Results from the Strong Families Start at Home/Familias Fuertes Comienzan en Casa: feasibility randomised control trial to improve the diet quality of low-income, predominantly Hispanic/Latinx children.

OBJECTIVE: To describe the feasibility, acceptability and results of Strong Families Start at Home, a 6-month pilot trial of a home-based food parenting/nutrition intervention. DESIGN: Pilot randomised controlled trial. SETTING: Participants received six visits with a community health worker trained in motivational interviewing (three home visits, three phone calls); an in-home cooking or reading activity; personalised feedback on a recorded family meal or reading activity; text messages and tailored printed materials. PARTICIPANTS: Parents and their 2-5-year-old child were randomised into intervention (responsive food parenting practices/nutrition) or control (reading readiness) groups. RESULTS: Parents (n 63) were mostly mothers (90 %), Hispanic/Latinx (87 %), born outside the USA (62 %), with household incomes <$25 k (54 %). Despite delivery during COVID-19, 63 % of dyads were retained at 6 months. The intervention was delivered with high fidelity. All parents in the intervention group (n 24) expressed high levels of satisfaction with the intervention, which produced positive treatment effects for whole and total fruit component Healthy Eating Index-2015 scores (point estimate (PE) = 2·14, 95 % CI (0·17, 1·48); PE = 1·71, 95 % CI (0·16, 1·47), respectively) and negative treatment effects for sodium (PE = -2·09, 95 % CI (-1·35, -0·04)). Positive treatment effects also resulted for the following food parenting practices: regular timing of meals and snacks (PE = 1·08, 95 % CI (0·61, 2·00)), reducing distractions during mealtimes (PE = -0·79, 95 % CI (-1·52, -0·19)), using food as a reward (PE = -0·54, 95 % CI (-1·35, -0·04)) and providing a supportive meal environment (PE = 0·73, 95 % CI (0·18, 1·51)). CONCLUSION: Given the continued disparities in diet quality among low-income and diverse families, continued efforts to improve child diet quality in fully powered intervention trials are needed.

Food insecurity, food parenting practices, and child eating behaviors among low-income Hispanic families of young children.

Food insecurity is associated with negative food parenting practices that may promote child obesity, including pressure to eat and food restriction. Less is known about the relationship between food insecurity and positive food parenting practices, including exposing the child to new foods and involving the child in food preparation. Further, few studies have investigated the associations between food insecurity and child eating behaviors that have been linked to poor dietary outcomes. Using baseline data collected as part of a larger pilot intervention, we examined the relationships between food security status, food parenting practices, and child eating behaviors in a predominately Hispanic, low-income sample of parents and their preschool aged children (n = 66). Between July of 2019 and 2020, caregivers recruited from 4 urban communities in Rhode Island completed assessments of household food security, food parenting practices, and four child eating behaviors: food responsiveness, emotional overeating, enjoyment of food, and satiety responsiveness. Although 46% of caregivers reported food insecurity, food insecurity was not directly associated with any food parenting practice. Children in food insecure households were rated as higher in levels of food responsiveness and enjoyment of food as compared to children in food secure households. Children in food insecure households were rated as lower in satiety responsiveness as compared to children in food secure households. Child emotional overeating did not vary by food security status. Future interventions to reduce child obesity among low-income Hispanic families should assess food security status and consider any level of food insecurity as a potential signal of unhealthy child eating behaviors.

A recurrent cross-sectional qualitative study exploring how low-income mothers define snacks and reasons for offering snacks during infancy.

Despite rapid increases in snacking in recent decades, little is known about snacking during infancy. This study explored how low-income mothers define snacks and their reasons for offering snacks during infancy. A recurrent cross-sectional qualitative approach was used to identify themes from semi-structured interviews with low-income mothers when their infants were 6 and 12 months of age. A purposive sample of mothers (N = 15) was recruited from Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) offices and childcare centers serving low-income families in Rhode Island. Mothers also completed demographic and infant feeding questionnaires. Independent thematic analyses were conducted to identify themes from the 6 and 12 month interviews. Themes from the 6 month interviews for how mothers defined snacks were: snacks are consumed between meals, snacks are smaller portions, and snacks are sweet. Themes from the 12 month interviews also included snacks are consumed between meals and snacks are smaller portions with one additional theme: snacks do not include all food groups. Themes from the 6 month interviews for the reasons mothers offered snacks were: infants seemed hungry, infants showed interest, and snacks help manage behavior. Themes from 12 month interviews also included snacks help manage behavior with two additional themes: snacks expose infants to different flavors and snacks expose infants to different textures. Findings suggest that snacks are commonly offered during infancy and that mothers define snacks as smaller portions that help with hunger between meals. However, during early infancy mothers describe snacks as sweet, and across infancy report using snacks to manage behavior, underscoring the importance of providing parents with guidance on healthy snacking during the first year of life.

Socio-economic and racial prenatal diet quality disparities in a national US sample.

OBJECTIVE: To examine differences in prenatal diet quality by socio-economic status (SES) and race/ethnicity. DESIGN: A secondary, cross-sectional analysis. Race and SES were self-reported prenatally; SES was categorized into four groups: high-income, middle-income and low-income WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) participant/non-participant. The Alternative Healthy Eating Index for Pregnancy (AHEI-P) measured diet quality, including four moderation and nine adequacy components (higher scores = healthier diet). Generalized linear models adjusted for covariates and post hoc testing with Tukey adjustment compared AHEI-P scores between groups, using a threshold of P < 0·05. SETTING: Infant Feeding Practices Study II, conducted in a national US convenience cohort. PARTICIPANTS: Women in their third trimester (n 1322) with dietary history. RESULTS: Participants were of 28·9 (se 5·6) years on average and predominantly non-Hispanic White (84 %); approximately one-third participated in WIC and 17 % were high-income. The mean AHEI-P score was 61·7 (se 10·8) of 130 points. High-income women had higher total (62·4 (se 1·0)) and moderation component AHEI-P scores than middle-income (60·1 (se 0·8), P = 0·02), low-income WIC participants (58·3 (se 0·8), P < 0·0001) and non-participants (58·9 (se 0·9), P = 0·001). Non-Hispanic Black participants had lower total (57·8 (se 1·4)) and adequacy scores than Other races (i.e. neither non-Hispanic Black nor White, 62·1 (se 0·9), P = 0·02). CONCLUSIONS: Disparities in prenatal diet quality were observed, with non-Hispanic Black women, low-/middle-income and WIC participants having lower diet quality. However, interventions are needed to improve prenatal diet quality broadly among US women.

Maternal vegetable intake during and after pregnancy.

BACKGROUND: Improved understanding of vegetable intake changes between pregnancy and postpartum may inform future intervention targets to establish healthy home food environments. Therefore, the goal of this study was to explore the changes in vegetable intake between pregnancy and the postnatal period and explore maternal and sociodemographic factors that are associated with these changes. METHODS: We examined sociodemographic, dietary, and health characteristics of healthy mothers 18-43y from the prospective Infant Feeding Practices II cohort (n = 847) (2005-2012). Mothers completed a modified version of the diet history questionnaire, a food-frequency measure, developed by the National Cancer Institute. We created four categories of mothers, those that were: meeting vegetable recommendations post- but not prenatally (n = 121; improved intake), not meeting vegetable recommendations during pregnancy and postnatally (n = 370; stable inadequate), meeting recommendations pre- but not postnatally (n = 123; reduced intake), and meeting recommendations at both time points (n = 233; stable adequate). To make our results more relevant to public health recommendations, we were interested in comparing the improved vegetable intake group vs. stable inadequate vegetable intake group, as well as those that reduced their vegetable intake compared to the stable adequate vegetable intake group. Separate multivariable-adjusted logistic regression were used to examine sociodemographic predictors of improved vs. stable inadequate and reduced vs. stable adequate vegetable intake. RESULTS: Women with improved vegetable intake vs. stable inadequate smoked fewer cigarettes while women with reduced vegetable intake vs. stable adequate were more likely to experience less pregnancy weight gain. In adjusted models, employed women had greater odds of reduced vegetable intake (OR = 1.64 95% CI 1.14-2.36). In exploratory analyses, employment was associated with greater odds of reduced vegetable intake among low-income (OR = 1.79; 95% CI 1.03-3.1), but not higher income women (OR = 1.31; 95% CI 0.94-1.84). After further adjustment for paid maternity leave, employment was no longer associated with vegetable intake among lower income women (OR: 1.53; 95% CI: 0.76-3.05). CONCLUSIONS: More women with reduced vs. stable adequate vegetable intake were lower income and worked full time. Improved access to paid maternity leave may help reduce disparities in vegetable quality between lower and higher income women.

Pathways between maternal depression, the family environment, and child BMI z scores.

PURPOSE: Modifiable aspects of the family environment that contribute to overweight in younger children have been identified, including parental feeding practices, child eating behaviors, and parenting practices related to eating and household routines. Maternal depression influences many of these factors, yet research examining pathways that may link maternal depression through the family environment to child weight is lacking. The current study examined parental feeding practices, child eating behaviors, and eating and household routines as potential mediators between maternal depressive symptoms and child weight at age six. The study also tested for differential effects of early versus concurrent maternal depressive symptoms. METHODS: Longitudinal data on 1130 mothers and their children who participated in the Infant Feeding Practices Study II (IFSP II) and its Year 6 Follow-Up study were analyzed. A multi-step, multiple mediator model assessed direct and indirect relationships between early depressive symptoms (two months post-partum) and concurrent depressive symptoms with child Body Mass Index (BMI) z scores at age six. Potential mediators included parental feeding practices, child eating behaviors, and eating and household routines. RESULTS: Higher early depressive symptoms directly explained lower child BMI z scores. Early depression also worked through concurrent depression, the child's food responsiveness, and the hours the child slept on week nights to explain higher child BMI z scores. Parental efforts to make sure the child eats enough directly predicted lower child weight but did not mediate the effects of early or concurrent maternal depressive symptoms. CONCLUSIONS: The findings suggest the need for greater attention to the relationships between maternal depression and child weight as a critical step toward developing effective obesity prevention strategies.

Associations between family food behaviors, maternal depression, and child weight among low-income children.

Although low-income children are at greater risk for overweight and obesity than their higher income counterparts, the majority of poor children are not overweight. The current study examined why such variation exists among diverse young children in poor families. Cross-sectional data were collected on 164 low-income, preschool aged children and their mothers living in two Rhode Island cities. Over half of the sample was Hispanic (55%). Mothers completed measures of family food behaviors and depression while trained assistants collected anthropometric data from children at seven day care centers and a Supplemental Nutrition Assistance Program outreach project. Multivariate analysis of covariance revealed that higher maternal depression scores were associated with lower scores on maternal presence when child eats (P < .05), maternal control of child's eating routines (P < .03), and food resource management skills (P < .01), and with higher scores on child control of snacking (P < .03) and negative mealtime practices (P < .05). Multiple regression results revealed that greater maternal presence whenever the child ate was significantly associated with lower child BMI z scores (ß = .166, P < .05). Logistic regression analyses indicated that higher scores on food resource management skills reduced the odds of child overweight (odds ratios = .72-.95, P < .01). Maternal depression did not modify the relationship between family food behaviors and child weight. Overall, caregiver presence whenever a child eats, not just at meals, and better parental food resource management skills may promote healthier weights in low-income preschoolers. Further research is needed to identify the mechanisms that connect caregiver presence and food resource management skills to healthier weights for this age group.

Goals, Barriers, and Facilitators of Caregivers Who Participated in an In-Home Intervention to Improve Food Parenting Practices and Child Diet Quality.

OBJECTIVE: To explore the goals, barriers, and facilitators set by caregivers of preschool-aged children to improve food parenting practices and household food environments. DESIGN: Secondary qualitative analysis of collaborative goal sheets completed during in-home and telephone visits as part of a home-based pilot intervention. PARTICIPANTS: Thirty-three Hispanic/Latinx caregivers, predominantly of low income. PHENOMENON OF INTEREST: Patterns in goal content and anticipated barriers and facilitators. ANALYSIS: Thematic analysis of goal sheets with a mixed inductive-deductive approach. RESULTS: Almost half of the goals were to support a healthy environment (40.7%) by increasing the availability of healthy foods through food shopping and meal planning. Other goals were to increase structure (33.7%) by establishing food-related routines and decreasing distractions. Goals related to autonomy support (25.4%) included involving their children (eg, cooking together). Caregivers' perceived barriers encompass individual (eg, stress, lack of time), interpersonal (eg, other family members' eating behaviors), and environmental-level (eg, food availability) factors. Caregivers only identified facilitators at the individual and interpersonal levels (eg, motivation). CONCLUSIONS AND IMPLICATIONS: Understanding goals, barriers, and facilitators can be used to tailor key messages to improve food parenting practices and children's diets. Future interventions can target broader environmental barriers while increasing awareness of individual, interpersonal, and environmental-level facilitators.

Control and Chaos: Caregiver's Basic Psychological Need Frustration is Associated With the Socioemotional Climate When Feeding.

OBJECTIVE: The socioemotional climate when feeding is a focus in childhood obesity prevention efforts. However, little is known about why caregivers create nonsupportive or supportive climates. This cross-sectional study used a Self-Determination Theory perspective to identify factors associated with the socioemotional climate when feeding in ethnically diverse families with low income. METHODS: Caregivers of children aged 2-5 years (n = 66) completed the Parent Socioemotional Context of Feeding Questionnaire, the Basic Psychological Need (BPN) Satisfaction and Frustration Scale, and demographic surveys at baseline. Multivariable regressions assessed the association between BPN satisfaction/frustration with autonomy-supportive, structured, controlling, and chaotic feeding climates. RESULTS: Participants were predominately Hispanic/Latinx (86.6%), women (92.5%), and born outside the US (60%). Their BPN frustration was positively associated with controlling (ß = 0.96; SE = 0.26; P = 0.001) and chaotic (ß = 0.79; SE = 0.27; P = 0.01) feeding. CONCLUSIONS AND IMPLICATIONS: This analysis suggests that BPN frustration is associated with controlling and chaotic feeding and may be important to consider when encouraging responsive feeding.

Maternal Stress and Excessive Weight Gain in Infancy.

Rapid weight gain in infancy increases the risk of developing obesity early in life and contributes significantly to racial and ethnic disparities in childhood obesity. While maternal perceived stress is associated with childhood obesity, little is known about the impact it has on infant weight gain. Therefore, this study explores the impact of maternal perceived stress on change in weight-for-length (WFL) z-scores and the risk of rapid weight gain in infancy. We conducted a secondary data analysis of the longitudinal Nurture birth cohort (n = 666). Most mothers in the cohort were non-Hispanic/Latinx Black (71.6%). About one-half of mothers had a body mass index (BMI) greater than 25 prior to pregnancy, were unemployed, and had a low income. Most infants in the cohort were born full-term and were of normal weight. Data were collected at 3-, 6-, 9-, and 12-months postpartum. At each assessment, mothers completed the Cohen's Perceived Stress Scale (PSS), and research assistants weighed and measured each infant. Tertiles were used to compare mothers with high and low perceived stress. A mixed model analysis of repeated measures assessed the associations between baseline perceived stress and the change in infant WFL z-scores over time. Log-binomial models assessed the association between baseline perceived stress and rapid weight gain, defined as a change in WFL z-score > 0.67 standard deviations from three to twelve months. Just under one-half of the infants (47%) experienced rapid weight gain between three and twelve months of age. Birthweight for gestational age (RR = 1.18, 95% CI = 1.08−1.29, p-value = 0.004), gestational age at birth (RR = 1.07, 95% CI = 1.01−1.14, p-value = 0.031), and weeks breastfed (0.99, 95% CI 0.99−1.00, p-value 0.044) were associated with risk of rapid weight gain in unadjusted analyses. WFL z-scores increased significantly over time, with no effect of perceived stress on change in WFL z-score or risk of rapid weight gain. Rapid weight gain in infancy was prevalent in this sample of predominately Black infants in the Southeastern US. We did not find evidence to support the hypothesis that maternal perceived stress influenced the risk of rapid weight gain. More work is needed to identify and assess the risk factors for rapid weight gain in infancy and to understand the role that maternal stress plays in the risk of childhood obesity so that prevention efforts can be targeted.

Measuring family food environments in diverse families with young children.

This study reports the development and validation of the 20 item Family Food Behavior Survey, a measure designed to assess broad components of the family food environment that may contribute to child overweight. In a diverse sample of 38 parents, factor analyses verified 4 domains: (1) maternal control of child eating behavior; (2) maternal presence during eating; (3) child choice, and (4) organization of eating environment. All domains achieved acceptable internal reliability (alphas= .73, -.83), and test-retest reliability. Mothers of overweight children scored significantly lower on maternal presence and somewhat higher on maternal control than mothers of normal weight children.

Rationale, design and study protocol of the 'Strong Families Start at Home' feasibility trial to improve the diet quality of low-income, ethnically diverse children by helping parents improve their feeding and food preparation practices.

There is an urgent need to create effective interventions that help parents establish a healthy diet among their children early in life, especially among low-income and ethnically and racially diverse families. U.S. children eat too few fruits, vegetables and whole grains, and too many energy dense foods, dietary behaviors associated with increased morbidity from chronic diseases. Parents play a key role in shaping children's diets. Best practices suggest that parents should involve children in food preparation, and offer, encourage and model eating a variety of healthy foods. In addition, while parents help to shape food preferences, not all children respond in the same way. Certain child appetitive traits, such as satiety responsiveness (sensitivity to internal satiety signals), food responsiveness (sensitivity to external food cues), and food fussiness may help explain some of these differences. Prior interventions to improve the diet of preschool children have not used a holistic approach that targets the home food environment, by focusing on food quality, food preparation, and positive feeding practices while also acknowledging a child's appetitive traits. This manuscript describes the rationale and design for a 6-month pilot randomized controlled trial, Strong Families Start at Home, that randomizes parents and their 2-to 5-year old children to either a home-based environmental dietary intervention or an attention-control group. The primary aim of the study is to explore the feasibility and acceptability of the intervention and evaluation and to determine the intervention's preliminary efficacy on child diet quality, feeding practices, and availability of healthy foods in the home.

Associations between pre-pregnancy BMI, gestational weight gain, and prenatal diet quality in a national sample.

This secondary analysis explored the association between gestational weight gain, pre-pregnancy body mass index (BMI), and prenatal diet quality in a United States national sample. The sample comprised 1322 pregnant women in the longitudinal Infant Feeding Practices Study II with Diet History Questionnaire data. Diet quality in the third trimester was assessed using the Alternative Healthy Eating Index for Pregnancy. Self-reported pre-pregnancy BMI (categorized as underweight<18.5, normal weight 18.5-24.9, overweight 25.0-29.9, and obese≥30.0) and total gestational weight gain were used to categorize adherence to the Institute of Medicine's recommendations as inadequate, adequate, or excessive weight gain. Diet quality in pre-pregnancy BMI and gestational weight gain groups were compared using Tukey-adjusted generalized linear models adjusted for sociodemographic factors, Women, Infants, and Children participation, parity, and energy intake. Due to missing gestational weight gain data, sensitivity analyses with multiply imputed data were conducted. Women were on average 28.9 years old and of higher socioeconomic status (40% college graduates) and mostly non-Hispanic White (84%), and the mean Alternative Healthy Eating Index for Pregnancy score was 61.2 (of 130). Both pre-pregnancy BMI and gestational weight gain were inversely associated with diet quality scores (p<0.01). The interaction between pre-pregnancy BMI and gestational weight gain was significant (p = 0.04), therefore gestational weight gain models were stratified by BMI group. In stratified adjusted models, gestational weight gain was differently associated with diet quality scores (p<0.05) among women with underweight, normal weight, overweight, and obesity. The relationship between gestational weight gain and prenatal diet quality depended on pre-pregnancy BMI. For example, within women with normal weight, higher diet quality was observed in the adequate gestational weight gain group. Interventions to broadly improve prenatal diet quality are needed, however, resources can be used to target women with higher pre-pregnancy BMIs and women with inadequate or excessive gestational weight gain.

Associations of Less Healthy Snack Food Consumption with Infant Weight-for-Length Z-Score Trajectories: Findings from the Nurture Cohort Study.

Little is known about the impact of less healthy snack foods on weight trajectories during infancy. This secondary analysis of data from the Nurture cohort explored prospective associations of less healthy snack foods with infant weight trajectories. Pregnant women were recruited and, upon delivery of a single live infant, 666 mothers agreed to participate. Mothers completed sociodemographic and infant feeding questionnaires, and infant anthropometrics were collected during home visits at 3, 6, 9, and 12 months. Less healthy snack food consumption was assessed by asking how frequently baby snacks and sweets were consumed each day during the previous three months. Multilevel growth curve models explored associations of baby snacks and sweets with infant weight-for-length (WFL) z-scores. On average, mothers were 27 years old, 71.5% were non-Hispanic Black, and 55.4% had household incomes of ≤$20,000/year. Consumption of less healthy snack foods increased during infancy with a median intake of 3.0 baby snacks/day and 0.7 sweets/day between 10 and 12 months. Growth curve models showed that infants who consumed sweets >2 times/day had significantly higher WFL z-scores during the second half of infancy compared to infants who never consumed sweets. Less healthy snacks may contribute to the risk of obesity during infancy and promoting healthy snack food choices during this critical time is important.

The role of community in facilitating service utilization.

Guided by an integrated theory of parent participation, this study examines the role community characteristics play in influencing a parent's decision to use voluntary child abuse prevention programs. Multiple regression techniques were used to determine if different community characteristics, such as neighborhood distress and the community's ratio of caregivers to those in need of care, predict service utilization levels in a widely available home visiting program. Our findings suggest that certain community characteristics are significant predictors of the extent to which families utilize voluntary family supports over and above the proportion of variance explained by personal characteristics and program experiences. Contrary to our initial assumptions, however, new parents living in the most disorganized communities received more home visits than program participants living in more organized communities. The article concludes with recommendations on how community capacity building might be used to improve participant retention.

Maternal Strategies to Access Food Differ by Food Security Status.

BACKGROUND: Household food insecurity is associated with health and behavior risk. Much less is known about how food insecurity is related to strategies that adults use in accessing food: how and where they shop, use of alternative food sources, and their ability to manage resources. OBJECTIVE: To examine how maternal behaviors, including shopping, accessing alternative sources of food, and managing resources, are related to household food security status (HHFSS). DESIGN: Cross-sectional study collecting survey data on HHFSS, shopping behaviors, use of alternative food sources, and managing resources obtained from low-income mothers of preschool-aged children. PARTICIPANTS: One hundred sixty-four low-income mothers of young children (55% Hispanic) from two communities in Rhode Island. MEASURES: HHFSS was measured using 10 items from the 18-item Core Food Security Module to assess adult food security. Mothers were surveyed about where, when, and how often they shopped; the strategies they use when shopping; their use of alternative sources of food, including federal, state, and local assistance; and their ability to manage their resources. STATISTICAL ANALYSIS: Analysis of variance and χ2 analyses assessed the associations between demographic variables, shopping, accessing alternative food sources, and managing resources, and HHFSS. Multivariate logistic regression assessed the associations between HHFSS and maternal demographic variables, food shopping, strategies, alternative sources of food, and ability to manage resources. RESULTS: Maternal age and language spoken at home were significantly associated with HHFSS; food insecurity was 10% more likely among older mothers (adjusted odds ratio [aOR] 1.10, 95% CI 1.03 to 1.17) and 2.5 times more likely among Spanish-speaking households (compared with non-Spanish speaking [aOR 3.57, 95% CI 1.25 to 10.18]). Food insecurity was more likely among mothers reporting more informal strategies (aOR 1.98, 95% CI 1.28 to 3.01; P<0.05) and perceiving greater inability to manage resources (aOR 1.60, 95% CI 1.30 to 1.98; P<0.05). CONCLUSIONS: The results suggest that low-income mothers use a variety of strategies to feed their families and that the strategies they use vary by HHFSS. Community nutrition programs and providers will need to consider these strategies when counseling families at risk for food insecurity and provide guidance to minimize the influence on healthy food choices.

Understanding maternal intentions to engage in home visiting programs.

Little is known as to why some parents choose to engage in voluntary home visitation services while others refuse or avoid services. To address this knowledge gap, this study tests several hypotheses about the factors that influence maternal intentions to engage in home visitation services and the link between these intentions and the receipt of a home visit. The sample consists of an ethnically diverse group of mothers identified as at-risk for parenting difficulties (N = 343). These mothers were offered home visitation services from nine home visiting programs located across six states. Regardless of service acceptance or refusal, all mothers were interviewed within 2 weeks of the service offer and 3 months later.The findings suggest that mothers who intend to use services look substantially different from those who do not state an intention to participate in home visitation. The results indicate that lower infant birth weight and greater comfort with a provider in one's home are significant predictors of maternal intentions to utilize home visiting services. The study results also support the connection between intent and behavior as the expressed intention to engage in home visitation services was a key predictor of the receipt of a visit.

The influence of support and stress on maternal attitudes.

OBJECTIVES: This study examines an expanded version of Belsky's (1984) multi-dimensional process model of parenting to determine whether changes in stress and support influence maternal attitudes during the first year of a child's life. METHOD: Data were collected from mothers of newborns eligible for Hawaii's Healthy Start program who had been randomly assigned to home visitation (n=108) or control (n=104) status. Multiple regression analyses were used to test hypotheses regarding the influence of change in contextual sources of support and stress on parenting attitudes as measured by the Child Abuse Potential Inventory (CAPI) Abuse Scale. A post hoc analysis of variance was conducted to explore interactions among the predictor variables and home visitation. RESULTS: Stress in the form of change in public assistance status led to more punitive parenting attitudes while increased support from the partner and from close associates emerged as significant predictors of less punitive parental attitudes. The exploratory analyses suggest that home visitation may moderate the impacts of stress and support on maternal attitudes. CONCLUSIONS: In line with Belsky's (1984) process model of parenting, increased stress adversely impacted maternal attitudes regarding physical punishment while increased support exerted favorable effects. The results also support further elaboration of Belsky's model including the expansion of marital support to include unmarried partners and the need to consider the impact of formal support sources on parenting.

Food- and health-related correlates of self-reported body mass index among low-income mothers of young children.

OBJECTIVE: To examine how income-related challenges regarding food and health are associated with variation in self-reported maternal body weight among low-income mothers. DESIGN: Cross-sectional design. SETTING: Two Northeastern cities. Seven day care centers and a Supplemental Nutrition Assistance Program outreach project. PARTICIPANTS: Sample of 166 mothers; 67% were overweight or obese, 55% were Hispanic, and 42% reported household food insecurity (HFI). MAIN OUTCOME MEASURES: Maternal self-reported height and weight to calculate body mass index (BMI). Independent variables were food program participation, supermarket use, 8-item food shopping practices scale, HFI, maternal depressive symptoms, and self-rated health. ANALYSIS: Hierarchical multiple regression analysis tested relationships between maternal BMI with the independent variables of interest, adjusting for demographic confounds. RESULTS: Shopping practices to stretch food dollars (P = .04), using community food assistance programs (P < .05), and HFI (P < .04) correlated with heavier maternal BMIs; higher self-rated health corresponded to lower BMIs (P = .004). CONCLUSIONS AND IMPLICATIONS: Some strategies low-income mothers use to manage food resources are associated with heavier BMIs. Nutrition educators, public health practitioners, and researchers need to collaboratively address the associations between these strategies, food insecurity, poor health, and unhealthy weight.

Sustaining new parents in home visitation services: key participant and program factors.

OBJECTIVES: As prevention efforts have adopted more intensive service models, concerns over initial enrollment and retention rates have become more salient. This study examines the participant, provider and program factors that contribute to a longer length of stay and greater number of home visits for new parents enrolling in one national home visitation program. METHODS: Retrospective data were collected on a random sample of 816 participants served by one of 17 Healthy Families America (HFA) program sites around the country. Using case record reviews, research staff documented each participant's characteristics and service experiences. To capture relevant staff and program information, research staff collected basic descriptive information from published documents and interviews with program managers. All home visitors who had contact with sample families also completed a self-assessment instrument regarding personal and professional characteristics. Hierarchical linear modeling allowed us to examine the unique role of participant, provider and program characteristics while recognizing the lack of independence among these three sets of variables. RESULTS: The combined provider and program levels in the HLM model accounted for one-third of the variance in service duration and one-quarter of the variance in the number of home visits. Older participants, those unemployed, and those who enrolled in the program early in their pregnancy were more likely to remain in services longer and to complete a greater number of home visits. Compared to White participants, African Americans and Hispanics were significantly more likely to remain in services longer and, in the case of African Americans, to receive a greater number of home visits. Participants who were enrolled in school were more likely to remain in services longer. Age was the only consistent provider characteristic associated with positive results in both models, with younger home visitors performing better. Prior experience showed a significant relationship only in the service dosage model and African American workers demonstrated greater success than White home visitors did in retaining families in service. At the program level, programs with lower caseloads and greater success in matching their participants and providers on parenting status and race/ethnicity were significantly more likely to demonstrate stronger enrollment patterns.