Duration: 10/01/2008 to 09/30/2013

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Statement of Issues and Justification

Need and importance
Osteoporosis, a disease of the elderly, is most commonly connected to calcium; however it is not generally regarded as a childhood disease. Yet, the origins of osteoporosis putatively occur at the much younger age of 10 to 13 years during the period of peak bone acquisition. Many of the nutrition messages directed at improving intakes of calcium focus on picking a certain number of calcium rich foods (CRF) per day, e.g., the 3-A-Day campaign. The Dietary Guidelines 2005 and MyPyramid point to meeting recommended servings. Parents and caregivers are a dominant influence on eating and activity behaviors of early adolescents and therefore play an essential role in preventing osteoporosis by promoting intake of CRF. However, few messages about improving CRF intake among early adolescents are directed to the parents role. Little is known about what the content of these messages should be, how they would be perceived, and whether they would motivate parents to promote CRF to early adolescents. Key messages could address motivation and/or benefits to behavior change, barriers and strategies to enable parents to promote CRF intake among early adolescents.

Previous research from W-1003 identified several relevant factors that positively influenced early adolescents consumption of CRF. Availability of CRF, parental encouragement and expectations regarding beverage consumption, and role modeling were important parental and child-related factors. Some of the same factors have even been shown to be associated with bone mass in early adolescent girls. Therefore, research is needed to develop, test, and measure the effectiveness of messages based on these factors that motivate parents to promote early adolescents consumption of CRF.

Given that little has been done to determine which messages would resonate with parent audiences regarding their role in promoting intake of CRF for their children, we propose to fill this void through qualitative methods. Risk communication literature and social marketing concepts indicate that behavior change involves understanding perceptions and motivations concerning the behaviors of interest. Qualitative research methods provide data that can only come from the persons engaged (or failing to engage) in the behaviors. Understanding whether parents perceive that their child is susceptible to risk from consuming diets low in CRF as well as the belief systems that influence those perceptions are needed to craft messages and develop programming that will motivate parents to change behavior.

Based on the results of focus groups and open-ended interviews that utilize projective techniques, we will first explore parental motivations underlying the factors that influence CRF intake of early adolescents identified in W-1003. Second, we will identify salient actionable messages for use with parents and develop these ideas for message testing. Through testing, we will assess the potential relevance, acceptance, comprehension and potential impact of the pre-determined messages related to making CRF available, encouraging CRF intake, setting expectations regarding beverage consumption, and role modeling intake of CRF. Testing to evaluate the pre-determined messages will also involve projective techniques in conjunction with focus group and individual interviews. In addition, we will clarify preferred education methods and delivery means. Understanding what messages are credible and compelling to parents will inform and guide our future development of a directed nutrition intervention that would be quantitatively evaluated.

Technical feasibility of the research and advantages for doing the work as a multistate effort
The qualitative methods proposed for this project have been used previously by the researchers both in their own individual projects and collectively in this on-going multi-state effort (W-191, W-1003). In our experience, individual and focus group interviews are inexpensive data collection methods with recruitment and compensation accomplished easily. This approach has been successful in part because we have access to diverse populations through the Extension service and access to community locations and university buildings to conduct interviews with the populations of interest. In our previous projects, we have been able to recruit large sample sizes including participants from our targeted race/ethnic groups based on access in particular geographic regions. With several experienced nutrition educators, development of messages is feasible; however, expertise will be recruited to enhance the team relative to marketing approaches.

The collaborative efforts of a cohesive group produce high quality research outcomes. Working as an experienced team, this project will benefit from the diverse strengths each investigator brings to the research questions. No single state has the breadth of expertise provided by the collective group. Researchers involved in this proposal possess a wide range of expertise which is directly relevant to the project. Researcher expertise includes consumer behavior and consumer economics, specifically factors that lead to attitude changes as well as identification and evaluation of nutrition-related attitudes and beliefs. Many of the researchers have been involved in developing nutrition education materials and outreach efforts for a variety of audiences (children, adults, minorities, etc.) and have worked in the field with maternal, child and adolescent nutrition programs serving ethnically diverse audiences including Southeast Asians and Mexican Americans. There is shared expertise in work with underrepresented groups with project experience in Hispanic and Asian health and nutrition issues. Several of the researchers have expertise in using both quantitative and qualitative research methods, program evaluation as well as nutritional epidemiology, dietary assessment and analysis and theory-based behavior change interventions.

Several members of the research team have formal appointments as specialists in Cooperative Extension. The remaining members work closely with faculty and staff in Extension in their home states, through research and intervention/outreach projects, so that access to Extension audiences as described in the proposal is feasible and reasonable. A multistate perspective will provide greater abilities to recruit a wide representation of the sample population, which is not feasible for groups working within a more narrow geographic reach. Studying a population from multiple states with diverse demographic characteristics will provide a rich database from which to identify motivations and test messages based on factors that may promote intake of CRF by early adolescents.

Expected impacts
We expect that this project will result in:
a) A better understanding of the underlying motivations and/or perception of benefits and barriers for parental factors that influence intake of CRF by early adolescent Asian, Hispanic and non-Hispanic white children. These factors include making CRF available, encouraging intake of CRF, setting expectations for beverage consumption, and role modeling intake of CRF.
b) A set of messages based on this understanding that are relevant, convey what is intended, culturally appropriate, and likely to impact parental factors that influence intake of CRF by early adolescent children,
c) Tested key components for a future osteoporosis prevention program for parents including messages and information about preferred delivery methods and channels.

Related, Current and Previous Work

Introduction
Adequate calcium intake as an adolescent is crucial for sufficient mineralization of the skeleton to ensure bone health later in life (1) yet dietary calcium intake begins to fall during this stage of life (2). Most older children and adolescents in the United States do not consume enough calcium from food and beverages to meet the recommended intake. Calcium intake from food/beverages was estimated to meet only 67% and 88% of calcium requirements for girls and boys, respectively, aged 9 to 13 years (3). Calcium intake varied based on the race/ethnicity of the child (4-6). Family environmental factors, both physical and social, also influenced eating patterns and diet quality including intake of CRF by early adolescents (7-8).

Family environmental factors based on Social Cognitive Theory
Parents and caregivers are the dominant influence on childrens behaviors and therefore play an essential role in preventing osteoporosis by promoting healthy eating and activity behaviors. Social Cognitive Theory (SCT) explains human behavior in terms of a triadic, dynamic and reciprocal interaction between personal factors, behavior and environmental influences (9). SCT is the most widely used theory for designing nutrition education programs because it provides a comprehensive conceptual framework for both understanding determinants of behavior as well as mechanisms for behavior change (10).

Application of SCT involves a focus on families as an important element of both the physical and social environment influencing dietary behaviors of children (7) as follows:
Physical environment - includes the availability and accessibility of food which may be dependent on parents preferences, beliefs and attitudes, as well as parental characteristics such as income, education and time constraints,
Social environment - includes socioeconomic and sociocultural factors, mealtime social context and structure, and parental attitudes and behaviors such as modeling.

Personal, behavior and environmental factors that influence food choice and nutrition-related behaviors of children and adolescents have been studied from a parental/household perspective:
1) food related factors (taste preferences, familiarity, positive social affective context, models and rewards) (8, 11-14),
2) intra and interpersonal factors (perceptions and beliefs, attitudes, knowledge, personal meanings and values, family social norms and networks) (15-18), and
3) environmental factors (availability, social and cultural environments, social structures, cultural practices, price, time) (19-22).

Availability and Modeling
Parents serve as the primary food gatekeeper, controlling the availability of foods in the home, thus influencing intake of children (8, 19-20, 23). Results from several studies support a relationship between household availability of foods and beverages and intake by adolescents (24-25). Household availability of soft drinks was inversely associated with dairy intake of girls and serving milk at meals less often was negatively associated with dairy intake of boys (26). Calcium intake of adolescent boys and girls was associated with availability of milk with meals (17). Mothers indicated they were more likely to make CRF accessible for children after participation in an osteoporosis prevention trial (27).

Parents serve as role models to influence intake of healthy foods by children. Mothers who drank more milk and fewer soft drinks had daughters with similar beverage consumption patterns (28). In another study, modeling of milk consumption by a significant adult was associated with improved calcium intake for adolescents (29). Mothers intake of soft drinks/fruit drinks was positively associated with intake of these drinks by adolescents (30). The childs perceptions of parental modeling also influenced food intake of adolescents (21, 25, 31). In other studies, mothers and daughters showed similarities in milk consumption (22) and lifetime calcium consumption (32). Parental dairy intake was positively associated with increased dairy consumption among their adolescent children, but many parents did not consume the recommended dairy servings (26).

The availability of CRF and potential for parents to role model intake is influenced by meal patterns and whether foods are consumed at home or away from home (7, 33). Secular food consumption trends show an increase in the frequency of eating food away from home compared to 20-30 years ago (34). As children age, the predominant caloric source shifts from home to school/day care and fast food establishments while foods prepared at foodservice establishments contain less dietary calcium on a per-calorie basis compared to foods prepared at home (35). The frequency of eating at fast-food restaurants by children was related to not meeting the requirement for calcium intake (36) and children who ate fast food drank less milk compared with those who did not eat fast food on one survey day (37). Among 9 to 14 year olds, more healthful dietary patterns, including higher calcium intake, were associated with increased frequency of family dinners (38). When adolescents ate meals with all or most of their family more frequently, intake of CRF was greater (39).

Encouragement and Expectations
Parents and caregivers serve in a mentoring role to shape food-related beliefs, attitudes, knowledge, and preferences of children through the use of food socialization practices. These practices include the sharing of verbal and non-verbal messages regarding foods, nutritional explanations and discussions about foods and nutrition (40-41). Studies of the role of parental encouragement and support and eating behaviors of children and adolescents have focused on fruit and vegetable, fat or calcium intake (17, 23, 42) and were supportive of an association between this type of parental involvement and desired intake. For example, adolescents reported that encouragement from family was a common and helpful support mechanism for healthy eating (18). Among male adolescents, social support for healthful eating involving parental encouragement was positively associated with calcium intake (17). Parental concern over their own health may drive adolescent eating behaviors as mothers who began taking calcium supplements also increased calcium intake in their children (15). Mothers concern for healthful eating was associated with the home food environment and perceptions of maternal concern held by adolescents were positively associated with eating behaviors of adolescents (16).

Parental expectations regarding rules about the frequency with which particular foods should be offered and consumed can influence intake (21, 43-44). About 41% of 10-year old children indicated they were always obliged by parents to drink milk (44). When children were expected to engage in healthy eating practices at age 10, their intake of fat and sugar was lower as an adolescent. However, studies examining the impact of strict food-related parenting practices on the dietary intake of early adolescents have shown contradictory results. For example, a high level of parental strictness or demandingness was associated with lower consumption of sugar-sweetened beverage consumption in one study and with a higher intake of high fat and sugar snacks in another study (45-46).

Reduced milk intake and the concurrent increase in adolescent intake of other drinks over time (47) may be explained in part by parental expectations about consuming milk. As children become older and more autonomous, they become less likely to choose milk as a beverage (48-49). Parents may be able to moderate these changes by setting expectations for consumption. Zabinski et al. (43) showed that food and beverage intake among adolescents was correlated with household eating rules.

Effects of Culture
Cultural differences based on family racial/ethnic background can influence frequency and quality of parental practices that affect intake of CRF by children. Previous studies have shown that cultural differences may contribute to differences in observed intake of CRF (50) and calcium (51), and eating occasions related to calcium intake (52) by children and adolescents according to racial/ethnic group. The source of foods (at home and away from home) and thus availability, which influences CRF intake for children, may vary by age, race, and gender. These demographic factors played a significant role in the total amount, types, and relative proportions of beverages consumed by children and adolescents (49). Neumark-Stzainer et al. (39) indicated that Asian-American families reported more frequent family meals at home compared to other racial/ethnic groups. In another study, predictors of the importance that Asian immigrant mothers gave to family meals were based on health motivations and the need to eat familiar foods (53).

Cultural influences on parenting in the context of child-rearing and risk behaviors have been examined (54-56), but little is known about the cultural variations in parenting practices involving eating behavior of early adolescents. Cullen et al. (57) reported few ethnic group differences in parent food socialization practices, self-efficacy, or parenting style regarding fruit and vegetable consumption of school-aged children. Previous studies of parental influences on intake of CRF by children did not include cross-cultural comparisons (28, 58) while others have examined factors affecting intake of these foods only from the perspective of children from various cultural backgrounds (51, 59).

Effectiveness of Social Marketing Campaigns to Change Health-Related Behaviors
According to a recent review (60), social marketing has been successful at changing a range of health behaviors, including nutrition and physical activity, through the use of commercial marketing strategies based on competing messages. A well-known social marketing campaign is the National 5 A Day Program based on messages disseminated via a media campaign, retail point-of-purchase program, and community-level interventions to increase intake of fruits and vegetables. There has been a slow and steady increase in vegetable and fruit consumption in the United States during the implementation of the 5 A Day Program, but possible inferences on the effectiveness of the program are limited because other economic and cultural factors also influence dietary behavior (61). The effectiveness of social marketing approaches is based on (62): adequate formative evaluation research (63), grounding in social or behavioral theories, use of segmentation of the audience, use of components of the "marketing mix, and consideration of the influence of competing behaviors. Literature on message development is based on models of communication effects (62) emphasizing that messages must address factors relevant to the behavior according to perceptions of benefits and barriers of the target audience.

Critical review of accomplishments achieved under the previous project (W-1003)
Identification of parental factors affecting intake of CRF by Asian, Hispanic and non-Hispanic White early adolescents based on qualitative interview data
Results of in depth interviews with ~ 200 parents of Asian, Hispanic and non-Hispanic white early adolescents supported a commonality across racial/ethnic groups related to parental factors that affect intake of CRF by early adolescents (64). Parents made CRF available through purchasing and preparation. They also influenced intake of CRF to a lesser degree through setting expectations and imposing rules. Many parents did not have strong rules or expectations about eating particular foods or drinking milk with meals, in part, perhaps, because parents often accommodated food preferences of their children. Parents encouraged healthy food choices, often using reasoning to explain the relationship between intake of particular foods and health. Not all parents consciously modeled consumption of CRF, although nearly all parents understood the link between calcium and bone health.

Participants from all race/ethnic groups shared common at home and away from home meal patterns which influenced availability and potential for modeling intake (65). A lack of time and the need to accommodate activities of family members often resulted in negative factors that impacted intake of CRF and beverages including breakfast on the run, fewer home-prepared or shared family meals and more frequent meals eaten away from home.

NVivo®, a qualitative analysis software package, was used in the analysis of interviews with parents (66). We found that NVivo® can enhance the qualitative research process and expand analytical avenues and expect to use the software in the analysis of data generated in the proposed project.

Identification of parental factors affecting intake of CRF by Asian, Hispanic and non-Hispanic White early adolescents based on quantitative survey data
We developed and tested a tool to assess parental factors related to consumption of CRF among parents of early adolescents and their children (67). A questionnaire was constructed based on results from open-ended interviews and cognitive pretesting (66). A convenience sample of parents completed questionnaires for analysis of internal consistency and test-retest reliability. Two constructs (Attitudes and Preferences, Social and Environmental Factors) were identified and described by 17 subscales that met acceptable standards for psychometric properties.

Data were collected from 587 parent child pairs in eight participating states. Preliminary data from the first 386 dyads indicated that several parental psychosocial factors were significantly associated with calcium intake among early adolescents and their parents. Factors significantly associated with the childrens consumption of calcium were the parents expectations for childs intake of beverages and the availability of calcium rich foods. The parents calcium intakes were significantly associated with the parents perception of the importance of calcium sources for children, parental encouragement of the consumption of CRF (toward his/her child), and parental role modeling to consume CRF. Once the data from all of the 587 dyads have been entered, these observations will be confirmed as being salient in terms of influencing intake of calcium, CRF, and dairy foods by early adolescents.

Identification of areas requiring further investigation
Intake of adequate CRF is associated with the development of peak bone mass in early adolescent children. Currently most children at this age are not meeting recommendations for intake of CRF, thus putting them at risk for developing osteoporosis as an adult. Parents play a key role in facilitating adequate intake of CRF for children at this age, but limited studies have been conducted to address parental and household factors that affect intake of CRF in children. When these factors are identified, limited research results are available to explain the motivation and perceptions of benefits and barriers to practicing behaviors that address these factors. The consequence of not conducting the proposed research is that we will continue to lack basic information necessary to improve the effectiveness of parental interventions, and intake of CRF by early adolescent children will continue to be inadequate.

More research is needed to explore underlying motivations and perceptions regarding salient parental factors associated with intake of calcium and CRF of early adolescents. For example, parental expectations influence intake of children but little is known about how these expectations are formed and enforced in families regarding CRF choices of children. A better understanding is needed to explain why some parents maintain expectations while others appear to give up on their childrens choices, even within their homes. Barriers to availability of CRF in the home and away from home need to be further explored with parents regarding motivation to modify availability. Availability in turn affects the extent that parents can role model intake of CRF for their children. Role modeling by parents is also dependent on their own preferences and habits, but limited information is available about how to motivate parents to modify their intake to influence intake of children. Our previous research showed that encouragement regarding intake of CRF can take several forms involving reasoning and negotiation and may vary with gender and age of the child. However, further exploration is needed to determine how to motivate parents to promote intake of CRF through encouragement based on how and when parents use different forms of encouragement.

How the proposed work will extend previous and current work
Previous qualitative data collected in the W-1003 project was used to develop a quantitative survey which identified parental and household factors associated with calcium and CRF intake of early adolescents. However, while we now know which parental behaviors (salient factors) are associated with intake of CRF by children; we do not know how to get parents to practice these behaviors. Behavior change is typically based on motivation to act as well as skill-building to make and maintain the change (10). The hypothesized progression is first, enhanced motivation, second, activated decision-making, third, facilitating abilities, and fourth, providing encouragement to maintain the activity. The proposed project represents an extension of the work completed in W-1003 by examining the underlying motivation for behaviors (salient factors) which include making CRF available, encouraging intake of CRF, setting expectations for beverage consumption, and role modeling intake of CRF. This project will also examine perceived benefits and barriers involved in making positive behavior changes which should activate decision making. This project will extend previous and current work by developing and testing messages and strategies based on the salient parental and household factors for use in a future parent educational intervention to motivate parents to promote CRF intake by early adolescents. Strategies include facilitating the abilities of parents to make and maintain behavior changes related to the salient factors identified in W-1003.

Related multistate research projects or other multistate activities
A CRIS search was completed 7-11-07 resulting in 52 active projects coded 703 (Nutrition Education and Behavior) or 704 (Nutrition and Hunger in the Population) or 724 (Healthy Lifestyle), and a full word search for calcium or milk. All but 3 were being carried out by W-1003 members, were focused on different age or racial groups, or were focused more on general nutrition. The purpose of one of the three related projects is the validation of a food frequency tool including fortified foods for women (Karen Chapman-Novakofski, University of Illinois). Our project is currently already using a validated calcium food frequency questionnaire that was previously developed and tested as part of W-191 (68). Another is using qualitative and quantitative data from families about mealtime behaviors but is focused on the relationship to risk for obesity rather than intake of calcium or CRF (Sharon Hoerr, Michigan State University). The last addresses calcium intake of Chinese mothers under age 55 years, but not how this affects the childs intake of calcium or CRF (J. Lynne Brown, Pennsylvania State University). The proposed project, while related to some current Agricultural Experiment Station research projects, does not duplicate projects previously or currently funded by state experiment stations. The W-1003 project identified parental and household factors associated with calcium and CRF intake of early adolescents. The proposed project represents an extension of this work by examining the underlying motivation for 3-4 of these salient factors. This project will also develop and test messages and strategies based on these factors for use in a future parent educational intervention to change parental beliefs and practices associated with intake by children.

Objectives

1. Segment parents into homogenous subgroups based on promotion of CRF to early adolescents.
   
2. Explore motivations and/or perceived benefits and barriers underlying parental factors which include making CRF available, encouraging intake of CRF, setting expectations for beverage consumption, and role modeling intake of CRF to early adolescents.
   
3. Identify relevant messages and delivery methods that will motivate parents to promote CRF to early adolescents.
   

Methods

Target Audience Participants will include parents/family caregivers from three ethnic/racial groups (Asian, Hispanic or non-Hispanic white). Participants will have a child (10-13 years old) living in their home and will be the person primarily responsible for food acquisition and preparation. Researchers in each state will use fliers, word of mouth, personal contact, and e-mail to recruit parents through churches, youth groups, athletic teams and nutrition education programs for low income audiences. Participants in all phases of this proposed study will constitute a convenience sample and will not be a randomly selected, representative group. Thus, results will not be generalizable to a wider group of parents. The sample will also be only the responsive portion of the target population indicating different levels of interest in the subject matter. Where possible, we will try to determine whether demographic or other characteristics differed for respondents and nonrespondents and consider the differences in the interpretation of the results. Methods Objective 1. Segment parents into homogenous subgroups based on promotion of CRF to early adolescents. Segmentation procedures are based on the rationale that subdividing a large heterogeneous audience into smaller, more homogeneous segments will allow for more effective tailored interventions. Quantitative surveys are typically conducted with input variables based on characteristics of an individual that describes them in terms of behavior (food intake patterns, physical activity), demographics (age, gender) or psychographics (beliefs, interests, needs). Quantitative data are then analyzed using cluster analysis procedures to identify distinct audience segments likely to positively respond to tailored intervention strategies, messages, materials, and incentives. We will identify distinct parent subgroups based on parental factors associated with intake of CRF by early adolescents to serve as a basis for the development of tailored messages to motivate parents to promote intake of CRF. A quantitative segmentation study will be conducted to describe parent subgroups as defined by their attitudes and behaviors regarding making CRF available, encouraging intake of CRF, setting expectations for beverage consumption, and role modeling intake of CRF to early adolescents. We will use survey data previously collected from parents as part of W-1003 to segment parents into subgroups. Using the data in this manner was not related to the objectives for W-1003 and represents a new way to gain important insight regarding tailored message development. The segmentation analysis will be conducted by the project team with consultation from Dennis Degeneffe, MBA, Research Fellow and Koel Ghosh, PhD, Research Associate, The Food Industry Center, University of Minnesota. Statements based on attitudes and practices from the W-1003 parent questionnaire will be included in a k-means cluster analysis to identify parent clusters as implemented by the SAS FASTCLUS procedure (69-71). Data will be standardized to eliminate scale bias. Several cluster solutions will be evaluated with respect to their stability, logic, separation of clusters and implications for message development. Stability will be assessed using a discriminant analysis to determine the accuracy of classification of a hold out sample. A correct reclassification rate of 80% or greater will be sought. Separation of clusters will be assessed by plotting individual respondents by cluster to see how close or distant the clusters are from one another. Each parental subgroup will be described in narrative fashion based on particular attitudes and behaviors to provide a basis for further development of messages tailored to each subgroup in objective 3. We will identify a small subset of the segmentation variables to include in a brief screening instrument. We will use the instrument to classify parents into subgroups when we recruit subgroups from the broader target audience for message testing. Objective 2: Explore motivations and/or perceived benefits and barriers underlying parental factors associated with CRF intake of early adolescents A qualitative research design will employ focus group interviews with a convenience sample of parents. Focus group interviews will be conducted at each station led by trained moderators to generate information regarding motivations and/or perceived benefits and barriers underlying parental factors which include making CRF available, encouraging intake of CRF, setting expectations for beverage consumption, and role modeling intake of CRF to early adolescents. This information will be used in the formulation of messages that resonate with parent audiences regarding their role in their childs intake of calcium and CRF. Discussion questions will be developed to explore motivations and/or perceived benefits and barriers underlying parental factors including making CRF available, encouraging and role modeling intake, and setting beverage expectations for early adolescents. We will also explore strategies that enable parents to engage in these positive practices as well as preferred delivery methods and channels for future use of tailored messages in an educational intervention. We expect that the results will enhance our understanding of the relevance of these parental factors to the particular subgroups of the target audience which were identified via previous segmentation analysis in objective 1. As part of the focus group interviews, projective techniques or other exercises such as card sorts or conversation maps may be used to provide insights into underlying feelings and motivations for consumer behavior (72). According to Churchill (73), a projective technique involves the use of a vague stimulus that an individual is asked to describe, expand on or build a structure around; the basic assumption is that an individuals organization of the relatively unstructured stimulus is indicative of the persons basic perceptions of the phenomenon and reactions to it. Respondents can therefore project their subjective or true opinions and beliefs onto unstructured prompts or stimulus that encourage the respondent to project their underlying motivations, beliefs, attitudes, or feelings onto an ambiguous situation. Responses are unstructured as respondents are free to interpret and respond to the sentence content or pictures in terms of their own perceptions and own words. The most common types of projective methods are word association, sentence completion and storytelling. For example, sentence completion involves having respondents complete a number of sentences with the first thoughts that come to mind. This procedure allows the interviewer to provide direct stimulus to evoke association with the concept of interest. To use storytelling as a projective technique, respondents are shown pictorial material (cartoons, photographs, drawings), are given part of the story and asked to complete the story. In this manner, responses are used to assess attitudes toward the particular phenomenon. Other techniques may include a picture card sort and free listing where people freely discuss a specific topic generating a list of clustered items. The initial interview guide will be pilot tested with a small number of parents in several pilot focus group interviews. Results will be used to modify questions to ensure that the desired information is obtained. Audio taped focus group interviews will be conducted in each state with parents in public and community settings (workplaces, cooperative extension offices, community centers, athletic facilities). We anticipate conducting about 6-7 focus groups with each ethnic group for a total of 18-24 interviews balanced across race/ethnic groups across 8 states. Interviews will last from 60 to 90 minutes. Researchers in each state will conduct the interviews or will train others to serve as interviewers (graduate students and paid program assistants). Respondents will be given cash or gift certificates as compensation for participation. Interviews will be conducted in English or other languages according to the availability of bilingual interviewers and translators. Demographic information will be collected using a short written form before the interview. Interviewers will also take notes during the interviews. If focus group interviews do not provide the depth of information required, individual interviews may also be conducted in several states. Interview tapes will be transcribed verbatim in each state. Interviews taped in a language other than English will be translated by a bilingual interviewer or a translator during the interview or transcription process. Interview transcripts will be coded using NVivo software at Colorado State University (66). Queries designed to find portions of text that could answer particular research questions will be developed and submitted to search for and sort coded transcript segments for further analysis. Coded transcript segments will be sorted by race/ethnic group and gender of the child. At least two researchers will independently read the sorted coded segments from each race/ethnic group, generate common themes and identify exceptions using thematic content analysis procedures (74-75). The researchers will confirm themes with each other prior to preparing summaries of results. Objective 3. Identify relevant messages and delivery methods that will motivate parents to promote CRF to early adolescents. We will develop and test messages targeted towards underlying motivations and/or perceived benefits and barriers regarding making CRF available, encouraging intake of CRF, setting expectations for beverage consumption, and role modeling intake of CRF to early adolescents. Hornik and Kelly (76) recently presented an overview regarding communication experiences and principles related to diet. They indicated that communication campaign research is based on behavior change theories as well as message theory and marketing principles. In our project, we applied Social Cognitive Theory (SCT) as the broad theoretical framework within which we determined associations between parental factors and CRF intake of early adolescents. Message theory will be applied to determine features of messages and communication materials including message content and structure, and language style (77). In terms of a marketing perspective, a general model of the communication process for promoting changes in attitudes and behaviors will be employed (78) from a cognitive and affective processing perspective. Model of Communication Process The process begins when the source determines the information to be communicated and encodes the message in a form appropriate for the receiver. The message is transmitted via some medium and the receiver decodes or interprets its meaning prior to taking action. Through message testing, we will receive feedback from the receiver regarding how the message was received and interpreted, and if the message resulted in action. We will develop and test messages for 3-5 segments at minimum from the broader target audience which will be selected based on segmentation analysis results (objective 1) and parent responses to focus group questions (objective 2). The message development process will be guided by 1) SCT as the broad framework used to identify parental factors associated with intake of CRF, 2) a need to tailor messages to particular attitudes and behaviors of parental subgroups based on segmentation analysis, and 3) the common themes and dominant trends from the focus group interviews. The message development and pretesting process will be accomplished in 3 steps including 1) development, 2) pretesting (done prior to use to determine if elements need to be revised), and 3) revision, followed by additional pretesting. The fourth step in the process involves posttesting (done after the messages are shared to evaluate their effectiveness). The fourth step will not be addressed in this project but may be the focus of another project in the future. In Step 1, pilot versions of messages will be planned/outlined, written/designed based on preliminary research findings and tailoring to audience segments, and illustrated with photographs or pictorial representations. The following table provides information regarding the use of data from focus group interviews and segmentation analysis (79-82). Data source Use in message development Focus group interview results: 1) Common themes and dominant trends regarding motivations and perceptions of benefits/ barriers to making CRF available, encouraging intake of CRF, setting expectations for beverage consumption, and role modeling intake of CRF to early adolescents 2) Existing knowledge, literacy level, and cultural background, as well as educational objectives Positively frame messages involving benefits and value that parents will derive from acting on the messages Include strong, well-documented, issue-relevant arguments that encourage cognitive processing by asking questions to generate involvement Include rational or emotional arguments based on underlying motivations Cast the message in terms familiar to the audience by using key words and phrases that communicate to audience segments based on their role models, situations with which they identify, and desirable outcomes. Key words and phrases can be taken directly from representative quotes from focus group interviews. Segmentation analysis  attitudes and behaviors by audience segment regarding making CRF available, encouraging intake of CRF, setting expectations for beverage consumption, and role modeling intake of CRF to early adolescents Match message content to attitudes and behaviors being practiced Include an action closing by specifically stating the action we want parents to take based on what we already know they are doing Where a large proportion of the target audience has limited literacy, the messages may rely on pictures, symbols and metaphorical representations to convey the information. The messages will be developed based on intended use via educational delivery methods suggested by parent interviewees but may include newsletters, website development, factsheet/brochures, lesson plans, fridge magnets, etc. Pilot versions will be printed and distributed to each state for testing. This process will be done interactively with all states via conference calls, email and annual meetings. Step 2 involves pretesting as an essential formative technique that will ensure that our messages will effectively address the needs of our target audience subgroups. We will screen potential participants into the selected subgroups using the brief screening instrument developed based on a limited subset of segmentation variables. A convenience sample of parents is expected to participate based on recruitment methods described previously. Since we intend to disseminate tested messages in a future intervention via Extension/4-H, church and sports groups and Scout groups, these recruitment methods should allow us to test messages based on appropriate dissemination channels. Individual and focus group interview methods will be used to test pilot versions of the messages based on the following criteria: comprehension (the intended message is being conveyed), cultural acceptability, appropriateness of language used, relevance to the current beliefs and behaviors, and potential to positively modify parental factors associated with CRF intake of early adolescents. Individual interviews will be used to collect quantitative data based on agreement with statements regarding the criteria. Focus group interviews will be used to collect qualitative data based on opinions and ideas regarding whether the messages meet the evaluation criteria. Projective techniques may be used in the focus groups to elicit individuals perceptions of the messages and their reactions. The initial interview guides will be pilot tested with a small number of parents prior to further data collection. The number of pretest participants in individual and focus group interviews will depend on how soon a consistent response emerges from the qualitative and quantitative data (83). In general, about 75% of the participants should understand and like the messages before they are considered acceptable or that the messages communicate the information as intended. Step 3 involves revising the messages as needed to address issues generated by the audience during the pretesting step. If the messages do not generate the expected response during the pretest, the messages will be modified and tested again until the desired response is obtained. Research Skills By working with the marketing consultants from the University of Minnesota, the project team will enhance their skills in using the sophisticated statistical method of cluster analysis. To enhance researchers' skills in qualitative research techniques to carry out the project effectively, we will conduct training or refresher sessions at annual meetings regarding: a) individual and focus group interview methodology, b) projective and other techniques to enhance qualitative data collection, and c) segmentation analysis and interpretation of results. At the annual meetings, methods for data collection and analysis will be reviewed so that project members are prepared to train other interviewers or students after the meeting prior to data collection in each state. This will ensure consistency in data collection and assist in planning data collection. Training methods will include providing background information (from experts via presentations or readings); video tape demonstrations, conference calls facilitated by experts in qualitative methods, and supervised practice interviews.

Measurement of Progress and Results

Outputs

• The project team along with marketing consultants will segment parents based on survey data collected as part of W-1003 to identify subgroup characteristics for message tailoring. Publications reporting results of this work will be prepared and submitted for publication.
• Each state will collect focus group and/or individual interview data from parents regarding underlying motivations driving parenting factors associated with CRF intake of early adolescents and transcribe into verbatim transcripts. Interview data will be evaluated and summarized by teams including researchers from several states. States will communicate through conference calls and will prepare a summary report for the annual meeting. Publications reporting results of qualitative work will be prepared and submitted for publication.
• Each state will participate in message development through conference calls and work at annual meetings. Each state will collect focus group and/or individual interview data to test messages and strategies for relevance, acceptance, comprehension and potential impact. A summary report will be prepared for the annual meeting. Publications reporting results of the qualitative formative evaluation will be prepared and submitted for publication.
• A report will define how the messages could be incorporated into future parent educational interventions.
• Each state will participate in a review of qualitative research methodology at an annual meeting including the use of projective techniques/exercises to complement qualitative data collection methods. States will communicate through conference calls and will prepare a summary report for the annual meeting.

Outcomes or Projected Impacts

• Subgroups based on the four parental factors will be identified from data previously collected as part of W-1003. The descriptive characteristics of these subgroups related to the four parental factors will serve as a basis for the development of tailored messages to motivate parents to promote intake of CRF.
• The underlying motivations driving the four parental factors will be determined with population groups at risk for developing osteoporosis as older adults  Asian, Hispanic and non-Hispanic whites, and
• Messages based on the four parental factors will be identified and pretested with selected subgroups of the target audience.
• The messages which are shown to meet evaluation criteria for potential relevance can be used in future osteoporosis prevention programs for parents. The results of the proposed project should provide a strong basis from which to compete for further funding.

Milestones

(2009): Conduct segmentation analysis, interpret results, and prepare narrative description of segments for use in message development, present overview of process to multistate partners at the annual meeting

(2010): Explore motivations and/or perceived benefits and barriers underlying parental factors which include making CRF available, encouraging intake of CRF, setting expectations for beverage consumption, and role modeling intake of CRF to early adolescents.

(2011): Steps: Conduct exploratory focus group interviews with parents of early adolescent Asian, Hispanic and non-Hispanic white children, analyze and write manuscript(s).

(2012): Steps: Develop messages based on preferred delivery methods and evaluation criteria.

(2013): Conduct individual and focus group interviews with parents to pretest messages, analyze results, revise messages as appropriate. Continue manuscript and grant proposal development. Plan future intervention components in cooperation with state partners.

Projected Participation

View Appendix E: Participation

Outreach Plan

We will make the results of the project available in an accessible manner to intended users of the information through refereed publications in nutrition and health journals and presentations made at annual meetings of nutrition, health and education societies.

Organization/Governance

Each participant will cooperate in the design of the project, collection and analysis of data and co-authoring of publications and presentations that result from this work. The research team will use common protocols for conducting focus group interviews, and developing and testing messages. Data will be collected in individual states and aggregated for analysis by a subgroup of researchers. Findings will be shared with the entire project team. Research team subgroups will develop several manuscripts, reports and presentations. An executive committee will be formed annually by group consensus methods with a chair and reporter. The chair manages meetings, submits reports and plans the agenda for the annual meeting. The reporter provides minutes describing the discussion and actions suggested during the meetings.

Several members of the research team have Cooperative Extension appointments. The nature of their involvement includes nutrition education activities such as collecting and analyzing focus group interviews (needs assessment) and developing and testing nutrition education messages (program development, implementation and evaluation) with community audiences. This work is well aligned with expectations for Cooperative Extension involvement and general responsibilities.

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Attachments

Land Grant Participating States/Institutions

AZ, CA, HI, MN, OR

Non Land Grant Participating States/Institutions

Brigham Young University, Ohio State University, Washington State University