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Maternal and Child Health Journal (2018) 22:958–967 https://doi.org/10.1007/s10995-018-2472-7

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Challenges and Facilitators to Promoting a Healthy Food Environment and Communicating Effectively with Parents to Improve Food Behaviors of School Children

Hiershenee B. Luesse1  · Rachel Paul2 · Heewon L. Gray3 · Pamela Koch2 · Isobel Contento2 · Victoria Marsick4

Published online: 14 February 2018 © Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract Background Childhood obesity is a major public health concern and families play an important role. Improving strategies to reach parents and directing tailored nutrition education to them is needed. Purpose To investigate the challenges and facilitators to promoting a healthy environment at home and to identify communication preferences to inform intervention strategies for effectively reaching low-income urban minority families. Procedure Semi-structured focus group interviews were conducted with four groups involving 16 low-income urban parents (94% female; 88% Hispanic/Latino, 12% African American) of elementary school children. Interviews were transcribed and analyzed applying Social Cognitive Theory and using in-vivo coding. Main Findings The most common barriers to parents providing healthy foods to their children were accommodating child preferences and familial opposition. Parents showed intentionality to engage in healthy behaviors, and often shared procedural knowledge for reaching health goals. The analyses of desired communication channels yielded major preferences: tailored information, information provided through multiple mediums, appropriate duration/frequency of messages, and presented from a voice of authority. Conclusion and Implication While parents expressed desires to be healthy, the home food environment presented substantial challenges. Multi-media supports such as workshops, flyers, and text messaging may be useful to facilitate the sharing of information to minimize the tensions between intentionality and reaching desired goals to be healthy. Some parents thought that information received through text messaging could be easily shared and would act as a voice of authority to support child behavior change.

Keywords Home environment · Childhood obesity · Social cognitive theory · Qualitative study

Significance

Childhood obesity is a major public health issue with high prevalence in African American and Hispanic subgroups. School-based programs have been targeted as effective

venues to reach children. However, for elementary school- aged children, both the home and school are influential set- tings for healthy dietary intake. Among the school-based interventions that incorporate a family component, con- siderable variability exists across studies and a systematic

* Hiershenee B. Luesse [email protected]

Rachel Paul [email protected]

Heewon L. Gray [email protected]

Pamela Koch [email protected]

Isobel Contento [email protected]

Victoria Marsick [email protected]

1 Research, Evaluation, Strategy Consulting, 8RES, LLC, 8 West 87th Street, #7, New York, NY 10024, USA

2 Department of Heath & Behavior, Teachers College, Columbia University, 525 West 120th Street, New York, NY 10027, USA

3 Department of Community and Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, Tampa, FL 33612, USA

4 Department of Art and Humanities, Teachers College Columbia University, 525 West 120th Street, New York, NY 10027, USA

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approach for how best to reach and involve families has yet to be determined, particularly because reaching parents or families, can be difficult. For these reasons, improving strategies to reach parents and providing culturally-relevant and tailored nutrition education are valuable in supporting a coordinated approach for school and family settings.

This study reveals that although parents demonstrate some behavioral capacity to provide healthy foods to their children, they are still hindered by social pressures of other family members and picky eating. However, parents felt that acceptable forms of communication, which could be easily shared with other family members, would help to validate their efforts making it easier to provide healthy foods with- out resistance.

Introduction

Childhood obesity is a major public health issue. In 2011, 17% of American children and adolescents (aged 2–19) were obese, with higher prevalence rates seen among Hispanic (22.4%) and non-Hispanic Black (20.2%) racial and eth- nic groups (CDC Health Disparities & Inequalities Report (CHDIR) 2013). A child suffering from obesity is 6.2 times more likely to become an obese adult than his/her non-obese counterpart and is at increased risk of diet-related health conditions including cardiovascular, metabolic, and psycho- social illnesses (Herman et al. 2009). These health dispari- ties are alarming and indicate how our social and physical environments can have pronounced effects on disadvantaged and minority children.

For elementary school-aged children (aged 6–14), the home and school are influential settings for healthy dietary intake (Baranowski et al. 1993; Cullen et al. 2000). Schools provide continued and intensive contact with children and the provision of food (Cullen et al. 2000). However the home environment influences a significant proportion of the foods consumed by children, especially for younger cohorts (Carl- son et al. 2002; Mazur et al. 2003). Parents and families influence children’s food intake in a number of ways, promi- nent among them being that they provide food for their chil- dren. The availability and accessibility of healthy foods at home are highly correlated with intake in elementary school- aged children (Rasmussen et al. 2006). In addition, parents shape their children’s health-related practices through their modeling of healthful practices; their knowledge of nutri- tion, and the meal structure and eating patterns established in the home. These practices influence children’s develop- ment of lifelong habits (Lindsay et al. 2006). Although the majority of childhood obesity prevention programs exist in school settings, they show better outcomes when they are coupled with a family component (Lindsay et al. 2006; Wu et al. 2013). Among the school-based interventions that

incorporate a family component, considerable variability exists across studies and a systematic approach for how best to reach and involve families has yet to be determined (O’Connor et al. 2009).

Reaching parents or families, however, can be difficult and is especially the case for low-income and minority fami- lies, given the social, cultural, and economic environments in which they live. Language and communication can also pose a barrier for cultural minority families (Daniel-White 2002; Sohn and Wang 2006); and time constraints and logis- tical problems such as lack of childcare, transportation, and scheduling conflicts often exist (Hoover-Dempsey et  al. 2005; Kim 2009). Cultural attitudes and practices related to food and feeding vary among ethnic groups, which can contribute to differences in obesity patterns in children, and how willing a family is to accept or reject nutrition educa- tion (NE) information, especially if it is designed without cultural considerations (Liontos 1991). Lastly, economically disadvantaged parents may also have greater feelings of inadequacy or negative experiences with schools rendering them less receptive to communication (Kumanyika 2008). For these reasons, improving strategies to reach parents and providing culturally-relevant and tailored nutrition education are valuable in supporting a coordinated approach to health promotion programming for school and family settings.

Text messaging is one of the most prevalent cell phone activities; an estimated 85% of African-Americans and 87% of Hispanics/Latinos send and receive text messages (Duggan and Rainie 2013). The use of text messaging has emerged as a direct channel to reach parents at home (Fjeld- soe et al. 2009; Patrick et al. 2009; Sharifi et al. 2013; Webb et al. 2010). For example, the mHealth campaign used text messaging as an effective means of reaching racial and eth- nic minorities to remind them to receive flu vaccinations (Phillips et al. 2014) and Hyun and Glanz (2013) have used text messaging to encourage healthy physical activity behav- ior in African American adults. However gaps in the aca- demic literature still remain for researchers and practitioners on how to best use text messaging to support the delivery of heath messaging related to dietary intake and how this channel might be used with minority parents to encourage favorable and healthy food environments for children in the home (Wu et al. 2013).

The social cognitive theory (SCT) provides a suitable theoretical framework for studying the home environment because it emphasizes the simultaneous and dynamic inter- action of personal, behavioral, and environmental factors on behavior (Bandura 1986; McAlister et al. 2008). This theory has been commonly used in school-based and com- munity-based settings to understand intake of healthy foods with elementary school children, parents, and parent–child dyads (Brown and Ogden 2004; Cullen et al. 2000; Neu- mark-Sztainer et al. 2003; Robinson-O’Brien et al. 2009;

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Thompson et al. 2003). Key theoretical concepts in under- standing healthy behaviors in a family’s home environ- ment include the following: (a) personal factors: outcome expectations (beliefs about the consequences of a behav- ior), attitudes (favorable or unfavorable judgments about a given behavior), self-efficacy (confidence in abilities to execute desired behavioral outcomes); (b) behavioral factors: behavioral capability/competence (ability to execute given behaviors); and (c) environmental factors: social environ- ment (family, networks, and support) and the availability and accessibility of food.

The purpose of this qualitative study is to determine (a) perceptions of what facilitators and barriers exist for improv- ing the healthfulness of the home environment of families with elementary school children, and (b) to determine if text messaging could be a suitable way to reach parents with food and dietary information. An in-depth exploration of percep- tions of parents can provide important information for both researchers and practitioners for how to build in supports to reinforce school-based NE programs at home.

Methods

Study Setting and Population

We conducted four focus groups with parents of elementary- aged children attending public elementary schools in low SES communities of New York City. Focus groups were held from November 2013 to January 2014. A purposeful sample of two schools with a population of Hispanic/Latino and African-American, and traditionally underserved students, and with which the researchers had already established rela- tionships were selected for this study.

Recruitment and Enrollment

The sample of participants was recruited by each elementary school’s parent coordinator through direct outreach and by research assistants through presentations at parent associa- tion meetings and through English and Spanish-speaking research assistants’ direct outreach with parents at schools. Parents were then screened for eligibility and invited to attend a focus group in their preferred language.

Parents were eligible to participate in the study if they (1) had at least one child attending the elementary school; (2) lived with the child attending the school; and (3) could verbally communicate fluently in either English or Spanish.

Focus Group Protocol and Data Collection

A study team, including experienced NE researchers, created the focus group script, informed by standard focus group

techniques (Krueger and Casey 2009; Vaughn et al. 1996), study team discussions, and constructs of the SCT (Ban- dura 1986). Through several iterations, the script ultimately included 12 open-ended core questions derived from study aims and based on the constructs (personal, behavioral, and environmental) and the target mediators (outcome expec- tations, self-efficacy, behavioral capability/competence, social support) of the SCT (see Table 1 for how constructs and target mediators were utilized). These questions were supplemented with broad questions about the topic (before asking the focal questions), probes, follow-up questions, and member checks during the focus groups.

The focus group script spanned two domains: (1) the home environment: exploring motivational and facilitat- ing determinants of consuming healthful foods in the home focusing on drinks, snacks, fruit and vegetable intake, and general meals; and (2) communication methods: exploring current and possible means of communication for reaching parents to bolster healthful food practices focusing on types of communication, use of communications, and text mes- saging to communicate health messages. Each focus group began with a clarification of terms to be used throughout the discussion, having participants define “meals” and “snacks,” so as to not bias the discussion, and by providing a definition of “text message” for the participants to clarify the specific means of electronic communication.

Two focus groups were conducted in Spanish and two in English, based on the language preference of participants. Spanish focus groups were moderated by a native Latina behavioral nutrition researcher (PhD), fluent in Spanish and with experience in group facilitation. English focus groups were conducted by trained female research assistants (MS) with a working relationship with the schools. All partici- pants gave their informed consent prior to their inclusion in the study. One to two trained co-moderators and research assistants took extensive notes for the duration of the focus group discussions. Their notes included nonverbal and ver- bal responses (gestures, heightened expression, tone, and language) related to displays of emotion (e.g. sarcasm, anger, frustration) (Ryan and Bernard 2003; Vaughn et al. 1996), pauses in speech, and group consensus or disagree- ment (Ryan and Bernard 2003). Research staff convened immediately after each focus group to discuss major themes elucidated in the focus group discussions and took note of the meta-themes generated.

Focus groups were conducted in empty classrooms in the school where the parents’ children attended, were held for 90 min, and were audio recorded. All focus groups began with a brief introduction of the moderators and co-moder- ators and an explanation of their reasons for undertaking this research. After each focus group, participants completed a brief socio-demographic survey and received a $10 gift card for their participation. The focus groups were held in

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the early morning. Teachers College Columbia University Institutional Review Board (IRB) approved all procedures (Protocol # 15-087).

Analysis

Focus groups were audio recorded and transcribed verba- tim. Spanish transcriptions were then translated to English by a native Latina behavioral nutrition researcher. All tran- scriptions were reviewed along with their audio recording a minimum of two times by the lead investigator to ensure accuracy and along with field notes to translate and further explain transcribed text with nonverbal and verbal responses. All transcriptions were imported into Dedoose® software (Dedoose 2014–2017, SocioCultural Research Consultants, LLC). The lead researcher developed an initial codebook of themes using a framework analysis approach (Ritchie and Spencer 2002) that included a priori themes based on key mediators from the SCT (outcome expectations; attitudes; social norms; behavioral capability/competence; availability; accessibility; family support); definitions of these mediators, taken from Contento (2015), were used to identify codes within the transcripts. Meta-themes elucidated from and noted after each focus group discussion were integrated into the codebook as described below.

The lead investigator coded the transcripts applying the initial codebook. Additional in-vivo codes, identified using open-coding and margin-coding techniques to identify rep- etition, indigenous typography or categories, metaphors or

analogies, transitions, similarities and differences, linguis- tic connectors, and missing data (Ryan and Bernard 2003) were added to the codebook as new themes emerged. A final codebook was then created by the lead investigator. All tran- scripts were reviewed for inclusion of all applicable codes from the final codebook by two independent coders who applied the coding scheme and met to resolve differences by discussion. Analysis involved the systematic comparison of coded segments across all four focus groups transcripts to identify convergent, salient, and/or unique themes using DeDoose software.

Results

Of the 20 participants recruited, four dropped out for sched- uling reasons. Thematic saturation was reached after four focus groups with four participants in each (n = 16 total) as indicated by no new emerging themes in the last focus group. Participants were all Hispanic and African American racial/ethnic groups (94% female; 88% Latino;12% African American; average 41 ± 7  years of age). See Table  2 for demographic distributions.

Home Food Environment

Analyses yielded the following major themes in parents’ perceptions about the home-food environment related to parents’ outcome expectations and social environment: (1)

Table 1 Focus group interview guide and social cognitive theory constructs and mediators related to each question

Home Food Environment

Question SCT construct Target SCT mediators

Please tell me about some of the drinks that your child really likes? That you have at home?

Environmental Social support; modeling

Do you prepare the snacks for your child? Please name for me some of the foods that your child has for snack

Behavioral Behavioral capacity/competence

Do you prepare the meals that your child has? Please describe some typical meals at your house

Behavioral Behavioral capacity/competence

How do you decide when it’s time to give your child a snack? Personal Physical outcome expectations; attitudes What kinds of things make it difficult to get your child to eat vegetables? Personal/Environmental Self-efficacy How would you feel if somebody from your child’s school made suggestions

to change the way you have a meal? Personal/Environmental Attitudes; social support

Communication techniques

Question SCT construct

What nutrition information have you received in the past? Environmental Social support How would text messaging nutrition information help you? Personal Self-efficacy/barriers; attitudes What are some reasons why you would not want to receive nutrition information

via text message? Personal Self-efficacy/barriers; attitudes

What are reasons that teachers would want to give parents nutrition information? Personal Attitudes What are some reasons parents would want to receive nutrition information? Personal Self-efficacy attitudes

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the importance of parents modeling desired behaviors; and (2) coping with satisfying children’s dislike of vegetables.

Modeling Desired Behaviors

The majority of participants recognized the importance of modeling good behavior to form good habits in their chil- dren, especially with respect to increasing vegetable con- sumption. Many discussed their personal roles and strate- gies. Some parents mentioned the importance of starting these good habits in early childhood. Some mentioned resistance from other family members as negatively influ- encing social and family norms around eating vegetables, often sabotaging their own intentions to encourage healthy behavior. Table 3 provides direct quotes.

Coping with Child Dislike of Vegetables

Child preferences and dislikes were mentioned most as a major consideration in meal preparation and the provision of foods. Many parents customize and alter cooking practices to accommodate their child’s dislikes and preferences and express frustration and exhaustion with the subsequent time and financial burdens. All parents exemplified procedural knowledge and readily shared steps/strategies for overcom- ing these barriers in feeding their children. Table 4 provides direct quotes.

Definitions and Uses of Snacks

Although participants all defined meals similarly, there was variability in the way in which snacks were understood and therefore provided inside and outside the home. Some par- ticipants defined snacks based on the type of food that was provided (e.g. chips, crackers, cookies, fruits); some consid- ered snacks as inherently unhealthy while others considered them as inherently healthy.

Other participants defined snacks based on the portion size but not composition of the food (e.g. smaller than a meal and composed of any foods, for example half a bur- rito or a small portion of rice and beans). Others defined snacks based on a temporal component (e.g. the time of day in which it was offered, e.g. in between meals). In these circumstances, snacks could range from a volume of food

Table 2 Participant characteristics

Variable Mean (range or proportion)

Age [years (range)] 40.4 (29–51) Gender  Female 15 (93.75%)

Ethnicity  African American 6 (37.5%)  Hispanic 10 (62.5%)

Table 3 The Importance of Modeling Desired Behaviors

Theme Direct quotes

Social and family norms Maria: “Listen, you know what it is with vegetables and kids? Well, […] I even have to just put it on their plate from very young, even if they don’t eat it. Eventually, […] they’re gonna get used to it. Most kids will eat what their parents eat.”

Toya: “Now if I make some meal or something like a sauce like we make it in Mexico, for instance, adobo with […] pork adobo and some sauces […], instead of having tortillas […] I wash one of those long lettuce and I put it com- plete. […] Now when they see I eat these kind of things they also crave it and they eat it.”

Amanda: “My husband comes ‘Oh, take away that junk. Don’t put it in here.’ And I say no, I’m going to eat right here and I sit down and eat and I eat my green beans.”

Table 4 Coping with children’s dislikes

Theme Direct quotes

Prefer- ences and Dislikes

Shondra: “I cook a lot of lentils but not beans because my little one doesn’t really like beans. The older one, he does like beans but I make mostly lentils because […] he likes that. […] But I mainly do lentils because he will eat them.”

Maria:”She don’t like carrot, she don’t like [clears her throat], she don’t like carrots. And I make stew and I saw her, she’s picking out all the carrots and like what… I said you don’t take some, she won’t eat carrots’ [sighs with exasperation].”

Behavioral Capabil- ity/Com- petence

Alexis: “They [eat] vegetables but mostly [because] I put them in the soup […] until they all become indistinguishable. […] So if I put cauliflower, broccoli… I mush it without [the children] seeing… and they are eating everything. For instance, the older one, he will not have any meat, no meat at all. So I make the soup. I make fish soup or beef soup and I mush everything and since he doesn’t see anything… Kids, you know, they eat by what they see and since he doesn’t see anything in the soup he has it and he says, “Mom, this is delicious.”

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typically smaller than provided at a meal to a volume equiva- lent to a full meal.

Some participants defined snacks based on pragmatic considerations, such as what is convenient (what is avail- able, easy to divide up and serve, and easy for their children to assemble and prepare on their own). Table 5 provides direct quotes.

Communication Techniques

Analysis revealed major themes related to health commu- nications’ content, logistics of delivery, and tone of mes- sages. Specifically, themes included: (1) the importance of tailored and personalized messaging, (2) temporal strategies, (3) multimodal communication efforts, and (4) creating a voice of authority. Table 6 provides direct quotes.

Content of Health Communications: Tailored and Personalized

Parents expressed a need for tailored and personalized mes- sages for health information. Participants felt that the more personalized a message was, the more likely that it would be used and hold attention. Suggestions included tailoring messages in communication channels that parents already frequently used such as e-mail, websites, text messages, and social media sites like Facebook, as well as messaging in parents’ primary language.

They preferred advice that related to particular themes rather than general information about healthy behaviors which were successful in health promotion programs they had experienced in the past.

Additionally, the use of pictures was mentioned as impor- tant to ensure that low literacy parents have improved access to the content. Generally, examples of useful visual and writ- ten information included (1) healthful cooking techniques, (2) recipes for healthful and inexpensive meals, and (3) information on appropriate portion sizes.

Health Communication Logistics: Temporal Strategies

Some participants indicated that written information sent home may be helpful as long as it was infrequent, e.g. on a monthly basis. Some parents were strongly opposed to receiving text messages, while others thought they would be helpful. There was some consensus that text messages received in the evening would be a suitable time.

Health Communication Logistics: Multiple Channels

Participants suggested that communications should be pro- vided in more than one forum: e.g. text messages provid- ing links to websites and using e-mail in addition to text messaging; using flyers, posters, calendars, and workshops/ demonstrations.

Inclusion of a Voice of Authority

Participants noted that nutrition information from a figure outside the family would provide a “voice of authority.” They anticipated greater responsiveness from their children simply because the source of information was from someone other than themselves as parents. This idea seemed to alle- viate tensions and exasperations that parents felt trying to

Table 5 Definitions and use of snacks

Theme Direct quotes

Type of foods Mira: “He can have some Doritos, some chips […] or he can have like a banana or an apple.” Lavinia: “I was diagnosed with diabetes plus high cholesterol. So I cook no salt, no sugar, no snacks. So we don’t

give snacks at home.” Diana: “I buy sometimes some of those little boxes of cookies that come with like Mickey Mouse or Winnie the

Pooh, animal crackers! Or I give granola bars to give them something healthy.” Suki: “[…] always have fruits, they’ll get, you know, an apple or something like that.”

Serving Size or Time of Day Provided

Amanda: I give her, you know, like I give her a lot of things but it’s small portions. I portion it out. I don’t think she needs six pieces of bacon. I give her one, one piece of bacon, one piece of sausage, an egg

Harden: “Yeah. It depends on the attitude one has that day. A good soup, some rice, that is very good. I give them a small bowl or some little plate of something.”

Suki: “Yeah, it’s the same thing. They’ll drink their juice when they get home; they get a snack, always have my fruits, they’ll get, you know, an apple or something like that.”

Edna: My daughter gets a snack at bedtime. That’s it. The only time of the day she gets a snack is bedtime Pragmatic Considerations Maria: Cereal, fruit, one granola bar, sometimes some Jell-O if I have Jell-O. Sometimes I have Jell-O. Anything that

I have there Jennifer: “Well, like I said, I give my kids money every day ‘cause I’m working and my son will get a pizza for a

snack or my daughter go and grab two bags of chips for a dollar and that’s what they have.”

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implement healthful behavior change, and was seen as proof to validate their efforts.

Discussion

Home Food Environment

This study applied the SCT as a framework for exploring the home food environment from the perspective of parents of elementary school-aged children. Parents primarily dis- cussed their outcome expectations, behavioral capability/ competence, and the influence of others, indicating that these mediators may be important to address in nutrition interventions with parents of children. Reynolds et al. (2002) have demonstrated through mediation analysis that parental change in outcome expectations and behavioral capability/ competence may increase intake of fruits and vegetables in elementary school-aged children. However, findings from

this study suggest that despite demonstrations of behavioral capability/competence for providing and preparing fruits and vegetables, parents felt other barriers persisted in making it difficult to encourage fruit and vegetable intake with their children.

A large proportion of the parents in our study indicated that pickiness posed a major barrier to their child’s con- sumption of fruits and vegetables and they commonly accommodated their children’s mealtime requests and strug- gled to prepare acceptable healthy foods. In a similar study, Slusser et al. (2011) demonstrated that parents found cost, getting their kids to eat healthy foods, and easy access to fast foods were the most common barriers to providing healthy foods for their family. Although cost and accessibility issues were mentioned by parents in this study, they were not the prominent barriers.

Other research with low-income African-American, White, and Hispanic mothers (but to a lesser degree with middle-income mothers) found a similar dynamic of

Table 6 Health communications’ content, logistics of delivery, and tone of messages

Theme Direct quotes

Content of Health Communications: Tailored and Personalized Edna: “Like Diana said, you send them a flyer with the information to an internet site to parents where they can communicate and ask questions for help there where the help would be, the explanation and all.”

Delma: “One more thing also. We are many parents that speak Spanish, and many of us we can read some of it but maybe there is one word we do not understand and that changes the sentence. So it is important to send it in Span- ish.”

Diana: “We usually have parent workshops, sometimes through handouts, when we give away pamphlets about some themes, something that is already in place, different themes, those could be good options.”

Suki: “[…] always have fruits, they’ll get, you know, an apple or something like that.”

Health Communication Logistics: Temporal Strategies Jessica: “Depending on how many you are going to send because sometimes there you go back and forth sending messages and hear the machine going “ting, ting, ting” every second. Sometimes it good, sometimes yes and some- times not.”

Health Communication Logistics: Multiple Channels Jessica: “The papers that they send home. Sometimes I look at the papers and sometimes the children do not even bring them home. So I would want both ways, you can see it from the papers or see it in the computer. […] Yes, because sometimes one cannot arrive and see the papers or go on a computer, so you can have them in the phone, also.”

Edna: “That could be good, once in a while, a text message. I try to get into the Internet […] I try to navigate […] I try to use it as much as possible and if my phone is not good enough to get the information I want other means to try to get the exact information.”

Inclusion of a Voice of Authority Mirna: “Not the parents ‘cause they think the parents just don’t want them to have certain stuff, and they’re like oh, you just don’t want me [to have this]. And at least when somebody else comes in and teaches them about every- thing, no, they were not just talking, talking, ‘cause we don’t want to spend the money.”

Delma: “Yes, because if I had explained to my son what you explained, forget about it, but since it was you who explained, he came and told me. So it is good because sometimes the kids listen more to their teachers, the people that go and talk to them than to us, their parents.”

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parents accommodating their child’s preferences and dis- likes through individualized meal preparation (Sherry et al. 2004). Parents in this study aimed to improve the accept- ability of certain foods by adding flavors, like sweeteners, and modifying preparation to hide vegetables to encourage liking, as seen elsewhere (Cullen et al. 2000; Mascola et al. 2010). Although these strategies are well intended, they may be counterproductive to developing long-term healthy habits and could create greater neophobia (Carruth and Skinner 2000) and picky eating syndrome over time (Mascola et al. 2010). Galloway et al. (2003) have demonstrated that picky eating behaviors are derived from insufficient exposure to novel flavors; other research demonstrates that parenting style, the use of rewards and punishments, and excessive restriction of certain foods over others may also influence dietary intake of fruits and vegetables in children (Birch et al. 2007). Collectively, these factors may be of importance in developing health promotion materials for members of this cohort.

In general, parents felt that setting a good example as models for healthy eating was important, and that introduc- ing vegetables early and allowing their children to “get used to them” was encouraged. However, parents felt their social environments had a great impact on food practices at home (rather than their own modeling) with other family members setting “bad examples.” A body of literature exists support- ing this phenomenon and suggests that social support of all family members for healthy eating is an essential component to sustained healthy patterns of children (Ball et al. 2010; Kiernan et al. 2012). An emphasis on family may be particu- larly important with Hispanic families who are strongly fam- ily-centric and for whom community-focused interventions may generate more culturally appropriate health promotion programs (Gruber and Haldeman 2009). In a similar study with a predominantly Hispanic population, Slusser et al. (2011) found that parents expressed a desire for educational materials that engage the entire family, especially fathers.

Even though parents faced many challenges with respect to picky eating, they were also eager to share procedural knowledge and skills with each other about food prepara- tion, shopping, and improving their children’s health, dem- onstrating high behavioral capability/competence. Research shows that parents have a high level of interest in peer-led education, in which parents share resources and disseminate healthful practices, indicating an area of research that could further be developed (Duncanson et al. 2014).

This study demonstrates that parents may already recog- nize their important role in modeling positive food behav- iors, and have procedural knowledge and skills and self- efficacy for preparing and providing fruits and vegetables but need help in addressing other challenges, such as getting their children to eat healthfully and dealing with unsupport- ive family members.

Lastly, ethnic differences and differences in acculturation emerged in the definitions and use of snacking among our participants. Most African American parents and Hispan- ics born within the USA tended to identify snacks as chips, cookies, bars, and fruits compared to parents born to Latin America who tended to define snacks as any food provided either in smaller portions or at specific times in the day; which were often similar to what might be considered meal time foods. Some research indicates that degree of accultura- tion leads to decreased diet quality in people immigrating to the United States (Pérez-Escamilla 2009). Native born Americans or families with greater acculturation to the American lifestyle may be more likely to consider snacks a daily routine, usually involving the provision of highly- processed foods, such as chips, candy, and soda, contributing to an increase in the proportion of discretionary calories that make up their children’s diets.

Above tailoring nutrition education interventions to dif- ferent cultural and socioeconomic practices, it may also be important to ensure that foods and concepts are understood, defined, and used in similar ways.

Communication Techniques

Parents reported general acceptability and enthusiasm for personalized and tailored communications. They felt com- munications that they could share with their children and friends would validate their efforts to engage in healthier behaviors, and could act as a persuasive means of encour- aging others in their lives as it could provide a “voice of authority.” Parents indicated that multiple forums of communication were important to them, and expressed the need for bilingual print, and the use of images to address literacy issues. Some parents were opposed to text mes- saging due to the associated costs and inconsistent cell service and were not interested in providing their contact information, while others thought that it was preferable because of the immediate, brief, and sharable nature of a text message. Although cellular phones are increasing in ubiquity and the socioeconomic divide to access is nar- rowing, privacy issues related to legal status in the country may have been a reason for some additional opposition to text message use in our cohort. Previous studies have already demonstrated success with respect to text messag- ing interventions in promoting behavior change for parents (Kharbanda et al. 2010; Sharifi et al. 2013). Sharifi et al. (2013) demonstrated that parents of children enrolled in obesity prevention programs felt supported through text messaging. However, unlike in our study, their parents preferred text messaging to other forms of communica- tion (including paper or e-mail). Parents in these studies who were accepting of text messaging suggested limiting

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frequency, and reserving messages for particular times of the day as suggestions to increase acceptability (Khar- banda et al. 2010; Sharifi et al. 2013).

These findings indicate the importance of tailoring nutrition communications for culturally diverse and/or low- income populations. Tailoring communication may need to consider use and penetration of cell phones, the need for bilingual communications, and using multimodal forms of communication. Finding acceptable forms of communica- tion to provide health-information that parents can easily share with other family members, may help validate and sup- port their efforts to make healthy changes at home. Platforms that interact with all family members may also be more cul- turally appropriate and help to increase buy-in, especially for Hispanic families.

Strengths and Limitations

Data collected in the focus groups were based on self- report and were not verified by other means. Additionally, translations of audio files from Spanish to English were not back translated for accuracy although all audio files were reviewed a minimum of two times in the translation and tran- scription process. Also, generalizability is limited because of the small sample size. Although a range of Latino and African-American parents were involved, and representa- tive of people found in low-income New York neighbor- hoods, participants with lower literacy or that may have been undocumented were not represented in our sample. Further research should include efforts to recruit a more broadly representative group of Hispanic and African- American parents. Although this study focused primarily on text messaging, other researchers and the food industry have also been successful in reaching parents via the Inter- net and social media. Further research may also expand on this work to determine how these other platforms might be received alongside text messaging with this cohort. Though the number of participants per group was small, the number of focus groups was based on saturation of information from the participants. Additionally, the use of SCT as a broad framework allowed for cultural and socioeconomic factors to be considered in the home food environment with minor- ity participants.

Many of the feeding practices revealed in our focus groups need to be examined further, preferably in experi- mental studies to help elucidate the mechanisms for their use. Examples of topics needing further study include the preparation of different meals to accommodate picky eaters, and successfully navigating “saboteurs” to healthy practices at home. The application of text messaging and other sup- portive communication means to help families effectively manage these concerns is also warranted.

Acknowledgements The authors thank parent coordinators for their technical assistance with this study. A portion of this study has been presented in abstract form at the Society for Nutrition Education and Behavior conference in Wisconsin, 2015.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflict of interest.

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