Persistent optimizing: how mothers make food choices for their preschool children.

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research-article2014

QHRXXX10.1177/1049732314552456Qualitative Health ResearchWalsh et al.

Article

Persistent Optimizing: How Mothers Make Food Choices for Their Preschool Children

Qualitative Health Research 1–13 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314552456 qhr.sagepub.com

Audrey Walsh1, Donna Meagher-Stewart2, and Marilyn Macdonald2

Abstract Mothers’ ability to provide healthy food choices for their children has become more complex in our current obesogenic environment. We conducted a total of 35 interviews with 18 mothers of preschool children. Using constructivist grounded theory methods, we developed a substantive theory of how mothers make food choices for their preschoolers. Our substantive theory, persistent optimizing, consists of three main integrated conceptual categories: (a) acknowledging contextual constraints, (b) stretching boundaries, and (c) strategic positioning. Implications to improve mothers’ ability to make healthy food choices that reduce their children’s risk of becoming overweight or obese are discussed. Keywords children; grounded theory; health promotion; mothers; mothering; obesity / overweight Mothers play a vital role in providing healthy food choices for their young children. The complexity of this role has increased over the last few decades. Mothers are now making food choices in an environment that is considered obesogenic or obesity-producing. This environment has contributed to a rapid increase in the number of Canadian children becoming overweight and obese (Canadian Population Health Initiative [CPHI], 2004), constituting a critical public health issue in Canada. Since the late 1970s the prevalence of childhood overweight and obesity in Canada has risen (Shields, 2006). Using the 2004 age-/sex-specific body mass index (BMI) classification cut-offs established by the International Obesity Task Force (IOTF), 26% of Canadian children and youth are overweight or obese (Statistics Canada, 2004). This prevalence rate increases when using the more recent 2007 World Health Organization (WHO) age-/sexspecific BMI classification cut-offs for children and adolescents (de Onis et al., 2007). The WHO growth charts estimate that 31.5% of Canadian children aged 5 to 17 years are overweight or obese (Statistics Canada, 2012). Compared with their normal-weight peers, overweight and obese children suffer disproportionately from a number of chronic conditions such as type 2 diabetes, heart disease, bone and joint problems, and sleep apnea (Lobstein, Baur & Uauy, 2004; Public Health Agency of Canada [PHAC], 2011). These children report poorer health-related quality of life, intense stigmatization, lower self-esteem, and increased loneliness as their

ability to move freely, play sports, and engage with peers is affected (Institute of Medicine [IOM], 2004; Lobstein et al., 2004). In addition, obesity-related health problems place a tremendous strain on present and long-term Canadian health care costs (Kuhle et al., 2011; PHAC, 2011). Kuhle et al. found that obese children living in Nova Scotia had significantly higher health care costs, more physician visits, and more specialist referrals than their normal-weight peers. Feeding one’s family is work taken on primarily by mothers. Its gendered nature is well noted in the literature (Attree, 2005; Spitzer, 2005; Travers, 1996). On a daily basis, mothers generally make their young children’s food choices (Lindsay, Sussner, Kim, & Gortmaker, 2006; Statistics Canada, 2010a). Although seemingly simple, because much of the work involved is not visible to others (DeVault, 1991), making food choices is a complex social practice determined by many factors and their interactions (Delormier, Frohlich, & Potvin, 2009; Furst, Connors, Bisogni, Sobal, & Falk, 1996). Contextual factors such as social, economic, political, and environmental conditions can limit one’s agency and consequent capacity to make 1

Cape Breton University, Sydney, Nova Scotia, Canada Dalhousie University, Halifax, Nova Scotia, Canada

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Corresponding Author: Audrey Walsh, Cape Breton University, 1250 Grand Lake Rd., Sydney, Nova Scotia, Canada B1P 6L2. Email: [email protected]

Downloaded from qhr.sagepub.com at WESTERN OREGON UNIVERSITY on June 3, 2015

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Qualitative Health Research

healthy choices. Therefore, it is important to examine the role that personal and environmental circumstances play when exploring how mothers make food choices for their children. In this article, we report on a research project in which we explored the individual, interpersonal, and socioenvironmental factors and conditions that constrained mothers’ ability to make preferred food choices for their preschool-aged children, and the strategies that mothers used to push back against these constraints. We present a theoretical understanding of the process in which mothers engaged while making food choices for their preschoolaged children. This research was carried out by the first author as part of her PhD work and was guided by her supervisors, who are the coauthors.

Contextual Factors Influencing Mothers’ Food Choices A complex and interacting set of social, economic, cultural, technological, and environmental factors and conditions contributes to the problem of childhood overweight and obesity (Eriksen, Lyn, & Moore, 2010; PHAC, 2011). Combined, many of these factors and conditions create an environment that is obesogenic. An obesogenic or obesity-producing environment was defined by Swinburn, Egger, and Raza (1999) as “the sum of influences that the surroundings, opportunities or conditions of life have on promoting obesity in individuals or populations” (p. 564). This obesity-producing environment is the backdrop against which mothers are expected to make food choices that promote and protect their children’s health. The literature contains descriptions of the many factors at different levels of influence that affect mothers’ ability to make healthy food choices for their children. On an individual level, a child’s food preferences might pose a barrier. Mothers are frequently challenged to promote nutritious food choices because children’s preferences are often for energy-dense foods and drinks that are high in sugar (Dwyer, Needham, Simpson, & Heeney, 2008; Holsten, Deatrick, Kumanyika, Pinto-Martin, & Compher, 2012). A mother’s income, race, and education play a significant role. In Canada, single mothers with children and individuals living on social assistance are among the groups that experience the highest rates of food insecurity (Health Canada, 2006; McIntyre & Rondeau, 2009). Aboriginal women experience greater levels of poverty and therefore endure higher levels of food insecurity than non-Aboriginals (Health Canada; Power, 2008). Singleparent households, low-income households, and those with two working parents more often report having less time to prepare nutritious meals made from whole foods. They consequently rely on convenience foods that are

less costly, quicker, and easier to prepare, but higher in fat and sodium (Broughton, Janssen, Hertzman, Innis, & Frankish, 2006; Raine, 2005). Homes of parents with higher levels of education tend to purchase healthy food on a more frequent basis (Cribb, Jones, Rogers, Ness, & Emmett, 2011; Ricciuto, Tarasuk & Yatchew, 2006). At the interpersonal level, the mother–child relationship is an important factor in determining the foods that mothers select for their children. Although most studies indicate that mothers’ food choices are motivated mainly by their concern for their children’s health, many of these studies highlight inconsistencies between motivation and behavior as mothers engage in practices such as offering unhealthy foods to motivate their children’s eating behaviors (Slater, Sevenhuysen, Edginton, & O’Neil, 2012; Tucker, Irwin, He, Bouck, & Pollett, 2006). Brewis and Gartin (2006) found that although parents wanted their children to eat low-sugar, low-fat foods, many children were consuming calorie-dense foods even when directly supervised by parents. In addition, children often vetoed their mother’s healthier food choices for foods that were lower in nutritional value and higher in calories, fat, and salt (Colapinto, Fitzgerald, Taper, & Veugelers, 2007; Slater et al., 2012). On a community level, features of the physical environment influence mothers’ food choices. Families that live in rural or deprived communities in North America often have less access to large supermarkets that provide variety and lower-priced healthy foods. Williams (2009) reported that the average monthly cost of a basic nutritious diet in rural Nova Scotia was greater compared to those in urban areas. In addition, rural and less-affluent communities are less conducive to maintaining a healthy weight (Oliver & Hayes, 2005) because they often lack resources such as safe and attractive trails, parks, and recreational facilities for indoor sports and activities (Dehghan, Akhtar-Danesh, & Merchant, 2005). Finally, societal and political factors influence mothers’ food choices. Invasive marketing practices and campaigns strongly sway the decisions made by the uncritical consumer (Nestle, 2006; Winson, 2004). According to Winson, the foods most heavily promoted, marketed, and prominently placed in grocery stores were those that yielded the greatest margin of profit. In particular, these products included “pseudo foods,” or foods that were highly processed and high in sugar and/or fat and calories, and low in nutrients. The types of foods that were made available, marketed, and advertised influenced individuals’ preferences, purchases, and children’s requests (Gantz Schwartz, Angelini, & Rideout, 2007; Hastings et al., 2003; Taylor, Evers, & McKenna, 2005; Winson). This overview of the literature provides valuable insight into the constraining factors from different levels of


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Walsh et al. influence that challenge mothers in their attempts to make healthy food choices for their children. Notably absent in the literature were findings on the process mothers use to make their food choices in the face of all these factors. This gap in the research was the focus of our study.

Methods We used a constructivist grounded theory methodology (Charmaz, 2002, 2006) to better understand the actions, interactions, or the process in which mothers engage when making food choices for their preschool-aged children. According to Charmaz (2005), a constructivist grounded theory demands going deeper into the phenomenon itself and its situated location in the world. In constructivist grounded theory, the researcher creates the data and ensuing analysis with the participants and reality arises from the interactive process and its temporal, cultural, and structural contexts (Charmaz, 2002, 2006). Constructivist grounded theorists enter the field with a set of guideposts or sensitizing concepts based on extant literature or past experiences (Blumer, 1969; Charmaz, 2006). Consistent with the literature and our public health nursing backgrounds and beliefs, we used sensitizing concepts from the multifactoral socioen-vironmental health promotion (SEHP) perspective (Cohen, 2012; Labonte, 1993). Our knowledge of the SEHP perspective sensitized us to be alert to multiple-level factors and underlying conditions that perpetuate differences between people and limit their ability to make healthy choices (Charmaz, 2006; Labonte). It is important to stress that sensitizing concepts were used to assist us in asking questions and approaching the data with greater consideration of the background issues. Sensitizing concepts were not used to force a preconceived framework onto the data.

Recruitment and Sampling Mothers with children between the ages of 3 and 5 were invited to take part in this study. Study participants were recruited from a variety of settings that provided services to preschool-aged children in a large municipality in eastern Canada. Upon receiving required research ethics board approval, mothers were recruited from settings that included public health services, family place resource centers, and early childhood centers. Participants included 18 mothers with children between the ages of 3 and 5, who did not have any dietary restrictions and represented a range of economic, educational, cultural, and geographical backgrounds. Mothers ranged in age from 23 to 48 years, with an average age of 30 years. All mothers except one with twins had one preschooler at home. Eleven mothers were married or living in common-law marriages. Fourteen had a high school

education or higher, 12 were unemployed, 10 had incomes below the Statistics Canada Low Income Cut-Off (LICO) rate (Statistics Canada, 2010b), and 8 had incomes above the LICO rate. Fourteen mothers resided in a city or town and 4 resided in a rural setting. Sixteen mothers were White, and 2 were Mi’kmaq (First Nations people indigenous to Canada). In keeping with Morse’s (2007) recommendation to begin with a demographically homogeneous sample, we started with a sample of participants whose estimated before-tax yearly family income was below Statistics Canada’s LICO rate (Statistics Canada, 2010b). To add dimension to our emerging theory, once we heard the same central concerns from these mothers we expanded our sample to include mothers whose incomes were above the LICO rate.

Data Collection The primary source of data collection was an initial faceto-face, semistructured interview followed by a second telephone or face-to-face interview. In addition, over the 16- month period of data collection, mothers brought to our attention issues such as child-focused product placement in grocery stores and increased pricing for products with cartoon or celebrity figures on the package. To obtain a clearer picture of the settings and situations described by mothers in their interviews, we made observations in local grocery stores and restaurants. These observations allowed us to create additional question probes to add to our interviews. All field notes were considered data and were analyzed using grounded theory methods. All interviews followed a semistructured approach to allow each participant greater control over the inquiry process. Initial questions were broad and open-ended; as we interacted with the data and as categories were coconstructed, we adjusted the range of topics to gather more specific data to develop our theoretical framework. For example, each time a mother introduced a new topic or idea such as money, time, interpersonal conflict, or unique strategies, we added this insight to future interviews to see if it was common for other mothers. Data analysis began with the first interview. Typed transcripts of the initial interviews were prepared and mailed to participants to read and verify. Following receipt of the transcript, we conducted a follow-up recorded interview with 17 of the 18 original participants. In the follow-up interviews, mothers were invited to discuss and provide further examples of findings that could be used to modify and saturate categories. Data collected during follow-up interviews were used to supplement those gathered from the initial narrative accounts.


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The question of how mothers make food choices for their children was a clear and obvious one. The mothers who participated in this study were willing to share their stories and provide extensive and detailed data. For this study, 35 interviews with 18 participants was a sufficient number to build robust theoretical categories and thus reach saturation.

Data Analysis Consistent with grounded theory methodology, data collection, coding, and analysis occurred concurrently (Glaser & Strauss, 1967). We used QSR International’s (2008) NVivo 8 qualitative software to sort and code data. We followed the two main grounded theory coding phases described by Charmaz (2002, 2006) that consist of an initial phase and a focused, selective phase. Theoretical coding followed the selective phase. In the initial or open coding phase, we read each transcript and asked questions of the data to identify pieces of data such as words, lines, or incidents to determine their analytical significance. In the second or focused selective coding phase, we took the most significant or frequently appearing initial codes to use in sorting and synthesizing larger segments of data. We used focused coding to develop categories, and like codes were subsumed into categories. For example, a number of initial codes pertained to a variety of strategies that some mothers used to better afford healthier foods; these were grouped together as a focused code, economizing. Other codes referred to strategies that mothers used to gain more time and to be better prepared to make healthier food choices; these were grouped together under enhancing time and effort. Both of these focused codes were subsumed under the category, managing resources. Theoretical coding, as described by Charmaz (2006), is a sophisticated level of coding that suggests relationships between the categories developed during the selective phase of analysis. It is a process of coding that yields the conceptual relationship between categories and their properties (Glaser, 1978). For example, the managing resources category referred to a previously described set of strategies that mothers used to counteract contextual constraints. Two other categories, namely advancing healthy food choices and minimizing societal deterrents, also described different strategies that mothers used to moderate constraints. Three of these categories were subsumed under the major conceptual category, stretching boundaries. Coding was accompanied by writing and sorting memos, which assisted us in exposing the connections between categories, better defining subcategories, and recognizing the core category. The core category that captured our overall understanding of how mothers were making food choices for their children was identified

during this phase of research and was named persistent optimizing.

Findings The central problem affecting mothers in this study was facing numerous interpersonal, social, economic, and environmental factors that constrained their ability to make healthy food choices for their preschool-aged children. To overcome this problem and to reach their goal of providing preferred food choices to their children on a more consistent basis, mothers used a multidimensional process called persistent optimizing. Optimizing, as used in this study, refers to mothers’ persistent efforts at negotiating the abovementioned factors to more consistently make the best food choices for their children in each food choice situation. Persistent optimizing consists of three main integrated, conceptual categories constructed from the data: acknowledging contextual constraints, stretching boundaries, and strategic positioning. The central process of persistent optimizing is depicted in Figure 1.

Overview of Persistent Optimizing As reflected in Figure 1, the persistent optimizing graphic representation depicts a spiral that denotes the persistent forward motion of mothers in making their preferred food choices for their children. Mothers entered the spiral with the intention of making food choices that promoted their children’s health. To reach this goal they moved through the three main conceptual categories: (a) acknowledging contextual constraints, (b) stretching boundaries, and (c) strategic positioning. The categories, although depicted separately, were interactive and interrelated. Persistent optimizing was not an orderly, sequential process; rather, it describes a somewhat messy, complex process of how mothers dealt with a variety of competing constraints to make healthy food choices for their children. Mothers’ success in each conceptual category helped propel them toward making the best possible food choice in a given situation. The spiral represents the building of mothers’ awareness, knowledge, successful strategizing, and subsequent agency to procure preferred food choices on a more consistent basis.

Acknowledging Contextual Constraints Mothers set out to make food choices consistent with their feeding goals for their children. All mothers expressed that their overall intention was to provide their children with healthy food choices. They acknowledged various competing contextual constraints at multiple levels of influence that hindered their ability to make their intended food choices. Acknowledged constraints were subsumed


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Walsh et al. Mothers’ best food choice at that time

STRATEGIC POSITIONING

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Compromising Invisible Balancing Reflecting Critically

Increasing reflectivity

Advancing Healthy Food Choices Managing Resources Minimizing Societal Deterrents STRETCHING

BOUNDARIES

I

Increasing reactivity

cts Relational Conflicts Restrained Resources Societal Deterrents

a

ACKNOWLEDGING 1 CONTEXTUAL CONSTRAINTS Increasing dissonance

Mothers’ intention to provide food choices that promote health Figure 1. Persistent optimizing graphic representation.

under three subcategories: (a) relational conflicts: discerning food values of self and significant others; (b) restrained resources: recognizing individual and structural realities that constrain choice; and (c) societal deterrents: discovering the unaccommodating food environment.

Relational conflicts: Discerning food values of self and significant others. In making food choices for their preschoolers, mothers acknowledged relational conflicts with their child, their partner, extended family, or friends. One professionally employed mother described trying to make


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healthy food choices as a battle. She struggled with maintaining control over her children’s food choices when they were around other children: It’s hard, too, when there are other kids [children] around, because if they have it, and typically, like I said, we’re not terrible. If they’re having a treat, then I will let them have it, but if another one comes out and another one. But it’s so hard, because the other kids are eating it, and I’m saying, “No, you’ve had enough.”

When asked what it would take to make the food choices that she would like to make, she replied, “If everyone would listen and the kids would eat healthy.” Another mother, whose child visited her grandparents regularly, highlighted the challenges of dealing with wellmeaning extended family members whose views on giving junk foods were different from hers: She [mother-in-law] is a huge influence on their life, and she kind of takes over. She hadn’t seen them in a week, so she wanted to pick them up the other night, and when she came home, she didn’t just have a treat of a chocolate bar for them, she had bought them six bars. I was like, “They don’t need that,” but she’s so influencing that way.

Restrained resources: Recognizing individual and structural realities that constrain choice. Mothers in this study acknowledged restrained resources such as money, time, and cooking ability. Those who lived below the Statistics Canada LICO rate (Statistics Canada, 2010b) frequently described not having enough money to make preferred food choices for their children. One mother was not able to afford on a regular basis the salads her son enjoyed. She said, “To buy a salad that’s not cheap, and it’s one meal, and it’s like seven dollars [Canadian] for one meal, and it’s only a side of a meal, so it doesn’t happen very often.” Lack of time to prepare healthy meals was another constraint that mothers acknowledged. For almost all mothers, life did not allow time to cook nutritious meals every day. This was true both for working mothers and for mothers who stayed at home caring for their young children. For example, a mother with an income below the LICO rate noted, Lengthy meals are very, very hard. Like last week I made cabbage rolls and it took hours and hours before I even got them in the oven. Like something that would have taken me normally an hour probably took me four, just because of having to take care of the baby at the same time.

Food marketing practices directed toward children: Discouraging health. Mothers acknowledged societal deterrents in the form of counterproductive food-marketing practices.

Mothers were challenged to provide healthy food choices for their children because of the way foods were displayed in the grocery stores. All mothers described grocery stores as being designed to encourage children to ask for less-healthy, often more expensive foods. Such foods were displayed at children’s eye level and with cartoon figures that their children recognized from TV advertisements. Pestering was a serious issue that all mothers encountered while they were shopping with their children. Similar to other mothers, one mother noted how her child always noticed the big bin of chocolate bars that was located next to the checkout counter. She commented, “So she sees it no matter what, because when you go to the checkout, there’s the big bin. And then she just starts asking for them. Every time; it never fails.” The multiple competing, interpersonal, and socioenvironmental factors or conditions that mothers recognized as contextual constraints heightened their feelings of dissonance and motivated them to devise strategies to reach their goal of choosing healthier foods for their children. Mothers who wanted to severely restrict their children’s access to unhealthy foods experienced more dissonance than mothers who allowed their children to eat varying amounts of such foods. Mothers with more restrictive feeding goals described their feeding work as “a battle,” “a lot of work.” Mothers moved from acknowledging contextual constraints to the other categories of stretching boundaries and strategic positioning. Here they enacted a variety of moderating and optimizing strategies to negotiate the constraints that deterred them from providing preferred food choices for their children.

Stretching Boundaries Stretching boundaries was characterized by increasing levels of reaction or reactivity. Many of the healthier food choices preferred by mothers appeared at first glance to be out of bounds. Mothers were bounded or constrained by many factors, such as their children’s food preferences, money, or the time they had to shop or prepare meals. Reacting to the dissonance they experienced in acknowledging contextual constraints, mothers constructed and employed a series of moderating strategies to stretch the boundaries of their capacity to make healthy food choices for their children. These strategies were subsumed under the subcategories of (a) advancing healthy food choices; (b) managing resources: mothers’ income, time, ability, and effort; and (c) minimizing societal deterrents. Advancing healthy food choices. According to most mothers in this study, their children’s food preferences often tended toward less-healthy foods. As a strategy to get their children to make different choices, mothers stretched


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Walsh et al. the boundaries of the number of food options from which their children could choose. In these ways, children’s exposure to less-healthy foods was limited. Mothers creatively prepared healthy foods, created diversions that encouraged their children to eat healthier foods, regulated food rewards and treats, and found ways to reconcile conflicting food values of family and friends. All mothers described using tricks such as hiding vegetables or meat in mashed potatoes. One mother who lived below the LICO rate commented, “I’ll take all of her food, and I’ll mix it up into one if I’m having potatoes, because she just thinks she’s eating potatoes, and she doesn’t know the meat is in there.” Mothers attempted to limit the number of treats or reward foods filled with empty calories. A strategy used was to hide these foods and eat them after their children went to bed. One mother reported that she and her husband often bought and then hid snacks such as chips and soda pop. She commented, “We will hide our chips so that he doesn’t see it. Or the pop, we will hide it where he can’t see it. And then when he’s asleep, that’s when we’ll have our snack.” Sometimes a mother’s desire to give her child nutritious foods was thwarted by her partner, the child’s grandparents, or by her friends. This was a cause of dissension for the mother when others wanted to give the child unhealthy foods more often than she felt was appropriate. Mothers strategized to find ways to reconcile these differences. A mother spoke about her partner’s tendency to be more lenient in offering unhealthy snacks to their child, and noted, “I have to speak to him sometimes because we have to be on the same ground [regarding giving junk food to child]: ‘We can’t give in. If I put my foot down, don’t let her [child] run to you.’” Some mothers limited their time spent with family members or friends who offered too many unhealthy food choices. Another mother countered this problem by sending healthy food when her child went to visit her grandparents: So it is kind of a bit of a treat day if she does go. But I do offer suggestions to my mother. And sometimes I will send out some of her favorite foods with her and tell her, “This is for you and Nanny to share.” It kind of gives them an opportunity then to have what I want them to have, and have it be a treat like fresh strawberries, fresh peaches, or some fresh grapes.

Mothers enacted many strategies for dealing with family and friends and were placed in the difficult position of maintaining family harmony while also attempting to promote their children’s health. Managing resources: Mothers’ income, time, ability, and effort. The amount of money and time mothers had

available greatly affected the food choices they were able to make for their children. All mothers worked to secure healthier choices whenever possible. Mothers with a limited income searched for discounts on healthier food items. This took a great deal of effort because unhealthy foods were on sale more frequently. Mothers with a higher income had greater selection because they could afford more. Generally, all mothers struggled with a lack of time to prepare preferred meals. To manage their resources, mothers economized to stretch their food dollars and tried to maximize their time and energy when feeding their children. Mothers found, collected, and used coupons to save money on preferred purchases. As illustrated by one mother, some were more adept at finding and using coupons: “Oh, I live on coupons. I get them off the computer—save.ca and through fliers.” Characteristically, mothers who lived below the LICO rate planned ahead and exercised patience; for instance, one waited a month to buy the oil she needed to make a carrot cake after being given extra carrots at the food bank the month before. In addition, mothers exercised ingenuity by substituting less-expensive items for more-expensive ones. One mother stated, Yeah, sometimes the ingredients are just too expensive. Sometimes I try to substitute it with cheaper. Like most recipes, you can substitute with a cheaper no-name version. No-name is my friend. There are certain things that I won’t eat no-name because they don’t taste as good.

Mothers with an income below the LICO rate had to work harder to acquire and prepare sufficient nutritious foods to feed their children. In addition, all mothers strategized to save time in preparing healthy meals. Mothers described planning ahead, such as preparing meals the night before or making extra on weekends to use during the week. Some mothers were able to share the workload with their partner. Mothers’ efforts at moderating time constraints helped to stretch the boundaries or increase their capacity to make healthy food choices for their children. Minimizing societal deterrents. Mothers used strategies to counteract persuasive food-marketing practices. Some mothers prevented their children from making unhealthy food requests by avoiding the junk food aisles in grocery stores. Notably, navigating away from the junk food aisles did not stop children’s requests for child-oriented food items dispersed throughout the store. One mother stated, “I try to avoid the junk food aisle. If they go down that aisle, I try to trick them, saying, ‘Oh, look at this. This is nicer.’” A few mothers avoided conflict with their children by using a tactic we describe as stealth. When a child asked for an item that the mother did not want to buy, she put it in the cart, and when the child was not


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watching, she removed the item. A mother who lived below the LICO rate noted, Mother (M): Pick, pick, and then sometimes, I’ll hide it. Interviewer (I): What do you mean by hiding it? Do you mean when you get home? M: No, when I’m not going to buy it, I’ll put it back on the shelf when they’re not looking.…I don’t have to hear her yelling, no temper tantrums.

To avoid a public confrontation with their preschoolaged child, some mothers simply gave in and let the child have the item or left the store without finishing their shopping. Mothers tended to view the grocery store as a potential battlefield, and they created multiple strategies to keep the peace. Overall, the strategies that mothers employed to moderate contextual constraints helped to stretch the boundaries of the food options available to them, thus enhancing their agency in making preferred choices. Once mothers exhausted their use of moderating strategies they were left with making their food choices from the options available to them.

Strategic Positioning With strategic positioning, mothers demonstrated increasing levels of reflection. They reflected on the success of the moderating strategies they had used and employed optimizing strategies to position them closer to making the best food choice in a given situation. Optimizing strategies included: (a) compromising, (b) invisible balancing, and (c) reflecting critically. Compromising. Mothers generally had to make compromises among the food options available. They attempted to take action consistent with their personal standards and make choices that enhanced their satisfaction with the food they offered their children. Mothers had to consider their children’s needs and wants; their own income, time, and energy; and keeping peace in the family. Mothers with an income below the LICO rate were often forced to compromise between a more-expensive, healthier food and a less-expensive, less-healthy choice. To illustrate, one mother remarked, It’s really hard for me to shop healthy because of the cost. If you do the comparisons, if you get just white plain bread to whole wheat bread, whole wheat bread would be more. I would rather buy white bread.

Time scarcity also compelled mothers to compromise; in the end, making sure their child had food was the priority. One mother offered unhealthy foods on occasion because of the convenience: “They certainly get more

junk than I would like them to get, and that’s from me as well—sometimes, like I said, because of convenience and whatnot.” In other situations, mothers felt compelled to compromise their child’s nutrition for a brief period to keep peace with a family member. To counteract compromised food choices that were inconsistent with their feeding goals, mothers immediately started preparing for future food choices that would balance out their child’s health over a period of time. There was fluidity around choice making. Many choices over a period of time contributed to a mother’s goal of getting her child to eat healthy foods on a more consistent basis. Invisible balancing. In invisible balancing, mothers stayed alert and prepared so that if an optimal food choice or situation presented itself they would be able to take advantage of it. Mothers used resources wisely to find ways of acquiring and presenting healthier food options to their preschoolers. They looked at the big picture to ensure that, over a particular period of time, the healthier foods their children consumed outweighed the lesshealthy ones. A mother remarked, I would say over a couple of days, simply because some days she simply doesn’t eat a whole lot, and other days she’ll eat everything. So I’m more concerned with over a few days. If she doesn’t eat her entire lunch one or two days, but I know she’s having a good supper that night, then I’m okay with that.

Mothers were vigilant and always thinking forward to the next choice in an effort to balance the healthfulness of their children’s food choices. Reflecting critically. Finally, by reflecting critically, a few mothers in this study were able to examine their situation through a broader, more critical lens. These mothers inquired and reflected more critically on the power relationships and underlying social structures that affected their ability to make their preferred food choices. Taking a futuristic view, these mothers planned for their children’s future health; they wanted to teach them healthy eating habits that would endure. One mother stated, “If you teach them early to eat the better stuff, make sure they get their fruit and stuff, they are more likely to keep that when they get older, instead of going to the junk all the time.” Possessing a higher level of literacy or income than did their parents, some mothers attempted to recreate themselves, making different food choices than the ones they were given as children. A mother commented, My mother didn’t know, and she still doesn’t know. She thinks that she is doing the kids a favor by giving them Froot Loops [a sugary breakfast cereal], and it’s hard to convince her that it’s not. She feels that they would be deprived if they lived in a world without Froot Loops or bologna.


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Walsh et al. Other mothers recognized their need to learn more about feeding issues so that they could provide ageappropriate, healthy foods for their children on a more consistent basis. One mother who was a teenager when she had her first child stated that at that time she knew very little about feeding her infant and managing money. She considered herself fortunate that she was able to take advantage of the services offered by the local family resource center. She stated, Family Resource.…They’re my lifeline. They taught me a lot. I was nineteen when I had my son, and I didn’t really know too much. So I take as many courses there as I can, and they answer all my questions for me and help me be the best parent I can be.…They also helped with meal planning and stuff. I took a couple of courses that helped me with that.

Another mother was critical of the financial structures that restrained her food choices. She pointed out the disparity between health messages that recommended what her children should eat and constraints such as grocery store pricing and social assistance allowances that kept her from buying these foods. She questioned why the healthy options were the most difficult to afford: “They got to price it up so much because they know you got to buy it. Just like with milk. Like they know that you need it. But they price it right up. You still got to buy it.” This overview of persistent optimizing shows how a mothers’ ability to make food choices in any situation was conditioned by the identified constraints and her agency to counteract these constraints. Mothers were not always successful at making their preferred food choices, but they persisted, choice by choice, day by day, and even week by week to increase their ability to make such choices. Mothers’ agency was influenced by their life circumstances; the amount of money, time, and energy they possessed at any one moment was prone to change, as were the contextual constraints mothers encountered. In this regard, no one set of strategies was exclusively successful; mothers generally had to revise and refine old strategies and develop new ones. They also often had to use strategies in layers; for example, following moderating strategies with compromising strategies, and following compromising strategies with strategies to balance their children’s health. By employing these strategies to overcome contextual constraints, mothers developed new knowledge and skills that enhanced their ability to make preferred food choices.

Discussion The substantive theory, persistent optimizing, integrates the voices, values, and perspectives of 18 mothers of preschool-aged children. It represents the process of how

mothers responded to a variety of constraining factors and conditions from multiple levels of influence and enhanced their ability to make healthier food choices for their children. Most studies exploring the food-choice decision process concentrate on how adults make food choices for themselves (Connors, Bisogni, Sobal, & Devine, 2001; Falk, Bisogni, & Sobal, 1996; Furst et al., 1996; Sobal, Bisogni, Devine, & Jastran, 2006); they do not account for the complexities involved in making food choices for others and the intricacies of the mother–child feeding relationship. Studies that have explored how mothers make food choices for their children generally focus on a specific influencing factor and the strategies mothers use to respond to this factor. Some of these factors include parental feeding styles and cultural influences (Clark, Goyer, Bissell, Blank, & Peters, 2007; Patrick, Nicklas, Hughes, & Morales, 2005; Ventura, Gromis, & Lohse, 2010), income (Attree, 2005; McIntyre & Rondeau, 2009; Raine, 2005), time (Bava, Jaeger, & Park, 2008; Jabs et al., 2007; Wethington & Johnson-Askew, 2009), education (Cribb et al., 2011; Ricciuto et al., 2006), and food marketing practices (Hastings et al., 2003; Winson, 2004). Persistent optimizing shares some similarities with Gillespie and Gillespie’s (2007) conceptual framework that identified four stages in the family food decisionmaking process. Unlike persistent optimizing, in Gillespie and Gillespie’s decision-making framework, mothers were not singled out but were part of the family in the food decision-making process. Families in their study consisted of any configuration of people who regularly ate together, shared household food resources, and who mutually influenced decisions about food. The particular makeup of each family studied was not described, and preschool-aged children were not mentioned. Persistent optimizing, by focusing on mothers and preschool-aged children, extends and enhances Gillespie and Gillespie’s framework. Persistent optimizing lends support for Giddens’ (1984) structuration theory, wherein capacity is understood as being limited by structural constraints that come about through the agency–structure interplay. In this study, the capacity of mothers to recognize and respond to socioenvironmental constraints in food choice situations was significantly influenced by the resources available to them. Delormier et al. (2009) borrowed notions from Giddens’ structuration theory to develop a conceptual framework that explores eating as a social practice. Focusing on family feeding practices, these authors noted that the conditions under which food choices are made are structured by “rules and resources” (Giddens) that limit an individual’s range of options. Persistent optimizing, as an explanation of how mothers make food choices,


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supports Delormier et al.’s (2009) structuration analysis of family feeding practices, because mothers’ agency to make preferred food choices for their children was influenced by contextual factors and conditions that could be subsumed under Giddens’ rules and resources. Persistent optimizing is original because it considers factors from all levels of influence and the interaction between these factors to explain how mothers make food choices for their preschool-aged children. In this study, mothers’ food choices were constrained by multiple competing interpersonal and structural constraints. Furst et al. (1996) contended that people’s perceptions of what is available to them demarcate their boundaries in food choice situations. In this study, mothers developed and enacted a variety of moderating strategies to stretch the boundaries of the food choices that were available to them at first glance. They worked to increase their agency to make preferred choices. Many of the moderating strategies in persistent optimizing are supported by the literature. Freeman, Ekins, and Oliver (2007), Noble, Stead, Jones, McDermott, and McVie (2007), and Tucker et al. (2006) described a variety of strategies that mothers use to enhance the quality and quantity of their children’s food choices. Bevan and Reilly (2011), Brewis and Gartin (2006), Noble et al., and Slater et al. (2012) described mothers accommodating the food preferences or needs of other family members over their own, and trying to keep peace within the family. Notably, the need to maintain peace with extended family and friends, which mothers in this study encountered, was not strongly identified in most studies that were reviewed. This finding extends and adds nuance to the literature in this area. Strategies to manage resources, such as stretching a meager income (Attree, 2005; Devault, 1991; Travers, 1996) and maximizing time (Bava et al., 2008; Bevan & Reilly, 2011; Jabs et al., 2007; Wethington & JohnsonAskew, 2009), were also noted. In addition, mothers in this study created strategies to deal with their children’s demands for less-healthy, often more-costly foods that were designed to attract and tempt children. Pestering, according to McDermott, O’Sullivan, Stead, and Hastings (2006), directly influences mothers to buy foods that are less healthy and that increase children’s risk of becoming overweight. Notably, the findings of the present study extend some results found in the literature, add depth and understanding to others, and add nuance to what is already known. Many of the strategies that mothers used in this study were previously described in the literature. Persistent optimizing adds an original way of looking at these strategies, to view them as moderating strategies that help to lessen the impact of negative forces on mothers’ capacity to make healthy food choices.

Mothers used these strategies to stretch the boundaries of the food choices available to them, enhancing their agency by placing them in a stronger position to make preferred food choices for their children. Their success with using moderating strategies provided them with their range of choices. For example, the mother who took time on the weekend to prepare and freeze meals was better positioned to offer a healthy meal during the week when evening schedules did not permit this option, Mothers living below the LICO rate who closely monitored their food supplies, shopped for bargains, used coupons, and stocked up on sale items had more money to make preferred food choices than mothers who did not use these strategies. Without these daily moderating strategies, a mother’s agency to make choices was more limited. In strategic positioning, mothers were more reflective, enacting a variety of optimizing strategies to make the best choice from among the range of existing options. Consistent with other findings, mothers used a variety of compromising strategies (Bava et al., 2008; Connors et al., 2001; Furst et al., 1996; Slater et al., 2012; Sobal et al., 2006; Sobal & Bisogni, 2009). Mothers followed compromised food-choice situations with strategies that allowed them to balance their children’s health over a period of time. Balancing as a strategy used to resolve food-choice value conflicts is noted in the literature (Connors et al., 2001; Falk et al., 1996; Furst et al.; Gillespie & Gillespie, 2007). All mothers in this study acknowledged the contextual factors and conditions that limited their ability to make preferred, healthier food choices for their children. A few mothers were able to go beyond these constraints to view more critically some of the invisible forces that created and sustained these barriers. These mothers described the food environment as one designed more toward making a profit than promoting health. Mothers enacted strategies to assist their preschool-aged children in developing good food habits at an early age, so that they would be better able to resist a food environment that promotes unhealthy, obesogenic food choices in the future. Persistent optimizing highlights the relentless reflective work that mothers engaged in on a daily basis to increase their ability to make preferred food choices for their children. A strength of persistent optimizing is that it makes visible the dynamic process of mothers’ feeding work, including the many dimensions and strategies that are frequently invisible. It highlights the repertoire of strategies that mothers employed to push back against the contextual conditions and factors that constrained their ability to make preferred, healthy food choices. In conclusion, persistent optimizing captures and organizes the many aspects of mothers’ food-choice practices that must be in place for them to be successful. It


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Walsh et al. emphasizes that much work is needed to increase the opportunities for mothers to make preferred food choices for their children on a more consistent basis. Helping mothers to make healthy food choices that minimize their children’s risk of becoming overweight or obese will require collective action from multiple levels of influence, including policy-level changes that address the socioenvironmental determinants of health to supporting individuals and families to make healthier food choices on a more consistent basis. Further studies in this area are needed to emphasize repeatedly that contextual constraints must be altered to create the socioenvironmental conditions that allow all mothers to make preferred, healthier food choices for their children. In this way, the burden that mothers face will be diminished, children’s risk of becoming overweight or obese will be reduced, and opportunities for children to grow into healthy adults will be improved. Authors’ Note Portions of this article were presented at the 3rd International Public Health Nursing Conference, August 27, 2013, in Galway, Ireland, and at the 19th Annual Qualitative Health Research Conference, October 29, 2013, in Halifax, Nova Scotia, Canada.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support was received through a Nova Scotia Health Research Foundation Doctoral Student Research Award.

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Author Biographies Audrey Walsh, PhD, RN, is an associate professor at the Cape Breton University Department of Nursing in Sydney, Nova Scotia, Canada. Donna Meagher-Stewart, PhD, RN, is a retired associate professor, Dalhousie University School of Nursing, Halifax, Nova Scotia, Canada. Marilyn Macdonald, PhD, RN, is the associate director of graduate studies and an associate professor at Dalhousie University School of Nursing, Halifax, Nova Scotia, Canada.


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