Preventing childhood obesity is a national priority for health professionals and policy makers. Consistent with a general call for researchers to engage parents in child health research [1
], parental involvement specifically in childhood obesity programs and prevention efforts has been stressed [2
]. This case study responds to the need for parent engagement as experts throughout the entire research process and, using the example of a childhood obesity prevention initiative, illustrates strategies to engage parents in program development, implementation and evaluation. Parent participation in obesity prevention is increasingly emphasized given links between parents’ attitudes, knowledge, and behavior and children’s dietary, physical activity, and screen-based behavioral factors associated with childhood obesity [5
]. Parents are the most knowledgeable about their family’s needs, motivations, and resources for behavioral change, and they understand family dynamics and ecological factors that influence daily living [1
]. Parents also have insight regarding program relevance and feasibility. As such, parents active family engagement is crucial for the success of preventive interventions [6
A growing body of research and relevant theory emphasizes the importance of utilizing parents as change agents in childhood obesity prevention [2
]. Although parents have been targeted for studies on treatment of childhood obesity [4
], parents are less frequently the direct targets for the prevention of childhood obesity. What is more, the evidence for effective involvement of parents in obesity prevention such as dietary [10
] and physical activity [11
] interventions is weak. Evidence of program effectiveness among low-income and ethnic minority children who disproportionately experience childhood obesity is also minimal [12
]. Parent engagement in research is challenged by low participation rates and high attrition [13
]. New approaches are needed to ensure successful engagement of parents in prevention efforts.
One approach is to engage parents in the development, implementation and evaluation of childhood obesity prevention interventions to better integrate parent’s sociocultural context in order to improve program acceptance, cultural relevance and participation. A strategy for operationalizing the level of participation is to utilize the Ladder of Citizen Participation [14
], with slight modifications to emphasize the role of parents in health promotion. The Ladder of Parent Participation provides a useful framework for describing the characteristics and extent of parent participation and therefore, the application of CBPR in the literature (See Fig. ). The ladder has eight rungs representing progressively increasing levels of community engagement. In the case of childhood obesity prevention, high levels of parent participation, in which parents have more contribution to the research process, may improve parent buy-in, participation and program sustainability.
Fig. 1 Ladder of Parent Participation. Modified from Sherry Arnstein’s 1969 Ladder of Citizen Participation 
Community-Based Participatory Research (CBPR) is an approach that can be used during the research process to increase the level of parent participation to achieve higher rungs on the Ladder of Participation. CBPR involves community members actively and equitably in decisions throughout the research process, which is often guided by participatory principles [15
]. The use of CBPR in childhood obesity research is increasing, but parents, as key stakeholders, are still infrequently engaged. Many CBPR intervention studies to address childhood obesity have primarily engaged community representatives who are in a profession that serves the target population or who have expertise in some area of childhood obesity. Such stakeholders typically include school administrators, teachers, cooks, providers and other community-based professionals [16
]. Studies that engage parents, most often fall between Rung 3 and 5 of the Ladder of Participation in which parents provide input and are informed of study processes, often during formative stages of the study, but do not have decision making power. Although other studies have involved parents, there are no known examples in which parents are engaged throughout the entire
research process. Given the history of hierarchical relationships between low-income families and service or health professionals [17
], engaging parents throughout the research process may serve to open communication, break down hierarchical relationships and build trust.
Case Study Overview
This manuscript describes a parent-centered CBPR case study that expands upon the CBPR literature on childhood obesity prevention by engaging parents directly throughout the entire research process with the goal of fostering parent empowerment and encouraging co-learning across all stakeholders [18
]. Low-income parents are engaged as equal partners, providing unique expertise during the development, implementation and evaluation of a childhood obesity prevention initiative. The case study of Communities for Healthy Living (CHL)
, so named by the partnership, is intended to provide a starting point from which dialogue around engaging parents throughout the research process can begin, propelling the identification of effective engagement strategies that can be tested alongside gains in program effectiveness and sustainability. To this end, we discuss (a) the process of partnership development (Phase 1 of the study), (b) the operation of the advisory board as an effective decision making body, and (c) the provision of structural supports to foster active and equal parent involvement. The conclusion outlines the benefits and challenges of using the CBPR approach to engage parents and lessons learned along the way.
The Communities for Healthy Living
case study takes place within the context of a study funded by the National Institute of Minority Health and Health Disparities of NIH, which funded 6 research studies utilizing CBPR in the development of interventions addressing health disparities. Because the studies were funded under the American Recovery and Reinvestment Act of 2009, each was constrained to a rapid 2-year timeline to develop and pilot test the intervention. The goal of this study was to develop and pilot test a childhood obesity intervention for low-income families using a CBPR approach to actively engage parents across three phases, Phase 1: Partnership development, Phase 2: Community assessment and intervention development, and Phase 3: Intervention implementation and evaluation. The family-centered intervention targeted parent/caregivers with children participating in Head Start programs in Rensselaer County, NY (about 500 children ages 6 weeks–5 years old) for childhood obesity prevention. Rensselaer County, in Upstate New York, has areas designated as Medically Underserved Areas [19
], and 28 % of all families with children under age 5 living below the poverty level [20