Background
A high number of children engage in unhealthy energy balance–related behaviors (EBRBs), including excessive television watching and computer use, and low consumption of fruits and/or vegetables [
1‐
4]. Over the long term, these behaviors cause a chronical positive net energy balance in the child, which can result in the child becoming overweight. Childhood weight problems are a major public health concern in Western countries [
5,
6]. In addition, being overweight is more prevalent among children in families with low socio-economic status (SES) and families of Turkish and Moroccan descent [
7,
8]. Preventing the development of overweight is important due to the high complexity of treating the condition [
9], an increased likelihood of being overweight or obese in adulthood [
10], and the associated detrimental health and social consequences. Negative health consequences can include developing hypertension, atherosclerosis, type 2 diabetes mellitus, and/or various forms of cancer [
5]; in addition, psychosocial consequences can include depression-like symptoms [
11,
12]. Together, these consequences can severely decrease health-related quality of life, contributing to rising healthcare costs [
13], and even leading to premature mortality [
12].
Parents can clearly influence their child’s development of healthy dietary and physical activity behaviors and are important role models both in terms of promoting these healthy behaviors in the child’s micro-environment and in terms of dealing with numerous environmental obesogenic factors [
14,
15]. Published reviews increasingly emphasize the impact of parenting on preventing childhood overweight and obesity [
16‐
21]. In addition to regular physical activity and a healthy diet, parenting styles and practices are key components of interventions designed to prevent overweight in children, and incorporating the parenting component within these interventions can greatly increase their effectiveness [
17,
18,
22,
23]. The review studies by Snoek (2010) and Waters (2011) revealed that parents should be involved in interventions for the prevention of overweight [
16,
23]. Parents should, for example, be supported in the following roles:
i) helping facilitate a healthy lifestyle,
ii) using specific EBRB parenting practices, and
iii) learning general parenting practices [
23]. However, to date, most Dutch and international obesity prevention programs have paid limited attention to parenting aspects [
23‐
29].
According to several Dutch healthcare practitioners and policy-makers, motivating and involving parents to participate in interventions, in particular immigrant parents and parents with a low socioeconomic status (SES) is both difficult and problematic [
30]. To incorporate parental involvement and support, and the parenting component (e.g. the role model, facilitator of healthy EBRB’s, and applying EBRB rules) into existing overweight prevention programs in the Netherlands, we developed a web-based Dutch parenting program (also known as an e-learning program) for parents of children 8–13 years of age. We chose parents of children 8–13 years of age, because we selected the already existing school-based overweight prevention intervention, entitled “Scoring for Health” to which we will add the e-learning. Scoring for Health is offered on a large scale to primary schools in low-SES neighborhoods for children 8–13 years of age. The e-learning program’s effectiveness will be tested in an upcoming cluster randomized controlled trial [
31]. Importantly, parents will be able complete the e-learning program in their homes, at a time that suits them. The e-learning program will teach parents how to encourage and support their child’s decision to develop and maintain healthy EBRBs, as well as how to handle everyday life conflict situations that can jeopardize healthy EBRBs.
Moreover, it is important to ensure that overweight prevention programs fit the lifestyle and needs of the parents and children. Previous studies have investigated the challenges that parents face when attempting to provide their children with healthy EBRBs, parents’ perceptions regarding healthy behaviors, and parents’ opinions regarding obesity prevention programs [
32‐
36]. However, little is known regarding the specific everyday life situations in which parents experience difficulties; moreover, the underlying reasons for why parents encounter these difficulties are poorly understood. We reasoned that if we use these specific situations and the underlying reasons when creating our e-learning program (based on the theoretical insights from Parent Effectiveness Training and Parent-Management Training-Oregon Model [
37,
38]), many parents would recognize these situations and would be willing to learn parenting skills that teach them how to deal with difficult everyday life situations. Thus, many parents would feel more compelled to complete the e-learning program. Studies have shown that when a message is personally relevant to someone, that individual will encode and internalize the message more efficiently [
39]. Thereby this is increasing the likelihood of achieving a more positive attitude and a more favorable outcome; importantly, this change in attitude is often associated with a change in behavior [
40,
41].
Therefore, as a first step towards developing this e-learning program and to get more insight into determinants of everyday EBRB parenting, we conducted focus groups with mothers who live in low-SES neighborhoods in the Netherlands. We chose for parents who live in low-SES neighborhoods, because low-SES parents are difficult to reach with interventions [
30], and also the group where childhood overweight is more prevalent [
8]. The aims of this study were to
i) explore and identify everyday life situations in which mothers experience difficulty stimulating healthy EBRBs in their school-age child, and
ii) identify the reasons why mothers encounter these difficulties.
Methods
Study design
We chose to study focus groups rather than conducting interviews and/or questionnaires, as focus groups are particularly valuable for exploring the experiences and issues that are important to the participants, and it allows the participants to provide this information using their own words and phrases [
42]. A focus group encourages interaction between participants, which facilitates a rich discussion, and group discussion can encourage contributions from people that may normally not respond [
42]. In addition, focus groups are an appropriate means to approaching low-SES groups, because the interaction that focus groups bring, allows groups of peers to express their perspective. Having the security of being among others who share many of their feelings and experiences, the participants possess a basis for sharing their views [
43]. Further, focus groups do not discriminate against people who cannot read or write and they can encourage participation from people reluctant to be interviewed on their own or who feel they have nothing to say [
42].
Because the prevalence of overweight children varies with ethnicity, we selected ethnically heterogeneous groups comprised of mothers of Dutch, Turkish, and Moroccan descent. On the other hand, we attempted to make the groups as homogeneous as possible with respect to other factors, including the children’s age, the parents’ gender (all parents were female) and neighborhood (low-SES, based on lower levels of education and lower incomes), thereby facilitating communication and ensuring that the majority of participants share their experiences with their peers.
The Medical Review Ethics Committee of the Region Arnhem-Nijmegen, the Netherlands approved this study (Reg. nr.: 2012/145).
Participants
In the spring of 2012, mothers of children 8–13 years of age were invited to meet as a group with other mothers to discuss their opinions and experiences regarding encouraging healthy EBRBs among their children. A purposeful sample of mothers was recruited. The inclusion criteria for participation were as follows: mothers who live with a child 8–13 years of age in a low-SES neighborhood (because the e-learning is intended for parents live with a child 8–13 years of age in a low-SES neighborhood); families of Dutch, Turkish, or Moroccan descent; and an understanding of the Dutch language at the speaking level. We included only mothers, because they are often the primary caretakers. Moreover, we wanted to create a safe focus group for the immigrant mothers in which they all dare to talk [
44]. That is why we have chosen only mothers instead of mothers and fathers together. Each focus group consisted of a combination of Dutch, Turkish, and Moroccan mothers.
Recruitment
We contacted six primary schools by telephone, each of which was located in another low-SES neighborhood in Nijmegen, the Netherlands. All six primary school principals gave permission to recruit mothers at their school. Key informants, which were female volunteers who routinely organize various parent activities, were asked to help recruit mothers face-to-face who fulfilled the inclusion criteria. Using a purposeful sampling strategy, these key informants directly contacted mothers who were likely to participate and arranged a convenient date and time for the mothers. All contacted mothers agreed to participate. The key informants at four schools successfully recruited an ethnically heterogeneous group of mothers. All recruited mothers showed up for the focus group conversation. The informants at the two remaining schools failed to recruit an ethnically heterogeneous group, as these schools contained no Dutch-speaking Turkish or Moroccan mothers; therefore, no focus groups were performed at these two schools.
Focus groups
The four focus group meetings were held in a multifunctional room at their school; these locations were chosen because various child and parent activities are held there, and the rooms were therefore familiar to the participants. All participating mothers provided written informed consent and gave permission for making an audio recording of the meeting. The participants also completed a brief socio-demographic questionnaire. Each focus group session lasted approximately 2 hours.
The focus group meetings were guided by a trained moderator (author E.R.) with the support of a trained assistant (author M.H.). The moderator was female and worked as a youth health care doctor (MD) and PhD-student. She followed a certified training [
45] on moderating focus groups, where she tested the semi-structured interview guide (See Additional file
1). Prior to the study, there was no relationship with the participants. The moderator facilitated the discussion, asked questions, and probed for more information to elucidate the participants’ comments (e.g. ‘Can you give an example of how this is done in your home?’ or ‘Why is that situation so difficult?’). The assistant took detailed notes and tracked the individual contributions of each participant. The moderator used a semi-structured interview guide, which was based on the research questions. The mean questions were “Which factors are promoting or hindering you as a parent in promoting healthy eating and physical activity habits in your child?” and “In which everyday life situations do you experience difficulties?” The questions were designed to be open-ended. To increase the credibility, member checking was conducted between each focus group question and at the end of each focus group to make certain that the moderator accurately understood the answer provided by the participants [
46,
47]. During a brief “warm-up” session, the moderator asked mothers to list in writing—as quickly as possible—all of the words that came to mind when they first thought about diet and their child; in the second part of the meeting, they were asked to list the words that came mind when thinking about physical activity and their child. After these brief warm-up sessions, the moderator used open-ended questions to start the discussion and then focused on elucidating the mothers’ responses. Thereafter, the moderator focused specifically on asking which everyday life situations mothers experience difficulty when encouraging their children to maintain a healthy EBRB. Finally, the questions from the moderator focused on elucidating the comments in order to better understand why some mothers find it challenging to encourage healthy EBRB in their children. All focus group sessions were recorded, and transcribed verbatim. The participants were rendered anonymous by assigning each participant a numeric code. Transcripts were not returned to participants for comment and/or correction.
Data analysis
We performed a conventional qualitative content analysis in order to inductively derive quotations and subsequent themes from the data [
48]. The data were analyzed using the ATLAS.ti 6 software package. Quotations were chosen based on the unit of analysis, which was defined as: all text passages containing any information about daily routine pursuits or situations regarding diet, physical activity, or sedentary behavior that were considered difficult by the mothers. A difficult everyday life situation was linked to a specific activity (e.g., watching television) and—where possible—to a setting (e.g., eating fruit at school). All comments regarding the reasons why mothers reported difficulties were categorized as child-related factors (e.g., preference for a certain food), parental factors (e.g., inconsistent parental practices), environmental factors (e.g., school, friends, etc.), or “other”.
To increase the dependability [
46,
47], two researchers (authors E.R. and M.H.) independently highlighted quotations in the transcripts from the first two focus groups and assigned codes to all quotations. Thereafter, the code lists were discussed, and consensus was reached regarding the final codes. To obtain a code tree, the codes were independently grouped into categories and themes by two researchers (authors E.R. and M.H.), and the code tree was discussed in order to reach consensus. The other two focus groups were coded together, and the code tree was adjusted accordingly. To increase reliability, the code tree was reviewed, discussed, and confirmed by an independent member of the research team (author G.F.). Participants were not asked to provide feedback on the findings.
Using an iterative approach, the researchers reviewed the transcripts in order to reflect upon each focus group meeting prior to conducting the next focus group meeting, thereby allowing newly identified codes and themes to be incorporated into subsequent sessions. After the four focus group meetings, recruitment was stopped because data saturation had been reached. This point was defined as no new themes emerged from the fourth focus group.
A Dutch-to-English translator at the Radboud University Nijmegen translated all of the quotations used in this publication.
Discussion
Our aim was to explore the difficult everyday life situations that mothers in low-SES neighborhoods face with respect to encouraging healthy EBRBs in their school-age children. Although previous studies identified several barriers that prevent parents from providing their children with a healthy lifestyle [
32‐
36], our results describe real-world everyday life situations that mothers perceive as challenging. In the focus groups, the mothers reported several everyday life difficulties with respect to eating dinner, eating breakfast, avoiding candy and snacks, eating fruit at school, playing sports, playing outdoors, restricting computer use, and limiting television time. In addition, this study provides important insights into the reasons why mothers encounter these difficulties.
The most frequently cited problematic and discouraging situation for the mothers was the daily struggle at the dinner table. This finding supports the results of a cross-sectional study that examined parents’ perceptions of the mealtime environment [
49]. One of the mealtime challenges of 40 % of the parents was a “conflict about food” on a daily basis, and these conflicts were related to the child’s “pickiness” regarding food [
49].
The mothers in our focus groups also worry about their child’s constant desire for candy and snacks, as well as the negative influence of friends and other peers on the child’s eating behavior. The mother’s feeling of “losing control” and that other individuals undermine their rules were considered to be particularly difficult. This finding is consistent with a focus group study by Hart et al., who qualitatively investigated parental barriers and benefits for providing children with a healthy diet and adequate exercise. Siblings, non-resident parents, grandparents, and the child’s friends were all viewed as potentially negative food role models by both low-SES and high-SES mothers of children 7–12 years of age [
50]. Furthermore, in a large survey conducted among Dutch children 4–16 years of age and their parents, 16% of parents indicated that they found it difficult to not have control over what their child eats [
51].
The feeling of losing control when the child plays outdoors was also reported in previous studies, and is often referred to as a “lack of perceived neighborhood safety”. For example, inner-city parents are considerably more anxious regarding neighborhood safety than suburban parents, and this concern is inversely correlated with the child’s level of physical activity [
52]. In their review, Carver et al. concluded that road safety and “danger of strangers” are responsible for most parents’ anxieties related to the child’s safety when playing outside. However, to date, little evidence is available to suggest that this has an impact on the child’s physical activity and walking and/or biking to school [
53].
Only a few mothers in our focus groups mentioned encouraging their child to be physically active as a specific problem. Moreover, the consumption of sugar-sweetened beverages (SSBs) was not mentioned at all by the mothers. However, research by the Municipal Health Service, region Nijmegen and national research found that the majority of children do not meet established physical activity recommendations, and one in four children 0–12 years of age consumes at least three SSBs per day [
1,
54,
55]. For example, in 2011 and 2013, respectively 16 and 21% of children 4–12 years of age met the Dutch recommendation for physical activity [
54,
55].Thus, mothers in low-SES neighborhoods might overestimate their child’s physical activity while underestimating their child’s intake of SSBs. A possible explanation for this could be that the mothers are simply not aware of their child’s activity level and SSB consumption outdoors (e.g. at school or at children’s friends’ houses). Or because mothers think the physical activity level and SSB consumption of their child is within the healthy norm and not a problem, due to their lack of knowledge regarding physical activity recommendations, SSB consumption recommendations, and health risks of high SSB consumption.
Although the mothers stated that their child’s screen time (e.g., computer use and television watching) was a problem, they noted that they did not establish clear rules regarding using the computer and—in particular— watching television. This is in line with Jordan’s findings among parents of children 6–13 years of age, that reported that only few parents had rules restricting the time children spend watching television [
56] and also in line with the findings of a survey of the Municipal Health Service in the Nijmegen Region [
1]. Establishing rules and limits regarding screen time can be effective at reducing the time that children spend performing screen-based activities [
57]. Therefore, interventions should provide parents with information to help them establish rules regarding screen-time activities in order to reduce their children’s screen time.
One important finding is that mothers in low-SES neighborhoods indicated that they face several difficulties with respect to parenting. The inability to establish rules and the failure to consistently enforce those rules were mentioned most frequently. Moreover, the mothers indicated that they would like to see a consistent healthy food policy established in their child’s school, which would support them in their efforts to promote healthy dietary behavior in their child. According to other Dutch data, more than one-third of parents experience parenting difficulties at some time, and this percentage is even higher among parents with low SES; low-SES parents also express a greater need for parenting support [
58].
Despite its benefits, this study also had limitations that warrant discussion. First, the purposeful sampling strategy does potentially not reflect the general population. The mothers were recruited using so-called “key informants”. Thus, it is possible that these mothers were highly motivated and interested in their children’s health, as they are often involved in school activities. Furthermore, the key informants also participated in the focus groups, although they did not have children 8–13 years of age. However, none of these mothers were excluded, as they contributed to the discussion and the other mothers responded to their input. The informants were mothers who are connected to the living room projects at the primary schools and trusted persons (peers) for our participants. The informants had the same cultural background as the participants, which ensured a safe, secure atmosphere during group consultations. Nevertheless, our analysis revealed that omitting the statements made by the key informants did not change the primary findings of this study. Moreover, it is possible the mothers simply gave the answers that they felt to be socially desirable. However, we made every effort to make the focus group an open, safe environment; consequently, the mothers seemed to feel comfortable, so we believe that they provided honest answers.
Because of the relatively small sample size and the use of purposeful sampling, our findings do of course not include the experiences of all mothers who live in low-SES neighborhoods within the Netherlands extensively. Yet, our findings provide an approximation of the situation experienced by mothers in low-SES neighborhoods in the region, as we included ethnically diverse mothers from four different low-SES neighborhoods throughout the city, and data saturation was achieved after four focus groups. Moreover, the views represented by fathers were not included in this current study. Studies show that the parenting styles of fathers and mothers have different effects on the EBRBs of the child [
21,
59]; therefore, it would be interesting to conduct future focus groups with fathers to determine whether their opinions and problems differ from those of the mothers. Finally, additional research should investigate further parental experiences regarding parenting in general and/or whether parents of children with overweight or obesity experience different challenges.
Implications for practice
Based on this focus group study, we identified everyday life situations in which mothers experience difficulty stimulating healthy EBRBs in their children. In addition, we found that the parenting difficulties mentioned by mothers can be subdivided into the following three negative core dimensions of parenting style as describes by Skinner [
60]: i) rejection: irritability and difficulty remaining calm, ii) chaos: inconsistency, father-mother inconsistency, and a lack of parental rules, and iii) coercion: punitive measures and forcing the child to eat. In addition, we found that mothers who live in a low-SES neighborhood were easily willing to participate in the focus groups and discuss EBRB-related topics. Thus, these mothers value EBRBs and seem willing to learn how to deal with these everyday life difficulties. These results were used as input for developing our e-learning program for parents of children 8–13 years of age in order to prevent weight problems. The difficult situations and the transcripts from the focus group meetings were used for the content of the e-learning program. In this e-learning program, parents receive tools that they can use to encourage their child to develop healthy EBRBs. These tools use both general and specific parenting and conflict-management approaches [
37,
38,
61]. By using the information obtained directly from the parents in our focus groups to develop our e-learning program, and by using video clips that show how difficult situations handled using both “good” and “less good” approaches, parents will likely identify with the everyday life situations described in the program. We therefore expect that parents will feel compelled to follow the program and will be more willing to learn new parenting skills in order to help them overcome these difficult situations. Nevertheless, we will perform a randomized controlled trail in order to investigate parents’ willingness to follow the e-learning program, as well as the effects of the program on parenting styles and practices and on EBRBs among children 8–13 years of age.