This dissertation is dedicated to my family who supported me and encouraged me to pursue my study. Without them, this thesis would never been accompli

Family Influences and Healthy Weight for Korean-American Preschool Children BY SO HYUN PARK B.S.N., Yonsei University, Seoul, Republic of Korea, 2004 M.S.N., Yonsei University, Seoul, Republic of Korea, 2010 THESIS Submitted as partial fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing Sciences in the Graduate College of the University of Illinois at Chicago, 2014 Chicago, Illinois Defense Committee: Kathleen F. Norr, Chair and Advisor Mi Ja Kim Chang Gi Park Linda McCreary Crystal Patil, Department of Anthropology

This dissertation is dedicated to my family who supported me and encouraged me to pursue my study. Without them, this thesis would never been accomplished. ii

ACKNOWLEDGEMENTS I can do everything through him who gives me strength (Philippians 4:13). I would like to express my deepest gratitude to my advisor and mentor Dr. Kathleen F. Norr, for her excellent guidance, caring, and patience. Her wisdom, knowledge, and commitment to the highest standards inspired and motivated me. I would also like to express my gratitude to my dissertation committee for their time and expertise in guiding my study. I would like to thank Dr. Mi Ja Kim, who provided me the experience of participating in the quality of nursing doctoral education study and financially supported me during doctoral program. It was an honor to have an opportunity to working with her. I would also like to thank Dr. Chang Gi Park; he provided me not only academic support but also emotional support during my doctoral program. He always stood by me through the good times and hard times. I also sincerely appreciate Dr. Linda McCreary for guiding my research regarding family factors and helped to conduct cognitive interviews. My special appreciation goes to Dr. Crystal Patil, who helped me to identify themes from focus group interviews and gave me an opportunity to use her child s anthropometry measuring instruments. I would like to thank my parents, Jang Sung Park, and Bok Kyo Lee, and my elder brother In Gi Park. They were always there supporting me, sending me their endless love, and encouraging me with their best wishes. I also would like to thank faculty, staff, and friends at the University of Illinois at Chicago (UIC) College of Nursing. Their friendship and sincere support helped me to spend happy time in Chicago and at the UIC. Many thanks to Dr. Hyunjoo Na, Ms. Hyejeong Hong, and Dr. Hanjong Park, who were excellent research assistants for my dissertation project; without them, I could not collect my data. Thank you for my friends in Korea who always sent iii

me their encouragement and wishes. Special thanks go to Dr. Jon Mann for his time and dedication in editing all of my academic papers throughout the program. I would also like to extend my appreciation to the directors of preschools and Korean- American churches in Chicago metropolitan area, who allowed me to conduct my research at their organization. I thank all the KA mothers and their preschool-age children who participated in my study. Thanks to their time and efforts, my study has been completed. I would like to acknowledge the financial support I received from the UIC Graduate College Chancellor s Graduate Research Fellowship, the UIC College of Nursing Seth and Denise Rosen Memorial Research Award, UIC College of Nursing Virginia M. Ohlson Scholarship, UIC College of Nursing Academy of International Leadership Development Scholarship, the Global Korean Nursing Foundation Research Scholarship, and the Korean Nurses Association of Chicago Scholarship. iv

TABLE OF CONTENTS CHAPTER PAGE I. INTRODUCTION A. Background...1 B. Significance of the Study...3 C. Purpose of the Study...5 D. Methods...6 II. KOREAN-AMERICAN MOTHERS PERSPECTIVES ON CHILD REARING AND CHILD WEIGHT A. Introduction...8 B. Methods...10 1. Approach...10 2. Sample and Setting...11 3. Procedures...11 4. Data Analysis...12 C. Results...12 1. Trying to retain Korean culture in the U.S....13 2. Fulfilling the Korean mother s role without usual supports...14 3. Perception about the child s body and efforts to maintain the child s health...16 D. Discussion...19 E. Limitations...21 F. Implications...22 III. FAMILY INFLUENCES AND HEALTHY WEIGHT FOR KOREAN-AMERICAN PRESCHOOL CHILDREN A. Introduction...26 1. Family influences on childhood overweight and obesity... 28 B. Methods...31 1. Sample and Setting... 31 2. Procedures... 32 3. Measures... 32 4. Data Analysis...36 v

TABLE OF CONTENTS (continued) CHAPTER PAGE C. Result...37 1. Bivariate relationships between family factors and child overweight...37 2. Testing the conceptual model: family factors and child s BMI z-score...39 3. Logistic regression: factors related to being overweight versus normal weight...41 D. Discussion...42 E. Limitations...46 F. Implications...47 CITED LITERATURE...57 APPENDICES...65 Appendix A...66 Appendix B...70 Appendix C...72 Appendix D...87 VITA...118 vi

TABLE LIST OF TABLES PAGE I. FOCUS GROUP INTERVIEW QUESTIONS... 23 II. CHARACTERISTICS OF PARTICIPATING KOREAN-AMERICAN MOTHERS...24 III. CONCEPTS, OPERATIONAL MEASURES, AND RELIABILITY /VALIDITY... 49 IV. CHILD WEIGHT CATEGORIES... 51 V. FAMILY FACTORS AND CHILD OVERWEIGHT... 52 VI. HIERARCHICAL MULTIPLE LINEAR REGRESSION... 54 VII. MULTIPLE LOGISTIC REGRESSION OF CHILDHOOD OVERWEIGHT... 55 vii

FIGURE LIST OF FIGURES PAGE 1. Korean-American Mothers Challenges Raising Children in the United States... 25 2. Family System and Preschool-age Child Overweight: Conceptual Model. 56 viii

LIST OF ABBREVIATIONS AR BMI CDC CFQ CI FAD FNPA FST KA KNHANES NHANES OR VIA Adiposity Rebound Body Mass Index Centers for Disease Control and Prevention Child Feeding Questionnaire Confidence Interval Family Assessment Device Family Nutrition Physical Activity Family Systems Theory Korean-American Korean National Health and Nutrition Examination Survey National Health and Nutrition Examination Survey Odds Ratio Vancouver Index of Acculturation ix

SUMMARY The number of Korean-Americans (KA) and the prevalence of obesity among them are increasing, but little is known about obesity among KA preschoolers. This doctoral dissertation was conducted to explore KA family context regarding child s obesity and to examine family factors that relate to obesity among KA preschool-age children. This dissertation consists of two different manuscripts. Because there were no studies of KA mothers experiences raising children in the U.S., manuscript one describes a preliminary qualitative study carried out to better understand KA families and children s weight prior to conducting a quantitative study. The second manuscript describes a quantitative cross-sectional study testing a conceptual model to identify family factors associated with obesity among KA preschool-age children. In the first study, focus group interviews with 15 mothers were conducted. A semistructured focus group guide allowed women to share their experience in bringing up children in the U.S., their perspectives about childhood obesity, and their children s dietary habits and physical activities. The first study found that KA mothers work to retain Korean culture in the U.S. They try to fulfill high expectation of mother s role without the supports they would have in Korea. KA mothers prefer plumpness in children and are not concerned about obesity among KA children because they belive their efforts in shaping a healthy environment are protective. Culturally appropriate approaches are needed to reduce KA mothers stress and help them maintain a healthy lifestyle and appropriate weight for their children. The second study was a cross-sectional study conducted with 104 KA preschoolers and their mothers in the Chicago metropolitan area. Twenty-two percent of the KA preschoolers were overweight or obese (Body Mass Index (BMI) 85th percentile), and family factors explained x

30% of the variance in child s obesity. When the children s BMI z-scores were dichotomized (overweight/obese vs. normal/underweight), the number of children in the family and perceived child weight were positively associated with obesity, while pressure to eat, monitoring of eating, and behavior control of children were negatively associated with obesity. Parental feeding style and child weight perception should be considered when advising KAs about reducing child s overweight and obesity. Taken together, this dissertation research shows that overweight and obesity among KA preschool-age children is a substantial problem in KA communities. KA mothers make efforts to shape healthy habits in their children despite several challenges such as high role expectation and lack of supports. However, most KA mothers had a lack of awareness about obesity issue among their children. Therefore, more efforts are needed to arouse mother s attention to obesity prevention and control among KA preschool-age children. In future studies, the influence of siblings and the child s routines during their stay in formal care settings, such as preschools, should be explored to comprehensively understand factors contributing child s obesity. Longitudinal studies are needed to examine causal relationships. These results should contribute to the development of culturally appropriate intervention programs reflecting KAs unique attitudes and values toward obesity. Interventions should include enhancing supports for KA mothers, including utilizing available support though social networks such as KA churches. xi

A. Background I. INTRODUCTION Childhood obesity has both immediate and long-term negative effects on the physical and psychological health and social well-being of children (Center for Disease Control and Prevention [CDC], 2012). According to the National Health and Nutrition Examination Survey (NHANES), the number of obese children in the U.S. more than tripled during last three decades (rising from 5% to 17%) (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). The prevalence of childhood obesity increases between preschool age (ages two to five) and grade school age (ages six to eleven) (Rhee, 2008). Health problems such as type 2 diabetes and cardiovascular disease among obese children may persist not only throughout childhood but also into adulthood (McCurdy, Winterbottom, Mehta, & Roberts, 2010; Wofford, 2008). Obese children are also reported to experience a lower health-related quality of life. One study found that severely obese children have a quality of life similar to that of children diagnosed with cancer (Schwimmer, Burwinkle, & Varni, 2003). The major modifiable factors contributing to childhood obesity are known to be unhealthy dietary habits, insufficient physical activity, and sedentary behavior. Increased highfat and sugar-containing food consumption leads to higher BMI in children (Skelton, Irby, Miller, & Grzywacz, 2011). Decreased physical activities and increased screen time are associated with higher risk of being overweight and obese (Vos & Welsh, 2010). These factors are shaped within a family environment and can be changed by means of parental modeling and modification of lifestyles by family members. The familial approach to obesity prevention and control emphasizes the importance of providing healthy environments (Golan & Weizman, 2001). Family is the proximal environment

2 of children; the influence of the family is crucial to healthy child development, including healthy eating, sufficient exercise, and weight management (Sousa, 2009). The Family Systems Theory (FST) was derived from the General Systems Theory (Chibucos, Leite, & Weis, 2005). The FST involves two aspects of families: the elements comprising families and the processes existing within and between families (Chibucos et al., 2005). The FST provides a framework for examining the impact of a family system on children s health-related behaviors (Kitzman-Ulrich et al., 2010). According to the FST, family members function as a whole and have reciprocal influences. Because family members are closely interrelated, problems experienced by one family member affect all the members. The family s mutually influencing relationships may affect dietary habits and physical activity patterns among children (Berge, 2009). To guide this study, we modified the conceptual model developed by Berge (2009) based on the FST, which views the family as a system in which change in one part of the system is followed by reciprocal changes in other parts (Bowen, 1966). In the conceptual model, we have defined the family domain as consisting of the family background, family system (family structure, family functioning, and family interactions affecting the child), childcare arrangement, and child s routines. The relationships among the factors of the family system, childcare arrangement, and child s routines have not been studied, and how these factors affect overweight and obesity in KA preschool-age children has not been examined. The conceptual model in this study is presented in Figure 1 in the second manuscript.

3 B. Significance of the Study Racial and ethnic differences in risk factors for obesity begin in early childhood (Taveras, Gillman, Kleinman, Rich-Edwards, & Rifas-Shiman, 2010). The preschool years are a critical period for obesity prevention, because earlier adiposity rebound (AR), a point of maximal leanness or minimal BMI, is related to a higher risk of adult obesity. The earlier AR occurs, the greater the risk of adult obesity (Whitaker, Pepe, Wright, Seidel, & Dietz, 1998; Wofford, 2008). One study reported gender and racial/ethnic differences in AR: non-hispanic African-American children have an earlier AR than other ethnic groups such as non-hispanic Caucasian and Mexican-American, and girls in all racial and ethnic groups tended to experience AR earlier than boys (Boonpleng, Park, & Gallo, 2012). Obesity prevention should be implemented in early childhood because childhood obesity typically persists into adulthood (Gruber & Haldeman, 2009; Salsberry & Reagan, 2005). Children s dietary habits and physical activity patterns are also shaped within this period. Although the preschool period is important in this regard, few studies related to childhood obesity have focused on preschool-age children. Obesity prevention may be especially important to the health of Asian-Americans. Asian- Americans have a greater central adiposity, which may influence their greater susceptibility to chronic diseases (Wells, 2007). Therefore, although Asian-Americans have a lower prevalence of obesity compared to other ethnic groups, they are at higher risk of developing chronic diseases at the same BMI (Cho & Juon, 2006). Similar to other American children, the prevalence of obesity among Korean children also has been gradually increasing; 9.1% of preschool-age children were overweight and 9.6% were obese in 2010 (Korean Natonal Health and Nutrition Examination Survey [KNHANES],

4 2011). KAs are one of the most rapidly increasing minority populations in the U.S. ( Kim & Wolpin, 2008). In 2010, KA comprised the fifth largest subgroup among Asians, lived in the U.S. numbering more than 1.7 million (Barnes, Adams, & Powell-Griner, 2008; United Census Bureau, 2012). Most of them are concentrated in large cities such as Los Angeles (24%), New York (16%), Washington DC (7%), Chicago (5%), and San Francisco (5%) (Kim & Wolpin, 2008). Koreans place an especially strong emphasis on family and tend to maintain their traditional cultural values, customs, and language: eating Korean food, using Korean language media, and engaging in Korean organizations (Kim & Wolpin, 2008; Lee, 1995). A strong sense of family obligation continues to be reinforced for the children as they grow older (McAdoo, Martinez, & Hughes, 2005). These unique characteristics of KA family may influence family systems and development of children s lifestyle. Approximately 30% of KA adults in the U.S. were overweight or obese, and their obesity prevalence has increased with their acculturation to the U.S. (Barnes et al., 2008; Chen, Juon, & Lee, 2012; United Census Bureau, 2012). In spite of the increasing number of KAs and the increasing prevalence of obesity among Korean children and KA adults, there are no studies of how their family and childrearing patterns affect their children s weight. In addition, the voices of KA mothers regarding childrearing in the U.S. and child weight have not been heard. In summary, the increasing prevalence of childhood obesity is a major health problem, because it is related to poor health outcomes across the lifespans and it places a large economic burden on society. Previous studies have found that racial and ethnic disparities exist with regard to childhood obesity and have emphasized importance of obesity prevention during early childhood. In addition, family involvement is pivotal to reduce and prevent childhood obesity

5 among preschool-age children. However, most studies of childhood obesity have focused on school-age children, and little is known about preschool children or how family factors influence obesity during the preschool years. Moreover, despite the growing number of KAs and known obesity issues among KA adults, there are no studies of family factors and preschool children s obesity for KA families. KA families have unique characteristics influencing development of children s health and habits. Identifying the family factors that influence the obesity of KA preschool-age children will be useful in developing culturally relevant obesity prevention strategies. C. Purpose of the Study The long-term goal of the proposed research is to develop an intervention to prevent and decrease overweight and obesity among Korean-American (KA) preschool-age children. The primary purpose of the study was: (1) to explore characteristics of KA families and the prevalence of overweight and obesity among KA preschoolers, (2) to test a conceptual model based on the FST that reflects relationships between family factors and BMI z-scores among these children, and (3) to understand the clinical implications of family factors with regard to overweight and obese KA children. Little work has been done about KA family contexts regarding obesity among KA children. Therefore, two preliminary studies were conducted in preparation for addressing the primary study purpose. The first was undertaken to better understand the family context of KA in relation to childhood obesity. Focus group interviews were conducted: (1) to explore KA mothers challenges while raising their children in the U.S. and (2) to obtain KA mothers perspectives regarding childhood obesity among KA preschool-age children.

6 The second preliminary study was to provide evidence of construct reliability of the Family Nutrition Physical Activity (FNPA) instrument, a measure of child s routines, for use with KA families. Cognitive interviews were performed: (1) to develop a Korean language version of the FNPA instrument and (2) to confirm the appropriateness and comprehensibility of the translated FNPA in the KA context. D. Methods A qualitative descriptive study was conducted using three focus group interviews with a total of 15 KA mothers. Detailed information about the methods and findings of the focus group interviews is presented in Manuscript 1. Cognitive interviews were conducted to develop a Korean version of the FNPA instrument and to evaluate the cultural appropriateness, construct validity and the conceptual equivalence of the Korean and English versions of the FNPA for KAs. The FNPA was developed to assess family lifestyle factors, including the child s routines, that may contribute to childhood obesity (Ihmels, Welk, Eisenmann, & Nusser, 2009). The FNPA has never been translated into Korean or used for KA families. Therefore, the FNPA instrument was translated into Korean using a parallel blind technique (Behling & Law, 2000). The translation committee consisted of three bilingual members whose primary language is Korean and who had research experience in both Korea and the U.S. All the translation committee members had master s or doctoral degrees. Three translators independently prepared translations of the original English version into Korean. During translation, some FNPA questions were modified to reflect the KA family lifestyle while maintaining the core meaning of the questions. Subsequently, the three translators met to compare their versions and minor

7 inconsistencies were resolved to prepare a single draft version. The Korean version of the FNPA was finalized after modifying any inconsistent items. To determine comprehensibility and appropriateness, the think aloud method was used for cognitive interviews with 19 KA mothers. The principal investigator read all questionnaire items and asked how they interpreted the question. If a question was misinterpreted or confusing, the participant was asked for suggestions to improve the phrasing. FNPA questionnaire items were modified using participants suggestions to improve the items comprehension. For example, Item 20 (My child gets 9 hours of sleep a night) was modified to state "at least 9 hours of sleep. The revisions were discussed with the FNPA developer, and we agreed upon the changes to be made. We plan to write an article describing the adaptation of the instrument for KAs, including psychometric analyses using the larger survey sample. Finally, a cross-sectional study that included a survey and weight and height measurements was conducted with 104 KA mothers and their children. The methodological details of this study are presented in Manuscript 2.

8 II. Korean-American Mothers Perspectives on Child Rearing and Child Weight A. Introduction Childhood obesity is an important public health problem that is negatively associated with physical, psychological, and social well-being of children (Center for Disease Control and Prevention [CDC], 2012). Childhood obesity rates also are high among children of immigrant minority populations in the U.S., including Asian-Americans (26%) (Ike-Chinaka, 2013). The major modifiable factors contributing to childhood obesity are unhealthy dietary habits, insufficient physical activity, and sedentary behavior. All of these lifestyle factors are shaped within a family environment, especially for young children. These factors have the potential to be changed by means of parental modeling and modification of lifestyles by family members. Therefore, family contexts contributing to childhood obesity should be explored. The family is especially important for preschool-age children, yet few studies have focused on how the family affects diet, physical activity and sedentary behaviors for preschool- age children. Immigrants family structures and lifestyles differ from those of people who do not immigrate, and these differences may influence preschool-age children s health (Lee, Sobal, & Frongillo, 2000). Among Asian-Americans, childood obesity rates vary by country of origin and processes of assimilation for that group (Jain et al., 2012). The few studies that have been conducted regarding different Asian groups identified cultural factors that may affect the child s obesity. For example, in Chinese families, overfeeding children is considered a way parents show their love, and the dominant parent s unhealthy lifestyle contributes to the child s weight (Wong, 2011). In another study, Vietnamese mothers reported that they are more concerned about their children s underweight than overweight (McGarvey et al., 2006).

9 There are more than 1.7 million KAs now living in the U.S., mostly in large cities such as Los Angeles, New York, and Chicago (Kim & Wolpin, 2008; United Census Bureau, 2012). Most KAs have come to the U.S. relatively recently, within the last 50 years, after the U.S. government eased restrictions on Asian immigration in the late 1960 s. KAs place an especially strong emphasis on family and tend to maintain their traditional cultural values, and customs: eating Korean food, using Korean language media, and being active in Korean organizations in the U.S. (Kim & Wolpin, 2008; Lee, 1995). Family is treated as an extension of the self and emphasizes children s obedience to parents (Kim & Wolpin, 2008). A strong sense of family obligation continues to be reinforced to the children as they grow older (McAdoo et al., 2005). Moreover, Korean parents place high importance on providing their children with a good education; educational success becomes a serious family concern (Sohng & Song, 2004). One study reported that authoritarian control and subsequent poor communication between parents and children are sources of conflict in the KA families (Sohng & Song, 2004). These characteristics of KA family may influence childhood obesity. Although KAs are one of the most rapidly growing minority populations in the U.S., there are no studies investigating the relationship of family and childrearing patterns to children s weight (Jang & Chiriboga, 2010; Kim & Wolpin, 2008). In both Korea and among KAs, the primary caregiver of young children is almost always the mother. Responsibility for care taking is in their domain and they are well informed about their families and children (Sosa, 2012). Therefore mothers are a good source of information about their families, yet their perspectives are rarely brought into the discussion of child rearing and child weight. Moreover, mothers perspectives on children s obesity can provide information to help develop culturally

10 appropriate childhood obesity prevention. However, little is known about KA families and KA preschool-age children s obesity. The purpose of this study was to explore KA mothers challenges while raising their children in the U.S. and to obtain KA mothers perspectives regarding obesity among KA preschool-age children. B. Methods 1. Approach The goal of qualitative descriptive research is to provide a comprehensive summary of a particular group or situation about which little is currently known (Sandelowski, 2000). Therefore, a qualitative descriptive study was selected to provide a detailed description of the phenomenon of childrearing within KA families in the U.S. from the perspectives of KA mothers. A focus group interview is a group interview that involves listening to people and learning from them (Morgan, 1998). Focus groups are small groups that are homogeneous in regard to the topic of inquiry. One strength of the focus group interview is that it allows participants to respond to others perspectives and is an excellent way to elicit shared group norms as well as variations (Herman, Malhotra, Wright, Fisher, & Whitaker, 2012). Few studies explicitly focused on living experiences and challenges of KA mothers bringing up their preschool-age children in the U.S. Therefore, focus group interviews were conducted for this initial exploration of mothers concerns and opinions about their children rearing and children s obesity.

11 2. Sample and Setting Three focus group interviews with a total of 15 KA mothers were conducted between March to May 2013 in the Chicago metropolitan area. Interview participants were recruited with the assistance of the director of one preschool and the pastors of two KA churches. The inclusion criteria for the participants were as follows: (1) mothers who self-identify as KA, (2) KA mothers who have lived in the U.S. at least 5 years, and (3) KA mothers who live with their 2 to 5 year old child. The interviews were held in private rooms at the research sites to maintain participant confidentiality and avoid disturbances. 3. Procedures The University of Illinois at Chicago Institutional Review Board approved this study. We contacted the director of each organization. The directors and pastors made announcements about our study to potential participants at meetings. Once participants showed their interest in the study and provided their contact information, we contacted them individually to establish eligibility, explain the study and set the interview date. Prior to each focus group discussion, the interviewer explained the purpose and procedures of the interview, assured the participants that the discussion would be kept confidential by the interviewer and research team, and asked the participants not to talk about the discussion with others. We then obtained their signed informed consent. The principal investigator (PI) led the interviews, and a research assistant took comprehensive notes of the discussions as they proceeded. All the discussions were audiorecorded and transcribed verbatim. The interviews were conducted in Korean and lasted 60 to 120 minutes. Immediately after each focus group interview, all the participants completed a

12 background questionnaire, including age, level of highest education, and household income. All the participants received a gift card for their time and effort. A focus group interview guide was developed and followed for the interviews to identify (1) major challenges of KA mothers with regard to raising their children in the U.S., (2) perspectives of KA mothers regarding obesity among KA children, (3) the dietary habits of KA children, (4) physical activity patterns among KA children, and (5) KA family physical activities. Table 1 summarizes the focus group questions used to guide the focus group interviews. 4. Data Analysis Descriptive analysis was performed using SPSS version 20 to examine demographic characteristics of KA mothers. Qualitative content analysis, which is a dynamic form of verbal data analysis, was performed (Sandelowski, 2000). The Korean interviews were transcribed (written by the research assistant) and the PI s written transcripts based on the audio-tapes were compared for completeness and accuracy. The PI then translated Korean transcripts into English. Early coding was conducted and the final codes were identified in collaboration with two coauthors who are qualitative research experts (Norr & Patil). Codes similar in meaning were merged and then labeled as a category. Finally, primary interview themes were described and relationships between codes were found. Three major interrelated interview themes were identified. C. Results Demographic characteristics of participants are presented in Table 2. All but one of the mothers was born in Korea, all mothers were married, and lived with their husband. The mean age of the mothers was 38.53 years (range 31 to 44), and mothers had lived in the U.S. for an

13 average of 18 years (range 8 to 34). Most of them were working (73%) outside their homes, 40% had at least a master s degree, and 40% had a family household income of more than $75,000 per year. In the focus groups, KA mothers shared their challenges and experiences of raising their children in the U.S. Three themes emerged from the focus group interview discussions: (1) retaining Korean culture in the U.S.; (2) fulfilling the Korean mother s role without the supports they felt they would have in Korea; and (3) perceptions about the child s body and efforts to maintain their child s health. As depicted in Figure 1, all themes were interconnected and reflected the influences of KA culture in the American environment on child health. 1. Trying to Retain Korean Culture in the U.S. KA mothers made efforts to retain Korean culture when they are raising their children in the U.S. KA mothers pointed out that they emphasize strong relationships between family members. To maintain close relationships among family members, they intentionally engage in many activities together, including going to church together, grocery shopping, and participating together in outdoor activities. One mother said: During the weekend, there is also not enough time because children spend most of their time in Korean language school and the Catholic church and they go to piano lessons. I take my children to the park if the weather is nice, or we go to watch soccer games during soccer season. Despite their efforts to maintain family ties, mothers expressed concern about cultural gaps between their children and themselves. Mothers feel they cannot fully understand their children, because they did not grow up in the U.S.; as their children are getting older, the gaps between them are getting bigger. One mother said: Sometimes when I talk with my children, I do not understand them at all. My older child used the word grounded, and I did not know what it meant. Although I have studied

14 and lived here, I only know the dictionary meaning of words. Since I did not grow up here, there are many things that I cannot understand. My children are getting older, and the gaps between us are getting wider. Moreover, KA mothers experienced conflicts between the traditional Korean value of respect for elders and what they perceive as overindulgence by grandparents. They disagree with their children s grandparents regarding parenting styles. Grandparents do not limit their children s behaviors and provide some unhealthy food (e.g., soda or snacks). Although KA mothers disagree with these indulgences, they try not to argue with grandparents to maintain the cultural value of respect for elders. Mothers said: My father stays at home since his retirement, and my preschooler knows that her grandfather will turn on the TV for her. When she comes home, she grabs her grandfather s hand and then takes him upstairs to ask him to turn on the TV. If my children see that I have a conflict with their grandparents, they will see it as a kind of disrespect for older people. It is a kind of conflict between educating children and respecting older people. Family meals and foods are another aspect of traditional culture mothers try to maintain. Most mothers pointed out that they prefer to eat homemade Korean food because they believe it is healthier than American food. Therefore, they try to make sure that their children eat homemade Korean food (e.g., Kimchi, steamed rice, and hot soup) at home. One mother said: I try to feed my children more Korean food at home because they eat more American food as they get older. 2. Fulfilling the Korean Mother s Role Without Usual Social Supports These KA mothers said they are struggling to meet the high expectations of the mother s role in Korean culture without the usual supports they would have in Korea. All KA mothers had high cultural expectations of mother involvement in early child rearing. In Asian culture, it is considered that child s growth and development, and even academic achievement are decided by

15 mother s dedication and efforts. Therefore, KA mothers stated that they felt strongly that they must take care of all of their children s needs. Mothers said: Compared to Korea, children living here spend more time with their mothers. Although mothers are working, they stay with their children except during their working hours. Children learn lots of things from their mothers. They can also learn bad things from their mother. There are few opportunities for children to be exposed to other things, so children learn a lot from their mothers. I think Americans raise their children to be independent from the time that they are young. Americans let their children eat and sleep by themselves. However, Koreans help their children to eat, and it becomes a habit; therefore, one of my children lacks independence even though she is 4 years old. I think Asians have such habits. Still, I feed my child by following her around, and we sleep together until my child falls asleep. The strains of trying to fulfill the Korean mother role in an environment that does not share this perspective on mothering and lacks support for it leads KA mothers to feel highly stressed and guilty about their performance as mothers. One mother said: In my case, I did not cook in Korea. Then I started to cook here. I try to find one or two things that I can cook, and I feel that I have a limitation. I never learned how to cook and lack information, as I do not know what I have to cook. It takes time and effort to buy food and make it. I wish there was someone like my mother who could help me. In Korea, mothers can utilize their social support network such as relatives when they need help. In addition, there are various types of local restaurants and delivered foods available, which may reduce mother s cooking responsibilities. Children can easily engage in physical activities by walking and using public transportations. However, in the U.S., KA mothers feel they have to take the responsibilities for raising their child without such supports. Available childcare arrangements are limited because their families, including children s grandparents live in Korea. Most delivery foods available in the U.S. are unhealthy, and eating at local restaurants is inconvenient because of long distances (they have to drive to get there). Moreover, there is no place to go outdoors unless the mother drives her children. In other words, mothers wish to have more resources, which could help them when they raise their children. As one mother put it,

16 I do not have much time, so my family tries to do things together. My children come home after preschool, eat dinner, and take a bath, and then it is around 8 p.m. The schedule is too tight, so we try to spend time together as much as possible. That is why Korean mothers eat and sleep with their children when they are young. We feel sorry for our children. This situation is especially difficult for KA mothers who are working outside the home. They pointed out that they feel highly stressed and guilty about having too little time to spend with their children. Mothers said: I am a working mother, so cooking is the most problematic thing for me. I cannot make food properly, so I just feed my children anything. 3. Perceptions About the Child s Body and Efforts to Maintain the Child s Health KA mothers felt that children should look plump or chubby by the time that they are 3 years old and mothers are responsible for ensuring this. They felt that a chubby or plump toddler is healthier than a skinny child, and mothers are more concerned about their child s well-being and development rather than overweight or obesity. Most KA mothers said that they have not seen or heard about childhood obesity among KA children. KA mothers stated that they did not worry about obesity among KA children, because they consciously work to provide healthy food and encourage their children to participate in physical activities. Mothers said: I prefer to see children who are plump like a Michelin tire because my two children did not get plump. I heard that children, who are plump when they are young, become tall when they get older, so I envy them. If I fed my children at McDonald s or KFC, I would have to worry about their becoming obese. However, since I feed my children healthy food such as meat and vegetables, I think they will be fine. KA mothers think that a mother is largely responsible for her child s health. Therefore, KA mothers try to shape healthy habits for their children by providing healthy food, encouraging them to have adequate sleep time, and limiting screen time. Mothers think that they are primarily

17 responsible for feeding their children and try to make sure that their children eat well. Therefore, mothers put the highest priority on shaping their children s healthy dietary habits. Mothers try to cook homemade Korean food and when they eat outside the home, they try to go to Korean restaurants. Furthermore, many of the KA mothers interviewed stated that they mostly eat meals at home, because they believe eating at restaurants is unhealthy, expensive, and takes time. Some mothers pointed out that sometimes they struggle to provide homemade Korean food, because they have less cooking experience or skills with such foods or do not have the time to cook these meals. In addition, mothers reported that even though eating vegetables is important and necessary, cooking meat is easier and it keeps longer. So they tend to have more meat-based rather than vegetable-based meals. One mother said: In my case, although I buy vegetables there is no time to cook it. Then few days later I throw the rotten vegetables away. So I rarely buy them. Meat does not easily decay and is easy to eat, so we eat it often. All mothers pointed out they work hard to keep unhealthy foods out of their children s diet (e.g., snacks and soda). However, they noted that once children are exposed to these tastes, children request these foods at home and it is hard to control. While mothers do define promoting healthy eating as an important part of their job as mothers, they also noted that the health of family members influences how much concern they have. For example, if a grandparent has been diagnosed with a chronic disease such as diabetes or cancer, then they are much stricter about their children s diet. In other words, feeding styles are affected by family health history. Moreover, mothers mentioned that children s eating habits are affected by what those around them are eating (e.g., parents and siblings). Therefore, KA parents try to model healthy eating behaviors and avoid eating what they define as unhealthy foods, including snacks, soda, and premade foods in front of their children. Mothers said:

18 Although mothers are strict about food and feed their children well at home, once children go to school and experience new tastes such as sweet and salty foods, then they become addicted to those tastes. Even though I try not to feed my children such foods, after they started to eat them at school, then they wanted to eat them at home. Since I started to eat snacks, my children also eat more snacks. My children do not ask to have snacks, but I think they are affected by snacking. Therefore, we should be careful to set a good example. Mothers said that setting limits on their children s screen time (e.g., watching TV and playing computer games) is harder than controlling their diet and physical activity. They mentioned that most KA families do not place televisions in their children s rooms. KA parents try to implement screen time rules and the imposed limitation often creates tensions between parents and children. For example, mothers noted that they try to limit television watching or computer games to weekends. But even then, they try to limit the total amount of time spent watching TV and using the computer. One mother said: We do not allow our children to watch TV on weekdays, but we allow them to watch it during the weekend. Once I allow my children to watch TV, they want to watch it without limitation, so it is hard to control. In addition, KA mothers expressed concerns about their child s sleep. They think that children should have adequate sleep time for their growth and development. While KA parents want their children go to bed early in the evening, the children want to go to sleep late at night. Some mothers said that they sleep with their children until they fall asleep, and this makes mothers tired. Despite high attention to diet, sleep, and screen time, mothers voiced less concerned about their children s physical activities. Mothers described that they encourage physical activity in their children by registering children in formal sports programs, but that they themselves rarely participated in family outdoor physical activity and do not see physical activity as entirely their responsibility. They noted that fathers take charge of outdoor physical activity. Therefore,

19 children s outdoor physical activity is primarily determined by what the father does. For example, if a father likes to go outside, he takes his children with him for outdoor activities. As one mother explained: Whether or not children play outdoors is determined by characteristics of their fathers. If a child s father came to the U.S. when he was young or was born in the U.S., or likes sports, he goes out and plays with his children. However, as typical Koreans, we [mothers] are not used to doing physical activity, and we do not have an interest in sports. D. Discussion The purpose of this study was to identify KA mothers experiences and challenges while raising their children in the U.S., and to explore their perspectives regarding obesity among KA preschool-age children. Previous research has shown that KAs tend to maintain their traditional cultural values (Kim & Wolpin, 2008; Lee, 1995). Consistent with previous studies, KA mothers in this study made strong efforts to keep Korean cultural identities. Retaining Korean culture is the overarching theme in these KA mothers perspectives and behaviors with respect to child rearing. For example, they emphasized building strong family relationships and they intentionally engaged in family activities together to do so. These strong efforts mothers make to retain Korean culture may reflect the fact that almost all mothers in this study were born in Korea. These finding are congruent with the previous work describing KAs as accepting social order based on hierarchies of age and social status to maintain harmony, which is highly valued philosophy in Confucian cultures (Moon, 2012). However, maintaining Korean culture in the U.S., such as respecting elders and providing homemade Korean foods to their children, sometimes lead to conflicts and increased levels of stress for these mothers. In this study, KA mothers said they try not to argue with children s grandparents to maintain the cultural value of respect for elders. This tension between

20 grandparents and mothers regarding grandparents indulgence also has been identified in Chinese and Hispanic families (Herman et al., 2012; Lindsay, Sussner, Greaney, & Peterson, 2011). KA mothers expressed concern about cultural and language gaps between their children and themselves. While KA mothers tend to maintain Korean cultural identities, their children very quickly become Americanized, so that KA mothers felt they couldn t keep up with them (Zhou, 1997). In a previous study, poor communication between KA parents and children was found to result in conflict among family members (Sohng & Song, 2004). Korean immigrant mothers, whether they work outside home or not, are highly responsible for household work and raising their children (Hong & Hong, 1996). KA mothers in this study tried to meet these high expectations role. However, mothers struggled to fulfill these roles without available support resources such as a relative s childcare support. Moreover, time constraints made working mothers experience more stresses so that they sometimes indulged their children to compensate for their guilt (e.g., by allowing snacking). One study reported that lack of English fluency and lack of the usual support network available in their homeland made the task of good motherhood hard to achieve for Southeast Asian immigrant mothers (Liamputtong, 2006). KA mothers think that their child s weight and health reflect the mother s care for their child. This is consistent with previous studies with Latina mothers. The child s weight status reflects parenting skills; therefore a skinny child is seen as a sign of bad parenting and poor health (Lindsay et al., 2011). KA mothers prefer a chubby child, because they believe that chubbiness represents healthy development. This preferences for plumpness are also found among other ethnic/racial groups such as Vietnamese and Hispanics (McGarvey et al., 2006; Wong, 2011). Preferences for chubby children may lead to underestimation of their children s

21 actual weight, and this could increase the prevalence of overweight and obesity among KA children. One study of mothers from China and Korea reported that if mothers experienced food insecurity, they evaluated their child as weighing less than ideal (Van Hook & Cheah, 2012). KA mothers believed that they shaped their children s healthy environments by providing healthy foods, limiting screen time, and encouraging adequate sleep. Therefore, they felt they did not need to be concerned about obesity among KA preschool-age children. In this study, even though the majority of KA mothers are currently working outside the home, KA fathers take responsibility only for children s physical activities. This indicates that an imbalance of parents roles in child rearing still exists, reflecting gender inequalities. One study reported that KA mother s heavy burden and the lack of role sharing might negatively impact family functioning (Kim & Grant, 1997). E. Limitations This study has several limitations. A relatively small number of KA mothers, all living in one metropolitan area, participated in this study. In addition, nearly all were born in Korea, so the findings in this study may not represent KA mothers who were born and raised in the U.S. Participants also were predominately middle-class, with high education and adequate income, and living with their husbands in a two-parent household. Experiences and challenges of mothers who are second or third generation, single mothers or with low education and/or income might be different. Moreover, it should be noted that these mothers may have a tendency to idealize life in Korea and may not have a realistic understanding of the supports they would have for rearing children there.

22 F. Implications Emerging themes from this study have implications for developing effective future intervention programs. Further studies should explore how KA mothers utilize their social network when they raise their children and what types of supports they may need. Introducing new supports and utilizing available support through social networks such as KA churches or community organizations should help to reduce the excessive responsibilities of mothers, which lead to high stress and guilt. This high stress and guilt can lead mothers to engage in behaviors that do not promote health to save time and/or to make up for their lack of time with their children, such as using fast foods and giving unhealthy snacks. Providing opportunities such as support groups can help KA mothers share their challenges and obtain advice about raising their children from each other that will be beneficial. Future studies should be conducted with more diverse groups, including second and third generation KAs, and should include the father s perspectives. Families who recently immigrated from Korea may have different and greater challenges such as struggling to settle down to the new environment and not enough time to take care of their children. Therefore, understanding new immigrant families experiences is an important first step to develop supportive programs. In addition, culturally appropriate approaches are needed to help KA mothers realize that plump is not optimal for children and to increase awareness of the value of physical activity. Furthermore, awareness of cultural differences among family members (mothers and children) may be helpful when providing obesity control and prevention programs.

TABLE I FOCUS GROUP INTERVIEW QUESTIONS Can you tell me about your experiences in bringing up your children in the U.S.? Are there any things that are different in bringing up a preschool child in the U.S.? Do you think childhood overweight and obesity is a problem in the Korean-American community? Why? Why not? Is overweight a problem for preschool children? Why? Why not? Tell me what preschool children eat. Tell me what kinds of activities preschool children do. What about physical activities like walking and playing outdoors for preschoolers?

24 TABLE II CHARACTERISTICS OF PARTICIPATED KOREAN-AMERICAN MOTHERS (N=15) Mean (SD) N (%) Age (years) 38.53 (4.19) Born in Korea 14 (93.3) Living with husband 15 (100) Years lived in the U.S. 17.57 (8.67) Education level Bachelor or less Master or higher 9 (60.0) 6 (40.0) Employment Working Homemaker 11(73.3) 4 (26.7) Household income $20,000-74,999 $75,000 or more 9 (60.0) 6 (40.0)

25 FIGURE I KOREAN-AMERICAN MOTHERS CHALLENGES RASING CHILDREN IN THE UNITED STATES

III. Family Influences and Healthy Weight for Korean-American Preschool Children A. Introduction The increasing prevalence of childhood obesity is a major health concern in the U.S. and globally. The number of obese children in the U.S. more than tripled during the last three decades, rising from 5% to 17% (Ogden et al., 2010). Childhood obesity in the U.S. is responsible for $14.1 billion in annual medical costs for drug prescriptions, emergency room visits, and outpatient visits (Trasande & Chatterjee, 2009). In addition to the economic burden associated with obesity, it has both immediate and long-term negative effects on the physical and psychological health and quality of life of children. It is significantly related to development of type 2 diabetes, cardiovascular disease, and other chronic illnesses (Berenson & Heart, 2012; Crawford, Story, Wang, Ritchie, & Sabry, 2001; Daniels, 2006). In addition, obese children are stigmatized due to negative attitudes toward obesity and thus have lower levels of self-esteem and higher depression rates than non-obese children (Schwartz & Puhl, 2003; Sheslow, Hassink, Wallace, & DeLancey, 1993). These health problems may persist not only throughout childhood but also into adulthood (McCurdy et al., 2010; Wofford, 2008). Because overweight is more common than obesity and is a risk factor for becoming obese, these two groups are often combined. In this study, we used the term overweight to include overweight and obesity. There are racial/ethnic disparities in the prevalence of childhood overweight and obesity. Hispanic and non-hispanic African-American children are at a higher risk of becoming overweight and obese than other racial/ethnic groups in the U.S. (Fox & Kumanyika, 2008). Moreover, obesity among children has begun increasing in other industrialized countries. In

27 Korea, the prevalence of obesity among children has been gradually increasing in recent decades; 9.1% of preschool children were overweight and 9.6% were obese in 2010 (Korean Natonal Health and Nutrition Examination Survey [KNHANES], 2011). Asian-Americans have a lower prevalence of overweight and obesity than other racial/ethnic groups (World Health Organization [WHO] Expert Consultation, 2004) However, chronic diseases in Asian-Americans may develop at lower BMI than in other racial/ethnic groups because of Asian-Americans greater tendency toward abdominal obesity (Taveras, Gillman, Kleinman, Rich-Edwards, & Rifas-Shiman, 2010; WHO Expert Consultation, 2004). In addition, the risk of overweight and obesity among Asian- Americans increases with their time in the U.S. (Unger, Reynolds, Shakib, Spruijt-Metz, Sun, & Johnson, 2004). The number of Asians increased faster than that of any other racial group in the U.S. between 2000 and 2010 (United Census Bureau, 2012). Approximately 1.7 million KAs live in the U.S., and they are the fifth-largest subgroup among Asian-Americans (United States Census Bureau, 2013). Almost one in three KAs do not have health insurance, and approximately 30% of KA adults in the U.S. are overweight or obese (Asian and Pacific Islander American Health Forum, 2012; Barnes et al., 2008). Korean families tend to maintain Confucian values with respect to child-rearing practices and family interactions (Farver & Lee-Shin, 2000; Lee et al., 2000). These unique characteristics of KA families may influence the prevalence of childhood overweight and obesity. Understanding overweight and obesity issues among KA children is important to develop effective and culturally appropriate obesity interventions. However, the familial factors that are linked to early childhood overweight and obesity among KAs have not been studied.

28 The preschool years are a critical period for obesity prevention and control. During this period, children experience adiposity rebound (AR), which means that their body fat is at its lowest level in their entire life. Previous studies have shown that the earlier AR occurs, the greater the risk of adult obesity (Whitaker et al., 1998; Wofford, 2008). In one study, AR was found to vary according to racial/ethnic and gender differences at an early age: non-hispanic African-American children have a earlier AR than children of other ethnic groups such as non- Hispanic Caucasians and Mexican-Americans, and girls in all racial and ethnic groups tend to experience AR earlier than boys (Boonpleng et al., 2012). Moreover, children s dietary habits and physical activity patterns are shaped during the preschool period, and persist into adulthood (Gruber & Haldeman, 2009; Salsberry & Reagan, 2005). 1. Family Influences on Childhood Overweight and Obesity The family plays a pivotal role in shaping lifestyles related to childhood obesity, especially for preschool-age children. Modifiable factors contributing to obesity include excessive calorie intake, lack of physical activity, and increased sedentary behavior. Increased high-fat and sugar-containing food consumption leads to higher BMI in children (Skelton et al., 2011). Decreased physical activities and increased screen time are associated with a higher risk of being obese (Vos & Welsh, 2010). In a multilevel analysis, Boonpleng and her colleagues (2012) found that variation in childhood obesity was mostly explained at the family level (71%), followed by the school level (27%) and community level (2%). Identification of obesity risk factors within a shared family environment is necessary to provide successful intervention for obese preschool-age children (Kitzman-Ulrich et al., 2010). In addition, participation of family members in childhood obesity intervention leads to better outcomes than efforts focused on children alone (Spruijt-Metz, 2011).

29 Family factors have been found to be significantly associated with childhood obesity in previous studies. Children are more likely to be obese if they have working mothers, if they live with single parents, if the mother s educational level is low, if they have a low family income, or if they are cared for in informal care (e.g., by relatives and babysitters) (Chen & Escarce, 2010; Gibson, Byrne, Davis, Blair, & et al., 2007; Huffman, Kanikireddy, & Patel, 2010; Kang et al., 2006; Maher, Li, Carter, & Johnson, 2008; Patrick & Nicklas, 2005; Pearce et al., 2010) Acculturation is related to ethnic, racial, and cultural identity, and the degree of acculturation also may contribute to racial and ethnic disparities regarding childhood obesity (Peña, Dixon, & Taveras, 2012). However, prior research results are inconsistent with respect to the association of acculturation with childhood obesity. Family functioning is another aspect of the family environment that is related to childhood obesity (Kitzman-Ulrich et al., 2010). However, the relationships identified between family functioning and childhood obesity have been inconsistent. Some studies have found that family dysfunction is associated with greater BMI of children (Kennedy & Chen, 2004; Moens, Braet, & Soetens, 2007; Sousa, 2009). In contrast, Gibson and his colleagues (2007) did not find a significant relationship between childhood obesity and poor family functioning. Parental feeding style refers to parents approach to feeding their children, and it affects children s eating styles and weight outcomes (Johnson & Birch, 1994; Patrick, Nicklas, Hughes, & Morales, 2005). Prompting children to eat, use of rewards, and restricting access to food tend to result in intake of more food than is healthful for children (Rhee, 2008). Parents of overweight children monitor and restrict their food consumption more than parents of children who are not overweight (Moens et al., 2007). Furthermore, it has been reported that parental encouragement

30 of the choice of healthful foods through role modeling is important to establishing healthful dietary patterns for children (Tibbs et al., 2001). Previous studies have suggested that healthy child s routines are key factors in preventing childhood obesity (Slusser et al., 2012). Anderson and Whitaker (2010) analyzed a nationally representative sample of preschool-age children and found that children who had dinner with their families, had adequate nighttime sleep, and had limited television viewing time exhibited a lower prevalence of obesity. The family factors that contribute to KA childhood obesity may be different from other families because of their unique cultural attitudes and lifestyles with regard to obesity. The family systems approach provides a comprehensive perspective on families with regard to childhood obesity that can be adapted for examining KA families. According to Family Systems Theory (FST), family members function as a whole and have reciprocal influences (Chibucos et al., 2005). Therefore, the FST was chosen as the framework for this study. Recent childhood obesity research has adapted the FST to focus on the specific issue of obesity. Berge (2009) has proposed a conceptual model of family domains that correlate with child and adolescent obesity and weight-related outcomes, and this conceptual model was modified for use in this study (Berge, 2009). Factors within the family domains, including the parental, family functioning, and sibling domains, have been found to exhibit significant associations with child and adolescent obesity (Lee, 1995). Because the child s routines and the childcare arrangement may directly impact obesity in KA preschool-age children, these two factors were added to the conceptual model for this study. In addition, family background factors that have been associated with childhood obesity were included in the conceptual model. With the inclusion of the child s routines, the childcare

31 arrangement, and family background factors, the conceptual model can be used to comprehensively explore childhood obesity among KA preschool-age children. In the conceptual model, we have defined the family domain as consisting of family background, family system (family structure, family functioning, and family interactions affecting the child), childcare arrangement, and child s routines. While siblings also may be important with regard to childhood obesity, including them was beyond the scope of this study (see Figure 1). Childhood obesity is a growing health problem among all ethnic groups, but there have been few studies of preschool-age children and none of obesity among KA preschool-age children. This study focused on the family factors that related to obesity among KA preschoolage children. The purpose of this study was to identify the association between characteristics of KA families and the prevalence of obesity among KA preschoolers, and to test a conceptual model based on the FST that reflects relationships between family factors and BMI z-scores (overweight/obese status) among these children. B. Methods 1. Sample and Setting This study was conducted from May through August 2013 in the Chicago metropolitan area. A total of 104 KA mothers and their preschool-age children participated. Mothers had to meet the following inclusion criteria: (a) had lived in the U.S. for at least 5 years, (b) selfidentified as KA, and (c) lived with their preschool-age children. The mean age of the preschoolage children was about 47 months, and 60% were boys. The mothers mean age was 37.3 years, and their ages ranged from 29 to 49 years.

32 2. Procedures Study approval was obtained from the Institutional Review Board of the University of Illinois at Chicago. We contacted the directors of preschools and KA churches, and they then announced the study to potential study participants. The principal investigator (PI) and two research assistants visited each research site. The PI checked the eligibility of each KA mother participant, explained the study s purpose and procedures, and obtained informed consent from the mothers and verbal assent from their preschool-age children. Children's weights and heights were measured three times each to reduce measurement error, and the means were used in data analysis. During these measurements, the KA mothers were present to reassure their children, and a screen was used to protect children s privacy and to increase their cooperation. No children refused to allow us to measure their weights and heights. Subsequently, the KA mothers completed self-administered survey questionnaires. The questionnaires were prepared in both Korean and English versions so that participants could select their preferred language; 60 of the 104 mothers chose to complete the Korean version. Questionnaire completion took approximately 20 to 40 minutes. After the measurements and survey were completed, each KA mother received a gift card and each child received a small gift for their time and effort. 3. Measures The concepts and operational measures used in this study and their reliability and validity are summarized in Table 1. Family background factors consisted of parental employment status, level of parental education, household income, length of stay in the U.S., whether mothers are first-, second-, or third-generation immigrants to the U.S., and level of acculturation. The Vancouver Index of Acculturation (VIA) was used to measure the level of acculturation of KA mothers. The VIA is self-administered and assesses two dimensions of

33 acculturation, identification with the culture of origin and identification with American culture, including adherence to traditions, social interactions, and values (Ryder, Alden, & Paulhus, 2000). The level of measurement is an interval scale with a 9-point Likert scale ranging from 1 (strongly disagree) to 9 (strongly agree). The total scores for each subscale range from 10 to 90. The concurrent validity of the VIA was confirmed in a previous study (Ryder et al., 2000). The reliability of the VIA was established in prior studies and continued to be high in this study (Choi, Miller, & Wilbur, 2009). Family system factors included family structure, family functioning and family interactions affecting the child. Family structure factors included status as a single-parent or dual-parent family, generational composition (two-generation or three-generation), and total number of children in the household. Family functioning was assessed using the Family Assessment Device (FAD), which included seven dimensions that distinguished between healthy and unhealthy families (Epstein, Baldwin, & Bishop, 1983). The concurrent validity of the FAD was confirmed in previous studies (Aarons, McDonald, Connelly, & Newton, 2007; Epstein et al., 1983; Miller, Epstein, Bishop, & Keitner, 1985). The FAD was modified and translated into Korean; items were deleted that showed low correlation and were culturally difficult to understand (Chung, 1993). The modified Korean version of the FAD consisted of 34 items across the same seven dimensions. Higher scores indicate fewer family problems and better family functioning. In our study, the internal consistency coefficients of the FAD ranged from 0.66 to 0.87. Family interactions affecting the child included parental feeding style and parental role modeling of healthy behaviors. The Child Feeding Questionnaire (CFQ) was used to measure parental feeding style. The CFQ is a self-reporting instrument used to assess parental beliefs,

34 attitudes, and practices regarding child feeding, with a focus on obesity proneness in children (Birch et al., 2001). The construct validity of the CFQ was confirmed using confirmatory factor analysis, which confirmed that the seven-factor model fit the data well (Birch et al., 2001). The reliability of the CFQ has been established in prior studies (Birch et al., 2001; Van Hook & Cheah, 2012). The internal consistency coefficients of the Korean version of the CFQ used in this study ranged from 0.56 to 0.92. Despite the conceptual importance of healthy parental modeling, there are no established measures of this factor. Therefore, we developed healthy parental modeling index from national surveillance data such as National Health and Nutrition Examination Survey (NHANES) to assess lifestyle patterns, including dietary, physical activity, drinking, and smoking habits. Mothers were asked about their own habits as well as their husbands habits. The healthy parental modeling questions about two types of dietary habits (fruits/vegetables and salty snacks consumption) used a 4-point Likert scale (1 = less than once a day and 4 = 5 or more per day). One example of these questions is How often do you eat fruits or vegetables at home? Physical activity items also used a 4-point Likert scale (1 = Less than once a week and 4= 5 or more per week). The questions about drinking and smoking asked about habits both at home and outside the home. One example of smoking question is How many cigarettes per day do you usually smoke at your home? The frequency of drinking was asked using a question How often did you drink any type of alcoholic beverage? Summary scores for healthy parental modeling were dichotomized as indicating healthy and unhealthy modeling. Parents were considered to be doing healthy modeling if they ate vegetables/fruits at least three times per day, ate snacks less than two times a day, exercised more than three times per week, did not smoke, and did not drink alcohol.

35 The child s routines were measured using the Family Nutrition and Physical Activity (FNPA). The FNPA was developed to assess family lifestyles, including the child s routines, which may contribute to childhood obesity (Ihmels et al., 2009). The FNPA contains 20 items and uses a 4-point Likert scale (1=almost never, 2=sometimes, 3=usually, and 4=almost always); possible scores range from 20 to 80. A higher score on the FNPA implies a healthier family lifestyle. The FNPA s construct validity and predictive validity were supported in a longitudinal study (Ihmels et al., 2009). The reliability of the FNPA has been established, with a Cronbach s alpha = 0.72 (Ihmels et al., 2009). The FNPA had never been translated into Korean or used for KA families. Therefore, we translated this instrument and conducted cognitive interviews with KA mothers to confirm the appropriateness and comprehensibility of the translated FNPA in the KA context. Only minor changes were needed. The internal consistency coefficient of the Korean version of the FNPA used in this study was 0.80. Childcare arrangements included types of regular childcare arrangements and the hours of non-parental care per week. Because some children had more than one type of childcare, mothers were asked whether their child had each of four types of care (yes/no), including formal care (preschool or daycare), relative care, informal daycare by a non-relative, and parental care only, creating 5 partially overlapping dichotomous variables. Trained nurse research assistants measured children s body weight to the nearest 0.1 lb. using a portable digital weight scale (Lifesource MD, Milpitas). During weight measurements, children were dressed in light clothing and were not wearing shoes. Children s height was measured to the nearest 0.1 cm. using a portable stadiometer (Seca Stadiometer, Seca Ltd, Birmingham, UK). Ages in years and months of preschoolers were recorded to calculate BMIfor-age values. BMI was calculated as weight in kilograms divided by the square of height in

36 meters. BMI values were transformed into age- and sex-specific BMI z-scores and percentiles using 2000 CDC growth chart data (CDC, 2012). Child s overweight and obesity was defined as BMI-for-age equal to or greater than 85th percentile. In this study, normal weight children refer to children who are underweight (BMI < 5 th percentile) and normal weight (5 th percentile BMI < 85 th percentile). Overweight indicates children who are overweight (85 th percentile BMI < 95 th percentile) and obese (BMI 95 th percentile). 4. Data Analysis Statistical analyses were performed using SPSS version 20.0 and STATA version 12.0 statistical software. Descriptive statistics (percentages, means, and standard deviations) were used to describe the family factors and prevalence of overweight among the KA preschool-age children. To compare characteristics of participants in between the normal weight and overweight child groups, independent t-test and chi-square test were utilized. When the dependent variable was not normally distributed, the Mann-Whitney U test was used. Fisher s exact test was applied when the expected frequency in any cell was less than five. To test our conceptual model, we used hierarchical multiple linear regression to test the effect of each factor on the child s BMI z-score. To estimate the final model, only factors with at least some relationship with BMI z-scores (p <.20) were entered, including perceived child weight, restriction, pressure to eat, monitoring, behavior control, and child s routines. The statistical significance was set at an alpha level of.05. We also examined factors associated with children who were overweight versus those who were not, a way of looking at weight that has more practical relevance. We used multiple logistic regression to examine family factors on overweight status among children with an a priori significance level of p value of <.05.

37 C. Results 1. Bivariate Relationships Between Family Factors and Child Overweight Table 2 shows characteristics of participating KA preschool children in this study. Among children, 22% of them were overweight or obese. Table 3 shows the family characteristics expected to affect preschool children s weight for the total sample and for the children who were overweight or obese compared to those who were not. The first set of factors was the family s background characteristics. Mothers were predominately born in Korea (95 %) and were living with their husbands (97%). The mean length of their stay in the U.S. was 15 years. Approximately 30% of mothers had at least a master s degree, more than half of them (56%) were working outside the home, and about 44% had a family household income of more than $75,000 per year. Mothers had a higher level of Korean identity than American identity. The mean scores of Korean identity were 69.86 (range: 10 to 90), whereas mean American identity scores were 54.53 (range: 10 to 90), indicating a stronger identification with Korean than American culture. None of these factors was significantly related to child s overweight. Family system factors were the next component of the model and included family structure, family functioning, and parental interactions with the child (parental feeding style and parental modeling). In terms of family structure, almost all (97.1%) mothers lived with their spouse or partner. and only 8.7% of them lived in a three-generation household. The majority of mothers (80.8%) had two or more children and almost half of the children (46.6%) had an older sibling. None of these factors was significantly related to the child s weight, but the number of children showed a trend, with overweight children more likely to have two or more siblings (p =.064).

38 Family functioning was measured with seven subscales, including problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, and general functioning. The general functioning subscale had the highest scores and roles had lowest scores. Problem solving, roles, behavior control, and general functioning were negatively related to child s overweight, but none of these relationships were statistically significant. Parental interactions with the child included parental feeding style and healthy parental modeling. Parental feeding style was measured with seven subscales, including perceived responsibility, perceived parent weight, perceived child weight, concern about child weight, restriction, pressure to eat, and monitoring. Among subscales of parental feeding style, perceived child weight (r =.418) and pressure to eat (r = -.244) were significantly related to child s weight. The mean score of overall parental feeding style was 3.43 (range 1 to 5). Participants had lower scores on concern about child weight, perceived child weight, and perceived parent weight, and higher scores on monitoring and perceived responsibility. There was a significant difference in perceived child weight (t = -4.610, p <.001) and pressure to eat (t = 2.551, p =.025) between normal weight and overweight groups. Mothers of overweight children perceived their child to be more overweight than those of normal weight mothers. However, normal weight children s mothers provided more restriction, pressure to eat, and monitoring than those of overweight children s mothers. Another factor was healthy parental modeling. About 76.9% of mothers showed healthy lifestyle role-modeling to their children while mothers reported that 59.2% of fathers did so. Mother modeling and father modeling were significantly correlated (r =.244), but neither of these factors significantly related to the child s weight.

39 The last two factors were child s routines at home and childcare arrangements. The mean score of child routines was 63.28. The majority of children (68.3%) were cared for in formal care settings such as preschools and daycare centers at least part of the time. Twenty three percent of children were cared for their relatives, followed by parental only care (18.4%) and non-relative informal care (e.g., baby sitter) (14.4%). There was a significant difference in formal care (χ 2 = 4.492, p =.034) between normal weight and overweight groups with overweight children more likely to be cared for in formal settings. Although child s routines was not related to child s weight, it was significantly related to healthy mother modeling (r =.223), healthy father modeling (r =.214), perceived responsibility (r =.351), control (r =.210), and monitoring (r =.333). Child s routines were also significantly related to all subscales of family functioning: problem solving (r =.264), communication (r =.353), roles (r =.276), affective responsiveness (r =.321), affective involvement (r =.296), behavior control (r =.297), and general functioning (r =.335). 2. Testing the Conceptual Model: Family Factors and Child s BMI z-score Table 4 shows the results of the hierarchical multiple linear regression to test our conceptual model. Family background and family structure factors were not included in this linear regression model. The KA families had very homogeneous backgrounds. According to the bivariate analysis in the previous section, there were no significant differences in family background factors (level of mother s acculturation, mother s education level, household income, employment status, and length in the U.S) and family structure (number of children, living with both parents, and living with relatives) between the normal weight and overweight groups. Healthy parental modeling was also excluded because these variables had no significant bivariate relationships with child weight.

40 In the first step of hierarchical multiple linear regression, seven subscales of family functioning (problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, and general functioning) were entered. This model was not statistically significant [F (7, 93) =.941; p =.479] and explained only 6.6% of variance in child s BMI z-score. In step two, the seven subscales of parental feeding style (perceived responsibility, perceived parent weight, perceived child weight, concern about child s weight, restriction, pressure to eat, and monitoring) were added. The introduction of parental feeding style explained an additional 23.4% of variance in children s BMI z-score. When these factors were added, the total variance in child s BMI z-score explained by the model as a whole was 30.0%, and this model was statistically significant [F (14, 86) = 2.635; p =.003]. In the third step, formal childcare was entered; this model was statistically significant [F (15, 85) = 2.435; p =.005] and explained 30.1% of variance in child s BMI z-score. In the fourth step, we added child s routines. This model was statistically significant [F (16, 84) = 2.256; p =.009] and explained 30.1% of variance in child s BMI z-score. Perceived child weight (β =.357, p <.001) and behavior control (β = -.271, p =.037) were statistically significant. If mothers perceived their children as more overweight, children were more likely to be obese while if mothers provided more behavior control, their children were less likely to have a high BMI z-score. However, adding formal childcare and the child s routines did not increase the model s explained variance. In the final model, only variables which had p-value less than.20 were entered: affective responsiveness, affective involvement, behavior control, general functioning, perceived child weight, concern about child weight, pressure to eat, and monitoring. This model was statistically

41 significant [F (8, 92) =4.777; p <.001] and explained 29.3% of variance in child s BMI z-score. Behavior control (β = -.246, p =.026), perceived child weight (β =.355, p <.001), pressure to eat (β = -.189, p =.056), and monitoring (β = -.200, p =.043) were statistically significant. Consistent with the conceptual framework, family factors explained 30% of the variance in the children s BMI z-scores in both our complete and final (reduced) hierchical multiple linear regression. Factors related to family feeding style made the greatest contribution to the explained variation. 3. Logistic Regression: Factors Related to Being Overweight Versus Normal Weight We used multiple logistic regression to examine effects of family factors on whether children were overweight or normal weight (Table 5). The model as a whole was statistically significant (χ 2 =.008) and was explained by the fitted model (Pseudo R 2 = 0.326). Among the family factors, the number of children in the family, perceived child weight, pressure to eat, monitoring, behavior control, and child s routines were statistically relate to child s overweight. Children were more likely to be overweight if: a family had more children in their home (OR 2.46, 95% CI 1.20-5.05); the mother perceived her child as overweight (OR 20.03, 95% CI 3.28-122.10); and the family had a regular child s routines (OR 1.10, 95% CI 1.02-1.18). If mother provided more pressure to eat (OR.42, 95% CI.18-.98), monitored more to restrict unhealthy food (OR.55, 95% CI.30-1.02), or expressed and maintained standards for the behavior of children (OR.27, 95% CI.08-.92), the children were less likely to be overweight.

42 D. Discussion The purpose of this study was to explore KA family contexts and examine the relationships between family factors and childhood overweight among KA preschool-age children. In this study, 22% of KA preschool-age children were found to be overweight or obese. The proportion of overweight KA preschool-age children in this study was similar to that reported for KA preschool-age children in U.S. national data (20%) (Jain et al., 2012). This similarity suggests that our small sample reasonably represented KA preschoolers overweight. KA preschool-age children have a lower prevalence of overweight compared to other racial/ethnic groups; in previous studies, 33.1% of Hispanic preschoolers, 28.9% of Non- Hispanic Black preschoolers, and 23.8% of Non-Hispanic White preschoolers were overweight (Ogden, Carroll, Kit, & Flegal, 2012). This study tested a conceptual model based on the Family Systems Theory (FST), which assumes that family members have reciprocal relationships that influence child health. Family factors, including family functioning, parental feeding style, parental modeling, childcare arrangement, and child s routines, explained 30% of the variance in the children s BMI z-scores. Parental feeding style (23.4%) and family functioning (6.6%) were the factors that most contributed to the variance explained in the BMI-z scores. These findings are consistent with a previous study analyzing national surveillance data which found that family-level factors were the main contributing factors and explained 70% of the varience for childhood overweight (Boonpleng et al., 2012). Childcare arrangement and child s routines did not increase the model s explained variance. Our final model (which excluded the non-related variables)

43 explained 29.3% of the variance in the children s BMI z-scores. In this model, behavior control, perceived child s weight, pressure to eat, and monitoring were statistically significant. Consistent with the findings of the linear regression model using the children s BMI z- scores, a multiple logistic regression comparing overweight to non-overweight children identified similar factors. Specifically, a child was more likely to be overweight if the mother perceived her child as being overweight, if the family had more children in the home, or if the child had regular routines. A child was less likely to be overweight if the mother reported higher monitoring of unhealthy food consumption, more restriction of unhealthy food intake, and maintaining standards for the child s behavior. Although family background factors have been associated with children s overweight in prior studies, none of the family background factors was found to be related to children s weight in this study. Because of the homogeneity among the KA families included in the study, such relationships may not be evident. For example, prior studies have found that a lower level of acculturation was associated with an increased risk of childhood overweight in minority groups, but no such relationship was found in this study (Balistreri, 2010; Jiménez-Cruz, Schwartz, Bacardi-Gascon, Heyman, & Wojcicki, 2012). The reason may be that the mothers were highly similar: they were predominantly born in Korea and had a higher level of Korean cultural identification than American cultural identification. The overall mean family functioning score for the KA families in the study was higher than that of Chinese-American families in another study using the same measure (Kennedy & Chen, 2004). In addition, the KA families had lower scores for roles and behavior control subscales than for other family functioning subscales, while Chinese-American families had higher scores for the roles and behavior control subscales. This evidence suggests that different

44 Asian-American subgroups may have different family characteristics. These differences may relate to unique family structures and levels of acculturation. Therefore, future studies should separately examine Asian-American families from different countries of origin whenever possible. In the previous studies, different subscales of family functioning such as general functioning or affective responsiveness have been negatively related to higher scores of BMI of children (Kennedy & Chen, 2004; Moens et al., 2007; Sousa, 2009). That broad idea was confirmed in this study, but in our measure of family functioning only one of the seven subscales, behavior control, was significantly associated with lower children s BMI z-scores; if the family expressed and maintained standards for the behavior of its members, such as having family rules, children were less likely to be overweight. Parental feeding style (perceived child s weight, pressure to eat, and monitoring) was significantly related to children s overweight in the study sample. The mothers perception of children s weight was highly correlated (r = 0.42) with the actual children s weight. Considering that this was a cross-sectional study that measured children s BMI and other variables at one point in time, the direction of the relationship between mothers perceptions of children s weight and actual children s weight is unclear. The general body image held by KA mothers may influence their perceptions of children s weight. In Asian cultures, child overweight is typically regarded as healthy and part of normal child development. These attitudes and preferences toward overweight children are also reported among Hispanic mothers (Nobari et al., 2013; Sosa, 2012). Another study found that KA and Chinese-American mothers evaluated their children as weighing less than the ideal if the mother experienced food insecurity in her childhood (Van

45 Hook & Cheah, 2012). Such attitudes toward children s weight may influence not only parental feeding styles but also mothers misperceptions about children s weight. Many of the KA mothers reported applying pressure to eat, monitoring, and behavior control, and these behaviors were negatively related to children s overweight. These findings are inconsistent with prior research that has reported that if parents monitor and restrict children s food consumption, the children are more likely to be obese (Moens et al., 2007; Rhee, 2008). KA mothers reported relatively little concern about their children s risk of being overweight or their children s weight status, and also reported little concern about their own weight status. However, KA mothers expressed a high level of responsibility for their children s feeding and reported that they closely monitored their children s eating. This may reflect traditional cultural traits; when KA mothers monitor and restrict their children, they are behaving according to the cultural expectations of a good mother, and this attention may have a positive effect on children s eating patterns rather than a negative one. KA mothers high interest in and motivation toward their children s feeding should be considered when developing overweight intervention programs. In this study, a child was more likely to be overweight if the family had more children in the home. One prior study reported that children who had siblings spent more time in physical activities than those without siblings (Bagley, Salmon, & Crawford, 2006). However, how siblings influence a preschool child s physical activity patterns, food consumption, and weight outcomes has not been examined. Further studies should be conducted to examine siblings roles in overweight among preschool-age children. Organizing regular healthy routines is important to shaping healthy environments for children during the preschool-age period. Child s routines, including adequate nighttime sleep

46 and family meals, has been related to a lower prevalence of overweight in prior studies (Anderson & Whitaker, 2010; Carskadon, Wolfson, Acebo, Tzischinsky, & Seifer, 1998; Crawford et al., 2001; Sekine et al., 2002; Sousa, 2009; Spruijt-Metz, 2011). In contrast to these findings, child s routines have a small positive relationship to child s overweight in this study. This study included a relatively small and homogeneous sample, and the KA children may have had similar family environments and routines. In the future, more studies should be conducted with greater numbers and more diverse groups of children and their families to identify how a child s routines relate to child overweight in KA families. Moreover, future studies should explore how child s routines of KAs differ from those of other racial/ethnic groups. The childcare arrangement is a potentially important resource for shaping healthy dietary habits and physical activity patterns among preschool-age children (Robert Wood Johnson Foundation [RWJF], 2011). In this study, about 70% of the preschool-age children were cared for in formal care settings such as preschools and daycare centers. This indicates that formal care settings should be considered as important potential sites for future intervention studies. In addition, KA churches are one of the major resources for social interaction and networking among KAs; more than 70% of KAs attend KA churches (Kim & Wolpin, 2008). Therefore, collaboration with such organizations would be helpful in providing effective interventions to prevent and reduce childhood overweight among KA preschool-age children. E. Limitations There are several limitations in this study. Most KA mother participants were firstgeneration. The small number of second- and third-generation participants, a growing segment of the KA population, may underrepresent U.S.-born KA families. A cross-sectional study that

47 measures children s BMI and other variables at one point in time cannot identify causal relationships between family factors and overweight among preschool-age children. Selfadministered questionnaires were used, and the participants may have provided biased answers because of social desirability issues. Because the convenience sample of study participants was recruited from KA churches and preschools in the Chicago metropolitan area, the findings do not fully represent KA families with preschool-age children living in the U.S. F. Implications KA preschool-age children have a lower rate of overweight than children in general in the U.S. However, this rate is high (22%) and suggests that childhood overweight is a substantial problem in the KA community. Longitudinal studies should be conducted to examine causal relationships between family factors and childhood overweight. Further studies should be conducted to explore KA mothers body image and their weight perceptions about their children, which are significantly related to children s overweight. In terms of clinical implications for future interventions to reduce overweight among young KA children, health care professionals should consider the family as one unit of care and should use this strong social network to implement culturally appropriate childhood overweight prevention for KA preschool-age children. Parental feeding style and child weight perception should be considered when advising KAs about reducing childhood overweight. In addition, KA churches and preschools should be considered as important potential sites for future intervention studies. Furthermore, KA children s physical activity patterns and food intake in formal care settings such as preschools

48 and daycare centers should be measured to fully examine the factors contributing to children s overweight.

49 TABLE III CONCEPTS, OPERATIONAL MEASURES, AND RELIABILITY/VALIDIDITY Concept Operational measures Reliability and validity Acculturation Family functioning Parental feeding style Vancouver Index of Acculturation (VIA) (Ryder, Alden, & Paulhus, 2000) - two subscales (10 items each, 9-point Likert scale, scores 10-90) a. heritage culture b. mainstream culture McMaster Family Assessment Device (FAD) (Epstein, Baldwin, & Bishop, 1983) - self-reporting instrument with seven subscales with Korean-American sample (34 items, 4-point Likert scale) Child Feeding Questionnaire (CFQ) (Birch et al., 2001) - self-reporting instrument with 2 dimensions and 7 subscales (31 items, 5-point Likert scale): a. parents perceptions and concerns regarding child obesity: perceived responsibility (3 items), parent perceived weight (4 items), perceived child weight (6 items), parents concerns about child weight (3 items), b. child-feeding attitudes and practices: restriction (8 items), pressure to eat (4 items), monitoring (3 items) Reliability 1. Original: - heritage (α=0.91-0.92) - mainstream (α=0.85-0.89) 2. Korean-Americans: - heritage (α=0.79-0.85) - mainstream (α=0.83-0.86) 3. In this study - heritage (α=0.82) - mainstream (α=0.92) Validity: concurrent validity established Reliability 1. Original: α=0.72-0.92 2. Korean: α= 0.67-0.78 3. In this study: α=0.66-0.92 Validity: concurrent validity was established Reliability 1. Original: α=0.70-0.92 2. Korean-Americans: α=0.67-0.97 3. In this study: α=0.56-0.92 Validity: construct validity was established

50 Parental modeling Mother s role modeling (healthy dietary habits, including consumption of fruits and vegetables, avoidance of fatty, salty and sweet snacks; parental physical activity patterns (regular moderate exercise); parental smoking and drinking habits Items developed for this study; pretested with KA mothers to establish comprehension and content validity Child s routines Father s role modeling (same questions, reported by mother) Family Nutrition and Physical Activity (FNPA) (Ihmels, Welk, Eisenmann, & Nusser, 2009) - self-reporting instrument with 10 dimensions (4-point Likert): family meal patterns, family eating habits, food choices, beverage choices, restriction/reward, screen time behavior and monitoring, healthy environment, family activity involvement, child activity involvement, family routine * α= Cronbach s α coefficient of internal consistency reliability Reliability: 1. Original: α=0.72 2. In this study: α=0.80 Validity: construct validity and predictive validity were established

51 TABLE IV CHILD WEIGHT CATEGORIES BMI Category Percentage Underweight (< 5 th percentile) 1.9% Normal (5 th - < 85 th percentile) 75.8% Overweight (85 th - < 95 th percentile) 19.4% Obese ( 95 th percentile) 2.9%

52 Characteristic TABLE V FAMILY FACTORS AND CHILD OVERWEIGHT Total (N=104) Normal weight (N=81) Overweight (N=23) p-value Family background First generation 95.2% 95.0% 95.7% NS Mother years in the U.S. (Mean, 15.1 (9.4) 14.7 (9.7) 16.5 (8.7) SD) NS Marital Status (Married) 97.1% 97.5% 95.7% NS Mother s education More than bachelor 29.8% 28.7% 30.4% NS Mother s employment Working 55.8% 57.5% 52.2% NS Family income (per year) < 40,000 21.8% 23.7% 17.4% 40,000-75000 34.7% 32.9% 39.1% NS >75,000 43.5% 43.4% 43.5% Mother s acculturation (Mean, SD) Heritage Mainstream 69.86 (10.82) 54.53 (17.09) 69.49 (10.89) 54.30 (16.46) 71.13 (10.95) 55.04 (19.79) Family system Family structure Living with spouse or partner 97.1% 96.3% 100.0% NS Living with relatives 8.7% 8.8% 8.7% NS Number of children in family One Two Three or more Family functioning (Mean, SD) Family Assessment Device (FAD) 19.2% 62.5% 18.3% 3.10 (0.35) 22.5% 61.3% 16.2% 3.10 (0.36) 8.7% 65.3% 26.0% 3.08 (0.27) NS.064 Problem solving Communication Roles Affective responsiveness Affective involvement Behavior control General functioning* Family interaction (Mean, SD) Parental feeding style (CFQ) 3.17 (0.48) 3.10 (0.49) 2.76 (0.43) 3.20 (0.53) 3.16 (0.53) 3.02 (0.46) 3.26 (0.44) 3.43 (0.38) 3.18 (0.52) 3.12 (0.51) 2.77 (0.46) 3.18 (0.56) 3.13 (0.56) 3.04 (0.49) 3.26 (0.45) 3.44 (0.40) 3.13 (0.31) 3.03 (0.44) 2.73 (0.31) 3.23 (0.41) 3.21 (0.44) 2.93 (0.32) 3.26 (0.42) 3.38 (0.34) NS NS Perceived responsibility* Perceived parent weight 4.44 (0.60) 2.96 (0.39) 4.43 (0.63) 2.93 (0.40) 4.45 (0.53) 3.08 (0.32) NS.119

53 Perceived child weight* Concern about child weight Restriction* Pressure to eat* Monitoring Parental modeling Mother modeling (good) 2.91 (0.48) 2.48 (1.03) 3.58 (0.75) 3.47 (0.76) 4.01 (0.95) 2.80 (0.44) 2.48 (1.07) 3.60 (0.75) 3.57 (0.71) 4.08 (0.95) 3.28 (0.41) 2.51 (0.91) 3.47 (0.73) 3.14 (0.87) 3.77 (0.93) <.001 NS NS.025.178 Father modeling (good) 76.9% 59.2% 73.8% 62.0% 87.0% 52.2% NS NS Child s routines* (Mean, SD) 63.28 (7.46) 63.09 (7.75) 63.48 (6.28) NS Childcare Type of childcare Parental only Relative care Non-relative informal care Formal care (e.g., preschool) 18.4% 23.1% 14.4% 68.3% 18.8% 21.3% 17.5% 63.7% 13.0% 30.4% 4.3% 87.0% Fisher s exact test * Mann-Whitney U P values from chi-square or independent t-test, testing for differences between non-obese and overweight group NS.358.180.034

54 TABLE VI HIERARCHICAL MULTIPLE LINEAR REGRESSION Variables Model 1 a Model 2 b Model 3 c Model 4 d Final Model Intercept 1.355.560.438.404.192 Family functioning a Problem solving Communication Roles Affective responsiveness Affective involvement Behavior control General functioning.047.002 -.099.233.163 -.269* -.203.022.023 -.063.173.210 -.268* -.181.021.026 -.066.176.208 -.268* -.175.023.024 -.067.175.209 -.271* -.176 Parental feeding style b Perceived responsibility Perceived parent weight Perceived child weight Concern about child weight Restriction Pressure to eat Monitoring.001 -.045.355**.151.061 -.225* -.205 -.002 -.041.357**.155.058 -.220 -.208 -.002 -.040.357**.153.059 -.220 -.210.156.174 -.246* -.154.355**.160 -.189* -.200* Formal childcare c.022.023 Child s routines d.008 R 2.066.300.301.301.293 R 2 change.234.001.000 Sig F. Change.001.830.950 * p<.05 **p<.01

55 TABLE VII MULTIPLE LOGISTIC REGRESSION OF CHILDHOOD OVERWEIGHT Variables OR 95% CI Lower Upper Number of children in family 2.460* 1.199 5.046 Family functioning Behavior control.270*.079.919 Feeding Style Perceived child weight Restriction Pressure to eat Monitoring 20.025** 1.253.424*.552* 3.284.663.184.300 122.103 2.367.977 1.015 Child s routines 1.095* 1.018 1.179 OR: Odds Ratio, CI: Confidence Interval * p<.05 **p<.01

56 FIGURE II FAMILY SYSTEM AND PRESCHOOL-AGE CHILD OVERWEIGHT: CONCEPTUAL MODEL

CITED LITERATURE Aarons, G. A., McDonald, E. J., Connelly, C. D., & Newton, R. R. (2007). Assessment of family functioning in Caucasian and Hispanic Americans: Reliability, validity, and factor structure of the Family Assessment Device. Family process, 46(4), 557 569. Anderson, S. E., & Whitaker, R. C. (2010). Household routines and obesity in US preschoolaged children. Pediatrics, 125(3), 420 428. doi:10.1542/peds.2009-0417 Asian and Pacific Islander American Health Forum. (2012). Opportunities and Challenges in the Affordable Care Ac t for Asian American, Native Hawaiian, and Pacific Islander Small Businesses. Bagley, S., Salmon, J., & Crawford, D. (2006). Family structure and children s television viewing and physical activity. Medicine & Science in Sports & Exercise. Balistreri, K. S.. B. E.. & H. J. V. (2010). Generation, acculturation and weight: Obesity among the children of immigrants.. Retrieved from http://papers.ccpr.ucla.edu/papers/pwp- BGSU-2012-001/PWP-BGSU-2012-001.pdf Barnes, P. M., Adams, P. F., & Powell-Griner, E. (2008). Health characteristics of the Asian adult population: United States, 2004-2006. Advance data from vital and health statistics; no 394. Advance data (pp. 1 22). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18271366 Behling, O., & Law, K. S. (2000). Translating questionnaires and other research instruments. Thousand Oaks: Sage Publications. Berenson, G. S., & Heart, B. (2012). Health consequences of obesity, (September 2011), 117 121. doi:10.1002/pbc Berge, J. M. (2009). A review of familial correlates of child and adolescent obesity: what has the 21st century taught us so far? International journal of adolescent medicine and health, 21(4), 457 83. Birch, L.. L., Fisher, J.. O., Grimm-Thomas, K., Markey, C.. N., Sawyer, R., & Johnson, S.. L. (2001). Confirmatory factor analysis of the Child Feeding Questionnaire: a measure of parental attitudes, beliefs and practices about child feeding and obesity proneness. Appetite, 36(3), 201 10. doi:10.1006/appe.2001.0398 Boonpleng, W., Park, C. G., & Gallo, A. M. (2012). Timing of adiposity rebound: a step toward preventing obesity. Pediatric nursing, 38(1), 37 42.

58 Bowen, M. (1966). The use of family theory in clinical practice. Comprehensive Psychiatry, 7(5), 345 374. Retrieved from http://www.sciencedirect.com/science/article/pii/s0010440x66800652 Carskadon, M. A., Wolfson, A. R., Acebo, C., Tzischinsky, O., & Seifer, R. (1998). Adolescent sleep patterns, circadian timing, and sleepiness at a transition to school days. Sleep.21(8),871-881. Center for Disease Control and Prevention [CDC]. (2012). Basics about childhood obesity: How is childhood overweight and obesity measured? Retrieved from http://www.cdc.gov/obesity/childhood/basics.html Chen, A. Y., & Escarce, J. J. (2010). Family structure and childhood obesity, early childhood longitudinal study - kindergarten cohort. Preventing chronic disease, 7(3), A50. Chen, L., Juon, H.-S., & Lee, S. (2012). Acculturation and BMI among Chinese, Korean and Vietnamese adults. Journal of community health, 37(3), 539 46. doi:10.1007/s10900-011- 9476-1 Chibucos, T. R., Leite, R. W., & Weis, D. L. (2005). Readings in family theory. Thousand Oaks: Sage Publications. Cho, J., & Juon, H. S. (2006). Assessing overweight and obesity risk among Korean Americans in California using World Health Organization body mass index criteria for Asians. Public Health Research, Practice, and Policy, 3(3), 1 11. Choi, J., Miller, A., & Wilbur, J. (2009). Acculturation and depressive symptoms in Korean immigrant women. Journal of immigrant and minority health / Center for Minority Public Health, 11(1), 13 19. doi:10.1007/s10903-007-9080-8 Chung, S. K. (1993). A study on the effectiveness of family functioning by the duration of schizophrenia. Journal of Korean Family Therapy, 1, 121 136. Crawford, P. B., Story, M., Wang, M. C., Ritchie, L. D., & Sabry, Z. I. (2001). Ethnic issues in the epidemiology of childhood obesity. Pediatric clinics of North America, 48(4), 855 878. doi:10.1016/s0031-3955(05)70345-x Daniels, S. R. (2006). The consequences of childhood overweight and obesity. The Future of children / Center for the Future of Children, the David and Lucile Packard Foundation, 16(1), 47 67. Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (1983). The McMaster family assessment device. Journal of Marital and Family Therapy, 9(2), 171 180. doi:10.1111/j.1752-0606.1983.tb01497.x

59 Farver, J. A., & Lee-Shin, Y. (2000). Acculturation and Korean-American children s social and play behavior. Social Development, 9(3), 316 336. Fox, E. A., & Kumanyika, S. K. (2008). Environmental influences on childhood obesity: Ethnic and cultural influences in context. Physiology & Behavior, 94(1), 61 70. Gibson, L. Y., Byrne, S. M., Davis, E. A., Blair, E., & et al. (2007). The role of family and maternal factors in childhood obesity. Medical Journal of Australia, 186(11), 591 595. Golan, M., & Weizman, A. (2001). Familial approach to the treatment of childhood obesity: conceptual model. Journal of Nutrition Education, 33(2), 102 107. Gruber, K. J., & Haldeman, L. A. (2009). Using the family to combat childhood and adult obesity. Preventing chronic disease, 6(3), A106. Herman, A. N., Malhotra, K., Wright, G., Fisher, J. O., & Whitaker, R. C. (2012). A qualitative study of the aspirations and challenges of low-income mothers in feeding their preschoolaged children. The international journal of behavioral nutrition and physical activity, 9(1), 132. doi:10.1186/1479-5868-9-132 Hong, J. J., & Hong, S. (1996). The Korean American family: assimilation and its toll on the first and second generation relationship. ERIC Institute of Education Sciences, 1 19. Retrieved from http://eric.ed.gov/?id=ed401348 Huffman, F. G., Kanikireddy, S., & Patel, M. (2010). Parenthood--a contributing factor to childhood obesity. International journal of environmental research and public health, 7(7), 2800 2810. Ihmels, M., Welk, G., Eisenmann, J., & Nusser, S. (2009). Development and preliminary validation of a Family Nutrition and Physical Activity (FNPA) screening tool. International Journal of Behavioral Nutrition and Physical Activity, 6(1), 14. Ike-Chinaka, C. G. (2013). Acculturation and childhood obesity among immigrant Nigerian children in northern California. Interdisciplinary Journal of Contemporary Research in Business, 4(10), 892 917. Jain, A., Mitchell, S., Chirumamilla, R., Zhang, J., Horn, I. B., Lewin, A., & Huang, Z. J. (2012). Prevalence of obesity among young Asian-American children. Childhood Obesity, 8(6), 518-525. doi: 10.1089/chi.2011.0077. Jang, Y., & Chiriboga, D. A. (2010). Living in a different world: acculturative stress among Korean American elders. The journals of gerontology. Series B, Psychological sciences and social sciences, 65B(1), 14 21. doi:10.1093/geronb/gbp019 Jiménez-Cruz, A., Schwartz, N., Bacardi-Gascon, M., Heyman, M. B., & Wojcicki, J. M. (2012). Acculturation, dietary practices and risk for childhood obesity in an ethnically

60 heterogeneous population of Latino school children in the San Francisco bay area. Journal of Immigrant and Minority Health, 14(4), 533-539. doi:10.1007/s10903-011-9553-7 Johnson, S. L., & Birch, L. L. (1994). Parents and children's adiposity and eating style. Pediatrics, 94(5), 653 661. Kang, H.-T., Ju, Y.-S., Park, K.-H., Kwon, Y.-J., Im, H.-J., Paek, D.-M., & Lee, H.-J. (2006). Study on the relationship between childhood obesity and various determinants, including socioeconomic factors, in an urban area. Journal of preventive medicine and public health = Yebang Uihakhoe chi, 39(5), 371 378. Kennedy, C., & Chen, J.-L. (2004). Family functioning, parenting style, and Chinese children s weight status. Journal of Family Nursing. doi:10.1177/1074840704264021 Kim, E., & Wolpin, S. (2008). The Korean American family: Adolescents versus parents acculturation to American culture. Journal of cultural diversity, 15(3), 108 16. Kim, Y. &, & Grant, D. (1997). Immigration patterns, social support, and adaptation among Korean immigrant women and Korean American women. Cultural Diversity and Mental Health,, 3(4), 235 245. Kitzman-Ulrich, H., Wilson, D. K., St George, S. M., Lawman, H., Segal, M., & Fairchild, A. (2010). The integration of a family systems approach for understanding youth obesity, physical activity, and dietary programs. Clinical child and family psychology review, 13(3), 231 253. doi:10.1007/s10567-010-0073-0 Korean Natonal Health and Nutrition Examination Survey [KNHANES]. (2011). 2010 National health report. Retrieved from http://knhanes.cdc.go.kr/knhanes/index.do Lee, S.. K., Sobal, J., & Frongillo, E. A. (2000). Acculturation and health in Korean Americans. Social science & medicine, 51(2), 159 173. doi:10.1016/s0277-9536(99)00446-3 Lee, W. (1995). Child care and parental beliefs in Korean-Americans. Doctoral dissertation. Utah State University. Liamputtong, P. (2006). Motherhood and moral career : discourses of good motherhood among Southeast Asian immigrant women in Australia. Qualitative Sociology, 29(1), 25 53. doi:10.1007/s11133-005-9006-5 Lindsay, A. C., Sussner, K. M., Greaney, M. L., & Peterson, K. E. (2011). Latina mothers beliefs and practices related to weight status, feeding, and the development of child overweight. Public health nursing, 28(2), 107 18. doi:10.1111/j.1525-1446.2010.00906.x Maher, E. J., Li, G., Carter, L., & Johnson, D. B. (2008). Preschool child care participation and obesity at the start of kindergarten. Pediatrics, 122(2), 322 330. doi:10.1542/peds.2007-2233

61 McAdoo, H. P., Martinez, E. A., & Hughes, H. (2005). Ecological changes in ethnic families of color. In Sourcebook of family theory and research. Thousa: Sage Publications. McCurdy, L. E., Winterbottom, K. E., Mehta, S. S., & Roberts, J. R. (2010). Using nature and outdoor activity to improve children s health. Current problems in pediatric and adolescent health care, 40(5), 102 17. doi:10.1016/j.cppeds.2010.02.003 McGarvey, E. L., Collie, K. R., Fraser, G., Shufflebarger, C., Lloyd, B., & Norman Oliver, M. (2006). Using focus group results to inform preschool childhood obesity prevention programming. Ethnicity & health, 11(3), 265 85. doi:10.1080/13557850600565707 Miller, I. W., Epstein, N. B., Bishop, D. S., & Keitner, G. I. (1985). The McMaster family assessment device: Reliability and validity. Journal of Marital and Family Therapy, 11(4), 345 356. doi:10.1111/j.1752-0606.1985.tb00028.x Moens, E., Braet, C., & Soetens, B. (2007). Observation of family functioning at mealtime: A comparison between families of children with and without overweight. Journal of pediatric psychology, 32(1), 52 63. doi:10.1093/jpepsy/jsl011 Moon, S. Y. (2012). Cultural perspectives on attention deficit hyperactivity disorder: A comparison between Korea and the U.S. Journal of International Business and Cultural Studies. Retrieved from http://www.aabri.com/manuscripts/11898.pdf Morgan, D. L. (1998). Why should you use focus groups? In The focus group guidebook. Thousand Oaks: Sage publications. Nobari, T. Z., Wang, M.-C., Chaparro, M. P., Crespi, C. M., Koleilat, M., & Whaley, S. E. (2013). Immigrant enclaves and obesity in preschool-aged children in Los Angeles County. Social science & medicine (1982), 92, 1 8. doi:10.1016/j.socscimed.2013.05.019 Ogden, C. L., Carroll, M. D., Curtin, L. R., Lamb, M. M., & Flegal, K. M. (2010). Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA : the journal of the American Medical Association, 303(3), 242 249. doi:10.1001/jama.2009.2012 Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2012). Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA : the journal of the American Medical Association, 307(5), 483 90. doi:10.1001/jama.2012.40 Patrick, H., & Nicklas, T. A. (2005). A review of family and social determinants of children s eating patterns and diet quality. Journal of the American College of Nutrition, 24(2), 83 92. doi:10.1080/07315724.2005.10719448 Patrick, H., Nicklas, T. A., Hughes, S. O., & Morales, M. (2005). The benefits of authoritative feeding style: caregiver feeding styles and children s food consumption patterns. Appetite, 44(2), 243 249. doi:10.1016/j.appet.2002.07.001

62 Pearce, A., Li, L., Abbas, J., Ferguson, B., Graham, H., & Law, C. (2010). Is childcare associated with the risk of overweight and obesity in the early years? findings from the UK millennium cohort study. International journal of obesity (2005), 34(7), 1160 1168. Peña, M.-M., Dixon, B., & Taveras, E. M. (2012). Are you talking to ME? The importance of ethnicity and culture in childhood obesity prevention and management. Childhood obesity (Print), 8(1), 23 7. doi:10.1089/chi.2011.0109 Rhee, K. (2008). Childhood overweight and the relationship between parent behaviors, parenting style, and family functioning. The Annals of the American Academy of Political and Social Science, 615(1), 11 37. doi:10.1177/0002716207308400 Robert Wood Johnson Foundation [RWJF]. (2011). Preventing obesity among preschool children: How can child-care settings promote healthy eating and physical activity? Retrieved from http://www.rwjf.org/content/dam/farm/reports/reports/2011/rwjf71500 Ryder, A. G., Alden, L. E., & Paulhus, D. L. (2000). Is acculturation unidimensional or bidimensional? A head-to-head comparison in the prediction of personality, self-identity, and adjustment. Journal of personality and social psychology, 79(1), 49 65. doi:10.1037/0022-3514.79.1.49 Salsberry, P. J., & Reagan, P. B. (2005). Dynamics of early childhood overweight. Pediatrics, 116(6), 1329 1338. Sandelowski, M. (2000). Focus on research methods whatever happened to qualitative description? Research in Nursing & Health, 23, 334 340. Schwartz, M. B., & Puhl, R. (2003). Childhood obesity: A societal problem to solve. Obesity reviews : an official journal of the International Association for the Study of Obesity, 4(1), 57 71. Schwimmer, J. B., Burwinkle, T. M., & Varni, J. W. (2003). Health-related quality of life of severely obese children and adolescents. JAMA : the journal of the American Medical Association, 289(14), 1813 9. doi:10.1001/jama.289.14.1813 Sekine, M., Yamagami, T., Handa, K., Saito, T., Nanri, S., Kawaminami, K., Kagamimori, S. (2002). A dose-response relationship between short sleeping hours and childhood obesity: Results of the Toyama Birth Cohort Study. Child: care, health and development, 28(2), 163 70. Sheslow, D., Hassink, S., Wallace, W., & DeLancey, E. (1993). The relationship between selfesteem and depression in obese children. Annals of the New York Academy of Sciences, 699, 289 291.

63 Skelton, J. A., Irby, M. B., Miller, G., & Grzywacz, J. G. (2011). Etiologies of obesity in children: nature and nurture. Pediatric Clinics of North America. doi:10.1016/j.pcl.2011.09.006 Slusser, W., Frankel, F., Robison, K., Fischer, H., Cumberland, W. G., & Neumann, C. (2012). Pediatric overweight prevention through a parent training program for 2-4 year old Latino children. Childhood obesity (Print), 8(1), 52 9. doi:10.1089/chi.2011.0060 Sohng, S. L., & Song, K. (2004). Korean children and families. In Culturally competent practice with immigrant and refugee children and families (pp. 81 99). Sosa, E. T. (2012). Mexican American mothers perceptions of childhood obesity: A theoryguided systematic literature review. Health education & behavior : the official publication of the Society for Public Health Education, 39(4), 396 404. doi:10.1177/1090198111398129 Sousa, A. D. (2009). Maternal, child and family factors in childhood obesity. International Journal of Diabetes & Metabolism, 17, 111 114. Spruijt-Metz, D. (2011). Etiology, treatment and prevention of obesity in childhood and adolescence: A decade in review. Journal of research on adolescence : the official journal of the Society for Research on Adolescence, 21(1), 129 152. doi:10.1111/j.1532-7795.2010.00719.x Taveras, E. M., Gillman, M. W., Kleinman, K., Rich-Edwards, J. W., & Rifas-Shiman, S. L. (2010). Racial/ethnic differences in early-life risk factors for childhood obesity. Pediatrics, 125(4), 686 95. doi:10.1542/peds.2009-2100 Tibbs, T., Haire-Joshu, D., Schechtman, K. B., Brownson, R. C., Nanney, M. S., Houston, C., & Auslander, W. (2001). The relationship between parental modeling, eating patterns, and dietary intake among African-American parents. Journal of the American Dietetic Association, 101(5), 535 541. doi:10.1016/s0002-8223(01)00134-1 Trasande, L., & Chatterjee, S. (2009). The impact of obesity on health service utilization and costs in childhood. Obesity (Silver Spring), 17, 1749 1754. doi:oby200967 [pii]\n10.1038/oby.2009.67 [doi] Unger, J.B., Reynolds, K., Shakib, S, Spruijt-Metz, D., Sun, P., & Johnson, A. (2004). Acculturation, physical activity, and fast-food consumption among Asian-American and Hispanic adolescents. Journal of Community Nursing, 29(6), 467 481. United Census Bureau. (2012). The Asian Population : 2010 (pp. 1 24). Retrieved from http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid =ACS_10_1YR_B02006&prodType=table

64 United States Census Bureau. (2013). Facts for features: Asian/Pacific American heritage month: May 2013 - Facts for Features & Special Editions - Newsroom - U.S. Census Bureau. Retrieved November 12, 2013, from http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb1 3-ff09.html Van Hook, J., & Cheah, C. S. L. (2012). Chinese and Korean immigrants early life deprivation: An important factor for child feeding practices and children s body weight in the United States. Social Science & Medicine. doi:10.1016/j.socscimed.2011.10.040 Vos, M. B., & Welsh, J. (2010). Childhood obesity: update on predisposing factors and prevention strategies. Current gastroenterology reports, 12(4), 280 287. Wells, J. C. K. (2007). Commentary: why are South Asians susceptible to central obesity?--the El Niño hypothesis. International journal of epidemiology, 36(1), 226 7. doi:10.1093/ije/dyl287 Whitaker, R. C., Pepe, M. S., Wright, J. A., Seidel, K. D., & Dietz, W. H. (1998). Early adiposity rebound and the risk of adult obesity. Pediatrics, 101(3), E5. doi:10.1542/peds.101.3.e5 Wofford, L. G. (2008). Systematic review of childhood obesity prevention. Journal of pediatric nursing, 23(1), 5 19. doi:10.1016/j.pedn.2007.07.006 Wong, O. L. (2011). Gendered power in eating habits: insight into childhood obesity in a Chinese family context. Journal of Family Therapy, 33(3), 332 352. doi:10.1111/j.1467-6427.2011.00536.x World Health Organization [WHO] Expert Consultation. (2004). Public health appropriate bodymass index for Asian populations and its implications for policy and intervention strategies. Lancet, 363(9403), 157 163. doi:10.1016/s0140-6736(03)15268-3 Zhou, M. (1997). Growing up American : The challenge confronting immigrant children and children of immigrants Annual Review of Sociology, 23(1997), 63 95. doi:10.1146/annurev.soc.23.1.63

APPENDICES

66 APPENDIX A University of Illinois at Chicago Institutional Review Board Notice of Determination of Human Subject Research March 20, 2013 So Hyun Park Women, Child, & Family Health Science Women, Children, and Family Sciences 845 S Damen, M/C 802 Chicago, IL 60661 Phone: (312) 996-2270 / Fax: (312) 996-8945 Approval Notice Initial Review (Response To Modifications) RE: Protocol # 2013-0156 Family Influences and Healthy Weight for Korean-American Preschool Children Dear Ms. Park: Your Initial Review application (Response To Modifications) was reviewed and approved by the Expedited review process on March 19, 2013. You may now begin your research Please note the following information about your approved research protocol: Protocol Approval Period: March 19, 2013 - March 19, 2014 Approved Subject Enrollment #: 505 Additional Determinations for Research Involving Minors: The Board determined that this research satisfies 45CFR46.404, research not involving greater than minimal risk. Therefore, in accordance with 45CFR46.408, the IRB determined that only one parent's/legal guardian's permission/signature is needed. Wards of the State may not be enrolled unless the IRB grants specific approval and assures inclusion of additional protections in the research required under 45CFR46.409. If you wish to enroll Wards of the State contact OPRS and refer to the tip sheet. Performance Sites: UIC, Korean Martyrs' Catholic Church - Chicago Sponsor: Chancellor's Graduate Research Fellowship

67 PAF#: Not applicable Grant/Contract No: Not applicable Grant/Contract Title: Not applicable Research Protocol: a) Research Protocol; Version 1; 02/15/2013 Recruitment Materials: a) Research Flyer (English); Version 1; 02/15/2013 b) Recruitment Script for Focus Group Interview (English); Version 1; 02/15/2013 c) Recruitment Script for Survey and Child Measurement (English); Version 1; 02/15/2013 d) Recruitment Script for Cognitive Interview (English); Version 1; 02/15/2013 e) Research Flyer (Korean); Version 1; 03/13/2013 f) Announcement Script for Cognitive Interviews (English); Version 1; 03/13/2013 g) Announcement Script for Survey and Child Measurement (English); Version 1; 03/13/2013 h) Recruitment Script for Focus Group Interview (Korean); Version 1; 03/13/2013 i) Announcement Script for Focus Group Interviews (English); Version 1; 03/13/2013 Informed Consents: a) Focus Group Interview Consent (English); Version 1; 02/15/2013 b) Cognitive Interview Consent (English); Version 1; 02/15/2013 c) Focus Group Interview Consent (Korean); Version 1; 03/13/2013 d) A waiver of informed consent for the collection of identifiable data from the mother about the mother subject's partner has been granted under 45 CFR 46.116(d) for this research (minimal risk; collection of secondary parenting data from the mother) e) An alteration of consent and waiver of documentation of informed consent for recruitment/screening purposes only has been granted under 45 CFR 46.116(d) and 45 CFR 46.117(c)(2) (minimal risk; written consent/permission will be obtained from mother at enrollment) Assent: a) A waiver of child assent for the collection of data from mothers about and measurements from their infants has been granted under 45 CFR 46.116(d) (minimal risk; written permission obtained from mother; impracticable to obtain assent from infants) Parental Permission: a) Survey and Child Measurement Consent/Permission (English); Version 1; 02/15/2013 Your research meets the criteria for expedited review as defined in 45 CFR 46.110(b)(1) under the following specific categories: (4) Collection of data through noninvasive procedures (not involving general anesthesia or sedation) routinely employed in clinical practice, excluding procedures involving X-rays or microwaves. Where medical devices are employed, they must be cleared/approved for marketing. (Studies intended to evaluate the safety and effectiveness of the medical device are not generally eligible for expedited review, including studies of cleared medical devices for new indications.)

68 Examples: (a) physical sensors that are applied either to the surface of the body or at a distance and do not involve input of significant amounts of energy into the subject or an invasion of the subject's privacy; (b) weighing or testing sensory acuity; (c) magnetic resonance imaging; (d) electrocardiography, electroencephalography, thermography, detection of naturally occurring radioactivity, electroretinography, ultrasound, diagnostic infrared imaging, doppler blood flow, and echocardiography; (e) moderate exercise, muscular strength testing, body composition assessment, and flexibility testing where appropriate given the age, weight, and health of the individual, (6) Collection of data from voice, video, digital, or image recordings made for research purposes., (7) Research on individual or group characteristics or behavior (including but not limited to research on perception, cognition, motivation, identity, language, communication, cultural beliefs or practices and social behavior) or research employing survey, interview, oral history, focus group, program evaluation, human factors evaluation, or quality assurance methodologies. Please note the Review History of this submission: Receipt Date Submission Type Review Process Review Date Review Action 02/15/2013 Initial Review Expedited 02/18/2013 Modifications Required 03/13/2013 Response To Modifications Expedited 03/19/2013 Approved Please remember to: Use your research protocol number (2013-0156) on any documents or correspondence with the IRB concerning your research protocol. Review and comply with all requirements on the enclosure, "UIC Investigator Responsibilities, Protection of Human Research Subjects" (http://tigger.uic.edu/depts/ovcr/research/protocolreview/irb/policies/0924.pdf) Please note that the UIC IRB has the prerogative and authority to ask further questions, seek additional information, require further modifications, or monitor the conduct of your research and the consent process. Please be aware that if the scope of work in the grant/project changes, the protocol must be amended and approved by the UIC IRB before the initiation of the change. We wish you the best as you conduct your research. If you have any questions or need further help, please contact OPRS at (312) 996-1711 or me at (312) 996-2014. Please send any correspondence about this protocol to OPRS at 203 AOB, M/C 672. Sincerely, Sandra Costello

69 Subjects Assistant Director, IRB # 2 Office for the Protection of Research Enclosures: 1. UIC Investigator Responsibilities, Protection of Human Research Subjects 2. Informed Consent Documents: a) Focus Group Interview Consent (English); Version 1; 02/15/2013 b) Cognitive Interview Consent (English); Version 1; 02/15/2013 c) Focus Group Interview Consent (Korean); Version 1; 03/13/2013 3. Parental Permission: a) Survey and Child Measurement Consent/Permission (English); Version 1; 02/15/2013 4. Recruiting Materials: a) Research Flyer (English); Version 1; 02/15/2013 b) Recruitment Script for Focus Group Interview (English); Version 1; 02/15/2013 c) Recruitment Script for Survey and Child Measurement (English); Version 1; 02/15/2013 d) Recruitment Script for Cognitive Interview (English); Version 1; 02/15/2013 e) Research Flyer (Korean); Version 1; 03/13/2013 f) Announcement Script for Cognitive Interviews (Engish); Version 1; 03/13/2013 g) Announcement Script for Survey and Child Measurement (English); Version 1; 03/13/2013 h) Recruitment Script for Focus Group Interview (Korean); Version 1; 03/13/2013 i) Announcement Script for Focus Group Interviews (English); Version 1; 03/13/2013 cc: Barbara McFarlin, Women, Child, & Family Health Science, M/C 802 Kathleen F. Norr (faculty advisor), Women, Child & family Health Science, M/C 802

Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 70 APPENDIX B Research Flyer (English) Family Influences and Healthy Weight for Korean-American Preschool Children Volunteers are Needed for a Research: Healthy Preschoolers in the Korean American Community The College of Nursing at the University of Illinois at Chicago is researching how families keep their preschoolers healthy. We are seeking Korean-American mothers who have a child aged 2 to 5 for a research. Please tell us about how you are bringing up your preschool child to be healthy! You are eligible for the research if you are a Korean-American mother, you live with your child aged 2 to 5, and you have lived in the United States at least 5 years If you decide to participate in the research, you will: Complete a survey that will take less than one hour Allow us to measure the weight, height, waist/arm circumference, and abdominal/arm skinfold of your child All participants who complete the research will receive a $10 Target gift card If you are interested in this research please contact So Hyun Park, MSN, RN Telephone: 312-996-2270 E-mail: spark224@uic.edu

Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 Korean-American Preschooler Research 312-996-2270 71 APPENDIX B Research Flyer (Korean) 한인미취학아동의건강체중에미치는가족의영향 한인미취학아동의건강연구를위한 연구참가자를모집합니다 UIC 간호대학에서는한인미취학아동의건강에대한연구를진행중입니다. 2-5 세의자녀와함께거주하는어머니들의협조를부탁드립니다. 한인미취학아동을건강하게키우는것에대해이야기해주세요! 귀하께서미국에서 5 년이상거주하시고, 2-5 세자녀와함께거주하고계신어머니이시면본연구에참여가능합니다 본연구에참여하시게되면 : 1 시간정도소요되는설문지를작성하시고 연구자가미취학자녀의키와몸무게, 허리둘레와팔둘레, 복부와팔피하지방두께를측정하게됩니다 연구에참여하시는분들께타겟상품권 ($10) 을드립니다 본연구에관심이있으신분들은연구책임자박소현 ( 아래의번호 ) 에게연락주십시오 Telephone: 312-996-2270 E-mail: spark224@uic.edu APPENDIX C

72 APPENDIX C Informed Consent Form for Focus Group Interview (English) University of Illinois at Chicago Research Information and Focus Group Interview Consent Family Influences and Healthy Weight for Korean-American Preschool Children You are being asked to participate in a research study. Researchers are required to provide a consent form such as this one to tell you about the research, to explain that taking part is voluntary, to describe the risks and benefits of participation, and to help you to make an informed decision. You should feel free to ask the researchers any questions you may have. Principal Investigator (PI) Name and Title: So Hyun Park, MSN, RN, Doctoral Candidate Department and Institution: College of Nursing, University of Illinois at Chicago Address and Contact Information: 845 S. Damen Avenue, Chicago, IL, 60612. 312-996-2270, spark224@uic.edu Why am I being asked? You are being asked to be part of a group discussion about family and healthy weight for preschoolers in the Korean-American (KA) community. This study will discuss by So Hyun Park a doctoral candidate in the College of Nursing at the University of Illinois at Chicago (UIC). You have been asked to participate in the research because you are a Korean American mother with a child between ages 2-5. Participating in this research is voluntary. Your decision of whether or not to participate will not affect your current or future dealings with UIC. If you decide to participate, you are free to withdraw at any time without affecting that relationship. During the research study, focus group interviews will be held with groups of 5 to 12 KA mothers. The total maximum number of focus group interview participants is 25. What is the purpose of this research? The purpose of this study is to examine family influences on healthy weight among KA preschool-age children. What procedures are involved? You will discuss regarding bringing up children in the Korean American community in a group with 5-12 mothers. One of the topics we ll discuss is the growing trend for even young children to be overweight and how this is viewed in your community. The PI and a research assistant will lead the focus group interviews. The interview sessions will be audio-taped, transcribed, and analyzed. What are the potential risks and discomforts? To the best of our knowledge, the things you will be doing pose no more risk of harm than you would experience in everyday life. Minimal risks are expected from participation in the study,

73 and no physical risks are associated with any of the procedures in the study. You may have some discomforts in thinking and talking about your family and relationships. There is also a risk of saying something in the group that you don t want others to know. Although we will ask everyone in the group to not discuss what other people say outside the group, we have no way to control this. You should not say anything in the group that you would not want others to repeat. You can decline to answer any question that you are not comfortable with, and you can withdraw from the study at any time. Are there benefits to taking part in the research? You will not directly benefit from participation in the research. However, we hope to learn new things about KA families and young children s healthy weight among their children. The findings of this study can provide better understanding of KA families and can identify factors influencing healthy weight among KA preschool-age children. Thus, the findings can be used to develop a culturally appropriate intervention to improve preschool children s health in the KA community. What other options are there? You have the option to not participate in this study. You can withdraw from the study at any time. What about privacy and confidentiality? Information about you will be disclosed to others only with your written permission or if necessary to protect your rights or welfare or if required by law. Before the group discussion starts we will remind everyone not to say anything they don t want repeated and to not talk about what others say outside the group. Others in the focus group may know who the subject is and although everyone will be told to please not repeat what is said, there is no guarantee of confidentiality. When the results of the research are published or discussed in conferences, no information will be disclosed that would reveal your identity. Any information that is obtained in connection with this study and that can be associated with you will remain confidential and will be disclosed only with your permission or as required by law. All study materials, including the interview audiotapes, transcripts, and consent forms, will be stored in a locked file cabinet in the PI s locked office at the UIC College of Nursing to ensure the protection of confidential participant information. Identifiable information (participant names and telephone numbers) as well as signed consent forms will be stored separately from the information collected during interviews in the PI s locked office at the UIC College of Nursing. Only de-identified information will be maintained on the PI s password protected computer. The data will be accessed only by the PI using a password known only to the PI. The data will be destroyed within approximately five years after this study ends. What are the costs for participating in this research? There are no costs to you for participating in this research. Will I be reimbursed for any of my expenses or paid for my participation in this research?

74 You will receive a $20 Target gift card upon completion of the focus group interview as compensation for your time and effort. Can I withdraw or be removed from the study? You can choose whether to participate in this study or not. If you decide to participate, you are free to withdraw your consent and discontinue your participation at any time without penalty. You may also refuse to answer any questions that you do not want to answer and still remain in the study. If serious disruptions arise from your participation in this study, you may be removed from the study by the PI. Who should I contact if I have questions? This study is being conducted by So Hyun Park, PI and doctoral candidate, and Dr. Kathleen F. Norr, PhD, Professor Emerita of the UIC College of Nursing. You may ask any questions you have now. If you have any questions about this study later, you may contact Ms. Park at (312) 996-2270, spark224@uic.edu or Dr. Norr at (312) 996-7490, knorr@uic.edu. What are my rights as a research subject? If you feel that you have not been treated according to the descriptions in this form, or if you have any questions about your rights as a research subject, including questions, concerns, complaints, or to offer input, you may call the Office for the Protection of Research Subjects (OPRS) at 312-996-1711 or 1-866-789-6215 (toll-free) or e-mail OPRS at uicirb@uic.edu. Remember: Your participation in this research is voluntary. Your decision of whether or not to participate will not affect your current or future relations with the University. If you decide to participate, you are free to withdraw at any time without affecting that relationship. You will be given a copy of this form for your information and to keep for your records. Signature of Subject or Legally Authorized Representative I have read (or someone has read to me) the above information. I have been given an opportunity to ask questions and my questions have been answered to my satisfaction. I agree to participate in this research. I will be given a copy of this signed and dated form. Signature Date Printed Name Signature of Person Obtaining Consent Date (must be same as subject s) Printed Name of Person Obtaining Consent

75 APPENDIX C Informed Consent Form for Focus Group Interview (Korean) University of Illinois at Chicago 그룹인터뷰참여에대한동의서 한인미취학아동의건강체중에미치는가족의영향 귀하께서는본연구에참여할것을요청받으셨습니다. 연구자는귀하께본연구에대해설명하고, 본연구에의참여가자발적인점과본연구참여의위험성과이득에대하여알려드리고, 정보가제공된상태에서결정하도록도와드리기위한동의서를제공해야합니다. 질문이있으시면연구자에게문의하시기바랍니다. 연구책임자 : 박소현, MSN, RN, Doctoral Candidate 소속 : 일리노이주립대학교시카고캠퍼스간호대학연락처 : 845 S. Damen Avenue, Chicago, IL, 60612. 312-996-2270, spark224@uic.edu 왜내가요청받았나요귀하는한인미취학아동의건강체중과가족의영향에대한그룹인터뷰에참여하도록요청되었습니다. 본연구는 University of Illinois at Chicago 의박소현 ( 박사과정생 ) 에의해진행될것입니다. 귀하는 2-5 세의한인미취학자녀를키우는어머니로서본연구에참여하게되었습니다. 본연구에의참여는자발적인것입니다. 귀하의참여여부에대한결정이귀하와대학의현재나미래의 관계에영향을미치지는않을것입니다. 귀하께서본연구에참여하기로하였다면, 언제든지자유롭게 참가취소를할수있습니다. 본연구의각그룹인터뷰는한그룹당 5-12 명의어머니들로구성되어진행될것입니다. 최대 25 명의 참가자가그룹인터뷰에참여할것입니다. 이연구의목적은무엇인가요? 본연구의목적은한인미취학아동의건강한체중에미치는가족의영향을알아보기위한것입니다.

76 어떤절차가필요한가요? 귀하께서는 5-12 명의어머니들로구성된그룹에서, 한인사회에서미취학자녀를양육하는것에대하여토론할것입니다. 우리가토론할주제중의하나는미취학아동들의비만증가와한인사회에서이문제를어떻게보는가에관한것입니다. 연구책임자와연구조교가그룹인터뷰를진행할것입니다. 본인터뷰내용은음성녹음되고, 기록되고, 분석되어질것입니다. 잠재적위험과불편함은무엇인가요? 본연구에의참여는일상생활에서일어날수있는정도의위험을넘지않을것입니다. 최소한의위험이있을수있으나이연구에참여함으로써일어나는신체적손상은없을것입니다. 귀하께서는귀하의가족과가족간의관계에대해서생각하고말하는것에대해불편함을느끼실수있을것입니다. 다른사람에게는알리고싶지않은내용을말하는것에대한위험또한있을수있습니다. 비록연구자가연구참여자전원에게다른사람들이그룹인터뷰에서했던이야기들을그룹밖에서이야기하지않도록요청할지라도비밀을완벽히보장할수는없습니다. 귀하께서타인이알게되는것을원하지않는내용을다른사람에게이야기하지마십시오. 귀하께서대답하기곤란하신문제는대답을하지않으셔도되며언제든지연구참여를중단하실수있습니다. 본연구에참여하는데따르는이익이있습니까? 본연구에참여함으로써얻게되는직접적인이익은없지만, 귀하께서한인가족과한인미취학아동의건강한체중에대한새로운사실을알게되는기회가될것입니다. 본연구의결과는한인가족과한인미취학아동의건강한체중에영향을주는요인들에대해이해하는데기여할것입니다. 본연구에서얻어진정보는한인미취학아동의건강을증진시키기위해한국의문화적인측면과관련된적절한프로그램을개발하는데이용될것입니다. 다른선택사항은무엇이있나요? 귀하께서는본연구에참여하지않을수있습니다. 귀하께서는언제든지본연구에의참여를중단하실수 있습니다. 사생활과비밀보장은? 귀하에대한정보는귀하의권리를보호할필요가있을때또는법에의해요구되어질때또는귀하의 문서화된허락이있을때에만다른사람에게공개될것입니다. 그룹인터뷰가시작되기전에우리는모든참여자분들께본인각자가다른사람이알게되는것을원하지않는부분에대해서그룹밖에서이야기하지않아야함을알려드릴것입니다. 그룹인터뷰내다른사람들은연구참여자가누구인지알수있을것입니다. 비록토론참가자들에게그들이그룹면담에서이야기한내용에대해발설하지말라고요청할지라도비밀보장을장담할수는없습니다. 연구결과가발표되거나학회에서논의될때귀하의신원은공개되지않을것입니다. 이연구와관련되어얻어진

77 정보나귀하에대한정보는비밀에부쳐질것이고, 귀하가허락하거나법에의해요구될때만공개될것입니다. 오디오녹취파일, 동의서, 기록지를포함한모든자료는귀하의비밀보장을위해 University of Illinois at Chicago 간호대학의사무실내잠겨진캐비닛에보관될것입니다. 귀하의신상정보 ( 이름과전화번호 ) 와사인된동의서는그룹인터뷰동안수집된자료와별개로관리되어 UIC 간호대학의사무실내에잠겨진다른캐비닛에보관될것입니다. 오직신상정보가씌여지지않은자료만이비밀번호로보호된연구책임자의컴퓨터에보관될것이고연구책임자만이비밀번호를이용하여자료에접근할수있을것입니다. 자료는연구가종료된후 5 년이내에파기될것입니다. 이연구의참가비용은? 귀하께서는본연구에대한참가비용을지불할필요가없습니다. 내가이연구에참여한비용을보상받을수있나요? 그룹인터뷰가끝나면귀하께서본연구를위해시간을내주시고참여해주신데에대한감사의마음으로 타겟상품권 ($20) 을드릴것입니다. 이연구에대한참여를거절할수있나요? 귀하께서는본연구의참여여부를결정할수있습니다. 만약귀하가연구에참여하기로결정하셨다면, 귀하께서는연구결과에상관없이언제든지연구참여를중단하실수있습니다. 귀하께서는대답하고싶지않은질문에대해대답하지않을수있고여전히연구에참여할수있습니다. 만약귀하의연구참여로인해심각한상황이발생할경우에연구책임자는귀하를본연구에서제외시킬수있습니다. 만약질문이있다면누구와연락해야하나요? 본연구를수행하는연구자는 UIC 간호대학의박소현 ( 박사과정생 ) 과 Dr. Kathleen Norr 교수 (PhD) 입니다. 귀하께서는질문이있으시면지금질문하실수있습니다. 만약귀하께서나중에질문이생길경우, 연구자인박소현 ( 박사과정생 ), 전화 (312) 996-2270, 이메일 spark224@uic.edu 또는 Dr. Kathleen Norr, 전화 (312) 996-7490, 이메일 knorr@uic.edu 로연락하시면됩니다. 연구대상자로서어떤권리가있나요만약귀하께서여기에적혀진대로대우되어지지않았다고생각하시거나, 연구대상자로서귀하의권리에대해질문이있다면, the Office for the Protection of Research Subjects (OPRS) 전화 312-996-1711 or 1-866-789-6215 (toll-free) 혹은 e-mail OPRS at uicirb@uic.edu. 로연락하십시오 중요사항 : 귀하의본연구에의참여는자발적인것입니다. 귀하의연구참여여부에대한결정이귀하와대학의 현재나미래의관계에영향을미치진않을것입니다. 귀하가참여하기로결정하였더라도, 언제든지

78 자유롭게연구결과에상관없이연구참여를중단할수있습니다. 귀하는귀하의정보와기록보관을 위해이동의서의복사본을받게될것입니다. 참가자, 연구자, 증인의서명본인은위의정보를읽었습니다 ( 혹은다른사람이본인을위해읽었습니다 ). 본인은질문을할기회를가졌고질문에대한만족스러운대답을받았습니다. 본인은이연구에참여하는데동의합니다. 본인은이연구의복사본을받았습니다. 서명 날짜 이름 동의서받은연구자서명 참가자와같은날짜 동의서받은연구자이름

79 APPENDIX C Informed Consent Form for Survey and Measurement (English) University of Illinois at Chicago Research Information and Consent for Survey and Child Measurement Family Influences and Healthy Weight for Korean-American Preschool Children You and your child are being asked to participate in a research study. Researchers are required to provide a consent form such as this one to tell you about the research, to explain that taking part is voluntary, to describe the risks and benefits of participation, and to help you to make an informed decision. You should feel free to ask the researchers any questions you may have. Principal Investigator (PI) Name and Title: So Hyun Park, MSN, RN, Doctoral Candidate Department and Institution: College of Nursing, University of Illinois at Chicago Address and Contact Information: 845 S. Damen Avenue, Chicago, IL, 60612. 312-996-2270, spark224@uic.edu Why am I being asked? You and your child are being asked to be a subject in a research study of family influences on healthy weight among Korean-American (KA) preschool-age children. This study will conduct by So Hyun Park a doctoral candidate in the College of Nursing at the University of Illinois at Chicago (UIC). You have been asked to participate because you are a Korean-American mother with a child between ages 2-5. Participating in this research by you and your child is voluntary. Whether or not you decide to participate will not affect your current or future dealings with UIC. If you and your child decide to participate, you are free to withdraw at any time without affecting that relationship. Approximately 225 mothers and 225 their children may be involved in this research. What is the purpose of this research? The purpose of this study is to examine family influences on healthy weight among KA preschool-age children. What procedures are involved? After you agree to participate in this study, your child s weight and height will be measured. The researchers will explain the weight and height measurement procedures to your child and ask if it s okay to do this. If your child does not want to be weighed and measured, you and your child will be withdrawn from the study. The researchers will record your child s age in years and months and will measure the weight, height, waist/arm circumference, and abdominal/arm skinfold of your child. A digital weight

80 scale and a portable height measuring stick will be used. Weight and height will be measured three times and will take 5 to 10 minutes. Then you will complete a 45-60 minute survey about your family and your child s routines. During this time we will provide fun quiet activities for your child. What are the potential risks and discomforts? To the best of our knowledge, the things you and your child will be doing pose no more risk of harm than you would experience in everyday life. Your child s weight and height will be measured using non-invasive methods (scale and measuring stick), and a screen will be used to protect your child s privacy. However, there are potential risks of breach of privacy (others may know you are participating in the research) and confidentiality (accidental disclosure of identifiable data). Also, you may have some discomfort in thinking about your family and relationships. You can decline to answer any survey question that you are not comfortable with, and you can withdraw from the study at any time. Are there benefits to taking part in the research? You and your child will not directly benefit from participation in the research, but we hope to learn new things about KA families and young children s healthy weights. Handouts providing diet and physical activity information for young children will be given to you. The findings of this study can provide a better understanding of KA families and can identify factors that will help improve health among KA preschool-age children, like getting exercise, eating healthy foods and not being overweight. Thus, the findings can be used to develop a culturally appropriate intervention to improve preschool-age children s health in the Korean American community. What other options are there? You and your child have the option to not participate in this study. You and your child can withdraw from the study at any time. What about privacy and confidentiality? Information about you will be disclosed to others only with your written permission, or if necessary to protect your rights or welfare or if required by law. When the results of the research are published or discussed in conferences, no information will be disclosed that would reveal your identity. Any information that is obtained in connection with this study and that can be associated with you will remain confidential and will be disclosed only with your permission or as required by law. All study materials, including children s weight and height data, consent forms, and survey questionnaires, will be stored in a locked file cabinet in the PI s locked office at the UIC College of Nursing to ensure the protection of confidential participant information. Identifiable information (participant names and telephone numbers) as well as signed consent forms will be stored separately from the information collected during interviews in locked filing cabinet in the locked office at the UIC College of Nursing. Only de-identified information will be maintained on the PI s password protected computer. The data will be accessed only by the PI using a

81 password known only to the PI. The data will be destroyed within approximately five years after the study ends. What are the costs for participating in this research? There are no costs to you and your child for participating in this research. Will I be reimbursed for any of my expenses or paid for my participation in this research? You will receive a $10 Target gift card upon completion of the survey questionnaire as compensation for your time and effort. Can I withdraw or be removed from the study? You and your child can choose whether to participate in this study or not. If you and your child decide to participate, you are free to withdraw your consent and discontinue your participation at any time without penalty. You may also refuse to answer any survey questions that you do not want to answer and still remain in the study. If your child refuses to be weighed and measured, you may be removed from the study by the PI. Who should I contact if I have questions? This study is being conducted by So Hyun Park, PI and doctoral candidate, and Dr. Kathleen F. Norr, PhD, Professor Emerita of the UIC College of Nursing. You may ask any questions you have now. If you have any questions about this study later, you may contact Ms. Park at (312) 996-2270, spark224@uic.edu or Dr. Norr at (312) 996-7490, knorr@uic.edu. What are my rights as a research subject? If you feel that you and your child have not been treated according to the descriptions in this form, or if you have any questions about your rights as a research subject, including questions, concerns, complaints, or to offer input, you may call the Office for the Protection of Research Subjects (OPRS) at 312-996-1711 or 1-866-789-6215 (toll-free) or e-mail OPRS at uicirb@uic.edu. Remember: You and your child s participation in this research are voluntary. You and your child s decision of whether or not to participate will not affect your current or future relations with the University. If you decide to participate, you are free to withdraw at any time without affecting that relationship. You will be given a copy of this form for your information and to keep for your records. Signature of Parent I have read (or someone has read to me) the above information. I have been given an opportunity to ask questions and my questions have been answered to my satisfaction. I also agree to have my daughter/son,, who is years old, participate in this research. I have been given a copy of this form. Signature Date

82 Printed Name Signature of Person Obtaining Consent Date (must be same as subject s) Printed Name of Person Obtaining Consent

83 APPENDIX C Informed Consent Form for Survey and Measurement (Korean) University of Illinois at Chicago 설문지와아동키 / 체중측정을위한동의서 한인미취학아동의건강체중에미치는가족의영향 귀하께서는본연구에참여할것을요청받으셨습니다. 연구자는귀하께본연구에대해설명하고, 본연구의참여가자발적인점과본연구참여의위험성과이득에대하여알려드리고, 정보가제공된상태에서결정하도록도와드리기위한동의서를제공해야합니다. 질문이있으시면연구자에게문의하시기바랍니다. 연구책임자 : 박소현, MSN, RN, 박사과정생 소속 : 일리노이주립대학교시카고캠퍼스간호대학 연락처 : 845 S. Damen Avenue, Chicago, IL, 60612. 312-996-2270, spark224@uic.edu 왜내가요청받았나요귀하과귀하의자녀는한인미취학아동의건강체중과가족의영향에대한연구에참여하도록요청되었습니다. 본연구는 University of Illinois at Chicago 의박소현 ( 박사과정생 ) 이진행할것입니다. 귀하는 2-5 세의한인자녀를키우는어머니로서본연구에참여하게되었습니다. 귀하와귀하자녀의본연구참여는자발적인것입니다. 귀하의참여여부에대한결정이귀하와대학의현재나미래의관계에영향을미치지는않을것입니다. 귀하께서본연구에참여하기로하였다면, 언제든지자유롭게참가취소를할수있습니다. 대략 225 명의어머니와 225 명의자녀가본연구에참여할것입니다. 이연구의목적은무엇인가요? 본연구의목적은한인미취학아동의건강한체중에미치는가족의영향을알아보기위한것입니다. 진행절차는어떻게되나요? 귀하께서본연구에참여하기로동의하셨다면, 연구자들이귀하자녀의키와몸무게를측정할것입니다. 연구자들은키와몸무게를측정하는절차를귀하자녀에게설명하고동의를구할것입니다. 만약귀하의자녀가키와몸무게측정을거절한다면귀하와귀하의자녀는본연구에서제외될것입니다.

84 연구자들은귀하자녀의나이 ( 년수와개월수 ) 를기록하고키와몸무게, 허리둘레와팔둘레, 복부와팔 피하지방두께를측정할것입니다. 디지털체중계와키측정기를사용하여키와몸무게를세번재는데 5 분에서 10 분이소요될것입니다. 자녀의키와몸무게를측정한뒤귀하께서는귀하의가족과자녀의일상생활에대한설문지를 45 분에서 60 분동안작성하실것입니다. 귀하께서설문지를작성하시는동안, 저의연구조교가귀하자녀와함께 놀이를하면서안전하게함께시간을보낼것입니다. 잠재적위험과불편함은무엇인가요? 본연구에의참여는일상생활에서일어날수있는정도의위험을넘지않을것입니다. 귀하자녀의키와몸무게는체중계와신장측정기를이용하여측정하는비침습적인방법으로측정될것이고자녀의사생활보호를위해칸막이가사용될것입니다. 하지만다른사람이귀하께서연구에참여한다는사실과불가피하게신원정보가알려지는것에대한잠재적인위험이있을수있습니다. 또한귀하께서는귀하의가족과가족간의관계에대해서생각하고말한것에대해불편함을느끼실수있을것입니다. 귀하께서대답하기곤란하신문제는대답을하지않으셔도되며언제든지연구참여를중단하실수있습니다. 본연구에참여하는데따르는이익이있습니까? 귀하와귀하의자녀가본연구에참여함으로써얻게되는직접적인이익은없지만, 귀하께서한인가족과한인미취학아동의건강한체중에대한새로운사실을알게되는기회가될것입니다. 귀하자녀의건강을위한식사와신체활동에대한정보를제공하는유인물을드릴것입니다. 본연구의결과는한인가족과, 한인미취학아동의건강을증진시키고비만해지지않도록도와주는요인들 ( 운동, 건강한음식섭취등 ) 에대한이해를높여줄것입니다. 그러므로, 본연구에서얻어진정보는한인미취학아동의건강을증진시키기위해한국인의문화에적합한프로그램을개발하는데이용될것입니다. 다른선택사항은무엇이있나요? 귀하께서는본연구에참여하지않을수있습니다. 귀하께서는언제든지본연구에의참여를중단하실수 있습니다. 사생활과비밀보장은? 귀하에대한정보는귀하의권리를보호할필요가있을때또는법에의해요구되어질때또는귀하의 문서화된허락이있을때에만다른사람에게공개될것입니다. 연구결과가발표되거나학회에서논의될때귀하의신원은공개되지않을것입니다. 이연구와관련되어 얻어진정보나귀하에대한정보는비밀에부쳐질것이고, 귀하가허락하거나법에의해요구될때만공개될 것입니다. 자녀의키와몸무게자료, 동의서, 설문지를포함한모든자료는귀하의비밀보장을위해 University of Illinois at Chicago 간호대학의사무실내잠겨진캐비닛에보관될것입니다. 귀하의신상정보 ( 이름과

85 전화번호 ) 와사인된동의서는자녀의키, 몸무게측정과설문지작성동안수집된자료와별개로관리되어 UIC 간호대학의사무실내에잠겨진다른캐비닛에보관될것입니다. 오직신상정보가씌여지지않은자료만이연구책임자의컴퓨터에보관될것이고연구책임자만이비밀번호를이용하여자료에접근할수있을것입니다. 자료는연구가종료된후 5 년이내에파기될것입니다. 이연구의참가비용은? 귀하께서는본연구에대한참가비용을지불할필요가없습니다. 내가이연구에참여한비용을보상받을수있나요? 그룹인터뷰가끝나면귀하께서본연구를위해시간을내주시고참여해주신데에대한감사의마음으로 타겟상품권 ($10) 을드릴것입니다. 이연구에대한참여를거절할수있나요? 귀하와귀하의자녀는본연구의참여여부를결정할수있습니다. 만약귀하와귀하자녀가연구에참여하기로결정하셨다면, 귀하께서는연구결과에상관없이언제든지연구참여를중단하실수있습니다. 귀하께서는대답하고싶지않은질문에대해대답하지않을수있고여전히연구에참여할수있습니다. 만약귀하의자녀가키와몸무게측정을거부할경우에연구책임자는귀하를본연구에서제외시킬수있습니다. 만약질문이있다면누구와연락해야하나요? 본연구를수행하는연구자는 UIC 간호대학의박소현 ( 박사과정생 ) 과 Dr. Kathleen Norr 교수 (PhD) 입니다. 귀하께서는질문이있으시면지금질문하실수있습니다. 만약귀하께서나중에질문이생길경우, 연구자인박소현 ( 박사과정생 ) 에게, 전화 (312) 996-2270, 이메일 spark224@uic.edu 또는 Dr. Kathleen Norr 에게, 전화 (312) 996-7490, 이메일 knorr@uic.edu 로연락하시면됩니다. 연구대상자로서어떤권리가있나요만약귀하께서여기에적혀진대로대우받지않았다고생각하시거나, 연구대상자로서귀하의권리에대해질문이있다면, the Office for the Protection of Research Subjects (OPRS) 전화 312-996-1711 or 1-866-789-6215 (toll-free) 혹은 e-mail OPRS at uicirb@uic.edu. 로연락하십시오 중요사항 : 귀하와귀하자녀의본연구의참여는자발적인것입니다. 귀하의연구참여여부에대한결정이귀하와대학의현재나미래의관계에영향을미치지않을것입니다. 귀하가참여하기로결정하였더라도, 언제든지자유롭게연구결과에상관없이연구참여를중단할수있습니다. 귀하는귀하의정보와기록보관을위해이동의서의복사본을받게될것입니다.

86 부모동의서본인은위의정보를읽었습니다 ( 혹은다른사람이본인을위해읽었습니다 ). 본인은질문을할기회를가졌고질문에대한만족스러운대답을받았습니다. 본인은 세의나의딸 / 아들 이연구에참여하는데동의합니다. 본인은이연구의참여동의서복사본을받았습니다. 서명 날짜 이름 동의서를받은연구자서명날짜 ( 참가자와같은날짜 ) 동의서를받은연구자이름

87 APPENDIX D Questionnaire for Survey and Measurement (English) Disagree Agree 1. I often participate in my heritage cultural traditions. 1 2 3 4 5 6 7 8 9 2. I often participate in mainstream American cultural traditions. 1 2 3 4 5 6 7 8 9 3. I would be willing to marry a person from my heritage culture. 1 2 3 4 5 6 7 8 9 4. I would be willing to marry a white American person. 1 2 3 4 5 6 7 8 9 5. I enjoy social activities with people from the same heritage culture as myself. 1 2 3 4 5 6 7 8 9 6. I enjoy social activities with typical American people. 1 2 3 4 5 6 7 8 9 7. I am comfortable interacting with people of the same heritage culture as myself.1 2 3 4 5 6 7 8 9 8. I am comfortable interacting with typical American people 1 2 3 4 5 6 7 8 9 9. I enjoy entertainment (e.g. movies, music) from my heritage culture. 1 2 3 4 5 6 7 8 9 10. I enjoy American entertainment (e.g. movies, music). 1 2 3 4 5 6 7 8 9 11. I often behave in ways that are typical of my heritage culture. 1 2 3 4 5 6 7 8 9 12. I often behave in ways that are typically American. 1 2 3 4 5 6 7 8 9 13. It is important for me to maintain or develop the practices of my heritage culture. 1 2 3 4 5 6 7 8 9 14. It is important for me to maintain or develop American cultural practices. 1 2 3 4 5 6 7 8 9 15. I believe in the values of my heritage culture. 1 2 3 4 5 6 7 8 9 16. I believe in mainstream American values. 1 2 3 4 5 6 7 8 9 17. I enjoy the jokes and humor of my heritage culture. 1 2 3 4 5 6 7 8 9 18. I enjoy white American jokes and humor. 1 2 3 4 5 6 7 8 9 19. I am interested in having friends from my heritage culture. 1 2 3 4 5 6 7 8 9 20. I am interested in having white American friends. 1 2 3 4 5 6 7 8 9

88 The following questions ask you how you feed your children. Please choose one response code number that indicates which choice most closely corresponds to your opinion. 1. When your child is at home, how often are you responsible for feeding him/her? 2. How often are you responsible for deciding what your child's portion sizes are? 3. How often are you responsible for deciding if your child has eaten the right kind of foods? Never Seldom Half of the time Most of the time Always 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 How would you describe your own weight during 4. Your childhood (5 to 10 years old) 5. Your adolescence 6. Your 20s 7. At present Markedly underweight Underweight Normal Overweight Markedly Overweight 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 How would you describe your child s weight 8. during the first year of life 9. as a toddler 10. as a preschooler 11. kindergarten through 2nd grade (if not applicable, leave blank) Markedly Underweight Underweight Normal Overweight Markedly Overweight 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

89 Unconcerned A Little Concerned Concerned Fairly Concerned Very Concerned 12. How concerned are you about your child eating too much when you are not around him/her? 13. How concerned are you about your child having to diet to maintain a desirable weight? 14. How concerned are you about your child becoming overweight? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Disagree Slightly Disagree Neutral Slightly Agree Agree 15. I have to be sure that my child does not eat too many sweets (candy, ice cream, cake or pastries) 16. I have to be sure that my child does not eat too many high-fat foods 17. I have to be sure that my child does not eat too much of his/her favorite foods 18. I intentionally keep some foods out of my child's reach 19. I offer sweets (candy, ice cream, cake, pastries) to my child as a reward for good behavior 20. I offer my child his/her favorite foods in exchange for good behavior 21. If I did not guide or regulate my child's eating, he/she would eat too many junk foods 22. If I did not guide or regulate my child's eating, he/she would eat too much of her favorite foods 23. My child should always eat all of the food on his/her plate 24. I offer my child his/her favorite foods to show my child that I love him/her 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

90 25. I have to be especially careful to make sure my child eats enough 26. If my child says I'm not hungry, I try to get her to eat anyway 27. If I did not guide or regulate my child's eating, he/she would eat much less than he/she should 28. I like my child to be a little plump because it is a sign of good health 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Never Rarely Sometimes Mostly Always 29. How much do you keep track of the sweets (candy, ice cream cake, pies, and pastries) that your child eats? 30. How much do you keep track of the snack food (potato chips, Doritos, cheese puffs) that your child eats? 31. How much do you keep track of the high-fat foods that your child eats? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

91 The following questions ask you about your habits regarding eating and exercise that your child sees at home. Please choose one response code number that indicates which choice most closely corresponds to your opinion. A. The following questions ask you about dietary habits and physical activity for your child. 1. How often do you eat fruits or vegetables at home? 1 Less than once a day 2 1-2 times per day 3 3-4 times per day 4 5 or more per day 2. How often do you eat salty snacks such as chips and crackers at home? 1 Less than once a day 2 1-2 times per day 3 3-4 times per day 4 5 or more per day 3. How often do you exercise? 1 Less than once a week 2 1-2 times per week 3 3-4 times per week 4 5 or more per week 4. Do you smoke? 1 Yes 2 No If you smoke, How many cigarettes per day do you usually smoke at your home? 1 pack= 20 cigarettes. If less than 1 per day, enter 1 (Enter number of cigarettes) How many cigarettes per day do you usually smoke outside your home? 1 pack= 20 cigarettes. If less than 1 per day, enter 1 (Enter number of cigarettes)

92 5. In the past 12 months, how often did you drink any type of alcoholic beverage? (for example, beer, wine, wine coolers drinks, Soju, or rice alcohol) a) At home 1 4 times a week or more 2 1-3 times per week 3 Every week 4 Once a month 5 Never b) Outside the home 1 4 times a week or more 2 1-3 times per week 3 Every week 4 Once a month 5 Never 6. In the past 12 months, on those days that you drank alcoholic beverages, on the average, how many drinks did you have? a) At home (Enter number of drinks) b) Outside the home (Enter number of drinks) 7. In the past 12 months, on how many days did you have 5 or more drinks of any alcoholic beverage? (Enter number of days drank 5 or more drinks)

93 B. The following questions ask you about your partner s dietary habits and physical activity for your child. 1. How often does your partner eat fruits or vegetables at home? 1 Less than once a day 2 1-2 times per day 3 3-4 times per day 4 5 or more per day 2. How often does your partner eat salty snacks such as chips and crackers at home? 1 Less than once a day 2 1-2 times per day 3 3-4 times per day 4 5 or more per day 3. How often does your partner exercise? 1 Less than once a week 2 1-2 times per week 3 3-4 times per week 4 5 or more per week 4. Does your partner smoke? 1 Yes 2 No If your partner smoke, How many cigarettes per day does your partner usually smoke at your home? 1 pack= 20 cigarettes. If less than 1 per day, enter 1 (Enter number of cigarettes) How many cigarettes per day does your partner usually smoke outside your home? 1 pack= 20 cigarettes. If less than 1 per day, enter 1 (Enter number of cigarettes)

94 5. In the past 12 months, how often did your partner drink any type of alcoholic beverage? (for example, beer, wine, wine coolers drinks, Soju, or rice alcohol) a) At home 1 4 times a week or more 2 1-3 times per week 3 Every week 4 Once a month 5 Never b) Outside the home 1 4 times a week or more 2 1-3 times per week 3 Every week 4 Once a month 5 Never 6. In the past 12 months, on those days that your partner drank alcoholic beverages, on the average, how many drinks did your partner have? a) At home (Enter number of drinks) b) Outside the home (Enter number of drinks) 7. In the past 12 months, on how many days did your partner have 5 or more drinks of any alcoholic beverage? (Enter number of days drank 5 or more drinks)

95 The following questions ask you about your family functioning. Family functioning refers to how family members manage their daily routines and communicate with one another. Please choose one response code number that indicates which choice most closely corresponds to your opinion. Strongly disagree Disagree Agree Strongly agree 1. After our family tries to solve a problem, we usually discuss whether it worked or not 1 2 3 4 2. We resolve most emotional upsets that come up 1 2 3 4 3. We try to think of different ways to solve problem 1 2 3 4 4. When someone is upset the others know why 1 2 3 4 5. People come right out and say things instead of hinting at them 1 2 3 4 6. We are frank with each other 1 2 3 4 7. When we don t like what someone has done, we tell them 1 2 3 4 8. Family tasks don t get spread around enough 1 2 3 4 9. We have trouble meeting our bills 1 2 3 4 10. There s little time to explore personal interests 1 2 3 4 11. If people are asked to do something, then need reminding 12. We are generally dissatisfied with the family duties assigned to us 13. We are reluctant to show our affection for each other 1 2 3 4 1 2 3 4 1 2 3 4 14. Some of us just don t respond emotionally 1 2 3 4 15. We don t show our love for each other 1 2 3 4 16. Tenderness takes second place to other things in our family 1 2 3 4

96 17. You only get the interest of others when something is important to them 1 2 3 4 18. We are too self-centered 1 2 3 4 Strongly disagree Disagree Agree Strongly agree 19. We get involved with each other only when something interests us 20. We show interest in each other only when they can get something out of it personally 21. Our family shows interest in each other only when they can get something out of it 22. If someone is in trouble, the others become too involved 23. We don t know what to do when an emergency comes up 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 24. You can easily get away with breaking the rules 1 2 3 4 25. We have no clear expectations about toilet habits 1 2 3 4 26. We don t hold any rules or standards 1 2 3 4 27. If the rules are broken, we don t know what to expect 28. Planning family activities is difficult because we misunderstand each other 29. Even though we mean well, we intrude too much into each other s lives 30. We cannot talk to each other about sadness we feel 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 31. We avoid discussing our fears and concerns 1 2 3 4 32. We can express feelings to each other 1 2 3 4 33. We don t get along well together 1 2 3 4 34. We confide in each other 1 2 3 4

97 The following questions ask you about your child s routines. For each question, please select the answer that best represents your child/family. Almost Some- Usually Almost Never times Always 1. My child eats breakfast 1 2 3 4 2. Our family eats meals together 1 2 3 4 3.Our family eats while watching TV 1 2 3 4 4.Our family eats fast food 1 2 3 4 5. Our family uses microwave or ready to eats foods 1 2 3 4 6. My child eats fruits and vegetables at meals or snacks 1 2 3 4 7. My child drinks soda pop or sugar drinks (drink with sugar added: does NOT include 100% juice) 1 2 3 4 8. My child drinks low fat milk at meals or snacks 1 2 3 4 9. Our family monitors eating of chips, cookies, and candy 1 2 3 4 10.Our family uses candy as a reward for good behavior 1 2 3 4 11. My child spends less than 2 hours on TV/games/computer per day 1 2 3 4 12. Our family limits the amount of TV/games/computer our child watches 1 2 3 4 13. Our family allows our child to watch TV/games/computer in their bedroom 1 2 3 4 14. Our family provides opportunities for physical activity 1 2 3 4 15. Our family encourages our child to be active every day 1 2 3 4 16. Our family finds ways to be physically active together 1 2 3 4 17. My child does physical activity during his/her free time 1 2 3 4 18. My child is enrolled in sports or activities with a coach or leader 1 2 3 4 19. Or family has a daily routine for our child s bedtime 1 2 3 4 20. My child gets at least 9 hours of sleep a night 1 2 3 4

98 Childcare The following questions ask you about your child s care situation 1. Does your child receive care from a relative (for example, grandparents or aunt) on a regular basis? 1 Yes 2 No Who is the relative? (Specify ) How many hours per week is your child under a relative s care? hours 2. Does your child receive care from private non-relative (for example, with a home day care or babysitter)? 1 Yes 2 No Who is the private non-relative? (Specify ) How many hours per week is your child under private non-relative care? hours 3. Does your child go to a preschool, daycare center, or kindergarten? 1 Yes 2 No What type of organization? Please check all that you apply Preschool.... 1 Daycare center 2 Kindergarten...... 3 Other ( )...... 4 How many hours per week is your child in a preschool, daycare center, or kindergarten? hours

99 Family Background The following questions ask you for general information about your family background. 1. What month and year were you born? (month)/ (year) 2. Were you born in the United States? 1 Yes 2 No If you were not born in the United States, when did you move to the United States? (month)/ (year) 3. Please check your generation in the U.S. 1 First generation: if you are not U.S. born and at least one parent is also non-u.s. born 2 Second generation: if you are U.S. born but at least one parent is non-u.s. born 3 Third generation: if you and both parents are U.S. born 4. What is your present marital status? 1 Married 2 Not married, living with partner 3 Separated 4 Divorced 5 Widowed 6 Never married 5. What is the highest level of schooling that you have completed or the highest degree that you have received? 1 Less than high school 2 High School 3 Associate s degree 4 Bachelor s degree 5 Master s degree 6 Doctoral degree or higher

100 6. What is your employment status? 1 Employed for wages full-time 2 Employed for wages part-time 3 Self-employed 4 Out of work for less than 1 year 5 Out of work for more than 1 year 6 Homemaker 7 Student 8 Retired 7. In 2012, what was the total income of all members of your household? Please indicate the income earned by all members of your household and from all sources (such as wages, salaries, tips, social security benefits, interest, rent from property, and so on) before taxes. 1 Less than $ 20,000 2 $20,000 to less than $39,999 3 $40,000 to less than $74,999 4 $75,000 to less than $99,999 5 $100,000 or more

101 Family Structure The following questions ask you about your family structure. 1. Are you living with your spouse or partner? 1 Yes 2 No 2. Do you live with your child s grandparents or any other relatives? 1 Yes 2 No Who do you live with? Please check all that you apply 1 My father (maternal grandfather) 2 My mother (maternal grandmother) 3 My husband/partner s father (paternal grandfather) 4 My husband/partner s mother (paternal grandfather) 5 Others (specify : ) 3. How many children of the following ages live in your household? A. Under 2years old B. 2 through 5 years old C. 6 through 12 years old D. 13 and over

APPENDIX D Questionnaire for Survey and Measurement (Korean) Disagree Agree 1. 한국문화적전통 / 전례에종종참여한다.. 1 2 3 4 5 6 7 8 9 2. 미국문화적전통 / 전례에종종참여한다 1 2 3 4 5 6 7 8 9 3. 한국인과결혼할의사가있다. 1 2 3 4 5 6 7 8 9 4. 미국인과결혼할의사가있다. 1 2 3 4 5 6 7 8 9 5. 나는한국인과의사교활동을즐긴다 1 2 3 4 5 6 7 8 9 6. 나는전형적인미국인과의사교활동을즐긴다.. 1 2 3 4 5 6 7 8 9 7. 나는전형적인한국인과일하는것이편하다. 1 2 3 4 5 6 7 8 9 8. 나는전형적인미국인과일하는것이편하다.. 1 2 3 4 5 6 7 8 9 9. 나는한국연예 / 오락 ( 예를들어음악, 영화 ) 을즐긴다 1 2 3 4 5 6 7 8 9 10. 나는미국연예 / 오락 ( 예를들어음악, 영화 ) 을즐긴다. 1 2 3 4 5 6 7 8 9 11. 나는전형적인한국인처럼행동하는경우가많다. 1 2 3 4 5 6 7 8 9 12. 나는전형적인미국인처럼행동하는경우가많다. 1 2 3 4 5 6 7 8 9 13. 한국식문화를지키고개발하는것은내게중요한일이다. 1 2 3 4 5 6 7 8 9 14. 미국식문화를지키고개발하는것은내게중요한일이다. 1 2 3 4 5 6 7 8 9 15. 한국의주된가치관을믿는다. 1 2 3 4 5 6 7 8 9 16. 미국의주된가치관을믿는다. 1 2 3 4 5 6 7 8 9 17. 전형적인한국식농담과유머를즐긴다. 1 2 3 4 5 6 7 8 9 18. 전형적인미국식농담과유머를즐긴다. 1 2 3 4 5 6 7 8 9 19. 한국인친구를갖는데관심이있다. 1 2 3 4 5 6 7 8 9 20. 미국인친구를갖는데관심이있다. 1 2 3 4 5 6 7 8 9

103 다음의질문들은귀하께서자녀들에게어떻게음식을주는지에관한것입니다. 귀하의의견에 가장적합하다고 ( 가깝다고 ) 생각되는답변을선택해주십시오. 전혀 거의 책임 자주 항상 책임안진다 책임안진다 질때도 책임진다 책임진다 있고 안질때도 있다 1. 자녀가집에있을때, 귀하께서는자녀의식사를얼마나자주책임지십니까? 2. 귀하께서는자녀의식사량을정해주시는책임을얼마나자주지십니까? 3. 귀하께서는자녀가올바른음식을먹었는지에대해얼마나자주책임지십니까? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 귀하의체중은어떠했습니까? 심한저체중저체중보통과체중심한 과체중 4. 귀하의어린시절 (5살에서 10살 ) 5. 귀하의청소년기 6. 귀하의 20대 7. 현재 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 자녀의체중은어떠했습니까? 심한저체중 저체중 보통 과체중 심한과체중 8. 생후일년 1 2 3 4 5 9. 걸음마기 (Toddler) 1 2 3 4 5 10. 미취학아동기 1 2 3 4 5

104 11. 유치원기에서초등학교 2 학년 ( 만약적용되지않으면, 여백으로남겨 두십시오.) 1 2 3 4 5 전혀신경 거의신경 신경 꽤신경 매우신경 쓰이지않는다 쓰이지 쓰이는 쓰인다 쓰인다 않는다 편이다 12. 귀하가옆에안계실때자녀가너무많이먹는것에대해얼마나신경이쓰이십니까? 13. 자녀가적당한체중유지를위해다이어트하는것에대해얼마나신경이쓰이십니까? 14. 자녀가비만이되는것에대해얼마나신경이쓰이십니까? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 동의하지않는다 동의하지 중립이다 동의하는 동의한다 않는편이다 편이다 15. 나는자녀가단음식을너무많이먹지않도록확실히한다. ( 사탕, 아이스크림, 케이크, 빵과자류 ) 16. 나는자녀가고지방음식을너무많이먹지않도록확실히한다. 17. 나는자녀가좋아하는음식을지나치게많이먹지않도록한다 18. 나는자녀가닿을수없는곳에일부음식들을둔다. 19. 자녀에게단음식 ( 사탕, 아이스크림, 케이크, 빵과자류 ) 을자녀가잘한행동에대한상으로준다 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

105 동의하지않는다 동의하지 중립이다 동의하는 동의한다 않는편이다 편이다 20. 자녀의잘한행동에대한대가로 1 2 3 4 5 자녀가좋아하는음식을준다 21. 만약내가자녀의식습관을감독하지않는다면, 자녀는불량식품을너무많이먹을것이다 22. 만약내가자녀의식습관을감독하지않는다면, 자녀는자신이좋아하는음식을너무많이먹을것이다. 23. 자녀는그릇에담긴음식은항상다먹어야한다 24. 내가자녀를사랑하고있다는것을보여주기위해자녀에게자녀가좋아하는음식을준다 25. 나는자녀가충분히먹는지에대해특별히신경을써야한다 26. 만약자녀가 배고프다 고하면, 나는어찌하던간에자녀가먹을수있게한다 27. 만약내가내자녀의식습관을감독하지않는다면, 자녀는적당량보다훨씬적게먹을것이다. 28. 포동포동하게살찌는것은건강하다는의미이기때문에나는내자녀가살짝포동포동한것이좋다. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

106 전혀 아니다 거의 아니다 때때로대체로한다항상한다 29. 귀하께서는자녀가단음식 ( 사탕, 아이스크림, 케이크, 파이, 빵과자류 ) 을얼마나먹는지파악하고계십니까? 30. 귀하께서는자녀가간식 ( 감자칩, 도리토스, 치즈퍼프 ) 을얼마나먹는지파악하고계십니까? 31. 귀하께서는자녀가고지방음식을얼마나먹는지파악하고계십니까? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

107 다음의질문은집에서귀하의자녀에게보여지는귀하의식습관과신체활동에관한내용입니다. 귀하의의견에가장적합한 ( 가까운 ) 답변을선택하여표시하십시오. A. 다음문항들은귀하의식습관과신체활동에대한것입니다. 1. 귀하께서는집에서과일이나채소를얼마나자주드십니까? 1 하루에한번미만 2 하루에 1-2 회 3 하루에 3-4 회 4 하루에 5 회이상 2. 귀하께서는집에서칩이나크래커와같이짠간식들을얼마나자주드십니까? 1 하루에한번미만 2 하루에 1-2 회 3 하루에 3-4 회 4 하루에 5 회이상 3. 귀하께서는얼마나자주운동하십니까? 1 일주일에한번미만 2 일주일에 1-2 회 3 일주일에 3-4 회 4 일주일에 5 회이상 4. 흡연하십니까? 1 예 2 아니오 만약흡연하신다면귀하께서는집에서하루에몇개비의담배를피십니까? 1 팩 = 20 개피. 만약하루에 1 개피이하면 1 로표시 ( 개피수표시 ) 귀하께서는집이외의장소에서하루에몇개피의담배를피십니까? 1 팩 = 20 개피. 만약하루에 1 개피이하면 1 로표시 ( 개피수표시 )

108 5. 지난 12 개월동안귀하께서는술을얼마나자주드셨습니까? ( 예를들어맥주, 와인, 소주, 막걸리, 정종 ) a) 집에서 1 일주일에 4 회이상 2 일주일에 1-3 회 3 일주일에한번 4 한달에한번 5 전혀마시지않음 b) 집이외의장소에서 1 일주일에 4 회이상 2 일주일에 1-3 회 3 일주일에한번 4 한달에한번 5 전혀마시지않음 6. 지난 12 개월동안귀하께서술을마셨을때평균적으로 1 회에몇잔정도마셨습니까? a) 집에서 ( 술잔수기입 ) b) 집이외의장소에서 ( 술잔수기입 ) 7. 지난 12 개월동안한번에술을 5 잔이상마신날이며칠입니까? ( 술을 5 잔이상마신일수기입 )

109 B. 다음의질문은집에서자녀에게보여지는귀하파트너의식습관과신체활동에관한 내용입니다. 1. 귀하의파트너께서는집에서과일이나채소를얼마나자주드십니까? 1 하루에한번미만 2 하루에 1-2 회 3 하루에 3-4 회 4 하루에 5 회이상 2. 귀하의파트너께서는집에서칩이나크래커와같이짠간식들을얼마나자주드십니까? 1 하루에한번미만 2 하루에 1-2 회 3 하루에 3-4 회 4 하루에 5 회이상 3. 귀하의파트너께서는얼마나자주운동하십니까? 1 일주일에한번미만 2 일주일에 1-2 회 3 일주일에 3-4 회 4 일주일에 5 회이상 4. 귀하의파트너께서는흡연하십니까? 1 예 2 아니오 만약흡연하신다면귀하의파트너께서는집에서하루에몇개비의담배를피십니까? 1 팩 = 20 개피. 만약하루에 1 개피이하면 1 로표시 ( 개피수표시 ) 귀하의파트너께서는집이외의장소에서하루에몇개피의담배를피십니까? 1 팩 = 20 개피. 만약하루에 1 개피이하면 1 로표시 ( 개피수표시 )

110 5. 지난 12 개월동안귀하의파트너께서는술을얼마나자주드셨습니까? ( 예를들어맥주, 와인, 소주, 막걸리, 정종 ) a) 집에서 1 일주일에 4 회이상 2 일주일에 1-3 회 3 일주일에한번 4 한달에한번 5 전혀마시지않음 b) 집이외의장소에서 1 일주일에 4 회이상 2 일주일에 1-3 회 3 일주일에한번 4 한달에한번 5 전혀마시지않음 6. 지난 12 개월동안귀하의파트너께서술을마셨을때평균적으로 1 회에몇잔정도마셨습니까? a) 집에서 ( 술잔수기입 ) b) 집이외의장소에서 ( 술잔수기입 ) 7. 지난 12 개월동안귀하의파트너께서한번에술을 5 잔이상마신날이며칠입니까? ( 술을 5 잔이상마신일수기입 )

111 다음은귀하의가족기능에관한질문입니다. 가족기능은가족들이함께일상생활을해나가고 서로의사소통을하는것을의미합니다. 귀하의의견에가장적합하다고생각하는답변을 선택하시오. 1. 집안문제를해결하려고애쓴후에그것이잘 되었는지아닌지에대해얘기하곤한다. 전혀그렇지 그렇지않다 그렇다 매우그렇다 않다 1 2 3 4 2. ( 나쁜 ) 감정문제가나타나면거의풀고지나간다. 1 2 3 4 3. 문제를해결하려고할때여러가지방법을생각해본다. 1 2 3 4 4. 누군가가기분이나쁘면왜그런지를안다. 1 2 3 4 5. 빗대어말하기보다는직접솔직하게얘기한다 1 2 3 4 6. 서로에게솔직하다 1 2 3 4 7. 누가해놓은일이마음에들지않으면그사람에게 말한다. 1 2 3 4 8. 집에서할일이충분히나뉘어져있지않다. 1 2 3 4 9. 각자의역할을다하지못한다. 1 2 3 4 10. 식구들의개인적인관심사를알아볼시간이별로 없다. 1 2 3 4 11. 어떤일을부탁하고나서나중에다시일러줘야한다. 1 2 3 4 12. 가족으로서각자가해야할일에대해불만을가지고 있다. 1 2 3 4 13. 서로에대한애정표현을하지않으려고한다. 1 2 3 4 14. 감정적으로반응하지않는식구들이있다. 1 2 3 4 15. 서로에대한사랑을표현하지않는다. 1 2 3 4 16. 다정다감한편은아니다. 1 2 3 4 17. 자신에게중요한일일때만서로에게관심을가진다. 1 2 3 4

112 18. 지나치게자기중심적이다. 1 2 3 4 19. 우리에게관계있는일에만서로관여하게된다. 1 2 3 4 20. 개인적으로얻는것이있다고생각할때서로에게 관심을보인다. 1 2 3 4 21. 어떤이득이있을때에만서로에게관심을보인다. 1 2 3 4 22. 비록좋자고하는것이지만서로의생활에너무많이 개입한다. 1 2 3 4 23. 갑자기큰일을맞게되면어떻게할바를모른다. 1 2 3 4 24. 규칙을어겨도그냥지나간다. 1 2 3 4 25. 화장실을사용하는방식이정해져있지않다. 1 2 3 4 26. 어떤규칙이나기준을고집하지않는다. 1 2 3 4 27. 집에서지켜야할약속들을어기면어떻게되는건지잘모른다. 28. 서로를잘이해하지못하기때문에우리가해야할일을계획하지못한다. 29. 위기가닥치면서로에게도와달라고부탁할수가있다. 30. 슬픈일이있어도서로에게그런얘기를하지않는다. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 31. 우리가두려워하는일이나걱정에대해얘기하기를 꺼린다. 1 2 3 4 32. 서로에게감정표현할수가있다. 1 2 3 4 33. 함께있으면잘지내지를못한다. 1 2 3 4 34. 서로를믿는다. 1 2 3 4

113 다음은귀하자녀의일상생활에관한질문입니다. 각각의질문에대해귀하의자녀와가족을 가장잘나타나는대답을선택하십시오. 항상 가끔 보통 항상 그렇지 그렇다 그렇다 그렇다 1. 우리아이는아침을먹는다 1 2 3 4 2. 우리가족은함께식사한다 1 2 3 4 3. 우리가족은 TV 를보면서식사를한다 1 2 3 4 4. 우리가족은패스트푸드를먹는다 1 2 3 4 5. 우리가족은컵라면냉동식품과같은인스턴트음식을먹는다 1 2 3 4 6. 우리아이는채소와과일을먹는다 1 2 3 4 7. 우리아이는탄산음료나과당음료 (100% 과일쥬스는제외 ) 를마신다 1 2 3 4 8. 우리아이는저지방우유 ( 무지방혹은 1% 우유 ) 를마신다 1 2 3 4 9. 우리가족은과자와사탕을먹는것을감독한다 1 2 3 4 10. 우리가족은잘한행동에대한대가로아이에게사탕을준다 1 2 3 4 11. 우리아이는 TV/ 게임 / 컴퓨터를하는시간이하루 2 시간미만이다 1 2 3 4 12. 우리가족은아이가 TV/ 게임 / 컴퓨터를하는시간을제한한다 1 2 3 4 13. 우리가족은아이가자기침실에서 TV/ 게임 / 컴퓨터를볼수있도록 허락한다 1 2 3 4 14. 우리가족은신체활동을할기회를아이에게제공한다 1 2 3 4 15. 우리가족은아이가매일신체활동을하도록격려한다 1 2 3 4 16. 우리가족은함께신체활동을할방법을찾는다 1 2 3 4 17. 우리아이는자유시간에신체활동을한다 1 2 3 4 18. 우리아이는지도자가있는신체활동에등록되어있다 1 2 3 4 19. 우리가족은아이가잠자리에들때일상적으로하는활동이있다 1 2 3 4 20. 우리아이는밤에적어도 9 시간동안잔다 1 2 3 4

114 육아상황 다음은귀하미취학자녀의육아상황에대한질문입니다. 1. 귀하의미취학자녀는정기적으로친척의돌봄을받고있습니까? ( 예를들어조부모나이모 ) 1 예 2 아니오친척은누구입니까? ( 자세히 ) 일주일에몇시간정도귀하의자녀를친척이돌봅니까? 시간 2. 귀하의미취학자녀는친척이아닌사람의돌봄을받고있습니까? ( 예를들어보모나일반가정집에서 ) 1 예 2 아니오친척이아닌돌보는사람은누구입니까? ( 자세히 ) 일주일에몇시간정도귀하의미취학자녀를친척이아닌사람이돌봅니까? 시간 3. 귀하의미취학자녀는유치원이나어린이집에다니고있습니까? 1 예 2 아니오 어떤종류의기관에다니고있습니까? 해당하는곳모두표시하시오 1 Preschool 2 Daycare center 3 Kindergarten 4 기타 ( 자세히 ) 일주일에몇시간정도유치원이나어린이집에갑니까? 시간

115 가족배경설문지 다음은귀하와귀하가족의일반적인사항에대한질문입니다. 1. 귀하께서는몇년몇월에태어났습니까? ( 월 )/ ( 년도 ) 2. 귀하께서는미국에서태어나셨습니까? 1 예 2 아니오만약미국에서태어나지않았다면, 몇년도에미국으로이민을왔습니까? ( 월 )/ ( 년도 ) 3. 귀하의미국내에서의이민세대를표시해주십시오 : 1 1 세대 : 귀하와, 적어도부모님중한분이미국에서태어나지않음 2 2 세대 : 귀하가미국에서태어나고, 적어도부모님중한분이미국에서태어나지않음 3 3 세대 : 귀하와부모님모두미국에서태어남 4. 귀하의현재결혼상태는무엇입니까? 1 기혼 2 결혼하지않고파트너와함께거주 3 별거 4 이혼 5 사별 6 미혼 5. 최종학력이어떻게되십니까? 1 고등학교이하 2 고등학교졸업 3 2 년제대학졸업 4 4 년제대학졸업 5 석사학위 6 박사학위

116 6. 현재직업상태는어떻게되십니까? 1 전일제고용 2 파트타임고용 3 자영업 4 1 년미만휴직상태 5 1 년이상휴직상태 6 주부 7 학생 8 은퇴 7. 2012 년에, 귀하가족의총수입은얼마였습니까? 모든가족구성원의모든종류의세전소득을포함하십시오 ( 임금, 팁, 사회보장연금, 이자, 임태료, 기타 ) 1 $ 20,000 미만 2 $20,000 에서 $39,999 미만 3 $40,000 에서 $74,999 미만 4 $75,000 에서 $99,999 미만 5 $100,000 이상

117 가족구조다음은귀하의가족구조에관한질문입니다. 1. 귀하께서는남편이나파트너와함께살고계십니까? 1 예 2 아니오 2. 귀하께서는귀하자녀의조부모나친척과함께살고계십니까? 1 예 2 아니오 누구와함께살고계십니까? 해당하는곳모두표시하시오 1 친정아버지 ( 자녀의외할아버지 ) 2 친정어머니 ( 자녀의외할머니 ) 3 시아버지 ( 자녀의친할아버지 ) 4. 시어머니 ( 자녀의친할머니 ) 5 다른친척 ( 자세히 : ) 3. 귀하의가정에아래나이에해당하는자녀가몇명입니까? A. 2 살미만 B. 2-5 살 C. 6-12 살 D. 13 살이상

118 CURRICULUM VITAE So Hyun Park EDUCATION 2014 PhD., Nursing, University of Illinois at Chicago, Illinois 2010 MSN., Nursing, Yonsei University, Seoul, Korea 2004 BSN., Nursing, Yonsei University, Seoul, Korea ACADEMIC AND PROFESSIONAL EXPERIENCE 2014 Research Associate University of Illinois at Chicago College of Nursing 2012-2013 Teaching Assistant University of Illinois at Chicago College of Nursing 2011-2013 Research Assistant University of Illinois at Chicago College of Nursing 2010 Clinical Instructor Sungshin Women s University College of Nursing 2008-2010 Teaching Assistant Yonsei University College of Nursing Research Assistant Clinical Instructor Yonsei University College of Nursing Yonsei University College of Nursing 2004-2008 Registered Nurse Yonsei University Health System AWARDS AND HONORS July 2013 Global Korean Nursing Foundation Research Scholarship April 2013 Virginia M. Ohlson Scholarship University of Illinois at Chicago College of Nursing March 2013 Seth and Denise Rosen Memorial Research Award University of Illinois at Chicago College of Nursing Nov. 2012 Chancellor s Graduate Research Fellowship University of Illinois at Chicago Graduate College Oct. 2012 Korean Nurses Association of Chicago Scholarship April 2012 Academy of International Leadership Development Scholarship University of Illinois at Chicago College of Nursing Aug. 2010 Global Korean Nursing Foundation PhD Fellowship 2008-2009 Academic Scholarship, Yonsei University Fall 2002 Academic Scholarship, Yonsei University PUBLICATIONS Kim, M. J., Park, C. G., Park, S. H., Khan, S., & Ketefian, S. (2014). Quality of Nursing Doctoral Education and Scholarly Performance in U.S. Schools of Nursing: Strategic Areas for Improvement. J Prof Nurs. Lee, C. Y., Lee, H. K., Jeon, K. M., Hong, Y. M., & Park, S. H. (2011). Self-Management Program for Obesity Control Among Middle-Aged Women in Korea: A Pilot Study. Jpn J Nurs Sci, 8(1), 66-75. doi:10.1111/j.1742-7924.2010.00160.x

119 Kim, G. S., Kim, E. G., Lee, C. Y., Yoo, M. A., Park, S. H., & Kim, J. E. (2009). Obesity Related Factors in Middle-Aged Women: Comparison of Body Mass Index and/or Waist Circumference as Measures of Obesity. Journal of Korean Academy of Public Health Nursing, 23(2), 273-284. Lee, C. Y., Lee, G. Y., Jeon, K. M., Park, S. H., Hong, Y. M., & Lee, H. K. (2009). Factors Influencing Stress Coping Behaviors of Elementary Students in Korea. Korean Society for Health Education and Promotion, 26(5), 1-13. PRESENTATIONS Park, S. H., & Norr, K. F. (July 2013). Family Effects on Obesity in Korean-American Preschool-age Children. Honor Society of Nursing, Sigma Theta Tau International 24 th International Nursing Research Congress. Prague, Czech Republic. (Poster presentation). Park, S. H., Park, C. G., & Norr, K. F. (March 2013). Racial Differences in the Effect of Caregiver Type on Early Childhood Obesity. Midwest Nursing Research Society 37 th Annual Research Conference. Chicago, IL. (Poster presentation). Park, S. H., & Na, H. J. (October 2012). Relationship Among Weight Perception, Depression, and Suicide Ideation among U.S. High School Students. Chicago International Nursing Conference. Chicago, IL. (Poster presentation). Yona, S., Park, S. H., Chimango, J. L., Chimwaza, A. F., Kaponda, C. P., Norr, K. F., & Norr, J. L. (October 2011). Factors Predicting HIV-Related Knowledge Among Urban Health Workers in Malawi. American Public Health Association 139 th Annual Meeting and Exposition. Washington, DC. (Poster presentation). Park, S. H. (December 2009). Comparison of Hypertension Knowledge and Health Service Quality Among Hypertension Patients Using Public Health Post and Hospitals. Korean Academy of Community Health Nursing, Fall Conference. Daegu, Korea. (Poster presentation). Park, S. H., Lee, C. Y., & Lee, H. K. (August 2009). Comparisons of Obesity Control Interventions for Middle-Aged Women in Korea. The 4 th International Conference on Community Health Nursing Research. Adelaide, Australia. (Oral presentation). Kim, G. S., Kim, B. J., & Park, S. H. (May 2009). Evaluation of Urinary Incontinence Prevalence and Program Demand in Middle-Aged Women. Korean Society of Public Health Nursing, Fall Congress, Seoul, Korea. (Poster presentation). PROFESSIONAL MEMBERSHIPS 2012 - Present Sigma Theta Tau International, Alpha Lambda Chapter (U.S.A.) 2012 - Present Midwest Nursing Research Society 2012 - Present Asian American/Pacific Islander Nurses Association 2011 - Present American Public Health Association 2009 - Present Sigma Theta Tau International, Lambda Alpha Chapter-at-Large (Korea)