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Open Access

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Master of Science (M.S.)

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Month Degree Awarded



nutrition, BMI letter, health literacy, weight communication


BACKGROUND: Since 2010, nurses in Massachusetts public schools have conducted state-mandated Body Mass Index (BMI) screening of first, fourth, seventh, and tenth graders and communicated results in a letter to parents/caregivers. The objective of this study was to explore parents’ responses to the BMI letter and their experiences with weight-related language used by health professionals. These two areas were examined in the context of parents’ health literacy skills and readability of the letter. METHODS: Readability of the letter was calculated using five common formulas. One-hour focus groups were conducted using a semi-structured interview guide with a convenience sample of parents/caregivers of 8- to 14-year-old obese children participating in a weight management program. Parents were asked to share reactions to 10 weight terms in random order. Parents also completed a written version of the Newest Vital Sign (NVS) health literacy assessment. Focus group data were transcribed verbatim, and content analyses conducted to identify emergent themes. Descriptive statistics were calculated for NVS scores. RESULTS: Reading-level estimates of the BMI letter ranged from fifth to seventh grade. Twenty-nine individuals participated in eight focus groups (83% female, mean age 41 yrs+9 yrs, 59% self-identified as Hispanic/Latino). NVS scores for 12 participants (41%) indicated a possibility (n=7) or high likelihood (n=5) of limited health literacy. “Emotions” emerged as a major theme. Parents expressed concern, guilt, fear, anger, rationalization, skepticism, and acceptance regarding the letter and weight-related terms. Parents had mixed reactions to the letter: finding the information helpful, voicing concern about privacy and self-esteem, and displaying confusion when interpreting the weight status. A majority (67%) of parents who expressed confusion about the letter or weight terminology received an NVS score indicating a possibility or high likelihood of limited health literacy. Among the weight terms, parents preferred weight, weight problem, and unhealthy weight more than obese or extremely obese. CONCLUSIONS: This is the first known study to evaluate how parents respond to and comprehend the Massachusetts BMI letter. Emergent themes could be used to inform quantitative assessment of communication challenges associated with the letter. This study has implications for respectfully and effectively communicating BMI results nationwide.


First Advisor

Elena T. Carbone