Issues in Comprehensive Pediatric Nursing, 2014; 37(4): 250–264 ß Informa Healthcare USA, Inc. ISSN: 0146-0862 print / 1521-043X online DOI: 10.3109/01460862.2014.951132
UNDERSTANDING PARENTAL PARTICIPATION IN HEALTH PROMOTION SERVICES FOR THEIR CHILDREN
Winsome Lam, RN, MN1, Sau Ting Cynthia Wu, RN, PhD1, and Cathrine Fowler, RN, PhD2 1
School of Nursing, The Hong Kong Polytechnic University and Centre for Midwifery, Child and Family Health, University of Technology, Sydney
2
The aim of this research was to explore parental participation in child health promotion services within a Hong Kong community. There are many elements influencing the effect of health promotion services. One is the extent of parental participation. However, research in this area is limited. Focus group data were content analyzed. Six themes were conceptualized. They are Equity, Equality, Evolution, Engagement, Consultation, and Continuity. We concluded that a strategic approach in partnership with families is required for health promotion activities for children. The findings contribute to an understanding of the crucial factors for the promotion of parental participation in health promotion services. Keywords: Children, health promotion, parent involvement
INTRODUCTION In today’s society, children’s health issues and their subsequent management have become complex, as an individual’s health is affected by multiple inter-related physical and psychological factors, as well as their relationship to the environment (Chan, 2011; Lohrmann, 2010). Increasing warnings are occurring about the threats to children’s health Received 29 June 2014; revised 29 July 2014; accepted 30 July 2014
Correspondence: Winsome Lam, The School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China. E-mail: winsome. [email protected]
250
Parental participation in child health promotion service
251
and the increase in diseases such as obesity, pandemic influenza, and avian flu (Center of Health Protection, 2008). Crucially, many diseases can be prevented or their impact on health minimized through efforts such as health promotion and disease prevention strategies (Center of Health Protection, 2008; National Scientific Council on the Developing Child, 2010; World Health Organization, 2002). These alternative efforts are deemed to be central to community illness and disease prevention interventions (World Health Organization, 2009). Taking obesity as an example, it is well accepted that preventive measures are the best way to avoid obesity and associated diseases, especially if commenced during the early years of a child’s life (Department of Health, 2012; National Scientific Council on the Developing Child, 2010). A focus group of parents of children from a primary school in Hung Hom, Hong Kong, was used to gather data for this qualitative research study. The aim of this research was to explore parental participation in child-related health promotion service within a Hong Kong community. In this article, six major themes that emerged from the data will be discussed. BACKGROUND A review of the literature identified limited Hong Kong studies investigating the factors required to facilitate adequate levels of parental health promotion participation. It is clear that further exploration is necessary about how to encourage parental participation in child health promotion activities in order to enhance Hong Kong children’s health status. Health promotion is recognized as an essential element of maintaining health and reducing future risk (World Health Organization, 2009). There are many elements that influence the success of health promotion services, such as: community participation, sufficient attention being given to the development of health resources, advocacy for legislative action, sustainability of the health practices, and adequate publicity about the activities (Nutbeam & Bauman, 2006: World Health Organization, 2009). Health promotion activities for primary school children such as the Eat Smart Campaign (Department of Health, 2012), require a close relationship between specific populations (children and parents) and service providers (teachers and community health nurses) to be successful and sustainable (World Health Organization, 2009). Parents are believed to be key in promoting their children’s health as primary school children are dependent on their parents’ ability to
252
W. Lam et al.
recognize health issues that require the application of disease prevention and health promotion activities. Parents are the role models for children to learn and behave, as children’s health is directly related to their family lifestyle and behavior (Lyles et al., 2012; Schor & Menaghan, 1995). Young children spend significant amounts of time at home with their parents. Parents are well positioned to reinforce their children’s health practices and behaviors and exert considerable influence through their daily interactions (National Scientific Council on the Developing Child, 2010; Schor & American Academy of Pediatrics Task Force on the Family, 2003). Literature demonstrates that there is a positive relationship between families and their children’s health (Beets et al., 2010; Gussy et al., 2008). The successful implementation and maintenance of child health promotion activities require increased parental engagement in child health promotion programs by raising awareness of the importance of the activities prior to staging these programs (Lyles et al., 2012; Nutbeam & Bauman, 2006). If parents are in engaged in health promotion activities they are more likely to extend these activities into the home and wider community. Evidence of success is provided in the studies of Aguirre et al. (2012) and Van Lippevelde et al. (2011) as they recognize the significant influence resulting from parental involvement and modeling to improve child physical fitness levels and increase dietary fruit and vegetable intake. Certainly, these studies position parents as the immediate and primary source of health education and information provision (Van Lippevelde et al., 2011). Given this backdrop, a qualitative research study was conducted in order to understand the level of parental participation in child related health promotion services within a Hong Kong community. METHODS A parent focus group using an interpretive descriptive approach (Thorne, 2008) was employed to guide the research process. This approach used in clinical nursing practice research enables a qualitative approach that is interpretive and exploratory in design (Thorne et al., 2004). A qualitative approach provides a rich and detailed description of issues that have had minimal exploration. Importantly the interpretations are ‘‘constructed truths’’ rather than facts (Thorne et al., 2004). This inductive approach creates opportunities to understand a clinical phenomenon (e.g., parental participation) that identifies application implications (Thorne et al., 2004). As stated by Morse & Field (2002) qualitative research is particularly useful for studying a phenomenon or event about which little is known.
Parental participation in child health promotion service
253
Participants A purposive sample of 11 parents of school children was recruited from a local Hong Kong primary school. There are two types of schools that are governed by the Hong Kong Education Bureau. Mainstream schools provide universal primary and secondary education to all children. Special schools provide education services for children with special educational needs, such as visual impairment, hearing impairment, physical disability, and intellectual disability (Education Bureau of Hong Kong, 2013). The researcher initially contacted the person in charge of several mainstream primary schools to provide information about the study and to invite them to participate. One of the schools agreed to participate in the study. A face-to-face meeting with the person in charge of the primary school was arranged to provide study information. The primary school teachers helped distribute the information sheets to parents to invite them to participate in the study. Interested parents were contacted by the researcher and personally invited to participate in the focus group. The criteria for inclusion in this study were: a parent with a primary school child aged 6 to 12 years old, the child being healthy, and the parent being the main caregiver and able to speak either Cantonese or English. The interviews were arranged at a convenient time and place with the participants. Ethical Considerations Ethical approval from a University Ethics Committee was obtained. Participation in the study was voluntary. All parents received a written information sheet explaining the research aims and purpose. Parents’ written consent was obtained prior to the focus group commencement. A separate phone line and postal address, in addition to the contacts of the researchers, were provided for further enquiries, doubts, and complaints. All data were de-identified and securely stored to maintain confidentiality. Data Collection The focus group was guided by the use of semi-structured questions informed by the findings of the literature review. The questions used consisted of three domains related to enhancing parent participation in their children’s health promotion services: opportunity, need fulfillment, and satisfaction. For example: what are your opinions about the current child health promotion services such as healthy eating, personal hygiene, and so on; do they match your concerns and needs around child health;
254
W. Lam et al.
and how could these health promotion activities be implemented successfully or effectively? The focus group continued until the parents expressed no new information/ideas. The group lasted for 90 minutes and was digitally recorded. All interviews were conducted in Cantonese. The interviews were transcribed in Cantonese and then translated into English. Data Analysis A thematic content analysis approach was adopted to analyze and identified thematic categories by using systemic coding. The data from the interview scripts were read line-by-line, coded, and categorized into themes. To ensure consistency of the identified themes each piece of data was compared with other relevant data. To maintain a rigorous analysis process, the research team reached agreement about the match between the themes and data extracts. This process also included ongoing questioning that included: why is this here; why not something else; and what does it mean (Thorne et al., 2004). Six major themes were identified from these data. FINDINGS The analysis identified six major themes within the data. The themes were associated with promoting parental participation in health promotion service for their children. These major themes were: Equity (equal access), Equality (service to all), Evolution (developmental health service), Engagement (involvement with health promotion), Consultation (quality advisory service), and Continuity (sustainability of care). Equity Equity was identified as parents having the equal ability to access health promotion programs. The participants claimed that in the community, there were minimal channels for them to access information related to health promotion, particularly about and for children, and that this often resulted in a lack of stimulus to participate. Failure to provide sufficient advertisement of the resource was a major factor blocking parents from actively joining health promotion activities. In the following extract, the health promotion information was identified as not being adequately posted or promoted to ensure maximum visibility. . . . in my housing estate, even when health promotion information is posted on the wall, I rarely notice it. Honestly, no one goes up to the notice board.
Parental participation in child health promotion service
255
The publicity agent stuck it [the poster] onto the wall of each lobby of each building. However, they did not do any publicity. They just wanted to get it done. (89P7)
Another participant emphasized that school was the only platform for her to engage in health promotion activities and stressed the importance of effective promotion of programs. She stated: I can only get information from the school [where] my child is studying. Because of this access, I can take part in health promotion activities. Or from the parent-teacher association (PTA) . . . if I am not a member of PTA, I have no chance to get such information. We are in a passive position; I think there are not that many opportunities for us to [have] contact with health promotion activities. (94P7)
Importantly in the above extract, the parent described the position of parents as passive due to the lack of access to health promotion information. This implied a lack of involvement with decision-making and alludes to a disconnection for many parents from proposed health promotion activities. Ease of access for the parents, whether for services or information, was identified by the parents as significant to the care and health of their children. Even though health promotion information was available, it received limited publicity. More active advertisement was required to create awareness and interest. Until this occurs, parents’ ability to participate or access programs or information would remain limited. Equality Several different informants complained that the existing health promotion services and focus were restricted. They went on to say that most health promotion services are specifically for the elderly or young children. The coverage of services provided was limited and not available to all age groups, and there was a health promotion service gap for school-age children and parents. On the other hand, the parents believed that if there were a mandatory set of health promotion topics, it would be more likely to succeed. The parents described their concerns as: . . . I don’t know why the health promotion service is only for elder people. For example, they can go to the elderly center for blood pressure monitoring or physical health assessment. However, for our age group, there is no service in our community. We don’t know where we can get blood pressure
256
W. Lam et al.
monitoring service. In the same way, children have the dental check-up service. Again we have no rights or services provided by the community or the government . . . . If the service [health promotion] is free and participation mandated [by the government], it is more likely to be successful. (111P7) . . . the health promotion service is usually for those who are old enough [the elderly], or young enough to receive the service [children] . . . . (153P8)
The parents clearly articulated the need for a stronger focus on the needs of parents and school-age children. The lack of comprehensive health promotion programs for all age groups remained an issue of equality. Evolution Enhancing parental participation in their children’s health promotion service was identified as an important issue. The participants stressed that health promotion services, interventions, and information should correspond to children’s physiological and psychological development stages. The following participant’s statement clearly illustrated her concerns and understanding of the importance of developmental anticipatory guidance: . . . when he [her child] enters Primary 4 or 5, he will have to face various public or school examinations. I think there will be some changes in his psychological well-being . . . or for example, after he is promoted to secondary school, his thinking will be very different from now. If I know about this kind of change in advance, I can be prepared. If we are really having trouble, I can seek help from whichever organization can offer help to me in the community. I wouldn’t be so nervous as I would know and could predict what would happen in the next stage. However, there is no such [health service] in the community at this time. (468P4)
Another participant reinforced her concern that there would be some changes in her child’s psychological state when the child reached puberty. At the same time, they also had to face several academic examinations held by the school or the Hong Kong Education Bureau. As parents, they really wanted to know more about children’s psychological development. However, this parent highlighted the difficulty for parents of obtaining relevant and useful information or knowledge relating to their child’s health. In her statement she implied a desire to be informed and prepared if her child encountered problems during his secondary school years.
Parental participation in child health promotion service
257
Engagement and Consultation The parents voiced their willingness to be involved in their children’s health promotion activities. They suggested allowing parents to be fully involved in the planning and implementation stages of the children’s health service. They also wanted to be able to contribute comments and make decisions on the health promotion activities/policies for the purpose of quality assurance. The father in the focus group suggested the following: . . . Taking the lunch box monitoring scheme in this school as an example, it is good for me to have the chance to participate as a ‘‘Food Quality Monitor’’ in this school. The nutritional value and taste of food can be assured. During the quality control process, I have the right to examine the taste and nutritional value of the food. I am also involved in the selection of food supplier. My comments can be passed on to the school . . . . which ensures that the students become healthier and happier eaters. (72P3)
This father envisaged a very proactive and engaged role in the decision-making process about the provision of food to the children. It was predicted that the outcome would be a much better nutritional and eating experience for the children. Consultation The majority of the parents stressed the importance of professional consultation when in doubt about issues of health and health promotion information. For example, some participants complained of fragmentation and excessive information in the community inhibiting their ability to make informed choices about the most appropriate option for their children and family. The parents provided examples of what they required and how the situation could be improved: . . . the government could set up a quick guide hotline for public health service enquiries. The aim of the service would be just like the function of the ‘‘Yellow Pages,’’ which help to create access for enquiries/communication between different areas . . . . such as if I have a problem related to a health issue, I will be able to identify where or whom I should call for advice or help. Eventually, appropriate assistance will be referred to me. Currently, there is no such service in the community. (203P7 & 340P7) . . . [Example regarding vaccination pamphlet] There is too much information in the community. It’s really abundant. The information delivered is from different channels and organizations . . . too much information comes out at once. It blocks my thinking . . . . makes me feel confused. There is no formal
258
W. Lam et al.
organization to monitor message dissemination and guide the use of it. The information comes from anywhere, and you don’t know which information is good enough and appropriate for me to pick up . . . (162P7)
A clear message from these examples was the need for a recognized and trusted organization to filter the information provided. These parents found it difficult and at times confusing to understand and make decisions about the health information provided from numerous sources. Continuity The last theme identified the importance of sustainability of the health promotion service and the problems that could be addressed by such a service. In the following extended example, the mother used the maternal outpatient clinic as a service that was functioning well and where there was a continuity of service: . . . I hope a health promotion service for school children will be launched in the same way as the service provided by the maternal outpatient clinic. I think the maternal outpatient clinics do a very good job in the provision of health services to families. When the baby is born, the hospital gives the parent a vaccination record book. Inside the booklet, there are useful instructions and medical appointments for parents’ reference and action. It is just like a guide, helping the parents to go through the babies’ developmental stages. Parents know when and where to bring the babies to the maternal clinics, when to have the maternal follow-up, when to get vaccinations. As parents, we only need to follow the instructions written down inside the records. (464P4)
In this second extract, the parent used the example of a health center where continuous health service could be provided. This was then compared with the inadequacies of the existing service: . . . If there is a health center, the children can receive any kind of continuous health service or intervention for a certain period of time, unlike the existing situation, where the service is provided on a one-off basis. If children have problems, only a fragmented service can be offered. I think the service can be offered in a ‘‘Through-Train’’ Mode, even [when] the children are healthy. The children can go through the health service or health assessment in one organization from infancy to adolescent. This would provide better follow-up and continuity of care to the children. (185P6)
In these quotes, the parents identified the deficiencies in the service while providing examples of health services that provided the desired
Parental participation in child health promotion service
259
continuity of service. Importantly, one parent recognized the crucial inclusion of all children in such a service—‘‘even [when] the children are healthy.’’ DISCUSSION Parental Initiatives and Collaboration in Health Promotion Activities Based on this study, the facilitators of parental participation in children’s health promotion services were identified and explored. In this local Hong Kong community, the parents noted that a well-organized health promotion service was seldom provided for primary school children or their parents. When services were provided, they were not advertised well enough to encourage parents to participate. Parents expressed their desire to participate and contribute to health promotion programs. In doing so, they also wanted to be included in their design and implementation, arguing that this would improve the programs and make them more acceptable to parents. In part this would be due to parents’ assistance in creating programs and activities that were linked to their children’s health needs. Taking greater ownership of the programs would enable parents to reinforce the health promotion messages at home (Golley et al., 2011). A significant outcome would be the creation of an environment where these health messages and activities were more likely to be embedded in the everyday life of the child, family, and community. Collaboration between parents and health professionals also ensures that services are provided in a direct, efficient, and parent- and child-friendly manner with less service duplication, thus providing increased time for client care (Lau, 2006). Besides, services through this type of collaborative approach would contribute to preventing fragmented care and create a safety net for children with unidentified problems. Findings of this study bear similarities to those of studies conducted in other countries. Parents in the study are rarely described as being the key person who participates in health promotion activities (Van Lippevelde et al., 2011). They generally identified health promotion service as the duty of health professionals or teachers, as an extension of the school’s role; these professionals are thought to have more influence than parents in supporting children’s health behavior (Baranowski et al., 2000; Trevino et al., 2005). Increased efforts are required to promote parents’ roles in initiating and engaging in health promotion activities with regard to children’s health service in the community (Van Lippevelde et al., 2011).
260
W. Lam et al.
Revisit Community Nursing Service for Better Child and Family Health Promotion Services The parents discussed the importance of providing easy-to-access healthpromoting resources. The lack of health promotion services to provide ongoing support was identified as an issue for several of the parents. Existing services were identified as not providing anticipatory guidance for parents about their child’s next developmental stage or continuity of care. This was a concern for several parents as they made statements that indicated a lack of power and available knowledge to manage the changing psychological needs of their children. Enhancing the collaboration between parents and health professionals in health promotion interventions is imperative in assisting with the complex physical and mental health needs of school students (Brener, 2007; Olds, 2006). In particular, nurses are ideally situated to be involved in health promotion. It was emphasized by the Royal College of Nursing (2007) that nurses should incorporate the provision of health promotion and health education activities into their professional roles. Their roles are not only to take care of the sick but also to help promote overall health and prevent sickness within the community. The provision of health promotion activities should not be treated as opportunistic, but rather embedded in clinical practice and routinely implemented. Importantly, having nurses more involved in health promotion service would address many of the needs and concerns raised by the parents in this study. Insights gained from this and other research studies clearly support nurses’ full integration into the community, working closely with families, other health professionals, and community organizations to devise health strategies for the whole community (Rothi & Leavey, 2006). As community-based health professionals, nurses can act as coordinators to create a platform for information sharing and exchange during collaboration between parents, children, teachers, and health professionals (Whyte et al., 2011). Acting as coordinators will enable nurses to view family health issues from a wider perspective and support increased decision making by parents. Collaboration and discussion between parents and various health professionals can present a valuable opportunity for the exchange of ideas and information and the development of new and unique thoughts and approaches for the development of services to promote children’s health. Similar to other developed countries, aging is a serious problem in Hong Kong society. Health services for elderly people are the priority for local community nursing services. According to Hospital Authority (2011), around 86.6% of the health service recipients cared for by
Parental participation in child health promotion service
261
community nursing personnel were aged above 65. Even though health promotion to people, families, and the community is one of the key roles of local community nursing service (Hospital Authority, 2007), the service provision in this area is very limited. This change requires a redesign of existing community family nursing services to assist in establishing a single entry point for parents and their children. Perceivably, it is a crucial moment to review existing community health practice and strategies about how to include child and family health promotion in routine practice and how to redirect nursing practice from being disease orientated towards a health promotion ideology (Mcilfatrick, 2004). A feature of the six major themes identified within this study is the potential to support a framework for including and improving parent participation in their children’s health-promoting activities and programs. The major themes were: Equity, Equality, Evolution, Engagement, Consultation, and Continuity. This work will be ongoing, as further research and development remain essential for this area of nursing practice. This study does have limitations due to data being collected from only one focus group with participants from a middle class socioeconomic area. Findings may be different from those in lowsocioeconomic areas within Hong Kong. A future study would be advised to have multiple focus groups from communities with a range of socioeconomic levels to obtain the views of participants until data saturation is reached. This would provide a comprehensive understanding of parental participation in health promotion activities. CONCLUSION In order to achieve better health promotion, services should be easy to access, be provided to all within the local community, be developmentally focused, encourage parental engagement, include parent consultation, and be sustainable within the community. The major themes identified in this study provide a framework to begin improving the provision of health promotion services and information, and to encourage and support parent participation. It provides practical and effective guidance for community nurses and others to utilize in future health promotion intervention or community mobilization to enable and support parent participation. To optimize nurses’ contribution to children’s health, a more strategic approach to the use and promotion of health education and activities is required in partnership with the family, along with research into the effectiveness of children’s health promotion. The findings of this study contribute to the inclusion of Hong Kong parents in the promotion of
262
W. Lam et al.
their children’s health. They provided important evidence to improve the understanding of nurses, health educators, and policy makers regarding how to enhance health promotion activities and services for children and their parents, which in turn can inform regional policy and practice. DECLARATION OF INTEREST The authors of this manuscript report no conflict of interest. FUNDING This research study was funded by the School of Nursing, The Hong Kong Polytechnic University, Departmental Grant #G-U512. REFERENCES Aguirre, T., Hudson, D. B., Weber, K., Pozehl, B., Boeckner, L., & Wilhelm, S. (2012). Mexican American mothers’ eating and child feeding behaviors. Issues in Comprehensive Pediatric Nursing, 35, 4–23. doi:10.3109/01460862.2012.646462. Baranowski, T., Davis, M., Resnicow, K., Baranowski, J., Doyle, C., & Lin, L. S. (2000). Gimme 5 fruit, juice, and vegetables for fun and health: Outcome evaluation. Health Education and Behavior, 27, 96–111. doi:10.1177/109019810002700109. Beets, M. W., Cardinal, B. J., & Alderman, B. L. (2010). Parental social support and the physical activity-related behaviour of youth: A review. Health Education & Behaviour, 37, 621–644. Brener, N. D., Wheeler, L., Wolfe, L. C., Vernon-Smiley, M., & Caldart-Olson, L. (2007). Health services: Results from the school health policies and programs study 2006. Journal of School Health, 77, 465–485. Center of Health Protection. (2008). Promoting health in Hong Kong: A strategy for prevention and control of non-communicable diseases. Statistics on Communicable Diseases. Retrieved from http://www.chp.gov.hk/files/pdf/ paper29_promoting_health_in_hong_Kong_a_strategy_for_prevention and_control_ of_non_communicable_diseases.pdf. Chan, C. W. (2011). Role of the school nurses in healthcare professional team for children. The Proceeding of the 16th Biennial School Nurses International Conference, Hong Kong, 25–29 July, 2011. Department of Health. (2012). Eat Smart campaign. Retrieved from http://school. eatsmart.gov.hk/en/template/home.asp. Education Bureau of Hong Kong. (2013). Education system and policy. Retrieved from http://www.edb.gov.hk/en/about-edb/policy/special/index.html. Golley, R. K., Hendrie, G. A., Slater, A., & Corsini, N. (2011). Interventions that involve parents to improve children’s weight-related nutrition intake and activity patterns— what nutrition and activity targets and behaviour change techniques are associated with intervention effectiveness? Obesity Review, 12, 114–130 doi:10.1111/j.1467789X.2010.00745.x.
Parental participation in child health promotion service
263
Gussy, M. G., Waters, E. B., Riggs, E. M., Lo, S. K., & Kilpatrick, N. M. (2008). Parental knowledge, beliefs and behaviours for oral health of toddlers residing in rural Victoria. Australian Dental Journal, 53, 52–60. Hospital Authority. (2007). Guidelines of specialty nursing services: Community care. Hong Kong: Hospital Authority. Hospital Authority. (2011). Hospital authority statistical report 2010–2011. Hong Kong: Hospital Authority. Lau, D. M. (2006). A pilot study on attitude and practice relating to the management of overweight and obese patients among primary health care professionals in four primary care clinics in Hong Kong. The Hong Kong Practitioner, 28, 155–165. Lohrmann, D. (2010). A complementary ecological model of the coordinated school health program. Journal of School Health, 80, 1–9. Lyles, A., Riesch, S. K., Sanders, L., Sass-Deruyter, S. M., Birchmeier, B., & Kotula, K. (2012). How do treatment-seeking overweight youth and their parents describe weight promoting factors in their family? Journal of Community Health Nursing, 29, 187–201 doi:10.1080/07370016.2012.724278. McIlfatrick, S. (2004). The future of nurse education: characterised by paradoxes. Nurse Educ Today, 24, 79–83. doi: 10.1016/j.nedt.2003.10.008. Morse, J. M., & Field, P. A. (2002). Qualitative research methods for health professionals (2nd ed.). Thousand Oaks, CA: Sage Publication. National Scientific Council on the Developing Child. (2010). The foundations of lifelong health are built in early childhood. Cambridge, MA: Center on the Developing Child, Harvard University. Nutbeam, D., & Bauman, A. (2006). Evaluation in a nutshell: A practical guide to the evaluation of health promotion service programs. Sydney: McGraw-Hill. Olds, D. L., (2006). The nurse-family partnership: an evidence-based preventive intervention. Infant Mental Health Journal, 24, 5–25. doi:10.1002/imhj.20077. Rothi, D. M., & Leavey, G. (2006). Mental health help-seeking and young people: A review. Pastoral Care in Education, 24, 4–13. doi:10.1111/j.1468-0122.2006.00373.x. Royal College of Nursing. (2007). Nurses as partners in the delivery of public health. London: Royal College of Nursing. Schor, E. L., & American Academy of Pediatrics Task Force on the Family. (2003). Family pediatrics: Report of the task force on the family. Pediatrics, 111, 1541–1571. Schor, E. L., & Menaghan, E. G. (1995). Family pathways to child health. In A. Benjamin, S. Levine, & A.D. Walsh (Eds.), Society and health. New York, NY: Oxford University Press. Thorne, S. (2008). Interpretive description. Walnut Creek, CA: Left Coast Press. Thorne, S., Kirkham, S. R., & O’Flynn-Magee, K. (2004). The analytic challenge in interpretive description. International Journal of Qualitative Methods, 3, 1–20. Article 1. Retrieved from http://www.ualberta.ca/iiqm/backissues/3_1/pdf/ thorneetal.pdf. Trevino, R. P., Hernandez, A. E., Zenong, Y., Garcia, O., & Hernandez, I. (2005). Effects of the Bienestar health program on physical fitness in low-income Mexican American children. Hispanic Journal of Behavioral Sciences, 27, 120–132. doi:10.1177/ 0739986304272359.
264
W. Lam et al.
Van Lippevelde, W., Verloigne, M., De Bourdeaudhuij, I., Bjelland, M., Lien, N., Fernandez-Alvira, J. M., Moreno, L. A., Kovacs E., Brug J., Maes, L. (2011). What do parents think about parental participation in school-based interventions on energy balance-related behaviours? A qualitative study in 4 countries. BMC Public Health, 11, 881. doi:10.1186/1471-2458-11-881. Whyte, M. D., Whyte Iv, J., Cormier, E., & Eccles, D. W. (2011). Factors influencing parental decision making when parents choose to deviate from the standard pediatric immunization schedule. Journal of Community Health Nursing, 28, 204–214. doi:10.1080/07370016.2011.615178. World Health Organization. (2002). Community participation in local health and sustainable development approaches and techniques. Geneva: WHO. World Health Organization. (2009). Milestones in health promotion: statements from global conferences. Geneva: WHO.
Copyright of Issues in Comprehensive Pediatric Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
UNDERSTANDING PARENTAL PARTICIPATION IN HEALTH PROMOTION SERVICES FOR THEIR CHILDREN
Winsome Lam, RN, MN1, Sau Ting Cynthia Wu, RN, PhD1, and Cathrine Fowler, RN, PhD2 1
School of Nursing, The Hong Kong Polytechnic University and Centre for Midwifery, Child and Family Health, University of Technology, Sydney
2
The aim of this research was to explore parental participation in child health promotion services within a Hong Kong community. There are many elements influencing the effect of health promotion services. One is the extent of parental participation. However, research in this area is limited. Focus group data were content analyzed. Six themes were conceptualized. They are Equity, Equality, Evolution, Engagement, Consultation, and Continuity. We concluded that a strategic approach in partnership with families is required for health promotion activities for children. The findings contribute to an understanding of the crucial factors for the promotion of parental participation in health promotion services. Keywords: Children, health promotion, parent involvement
INTRODUCTION In today’s society, children’s health issues and their subsequent management have become complex, as an individual’s health is affected by multiple inter-related physical and psychological factors, as well as their relationship to the environment (Chan, 2011; Lohrmann, 2010). Increasing warnings are occurring about the threats to children’s health Received 29 June 2014; revised 29 July 2014; accepted 30 July 2014
Correspondence: Winsome Lam, The School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China. E-mail: winsome. [email protected]
250
Parental participation in child health promotion service
251
and the increase in diseases such as obesity, pandemic influenza, and avian flu (Center of Health Protection, 2008). Crucially, many diseases can be prevented or their impact on health minimized through efforts such as health promotion and disease prevention strategies (Center of Health Protection, 2008; National Scientific Council on the Developing Child, 2010; World Health Organization, 2002). These alternative efforts are deemed to be central to community illness and disease prevention interventions (World Health Organization, 2009). Taking obesity as an example, it is well accepted that preventive measures are the best way to avoid obesity and associated diseases, especially if commenced during the early years of a child’s life (Department of Health, 2012; National Scientific Council on the Developing Child, 2010). A focus group of parents of children from a primary school in Hung Hom, Hong Kong, was used to gather data for this qualitative research study. The aim of this research was to explore parental participation in child-related health promotion service within a Hong Kong community. In this article, six major themes that emerged from the data will be discussed. BACKGROUND A review of the literature identified limited Hong Kong studies investigating the factors required to facilitate adequate levels of parental health promotion participation. It is clear that further exploration is necessary about how to encourage parental participation in child health promotion activities in order to enhance Hong Kong children’s health status. Health promotion is recognized as an essential element of maintaining health and reducing future risk (World Health Organization, 2009). There are many elements that influence the success of health promotion services, such as: community participation, sufficient attention being given to the development of health resources, advocacy for legislative action, sustainability of the health practices, and adequate publicity about the activities (Nutbeam & Bauman, 2006: World Health Organization, 2009). Health promotion activities for primary school children such as the Eat Smart Campaign (Department of Health, 2012), require a close relationship between specific populations (children and parents) and service providers (teachers and community health nurses) to be successful and sustainable (World Health Organization, 2009). Parents are believed to be key in promoting their children’s health as primary school children are dependent on their parents’ ability to
252
W. Lam et al.
recognize health issues that require the application of disease prevention and health promotion activities. Parents are the role models for children to learn and behave, as children’s health is directly related to their family lifestyle and behavior (Lyles et al., 2012; Schor & Menaghan, 1995). Young children spend significant amounts of time at home with their parents. Parents are well positioned to reinforce their children’s health practices and behaviors and exert considerable influence through their daily interactions (National Scientific Council on the Developing Child, 2010; Schor & American Academy of Pediatrics Task Force on the Family, 2003). Literature demonstrates that there is a positive relationship between families and their children’s health (Beets et al., 2010; Gussy et al., 2008). The successful implementation and maintenance of child health promotion activities require increased parental engagement in child health promotion programs by raising awareness of the importance of the activities prior to staging these programs (Lyles et al., 2012; Nutbeam & Bauman, 2006). If parents are in engaged in health promotion activities they are more likely to extend these activities into the home and wider community. Evidence of success is provided in the studies of Aguirre et al. (2012) and Van Lippevelde et al. (2011) as they recognize the significant influence resulting from parental involvement and modeling to improve child physical fitness levels and increase dietary fruit and vegetable intake. Certainly, these studies position parents as the immediate and primary source of health education and information provision (Van Lippevelde et al., 2011). Given this backdrop, a qualitative research study was conducted in order to understand the level of parental participation in child related health promotion services within a Hong Kong community. METHODS A parent focus group using an interpretive descriptive approach (Thorne, 2008) was employed to guide the research process. This approach used in clinical nursing practice research enables a qualitative approach that is interpretive and exploratory in design (Thorne et al., 2004). A qualitative approach provides a rich and detailed description of issues that have had minimal exploration. Importantly the interpretations are ‘‘constructed truths’’ rather than facts (Thorne et al., 2004). This inductive approach creates opportunities to understand a clinical phenomenon (e.g., parental participation) that identifies application implications (Thorne et al., 2004). As stated by Morse & Field (2002) qualitative research is particularly useful for studying a phenomenon or event about which little is known.
Parental participation in child health promotion service
253
Participants A purposive sample of 11 parents of school children was recruited from a local Hong Kong primary school. There are two types of schools that are governed by the Hong Kong Education Bureau. Mainstream schools provide universal primary and secondary education to all children. Special schools provide education services for children with special educational needs, such as visual impairment, hearing impairment, physical disability, and intellectual disability (Education Bureau of Hong Kong, 2013). The researcher initially contacted the person in charge of several mainstream primary schools to provide information about the study and to invite them to participate. One of the schools agreed to participate in the study. A face-to-face meeting with the person in charge of the primary school was arranged to provide study information. The primary school teachers helped distribute the information sheets to parents to invite them to participate in the study. Interested parents were contacted by the researcher and personally invited to participate in the focus group. The criteria for inclusion in this study were: a parent with a primary school child aged 6 to 12 years old, the child being healthy, and the parent being the main caregiver and able to speak either Cantonese or English. The interviews were arranged at a convenient time and place with the participants. Ethical Considerations Ethical approval from a University Ethics Committee was obtained. Participation in the study was voluntary. All parents received a written information sheet explaining the research aims and purpose. Parents’ written consent was obtained prior to the focus group commencement. A separate phone line and postal address, in addition to the contacts of the researchers, were provided for further enquiries, doubts, and complaints. All data were de-identified and securely stored to maintain confidentiality. Data Collection The focus group was guided by the use of semi-structured questions informed by the findings of the literature review. The questions used consisted of three domains related to enhancing parent participation in their children’s health promotion services: opportunity, need fulfillment, and satisfaction. For example: what are your opinions about the current child health promotion services such as healthy eating, personal hygiene, and so on; do they match your concerns and needs around child health;
254
W. Lam et al.
and how could these health promotion activities be implemented successfully or effectively? The focus group continued until the parents expressed no new information/ideas. The group lasted for 90 minutes and was digitally recorded. All interviews were conducted in Cantonese. The interviews were transcribed in Cantonese and then translated into English. Data Analysis A thematic content analysis approach was adopted to analyze and identified thematic categories by using systemic coding. The data from the interview scripts were read line-by-line, coded, and categorized into themes. To ensure consistency of the identified themes each piece of data was compared with other relevant data. To maintain a rigorous analysis process, the research team reached agreement about the match between the themes and data extracts. This process also included ongoing questioning that included: why is this here; why not something else; and what does it mean (Thorne et al., 2004). Six major themes were identified from these data. FINDINGS The analysis identified six major themes within the data. The themes were associated with promoting parental participation in health promotion service for their children. These major themes were: Equity (equal access), Equality (service to all), Evolution (developmental health service), Engagement (involvement with health promotion), Consultation (quality advisory service), and Continuity (sustainability of care). Equity Equity was identified as parents having the equal ability to access health promotion programs. The participants claimed that in the community, there were minimal channels for them to access information related to health promotion, particularly about and for children, and that this often resulted in a lack of stimulus to participate. Failure to provide sufficient advertisement of the resource was a major factor blocking parents from actively joining health promotion activities. In the following extract, the health promotion information was identified as not being adequately posted or promoted to ensure maximum visibility. . . . in my housing estate, even when health promotion information is posted on the wall, I rarely notice it. Honestly, no one goes up to the notice board.
Parental participation in child health promotion service
255
The publicity agent stuck it [the poster] onto the wall of each lobby of each building. However, they did not do any publicity. They just wanted to get it done. (89P7)
Another participant emphasized that school was the only platform for her to engage in health promotion activities and stressed the importance of effective promotion of programs. She stated: I can only get information from the school [where] my child is studying. Because of this access, I can take part in health promotion activities. Or from the parent-teacher association (PTA) . . . if I am not a member of PTA, I have no chance to get such information. We are in a passive position; I think there are not that many opportunities for us to [have] contact with health promotion activities. (94P7)
Importantly in the above extract, the parent described the position of parents as passive due to the lack of access to health promotion information. This implied a lack of involvement with decision-making and alludes to a disconnection for many parents from proposed health promotion activities. Ease of access for the parents, whether for services or information, was identified by the parents as significant to the care and health of their children. Even though health promotion information was available, it received limited publicity. More active advertisement was required to create awareness and interest. Until this occurs, parents’ ability to participate or access programs or information would remain limited. Equality Several different informants complained that the existing health promotion services and focus were restricted. They went on to say that most health promotion services are specifically for the elderly or young children. The coverage of services provided was limited and not available to all age groups, and there was a health promotion service gap for school-age children and parents. On the other hand, the parents believed that if there were a mandatory set of health promotion topics, it would be more likely to succeed. The parents described their concerns as: . . . I don’t know why the health promotion service is only for elder people. For example, they can go to the elderly center for blood pressure monitoring or physical health assessment. However, for our age group, there is no service in our community. We don’t know where we can get blood pressure
256
W. Lam et al.
monitoring service. In the same way, children have the dental check-up service. Again we have no rights or services provided by the community or the government . . . . If the service [health promotion] is free and participation mandated [by the government], it is more likely to be successful. (111P7) . . . the health promotion service is usually for those who are old enough [the elderly], or young enough to receive the service [children] . . . . (153P8)
The parents clearly articulated the need for a stronger focus on the needs of parents and school-age children. The lack of comprehensive health promotion programs for all age groups remained an issue of equality. Evolution Enhancing parental participation in their children’s health promotion service was identified as an important issue. The participants stressed that health promotion services, interventions, and information should correspond to children’s physiological and psychological development stages. The following participant’s statement clearly illustrated her concerns and understanding of the importance of developmental anticipatory guidance: . . . when he [her child] enters Primary 4 or 5, he will have to face various public or school examinations. I think there will be some changes in his psychological well-being . . . or for example, after he is promoted to secondary school, his thinking will be very different from now. If I know about this kind of change in advance, I can be prepared. If we are really having trouble, I can seek help from whichever organization can offer help to me in the community. I wouldn’t be so nervous as I would know and could predict what would happen in the next stage. However, there is no such [health service] in the community at this time. (468P4)
Another participant reinforced her concern that there would be some changes in her child’s psychological state when the child reached puberty. At the same time, they also had to face several academic examinations held by the school or the Hong Kong Education Bureau. As parents, they really wanted to know more about children’s psychological development. However, this parent highlighted the difficulty for parents of obtaining relevant and useful information or knowledge relating to their child’s health. In her statement she implied a desire to be informed and prepared if her child encountered problems during his secondary school years.
Parental participation in child health promotion service
257
Engagement and Consultation The parents voiced their willingness to be involved in their children’s health promotion activities. They suggested allowing parents to be fully involved in the planning and implementation stages of the children’s health service. They also wanted to be able to contribute comments and make decisions on the health promotion activities/policies for the purpose of quality assurance. The father in the focus group suggested the following: . . . Taking the lunch box monitoring scheme in this school as an example, it is good for me to have the chance to participate as a ‘‘Food Quality Monitor’’ in this school. The nutritional value and taste of food can be assured. During the quality control process, I have the right to examine the taste and nutritional value of the food. I am also involved in the selection of food supplier. My comments can be passed on to the school . . . . which ensures that the students become healthier and happier eaters. (72P3)
This father envisaged a very proactive and engaged role in the decision-making process about the provision of food to the children. It was predicted that the outcome would be a much better nutritional and eating experience for the children. Consultation The majority of the parents stressed the importance of professional consultation when in doubt about issues of health and health promotion information. For example, some participants complained of fragmentation and excessive information in the community inhibiting their ability to make informed choices about the most appropriate option for their children and family. The parents provided examples of what they required and how the situation could be improved: . . . the government could set up a quick guide hotline for public health service enquiries. The aim of the service would be just like the function of the ‘‘Yellow Pages,’’ which help to create access for enquiries/communication between different areas . . . . such as if I have a problem related to a health issue, I will be able to identify where or whom I should call for advice or help. Eventually, appropriate assistance will be referred to me. Currently, there is no such service in the community. (203P7 & 340P7) . . . [Example regarding vaccination pamphlet] There is too much information in the community. It’s really abundant. The information delivered is from different channels and organizations . . . too much information comes out at once. It blocks my thinking . . . . makes me feel confused. There is no formal
258
W. Lam et al.
organization to monitor message dissemination and guide the use of it. The information comes from anywhere, and you don’t know which information is good enough and appropriate for me to pick up . . . (162P7)
A clear message from these examples was the need for a recognized and trusted organization to filter the information provided. These parents found it difficult and at times confusing to understand and make decisions about the health information provided from numerous sources. Continuity The last theme identified the importance of sustainability of the health promotion service and the problems that could be addressed by such a service. In the following extended example, the mother used the maternal outpatient clinic as a service that was functioning well and where there was a continuity of service: . . . I hope a health promotion service for school children will be launched in the same way as the service provided by the maternal outpatient clinic. I think the maternal outpatient clinics do a very good job in the provision of health services to families. When the baby is born, the hospital gives the parent a vaccination record book. Inside the booklet, there are useful instructions and medical appointments for parents’ reference and action. It is just like a guide, helping the parents to go through the babies’ developmental stages. Parents know when and where to bring the babies to the maternal clinics, when to have the maternal follow-up, when to get vaccinations. As parents, we only need to follow the instructions written down inside the records. (464P4)
In this second extract, the parent used the example of a health center where continuous health service could be provided. This was then compared with the inadequacies of the existing service: . . . If there is a health center, the children can receive any kind of continuous health service or intervention for a certain period of time, unlike the existing situation, where the service is provided on a one-off basis. If children have problems, only a fragmented service can be offered. I think the service can be offered in a ‘‘Through-Train’’ Mode, even [when] the children are healthy. The children can go through the health service or health assessment in one organization from infancy to adolescent. This would provide better follow-up and continuity of care to the children. (185P6)
In these quotes, the parents identified the deficiencies in the service while providing examples of health services that provided the desired
Parental participation in child health promotion service
259
continuity of service. Importantly, one parent recognized the crucial inclusion of all children in such a service—‘‘even [when] the children are healthy.’’ DISCUSSION Parental Initiatives and Collaboration in Health Promotion Activities Based on this study, the facilitators of parental participation in children’s health promotion services were identified and explored. In this local Hong Kong community, the parents noted that a well-organized health promotion service was seldom provided for primary school children or their parents. When services were provided, they were not advertised well enough to encourage parents to participate. Parents expressed their desire to participate and contribute to health promotion programs. In doing so, they also wanted to be included in their design and implementation, arguing that this would improve the programs and make them more acceptable to parents. In part this would be due to parents’ assistance in creating programs and activities that were linked to their children’s health needs. Taking greater ownership of the programs would enable parents to reinforce the health promotion messages at home (Golley et al., 2011). A significant outcome would be the creation of an environment where these health messages and activities were more likely to be embedded in the everyday life of the child, family, and community. Collaboration between parents and health professionals also ensures that services are provided in a direct, efficient, and parent- and child-friendly manner with less service duplication, thus providing increased time for client care (Lau, 2006). Besides, services through this type of collaborative approach would contribute to preventing fragmented care and create a safety net for children with unidentified problems. Findings of this study bear similarities to those of studies conducted in other countries. Parents in the study are rarely described as being the key person who participates in health promotion activities (Van Lippevelde et al., 2011). They generally identified health promotion service as the duty of health professionals or teachers, as an extension of the school’s role; these professionals are thought to have more influence than parents in supporting children’s health behavior (Baranowski et al., 2000; Trevino et al., 2005). Increased efforts are required to promote parents’ roles in initiating and engaging in health promotion activities with regard to children’s health service in the community (Van Lippevelde et al., 2011).
260
W. Lam et al.
Revisit Community Nursing Service for Better Child and Family Health Promotion Services The parents discussed the importance of providing easy-to-access healthpromoting resources. The lack of health promotion services to provide ongoing support was identified as an issue for several of the parents. Existing services were identified as not providing anticipatory guidance for parents about their child’s next developmental stage or continuity of care. This was a concern for several parents as they made statements that indicated a lack of power and available knowledge to manage the changing psychological needs of their children. Enhancing the collaboration between parents and health professionals in health promotion interventions is imperative in assisting with the complex physical and mental health needs of school students (Brener, 2007; Olds, 2006). In particular, nurses are ideally situated to be involved in health promotion. It was emphasized by the Royal College of Nursing (2007) that nurses should incorporate the provision of health promotion and health education activities into their professional roles. Their roles are not only to take care of the sick but also to help promote overall health and prevent sickness within the community. The provision of health promotion activities should not be treated as opportunistic, but rather embedded in clinical practice and routinely implemented. Importantly, having nurses more involved in health promotion service would address many of the needs and concerns raised by the parents in this study. Insights gained from this and other research studies clearly support nurses’ full integration into the community, working closely with families, other health professionals, and community organizations to devise health strategies for the whole community (Rothi & Leavey, 2006). As community-based health professionals, nurses can act as coordinators to create a platform for information sharing and exchange during collaboration between parents, children, teachers, and health professionals (Whyte et al., 2011). Acting as coordinators will enable nurses to view family health issues from a wider perspective and support increased decision making by parents. Collaboration and discussion between parents and various health professionals can present a valuable opportunity for the exchange of ideas and information and the development of new and unique thoughts and approaches for the development of services to promote children’s health. Similar to other developed countries, aging is a serious problem in Hong Kong society. Health services for elderly people are the priority for local community nursing services. According to Hospital Authority (2011), around 86.6% of the health service recipients cared for by
Parental participation in child health promotion service
261
community nursing personnel were aged above 65. Even though health promotion to people, families, and the community is one of the key roles of local community nursing service (Hospital Authority, 2007), the service provision in this area is very limited. This change requires a redesign of existing community family nursing services to assist in establishing a single entry point for parents and their children. Perceivably, it is a crucial moment to review existing community health practice and strategies about how to include child and family health promotion in routine practice and how to redirect nursing practice from being disease orientated towards a health promotion ideology (Mcilfatrick, 2004). A feature of the six major themes identified within this study is the potential to support a framework for including and improving parent participation in their children’s health-promoting activities and programs. The major themes were: Equity, Equality, Evolution, Engagement, Consultation, and Continuity. This work will be ongoing, as further research and development remain essential for this area of nursing practice. This study does have limitations due to data being collected from only one focus group with participants from a middle class socioeconomic area. Findings may be different from those in lowsocioeconomic areas within Hong Kong. A future study would be advised to have multiple focus groups from communities with a range of socioeconomic levels to obtain the views of participants until data saturation is reached. This would provide a comprehensive understanding of parental participation in health promotion activities. CONCLUSION In order to achieve better health promotion, services should be easy to access, be provided to all within the local community, be developmentally focused, encourage parental engagement, include parent consultation, and be sustainable within the community. The major themes identified in this study provide a framework to begin improving the provision of health promotion services and information, and to encourage and support parent participation. It provides practical and effective guidance for community nurses and others to utilize in future health promotion intervention or community mobilization to enable and support parent participation. To optimize nurses’ contribution to children’s health, a more strategic approach to the use and promotion of health education and activities is required in partnership with the family, along with research into the effectiveness of children’s health promotion. The findings of this study contribute to the inclusion of Hong Kong parents in the promotion of
262
W. Lam et al.
their children’s health. They provided important evidence to improve the understanding of nurses, health educators, and policy makers regarding how to enhance health promotion activities and services for children and their parents, which in turn can inform regional policy and practice. DECLARATION OF INTEREST The authors of this manuscript report no conflict of interest. FUNDING This research study was funded by the School of Nursing, The Hong Kong Polytechnic University, Departmental Grant #G-U512. REFERENCES Aguirre, T., Hudson, D. B., Weber, K., Pozehl, B., Boeckner, L., & Wilhelm, S. (2012). Mexican American mothers’ eating and child feeding behaviors. Issues in Comprehensive Pediatric Nursing, 35, 4–23. doi:10.3109/01460862.2012.646462. Baranowski, T., Davis, M., Resnicow, K., Baranowski, J., Doyle, C., & Lin, L. S. (2000). Gimme 5 fruit, juice, and vegetables for fun and health: Outcome evaluation. Health Education and Behavior, 27, 96–111. doi:10.1177/109019810002700109. Beets, M. W., Cardinal, B. J., & Alderman, B. L. (2010). Parental social support and the physical activity-related behaviour of youth: A review. Health Education & Behaviour, 37, 621–644. Brener, N. D., Wheeler, L., Wolfe, L. C., Vernon-Smiley, M., & Caldart-Olson, L. (2007). Health services: Results from the school health policies and programs study 2006. Journal of School Health, 77, 465–485. Center of Health Protection. (2008). Promoting health in Hong Kong: A strategy for prevention and control of non-communicable diseases. Statistics on Communicable Diseases. Retrieved from http://www.chp.gov.hk/files/pdf/ paper29_promoting_health_in_hong_Kong_a_strategy_for_prevention and_control_ of_non_communicable_diseases.pdf. Chan, C. W. (2011). Role of the school nurses in healthcare professional team for children. The Proceeding of the 16th Biennial School Nurses International Conference, Hong Kong, 25–29 July, 2011. Department of Health. (2012). Eat Smart campaign. Retrieved from http://school. eatsmart.gov.hk/en/template/home.asp. Education Bureau of Hong Kong. (2013). Education system and policy. Retrieved from http://www.edb.gov.hk/en/about-edb/policy/special/index.html. Golley, R. K., Hendrie, G. A., Slater, A., & Corsini, N. (2011). Interventions that involve parents to improve children’s weight-related nutrition intake and activity patterns— what nutrition and activity targets and behaviour change techniques are associated with intervention effectiveness? Obesity Review, 12, 114–130 doi:10.1111/j.1467789X.2010.00745.x.
Parental participation in child health promotion service
263
Gussy, M. G., Waters, E. B., Riggs, E. M., Lo, S. K., & Kilpatrick, N. M. (2008). Parental knowledge, beliefs and behaviours for oral health of toddlers residing in rural Victoria. Australian Dental Journal, 53, 52–60. Hospital Authority. (2007). Guidelines of specialty nursing services: Community care. Hong Kong: Hospital Authority. Hospital Authority. (2011). Hospital authority statistical report 2010–2011. Hong Kong: Hospital Authority. Lau, D. M. (2006). A pilot study on attitude and practice relating to the management of overweight and obese patients among primary health care professionals in four primary care clinics in Hong Kong. The Hong Kong Practitioner, 28, 155–165. Lohrmann, D. (2010). A complementary ecological model of the coordinated school health program. Journal of School Health, 80, 1–9. Lyles, A., Riesch, S. K., Sanders, L., Sass-Deruyter, S. M., Birchmeier, B., & Kotula, K. (2012). How do treatment-seeking overweight youth and their parents describe weight promoting factors in their family? Journal of Community Health Nursing, 29, 187–201 doi:10.1080/07370016.2012.724278. McIlfatrick, S. (2004). The future of nurse education: characterised by paradoxes. Nurse Educ Today, 24, 79–83. doi: 10.1016/j.nedt.2003.10.008. Morse, J. M., & Field, P. A. (2002). Qualitative research methods for health professionals (2nd ed.). Thousand Oaks, CA: Sage Publication. National Scientific Council on the Developing Child. (2010). The foundations of lifelong health are built in early childhood. Cambridge, MA: Center on the Developing Child, Harvard University. Nutbeam, D., & Bauman, A. (2006). Evaluation in a nutshell: A practical guide to the evaluation of health promotion service programs. Sydney: McGraw-Hill. Olds, D. L., (2006). The nurse-family partnership: an evidence-based preventive intervention. Infant Mental Health Journal, 24, 5–25. doi:10.1002/imhj.20077. Rothi, D. M., & Leavey, G. (2006). Mental health help-seeking and young people: A review. Pastoral Care in Education, 24, 4–13. doi:10.1111/j.1468-0122.2006.00373.x. Royal College of Nursing. (2007). Nurses as partners in the delivery of public health. London: Royal College of Nursing. Schor, E. L., & American Academy of Pediatrics Task Force on the Family. (2003). Family pediatrics: Report of the task force on the family. Pediatrics, 111, 1541–1571. Schor, E. L., & Menaghan, E. G. (1995). Family pathways to child health. In A. Benjamin, S. Levine, & A.D. Walsh (Eds.), Society and health. New York, NY: Oxford University Press. Thorne, S. (2008). Interpretive description. Walnut Creek, CA: Left Coast Press. Thorne, S., Kirkham, S. R., & O’Flynn-Magee, K. (2004). The analytic challenge in interpretive description. International Journal of Qualitative Methods, 3, 1–20. Article 1. Retrieved from http://www.ualberta.ca/iiqm/backissues/3_1/pdf/ thorneetal.pdf. Trevino, R. P., Hernandez, A. E., Zenong, Y., Garcia, O., & Hernandez, I. (2005). Effects of the Bienestar health program on physical fitness in low-income Mexican American children. Hispanic Journal of Behavioral Sciences, 27, 120–132. doi:10.1177/ 0739986304272359.
264
W. Lam et al.
Van Lippevelde, W., Verloigne, M., De Bourdeaudhuij, I., Bjelland, M., Lien, N., Fernandez-Alvira, J. M., Moreno, L. A., Kovacs E., Brug J., Maes, L. (2011). What do parents think about parental participation in school-based interventions on energy balance-related behaviours? A qualitative study in 4 countries. BMC Public Health, 11, 881. doi:10.1186/1471-2458-11-881. Whyte, M. D., Whyte Iv, J., Cormier, E., & Eccles, D. W. (2011). Factors influencing parental decision making when parents choose to deviate from the standard pediatric immunization schedule. Journal of Community Health Nursing, 28, 204–214. doi:10.1080/07370016.2011.615178. World Health Organization. (2002). Community participation in local health and sustainable development approaches and techniques. Geneva: WHO. World Health Organization. (2009). Milestones in health promotion: statements from global conferences. Geneva: WHO.
Copyright of Issues in Comprehensive Pediatric Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
