Parental experience of the obesity and social exclusion intervention “Our important children”

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Parental experience of the obesity and social exclusion intervention “Our important children”

Anita Seitz

Public Health Science, Scientific thesis II

Main field of study: Folkhälsovetenskap, Avancerad nivå Credits: 15 Higher Education Credits

Semester/Year: Autumn/2018 Supervisor: Åsa Svensson Examiner: Katja Gillander Gådin

Course code/registration number: FH020A

Degree programme: Master Programme in Health Science, 120 Higher Education Credits

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Abstract

Background: Childhood overweight and obesity are becoming more prevalent worldwide, which causes increased risks for a number of diseases. Family-based interventions are a promising approach to reduce weight and introduce a healthy lifestyle in an early stage. This study aimed to gain knowledge about the experience and perceptions of parents whose 10- to 13-year children participated in the “Our important children” intervention in Sweden. It combined various physical activities, seminars and practical food advice. The parents were involved in many of the activities.

Methods: Semi-structured interviews were conducted with seven parents of children who took part in the intervention. Qualitative manifest content analysis with an inductive approach was employed to process the data.

Results: The analysis identified seven subcategories and two categories. The parents observed an improvement of self-esteem, self-confidence and social life. Food habits and amount of physical activity improved. It was difficult to sustain these improvements after the intervention, which was attributed among other things to a lack of motivation, teenage problems and the children’s company.

Conclusions: The insights from this study are in agreement with previous research. The results indicate that the effects on food habits and physical activity may only be temporary. An extension of the program would allow further research on possible long- term effects.

Keywords: childhood obesity, childhood overweight, community-based intervention, family-based intervention, healthy eating, parent experience, physical activity, social support

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Sammanfattning

Bakgrund: Övervikt och fetma i barndomen blir allt vanligare i hela världen, vilket medför ökade risker för ett antal sjukdomar. Familjebaserade interventioner är en lovande ansats för att minska vikt och introducera en hälsosam livsstil i ett tidigt skede.

Denna studie syftade till att få kunskap om erfarenheterna och upplevelserna hos föräldrar vars 10 till 13-åriga barn deltog i interventionen "Våra Viktiga Barn" (VVB) i Sverige. Den kombinerade olika fysiska aktiviteter, seminarier och praktisk matrådgivning. Föräldrarna var inblandade i många av aktiviteterna.

Metoder: Semistrukturerade intervjuer genomfördes med sju föräldrar till barn som deltog i interventionen. Kvalitativ manifest innehållsanalys med en induktiv ansats användes för att analysera data.

Resultat: Analysen identifierade sju subkategorier och två kategorier. Föräldrarna observerade en förbättring av självkänsla, självförtroende och social umgänge.

Matvanor och mängden fysisk aktivitet förbättrades. Det var svårt att upprätthålla dessa förbättringar efter interventionen, vilket kopplades bland annat till motivationsbrist, tonårsproblem och barnens umgänge.

Slutsatser: Resultaten från denna studie överensstämmer med tidigare forskning. De tyder på att effekterna på matvanor och fysisk aktivitet endast kan vara tillfälliga. En förlängning av programmet skulle möjliggöra ytterligare forskning om eventuella långsiktiga effekter.

Nyckelord: barnfetma, barnövervikt, familjebaserad intervention, fysisk aktivitet, förälderns upplevelse, hälsosam kost, samhällsbaserad intervention, socialt stöd

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Background

In recent decades the prevalence of obesity around the world has increased substantially (Abarca-Gómez et al., 2017). Sweden is no exception: overweight and obesity in younger generations is generally higher than in older generations. However, although recent studies indicate a slight decrease in the prevalence of obesity and overweight individuals (Bygdell et al., 2017), the percentage still remains high, with records suggesting around 15 to 25 percent, depending on the exact population considered (Ahrens et al., 2014;

Bygdell et al., 2017; de Munter et al., 2016; Lobstein & Frelut, 2003). This poses a significant health risk and is a growing concern for public health (Koyuncuoğlu Güngör, 2014).

Overweight and obesity are an abnormal accumulation of body-fat. It is commonly diagnosed using the Body Mass Index (BMI), which is calculated using the body weight in kilograms divided by the body height in metres squared. A BMI of 25 or more is defined as overweight, a BMI of 30 or more as obesity. As the BMI does not take the age into account, IsoBMI provides the same scale for persons age 2 to 18. It is converted from BMI using standardised tables (Cole, Bellizzi, Flegal & Dietz, 2000).

Childhood obesity is significantly correlated with high blood pressure and other cardiovascular disease risk factors in an adult age. Furthermore, cardiovascular damage already at a young age (Cote, Harris, Panagiotopoulos, Sandor & Devlin, 2013). Death by coronary heart disease is also correlated to BMI in childhood (Baker, Olsen &

Sørensen, 2007). There are further associated problems, among them type 2 diabetes and sleep apnoea (Lobstein, Baur & Uauy, 2004). It has been suggested that obesity is also a risk factor for depression (Mannan, Mamun, Doi & Clavarino, 2016; Martinson &

Vasunilashorn, 2016) and social exclusion (Lobstein et al., 2004). There is evidence that overweight and obese children have greater difficulties to establish friendships (Harrist et al., 2016), even depending on the level of obesity (de la Haye, Dijkstra, Lubbers, van Rijsewijk & Stolk, 2017). As childhood obesity increases the risk for overweight later in life it is of high importance to develop effective interventions to reduce the prevalence of obesity and overweight (Juonala et al., 2011; Sahoo et al., 2015).

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Several interventions to reduce overweight and obesity have been tested with varying success. There is evidence that the family is a key component as children follow the example of other family members (Gruber & Haldeman, 2009), especially their parents (Pyper, Harrington & Manson, 2016).

Burchett et al. (2018) identified three pathways for success of such studies: showing such families how to change, ensuring that all family members are on board and showing social support. According to House and Kahn (1985) social support is the provision of resources, both material and psychological, with the intention to help a person coping with stress. It is often categorised into instrumental support (i.e. material and financial support), informational support (i.e. measures to provide information to the individual) and emotional support (e.g. showing empathy and care).

A number of family-based interventions have been studied with some able to achieve a significant reduction of the BMI (F. Chen et al., 2012; Hunter, Steele & Steele, 2008;

Pakpour, Gellert, Dombrowski & Fridlund, 2015). These interventions typically involved parents and other family members and included a combination of talk sessions and seminars as well as physical training and other activities. Other inventions also included school-based or community-based components. A mostly school-based intervention by Nyberg et al. (2016) which also made use of brochures, teacher-led activities and interviews with the parents, only achieved short-term BMI reduction. Another study with a variety of measures by Safdie et al. (2013) even resulted in a negative BMI development. Following a 12-week-long intervention which required parent participation and included a variety of activities for children, Moore & Bailey (2013) found that the children were motivated by social exchange with other children which improved self-confidence with practical issues such as scheduling mentioned as barriers.

The intervention at the core of this study is “Våra viktiga barn” (Swedish ambiguous for

“Our important children” and “Our weighty children”, abbreviated VVB), which was

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conducted from 2004 to 2017. The participants were recruited from overweight and obese school children in Nacka municipality in Sweden.

Nacka is an affluent suburb of the Swedish capital Stockholm with a comparatively well- educated population of 101,231 persons. The average annual income for persons 20 years or older is 406,500 SEK, compared to above the national average of 300,000 SEK. 48.5%

of the population have an education beyond a high-school degree, compared to a national average of 34.9% (Statistika Centralbyrån (SCB), 2017).

Initially 12 children, aged 12, participated each year, which was later extended to about 25 in grades 4 to 6 (ages 10 to 13). The intervention lasted one year, in later instalments of the program, the children were able to continue, if they wished to do so after they had finished the first year.

Introductory interviews were conducted with each family. They contained advice on eating, sleeping and motion habits. Individual health goals were agreed upon. Both parents and children signed a pledge to commit to these goals and to participate in the program. The program’s activities consisted of weekly physical training with instructors.

This involved gym training, outdoor training, swimming and other activities such as riding. Furthermore, dietician-led tours through a local supermarket and cooking lessons were offered to provide information on healthy food and how to prepare healthy meals. Seminars on related topics complemented these measures. The parents participated in some of these activities. Furthermore, there were parent meetings, some of them with guided discussions about e.g. parenthood.

Considering the growing prevalence of overweight and obesity around the world and the accompanying health issues, it is of interest to optimize interventions to counter this trend. Family-based approaches to interventions can reduce the BMI as previous studies have shown. This is also indicated by the varying results of interventions without family involvement. There is only limited research which assesses the experiences of parents who have participated in such interventions (Clarke et al., 2015). Such an assessment

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may provide further insight into the parents’ influence on the intervention outcome. This is especially relevant due to the parents’ central role in the child’s development.

This qualitative study aimed to gain knowledge about the parents' experiences and perceptions of the VVB intervention.

Methods

Study design

This study was an inductive qualitative study. Several mothers were interviewed with regards to their experiences and perceptions of the VVB program. Qualitative methods try to understand the human experience through the collection and analysis of subjective and narrative data. As the goal of this study was to obtain a richer and more detailed understanding of the experiences and perceptions of the parents, a qualitative method can be useful to explore this little researched topic. The inductive approach employed by this study tried to develop generalisations from the specific narratives of those who were interviewed (Polit & Beck, 2012).

Respondents

Respondents in this study, consisted of mothers whose children had participated in VVB.

Purposive sampling was employed, which is commonly used in qualitative research (Palinkas et al., 2015). To be included in the study, respondents had to fulfil a number of requirements. Firstly, that one of their children was enrolled in the VVB project in 2015 and secondly, that the children participated in the entire year. A third requirement was fluency in Swedish.

All 20 families of the 23 children in the program were contacted by the school physician who directed the intervention. One family decided against participating during this stage. The contact data of the remaining 19 families were made available to the author.

They were then sent an information letter with relevant information about the study

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(Appendix 1) and an informed consent form (Appendix 2). Five families subsequently declined to participate. Two families did not respond to three contact attempts. Among the remaining 12 families, there were three families whose children did not complete the entire year. One family was excluded due to insufficient language proficiency in Swedish. Interviews were performed with the remaining eight families. In all cases, only the mother of the child was willing to participate. Thus, this study mostly reflects the experiences and receptions of the mothers of the participating children. The first interview was used as a pre-interview. Consequently, there are seven interviews reflected in the results.

The children of the interviewees continued with one exception after 2015 in VVB’s program for alumni which included mostly regular gym training. Some of the children had neuropediatric diagnoses.

The median age of the mothers was 47 years and the mean age 45.1 years (range 38 to 51 years). All of them were employed. Five of them had more than one child. None of the siblings participated in VVB.

Collection of data

This study was conducted using face to face semi-structured interviews. An interview script (Appendix 3) was used, consisting of predetermined open-ended questions that concerned the various activities in the VVB program. Information about the activities was provided by the report on VVB from 2015 by Nacka municipality (Ståhl, 2016). This method touches upon the area that answers the main question, and the participant is given the opportunity to talk freely about his/her experience. This makes sure that all required information can be gathered (Polit & Beck, 2012).

A pre-interview was conducted after which the interview guide was slightly adjusted.

Data collection took place March to May 2018. The author met the interviewees at a time and place of their convenience. The author did the interviews by herself. The first step

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was to introduce the purpose of the study and to inform them that the study was voluntary and the participants could cancel the interview at any moment. Before the interviews started the participants signed an informed consent form. All interviews were recorded with the permission of the interviewees. The advantage of this was that the researcher could focus on the conversation (Jamshed, 2014). The length of the interviews varied between 30-90 minutes.

The author is a paediatric nurse and public health science student, and had some pre- understanding of the area studied from meetings with parents whose children were overweight or suffering from obesity, but no prior experience from the VVB project. In order to minimise the bias of her own influence, the researcher took into account her own understanding during the study (Elo et al., 2014).

Data analysis

The data was analysed with manifest content analysis using the Graneheim and Lundman strategies (Graneheim & Lundman, 2004). The first step was to read the transcribed interviews several times to obtain complete understanding of the contents.

In the second step, the units were identified to find relevant sentences and phrases which answered the purpose of the study. The following step was to condense the units without losing the important content. Thereafter, the condensed meaning units were encoded. The codes are labels for the meaning unit. The codes of similar content formed seven sub-categories and finally two categories, which constituted the manifested content (Graneheim & Lundman, 2004). Examples of this process can be found in the table (see Table 1).

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Table 1. Example of meaning units, condensed meaning units, codes, sub-categories and categories

Meaning unit Condensed

meaning units Code Sub-

categories Categories He/She has probably

opened his/her eyes to the fact that she has to be more physical active, and that she has to limit his/her food.

Opened eyes, be more active, less food

Increased

awareness for physical activity needs, better food

Effects on nutrition, physical activity and weight

Impact on the child and family

… she/he would like to go to the gym but one of the parents has to come along, and then it’s mostly daytime and that’s when you work.

Would like to go to gym, parents have to come along, often work hours

Further gym visits difficult, adult has to come along and inconvenient hours.

Barriers to sustain healthy lifestyle

Impact on the child and family

They also had workout together in a gym and I think that was good for self- confidence to work out with others who were not in good shape either, who were a little bit chubby, they did not stand out.

Workout

together in gym good for self- confidence, to work out with others without standing out

Increased self- confidence, training without standing out

Experience of social

inclusion and mutual support

Social support and community

Ethical consideration

This study was designed according to the ethical guidelines of the World Medical Association (World Medical Association General Assembly, 2018). The respondents received a written cover letter and verbal information and signed an informed consent form before the interviews took place. The respondents were informed that the study was voluntary and could be terminated at any time. Furthermore, the respondents could ask additional questions over the course of the whole study. The data was handled confidentially and was kept from third parties. It was then disclosed that any material

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obtained during the process would only be used for this study and a possible report of VVB. According to the guidelines of Mid Sweden University (Mid Sweden University, 2018), a study that is not intended for publication it is not necessary to undergo an ethics committee review.

Results

The analysis of the seven transcribed interviews revealed two categories and seven subcategories. These main and subcategories are presented in Table 2.

Table 2: Main and subcategories

Main category Subcategory

Social support and community Social support by VVB

Experience of social inclusion and mutual support

Parents’ experience exchange and mutual support

Impact on the child and family Effects on nutrition, physical activity and weight

Impact on child’s self-esteem and self- confidence

Parental influence, its limitations and parents’ anxieties

Barriers to sustain healthy lifestyle

Social support and community

Social support by VVB

All parents had a positive experience regarding the support from VVB.

In the emotional area, parents mentioned that they found the staff involved in the project competent, friendly and dedicated; “Fantastic and dedicated instructors and staff. They had patience, they listened and gave support to us. Through that, we can be the parents that we are today.” Some stressed that the children felt appreciated; “There is somebody who cares, somebody who wants the best for [him/her]. ”Most parents also felt that this extended to themselves; “We parents feel good and that strengthens our relationship.

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Not only to the children but the relations within the whole family.” E.g., the VVB staff was available when support was required. Also, the assistance by VVB helped to talk about the children’s weight in some cases; ”I think it makes that we talk in another way when you know how you can talk to the children, that it is not a problem to talk about weight:” Others did not feel any improvement by this; “I still think it’s like trespassing to go to them and point that out. For them, it is there anyway and it’s judging somehow no matter how you put it.”

The emotional support from VVB motivated the children to participate in the program’s activities. All interviewees observed a positive attitude towards the program; “[He/She]

went herself. [He/She] planned and packed her bag.”

In the informational support domain the lectures were mostly mentioned in a positive way; “Yes, they absolutely gave us something […] It was a positive development both for me and [child’s name] ….” Especially the lectures about daily physical activity and the dietician’s information was appreciated; “It wouldn’t have been as much focus on daily activity in the same way.” Some found that they had already been familiar with the topics and thus felt that they were not helpful for themselves. They found though that the children benefited from them; “The contents were nothing new to me, but my [son/daughter]

thought they were good, and it was good that [he/she] heard it from somebody else than me.”

In the instrumental area, it was widely appreciated that VVB organized the transport to various activities such as swimming lessons; “It was always fantastic, e.g. when they went to [the swimming facility] it was [name of staff member] who gave them a ride.

[…] It was always possible to participate”. It was also mentioned that the program participation was free; “This was really good because not everyone would be able to do that otherwise.” Some parents also named the contract that the children signed when they started VVB helped to support participation in the program as they felt more obliged to continue. The chance to go to the gym regularly was mentioned repeatedly as

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very positive; “[He/She] thought it was cool that [he/she] was allowed to go there despite being too young. That was a great thing for [him/her].”

One of the mothers whose child continued after the first year with VVB criticised that it gave too much freedom to the children which did not fit well with their individual needs.

She would have liked to receive more support even in that course.

The discontinuation of the program in 2017, which was experienced by six of the interviewees, was also picked up in the context of support. Some criticised that the flow of information by e-mail ceased and they were taken by surprise when they heard the program was cancelled as funding was terminated. Most children were sad; “… and on the final day I saw [him/her] with a trembling lower lip.” The parents would have liked to see the program continue. Some would even pay for it.

Experience of social inclusion and mutual support

All parents considered participation in VVB to have a positive impact on the children’s social life. It created a sense of community which was mentioned in a positive context repeatedly; “It was a fun crowd. [He/she] went there every week and was happy.”

Especially the opportunity to train without being judged by others was mentioned repeatedly. Being unconditionally accepted and respected also helped to create an environment where the children felt safe; “To have a place where they feel: I am OK just as I am, I can do things and I am here, I am training, and I am happy. This is the most important thing I want to tell you.” Furthermore, several parents praised the mutual support of the participating children as a positive influence; “They supported each other through thick and thin.” Some of the children found new friends within the program;

“[He/She] has still friends from there who [he/she] meets and calls.”

Parents’ experience exchange and mutual support

The experience of the parents’ meetings was mostly positive. The ability to share their experiences with other parents in a similar situation was considered helpful; “It was good for us parents to discuss about what can be problems at home and such things.”

The attitude towards the meetings differed depending on the individual situation and

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previous knowledge; “It was more helpful for me when we were together with the kids and learned new things, but I think it is good that it is done.” Though some felt that they did not need the meetings themselves as they had emotional support from other persons in their environment, they found it important that the meetings took place as these meetings may be helpful to others.

Impact on the child and family

Effects on nutrition, physical activity and weight

Almost all parents reported that the visits to the local supermarket were inspiring both for themselves and for the child. Some parents said that they did not gain new knowledge from these visits, but the children did. With the help of the dieticians at the food store, the families learned to read the nutritional information on food packaging.

“It gave [him/her] something new for a long time. [He/She] can still point out [the food labeling]. That sticks really.” The kids dared to try new things and became inspired to cook themselves, or help to cook at home; “We could taste vegetables and fruits that we had never heard of.” A parent also reported that her daughter now dares to ask dieticians when she is wondering anything. Some parents observed that the food habits of their children have changed, both in choice and portion size; “[His/Her] food habits have changed to the positive. I can tell [him/her] that [he/she] may eat. After a certain amount [he/she] does not take more even if it tastes good.” However, it has also been observed that some improvements subsided after the program participation ended;

“[He/She] pulled herself together more while we were there. It was easier to control somehow.” The effects on physical activity vary considerably. Only one of the children is still going to the gym regularly with the parents, but is sometimes reluctant;

“Sometimes [he/she] is a bit motivated and thinks it’s cool, but mostly [he/she] thinks mom is stupid”. Another child is going to the gym with other near relatives. The others have finished for various reasons, mostly due to lack of motivation, resulting low attendance frequency. Apart from that all participants report that their child’s physical activity has improved after VVB, but in various forms. While some only walk more than before or take the stairs, others have found new sports such as archery and riding;

“[He/She] is able to walk now. You should have seen how we fought with [him/her]

previously when we wanted to walk.” To find suitable activities has been difficult. Some

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children did not want to do activities alone. Others took up new activities, but did not continue with them. For example, one child started swimming but quit when the coach changed. However, the parent noted that the child was able to train in a group which was not the case prior to VVB. Several parents observed a positive effect from the usage of a pedometer, which continued even after VVB ended; “Recently we had some fun […]

[he/she] had not done her 10,000 steps yet. So after school […] [he/she] took a longer route to get [his/her] steps together.” Regarding weight change the parents reported that the child’s weight had gone down during VVB. In some cases the weight levelled off afterwards, others saw a weight increase. None reported a further weight reduction.

Most parents reported that they experienced that their child was more aware of the need to change his/her nutrition and to perform regular physical activity. This is generally attributed to VVB: “I think they laid the foundation for an understanding and awareness that you have to take care of yourself.” One mother was not sure if the change originates from VVB. The parents see that their child has difficulties to sustain these improvements in everyday life: “[He/She] has more knowledge. [He/She] wants it actually and that is positive. But it goes wrong because, well, it’s too difficult to withstand.” The parents themselves reported in some cases that also their own awareness has changed: “It was very good for us to open our eyes and see how the situation actually is.”

Impact on child’s self-esteem and self-confidence

All parents except one observed that VVB improved the child’s self-esteem and self- confidence; “I have to say that VVB has helped very much in the respect that [he/she]

has gotten a very strong self-confidence and dares to believe in herself.” The one exception stated that the child already had a good self-confidence prior to VVB. Several parents attribute the improvement to training, weight loss and the resulting comfort in their bodies; “I think it has gotten better just by being able to say ´Well, I am going to work out.´ That alone improves self-esteem.” This had also positive effects at home by improving both the child’s and the parents well-being. Also, difficulties with mobbing in school subsided due to VVB in one case. One parent noted that the improvement of self-confidence was limited to the time when the child participated in VVB. Some parents also report that their child’s self-confidence had gotten worse after VVB concluded,

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attributed in to a weight increase and teenage problems. The other parents considered their child’s self-confidence was still improved compared to the state before VVB; “I think it was good for their self-conscience to work out with others who were not so good in shape either and a little bit chubby. They did not stand out then.”

Parental influence, its limitations and parent’s anxieties

The parents spoke repeatedly about their own influence during and after VVB, but also about the limits of control and their anxieties. Several parents described how they must encourage and sometimes push their children to be physically active. This was not as much the case during VVB; “I just said that [he/she] has to work out, not just hang out in the city. She was certainly encouraged [by VVB], too, such that it wasn’t just me.”

Most parents were aware of their role during VVB; “We had a lot of influence. If we aren’t there for them VVB can’t do that much.”

Some imposed strict rules during VVB and found it hard to follow them permanently as the children became teenagers. The concern to lose control is mentioned repeatedly. One example is that they cannot control anymore how the children spend their money; “I had more control over what [he/she] ate because [he/she] was younger and did not have [his/her] own money’. They feared health problems and a possible relapse; ‘There is a certain concern that [he/she] goes back to these old habits when [he/she] does not continue. Now [he/she] is hanging out at home instead of working out.”

Barriers to sustain healthy lifestyle

Difficulties to sustain changes which support a healthy lifestyle are a recurring topic in the interviews. A repeatedly named reason is the influence of friends outside VVB who eat unhealthy food. “Now there are friends who are great in many ways, but they are skinny and can eat anything without ramifications. […] [he/she] does as they do. They are at the friends’ home and bake and eat.” Most parents also said that the children are in their teenage years now and are refusing any encouragement from the parents; “Now it is teenage defiance. The computer, the telephone and the [boyfriend/girlfriend] are important now.” But also practical difficulties are mentioned. There are time constraints due to the work hours of the parents; “Then I have to say to [child’s name] that it will

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not be happening today, and by that I undermine [the effort].” They also have difficulties to find suitable activities; “We are trying to find new activities, but it is difficult with group sports. It has to be something which you do on your own.” Some parents also named age restrictions of the gyms as problem.

Discussion

Result discussion

In this study it was found that the measures of VVB had a positive impact on the participant’s self-esteem, self-confidence and social life. Awareness for a healthy lifestyle, nutritional habits and the amount of regular physical activity improved.

However, it was difficult to sustain these changes after the participants had finished the program. The results are generally in line with what previous research has found.

The generally positive attitude to VVB is often associated with statements on the social support provided by staff and peers of the children, as is also identified as a pathway by Burchett et al. (2018). As previous research has found, close friends, parents, teachers and classmates act as importance sources of support to children with obesity (Herzer, Zeller, Rausch & Modi, 2011; Moore & Bailey, 2013). The commitment of the VVB staff to the support of the children was appreciated by the parents and considered important in program participation, which has also been observed by Moore & Bailey (2013) in a similar intervention. Furthermore, some parents mentioned the benefits of the program being free of charge, as additional regular costs may hinder participation (Schalkwijk et al., 2015). Thus, VVB’s instrumental support by e.g. providing transportation may have alleviated such difficulties, which was mentioned repeatedly, and by this promoted the program’s outcomes. The importance of support with logistical challenges such as transportation is also illustrated by the results of Moore & Bailey (2013) where parents experienced difficulties when this support was lacking.

Another topic which was reflected extensively in the interviews is the social inclusion and mutual support by the other participants. As has been found before, a lack of friends

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who encourage physical activity may be a barrier to such activities (Puglisi, Okely, Pearson & Vialle, 2010) and that weaker social contacts lead to lower levels of physical activity (Lehto, Reunamo & Ruismäki, 2012). Thus, it is not surprising to see peers having a positive impact on the motivation to take part in physical activity, which has also been found in other studies (Coppinger, Jeanes, Dabinett, Vögele & Reeves, 2010).

As overweight children are more likely to have psychological problems and peer problems than children with normal weight (Janicke et al., 2014), the unconditional support by children in similar situations may be especially attractive (Hestetun, Svendsen & Oellingrath, 2015). Consequently, the lack of peers in a similar situation constituted a barrier to continue with the activities, as also repeated statements of problems finding suitable activities illustrate.

Though the parents had different views on the benefits of the parent meetings and lectures to them individually, they expressed a belief that such events may help the parents cope with their situation. This pattern is supported by observations such as the ones by Schalkwijk et al. (2015) where such mutual support by parents in the respective program helped to compensate for a lack of support by family members.

Childhood is crucial in developing behavioural habits (Bandura, 2004), and an intervention such as VVB provides a chance to influence awareness and habits. As examples such as knowledge on food labelling illustrate, information on food is absorbed readily by children, which has also been found in other studies (Clarke et al., 2015; Dinkel et al., 2017). Further parallels were that children were eagerly trying new foods in the intervention and at home as well as an increased awareness for a healthy lifestyle (Clarke et al., 2015).

This can be seen in relation to the lectures and provided education which was given to the parents and children. It involved the rest of the family and showed them how to change. This is also a pathway identified by Burchett et al. (2018), such that all three pathways can be found in VVB. Previous research has also shown that an educative approach can improve both parent’s and the children’s food habits (C.-Y. Chen, Kao,

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Hsu, Wang & Hsu, 2015). In addition, the observation of the parents is similar to this, as the majority observed an effect on the children’s nutritional habits. It is known that interventions can influence eating habits in the short term. Also, interventions based in supermarkets can change shopping behaviour temporarily (Jepson, Harris, Platt &

Tannahill, 2010), which closely resemble the observations of the parents regarding the lessons in the local supermarket during VVB. The positive effect of the use of a pedometer, which has been mentioned by several parents, has also been found in other cases (Bravata et al., 2007; Horne, Hardman, Lowe & Rowlands, 2009).

Observed improvements in self-esteem and self-confidence through increased self- efficacy falls in line with previous research (Liu, Wu & Ming, 2015; Lt & Loke, 2012). As several statements indicated, the children not only thrived in the program’s activities.

They were more willing to try new things, as observed also in other research (Moore &

Bailey, 2013). Furthermore, this also extended to the home environment.

The parents serve as role models, and their behaviour greatly influences the children’s health habits (Pyper et al., 2016). Following the lectures and activities of VVB, several parents actively tried to influence their children’s nutrition, by portion sizes and selection. The home environment was also affected as children introduced new food and took part in food preparation. This has been observed before by Moore & Bailey (2013).

Parents expressed their concerns that they might lose influence over their children, particularly as they had become teenagers. One aspect was that they had pocket money and were able to buy energy-dense food. This resembles the observations of Gray et al.

(2015) in which teachers and parents voice their dismay about snacks which are for sale in school and the problem that friends of the children buy this food for them. The view that a child’s circle of friends might be a negative influence was mentioned repeatedly.

There is some evidence which sees an association between peer’s influence and health habits, both to the negative and the positive (de la Haye, Robins, Mohr & Wilson, 2010;

Efrat, 2009; Puglisi et al., 2010; Schalkwijk et al., 2015; Sirard et al., 2013). One especially contributing factor may be that the friend’s interests were adverse to physical activity

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and healthy nutrition, such as going out for having pastries. It may be worth considering trying to extend the physical activity offers to friends of the participants, as has been suggested by researchers (Shin et al., 2014).

Previous research such as Nyberg et al. (2016) found that the long-term effects on health habits of such an intervention may be weak or non-existent. The parents’ observations indicate this as well: the short-term effects while participating in the program were difficult to sustain afterwards without the program as a supporting framework. The program motivated the children to engage in physical activity and healthy nutrition. A continuation of the program might have helped to alleviate the lack of motivation observed by several parents.

Although the interview guide was not designed with a particular theory as fundament, the results can be easily seen in the context of social cognitive theory (Bandura, 2004).

Based on the parent’s statements a perceived self-efficacy can be deduced from the improvements in self-esteem and the awareness of nutritional habits and physical activity. This is key to improved health habits. Bandura (2004) also stresses that habits which are detrimental to good health can be more easily changed in childhood than later in life. An effective prevention program should, according to Bandura (2004), include four components: health information, social and self-management skills to apply the information, a resilience to continue in face of difficulties and social support for the desired changes. VVB’s focus was secondary prevention, and all four components can be found in the program’s design and the parents’ statements.

Method discussion

The goal of this study was to draw conclusions from the parents’ experience with a low number of respondents, therefore, an inductive qualitative study was the most suitable choice (Priebe & Landström, 2017). Considering that this study is the first on VVB, there was no empirical data. It seemed appropriate to gather such data before initiating any deductive or quantitative study. A focus group study was not pursued due to several

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concerns, primarily due to the low number of participants which would not have allowed more than one focus group session (Wibeck, 2017).

The trustworthiness of the retrieved data was assessed in terms of credibility, dependability, transferability (Graneheim & Lundman, 2004) and confirmability (Lincoln & Guba, 1985) .

The number of interviews is at the lower end of the usual (Kvale & Brinkmann, 2014) due to the low number of participating children per year. This could possibly limit the scope of experiences presented in this study and its credibility and transferability.

However, it was important that enough experience with the program was present, which limited the number of possible participants. It is preferable to have fewer interviewees but with a richer experience (Henricson & Billhult, 2017). This was the case here as most children continued for another year. Alumni of earlier VVB years were not included in the selection as those parents may have more memory lapses and their children are of a different age.

Although study participation was open to all parents, the communication was handled by the mothers in most cases. All families who were ready to take part preferred to have the mother do the interview. In some cases the fathers were unavailable due to different private reasons. There were no indications that the fathers’ views on the program were considerably different. The neuropediatric diagnoses of the children were not taken into consideration in the selection process and result analysis as the parents’ experiences were the focus of this study.

As the access to data is limited to the main researcher alone for ethical reasons, no review by other persons during data processing was possible. This may limit credibility (Lundman & Graneheim, 2017). However, the extraction of meaning units was done with utmost care and with feedback from the author’s supervisor (Lincoln & Guba, 1985). The choice of categorisation was done with several iterations, but the intertwined character of some statements which made references to several topics often blurred the lines (Graneheim & Lundman, 2004) The use of citations in the presentation of the results

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is to provide the reader an opportunity to assess the interpretations’ validity (Graneheim, Lindgren & Lundman, 2017).

The interview guide was only updated once after the test interview and then used in all interviews without revisions. It is possible though that the researcher changed the style of the interviews due to the experience gained from previous interviews. As the interviews were conducted by the same person over the time span of only two months, the effect on dependability can be considered small.

The detailed description of the data gathering and processing, as well as an extensive review by the author’s supervisor, is to provide the best possible account.

A study with an identical setup cannot be repeated as the program was cancelled prior to the study, setting limits on transferability. However, the program’s measures were not unique and similar studies could be investigated with the same set of tools. The results cannot be generalised, but a detailed description and the use of the citations may give a better fundament for judging the results in different contexts.

The ethical guidelines were followed as intended in the project’s plan. The information about the participants and their parents were kept to a minimum. Since they knew each other from the parents meetings and common activities, additional details such as employment status, educational backgrounds and the sex of the children would have made it possible to identify the person. There are no concerns that any additional ethical issues arose during the execution of the study.

Conclusions

The central observations of this study are similar to previous research: an increased awareness for a healthy lifestyle and an improvement in self-esteem, self-confidence and social relations with at least temporary effects on physical activity and healthy nutrition.

Some effects were difficult to sustain mostly due to a lack of motivation after the

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program ended. The long-term effects of an intervention such as VVB are little researched. A continuation of the program and an evaluation over a longer time span may provide further insights into the prevention of obesity in teenagers and young adults.

List of abbreviations

BMI: Body-Mass Index

IsoBMI: Body-Mass Index adjusted for age VVB: Våra viktiga barn

Declarations

Ethics approval and consent to participate

As the article is only intended to be published as part of a master thesis, no ethics approval was sought after discussion with the supervisor. All participants in the study signed the written consent form in Appendix 2.

Consent for publication

The author accepts publication as a master thesis at Mid Sweden University.

Availability of data and material

In line with the ethical standards laid out in the article, the data is not publicly available for reasons of privacy.

Competing interests

There are no known conflicts of interest.

Funding

This study was entirely self-funded by the author.

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Authors' contributions

The author conducted the interviews, analysed the data and compiled the article.

Acknowledgements

The author thanks the parents who participated in this study. Further thanks to Gunilla Myhrman and Maria Ståhl provided assistance with recruitment and information. The author is grateful to Åsa Svensson for supervising the writing process. Also thanks to Kirsty Loehr who proof-read the drafts. And finally, a big thank you to my husband Fabian and my children Ebba and Linus.

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Appendix 1: Information letter to participants

Informationsbrev till studiedeltagarna

Till föräldrar som har barn som har deltagit i projektet

Våra viktiga barn med förfrågan om deltagande i intervjuundersökning.

Informationsbrev och förfrågan om medverkan i en intervjustudie, med titeln;

Föräldrars upplevelse och erfarenhet av interventionen Våra viktiga barn

Du har fått det här brevet då ditt barn har tidigare deltagit i projektet Våra viktiga barn (tidigare e12).

Under våren/sommaren 2018 planerar jag att genomföra en intervjustudie. Syftet med intervjustudien är att få kunskap om föräldrars upplevelser och erfarenheter av projektet Våra viktiga barn. Att få bättre insyn i dessa skulle underlätta att utvärdera projektets resultat. I forskningen är det ett viktigt område att utveckla projekt och åtgärder som kan minska vikten hos barn och ungdomar. Övervikt och fetma drabbar allt fler och leder till ett antal följdsjukdomar såsom hjärtproblem och hög blodtryck. För att motverka detta på bästa möjliga sättet ska det utvärderas hur befintliga projekt har fungerat. Studien genomförs inom ramen för masteruppsatsarbete inom ämnet folkhälsovetenskap vid Mittuniversitetet, Sundsvall.

Studien kommer att genomföras med individuella intervjuer under vår/sommaren 2018.

Intervjun kommer att beröra dina upplevelser och erfarenheter av projektet Våra viktiga barn. Därför är det viktigt att Du känner dig bekvämt med att prata om projektet.

Intervjun beräknas ta 40-60 minuter, det är viktigt att intervjun sker i ostörd miljö, på en tid och plats som vi kommer överens om. Intervjun kommer att spelas in med syfte att ingen information missas och för att sedan underlätta bearbetningen av intervjusvaren.

Intervjun genomförs av mig, Anita Seitz, legitimerad sjuksköterska och masterstudent inom ämnet folkhälsovetenskap vid Mittuniversitetet.

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Den information som Du lämnar kommer att behandlas säkert och förvaras inlåst så att ingen obehörig kommer att få ta del av den. Redovisningen av resultatet kommer att ske så att ingen individ kan identifieras. Resultatet kommer att presenteras i form av en muntlig och skriftlig presentation på konferenser, till andra studerande och universitetspersonal, samt i form av ett examensarbete. Materialet kommer att användas för utvärdering av projektet Våra viktiga barn, där även Gunilla Myhrman kommer att ta del av materialet. När examensarbetet är färdigt och godkänt kommer det att finnas i en databas som kallas för DIVA (Digitala Vetenskapliga Arkivet). Inspelningarna och den utskrivna texten kommer att sparas så länge studien pågår dock inte längre än 10 år. Du kommer ha möjlighet att ta del av examensarbetet genom att få en kopia av arbetet.

Samtalet kan beröra känsliga ämnen. Det är viktigt att Du kommer ihåg att deltagandet är helt frivilligt och Du kan när som helst avbryta din medverkan utan närmare motivering. Tyvärr har jag ingen möjlighet att ge ersättning för deltagandet.

Jag frågar härmed om Du vill delta i denna studie. Om du kan medverka i en intervju – kontakta mig: [kontakt]

Ansvariga för studien är Anita Seitz och handledaren Åsa Svensson. Har Du frågor om studien är Du välkommen att höra av dig till någon av oss

Anita Seitz Åsa Svensson

Student, Mittuniversitetet Handledare, Mittuniversitetet

Mail: [e-post] Mail: [e-post]

Telefonnummer: [telefon] Telefonnummer: [telefon]

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Appendix 2: Informed consent form

Informerat samtycke

Nedan ger du ditt samtycke till att delta i studien Föräldrars upplevelse och erfarenheter av projektet ”Våra viktiga barn”. Läs igenom detta noggrant och ge ditt medgivande genom att skriva under med din namnteckning längst ned.

Medgivande

• Härmed intygar jag att jag har tagit del av informationen om studien som har som syfte att undersöka föräldrars upplevelser och erfarenheter av projektet Våra viktiga barn. Jag är medveten om hur studien kommer gå till och att tiden för intervjuerna inte ersätts ekonomiskt.

• Jag har fått möjlighet att ställa frågor samt svar på mina frågor. Dessutom har jag fått information om kontaktuppgifter till vem jag kan vända mig till om fler frågor skulle uppstå.

• Jag har blivit informerad om att deltagande är helt frivilligt och att jag kan avbryta mitt deltagande när som helst under studiens gång utan att behöva förklara varför.

• Jag har fått information om att all information kommer att behandlas konfidentiellt, det vill säga avidentifieras.

• Jag ger mitt medgivande till Anita Seitz att lagra och bearbeta den information som samlades in under studiens gång och spara materialet i maximalt tio år.

• Jag ger medgivande förutsatt att det insamlade materialet endast används i samband med Anita Seitz masteruppsats, samt i utvärdering av projektet Våra viktiga barn och presentationer på konferenser.

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Appendix 3: Interview script

Intervjuguide

• Information om intervjun, konfidentialitet och samtycke.

Syftet med studien är att få kunskap om föräldrarnas upplevelser och erfarenheter av intervention Våra viktiga barn.

-Vilka upplevelse och erfarenheter har föräldrarna av projektet "Våra viktiga barn"?

-Vilken inverkan har projektens åtgärder haft på familjen livsstil?

Genom att fylla i ett samtyckesblankett ger du ditt skriftliga medgivande att

delta i studien. Deltagande är frivilligt du kan när som helst avbryta ditt deltagande Information kommer att behandlas konfidentiellt, det vill säga avidentifieras.

Inledande frågor:

- Är okej att jag spelar in intervjun?

- Kan du berätta lite kort om dig själv? (Ålder, sysselsättning)

- Hur gammal är ditt/dina barn som har deltagit i projektet Våra viktiga barn?

- Hur länge har ditt barn deltagit i Våra viktiga barn (Grundkurs/fortsättningskurs) - Har barnet något hälsoproblem, medicinisk diagnos (kroppslig/NPF), om ja vad?.

- Kan du berätta för mig vad som motiverade dig att ditt barn fick delta i Våra viktiga barn?

- Kan du berätta om dig och ditt barns övergripande erfarenhet av att vara involverad i projektet Våra viktiga barn?

Parental experience of the obesity and social exclusion intervention “Our important children”