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An Investigation of Parents’ Perceptions of BMI and BMI-for-age, School-Based BMI Screening Programs and BMI Report Cards: Using Framing Theory and Perceptual Mapping Methods to Develop a Tailored BMI Report Card for the School District of Philadelphia A Dissertation Submitted to The Temple University Graduate Board in Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY By Dominique G. Ruggieri May, 2012 Examining Committee Members: Sarah Bauerle Bass, PhD, MPH, Advisory Chair, Public Health Thomas F. Gordon, PhD, Public Health Jay S. Segal, PhD, Public Health Melissa A. Napolitano, PhD, External Member, Kinesiology i © Copyright 2012 by Dominique G. Ruggieri All Rights Reserved ii ABSTRACT School-based body mass index (BMI) screenings seek can improve parents’ recall about their child’s weight, increase concern about excess weight, and correct parents’ misperceptions to help them make informed decisions about their child’s health. However, schools have questioned parents’ understanding of and attitudes about BMI, and have expressed concern about parents’ reactions to BMI reports. Using a sample of school nurses (n=7) and parents/guardians (n=125) from the School District of Philadelphia (SDP), this research addressed these concerns by clarifying: 1) parents’/guardians’ perceptions and knowledge about BMI; 2) the challenges schools face in communicating with parents/guardians; and 3) the messages that can be communicated to parents/guardians to help them understand their child’s BMI-for-age category and why their child’s BMI is measured in his/her school. The research used framing theory and perceptual mapping methods to study and improve communication about BMI to parents/guardians in the School District. The four-phase study design incorporated qualitative (focus groups and semi-structured in-depth interviews) and quantitative (cross-sectional survey) methods to assist in the development of an evidence-informed BMI report card template for the SDP. Messages were constructed to meet the needs of four distinct groups of parents/guardians that emerged from the factor and cluster analyses – “Passive Parents,” “Neutral Parents,” “Confident Advocates” and “Active Worriers.” Although each cluster of parents/guardians had their own unique perceptions and varying degrees of assuredness and confidence related to BMI concepts, the majority of parents/guardians in this study shared common favorable perceptions about BMI measures, school-based screening programs and BMI report cards. iii ACKNOWLEDGEMENTS First, I would like to emphasize that no words can sufficiently express the depth of my gratitude for the years of support, guidance, encouragement, assistance, and mentorship that have brought me to this point. Although pursuing a PhD requires many hours of solitude and sacrifice, it can only be realized with the support of family, friends, colleagues, and faculty. To say that it has taken a village to complete this degree is neither cliché nor an understatement. Through two separate programs I have grown to appreciate that the most important key to success in a PhD program is the support provided by others. This is never far from my mind and this goal is an accomplishment that is shared. I know I am not the only one who is relieved that I am moving on to the next chapter in my life. I would like to thank my advisor, committee chair, and mentor, Dr. Sarah Bass, without whom none of this would have been possible. Sarah, you have given me years of guidance, support, and friendship that have meant more to me than I could ever express to you. You are an incredible role model whom I continue to look up to. Although you balance more with work and family than anyone I know, you have always given me your undivided time and attention in a manner that goes above and beyond any of my expectations. You have a special way of pushing me to be better, and it’s always with sincerity and kindness. I am honored to have you in my corner. I would also like to thank my committee member, Dr. Tom Gordon, for the guidance, patience, and unique insights he provided me throughout the development of this dissertation. Tom, your ability to quietly encourage me to think deeper and more critically have never gone unnoticed. You introduced me to new research, new iv methodologies, and new statistical tests in a way that fueled my excitement for the dissertation process and public health research. For that, I will always be especially grateful. Sincerest thanks also go to my committee member, colleague, and partner-in- crime, Dr. Jay Segal. Without you, Jay, I certainly would not be realizing this dream. You held me up and pulled me through the darkest hours of my former program. You will never know how grateful I am for your guidance, support, and friendship. When I thought my PhD would be an unattainable goal you told me to keep going with the knowledge that you would pick me up and carry me to the finish line if I fell along the way…I think of this almost daily. You continue to help me discover my talents and passions in the field of public health, and I look forward to all of our work to come with excitement and readiness. To my external committee member, Dr. Melissa Napolitano, I want to thank you for your encouragement, support, friendship, and guidance through the toughest years of my graduate school career. You provided me with opportunities and experiences that reminded me about the kind of work I want to pursue post graduate school and, in doing so, inspired me to keep going and start over again. I am so happy to be moving forward with the knowledge that I can contribute to the field of obesity research and practice in a meaningful way. I am grateful for this confidence, and it stems from our work together. I would also like to acknowledge the people who provided me with their time, help, and support for this research. In no particular order, many thanks go to: Dr. Jay Schinfeld and the Sandy Schinfeld Memorial Fund, for their financial assistance for my research; Ms. Rhona Cooper and the school nurses in the School District of Philadelphia v who granted me interviews during their packed school days; Mr. Harold Reed and the Directors of the recreation centers who assisted me with recruitment; Khalia Pitts and Caite Wolak, for their help with the parent/guardian focus groups and data preparation; Gabriella Mora, for her help with recruitment and data preparation; and especially Becky Molotsky, for sacrificing her winter break from grad school to become my personal research assistant and stats checker…you are a trooper! There is no question that I would not be at this point without the support of my loyal family and friends, who have shown me love and encouragement throughout both of my programs. I would like to express my gratitude for those who are still with me and those who passed away before seeing me graduate – my grandparents, my Uncle Tom, and Sandy Schinfeld. Thank you to all of you who have cheered me on, listened to me ramble about graduate school for the past decade, and above all, showed forgiveness when I canceled plans and failed to respond to emails, texts, and phone calls because I needed to drop off the face of the Earth to focus on school work. I have hated the time away from all of you and I am so grateful for your understanding and encouragement. Thank you for supporting me and for celebrating every small accomplishment that got me to this point. To my parents, Odette and Dan, I could write another whole dissertation and still not be able to express the depth of my gratitude for your support (I won’t, of course, as I think four dissertations are enough for a lifetime!). You have supported my graduate school career in every way a parent can – with love, home cooked meals, free room and board, financial support, late nights of edits, long days and evenings of endless discussions about my classes, professors, administrators, dissertation research…the list vi goes on. Moreover, you have supported me in a way that has always focused more on pride in my accomplishments than on the time it took me to get there. For every way you have been there to support me, thank you! I love you and I am so lucky for both of you! Last, and certainly not least, I would like to thank my fiancé, Ryan. Although the time and energy you spent making all of my tables and figures, fixing me dinners during my late nights on the computer, tutoring me in statistics, editing my writing, and taking care of Snoopy so that I could work without distractions are all deeply appreciated, these are not the most significant ways that you have contributed to this work and to my program. You have made it possible for me to pursue this degree with your unconditional love and support every single day. You have carried the financial load while I finish school, and all that you ask of me is that I pursue what makes me happy and that I work hard to get there. I am so appreciative for your love and support for my work and my goals. I love you so much and I can’t wait for all of the exciting things to come in the next chapter of our lives together! vii DEDICATION For my parents, Odette and Dan You provided me with unyielding support through what seemed like a never-ending graduate school career…thank you! viii TABLE OF CONTENTS ABSTRACT ......................................................................................................................

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