Head Start Health and Nutrition Managers’ Perceptions of the Process of Measuring BMI and Communicating Preschooler’s Weight Status

Participants and Setting

This study utilized a phenomenological approach, which describes common experiences across participants (Creswell & Poth, 2018). The institutional review board (IRB) approval was obtained from East Carolina University. Researchers developed an interview guide using the results of previous research (Miller et al., 2021; Nicely et al., 2019). The interview contained 12 open-ended questions with additional probes. Key questions included the following: “What process do you use to conduct height and weight measurements?” “Who conducts these measurements and how often?” “Can you describe how the measurements are tracked and reported?” and “What policies/practices would improve the process of measuring childhood obesity in your HS program?” Key probes included the following: “Can you explain this more?” and “Can you give me an example?” HS HNMs were selected as the target for interviews due to the fact that the child health and nutrition assessments, including BMI measurement, are the responsibility of the HNMs. The interview guide was reviewed and pilot-tested with HNMs external to the research. Small changes related to the wording of questions were incorporated into the revised interview guide. After the revisions were completed, trained qualitative researchers conducted interviewer training and practice interviews to increase consistency in the interview process (Goodell et al., 2016).

Data Collection

The states of Ohio and North Carolina were utilized because researchers at institutions in each of these states had well-established partnerships with both the local and state-level HS organizations. A list of funded HS programs in both Ohio (n = 48) and North Carolina (n = 52) was obtained through each state’s HS Office of Collaboration. All HNMs in each program across the two states were sent one initial and two follow-up emails by the Director of Professional Development and the HS Office of Collaboration, inviting them to participate in interviews from July 2019 to March 2020. The follow-up emails were sent 1 and 2 weeks, respectively, following the initial email. As a measure of research reliability (Lincoln & Guba, 1985), purposive sampling of the HNM was utilized to provide multiple perspectives and common experiences across programs in the two states.

Participants who responded to the email invitation were sent a preinterview demographic survey to complete, which included information about HS site location, age, and their current health-related role in HS, as well as a consent form. After completion of the online demographic form, participants were contacted to schedule a day and time for a 60-minute telephone interview. Participants received a US$20 gift card for participation. Interviews were conducted until saturation was achieved where no new information was elicited (Bowen, 2008). A minimum of 10 participants are recommended to achieve saturation in phenomenological research (Bowen, 2008).

Data Analysis

Interviews were conducted by two trained research assistants (one in each state), recorded using a mobile phone voice recording app, and transcribed verbatim utilizing pseudonyms for all participants. Interview responses were reviewed with participants as a method of member checking to assure trustworthiness and accuracy of the data (Lincoln & Guba, 1985). Transcripts were independently reviewed for understanding by four trained qualitative researchers (two in each state); significant statements/segments of text and experiences relevant to the phenomena were identified, grouped, described through memos, and inductively assigned a code, which allowed for the identification of patterns across the data. Codes, descriptions, and sample quotes were organized into an excel spreadsheet, compared across the two states, refined, agreed upon, and organized into themes (Creswell & Poth, 2018). To ensure coding reliability and consistency, coders were trained using the five-step Goodell method (Goodell et al., 2016). The first phase of data analysis was conducted independently with two-trained coders within each state, utilizing identical procedures for analysis. Participant statements related to the phenomenon of interest were highlighted and used to develop a preliminary coding manual and to identify emergent themes. Consensus on codes and code definitions were reached through 100% verbal agreement between the coders (Creswell & Poth, 2018). Coders from each state reviewed each codebook and collectively created themes and subthemes, reflecting the findings from both states.

Personnel, Equipment, and Training for BMI Measurement

The majority of HNMs across Ohio and North Carolina programs described measuring height and weight on-site 2 times per year versus utilizing anthropometric data from the child’s required annual health form. Various individuals were identified as responsible for conducting BMI measurements (e.g., teachers, family service workers/social workers, nutrition assistants, and nursing students); however, teachers were identified most often. Equipment used for BMI measurement also varied across and within programs, with some using standardized medical equipment, such as stadiometers, and others using growth charts taped to the wall. Most participants reported using digital scales; however, different equipment may be used by programs at different sites or transported from site to site. Some HNMs described BMI measurement training for staff (e.g., during preservice training, providing written information, or conducting one-on-one conversations), although most of the training described was related to the required meal/nutrition guidelines. HNMs highlighted limited time to provide training specific to growth assessments and acknowledged that inconsistencies in the persons responsible for data collection, training of collectors, errors in data entry, and lack of standardized data collection protocols may affect the accuracy of reporting.

Classifying and Communicating BMI and Referrals

HNMs across states reported utilizing data management software (most often ChildPlus/Promise) where height and weight were entered, BMI calculated, and weight status classifications generated for reporting to caregivers and on the HS annual PIR. They described these as helpful because they did not have to calculate the child’s BMI or convert to the appropriate BMI-for-age percentile and weight status classification, which assisted in accuracy. However, they did describe staff errors in inputting the data into the computer software. HNMs described utilizing the BMI-for-age percentile and the weight status classification information to provide referrals to The Women, Infants, and Children Program (WIC) dietitians, physicians, or the HS dietitian when a child’s BMI was identified outside the healthy range. However, the descriptions of the referral process were not consistent across programs or states. Some programs used folders (containing the BMI report and educational materials) sent home in the child’s backpack by teachers, internal nutrition care plans, telephone calls, and letters to communicate the BMI results and the referral to caregivers. The WIC dietitian and physician were identified as the predominant referrals, but the follow-through was left to the caregiver to pursue. Several HNMs described staff concern around communicating a child’s BMI screening results to caregivers, recognizing the sensitive nature of this communication and the uncertainty surrounding the caregivers’ response. HNMs indicated a need for communication training and the development of guided talking points for discussing children’s weight status with caregivers.

Professional Development Opportunities

The HNMs described a variety of webinars, online tools, and local and national health/nutrition conferences available for the HS professional development requirement, but noted limited professional development resources specifically focusing on various aspects of obesity, such as conducting BMI measurements, interpreting results, communicating with families, and prevention strategies. They also described providing training (e.g., health goals, Child and Adult Care Food Program (CACFP) nutrition guidelines) for HS staff within their program, but either no training around BMI measurements and health or limited training related to these topics.

Resource, Training, and Policy Needs to Support BMI Practices

The HNMs recommended structuring additional time to conduct focused training on accuracy of BMI measurements, staff understanding of obesity, and the impact of BMI on child health. In terms of policy development, HNMs recommended utilizing dedicated staff for conducting BMI measurements, with guidance on uniform measuring practices, communication, and follow-up on referrals for at-risk children. They stressed the importance of the accuracy of the data and subsequent BMI-for-age percentile and weight classification, particularly as it is reported to caregivers.

Recommendations

This qualitative study provided insights into HS HNMs common experiences with the BMI measurement, reporting, and referral process where research has been limited. HNMs identified a need for more structured guidance, training, and process standardization for best practice and accurate measurements and reporting consistent with other research studies (Himes, 2009; Imoisili et al., 2021; Miller et al., 2021; Tovar et al., 2022). Based on the identified challenges in collecting height and weight data in HS children, HNMs also suggested including best practices such as utilizing dedicated personnel with specific expertise and training in BMI measurement to ensure the accuracy of data and reporting to caregivers (Himes, 2009; Miller et al., 2021). Communicating accurate data to parents in HS has been identified as an important link to garnering support and trust in the BMI data collection for HS parents (Nicely et al., 2019).

Due to HNMs’ expressed apprehension in communicating BMI screening results, National/state-level HS may consider providing HS staff technical assistance and support, specifically focused on communicating BMI screening results to families as this is often done by non–health professionals (e.g., teachers/social workers) in HS. Training in communication practices could better facilitate clear, actionable follow-up messages and strategies provided to families that may enhance the utility of HS BMI reports and families’ intention to elicit behavior changes that modify obesity risk factors (Bailey-Davis et al., 2017; Nicely et al., 2019). Previous research has shown that parents need brief, clear, concise, individualized communication that includes specific strategies and examples of how the desired behavior could be included into their daily lives (Nicely et al., 2019; Uy et al., 2019). In addition, having regard for parent expertise and views of their child’s weight, focusing on the child’s health and behaviors rather than weight, and not having the child present during discussions have been important communication strategies identified by parents (Uy et al., 2019).

Finally, because HNMs perceived follow-through on referrals to be low, HS could utilize their existing health advisory board to include primary care pediatricians, HS-registered dietitians, WIC, and enrolled families to collaboratively establish best practices for health/nutrition referrals and follow-up, similar to the HS mental health referral process, with the goal of enhancing the utilization of these services. Specifically, creating a checklist where appropriate staff can engage with the appropriate family member to highlight reasons for the referral; identify providers; discuss barriers, concerns, or worries about the referral; and establish a follow-up plan with the family may better facilitate the weight-based referral process (Head Start/ECLKC, 2020).

Limitations and Implications for Future Research

The results of this study were limited to HS programs and the experiences of the HNMs in Ohio and North Carolina, however, these findings may be transferable to other HS programs and the lived experiences may be similar to HNMs’ in other states. HNMs interviewed were all female and primarily non-Hispanic White with limited diversity; however, this is comparable to a national sample of Health Managers in HS programs (Martin & Karoly, 2016). Based on the limitations identified, additional qualitative research is warranted to confirm findings in HS programs nationally and may also include examining caregiver perceptions of the best communication methods (face-to-face, written, text, telephone, or virtual) used for conveying child BMI screening results and the referral process utilized by HS.

As this study’s results highlighted the need for implementation of best practice guidelines for conducting BMI screenings, including collecting height and weight measurements among HS preschoolers, future research could explore the effects of implementing best practice guidelines for height and weight data collection and the subsequent impact on accurate BMI reporting. More research is also needed to better understand the policies guiding the referral and referral-tracking process of HS children with BMIs outside of the healthy range. Standardized BMI and referral processes can assist HS with tracking and evaluating the impact of program-level interventions to address child obesity as programs are expected to address this when obesity rates of their enrolled children are high.