J Community Health (2016) 41:593602
DOI 10.1007/s10900-015-0134-x
ORIGINAL PAPER
Perceived Parental Barriers to and Strategies for Supporting
Physical Activity and Healthy Eating among Head Start Children
Jiying Ling1 Lorraine B. Robbins2 Vicki Hines-Martin3
Published online: 11 December 2015
 Springer Science+Business Media New York 2015
Abstract Despite the need for parents to support their
childrens healthy behaviors, knowledge of factors pre-
venting parents from doing so is still rudimentary. This
study primarily aimed to explore perceived parental bar-
riers to and strategies for supporting physical activity and
healthy eating among Head Start children. A semi-struc-
tured interview format was used with four focus groups
conducted at two urban Head Start centers in the Mid-
western U.S. A qualitative content analysis of audio-
recorded sessions was facilitated using ATLAS.ti7. A
convenience sample of 32 parents (Mage = 34.97 years)
participated. Over half were female (78.1 %), African
Americans (65.6 %), and single (65.6 %). About 61.3 %
reported an annual family income \$20,000, and 43.8 %
were unemployed. Three themes reflected the barriers: (1)
intrapersonal (child): short attention span and limited eat-
ing preferences; (2) interpersonal (parent): lack of time and
cooking skills and a tight family budget; and (3) environ-
mental: inaccessible programs, lack of age-appropriate
education, electronic media use, and unsafe environment.
& Jiying Ling
jiying.ling@hc.msu.edu
Lorraine B. Robbins
robbin76@msu.edu
Vicki Hines-Martin
vphine01@louisville.edu
1
Michigan State University College of Nursing, 1355 Bogue
St. C241, East Lansing, MI 48824, USA
2 5 years than children who participate in the intervention at
Michigan State University College of Nursing, 1355 Bogue
St. C245, East Lansing, MI 48824, USA
3 habits become established in the preschool years [7, 8],
Office of Health Disparities and Community Engagement,
University of Louisville School of Nursing, 555 South Floyd
St. R4055, Louisville, KY 40202, USA
Parents across all groups expressed high interest in enrol-
ling in a program with their children. Recommendations
included: parents support team; family outings at parks;
taking a walk or enrolling in a class with children; and
planting a garden. Many parents showed their preference
for face-to-face meetings and a support group, but repul-
sion of counseling. To promote parental support in future
interventions with Head Start children, their perceived
intrapersonal, interpersonal, and environmental barriers
should be considered as intervention targets. Involving
parents through a support group and face-to-face meetings
is recommended.
Keywords Barriers
Parental involvement
Childhood
obesity
Head start children
Qualitative
Introduction
About 34.9 % of U.S. Head Start children, 1.5 times the
rate of U.S. children aged 25 years (22.8 %), are over-
weight or obese [1, 2]. The incidence of obesity is highest
before age 6 (5.4 vs. 1.7 % after age 6) [3]. Children who
are overweight at age 5 are four times more likely to
become obese later in life, as compared to their healthy
weight peers [3]. Lifestyle interventions promoting physi-
cal activity (PA) and healthy eating in preschoolers are
critical for preventing overweight/obesity (OW/OB) [4, 5].
Children who participate in a lifestyle intervention at an
earlier age (47 years) have greater weight loss over
an older age ([11 years) [6]. Given that PA and eating
intervening with a program during this critical time period
to address the problem is essential.
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Although many interventions have been aimed at con-
trolling OW/OB in preschoolers, their cumulative inter-
vention effect is dismal [9]. One recent systematic review
with 23 OW/OB prevention programs noted that eight
resulted in significant weight loss, and three showed sig-
nificant sustained effects in preschoolers [10]. Though
Head Start children have a high risk of being OW/OB [1],
participating in unhealthy lifestyle behaviors [11], and
having elevated cardiovascular risk factors [12], only two
interventions have been conducted to prevent and reduce
OW/OB among these children: the Food Friends: Get
Movin With Mighty Moves program and the Hip-Hop to
Health Jr. intervention [13, 14]. However, neither program
resulted in significant effects on Head Start childrens body
mass index (BMI). Thus, increased effort is needed to
target Head Start children to reduce their high OW/OB
prevalence.
Evidence supports combining high-level parental
involvement with interactive school-based learning to
prevent and reduce OW/OB among preschoolers [15, 16],
yet the Hip-Hop to Health Jr. intervention that engaged
parents via a weekly newsletter and assignments showed no
effect on Head Start childrens BMI [14]. The intervention
was then expanded to include an intensive parental com-
ponent (one 90-min interactive education class per week
for 6 weeks), but still no significant effects were observed.
Furthermore, only 38 % of the parents attended C one
class [17]. The findings indicate that research is needed to
explore reasons for low session attendance among Head
Start parents, along with strategies for effectively involving
them.
A thorough understanding of Head Start parents per-
ceived barriers to participating in an OW/OB intervention
for their children and strategies to overcome them is
lacking. To ensure acceptability of an intervention by
parents, De Bock and colleagues emphasized the impor-
tance of involving parents in all phases of an intervention,
including the initial design [18]. Based on this recom-
mendation and the sparse literature found about Head Start
parents involvement in OW/OB interventions, a qualita-
tive research method, rather than a quantitative research
method, was selected in order to acquire an in-depth
understanding of Head Start parents personal experiences
and perceptions related to participating in an intervention
program with their children [19]. Applying a focus group
strategy, this study had three aims: (1) identify perceived
parental barriers to supporting their Head Start childrens
PA and healthy eating and strategies to overcome them; (2)
explore parents suggestions for a PA and nutrition inter-
vention; and (3) determine acceptable strategies to involve
them in a PA and nutrition intervention.
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J Community Health (2016) 41:593602
Methods
A qualitative study employing a focus group strategy was
used. Focus groups allow for direct and in-depth conver-
sation about a topic, while encouraging the flow of new
ideas from participants [20]. Approval to conduct the study
was obtained from the University Institutional Review
Board and program manager at the Head Start centers.
Setting and Participant Recruitment
Parents were recruited from two urban Head Start centers
in Midwestern U.S. in three ways: (1) recruitment flyers
with investigator contact information were posted on each
entrance door of Head Start centers and classrooms; (2) the
first author and a research assistant visited each center
twice to distribute flyers to parents, and register eligible
participants willing to participate; and (3) each child
received a flyer attached to his/her standard school parent
correspondence folder to take home to parents. A maxi-
mum of 10 participants were recruited for each focus group
because 610 is a manageable and adequate number, and
1025 % of those recruited do not follow through (non-
response rate) [21].
Parents were included if they: (1) had a child aged
25 years, (2) could read, understand, and speak English,
and (3) were the primary caregiver for the child. The only
exclusion criterion was having a health condition pre-
venting participation in PA, because the study aimed to
identify parental support for childrens PA, including role
modeling of the behavior.
Data Collection
Two masters-prepared interview moderators (one African
American; one Caucasian) and two bachelors-prepared
research assistants (one African American; one Caucasian)
were hired. Their college degrees were in kinesiology,
nutrition, or nursing. Adhering to Morgan and Kruegers
guidelines [20], the first author conducted a 2-h training on
the study for all interview moderators and research assis-
tants followed by an additional 2-h training focusing on
moderating skills and strategies for both interview
moderators.
One day before each focus group, participants received a
reminder call, email, or text message to remind them about
the focus group time and location. Two focus groups were
conducted in a quiet and private room at each of two Head
Start centers after work hours (5:307:00 P.M.). At the
beginning of each focus group, all participants were asked
to sign the consent form to give permission to record the
J Community Health (2016) 41:593602 595

participating focus group session and complete an inves- Results

tigator-developed demographic survey.
After participants completed the consent form and sur-
vey, the moderator led the discussion by following a semi-
structured interview guide developed for this study based
on guidelines specified by Morgan and Krueger [20]. The
semi-structured interview guide with open-ended questions
was used to ensure question consistency but allow flexi-
bility to highlight areas of specific interest across groups
and promote conversational style among participants [22,
23]. Prior to the focus groups, the first author tested the
interview guide in three individual interviews and changes
were made based on participants suggestions.
The research assistant took detailed field notes, includ-
ing participants nonverbal behaviors. All focus groups
were audiotaped using two digital voice recorders, and
each focus group lasted on average about 80 min. At the
end of each focus group, the moderator shared a brief
summary with participants to validate discussion and
encourage comments or corrections. Data saturation or
redundancy in participant responses determined the num-
ber of focus groups that were conducted. All participants
received $30 cash as compensation for their time and tra-
vel. Boxed meals and bottled water were available during
each focus group.
Participants
Thirty-seven parents verbally signed up, and 32 (86.5 %)
actually participated in four focus groups. Parents age
ranged from 22 to 63, with an average age of 33.97
(SD = 9.44) years. Twenty-five (78.1 %) were female, 21
(65.6 %) were African Americans, and 5 (15.6 %) were
Hispanic. Most were single (n = 21, 65.6 %), and nearly
half (n = 14, 43.8 %) were unemployed. Their occupations
included customer services/relations (n = 6, 33.3 %),
health care professional/assistant (n = 5, 27.8 %), cook
(n = 3, 16.7 %), educator/researcher (n = 2, 11.1 %), and
freelancer (n = 2, 11.1 %). Approximately 65.6 %
(n = 21) did not receive a college degree, and 61.3 %
(n = 19, one missing) had an annual family income less
than $20,000. Table 1 demonstrates the detailed demo-
graphic information.
Table 1 Demographic Characteristics of Participants (N = 32)
Variable n %

Sex (female) 25 78.1

Data Analysis Hispanic 5 15.6
Race
Focus group data were analyzed using qualitative content Caucasian 4 12.5
analysis [24]. Content analysis is an approach involving African American 21 65.6
empirical, systematic analysis of texts within their context Mixed-race/other 7 21.9
of communication. Content analysis results in the devel- Marital status
opment of categories: every unit of analysis must be coded Single 21 65.6
and allocated to one or more categories. Categories are
Separated/divorced/widowed 7 21.9
understood as the operational definitions of the variables
Married 4 12.5
under study. One research assistant transcribed verbatim all
Family annual income
audiotaped information. Field notes, including participants
\$20,000 19 61.3
nonverbal behaviors (e.g., laugh, smile, shake head, nod
$20,000$29,999 11 35.5
head), were inserted to accompany relevant content in the
$30,000$49,999 1 3.2
corresponding transcripts. The other research assistant lis-
Employment status
tened to the audiotapes to verify the transcribed informa-
No 14 43.8
tion. The transcripts from the four focus groups were
Part-time 6 18.8
imported into ATLAS.ti7 to facilitate coding and analysis.
Full-time 12 37.5
A constant comparison method [25], coding participants
responses by continually referring to previously coded Education level
responses for comparison, was applied to inductively \High school 3 9.4
develop categories and themes. Two researchers indepen- High school 6 18.8
dently coded all transcripts then jointly discussed the Some college 12 37.5
results until agreement was obtained. Any disagreement Technical or community college 5 15.6
was then discussed with a third researcher, who had Bachelor degree 2 6.3
expertise in qualitative methods, until a resolution was Graduate degree 4 12.5
achieved.

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Perceived Parental Barriers
The social ecological model [26] was used to present the
themes describing perceived parental barriers. Specifi-
cally, the themes were conceptually organized as intrap-
ersonal (child), interpersonal (parent), and environmental
barriers. Table 2 presents the direct quotes from partici-
pants to illustrate the themes for the perceived parental
barriers.
Intrapersonal Barriers (Child)
Short Attention Span
Parents in all groups reported that their children easily got
bored with same food or PA due to short attention spans at
a young age. Some parents complained that getting
preschoolers to sit still and pay attention was difficult, and
children usually did what they wanted to do without any
structure or limit. Most parents repeatedly identified
making it fun/interesting, as a key strategy and reported
accomplishing the task by providing a variety of colorful
healthy foods and fun physical activities, helping children
to form a routine starting with short-term goals, partici-
pating in PA with children, using music, providing treats or
rewards, and suggesting that their children play with
others.
Limited Eating Preferences
Parents in three groups described their children as picky
or sweets eaters and reported multiple challenges trying
to overcome their childrens resistance to healthy food.
Most parents tried to find ways to guide their picky
eaters to try healthy food by providing healthy choices
only, placing healthy food within their childs reach,
involving children to make food colorful, rewarding them
with a treat (e.g., an extra cookie, a piece of candy), and
setting examples as good role models. Interestingly, one
mother could not cope with her daughters picky eating
behavior and another reported that she found it too chal-
lenging to cook colorful food that interested her children so
both mothers chose to eat outside the home.
Interpersonal Barriers (Parent)
Lack of Time
Parents across all focus groups considered lack of time as
their primary barrier to supporting their preschoolers in
participating in more PA and eating healthier. This barrier
was particularly problematic for single mothers or fathers
with a full-time job. Due to their busy schedule, eating
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outside the home was more convenient than preparing
meals at home. Some parents reported feeling very bad
about their inability to spend some quality time with their
children, do things with their children as they grew up, or
cook family meals. Even though they would have liked to
have some quality time and participate in PA with their
children, they were already physically drained after
working all day.
Tight Family Budget
Although parents across all groups understood the benefits
of eating healthy and participating in PA, they could not
afford to buy fresh fruits and vegetables, sign their children
up for a PA program, or provide transportation due to their
tight family budget. As a result, they had to buy prepared
food, eat inexpensive fast food, and keep their children at
home after school. Therefore, they were interested in
affordable or free activity programs and free meals. Some
parents expressed their appreciation for the Women,
Infants, and Children (WIC) program that provided milk,
bread, fruits, and vegetables.
Lack of Cooking Skills
Parents in three groups reported struggling to cook
cheap, colorful, and healthy food that interested their
children and did not take a long time to prepare. Due to a
lack of cooking skills, young parents, in particular, did not
have home-cooked meals at all or home-cooked meals were
very rare for them. Some parents expressed concern that
this unhealthy lifestyle would transfer to their children.
Many parents obtained health information and healthy
recipes primarily through the WIC program, and only a few
used the Internet as a source. Thus, most parents suggested
that health promotion programs need to provide them with
healthy, but easy and quick recipes as an important
component.
Environmental Barriers
Inaccessible Programs
Parents in all groups reported that their children did not
have the same access to afterschool programs in their
communities that the participating parents had years ago.
They commented that afterschool programs in their com-
munities had provided them with a great opportunity to
participate in PA and learn about healthy eating. Currently,
very few free afterschool programs were offered in their
communities, and existing programs did not provide
opportunities for healthy eating and PA or were far away
from their homes. Parents across all groups expressed their
J Community Health (2016) 41:593602
Table 2 Direct quotes from participants to illustrate the themes for the perceived parental barriers
Themes
Intrapersonal barriers (child)
Short attention span
Limited eating preferences
Interpersonal barriers (parent)
Lack of time
Tight family budget
Lack of cooking skills
Environmental barriers
Inaccessible programs
597
Quotes
It has to be very fun because we are talking about little kids so it has to be engaging, because kids attention span is
like 2 min, so you want something engaging with colors and stuff
For that age, its hard to get them to sit still and pay attention, you know, so they are kind of on their own program.
With that age, they do what they want
I think music is big too. Music is a big thing and kids like anything they can sing or clap. So you know the head-
shoulders-knees-and-toes, they love that; so do something like that keeping them engaged, and being very
energetic, loud, and colorful
My daughter is very picky and I kind of dont give her options really. You know she doesnt like vegetables really,
but Ill put couple pieces of broccoli on there and a few little peas, its only a little bit, just try it, eat it, so its not
an option really
I eat what my child eats but she is a picky child, like she smells everything, but if she sees you eating it and its
tasty, she will eat it too. Youve got to start somewhere to encourage them otherwise she would only eat
macaroni and cheese
I dont let them eat candy all of the time because they always want candy, so you have got to just reinstate that fact
that, you know, you cant have it all of the time, just give them something healthy, and that can taste just as good
at the same time
Working full time and then having a child in that age and then saying oh, I want to go, they want to go outside and
play. Oh, I am tired, I am exhausted. I dont feel like taking them outside right now, or going to the park. But I
believe its very important, and I know, that is important. But, ah, I also think that time, the single parent is hard
to be able to find a time to take your child to the park
I think physical activity and healthy eating, like in our ages like, it becomes time consuming. Like it is a lot of
more convenient to just go for me and my lifestyles, convenient to go and get something to eat, than it is to make
something and with what all of the thousand things I have to do during the day
When you are tired, you need to say that too hard to tell kids I have to work. You know like other word, maybe like
take some time off work, my daughter tell me such, such mom came, such, such dad came, and it makes you feel
worse
I think the biggest thing is that its time; its that your job is not flexible, or your job is not accommodating, and its
hard, because you want to go, but your job is like sorry. I am like, I am sorry, I cant take off another afternoon
I would love to be able to afford healthier foods, but unfortunately, being low-income and when you are on food
stamps, it is easier for me to go buy cheaper foods that seems to be, its cheaper to buy fatty food
The YMCA is available, and they do, do it by your income, but when I added that up, that was so expensive, I am
not going to pay like $80-90 for a program when I can go to the park every day, so something affordable, and
something that is close in your area where you live so you dont have to worry about the gas prices, trying to get a
ride or whatever
I know what is good to eat and I know what is healthy, but its not necessarily always the fastest or what is
available to you, especially with a tight budget. You just tend to get what is cheap, what is fast convenient, you
know fast food, a lot of people go there because they have got eh dollar menus, or whatever, and you are on the
go
It is hard for me to find stuff for her to eat, and enjoy it at the same time and eat healthy. I would appreciate it if
there is information about substitution thing and recipes for her in healthy eating
usually I cant keep getting stuff that interests them, like the colors so Ill take them out to eat
My son, he eats vegetables. I think I mess up though because I fry everything, but they eat, theyre pretty good
eaters, but yeah that would be my concern
I dont know they do it nowadays. When I was a kid, we used to go to like afterschool programs, we have 4 h.
Like, it was at the church, we go there, we play basketball, we have access to gym, and then we would all make a
lunch. Like all the kids, I would like it, I grew upon that program
I mean we would probably do just family time and be at the park. If we could get a discount somewhere like the Y,
thats another thing. I know a lot of people in [city] that is all you have
There are so many places in [city], but no transportation, and if youre looking at the lower income people, thats
going to be a big deal. I dont know anything centrally located beside [community center 1] or [community
center 2], but thats a little too far
They get one break, maybe for 15 min for another break, thats not enough for five year-old child, and so
incorporate into the schools so they learn
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Table 2 continued
Themes Quotes

Lack of age-appropriate Back when we were little, you would have someone dress up as an orange, a banana suit, and a grape suit, and they
education would just walk around, and you know presentation, I hate to be funny, but presentation is key. If you attract it
you are going to get it, you know. So you have to show it, they dont know what it is, If you eat a banana it is
going to give you Vitamin C. They dont know until you break it down to them, in a kid form
And make sure you are saying it in a way they can understand it. Like you said, the sugar bug, you have got to
break it down so they can get it because you may just tell them, Youre going to catch a cavity and, you know,
they just say, Uhh, okay. Then they come up and say, My mouth hurts
At times he can take it as a rejection, and say Oh, someone is just telling me to do it because theyre an adult, but
once they get older, at 25 they are doing eight mile runs, where me at 25, its not going to happen because I am
not as physically in shape as they are, there is a big difference. So rejections can turn into progression in the long
run
Electronic media use My kids think Im crazy when I talk to them about kickball, they dont know what it is, but they have that Internet,
and thats the problem.
My daughter stays with her mom, and if I were to go over there after school, they would be sitting side by side on
the couch playing with their phones, that Candy Crush
I think kids today are losing interest in playing outside because there are too many TV programs and video games
Unsafe environment Where we stay is not a bad area compared to where we have been, but playgrounds and stuff, I dont like letting my
kids go on there, the dog poop, broken glass, and they had the thing on the news with people putting razors on
My 4-year-old, she got injured in school, and no one ever told me
My son came home today with his lip busted up, and its like, it happens all the time

pressing need for accessible afterschool programs for their result, many parents reported that most young children did
young children. In addition, some parents suggested that not know how to ride a bike or jump rope and did not play
Head Start programs should offer more breaks and PA kickball, softball, or other physical games as children did in
opportunities for their children. the past.

Lack of Age-Appropriate Education Unsafe Environment

Parents in all groups reported that their children did not
know the benefits of healthy eating and PA, and could not
even recognize vegetables and fruits due to lack of age-
appropriate education in school or at home. Many parents
suggested that effective strategies used when they were
young should be employed with this age group of children,
including role-playing, dressing up like fruits or vegeta-
bles, watching TV shows about healthy knowledge and
behaviors, and drawing pictures. Some parents recom-
mended that schools should provide age-appropriate health
education to their children in a kid form. Some parents
said that even though children might not immediately
accept the information or apply it, they would more likely
do so when they grew up.
Electronic Media Use
Parents in two groups expressed concern about the negative
influence of electronic media (e.g., computer, TV, phone)
on their childrens healthy behaviors. Due to the influence
of electronic media, children were more interested in
watching TV shows and playing video games at home. As a
Parents in two groups discussed the unsafe outdoor envi-
ronment as a barrier for their children to participate in
outside PA. Many parents were concerned about the safety
of their neighborhood environment as well as the school or
program environment. Once they turned their child over
to a program, they want to be sure that their child was safe
in a structured environment. Most parents understood that
accidents might happen, but they wanted to be the first
person informed.
Suggestions for Developing a PA and Nutrition
Intervention
For this age group of children, a PA and nutrition program
should provide fun and enjoyable activities with colorful
and healthy foods, music, field trips, and games. Many
parents agreed that field trips would be an excellent strat-
egy to make learning and participation attractive for chil-
dren. Low-income parents preferred a program located
within or near their communities or one that offered reli-
able transportation. Safety was another priority with par-
ents wanting to be sure that their children were safe in the

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program and its location was safe as well. Moreover, the
qualifications of the staff members working with their chil-
dren were important with parents preferring those who were
educated, experienced, caring, responsible, trustworthy,
patient, creative, and high-energetic. Some parents sug-
gested programs should combine PA and nutrition, be
offered for free or at a reasonable cost, and include structured
activities. Many parents reported that incentives, such as
small gifts, were very important for both children and parents
to motivate them to participate. They indicated that on-going
incentives received periodically throughout the program
would be more beneficial than a one-time incentive.
Parents across all groups highly recommended involving
parents at all phases of the program, so they would know
what they could do for their children and feel important.
They emphasized that family played a big role in sup-
porting this age group of children to be physically active
and eat healthy and stated everything starts at home.
Even though parents might not have time to be a good role
model, siblings or other family members could participate
in PA with preschoolers. In addition, parents highlighted
the influence of other kids on their childrens establish-
ment of healthy behaviors. They suggested involving ele-
mentary or middle school children to teach preschoolers
about healthy eating and PA and indicated that this
approach might also help to reduce the bullying. Many
parents suggested acquiring community support to help
sustain the program.
Strategies to Involve Parents
Parents across all groups expressed high interest in directly
enrolling in a program with their children. Most parents
wanted to be informed about the activities their children
were doing in a program. The strategies that parents sug-
gested to increase their involvement included: forming a
parents support team; having family outings at parks;
taking a walk or enrolling in a class with children; and
planting a garden. Many parents reported that face-to-face
involvement would be more effective than other approa-
ches, and information on PA and healthy eating could be
sent home by email or mail. For the materials sent home,
they preferred a simple sheet with some bullet points to
prevent them from being overwhelmed. Most suggested
forming a parental support group to facilitate socializing,
sharing, and support among Head Start parents. In addition,
many parents wanted to choose how to be involved from
several available options. In contrast, some parents men-
tioned that parental counseling would not work because
they did not like being told what to cook or to provide
healthy meals, shop for healthy groceries, or do PA with
their children.
599
Discussion
Few studies have examined the perceived parental barriers
to supporting their Head Start children to participate in
more PA and eat healthier, and strategies for actively
involving parents into an intervention with their children
[27]. Results from this study add to the limited literature on
perceived parental barriers to and strategies for supporting
their Head Start children to be physically active and eat
healthy, and provide valuable information to inform the
development of a PA and nutrition program for Head Start
children with active parental involvement.
Childrens normal attention span is usually 35 min per
year of their age [28]. Therefore, when designing programs
for preschoolers, each session should be within 20 min and
fun is the key to draw their attention and keep them
engaging [29]. Consistent with one study among 39 parents
in Ontario [30], findings from this study indicate childrens
limited eating preferences make it difficult for parents to
provide them healthy foods. Strategies used by Head Start
parents, including restriction, over control, and rewards for
eating, have shown negative influence on childrens food
acceptance [31]. The recommended strategies for
decreasing eating preferences are: (1) eating in positive and
supportive environments, (2) engaging parents and siblings
as role models for healthy foods, and (3) offering repeated
exposure to novel or disliked foods [32]. This information
indicates that Head Start parents need assistance to select
and use effective strategies to guide their picky eaters.
Similar to other parents of preschoolers, though Head
Start parents understood the benefits of PA and healthy
eating, they had little time and energy to engage in PA with
and prepare healthy foods for their children [30, 33].
Because children spend a majority of their awake time in
childcare facilities, these organizations play a vital role in
shaping healthy behaviors [34]. Thus, intervening in
childcare settings to provide opportunities for healthy
foods and PA may be an alternative and essential strategy
to overcome parents lack of time. Parents low-socioeco-
nomic status, resulting in the inability to afford healthy
foods or recreation/gym memberships, is a commonly
reported parental barrier to supporting their childrens PA
or healthy eating [35]. Moreover, foods in low-income food
desert communities are costly, of poor quality, and limited
in number and type available [36]. One possible strategy to
help parents overcome their problem of limited finances is
to facilitate affordable healthy foods with farmers markets
in the underserved communities [37]. Lack of cooking skill
has been reported as a barrier for American individuals
under 50 to eat vegetables [38]. To overcome this barrier,
demonstrating and educating parents quick fix, afford-
able but healthy recipes is a promising strategy.
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To overcome the lack of access to PA and healthy foods
and insufficient age-appropriate education barriers, local
authorities need to provide free or incentivized PA pro-
grams, safe PA areas, and affordable local food markets
[39]. Interactive age-appropriate education and hands-on
experiences for PA and healthy eating are popularly used
strategies to promote healthy behaviors among preschool-
ers [10]. As indicated by the parents in this study, children
may apply the health knowledge received at an early age
when they become adults [40]. Additionally, the built
environment, including accessibility, safe neighborhoods,
and local farmers markets, has been found to be related to
PA and healthy eating [41], although in one study with
3141 3-year-old children, mothers perceptions of neigh-
borhood safety was correlated with their preschoolers TV
viewing time, but not outdoor PA time or obesity risk [42].
Appropriate media use can promote safe health practices
and foster social connectedness [43], but excessive media
use is significantly correlated with higher adiposity in
preschoolers [44]. Thus, with children growing up in a
media-saturated environment, limiting, but not prohibiting
entertainment media use, is suggested. Considering that
environmental and policy interventions are the most
effective strategies for fostering population-wide healthy
lifestyle [45], future intervention efforts need to include an
environmental or policy component.
Although the literature supports that actively engaging
parents at all phases of a program can help to develop
positive partnerships between researchers and partici-
pants [46], the added value of parental involvement is not
conclusive and needs further investigation [47]. Previous
interventions have used a variety of strategies to involve
parents in an intervention, including interactive healthy
behavior education, behavioral therapy, parenting skill
training, group meetings/trainings, or sending home hand-
outs, flyers, newsletters, or text messages [10]. Involving
parents through a family visit or via a phone to provide
education and training also offers some promise in
increasing childrens PA [48]. This studys findings high-
light Head Start parents preference for face-to-face
meetings and a support group, but repulsion of counseling.
Forming a support group involving participants has been
used to improve mental health and disease self-manage-
ment, but no study was found that included a support group
of parents to promote PA and healthy eating among their
children [49]. Therefore, further research is needed to
explore the effects of using a parental support group to
increase PA and healthy eating among preschoolers. Evi-
dence from studies with adults indicates that counseling,
including motivational interviewing, may be effective in
improving PA and healthy eating, but insufficient data
exists to determine its efficacy among children [50]. Since
parents in this study strongly expressed their unwillingness
123
J Community Health (2016) 41:593602
to be advised on ways to support their young children to be
physically active and eat healthy, using counseling sessions
with parents in interventions to prevent pediatric obesity
needs further exploration.
Conclusion
A healthy lifestyle intervention for preschoolers may help
establish a healthy lifestyle that can prevent obesity later in
life. This study uncovers important factors that can be
targeted to promote parental support in future interventions
with Head Start children. As proposed by the Patient-
Centered Outcomes Research Institute (PCORI), engaging
targeted populations throughout the research process and
designing interventions based on participants perspectives
can produce more participant-centered research and lead to
useful and trustworthy results. Therefore, barriers and
strategies perceived by Head Start parents should be con-
sidered when involving parents into an intervention with
their children.
Acknowledgment This study was funded by Michigan State
University College of Nursing. The authors thank Emily Roth, Jordyn
Roberts, Ashley Triplett, and Fujun Wen for their assistance on
conducting the focus groups and transcribing the audiotaped
interviews.
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