The Journal of School Nursing2022, Vol. 38(3) 259–269© The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520930071journals.sagepub.com/home/jsn
School-based body mass index (BMI) screening is required in 50% of states with parent notification letters distributed among 11 of those states. Additional research is needed to effectively communicate screening results to parents. We conducted a pilot investigation of parent acceptability of an electronic, interactive BMI parental notification letter (e-BMI) along with the feasibility of implementing an e-BMI letter in the school setting. In addition, we assessed parental attitudes and practices regarding their child’s weight-related behaviors. Electronic letter distribution and parent receipt were consistent with traditional paper letter mailings; however, we did not observe any significant behavioral impacts with either letter format. Parents reported interest in wellness programming offered by the school, a potential opportunity for schools to engage families in healthful practices. Additional research is needed to understand the impact of e-BMI letters and accompanying web-based resources specifically for parents of students with overweight or obesity.
school nurse, childhood obesity, body mass index (BMI), screening/risk identification, communication
Nearly one in three children is overweight or obese, making childhood obesity one of the most critical public health issues in the United States (Nihiser et al., 2009; Ogden et al., 2014). For the first time in history, children today are expected to live less healthy and potentially shorter lives than their parents as a direct result of the current obesity epidemic (Olshansky et al., 2005). The extensive list of associated health risks include high blood pressure, high cholesterol, diabetes (Freedman et al., 2001; Whitlock et al., 2005), breathing issues (Han et al., 2010), joint problems and musculoskeletal discomfort (Taylor et al., 2006), and gastrointestinal conditions (Whitlock et al., 2005), all of which can progress in severity in adulthood (Freedman et al., 2001; Reilly & Kelly, 2011). In addition, overweight and obese children have a greater risk of social and psychological problems (i.e., discrimination and poor self-esteem; Whitlock et al., 2005) and are significantly less likely to graduate from high school than their healthy weight peers (Kaplan, 2015). Therefore, implementing interventions aimed at the prevention and treatment of early childhood obesity is a national priority.
Given the significant amount of time youth spend in school and the considerable weight fluctuations that occur in the elementary years (Datar et al., 2011), school-based behavioral interventions may hold merit in the fight against childhood obesity. The use of body mass index (BMI) measurement in schools has garnered attraction across the nation as a promising approach for addressing obesity due to its quick screening process and accurate measure of adiposity (Barlow & Expert Committee, 2007; Gance-Cleveland & Bushmiaer, 2005). Research by Ruggieri and Bass (2015) reported that, as of 2015, 25 states throughout the United States, including Pennsylvania, require schools to conduct BMI screenings. Further, 11 of these states report results to parents/guardians in the form of a BMI letter (Ruggieri & Bass, 2015; Vogel, 2011). However, the effectiveness of BMI screening and parental notification programs to date is limited and conflicting in the literature (H. R. Thompson & Madsen, 2017). There is a growing body of evidence suggesting such programs have failed to reduce childhood obesity prevalence (Ebbeling et al., 2002; Nihiser et al., 2009; Soto & White, 2010). Concerns have also been raised that they may do more harm than good (Evans & Sonneville, 2009; Moyer et al., 2014; Scheier, 2004), particularly in raising the risk of eating disorders and lowering selfesteem among youth (Ikeda et al., 2006; Portilla, 2011). Conversely, a comprehensive review of school-based BMI screening programs concluded that most BMI screening programs are an effective part of school-based obesity prevention programs (Ruggieri & Bass, 2015). For example, a BMI notification program included in Arkansas Act 1220 to address school wellness found promising results including increased parental awareness of child’s weight, stagnant overall childhood obesity rates during programming period, and no adverse events ensuing from the notification process (J. W. Thompson & Card-Higginson, 2009), though other BMI notification programs fail to reproduce these results.
To further elucidate school-based BMI screening/parental notification effectiveness, the Centers for Disease Control and Prevention (CDC) has called for more research to determine program impact on prevention and reduction of obesity, the types of follow-up actions taken by parents and students, and effectiveness of different methods for communicating BMI results and related risk information to parents and youth (Nihiser et al., 2007). Our prior work has aimed to improve school communication of BMI results via a revised BMI letter and address communication methodology gaps in the literature. Through our preliminary qualitative research with parents of school-aged children, we developed and tested a parent-preferred letter that has since been adopted by the Pennsylvania Department of Health as the recommended parent notification letter (data not published—link to letter: https://prowellness.childrens.pennstatehealth.org/school/physical-environment/health-services/).
While literature and our prior findings indicate that screening result notifications should include the child’s BMI-for-age percentile; an explanation of the results; recommended follow-up actions; and tips on healthy eating, physical activity, and healthy weight management (Nihiser et al., 2009), the extent that a mailed BMI notification letter—as adopted by most schools—can accomplish this task is questionable at best. An electronic interactive letter (e-BMI), however, can direct parents to a wealth of resources to provide education and appropriate next steps. In addition, e-BMI parent notification can reduce costs in translating, printing, and mailing BMI letters by utilizing a parent-preferred electronic engagement and communication mechanism (O’Brien, 2011; Stalter et al., 2010, 2011). More research is needed to understand parent preferences about receiving their child’s BMI notification information. To address this, we conducted a pilot investigation of parent acceptability of an electronic, interactive BMI parental notification letter (e-BMI) along with the feasibility of implementing an e-BMI letter in the school setting. In addition, we assessed parental attitudes and practices regarding their child’s weight-related behaviors (diet, physical activity, screen time).
The two-phase pilot study design began with the development and refinement of an e-BMI notification letter through feedback gained from focus groups with parents. Focus group results informed the second phase to determine the feasibility and acceptability of the e-BMI letter with schools and parent populations. We also conducted a pilot randomized controlled trial to explore parental attitudes and practices of child weight behaviors after receiving the e-BMI letter or the Commonwealth of Pennsylvania’s standard printed letter. This study was conducted with full institutional review and approval by the Pennsylvania State University’s Institutional Review Board.
Parents or guardians (hereafter, parents) of students from an urban Pennsylvania school district shared comments and concerns about the BMI letter formats and supporting resources through three, 60-min, semi-structured focus groups conducted in the school setting. Participants (n = 12) were recruited through the distribution of letters (n = 200) sent out by the district’s five elementary schools directly to parents. In order to participate, parents needed to be English speaking and have a child with overweight or obesity (as identified by school-based BMI measurement) in Grades 3–5 who attended one of the participating elementary schools. These criteria were developed to best understand what resources parents of children with overweight or obesity may find most useful. Criteria were confirmed through a screening assessment conducted with a study team member.
Parents were asked to provide feedback about a previously developed parent-preferred BMI letter format (i.e., Do you remember what kinds of thoughts or questions you had after you read the BMI letter?) and proposed impact of modifying to an electronic format (i.e., Would it be helpful if the BMI letter was presented or delivered differently?). Parents were also asked to weigh in on the kinds of resources that would be valuable to receive with the BMI letter. The focus groups were facilitated by the principal investigator and recorded, transcribed, and coded for emerging themes.
While focus group participants shared mixed feelings on the delivery method of BMI parent notification letters, they offered valuable feedback on resources that would improve the understanding and usability of the information presented. The feedback was summarized into three general categories: (1) BMI should be more clearly explained in the letter, (2) there should be information and resources written at the level of the child, and (3) resources and links to additional information should be included in the letter (Figure 1). Focus group feedback resulted in a revised intervention featuring web-based resources made available through electronically distributed BMI letters as described below.
Parents (n = 72) of students in five elementary schools in an urban Pennsylvania school district were recruited to complete online questionnaires about their child’s nutrition and physical activity practices both before and after receiving either the e-BMI letter or the standard paper screening result notification letter.
Parents were recruited through flyers distributed at elementary school open houses as well as advertisements on Facebook and the school district’s website. Interested participants (n = 185) were contacted by research staff and explained the study in detail, resulting in 102 parents agreeing to be screened for eligibility. To be eligible for the study, parents needed to have a child in an elementary school within the participating school district, fluently speak and read English, have access to the internet and email, and be at least 18 years old. Upon screening, 86 individuals were eligible and ultimately 72 were randomized (Figure 2) via opaque sealed envelopes that were opened after the participant completed the baseline questionnaire and the child’s BMI was collected through the annual screening process conducted by the district’s nurses.
The study team developed an interactive webpage featuring resources to address gaps identified through parent feedback in the focus groups. This method was selected over the revision of the actual letter to allow for a more robust offering of resources than what would typically be included in a onepage letter, including those for both parent and child audiences. The webpage featured animated videos explaining (1) BMI and (2) overweight and obesity in layman, nonstigmatizing language. Family-friendly resources for building and maintaining a healthy diet and active lifestyle were also included. These additional resources are consistent with other qualitative reports of critical elements to include in BMI notification programs (H. R. Thompson et al., 2015; H. R. Thompson & Madsen, 2017).
The paper BMI parent notification letter featured silhouette images representative of BMI status, brief dietary recommendations, and the web address to the Penn State PRO Wellness website that contains evidence-based parental resources for encouraging a healthy diet and physical activity (med.psu.edu/PROwellness). The e-BMI letter (Figure 3) featured the same elements in addition to a clickable hyperlink to the interactive webpage in place of the general Penn State PRO Wellness webpage address. The hyperlink was paired with a trackable short link allowing researchers to measure the website usage analytics.
Researchers partnered with the participating school district and generated electronic and printed BMI letters using BMI measurements recorded in Health e-Tools Version 1, a school-based health screening data collection software. School staff assisted researchers by emailing a PDF of the e-BMI letter to participants randomly assigned to the intervention condition while mailing the standard parent notification letter to participants in the control condition. Both electronic and paper letters were distributed in the same time frame.
Feasibility of using the e-BMI letter in place of the standard mailed letter was measured by the ability to distribute the e-BMI letter to parents in the intervention group with the same rate of receipt as the standard mailed BMI letter. Parent acceptability was measured by the number of parents in the intervention group who clicked on the trackable short link for additional resources.
Secondary outcomes of this pilot study included parental attitudes and practices regarding their child’s weightrelated behaviors (diet, physical activity, screen time) assessed through parent surveys distributed at baseline (September/October) and 1 month after BMI letter distribution (November). Investigators developed a baseline questionnaire that collected standard demographic information including age, gender, race and ethnicity, household income, and level of education. At each data collection time point, participants completed questions about family nutrition and physical activity habits and interests. An adapted version of the Family Nutrition and Physical Activity (FNPA, n.d.) screening tool, developed by Ihmels, Welk, Eisenmann, and Nusser (2009) and Ihmels, Welk, Eisenmann, Nusser, and Myers (2009), was used to assess family environments and practices (described in results shown in Table 1). This tool was selected as it aligned with themes emerging from the focus group regarding child and family food choices and resources included on the webpage accessible through the clickable link in the e-BMI letter. Other survey items measured parental feelings about the importance of school-based screenings (i.e., How important do you think it is for schools to include height and weight as part of the yearly student health screening?) and parent interest in school-offered wellness programming (i.e., How interested would you be in attending a program for parents focused on healthy eating?). The latter aimed to understand opportunities for providing additional resources for parents to support their child’s health as noted in the focus groups.
In addition to the parent questionnaires, research staff collected height, weight, and BMI (obtained by the school’s yearly screening) for the child of each participating parent. The CDC age- and sex-specific percentile definitions were used to describe a child’s weight status (Barlow & Expert Committee, 2007). Study data were collected and managed using the Research Electronic Data Capture (REDCap) Version 6 tool hosted at the Pennsylvania State University (Harris et al., 2009). RED-Cap is a secure, web-based application designed to support data capture for research studies.
For secondary outcome measures, all study variables were summarized prior to any analysis to assess their distributions. Demographic variables were compared between study groups using w2 tests to determine any significant differences. Data from the FNPA questionnaire were analyzed by creating an overall score and a score for each construct by calculating a total for each item included in the construct as described by Ihmels, Welk, Eisenmann, Nusser, and Myers (2009) and within the publicly available 4-point scale tool instructions (FNPA, n.d.). For continuous outcome variables such as FNPA outcomes, the change from baseline to 1 month was calculated and then compared as the outcome variable between study groups using an analysis of covariance that adjusted for the baseline outcome measurement and Hispanic ethnicity as covariates. For binary outcome variables such as the programming interest outcomes, a generalized estimating equations (GEE) model, which also accounts for correlation between repeated measures made on the same subject, was applied. The GEE-included factors were the study group, the study visit, the interaction between the study group and study visit, and adjustment for Hispanic ethnicity as a covariate. This analysis included the baseline measure along with the 1-month visit as part of the outcome variable analyzed. For the analysis of covariance, differences in the mean change from baseline were used to quantify any differences within and between study groups. For the GEE model, odds ratios were used for the same purpose. Bonferroni’s correction for multiple comparisons was employed to account for making multiple comparisons at more than one time point to keep the overall significance level and Type I error rate at .05. All analyses were performed using Statistical Analysis System Version 9.4 (SAS Inc., Cary, NC).
As described in Table 2, participants (n = 72) were primarily non-Hispanic (71%), white (78%), and females (94%) reporting a household income of up to $40,000 US dollars (63%). The majority of participants owned a phone with access to data (82%). Resulting study groups were balanced across demographic categories, except for participants identifying as Hispanic, who were significantly underrepresented in the intervention group (p = .02). Participants were primarily parents of students with a normal weight (64%); however, each study group included an equal number of students in both the normal and overweight/obese weight categories. Overall, participants (n = 72) across both groups reported school health screenings were somewhat or very important (90%).
Electronic BMI letters were successfully distributed to all participants in the intervention group (n = 36) via email following the collection of student height and weight data. All e-BMI and paper letters were received by parents qualified by the fact that no emails or letters were returned to the sender. Three of the 36 participants who received the e-BMI letter accessed the tailored webpage (8%) byclickingtheshortlinkincludedintheelectronic letter.
Upon analyzing the FNPA subset of the survey, we identified a significant positive difference in total score for the intervention group (p = .03) when comparing baseline to the 1-month follow-up. However, there was no difference noted in the control group or between groups. Scores for family routine (regular bedtime and enough sleep at night) significantly improved among control (p = .001) and intervention (p = .03) groups at follow-up; however, no significant differences were identified between groups. Within the control group, we identified a significant difference within the family activity category (increased encouragement of activity and activity with family members) when comparing baseline to 1- month postintervention. No additional significant differences were noted either within or between groups when comparing baseline to 1-month postintervention (Table 1).
At baseline, at least two thirds of the participants (n = 72) in the total sample described wellness programming for children or their families as helpful. Respondents were most interested in school-based fitness and healthy eating offerings for children (79% and 74%, respectively) and slightly less interested in parent-specific or whole FNPA program offerings (range 58%–65%). Participants also identified face-to-face wellness programming as more helpful (80%) than online programming (69%). However, they thought it more feasible to access the online offerings (75%) compared to those offered face-to-face (66%). We identified an increased interest in school-based healthy eating programs for children among participants in the intervention group (3.6% increase). However, these results were not significant (p = .06). Participants in the intervention group expressed a decreased interest in online wellness programming from baseline to 1-month postprogram (23%; p = .01), which was also significantly different from the control group (p = .03).
The e-BMI letter is a tool that can offer real-time, click-of-abutton access to the supporting resources and education needed to interpret the results. This approach aims to address a knowledge gap where parents (1) stated they understood BMI but didn’t believe it reflected health status and (2) were unable to correctly identify their child’s BMI category (Jones et al., 2018). These data were congruent with focus group feedback that informed this study (Figure 1).
According to the CDC’s 10 safeguards for BMI letters, schools are advised to mail letters directly to parents as opposed to distributing them through students (CDC, 2017). These measures intend to safeguard student privacy and ensure parents receive the letters; however, postage costs have been cited as a fundamental barrier by schools with screening programs (Ruggieri & Bass, 2015). An electronic notification letter could save a school district with 5,000 students over $2,000 per year in postage costs alone. Additional cost savings include those associated with paper, ink, labels, envelopes, and staff time required to match and stuff envelopes. In addition, electronic distribution methods may provide a more direct path to parents in school districts that experience high rates of transient families whether to different dwellings in the same district or different districts altogether. In this study, electronic dissemination appears to be a feasible option for schools to distribute BMI screening information to parents as no electronic letters were returned undeliverable.
In a recent study, school nurses cited a lack of time to respondtoparentinquiriesafter BMI letter distribution (Francis et al., 2018). Parents in our study exhibited the ability to access additional information through the tailored webpage, however limited (8%), providing an opportunity to further explore the use of electronic BMI communication and appropriate resources. It is worth noting that fewer than half of parents in the intervention group had students with overweight or obesity, potentially limiting the sense of urgency for parents to access additional resources. Parents seeking additional information or consultation from school nurses may benefit from using the self-serve, web-based answers to frequently asked questions, such as “what is BMI,” as a supplement to traditional school nurse/parent communication.
Whilewewereunabletotrackthetimespentonthe webpage exclusively for the individuals receiving our intervention, it is worth highlighting that the average time on the webpage once made available to a general audience was over 3 min, an average of 1 min longer than the industry average for time on webpage analytics (Baker, 2017). This begs the question of how to improve traffic to web-based resources that may supplement e-BMI letter usage in school settings. One strategy may be to enhance the email communication that accompanies the letter distribution, such as including messaging in the body of the email or using an action-oriented subject line.
Parents participating in this study overwhelmingly indicated their support of school-based screenings (90%; n = 65). Despite this support, the feasibility of an electronic dissemination method, and the potential for reduced cost for schools, barriers still exist in the process of completing and disseminating letters. For many schools, screening results are handwritten or manually typed into an electronic template, adding to an already overwhelming workload for school nurses (Stalter et al., 2011). In this study, letters were automatically generated using a school-based screening software program but were still individually emailed to participating parents. Few software programs with these capabilities exist, and those that do are expensive. Schools would benefit from tools that reduce the burden of reporting screening results to parents.
We did not observe any statistically significant differences in healthy food, beverage, or physical activity practices among participants who received the e-BMI letter when compared to participants receiving the standard letter. We acknowledge that effect size may have been mitigated by the study sample size, inclusion of parents with normal-weight children, and the modest effect on behavior noted in previous BMI letter studies (H. R. Thompson & Madsen, 2017). A larger sample size may help to elucidate additional effects of accessing the content of the letter and accompanying resources electronically (single-click access) as compared to manually accessing the resources through web addresses provided on the paper version. Although the web-based resources were developed to best support parents reviewing the BMI notification letter, the materials did not include a specific call to action. In a study conducted by Bailey-Davis and colleagues (2017), parents received educational materials and access to an online FNPA screening tool that provided immediate access to action steps based on their assessment results. Parents of children who screened overweight or obese were more likely to reduce sugar-sweetened beverages and consult their physician about the screening results. This is further supported by research conducted by H. R. Thompson et al. (2015) who reported on qualitative research describing the inclusion of action-based recommendations in parent communications as a best practice. Future studies should emphasize a stronger intervention that includes specific action steps for parents who accessed the web resources to determine the potential effect.
High-quality BMI screening programs mindfully communicate results with parents and offer action steps, including discussing results with a physician and accessing programming to support healthy families, either through the school or other community organizations (CDC, 2017). Before the intervention, participants in this study reported interest in school-sponsored wellness programming for their children and families. Both online and face-to-face offerings were appealing; however, online offerings were described as more feasible. Interestingly, participants in the intervention group reported a significant decrease in their interest in online wellness programming after receiving the e-BMI letter and an increased interest in school-based healthy eating programs for children (not significant), though the pilot sample size may have affected significance in this case. This is in line with other research suggesting BMI parent notification letters may be a useful tool in raising awareness (Ikeda et al., 2006), despite mixed reviews about their ability to create behavior change. In addition, a recent review describes the benefit of multifaceted school-based interventions (H. R. Thompson & Madsen, 2017); schools participating in BMI screening and parent notification programs should also consider offering family-centered wellness activities (i.e., cooking classes, physical activity events) to increase engagement and support families participating in the screening program.
To our knowledge, this study is the first to evaluate the utilization of an e-BMI letter notification. However, we note several study limitations. First, participant attitudes and actions were self-reported, limiting our ability to verify the data. In addition, the small sample size of this pilot study limits the conclusions that can be drawn especially related to parental attitudes and behavior changes between study groups. The sample represents parents from an urban, socioeconomically disadvantaged school district who selfselected to participate in this study, potentially limiting the generalizability of findings to populations with different demographic characteristics. There was a larger percentage of parents in this study who were White and female than school district demographics reported through local census data though similar rates of those identifying as Hispanic. Additionally, in our sample, 82% of participants reported having a data-enabled cell phone, which is higher than general smartphone ownership reported through a study conducted by the Pew Research Center in 2014 (Smith, 2015). Although this study identified the distribution of the e-BMI letter as a viable alternative to the standard notification letter, further work is needed to understand the rate at which parents read and understand the contents of the letter and supplemental electronic resources. Additional exploration of the utility of these resources specifically for parents of students with overweight or obesity is also needed.
School nurses play a central role in the school-based student screening process. However, the tracking and distribution of screening data often taxes an overburdened nurse. The use of an electronic notification system, such as that described with the described e-BMI letter study, may provide less burdensome alternatives to communicating BMI information to parents. Nurses should review their current processes for conducting, tracking, and distributing student screening information and perhaps explore features of their current electronic medical record and student information systems for integration into the screening and parent notification process.
This pilot study assessed the feasibility of using an electronic version of the BMI screening letter for parents in an economically disadvantaged school district. While the e-BMI letter was able to be distributed by the participating school and received by parents at equal rates as standard paper letters, our study findings were consistent with existing literature that describes limited effectiveness of BMI screening letters in evoking family weight-related behavior change. Despite this, parents overwhelmingly reported an interest in wellness programming offered by the school, a potential opportunity for schools to engage families. Future research should focus on the cost-effectiveness of electronic BMI letter distribution and further exploration of strategies to increase parent engagement in BMI notification letter results specifically around healthy activities and offerings. In addition, supplementary research to examine differences in parent action steps when receiving paper or electronic communications may further inform best practices for screening and dissemination programs particularly among parents of children with overweight or obesity.
The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or NCATS.
The authors would like to thank the school staff and community for their participation in this project and also recognize the following individuals for their contribution and support of this project: Judy Dillon, MSN, MA, RN, Antoinette Henning, RN, Donna K. Kephart, MPA, Kari C. Kugler, PhD, MPH, Erika S. Poole, PhD, Madhu Reddy, PhD, and Janet Welsh, PhD.
Jennifer L. Kraschnewski contributed to the conception of the manuscript, while the draft was prepared by Alicia M. Hoke and Jennifer M. Poger. Erik B. Lehman and Jennifer L. Kraschnewski were involved in the subsequent revisions of the manuscript. All authors contributed to the acquisition, analysis, and interpretation of the data; gave final approvals; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication was supported by the Penn State Clinical & Translational Research Institute; Pennsylvania State University CTSA; and NIH/NCATS grant numbers UL1 TR002014 and UL1 TR00045.
Alicia M. Hoke, MPH, CHES https://orcid.org/0000-0001-9061-6738
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Alicia M. Hoke, MPH, CHES, is a Research Project Manager at Penn State College of Medicine.
Jennifer M. Poger, Med, is a Research Project Manager at Penn State College of Medicine.
Erik B. Lehman, MS, is a Biostatistician/scientific coordinator at Penn State College of Medicine.
Jennifer L. Kraschnewski, MD, MPH, is an Associate Professor of Medicine, Pediatrics, and Public Health Sciences at Penn State College of Medicine.
1 Penn State College of Medicine, Hershey, PA, USA
Corresponding Author:Alicia M. Hoke, MPH, CHES, Penn State College of Medicine, 90 Hope Drive, Hershey, PA 17033, USA. Emails: ahoke@psu.edu; ahoke1@pennstatehealth.psu.edu
