RESEARCH Research and Practice Innovations

An Interactive Parents’ Guide for Feeding Preschool-Aged Children: Pilot Studies for Improvement Melissa M. Reznar, PhD, MPH; John S. Carlson, PhD; Sheryl O. Hughes, PhD; Amol S. Pavangadkar, MBA, MA; Marci K. Scott, PhD, RD; Sharon L. Hoerr, PhD, RD, FACN ARTICLE INFORMATION

ABSTRACT

Article history:

There are few motivational materials to help families with limited resources develop optimal, practical feeding strategies for young children to reduce dietary risk for poor diet and weight status. Formative evaluation strategies consisting of both qualitative and quantitative data helped to refine the parent feeding guide Eat Healthy, Your Children are Watching, A Parent’s Guide to Raising a Healthy Eater. An interdisciplinary planning team developed a five-topic, multimedia, interactive guide addressing the strategies most associated with improved diet quality and weight status of children aged 3 to 5 years. Research staff conducted iterative phases of field testing, reformatting, in-depth interviews, and materials testing with Head Start or Supplemental Nutrition Assistance ProgrameEducation caregivers (N¼38) of children aged 3 to 5 years during 2011 and 2012. Convergence of feedback from caregivers’ interviews and each booklet’s attention, relevance, confidence, and satisfaction subscale scores were used to determine and affirm areas for improvement. Lower than desired attention, relevance, confidence, and satisfaction scores (optimal score¼5) in 2011 and too much text resulted in revisions and reformatting that improved scores from 3.8 to 4.9 in 2012. The revision of materials to reflect less text, additional white space, checklists of mealtime behaviors, and learning activities for preschool-aged children resulted in dramatically improved materials and greater acceptance by parents, as shown by both quantitative and qualitative evaluations. Formative evaluation procedures involving the use of data-based decision making allowed for the development of intervention materials that met the unique needs of the population served.

Accepted 12 November 2013 Available online 7 February 2014

Keywords: Formative evaluation Preschool Nutrition education Parents Curriculum Copyright ª 2014 by the Academy of Nutrition and Dietetics. 2212-2672/$36.00 http://dx.doi.org/10.1016/j.jand.2013.11.018

J Acad Nutr Diet. 2014;114:788-795.

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HE POOR DIET QUALITY OF YOUNG CHILDREN’S diets has been implicated, in part, for one of the most pressing health issues today: childhood obesity.1,2 Yet parents have requested help for decades on how to feed picky eaters3 and get their children to like vegetables.4 Despite these needs from both parents and health professionals, there remains a lack of evidenced-based guidelines for optimal and practical feeding strategies to use with young children to reduce dietary risk for weight issues,1,5 especially for families with limited resources.1 To develop and test such guidelines, materials for both measurement and education are needed. To this end, a cross-disciplinary team composed of experts in nutrition education, communications, and child development designed and tested an interactive and innovative intervention based on best practices1,2 to improve the home food environment and child diet quality. Although formative and process evaluation tend to be underused compared with outcome evaluation,5 registered dietitian nutritionists (RDNs) need to know how to use them in developing effective and motivational educational materials. The literature on use of these processes appears primarily in journals of health education and promotion6-9 or evaluation and program planning,10,11 but not frequently in 788

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journals focused on dietetics or nutrition education.12,13 Although there remains confusion in the literature about these terms, investigators used definitions provided, in part, by Dehar and colleagues,10 whereby formative evaluation is used at an early stage to help develop and improve programs.14 On the other hand, process evaluation provides information on program implementation, also important for interpreting program outcomes, but not described here. The purpose of this article is to describe the effective use of formative evaluation methods in developing and testing an interactive intervention to improve child diet quality and reduce child obesity for caregivers of preschool-aged children with limited resources. The formative evaluation methods described here were both qualitative, such as explanatory interviews with mothers, and quantitative, like use of the Attention, Relevance, Confidence, and Satisfaction (ARCS) model adapted from the Instructional Material Motivation Survey.15,16

MATERIALS AND METHODS Study Design and Participants The process to develop materials began with a literature review of child feeding practices by parents17 and studies on ª 2014 by the Academy of Nutrition and Dietetics.

RESEARCH how child feeding strategies relate to diet quality outcomes.17,18 Then sequential and iterative phases followed with both an interdisciplinary planning team and an expert panel review, cognitive and field testing, reformatting, and in-depth interviews with caregivers. Parents of a preschool child aged 3 to 5 years in a north central state who were eligible for the Supplemental Nutrition Assistance Program or in Head Start comprised the participants for these evaluations. One set of parents (n¼19) completed a pilot test of the program materials during summer 2011 and a second set (n¼18) during summer 2012 evaluated each redesigned topic and did cognitive interviews with investigators. There was no crossover in participants from Year 1 to Year 2. The university’s institutional review board approved all phases of the research and development and participants signed informed consent before any data collection.

Program Description and Development The Eat Healthy program (EH) was designed as an interactive, educational intervention for low-income parents with preschool-aged children to improve home food environments and food parenting, thereby improving diet quality and weight status of household members.19 Previous research to develop a measurement instrument informed the selection of the five key topics.17,18 The EH consisted of the following topics: Home Food Environment, Food Modeling, Praise and Encouragement, Making Mealtime Fun, and How to Handle Difficult Behaviors. Topic 1, Home Food Environment, prompts parents to think about what they typically have in their refrigerators and pantries and methods for overcoming barriers to having healthy foods in their homes. The concept of “sometimes” vs “anytime” foods is introduced and reinforced throughout. “Sometimes” foods are those the 2010 Dietary Guidelines for Americans defines as energy-dense, and “anytime” foods are those that are nutrient-dense.20 Food Modeling, Topic 2, helps parents to model the eating behaviors they wish their children to learn, particularly when trying new foods. Use of specific, rather than general, praise and using positive body language are discussed in Topic 3, Praise and Encouragement. Parent feeding styles and ways to make mealtime fun are covered in Topic 4, Making Mealtime Fun. Topic 5, How to Handle Difficult Behaviors, discusses benefits of reasonable mealtime rules and how to avoid using punishment at the table. The Eat Healthy materials include five booklets by topic and 23 supplementary DVD clips, each 2 to 3 minutes in length that feature Head Start parents discussing their experiences with each topic. Video content was used to make the material more engaging than print alone, appeal to parents with lower literacy levels, and capture a true picture of family eating habits. In fact, Healthy People 2010 cited a goal to “use communication strategies strategically to improve health,” especially with low-income populations to reduce the digital divide from middle-income families.21 Also, a review of evidence-based communication tools demonstrated that structured, tailored, and interactive tools were those most likely to increase understanding of the health message.22 Furthermore, video-based interventions targeting lowincome parents have improved parenting skills.23,24 Educational objectives, not shown in the parents’ booklets, are emphasized by a standard structure of DVD clips. Then there May 2014 Volume 114 Number 5

are questions about the DVD clip for parents to reflect and anchor to their own situations; additional knowledge about healthy feeding practices as key points; activities to apply new information; and, finally, an activity or goal to be completed within the next week while the educator was away.25

A Two-Phase Evaluation Process Phase I. During 2011, researchers recruited 23 participants from 20 area Head Start locations using fliers, announcements at parent meetings, and direct invitations from teachers. The parents completed the materials over a course of 6 weeks, one topic per week, except for Topic 1, which took 2 weeks. Research aides contacted participants weekly, either in their homes (even-number weeks) or by telephone to review the content and to assess strengths and limitations of the materials. As each topic was completed, participants filled out an instrument to assess how well the topic addressed the concepts of ARCS.15,16

Phase II. During 2012, after finding that the participants liked the materials, but that seven of 17 did not think that they needed them, perhaps because they thought they already knew how to feed their child, the EH materials were revised to improve relevance and engagement. Researchers redesigned the five topics into separate booklets working with a professional graphic designer and several RDNs specializing in pediatrics. Parents reported that they most wanted tips and tricks for feeding their children, so these were featured in the revised materials. Revisions included reformatting with less text and more bullets, using only photos—no cartoons—of people and food, more interactive activities for both parents and children, and doing four to six in-depth interviews with parents to learn what resonated well. Research aides using the same recruitment methods as in 2011 gave parents one revised topic and returned the next week to ask questions and have the parents complete an ARCS scale for that topic. The 30-minute interviews were audiorecorded, transcribed, and coded following established practices for qualitative data analysis.26 Two to four research aides coded each transcript beginning with the question asked. Then the group reviewed the transcripts to reach consistency by themes. For each booklet, the frequency of response was tallied and sample quotes included. The interview data were used in 2012 to revise and refine the materials as well as to interpret the ARCS data for that year by triangulation.

Motivation Instrument Keller15 presented a theoretical, yet practical, framework for motivation and educational materials design sometimes called the Instructional Materials Motivational Survey or ARCS for the four subconstructs assessed.15 The original validated and internally reliable 36-item questionnaire was scored from 1¼not true to 5¼very true.15 The scores are averaged by each construct and range from one to five, with scores >3.5 preferred as representing “Moderately to mostly true.”27 Based on advice from Huang and colleagues16 and for use with our parents, the 36-item scale was reduced to 15 items using factor analysis with varimax rotation on a sample of >300 young adults (Statistical Package for the Social Sciences, version 15.0, 2012, IBM SPSS, Inc). Using factor JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH loadings >0.6 and the SPSS function of Cronbach’s alpha with item deleted, the ARCS instrument used here had the following properties. For the attention scale, there were four items such as, “The style of writing held my attention,” a¼.80. For the relevance scale, there were four items like, “This material relates to things I have seen or thought about,” a¼.69. Confidence scale had four items like, “The activities in this booklet were too difficult,” a¼.74. Finally, the satisfaction scale had three items such as, “The well-organized content helped me feel that I could learn this material,” a¼.82. Scores were averaged by subconstruct and compared by year.

RESULTS During 2011, 19 of 23 parents completed all five topics. In 2012, 18 different parents were assigned one of five revised topics to review and comment. The demographic characteristics of each group are shown in Table 1 as mostly white, non-Hispanic women younger than age 40 years with some college education. In comparing the ARCS scores for the same topics for both the original and revised materials, there was an increase in every ARCS score for all topics after the secondyear revisions (Table 2). The Cronbach’s alpha scores for the subscales were mostly >0.60, when the sample size was six or more participants. Information from the coded interviews in the Figure helped the evaluation team determine what was read and enjoyed vs what was missing, overlooked, or irritating. With Topic 1,

Table 1. Demographic characteristics of two parent samples in the formative evaluation of the interactive, web-based parent feeding guide

Characteristic

2011 (n[19)

2012 (n[18)

Age (y) 20-29

10

7

30-39

9

6

40

0

5

White, non-Hispanic

11

11

Black, non-Hispanic

6

5

Hispanic

1

2

Mixed

2

0

Race/ethnicity

Education High school diploma or GEDa Some college College graduate or more SNAPb recipient c

SNAP-ED participant WICd participant

2

3

13

6

4

8

15

9

2

1

10

10

a

GED¼General Educational Development. SNAP¼Supplemental Nutrition Assistance Program. c SNAP-ED¼Supplemental Nutrition Assistance ProgrameEducation. d WIC¼Special Supplemental Nutrition Program for Women, Infants, and Children. b

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Home Food Environment, greater engagement with less text, more white space, and more photos became immediately apparent as shown in the parents’ quotes. Parents liked the interactive activities of what they should be doing more than having lists and bullet points. Parents wanted to see what foods and beverages should be in their refrigerator and why, ideas for simple healthy snacks, and activities to do with their child. For Topic 2, Be a Good Role Model, the query that prompted parents to consider how they themselves as a child had to learn to eat resonated well. Both a video clip and follow-up questions about keeping the television off during meals made an impression, as shown in parent quotes in the Figure. Parents liked the activity to involve their child as a produce picker in the grocery store.28 Children liked the super taster stickers that they could place in a spot in the booklet or on their clothing for tasting a new fruit, new vegetable, wholegrain bread, or low-sugar cereal. Favorite parts of this topic for parents were produce picking, tasting new food many times, and reflecting on themselves as food models. Topic 3, Many Ways To Praise At Meals, seemed to be new information for parents, in that there were many ways to praise and encourage their child that they had not yet considered. The idea that small steps (such as licking and tasting a food many times) counted in learning to like new foods was also received well. One concept about ignoring some food behaviors that were not safety issues had to be changed. The original example was that parents might ignore it when their children played with food. When this example upset all five parents in 2012, it was removed. This dissatisfaction likely explained the lower ARCS scores in 2011. Parents appreciated how we turned bulleted lists of things that they should be doing at meals into a family checklist of things people can do to enhance family meals. This helped parents to think about these things without feeling bad about what they were not doing. Because Topic 4 on feeding styles, called Make Mealtime Fun, and Topic 5 on meal structure, called Learning To Eat Healthy, were short, the ARCS survey and interview questions were combined for one set of parents to review both topics in 2012. Parents’ attention was immediately captured with the three commands that nearly all parents give to children, “Don’t waste food,” “Eat all your vegetables,” and “Clean your plate.” The DVD clip and parent guide illustrated how these commands do not help children learn how to eat well and then offered alternative responses for parents. Make Mealtime Fun described the four types of parent feeding strategies dichotomized by demands that a parent makes of a child vs how a parent responds to a child,29 with two renamed for clarity as: Positive Pattern (authoritative), Controlling Pattern (authoritarian), Indulgent, and Uninvolved.30 Parents found this to be new and interesting information and everyone was curious to see which style they displayed. Parents liked the age-appropriate rules for preschool-aged children. The comments about confidence in the Figure supported the quantitative scores for Topics 4 and 5 and were reflected in the high ARCS score of 4.69 out of 5.00. Parents liked that fruit could be a dessert and it was an “anytime” food—high in vitamin and minerals and low in solid fat, added sugar, and salt. Suggestions for low-cost, nonfood rewards for good behavior were especially well received and parents liked to be reinforced for what some were doing already. May 2014 Volume 114 Number 5

RESEARCH Table 2. Subscale scores for Attention, Relevance, Confidence, and Satisfaction (ARCS) subscales15,16 by the Eat Healthy topics for 2011 vs 2012 ARCS Subscalea Eat Healthy topic

Year

Attention

Relevance

Confidence

Satisfaction

Overall score

1. Kids are what they eat

2011 (n¼23)b 2012 (n¼6)c

4.00.4 4.40.3

3.90.6 4.30.4

3.90.4 4.70.4

3.90.7 4.50.3

3.90.1 4.50.2

2. Be a good role model

2011 (n¼5) 2012 (n¼4)

2.70.1 4.90.1

4.10.23 4.80.2

2.60.1 4.20.5

4.30.3 4.80.2

3.40.9 4.70.3

3. Many ways to praise at meals

2011 (n¼19) 2012 (n¼5)

3.30.6 4.30.5

3.90.6 4.30.6

3.20.6 4.50.4

4.20.7 3.80.9

3.70.5 4.20.3

Topics 4 and 5d

2011 (n¼19)

2.90.3

3.20.4

3.70.4

4.30.4

3.50.6

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒmeanstandard deviationƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ!

4. Make mealtime fun 5. Learning to eat healthy

2012 (n¼3)

Topics 4 and 5e

2012 (n¼4)

4.60.2

4.50.3

4.70.2

4.30.6

4.50.2

Overall

2011

3.20.6

3.80.4

3.40.6

4.20.2

3.60.2

Overall

2012

4.60.3

4.50.2

4.50.2

4.40.4

4.50.2

a

Scored from 1¼not true to 5¼very true.16 Sample sizes varied in 2011. The sample for Topic 1 is larger than the 19 who completed the program due to dropouts. The smaller samples for Topics 2 and 5 were due to data collectors’ omissions. c Sample sizes varied in 2012 because there were different participants for each topic. d A weighted average was calculated for Topics 4 and 5 scores for 2011. e Because Topics 4 and 5 were short, the evaluation was combined and the same parents did both topics as one unit. b

Topic 5, originally titled, How to Handle Mealtime Struggles, was renamed to Learning To Eat Healthy, to emphasize that eating well is something that must be learned and to reinforce the role of parents as teachers. Included was a checklist of eight ways for parents to encourage their child to eat without pressure, to help parents do a self-check, and to rate themselves. The last interactive activity to use rules to reduce struggles was popular with both parents and children. The child got to draw a smiley face for each rule he or she followed, like, “Stay seated at meals.”

DISCUSSION Our study describes the use of formative evaluation methods, primarily cognitive interviews and the ARCS questionnaire, in developing and testing an interactive intervention designed to help parents learn how to improve diet quality and weight status of their preschool-aged children. The revised EH materials were well liked by and engaged parents of preschoolaged children. In addition, the findings suggest that RDNs consider using these simple tools to improve everything from lesson plans to counseling handouts. Formative evaluation strategies, ongoing processes that provided assessment information within a feedback loop,6 was key to the final design of the EH materials. Both qualitative and quantitative data collection strategies were used, such as explanatory interviews with mothers and use of the ARCS model from the Instructional Material Motivation Survey.15,16 Use of the cognitive interviews with parents helped to identify the specific components of the materials that were useful and engaging as well as to inform investigators about May 2014 Volume 114 Number 5

what was missing, like interactive activities for them to do with their child. In addition, the coded interview findings helped to provide specific insights to the ARCS scores that the scores alone could not elicit. To our knowledge the ARCS model has not been used widely by RDNs or nutrition educators outside of a multistate nutrition education group’s use with college-aged adults participating in online diet and activity interventions.27 That research group reported ARCS scores for an interactive online obesity prevention program for college students as follows: attention¼3.5, relevance¼3.6, confidence¼4.1, and satisfaction¼3.6. By comparison in 2012, the EH materials appeared to be rated higher overall for attention¼4.6, relevance¼4.5, confidence¼4.5, and satisfaction¼4.3. Use of the ARCS scores helped to support that the target audience found the revised materials to be motivational in terms of being attention worthy, relevant to low-income parents, confidence-building, and satisfying to use. In designing the EH for low-income families, several barriers were recognized and addressed: the need for motivational, interactive, eye-catching materials to support learning and enhance motivation; the low literacy level of some caregivers; and that busy families have little time to attend a series of group lessons.31 Participant responses to EH materials in 2012 clearly demonstrated that parents found them eye-catching and motivational. Investigators edited EH materials to maintain a reading level between third and fifth grades using the Flesh-Kincaid Grade Level Readability Test available in Word 2007 (Microsoft Corp), with only a few exceptions. The EH materials were designed for delivery as a combination of three home visits alternating with telephone JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH Topic title, content

Change or findings

Sample quotes from parents

There was greater engagement with less text, more white space, and more photos

“It grabs your attention and makes you want to know more.” “The kid with the fruit looks nice and the mom with the groceries.”

Added an interactive self-quiz for anytime vs sometimes foods

“I didn’t read the pointers.” “The (selfevaluation) quizzes made it interesting and personal.” “Having an answer key with explanations was good.”

Added ideas on simple healthy snacks and more activities to do with their child

“Make it more kid, as well, like a portion of this should be kid.”

Added an activity about people that parents modeled their own behaviors from as a child

“It made me realize that Papa has to start eating good in front of him too.” “We (parents) need to disagree about food in private.”

Both a video clip and reasons for keeping the television off at meals had an effect

“Big things matter too, like turning off the TV.” “Listing things to do to reduce distractions helped.” “Before he wouldn’t finish or pay attention to the food. Now he is eating and not getting up from the table to run around.”

Parents and children liked the activity where they went to the store for the child to be a produce picker28

“He picked out a fruit that was a dessert.” “We ended up with mangos.” “As soon as we got done, she wanted to try another one.”

Parents liked examples of how to make praise be specific

“I didn’t understand that there was more than just saying, ‘good job’.” Praise the action, not the person; it’s really good.”

Parents liked that even licking a new food and tiny tastes could be praised

“This was absolutely new concept for me that I can praise for (food) licks and smells.” “When my daughter heard that she’s not brave enough to lick broccoli, she even bit it.”

Transformed a bulleted list of things families should do at meals into a checklist of things people do to enhance family meals

“I thought it was a good way of taking inventory in terms of better food habits for the family.”

1. Kids are what they eat Healthy food environment; anytimea vs sometimesb foods; portion size

2. Be a good role model Model behaviors they want children to learn, use team effort, taste new foods many times, make tasting new foods fun

3. Many ways to praise at meals Use specific praise, use touch and eye contact to encourage, praise even tiny tastes

(continued on next page) Figure. Qualitative findings and selected quotes from coded interviews by topic for the formative evaluation of the Eat Healthy parent materials. 792

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RESEARCH Topic title, content

Change or findings

Sample quotes from parents

Illustrated how food commands like, don’t waste food, eat all your vegetables, and clean your plate, don’t help children learn how to eat well and offered alternatives

“To see the alternatives that you highlighted in different colors stood out to me. I took it to my partner and I was like, ‘Look you should be saying these.’ That was definitely eye-catching.”

Added an activity to identify into which of four feeding patterns/styles they fit. Listed advantages and disadvantages of each pattern

“Easy to understand the advantages and disadvantages, because I found myself doing some of them and I don’t want to be in that pattern.” “I’ll let my kids sit at the table by themselves and I’ll go in the other room. Then I’ll be like, hey, that stuff can wait.

Emphasized and illustrated age appropriate mealtime rules

“We can all sit at the table for 15-20 minutes.”

Emphasized the video clip about mealtime rules

“Watching the video about rules, it was kind of rewarding to know that those are rules we already have.” “.Like making a rule that mealtime last 15 minutes. I didn’t know it takes 15 minutes to feel full.”

Added additional information about “sometimes” foods

“Now I’m going to implement it and be like, ‘No this is a “sometimes” food and we get “sometimes” foods only once a week.’”

Added a child activity to draw a smiley face for each mealtime rule followed

“I like that you can get the kids involved in your meals and make it fun for them and the reward system.”

4. Make mealtime fun Described feeding patterns like positive (authoritative), controlling (authoritarian), indulgent, and not involved; mealtime rules; nonfood treats

5. Learning to eat healthy Patience works better than pressure, how to handle “sometimes foods,” use rules to reduce struggles

Sometimes foods were those that the Dietary Guidelines for Americans defined as being “energy-dense.” Anytime foods were those that the Dietary Guidelines for Americans defined as being “nutrient-dense.”

a

b

Figure. (continued) Qualitative findings and selected quotes from coded interviews by topic for the formative evaluation of the Eat Healthy parent materials.

calls on the odd weeks to address the fact that low-income families can face many barriers that prevent consistent attendance at a series of group sessions. EH materials were modeled, in part, after the award-winning Incredible Years, an evidence-based video and guidebook program that Webster-Stratton and colleagues32.33 developed for use by for parents or teachers of children with behavior problems. As with that program, EH starts with general skill building and behaviors and progresses to increasingly specific skills. In addition, the theoretical framework of the Social Cognitive Theory guided content development targeting the May 2014 Volume 114 Number 5

constructs of self-efficacy (confidence in one’s ability to perform a behavior), skill building, outcome expectancies (positive or negative outcomes expected as a result of performing a behavior), and knowledge.34 Given the challenges that resource-limited parents face in providing a healthy home food environment, it is imperative that interventions target resource-limited parents with young children to establish healthy eating patterns as early in the life course as possible. Such interventions must be motivating to an audience already stressed by many factors and this study provides a framework and tools to develop and JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH evaluate such materials. That is, begin with existing research findings, draft materials, use expert reviewers like RDNs who work with the target audience, and test materials with parents either in focus groups or interviews. Using the ARCS model or open-ended questions to elicit specific feedback and areas for improvement is also helpful in this process of creating new materials. Developing materials for a resource-limited and understudied group were strengths of this study, as was using both qualitative and quantitative procedures. The use of a multidisciplinary development team—from dietetics, behavioral nutrition, developmental psychology, education, and communication arts—and experienced RDNs specializing in pediatrics as expert reviewers were other strengths. A limitation of this study was that the original EH materials were expert-driven by the findings of what the target group needed to learn, rather than what they wanted to learn. In other words, the original design did not use feedback from participants.35 As with all well-designed educational interventions, the best materials provide what people want along with what they need. Another limitation was that this was a pilot study with a small number of participants. Furthermore, those who volunteered in the second year for the interviews were older than first-year parents. The degree of collegiate education that many parents reported, although perhaps reflective of the recent economic downturn, might not reflect the broader audience of Head Start parents. The close proximity to a college town likely also influenced educational level as does the tendency for some to overreport their education. Of note was that even one course at a community college could count as some “college.” Finally, some researchers might consider Cronbach’s a>.60 too low to be acceptable, even though this was acceptable according to the reference used.36 Regardless, because this was formative evaluation with a small sample size, the alpha values would need to be rechecked with larger samples.

CONCLUSIONS Formative evaluation techniques of both structured parental interviews along with a Likert-scaled questionnaire adapted from psychology resulted in a greatly improved set of child feeding materials for parents of preschool-aged children. Both this process and the EH materials might be helpful for RDNs who work with parents of preschool-aged children with special needs like picky eating or obesity.

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AUTHOR INFORMATION M. Reznar is an assistant professor, Department of Health Sciences, Oakland University, Rochester, MI. J. Carlson is a professor, Department of Counseling, Educational Psychology, and Special Education, A. S. Pavangadkar is a senior producer and teaching specialist, Department of Telecommunication, Information Studies, and Media, and S. L. Hoerr is a professor, Department of Food Science and Human Nutrition, all at Michigan State University, East Lansing. S. O. Hughes is an assistant professor, Department of Pediatrics, Baylor College of Medicine, Houston, TX. M. K. Scott is vice president of health programs, Michigan Fitness Foundation, Michigan Nutrition Network, Governor’s Council on Physical Fitness, Health, and Sports, Lansing. Address correspondence to: Sharon L. Hoerr, PhD, RD, FACN, Department of Food Science and Human Nutrition, 469 Wilson Rd, Michigan State University, East Lansing, MI 48824. E-mail: [email protected]

STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.

FUNDING/SUPPORT This material was supported in part by grant no. 1R21HD064876-01A1 from the Eunice Shriver Institute of Child Health and Development of the National Institutes of Health. This material was also supported by the State of Michigan with federal funds from the US Department of Agriculture Supplemental Nutrition Assistance Program though the Michigan Nutrition Network at the Michigan Fitness Foundation. This work was supported by the Michigan Department of Human Services, under contract nos. 13-99011 and 12-99011. These institutions are equal opportunity employers.

ACKNOWLEDGEMENTS These findings were presented in part at the annual conference for the Society of Nutrition Education and Behavior in Portland, OR, during August 2013. The authors thank Gail Hagbom, RD, Greater Lansing Area Head Start, and the pediatric dietitians in the greater Lansing area who reviewed content of the Eat Healthy materials and provided input.

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