. Does method of delivery of the BMI Health Report Card Letter (mail vs. backpack) impact parental acknowledgement of receipt of the letter and furthermore whether or not the parent reads the letter? Research Question 2. After reading the BMI Health Report Card L etter, are there including: a) seeking professio nal help; b) food restriction; and c) physical activity? Research Question 3. Do the psychosocial determinants of behavior (outcome expectations and outcome expectancy), environmental determinants of behavior (facilitation) and modeling behaviors (observat ional learning) differ among parents who read the BMI Health Report Card L etter vs parents who did not read the BMI Health Report Card L etter? Research Question 4. Among parents who read the BMI Health Report Card L etter do the psychosocial determinants o f behavior (outcome expectations and

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21 outcome expectancy), environmental determinants of behavior (facilitation) and Research Question 5. Do the parental psychosocial determinants of behavior (outcome expectations and outcome expectancies) relate to the parental environmental determinants of behavior (facilitation) and parental modeling beh aviors (observational learning)? built environment (home)? Research Question 7. Do pare nt reported environmental determinants of behavior (facilitation) and modeling behaviors (observational learning) relate to child reported behaviors (Nutrition, Physical Activity, Sedentary and Weight Control Behaviors).

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22 Chapter III Methods The cur rent study is part of a larger pilot study funded through the University of South Florida Office of Research and Innovation and Graduate School as part of the Graduate Student Challenge Grant Program. In addition to the purpose of the current study, the la rger study also assessed psychosocial impacts of the BMI measurements among 6 th grade students and included a capacity assessment pertaining to the BMI Health Report Card intervention. The University of South Florida Human Subjects Institutional Review Boa rd as well as the Hillsborough County Public School Research Board granted approval for the current study. Study Design A non experimental, post test only study design involving child/parent dyads was employed to answer the proposed research questions. Quantitative data were gathered using self report paper pencil Likert type questionnaires. Research Setting One middle school in Hillsborough County, FL, was used as the study location. A school staff member (i.e. the school based health assistant) was re cruited as the school coordinator and was compensated with a $500.00 stipend for their time. BMI Health Report Card Intervention As stated previously, Hillsborough County Florida requires BMI measurements in the school setting, with results sent home to p a rents in the form of a BMI Health Report Card Letter (Appendix B) In the study school, the School Health Services Nurse and

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23 School Health Assistant took height and weight measurements and then manually calculated BMI figures during the spring semester. Ap proximately one month after the measurements were taken, the BMI Health Report Card Letters were sent home. For the current study, half the letters were mailed to parents and half were sent home in the livery methods. Participants Participants for this study included male and female sixth grade students attending the aforementioned middle school in addition to the parent or guardian of the participating child. Based upon the number of 6 th grade student s attending the study school, three hundred and forty six (N = 346) 6 th grade students and their parents/guardians were invited to participate in this study. Participant Recruitment Parent A cover letter for the survey, which served as an invitation to p articipate, along with an Informed Consent document was mailed to the home of every child in the sixth grade in the participating school (n=346). Parents were instructed to return the signed informed consent document along with their completed survey. The cover letter and informed consent document can be found in Appendix C and D respectively. Student Three days prior to survey administration the school coordinator sent a permission letter to all parents of 6 th grade students attending the study school. T he letter provided a description of the study and directed parents to return the bottom section if the parent did not wish to give permission for their child to participate in the survey. An example of this letter can be found in Appendix E.

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24 Procedures Surveys were pre coded in order to match student and parent surveys while still protecting anonymity. The school coordinator maintained and stored a code sheet that listed student names and the corresponding survey code. The principal investigator never sa w these code sheets to protect the anonymity and confidentiality of the surveys. All surveys were distributed by and returned to the school research coordinator to maintain anonymity. Parent The survey packet mailed to parents included the following: (a) a cover letter on Univers ity of South Florida letterhead ; ( b) an informed consent document ; (c) the survey ; and (d) a postage paid reply envelope to increase response rate. To increase participation rate, one and a half weeks after the initial mailing, a reminder letter was mailed to those parents who had not yet retuned the survey. The reminder letter can be found in Appendix F. Parents who returned the survey received a $20 gift card as an incentive. S tudent Classroom teachers administered the student s urveys during geography class on the same day. Geography class was chosen based on the fact that every 6 th grade student takes this class. Prior to administration, the school coordinator removed the survey of any students whose parent returned the permiss ion letter stating they did not want their child to participate. Each teacher received detailed instructions for administering the survey and obtaining assent from the students (See Appendix G). Each student survey had a cover page with the students' name to make it easier for teachers to distribute the surveys. Teachers distributed surveys to each child and then read aloud the informed assent statement to the students. Students who did not provide

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25 assent were instructed to return their blank survey to the teacher and work quietly on homework. Among those who provided assent, teachers instructed students to read the instructions and begin the survey. To maintain anonymity, the students were instructed to remove the cover sheet with their name on it before h anding in their completed survey. Instruments Two survey instruments were developed based on the SCT constructs to gather information from parents and students respectively. The surveys were developed based upon Social Cognitive Theory constructs and were adapted from a survey previously related attitudes and behaviors by Haines et al. (2008). The parent survey was used to explore: (a) Parental response and action following receipt o f the BMI Health Report Card Letter; and (b) eating, physical activity, negative behaviors and home environment. The student survey was used to explore: (a) eating, physi cal activity and weight control behaviors following BMI measurement; and (c) self esteem and body image. The parent and student surveys can be seen in Appendix H and I respectively. Parent Survey Parents were asked about their actions following receipt o f the BMI letter with into three categories, as follows: (1) Seeking Professional Help measured using the following question:

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26 care provider, Seen a weight specialist or nutritio nist, Seen a school nurse, gone to a weight loss clinic (Yes or No, Category score of 0 or 1; 0 represents took no action in this category, 1 represents took one or more action in this category); (2) Food Restriction, measured using the following question: After receiving the letter regarding child on a diet, had child skip meals or snacks, Given diet pills or herbal supplements (Yes or No, Category score of 0 or 1; 0 r epresents took no action in this category, 1 represents took one or more action in this category); (3) Physical Activity, measured using the following question: you done any of the following to c physical activity, Signed child up for a sport class (Yes or No, Category score of 0 or 1; 0 represents took no action in this category, 1 represents took one or more action in this category). Parent survey questions were adapted to assess the social cognitive theory constructs discussed previously, specifically psychosocial determinants of behavior, environmental determinants of behavior and observational learning (See Appendix A, Table 2). Psychosocial de terminants of behavior include the constructs outcome expectations and outcome expectancy. Outcome expectations was further divided into two sub constructs including: (1) Perceived Importance of Child Physical Activity Behaviors (Chron measured using the following question: How important is it to you that this child: Be physically active, Limits how much TV they watch ? (Likert scale ranging from Not at all important to Very I mportant, Sum Score Range 0 6; the higher the score, the hig her the perceived importance of child physical activity behaviors), and (2) Perceived Importance of Child Nutrition Behaviors

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27 measured using the following question: How important is it to you that this child: Eats a healthy diet Limits their soda consumption, Eats fruits and vegetables each day ? (Likert scale ranging from Not at all important to Very Important, Sum Score Range 0 9; the higher the score, the higher the perceived importance of child nutrition behaviors). Outcome expectancy included an assessment of Parental How concerned ? (Likert scale ranging from Not at all concerned to very concerned, Range 0 3; the higher the score, the higher the concern; See Appendix A, Table 3, for more detail). Environmental Determinants of behavior (i.e. Facilitation) was further divided into two sub measur ed using the following three questions: During a typical week, how often have you or another member of your household bought fruit or vegetables you know this child likes ? (Likert scale ranging from Not at all to Every day); How often are the following tru e: We have soda in our home, Water is available in our home, In our home, vegetables are served at meals, In our home, fruit is served for dessert, In our home, there is fruit available for my children to have as a snack, In our home, there are vegetables available for my children to have as a snack, In our home, there are cut up vegetables in the fridge for my childr en to eat, In our home there are fresh fruit on the counter, table, or somewhere else where my children could easily get them ? (Likert scale r anging from Hardly ever to Almost always); During the past week, how many times did all or most of your family living in your house eat a meal together ? (Range Never to 7 or more times; Sum Score Range 0 34; the higher the score, the greater the facilita tion of positive nutrition behaviors in the home); and (2) Facilitation of Physical Activity, measured using the following question: During a typical week, how often have

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28 you or another member of your household provided transportation to a place where this child can do physical activity or sports ? (Likert scale ranging from Not at all to Every day, Range 0 3; the higher the score, the greater the facilitation of physical activity behaviors; See Appendix A, Table 3, for more detail). Observational Learning was divided into six sub constructs including: (1) Observational Learning the following question: During a typical week, how often have you or another member of your household: Encouraged this child to eat more fruit, Encouraged this child to eat more vegetables, Encouraged this child to drink less soda, Encouraged this child to drink water instead of soda ? (Likert scale ranging from Not at all to Every day, Sum Score Range 0 12; the higher th e score, the greater the modeling of nutrition behaviors by the family); (2) Observational Learning Parent Nutrition alpha = .346), measured using the following question: Over the past week, how often did you drink Sweetened drin ks like kool aid, lemonade, or fruit drinks, sports drinks, like Gatorade, regular soda (not diet), water ? (Likert scale ranging from Less than once a week to 4 or more times per day, Sum Score Range 0 24; the higher the score, the greater the frequency of modeling poor beverage choices by parents); (3) Observational Learning following question: During a typical week, how often have you or another member of your household: Encourage d this child to do physical activities or played sports, Done a physical activity or played sports with this child, watched this child participate in physical activities or sports, Told the child that they are doing well in physical activities or sports, E ncouraged this child to watch less TV, Limited the amount of TV this child watches ? (Likert scale ranging from Not at all to Every day, Sum Score Range 0 18; the higher the score, the greater the modeling of physical activity behaviors by the family); (4 )

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29 Observational Learning Parent Physical Activity, measured using the following question : During the past month, other than your regular job, did you participate in any physical activity such as running, walking, weight lifting, golf, or gardening for ex ercise ? (Yes or No); (5) Observational Learning alpha = .701), measured using the following two questions: On one average weekday, how many hours do you spend watching TV/Videos/DVDs or using the computer at home ? ( Range 0 to 6 or more hours); On one average weekend, how many hours do you spend watching TV/Videos/DVDs or using the computer at home ? (Range 0 to 8 or more hours; Sum Score Range 0 14; the higher the score, the greater the modeling of sedentary behavio rs by parents); and (6) Observational Learning Negative Talk / In the past month, how often have you or y our spouse/partner: Made a comment to this child about their weight, Enc ouraged this child to diet in order to lose weight, Complained about your appearance in front of your children, Complained about your weight in front of your children, Talked about wanting to lose weight in front of your children, Gone on a diet, Made comm ? (Likert scale ranging from Not at all to Every day, Sum Score Range 0 21; the higher the score, the greater the modeling of negative talk / behaviors by the parents; See Appendix A, Table 3, for more detail). Student Survey For this study, survey questions for the 6 th grade students were adapted to assess child perceptions of parental modeling behaviors and home environment as well as child behaviors (See Appendix A, Table 4). Child Report of Observational Learning was divided into three sub constructs including: (1) Child Report of Observational Learning

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30 alpha = .814), measured using the following question: During a typical week, how often are the following true : My parents/guardians try to get me to eat more fruit, My parents/guardians try to get me to eat more vegetables, My parents/guardians try to get me to drink less soda, My parents/guardians try to get me to drink water instead of soda ? (L ikert scale ranging from Not at all to Every day, Sum Score Range 0 12; the higher the score, the greater the child report of modeling of nutrition behaviors by the family); (2) Child Report of Observational Learning Family Physical Activity (Chronbach During a typical week, how often has a member of your household: Encouraged you to do physical activities or played sports, Done a physical activity or played sports with you, watched you participate in physical activities or sports, Told you that they are doing well in physical activities or sports, Encouraged you to watch less TV, Limited the amount of time you can watch TV ? (Likert scale ranging from Not at all to Every day, Sum Score Range 0 18; the higher the score, the greater the child report of modeling of physical activity behaviors by the family); and (3) Child Report of Observational Learning question: In the past month, how often have your parents/guardians: Made a comment to you about your weight that made you feel bad, Encouraged you to diet in order to lose weight, Complained about how they look, Complained about their weight Talked about wanting to lo ? (Likert scale ranging from Not at all to Every day, Sum Score Range 0 21; the higher the score, the greater the child report of modeling of negative talk / behaviors by the parents; Se e Appendix A, Table 5, for more detail). Child Report of Environmental Determinants of behavior (i.e. Facilitation) was further divided into two sub constructs: (1) Child Report of Facilitation of Nutrition

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31 ), measured using the fol lowing three questions: During a typical week, how often are the following true: My parents/guardians buy fruit or vegetables they know I like (Likert scale ranging from Not at all to Every day); How often are the following true: We hav e soda in my home, W ater is available in my home, In my home, vegetables are served at meals, In my home, fruit is served for dessert, In my home, there is fruit to have as a snack, In my home, there are vegetables available to have as a snack, In my home, there are cut up ve getables in the fridge for me to eat, In my home there are fresh fruit on the counter, table, or somewhere else I can easily get them ? (Likert scale ranging from Hardly ever to Almost always); During the past week, how many times did all or most of your fa mily living in your house eat a meal together ? (Range Never to 7 or more times; Sum Score Range 0 34; the higher the score, the greater the child report of facilitation of positive nutrition behaviors in the home); and (2) Child Report of Facilitation of Physical Activity, measured using the following question: During a typical week, how often has a member of your household provided transportation to a place where you can do physical activity or sports ? (Likert scale ranging from Not at all to Ever day, R ange 0 3; the higher the score, the greater the child report of facilitation of physical activity behaviors; See Appendix A, Table 5, for more detail). Child Behaviors were divided into five sub categories including: (1) Nutrition 64), measured using the following question: Check the answer that best describes you: I eat fruit for dessert, I eat vegetables at dinner, I eat fruit for a snack, I eat cut thirsty ? (Liker t scale ranging from Hardly ever to Almost always, Sum Score Range 0 15; the higher the score, the great the child positive nutrition behaviors); (2) Physical Activity, measured using the following question : During the past 7 days, on how many

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32 days were you physically active for a total of at least 60 minutes ? (Range 0 7); (3) Nutrition question: Over the past week, how often did you drink Sweetened drinks like kool aid, lemonade, or f ruit drinks, sports drinks, like Gatorade, regular soda (not diet), water ? (Likert scale ranging from Less than once a week to 4 or more times per day, Sum Score Range 0 24; the higher the score, the greater the frequency of modeling poor beverage choice s by the child); (4) measured using the following two questions: On one average weekday, how many hours do you spend watching TV/Videos/DVDs or playing computer or video games ? (Range 0 to 6 or more hours); On one average weekend, how many hours do you spend watching TV/Videos/DVDs or playing computer or video games ? (Range 0 to 8 or more hours; Sum Score Range 0 14; the higher the score, the greater the child sedentary behaviors); and (5) Weight Control Beha using the following question: Have you done any of the following to lose weight or keep from gaining weight: Ate more fruits and vegetables, Exercised more, Skipped breakfast, Ate less high fat foods, Skipped meal s other than breakfast, Took diet pills, Ate very little food for a day or more, Ate less sweets ? (Yes or No, Sum Score Range 0 8; the higher the score, the greater the number of child weight control behaviors; See Appendix A, Table 5, for more detail). Analysis Survey data was analyzed using the Statistical Package for the Social Sciences (SPSS) version 17. Descriptive statistics were calculated for demographics, survey ht status category according to parent, delivery method of BMI letter, parent receipt of the letter, parent reading the letter, parental preference for a yearly BMI letter, actions taken

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33 by parents after receiving the BMI letter, and comfort of the child w hen parent shared the BMI information with them. Reliability analyses were conducted for SCT sub constructs and child behavior themes (See Appendix A, Table 3 and Table 5 respectively). The following outlines the statistical test(s) used to answer each res earch question. An alpha level of .05 was used to determine significance. Research Question 1. Does method of delivery of the BMI Health Report Card Letter (mail vs. backpack) impact parental acknowledgement of receipt of the letter and furthermore whether or not the parent reads the letter? The chi square test of significance was used to answer this question. Research Question 2. After reading the BMI Health Report Card L etter, are there differences between parents of children of nts of children that including: a) seeking professional help; b) food restriction ; and c) physical activity? The chi square test of significance was used to answ er this question. The following actions were not reported by any parents and were therefore omitted prior to analysis: Seen a school nurse, gone to a weight loss clinic, given diet pills or herbal supplements. Research Question 3. Do the psychosocial det erminants of behavior (outcome expectations and outcome expectancy), environmental determinants of behavior (facilitation) and modeling behaviors (observational learning) differ among parents who read the BMI Health Report Card Letter vs. parents who did n ot read the BMI Health Report Card Letter? Independent samples t tests and the chi square test of significance was used to answer this question. Research Question 4. Among parents who read the BMI Health Report Cad Letter do the psychosocial determinants o f behavior (outcome expectations and outcome expectancy), environmental determinants of behavior (facilitation) and

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34 Independent samples t tests and the chi square test of significance was used to answer this question. Research Question 5. Do the parental psychosocial determinants of behavior (outcome expectations and outcome expectancies) relate to the parental environmental determinants of be havior (facilitation) and parental modeling behaviors (observational learning)? The Pearson Product Moment Correlation Coefficient was used to answer this question. Research Question 6. Does the chil built environment (home)? Paired samples T tests were used to answer this question. Research Question 7. Do parent report ed environmental determinants of behavior (facilitation) and modeling behaviors (observational learning) relate to child reported behaviors (Nutrition, Physical Activity, Sedentary and Weight Control Behaviors). The Pearson Product Moment Correlation Coeff icient was used to answer this question.

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35 Chapter IV Results The following presents the results for the current study. Descriptive statistics are reported first, followed by the analysis results for each research question. Results tables can be found i n Appendix J. Participants Seventy Six (n=76) parent surveys were returned for a return rate of 22%. Of those, 67 had a child who completed a survey as part of the larger study. These students and parents (n=67) were included as child/parent dyads for ce rtain analyses. Not all participants responded to every question. In addition, if the parent responded that they did not receive the letter or did not read the letter, they were instructed to skip certain questions. Therefore, not all results have the same n value. Parent participant characteristics are depicted in Table 6. The mother of the household returned a majority of the surveys (88%). A high percentage of participants (81.6%) had completed at least some college. More than half (65.8%) of the partic ipants were employed full time or part time. The majority of participants were white (76.9%), followed by Black / African American (15.4%) and Asian (7.7%). Twenty percent identified themselves as Hispanic / Latino ethnicity. Demographic data representing the students of parent participants are depicted in Table 7. Approximately 45% of these students were male while approximately 55% were female. Child Weight Status Category based on BMI fall in line with national statistics and were as follows: 1.3 % of p articipants were categorized as underweight,

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36 69.7% of participants were categorized as normal weight, 17.1% of participants were categorized as at risk of overweight and 11.8% of participants were categorized as overweight. Comparatively, parent reports of Child Weight Status Category were as follows: 1.3% of parents categorized their child as underweight, 78.9% of parents categorized their child as normal weight, 14.5% of parents categorized their child as at risk of overweight, and 5.3% of parents categor ized their child as overweight. The followed by 31.6% being somewhat concerned and 15.8% very concerned. Descriptive Data Delivery method of BMI letters was fair ly evenly distributed among parents who returned a survey, with 52.6% (n = 40) having their letter sent by mail and 47.4% (n= 36) having their letter sent home in the backpack. Table 8 presents frequency data for selected participant responses. When asked if they actually received the BMI letter, 77.6% of respondents acknowledged receiving the letter, 15.8% reported that they did not receive the letter and 6.6% were not sure if they received the letter. Of those who reported receiving the letter, 79.5% sai d they read the letter, 19.2% did not read the letter and 1.4% were not sure if they had read the letter. The majority of participants (75.3%) said they would like to receive a BMI letter on a yearly basis. Of the parents who read the letter, 79.3% report ed discussing the letter with their child. Nearly half of parents (47.8%) reported that their child was very uncomfortable when discussing this information, 19.6% were somewhat uncomfortable and 32.6% were not at all uncomfortable. Parents who read the l etter were also asked about their actions following receipt

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37 presents post letter weight control actions. The highest reported action was increasing (12.3%). Other actions included putting their child on a diet (10.5%), seeing a healt h care provider (8.8%), having their child skip meals or snacks (7%) and seeing a weight specialist / nutritionist (1.8%). No parents reported seeing a school nurse, taking their child to a weight loss clinic or having their child take diet pills or herbal supplements. Research Questions Research Question 1. Does method of delivery of the BMI Health Report Card Letter (mail vs. backpack) impact parental acknowledgement of receipt of the letter and furthermore whether or not the parent reads the letter? Hy pothesis 1a : The number of parents who acknowledge receipt of the BMI Health Report Card L etter sent by mail is not equal to the number of parents who acknowledge receipt of the BMI Health Report Card L etter sent in the backpack. Of the 40 parents who were sent the letter in the mail, 38 acknowledged receiving the letter and 2 responded that they did not receive the letter. On the other acknowledged receiving the letter, 10 respo nded that they did not receive the letter and 5 were not sure if they received the letter. Results indicate a statistically significant difference between delivery methods (mail vs. backpack, p = .001) as a greater number parents who were sent the letter i 2 (2, n = 76) = 15.063 (Table 8). Hypothesis 1b : The number of parents who read the BMI Health Report Card L etter sent by mail is not equal to the number of parents who read the BMI letter sent in the backpack.

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38 O f the 40 parents who were sent the letter in the mail, 37 read the letter and 3 did not read the letter. On the other hand, of the 36 parents who were sent the letter in their and 3 did not answer. Results indicate a statistically signific ant difference between delivery methods (mail vs. backpack, p = .005) as a greater number parents who were sent the 2 (3, n = 76) = 12.810 (Table 8). R ese arch Que stion 2. After reading the BMI Health Report Card L etter, are there including: a) seeking professional help; b) food restrictio n; and c) physical activity? Hypothesis 2a Fifty Seven parents responded to the question concerning post letter weight control actions. Of the 41 parents of chi Results indicate no statistically signif 2 (1, n = 57) = 1.597 (Table 10) Hypothesis 2 b

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39 took one or restriction. with a greater number of p to 2 (1, n = 57) = 7.885 (Table 10) Hypothesis 2c increased physical activity. Results indicate a statistically significant difference between greater number of parents of children taking one or more action 2 (1, n = 57) = 14.224 (Tab le 10) Research Question 3. Do the psychosocial determinants of behavior (outcome expectations and outcome expectancy), environmental determinants of behavior (facilitation) and modeling behaviors (observational learning) diff er among parents who

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40 read the BMI Health Report Card L etter vs parents who did not read the BMI Health Report Card L etter? Hypothesis 3a : The mean sum score for perceived importance of child physical activity beh aviors of parents who read the BMI Health Report Card L etter is not equ al to the mean sum score for perceived importance of child physical activity behaviors o f parents who did not read the BMI Health Report Card Le tter. Parents who read the letter had a mean sum score of 5.09 for perceived importance of child physical activi ty, whereas parents who did not read the letter had a mean sum score of 4.93. The possible sum score range was 0 6. Results indicate no statistically significant difference between those who read the letter and did not read the letter (p = .647) in regar ds to perceived importance of child physical activity (Table 11). Hypothesis 3b : The mean sum score for perceived importance of child nutrition beh aviors of parents who read the BMI Health Report Card L etter is not equal to the mean sum score for perceived importance of child nutrition behaviors o f parents who did not read the BMI Health Report Card L etter. Parents who read the letter had a mean sum score of 8.21 for perceived importance of child nutrition behaviors, whereas parents who did not read the let ter had a mean sum score of 7.86. The possible sum score range was 0 9. Results indicate no statistically significant difference between those who read the letter and did not read the letter (p = .468) in regards to perceived importance of child nutritio n behaviors (Table 11). Hypothesis 3c parents who read the BMI Health Report Card L etter is not equal to the mean sum score ad the BMI Health Report Card L etter.

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41 Parents who read the letter had a mean score of .71 for parental concern about The possible score range was 0 3. Results indicate no statistically significant difference between those who read the letter and did not read the letter (p = .230) in Hypothesis 3d : The mean sum score for facilitation of nutrition of parents who read the BMI Health Report Card L etter is not equal to the mean sum score for facilitation of nutrition o f parents who did not read the BMI Health Report Card L etter. Parents who read the letter had a mean sum score of 24.39 for facilitation of nutrition, whereas parents who did not read the letter had a mean sum score of 24.57. The possible sum score range was 0 34. Results indicate no statistically significant difference between those who read the letter and did not read the letter (p = .894) in regards to facilitation of nutrition scores (Table 12). Hypothesis 3e : The mean sum score for facilitation of physical activity of parents who read the BMI Health Report Card L etter is not equal to the mean sum score for facilitation of physical activity of paren ts who did not read the BMI Health Report Card L etter. Parents who read the letter had a mean sum score of 1.36 for facilitation of physical activity, whereas parents who did not read the letter had a mean sum score of 1.38. The possible sum score range wa s 0 3. Results indicate no statistically significant difference between those who read the letter and did not read the letter (p = .901) in regards to facilitation of physical activity scores (Table 12). Hypothesis 3f : The mean sum score for observationa l learning family nut rition of parents who read the BMI Health Report Card L etter is not equal to the mean sum score

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42 for observational learning family nutrition of parents who did not read the BMI Health Report Card L etter. Parents who read the letter had a mean sum score of 7.64 for observational learning family nutrition, whereas parents who did not read the letter had a mean sum score of 7.29. The possible sum score range was 0 12. Results indicate no statistically significant difference between those who read the letter and did not read the letter (p = .685) in regards to observational learning family nutrition scores (Table 13). Hypothesis 3g : The mean sum score for observational learning parent nutrition beverages of parents who read the BM I Health Report Card L etter is not equal to the mean sum score for observational learning parent nutrition beverages of parents who did not read the BMI Health Report Card L etter. Parents who read the letter had a mean sum score of 3.59 for observational learning parent nutrition beverages, whereas parents who did not read the letter had a mean sum score of 2.36. The possible sum score range was 0 24. Results indicate no statistically significant difference between those who read the letter and did no t read the letter (p = .124) in regards to observational learning parent nutrition beverage scores (Table 13). Hypothesis 3h : The mean sum score for observational learning family physical activity of parents who read the BMI Health Report Card L etter i s not equal to the mean sum score for observational learning family physical activity of parents who did not read the BMI Health Report Card L etter. Parents who read the letter had a mean sum score of 8.98 for observational learning family physical act ivity, whereas parents who did not read the letter had a mean sum score of 9.86. The possible sum score range was 0 18. Results indicate no statistically significant difference between those who read the letter and did not read the

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43 letter (p = .304) in r egards to observational learning family physical activity scores (Table 13). Hypothesis 3i : The mean sum score for observational learning parent sedentary behaviors of parents who read the BMI Health Report Card L etter is not equal to the mean sum scor e for observational learning parent sedentary behavior o f parents who did not read the BMI Health Report Card L etter. Parents who read the letter had a mean sum score of 7.62 for observational learning parent sedentary behaviors, whereas parents who di d not read the letter had a mean sum score of 6.86. The possible sum score range was 0 14. Results indicate no statistically significant difference between those who read the letter and did not read the letter (p = .461) in regards to observational learn ing parent sedentary behavior scores (Table 13). Hypothesis 3j : The mean sum score for observational learning negative behaviors of parents who read the BMI Health Report Card L etter is not equal to the mean sum score for observational learning negat ive behaviors of parents who did not read the BMI Health Report Card L etter. Parents who read the letter had a mean sum score of 5.57 for observational learning negative talk / behaviors, whereas parents who did not read the letter had a mean sum score o f 5.50. The possible sum score range was 0 21. Results indicate no statistically significant difference between those who read the letter and did not read the letter (p = .963) in regards to observational learning negative behavior scores (Table 13). H ypothesis 3k : The number of parents who read the BMI Health Report Card L etter and model ed physical activity behaviors is not equal to the number of parent s who did not read the BMI Health Report Card L etter and model ed physical activity behaviors.

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44 Of the 58 parents who read the letter, 48 modeled physical activity and 10 did not. Of the 14 parents who did not read the letter, none of the 14 modeled physical activity. Results indicate no statistically significant difference between those who read the letter and did not read the letter (p = .094) in regards to parental modeling of physical 2 (1, n = 72) = .094 (Table 14). Research Question 4. Among parents who read the BMI Health Report Card L etter do the psychosocial determinants of behavior (outco me expectations and outcome expectancy), environmental determinants of behavior (facilitation) and modeling behaviors (observational learning) differ between parents of children of compared to parents of children ? Hypothesis 4a : The mean sum score for perceived importance of child physical activity behaviors of parents of children of normal weight is not equal to the mean sum score for perceived importance of child physical activity behaviors of paren ts of children ean sum score of 4.63. The possible sum score range was 0 perceived importance of child physi cal activity (Table 15). Hypothesis 4b : The mean sum score for perceived importance of child nutrition behaviors of parents of children of is not equal to the mean sum score for perceived importance of child nutrition behaviors of parents o f children

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45 an sum score of 7.63. The possible sum score range was 0 igher scores for perceived importance of child nutrition behaviors (Table 15). Hypothesis 4c parents of children of is not equal to the mean sum score for parental concern abo 3. ove 15). Hypothesis 4d : The mean sum score for facilitation of nutrition of parents of children of is not equal to the mean sum score for facilitation of nutri tion of parents of children score of 23.80. The possible sum score range was 0 34.

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46 scores (Table 16 ). Hypothesis 4e : The mean sum score for facilitation of physical activity of parents of children of is not equal to the mean sum score for facilitation of physical activity of parents of children Pa 3. Results i activity scores (Table 16). Hypothesis 4f : The mean sum score for observational lea rning f amily nutrition of parents of children of is not equal to the mean sum score for observational learning family nutrition of parents of score of 7.63 for observational learning range was 0 12. Results indicate no statistically significant diffe observational learning family nutrition scores (Table 17). Hypothesis 4g : The mean sum score for observational learning parental nutrition beverag es of parents of children of is not equal to the mean sum score for observational learning parental nutrition beverages of parents of children

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47 score of 3.56 for observational learning family parent nutrition beverages, whereas parents of the possible sum score range was 0 24. Results indicate no statistically s ignificant = .832) in regards to observational learning parent nutrition beverage scores (Table 17). Hypothesis 4h : The mean sum score for observational learning f amily physical activity of parents of children of is not equal to the mean sum score for observational learning family physical activity of parents of children observational learning range was 0 18. Results indicate no statist observational learning family physical activity scores (Table 17). Hypothesis 4i : The mean sum score for observational learn ing parent sedentary behaviors of parents of children of is not equal to the mean sum score for observational learning parent sedentary behavior of parents of children observational learning score range was 0 14. Results indicate no statistically significant difference between

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48 to observational learning parent sedentary behavior scores (Table 17). Hypothesis 4j : The mean sum score for observa tional learning negative talk / behaviors of parents of children of is not equal to the mean sum score for observational learning negative talk / behaviors of parents of children Parents of child observational learning score range was 0 21. Resul ts indicate a statistically significant difference between negative talk / behavior scores (Table 17). Hypothesis 4k : The number of parents of children of model ed physical activity behaviors is not equal to the number of parent at risk of overweight overweight model ed physical activity behaviors. modeled physical activity and 1 did not. Results indicate no statistically s ignificant = .161) in regards to parental modeling of physical activity 2 (1, n = 57) = .161 (Table 18). Research Question 5. Do the parental psychosocial determinants of behavior (outcome expectations and outcome expectancies) relate to the environmental determinants of behavior (facilitation) and modeling behaviors (observa tional learning)?

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49 Hypothesis 5a : The sum score for perceived importance of child nutrition behaviors positively correlates with the sum score for facilitation of nutrition Scores for perceived importance of child nutrition behaviors were positively corre lated with facilitation of nutrition scores (r = .404). In other words, facilitation of nutrition scores increased as perceived importance of child nutrition behaviors scores increased. Results indicate a statistically significant relationship (p < .001; T able 19) Hypothesis 5b : The sum score for perceived importance of child physical activity behaviors positively correlates with the sum score for facilitation of physical activity Scores for perceived importance of child physical activity were positively correlated with facilitation of physical activity scores (r = .012). However, r esults indicate no statistically significant relationship (p = .917 ; Table 19 ). Hypothesis 5c : The sum score for perceived importance of child nutrition behaviors positively co rrelates with the sum score for observational learning family nutrition. Scores for perceived importance of child nutrition behaviors were positively correlated with observational learning family nutrition scores (r = .265). In other words, observation al learning family nutrition scores increased as perceived importance of child nutrition behaviors scores increased. Results indicate a statistically significant relationship ( p = .023; Table 19 ). Hypothesis 5d : The sum score for perceived importance of child nutrition behaviors negatively correlates with observational learning parent nutrition beverages. Scores for perceived importance of child nutrition behaviors were negatively correlated with observational learning parent nutrition beverage score s (r = .082). However, r esults indicate no statistically significant relationship (p = .479 ; Table 19 ).

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50 Hypothesis 5e : The sum score for perceived importance of child physical activity behaviors positively correlates with observational learning family p hysical activity. Scores for perceived importance of child physical activity were positively correlated with observational learning family physical activity scores (r = .229). In other words, observational learning family physical activity scores incre ased as perceived importance of child physical activity scores increased. Results indicate a statistically significant relationship (p = .047 ; Table 19 ). Hypothesis 5f : The sum score for perceived importance of child physical activity behaviors negatively correlates with observational learning parent sedentary behaviors. Scores for perceived importance of child physical activity were negatively correlated with observational learning parent sedentary behavior scores (r = .112). However, r esults indicate no statistically significant relationship (p = .337 ; Table 19 ). Hypothesis 5g the sum score for facilitation of nutrition Scores for p were positively c orrelate d with facilitation of nutrition scores (r = .024). However, r esults indicate no statistically significant relationship (p = .840 ; Table 19 ). Hypothesis 5h the sum score for facilita tion of physical activity Scores for p were positively correlate d with facilitation of physical activity scores (r = .038). However, r esults indicate no statistically significant relationship (p = .745 ; Table 19 ). Hypot hesis 5i sum score for observational learning family nutrition.

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51 Scores for p were positively correlate d with observational learning family nutrition scores (r = .346). In other words, observational learning increased. Results indicate a statistically significant relationship (p = .003 ; Table 19 ). Hypothesis 5j : Parental conce observational learning parent nutrition beverages. Scores for p were positively correlate d with observational learning parent nutrition beverage scores (r = .225). However, r esults indicate no statistically significant relationship (p = .050 ; Table 19 ). Hypothesis 5k observational learning family physical activity. Scores for p arental concern about c were positively correlate d with observational learning family physical activity scores (r = .104). However, r esults indicate no statistically significant relationship (p = .372; Table 19) Hypothesis 5l t negatively correlates with observational learning parent sedentary behaviors. Scores for p arental concern correlate d observational learning parent sedentary behavior scores (r = .123). However, r esults indicate n o statistically significant relationship (p = .290 ; Table 19 ). Hypothesis 5m observational learning negative behaviors. Scores for p were positively cor relate d observational learning negative behavior scores (r = .199). However, r esults indicate no statistically significant relationship (p = .094 ; Table 19 ).

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52 built environment built environment (home)? Hypothesis 6a family family nutrition. Parents had a mean sum score of 7.72 for observational learning family nutrition, whereas children had a mean sum score of 6.95. The possible sum score range was 0 12. Results indicate no statistically significant difference betwee n parent and child report (p = .161) in regards to observational learning family nutrition scores (Table 20). Hypothesis 6b family bservational learning family physical activity. Parents had a mean sum score of 9.28 for observational learning family physical activity, whereas children had a mean sum score of 9.29. The possible sum score range was 0 18. Results indicate no statist ically significant difference between parent and child report (p = .978) in regards to observational learning family physical activity scores (Table 20). Hypothesis 6c negative talk / behaviors wi learning negative talk / behaviors. Parents had a mean sum score of 5.28 for observational learning negative behavior, whereas children had a mean sum score of 5.30. The possible sum score range was 0 21. Results indicate no statistically significant difference between parent

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53 and child report (p = .977) in regards to observational learning negative behavior scores (Table 20). Hypothesis 6d facilitation of nutr ition will not facilitation of nutrition Parents had a mean sum score of 24.63 for facilitation of nutrition, whereas children had a mean sum score of 23.29. The possible sum score range was 0 34. Results indicate no statistically significant difference between parent and child report (p = .099) in regards to facilitation of nutrition (Table 21). Hypothesis 6e facilitation of physical activity for facilitation of physical activity Parents had a mean sum score of 1.37 for facilitation of physical activity, whereas children had a mean sum score of 1.40. The possible sum score range was 0 3. Results indicate no statistically significant differen ce between parent and child report (p = .829) in regards to facilitation of physical activity scores (Table 21). Research Question 7. Do parent reported environmental determinants of behavior (facilitation) and modeling behaviors (observational learning) r elate to child reported behaviors (Nutrition, Physical Activity, Sedentary and Weight Control Behaviors). Hypothesis 7a : The sum score for facilitation of nutrition positively correlates with the sum score for child nutrition behaviors. Parent scores for facilitation of nutrition were negatively correlated with child nutrition behavior scores (r = .391). In other words, child nutrition behavior scores decreased as parent scores for facilitation of nutrition increased. Results indicate a statistically sign ificant relationship (p = .002; Table 22).

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54 Hypothesis 7b : The sum score for facilitation of physical activity positively correlates with the sum score for child physical activity behaviors. Parent scores for facilitation of physical activity were positivel y correlated with child physical activity behavior scores (r = .195). However, r esults indicate no statistically significant relationship (p = .117 ; Table 22 ). Hypothesis 7c : The sum score for observational learning family nutrition positively correlates with the sum score for child nutrition behaviors. Parent scores for observational learning family nutrition were negatively correlated with child nutrition behavior scores (r = .013). However, r esults indicate no statistically significant relationship (p = .918 ; Table 22 ). Hypothesis 7d : The sum score for observational learning parent nutrition beverages positively correlates with the sum score for child nutrition beverages. Parent scores for observational learning parent nutrition beverages were po sitively correlated with child nutrition beverage scores (r = .087). However, r esults indicate no statistically significant relationship (p = .498 ; Table 22 ). Hypothesis 7e : The sum score for observational learning family physical activity positively cor relates with the sum score for child physical activity behaviors. Parent scores for observational learning family physical activity were positively correlated with child physical activity scores (r = .097). However, r esults indicate no statistically sign ificant relationship (p = .433 ; Table 22 ). Hypothesis 7f : The sum score for observational learning parent sedentary behavior positively correlates with the sum score for child sedentary behavior. Parent scores for observational learning sedentary behav ior were positively correlated with child sedentary behavior scores (r = .163). However, r esults indicate no statistically significant relationship (p = .181 ; Table 22 )

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55 Hypothesis 7g : The sum score for observational learning negative talk / behaviors ne gatively correlates with the sum score for child nutrition behaviors. Parent scores for observational learning negative talk / behavior were positively correlated with child nutrition behavior scores (r = .120). However, r esults indicate no statistically significant relationship (p = .359 ; Table 22 ) Hypothesis 7h : The sum score for observational learning negative talk / behaviors negatively correlates with the sum score for child physical activity behaviors. Parent scores for observational learning n egative talk / behavior were negatively correlated with child physical activity behavior scores (r = .166). However, r esults indicate no statistically significant relationship (p = .190; Table 22) Hypothesis 7i : The sum score for observational learning negative talk / behaviors positively correlates with the sum score for child nutrition beverages. Parent scores for observational learning negative talk / behavior were positively correlated with child nutrition beverage scores (r = .056). However, r esu lts indicate no stati stically significant relationship (p = .673; Table 22) Hypothesis 7j : The sum score for observational learning negative talk / behaviors positively correlates with the sum score for child sedentary behavior. Parent scores for observ ational learning negative talk / behavior were positively correlated with child sedentary behavior scores (r = .217). However, r esults indicate no statistically sign ificant relationship (p = .080; Table 22). Hypothesis 7k : The sum score for observational learning negative talk / behaviors positively correlates with the sum score for child weight control behaviors. Parent scores for observational learning negative talk / behavior were positively correlated with child weight control behavior scores (r = .120). However, r esults indicate no statistically significant relationship (p = .056; Table 22)

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56 Chapter V Discussion As discussed previously, s tates and local school districts across the US have mandated Body Mass Index (BMI) measurement programs wi thout the evidence to support their effectiveness in preventing and/or reducing further increases in childhood and adolescent obesity. Additionally, more research is needed with regard to the intended and u nintended effects of measuring BMI in the school setting as well as sharing the information with students and their parents. As such, the purpose of this study was to explore the psychosocial, environmental and behavioral effects of BMI Health Report Card Letters among 6 th grade students and their paren ts in one Hillsborough County middle school. More specifically, the Social Cognitive Theory served as the conceptual and theoretical framework to assist with assessing the effects of the BMI Letter with regard to parental behavior, home environment and ul timately child behavior. To my knowledge, this is the first theory based study to explore the impact of BMI Health Report Card. Generally speaking, the majority of the parental respondents (n = 57) reported reading the BMI letter; therefore the number of parent respondents who did not read the letter was small (n= 14). This made it somewhat difficult to compare these two groups. However, the overall sample was evenly distributed in regards to delivery method of the BMI Letter as well as child gender. In addition, the sample was fairly representative of the overall population of sixth grade students in regards to child BMI and race / ethnicity.

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57 The first area of inquiry was to assess if delivery method of the BMI Healthy Report Card Letters impacted whether parents received and read the letter. Study results indicate that delivery method of the BMI letter does impact whether or not the parent actually receives the letter and whether or not they read the letter. More specifically, a greater number of p arents who were sent the letter in the mail received the backpack. These results are similar to a study conducted by Johnson, Pilkington, Lamp, He & Deeb (2009), in w hich BMI letters were mailed to parents. A high percentage (70.8%) of the parents recalled receiving the letter and only two chose not to read the letter R esults of the current study indicate that by sending the letter in the backpack, fewer parents may a ctually receive and read the information. In addition, students have a greater opportunity to read the information without their parent(s), which could lead to unintended psychosocial impacts. A high percentage of parents reported reading the BMI letter and said they would like to receive a BMI letter on a yearly basis (79.5% and 75.3% respectively). This indicates that parents are receptive to receiving weight information for their children, highlighting the importance of providing the information in s uch a way that is beneficial to the parent and the child, without unintended consequences. A majority of the parents who read the letter (79.3%) discussed the information with their child; however, most (67.4%) indicated that their child was either very un comfortable or somewhat uncomfortable when discussing the contents of the letter. These findings support the work of Grimmett, Croker, Carnell & Wardle (2008) who also found that parents found it ver, there were parents and children who found it to be distressing, with older overweight children being most affected. They recommend that services be in place to assist families by providing

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58 advice and support. Additionally, it may be beneficial for BM I Health Report Card Letters to contain simple tips for parents on the best way to share this information with their children. Ikeda, et al. (2008) warn that obesity prevention and health promotion programs can actually harm one aspect of health while atte mpting to improve another. Therefore, parents should be encouraged to discuss the BMI screening results in terms of healthy growth, rather than focus on weight. The discussion should be positive and should avoid making the child feel bad about their weigh t or that there is something wrong with them. Parents can discuss feeling good about their body and taking pride in keeping their body healthy. This can shift the focus onto healthy lifestyle habits that the whole family can adopt rather than on the weight of the child. The second area of inquiry involved actions taken by parents after reading the BMI Health Report Card Letter. After reading the BMI letter, both parents of children of groups. To avoid unintended negative consequences, program planners should consider to control their may be unnecessary or potentially harmful, as discussed below. In terms of actions associated with seeking professional help, results indicate no sta family history. It is

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59 unintended consequence of the BMI letter. Ikeda et al. (2008) present the concern that as many children and adolescents place great importance on being thin. In fact, there is often a desire to be thinner even when their weight fa to focus on their weight rather than th eir health and positive body image. The child may relate seeing a professional as a negative experience and that something is wrong with research that adolescent perception s of body weight may be more important than actual weight or BMI. Additionally, the results of the current study indicate statistically significant terms of actions t and physical activity. Johnson, et al. (2009), Grimmett, et al. (2008) & Chomitz, et al. (2003) also reported that parents of overweight children were more likely to initiate action associated with food restriction as well as physical activity. While increasing physical activity can be a positive behavior change, food restriction, in the form of dieting or having a child skip meals or snacks is not a recommended method for w eight management in children (Ikeda, et al. 2008) and could also be considered a negative

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60 unintended consequence of the BMI letter. This is especially alarming considering that diet or having them skip meals or snacks. Regardless of weight status, parents should emphasize healthy eating behaviors, such as increased intake of fruits, vegetables, whole grains and low fat dairy, rather than food restriction or dieting. Ikeda et al. (2008) warn of this as a possible harm of BMI screening, due to the fact that caloric restriction before puberty can stunt growth and/or lead to behavioral problems such as sneaking food, hiding food and overeating. Additionally, it can lead to teenagers viewing dieting as an effective means to control weight, even though dieting has been shown to increase the risk of overweight and obesity (Ikeda, et al.). The third area of inquiry involved applying the Social Cognitive Theory to further explore the effec ts of the BMI Health Report Card Letter with regard to its influence on the behavior and modeling behaviors in the home, and ultimately dietary and physic al activity behaviors. Results of this study provide information regarding the relationship between the person, behavior and environment that is central to SCT. For example, parents who perceived healthy eating as important, also reported creating a home e nvironment conducive to healthy eating and encouraged their child to encouraged their child to eat a healthy diet. In regards to physical activity, parents who perc eived physical activity behaviors to be important for their child, also reported one or more family member encouraging their child to do physical activities, play sports and hing, participating or providing positive feedback.

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61 More specifically, with regard to the Social Cognitive Theory constructs that were assessed, no difference was found pertaining to outcome expectations, outcome expectancies, facilitation and observatio nal learning between parents who read the letter and did not read the letter. However, among parents who did read the letter, study onstructs. as eating a healthy diet with fruits and vegetables daily and limiting soda consumption to It there is an important relationship between healthy nutrition behaviors and maintaining a healthy weight, and therefore support these behaviors an d facilitate them in the home. Conversely, consequences of childhood overweight, however, there may be a disconnect in linking child healthy behaviors to healthy weight. tively about their own weight, their Observing these negative ideas and behaviors associated w ith weight adds to the difficulty that children impacts. Psychosocial impacts may include negative stereotypes of overweight individuals, body image dissatisfaction, poor self esteem and/or the adoption of unhealthy weight loss behaviors (Gibbs, et al., 2007).

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62 Furthermore, results indicate no statistically significant difference between the and (home). The survey used in the current study was adapted from one used by Haines, et al. (2008) who found that child and parent report was significantly different for what was categorized as observational learning negative talk / behaviors in the current study. One possible explanation for the discrepancy in results is the difference in sample characteristics. Participants in the Haines et. al study had a higher perc entage of girls, younger child participants and a primarily African American sample as compared to the current study. With regard to the determinants of behavior and modeling behaviors in the h ome ultimately influencing the behaviors, evidence from the current study is inconclusive. Parents who reported eating family meals often and greater availability of fruits, vegetables and water in the home, had children who reported low levels of positive nutrition behaviors. We do not have enough information to postulate the reason for this finding; however, it does not seem unrealistic for adolescents to behave in such a way that is unmatched to what parents are attempting to facilitate in the ho me. In addition, based on the study design, child and parent surveys were filled out relatively at the same period in time. Because home environment and modeling behavior s was based on what was true at the time of survey administration. It is not known if this represented a recent change. Therefore, it is possible that changes were made based on the letter and there was not a long enough time span for parent facilitation and modeling to impact child behavior at the time of the survey. It is also worth mentioning that children of parents who reported speaking

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63 dieting or encouraging t heir child to diet reported greater weight control behavior Child weight control behaviors include skipping meals, eating very little food for a day or more, taking diet pills, increased exercise and dieting behaviors such as eating less sweets or high fa t foods and eating more fruits and vegetables. This relationship did approach statistical significance, indicating that negative parental modeling may be increasing negative child behaviors associated with weight control. Limitations There are limitatio ns to every study and research design. In particular, working with a school district presents unique challenges. Based on school willingness to participate and study resources, participants were selected from only one school and one grade in a very large and diverse district. Additionally, based on the study design, there were several threats to internal validity. Participation was voluntary; therefore selection bias could influence the characteristics of the sample and their responses, limiting the abilit y to generalize outside of this population (Posavac & Carey, 2007). School administrators were concerned with placing additional burden on teachers by asking them to administer a survey during class time. As a result, data was collected post BMI measuremen t only rather than a pre post test design. This limited ability to determine if the BMI Health Report Card Letters impacted the reported behaviors or if there were other plausible influences. Furthermore, parent and child surveys were completed within the same period of time soon after parents received the BMI Letters. If parents made changes as a result of the BMI Letter, there may not have been enough time to capture if these changes ultimately influenced child behavior. In addition, there was a lower r esponse rate than expected. In particular, a high percentage of respondents reported reading the BMI letter, which resulted in a small

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64 group of parent respondents who reported not reading the letter (n = 14). This presented challenges and limited the abili ty to compare these two groups. The small sample size reduced power and may have limited variability of survey responses. Furthermore, with the large number of analyses and comparisons that were used to answer the research questions, a Bonferroni correctio n would have lessened the possibility of type 1 error or rejecting a true null hypothesis (Blair & Taylor, 2008). However, with the small sample size this was not realistic. Lastly, parental and student survey responses may have been influenced by social desirability bias (Posavac & Carey, 2007). Participants may have responded how they thought they were supposed to rather than indicate what is actually occurring. In addition, responses are limited to those provided on the survey, therefore it is not poss ible to gather additional information from participants to further explain their responses, which could provide richer data to better explain the impact of BMI Health Report Cards. Conclusion Based on the results of the current study, there are valuable i mplications for school personnel who are considering both the value and method of sending BMI information to parents. Ikeda et al. (2008) suggest that the goal of all obesity prevention programs should be to improve total health, while doing no harm, not just doing as little harm as possible. To achieve this, careful consideration must be taken before providing BMI information to parents. Information without proper tools and resources for follow up may leave parents unsure of how to act and therefore limi t the ability of such a program to elicit valuable outcomes toward improving the childhood obesity epidemic. A key finding of the current study was that delivery method, specifically mailing BMI information, may be critical to the success of BMI measureme nt programs as well

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65 as critical to minimizing the possible negative effects. Schools that wish to provide BMI information to parents should make it a priority to mail BMI Letters to parents to ensure receipt, confidentiality and facilitate reading of the l etter. Parents within this sample were receptive to receiving BMI information from the school. However, based on the fact that a high percentage of parents reported that their child experienced discomfort while discussing the information, they may need add itional information, skills, and resources to increase their capacity to share and discuss the information with their child. It is important to realize that parents may not know the best way to approach speaking to their child about something as sensitive as weight. Information should be provided on how to share the BMI information with their child in a way that is positive and comfortable. Furthermore, the BMI Health Report Card Letters want to take action, but be unaware of what to do. This can lead to unhealthy weight control behaviors, such as dieting or modeling of negative ta lk associated with being overweight as seen in the current study. One possible way to address these issues would be to provide parents with information about the BMI screening procedures in advance. This provides an opportunity to educate parents prior to Parents would most likely be more receptive to this information and less defensive than when the information is provided along with results of the screening. The school would have the opportunity to promote BMI screening as a way to assess healthy growth and screening in a positive manner. Parents may feel more prepared and better informed results. The advance information could provide

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66 information on how to facilitate a healthy lifestyle in the home as well as the importance weight status. Most impo rtantly, by providing the information separate from the screening results, it decreases the focus on the weight of the child hopefully encouraging healthy lifestyle behaviors from which the whole family can benefit. The results of the current study also sh owed some evidence that certain Social weight. Therefore, it may be beneficial to tailor the BMI Health Report Card Letters recommendations for healthy lifestyle behavior s to be encouraged and adopted in the home as well as encouragement to discuss the results with their child by focusing on letters could include more detailed informati on concerning (a) the link between good nutrition, physical activity and healthy weight; (b) the possible need for further assessment by a medical professional; and (c) the benefits of speaking positively about s could clearly state that no specific action is necessary so long as their child continues to have a healthy growth pattern. further assessment if the results of the curr ent screening represent a change in the and body image. Lastly, to assist schools with the above mentioned recommendations, state policy should include provisions for r esources and standards to ensure that schools are

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67 following procedures that are based on current research that is available regarding BMI screening. In addition, because current research remains unclear regarding the effectiveness of BMI screening programs to improve overall student weight status, policy initiatives should be aimed at providing provisions and resources for monitoring and evaluation of current BMI screening programs. These programs are being recommended and in many cases mandated without the evidence to support effectiveness, which could lead to a waste of scarce school health resources. Future Research Directions The results of this study add to the growing body of research on the topic of BMI Measurement programs in schools. Improvements t o the current study design could include pre post data collection and a larger, more diverse sample. Additionally, studies of larger scale are needed to gather long term and more robust data to adequately show the impact of BMI Health Report Card Letters. For example, BMI measurements are taken for multiple grades; therefore data needs to be collected from parents and students (when age appropriate) for all grade levels screened. In addition, collecting this data over time through a longitudinal study could help determine if the BMI letters can be distributed without causing harm as well as whether the process is effective at changing the home environment, improving child and family lifestyle behaviors and ultimately improving childhood and adolescent BMI st atus. BMI screening is a timely process that costs schools money; therefore, if it is either harmful or ineffective, the money and time should be redistributed to proven effective programs. Summary This study attempted to determine the psychosocial and behavioral effects of BMI Health Report Card Letters among 6 th grade students and their parents. Results indicate the importance of delivery method of BMI Health Report Card Letters as well as

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68 the occurrence of certain unintended negative consequences. Mo reover, differences were found for certain Social Cognitive Theory constructs between parents of children of Implications of the findings include the need for: (a) tailored in formation for parents based on child weight status; (b) policy initiatives that focus on state standards for BMI measurement procedures; and (c) resources for monitoring and evaluation of programs.

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69 References Barlow, S., and the Expert Committee. (2007). Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report [Electronic version]. Pediatrics 120, S164 S192. Blair, R.C., & Taylor, R.A. (2008) Biostatistics f or the Health Sciences (p. 285). Upper Saddle River, NJ: Pearson Prentice Hall. Blass, E.M. (2003). Biological and environmental determinants of childhood obesity [Electronic version]. Nutr Clin Care, 6,13 19. Boutelle, K.N., Lytle, L.A., Murray, D.M., Birnbaum, A.S., Story, M. (2001). Perceptions of the family mealtime environment and adolescent mealtime behavior: do adults and adolescents agree? [Electronic Version]. Journal of Nutrition Education. 33, 128 133. Budd, G.M., & Hayman, L.L. (2006). Child hood obesity determinants, prevention, and treatment [Electronic version]. J Cardiovascular Nurs 21, 437 441. Butterfoss, F.D., Kegler, M.C., & Francisco, V.T. (2008). Mobilizing organizations for health promotion. Theories of organizational change. In K. Glanz, B.K. Rimer, K. Viswanath (Ed.), Health Behavior and Health Education, 4 th ed. (p. 337). San Franciso, CA: Jossey Bass. Chomitz, V.R., Collins, J., Kim, J., Kramer, E., & McGowan, R. (2003). Promoting healthy weight among elementary school childr en via a helath report card approach [Electronic version]. Arch Pediatr Adolesc Med, 157, 765 772.

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70 preference for large portions: Prevalence, determinants and consequences [Electronic version]. J Amer Diet Assoc, 107, 1183 1190. Committee on Food Marketing and the Diets of Children and Youth. (2006). Food marketing to children and youth: Threat or Opportunity? Executive Summary. National Academy of Sciences. Retrieved Februa ry 16, 2009 from: http://www.nap.edu/catalog/11514.html Davis, M.M., Gance Cleveland, B., Hassink, S., Johnson, R., Gilles, P., & Resnicow, K. (2007). Recommendatinos for prevention of childhood obes ity [Electronic version]. Pediatrics 120, S229 S253. Fulkerson, J.A., Story, M., Mellin, A., Leffert, N., Neumark Sztainer, D., French, S.A. (2006). Family dinner meal number and adolescent development: relationship with developmental assets and high ris k behaviors [Electronic version]. Journal of Adolescent Health 39, 337 345. effects of school version]. Int. J Pediatr Obesity 3, 52 57. weight status: Psychological impact of a weight screening program (Electronic version]. Pediatrics 122, e682 e688. Haines, J., Neumark Szta iner, D., Hannan, P., Robinson O Brien, R. (2008) Child versus related attitudes and behaviors [Electronic version]. J Ped Psych, 33, 783 388.

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71 Hanson, N.I., Neumark Sztainer, D., Eisenbert, M.E., Story, M., Wall, M. (2004). Associations between parental report of the home food environment and adolescent intakes of fruits, vegetables and dairy foods. [Electronic version]. Journal of Public Health Nutr 8, 77 85. Ikeda, J.P., Crawford, P.B., & Woodw ard Lopez, G. (2006). BMI screening in schools: helpful or harmful [Electronic version]. Health Educ. Res, 21, 761 769. Johnson, S.B., Pilkington, L.L., Lamp, C., He, J., Deeb, L.C. (2009). Parent reactions to a school based body mass index screening prog ram [Electronic version]. J School Health 79, 216 223. Krebs, N.F., Himes, J.H., Jacobson, D., Nicklas, T.A., Guilday, P., & Styne, D. (2007). Assessment of child and adolescent overweight and obesity [Electronic version]. Pediatrics ., 120, S193 S228. Ku bik, M.Y., Fulkerson, J.A., Story, M., Rieland, G. (2006). Parents of elementary school students weight in on height, weight, and body mass index screening at school. Journal of School Health, 76, 496 501. Larson, N.I., Story, M. (2007). The pandemic of ob esity among children and adolescents: What actions are needed to reverse current trends? Journal of Adolescent Health, 41, 521 522. Lumeng, J.C., Gannon, K., Cabral, H.J., et. al. (2003). Association between clinically meaningful behavior problems and ov erweight in children [Electronic version]. Pediatrics 112, 1138 1145. McAlister, A.L., Perry, C.L., & Parcel, G.S. (2008). How individuals, environments, and health behaviors iunteract. Social cognitive theory. In K. Glanz, B.K. Rimer, K. Viswanath (Ed.) Health Behavior and Health Education, 4 th ed. (p. 337). San Franciso, CA: Jossey Bass.

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72 National Association of State Boards of Education. State School Health Policy Database. Retrieved February 1, 2009, from the National Association of State Boards of E ducation Web site : http://www.nasbe.org/index.php/shs/health policies database Nihiser, A.J., Lee, S.M., Wechsler, H., et. al. (2007). Body mass index measurement in schools [El ectronic version]. J Sch Health 77, 651 671. Ogden, C.L., Carroll, M.D., & Flegal, K.M. (2008). High body mass index for age among us children and adolescents, 2003 2006 [Electronic version]. J Amer Med Assoc, 299, 2401 2405. Pearson, N., Biddle, S.J.H. Gorely, T. (2008). Family correlates of fruit and vegetable consumption in children and adolescents: a systematic review. [Electronic version]. Journal of Public Health Nutr, 12, 267 283. Posavac, E.J., Carey, R.G. (2007). Program Evaluation: Methods and Case Studies (p. 171 191). Upper Saddle River, NJ: Pearson Prentice Hall. Robert Wood Johnson Foundation. Energy gap contributes to adolescent obesity. Research highlight 17, December. 2006. Story, M., Neumark Sztainer, D., French, S. (2002). Individu al and Environmental Influences on Adolescent Eating Behaviors. [Electronic version]. J Amer Diet Assoc, 12, S40 S51. Torgan, C. (2002, June). Childhood obesity on the rise. The NIH Word on Health Retrieved February 27, 2009 from http://www.nih.gov/news/WordonHealth/jun2002 /childhoodobesity.htm United States Department of Agriculture. (2009a). National Food Breakfast Program. Available from http://www.fns.usda.gov/cnd/breakfast/ United States Department of Agriculture. (2009b). National Food Lunch Program. Available from http://www.fns.usda.gov/cnd/lunch/

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73 United State s Department of Health and Human Services, Centers for Disease Control and Prevention. The Obesity epidemic and Hillsborough County, Florida students (n.d.) Retrieved February 27, 2009 from, the Centers for Disease Control Web site http://www.cdc.gov/ HealthyYouth/yrbs/pdf/obesity/yrbs07_ hillsborough _county _florida_obesity.pdf Wang Y., Beydoun, M.A. (2007). The obesity epidemic in the un ited states gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta regression analysis. [Electronic version]. Epidemiol Rev, 29, 6 28. Year Three Evaluation: Arkansas Act 1220 of 2003 to Combat Childhood Obesity. (2006). University of Arkansas for Medical Sciences, Fay W. Boozman College of Public Health

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74 Appendices

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75 Appendix A: Non Results Tables Table 1 BMI Categories with Recommended and Previous Termin ology BMI Category 2005 Recommended Terminology Previous Terminology > 5 th percentile Underweight Underweight 5 th 84 th percentile Healthy Weight Healthy Weight 85 th 94 th percentile Overweight At risk of overweight 95 th percentile Obesity Overweight

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76 Appendix A (Continued) Table 2 Parent Survey Questions related to Social Cognitive Theory Constructs Question SCT Construct 8 How concerned are you about this child's weight? Psychosocial Very Concerned Deter minants of Behavior Somewhat Concerned Outcome Expectancy Not at all Concerned 10 How important is it to you that this child: Psychosocial a Be physically active? Determinants of Behavior b Limits how much TV they watch? Outcome Expectations c Eat s a healthy diet? d Limits their soda consumption? e Eats fruits and vegetables each day? f Be at a healthy weight? 12 In the past month, how often have you or your spouse/partner: Observational Learning a Made a comment to this child about their weight? b Encouraged this child to diet in order to lose weight? c Complained about your appearance in front of your children? d Complained about your weight in front of your children? e Talked about wanting to lose weight in front of your children ? f Gone on a diet? g children? 13 During a typical week, how often have you or another member of your household: a Encouraged this child to do physical activities or play sports? Observati onal Learning b Done a physical activity or played sports with this child? c Provided transportation to a place where this child can do physical activities or sports? Environmental Determinants of Behavior Facilitation d Watched this child participa te in physical activities or sports? Observational Learning e Told the child that they are doing well in physical activities or sports? f Encouraged this child to watch less TV? g Limited the amount of TV this child watches?

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77 Table 2 (cont inued) Question SCT Construct 14 During a typical week, how often have you or another member of your household: a Bought fruit or vegetables you know this child likes? Environmental Determinants of Behavior Facilitation b Encouraged this child to eat more fruit? Observational Learning c Encouraged this child to eat more vegetables? d Encouraged this child to drink less soda? e Encouraged this child to drink water instead of soda? 15 How often are the following true? Environmental Determin ants of Behavior Facilitation a We have soda in our home. b Water is available in our home to drink. c We have fruits and vegetables in our home. d In our home, vegetables are served at meals. e In our home, fruit is served for dessert. f In ou r home, there is fruit available for my children to have as a snack. g In our home, there are vegetables available for my children to have as a snack. h In our home, there are cut up vegetables in the fridge for my children to eat. i In our home, the re are fresh fruit on the counter, table, or somewhere else where my children could easily get them. 16 During the past week, how many times did all or most of your family living in your house eat a meal together? 17 Over the past week, how often did y ou drink: a Sweetened drinks like kool aid, lemonade, or fruit drinks Observational Learning b Sports drinks (like Gatorade) c Regular soda (not diet) d Water e Diet soda 18 During the past month, other than your regular job, did you participat e in any physical activity such as running, walking, weight lifting, golf, or gardening for exercise? Observational Learning 19 On one average weekday, how many hours do you spend watching TV/Videos/DVDs or using the computer at home? Observational Learni ng 20 On one average weekend, how many hours do you spend watching TV/Videos/DVDs or using the computer at home? Observational Learning

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78 Appendix A (Continued) Table 3 Social Cognitive Theory Constructs, Themes and Scoring for Parent Survey Parent Sur vey SCT Construct Theme Question s Scoring Outcome Expectation Perceived Importance of Child Physical Activity Behaviors 10 How important is it to you that this child: .493 Range = 0 6 The higher the score, the higher the pe rce ived importance of child physical activity behaviors a Be physically active? b Limits how much TV they watch? Outcome Expectation Perceived Importance of Child Nutrition Behaviors 10 How important is it to you that this child: .500 Range = 0 12 The higher the score, the higher the perce ived importance of child nutrition behaviors c Eats a healthy diet? d Limits their soda consumption? e Eats fruits and vegetables each day? Outcome Expectancy Parental C oncern about C hild's W ei ght 8 How concerned are you about this child's weight? N/A Range = 0 3 The higher the score, the higher the concern Very Concerned Somewhat Concerned Not at all Concerned

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79 Table 3 (continued) SCT Construct Theme Question s Alpha Scoring Facilitation Nutrition 14 a During a typical week, how often have you or another member of your household bought fruit or vegetables you know this child likes? .714 Range = 0 34 The higher the score, the greater the facilitation o f positive nutrition behaviors in the home 15 How often are the following true? a We have soda in our home. b Water is available in our home to drink. c We have fruits and vegetables in our home. d In our home, vegetables are served at meals. e In our home, fruit is served for dessert. f In our home, there is fruit available for my children to have as a snack. g In our home, there are vegetables available for my children to have as a snack. h In our home, there are cut up vegetables in the fridge for my children to eat. I In our home, there are fresh fruit on the counter, table, or somewhere else where my children could easily get them. 16 During the past week, how many times did all or most of your family living in your house eat a meal together?

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80 Table 3 (continued) SCT Construct Theme Question s Scoring Facilitation Physical Activity 13 c During a typical week, how often have you or another member of your household provided t ransportation to a place where this child can do physical activity or sports? N/A Range 0 3 The higher the score, the great the facilitation of physical activity behaviors Observational Learning Family Nutrition 14 During a typical week, how often have you or another member of your household: .810 Range = 0 12 The higher the score, the greater the modeling of nutrition behaviors by the family b Encouraged this child to eat more fruit? c Encouraged this child to eat more vegetables? d Enco uraged this child to drink less soda? e Encouraged this child to drink water instead of soda? Parent Nutrition Beverages 17 Over the past week, how often did you drink: .346 Range = 0 24 The higher the score, the greater the frequency of model ing poor beverage choices by parents a Sweetened drinks like kool aid, lemonade, or fruit drinks b Sports drinks (like Gatorade) c Regular soda (not diet) d Water

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81 Table 3 (continued) SCT Construct Theme Question s S coring Observational Learning Family Physical Activity 13 During a typical week, how often have you or another member of your household: .758 Range = 0 18 The higher the score, the greater the modeling of physical activity behaviors by the family a Encouraged this child to do physical activities or play sports? b Done a physical activity or played sports with this child? d Watched this child participate in physical activities or sports? e Told the child that they are doing well i n physical activities or sports? f Encouraged this child to watch less TV? g Limited the amount of TV this child watches? Parent Physical Activity 18 During the past month, other than your regular job, did you participate in any physical act ivity such as running, walking, weight lifting, golf, or gardening for exercise? N/A 0 = No 1 = Yes Parent Sedentary Behavior 19 On one average weekday, how many hours do you spend watching TV/Videos/DVDs or using the computer at home? .701 Range = 0 1 4 The greater the score, the greater the modeling of sedentary behaviors by parents 20 On one average weekend, how many hours do you spend watching TV/Videos/DVDs or using the computer at home?

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82 Table 3 (continued) SCT Construct Theme Question s Chro Scoring Observational Learning Negative Talk / Behaviors 12 In the past month, how often have you or your spouse/partner: .753 Range = 0 21 The greater the score, the greater the modeling of negative behaviors by parents a Made a comment to this child about their weight? b Encouraged this child to diet in order to lose weight? c Complained about your appearance in front of your children? d Complained about your weight in front of your children? e Talked about w anting to lose weight in front of your children? f Gone on a diet? g weight in front of your children?

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83 Appendix A (Continued) Table 4 Survey Questions related to Child Report of Modeling Behaviors, Home Env ironment and Child Behaviors Child Question Theme 9 During a typical week, how often are the following true? Modeling Behaviors a My parents/guardians try to get me to eat more fruit b My parents/guardians try to get me to eat more vegetables d My parents/guardians try to get me to drink less soda e My parents/guardians try to get me to drink water instead of soda when I'm thirsty 2 During a typical week, how often has a member of your household (for example, your mother, father, sister, grandparent, or other relative): Modeling Behaviors a Encouraged you to do physical activities or play sports? b Done a physical activity or played sports with you? d Watched you participate in physical activities or sports? e Told you that they are doing well in physical activities or sports? f Encouraged you to watch less TV? g Limit ed the amount of time you can watch TV? 13 In the past month, how often have your parents/guardians: Modeling Behaviors a Made a comment to you about your weigh t that made you feel bad ? b Encouraged you to diet to lose weight ? c Complained about how they look ? d Complained about their weight ? e Talked about wanting to lose weight ? f Gone on a diet ? g Made comments about other people's weight ?

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84 Table 4 (Continued) Child Question Theme 9 c During a typical week, how often are the following true? My parents/guardians buy fruits and vegetables they know I like Home Environment 10 How often are the following true? Home Environment a We have soda in my home b Water is available in my home to drink c We have fruits and vegetables in my home d In my home, vegetables are served at meals e In my home, fruit is served for dessert f In my home, there is fruit available to have as a snack g In my home, there are vegetables available to have as a snack h In my home, th e re are cut up vegetables in the fridge for me to eat i In my home, th e re are fresh fruit on the counter, table, or somewhere else where I can easily get them 6 Dur ing the past week, how many times did all, or most, of your family living in your house eat a meal together? Home Environment 2 c During a typical week, how often has a member of your household (for example, your mother, father, sister, gr andparent, or ot her relative) p rovided transportation to a place where you can do physical activities or sports? Home Environment 7 Over the past week, how often did you drink: Nutrition Behavior Beverages a Sweetened drinks like Kook aid, lemonade, or fruit drinks b Sports drinks (like Gatorade) c Regular soda (not diet) d Water e Diet Soda 11 Check the answer that best describes you: Nutrition Behavior a I eat fruit for dessert b I eat vegetables at dinner c I eat fruit for a snack d I eat cut up v egetables for a snack e I choose water instead of soda when I'm thirsty

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85 Table 4 (Continued) Child Question Theme 1 During the past 7 days, on how many days were you physically active for a total of at least 60 minutes? Physical Activity Behavior 4 On one average weekday, how many hours do you spend watching TV/Videos/DVDs or playing computer or video games (including Gameboy)? Sedentary Behavior 5 On one average weekend, how many hours do you spend watching TV/Videos/DVDs or playing computer or vid eo games (including Gameboy)? Sedentary Behavior 12 In the past month, have you done any of the following to lose weight or keep from gaining weight? Weight Control Behaviors a Ate more fruits and vegetables b Exercised more c Skipped breakfast d A te less high fat foods e Skipped meals other than breakfast f Took diet pills g Ate very little food for a day or more h Ate less sweets i Other _______________________________

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86 Appendix A (Continued) Table 5 Social Cognitive Theory Construc t s, Themes and Scoring for Student Survey SCT Construct Theme Question Scoring Observational Learning Family Nutrition 9 During a typical week, how often are the following true? .814 Sum Score Range = 0 12 The higher the score, the greater the child report of modeling of nutrition behaviors by the family a My parents/guardians try to get me to eat more fruit b My parents/guardians try to get me to eat more vegetables? d My parents/guardians try to get me to drink le ss soda e My parents/guardians try to get me to drink water instead of soda when I'm thirsty Observational Learning Family Physical Activity 2 During a typical week, how often has a member of your household (for example, your mother, father, sister grandparent, or other relative): .804 Sum Score Range = 0 18 The higher the score, the greater the child report of modeling of physical activity behaviors by the family a Encouraged you to do physical activities or play sports? b Done a physica l activity or played sports with you? d Watched you participate in physical activities or sports? e Told you that they are doing well in physical activities or sports? f Encouraged you to watch less TV? g Limited the amount of time you can watch TV?

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87 Table 5 (Continued) SCT Construct Theme Question Scoring Observational Learning Negative Talk / Behaviors 13 In the past month, how often have your parents/guardians: .829 Sum Score Range = 0 21 The greater th e score, the greater the child report of modeling of negative behaviors by parents a Made a comment to you about your weight that made you feel bad b Encouraged you to diet to lose weight c Complained about how they look d Complained abou t their weight e Talked about wanting to lose weight f Gone on a diet g Made comments about other people's weight Facilitation Nutrition 9 c During a typical week, how often are the following true? My parents/guardians buy fruits and veg etables they know I like .769 Sum Score Range = 0 34 The higher the score, the greater the child report of facilit ation of positive nutrition beh a v iors in the home 10 How often are the following true? a We have soda in my home b Water is ava ilable in my home to drink c We have fruits and vegetables in my home d In my home, vegetables are served at meals e In my home, fruit is served for dessert f In my home, there is fruit available to have as a snack g In my home, th ere are vegetables available to have as a snack h In my home, there are cut up vegetables in the fridge for me to eat

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88 Table 5 (Continued) SCT Construct Theme Question Scoring Facilitation Nutrition (Continued) i In my ho me, there are fresh fruit on the counter, table, or somewhere else where I can easily get them 6 During the past week, how many times did all, or most, of your family living in your house eat a meal together? Facilitation Physical Activity 2c Duri ng a typical week, how often has a member of your household (for example, your mother, father, sister, grandparent, or other relative): Provided transportation to a place where you can do physical activities or sports? N/A Range 0 3 The higher the score the greater the child report of facilitation of physical activity behaviors Child Behaviors Nutrition Beverages 7 Over the past week, how often did you drink: .308 Sum Score Range = 0 30 The higher the score, the greater the frequency of poor be vera ge choices by the child a Sweetened drinks like Kook aid, lemonade, or fruit drinks b Sports drinks (like Gatorade) c Regular soda (not diet) d Water e Diet Soda Child Behaviors Nutrition 11 Check the answer that best describes yo u: .664 Sum Score Range = 0 15 The higher the score, the greater the child positive nutriti on behaviors a I eat fruit for dessert b I eat vegetables at dinner c I eat fruit for a snack d I eat cut up vegetables for a snack e I choo se water instead of soda when I'm thirsty

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89 Table 5 (Continued) SCT Construct Theme Question Scoring Child Behaviors Physical Activity 1 During the past 7 days, on how many days were you physically active for a total of at leas t 60 minutes? N/A Range = 0 7 days Child Behaviors Sedentary Behavior 4 On one average weekday, how many hours do you spend watching TV/Videos/DVDs or playing computer or video games (including Gameboy)? .655 Sum Score Range = 0 14 The higher the scor e, the greater the child sedentary behaviors 5 On one average weekend, how many hours do you spend watching TV/Videos/DVDs or playing computer or video games (including Gameboy)? Child Behaviors Weight Control 12 in the past month, have you done any of the following to lose weight or keep from gaining weight? .571 Sum Score Range = 0 8 The higher the score, the greater the number of child weight control behaviors a Ate more fruits and vegetables b Exercised more c Skipped breakfas t d Ate less high fat foods e Skipped meals other than breakfast f Took diet pills g Ate very little food for a day or more h Ate less sweets

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90 Appendix B: BMI Health Report Card Letter

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91 Appendix B: (Continued)

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92 Appendix C: Parent Survey Cover Letter May 20, 2009 Dear Parent/Guardian: I would like to invite you to participate in an important project regarding the impact of Health Report Cards that is being conducted by a group of student researchers at the Uni versity of South Florida. You were selected because you are the parent or guardian of a 6 th grade student at Benito Middle School. Your responses will not only help us complete our degree requirements, but will also provide valuable information regarding adolescent health. Your participation is greatly appreciated! Enclosed is a survey, which has 24 questions. The survey will take approximately 20 minutes of your time. All responses will be confidential. The code on the back of the survey is strictly fo information. The informed consent that you sign will be separated from the survey before the researchers see your responses. To complete the survey: Read the informed consent docume nt. Sign and date page 3 of the informed consent and print your name below your signature. Return the completed survey and the signed informed consent in the enclosed self addressed pre paid envelope by May 29, 2009. The first 100 parents to return th e completed survey will receive a $20.00 gift card. If you have any questions, please do not hesitate to contact me at 863 647 4090. On behalf of those involved with this project, I want to thank you for your involvement in this important project. Respe ctfully, Jenna Brunaugh 863 647 4090

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93 Appendix D: Parent Survey Informed Consent Informed Consent to Participate in Research: Health Report Cards Survey Information to Consider Before Taking Part in this Research Study Researchers at the Uni versity of South Florida (USF) study many topics. To do this, we need the help of people who agree to take part in a research study. This form tells you about this research study. We are asking you to take part in a research study that is called: Explor ing the Impact of Health Report Cards The Principal Investigator or person who is in charge of this research study is: Jenna Brunaugh and the Co Investigators are Rheanna Ata, John Trainor, MS and Emily Koby. The research will involve the participation o f Benito Middle School in Hillsborough County. The Hillsborough County School Board has reviewed our research and given us permission to request your approval to participate in this study. We are asking that you participate because you are a parent of a sixth grade student in Hillsborough County. Purpose of the study In this study we seek to assess the impact of Health Report Cards on sixth grade students and their parents. Study Procedures If you take part in this study, you will be asked to complete the survey in this packet. Prior to completing the survey you will first read and sign the consent form. Only those participants who read and sign the consent form should complete the survey. Alternatives You have the alternative to choose not to participat e in this research study. Benefits There are no known benefits to those who take part in this study. However, conducting this research provides a benefit to society by adding to our understanding of adolescent health. Risks or Discomfort There are no kno wn risks to those who take part in this study.

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94 Appendix D: (Continued) Compensation The first 100 people who return this survey will receive one $20.00 gift card. Confidentiality We must keep your study records confidential. No individual identifiers will be collected. office. However, certain people may need to see your study records. By law, anyone who looks at your records must keep them completely confid ential. The only people who will be allowed to see these records are: The research team, including the Principal Investigator and all other research staff. Certain government and university people who need to know more about the study. For example, ind ividuals who provide oversight on this study may need to look at your records. This is done to make sure that we are doing the study in the right way. They also need to make sure that we are protecting your rights and your safety. These include: o The Univ ersity of South Florida Institutional Review Board (IRB) and the staff that work for the IRB. Other individuals who work for USF that provide other kinds of oversight may also need to look at your records. o People from the Department of Health and Human Services (DHHS) We may publish what we learn from this study. If we do, we will not let anyone know your name. We will not publish anything else that would let people know who you are. Voluntary Participation / Withdrawal You should only take part in this study if you want to volunteer. You should not feel that there is any pressure to take part in the study. You are free to participate in this research or withdraw at any time. There will be no penalty or loss of benefits you are entitled to receiv e if you stop taking part in this study. Your decision to participate or not to participate will not affect your student or employment status. Questions, concerns, or complaints If you have any questions, concerns or complaints about this study, call Je nna Brunaugh at 863 647 4090. If you have questions about your rights, general questions, complaints, or issues as a person taking part in this study, call the Division of Research Integrity and Compliance of the University of South Florida at (813) 974 93 43. If you experience an adverse event or unanticipated problem call Jenna Brunaugh at 863 647 4090.

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95 Appendix D: (Continued) Consent to Take Part in this Research Study It is up to you to decide whether you want to take part in this study. If you want to take part, please sign the form, if the following statements are true. I freely give my consent to take part in this study. I understand that by signing this form I am agreeing to take part in research. I have received a copy of this form to keep. Signature of Person Taking Part in Study Date Printed Name of Person Taking Part in Study Statement of Person Obtaining Informed Consent I have carefully explained to the person taking part in the study what he or she can expect. I hereby certify that when this person signs this form, to the best of my knowledge, he or she understands: What the study is about. What procedures/interventions/investigational drugs or devices will be used. What the potential benefits might be. What th e known risks might be. I also certify that he or she does not have any problems that could make it hard to understand what it means to take part in this research. This person speaks the language that was used to explain this research. This person rea ds well enough to understand this form or, if not, this person is able to hear and understand when the form is read to him or her. To the best of my knowledge, this person does not have a medical/psychological problem that would compromise comprehension a nd therefore makes it hard to understand what is being explained and can, therefore, give informed consent. To the best of my knowledge, this person is not taking drugs that may cloud their judgment or make it hard to understand what is being explained and can, therefore, give informed consent. Signature of Person Obtaining Informed Consent Date Jenna Brunaugh Printed Name of Person Obtaining Informed Consent

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96 Appendix E: Parent Permission Letter Dear Parent: We are fro m the College of Public Health at the University of South Florida and we would like to include your child, along with his or her classmates, in a research project. The research will involve the participation of one middle school in Hillsborough Co: Benito Middle School. Inclusion of your child's data in this project is completely voluntary. You are free to withdraw your permission for your child's data to be included at any time and for any reason without penalty. These decisions will have no effect on yo status or grades there. We will be collecting information on individual and family behaviors related to physical activity and nutrition, and perceptions of body mass index. The information that is obt ained during this research project will be kept strictly confidential and will not become a part of your child's school record. Any sharing or publication of the research results will not identify any of the participants by name. If you do not want your c hild to participate in this project, please sign and return this note to your If you have any questio ns about this project, please contact us using the information below. If you have any questions about your rights as a participant in research involving human subjects, please feel free to contact the Division of Research Integrity and Compliance of the Un iversity of South Florida at (813) 974 9343. Sincerely, USF College of Public Health Research Project Attention Starla Rohl, School Health I DO NOT want my child, to participate in this project. ____________________ _________________ (Print) Parent name ____ Date: __ Parent signature Rita DeBate Associate Professor College of Public Health University of South Florida 974 6682 rdebate@health.usf.edu Jenna Brunaugh MSPH Student University of South Florida 974 6682 jbrunaug@mail.usf.edu Starla Rohl School Health Benito Middle School 631 4694 ext 252 starla.rohl@sdhc.k12.fl.us

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97 Appendix F: Parent Survey Reminder Letter June 1, 2009 Dear Parent/Guardian: You were recently invited to participate in an important project regarding the impact of Health Report Cards that is being conducted by a group of student researchers at the University of South Florida. Your response is critical to the success of our project and will not only help us complete our degree requirements, but will also pr ovide valuable information regarding adolescent health. Your participation is greatly appreciated! You received a survey, which has 24 questions. The survey will take approximately 20 minutes of your time. All responses will be confidential. The code on the back of the information. The informed consent that you sign will be separated from the survey before the researchers see your responses To complete the survey : Read the informed consent document. Sign and date the top of page 3 of the informed consent and print your name below your signature. Return the completed survey and the signed informed consent in the enclosed self addressed pre paid envelope by June 8 2009. If you have any questions, please do not hesitate to contact me at 863 647 4090. On behalf of those involved with this project, I want to thank you for your involvement in this important project. Respectfully, Jenna Brunaugh 863 647 4090 Health Report Cards Survey Reminder

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98 A ppendix G: Teacher Instructions / Student Assent Distribute the surveys to the students. Please read the following aloud to the students: Please return completed surveys to Starla Rohl. Thank you for your time! TITLE OF STUDY: Exploring the Impact of Health Report Cards You are being asked to take part in a research study about Health Report Cards. You are being asked to take part in this research study because you are a 6 th grader. If you take part in this study, you will be one of about 360 students in this study. The person in charge of this study is Jenna Brunaugh of The University of South Florida. By doing this study, the researchers hope to learn about your feelings about body weight, body image and body esteem. The study will take place within the Hillsborough County School System and will last nine months. You will be asked to fill out a survey that asks about your physical activity behaviors, nutrition behaviors and how you feel about body weight, body image and body esteem. The end of the survey asks about your age, if you are a boy or girl, and your race/et hnicity. To the best of our knowledge, the things you will be doing will not harm you or cause you any additional unpleasant experience. We cannot promise you that anything good will happen if you decide to take part in this study. You have the alternat ive to choose not to participate in this research study. You should talk with your parents or anyone else that you trust about taking part in this study. If you do not want to take part in the study, that is your decision. You should take part in this study because you really want to volunteer. If you do not want to be in the study, nothing else will happen. You will not receive any rewards for taking part in the study. Your information will be added to the information from other people taking part in the study so no one will know who you are. If you decide to take part in the study you still have the right to change your mind later. No one will think badly of you if you decide to quit. Also, the people who are running this study may need for yo u to stop. If this happens, they will tell you why. You can ask questions about this study at any time. You can talk with your parents or other adults that you trust about this study. You can talk with the person who is asking you to volunteer. If you think of other questions later, you can ask them. Assent to Participate I understand what the person running this study is asking me to do. I have thought about this and agree to take part in this study. Wellness Survey Teacher Instructions

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99 Appendix H: Parent Survey Parent Health Report Card and Wellness Survey Directions There are 24 questions on this s urvey. Please read all the questions and the answer options carefully. There are no right or wrong answers to any of the questions. Please be as honest as possible. You do not have to answer any question that makes you uncomfortable; however completing the entire survey will provide us with the best information. Please return the completed survey along with the signed informed consent using the stamped envelope that was provided by May 29, 2009. Thank you for participating!

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100 2. Was a letter sent ho body mass index (BMI)? Yes No ( please skip to question 6 ) 3. Did you read the letter? Yes No ( please skip to question 6 ) now/ not sure 4. Did you discuss the contents of the letter with this child? Yes No ( please skip to question 6 ) 5. When you discussed the contents of the letter with your child, how comfortable were they with the i nformation? Very uncomfortable Somewhat uncomfortable 1. What is your relation to your 6 th grade child who attends Benito Middle School? Mother Father Stepmother Stepfather Grandmother Grandfather Aunt Uncle Other _____________________

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101 5. When you discussed the contents of the letter with your child, how comfortable were they with the i nformation? Not at all uncomfortable 6. Would you be interested in receiving an annual letter about Body Mass Index (BMI) Yes No 7. Do you think your child is? Underweight Normal Weight At Risk for Overweight Overweight 8. Very concerned Somewhat concerned Not at all concerned 9. BMI, have you done any of the a. Seen a pediatrician or primary health care provider Yes No b. Seen a school nurse Yes No c. Seen a weight specialist or nutritionist Yes No d. Gone to a we ight loss clinic Yes No e. Put child on a diet Yes No f. Had child skip meals or snacks Yes No g. Given diet pills or herbal supplements Yes No h. Increased exercise or physical activity Yes No i. Signed child up f or a sport class Yes No j. Other _________________________ Yes No

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102 10. How important is it to you that this child: Not at all important A little important Somewhat important Very important a. Be physically active? b. Limits how much TV they watch? c. Eats a healthy diet? d. Limits their soda consumption? e. Eats fruits and vegetables each day? f. Be at a healthy weight? 11. In the last week did this c hild ask you or another member of your household to: a. available at home? Yes No b. Prepare a fruit or vegetable for a meal? Yes No c. home? Yes No d. Prepare a healthy food for a meal? Yes No e. Have fruits or vegetables in a place where they can easily reach them? Yes No f. Have water available for them to drink? Yes No g. Be physically active with them? Yes No h. Provide transportation for them to a place where they can be physically active or play sports? Yes No

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103 12. In the past month how often have you or your spouse/partner: Never Once a month A few times a month At least once a week a. Made a comment to this child about their weight? b. Encouraged this child to diet in order to lose weight? c. Complained about your appearance in front of your children? d. Complained about your weight in front of your children? e. Talked about wanting to lose weight in front of your children? f. Gone on a diet? g. weight in front of your children? 13. During a typical w eek how often have you or another member of your household: Not at all Some times Almost every day Every day a. Encouraged this child to do physical activities or play sports? b. Done a physical activity or played sports with this child? c. Provided transportation to a place where this child can do physical activities or sports? d. Watched this child participate in physical activities or sports? e. Told the child that they are doing well in physical activities or sports? f. Encouraged this child to watch less TV? g. Limited the amount of TV this child watches?

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104 15. How often are the following true? Hardly ever Some times Often Almost always a. We have soda in our home. b. Water is available in our hom e to drink. c. We have fruits and vegetables in our home. d. In our home, vegetables are served at meals. e. In our home, fruit is served for dessert. f. In our home, there is fruit available for my child ren to have as a snack. g. In our home, there are vegetables available for my children to have as a snack. h. In our home, there are cut up vegetables in the fridge for my children to eat. i. In our home, there are fr esh fruit on the counter, table, or somewhere else where my children could easily get them. 14. During a typical week how often have you or another member of your household: Not at all Some times Almost every day Every day a. Bought fruit or vegetables you know this child likes? b. Encouraged this child to eat more fruit? c. Encouraged this child to eat more vegetables? d. Encouraged this child to drin k less soda? e. Encouraged this child to drink water instead of soda?

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105 18. During the past month other than your regular job, did you participate in any physical activity such as running, walking, weight lifting, golf, or gardening for exercise? Yes No 16 During the past week how many times did all or most, of your family living in your house eat a meal together? Never 1 2 times 3 4 times 5 6 times 7 or more times 17 Over the past WEEK how often did you drink: Less than once a week 1 2 times per week 3 4 times per week 1 time per day 2 times per day 3 times per day 4 or more times per day a. Sweetened drinks l ike kool aid, lemonade, or fruit drinks b. Sports drinks (like Gatorade) c. Regular soda (not diet) d. Water e. Diet soda

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106 19. On ONE average WEEKDAY, how many hours do you spe nd watching TV/Videos/DVDs or using the computer at home ? 0 hours 1 hour 2 hours 3 hours 4 hours 5 hours 6 or more hours 20. On ONE average WEEKEND, how many hours do you spend watching TV/Videos/DVDs or using the computer a t home ? 0 hours 1 hour 2 hours 3 hours 4 hours 5 hours 6 hours 7 hours 8 or more hours

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107 21. What is the highest level of education you have completed? 8 th grade or less Attended some high school High school graduate/GED Some college College graduate Post graduate study 22. Are you currently employed outside the home? Yes Part time? Full time? No 23. Are you Hispanic or Latino? Yes No 24. Do you think of yourself as: ( you may select more than one ) White Black or African American Asian Hmong Native Hawaiian or Other Pacific Islander American Indian or Alaskan Native Other: _________________ This completes the survey. Please return this survey along with the signed informed consent using the stamped envelope that was provided. Thank you for your time!

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108 Appendix C: Student Survey Grade 6 Wellness Survey Thank you for participating! DO NOT write your name on this survey The answers you give will be kept private. No one will know what you write. Please read all the questions and the answer options carefully. Be as honest as possible. There are no right or wrong answers to any of the questions. Completing this survey is voluntary. Whether or not you answer the questions will not change your grade in this class. If you are not comfortable answering a question, just leave it blank. Please raise your hand if you have any questions while filling this out. Return this sur vey to your teacher when you are done. Remove the sheet with your name on it before returning.

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109 The following questions are about physical activity. Physical activity i ncludes activities like walking, running, riding a bike, swimming, jumping rope, playing baseball, basketball, football, soccer, and dancing. 1. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes ? 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days 2 During a typical WEEK, how often has a member of your household (for example, your mother, father, sister, grandparent, or other relative): Not at all Som e times Almost every day Every day a. Encouraged you to do physical activities or play sports? b. Done a physical activity or played sports with you? c. Provided transportation to a place where you can do physical activities or sp orts? d. Watched you participate in physical activities or sports? e. Limited the amount of time you can watch TV? f. Told you that they are doing well in physical activities or sports? g. Encouraged y ou to watch less TV?

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110 3. In the last WEEK, did you ask someone in your family to: Yes No a. Be physically active or do a sport with you? b. Give you a ride to a place where you can be physically active? c. Watch you be physically active? 4. On ONE average WEEKDAY, how many hours do you spend watching TV/Videos/DVDs or playing computer or video games (including Gameboy)? 0 hours 1 hour 2 hours 3 hours 4 hours 5 hours 6 or more hours 5. On ONE average WEEKEND, how many hours do you spend watching TV/Videos/DVDs or playing computer or video games (including Gameboy)? 0 hours 1 hour 2 hours 3 hours 4 hours 5 hours 6 hours 7 hou rs 8 or more hours

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111 These questions ask about what you eat/drink. Again, there are no right or wrong answers to these questions. 6. During the past WEEK, how many times did all, or most, of your family living in your house eat a meal togethe r? Never 1 2 times 3 4 times 5 6 times 7 or more times 7. Over the past WEEK, how often did you drink: Less than once a week 1 2 times per week 3 4 times per week 1 time per day 2 times per day 3 times per day 4 or more times per day a. Sweetened drinks like Kool aid, lemonade, or fruit drinks b. Sports drinks (like Gatorade) c. Regular soda (not diet) d. Water e. Diet soda

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112 8. In the last WEEK, did you ask someone in your family to: Yes No a. Buy fruit or vegetables? b. Prepare a fruit or vegetable for a meal? c. Have fruit or vegetables in a place where you can easily get to them? d. Have water available for you to drink? e. Buy healthy food? f. Serve healthy food for dinner? 9. During a typical WEEK how often are the following true? Not at all Some times Almost ever y day Every day a. My parents/guardians try to get me to eat more fruit b. My parents/guardians try to get me to eat more vegetables c. My parents/guardians buy fruits and vegetables they know I like d. My pare nts/guardians try to get me to drink less soda e. My parents/guardians try to get me to thirsty

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113 10. How often are the following true? Hardly ever Some times Often Almost always a. W e have soda in my home b. Water is available in my home to drink c. We have fruits and vegetables in my home d. In my home, vegetables are served at meals e. In my home, fruit is served for dessert f. In my home, there is fruit available to have as a snack g. In my home, there are vegetables available to have as a snack h. In my home, there are cut up vegetables in the fridge for me to eat i. In my home, t here are fresh fruit on the counter, table, or somewhere else where I can easily get them. 11. Check the answer that best describes you: Hardly Ever Some times Much of the Time Almost Always a. I eat fruit for dessert b. I eat vegetables at dinner c. I eat fruit for a snack d. I eat cut up vegetables for a snack e. I choose water instead of soda

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114 12. In the past MONTH, have you done any of the following to lose weight or keep from gaining weight? Yes No a. Ate more fruits and vegetables b. Exercised more c. Skipped breakfast d. Ate less high fat foods e. Skipped meals other than breakfast f. Took diet pills g. Ate very little food for a day or more h. Ate less sweets i. Other ______________________ 13. In past MONTH, how often have your parents/guardians: Never Once a month A few times a month At least once a week a. Made a comment to you about your weight that made you feel bad b. Encouraged you to diet to lose weight c. Complained about how they look d. Complained about their weight e. Talked about wanting to lose weight f. Gone on a diet g. weight

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115 We a re now going to ask you some questions about how you feel about yourself. Please be as honest as possible, and remember that there are no right or wrong answers. 14. The following statements deal with general feelings about yourself: Strongly a gree Agree Disagree Strongly disagree a. On the whole, I am satisfied with myself. b. At times, I think I am no good at all. c. I feel that I have a number of good qualities. d. I am able to do things as well as mo st other people. e. I feel I do not have much to be proud of. f. I certainly feel useless at times. g. I feel that I am a person of worth, at least on an equal plane with others. h. I wish I could have more respect for myself. i. All in all, I feel that I am a failure. j. I take a positive attitude toward myself.

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116 15. How often do you agree with the following statements? Never Almost never Sometimes Often Alw ays a. I like what I look like in pictures. b. Other people consider me good looking. c. d. I am preoccupied with trying to change my body weight. e. I think my appear ance would help me get a job. f. I like what I see when I look in the mirror. g. my looks if I could. h. I am satisfied with my weight. i. I wish I lo oked better. j. I really like what I weigh. k. I wish I looked like someone else. l. People my own age like my looks. m. My looks upset me. n. e. o. p. I feel I weigh the right amount for my height. q. I feel ashamed of how I look. r. Weighing myself depresses me. s. My weight ma kes me unhappy. t. My looks help me to get dates. u. I worry about the way I look. v. I think I have a good body. w.

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117 16. Please look carefully at the figures below. A B C D E F G H I A B C D E F G H I Using the figures as guides, ra te what you would like to look like and what you look like right now. Write the letters of the figures on the lines below. a) What I want to look like: figure _____ b) What I look like right now: figure _____

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118 These last few questions are ab out you. 17. How old are you? 10 years old 11 years old 12 years old 13 years old 18. Who do you live with most of the time? Both of my parents (mother and father) My mother My father One or both of my grandpare nts Other: 19. Are you a boy or a girl? Boy Girl 20. Are you Hispanic or Latino? Yes No 21. Do you think of yourself as (you may select more than one) White Black or African American Asian Hmong Native Hawaiian or Other Pacific Islander American Indian or Alaskan Native Other: _________________

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119 Appendix M: Results Tables Table 6 Characteristics of Parent Participants Characteristic n (% ) Relationship to Child Mother 66 (88) Father 5 (6.7) Stepmother 1 (1.3) Stepfather 0 (0) Grandmother 1 (1.3) Grandfather 0 (0) Aunt 2 (2.7) Uncle 0 (0) Total 75 (100) Parent Education 8 th grade or less 0 (0) Attended some high school 5 (6.6 ) High School Graduate / GED 9 (11.8) Some College 12 (15.8) College Graduate 33 (43.4) Post Graduate Study 17 (22.4) Total 76 (100) Parent Employment Full Time 38 (50) Part Time 12 (15.8) Not Employed 26 (34.2) Total 76 (100) Parent Ethnicity Hispanic / Latino 15 (20) Non Hispanic Latino 60 (80) Total 75 (100)

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120 Table 6 (Continued) Characteristics of Parent Participants Characteristic n (%) Parent Race White 50 (76.9) Black / African American 10 (15.4) Asian 5 (7.7) Native Hawaiian o r other Pacific islander 0 (0) American Indian or Alaskan Native 0 (0) Total 65 (100)

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121 Appendix M (Continued) Table 7 Data R elated to Student Participants Student Data n (%) Child Gender Male 34 (44.7) Female 42 (55.3) Total 76 (100) Child Actu al Weight Status Category Underweight 1 (1.3) Normal Weight 53 (69.7) At Risk of Overweight 13 (17.1) Overweight 9 (11.8) Total 76 (100) Child Weight Status Category According to Parent Underweight 1 (1.3) Normal Weight 60 (78.9) At Risk of Over weight 11 (14.5) Overweight 4 (5.3) Total 76 (100) Parental Concern about Not at all concerned 40 (52.6) Somewhat concerned 24 (31.6) Very concerned 12 (15.8) Total 76 (100)

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122 Appendix M (Continued) Table 8 Frequencies of Selected P articipant Responses Selected Response Total n (%) By Delivery Method Mailed (n) Backpack (n) p value* Received the Letter Yes 59 (77.6) 38 21 .001* No 12 (15.8) 2 10 5 (6.6) Total 76 (100) Read the Letter Y es 58 (79.5) 27 21 .005* No 14 (19.2) 3 11 1 (1.4) Total 73 (100) Preference for Yearly Letter Yes 55 (75.3) No 18 (24.7 Total 73 (100) Discussed Letter with Child Yes 46 (79.3) No 10 (17.2) Do 2 (3.4) Total 58 (100) How Comfortable was the Child? Not at all uncomfortable 15 (32.6) Somewhat uncomfortable 9 (19.6) Very uncomfortable 22 (47.8) Total 46 (100) *tests are significant if p < .05

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123 Append ix M (Continued) Table 9 Post Letter Weight Control Actions Post Letter Actions n (%) Saw a Health Care Provider Yes No Total 5 ( 87.7 ) 52 (91.2 ) 5 7 (100) Saw a School Nurse Yes No Total 0 (0) 5 7 (100) 5 7 (100) Saw a Weight Specialist / Nutritionist Y es No Total 1 (1.8 ) 56 (98.2 ) 57 (100) Took Child to Weight Loss Clinic Yes No Total 0 (0) 5 7 (100) 5 7 (100) Put Child on a Diet Yes No Total 6 (10.5 ) 51 (89.5 ) 5 7 (100)

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124 Table 9 (Continued) Post Letter Weight Control Actions Post Letter Actions n (%) Had Child Skip Meals or Snacks Yes No Total Had Child take Diet Pills or Herbal Supplements Yes No Total 4 (7 ) 53 (9 3 ) 5 7 (100) 0 (0) 5 7 (100) 5 7 (100) Increased Exercise / Physical Activity Yes No Total 17 (29.8 ) 40 (70.2 ) 5 7 (100) Put Child in a Sports Class Yes No Total 7 (12.3 ) 5 0 (87.7 ) 57 (100)

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125 Appendix M (Continued) Table 10 Number of Parents wh Category Post Letter Weig ht Control Action Took Action(s) Did Not Take Action Pearson Chi Square p value* Seek Professional Help Normal Weight Child At risk of Overweight or Overweight Child 3 3 38 13 1.597 .206 Food Restriction Normal Weight Child At risk of Overwei ght or Overweight Child 3 6 38 10 7.885 .005* Physical Activity Normal Weight Child At risk of Overweight or Overweight Child 7 11 34 5 14.224 <.001* *tests are significant if p < .05

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126 Appendix M (Continued) Table 11 Differences in Psychosocial Determinants of Behavior Scores among Parents who Read the Letter and Did Not Read the Letter Psychosocial determinant of Behavior n m sd t test p value* Perceived Importance of Child Physical Activity (Outcome Expectancy) Read the Lett er Did not read the Letter 58 14 5.09 1.13 4.93 1.14 .465 .647 Perceived Importance of Child Nutrition Behaviors (Outcome Expectancy) Read the Letter Did not read the Letter 58 14 8.21 1.21 7.86 1.66 .743 .468 Parental Concern ab Weight (Outcome Expectation) Read the Letter Did not read the Letter 58 14 .71 .749 .43 .756 1.24 .230 *tests are significant if p < .05

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127 Appendix M (Continued) Table 12 Differences in Environmental Determinants of Behavior Sco res among Parents who Read the Letter and Did Not Read the Letter Environmental determinant of Behavior n m sd t test p value* Facilitation of Nutrition Read the Letter Did not read the Letter 57 14 24.39 4.93 24.57 4.54 .135 .894 Facil itation of Physical Activity Read the Letter Did not read the Letter 58 13 1.36 .852 1.38 .506 .126 .901 *tests are significant if p < .05

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128 Appendix M (Continued) Table 13 Differences in Modeling Behaviors among Parents who Read the L etter and Did Not Read the Letter *tests are significant if p < .05 Modeling Behavior n m sd t test p value* Observational Learning Family Nutrition Read the Letter Did not read the Letter 56 14 7.64 3.27 7.29 2.81 .411 .685 Observational Learning Parent Nutrition Beverages Read the Letter Did not read the Letter 58 14 3.59 3.71 2.36 2.27 1.58 .124 Observational Learning Family Physical Activity Read the Letter Did not read the Letter 58 14 8.98 3.98 9.86 2.45 1.05 .304 Observational Learnin g Parent Sedentary Behavior Read the Letter Did not read the Letter 58 14 7.62 3.47 6.86 3.39 .752 .461 Observational Learning Negative Talk / Behaviors Read the Letter Did not read the Letter 56 12 5.57 4.26 5.50 4.85 .047 .963

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129 Appendix M (Continued) Table 14 Modeling of Physical Activity among Parents who Read the Letter and Did not Read the Letter Read the Letter Model ed Physical Activity Did not model Physical Activity Pearson Chi Square p value* Yes 48 10 2.80 .094 No 0 14 *tests are significant if p < .05

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130 Appendix M (Continued) Table 15 Differences in Psychosocial Determinants of Behavior Scores among Parents of Psychosocial determinant of Behavior n m sd t test p value* Perceived Importance of Child Physical Activity (Outcome Expectancy) Normal Weight Child At risk of Overweight or Overweight Child 41 16 5.24 1.02 4.63 1.31 1.69 .063 Perceived Importance of Child Nutrition Behaviors (Outcome Expectancy) Normal Weight Child At risk of Overweight or Overweight Child 41 16 8.41 .948 7.63 1.63 2.28 .026* Weight (Outcome Expectation) Normal We ight Child At risk of Overweight or Overweight Child 41 16 .51 .675 1.25 .683 3.68 .001* *tests are significant if p < .05

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131 Appendix M (Continued) Table 16 Differences in Environmental Determinants of Behavior Scores among Parents o f Environmental determinant of Behavior n m sd t test p value* Facilitation of Nutrition Normal Weight Child At risk of Overweight or Overweight Child 41 15 24.61 4.76 23.8 0 5.67 .493 .627 Facilitation of Physical Activity Normal Weight Child At risk of Overweight or Overweight Child 41 16 1.46 .869 1.06 .772 1.69 .099 *tests are significant if p < .05

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132 Appendix M (Continued) Table 17 D *tests are signif icant if p < .05 Modeling Behavior n m sd t test p value* Observational Learning Family Nutrition Normal Weight Child At risk of Overweight or Overweight Child 40 15 7.63 3.20 8.13 3.18 .527 .603 Observational Learning Parent Nutrition Beverages Normal Weight Child At risk of Overweight or Overweight Child 41 16 3.56 3.61 3.81 4.11 .214 .832 Observational Lea rning Family Physical Activity Normal Weight Child At risk of Overweight or Overweight Child 41 16 9.41 4.04 7.94 3.84 1.29 .209 Observational Learning Parent Sedentary Behavior Normal Weight Child At risk of Overweight or Overweig ht Child 41 16 7.56 3.30 7.94 4.00 .334 .741 Observational Learning Negative Talk / Behaviors Normal Weight Child At risk of Overweight or Overweight Child 39 16 4.62 3.84 7.88 4.59 2.51 .019*

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133 Appendix M (Continued) Table 18 Weight Status Model Physical Activity Do not model Physical Activity Pearson Chi Squar e p value* Normal 32 9 1.96 .161 At risk of Overweight or Overweight 15 1 *tests are significant if p < .05

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134 Appendix M (Continued) Table 19 Relationship between Environmental Determinants of Behavior and Modeling Behaviors and Psychosoci al Determina nts of Behavior Environmental determinant of Behavior / Modeling Behavior Psychosocial Determinant of Behavior Perceived Importance of Child Nutrition Behaviors (r) Perceived Importance of Child Physical Activity Behaviors (r) Parental Concern about Chi Weight (r) Facilitation of Nutrition .404 (p = <.001)* n = 75 .024 (p = .840) n = 75 Facilitation of Physical Activity .012 (p = .917) n = 75 .038 (p = .745) n = 75 Observational Learning Family Nutrition .265 (p = .023)* n = 73 .346 (p = .0 03)* n = 73 Observational Learning Parent Nutrition Beverages .082 (p = .479) n = 76 .225 (p = .050) n = 76 Observational Learning Family Physical Activity .229 (p = .047)* n = 76 .104 (p = .372) n = 76 Observational Learning Parent Sedentary Behavior .112 (p = .337) n = 76 .123 (p = .290) n = 76 Observational Learning Negative Talk / Behaviors .199 (p = .094) n = 72 *tests are significant if p < .05

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135 Appendix M (Continued) Table 20 Differences in Report of Modeling Behaviors betwee n Parent and Child *tests are significant if p < .05 Modeling Behavior n m sd t test p value* Observational Learning Family Nutrition Parent Report Child Report 65 65 7.72 3.12 6.95 3.45 1.42 .161 Observational Learning Family Physical Activity Parent Report Child R eport 65 65 9.28 3.64 9.29 4.26 .027 .978 Observational Learning Negative Talk / Behaviors Parent Report Child Report 60 60 5.28 4.27 5.30 4.82 .029 .977

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136 Appendix M (Continued) Table 21 Differences in Report of Home Environment between Parent and Child Home Environment n m sd t test p value* Facilitation of Nutrition Parent Report Child Report 63 63 24.63 4.66 23.29 5.91 1.67 .099 Facilitation of Physical Activity Parent Report Child Report 67 67 1.37 .795 1.40 1.02 .217 .829 *tests are significant if p < .05

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137 Appendix M (Continued) Table 22 Relationship between Parent Reported Environmental Determinants of Behavior and Modeling Behaviors and Child Reported Behaviors Parent Reported Environmental Determinants of Behavior / Modeling Behaviors Child Behaviors Nutrition (r) Physical Activity (r) Nutrition Beverages (r) Sedentary (r) Weight Control (r) Facilitation of Nutrition .391 (p = .002)* n = 63 Facilitation of Physical Activity .195 (p = .117) n = 66 Observational Learning Family Nutrition .013 (p = .918) n = 61 Observational Learning Parent Nutrition, Beverages .087 (p = .498) n = 63 Observational Learning Family Physical Activity .097 (p = .433) n = 67 Observational Learning Parent Sedentary Behavior .163 (p = .181) n = 67 Observational Learning Negative Talk / Behaviors .120 (p = .359) n = 61 .166 (p = .190) n = 64 .056 (p = .6 73) n = 60 .217 (p = .080) n = 66 .244 (p = .056) n = 62 *tests are significant if p < .05


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Kaczmarski, Jenna M.
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Exploring the effects of BMI health report card letters among 6th grade students and parents :
b an application of the social cognitive theory
h [electronic resource] /
by Jenna M. Kaczmarski.
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[Tampa, Fla] :
University of South Florida,
2009.
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Title from PDF of title page.
Document formatted into pages; contains 137 pages.
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Thesis (M.S.P.H.)--University of South Florida, 2009.
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Includes bibliographical references.
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Text (Electronic thesis) in PDF format.
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ABSTRACT: In response to the growing child and adolescent obesity epidemic, some states and local school authorities are mandating the measurement of Body Mass Index (BMI). However, there is limited research addressing whether schools are an appropriate setting and the intended as well as unintended effects of sharing this information with parents. Furthermore, there is yet to be conclusive evidence that shows that BMI screening in the school setting is an effective way to improve student BMI status. Therefore, the purpose of this research study was to explore the effects of BMI Health Report Card Letters among 6th grade students and their parents by applying a Social Cognitive Theory conceptual framework. A non-experimental, post test only study design involving child/parent dyads was employed to answer the proposed research questions. Quantitative data were gathered from students and parents using separate theory based questionnaires.Key results include a statistically significant difference between delivery methods (mail vs. backpack) for the number parents who confirmed receiving the BMI letter (p = .001) and reading the BMI letter (p = .005). Additionally, there were statistically significant differences between parents based on child BMI categories. Specifically, a greater number of parents of children "at risk of overweight" or "overweight" took one or more action to control their child's weight associated with food restriction (p = .005) and physical activity (p<.001) and reported greater parental concern about child's weight (p = .001) and parental modeling of negative talk /behaviors (p = .019). Parents of children of "normal weight" reported greater perceived importance of child nutrition behaviors (p = .026). Results indicate the importance of mailing BMI Health Report Card Letters as well as the occurrence of unintended negative consequences.Implications include the need for tailored BMI letters, based on child weight status, which include information and resources to increase parent's capacity to share BMI information with their child as well as make healthy changes in the home.
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Mode of access: World Wide Web.
System requirements: World Wide Web browser and PDF reader.
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Advisor: Rita Debate, Ph.D.
2 650
Body Mass Index.
Obesity.
Overweight.
Child.
Parents.
School Health Services.
Health Promotion.
Models, Psychological.
Questionnaires.
653
Adolescent
Obesity
Nutrition
Physical activity
Parent modeling
690
Dissertations, Academic
z USF
x Community and Family Health
Masters.
773
t USF Electronic Theses and Dissertations.
4 856
u http://digital.lib.usf.edu/?e14.3198