Organisation submitting example
Leeds Metropolitan University
Local authority/local area:
The context and rationale
The increasing prevalence of childhood obesity worldwide has been recognised as a public health priority and current data highlights that obesity often manifests in early childhood.
Evidence from international and national research shows that:
• pre-school age is a critical period for targeting interventions to address obesity-related risk factors
• targeting parents’ attitudes, beliefs, knowledge and behaviours in order to prevent childhood obesity is fundamental
• that behaviour-change interventions need to be underpinned with appropriate psychological theories of behaviour change
• generic interventions cannot be universally applied effectively across different target populations.
The HELP (Healthy Eating and Lifestyles for Parents) intervention aimed to explore the childhood obesity risk factors of diet and parental feeding behaviours in pre-school parents accessing services in Children’s Centres in Leeds. It also aimed to develop, implement and evaluate an evidence-based, sustainable intervention using appropriate theoretical underpinning and a robust planning framework to target these risk factors.
HELP targeted low-income parents of pre-school children accessing services at four Children’s Centres in Leeds. The intervention was informed by a local needs assessment of parents and staff perceived concerns and needs relating to healthy eating and child feeding practices. The emerging themes included limited knowledge about healthy eating and appropriate portion sizes, lack of cooking skills, limited sensitivity of child feeding cues of hunger and satiety.
The intervention consists of an 8 week programme (including the HELP manual) targeting parents’ nutritional knowledge and healthy feeding behaviours related to feeding their toddler.
The HELP programme aimed to:
1. Explore the views, attitudes and behaviours of staff and parents of pre-school aged children towards childhood obesity and issues around healthy eating and child feeding practices.
2. Utilise the needs assessment findings and develop and implement an intervention tailored to the parents and staffs’ needs in collaboration with selected Children’s Centres.
3. Assess the feasibility of Children’s Centres as a setting for the delivery of an obesity prevention intervention aimed at improving the diets of pre-school children.
4. Evaluate the process of implementation e.g. programme reach, acceptability, quality and whether the intervention was effective in changing knowledge, behaviour and self-efficacy of parents and centre staff.
The HELP 8 week Programme aimed:
‘to increase participants’ knowledge, skills and confidence at being able to provide a balanced diet for their child.’
• that parents offer their child a more balanced diet
• that parents develop feeding strategies and modelling of eating that promote a healthy relationship with food in their toddler.
This work was undertaken by a researcher for her PhD thesis.
An initial exploratory study was conducted in all 41 Children’s Centres (postal questionnaires to Centre Managers) across the city to assess current services offering parents dietary advice with regards to feeding their toddler.
In addition, a qualitative observation study was carried out to explore immediate environments around each Children’s Centre and the Indices of Multiple Deprivation (IMD). The findings were contextualised within the wider policy underpinning the development of Sure Start Children’s Centres (DCSF, 2009).
The results were used to develop recruitment criteria to select four Children’s Centres to participate in the pilot HELP study. Six focus groups were conducted with twenty six parents across the four Centres and four focus groups were conducted with fifteen staff in each Centre. These provided insight into staff and parents’ perceptions, attitudes and degree of knowledge and skills about healthy eating. A further seven parents were interviewed individually about their specific views, attitudes about mealtime practices and behaviours.
The findings informed the development of an 8 week programme (HELP) which targeted parents’ nutritional knowledge and healthy child feeding behaviours. The group sessions covered basic cooking and shopping skills, balanced diet, healthy snacks and appropriate parental feeding behaviours.
Each centre allocated a member of staff to recruit parents, organise the weekly sessions and co-deliver them with the researcher. The sessions were run as group sessions, allowing the sharing of ideas and peer-support. After each session weekly goals were set by the parents to implement changes within the home environment. The following week the progress of goals was assessed within the groups.
Intended measurable outcomes
A mixed methodology was used to fully capture intervention effects and chart intervention implementation.
Specifically, measures aimed to determine improvement in::
• parents’ knowledge about balanced diet, fussy eating, portion sizes and appropriate parental feeding behaviours,
• their shopping and cooking skills,
• child feeding behaviours, and
• self efficacy, perceived competence and degree of autonomous motivation at being able to provide their child with a balanced diet.
The measures (knowledge, feeding behaviour, skills and self-efficacy) were assessed at baseline, post intervention (8 weeks) and at follow-up at 6 months.
Additionally, qualitative process measures (programme acceptability, quality etc.) were assessed after each weekly session.
Evidence and evaluation - making a difference to children, young people and families
The results from this study indicated that the HELP programme had a significant effect on the toddler feeding practices of parents accessing services at Children’s Centres.
The impact of the intervention was assessed at post-programme (8 weeks).
Specifically, significant improvements were reported post-programme in parents’ self efficacy (z = -0.25, p=0.01) and perceived competence (z = -3.02, p=0.003) in giving their child a balanced diet.
Parents also felt more confident in monitoring foods eaten (z = -3.39, p = 0.001); control over routine of meals (z = -2.82, p = 0.005); creating a healthier food environment at home (z = -3.28, p = 0.001) and cooking (z = -2.530, p = 0.011).
Qualitative results post-programme showed that parents reported the following.
1. Changing their feeding behaviours. For instance, parents’ degree of monitoring and control over their child’s diet and snacking behaviours as well as their provision of a healthy food environment at home.
2. Choosing more single ingredients than composite foods during shopping to enable more cooking at home.
3. Giving their children fewer sugary drinks and swapping snacks for lower fat and sugar items.
4. The researcher and co-worker were supportive.
5. The resources were of good quality.
6. The programme was implemented consistently across the 4 Centres.
7. Enjoying attending and, once recruited, attendance was high and retention was good.
For some behaviours, 6 month follow up results indicated either parents reporting retention (e.g. confidence in cooking mean scores) or improvement (e.g. environment mean scores).
The resource manual was rated highly by the centre staff and 3 out of the 4 Centres ran the programme after the pilot stage.
The pilot study was undertaken as part of PhD studies and therefore no further input was possible after the pilot. However, the centres have remained in contact and have reported that the programme was re-run in 3 of the 4 centres and with continued use of the resource manual.
Helping others to replicate your practice
Whilst cost-effectiveness was not specifically measured, the HELP programme was designed to be sustainable.
Sustainability was addressed by:
1. Involving a member of staff in each centre who was responsible for recruitment, internal organisation and co-delivery with the researcher.
2. Making resources reproducible at low cost and providing Centres with a manual of resources and lesson plans. It was found that resources with simple messages, often in picture form, were the most effective. The resource booklet was devised complete with resources, equipment lists, lesson plans, recipes and guidance for the staff member leading the session.
3. Participants were asked to contribute a small amount of money to cover the cost of ingredients on those weeks when cooking was done.
Although the programme can be sustained due to the training in situ of the co-worker from the centre and the use of the resource manual, it is felt that the following aspects would enhance the intervention.
Tips for others
• The needs assessment stage and incorporating users’ (staff and parents’) views is essential to develop a tailored intervention.
• Involving the Children’s Centres and a staff member to help in recruitment, internal organisation and co-delivery enhances sustainability.
• Developing a resource manual facilitates delivery.
• All Centre staff need training in nutritional knowledge to ensure consistency of messages.
• Centres need to consider a whole-Centre approach to promoting the service.
• Discussion is key. Parents benefit from learning from each other and discussing issues that concerned them. (In light of this staff running courses such as HELP would benefit from training on how to run groups effectively).
• To maximize effectiveness as a behaviour change technique, goal setting needs to be taught to parents as a practical strategy.
• Assertiveness training, organisational and time management skills can be enablers in attaining the goals set by parents.
• Staff need to recognise the wider influences of the family on mealtime routines and decisions made when shopping or cooking. More time is needed on appropriate parental feeding behaviours and supporting parents as they implement these at home.
• In light of the judgmental social environment found in HELP and parents’ fear of social surveillance, Centre staff need to forge supportive relationships with parents. Considering an approach as advocated in the Family Partnership Model may be appropriate.
• Eating messages: parents would have benefited from continued reinforcement of messages presented through the HELP course and from continued support as they implement parental feeding behaviours at home.
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