Parent and child perceptions of school-based obesity prevention in England: a qualitative study

Childhood obesity is a global public health challenge [1], and its health consequences are well-documented [2]. Schools offer an environment in which eating and activity occur, providing opportunities to learn about and implement healthy behaviours. In addition, they have the potential to engage parents to support activities in the home setting [3, 4], and promote consistent messages between home and school. Schools are therefore often seen as an important setting for childhood obesity prevention interventions [5].

Systematic review evidence indicates that school-based obesity prevention programmes targeting both physical activity and eating behaviours can be effective [3]. The complexity and heterogeneity of such interventions, however, make it difficult to disentangle the relative effectiveness of individual components and their potential interactions [6]. Qualitative techniques can be useful in generating data which provide insight into the attitudes, perceptions, motivations, concerns and opinions of participants [7]. This in turn helps us to understand and contextualise the active ingredients, and their mechanism of action, within interventions [8].

The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study is an ongoing cluster randomised controlled trial evaluating the effectiveness of an obesity prevention intervention for children aged 6-7 years. From 54 randomly selected primary schools in the West Midlands, UK, 26 were allocated at random to the intervention arm of the trial. For logistical reasons, half of the schools were scheduled to receive the 12-month intervention in 2011-12, the remainder in 2012-13. Full details of the WAVES study are described elsewhere [9], but in summary, the intervention focused on promoting healthy eating and physical activity. Teachers were asked to: (i) Incorporate an extra 30 min of physical activity into each school day; (ii) Deliver three cooking workshops with children and parents focusing on nutrition education and food preparation skills; (iii) Supervise class attendance at Villa Vitality, a healthy lifestyle programme run at an English Premier League football club; (iv) Distribute two signposting sheets with ideas on how to be more active and specifically directing families to local physical activity opportunities, and a termly newsletter to reiterate the importance of healthy lifestyles.

This qualitative study aims to explore parent and child experiences of the WAVES study, in order to gain understanding of the mechanisms by which the intervention results in behaviour change, and provide context to support interpretation of the main trial results. Although a number of studies have investigated parent and child views in the development phase of obesity prevention interventions [10‐14], there is a paucity of published research on their views in the evaluation phase of such interventions. In addition, recent guidance emphasises the importance of considering and presenting qualitative findings ahead of the main trial outcome to minimise interpretation bias [15]. This qualitative study was conducted as part of the WAVES study process evaluation [16]; related findings from interviews with teachers have previously been reported [17].

This study uses a descriptive-interpretive qualitative methodology [18]. A sub-sample of schools participating in the WAVES study intervention programme was purposively selected to ensure contributions from a range of schools (diverse in location, ethnic mix of pupils, school size and deprivation (indicated by free school meal entitlement)). Data collection took place towards the end of the intervention period (May-July 2012 or May-July 2013). Ethical approval was obtained from the National Research Ethics Service Committee West Midlands, The Black Country (10/H1202/69). Parents provided written consent for themselves and/or their child prior to the focus groups. A £5 shopping voucher was given to parents attending the focus groups.

Ten schools (out of 15 invited) agreed to participate in this qualitative study. Three schools declined due to time pressures and the remaining two failed to respond. In the 10 participating schools, teachers were given letters of invitation to distribute to the parents of all children in their class (380 letters in total) inviting them to take part and/or permit their child to take part in a WAVES study focus group. Two of the schools held child focus groups but advised against the running of parent focus groups in their schools due to an anticipated poor response from parents. One school held a parent focus group but was unable to hold a child focus group due to time constraints in the curriculum. In total, 30 parents and 62 children participated in the study. Seven parent focus groups (mean group size, n = 4; range 2-12) (plus one interview (n = 1) because only one parent attended a planned focus group), and 13 child focus groups (mean group size, n = 5; range 2-7) were conducted. Characteristics of the schools, and participant numbers, are shown in Table 1.

Focus groups were run by two female researchers with training in qualitative research methods (J Clarke, MSc, Research Associate, and T Griffin, PhD, Research Fellow). One researcher led the focus group, whilst the other made field notes (contextual details and non-verbal expressions to aid data analysis and interpretation). The researchers were previously known by some participants through school visits as part of the WAVES study. Child and parent focus groups were conducted separately, within the participants’ school, without the presence of school staff (except in one child focus group where a teaching assistant helped a child with additional needs, but made no contribution to the discussion). A 45-min time slot was made available for each focus group. Average duration of discussion was 24 min for children and 28 min for parents. Topic guides (Table 2) were used to help direct discussions and participants were encouraged to talk openly about their experiences. Within parent and child focus groups, participants were asked to recount their experience of the WAVES study overall, and of the separate intervention components (additional physical activity, cooking workshops, Villa Vitality, signposting). Parents were also asked to consider any beneficial effects of the intervention (including any behaviour change) as well as the wider role of the school in preventing obesity.

Due to the young age of the children in this study (6-7 years), the facilitation of focus groups required special attention. As recommended by Stewart and Shamdasani [19], the moderators (JC and TG) were experienced in working with young children. First names were used to moderate the hierarchical adult-child relationship [20], and a short, fun ice-breaker helped children to feel comfortable and relaxed. Discussion was encouraged through the use of photographs of the intervention activities, and further prompts were used when necessary to clarify children’s responses.

Group discussions were voice recorded, transcribed verbatim, and anonymised. Thematic data analysis, guided by the Framework Approach [21], was undertaken in five stages: data familiarisation, theme identification, indexing, charting, and mapping the data. As recommended by Gale et al., [22], two researchers (JC and TG) independently reviewed all transcripts, identified themes and applied codes to the data. Codes were compared and discussed, and a thematic framework agreed. This framework was applied (independently) to the transcripts which were indexed using NVivo 10 (QSR International Pty Ltd. Version 10, 2012). At first, child and parent data were analysed separately, but due to the identification of common themes, the two datasets were subsequently reviewed together by all authors to identify and map overarching themes. For pragmatic reasons, member checking was not implemented.

Three overarching themes were identified from the data: ‘Impact (of the WAVES study)’, ‘Sustainability’ and ‘Responsibilities (for obesity prevention)’, under which sub-themes were determined. The ‘Impact’ and ‘Responsibilities’ overarching themes, and the ‘role of schools’ subtheme arose from the Topic Guide, and thus were researcher-led. All other themes emerged from the data analysis. Fewer themes were generated from the focus group discussions with children than with parents, and these were mainly assigned to ‘Impact’. Table 3 shows all themes, and indicates whether these arose from both parent and child discussions, or just from the parent discussions.

In this qualitative study, we found that parents and children value healthy lifestyle interventions delivered through schools, and report changes in knowledge, skills and family lifestyle behaviour as a result. There were concerns that changes in behaviour would not be sustained longer term. Several practical barriers to behaviour change, which could reduce intervention effects, were also discussed.

Parental involvement in health promotion interventions for children has been identified as an important factor in improving intervention effects [3]. Findings from this study suggest that such involvement improves parental knowledge and facilitates consistency of messages between school and home. A key theme was that intervention delivery through school, with teachers as role models and authoritative messengers, leads to a sense of empowerment for parents as they feel supported by schools in their attempts to promote healthy lifestyles for their children. Data from teacher interviews undertaken as part of the WAVES study process evaluation indicated that teachers were generally not in a position to assess the impact of the intervention on behaviour change [17], which may result in their underestimation of the positive effect of intervention delivery. Creating a feedback mechanism, to make teachers aware of intervention impact, may help motivate them to more consistently promote healthy lifestyles. In addition to parental empowerment and teacher influence, there was indication that children themselves were instrumental in influencing parents to implement lifestyles changes at home. This promising finding is similar to a recent study showing that empowering primary school children to educate their families was effective in lowering salt intake [23].

Food neophobia (a reluctance to try new foods) is believed to peak at the age of six years [24], and research suggests that novel food needs to be presented in a positive light, including highlighting the fun of preparing or cooking the food [24]. Willingness to try new foods has also been shown to increase when more people around the child consume the food [25]. We describe how the practical cooking aspects of the intervention, including preparation and trying of new foods by children (aged 6-7 years) alongside their classmates, parents and teachers, facilitated many to try new, healthy foods. This aspect of the intervention may have been successful in behaviour change which was translated to the home environment.

Although behaviour change theory was not explicitly used in the development of the WAVES study intervention, the empirical data from this study resonate with the framework set out in the Behaviour Change Wheel [26]. This has at its centre the COM-B model which describes three conditions necessary for behaviour change to occur; Capability, Opportunity and Motivation. This conceptual model can be used to theoretically explain the reported lifestyle changes resulting from the intervention. For example, improved skills in physical activity and nutrition (physical capability) alongside the empowerment of parents to implement changes with their children (psychological capability leading to increased motivation); the normalisation of healthy lifestyle behaviours, both in and out of school, e.g. at the football club (reflective motivation); positive role modelling from teachers and at the football club (automatic motivation), and the intervention programme providing occasions to promote and enact healthy lifestyle behaviours with children and families (physical and social opportunity). If capability, opportunity and motivation of children and parents, as well as schools and their staff, are addressed in future interventions, they may be more likely to result in behaviour change within families.

Parents and children in this study reported various barriers to behaviour change, many of which were also recognised by the teachers [17], and are consistent with findings from previous studies [11, 27]. This study also revealed a differential intervention impact on individual families, with some parents and children reporting significant behavioural changes, and others, despite appreciating the intervention as valuable education for children, reporting no impact as they considered themselves to be already leading healthy lifestyles. In considering the differential impact that the intervention might have had in different strata of the population, we posit that disparities observed could possibly be explained by the socio-economic circumstances of families, as our observations were that the parents who reported higher knowledge and existing healthier practices at home tended to be from schools serving areas of higher socioeconomic status. We propose that an important factor in this apparent potential of the WAVES study to affect positive lifestyle changes among families with poorer prior healthy lifestyle knowledge (which in this study tended to be amongst the participants from more deprived communities) was that the intervention targeted simple and achievable behaviour change. This variable impact, depending on family circumstances, resonates with some previous health behaviour change intervention research that showed greater effects amongst populations from lower, compared to higher socio-economic backgrounds [28, 29]. Although all schools have an important role to play in the promotion of healthy lifestyles, the level of involvement required is likely to vary depending on the circumstances of, and the challenges faced by, the families of the children who attend. Schools, and those developing school-based healthy lifestyle interventions, need to be sensitive to barriers faced by families, and consider the context of the home and local environment when designing programmes. Different families will have distinct capabilities, opportunities and motivations, depending on their social, cultural and economic circumstances. Tailoring programmes to suit local needs has been reported as an important approach for maximising parental compliance [30]. Our study supports this and suggests that future childhood obesity prevention intervention programmes need to incorporate a degree of flexibility to enable adaptation to individual school and family circumstances.

While participants perceived school-time as an important opportunity for children to be physically active, suggestions that physical activity had increased outside of the school setting were scarce. Equally, there were no reports of any positive impact of the physical activity ‘signposting sheets’. The fact that the physical activity component of the intervention was delivered only to children within school, with no parental involvement, combined with the barriers reported by participants when discussing the ‘signposting sheets’ (for example, high cost or lack of local activities, vying needs of siblings, lack of time, competing demands, and the draw of sedentary activities), suggest that the intervention is unlikely to have promoted physical activity outside of school.

Although the emphasis of the WAVES study intervention programme was encouragement of lifestyle behaviours to help children stay healthy, some parents discussed the possibility of a negative impact on children’s perception of body image and risk of developing eating disorders. The Cochrane review of interventions for preventing obesity in children [3] considered the potential harm of such interventions, and although few trials have considered this, none have reported any risk of eating disorders or other harms. It has been suggested, however, that programmes could simultaneously prevent eating disorders and obesity based on the idea that they have common risk factors [31]. In such a programme, the focus would be on health and behaviour change, regardless of weight status, alongside the promotion of positive body image and the acceptance of the diversity of body shapes and sizes [32].

The reports of positive behaviour change resulting from the intervention are encouraging, supporting the promotion of healthy lifestyles through schools. However, sustainability of the impact was a concern for parents. Whether children would retain the acquired knowledge, and have a continued motivation to implement it once the intervention ended, echoes concerns reported by teachers [17], suggesting that healthy lifestyle messages needed to be re-visited and embedded within the school curriculum. This issue of sustaining impact over time, and the need to embed effective interventions into standard practice has been raised previously [3]. Incorporating successful components of the WAVES study intervention programme into a ‘whole school approach’, advocated by the Health Promoting School model [5], would help improve its sustainability.

This qualitative study enabled us to better understand aspects of the WAVES study intervention programme that have the potential to initiate positive behaviour changes in families, and indicated that a combination of pathways influenced such changes. Pathways included: increasing capability through improving knowledge and skills of children and parents; increasing motivation through parental empowerment and role modelling; and the direct provision of opportunities to lead healthier lifestyles. Strategies to sustain behaviour changes, and the school role in supporting these, are important considerations.