From Pilot to Practice: Developing a Family-Based Nutrition, Literacy, and Parenting Protocol for the Books & Cooks Education Intervention

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Overall, it is helpful to have a protocol describing how this program was developed and is being evaluated. It is an innovative combination of topics to address a population with overlapping needs and build different skills for families using research-based outreach! There is some room for improvement, especially in expressing why these topic areas of literacy and nutrition should be connected, but based on the writing, I believe this is mostly an opportunity for clarifying connections and steps the authors are likely already taking. I look forward to seeing this and future findings in publication! 

• Intro makes some good arguments about need, but I’m missing the theoretical connection where addressing food insecurity (through nutrition education?) and literacy at the same time is going to create positive change for both.  There is limited case and a fair amount of research suggesting that food insecurity is not about lack of nutrition knowledge, but more about contextual access, affordability, and quality of food resources. 

• I would also be curious to know a bit more of what kind of literacy these books focus on- it seems broadly about reading literacy in general as opposed to food literacy, is that accurate? 

• Is this outreach series only going to those families who express interest in the topic of cooking/nutrition? (line 84-85) 

• While it has a less explicit literacy focus and is more tailored to native or hispanic families, these may be an interesting study involving outreach programs with low income families, nutrition, and connected/hands on resources including books to contextualize your program and it’s unique attributes (there are many more papers on these- note Healthy Children, Strong Families is now called Turtle Island Tales):  

• Adams, A. K., LaRowe, T. L., Cronin, K. A., Prince, R. J., Wubben, D. P., Parker, T., & Jobe, J. B. (2012). The Healthy Children, Strong Families intervention: design and community participation. The journal of primary prevention, 33(4), 175-185. 

• And 

• Barragan, M., Luna, V., Hammons, A. J., Olvera, N., Greder, K., Drumond Andrade, F. C., ... & Team, T. A. C. R. (2022). Reducing obesogenic eating behaviors in Hispanic children through a family-based, culturally-tailored RCT: Abriendo Caminos. International journal of environmental research and public health, 19(4), 1917. 

• Were efforts made in programming to review/consider the literacy level of nutrition materials? Or alternately to include literacy materials that incorporate food/family? 

• Make sure to clarify how data was collected (self-administered on qualtrics? Even for children?) 

• Does the power analysis account for confounding variables or only primary variables included? 

• How will you handle data missingness? 

• What will your data reporting look like and to whom? 

• Will your evaluation only explore outcomes or will you incorporate outputs as well? If so, how were those tracked? 

• Explain further what you mean by family nutrition capacity (612-613)- is this connected to food parenting or food literacy? And/or how is it related to food insecurity described in the intro? 

• Some citations (beyond seminal theory works) are fairly old, I would recommend looking again for more recent citations on these topics. 

Author Response

Please see the attached PDF. 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript reports a protocol for a study that develops, implements, and evaluates a brief interdisciplinary literacy and nutrition education program for parent-child dyads, called Books& Cooks (B&C).  The protocol was informed by a pilot study, but no results of the pilot have been published nor shared in this document. It is thereby difficult to understand some aspects without the data from the protocol.

There is a substantial literature on family-based nutrition education programs, another on food parenting practices, and another on screen media parenting practices which were not cited here.

Please provide an explanation for why home literacy environment was the primary outcome when its enhancements may not influence parent or child reading, which would appear to be the most socially valuable outcomes? 

The intervention will be implemented/delivered in five counties in Florida. A waitlist control design is proposed. It is not clear what unit of analysis will/should be employed, e.g. country, school district, school, individual. Anything more complex than the individual should be a clustered waitlist-control. Apparently the intervention was delivered in groups. Shouldn’t groups be considered a clustering variable? These aspects of the design and analysis need more attention, and power calculations revised in light of the revisions.

The authors provide priority enrollment criteria, but do not provide a description of the cap(s) at which enrollment will be discontinued. What is the unit for these caps (counties, school districts, etc)? And what is the numerical value? Please justify both.

The intervention is provided weekly in three age-grade bands: K-1, Grades 2-3, Grades 4-5. These grade levels encompass very different developmental cognitive and behavioral capabilities. Please identify how these differences were taken into account in the design of the curricula?

Will observations be conducted and recorded of the quality of the delivery of each session and the quality of audience engagement/response?

How is the research designed to test the comparative effectiveness of meal kits and grocery stipends?

The parenting education component would be enhanced by observing related parent child interactions and providing feedback on how it might be improved. 

The sample of 300 needs to be increased to take into account likely drop out.

Summers are a hard time to recruit due to some families on vacation, others having sent their child(ren) to be with grandparents or other family members, often in Mexico; summers provide no centralized access to the families for easy contact, etc. It is not clear the authors have taken these factors into account. 

The authors should consider employing one of the several measures of food and screen media parenting practices.

The primary indicator of a difference in outcome between groups should be a group by time interaction term. 

The expected distribution of participating families by ethnic group is not clear. If a large percentage of the target group will be Hispanic/Latinx/Latino (not unexpected for low income families in Florida), the authors should consider one of the several methods of cultural adaptation of their intervention. 

Several studies have indicated that for an intervention to achieve change in a primary health education outcome takes 24 to 26 separate contacts. Even the authors cite at least one study that indicated that 5 months of contact were necessary to achieve literacy outcome change. This study proposes to achieve change in three large categories of outcomes. Is seven contacts enough? I am not convinced that the factors cited under Strengths enable the authors to substantially modify the duration of the intervention. Although the authors cite literature that certain variables correlate with health outcomes and have been taken into account in their intervention, e.g. families eating together, detecting a correlation is quite different than obtaining change in that behavior.

 

 

 

 

 

 

 

Author Response

Please see the attached. 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this protocol. This is a well-developed and timely piece of work that addresses a critical gap in integrated family interventions, and it was a pleasure to read such a thoroughly prepared manuscript. While the protocol is robust, I have a few questions regarding its implementation and long-term impact.

First, I would appreciate more detail on participant engagement and retention. Since the success of family-based interventions often depends on long-term commitment, could the authors describe the specific strategies used to motivate families to join and remain in the program? It would also be helpful to know if there were any dropouts during the pilot phase and if there were specific reasons for their withdrawal.

Furthermore, I am curious about how the nutrition module accounts for socio-cultural factors, as dietary habits are deeply personal. For instance, are the recipes and advice tailored to be culturally resonant for specific groups, such as Hispanic families?

Regarding the use of meal kits and grocery stipends mentioned in lines 364-365, I wonder about the sustainability of the program's impact. Since food insecurity is a major barrier, what is the expected outcome once these supports end, and how does the program bridge the gap between subsidized aid and long-term behavioral change?

In terms of assessment, I would like to know if the authors plan to use specific nutritional indices, such as Diet Quality (HEI) or Diet Diversity scores, at the baseline, post-intervention, and follow-up stages to provide a more nuanced understanding of the results.

Finally, regarding line 355, could the authors clarify the delivery of the nutrition lessons? The manuscript states that lessons do not differ across grade-level bands, but it is unclear if the actual content is identical for all ages. It would be beneficial to explain if the complexity of the information is adapted to suit the different developmental stages of the children involved.

Author Response

Please see the attached. 

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors were somewhat responsive to reviewer comments.