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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=when20 Download by: [96.86.0.61] Date: 16 October 2017, At: 12:39 Journal of Hunger & Environmental Nutrition ISSN: 1932-0248 (Print) 1932-0256 (Online) Journal homepage: http://www.tandfonline.com/loi/when20 Using text messages to engage low-income parents in school-based nutrition education Stephanie K. Grutzmacher, Erin Braunscheidel Duru, Katherine E. Speirs, Laryessa Worthington, Ashley L. Munger & Lisa A. Lachenmayr To cite this article: Stephanie K. Grutzmacher, Erin Braunscheidel Duru, Katherine E. Speirs, Laryessa Worthington, Ashley L. Munger & Lisa A. Lachenmayr (2017): Using text messages to engage low-income parents in school-based nutrition education, Journal of Hunger & Environmental Nutrition, DOI: 10.1080/19320248.2017.1364196 To link to this article: http://dx.doi.org/10.1080/19320248.2017.1364196 Published online: 09 Oct 2017. Submit your article to this journal Article views: 17 View related articles View Crossmark data

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Page 1: Using text messages to engage low-income parents in school ... · Using text messages to engage low-income parents in school-based nutrition education Stephanie K. Grutzmacher a,

Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=when20

Download by: [96.86.0.61] Date: 16 October 2017, At: 12:39

Journal of Hunger & Environmental Nutrition

ISSN: 1932-0248 (Print) 1932-0256 (Online) Journal homepage: http://www.tandfonline.com/loi/when20

Using text messages to engage low-incomeparents in school-based nutrition education

Stephanie K. Grutzmacher, Erin Braunscheidel Duru, Katherine E. Speirs,Laryessa Worthington, Ashley L. Munger & Lisa A. Lachenmayr

To cite this article: Stephanie K. Grutzmacher, Erin Braunscheidel Duru, Katherine E. Speirs,Laryessa Worthington, Ashley L. Munger & Lisa A. Lachenmayr (2017): Using text messagesto engage low-income parents in school-based nutrition education, Journal of Hunger &Environmental Nutrition, DOI: 10.1080/19320248.2017.1364196

To link to this article: http://dx.doi.org/10.1080/19320248.2017.1364196

Published online: 09 Oct 2017.

Submit your article to this journal

Article views: 17

View related articles

View Crossmark data

Page 2: Using text messages to engage low-income parents in school ... · Using text messages to engage low-income parents in school-based nutrition education Stephanie K. Grutzmacher a,

Using text messages to engage low-income parents inschool-based nutrition educationStephanie K. Grutzmacher a, Erin Braunscheidel Durub, Katherine E. Speirs c,Laryessa Worthingtonb, Ashley L. Munger d, and Lisa A. Lachenmayrb

aCollege of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon, USA;bMaryland Food Supplement Nutrition Education, University of Maryland Extension, Columbia,Maryland, USA; cDepartment of Family Studies and Human Development, University of Arizona,Tucson, Arizona, USA; dDepartment of Child and Family Studies, California State University, LosAngeles, Los Angeles, California, USA

ABSTRACTBecause children spend significant time in school settings,school-based programs have great potential to prevent child-hood obesity. Nutrition education and physical activity programsmay be more effective, however, when they engage parents toreinforce key messages and behaviors outside of school settings.The Maryland Food Supplement Nutrition Education program(FSNE) partnered with 23 Title I elementary schools in Marylandto develop and administer Text2BHealthy, an innovative textmessage program that engages parents in their children’sschool-based nutrition education. Text2BHealthy sends 2 beha-viorally focused text messages to enrolled parents each week.These messages provide actionable nudges that encourageimproved nutrition and physical activity and reference upcomingfree or low-cost opportunities and events in the child’s school andthe surrounding community. Preliminary evaluation results sug-gest that Text2BHealthy resulted in improvements on a numberof fruit and vegetable practices of parents and their children.Additional evaluation research is needed to demonstrate efficacyof text message programs and program components.

KEYWORDSCommunity involvement;low-income parents;nutrition education; obesityprevention; parentalinvolvement; school-agedchildren; school-basedintervention; text messages

Children spend significant amounts of time in school settings, where schoolstaff, peers, programs, and policies addressing nutrition, school meals, andphysical activity have potential to substantially influence children’s foodenvironments and weight health. Evidence of significant, long-term impactof school-based childhood obesity prevention programs on children’s eatingpatterns, physical activity levels, or weight status, however, is inconsistentand inconclusive and fails to identify necessary intervention components orstrategies.1,2 Programs that target both children and their parents may have agreater impact than those that only target children so that positive features ofthe school food environment can be replicated and reinforced at home,3,4 butparents, especially low-income parents, can be hard to engage. Though most

CONTACT Stephanie K. Grutzmacher [email protected] College of Public Healthand Human Sciences, Oregon State University, 118B Milam Hall, Corvallis, Oregon 97333, USA.

JOURNAL OF HUNGER & ENVIRONMENTAL NUTRITIONhttps://doi.org/10.1080/19320248.2017.1364196

© 2017 Taylor & Francis Group, LLC

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parents are busy regardless of income, low-income parents may be less likelyto engage with in-person, school-based programs5 due to logistical challenges(e.g., transportation, child care, work schedules),6,7 not due to lack of interest.

Text messages may be an effective way to deliver program content to busyparents for several reasons. Text messages are a quick, low-burden, cost-efficient method for communicating with hard-to-reach populations, includ-ing low-income, geographically remote, and low-literacy audiences.8,9 Thevast majority of parents have cell phones that can receive text messages,10

and most pay a set monthly fee for unlimited text messages. There is alsogrowing evidence that text message–based health promotion programs canlead to behavior change in a variety of populations.11–13 Though moreresearch is needed to determine the long-term efficacy of text message healthpromotion programs and best practices in implementation, a recent meta-analysis of text message programs showed that the majority of programsaddressing physical activity, weight loss, and diabetes self-management werefound to be effective.13

Text2BHealthy program overview

The Maryland Food Supplement Nutrition Education program (FSNE), theSupplemental Nutrition Assistance Program Education (SNAP-Ed)-imple-menting agency in Maryland, partnered with 23 unique Title I elementaryschools (see Table 1) in Maryland to develop and administer Text2BHealthy.Schools with SNAP-Ed programs in at least half of the grades were selected toparticipate. Text2BHealthy was the first SNAP-Ed texting program to receiveapproval and funding and has been operating for 4 years following a 4-month pilot.

Parents who enroll in Text2BHealthy receive 2 text messages each weekduring the school year and 2–3 messages each month during the summer.

Table 1. Text2BHealthy school characteristics, 2012–present.a

Year Schools, nFree and reducedmeal rate,b M, (%)

Rural–urbancontinuum code,c M

2012–2013 10 80.89 2.22013–2014 18 81.07 2.62014–2015 15 77.47 2.52015–2016 16 76.69 2.4

a2016–2017 data not yet available.bFree and reduced meal rate is the combined proportion of students receivingfree and reduced meals.

cRural–urban continuum code is a classification system of the USDA EconomicResearch Service that classifies counties into one of 3 metropolitan or 6 non-metropolitan categories, with 1 representing the most urban and 9 representingthe most rural. The classifications are issued decennially, and the current dataare for 2013–2023.

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Messages provide actionable nudges that encourage nutrition or physicalactivity behavior change and reference opportunities and events in the child’sschool or local community. These message complement the in-person,school-based nutrition education that FSNE provides to elementary schoolstudents to support parents in reinforcing key messages. In order to increaseparent engagement and message relevance, FSNE staff collaborated withschool staff to develop messages that are targeted to and unique by schoollocation. Sample messages include the following:

● Some students had a lesson today on seeds, soil & sun. All students tookhome a newsletter. Check the backpack for more info on growing plantsat home.

● Fresh berries like strawberries & blackberries are in season now. Visitthe Catonsville Market for fresh local veggies. You can even use EBTcards!

Text2BHealthy program evaluation

Various forms of process and outcome evaluation are ongoing and includedata from intervention and control schools. In order to examine whetherText2BHealthy improves outcomes in school-based FSNE programs, childrenat both Text2BHealthy schools and control schools received standard class-room-based nutrition education from FSNE educators and classroom tea-chers trained by FSNE educators using US Department of Agriculture(USDA) Food and Nutrition Service nutrition education curricula.

Data from the pilot and first 2 program years were used to refine recruit-ment, enrollment, and retention methods, as well as improve timing, fre-quency, and content of messages. During the first year, Text2BHealthy wasoffered in 11 schools and enrolled 1149 participants, 25% of eligible parents.Using recruitment and retention strategies refined over time,14 programenrollment and retention improved to enroll about a third of eligible parents(n = 2297) and consistently retain between 90% to 92% of participants (seeTable 2) across 23 unique schools.

At the beginning and end of the third school year, a survey was conductedwith a sample of 142 participants who consented to participate and hadcomplete pre and post data. Parents chose whether to receive the survey ina web-based or paper format mailed to their homes. Parents self-reportedfood purchasing behaviors, characteristics of the home nutrition environ-ment, and basic demographic characteristics and reported on children’sbehavior related to eating and physical activity behaviors and screen time.However, insufficient data were collected from control participants to includethem in data analysis. Overall, the intervention group significantly improved

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from pre- to posttest over several domains, such as fruit and vegetableavailability in the home, children’s fruit and vegetable consumption, andparents’ modeling fruit and vegetable consumption in the home.Additionally, from pre- to posttest, 31% and 29% of parents reportedincreased frequency of children’s vegetable and fruit consumption, respec-tively; 29% reported increased frequency of keeping both fruit and vegetablesready for children to eat; and 23% and 35% reported increased frequency ofchildren seeing parents eating vegetables and fruits, respectively.

These findings are similar to those found in studies of similar programs,showing positive changes as a result of behaviorally focused text messages butlacking in research design sufficient to demonstrate long-term effects. Thoughmore comprehensive outcome evaluation is needed to examine program effi-cacy and long-term effects, these preliminary findings indicate the potential oftext message–based programs to reach low-income parents or other hard-to-reach populations with nutrition and physical activity messages. This tool mayserve as an important means of engaging parents to reinforce key healthmessages learned and practiced by children in school settings. Text2BHealthydemonstrates the feasibility of implementing a targeted text message nutritionpromotion program in community nutrition settings.

Acknowledgements

The authors acknowledge the contributions of Lindsey Zemeir, Kaitlyn Moberly, LaurenMessina, and Nicole Finkbeiner in evaluating the Text2BHealthy program; Amy Bortnickand Sally Kamen in implementing the program; and Lisa Gonzales, Quinney Harris, JaneKostenko, Mary Rooks, Kristin Spiker, Haylee Staruk, Karen Turner, Joi Vogin, and MichelleWilson in supporting recruitment and evaluation activities and facilitating relationships withparticipating schools.

Funding

Funding for the SNAP-Ed program is provided by USDA in cooperation with the MarylandDepartment of Human Resources and the University of Maryland.

Table 2. Text2BHealthy participation, 2012–present.

Year N % of Parents enrolled% of Enrolled

parents retained No. of schoolsa

1 (September 2012–August 2013) 1149 25 90 102 (September 2012–August 2014) 2473 33 90 183 (September 2014–August 2015) 2297 35 92 154 (September 2015–August 2016) 2223 29 90 165 (September 2016–present) 1445 21

aText2BHealthy has been offered at some schools over multiple program years, though it has beendiscontinued and added at other schools for various reasons, including Title I eligibility, school staffchanges, and exposures from other nutrition education programs.

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ORCID

Stephanie K. Grutzmacher http://orcid.org/0000-0002-3060-7642Katherine E. Speirs http://orcid.org/0000-0002-4900-2766Ashley L. Munger http://orcid.org/0000-0003-2640-8381

References

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3. McLean N, Griffin S, Toney K, Hardeman W. Family involvement in weight control,weight maintenance, and weight-loss interventions: a systematic review of randomizedtrials. Int J Obes Relat Metab Disord. 2003;27:987–1005. doi:10.1038/sj.ijo.0802383.

4. Flynn M, McNeil D, Maloff B, et al. Reducing obesity and related chronic disease riskin children and youth: a synthesis of evidence with “best practice” recommendations.Obes Rev. 2006;7(Suppl 1):7–66. doi:10.1111/j.1467-789X.2006.00242.x.

5. Lareau A. Home Advantage: Social Class and Parental Intervention in ElementaryEducation. Lanham, MD: Roman & Littlefield; 2001.

6. Child Trends. Parental Involvement in Schools. Available at: http://www.childtrends.org/?indicators=parental-involvement-in-schools Published September 2013. AccessedAugust 19, 2016.

7. De Carvalho ME. Rethinking Family School Relations: A Critique of ParentalInvolvement in Schooling. New York, NY: Teacher’s College Press; 2001.

8. Fjeldsoe B, Marshall A, Miller Y. Behavior change interventions delivered by mobiletelephone short-message service. Am J Prev Med. 2009;32(2):165–173. doi:10.1016/j.amepre.2008.09.040.

9. U.S. Department of Health and Human Services. Health Resources and ServicesAdministration. Using Health Text Messages to Improve Consumer Health Knowledge,Behaviors, and Outcomes: an Environmental Scan. Rockville, MD: US Department ofHealth and Human Services; 2014.

10. Ahlers-Schmidt CR, Chesser A, Hart T, Paschal A, Nguyen T, Wittler RR. Textmessaging immunization reminders: feasibility of implementation with low-incomeparents. Prev Med. 2010;50:306–307. doi:10.1016/j.ypmed.2010.02.008.

11. Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in diseaseprevention and management. Epidemiol Rev. 2010;32:56–69. doi:10.1093/epirev/mxq004.

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14. Speirs K, Grutzmacher S, Munger A, Messina L. Recruitment and retention in an SMS-based health education program: lessons learned from Text2BHealthy. Health Info J.2015;22(3):651–658. doi:10.1177/1460458215577995.

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