Health and Social Care in the Community (2015)
doi: 10.1111/hsc.12247
Australian Middle Eastern parents’ perceptions and practices of children’s weight-related behaviours: Talking with Parents’ Study Louise L. Hardy
PhD,
Debra Hector
PhD,
Shay Saleh
MPH
and Lesley King
MSc
Physical Activity Nutrition Obesity Research Group, School of Public Health, University of Sydney, Sydney, New South Wales, Australia Accepted for publication 23 March 2015
Correspondence Louise L. Hardy Physical Activity Nutrition Obesity Research Group The Hub, University of Sydney Charles Perkins Centre D17 Level 6, New South Wales 2006, Australia E-mail: [email protected]
What is known about this topic
•
•
The prevalence of overweight/ obesity is higher among Australian children from Middle Eastern backgrounds, compared with their English-speaking background peers. Parents are key agents of change for primary school-age children and must be engaged in child obesity prevention strategies.
What this paper adds
• •
State government healthy messages do resonant with parents from Middle Eastern backgrounds living in Australia. Like other Australian parents, those from a Middle Eastern background would benefit from initiatives, including early childhood and school-based programmes, which focused on specific, detailed messages and guidance around approaches to enhancing health-promoting aspects of the home environment.
Abstract The home environment is associated with obesity-related behaviours among children, and research in Australia has shown that some of these behaviours are more prevalent among children from particular cultural backgrounds including Middle Eastern. This study presents findings from face-to-face, semi-structured interviews conducted in April 2013 with a convenience sample of Middle Eastern parents of primary school-age children at an Islamic private school in Sydney, Australia. The interviews explored parental perceptions and practices regarding state government health messages addressing children’s eating, physical activity and screen time. The purpose of the study was to investigate whether the content of these generic public health messages is relevant and acceptable to Middle Eastern parents of young children, and to identify any enablers and barriers to adopting these healthy practices at home. Thematic analysis identified predominant themes. In total, 21 interviews were conducted (reference children: 12 boys/9 girls, aged 5–12 years). The content of current health messages regarding children’s weight-related behaviours was familiar to respondents, and accepted as relevant for guiding their parenting practices. Parents perceived that they typically encouraged healthy behaviours, although they also reported making regular exemptions, in response to various circumstances. Overall, the perceptions and reported practices of the parents were consistent with other studies with Australian parents. There were no apparent culturally specific barriers or enablers to children’s weight-related behaviours. There is however scope for health promoters to provide more precise information on health recommendations, health risks and benefits, and to provide more specific ideas for ways in which parents can act on these health messages within the home and family environment, to encourage and support healthy behaviours in their children. Keywords: ethnicity, health behaviour, qualitative study
Introduction In Australia’s most populous state, New South Wales (NSW), one in four primary school-age children are overweight/obese; however, the distribution of © 2015 John Wiley & Sons Ltd
overweight/obesity varies for different population groups (Hardy et al. 2011). Australian data from large, population-based studies, as well as more locally based studies, indicate that children and adolescents of low socioeconomic status (SES) and of 1
L. L. Hardy et al.
particular cultural backgrounds are at increased risk of overweight/obesity (O’Dea 2008, Waters et al. 2008, O’Dea & Dibley 2010, Achat & Stubbs 2014, Hardy et al. 2013). The prevalence of overweight/ obesity has been found to be higher among Australian children from Pacific Island, European, North African and Middle Eastern cultural backgrounds compared with their English-speaking background peers. While some studies found that ethnicity and SES are independently related to unhealthy weight in children in Australia (Waters et al. 2008, O’Dea & Dibley 2010, Achat & Stubbs 2014), a NSW study showed that, among low SES children, there were clear differences in weight and weight-related behaviours according to cultural background (Hardy et al. 2013). In particular, boys from Asian or Middle Eastern and a low SES background were significantly more likely to be obese compared with their peers from an English-speaking background. The NSW population data (Hardy et al. 2011, 2013) show that primary school-age children of Middle Eastern descent were more likely than children of English-speaking background to have low cardiorespiratory fitness, less likely to meet the national recommendations for physical activity, less likely to attend after-school activity programmes and more likely to spend more time in sedentary behaviours. In addition, there was evidence of excessive consumption of fruit juice, high consumption of energy-dense, nutrient-poor (EDNP) foods; parental reward of good behaviour with sweets was also prevalent among Middle Eastern children. Although individual-level behaviours are influenced by broader social and physical environments, parents also exert influence, both through their parenting practices and shaping aspects of the home environment (Golan & Crow 2004, Johannsen et al. 2006, Ventura & Birch 2008, Grunseit et al. 2011). Quantitative and qualitative studies on Australian parents’ perspectives on weight-related practices have found that parents seek to balance a range of considerations regarding their families’ well-being, and that while weight, physical activity and healthy eating form part of this set of considerations, they may be compromised in order to minimise being overly restrictive, or to manage competing influences or circumstantial demands (Campbell et al. 2007, Pagnini et al. 2007, Hattersley et al. 2009, Shrewsbury et al. 2010, Hesketh et al. 2012, Petrunoff et al. 2014). To date, no studies have specifically focused on the perceptions of Middle Eastern parents living in Australia, despite the evidence of increased obesity risk; this could be valuable in guiding culturally appropriate 2
and targeted interventions of obesity prevention efforts among this group. The NSW Ministry of Health portfolio of strategies to address childhood obesity includes the promotion of five key lifestyle messages for children and their families through a range of channels and programmes, which have been consistently implemented since 2006 (Hardy et al. 2010, Rissel et al. 2012). These messages are: (i) Get active each day; (ii) Turn off the TV or computer and get active; (iii) Eat fewer snacks and select healthier alternatives; (iv) Choose water as a drink; and (v) Eat more fruit and vegetables (http://www.healthykids.nsw.gov.au). As these messages represent the key content of public education related to child obesity prevention in NSW, they were used in this study as the focal point for exploration of the perceptions and practices of parents of a Middle Eastern cultural background in NSW with respect to the healthy eating and physical activity of their primary school-age children. The overall purpose of this qualitative study was to investigate whether the content of these health messages is relevant and acceptable to Middle Eastern parents of young children and to identify any enablers and barriers to adopting these healthy practices at home. Specifically, this involved the exploration of (i) parents’ attitudes regarding the personal relevance and importance of current health messages on children’s eating, physical activity and screen time (ST); (ii) parents’ practices regarding aspects of their home environment that are related to their child’s eating, physical activity and ST; and (iii) parents’ strategies for promoting healthier behaviours.
Methods Study design and participants A qualitative study design using individual, face-toface, semi-structured interviews (Drever 2003), rather than focus groups, was selected because the participants were recruited from one school and this approach allowed parents to express their views anonymously and reduce any propensity of socially biased opinions which can occur in a group situation given the health messages under investigation. The only role of the schools was to distribute the study information and consent sheet to parents, which asked interested parents to directly contact the study researchers by phone. Participants were parents of Middle Eastern primary school-age children from one private Islamic school in Metropolitan Sydney, Australia. Parents were required to speak English in order to be able to participate. The sample size was © 2015 John Wiley & Sons Ltd
Talking with Parents’ Study
informed by a similar study of parents that showed data saturation occurred at approximately 20 participants (Pagnini et al. 2007). Written consent was a condition of participation and included assurances of anonymity and confidentiality. Participating parents received a $AUD40 Rebel Sports Store voucher, as a token of gratitude for their time. The study was approved by the University of Sydney Human Research Ethics Committee (#15810). Procedure The interviews were conducted in April 2013 by a trained female facilitator of Arabic heritage, on the school premises during school hours at a time convenient to the parent. Questions and prompts (Table 1) were developed which would address the research questions in a way that would promote interest and open discussion. Parents were asked about their perspectives and practices in relation to each of the five NSW Ministry of Health’s healthy lifestyle messages. For each interview, the order of messages discussed was consistent. The messages were used to start discussion on key behaviours related to weight status and areas where parents influence their child’s environment and behaviours, and where recent research evidence suggests there is scope for strengthening practices within the home environment.
The parent was asked to think about their child with the most recent birthday, who became the reference child for the interview. Each interview was audio-recorded with the participant’s consent. Data analysis Anonymised transcripts of the audio records were typed verbatim by an independent transcription agency, and checked for quality by the study interviewer (S.S.). The data were analysed with a view to gain a contextualised understanding of factors influencing parents’ perception of the key messages. Relevant themes to each message were generated from the interviews rather than an a priori approach, consistent with a framework analysis approach (Ritchie et al. 2003). Segments of text were identified where parents described their perception and understanding of the messages, and then coded in a systematic way in NVivo. Quotes were coded according to themes/ nodes. All researchers read the transcripts and identified an agreed system for coding themes and content for each message. Any discrepancies were resolved by discussion. Data were then analysed for recurrent themes through an iterative process and an integrated summary across interviewees created for each message, with cross-referencing to original transcripts.
Table 1 Discussion prompts for study topics used in interviews Topic area and NSW Ministry of Health key health messages Physical activity (‘get active each day’)
Sedentary behaviour (‘turn off the TV or computer’)
Water consumption (‘choose water as a drink’)
Fruit and vegetable consumption (‘eat more fruits and vegetables’)
Reduce snacks (‘eat fewer snacks and select healthier alternatives’)
© 2015 John Wiley & Sons Ltd
Questions Common themes explored included perceived importance of being physically active, barriers to physical activity, child’s enjoyment of physical activity, whether the child was involved in any outside sports, parental suggestions on how to increase physical activity and active travel (e.g. If you wanted to get your child to be more active, what sort of things might work?) Questions explored the amount of time spent watching television or on the computer, whether there were TVs or computers in the child’s bedroom, any existing rules and restrictions regarding small-screen recreation, and attitudes towards reducing sedentary behaviours (e.g. Do you have any rules about watching TV/playing computer games?) This included the types of drinks purchased at home and that children generally drink, rules regarding access to various drinks, strategies to increase water consumption, and parental and child drinking preferences (e.g. What types of strategies have you used to get your child to drink more water?) Questions investigated the frequency of consumption of fruits and vegetables; perceived liking for fruits and vegetables; strategies to increase consumption of fruits and vegetables; access to fruits and vegetables, frequency of taking fruits and vegetables to school; and consequences of not eating vegetables at mealtime (e.g. What do you do to try and encourage your child to eat more fruits and vegetables?) This explored the frequency and type of consumption of energy-dense, nutrient-poor snack foods; whether these food items were regularly found in the household; ease of access to snack foods; the use of sweets as a reward for good behaviour; and what parents perceived as healthier substitutes for unhealthy snacks (e.g. If you wanted to cut down on the number of snacks your child eats, how would you try and do that?)
3
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Findings Twenty-one parents (20 mothers, 1 father) of Middle Eastern background participated in the study. All were married and resided in the same local government area, which is classified as an area of social disadvantage. The majority (17/21) of parents were either born in Australia or had arrived during childhood. The reference children consisted of 12 boys and 9 girls between 5 and 12 years old and had between 1 and 5 siblings. The mean duration of interviews was 19 minutes. The key findings and supporting quotations to each of the key health messages explored are summarised below. Get active each day Nearly all parents (19/21) explicitly recognised the importance of their child being physically active every day, in particular for their health: It’s important to me because basically I want him to be healthy. (Mother, boy 7 years) Because I’d love my boys to grow up to be healthy and active and fit. (Mother, boy 6 years) Obviously so that for health reasons, for his upbringing, for his well-being, bones, development. (Mother, boy 5 years)
Parents typically generated (unprompted) a range of reasons why physical activity was important, such as for well-being, the ‘brain’ and development. However, most parents also considered that their child needed to be more physically active. I’m glad he has a school now that he has a lunchtime playtime. So I think that kind of makes up for the playtime outside time. (Mother, boy 5 years) Like I don’t want her to just sit down and watch TV all day, it’s just, you know, I don’t think it’s right. (Mother, girl 5 years) Because he’s overweight. So I know he’s got a weight problem. (Mother, boy 10 years)
Most parents (18/21) believed that their child enjoyed being physically active and described that they promoted their child’s physical activity through organised sport and encouraging regular outdoor play. Parents said that their child ‘. . .enjoyed being outside’ and ‘. . .likes to play outside’. Parents mentioned using outdoor spaces, such as backyards and parks, and purchasing outdoor equipment including trampolines, scooters and bicycles to promote their child’s physical activity. The most popular activities mentioned were chasing, ball games, general play, swimming, trampolining and bicycling. Two-thirds of children were 4
involved in at least one organised sport and most parents indicated that organised sport was their preferred method for increasing their child’s physical activity levels. The reasoning behind this seemed to be that it required commitment by the parent to take the child to the sporting activity, whereas more ‘ad hoc’ activities, e.g. taking them to the park, required motivation by the parents that was often lacking, mainly due to a real or perceived lack of time. Barriers described by parents to promoting children’s physical activity included lack of time, parent ‘laziness’, living in a unit/townhouse, child safety, child preference for sedentary activities, poor weather and lack of facilities. The most commonly reported barrier to promoting their child’s physical activity was, however, school-associated demands (14/21), predominantly homework. Parents indicated they felt there was too much homework and their use of pronouns when describing their child’s homework indicated that they felt responsible for the homework, as described by these mothers: Sometimes we’ve got projects and homework even on the weekends. So it’s really sad, I’ll go, when we drive past home I’ll see the kids in the park and I’m saying, oh, my goodness, my kids don’t get to go to the park anymore. (Mother, boy 7 years) The reason he’s not active every day is because of study overload . . . Takes over your life, oh yeah, it does. (Mother, boy 10 years) I did want to put him up again into football but the school demands this year is just killing us really. (Mother, boy 10 years)
Interestingly, while organised sport was the preferred activity option for parents, they also commented on the commitment to sporting activities highlighting time and ‘busyness’ as barriers which can influence decisions: He used to attend soccer. Unfortunately, we’ve had to scrap that this year . . . Because I couldn’t keep up. It was really hard because I was the one who had to take him to training, take him to the matches and be at a certain time. I’d have to drag off the other two kids with me and it was just a bit hard. We tried it for a while and then it became a bit difficult. (Mother, boy 10 years) . . .if you have to do organised sport there is a certain schedule that you have to stick to and you have to really show up . . . It’s about dropping off and picking up and all that stuff. (Mother, boy 6 years)
During discussions about active travel, the majority of parents (17/21) stated that their child engaged in some form of active travel in their neighbourhood and almost all parents (19/21) thought that their chil© 2015 John Wiley & Sons Ltd
Talking with Parents’ Study
dren enjoyed walking or cycling, and that more occasions using this mode of travel would be desirable. Parents’ responses (18/21) showed that they were interested in active travel, but cited safety and distance as obstacles:
a bit more lenient with them because they are not allowed to go on video games or like the Wii or console games and stuff. (Mother, boy 6 years)
Unfortunately not, because of where we live. There is no corner shop, or park, or whatever. Even when we do go to the park, we’ve got to hop in the car and go to the park. (Mother, boy 10 years)
Almost all parents (20/21) stated that water was their preferred drink for their child, and thought their child drank an adequate amount, with many indicating that their child loved water and drank large quantities. Nevertheless, more than half of the parents also indicated that they still had to encourage their child to drink water. Parents’ strategies for increasing their child’s water intake included offering water as an alternative to other drink requests, verbal encouragement, having easily accessible water such as a water dispenser in the home, purchasing appealing reusable water bottles, sending water bottles to school with their child. Water was the main drink at mealtimes, although around a third of children were allowed soft drink/fruit juice at mealtimes:
Switch off the screen and get active Almost all parents reported that their children enjoyed ST (e.g. televisions, computers), with television generally more attractive to girls and computers more attractive to boys. Most parents were accepting of the relevance of this health message, although few specifically identified ST as a barrier to physical activity. Most parents were happy with the amount of time their child spent on ST, especially as a substantial number indicated that they put limits or controls over the amount of time. Many still felt it was possible and desirable to reduce this time. A minority of parents struggled with limiting their child’s ST and who used ST as a reward: It was very hard [to reduce ST], it was really hard . . . he’d chuck tantrums. That’s what’s working yeah, that’s the reason he does his homework. (Mother, boy 7 years) [I’m happy with the amount of screen time] because he actually earns it. (Mother, boy 7 years) . . .the problem is like three boys, three different ages, each of them wants to watch something so they take turns who is going to watch what programmes at that time, so I find the TV has to be on more, because each one has to watch their programmes. (Mother, boy 10 years)
Other common ST reduction strategies were distracting children with another activity and enforcing rules requiring children to switch off screens. Rules regarding watching television also applied to content and the need to complete homework first. Only one child had a television in the bedroom. When specifically asked about their child’s ST, it appeared that most were within children’s ST recommendation (i.e.
doi: 10.1111/hsc.12247
Australian Middle Eastern parents’ perceptions and practices of children’s weight-related behaviours: Talking with Parents’ Study Louise L. Hardy
PhD,
Debra Hector
PhD,
Shay Saleh
MPH
and Lesley King
MSc
Physical Activity Nutrition Obesity Research Group, School of Public Health, University of Sydney, Sydney, New South Wales, Australia Accepted for publication 23 March 2015
Correspondence Louise L. Hardy Physical Activity Nutrition Obesity Research Group The Hub, University of Sydney Charles Perkins Centre D17 Level 6, New South Wales 2006, Australia E-mail: [email protected]
What is known about this topic
•
•
The prevalence of overweight/ obesity is higher among Australian children from Middle Eastern backgrounds, compared with their English-speaking background peers. Parents are key agents of change for primary school-age children and must be engaged in child obesity prevention strategies.
What this paper adds
• •
State government healthy messages do resonant with parents from Middle Eastern backgrounds living in Australia. Like other Australian parents, those from a Middle Eastern background would benefit from initiatives, including early childhood and school-based programmes, which focused on specific, detailed messages and guidance around approaches to enhancing health-promoting aspects of the home environment.
Abstract The home environment is associated with obesity-related behaviours among children, and research in Australia has shown that some of these behaviours are more prevalent among children from particular cultural backgrounds including Middle Eastern. This study presents findings from face-to-face, semi-structured interviews conducted in April 2013 with a convenience sample of Middle Eastern parents of primary school-age children at an Islamic private school in Sydney, Australia. The interviews explored parental perceptions and practices regarding state government health messages addressing children’s eating, physical activity and screen time. The purpose of the study was to investigate whether the content of these generic public health messages is relevant and acceptable to Middle Eastern parents of young children, and to identify any enablers and barriers to adopting these healthy practices at home. Thematic analysis identified predominant themes. In total, 21 interviews were conducted (reference children: 12 boys/9 girls, aged 5–12 years). The content of current health messages regarding children’s weight-related behaviours was familiar to respondents, and accepted as relevant for guiding their parenting practices. Parents perceived that they typically encouraged healthy behaviours, although they also reported making regular exemptions, in response to various circumstances. Overall, the perceptions and reported practices of the parents were consistent with other studies with Australian parents. There were no apparent culturally specific barriers or enablers to children’s weight-related behaviours. There is however scope for health promoters to provide more precise information on health recommendations, health risks and benefits, and to provide more specific ideas for ways in which parents can act on these health messages within the home and family environment, to encourage and support healthy behaviours in their children. Keywords: ethnicity, health behaviour, qualitative study
Introduction In Australia’s most populous state, New South Wales (NSW), one in four primary school-age children are overweight/obese; however, the distribution of © 2015 John Wiley & Sons Ltd
overweight/obesity varies for different population groups (Hardy et al. 2011). Australian data from large, population-based studies, as well as more locally based studies, indicate that children and adolescents of low socioeconomic status (SES) and of 1
L. L. Hardy et al.
particular cultural backgrounds are at increased risk of overweight/obesity (O’Dea 2008, Waters et al. 2008, O’Dea & Dibley 2010, Achat & Stubbs 2014, Hardy et al. 2013). The prevalence of overweight/ obesity has been found to be higher among Australian children from Pacific Island, European, North African and Middle Eastern cultural backgrounds compared with their English-speaking background peers. While some studies found that ethnicity and SES are independently related to unhealthy weight in children in Australia (Waters et al. 2008, O’Dea & Dibley 2010, Achat & Stubbs 2014), a NSW study showed that, among low SES children, there were clear differences in weight and weight-related behaviours according to cultural background (Hardy et al. 2013). In particular, boys from Asian or Middle Eastern and a low SES background were significantly more likely to be obese compared with their peers from an English-speaking background. The NSW population data (Hardy et al. 2011, 2013) show that primary school-age children of Middle Eastern descent were more likely than children of English-speaking background to have low cardiorespiratory fitness, less likely to meet the national recommendations for physical activity, less likely to attend after-school activity programmes and more likely to spend more time in sedentary behaviours. In addition, there was evidence of excessive consumption of fruit juice, high consumption of energy-dense, nutrient-poor (EDNP) foods; parental reward of good behaviour with sweets was also prevalent among Middle Eastern children. Although individual-level behaviours are influenced by broader social and physical environments, parents also exert influence, both through their parenting practices and shaping aspects of the home environment (Golan & Crow 2004, Johannsen et al. 2006, Ventura & Birch 2008, Grunseit et al. 2011). Quantitative and qualitative studies on Australian parents’ perspectives on weight-related practices have found that parents seek to balance a range of considerations regarding their families’ well-being, and that while weight, physical activity and healthy eating form part of this set of considerations, they may be compromised in order to minimise being overly restrictive, or to manage competing influences or circumstantial demands (Campbell et al. 2007, Pagnini et al. 2007, Hattersley et al. 2009, Shrewsbury et al. 2010, Hesketh et al. 2012, Petrunoff et al. 2014). To date, no studies have specifically focused on the perceptions of Middle Eastern parents living in Australia, despite the evidence of increased obesity risk; this could be valuable in guiding culturally appropriate 2
and targeted interventions of obesity prevention efforts among this group. The NSW Ministry of Health portfolio of strategies to address childhood obesity includes the promotion of five key lifestyle messages for children and their families through a range of channels and programmes, which have been consistently implemented since 2006 (Hardy et al. 2010, Rissel et al. 2012). These messages are: (i) Get active each day; (ii) Turn off the TV or computer and get active; (iii) Eat fewer snacks and select healthier alternatives; (iv) Choose water as a drink; and (v) Eat more fruit and vegetables (http://www.healthykids.nsw.gov.au). As these messages represent the key content of public education related to child obesity prevention in NSW, they were used in this study as the focal point for exploration of the perceptions and practices of parents of a Middle Eastern cultural background in NSW with respect to the healthy eating and physical activity of their primary school-age children. The overall purpose of this qualitative study was to investigate whether the content of these health messages is relevant and acceptable to Middle Eastern parents of young children and to identify any enablers and barriers to adopting these healthy practices at home. Specifically, this involved the exploration of (i) parents’ attitudes regarding the personal relevance and importance of current health messages on children’s eating, physical activity and screen time (ST); (ii) parents’ practices regarding aspects of their home environment that are related to their child’s eating, physical activity and ST; and (iii) parents’ strategies for promoting healthier behaviours.
Methods Study design and participants A qualitative study design using individual, face-toface, semi-structured interviews (Drever 2003), rather than focus groups, was selected because the participants were recruited from one school and this approach allowed parents to express their views anonymously and reduce any propensity of socially biased opinions which can occur in a group situation given the health messages under investigation. The only role of the schools was to distribute the study information and consent sheet to parents, which asked interested parents to directly contact the study researchers by phone. Participants were parents of Middle Eastern primary school-age children from one private Islamic school in Metropolitan Sydney, Australia. Parents were required to speak English in order to be able to participate. The sample size was © 2015 John Wiley & Sons Ltd
Talking with Parents’ Study
informed by a similar study of parents that showed data saturation occurred at approximately 20 participants (Pagnini et al. 2007). Written consent was a condition of participation and included assurances of anonymity and confidentiality. Participating parents received a $AUD40 Rebel Sports Store voucher, as a token of gratitude for their time. The study was approved by the University of Sydney Human Research Ethics Committee (#15810). Procedure The interviews were conducted in April 2013 by a trained female facilitator of Arabic heritage, on the school premises during school hours at a time convenient to the parent. Questions and prompts (Table 1) were developed which would address the research questions in a way that would promote interest and open discussion. Parents were asked about their perspectives and practices in relation to each of the five NSW Ministry of Health’s healthy lifestyle messages. For each interview, the order of messages discussed was consistent. The messages were used to start discussion on key behaviours related to weight status and areas where parents influence their child’s environment and behaviours, and where recent research evidence suggests there is scope for strengthening practices within the home environment.
The parent was asked to think about their child with the most recent birthday, who became the reference child for the interview. Each interview was audio-recorded with the participant’s consent. Data analysis Anonymised transcripts of the audio records were typed verbatim by an independent transcription agency, and checked for quality by the study interviewer (S.S.). The data were analysed with a view to gain a contextualised understanding of factors influencing parents’ perception of the key messages. Relevant themes to each message were generated from the interviews rather than an a priori approach, consistent with a framework analysis approach (Ritchie et al. 2003). Segments of text were identified where parents described their perception and understanding of the messages, and then coded in a systematic way in NVivo. Quotes were coded according to themes/ nodes. All researchers read the transcripts and identified an agreed system for coding themes and content for each message. Any discrepancies were resolved by discussion. Data were then analysed for recurrent themes through an iterative process and an integrated summary across interviewees created for each message, with cross-referencing to original transcripts.
Table 1 Discussion prompts for study topics used in interviews Topic area and NSW Ministry of Health key health messages Physical activity (‘get active each day’)
Sedentary behaviour (‘turn off the TV or computer’)
Water consumption (‘choose water as a drink’)
Fruit and vegetable consumption (‘eat more fruits and vegetables’)
Reduce snacks (‘eat fewer snacks and select healthier alternatives’)
© 2015 John Wiley & Sons Ltd
Questions Common themes explored included perceived importance of being physically active, barriers to physical activity, child’s enjoyment of physical activity, whether the child was involved in any outside sports, parental suggestions on how to increase physical activity and active travel (e.g. If you wanted to get your child to be more active, what sort of things might work?) Questions explored the amount of time spent watching television or on the computer, whether there were TVs or computers in the child’s bedroom, any existing rules and restrictions regarding small-screen recreation, and attitudes towards reducing sedentary behaviours (e.g. Do you have any rules about watching TV/playing computer games?) This included the types of drinks purchased at home and that children generally drink, rules regarding access to various drinks, strategies to increase water consumption, and parental and child drinking preferences (e.g. What types of strategies have you used to get your child to drink more water?) Questions investigated the frequency of consumption of fruits and vegetables; perceived liking for fruits and vegetables; strategies to increase consumption of fruits and vegetables; access to fruits and vegetables, frequency of taking fruits and vegetables to school; and consequences of not eating vegetables at mealtime (e.g. What do you do to try and encourage your child to eat more fruits and vegetables?) This explored the frequency and type of consumption of energy-dense, nutrient-poor snack foods; whether these food items were regularly found in the household; ease of access to snack foods; the use of sweets as a reward for good behaviour; and what parents perceived as healthier substitutes for unhealthy snacks (e.g. If you wanted to cut down on the number of snacks your child eats, how would you try and do that?)
3
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Findings Twenty-one parents (20 mothers, 1 father) of Middle Eastern background participated in the study. All were married and resided in the same local government area, which is classified as an area of social disadvantage. The majority (17/21) of parents were either born in Australia or had arrived during childhood. The reference children consisted of 12 boys and 9 girls between 5 and 12 years old and had between 1 and 5 siblings. The mean duration of interviews was 19 minutes. The key findings and supporting quotations to each of the key health messages explored are summarised below. Get active each day Nearly all parents (19/21) explicitly recognised the importance of their child being physically active every day, in particular for their health: It’s important to me because basically I want him to be healthy. (Mother, boy 7 years) Because I’d love my boys to grow up to be healthy and active and fit. (Mother, boy 6 years) Obviously so that for health reasons, for his upbringing, for his well-being, bones, development. (Mother, boy 5 years)
Parents typically generated (unprompted) a range of reasons why physical activity was important, such as for well-being, the ‘brain’ and development. However, most parents also considered that their child needed to be more physically active. I’m glad he has a school now that he has a lunchtime playtime. So I think that kind of makes up for the playtime outside time. (Mother, boy 5 years) Like I don’t want her to just sit down and watch TV all day, it’s just, you know, I don’t think it’s right. (Mother, girl 5 years) Because he’s overweight. So I know he’s got a weight problem. (Mother, boy 10 years)
Most parents (18/21) believed that their child enjoyed being physically active and described that they promoted their child’s physical activity through organised sport and encouraging regular outdoor play. Parents said that their child ‘. . .enjoyed being outside’ and ‘. . .likes to play outside’. Parents mentioned using outdoor spaces, such as backyards and parks, and purchasing outdoor equipment including trampolines, scooters and bicycles to promote their child’s physical activity. The most popular activities mentioned were chasing, ball games, general play, swimming, trampolining and bicycling. Two-thirds of children were 4
involved in at least one organised sport and most parents indicated that organised sport was their preferred method for increasing their child’s physical activity levels. The reasoning behind this seemed to be that it required commitment by the parent to take the child to the sporting activity, whereas more ‘ad hoc’ activities, e.g. taking them to the park, required motivation by the parents that was often lacking, mainly due to a real or perceived lack of time. Barriers described by parents to promoting children’s physical activity included lack of time, parent ‘laziness’, living in a unit/townhouse, child safety, child preference for sedentary activities, poor weather and lack of facilities. The most commonly reported barrier to promoting their child’s physical activity was, however, school-associated demands (14/21), predominantly homework. Parents indicated they felt there was too much homework and their use of pronouns when describing their child’s homework indicated that they felt responsible for the homework, as described by these mothers: Sometimes we’ve got projects and homework even on the weekends. So it’s really sad, I’ll go, when we drive past home I’ll see the kids in the park and I’m saying, oh, my goodness, my kids don’t get to go to the park anymore. (Mother, boy 7 years) The reason he’s not active every day is because of study overload . . . Takes over your life, oh yeah, it does. (Mother, boy 10 years) I did want to put him up again into football but the school demands this year is just killing us really. (Mother, boy 10 years)
Interestingly, while organised sport was the preferred activity option for parents, they also commented on the commitment to sporting activities highlighting time and ‘busyness’ as barriers which can influence decisions: He used to attend soccer. Unfortunately, we’ve had to scrap that this year . . . Because I couldn’t keep up. It was really hard because I was the one who had to take him to training, take him to the matches and be at a certain time. I’d have to drag off the other two kids with me and it was just a bit hard. We tried it for a while and then it became a bit difficult. (Mother, boy 10 years) . . .if you have to do organised sport there is a certain schedule that you have to stick to and you have to really show up . . . It’s about dropping off and picking up and all that stuff. (Mother, boy 6 years)
During discussions about active travel, the majority of parents (17/21) stated that their child engaged in some form of active travel in their neighbourhood and almost all parents (19/21) thought that their chil© 2015 John Wiley & Sons Ltd
Talking with Parents’ Study
dren enjoyed walking or cycling, and that more occasions using this mode of travel would be desirable. Parents’ responses (18/21) showed that they were interested in active travel, but cited safety and distance as obstacles:
a bit more lenient with them because they are not allowed to go on video games or like the Wii or console games and stuff. (Mother, boy 6 years)
Unfortunately not, because of where we live. There is no corner shop, or park, or whatever. Even when we do go to the park, we’ve got to hop in the car and go to the park. (Mother, boy 10 years)
Almost all parents (20/21) stated that water was their preferred drink for their child, and thought their child drank an adequate amount, with many indicating that their child loved water and drank large quantities. Nevertheless, more than half of the parents also indicated that they still had to encourage their child to drink water. Parents’ strategies for increasing their child’s water intake included offering water as an alternative to other drink requests, verbal encouragement, having easily accessible water such as a water dispenser in the home, purchasing appealing reusable water bottles, sending water bottles to school with their child. Water was the main drink at mealtimes, although around a third of children were allowed soft drink/fruit juice at mealtimes:
Switch off the screen and get active Almost all parents reported that their children enjoyed ST (e.g. televisions, computers), with television generally more attractive to girls and computers more attractive to boys. Most parents were accepting of the relevance of this health message, although few specifically identified ST as a barrier to physical activity. Most parents were happy with the amount of time their child spent on ST, especially as a substantial number indicated that they put limits or controls over the amount of time. Many still felt it was possible and desirable to reduce this time. A minority of parents struggled with limiting their child’s ST and who used ST as a reward: It was very hard [to reduce ST], it was really hard . . . he’d chuck tantrums. That’s what’s working yeah, that’s the reason he does his homework. (Mother, boy 7 years) [I’m happy with the amount of screen time] because he actually earns it. (Mother, boy 7 years) . . .the problem is like three boys, three different ages, each of them wants to watch something so they take turns who is going to watch what programmes at that time, so I find the TV has to be on more, because each one has to watch their programmes. (Mother, boy 10 years)
Other common ST reduction strategies were distracting children with another activity and enforcing rules requiring children to switch off screens. Rules regarding watching television also applied to content and the need to complete homework first. Only one child had a television in the bedroom. When specifically asked about their child’s ST, it appeared that most were within children’s ST recommendation (i.e.
