Background
Healthy lifestyle habits, including regular physical activity (PA), have many physical and psychosocial health benefits for both children and adults [
1‐
4]. Psychosocial health is a multidimensional concept, comprising of psychological and social aspects [
5,
6]. Psychological aspects of health are understood in line with the term for mental health, that refers to processes of the mind, such as thinking, feeling and sensing and social aspects of health include interaction with other people, for example in a group or community [
6]. Numerous reviews have demonstrated the positive impact of PA on psychosocial and mental health, including improved social interaction, mastery in the physical domain, self-perceptions, well- being, resilience and independence [
2‐
4,
6,
7]. Among children and adolescents, level of PA has also been associated with better health-related quality of life [
2]. However, few children and adults reach recommended levels for PA [
8,
9]. There are also socioeconomic inequalities in health where unhealthy lifestyle habits, including lower levels of PA are more prevalent in populations with low socioeconomic status (SES) than in high SES populations [
8,
10]. Children in low SES families are less likely to participate in organised sports than children in high SES families [
11,
12]. Given the health benefits of PA, it is therefore important to promote PA as part of a healthy lifestyle for both children and adults, especially in socioeconomically disadvantaged areas.
Social and environmental factors, such as parents, friends, PA leaders and local communities influence PA in children. Parents, in particular, play an important role as role models for their children’s life style habits including PA, sedentary behaviour and food habits [
13‐
15]. Different parental factors, such as logistical and financial support, co-participation and role modelling have been positively associated with increased PA in children [
16]. To involve parents in health-promoting interventions has therefore been proposed as a promising solution to promote positive lifestyle changes for the whole family, as well as to increase children’s PA [
17]. Previous studies investigating parents and their children’s views on family-based interventions have mostly focused on recruitment, content and delivery of the interventions [
18]. Brown et al. [
13] have investigated how best to recruit and retain participation in family interventions. Social, health and educational benefits were proposed as key elements for participation [
13]. Jago et al. [
18] have shown that enjoyment, and the opportunity to try PA, are important for recruitment, and that social aspects are important for continued participation in PA interventions. Although, some research exists on health-promoting PA interventions directed at families, few interventions have included an intervention component where parents and children exercise together. Van Slujs et al. [
19] have concluded that the effect of family and community interventions remains uncertain and call for more research to further identify important key approaches. The family programme A Healthy Generation is a health-promoting programme which is directed to families with children in grade two, including siblings. The programme is currently delivered in 17 socioeconomically disadvantaged areas in 10 municipalities in Sweden. A previous pilot evaluation of the programme has shown significant intervention effects between intervention and control group on total PA and in vigorous PA during the weekends, but not in other PA measures [
20]. In terms of Health Related Quality of Life (HRQOL), a previous study from the same intervention showed no significant differences between intervention and control among children or adults after the intervention [
21]. There were, however, a significant improvement in HRQOL in a subgroup of children and adults with initial low HRQOL scores at baseline [
21].
There is a scarcity of research on family-based PA interventions. Specifically, there is a lack of knowledge about participating families’ experiences of PA interventions in relation to psychosocial health and especially among participants in socioeconomically disadvantaged areas. To increase such understanding is crucial for the development of family-based PA interventions in order to promote health and decrease inequality in health in socioeconomically disadvantaged areas. The purpose of this study was to explore how families experienced psychosocial aspects of health after participation in a family-based programme, A Healthy Generation.
Methods
A healthy generation
The programme A Healthy Generation was initiated in 2011 by an eonymous, non- profit foundation, in collaboration with municipalities, local sport associations and enterprises. The programme includes four components: 1) Activity sessions, 2) Healthy meals, 3) Health information; and 4) Parental support groups. The activity sessions are conducted twice a week, one weekday and one weekend day. Different activities are offered led by a health coordinator together with a leader from local sport clubs. Examples of activities are football, basketball, dance and floorball. Most activities are held in the school’s sport hall. After each activity, a healthy, hot meal is served on weekdays and a fruit break at weekends. Discussions about healthy lifestyle habits are initiated by the health coordinators, both in activity sessions and during the healthy meals, during the different activities in the programme. Parental support groups are offered to parents four times during the programme by external coaches in each municipality. The parents attend these sessions, while their children have a regular activity session in the programme to facilitate higher attendance among the parents.
Design
This study has a qualitative design, and draws on a phenomenological, hermeneutical approach to interpret the essential meaning of the participants´ lived experiences of psychosocial health after participation in the programme, A Healthy Generation [
22,
23].
The current study is part of a controlled pilot trial that has been further described elsewhere [
20,
21]. The intervention took place between August 2016 to May 2017 in 4 schools, 2 intervention- (
n = 88) and 2 control (
n = 83) schools, in one of the municipalities where the programme was delivered. Data for this qualitative study was collected through interviews with participants from the pilot trial about 6–8 months after the programme year. Interviews were chosen since it is a sensitive data collection method that allows the participants to reflect on their lived experiences, and for the interviewee to follow-up on what is said, how it is said and its implicit meanings [
24].
Data collection
Participants
A purposive sample of participants in the intervention part of the controlled pilot trial were invited to participate in interviews. The sample was based on a maximum variation in terms of age, sex, number of children, and participation in the activities during the intervention. Selected parents were first contacted by phone. Parents were informed about the study and asked if they, and their child, would like to participate. Most parents of those who were contacted agreed to participate in interviews. In total, 15 parents were contacted and 13 of them and 10 children decided to participate. Reasons for not participating were a lack of time or language skills for parents and late cancellation or that parents had declined participation for their children.
Interviews with parents and children
In total, 23 interviews were conducted with parents (
n = 13) and children (
n = 10) from the intervention group about 6 months after the programme year, see Table
1 for participant characteristics. All interviews were performed by one of the authors (SA), a female experienced qualitative researcher with training in anthropology, public health and caring science. The interviews were conducted in a place selected by the participants; either in their homes, at the children’s school or at the parents’ work. Interviews with children were conducted in their respective school or home. All parental interviews, except one interview, were conducted without the child being present in order to allow them to reflect and discuss without interruption. When children were interviewed, parents could be present if they and their child wanted, but they were advised to let the children speak for themselves. Three parents attended when their children were interviewed. During the interviews, an interview guide with semi-structured questions was used, see Appendix 1. The interview guide included questions about; the participants’ experiences from participation in the programme and the meaning in relation to their health and lifestyle. Follow-up questions, such as,” Can you tell me more/ give examples?”, were used to further explore the meaning of the participants lived experience and to encourage the ongoing narrative [
25]. The interviewer tried to be sensitive to experiences that seemed to be significant for the participants. In the case of fragmented memories, especially in the interviews with children, concrete examples of activities were given to encourage the child to narrate their experiences. The interview guide was developed and discussed between the researchers, and piloted in the first interview, with the intention to include the data from the interview if the guide worked well and change the guide if necessary. The interview guide worked as intended and was not changed after the interview and the interview data was included. The interviews lasted between 30 and 70 min for parents and between 15 and 30 min for children. The interviews were digitally recorded and transcribed verbatim for analysis.
Table 1
Descriptive characteristics of participating adults and children
Adults |
Age, mean (SD) in years | 40 (6) |
Nr. of children (mean) | 2.4 |
Female, % (count) | 62 (8) |
Male, % (count) | 38 (5) |
Born in Sweden, % (count) | 54 (7) |
University education, % (count) | 23 (3) |
Participation in the programme, mean number/total number, (SD) | 30/65 (12) |
Children |
Age, mean (SD) in years | 9 (0.4) |
Female, % (count) | 80 (8) |
Male, % (count) | 20 (2) |
Participation in the programme,mean number/total number, (SD) | 37/65 (14) |
Data analysis
All data was analysed using a phenomenological-hermeneutic method [
22]. At first the transcripts were read several times by one of the authors (SA) to capture the whole meaning and the first interpretation was then formulated in a naïve understanding. This process enabled an initial understanding of areas of interest in the data and their meaning. The first reading was followed by a structural analysis by the same author (SA), where meaning units were condensed by a reformulation of the essence of the text. The condensed meaning units were then sorted into sub-themes and themes. In addition, half of the transcripts were analysed by another author (ML) and sub-themes and themes were then discussed. The meaning units, condensed meaning units and themes were then reflected upon in relation to the naïve understanding, alternative themes, and possible divergent interpretations. In this sense, the meaning of the initial naïve understanding and the structural analysis was interpreted and reformulated in a circular movement between part of the text and the whole. Finally, the structural analysis was contextualised in relation to the participants’ experiences of the programme for a more comprehensive understanding. During data collection and the process of analysis, saturation of themes and sub-themes was considered to be reached. The transcripts were not returned to the participants and the participants did not provide feedback on the findings.
Ethical considerations
The study follows the ethical principles of the Declaration of Helsinki 1964 and was approved by the Regional Ethical Review Board in Stockholm (2016/447–31/2, 2016/1254–32 and 2017/2379–32). All participants received verbal and written information about the study and parents gave informed consent in writing for themselves and their children before participation in the study. For parents, this information was first given verbally when they were invited to the interviews, and then repeated verbally and in writing before the interview. All participants were informed that participation was voluntary, about the study and how the data were handled and stored.
Discussion
The results of this study highlight the importance of co-participation in family-based health-promoting programmes to enhance psychosocial health among families in socioeconomically disadvantaged areas. Even though family- based interventions have been suggested as a promising strategy to increase children’s PA [
19,
26], there is limited knowledge on participant’s experiences of the psychosocial aspects of health.
To our knowledge, this is the first study exploring how families experienced psychosocial aspects of health after participation in a family-based programme that is delivered in collaboration with local municipalities and sport associations in socio- economically disadvantaged areas.
The result of this study emphasises a range of psychosocial aspects of health from the perspective of participating families, presented in the themes: “A sense of belonging”, “An awareness of one’s roles as parents” and “Inspiration towards new and healthier behaviours”. Similar to the results in our study concerning participants’ experience of a sense of belonging and a free zone for the family, Noonan et al. [
27] have previously identified that parents of 10–11 year old children viewed” Family-based time” as a beneficial factor that influenced PA intervention engagement. In their study, the included parents had a higher socioeconomic status than average, and the children participated in organised sport. The results of our study provide new insights into the psychosocial dimension of participation in family-based PA programmes in socioeconomically disadvantaged areas. Furthermore, the results of our study also suggest the potential to overcome social isolation through family-based PA programmes. Considering that both actual and perceived social isolation have been associated with an increased risk for early mortality [
28] and that low social- and economic capital has been associated with poor health [
29] there is an urgent need to find ways to promote psychosocial health, especially in socioeconomically disadvantaged areas. The ability to enhance a sense of belonging, including social participation through family-based interventions may therefore be of outmost importance to public health.
The result of this study also showed that participating parents achieved an awareness of their role as parents. The social dynamic and the interaction between families and leaders, despite identified challenges, were described as a means to get new insights on how to act as a parent. This is consistent with other studies about the importance of collective family activities and a sense of social connectedness with a wider family and community network for role modelling of children’s health related behaviours [
30,
31], as well as research about parents’ views on parental training and the importance of group-based approach to support peer learning [
32]. In contrast to the results in this study, a previously conducted review of reviews has suggested that family-based PA interventions were more effective to change PA when they were conducted in the home setting than in a community setting [
19]. These results were partly explained by a higher retention rate in home-based than in community-based interventions which may facilitate increased PA. Wiltshire and Stevinson [
33] have, on the other hand, addressed the importance of social relations in community-based PA interventions to increase social capital, specifically in low SES areas. This is also important considering that research has shown that families from different socioeconomic backgrounds support their children in different ways [
16].
Although, some participants in this study had various sport experiences, many were unfamiliar with the different activities provided during the programme. Specifically, winter sports were new to many participants. As the results in this study show, experienced-based insights during the programme were important to get inspiration towards new and healthier behaviours. The content of the programme, and the opportunity to try different PA activities facilitated participants’ new and healthier behaviours and lifestyle changes. Furthermore, the possibility to be together with family and friends were important for participating families to feel comfortable when trying new activities. Enjoyment and social interaction have been reported in a review [
34] as common reasons for participation in sport and PA. In the review, is was commented that children appreciate the chance to try different activities in a non-competitive environment with parental support [
34]. Taken together, the results of our study highlight family co-participation in a community setting for psychosocial health and for promotion of healthy lifestyle changes.
Strength and limits of the study
There are several strengths, but also limitations to this study. A strength was to focus the data collection to on one location were the programme was delivered, which provided relevant in-depth understanding on the local context and facilitated interpretation of data. In this site, the programme is well established since 2013. The programme builds on a collaboration between local municipalities, sport associations and enterprises. However, a possible limitation could also be that the result of this study may be partly dependent on contextual factors such as; the local environment, including programme facilities and leadership.
The use of interviews enabled us to capture rich data of the participants’ experiences of psychosocial health. The use of an interview guide with semi-structured questions also allowed for the participants to express their lived experiences [
25] and for the interviewer to be sensitive to the areas that were brought up and experienced as meaningful by the participants. For participating parents, the period between the programme and data collection gave them enough time to reflect on the meaning of the programme for their psychosocial health. For some children, on the other hand, it is possible that it would have been better to conduct the interviews directly after or during the programme to get their immediate experiences.
Another strength of the study was the process of data analysis, with two researchers analysing and discussing the interpretation of data. Furthermore, to ensure credibility and dependability, the process of data analysis was well documented and the researchers’ pre- understanding was reflected upon to create awareness and ensure the interpretation to focus the lived experiences of the participants.
Conclusions
This study highlights the need for family co- participation in health-promoting PA programmes to enhance psychosocial health. The findings showed how the participants created a sense of belonging, got new insights on how to act as a parent, despite some difficulties in relation to differences between participating families, and how they were able to make healthy lifestyle changes. The present study was conducted in a socioeconomically disadvantaged area. The results are relevant to the further development of family-based, health-promoting programmes to increase psychosocial health and decrease inequalities in health. Further investigation is needed on different stakeholders’ perspectives and experiences on content and delivery of the programme. Such studies could include a larger variation of intervention settings to further explore contextual opportunities and challenges.
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