The Effectiveness of a Personalized Healthy Eating Report Card in Improving Children's Eating Practices: A Randomized Controlled Trial

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L. Wan, Kevin Kien Hoa Chung, Jian-Bin Li, Shebe Siwei Xu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5963247/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The present study developed an intervention using a personalized Healthy Eating Report Card to provide parents with personalized insights into the extent to which their child adhered to international healthy eating guidelines and engaged in favorable family home food environments. This study aimed to assess the effectiveness of this intervention in improving preschool-aged children’s eating practices. Methods: A three‐armed, single‐blinded randomized controlled trial was conducted with 331 parent-child dyads recruited from eight local kindergartens in Hong Kong. Parents were asked to complete the International Healthy Eating Report Card Scale at baseline and one-month post-intervention. The participants were randomly assigned to one of three groups: (i) the intervention group (who received a personalized Healthy Eating Report Card), (ii) the usual care group (who received a standard government-issued leaflet on healthy eating), or (iii) the mere-measurement control group (who received no healthy eating materials). We examined if the improvement in the overall report card score of the intervention group was statistically higher than that of the other two groups using ANCOVA. Results: The results of ANCOVA demonstrated that the overall report card score was significantly different among the three groups after adjusting for the baseline value [ F (2,327) = 3.98, p = .020, η p 2 = .02]. Bonferroni post-hoc tests revealed that children in the intervention group improved significantly more than those in the mere-measurement control group ( p .05). Conclusions: This study provides promising evidence for the effectiveness of the personalized Healthy Eating Report Card in promoting healthy eating practices among preschool-aged children. It also demonstrated its potential as a cost-efficient and scalable tool for health interventions. Trial registration: This trial was registered retrospectively on November 19, 2024, at chictr.org.cn (ChiCTR number: ChiCTR2400092558). healthy eating intervention report card eating behaviors family home food environment preschool-aged children Figures Figure 1 1. Introduction Promoting healthy dietary patterns in young children is essential for optimizing their growth and development (1, 2). The preschool period is a critical stage for young children to develop healthy eating patterns, as early adoption of these patterns tends to have a lasting impact on their dietary behaviors and potentially reduces the risk of obesity and diet-related chronic diseases during adolescence and adulthood (3, 4). Despite increasing awareness of the importance of healthy eating in young children, unhealthy dietary patterns, such as frequent consumption of low-nutrient-density snack foods and sugar-sweetened beverages and insufficient consumption of fruits or vegetables, are prevalent worldwide (5, 6). Given the widespread prevalence of unhealthy eating behaviors among young children, it is essential to implement targeted interventions that account for the influential role of parents and families in shaping children’s dietary habits. Parents and families play pivotal roles in shaping children’s eating patterns by determining the types of food provided, the methods of food preparation, mealtime interactions, and the structure of the mealtime environment (1, 7, 8). Therefore, involving parents in healthy eating interventions is effective in improving children’s dietary patterns (9). A report card intervention is the traditional method used by schools to communicate with parents by using letter grades to evaluate, inform and monitor an individual’s particular performance (10). It provides parents with summative information about their child’s progress and outcomes (e.g., grades, attendance, or behavior) which allows them to identify areas of achievement and those requiring additional support. While widely used in educational settings, a few studies have also adopted the report card approach in health promotion interventions, given its potential to enhance parental awareness and accountability regarding children’s health behaviors. For example, Chomitz et al. (11) developed a BMI report card to monitor elementary school children's weight and fitness status. The intervention involved sending personalized weight and fitness health report cards to parents. In the report card of Chomitz et al.’s study (11), information about the weight category and related fitness data of the children were provided to parents in order to enhance parental awareness of their children’s weight status and fitness level. While the findings indicated that the intervention significantly increased parental awareness of overweight children, the study did not examine the extent to which the intervention improved children’s actual health outcomes, such as BMI or other fitness levels, thereby limiting its ability to demonstrate the effectiveness of the intervention. Similarly, Wansink et al. (12) introduced a Nutrition Report Card for children aged 5-14 years. In this study, they utilized school purchase records to inform parents about their children’s food choices at school lunch, such as fruits, vegetables, snacks, and desserts. The results showed that the selection of some of the unhealthy foods (e.g., cookies) in the treatment group significantly decreased from pre- to post-intervention. However, the evidence offered by this study was limited because the report card only reflected the food choices of the child and overlooked other important aspects of healthy eating practices, namely daily breakfast consumption and adequate fruit and vegetable consumption. Additionally, the study did not apply any validated measurement tools for evaluating the effectiveness of the intervention. It is worth pointing out that these previous studies (11, 12) on health-related report cards targeted older children or adolescents rather than preschool-aged children, so the effectiveness of such interventions on preschool-aged children’s eating practices remains unclear. It is highly important to bridge this knowledge gap because establishing healthy eating habits during early childhood is critical for growth and development and can have lifelong effects on health (3, 4). Additionally, the report cards utilized in these previous studies (11, 12) only display the basic health-related information of the children, such as weight status and food selection records, without incorporating a traditional letter grade system (e.g., A+ to F) to evaluate how well the children adhere to the given health behaviors or health standards. Therefore, the interpretation of these report cards might be subject to the health literacy levels and understanding of health behavior standards among parents and children, which might vary between individuals and families (13). Previous research has developed a valid and reliable framework for a Healthy Eating Report Card using letter grades (i.e., from “A+; Excellent” to “F; Very Poor”) to reflect the extent to which preschool-aged children, on average, in a specific region or country could meet recommendations and guidelines for healthy eating established by global health authorities (14, 15). This report card provides a comprehensive assessment of various children’s eating behaviors (e.g., diet variety, breakfast consumption, vegetable and fruit intake, and mealtime behaviors) and family home food environments (FHFEs) (e.g., parental food preparation and choices and the family mealtime environment). The framework of the report card has been successfully applied in Australia, Hong Kong, Singapore, and the United States, demonstrating good score-reliability and validity, and high robustness across cultures (16). The results also revealed that Australia and Hong Kong received higher grades (“B-”; Good) compared to Singapore and the US (“C+”; Fair) (15). While this report card offers valuable insights into the status of healthy eating of preschool-aged children at the regional and international levels, it has not yet been used to assess children’s eating practices at the individual level. To preliminarily utilize the framework of the Healthy Eating Report Card (14, 15) at the individual level, our study aimed to develop a parent-based intervention of a personalized Healthy Eating Report Card that specifically focused on improving healthy eating practices among preschool-aged children. This intervention provided each child and parent with a Healthy Eating Report Card that was tailored to their specific eating patterns. The report card presented letter grades to inform parents about how well their child adhered to healthy eating guidelines (e.g., meeting the recommended daily intake of fruits and vegetables) and engaged in favorable home food and mealtime environments (e.g., following regular meal schedules). Based on the personalized letter grades of the report card, actionable feedback could be provided to parents and children to raise their awareness of children’s healthy eating and to facilitate an adaptive FHFE, ultimately improving their eating practices. The present study The present study examined the effect of presenting a personalized Healthy Eating Report Card to parents on improving preschool-aged children’s healthy eating practices (i.e., eating behaviors and FHFEs). We hypothesized that there would be significant differences in the overall report card score among the groups ( H1 ). Specifically, young children whose parents received their personalized Healthy Eating Report Cards (i.e., the intervention group) would show better improvement in their healthy eating practices compared to those who received the government leaflet (i.e., usual care group; H 1a ) or those who received no healthy eating material (i.e., mere-measurement control group; H1b ). There would be no significant differences in improvement between the usual care group and the mere-measurement control group ( H1c ). 2. Method 2.1 Participants , recruitment , and sample size In September 2023, invitation letters were randomly sent to 66 normal local kindergartens across 18 districts in Hong Kong. Eight kindergartens from three main regions of Hong Kong (i.e., four from New Territories, one from children from Kowloon, and three from Hong Kong Island) agreed to participate in this study and distribute the questionnaire to eligible parents. Parents were eligible for inclusion in the study if they (i) were Chinese parents or guardians, (ii) had at least one child aged 2 to 6, and (iii) were able to read Chinese to complete the questionnaire and read the materials. Children with any medical conditions were excluded from this study to ensure that their eating practices and outcomes were not influenced by underlying health issues. Our final sample comprised 331 parent-child dyads, which was considered adequate based on a priori statistical power analysis indicating that a minimum sample size of 314 was required (i.e., estimated by a small effect size (Cohen’s d = .24) from previous meta-analyses on children’s dietary interventions (17), 80% power, a Bonferroni-adjusted alpha of .017, and a potential dropout rate of 15%). The study sample consisted of mothers (87.9%), fathers (10.3%), and other guardians (1.8%). The parents had a mean age of 36.7 years ( SD = 5.44, range 24–55), and their children’s mean age was 4.8 years ( SD = 0.96), with 45.9% being girls. Most children were in upper kindergarten (K3) (41.1%), followed by lower kindergarten (K2) (29.0%), nursery (K1) (26.6%), and pre-nursery (PN) (3.3%). 2.2 Procedures The present study was a randomized controlled trial (RCT) that utilized a single-blinded, three-arm parallel group design. Outcome assessments of the trial were conducted at baseline (T0) and 1-month (T1). The protocol of this study was registered in the Chinese Clinical Trial Registry [Registration no.: ChiCTR2400092558] and was ethically approved by the Human Research Ethics Committee of the first author’s institution [Reference no.: 2022-2023-0450]. The kindergartens and parents of the child participants provided written informed consent before the study began. After the baseline assessment, we randomly allocated the participants into one of three groups: (1) the intervention group (i.e., the participants and their parents received the personalized Healthy Eating Report Card), (2) the usual care group (i.e., the participants and their parents received the standard leaflets of healthy diet from the Department of Health of the Hong Kong government, and (3) the mere-measurement control group (i.e., neither the personalized Healthy Eating Report Card nor the government leaflet was given). The randomization was performed by computer balloting to assign each block of participants to one of the three groups in a 1:1:1 ratio. Block randomization was performed by each recruitment site to ensure the balance in sample allocation, thereby minimizing bias and controlling for the potential effects of the location of the kindergarten on the outcomes, such as variations in socioeconomic or environmental factors (18). Under the single-blinded design, only the participants (not the research associates who delivered the assessments and intervention materials) were kept unaware of the study design, group allocation, and expected outcomes of the study, but they were informed of the study’s purposes. Follow-up assessments were completed approximately one month after the delivery of the report card. As a token of appreciation for their participation, each participant received a supermarket voucher of HKD$50 (approximately USD $6.42) after the completion of each assessment. The CONSORT diagram of the study is shown in Figure 1. Both the completed CONSORT checklist and TIDieR checklist are also presented in Additional Files 1 and 2. 2.3 Intervention design 2.3.1 Intervention group The target treatment of this RCT was a personalized Healthy Eating Report Card specifically tailored for each child in the intervention group. In this personalized Healthy Eating Report Card, we assigned letter grades that reflected children’s eating behaviors and FHFEs based on their responses to the International Healthy Eating Report Card Scale (IHERCS) (16) at baseline. The grades in each personalized Report Card represented the extent to which the healthy eating practices of a particular child could meet the predefined benchmarks for healthy eating, so this approach differed from the typical findings of the Healthy Eating Report Cards in previous studies (14, 15), which only evaluated the healthy eating practices of children at the population level rather than on an individual basis. In particular, the personalized Report Card focused on assessing two indicators of children’s eating behaviors (i.e., Children’s Eating Patterns and Children’s Mealtimes Behaviors) and three indicators of FHFEs (i.e., Parental Food Choices and Preparation, Home Healthier Food Availability and Accessibility, and Family Mealtime Environments) which aligned with those used in the previously published International Healthy Eating Report Card (15). We adapted the existing benchmarks for determining the letter grade to align with the unique context of each child and their parents. We also aimed to assess the extent to which the child or their parents adhere to the list of recommendations and guidelines of the global health authorities for healthy eating (15). The traditional letter grading rubric was adopted to demonstrate the percentage of benchmarks within the indicator that could be met by the child or parents (i.e., A (≥ 80%) = Excellent, B (60–79%) = Good, C (40%–59%) = Fair, D (20%–39%) = Needs Improvement, F (<20%) = Poor and using plus (+) and minus (-) grade scale to show the upper or lower 5% of the grade range) (15, 19). Each personalized Report Card included an overall letter grade (i.e., the average grade of eating behaviors and FHFEs), an overall score (i.e., the percentage of benchmarks met by the child or their parents), and individual subgrades for specific indicators. In addition to these assessments, the personalized Healthy Eating Report Card provided specific actionable recommendations for improving children's eating habits and enhancing the family mealtime environment. These recommendations were derived from guidelines established by international health authorities, such as the World Health Organization (6, 20-24). They were presented in a clear, accessible format to equip parents with practical strategies for supporting their children's healthy eating behaviors and fostering positive FHFEs. Once the research associates generated the personalized Healthy Eating Report Cards, kindergarten teachers were asked to distribute them to each participant in the intervention group. Examples of the Chinese and English versions of the Personalized Healthy Eating Report Card are presented in more detail [see Additional file 3]. 2.3.2 Usual care group and mere-measurement control group The participants in the usual care group received only the leaflet established by the Department of Health of the Hong Kong Special Administrative Region. The materials were also distributed by the corresponding kindergarten teachers. This leaflet provided guidance for establishing healthy eating habits and fostering favorable FHFEs for preschool-aged children. It also serves as the current standard of governmental promotional material for healthy eating among preschool-aged children in Hong Kong (25). The leaflet is accessible to the public through the government website and local health centers or clinics (https://www.fhs.gov.hk/tc_chi/health_info/child/12185.html). The participants who were allocated to the mere-measurement control group did not receive any healthy eating-related materials. They were only invited to complete outcome assessments at T0 and T1. 2.5 Measure The parent self-reported questionnaire of the International Healthy Eating Report Card Scale (IHERCS) (16) was adopted to assess the children’s eating behaviors and FHFEs. This scale has been validated cross-culturally and consisted of 43 items that align with the five dimensions of the Healthy Eating Report Card (i.e., (1) Children’s Dietary Patterns and (2) Children’s Mealtime Behaviours, (3) Parental Food Choices and Preparation, (4) Home Healthier Food Availability and Accessibility and (5) Family Mealtime Environments). Participants responded to the questionnaire items using a 5-point Likert scale (e.g., ranging from 1 = never to 5 = always ), open-ended questions (e.g., the average number of days in a week and the amount of vegetables consumed), and (3) multiple-choice questions (e.g., selecting from a list of snacks and drinks). The questionnaire was designed to be completed jointly by parents and caregivers familiar with the child’s dietary intake and eating behaviors. This scale has been tested across different Western and Chinese regions/countries, including Hong Kong, and has demonstrated an acceptable level of internal consistency and robust psychometric properties. The Cronbach’s alphas for the scale in this study were acceptable at baseline (α = .61–.84) and post-test (α = .64–.79). The assessment tool of the IHERCS is available in the supplementary document of the previous study (16). In addition, participants were asked to respond to self-reported measures of socioeconomic and demographic details, such as parents' age, gender, income, employment status, educational attainment, and the district they currently live in, as well as their children’s date of birth, gender, and grade. 2.7 Data analyses Descriptive statistics were performed to examine the baseline characteristics of the participants’ demographic information. A one-way analysis of variance (ANOVA) and a Chi-Square test of independence were conducted to ensure the equivalency of the intervention and control groups in sociodemographic factors and baseline measures and to determine whether there were any significant differences in attrition rates between groups. To test H1, an analysis of covariance (ANCOVA) was conducted to examine whether the mean differences in the outcome variable (i.e., the overall report card score) between the groups from baseline to post-test while following the intention-to-treat principle (26). The baseline overall report card score was used as a covariate, while the post-test score served as the dependent variable in the analysis. Sociodemographic characteristics (e.g., the continuous variable: parent’s education level and the dichotomous variable: median household income (below vs. above)) that demonstrated significant zero-order correlations with the outcome variable were included as covariates in the general linear model. Statistical assumptions of ANCOVA were assessed before conducting the analyses. The data were checked for normality using skewness (ranging from -.19 to -.18) and kurtosis (ranging from -.31 to -.30), which fall within the acceptable range for normal distribution. Homogeneity of variance was also confirmed using Levene’s test. When significant group differences were detected, Bonferroni’s post-hoc tests were performed to test H1a-H1c to determine which groups exhibited significant differences in their improvement of the overall report card score. To unpack the effect of improvement in healthy eating practices within each group, we conducted Bonferroni-corrected paired-sample t-tests to examine the change in the report card overall score from T0 to T1. Missing data, accounting for 13.2% of the data because of loss of follow-up at T1, were imputed using the expectation maximization (EM) method (27), which assumed that data were missing completely at random (Little's MCAR test: p = .337) and provided unbiased parameter estimates under this assumption. To further assess the robustness of the findings, a sensitivity analysis was conducted by repeating the abovementioned analyses using listwise deletion to determine if missing data significantly moderated the effectiveness of the intervention. The data were analyzed using the Statistical Package for Social Sciences (SPSS) 27.0. Statistical significance was defined as p ≤ .05, two-tailed. 3. Results 3.1 Preliminary analysis Descriptive statistics of the sociodemographic variables and the outcome variable (i.e., the overall report card score) assessed at T0 across the three groups are presented in Table 2. Regarding the equivalency between groups, no significant differences were found in the sociodemographic variables or the overall report card score among the three groups at baseline (all p > .05). In addition, no statistically significant differences were observed in attrition rates between the groups (χ²(2) = 2.048, p = .359). 3.2 Outcomes The correlation coefficients between the overall report card score at pre-test and post-test and demographic variables across the three groups are shown in Table 2. No significant correlations were found between demographic variables and the overall report card score (all p > .05), so the main analysis did not add any demographic variables as covariates. The ANCOVA analysis indicated that the overall report card score [ F (2,327) = 3.98, p = .020, η p 2 = .02] was statistically different between the three groups after adjusting for the baseline value. Bonferroni post-hoc tests revealed that children in the intervention group ( M T0 : 26.17, SD = 4.59; M T1 : 27.36, SD = 4.03) showed a significantly greater improvement compared to those in the mere-measurement control group ( M T0 : 26.63, SD = 4.64; M T1 : 26.48, SD = 4.93; p = .016). Specifically, the overall report card score for the intervention group significantly improved by 4.6% from T0 to T1 with a small-to-medium effect size ( t (113) = 3.96, p < .001, d = .37), whereas the mere-measurement control group experienced a slight decrease of 0.6%, which was not statistically significant ( t (108) = 0.45, p = .655, d = .04). The usual care group showed a 2.4% improvement in the overall report card score from T0 to T1 ( M T0 : 26.57, SD = 5.42; M T1 : 27.20, SD = 5.70), but this improvement was not statistically significant ( t (107) = 1.80, p = .074, d = .17). Additionally, the improvement of the overall report card score of the usual care group was not significantly different from that of either the intervention group ( p = .889) or the mere-measurement control group ( p = .255). Descriptive statistics for the overall report card scores at T0 and T1 by group are presented in Table 3. Sensitivity analysis revealed that the intervention effects in the complete case analysis ( n = 297) were comparable with those obtained using the EM method. Specifically, children in the intervention group showed a significantly greater improvement in the overall report card score compared to the mere-measurement control group ( p = .023), but not the usual care group ( p = .914), while no significant improvement was observed between the usual care group and the mere-measurement control group ( p = .306). Therefore, the main findings of the intervention using the EM method were demonstrated to be robust to missing data imputation. Discussion The current RCT study examined the effect of the parent-based healthy eating intervention on the healthy eating patterns of preschool-aged children in Hong Kong. While previous studies of the Healthy Eating Report Card only reflected regional or national grading of healthy eating (14, 15), our study was the first application of the Healthy Eating Report Card for revealing and intervening in the healthy eating practices of young children at the individual level. The results from a total of 331 parent-child dyads empirically supported the hypotheses about the effectiveness of the intervention ( H1a-H1c ). Specifically, the intervention group receiving the personalized Healthy Eating Report Card showed a significant improvement in children’s healthy eating practices, with a greater improvement in the overall report card score than those in the mere-measurement control group. In contrast, the improvement in children in the usual care group whose parents received governmental promotional material was not significantly different from that in either the intervention group or the mere-measurement control group. The intervention group demonstrated a small-to-medium effect size ( d = .37) with a 4.6% improvement in the overall report card score after the intervention. While the results were preliminary, the intervention demonstrated potential as an effective tool for improving children's eating practices. These findings are comparable with the previous RCTs, which have shown those report card interventions as effective strategies for health promotion, such as reducing children’s unhealthy food choices at school, increasing parents’ awareness of their child's weight status, and encouraging positive action to manage weight (11, 12, 28). Together, these findings support the effectiveness of using report cards to inform parents about a child’s health information, progress and outcomes as an effective awareness-raising strategy for promoting health-related behaviors in children. In contrast to the report card interventions of previous studies, namely the BMI Report Card (11) and the Nutrition Report Card (12), targeted primarily older children, the current intervention specifically focused on preschool-aged children, which is a critical age for developing healthy eating habits (3, 4). The report card of this study also incorporated the traditional letter grade system (i.e., A+; Excellent to F; Poor) to allow parents to understand their child's adherence to healthy eating practices more easily and quickly. The report card may also identify areas where improvements in eating behaviors are needed. Furthermore, the current report card assessed a broader range of children’s eating practices, such as regular breakfast consumption, fruit and vegetable intake, and the family mealtime environment, providing a more holistic evaluation compared to the previous interventions that provided only limited specific health information, such as weight status or food selection records. Notably, our study assessed actual behavioral health outcomes in children (i.e., improvement in children’s eating practices) rather than relying on parental awareness of children’s health, thereby addressing a limitation of previous studies in demonstrating the effectiveness of the report card. Moreover, this study utilized a rigorous RCT design and a validated measurement tool (i.e., the IHERCS) to enhance the statistical robustness of the findings, thereby increasing the reliability, validity and generalizability of the results to provide a more robust evaluation of the effectiveness of the intervention. The current personalized Healthy Eating Report Card represents a novel adaptation of the established framework of the International Healthy Eating Report Card, which provides a comprehensive assessment of children’s eating behaviors and FHFEs (15). However, it differs from the original framework by incorporating individualized letter grades that accurately reflect each child’s adherence to healthy eating guidelines established by global health authorities and their involvement in a favorable home food environment. This approach can provide a personalized assessment of each child’s progress by providing individualized letter grades, scores, and feedback, thereby enhancing parents’ understanding of their child’s current healthy eating status and highlighting areas for improvement. Moreover, it addressed the existing gaps in this prior version of the Healthy Eating Report Card by adapting it from an international tool to an individual-level intervention aimed at directly promoting healthy eating among young children (15). This adaptation could expand the utility of the report card by providing personalized and actionable recommendations tailored to the needs of children and their families. The Healthy Eating Report Card intervention is considered a highly cost-effective and scalable approach to promote healthy eating practices among preschool-aged children. In contrast to other healthy eating interventions, such as those that rely on smartphone applications or parenting workshops, which often incur higher implementation costs and labor resources (29), the report card can provide a more cost-effective alternative for enhancing parental awareness and promoting adherence to healthy eating guidelines for their children (30). The report card is generated based on parents’ responses to the IHERCS, thereby minimizing the reliance on costly technology or in-person sessions. The report card can be distributed to parents either digitally or in print, providing personalized feedback on the child's dietary behaviors and FHFEs without incurring additional ongoing costs, such as frequent technological updates, specialized personnel, or recurring program maintenance, therefore, reducing the financial burden compared to other traditional interventions. Future studies could assess the cost-effectiveness of the personalized Healthy Eating Report Card intervention by comparing its costs and health outcomes with those of traditional interventions (31, 32). Additionally, with its comprehensive benchmark framework to guide the process of assigning a letter grade and score to each child, the report card could serve as a scalable tool to enable standardized, systematic assessment of children's progress so that it allows parents to track changes over time and gain an accurate understanding of their child’s eating behaviors. Limitations Several limitations should be mentioned. First, the duration of the intervention was relatively short as the report card intervention was only distributed to parents once and evaluated over a one-month period which might not have provided sufficient time to observe sustained behavior changes. Therefore, future research should extend the intervention period by distributing the report card on a weekly or monthly basis while incorporating follow-up assessments to evaluate the long-term effects of the intervention. Second, this study solely relied on the parent-reported measure to assess the outcomes of children’s eating practices, so the results may be susceptible to response biases, including social desirability, acquiescence, and potential recall errors associated with dietary data (33-35). To enhance the validity of future research, objective measures, such as body mass index and assessments of children's body composition, should be considered as additional outcome measures. Lastly, while this study did not integrate a theoretical framework to support changes in parents' adherence to healthy eating guidelines for their children, future research could apply, such as an integrated model of self-determination theory and the theory of planned behavior (36), to further enhance parents' long-term commitment to these guidelines to promote sustained healthy eating practices for their children. Conclusion The current study examined the effect of a parent-based intervention using the personalized Healthy Eating Report Card to improve children’s healthy eating patterns. We expanded the utility of the established Healthy Eating Report Card from an international tool to an individual-level resource to promote healthy eating among children. The findings provide promising evidence that children in the intervention group whose parents received the Healthy Eating Report Card demonstrated greater improvement in their eating practices compared to those in the mere-measurement control group. In contrast, the usual care group, whose parents received governmental promotional material, showed no significant improvement compared to either the intervention or mere-measurement control group, highlighting the limited impact of the usual care group. We believe that this research supports the application of the personalized report card as an effective, cost-effective, and scalable tool to enhance parental awareness and promote children’s health-related behaviors. Abbreviations ANCOVA : An analysis of covariance ANOVA: A one-way analysis of variance CI: Confidence interval EM: Expectation maximization FHFEs: Family home food environments IHERCS: International Healthy Eating Report Card Scale Little's MCAR test: Little's Missing Completely at Random Test TIDieR checklist: Template for Intervention Description and Replication checklist RCT: Randomized controlled trial SPSS: Statistical Package for Social Sciences Declarations Ethics approval and consent to participate The study was approved by the Human Research Ethics Committee of the first author’s institution [Reference no.: 2022-2023-0450], and informed written consent was obtained from each participating school and participant. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors declare financial support was received for the research, authorship, and/or publication of this article. The project is funded by the Research Impact Cluster Fund by the first author’s institution. Authors' contributions A.W. contributed to conceptualization, data curation, formal analysis, investigation, methodology, project administration, validation, and writing (including both the original draft and review & editing). K.C. and J.-B.L. contributed to conceptualization, investigation, project administration, supervision, and writing (review & editing). S.X. contributed to formal analysis, investigation, validation, methodology, and writing (review & editing). D.C. contributed to conceptualization, funding acquisition, investigation, project administration, resource management, supervision, validation, and writing (review & editing). All authors reviewed and approved the final manuscript. Acknowledgements The authors thank Ms. Kiko Leung, Mr. Marco Choi, Ms. Ivy Wong and Ms. Tracy C. W. Tang from the first author’s institution for their assistance in preparing study materials and recruiting participants. The authors also thank the eight participating kindergartens in Hong Kong for facilitating the distribution and collection of questionnaires. References Schwartz C, Scholtens PA, Lalanne A, Weenen H, Nicklaus S. Development of healthy eating habits early in life. Review of recent evidence and selected guidelines. Appetite. 2011;57(3):796-807. Black AP, D’Onise K, McDermott R, Vally H, O’Dea K. How effective are family-based and institutional nutrition interventions in improving children’s diet and health? A systematic review. BMC Public Health. 2017;17:1-19. Craigie AM, Lake AA, Kelly SA, Adamson AJ, Mathers JC. Tracking of obesity-related behaviors from childhood to adulthood: a systematic review. 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The influence of parental dietary behaviors and practices on children’s eating habits. Nutrients. 2021;13(4):1138. Touyz LM, Wakefield CE, Grech AM, Quinn VF, Costa DSJ, Zhang FF, et al. Parent-targeted home-based interventions for increasing fruit and vegetable intake in children: a systematic review and meta-analysis. Nutr Rev. 2018;76(3):154-73. Vannest KJ, Davis JL, Davis CR, Mason BA, Burke MD. Effective intervention for behavior with a daily behavior report card: A meta-analysis. School Psych Rev. 2010;39(4):654-72. Chomitz VR, Collins J, Kim J, Kramer E, McGowan R. Promoting healthy weight among elementary school children via a health report card approach. Arch Pediatr Adolesc Med. 2003;157(8):765-72. Wansink B, Just DR, Patterson RW, Smith LE. Nutrition report cards: an opportunity to improve school lunch selection. PLoS One. 2013;8(10):e72008. Liechty JM, Saltzman JA, Musaad SM. Health literacy and parent attitudes about weight control for children. Appetite. 2015;91:200-8. Wan AWL, Chung KKH, Li J-B, Chan DKC. Healthy Eating Report Card for Preschool Children in Hong Kong. Hong Kong Medical Journal. 2024;30(3):209-17. Wan AWL, Chung KKH, Li J-B, Xu SS, Chan DKC. A report card assessment of the prevalence of healthy eating among preschool-aged children: a cross-cultural study across Australia, Hong Kong, Singapore, and the US. Front Nutr. 2024;11. Wan AWL, Chung KKH, Li J-B, Xu SS, Chan DKC. An assessment tool for the international healthy eating report card for preschool-aged children: A cross-cultural validation across Australia, Hong Kong, Singapore, and the United States. Front Nutr. 2024;11:1340007. Borrelli B, Tooley EM, Scott-Sheldon LA. Motivational interviewing for parent‒child health interventions: a systematic review and meta-analysis. Pediatr Dent. 2015;37(3):254-65. Efird J. Blocked randomization with randomly selected block sizes. Int J Environ Res Public Health. 2011;8(1):15-20. Silva DAS, Aubert S, Manyanga T, Lee E-Y, Salvo D, Tremblay MS. Physical Activity Report Card Indicators and the United Nations Sustainable Development Goals: Insights From Global Matrix 4.0. Journal of Physical Activity and Health. 2024;21(12):1372-81. World Health Organization. Healthy diet key facts. Geneva, Switzerland: World Health Organization; 2020. Available online: https://www.who.int/news-room/fact-sheets/detail/healthy-diet. Accessed 5 May 2022. World Health Organization. Healthy diet. Geneva, Switzerland: World Health Organization; n.d. Available online: https://www.who.int/initiatives/behealthy/healthy-diet. Accessed 5 May 2022. EFSA Panel on Dietetic Products, Nutrition, and Allergies. Scientific opinion on dietary reference values for water. EFSA Journal. 2010;8(3):1459-507. American Academy of Pediatrics. Preschooler food and feeding. Itasca, The United States: American Academy of Pediatrics; 2021. Available online: https://www.aap.org/en/patient-care/healthy-active-living-for-families/preschooler-food-and-feeding/. Accessed 5 May 2022. Centers for Disease Control and Prevention. Mealtime routines and tips. Atlanta, The United States: Centers for Disease Control and Prevention; 2021. Available online: https://www.cdc.gov/nutrition/infantandtoddlernutrition/mealtime/mealtime-routines-and-tips.html. Accessed 5 May 2022. HKSAR Family Health Service. Healthy eating for preschool children (2 years to 5 years old). Hong Kong SAR: Department of Health; 2019. Available online: https://www.fhs.gov.hk/english/health_info/child/12185.html. Accessed 5 July 2022. Montori VM, Guyatt GH. Intention-to-treat principle. CMAJ. 2001;165(10):1339-41. Little RJ, Rubin DB. Statistical analysis with missing data: John Wiley & Sons; 2019. Thompson HR, Madsen KA. The report card on BMI report cards. Current Obesity Reports. 2017;6(2):163-7. Snuggs S, Houston-Price C, Harvey K. Healthy eating interventions delivered in the family home: A systematic review. Appetite. 2019;140:114-33. Poole MK, Gortmaker SL, Barrett JL, McCulloch SM, Rimm EB, Emmons KM, et al. The societal costs and health impacts on obesity of BMI report cards in US schools. Obesity. 2023;31(8):2110-8. Weatherly H, Drummond M, Claxton K, Cookson R, Ferguson B, Godfrey C, et al. Methods for assessing the cost-effectiveness of public health interventions: key challenges and recommendations. Health Policy. 2009;93(2-3):85-92. Cobiac LJ, Vos T, Barendregt JJ. Cost-effectiveness of interventions to promote physical activity: a modeling study. PLoS Med. 2009;6(7):e1000110. Chan DKC, Ivarsson A, Stenling A, Yang XS, Chatzisarantis NLD, Hagger MS. Response-order effects in survey methods: A randomized controlled crossover study in the context of sport injury prevention. J Sport Exerc Psychol. 2015;37(6):666-73. Chan DKC, Stenling A, Yusainy C, Hikmiah Z, Ivarsson A, Hagger MS, et al. Editor's Choice: Consistency tendency and the theory of planned behavior: A randomized controlled crossover trial in a physical activity context. Psychol Health. 2020;35(6):665-84. Althubaiti A. Information bias in health research: definition, pitfalls, and adjustment methods. Journal of multidisciplinary healthcare. 2016:211-7. Hagger MS, Chatzisarantis NLD. Integrating the theory of planned behavior and self-determination theory in health behavior: A meta-analysis. Br J Health Psychol. 2009;14(2):275-302. Tables Table 1 Baseline demographic characteristics of the participants in the three groups Characteristic Total ( N =331) Report card intervention ( n =114) Usual care ( n =108) Mere-measurement control ( n =109) p- value % n % n % n % n Child Gender .827 Girl 45.9 152 47.4 54 43.5 47 46.8 51 Boy 54.1 179 52.6 60 56.5 61 53.2 58 Child’s age, mean ( SD ) 4.8 (0.96) 4.8 (1.00) 4.7 (0.93) 4.9 (0.95) .306 Grade .902 PN 3.3 11 3.5 4 3.7 4 2.8 3 K1 26.6 88 26.3 30 30.6 33 22.9 25 K2 29.0 96 26.3 30 25.9 28 34.9 38 K3 41.1 136 43.9 50 39.8 43 39.4 43 Parent Respondent .439 Father 10.3 34 11.4 13 6.5 7 12.8 14 Mother 87.9 291 87.7 100 91.7 99 84.4 92 Guardian 1.8 6 0.9 1 1.9 2 2.8 3 Parent’s age, mean ( SD ) 36.8 (5.62) 36.4 (5.19) 36.2 (6.16) 37.8 (5.40) .072 Educational level .890 Primary education 60.7 201 60.7 71 62.0 67 57.8 63 Diploma/ Associate degree 19.9 66 19.9 21 18.5 20 22.9 25 Degree/ Postgraduate 19.3 64 19.3 22 19.4 21 19.3 21 Number of children, mean ( SD ) 1.9 (0.74) 1.8 (0.72) 1.8 (0.73) 2.0 (0.78) .178 Above median household income 42.0 139 43.9 50 41.7 45 40.4 44 .867 Two-parent family 88.5 293 88.6 101 87.0 94 89.9 98 .802 Working father 87.6 290 89.5 102 85.2 92 88.1 96 .615 Working mother 47.4 157 49.1 56 45.4 49 47.7 52 .853 Baseline scores Overall report card 26.5 (4.88) 26.2 (4.59) 26.6 (5.42) 26.6 (4.64) .739 Note. p values are shown for group comparisons using one-way ANOVA or Chi-Square test of independence. PN, Pre-nursery; K1, Nursery; K2, Lower Kindergarten; K3, Upper kindergarten. Table 2 Correlations between the report card scores at baseline and post-test and demographic variables 1 2 3 4 5 6 7 8 9 10 11 12 13 1. Overall report card score at T0 - 2. Overall report card score at T1 .74 ** - Continuous control variables 3. Parent’s age .04 .02 - 4. Parent’s level of education .09 .07 .09 - 5. Number of children .05 .10 .10 -.17 ** - 6. Child’s age .00 -.01 .12 * -.02 -.04 - 7. Child’s grade .04 .03 .13 * .07 -.07 .89 ** - Dichotomous control variables 8. Working father .03 .08 .06 .01 -.04 .03 .03 - 9. Working mother -.02 -.06 .02 .37 ** -.25 ** -.01 .08 -.08 - 10. Two-parent families .10 .09 .05 .02 .06 .05 .01 .64 ** -.09 - 11. Above median household income .04 .02 .21 ** .48 ** -.14 * -.04 .06 .13 * .37 ** .06 - 12. Parent’s gender -.01 .01 .23 ** .07 -.08 -.02 .05 .04 .12 * .06 .10 - 13. Child’s gender .07 .05 .02 .01 -.08 -.03 .00 .02 -.02 .05 .01 -.03 - Note. * p < .05, ** p < .01. Table 3 Descriptive statistics for the overall report card score at T0 and T1 by group Time Report card intervention group ( n =114) Usual care group ( n =108) Mere-measurement control group ( n =109) Mean ( SD ) 95% CI Mean ( SD ) 95% CI Mean ( SD ) 95% CI T0 26.17 (4.59) 25.32–27.02 26.57 (5.42) 25.54–27.61 26.63 (4.64) 25.75–27.51 T1 27.36 (4.03) 26.61–28.11 27.20 (5.70) 26.12–28.29 26.48 (4.93) 25.54–27.41 Improvement (T1–T0) 1.20 (3.22) 0.60–1.79 0.63 (3.63) 0.06–1.32 -0.16 (3.67) -0.85–0.54 Note . The intention-to-treat principle was performed, and missing data in the post-test were imputed using the expectation maximization method. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1CONSORT2010Checklist.doc Additionalfile2TIDieRChecklist.docx Additionalfile3ExampleofaPersonalizedHealthyEatingReportCard.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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C.","lastName":"Chan","suffix":""}],"badges":[],"createdAt":"2025-02-05 07:23:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5963247/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5963247/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":75909544,"identity":"9e311ece-deeb-4bee-b99f-610df47e3f46","added_by":"auto","created_at":"2025-02-10 12:25:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":164454,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT flow diagram.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5963247/v1/86ffec2fa8e3f5b11a4010fc.png"},{"id":81040564,"identity":"b770120e-cbf9-443d-938d-b2e0deb93718","added_by":"auto","created_at":"2025-04-21 13:31:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1210811,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5963247/v1/2c301020-e2a3-448c-8b65-06ec98829e20.pdf"},{"id":75909573,"identity":"2ec6e5f3-13b6-4040-9bb2-f87d08d9c4d7","added_by":"auto","created_at":"2025-02-10 12:25:22","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":223232,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1CONSORT2010Checklist.doc","url":"https://assets-eu.researchsquare.com/files/rs-5963247/v1/62c57377013a45585264ebd7.doc"},{"id":75909572,"identity":"6276b053-cd61-4721-8c03-37c7ba151da5","added_by":"auto","created_at":"2025-02-10 12:25:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":32995,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2TIDieRChecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-5963247/v1/ce0b5bd41290e4cf37f5df36.docx"},{"id":75909576,"identity":"a3e43d58-bd57-4c35-b117-79e5afa4ffde","added_by":"auto","created_at":"2025-02-10 12:25:22","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":4556233,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3ExampleofaPersonalizedHealthyEatingReportCard.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5963247/v1/e573de732f7b0867d2895e9a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effectiveness of a Personalized Healthy Eating Report Card in Improving Children's Eating Practices: A Randomized Controlled Trial","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePromoting healthy dietary patterns in young children is essential for optimizing their growth and development (1, 2). The preschool period is a critical stage for young children to develop healthy eating patterns, as early adoption of these patterns tends to have a lasting impact on their dietary behaviors and potentially reduces the risk of obesity and diet-related chronic diseases during adolescence and adulthood (3, 4). Despite increasing awareness of the importance of healthy eating\u0026nbsp;in young children, unhealthy dietary patterns, such as frequent consumption of low-nutrient-density snack foods and sugar-sweetened beverages and insufficient consumption of fruits or vegetables, are prevalent worldwide (5, 6). Given the widespread prevalence of unhealthy eating behaviors among young children, it is essential to implement targeted interventions that account for the influential role of parents and families in shaping children\u0026rsquo;s dietary habits. Parents and families play pivotal roles in shaping\u0026nbsp;children\u0026rsquo;s eating patterns by determining the types of food provided, the methods of food preparation, mealtime interactions, and the structure of the mealtime environment (1, 7, 8). Therefore, involving parents in healthy eating interventions is effective in improving children\u0026rsquo;s dietary patterns (9).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA report card intervention is the traditional method used by schools to communicate with parents by using letter grades to evaluate, inform and monitor an individual\u0026rsquo;s particular performance (10). It provides parents with summative information about their child\u0026rsquo;s progress and outcomes (e.g., grades, attendance, or behavior) which allows them to identify areas of achievement and those requiring additional support. While widely used in educational settings, a few studies have also adopted the report card approach in health promotion interventions, given its potential to enhance parental awareness and accountability regarding children\u0026rsquo;s health behaviors. For example, Chomitz et al. (11) developed a BMI report card to monitor elementary school children\u0026apos;s weight and fitness status. The intervention involved sending personalized weight and fitness health report cards to parents. In the report card of Chomitz et al.\u0026rsquo;s study (11), information about the weight category and related fitness data of the children were provided to parents in order to enhance parental awareness of their children\u0026rsquo;s weight status and fitness level. While the findings indicated that the intervention significantly increased parental awareness of overweight children, the study did not examine the extent to which the intervention improved children\u0026rsquo;s actual health outcomes, such as BMI or other fitness levels, thereby limiting its ability to demonstrate the effectiveness of the intervention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, Wansink et al. (12) introduced a Nutrition Report Card for children aged 5-14 years. In this study, they utilized school purchase records to inform parents about their children\u0026rsquo;s food choices at school lunch, such as fruits, vegetables, snacks, and desserts. The results showed that the selection of some of the unhealthy foods (e.g., cookies) in the treatment group significantly decreased from pre- to post-intervention. However, the evidence offered by this study was limited because the report card only reflected the food choices of the child and overlooked other important aspects of healthy eating practices, namely daily breakfast consumption and adequate fruit and vegetable consumption. Additionally, the study did not apply any validated measurement tools for evaluating the effectiveness of the intervention. It is worth pointing out that these previous studies (11, 12) on health-related report cards targeted older children or adolescents rather than preschool-aged children, so the effectiveness of such interventions on preschool-aged children\u0026rsquo;s eating practices remains unclear. It is highly important to bridge this knowledge gap because establishing healthy eating habits during early childhood is critical for growth and development and can have lifelong effects on health\u0026nbsp;(3, 4).\u0026nbsp;Additionally, the report cards utilized in these previous studies (11, 12) only display the basic health-related information of the children, such as weight status and food selection records, without incorporating a traditional letter grade system (e.g., A+ to F) to evaluate how well the children adhere to the given health behaviors or health standards. Therefore, the interpretation of these report cards might be subject to the health literacy levels and understanding of health behavior standards among parents and children, which might vary between individuals and families (13).\u003c/p\u003e\n\u003cp\u003ePrevious research has developed a valid and reliable framework for a Healthy Eating Report Card using letter grades (i.e., from \u0026ldquo;A+; Excellent\u0026rdquo; to \u0026ldquo;F; Very Poor\u0026rdquo;) to\u0026nbsp;reflect\u0026nbsp;the extent to which preschool-aged children, on average, in a specific region or country could meet recommendations and guidelines for healthy eating established by global health authorities\u0026nbsp;(14, 15). This report card provides a comprehensive assessment of various children\u0026rsquo;s eating behaviors (e.g., diet variety, breakfast consumption, vegetable and fruit intake, and mealtime behaviors) and family home food environments (FHFEs) (e.g., parental food preparation and choices and the family mealtime environment). The framework of the\u0026nbsp;report card\u0026nbsp;has been successfully applied in Australia, Hong Kong, Singapore, and the United States, demonstrating good score-reliability and validity, and high robustness across cultures\u0026nbsp;(16). The results also revealed that\u0026nbsp;Australia and Hong Kong received higher grades (\u0026ldquo;B-\u0026rdquo;; Good) compared to Singapore and the US (\u0026ldquo;C+\u0026rdquo;; Fair) (15). While this report card offers valuable insights into the status of healthy eating of preschool-aged\u0026nbsp;children at the regional and international levels, it has not yet been used to\u0026nbsp;assess children\u0026rsquo;s eating\u0026nbsp;practices at the\u0026nbsp;individual level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo preliminarily utilize the framework of the\u0026nbsp;Healthy Eating Report Card\u0026nbsp;(14, 15) at the individual level, our study aimed to develop a parent-based intervention of a personalized\u0026nbsp;Healthy Eating Report Card that specifically focused on improving healthy eating practices among preschool-aged children.\u0026nbsp;This intervention provided each child and parent with a Healthy Eating Report Card that was tailored to their specific eating patterns. The report card presented letter grades to inform parents about how well their child adhered to healthy eating guidelines (e.g., meeting the recommended daily intake of fruits and vegetables) and engaged in favorable home food and mealtime environments (e.g., following regular meal schedules). Based on the personalized letter grades of the report card, actionable feedback could be provided to parents and children to raise their awareness of children\u0026rsquo;s healthy eating and to facilitate an adaptive FHFE, ultimately improving their eating\u0026nbsp;practices.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe present study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study examined the effect of presenting a personalized Healthy Eating Report Card to parents on improving preschool-aged children\u0026rsquo;s healthy eating practices (i.e., eating behaviors and FHFEs). We hypothesized that there would be significant differences in the overall report card score among the groups (\u003cstrong\u003eH1\u003c/strong\u003e).\u0026nbsp;Specifically,\u0026nbsp;young children whose parents received their personalized Healthy Eating Report Cards (i.e., the intervention group) would show better improvement in their healthy eating practices compared to those who received the government leaflet (i.e., usual care group; \u003cstrong\u003eH\u003c/strong\u003e\u003cstrong\u003e1a\u003c/strong\u003e) or those who received no healthy eating material (i.e., mere-measurement control group;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eH1b\u003c/strong\u003e).\u0026nbsp;There would be no significant differences in improvement between the usual care group and the mere-measurement control group (\u003cstrong\u003eH1c\u003c/strong\u003e).\u003c/p\u003e"},{"header":"2. Method","content":"\u003cp\u003e\u003cstrong\u003e2.1\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003erecruitment\u003c/strong\u003e\u003cstrong\u003e, and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003esample size\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn September 2023, invitation letters were randomly sent to 66 normal local kindergartens across 18 districts in Hong Kong. Eight kindergartens from three main regions of Hong Kong (i.e., four from New Territories, one from children from Kowloon, and three from Hong Kong Island) agreed to participate in this study and distribute the questionnaire to eligible parents. Parents were eligible for inclusion in the study if they (i) were Chinese parents or guardians, (ii) had at least one child aged 2 to 6, and (iii) were able to read Chinese to complete the questionnaire and read the materials. Children with any medical conditions were excluded from this study to ensure that their eating practices and outcomes were not influenced by underlying health issues. Our final sample comprised 331 parent-child dyads, which was considered adequate based on a priori statistical power analysis indicating that a minimum sample size of 314 was required (i.e., estimated by a small effect size (Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e = .24) from previous meta-analyses on children\u0026rsquo;s dietary interventions (17), 80% power, a Bonferroni-adjusted alpha of .017, and a potential dropout rate of 15%). The study sample consisted of mothers (87.9%), fathers (10.3%), and other guardians (1.8%). The parents had a mean age of 36.7 years (\u003cem\u003eSD\u003c/em\u003e = 5.44, range 24\u0026ndash;55), and their children\u0026rsquo;s mean age was 4.8 years (\u003cem\u003eSD\u003c/em\u003e = 0.96), with 45.9% being girls. Most children were in upper kindergarten (K3) (41.1%), followed by lower kindergarten (K2) (29.0%), nursery (K1) (26.6%), and pre-nursery (PN) (3.3%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was a randomized controlled trial (RCT) that utilized a single-blinded, three-arm parallel group design. Outcome assessments of the trial were conducted at baseline (T0) and 1-month (T1). The protocol of this study was registered in the Chinese Clinical Trial Registry [Registration no.: ChiCTR2400092558] and was ethically approved by the Human Research Ethics Committee of the first author\u0026rsquo;s institution [Reference no.: 2022-2023-0450]. The kindergartens and parents of the child participants provided written informed consent before the study began. After the baseline assessment, we randomly allocated the participants into one of three groups: (1)\u003cstrong\u003e\u0026nbsp;the intervention group\u003c/strong\u003e (i.e., the participants and their parents received the personalized Healthy Eating Report Card), (2) \u003cstrong\u003ethe\u003c/strong\u003e \u003cstrong\u003eusual care group\u003c/strong\u003e (i.e.,\u0026nbsp;the participants and their parents received the standard leaflets of healthy diet from the Department of Health of the Hong Kong government, and (3) \u003cstrong\u003ethe mere-measurement\u003c/strong\u003e \u003cstrong\u003econtrol group\u0026nbsp;\u003c/strong\u003e(i.e., neither\u0026nbsp;the personalized Healthy Eating Report Card nor the government leaflet was given).\u0026nbsp;The randomization was performed by computer balloting to assign each block of participants to one of the three groups in a 1:1:1 ratio.\u0026nbsp;Block randomization was\u0026nbsp;performed\u0026nbsp;by each recruitment site\u0026nbsp;to\u0026nbsp;ensure\u0026nbsp;the balance in sample allocation, thereby minimizing bias and controlling for the potential effects of the\u0026nbsp;location of the\u0026nbsp;kindergarten\u0026nbsp;on the outcomes, such as variations in socioeconomic or environmental factors\u0026nbsp;(18). Under the single-blinded design,\u0026nbsp;only the participants (not the research associates who delivered the assessments and intervention materials)\u0026nbsp;were\u0026nbsp;kept\u0026nbsp;unaware of the study design, group allocation,\u0026nbsp;and expected outcomes of the\u0026nbsp;study, but they were informed of the study\u0026rsquo;s purposes.\u0026nbsp;Follow-up assessments were completed approximately one month after the delivery of the report card.\u0026nbsp;As a token of appreciation for their participation, each participant\u0026nbsp;received\u0026nbsp;a supermarket voucher of HKD$50 (approximately USD $6.42) after the completion of each assessment.\u0026nbsp;The CONSORT diagram of the study is shown in Figure 1. Both the completed CONSORT checklist and TIDieR checklist are also presented in Additional Files 1 and 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Intervention\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.1 Intervention group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe target treatment of this RCT was a personalized Healthy Eating Report Card specifically tailored for each child in the intervention group. In this personalized Healthy Eating Report Card, we assigned letter grades that reflected children\u0026rsquo;s eating behaviors and FHFEs based on their responses to the International Healthy Eating Report Card Scale (IHERCS) (16) at baseline. The grades in each personalized Report Card represented the extent to which the healthy eating practices of a particular child could meet the predefined benchmarks for healthy eating, so this approach differed from the typical findings of the Healthy Eating Report Cards\u0026nbsp;in previous studies\u0026nbsp;(14, 15), which only evaluated\u0026nbsp;the healthy eating\u0026nbsp;practices\u0026nbsp;of children at the population level rather than on an individual basis.\u0026nbsp;In particular, the personalized Report Card focused on assessing two indicators of children\u0026rsquo;s eating behaviors (i.e., Children\u0026rsquo;s Eating Patterns and Children\u0026rsquo;s Mealtimes Behaviors) and three indicators of FHFEs (i.e., Parental Food Choices and Preparation, Home Healthier Food Availability and Accessibility, and Family Mealtime Environments)\u0026nbsp;which aligned with those used in the previously published International Healthy Eating Report Card (15).\u0026nbsp;We adapted the existing benchmarks for determining the letter grade to align with the unique context of each child and their parents. We also aimed to assess the extent to which the child or their parents adhere to the list of recommendations and guidelines of the global health authorities for healthy eating\u0026nbsp;(15).\u0026nbsp;The traditional\u0026nbsp;letter grading rubric was adopted to demonstrate the percentage of benchmarks within the indicator that could be met by the child or parents (i.e., A (\u0026ge; 80%) = Excellent, B (60\u0026ndash;79%) = Good, C (40%\u0026ndash;59%) = Fair, D (20%\u0026ndash;39%) = Needs Improvement, F (\u0026lt;20%) = Poor and using plus (+) and minus (-) grade scale to show the upper or lower 5% of the grade range) (15, 19).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach personalized Report Card included an overall letter grade (i.e., the average grade of eating behaviors and FHFEs), an overall score (i.e., the percentage of benchmarks met by the child or their parents), and individual subgrades for specific indicators. In addition to these assessments, the personalized Healthy Eating Report Card provided specific actionable recommendations for improving children\u0026apos;s eating habits and enhancing the family mealtime environment. These recommendations were derived from guidelines established by international health authorities, such as the World Health Organization (6, 20-24). They were presented in a clear, accessible format to equip parents with practical strategies for supporting their children\u0026apos;s healthy eating behaviors and fostering positive FHFEs. Once the research associates generated the personalized Healthy Eating Report Cards, kindergarten teachers were asked to distribute them to each participant in the intervention group. Examples of the Chinese and English versions of the Personalized Healthy Eating Report Card are presented in more detail [see Additional file 3].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.2\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eUsual care group and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003emere-measurement control group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants in the usual care group received only the leaflet established by the Department of Health of the Hong Kong Special Administrative Region. The materials were also distributed by the corresponding kindergarten teachers. This leaflet provided guidance for establishing healthy eating habits and fostering favorable FHFEs for preschool-aged children. It also serves as the current standard of governmental promotional material for healthy eating among preschool-aged children in Hong Kong (25). The leaflet is accessible to the public through the government website and local health centers or clinics (https://www.fhs.gov.hk/tc_chi/health_info/child/12185.html). The participants who were allocated to the mere-measurement control group did not receive any healthy eating-related materials. They were only invited to complete outcome assessments at T0 and T1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Measure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe parent self-reported questionnaire of the International Healthy Eating Report Card Scale (IHERCS) (16) was adopted to assess the children\u0026rsquo;s eating behaviors and FHFEs. This scale has been validated cross-culturally and consisted of 43 items that align with the five dimensions of the Healthy Eating Report Card (i.e., (1) Children\u0026rsquo;s Dietary Patterns and (2) Children\u0026rsquo;s Mealtime Behaviours, (3) Parental Food Choices and Preparation, (4) Home Healthier Food Availability and Accessibility and (5) Family Mealtime Environments). Participants responded to the questionnaire items using a 5-point Likert scale (e.g., ranging from 1 = \u003cem\u003enever\u003c/em\u003e to 5 = \u003cem\u003ealways\u003c/em\u003e), open-ended questions (e.g., the average number of days in a week and the amount of vegetables consumed), and (3) multiple-choice questions (e.g., selecting from a list of snacks and drinks). The questionnaire was designed to be completed jointly by parents and caregivers familiar with the child\u0026rsquo;s dietary intake and eating behaviors. This scale has been tested across different Western and Chinese regions/countries, including Hong Kong, and has demonstrated an acceptable level of internal consistency and robust psychometric properties. The Cronbach\u0026rsquo;s alphas for the scale in this study were acceptable at baseline (\u0026alpha; = .61\u0026ndash;.84) and post-test (\u0026alpha; = .64\u0026ndash;.79). The assessment tool of the IHERCS is available in the supplementary document of the previous study (16). In addition, participants were asked to respond to self-reported measures of socioeconomic and demographic details, such as parents\u0026apos; age, gender, income, employment status, educational attainment, and the district they currently live in, as well as their children\u0026rsquo;s date of birth, gender, and grade.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.7 Data analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were performed to examine the baseline characteristics of the participants\u0026rsquo; demographic information. A one-way analysis of variance (ANOVA) and a Chi-Square test of independence were conducted to ensure the equivalency of the intervention and control groups in sociodemographic factors and baseline measures and to determine whether there were any significant differences in attrition rates between groups. To test H1, an analysis of covariance (ANCOVA) was conducted to examine whether the mean differences in the outcome variable (i.e., the overall report card score) between the groups from baseline to post-test while following the intention-to-treat principle (26). The baseline overall report card score was used as a covariate, while the post-test score served as the dependent variable in the analysis. Sociodemographic characteristics (e.g., the continuous variable: parent\u0026rsquo;s education level and the dichotomous variable: median household income (below vs. above)) that demonstrated significant zero-order correlations with the outcome variable were included as covariates in the general linear model. Statistical assumptions of ANCOVA were assessed before conducting the analyses. The data were checked for normality using skewness (ranging from -.19 to -.18) and kurtosis (ranging from -.31 to -.30),\u0026nbsp;which fall within the acceptable range for normal distribution. Homogeneity of variance was also confirmed using Levene\u0026rsquo;s test. When significant group differences were detected, Bonferroni\u0026rsquo;s post-hoc tests were performed to test \u003cstrong\u003eH1a-H1c\u003c/strong\u003e to determine which groups exhibited significant differences in their improvement of the overall report card score. To unpack the effect of improvement in healthy eating practices within each group, we conducted Bonferroni-corrected paired-sample t-tests to examine the change in the report card overall score from T0 to T1.\u003c/p\u003e\n\u003cp\u003eMissing data, accounting for 13.2% of the data because of loss of follow-up at T1, were imputed using the expectation maximization (EM) method (27), which assumed that data were missing completely at random (Little\u0026apos;s MCAR test: \u003cem\u003ep\u003c/em\u003e = .337) and provided unbiased parameter estimates under this assumption. To further assess the robustness of the findings, a sensitivity analysis was conducted by repeating the abovementioned analyses using listwise deletion to determine if missing data significantly moderated the effectiveness of the intervention. The data were analyzed using the Statistical Package for Social Sciences (SPSS) 27.0. Statistical significance was defined as \u003cem\u003ep\u003c/em\u003e \u0026le;\u0026thinsp;.05, two-tailed.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Preliminary analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics of the sociodemographic variables and the outcome variable (i.e., the overall report card score) assessed at T0 across the three groups are presented in Table 2. Regarding the equivalency between groups, no significant differences were found in the sociodemographic variables or the overall report card score among the three groups at baseline (all \u003cem\u003ep\u003c/em\u003e \u0026gt; .05). In addition, no statistically significant differences were observed in attrition rates between the groups (\u0026chi;\u0026sup2;(2) = 2.048, \u003cem\u003ep\u003c/em\u003e = .359).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe correlation coefficients between the overall report card score at pre-test and post-test and demographic variables across the three groups are shown in Table 2. No significant correlations were found between demographic variables and the overall report card score (all \u003cem\u003ep\u003c/em\u003e \u0026gt; .05), so the main analysis did not add any demographic variables as covariates.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe ANCOVA analysis indicated that the overall report card score [\u003cem\u003eF\u003c/em\u003e(2,327) = 3.98, \u003cem\u003ep\u003c/em\u003e =\u0026nbsp;.020,\u0026nbsp;\u0026eta;\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e= .02] was statistically different between the three groups after adjusting for the baseline value.\u0026nbsp;Bonferroni post-hoc tests revealed that children in the intervention group (\u003cem\u003eM\u003csub\u003eT0\u003c/sub\u003e\u003c/em\u003e: 26.17, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 4.59; \u003cem\u003eM\u003csub\u003eT1\u003c/sub\u003e\u003c/em\u003e: 27.36, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 4.03) showed a significantly greater improvement compared to those in the mere-measurement control group (\u003cem\u003eM\u003csub\u003eT0\u003c/sub\u003e\u003c/em\u003e: 26.63, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 4.64; \u003cem\u003eM\u003csub\u003eT1\u003c/sub\u003e\u003c/em\u003e: 26.48, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 4.93; \u003cem\u003ep\u003c/em\u003e = .016). Specifically, the overall\u0026nbsp;report card\u0026nbsp;score for the intervention group significantly improved by 4.6% from T0 to T1 with a small-to-medium effect size (\u003cem\u003et\u003c/em\u003e(113) = 3.96, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .001, \u003cem\u003ed\u003c/em\u003e = .37), whereas the mere-measurement control group experienced a slight decrease of 0.6%, which was not statistically significant (\u003cem\u003et\u003c/em\u003e(108) = 0.45, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .655, \u003cem\u003ed\u003c/em\u003e = .04). The usual care group showed a 2.4% improvement in the overall report card score from T0 to T1 (\u003cem\u003eM\u003csub\u003eT0\u003c/sub\u003e\u003c/em\u003e: 26.57, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 5.42; \u003cem\u003eM\u003csub\u003eT1\u003c/sub\u003e\u003c/em\u003e: 27.20, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 5.70), but this improvement was not statistically significant (\u003cem\u003et\u003c/em\u003e(107) = 1.80, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .074, \u003cem\u003ed\u003c/em\u003e = .17). Additionally, the improvement of the overall report card score of the usual care group was not significantly different from that of either the intervention group (\u003cem\u003ep\u003c/em\u003e = .889) or the mere-measurement control group (\u003cem\u003ep\u003c/em\u003e = .255).\u0026nbsp;Descriptive statistics for the overall report card scores at T0 and T1 by group are presented in Table 3.\u003c/p\u003e\n\u003cp\u003eSensitivity analysis revealed that the intervention effects in the complete case analysis (\u003cem\u003en\u003c/em\u003e = 297) were comparable with those obtained using the EM method. Specifically, children in the intervention group showed a significantly greater improvement in the overall report card score compared to the mere-measurement control group (\u003cem\u003ep\u003c/em\u003e = .023), but not the usual care group (\u003cem\u003ep\u003c/em\u003e = .914), while no significant improvement was observed between the usual care group and the mere-measurement control group (\u003cem\u003ep\u003c/em\u003e = .306). Therefore, the main findings of the intervention using the EM method were demonstrated to be robust to missing data imputation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current RCT study examined the effect of the parent-based healthy eating intervention on the healthy eating patterns of preschool-aged children in Hong Kong. While previous studies of the Healthy Eating Report Card only reflected regional or national grading of healthy eating (14, 15), our study was the first application of the Healthy Eating Report Card for revealing and intervening in the healthy eating practices of young children at the individual level. The results from a total of 331 parent-child dyads empirically supported the hypotheses about the effectiveness of the intervention (\u003cstrong\u003eH1a-H1c\u003c/strong\u003e). Specifically, the intervention group receiving the personalized Healthy Eating Report Card showed a significant improvement in children\u0026rsquo;s healthy eating practices, with a greater improvement in the overall report card score than those in the mere-measurement control group. In contrast, the improvement in children in the usual care group whose parents received governmental promotional material was not significantly different from that in either the intervention group or the mere-measurement control group. The intervention group demonstrated a small-to-medium effect size (\u003cem\u003ed\u003c/em\u003e = .37) with a 4.6% improvement in the overall report card score after the intervention. While the results were preliminary, the intervention demonstrated potential as an effective tool for improving children\u0026apos;s eating practices.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese findings are comparable with the previous RCTs, which have shown those report card interventions as effective strategies for health promotion, such as reducing children\u0026rsquo;s unhealthy food choices at school, increasing parents\u0026rsquo; awareness of their child\u0026apos;s weight status, and encouraging positive action to manage weight (11, 12, 28). Together, these findings support the effectiveness of using report cards to inform parents about a child\u0026rsquo;s health information, progress and outcomes as an effective awareness-raising strategy for promoting health-related behaviors in children. In contrast to the report card interventions of previous studies, namely the BMI Report Card (11) and the Nutrition Report Card (12), targeted primarily older children, the current intervention specifically focused on preschool-aged children, which is a critical age for developing healthy eating habits (3, 4). The report card of this study also incorporated the traditional letter grade system (i.e., A+; Excellent to F; Poor) to allow parents to understand their child\u0026apos;s adherence to healthy eating practices more easily and quickly. The report card may also identify areas where improvements in eating behaviors are needed. Furthermore, the current report card assessed a broader range of children\u0026rsquo;s eating practices, such as regular breakfast consumption, fruit and vegetable intake, and the family mealtime environment, providing a more holistic evaluation compared to the previous interventions that provided only limited specific health information, such as weight status or food selection records. Notably, our study assessed actual behavioral health outcomes in children (i.e., improvement in children\u0026rsquo;s eating practices) rather than relying on parental awareness of children\u0026rsquo;s health, thereby addressing a limitation of previous studies in demonstrating the effectiveness of the report card. Moreover, this study utilized a rigorous RCT design and a validated measurement tool (i.e., the IHERCS) to enhance the statistical robustness of the findings, thereby increasing the reliability, validity and generalizability of the results to provide a more robust evaluation of the effectiveness of the intervention.\u003c/p\u003e\n\u003cp\u003eThe current personalized Healthy Eating Report Card represents a novel adaptation of the established framework of the International Healthy Eating Report Card, which provides a comprehensive assessment of children\u0026rsquo;s eating behaviors and FHFEs (15). However, it differs from the original framework by incorporating individualized letter grades that accurately reflect each child\u0026rsquo;s adherence to healthy eating guidelines established by global health authorities and their involvement in a favorable home food environment. This approach can provide a personalized assessment of each child\u0026rsquo;s progress by providing individualized letter grades, scores, and feedback, thereby enhancing parents\u0026rsquo; understanding of their child\u0026rsquo;s current healthy eating status and highlighting areas for improvement. Moreover, it addressed the existing gaps in this prior version of the Healthy Eating Report Card by adapting it from an international tool to an individual-level intervention aimed at directly promoting healthy eating among young children (15). This adaptation could expand the utility of the report card by providing personalized and actionable recommendations tailored to the needs of children and their families.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Healthy Eating Report Card intervention is considered a highly cost-effective and scalable approach to promote healthy eating practices among preschool-aged children. In contrast to other healthy eating interventions, such as those that rely on smartphone applications or parenting workshops, which often incur higher implementation costs and labor resources (29), the report card can provide a more cost-effective alternative for enhancing parental awareness and promoting adherence to healthy eating guidelines for their children (30). The report card is generated based on parents\u0026rsquo; responses to the IHERCS, thereby minimizing the reliance on costly technology or in-person sessions. The report card can be distributed to parents either digitally or in print, providing personalized feedback on the child\u0026apos;s dietary behaviors and FHFEs without incurring additional ongoing costs, such as frequent technological updates, specialized personnel, or recurring program maintenance, therefore, reducing the financial burden compared to other traditional interventions. Future studies could assess the cost-effectiveness of the personalized Healthy Eating Report Card intervention by comparing its costs and health outcomes with those of traditional interventions (31, 32). Additionally, with its comprehensive benchmark framework to guide the process of assigning a letter grade and score to each child, the report card could serve as a scalable tool to enable standardized, systematic assessment of children\u0026apos;s progress so that it allows parents to track changes over time and gain an accurate understanding of their child\u0026rsquo;s eating behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral limitations should be mentioned. First, the duration of the intervention was relatively short as the report card intervention was only distributed to parents once and evaluated over a one-month period which might not have provided sufficient time to observe sustained behavior changes. Therefore, future research should extend the intervention period by distributing the report card on a weekly or monthly basis while incorporating follow-up assessments to evaluate the long-term effects of the intervention. Second, this study solely relied on the parent-reported measure to assess the outcomes of children\u0026rsquo;s eating practices, so the results may be susceptible to response biases, including social desirability, acquiescence, and potential recall errors associated with dietary data (33-35). To enhance the validity of future research, objective measures, such as body mass index and assessments of children\u0026apos;s body composition, should be considered as additional outcome measures. Lastly, while this study did not integrate a theoretical framework to support changes in parents\u0026apos; adherence to healthy eating guidelines for their children, future research could apply, such as an integrated model of self-determination theory and the theory of planned behavior (36), to further enhance parents\u0026apos; long-term commitment to these guidelines to promote sustained healthy eating practices for their children.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe current study examined the effect of a parent-based intervention using the personalized Healthy Eating Report Card to improve children\u0026rsquo;s healthy eating patterns. We expanded the utility of the established Healthy Eating Report Card from an international tool to an individual-level resource to promote healthy eating among children. The findings provide promising evidence that children in the intervention group whose parents received the Healthy Eating Report Card demonstrated greater improvement in their eating practices compared to those in the mere-measurement control group. In contrast, the usual care group, whose parents received governmental promotional material, showed no significant improvement compared to either the intervention or mere-measurement control group, highlighting the limited impact of the usual care group. We believe that this research supports the application of the personalized report card as an effective, cost-effective, and scalable tool to enhance parental awareness and promote children\u0026rsquo;s health-related behaviors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eANCOVA\u003cem\u003e:\u003c/em\u003e\u0026nbsp;\u003c/strong\u003eAn analysis of covariance\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eANOVA:\u003c/em\u003e\u003c/strong\u003e A one-way analysis of variance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCI:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eConfidence interval\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEM:\u0026nbsp;\u003c/strong\u003eExpectation maximization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFHFEs:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eFamily home food environments\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIHERCS:\u003c/em\u003e\u003c/strong\u003e International Healthy Eating Report Card Scale\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLittle\u0026apos;s MCAR test:\u003c/em\u003e\u003c/strong\u003e Little\u0026apos;s Missing Completely at Random Test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTIDieR checklist:\u003c/em\u003e\u003c/strong\u003e Template for Intervention Description and Replication checklist\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRCT:\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eRandomized controlled trial\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSPSS:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eStatistical Package for Social Sciences\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Human Research Ethics Committee of the first author\u0026rsquo;s institution [Reference no.: 2022-2023-0450], and informed written consent was obtained from each participating school and participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare financial support was received for the research, authorship, and/or publication of this article. The project is funded by the Research Impact Cluster Fund by the first author\u0026rsquo;s institution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.W. contributed to conceptualization, data curation, formal analysis, investigation, methodology, project administration, validation, and writing (including both the original draft and review \u0026amp; editing). K.C. and J.-B.L. contributed to conceptualization, investigation, project administration, supervision, and writing (review \u0026amp; editing). S.X. contributed to formal analysis, investigation, validation, methodology, and writing (review \u0026amp; editing). D.C. contributed to conceptualization, funding acquisition, investigation, project administration, resource management, supervision, validation, and writing (review \u0026amp; editing). All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Ms. Kiko Leung, Mr. Marco Choi, Ms. Ivy Wong and Ms. Tracy C. W. Tang from the first author\u0026rsquo;s institution for their assistance in preparing study materials and recruiting participants. The authors also thank the eight participating kindergartens in Hong Kong for facilitating the distribution and collection of questionnaires.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSchwartz C, Scholtens PA, Lalanne A, Weenen H, Nicklaus S. Development of healthy eating habits early in life. Review of recent evidence and selected guidelines. Appetite. 2011;57(3):796-807.\u003c/li\u003e\n\u003cli\u003eBlack AP, D\u0026rsquo;Onise K, McDermott R, Vally H, O\u0026rsquo;Dea K. How effective are family-based and institutional nutrition interventions in improving children\u0026rsquo;s diet and health? A systematic review. BMC Public Health. 2017;17:1-19.\u003c/li\u003e\n\u003cli\u003eCraigie AM, Lake AA, Kelly SA, Adamson AJ, Mathers JC. Tracking of obesity-related behaviors from childhood to adulthood: a systematic review. Maturitas. 2011;70(3):266-84.\u003c/li\u003e\n\u003cli\u003eMovassagh EZ, Baxter-Jones ADG, Kontulainen S, Whiting SJ, Vatanparast H. Tracking dietary patterns over 20 years from childhood through adolescence into young adulthood: The Saskatchewan pediatric bone mineral accrual study. Nutrients. 2017;9(9):990.\u003c/li\u003e\n\u003cli\u003eKupka R, Siekmans K, Beal T. The diets of children: Overview of available data for children and adolescents. Global Food Security. 2020;27:100442.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. How healthy are children\u0026rsquo;s eating habits? \u0026ndash; WHO/Europe surveillance results. Geneva, Switzerland: World Health Organization; 2021. Available online: https://www.who.int/europe/news/item/03-03-2021-how-healthy-are-children-s-eating-habits-who-europe-surveillance-results. Accessed 5 May 2022.\u003c/li\u003e\n\u003cli\u003eFruh S, Williams S, Hayes K, Hauff C, Hudson GM, Sittig S, et al. A practical approach to obesity prevention: Healthy home habits. J Am Assoc Nurse Pract. 2021;33(11):1055-65.\u003c/li\u003e\n\u003cli\u003eMahmood L, Flores-Barrantes P, Moreno LA, Manios Y, Gonzalez-Gil EM. The influence of parental dietary behaviors and practices on children\u0026rsquo;s eating habits. Nutrients. 2021;13(4):1138.\u003c/li\u003e\n\u003cli\u003eTouyz LM, Wakefield CE, Grech AM, Quinn VF, Costa DSJ, Zhang FF, et al. Parent-targeted home-based interventions for increasing fruit and vegetable intake in children: a systematic review and meta-analysis. Nutr Rev. 2018;76(3):154-73.\u003c/li\u003e\n\u003cli\u003eVannest KJ, Davis JL, Davis CR, Mason BA, Burke MD. Effective intervention for behavior with a daily behavior report card: A meta-analysis. School Psych Rev. 2010;39(4):654-72.\u003c/li\u003e\n\u003cli\u003eChomitz VR, Collins J, Kim J, Kramer E, McGowan R. Promoting healthy weight among elementary school children via a health report card approach. Arch Pediatr Adolesc Med. 2003;157(8):765-72.\u003c/li\u003e\n\u003cli\u003eWansink B, Just DR, Patterson RW, Smith LE. Nutrition report cards: an opportunity to improve school lunch selection. PLoS One. 2013;8(10):e72008.\u003c/li\u003e\n\u003cli\u003eLiechty JM, Saltzman JA, Musaad SM. Health literacy and parent attitudes about weight control for children. Appetite. 2015;91:200-8.\u003c/li\u003e\n\u003cli\u003eWan AWL, Chung KKH, Li J-B, Chan DKC. Healthy Eating Report Card for Preschool Children in Hong Kong. Hong Kong Medical Journal. 2024;30(3):209-17.\u003c/li\u003e\n\u003cli\u003eWan AWL, Chung KKH, Li J-B, Xu SS, Chan DKC. 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Physical Activity Report Card Indicators and the United Nations Sustainable Development Goals: Insights From Global Matrix 4.0. Journal of Physical Activity and Health. 2024;21(12):1372-81.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Healthy diet key facts. Geneva, Switzerland: World Health Organization; 2020. Available online: https://www.who.int/news-room/fact-sheets/detail/healthy-diet. Accessed 5 May 2022.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Healthy diet. Geneva, Switzerland: World Health Organization; n.d. Available online: https://www.who.int/initiatives/behealthy/healthy-diet. Accessed 5 May 2022.\u003c/li\u003e\n\u003cli\u003eEFSA Panel on Dietetic Products, Nutrition, and Allergies. Scientific opinion on dietary reference values for water. EFSA Journal. 2010;8(3):1459-507.\u003c/li\u003e\n\u003cli\u003eAmerican Academy of Pediatrics. Preschooler food and feeding. Itasca, The United States: American Academy of Pediatrics; 2021. Available online: https://www.aap.org/en/patient-care/healthy-active-living-for-families/preschooler-food-and-feeding/. Accessed 5 May 2022.\u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention. Mealtime routines and tips. Atlanta, The United States: Centers for Disease Control and Prevention; 2021. Available online: https://www.cdc.gov/nutrition/infantandtoddlernutrition/mealtime/mealtime-routines-and-tips.html. Accessed 5 May 2022.\u003c/li\u003e\n\u003cli\u003eHKSAR Family Health Service. Healthy eating for preschool children (2 years to 5 years old). Hong Kong SAR: Department of Health; 2019. Available online: https://www.fhs.gov.hk/english/health_info/child/12185.html. Accessed 5 July 2022.\u003c/li\u003e\n\u003cli\u003eMontori VM, Guyatt GH. Intention-to-treat principle. CMAJ. 2001;165(10):1339-41.\u003c/li\u003e\n\u003cli\u003eLittle RJ, Rubin DB. Statistical analysis with missing data: John Wiley \u0026amp; Sons; 2019.\u003c/li\u003e\n\u003cli\u003eThompson HR, Madsen KA. The report card on BMI report cards. Current Obesity Reports. 2017;6(2):163-7.\u003c/li\u003e\n\u003cli\u003eSnuggs S, Houston-Price C, Harvey K. Healthy eating interventions delivered in the family home: A systematic review. Appetite. 2019;140:114-33.\u003c/li\u003e\n\u003cli\u003ePoole MK, Gortmaker SL, Barrett JL, McCulloch SM, Rimm EB, Emmons KM, et al. The societal costs and health impacts on obesity of BMI report cards in US schools. Obesity. 2023;31(8):2110-8.\u003c/li\u003e\n\u003cli\u003eWeatherly H, Drummond M, Claxton K, Cookson R, Ferguson B, Godfrey C, et al. Methods for assessing the cost-effectiveness of public health interventions: key challenges and recommendations. Health Policy. 2009;93(2-3):85-92.\u003c/li\u003e\n\u003cli\u003eCobiac LJ, Vos T, Barendregt JJ. Cost-effectiveness of interventions to promote physical activity: a modeling study. PLoS Med. 2009;6(7):e1000110.\u003c/li\u003e\n\u003cli\u003eChan DKC, Ivarsson A, Stenling A, Yang XS, Chatzisarantis NLD, Hagger MS. Response-order effects in survey methods: A randomized controlled crossover study in the context of sport injury prevention. J Sport Exerc Psychol. 2015;37(6):666-73.\u003c/li\u003e\n\u003cli\u003eChan DKC, Stenling A, Yusainy C, Hikmiah Z, Ivarsson A, Hagger MS, et al. Editor\u0026apos;s Choice: Consistency tendency and the theory of planned behavior: A randomized controlled crossover trial in a physical activity context. Psychol Health. 2020;35(6):665-84.\u003c/li\u003e\n\u003cli\u003eAlthubaiti A. Information bias in health research: definition, pitfalls, and adjustment methods. Journal of multidisciplinary healthcare. 2016:211-7.\u003c/li\u003e\n\u003cli\u003eHagger MS, Chatzisarantis NLD. Integrating the theory of planned behavior and self-determination theory in health behavior: A meta-analysis. Br J Health Psychol. 2009;14(2):275-302.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eBaseline demographic characteristics of the participants in the three groups\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eN\u003c/em\u003e =331)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003eReport card intervention\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e=114)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003eUsual care\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e=108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 104px;\"\u003e\n \u003cp\u003eMere-measurement control\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e=109)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cem\u003ep-\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChild\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.827\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e45.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e47.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e43.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e46.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e54.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e52.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e56.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e53.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eChild\u0026rsquo;s age, mean (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003e4.8 (0.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003e4.8 (1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4.7 (0.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.9 (0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.306\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eGrade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.902\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003ePN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eK1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e26.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e30.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e22.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eK2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e29.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e34.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eK3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e41.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e43.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e39.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e39.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eRespondent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.439\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eFather\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e87.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e87.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e91.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e84.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eGuardian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eParent\u0026rsquo;s age, mean (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003e36.8 (5.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003e36.4 (5.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e36.2 (6.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 104px;\"\u003e\n \u003cp\u003e37.8 (5.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.072\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eEducational level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.890\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003ePrimary education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e60.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e60.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e62.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e57.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eDiploma/\u003c/p\u003e\n \u003cp\u003eAssociate degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e19.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e19.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e22.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eDegree/\u003c/p\u003e\n \u003cp\u003ePostgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e19.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNumber of children, mean (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.9 (0.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.8 (0.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.8 (0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.0 (0.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.178\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eAbove median household income\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e42.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e43.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e41.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e40.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.867\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eTwo-parent family\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e88.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e88.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e87.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e89.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.802\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eWorking father\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e87.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e290\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e89.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e85.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e88.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.615\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eWorking mother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e47.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e49.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e45.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e47.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.853\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline scores\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eOverall report card\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003e26.5 (4.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003e26.2 (4.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e26.6 (5.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 104px;\"\u003e\n \u003cp\u003e26.6 (4.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e.739\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote. \u003cem\u003ep\u003c/em\u003e values are shown for group comparisons using one-way ANOVA or Chi-Square test of independence. PN, Pre-nursery; K1, Nursery; K2, Lower Kindergarten; K3, Upper kindergarten.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e\u003cem\u003eCorrelations between the report card scores at baseline and post-test and demographic variables\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"926\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1. Overall report card score at T0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2. Overall report card score at T1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.74\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContinuous control variables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3. Parent\u0026rsquo;s age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4. Parent\u0026rsquo;s level of education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5. Number of children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.17\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e6. Child\u0026rsquo;s age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.12\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e7. Child\u0026rsquo;s grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.13\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.89\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDichotomous control variables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e8. Working father\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e9. Working mother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.37\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.25\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e10. Two-parent families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.64\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e11. Above median household income\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.21\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.48\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.14\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.13\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.37\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e12. Parent\u0026rsquo;s gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.23\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.12\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e13. Child\u0026rsquo;s gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote. \u003csup\u003e*\u003c/sup\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .05,\u003csup\u003e\u0026nbsp;**\u003c/sup\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; .01.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003e\u003cem\u003eDescriptive statistics for the overall report card score at T0 and T1 by group\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 242px;\"\u003e\n \u003cp\u003eReport card intervention group\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e=114)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 242px;\"\u003e\n \u003cp\u003eUsual care group\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e=108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 242px;\"\u003e\n \u003cp\u003eMere-measurement control group\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e=109)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eMean (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eMean (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eMean (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eT0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e26.17 (4.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e25.32\u0026ndash;27.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e26.57 (5.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e25.54\u0026ndash;27.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e26.63 (4.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e25.75\u0026ndash;27.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e27.36 (4.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e26.61\u0026ndash;28.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e27.20 (5.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e26.12\u0026ndash;28.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e26.48 (4.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e25.54\u0026ndash;27.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eImprovement\u003c/p\u003e\n \u003cp\u003e(T1\u0026ndash;T0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e1.20 (3.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e0.60\u0026ndash;1.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e0.63 (3.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e0.06\u0026ndash;1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e-0.16 (3.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e-0.85\u0026ndash;0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote\u003cem\u003e.\u0026nbsp;\u003c/em\u003eThe intention-to-treat principle was performed, and missing data in the post-test were imputed using the expectation maximization method.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"healthy eating intervention, report card, eating behaviors, family home food environment, preschool-aged children","lastPublishedDoi":"10.21203/rs.3.rs-5963247/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5963247/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe present study developed an intervention using a personalized Healthy Eating Report Card\u003cstrong\u003e \u003c/strong\u003eto provide parents with personalized insights into the extent to which their child adhered to international healthy eating guidelines and engaged in favorable family home food environments. This study aimed to assess the effectiveness of this intervention in improving preschool-aged children’s eating practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA three‐armed, single‐blinded randomized controlled trial was conducted with 331 parent-child dyads recruited from eight local kindergartens in Hong Kong. Parents were asked to complete the International Healthy Eating Report Card Scale at baseline and one-month post-intervention. The participants were randomly assigned to one of three groups: (i) the intervention group (who received a personalized Healthy Eating Report Card), (ii) the usual care group (who received a standard government-issued leaflet on healthy eating), or (iii) the mere-measurement control group (who received no healthy eating materials). We examined if the improvement in the overall report card score of the intervention group was statistically higher than that of the other two groups using ANCOVA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe results of ANCOVA\u003cstrong\u003e \u003c/strong\u003edemonstrated that the overall report card score was significantly different among the three groups after adjusting for the baseline value [\u003cem\u003eF\u003c/em\u003e(2,327) = 3.98, \u003cem\u003ep\u003c/em\u003e = .020, η\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e2 \u003c/sup\u003e= .02]. Bonferroni post-hoc tests revealed that children in the intervention group improved significantly more than those in the mere-measurement control group (\u003cem\u003ep\u003c/em\u003e \u0026lt; .05) with an improvement of 4.6%. The overall report card score of the usual care group was not significantly different from that of the intervention group or the mere-measurement control group (\u003cem\u003ep\u003c/em\u003e \u0026gt; .05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis study provides promising evidence for the effectiveness of the personalized Healthy Eating Report Card in promoting healthy eating practices among preschool-aged children.\u003cstrong\u003e \u003c/strong\u003eIt also\u003cstrong\u003e \u003c/strong\u003edemonstrated its potential as a cost-efficient and scalable tool for health interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eThis trial was registered retrospectively on November 19, 2024, at chictr.org.cn (ChiCTR number: ChiCTR2400092558).\u003c/p\u003e","manuscriptTitle":"The Effectiveness of a Personalized Healthy Eating Report Card in Improving Children's Eating Practices: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-10 12:25:17","doi":"10.21203/rs.3.rs-5963247/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5cca3291-0a97-4596-916f-4def2b835fdf","owner":[],"postedDate":"February 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-21T13:23:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-10 12:25:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5963247","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5963247","identity":"rs-5963247","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}