Background
The global obesity epidemic is recognised as a critical public health issue that needs to be tackled in early childhood [
2]. Unhealthy eating behaviours, physical inactivity, and inadequate sleep increase obesity risk, and these behaviours often cluster together in children and adolescents to further increase that risk [
3]. Obesity-related behaviours develop during the early years of life, so interventions need to target these behaviours before they become established [
4]. Parents and other primary caregivers are the major influencers in the development of the behaviours through their parenting practices [
5].
Parenting practices are the way parents behave or what they do in the performance of their parental duties [
6]. Parenting practices include the setting of rules, explaining rules, restriction of certain foods, providing structure, setting limits on screen-time or taking children to sporting activities [
7]. There is increasing evidence that certain parenting practices in each of the obesity-related behavioural domains may increase or decrease the risk of childhood obesity [
8,
9].
Autonomy supporting parenting practices are crucial for the development of self-regulation and the internalisation of healthy behaviours in children [
10]. Examples of autonomy supporting parenting practices include using feeding practices that support the child to recognise their own hunger and satiety cues [
11], providing support for physical activity [
12], providing rules and limits around screen time [
13], and establishing bedtime routines [
14]. In order to effectively use autonomy supporting parenting practices, parents require skills and knowledge, and the confidence to use them [
9,
15]. However, there is limited understanding of the barriers and facilitators to parents using autonomy supporting parenting practices with their children aged 0–5 years [
16].
General parenting programs provide advice and strategies for dealing with challenging child behaviours. In school-age children, there are some examples where general parenting programs have been applied to address obesity-related behaviours directly [
17‐
19]. However, the majority of interventions target only one or two behavioural domains, usually nutrition and/or physical activity [
20,
21], and few have targeted sleep behaviours or sleep parenting practices [
20]. Interventions that have included sleep behaviours generally target parents of infants, particularly first-time mothers [
22]. Few interventions have targeted all four obesity-related behaviours [
23].
Childhood obesity prevention interventions targeting parents of children under the age of 2 are typically home-based, or delivered in a primary care setting [
24]. The majority that focus on toddlers and preschoolers have been implemented in Early Childcare and Care settings [
25], with some parental involvement as an adjunct to the main program [
26]. Few interventions that target parents of young children have been delivered in a community group setting [
23]. A unique advantage of an intervention delivered to existing parent groups is that they are already a source of support for parents of young children [
27]. However, little is known about the potential for targeting parenting practices, knowledge, skills and confidence in this setting [
4].
In Australia, a widely available parent group is the community playgroup, a place where parents and their young children meet informally, once or twice a week for 2–3 h at a community venue, for social interaction and for the children to play [
28]. Community playgroups are run by volunteer parents and are open to all parents and carers of children aged from birth to 5 years [
1]. The vision and values of community playgroup are to nurture young children and support the wellbeing of families [
1]. The organisation recognises parents as first teachers, and provides an environment that encourages peer support and family bonding [
29]. The philosophy behind the playgroup values, therefore, creates a synergy with childhood obesity prevention initiatives that focus on supporting positive and effective parenting practices. In addition, the reach of playgroups is vast. Across Australia, there are over 8000 Community playgroups operating in 80% of postcodes, and they are made up of families with a diverse range of cultural, social and economic backgrounds [
1]. Despite community playgroups providing a unique opportunity to reach parents with young children, few obesity prevention interventions have been delivered in this setting [
30].
The aim of this study, therefore, was to inform the design of a childhood obesity prevention intervention in the community playgroup setting by 1) identifying the barriers and facilitators in respect to using parenting practices that support the development of healthy obesity-related behaviours in their child; and 2) determine what parents would find acceptable in terms of delivery mode and timing of an intervention.
Discussion
The objective of this study was to gain an understanding of the barriers and facilitators to autonomy supporting parenting practices with respect to obesity-related behaviours in children. Parents openly discussed barriers related to encouraging healthy behaviours in their children, although they generally felt they had sufficient knowledge around what those behaviours should be. They provided insights into the challenges of parenting, and the difficulties in engaging in autonomy supporting practices in the moment of feeling stressed, overwhelmed, tired or time restricted. Participants also provided insights into the barriers and facilitators to an intervention for parents in a community playgroup setting, and their preferences for mode of delivery.
Consistent with the results from other studies [
37,
38], managing child food refusal through the use of non-responsive feeding practices, such as hiding vegetables, using food bribes, or only providing foods they know their child will eat, was common [
39]. The use of non-responsive feeding practices has been linked to a decrease in child self-regulation and satiety responsiveness [
40,
41]. In addition, the anxiety and frustration around food refusal also impacts on the maternal emotional state [
42]. In the current study, most parents felt bribing children with chocolate, for example, was justified because it meant the child ate their vegetables, or finished their main meal. However, some expressed the view that, although they used this strategy, they knew it was not ideal. The use of dessert or chocolate as an incentive, and parent’s feelings of guilt about doing so, is widely reported amongst parents of young children [
43,
44].
Parents discussed similar trade-offs with respect to their parenting practices around their child’s screen time. Limiting screen time is a challenge for many parents for a range of reasons, many of which relate to its appeal as a babysitter [
45]. Parents talked about iPads®, iPhones® and hand-held computer games being particularly useful to occupy or distract their child due to their portability and convenience outside the home [
46]. Parents felt guilty for using electronic media in this way, because they believed screen time should be restricted for children. However this attitude was undermined by the parallel belief that iPads® and computers are not only ubiquitous, but also necessary for children to master before starting school.
For most parents, physical activity was not a high priority as they felt their child was sufficiently active. Other studies have found that parents of young children often believe that children are inherently active, [
45,
47]. This is a potential barrier for an intervention aiming to increase physical activity in young children [
47,
48], and is supported by research that found parents feel that the physical activity guidelines apply to “other” families [
49]. Conversely, some parents described their child as “not active” and stated their belief that their child’s preference for sedentary play was fixed, and they were powerless to influence this preference. Another barrier to increasing physical activity was the need to supervise the activity, either at a park or when the child was playing in the backyard at home. Parents in another qualitative study also cited safety concerns in terms of children needing to be supervised in a public location [
45].
Parents felt frustrated about bed time and sleep, and believed that this was out of their control. They discussed strategies they had tried, mostly with limited success, or which impacted on themselves or their family in other ways. Consistent with other studies, parents cited daytime naps, and arriving home from work late and wanting to spend time with their children, as reasons for inconsistent bedtimes [
39].
Playgroups are an important source of social support and friendship for parents, especially for those who are socially isolated [
50], and they provide parents with a sense of belonging and validation as a parent [
50,
51]. All parents endorsed the importance of the social support they received at playgroup. They discussed the benefits of being able to talk about their parenting challenges in an environment where the other parents understood, could offer genuine support and also suggest strategies that might help with specific issues. An intervention program that leverages this supportive environment and enables parents to share and discuss positive and responsive parenting practices therefore may be effective [
39].
Parents were supportive of a program that could help them deal with the challenges of parenting, but they did not want to lose the social and informal aspects of playgroup. As such, an intervention would need to be brief, flexible and supportive. It would need to be delivered by someone they could relate to, and whom they felt would understand their parenting challenges. They commented that conversations with other parents are often interrupted by their child, or that they may be distracted by what their child is doing. However, they also indicated that they were accustomed to having disrupted conversations, so the presence of children may not be a barrier to effective implementation.
A strength of this study was the use of focus groups to explore the views of parents, allowing them to build on the views and experiences of the other parents during the discussions [
52]. Another strength was the use of Social Cognitive Theory and Self-Determination Theory as conceptual frameworks. A deductive approach was taken initially in this study but then a more inductive approach was used to refine the codes and themes that emerged from the focus group discussions. This flexible analysis method enabled the research questions and aims of the study to be fully explored without being constrained by the conceptual framework.
A limitation of the study is that focus group data can only represent the views of the study participants, which may not reflect the views of a wider group of playgroup parents [
53]. Even though we reached a saturation of opinions and preferences, focus groups cannot provide information about the prevalence of those opinions across the entire playgroup community [
53]. Further, the playgroups that expressed an interest in taking part in the focus groups were all located in metropolitan areas of mid to high socio-economic advantage. As such, the results may not fully apply to playgroups and parents in lower socio-economic areas or to those located in regional cities or rural areas of Queensland. Another limitation of focus group data is that there may be some social desirability attached to the responses [
54]. This may occur, for example, when a parent may not want their parenting challenges to be subject to judgment by other parents, or they may just conform to the general consensus of the group’s opinion [
53]. This potential limitation was mitigated by the fact that the parents in each group had already established supportive and non-judgmental relationships.
Conclusions
Parents provided insights into the challenges of parenting, and the difficulties in engaging in autonomy supporting parenting practices when feeling stressed, overwhelmed, tired or time restricted. Childhood obesity prevention interventions targeting parenting practices related to healthy lifestyle behaviours thus need to be implemented in a way that supports parents, increases parental self-efficacy, and decreases parental stress. The community playgroup environment is mostly unstructured, often noisy, and conversations are frequently interrupted by the needs of the children. As such, any obesity prevention program implemented in this setting would need to be light touch, flexible, and where possible, facilitated by a peer. Studies exploring the feasibility and potential efficacy of a peer-facilitated childhood obesity prevention intervention, delivered in a community playgroup setting, are thus warranted.
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