Parent Website Engagement and Health Equity Implications in a Childcare-based Wellness Intervention

Abstract

Objective:

To evaluate demographic differences in parent website engagement in a childcare-based wellness intervention.

Design:

Parent-reported demographic characteristics and observed website engagement were averaged by childcare centers participating in the web-based intervention arm of a cluster randomized controlled trial of wellness interventions.

Setting and Participants:

Parents of preschoolers in 17 Maryland childcare centers.

Main outcome measures:

Website engagement: (a) webpage views, (b) average time on webpage, and (c) intervention activity completion.

Intervention:

Parents received access to a website containing content on wellness-promoting topics (e.g., parenting, nutrition, physical activity), and on their childcare center’s activities.

Analysis:

Cross-sectional differences in website engagement by demographic characteristics were assessed using ANOVA.

Results:

Centers with a high proportion of parents who identified as other than non-Hispanic white and had less than a bachelor’s degree had significantly fewer webpage views and completed significantly fewer intervention activities compared to centers with parents who were predominantly non-Hispanic white and had more than a bachelor’s degree.

Conclusions and Implications:

Demographic differences in parents’ childcare center website engagement represent disparities that could contribute to health inequities in parents’ access of wellness-promoting material. Future efforts could identify factors that eliminate demographic disparities in parent engagement in web-based interventions.

INTRODUCTION

Excess weight gain by age 5 years often persists throughout childhood and increases the risk of adult obesity and associated chronic diseases.^1,2 Parents play a key role in obesity prevention as they influence children’s development of health behaviors (e.g., eating and physical activity)³ and self-regulation.⁴ Over 60% of children between birth and 5 years are enrolled in nonparental care, making childcare a promising setting to implement population-based childhood wellness and obesity prevention interventions.^5,6 Leveraging parents at home and educators in childcare settings as agents of change in pediatric wellness interventions may lead to positive child health behaviors.⁶ c,^7,8 there is limited consensus on strategies to engage parents.⁹ Previous studies have identified barriers to parent engagement in childcare center-based programs such as coordinating teacher and parents’ schedules.^10–12 Parent engagement in in-person interventions is often low for parents with low socio-economic status (SES) and/or parents from marginalized racial and ethnic groups.^13–15 Differential parent participation in child-focused programs due to demographic characteristics can contribute to health inequities, denying children a fair and just opportunity to be as healthy as possible.¹⁶

Web-based tools (e.g., websites, mobile applications) may be an effective strategy to promote parent engagement in childcare center-based programs. The broad reach, high accessibility, relatively low cost, and flexible timing of web-based tools may overcome many of the barriers associated with parent engagement.¹⁷ Based on a national survey, in 2019, at least 75.9% of households in every state in the U.S. had broadband internet access (88.3% in Maryland),¹⁸ supporting the wide potential reach of web-based tools where service is available. In addition, both parents and childcare providers have reported preferring web-based tools over in-person approaches for general parenting,¹⁷ nutrition education,¹⁹ early childhood education.²⁰

Although web-based tools appear to be a promising strategy to promote parent engagement in childcare programs, differences in digital and health literacy linked to demographic characteristics such as income, education, and race and ethnicity, may lead to inequitable engagement in web-based programs and contribute to, rather than mitigate, health disparities.^21,22 Results from formative studies suggest that parents with low-SES and/or marginalized racial and ethnic identities regularly use technology and are interested in receiving child health information through web-based platforms (e.g., websites).^23,24 It remains unclear, however, whether web-based interventions actually promote equitable parent engagement in child-focused programs.²⁵

At least 2 studies have evaluated parent engagement with web-based childhood wellness interventions implemented outside of childcare settings using measures of engagement such as the number of webpage views or educational modules completed.^26,27 The CAPE model (Connect, Attend, Participate, Enact), developed to strengthen research on parent engagement in parenting programs, defines engagement as a progression of 4 components that capture passive engagement such as enrolling and attending intervention sessions (Connect and Attend), and active engagement including practicing and applying intervention content (Participate and Enact).¹⁵ Multidimensional measures of parent engagement with web-based childhood wellness interventions implemented in childcare centers can guide program development and dissemination, and promote health equity by determining whether variation in parent engagement is linked to demographic characteristics.

This study applied the CAPE model to evaluate parent engagement with the web-based component of a childcare-based wellness intervention.¹⁵ The web-based component included a website exclusively for parents of 3- to 5-year-old children receiving nutrition and physical activity curricula delivered by teachers in childcare centers.²⁸ The website contained content on wellness-promoting topics (e.g., parenting, nutrition, physical activity), and on their childcare center’s intervention delivery. The primary objective was to evaluate the health equity potential of the intervention by assessing demographic differences in parent website engagement, including measures of (a) webpage views (Connect and Attend), (b) average time on webpage (Attend), and (c) completion of intervention activities (Practice and Enact).

METHODS

Overall Study Design

This study included data from a 3-arm cluster randomized controlled trial – Creating Healthy Habits Among Maryland Preschoolers (CHAMP).²⁸ The aim of the larger study was to prevent childhood obesity by improving eating and physical activity habits of preschoolers (age 3 to 5 years) in childcare settings and at home in a sample of 54 childcare centers across Maryland recruited in 3 cohorts (2017–2018; 2018–2019; 2019–2020).²⁸ In the 2 intervention arms, childcare teachers were trained to deliver an evidence-based nutrition and physical activity curricula that provided opportunities for children to try new foods twice weekly, and to practice motor skills and engage in physical activity 4 days/week for 15–20 minutes per day.^28,29 One intervention arm also included a website for parents that was updated and accessible during the intervention period. The control arm received intervention materials the following year. This study examined data from the intervention arm with the parent website implemented in the first 2 cohorts. Teachers implemented the intervention content for 29 weeks (7 months: November to May) in cohort 1, and 33 weeks (8 months: November to June) in cohort 2. Of the 19 web-based intervention childcare centers, 2 were non-compliant, resulting in 17 centers with valid data.

Participants and Setting

The CHAMP study was implemented in licensed childcare centers serving low- and middle-income communities in semi-urban and urban areas in 10 Maryland counties. Childcare eligibility included acceptance of childcare vouchers or fee per child less than $300/week. Children from participating childcare centers were eligible to join the study based on the following criteria: between age 3–5 years, English-speaking, intended enrollment through the spring, and without developmental delays that would prevent participation (based on parent report). Data were collected at 3 time points per cohort: baseline (fall enrollment), midline (winter), and end-line (spring/summer). The current study included 261 children across the 17 childcare centers who received the childcare-based intervention and the parent website. The number of participating children in each childcare center ranged from 7 to 41 (M = 15.35, SD = 8.68).

Intervention

A web-based intervention was developed and delivered via a website hosted by the university. The intervention design facilitated opportunities for parent engagement across all 4 components of the CAPE model.¹⁵ All parents in participating intervention centers received instructions on how to connect with the intervention website home page, (www.champfamilies.org), and with the center page, (‘My Center’), a password-protected webpage specific to their child’s childcare center. Both the home and center pages contained health-promoting material on nutrition, exercise, parenting, and other wellness topics relevant to parents of preschoolers and coordinated with classroom activities.²⁸ The center webpage provided a weekly summary of the teacher-delivered CHAMP curriculum, photos of the children participating in intervention-related activities, and a link to the weekly parenting tip. To encourage parents to Connect and Attend, research assistants sent parents a weekly email and/or text message (based on the parents’ preference) that announced new website content, including photographs of their child, and directed them to the website. To encourage parents to Participate and Enact, the home and center pages included infographics and short videos describing nutritious and child-friendly recipes, strategies to encourage modeling by showing parents and preschoolers trying new foods, tips for handling picky eating, examples of family-friendly physical activity, and information on sleep and stress management (see the Supplemental Figure). Although the structure of the website was similar across the 2 cohorts, some website content was modified based on participant feedback.

Beginning in cohort 2, monthly family-based intervention activities, “CHAMP Challenges,” were added to the intervention website to provide additional opportunities for parents to actively apply intervention content (Enact). Examples included: “Try at least one new food,” “Play a sport with your child,” and “Take your child to the grocery store.” Families had the opportunity to complete 7 intervention activities (CHAMP Challenges) throughout the intervention. Parents were asked to email a photo of the family completing the activity to the CHAMP research team. Some CHAMP Challenges included a $10 electronic gift card incentive.

Measures

Website engagement.

Data were collected on 3 measures of parent website engagement throughout the intervention: (a) webpage views; (b) average time on webpage; and (c) intervention activity completion (CHAMP Challenges). The first 2 measures captured the Connect and Attend components of the CAPE model, consistent with website engagement from previous studies.^26,30,31 The third measure captured the Participate and Enact components of the CAPE model, an expansion compared to previous studies that measures active parental participation with the intervention content. Data for webpage views and average time on webpage were collected via Google Analytics (Google LLC, Mountain View, CA) and summarized into a weekly report. Due to the design of the intervention website, these measures were based on center-level data generated from the password-protected ‘My Center Page.’ All parents from a given center accessed the ‘My Center Page’ using the same center-specific password.

Webpage views, average time on webpage, and intervention activity completion were measured at the center-level. To measure webpage views, the number of weekly ‘My Center Page’ views (shown as ‘Unique Pageviews’ in Google Analytics) was summed for each center throughout the intervention period. To measure average time on webpage, the average time (seconds) spent on the ‘My Center Page’ (shown as ‘Avg. Time on Page’ in Google Analytics) was calculated for each center throughout the intervention period. To measure intervention activity completion, the number of valid emails received from parents in each childcare center with a photo documenting their completion of a ‘CHAMP Challenge’ was summed for each center throughout the intervention period. To adjust for childcare center size, the total number of center webpage views and CHAMP Challenges completed were divided by the number of children enrolled in the study at each childcare center (Supplemental Table 1). The 3 measures of website engagement were rescaled to 0–1 using the min-max normalization method.

Demographic characteristics.

At baseline, each child’s primary parent reported their demographic characteristics and height and weight in an online survey administered through Qualtrics (Qualtrics International Inc., Provo, Utah). Parents selected race and ethnicity from a list: Asian, Asian Vietnamese, Black or African American, Mixed Race, Native American/American Indian/Alaskan Native, Native Hawaiian or Pacific Islander, White or Caucasian, and whether they identified as Hispanic or Latino. Parents selecting more than 1 race were coded as mixed. Data from all parent baseline survey responders (n = 146; 56% of the target sample) were included in the study, ranging from 13% to 88% (M = 53%, SD = 22%) within each center. Most parents had complete data for the items in the current study (n = 137, 94% of baseline survey responders). Missing data were treated as missing values in the analyses.

Parent demographic characteristics were coded as: age (0 ≤ 35 years, 1 > 35 years), based on the median age of 35 years, gender (0 male, 1 female), race/ethnicity (0 non-Hispanic White, 1 other race/ethnicity, including parents who identified as Black or African American, Asian, Asian-Vietnamese, Native American, Mixed-Race, and any race endorsing Hispanic or Latino ethnicity), education level (0 completed more than a bachelor’s degree, 1 completed a bachelor’s degree, 2 completed less than bachelor’s degree), annual household income (0 ≥ US$ 100,000; 1 US$ 50,000–99,999; 2 < US$ 50,000), participation in federal nutrition assistance programs (Supplemental Nutrition Assistance Program (SNAP), or the Special Supplemental Nutrition Program for Women Infant & Children (WIC); 0 no, 1 yes, respectively), and body mass index (BMI) (0 underweight or healthy weight (≤ 24.9 kg/m²), 1 overweight (25–29.9 kg/m²), 2 obese (≥30kg/m²)). Underweight and healthy weight categories were combined for analyses due to the low prevalence of underweight (n = 2).

Center-level demographic characteristics variables were computed. The mean value for each demographic characteristic by center was calculated, and the center-level means were recoded by rounding to their nearest whole value to correspond to the original parent demographic characteristics coding. Demographic characteristics that could take on a maximum of 2 values were recoded to 0 (if the center-level mean was between 0.00 and 0.49) or 1 (if between 0.50 and 1.0). For example, a childcare center with a mean race/ethnicity score of 0.36 (indicating that most parents were non-Hispanic White) was recoded as 0. Demographic characteristics that could take on a maximum of 3 values were recoded to 0 (if the center-level mean was between 0.00–0.49), 1 (if between 0.50–1.49) or 2 (if between 1.50–2.00). For example, a childcare center with a mean education score of 1.17 (indicating that most parents completed a bachelor’s degree) was recoded as 1 (See Supplemental Table 1).

Statistical Analysis

The IBM SPSS software (version 26.0, Armonk, NY) was used to conduct the analyses. In the preliminary phase, comparisons in website engagement between the 2 cohorts of participating childcare centers were examined using a 2-tailed t-test. No significant cohort differences (all P-values > 0.05) were found and data from both cohorts were combined. The standardized residuals of the 3 rescaled website engagement scores were examined using the Shapiro-Wilk test, confirming that they were normally distributed (all P-values > 0.05).

For the descriptive analyses, the full sample of parents was characterized by calculating the frequency of parent demographic characteristics at the individual and center-level. Descriptive statistics for the raw center-level website engagement scores (median and interquartile range: IQR) were calculated, and Pearson correlations were computed to assess the correlations among the rescaled website engagement variables. One-way univariate analysis of variance (ANOVA) tests with planned contrasts were conducted to evaluate cross-sectional differences in website engagement by center-level demographic characteristics, with no covariates. Statistical significance was defined by P-value < 0.05.

Ethics

This study was approved by the University of Maryland Institutional Review Board (Protocol Review Number: HP-00058285). Parents signed written informed consent for themselves, for their child, and for photographs of their child to be uploaded to a password-protected webpage specific to their child’s childcare center.

RESULTS

Descriptive Analyses

Parent baseline demographic characteristics are displayed in Table 1. The highest prevalence of parents identified as female (91.8%), non-Hispanic White (57.5%), and attained a bachelor’s degree or greater (56.8%). Parents’ endorsement of demographic characteristics varied by center. Half (52.1%) of the parents across centers reported an annual household income of ≥ $100,000, with the percent of parents in this income category ranging from 0% to 89% within each center. See Supplemental Table 1 for center-level parent demographic characteristics.

Table 1.

Baseline Demographic Characteristics of Parents in Participating Child Care Centers receiving the Web-based Intervention (n = 17)

Demographic characteristic	n	Valid %	Valid % range by center (min – max)1
Individual-level
Age2
<35 year	80	54.8%	0 – 100%
≥ 35 year	66	45.2%	0 – 100%
Sex2
Male	12	8.2%	0 – 50%
Female	134	91.8%	50 – 100%
Race/Ethnicity2
Non-Hispanic White	84	57.5%	0 – 100%
Other race/ethnicity6	62	42.5%	0 – 100%
Education2
Less than bachelor’s degree7	63	43.2%	0 – 78%
Bachelor’s degree	33	22.6%	0 – 60%
More than bachelor’s degree8	50	34.2%	0 – 100%
Household-level
Household Annual Income (USD)3
< $50,000	37	26.1%	0 – 100%
$50,000–$99,999	31	21.8%	0 – 50%
≥ $100,000	74	52.1%	0 – 89%
Federal Assistance4
SNAP	23	16.0%	0 – 100%
WIC	16	11.1%	0 – 100%
Health
BMI (kg/m2)5
Underweight or healthy (<24.9)9	54	38.6%	0 – 75%
Overweight (25.0–29.9)	40	28.6%	0 – 63%
Obese (≥30.0)	46	32.9%	0 – 100%

Abbreviations: USD (United States Dollar), SNAP (Supplemental Nutrition Assistance Program), WIC (Special Supplemental Nutrition Program for Women, Infant, and Children), BMI (Body Mass Index),

Measures: BMI was calculated in kg/m², using self-reported parent height and weight

¹Range of the percent of parents within each child care center with the demographic characteristic;

²n = 146;

³n = 142;

⁴n = 144;

⁵n = 140;

⁶Includes: Black or African American, Asian, Asian-Vietnamese, Native American, Mixed-Race, and any race identifying as Hispanic or Latino;

⁷Includes: less than high school, high school diploma, General Educational Development (GED), less than 1 year of college, 1 or more year of college but no degree associate’s degree;

⁸Includes: master’s degree, professional degree beyond a bachelor’s degree, doctorate degree.

⁹Underweight and healthy weight categories were combined due to the low prevalence of underweight (n = 2).

Parents in each childcare center viewed the ‘My Center Page’ a median of 15 times (IQR = 5–50; min-max = 1–112) for a median of 107.7 seconds (IRQ = 56.2–176.2; min-max = 0.0–256.0) throughout the intervention. In response to CHAMP Challenges, parents in each childcare center completed intervention activities a median of 2.5 times (IQR = 0–12.5; 0–20). Detailed data on center-level parent website engagement prior to rescaling are presented in Supplemental Table 2. The only significant correlation was between webpage views and intervention activities completed (r = 0.79, p = 0.007).

Center-level Parent Demographics Characteristics and Website Engagement

Results of the ANOVA tests of the group differences among parent demographic characteristics and website engagement are displayed in Table 2. Webpage views were significantly lower in childcare centers with a high proportion of parents who identified as other than non-Hispanic White; completed less than a bachelor’s degree; or had an annual household income < US$ 50,000, compared to childcare centers with a high proportion of parents who identified as non-Hispanic White; had attained education beyond bachelor’s degree; or had an annual household income > US$ 100,000, respectively. Intervention activity completion was significantly lower in childcare centers with a high proportion of parents who did not identify as non-Hispanic White or had completed less than a bachelor’s degree, compared to childcare centers that had a high proportion of parents who identified as non-Hispanic White or had attained education beyond a bachelor’s degree. Time on webpage was not associated with any of the center-level parent demographic characteristics.

Table 2.

Comparison of Center-level Demographic Characteristics and Website Engagement, based on ANOVA with Planned Contrasts

	Total number of center webpage views1		Average view time of center webpage1		Total number of CHAMP challenges completed2
Center-level demographic characteristic	B (SE)	P-value	B (SE)	P-value	B (SE)	P-value
Individual-level
Age (Reference: <35 y)
>35 y	0.25 (0.18)	0.18	0.04 (0.18)	0.85	0.17 (0.24)	0.51
F-test (P-value)		1.94 (0.18)		0.04 (0.85)		0.47 (0.51)
Race/Ethnicity (Reference: Non-Hispanic White)
Other race/ethnicity3	−0.64 (0.11)	0.000	−0.07 (0.19)	0.73	−0.46 (0.19)	0.04
F-test (P-value)		31.99 (0.000)		0.12 (0.73)		5.70 (0.04)
Education (Reference: More than bachelor’s4)
Bachelor’s degree	−0.37 (0.19)	0.07	−0.42 (0.22)	0.08	−0.56 (0.16)	0.01
Less than bachelor’s5	−0.75 (0.19)	0.002	−0.01 (0.22)	0.98	−0.73 (0.18)	0.004
F-test (P-value)		8.14 (0.005)		3.56 (0.06)		9.71 (0.01)
Household-level
Household Annual Income (Reference: ≥100,000 USD)
50,000–99,999 USD	−0.37 (0.18)	0.06	−0.06 (0.22)	0.78	−0.08 (0.28)	0.78
<50,000 USD	−0.61 (0.17)	0.003	0.25 (0.21)	0.25	−0.38 (0.32)	0.27
F-test (P-value)		6.68 (0.009)		1.19 (0.33)		0.71 (0.52)
Federal Nutrition Assistance (Reference: Not participating)
SNAP	−0.40 (0.18)	0.05	0.35 (0.18)	0.07	−0.35 (0.28)	0.26
F-test (P-value)		4.80 (0.05)		3.92 (0.07)		1.51 (0.26)
WIC	−0.49 (0.27)	0.09	−0.01 (0.29)	0.96	−0.35 (0.39)	0.40
F-test (P-value)		3.36 (0.09)		0.002 (0.96)		0.80 (0.40)
Health
BMI (Reference: Underweight or Healthy Weight ≤24.9 kg/m2)
Overweight (25>29.9 kg/m2)	−0.21 (0.28)	0.47	0.06 (0.29)	0.83	−0.42 (0.41)	0.34
Obese (≥30 kg/m2)	−0.53 (0.32)	0.12	0.17 (0.33)	0.61	−0.60 (0.54)	0.31
F-test (P-value)		1.66 (0.23)		0.17 (0.85)		0.69 (0.53)

Abbreviations: CHAMP (Creating Healthy Habits Among Maryland Preschoolers), B (Beta, Unstandardized), SE (Standard Error), USD (United States Dollar), SNAP (Supplemental Nutrition Assistance Program), WIC (Special Supplemental Nutrition Program for Women, Infant, and Children), BMI (Body Mass Index)

Measures: BMI was calculated in kg/m², using self-reported parent height and weight

Statistical significance was defined by P-value < 0.05

One-way univariate analysis of variance (ANOVA) with planned contrasts

¹n=17;

²n=10;

³Includes Black or African American, Asian, Asian-Vietnamese, Native American, Mixed-Race, and any race identifying as Hispanic or Latino;

⁴Includes: master’s degree, professional degree beyond a bachelor’s degree, doctorate degree;

⁵Includes: < high school, high school diploma, General Educational Development (GED), < 1 year of college, ≥ 1 year of college but no degree, associate’s degree

DISCUSSION

In this study, childcare center-level demographic characteristics (race and ethnicity, education, and annual household income) were significantly related to the number of center webpage views and the number of intervention activities completed, illustrating disparities in website engagement across the Connect, Attend, Participate, and Enact components of the CAPE model. A unique contribution of this study is the identification of demographic differences in the Enact component of the CAPE model for parent engagement in a web-based, child-focused wellness intervention that complemented an intervention delivered to children in childcare centers. These findings extend previous studies that demonstrated group differences by parent demographic characteristics for attendance¹³ and quality of participation in in-person parenting interventions,³² and for webpage views in a web-based pediatric health intervention.³³ For example, in a study on parent engagement in a web-based pediatric asthma management intervention for children ages 2 to 10 years, parents with lower education levels and parents of non-White children were more likely to view the website only once rather than more than once compared to White parents and parents with higher education.³³ In addition, parent socio-economic status has been positively associated with parents’ nutrition knowledge,³⁴ parents’ nutrition literacy has been positively associated with children’s nutrition knowledge,³⁵ and parents with low technology literacy may have limited access to web-based nutritional information. These findings highlight that groups with disproportional higher rates of chronic diseases (i.e. low-income backgrounds, less schooling)³⁶ may be most in need of health-promoting material for their children, and also less likely to Connect with or Attend web-based interventions as shown in our study, thereby potentially increasing inequity.

There were no group differences in the average time spent on the center webpage by demographic characteristics of parents in the participating childcare centers. The finding that the amount of time spent on the center webpage did not vary by center-level parent demographic characteristics suggests that average time spent viewing the center webpage may be associated with the content of the webpage, such as video length and infographic size.

Overall, there was variability in website engagement across each component of the CAPE model by childcare center as seen by the large interquartile range for each measure of website engagement. For example, the total number of webpage views by center had a median of 15 and an interquartile range of 5–50, indicating variability in intervention connection and attendance. Previous studies have also reported variability in connection and attendance in website interventions.^26,27 In one intervention delivered over 4 weeks, the mean number of webpage logins was 11.42 with a range from 1 to 34.²⁶ Taken together, strategies to engage parents in web-based components of childcare center-based interventions need to be tailored to each participating childcare center to support equitable parent engagement.

In the current study, webpage views, corresponding to the passive components of the CAPE model (Connect and Attend), were positively correlated with the number of intervention activities completed, corresponding to the active engagement components (Participate and Enact) of the CAPE model. This finding suggests that parents in centers that were connecting with and attending the intervention content more frequently were also more likely to apply intervention content by enacting behaviors in an intervention activity designed to help parents practice achieving intervention targets (e.g., preparing nutritious recipes, increasing physical activity). Thus, parents who do not Connect or Attend web-based interventions may lose the opportunity to Practice and Enact parenting behaviors that promote child wellness, along with knowledge, resources, and support for implementing health behavior changes that promote health equity. Results from the current study demonstrate the potential for compounding inequity in parent engagement across the 4 components of the CAPE model.¹⁵ Additional studies that include measures of parents’ active application of intervention content are necessary to replicate these findings and to identify opportunities to increase parent engagement with childcare-based wellness interventions. At least two such studies are currently underway.^37,38

Vroom’s Expectancy Theory of Motivation, which posits that the likelihood of a behavior depends on the expectation that the behavior will result in an outcome that is valued,³⁹ could help explain the positive correlation between passive components (Connect and Attend) and application of behavior (Participate and Enact). Parents who completed the Connect and Attend interventions may have been sufficiently motivated by the material to expect that the outcome of the Practice and Enact interventions would be of value to them. In contrast, parents who did not log on to the intervention may have expected that the material would not be of sufficient value, compared to the value of competing activities. Alternatively, they may have had limited internet access, or misplaced the log-in instructions.

This study is subject to the following limitations. First, this study did not have data on parents’ individual-level website engagement because Google Analytics data could not be linked to baseline survey data. Study data were limited to Google Analytics data generated from the childcare center page (‘My Center Page’), as parents accessed this page using a password specific to each childcare center, limiting the analysis of website engagement to the childcare center-level. It is possible that parents accessed intervention content on the website’s home page without entering the password for the childcare center webpage; however, these data were not captured by this study. Thus, it is likely that overall website engagement is underestimated. Second, Google Analytics stops recording webpage view time after 30 minutes of inactivity, or when a session is closed. It is possible that the reported average webpage view time for the center webpage was higher than actual view time if parents did not close the webpage. Google Analytics reports ‘Time on Page’ as an average of all views of the webpage over a specified period, which prevents examination of individual data points. Studies that assess parent engagement in a web-based intervention would be strengthened by more precise observational measures of webpage view time. Third, grouping individual characteristics by childcare center, such as parents’ website engagement and demographic characteristics, reduces the sample size and limits the power to detect differences among subgroups. Fourth, both the survey and intervention for parents were conducted online, possibly introducing selection bias as survey data were gathered from 56% of parents from the target population. Parents who completed the baseline survey and participated in the web-based intervention may be more comfortable with and have more reliable access to the internet than non-respondents. Lastly, other factors that may have contributed to website engagement were not accounted for, including the frequency that teachers uploaded photos to the childcare center page, whether the teachers and childcare center promoted the website to the parents, and whether parents had easy access to the internet.

Strengths of this study are the attention to health equity by examining whether a web-based intervention supported equal parent engagement in a childhood wellness program implemented in childcare centers that varied in parent demographic characteristics, and the application of the CAPE model to evaluate parent engagement in a childcare center-based intervention. By applying the CAPE model, this study included traditional measures of parent engagement in web-based programs that assess connection and attendance (center webpage views and average time on the center webpage) and expanded to include a measure of parents’ active application of intervention content (parents’ completion of intervention activities). Studies that examine associations between parent intervention engagement across each level of the CAPE model and post-intervention parenting behavior (e.g., changes in parent dietary intake) would provide additional insight on the relative importance of each type of engagement specified in the CAPE model for behavior change.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Understanding how to engage parents in programs that are designed to enhance child wellness while addressing health inequities is an important direction in nutrition education research. This study adds to the body of knowledge regarding the association between parent demographic characteristics and parent website engagement. Although web-based tools may appear as an equalizer in providing wellness information to parents from diverse demographic backgrounds, these findings suggest that web-based tools may contribute to existing disparities in parent access to child wellness information when engagement is unequal. These results support the need for future programs that involve parents in the design and implementation of intervention methods to effectively reach parents and childcare centers from all demographic backgrounds.⁴⁰ Qualitative studies, based on Vroom’s Expectancy Theory of Motivation, could increase understanding of parents’ motivation for logging-in to an intervention website because once parents start viewing the website, they may be more likely to complete active components of the intervention. Together, these efforts could further expand knowledge on parent engagement in child wellness interventions and reduce inequities in access to health promotion material and chronic disease prevention. Designing studies that address inequities in parents’ access to health information and nutrition education could inform public policy and resource allocations and reduce health inequities among children.