Using Facebook and Participatory Learning in an Intergenerational Intervention to Prevent Obesity in Head Start Preschoolers
Phase: NA
Conditions: Pediatric Obesity, Risk Reduction Behavior, Early Intervention, Intergenerational Relations
Sponsor: Michigan State University

 
 
Title: Using Facebook and Participatory Learning in an 
Intergenerational Intervention to Prevent Obesity in Head 
Start Preschoolers 
 
 
IRB Approval ID: STUDY00001629 
 
Funding: National Institute of Nursing Research of the National 
Institutes of Health under Award Number R21NR017958 (PI: 
Dr. Jiying Ling) 
 
Clinical Trial Registration #: NCT04164277 
 
Date: December 22, 2023 

PROJECT SUMMARY 
Despite persistent overweight/obesity (OW/O) disparities by socioeconomic status (SES), interventions 
targeting preschoolers from low-SES backgrounds are sparse. Based on the intergenerational transmission of 
habits and obesity, targeting preschoolers and their caregivers (parents or legal guardians) simultaneously is a 
promising strategy for the prevention of OW/O. This project will determine the preliminary efficacy of an 
innovative intergenerational intervention among Head Start preschoolers, aged 3-5 years, and their caregivers. 
Methods: A two-group cluster randomized controlled trial will be conducted. Six Head Start centers will be 
randomly assigned to the intervention (n=3) or control group (n=3), and 24 caregiver-preschooler dyads will be 
recruited from each center (N=144 dyads). Grounded in an Actor-Partner Interdependence Model (APIM), the 
16-week intervention has 3 components: 1) a caregiver component, including 1a) a Facebook-based program
with weekly electronic retrievable flyers providing health information and behavioral change strategies and 4
weekly habit-formation tasks to improve parenting practices and home environment for preschoolers; and 1b) 3
face-to-face meetings (wks. 1, 8, & 16) to establish personal connections and communication networks among
caregivers, discuss strategies, and share community resources to support preschoolers’ behavioral changes at
home; 2) a caregiver-preschooler learning component via Facebook messenger to send preschooler letters to
each caregiver privately by the research team twice per week to 2a) share the preschooler’s experiences of
learning at school and his/her desires for a healthy diet and physical activity at home, and 2b) elicit caregivers’
response to the letters; and 3) a Head Start center-based preschooler component to help preschoolers
establish healthy habits via weekly healthy diet and physical activity participatory learning. AIM 1: Determine
the preliminary efficacy of intervention vs control on preschoolers’ proximal behavioral (e.g., MVPA, diet
quality) and distal anthropometric outcomes (e.g., proportion of OW/O, BMI z-score). AIM 2: Examine the
preliminary efficacy of intervention vs control on caregivers’ behavioral and anthropometric outcomes. AIM 3:
Compare intervention vs control on the bidirectional relationship (proposed in APIM) between preschoolers and
caregivers on MVPA, diet quality, and screen time. Innovation: The intervention extends beyond prior
research that focuses only on the unidirectional influence of caregivers on preschoolers with a bidirectional
approach that also emphasizes the influence of preschoolers on caregivers. The potential for sustainability and
scalability is high because the intervention is integrated into daily routines and capitalizes on the already-
existing social network Facebook to connect caregivers to an online private group. It facilitates the
communication of preschooler preferences to improve caregivers’ parenting practices through preschooler
letters sent to caregivers via Facebook messenger. Impact: The proposed study will set the stage for a future
large-scale study to prevent and reduce OW/O and promote health among underserved preschoolers.

 
 
PROJECT NARRATIVE 
Despite disparities in overweight/obesity (OW/O) by socioeconomic status (SES), preschoolers aged 3–5 years 
old from low-SES backgrounds have been underrepresented in OW/O preventive research. The proposed 
project, which includes low-SES caregiver-preschooler dyads and a rigorous study design, examines the 
preliminary efficacy of an innovative intergenerational intervention on preschoolers’ proximal behavioral and 
distal anthropometric outcomes. This research stands to make a significant public health impact to reduce the 
prevalence of OW/O among underserved preschoolers, with high potential for intervention sustainability and 
scalability among an underserved population of concern to nursing researchers and practitioners.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
SPECIFIC AIMS. Despite persistent disparities in overweight/obesity (OW/O) by socioeconomic status 
(SES),12-14 and a sharp increase in obesity prevalence from 2015 (9%) to 2016 (14%) in preschoolers aged 2–
5 years,15 preschoolers of low SES are significantly underrepresented in OW/O preventive research.16 
Lifestyles promoting high-quality diet and physical activity (PA) offer the most effective approach to achieving 
healthy weight long-term17-19 and reducing obesity-related comorbidities,20 such as heart disease,21,22 asthma,23 
impaired cognitive function,24,25 metabolic syndrome,26 and cancer.27 Moreover, the major sociocultural root 
causes of OW/O in low-SES preschoolers are poor parenting practices and poor home environment.8,9,28-30 
Despite calls from the American Academy of Pediatrics (AAP) and the Institute of Medicine (IOM) for 
interventions to prevent obesity that primarily target preschoolers,31,32 few interventions have been conducted 
with low-SES preschoolers and effects have been limited.16,33 This study addresses this gap in the science in a 
novel manner by targeting the bidirectional participatory learning34 that occurs between preschoolers and their 
parents or legal guardians (referred to as caregivers in this application) as an effective strategy for reducing the 
persistent OW/O disparities by SES35 given the intergenerational transmission of health habits and obesity.36,37  
Based on our prior study (n=69 dyads, see C.2.),38 we have established the feasibility (preschooler 
participation 77%; caregiver participation 87%) of our 10-week, intergenerational intervention called 
“FirstStep2Health.” This intervention addresses one important root cause of OW/O—poor parenting practices 
—by 1) using an existing social network, Facebook™, to involve caregivers in a private group39,40 to initiate a 
supportive network and overcome barriers to involving working caregivers in face-to-face programs;41,42 and 2) 
extending the commonly used unidirectional framework of caregivers shaping preschoolers to the bidirectional 
framework—the Actor-Partner Interdependence Model (APIM)43—that adds preschoolers’ preferences and how 
they influence caregiver-preschooler learning of healthy diet and PA.44-47  
Our long-term goal is to promote healthy parenting practices among underserved low-SES families to 
reduce OW/O disparities by SES. To achieve this goal, our 16-week (extended from 10 to 16 weeks per 
caregiver request in our prior study and behavior habit-formation needs 2-3 months48) intervention is sensitive 
to participants’ literacy level and low-SES and includes 3 components: 1) a caregiver component including 1a) 
a Facebook-based program with weekly electronically-retrievable flyers providing health information and 
behavioral change strategies and 4 weekly habit-formation tasks to create a healthier home environment for 
preschoolers; and 1b) 3 face-to-face meetings (weeks 1, 8, & 16) to establish personal connections and 
communication networks among caregivers, discuss strategies, and share community resources to support 
behavioral changes at home; 2) a caregiver-preschooler learning component34,47 via Facebook messenger to 
send preschooler letters to each caregiver privately by the research team twice per week to share the 
preschooler’s experiences of learning at school and his/her stated desires for healthy diet and PA at home, and 
to ask caregivers to respond to the letters; and 3) a Head Start center-based preschooler component to help 
preschoolers establish healthy habits via weekly healthy diet and PA participatory learning.34 
Our primary objective is to determine the preliminary efficacy of the intervention. Methods: We will 
conduct a two-group cluster randomized controlled trial (RCT). From the available 13 large Head Start 
centers, six centers will be randomly selected and then randomly assigned to the intervention (n=3) or control 
group (n=3, usual Head Start activities); 24 caregiver-preschooler dyads will be recruited from each center 
(N=144 dyads).  
AIM 1: Determine the preliminary efficacy of FirstStep2Health vs control among preschoolers on 
proximal behavioral changes of ↑ moderate-to-vigorous PA (MVPA) measured by accelerometry (primary 
outcome), ↑ diet quality (e.g., ↑ fruits/vegetables, ↑ fiber, ↑ whole grains, ↑ total protein, ↑ dairy, ↓ sugar-
sweetened beverages, ↓ total sugars/fats), and ↓ screen time (e.g., watching TV, playing video games); and 
distal anthropometric outcomes of ↓ proportion of OW/O and ↓ body mass index (BMI) z-score. We anticipate 
an overall decrease in BMI z-score in intervention preschoolers because we expect OW/O preschoolers’ BMI 
z-score to decrease and healthy-weight preschoolers to have no change. We focus on proximal behavioral 
changes as our primary outcome instead of distal anthropometric outcomes due to the brevity of this study and 
the need for behavioral changes to be maintained for at least a year before manifesting in changes in 
anthropometric outcomes.49,50 AIM 2: Examine the preliminary efficacy of FirstStep2Health vs control 
among caregivers on their ↑ MVPA measured by accelerometry, ↑ diet quality (e.g., ↑fruits/vegetables, ↑fiber), 
↓ screen time, ↓ proportion of OW/O, ↓ BMI, ↑ knowledge, ↑ feeding practice skill, ↑ self-efficacy, ↑ parental 
support of their child, ↑ parenting practices, and ↑ home environment. AIM 3: Compare FirstStep2Health vs 
control on the bidirectional relationship (as demonstrated in the APIM) between preschoolers and 
caregivers on MVPA, diet quality, and screen time. Further, we will validate established feasibility, 
acceptability, and satisfaction of the intervention using qualitative and quantitative data.  
Impact: This application integrates existing best practices for preventing OW/O into an innovative 
intergenerational intervention that targets caregivers via existing social network Facebook™ and promotes 
caregiver-preschooler learning based on a bidirectional framework. This study forms the foundation for a future 
large-scale RCT to prevent OW/O and promote health among low-SES preschoolers. 

 
 
A. SIGNIFICANCE A.1. A critical need exists to reduce overweight/obesity (OW/O) among preschoolers 
in low-socioeconomic status (SES) families.13,14 About 34% of U.S. Head Start preschoolers51,52—1.3 times 
the rate of U.S. children aged 2-5 years (26%)15—are OW/O. The OW/O prevalence rate was 46% in our prior 
study.38 Disparities in OW/O by SES persist from childhood through adolescence53 and are related to 
underlying SES disparities in dietary intake54 and PA.55 Children who experience poverty by 2 years of age are 
almost two-times more likely to be obese by age 15 compared to those not experiencing poverty at an early 
age.56 Head Start programs serve children and families with incomes under the poverty thresholds.57 This 
research is significant because it addresses the gap in literature involving studies targeting both 
preschoolers and their caregivers from low-SES backgrounds.16,33,58 Intervening with preschoolers <5 yrs. 
old results in better short- and long-term outcomes in weight reduction compared to intervening with 
elementary school children (6–11 yrs.) or adolescents (≥12 yrs.).17,18,59 Six interventions were identified that 
focused on low-SES Head Start preschoolers (including healthy weight and OW/O preschoolers). Two 
interventions used passive caregiver involvement by sending home materials, but had no effect on 
preschoolers’ BMI.60,61 Four interventions actively involved caregivers via face-to-face classes: one resulted in 
a significant but small BMI decrease (d=0.17), but lacked control group and caregiver attendance data;62 two 
had no significant BMI change with low caregiver attendance (32-38%);41,63 and one used a quasi-experimental 
design and had a high caregiver attendance (80%), but no significant BMI change.64 The high attendance may 
have occurred because only caregiver-transported preschoolers were included, and caregivers received the 
intervention when they arrived to pick up their child. Moreover, previous interventions with preschoolers only 
achieved a small effect on BMI (d=0.19), and the effect was even smaller (d=0.10) when including ≥ 50% low-
SES preschoolers.16,65 These dismal results, coupled with the sharp increase in obesity prevalence from 2015 
(9%) to 2016 (14%) in preschoolers15 and the low percentages of Head Start preschoolers meeting 
fruit/vegetable (9%)66-68 and MVPA (50%)69,70 recommendations, highlight the critical need for this innovative 
intergenerational intervention. Furthermore, health habits established in preschool years persist later in 
childhood,71,72 highlighting the importance of introducing preventive efforts before entering kindergarten.  
A.2. SCIENTIFIC PREMISE. The major root causes of OW/O in low-SES preschoolers and their primary 
caregivers include unhealthy diet (e.g., excessive sugar drinks and fat intake, increased portion size, low 
intakes of fruits and vegetables),6,73 decreased PA,6 increased screen time,74,75 poor parenting practices, and 
home environment.28-30,76 Previous interventions involving caregivers via face-to-face contact16,33,77 resulted in 
low attendance (32-38%) due to inflexible caregiver schedules.41,42,63 Internet-based interventions resulted in 
similar or even greater effects on weight loss compared to non-Internet-based interventions.78-80 However, they 
suffer high attrition and low usage rates.81 To address these limitations, this research uses existing social 
networks (i.e. Facebook)39 and incorporates activities into people’s daily routines.40 According to the Pew 
Research Center, about 80% of young U.S. adults10 and 74% of U.S. parents11 use Facebook. In our prior 
study, 91% of the participating young parents used Facebook. Facebook-based interventions have achieved 
high retention rates (77-100%).39,40 To date, Facebook-based interventions have focused on changing 
Facebook users’ behaviors directly82-85 but no intervention has targeted caregivers via Facebook to improve 
support for their preschoolers’ behavioral change. Some face-to-face contact is still crucial to connect 
caregivers to each other to initiate a communication network86,87 and create norms to boost participation.81 
Guided by the promising findings of our prior study,38 we plan to extend this science in 3 ways: 1) use the 
existing social network Facebook™ to form a private group with messaging designed to engage caregivers in 
the program and to create group norms to support ongoing interaction; 2) actively engage both preschoolers 
and their caregivers to target major root causes of OW/O including diet, PA, screen time, parenting practices, 
and home environment; and 3) send preschooler letters to caregivers via Facebook messenger to share their 
preschooler’s experiences of learning at school, his/her stated desires for healthy diet and PA at home, as well 
as ask caregivers to provide nutritious foods and types of PA the preschooler has tried and liked. Thus, we will 
increase caregiver engagement and retention by forming a private homogeneous virtual community on 
Facebook, supplemented with limited face-to-face contact to maintain participation. Our Facebook-based 
program has resulted in high caregiver attendance (87%).38 To our knowledge, this intervention is the first 
to apply a bidirectional framework that captures not only caregivers’ ability to influence their 
preschoolers but also preschoolers’ ability to influence caregivers. A bidirectional framework 
emphasizing the interaction between caregivers and preschoolers offers a new perspective for studying child 
behaviors.88,89 Preschool is the time when a child’s influence emerges. Erikson’s psychosocial stage theory90 
indicates that children begin to assert autonomy by making choices about what they like between 18 months 
and 3 yrs. Children as young as 3 yrs. begin to have a significant role in influencing family food purchasing and 
consumption,91,92 so increasing children’s exposure to healthy choices will help increase their requests for 

 
 
healthy items.92 Intervening with preschoolers who begin to assert autonomy is very important to help foster an 
intimate, long-term, positive relationship between caregivers and children.93-96 Prior research only emphasizes 
the influence of caregivers on preschoolers without considering caregiver-preschooler bidirectional 
influence.45,46,97,98 Longitudinal, observational studies among preschoolers and school-age children have 
supported the influence of children’s behaviors and weight status on parenting practices.99-102 Experimental 
studies with school-age children further support that children’s participation in a lifestyle intervention can 
significantly increase their parents’ health knowledge,103 improve home food environment,104 and decrease 
parents’ BMI.105 Our study is based on the scientific promise that an intervention focusing on the bidirectional 
caregiver-preschooler relationship will improve behavioral and anthropometric outcomes among participants.  
B. INNOVATION This intervention is innovative because it: 1) is integrated into participants’ daily routines 
without adding excessive burden to their daily lives to improve sustainability and scalability; 2) applies a 
bidirectional framework emphasizing both the influence of caregivers on preschoolers and of preschoolers on 
caregivers; 3) facilitates the communication of preschooler preferences to improve caregivers’ feeding and 
activity practices through preschooler letters sent to caregivers via Facebook messenger; and 4) connects 
caregivers through an online private group via social network Facebook to support and motivate each other. 
Additionally, we apply an innovative training method to assist Head Start teachers to transition from being 
intervention implementation assistants to classroom education leaders: 1) MSU Extension health educators will 
deliver the intervention and model the role of interventionist with teachers observing for weeks 1–6; 2) 
Extension health educators and teachers will deliver the intervention together for weeks 7–10; 3) Teachers will 
deliver the intervention with Extension health educators providing on-site coaching and feedback for weeks 
11–16. This training method was successful in our prior study and can help improve intervention sustainability.  
C. APPROACH To ensure rigor, the study will use a rigorous design, reliable and valid instruments, and 
training and supervision to maintain ethical conduct and intervention integrity.  
C.1. RESEARCH TEAM. Our multidisciplinary team includes researchers from nursing, nutrition, child 
development, engineering, and biostatistics. The team includes experts in preschooler obesity prevention (PI 
Ling, Co-I Kerver, & Consultant Brophy-Herb),4,38,106 Internet/social network-based intervention (PI Ling & Co-I 
Robbins),38,107,108 mHealth (Co-I M. Zhang),109-111 and cluster RCTs (Co-Is Robbins & N. Zhang).112,113  
C.2. PRELIMINARY STUDIES. In preparation for this application, we completed two systematic reviews16,33 
and two preliminary studies.4,38,67,87 The systematic reviews16,33 suggest that OW/O interventions should target 
preschoolers via participatory learning34 and provide caregivers with parenting skill training and behavioral 
change strategies. One preliminary study,4 with 32 Head Start caregivers, identified the unique needs and 
barriers to healthy behaviors in Head Start families and supported the intervention strategy of involving 
caregivers through an online support group supplemented with face-to-face meetings. The PI collaborated with 
the established research team on a quasi-experimental study to examine the feasibility and preliminary efficacy 
of the 10-week FirstStep2Health intervention.38,67,87 Sixty-nine dyads participated (39 in intervention). About 
81% of caregivers and 46% of preschoolers were OW/O, and 92% reported no difficulty to get the foods they 
needed.3 Feasibility. Enrollment rate was 37% and retention rate was 99%. Preschooler participation was 
77%, and caregiver participation was 87%. Completion rates for weekly tasks and quizzes were 82% and 88%, 
respectively. About 94% of caregivers were satisfied with the program; 97% would recommend the program to 
others. Efficacy. Intervention increased MVPA (raw d=0.42) and fruit/vegetable intake (d=0.40), and 
decreased screen time (d=-0.21) and BMI z-score (d=-0.30) in intervention preschoolers. It also increased 
caregivers’ fruit/vegetable intake (d=0.40), but had a small effect on their MVPA (d=0.08) and BMI (d=-0.07). 
Suggestions. Fifteen randomly selected caregivers were interviewed individually. They suggested: 1) holding 
each caregiver meeting on both weekday and weekend so working caregivers can attend; 2) covering topics 
on alternative cooking ingredients and portion size control during the meeting; 3) promoting more interactions 
via commenting on others’ postings; 4) including quick meal recipes and healthy snack ideas in the intervention 
cookbook; and 5) extending the program a few more weeks. Results support the feasibility of the intervention, 
but preliminary efficacy needs further evaluation using a more rigorous design and larger sample size.  
 
(Aim 1) 
Fig 1. Actor-Partner Interdependence Model 
(Aim 2) 
(Aim 3) 

 
 
C.3. CONCEPTUAL FRAMEWORK (Fig 1). The intervention is guided by an Actor-Partner Interdependence 
Model (APIM),43 which has been used in behavioral interventions to better understand the intergenerational 
relationships inside a family.114-116 The APIM demonstrates the bidirectional relationship between preschoolers 
and caregivers: 1) actor effects within preschoolers or caregivers, and 2) partner effects between preschoolers 
and caregivers.43 The proposed intervention targets both preschoolers’ and caregivers’ knowledge, skill, self-
efficacy, and social support, derived from social cognitive theory,117 and parenting practices and home 
environment118-123 to improve their MVPA, diet quality, and screen time, thereby reducing the proportion of 
OW/O and BMI. Participatory learning34 will be used to improve preschoolers’ knowledge, skill, self-efficacy, 
and social support, but will not be assessed due to preschoolers’ immature cognitive development.124 
Caregivers’ learning34 will be improved via weekly habit-formation tasks on child feeding practices and PA and 
preschooler letters where preschoolers describe their desires for healthy diet and PA at home. Through 
simultaneously targeting both preschoolers and caregivers to maximize the actor and partner effects, the 
intervention is hypothesized to result in positive outcomes.  
C.4. STUDY DESIGN. To decrease cross-group contamination among participants in the same location,125 we 
will employ a rigorous two-group cluster RCT design by randomizing 6 centers so participants in one center are 
in the same group. Data will be collected at baseline (wk. 0) and immediately post-intervention (wk. 17).  
C.5. SETTING & SAMPLE. Six Head Start centers (≥ 4 classes/center) will be randomly selected from the 
Capital Area Community Services (CACS) Head Start and Early Childhood Programs and the Head Start for 
Kent County, which had 13 centers with ≥ 4 classes in 2017.126,127 Among the 13 centers, two had 4, one had 
5, five had 6, one had 8, one had 9, two had 12, and one had 14 classes. The 13 centers cared for 1,932 
preschoolers: 49% female, 20% Hispanic, 38% Black, and 39% White. Four classes will be randomly selected 
from each center, and 6 caregiver-preschooler 
dyads will be randomly selected from the 
eligible participants in each class (total: 6 
centers, 24 classes, and 144 dyads). Inclusion 
and exclusion criteria are specified in Table 1. 
C.6. SAMPLE SIZE & POWER. Due to the 
exploratory/developmental focus of this R21 
grant proposal, our aim is to estimate effect 
sizes for proximal and distal outcomes in 
preschoolers to serve as foundation for future 
research. Assuming class cluster effects 
intraclass correlation (ICC)=0.01,128,129 and 
significance level=.05, a sample size of 130 will provide a power of .80 to identify an effect size of 0.50, < 0.66 
for MVPA achieved in the prior study after adjusting for demographics.38 Given the extended intervention 
duration from 10 to 16 weeks and the strengthened intervention, we anticipate to also achieve an effect size of 
0.50 in preschoolers’ diet quality, screen time, and BMI z-score. We conservatively assume a 10% dropout. 
C.7. RECRUITMENT. The two Head Start organizations have agreed to support implementing the proposed 
project in their Head Start centers (Support Letters). Based on our prior experiences working with Head Start 
families, we anticipate ≥ 6 of 18 (30%) dyads per class will be willing to participate. Replacement classes will 
be randomly chosen if a selected class teacher refuses to participate. Building on lessons learned from prior 
studies and recommendations from Head Start administrators, we will involve Head Start family advocates to 
help with recruitment because they already have an established, trusting relationship with each family. The PI 
and project manager (PM) will provide participant recruitment training with communication scripts to family 
advocates to ensure consistency. Family advocates will distribute the recruitment packet (including cover letter, 
parental consent/child assent, & screening tool) in an envelope and explain the study to each caregiver in 
person. Each family will be asked to return the packet in a sealed envelope to the family advocate. For non-
respondents, the family advocates will make a follow-up phone call, and then another packet will be mailed to 
each family. Each family will be asked to return the packet in an attached, prepaid envelope. Cash ($5) will be 
provided for returning the packet. Prior to any data collection, written parental consent is required; if the child is 
age 5, written child assent is required. No data will be collected from preschoolers in the selected classes who 
do not have written consent or assent, but these preschoolers will be allowed to participate in intervention 
activities at their Head Start center. Both male and female preschoolers and caregivers will be recruited. 
C.8. RANDOMIZATION AND BLINDING. Following baseline data collection, 6 randomly selected centers will 
be randomly assigned to intervention or control using a computerized random-number generator. Center 
directors and teachers will be informed of group assignment. There is no way to completely blind participants 
Table 1. Inclusion and Exclusion Criteria 
Preschoolers 
Caregivers 
Inclusion Criteria 
Parental written consent 
Provide written consent  
Understand and speak English  
Read, understand, and speak English 
3-5 years old 
Primary adult caregiver (≥ 18 years old) 
Enrolled in full-day or half-day Head 
Start program  
Have at least weekly Internet access 
using a smartphone, tablet, or a computer 
Child written assent if 5 years old 
Willing to use Facebook 
Exclusion Criteria for both Preschoolers and Caregivers 
Medical conditions precluding dietary changes or PA  
Diagnosed conditions known to impact weight (e.g., Prader-Willi Syndrome) or 
taking weight-affecting medications (e.g., stimulants) 
Diagnosed developmental disabilities 
Diagnosed mental health problems 

 
 
to group; however, having two conditions in different centers minimizes the likelihood of cross-group 
contamination.125 Interventionists and caregivers will not be informed of the study hypothesis and will be asked 
not to discuss the program with others. Data collectors and interviewers will be blinded to the randomization.  
C.9. STRATEGIES TO ENHANCE ATTENDANCE AND RETENTION. The research team has demonstrated 
the ability to successfully recruit and retain participants.38,106 Retention strategies include: 1) keeping up-to-date 
lists of center and participant contacts; 2) mailing thank-you cards to boost achievement following each step; 3) 
using incentives to compensate for transportation and daycare cost in data collection ($40 at baseline and $50 
post-intervention); and 4) sending reminders via telephone calls, text messages, or emails to caregivers who 
have not completed data collection, weekly tasks, or logged-on to the study’s Facebook group for a week.  
C.10. INTERVENTION. Rationale for the intervention duration is that 16 weeks provides a reasonable period 
for behavior habit formation48 and is feasible for Head Start calenders.130,131 Additionally, we incorporated 
feedback from our 10-week prior study indicating that increasing the intervention duration would be helpful. 
C.10.1. Caregiver Component. Facebook-based program including 4 habit-formation tasks/wk. (Table 
2): A Facebook study site was 
developed in our prior study38 and will 
be installed on each intervention 
caregiver’s smartphone, tablet, or 
computer. All caregivers will be 
connected via a private Facebook 
group. We anticipate >80% will be 
Facebook users and >90% will have a 
smartphone with Internet access based 
on previous literature10,11,132 and our prior study. To address the unique needs of this low-SES population,4 the 
program will 1) provide caregivers a weekly electronically retrievable flyer containing health information, family 
fun activities, and behavioral change strategies to help create a healthier home environment, and 2) encourage 
interactive positive communication to promote peer support. All program materials will be sensitive to 
participants’ literacy level, low-SES 
& use of images as confirmed in 
our prior work. The program has 6 
components (Table 3). 
Three face-to-face caregiver 
meetings: MSU Extension health 
educators will lead the meetings at 
Head Start centers (wks. 1, 8, & 
16; Support Letter) to connect 
caregivers to each other, offer 
health information, and discuss 
behavioral change strategies. To 
improve attendance and 
accommodate caregivers’ work 
schedules, each meeting will be 
held on a weekday and a weekend 
day at each center. Healthy food 
taste-testing activities will be offered to expose caregivers to a variety of healthy homemade meals provided by 
MSU Extension. Meeting 1: A healthy, slow cooking demonstration will be offered, and each family will receive 
a small bag of groceries to facilitate preparation of the demonstrated recipe at home. Alternative cooking 
ingredients will be discussed to help reduce sugar and fat. Each caregiver will also receive an intervention 
cookbook containing affordable, slow-cooking recipes, quick-fix recipes, and healthy snack ideas. Reasons for 
providing a cookbook are: 1) in our prior study, Head Start caregivers requested “quick fix,” affordable but 
healthy, recipes;4 and 2) using a slow cooker to prepare easy but healthy meals is an effective strategy to 
overcome low-SES parent barriers of lack of time and cooking skills.4,133 Meeting 2: Extension health 
educators will demonstrate how to spend less and shop healthy, and how to read nutrition fact labels to 
promote healthy purchasing behaviors. Each caregiver will receive two, durable plastic “MyPlate” adult and 
child meal-portion plates to guide their proper portion size. Meeting 3: Extension health educators will present 
community healthy eating and PA resources (e.g., farmer’s markets, community gardens, nearby parks or 
Table 2. Caregiver Weekly Habit-Formation Tasks via Facebook 
Task  
Instructions  
Get in the 
kitchen 
Post about a healthy meal you made for your family (e.g., make a recipe 
of your own OR make chicken noodle soup for your family). 
Make active 
time family time 
Post about physical activity in which you helped child engage (e.g., take 
a walk with child, play a family activity game with child). 
Leave a positive 
comment 
Positively respond to one other person’s posting (e.g., Yum! That looks 
like a delicious meal. Great job.). 
Take a quiz 
Reinforce information & strategies learned (e.g., repeatedly exposing 
child to novel or disliked food is an effective strategy to deal with picky 
eaters; true or false?). 
Table 3. Caregiver Facebook-based Program Components 
Component 
Contents & Instructions 
Front Page 
Caregiver progress (# tasks completed) will be updated daily on this page. 
Complete 
Tasks 
Each Sunday morning, caregivers will receive a notification on weekly tasks and 
will be asked to complete tasks by midnight the following Saturday.  
Each Friday morning, caregivers will receive a reminder via Facebook messenger 
and text messaging to complete the weekly tasks.  
For caregivers who have not logged-on to the study’s Facebook group for a week, 
reminders will be sent via text message, phone call, or email aligning with their 
preferred communication method. 
Past Tasks 
Past tasks can still be completed after due date because some caregivers may 
not be able to complete on time due to illness or other personnel events.  
The flexibility was highly appreciated by caregivers in the prior study. 
Take A Quiz 
After completing each quiz, immediate feedback will be provided (e.g., You bet! 
Every minute counts. The physical activity goal of 10,000 steps/day can be 
achieved in sessions: a morning walk, a midday walk, and an evening walk.). 
Encouraging 
Messages 
Messages on parental influence will be posted on the private Facebook group’s 
front page every other day to encourage caregivers to take little steps at a time to 
help make healthy behavioral changes in the family (e.g., To the world, you’re a 
mother, but to your child, you are the world.). 
Talk to a 
Researcher 
This will allow caregivers to send private messages to the research team via 
Facebook messenger if needed to obtain advice on healthy diet and PA. 

 
 
other free or affordable PA facilities) and provide caregivers a resource manual. Each caregiver will receive a 
binder including all intervention materials to ensure access to intervention information after intervention ends.  
C.10.2. Caregiver-Preschooler Learning. Each week, preschoolers will create two letters using stickers 
regarding a food or activity presented in the center-based program that they liked or wanted to try at home. 
Letters will be sent by the PM privately to each caregiver via Facebook messenger every Wed. and Fri. 
Caregivers will be encouraged to discuss letters with their preschoolers and offer foods and activities desired 
by preschoolers. They will also be asked to answer two Facebook multiple-choice questions related to the 
letters each week by Sun. midnight (a. What foods listed in your child’s letter did you provide? b. What 
activities listed in your child’s letter did your family try?). Caregiver responses to the questions will be summed 
to indicate caregiver responses to child requests. Each preschooler’s letters will be kept in his/her intervention 
binder with other intervention materials to present to his/her caregiver at Meeting 3. Weekly preschooler 
activities, with pictures or videos, will be shared with caregivers via the Facebook private group every week.  
C.10.3. Center-based Preschooler Component (Table 4). Built on previous research,16,33,38,134-136 
preschoolers will receive weekly, age-appropriate, participatory learning34 co-delivered by teachers and MSU 
Extension health educators. Session duration will be 20 minutes because children’s normal attention span is 
3–5 minutes per year of age,137 and 20 min/session is recommended for preschoolers.4  
Table 4. Weekly Healthy Eating and PA Program at Intervention Head Start Centers  
Theme 
Dose 
Objectives 
“Eat & Walk My ABCs” Curriculum* 
Healthy eating 
learning  
20 min. 
Mon. 
Increase knowledge  
• Learn where food comes from, how its grown, and its nutrition. 
• Use food cards, costumes, food handheld puppets, and role-playing games.  
Taste-testing 
activities 
20 min. 
Tues. 
Expose to healthy 
foods 
• Use senses to understand the foods covered on Monday (how a food looks, smells, feels, and 
tastes).  
Skill training  
20 min. 
Wed. 
Improve fundamental 
movement skill 
• Use animal movements to teach fundamental movement skills: balance (e.g., balance on one 
foot, walk on a line), locomotor (e.g., running, hopping), and ball skills (e.g., kicking, throwing). 
Fun physical 
activity 
20 min. 
Thur.  
Increase physical 
activity 
• Use fun activity games adapted from the CATCH early childhood activity box138 and Eat Well 
Play Hard139 to practice the movement skills covered on Wednesday. 
• Reflect on the benefits of participating in physical activity. 
* A nurse expert in child development, a pediatric nurse practitioner, and a Head Start dietitian reviewed and approved the curriculum.  
C.11. CONTROL. Control group will receive usual Head Start activities during intervention period. After post-
intervention data collection, each control caregiver will receive all intervention supplies and a mini program 
including a face-to-face caregiver meeting and 1-week preschooler program. The caregiver meeting will cover 
contents on alternative cooking ingredients, food labels, and portion sizes.  
C.12. TRAINING. To insure intervention fidelity and high quality data, the PI, Co-Is (Robbins & Kerver), and 
PM will conduct an initial training on study protocol for the whole research team. MSU Extension health 
educators will receive additional training on the preschooler curriculum. The statistician, Dr. N. Zhang, and Co-I 
(Dr. M. Zhang) will also train the PM as the data manager and Facebook moderator, respectively. Training 
manuals will be provided to all research staff.  
C.13. INTERVENTION FIDELITY MONITORING & EVALUATION. The PM will monitor the Facebook group 
daily to record task-completion rates and caregivers’ site visits, respond to caregivers’ questions and postings, 
and review records and posted content to ensure proper posting and functionality. Extension health educators 
will record caregiver meeting attendance and activities, as well as each preschooler’s attendance, punctuality, 
participation, and activities offered for the day in a daily activity log. The PI will communicate with Extension 
health educators weekly to review objectives, attendance, and intervention delivery dose, and discuss issues 
and solutions. Head Start teachers will complete an evaluation survey on preschooler program, and caregivers 
will complete an evaluation survey on caregiver program and preschooler letters (Appendix A). Two process 
evaluators will observe 6 randomly sampled sessions (2/center; 1 session from Extension health educator and 
1 session from teacher) to evaluate preschooler curriculum implementation and activity engagement. At post-
intervention, individual interviews (Appendix A) with 10 randomly selected caregivers will be conducted with 
the PM and PI to obtain in-depth evaluation of the intervention and future suggestions for improvement.   
C.14. DATA COLLECTION & OUTCOME MEASURES (Table 5, Appendix A). All outcomes will be assessed 
at baseline and post-intervention. Height and weight will be measured in a private room in Head Start centers. 
To improve compliance with wearing accelerometers, an auto text-message reminder will be sent to caregivers 
every morning at 7AM via the REDCap web application maintained by MSU CTSI-BRIC (Support Letter). The 
24-hour dietary recall will be administered by 4 trained interviewers via telephone140 on 2 weekdays and 1 
weekend day,141,142 using the Nutrition Data System for Research (NDSR) software developed by the Nutrition 
Coordinating Center,143 University of Minnesota. Trained interviewers will also observe the snacks and lunch 
offered at Head Start centers. Drs. Ling & Robbins, who have completed the 2-day training on NDSR, will 
assess and assure diet data quality. The Environment and Policy Evaluation and Observation-Self-Report 
(EPAO-SR)144 will be completed by each center supervisor and two teachers on a single day to assess each 

 
 
Head Start center environment, including the physical environment, provisions, practices, policies, training, and 
education. All other surveys will be completed by caregivers online via REDCap web application. Caregivers 
will be informed of online surveys via text-message or email. Data collectors and interviewers (blinded to group 
assignment) will be available by phone or in-person to answer questions.  
C.15. DATA ANALYSIS. Any missing at random (MAR) data will be imputed using procedures suggested by 
Potthoff.173 For non-MAR data, a sensitivity analysis will be performed following recommended approaches for 
continuous and discrete outcomes.174-177 All analyses will use the intention-to-treat178 principle. Data analysis 
will be disaggregated by sex in preschoolers. AIM 1 & 2: Mixed-effect models in SAS 9.4 will be used to 
evaluate the intervention efficacy. Fixed effect predictors will include group, time, groupXtime interaction, and 
potential confounders such as preschooler sex, race, baseline weight status, and caregiver marital status. The 
correlation of preschooler outcomes measured over time and dependence due to nesting in the same center or 
class will be accounted through center- and class-specific random cluster effect. Contrasts will quantify the 
intervention effects separately at the post-intervention. Holm’s method will be used to statistically control for 
multiple comparisons.179 Effect size (Cohen’s d) will be calculated. AIM 3: Path analysis will be conducted 
using EQS 6.2. Model fit will be assessed using root mean square error approximation, Normed Fit Index, and 
Tucker Lewis index. Chi-square difference test180 will be used to compare models. Model modification will be 
made if needed. Feasibility/acceptability/satisfaction will be determined through enrollment, intervention 
participation, and evaluation survey data. Recorded individual interviews will be analyzed using directed 
content analysis in ATLAS.ti 8 to evaluate reasons for satisfaction and suggestions for improvement.  
Table 6. Method Considerations 
Issue  
Justification and Strategies 
Different participation by Head Start 
teachers may influence intervention delivery.  
• Based on our prior 10-wk study, all six teachers in the intervention classes independently and 
successfully delivered the last 4 wks. of the program.  
Compliance with wearing ActiGraphs.  
• We will send daily auto reminders. We will replace broken or misplaced ActiGraphs. Imputation 
techniques will be used for missing data. 
Difficulty meeting recruitment goals. 
• We will use Head Start family advocates to help with recruitment. Another center or class will be 
randomly selected if selected center or class elects not to participate.  
 
 
Table 7. Timeline for Activities 
Months  
YEAR 1 
YEAR 2 
1-4 
5-10 
11-12 
1-2 
3-6 
7-12 
IRB approval; hire/train staff; prep materials; purchase supplies. 
X 
X 
 
 
 
 
Recruit; enroll; baseline data collection. 
 
X 
 
 
 
 
16-week “FirstStep2Health” intergenerational intervention. 
 
X 
X 
X 
X 
 
Immediate post-intervention data collection. 
 
 
 
X 
X 
 
Data entry, cleaning, and analysis; presentations and manuscripts. 
 
X 
X 
X 
X 
X 
Table 5. Study Measures 
Concept 
Measure and Description 
# Items 
Time 
Reliability/Validity 
Preschoolers (Aim 1) 
MVPA (min/day) 
7-day ActiGraph GT3X-plus accelerometer145  
Cut-points: sedentary activity (≤37 counts/15 s), light (38–419), 
moderate (420–841), & vigorous (≥842)146,147 
7-day 
5 min 
 
Reliability =0.69–0.84148 
r =0.66 with observational 
system145  
Diet quality (e.g., 
fruit/vegetable, fiber, 
sugar/fat) 
Intake at Head Start center: dietary observation system on 
snacks and lunch on two weekdays149 
Intake at home: proxy-reported 24-hour dietary recall  
3-day 
90 min 
ICC =0.99;149 accurate rate: 
95%;150 good agreement with 
actual energy intake151 
Screen Time 
NHANES-Physical Activity and Physical Fitness survey152 
2 
1 min 
Reliability: r =0.63–0.84153 
Proportion of OW/O, 
BMI z-score  
 
Calculated from height and weight using CDC growth charts154 
Height: Child/Adult Shorr Measuring Board Stadiometer  
Weight: Child/Adult Seca model 874 portable electronic scale 
In accordance with NHANES measurement protocol155 
N/A 
3 min 
Specificity 0.93; sensitivity 0.73156 
Caregivers (Aim 2) 
MVPA 
7-day ActiGraph GT3X-plus accelerometer  
Cut-points: light (0–2689 counts/60 s), moderate (2690–6166), 
& vigorous (≥6167)157 
7-day 
5 min 
ICC =0.97–0.99158 
r =0.81 with oxygen 
consumption159  
Diet quality 
Fruit-vegetable-fiber screener160  
10 
3 min 
r =0.71 with full Block survey160  
Screen Time 
NHANES-Physical Activity and Physical Fitness survey152 
2 
1 min 
Reliability: r =0.63-0.84153 
Proportion of OW/O, 
BMI 
Calculated using (weight kg/height m2)161 
Measures are similar to those used in preschoolers 
N/A 
3 min 
Specificity 0.97; sensitivity 0.42162 
Knowledge 
Knowledge on preschoolers’ dietary intake & physical activity163 
25 
5 min 
N/A 
Feeding Practice Skill 
Child Feeding Questionnaire164 measuring caregiver feeding 
practice behaviors 
33 
5 min 
α =0.71-0.9338,164,165 
r =-0.26-0.53 with child BMI164-166  
Self-Efficacy 
Parental self-efficacy scale163 
20 
4 min 
α =0.72-0.9438,163 
Parental Support 
Parental support scale for eating habits and physical activity167  
12 
3 min 
α =0.83-0.8738,167,168 
Parenting Practices 
Parenting Style and Dimensions Questionnaire169 assessing 
parenting styles: authoritative, authoritarian, and permissive 
32 
5 min 
α =0.64-0.91170 
Home Environment  
Family Nutrition and Physical Activity (FNPA) screening tool171 
assessing home obesogenic environments and practices 
20 
4 min 
Correlated with child BMI171,172 
Demographics 
Socio-demographic questionnaire (e.g., age, sex, race)  
12 
3 min 
N/A 
Center Environment 
EPAO-SR144 
1-day 
30 min 
Related to observational data144 

 
 
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