Parental support to promote children's dietary and physical activity behaviours in disadvantaged settings

Background: A clear socioeconomic gradient in prevalence of childhood overweight and obesity exists in Sweden whereby children with low socioeconomic status (SES) have higher rates. Parents are an important target group for interventions to promote healthy behaviours and prevent unhealthy weight development in children.

Aims: The overall aim of this thesis was to investigate the effects and implementation of the Healthy School Start (HSS) parental support intervention to promote healthy child dietary and physical activity (PA) behaviours and prevent unhealthy weight development in disadvantaged settings in Sweden. Study I. To evaluate the effectiveness of the six-month HSS parental support programme targeting dietary habits, PA and body weight of six-year-old children in families with low SES in the school context. Study II. To explore the variation of how mothers and fathers with low SES influence their children’s dietary behaviours as explored during a real-life session of Motivational Interviewing (MI). Study III. To evaluate the psychometric properties of an instrument to measure parental self-efficacy for influencing children’s dietary, PA, sedentary, and screen time behaviours in the home environment. Study IV. To describe barriers and facilitators, related to intervention characteristics and process, that teachers and parents perceived as influencing the implementation of the HSS intervention.

Methods: The HSS intervention was carried out for six months during 2012-2013 in pre-school classes with six-year-old children and included three components: 1. Health information to parents, 2. MI with parents, and 3. Classroom lessons with home assignments. Study I. Intervention effectiveness regarding children’s diet, and PA behaviours, and Body Mass Index standard deviation score (BMI-sds) was assessed in a cluster randomised wait-list controlled trial with 378 children randomised to either intervention or control group. Diet was measured by parent-report, PA objectively by accelerometer, and anthropometry was measured by the research group at baseline, post-intervention, and at five months follow-up. Study II. Phenomenography was applied to transcripts of MI sessions with 29 parents who focused on their children’s dietary habits in the session. Study III. Exploratory factor analysis was conducted on data regarding parental self-efficacy as reported by 229 parents in both intervention and control group at baseline. Correlations between factors and child behaviours were subsequently applied. Study IV. Qualitative content analysis was applied to focus groups with 14 parents and 10 teachers in the intervention group.

Results: Study I. A significantly lower intake of unhealthy foods and unhealthy drinks was observed after the intervention, of which the lower intake of unhealthy foods was still significant for boys at follow-up after five-months. A significantly lower BMI-sds was found after the intervention in children with obesity at baseline, but this effect was not sustained at follow-up. Study II, III, and IV: Results indicate that, in an intervention like the HSS, there is a need for increased focus on the parental capabilities to: - have a positive interaction around food with their child (study II) - recognize parental responsibility for the child’s dietary behaviours (study II and IV) - regulate own emotions around the child dietary behaviour (study II), and - trust the child’s satiety response (study II) - perform the intervention activities (study IV) - cooperate with the other parent (study II and IV) and with school (study IV) - believe in their own capability to support the child towards healthy dietary behaviours (study III).

Conclusion: The HSS intervention was effective in decreasing the children’s intake of unhealthy foods, and partly regarding BMI-sds in areas with low SES, but had no effect on children’s PA behaviours. In future interventions, parental capabilities for positive parenting, cooperation, and for performing intervention activities have to be taken into account.

List of scientific papers

I. Effectiveness of a universal parental support programme to promote health behaviours and prevent overweight and obesity in 6-year-old children in disadvantaged areas, the Healthy School Start Study II, a cluster-randomised controlled trial. Nyberg G, Norman A, Sundblom E, Zeebari Z, Elinder L S. International Journal of Behavioral Nutrition and Physical Activity. 2016 13(1).
https://doi.org/10.1186/s12966-016-0327-4

II. Parental strategies for influencing the diet of their children – a qualitative study from disadvantaged areas. Norman Å, Nyberg G, Elinder L S, Berlin A. [Submitted]

III. Psychometric properties of a scale to assess parental self-efficacy for influencing children’s dietary, physical activity, sedentary, and screen time behaviours in disadvantaged areas. Norman Å, Bohman B, Nyberg G, Elinder L S. [Submitted]

IV. One size does not fit all – qualitative process evaluation of the Healthy School Start parental support programme to prevent overweight and obesity among children in disadvantaged areas in Sweden. Norman Å, Nyberg G, Elinder L S, Berlin A. BMC Public Health. 2016 16(1).
https://doi.org/10.1186/s12889-016-2701-1