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Parents' perception of health promotion: What do parents think of a healthy lifestyle in parenting and the impact of the school environment? A qualitative research in the Netherlands

Open AccessPublished:September 20, 2021DOI:https://doi.org/10.1016/j.pedn.2021.09.005

      Highlights

      • Parents are role models in children's health related behaviour.
      • Healthcare professionals experience difficulties in tackling unhealthy lifestyles of children.
      • Parents perceive health behaviour promotion as an important aspect of their parenting role.
      • Parents indicate the teacher and the school environment as key factors in developing a healthy lifestyle for their children.
      • Parents are unaware of the position of healthcare professionals in developing a healthy lifestyle of their children.

      Abstract

      Purpose

      This study aimed at gaining insight into parents' perceptions towards health behaviour in parenting and the impact of the school environment. Healthcare professionals experience barriers to discuss health behaviour in families where levels of overweight and obesity are elevated. There is a need to understand parents' perception and perceived significance of health behaviour.

      Design and methods

      Sixty-three semi-structured interviews were conducted with parents of children from three primary schools located in two different neighbourhoods in Zwolle, the Netherlands. Parents were asked to formulate their top three priority goals in parenting, additionally supplemented with 15 predetermined goals, including a health behaviour related goal. Parents ranked the goals in order of importance and gave an explanation. Finally, parents shared their opinions regarding the school environment in promoting health behaviour, according to the EnrG framework.

      Results

      In 8 out of 63 interviews, health was reported in the top three self-formulated goals. Other goals considered important were happiness and being respectful to others. When health was ranked as less important in parenting, routine of health behaviour, own beliefs and religion were given as explanations. The physical school environment and teachers were mentioned as important factors in promoting health behaviour.

      Conclusions

      Parents indicate health behaviour as a key-element in parenting, even when health behaviour is not considered as the most important priority. Practice Implications: Since school is perceived as a logical and powerful environment, healthcare professionals should collaborate with school staff to empower their own, teachers' and parents' roles to address health promotion.

      Keywords

      Introduction

      Overweight and obesity have become more common in children the last few decades (
      • Visscher T.L.S.
      • Heitmann B.L.
      • Rissanen A.
      • Lahti-Koski M.
      • Lissner L.
      A break in the obesity epidemic? Explained by biases or misinterpretation of the data?.
      ), and these increases are associated with an increased burden of various chronic diseases and disabilities (
      • Daniels S.R.
      The consequences of childhood overweight and obesity.
      ;
      • Piche M.E.
      • Poirier P.
      • Lemieux I.
      • Despres J.P.
      Overview of epidemiology and contribution of obesity and body fat distribution to cardiovascular disease: An update.
      ;
      • Wang Y.
      • Lobstein T.
      Worldwide trends in childhood overweight and obesity.
      ). Several studies focused on investigating determinants of childhood overweight and obesity, and these determinants are therefore well-known, e.g. genetic predisposition, the influence of the physical, family and social environment (
      • Albuquerque D.
      • Nóbrega C.
      • Manco L.
      • Padez C.
      The contribution of genetics and environment to obesity.
      ;
      • Monasta L.
      • Batty G.D.
      • Cattaneo A.
      • Lutje V.
      • Ronfani L.
      • Van Lenthe F.J.
      • Brug J.
      Early-life determinants of overweight and obesity: A review of systematic reviews.
      ;
      • Plachta-Danielzik S.
      • Landsberg B.
      • Johannsen M.
      • Lange D.
      • Müller M.J.
      Determinants of the prevalence and incidence of overweight in children and adolescents.
      ;
      • Qiu G.
      • Liu X.
      • Amiranti A.Y.
      • Yasini M.
      • Wu T.
      • Amer S.
      • Jia P.
      Geographic clustering and region-specific determinants of obesity in the Netherlands.
      ;
      • Short S.E.
      • Mollborn S.
      Social determinants and health behaviors: Conceptual frames and empirical advances.
      ). Based on the evidence that a large variety of individual and environmental determinants play a role in health behaviour, integrated community-based prevention programs are being developed and carried out throughout the globe (
      • Borys J.M.
      • Le Bodo Y.
      • Jebb S.A.
      • Seidell J.C.
      • Summerbell C.
      • Richard D.
      • EEN Study Group
      EPODE approach for childhood obesity prevention: Methods, progress and international development.
      ;
      • Borys J.M.
      • Richard P.
      • Ruault du Plessis H.
      • Harper P.
      • Levy E.
      Tackling health inequities and reducing obesity prevalence: The EPODE community-based approach.
      ). The essence of these community-based programs is the involvement and support of both families and professionals impacting on the various determinants of unhealthy behaviours in children (
      • Chan R.S.
      • Woo J.
      Prevention of overweight and obesity: How effective is the current public health approach.
      ;
      • Van Koperen T.M.
      • Jebb S.A.
      • Summerbell C.D.
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      • Romon M.
      • Borys J.M.
      • Seidell J.C.
      Characterizing the EPODE logic model: Unravelling the past and informing the future.
      ). At the same time, healthcare professionals are improving their strategies to prevent and manage overweight and obesity during childhood in individuals (
      • Sijben M.
      • van der Velde M.
      • van Mil E.
      • Stroo J.
      • Halberstadt J.
      Landelijk model ketenaanpak voor kinderen met overgewicht en obesitas.
      ).
      Techniques such as shared-decision-making and motivational interviewing are now widespread strategies in supporting parents and children with their weight gain prevention and weight management (
      • Borrello M.
      • Pietrabissa G.
      • Ceccarini M.
      • Manzoni G.M.
      • Castelnuovo G.
      Motivational interviewing in childhood obesity treatment.
      ;
      • Verbeken S.
      • Braet C.
      • Bosmans G.
      • Goossens L.
      Comparing decision making in average and overweight children and adolescents.
      ). Still, research on individual approaches to prevent and manage overweight and obesity revealed that parents have difficulties finding support matching their needs, and that professionals have difficulties identifying the real need and options to support prevention or managing attempts (
      • Edmunds L.D.
      Parents’ perceptions of health professionals’ responses when seeking help for their overweight children.
      ;
      • Hennessy M.
      • Heary C.
      • Laws R.
      • van Rhoon L.
      • Toomey E.
      • Wolstenholme H.
      • Byrne M.
      The effectiveness of health professional-delivered interventions during the first 1000 days to prevent overweight/obesity in children: A systematic review.
      ;
      • Lithopoulos A.
      • Liu S.
      • Rhodes R.E.
      • Naylor P.-J.
      The role of identity in parental support for physical activity and healthy eating among overweight and obese children.
      ;
      • Zabinski M.F.
      • Saelens B.E.
      • Stein R.I.
      • Hayden-Wade H.A.
      • Wilfley D.E.
      Overweight children’s barriers to and support for physical activity.
      ).
      To date, in The Netherlands, there is increased attention to further develop individual, integral approaches to prevent and manage childhood overweight and obesity. Based on a national guideline (CBO) and a standard protocol (
      • Seidell J.
      Zorgstandaard obesitas.
      ), a national strategy (C4O) has been developed to support self-management of children and parents when promoting their health behaviour (
      • Halberstadt J.
      • Sijben M.
      Summary national model integrated care for childhood overweight and obesity.
      ). A key aspect of the strategy is that Youth Health Care (YHC) professionals are involved in identifying, preventing and managing overweight and obesity in children. The YHC professionals are part of a health care community constructed in a multidisciplinary team, as well as children and families (
      • Ben-Sefer E.
      • Ben-Natan M.
      • Ehrenfeld M.
      Childhood obesity: Current literature, policy and implications for practice.
      ;
      • Stender S.R.S.
      • Burghen G.A.
      • Mallare J.T.
      The role of health care providers in the prevention of overweight and type 2 diabetes in children and adolescents.
      ). However, the YHC professional, in particular the school nurse, experience barriers when preventing overweight and obesity in daily practice in Zwolle city. In the first place, it is not easy to discuss healthy behaviour in families where overweight or obesity occur (
      • Finne E.
      • Reinehr T.
      • Schaefer A.
      • Winkel K.
      • Kolip P.
      Overweight children and adolescents – Is there a subjective need for treatment?.
      ;
      • Perez A.
      • Holt N.
      • Gokiert R.
      • Chanoine J.-P.
      • Legault L.
      • Morrison K.
      • Ball G.
      Why don’t families initiate treatment? A qualitative multicentre study investigating parents’ reasons for declining paediatric weight management.
      ). Secondly, the number of no-shows is large when children are indicated for a follow-up in the prevention of (potential) overweight (
      • Ball G.D.C.
      • Garcia A.P.
      • Chanoine J.-P.
      • Morrison K.M.
      • Legault L.
      • Sharma A.M.
      • Holt N.L.
      Should I stay or should I go? Understanding families’ decisions regarding initiating, continuing, and terminating health services for managing pediatric obesity: The protocol for a multi-center, qualitative study.
      ;
      • Skelton J.A.
      • Irby M.B.
      • Beech B.M.
      • Rhodes S.D.
      Attrition and family participation in obesity treatment programs: Clinicians’ perceptions.
      ). There are several explanations for these barriers.
      • Pocock M.
      • Trivedi D.
      • Wills W.
      • Bunn F.
      • Magnusson J.
      Parental perceptions regarding healthy behaviours for preventing overweight and obesity in young children: A systematic review of qualitative studies.
      stated that preventing overweight and/or obesity by parents in families is complex and are influenced by many factors. For example, food prices may be a barrier for parents to obtain healthy food (
      • Maillot M.
      • Darmon N.
      • Darmon M.
      • Lafay L.
      • Drewnowski A.
      Nutrient-dense food groups have high energy costs: An econometric approach to nutrient profiling.
      ), and the home environment influences the development of children's healthy lifestyle (
      • Bates C.R.
      • Buscemi J.
      • Nicholson L.M.
      • Cory M.
      • Jagpal A.
      • Bohnert A.M.
      Links between the organization of the family home environment and child obesity: A systematic review.
      ;
      • Tinsley B.J.
      How children learn to be healthy.
      ). Parents are role models for both healthy and unhealthy behaviour factors related to child's weight (
      • Golan M.
      • Crow S.J.N.
      Parents are key players in the prevention and treatment of weight-related problems.
      ;
      • Hardy L.R.
      • Harrell J.S.
      • Bell R.A.
      Overweight in children: Definitions, measurements, confounding factors, and health consequences.
      ;
      • Rodenburg G.
      • Oenema A.
      • Kremers S.P.J.
      • van de Mheen D.
      Parental and child fruit consumption in the context of general parenting, parental education and ethnic background.
      ). Additionally, parental support of healthy behaviour has a positive influence on healthy child weight and diminishes risk of overweight and obesity (
      • Campbell K.J.
      • Hesketh K.D.
      Strategies which aim to positively impact on weight, physical activity, diet and sedentary behaviours in children from zero to five years. A systematic review of the literature.
      ;
      • Rodenburg G.
      • Oenema A.
      • Kremers S.P.J.
      • van de Mheen D.
      Parental and child fruit consumption in the context of general parenting, parental education and ethnic background.
      ). Therefore, healthcare professionals should focus on parents' responsibility of healthy behaviour towards their children (
      • Stender S.R.S.
      • Burghen G.A.
      • Mallare J.T.
      The role of health care providers in the prevention of overweight and type 2 diabetes in children and adolescents.
      ).
      There is a need to investigate the role of parents in their children's parenting and child care (
      • Bates C.R.
      • Buscemi J.
      • Nicholson L.M.
      • Cory M.
      • Jagpal A.
      • Bohnert A.M.
      Links between the organization of the family home environment and child obesity: A systematic review.
      ;
      • Hahn R.A.
      • Barnett W.S.
      • Knopf J.A.
      • Truman B.I.
      • Johnson R.L.
      • Fielding J.E.
      • Community Preventive Services Task, F
      Early childhood education to promote health equity: A community guide systematic review.
      ;
      • Tinsley B.J.
      How children learn to be healthy.
      ), in parents with a low socio-economic background predominantly (
      • Lindberg L.
      • Persson M.
      • Danielsson P.
      • Hagman E.
      • Marcus C.
      Obesity in childhood, socioeconomic status, and completion of 12 or more school years: A prospective cohort study.
      ;
      • Ogden C.
      • Lamb M.
      • Carroll M.
      • Flegal K.
      Obesity and socioeconomic status in children and adolescents: United States, 2005–2008.
      ). In order to facilitate interactive discussions between professionals and parents, it is valuable to know which goals are considered to be important by parents in parenting.
      • Kremers S.P.J.
      • de Bruijn G.-J.
      • Visscher T.L.S.
      • van Mechelen W.
      • de Vries N.K.
      • Brug J.
      Environmental influences on energy balance-related behaviors: A dual-process view.
      developed the EnRG framework (Environmental Research framework for weight Gain prevention) to identify both personal and environmental determinants of energy balance-related behaviours. According to this framework, energy balance-related behaviour is indirectly and directly determined by cognitive mediators, personal behaviour moderators and environmental factors. Crucial element in the promotion of a healthy lifestyle is the children's environment, such as school (
      • Hoelscher D.M.
      • Moag-Stahlberg A.
      • Ellis K.
      • Vandewater E.A.
      • Malkani R.
      Evaluation of a student participatory, low-intensity program to improve school wellness environment and students’ eating and activity behaviors.
      ), physical and social environment (
      • Ahrens W.
      • Bammann K.
      • de Henauw S.
      • Halford J.
      • Palou A.
      • Pigeot I.
      • Siani A.
      • Sjöström M.
      Understanding and preventing childhood obesity and related disorders—IDEFICS: A European multilevel epidemiological approach.
      ), and healthcare professionals (
      • Chan R.S.
      • Woo J.
      Prevention of overweight and obesity: How effective is the current public health approach.
      ). Nevertheless, it is unclear to what extent parents consider these environments to be important in developing a healthy lifestyle in children. At the same time, personal cognitive determinants are important predictors of behaviour, e.g. attitude, perceived behavioural control and motivation (
      • Kremers S.P.J.
      • Visscher T.L.S.
      • Seidell J.C.
      • van Mechelen W.
      • Brug J.
      Cognitive determinants of energy balance-related behaviours.
      ;
      • Kremers S.P.J.
      • de Bruijn G.-J.
      • Visscher T.L.S.
      • van Mechelen W.
      • de Vries N.K.
      • Brug J.
      Environmental influences on energy balance-related behaviors: A dual-process view.
      ). Therefore, a greater understanding of parents' perception of (un)healthy behaviour in parenting and the school environment is necessary to improve the professional attention towards the prevention of overweight and obesity of children.
      The aim of the present study was to investigate parents' perception towards health behaviour in parenting and to gain insight into the perceived significance of environmental determinants at school which may influence (un)healthy behaviour of primary schoolchildren from neighbourhoods where levels of overweight and obesity are elevated (
      • De Jong E.
      • Schokker D.F.
      • Visscher T.L.
      • Seidell J.C.
      • Renders C.M.
      Behavioural and socio-demographic characteristics of Dutch neighbourhoods with high prevalence of childhood obesity.
      ). The lessons learnt from this study are meant to inform parents, healthcare professionals and schools, and enhance the scope in future developments of health-related interventions.

      Methods

      The COREQ (COnsolidated criteria for REporting Qualitative research) Checklist was used to structurally report the methods and results of this study (
      • Tong A.
      • Sainsbury P.
      • Craig J.
      Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups.
      ).

      Study design

      A qualitative approach with semi-structured interviews was used to gain insight information into parents perceptions of their role in promoting health behaviour. Data were concurrently collected and analysed in order to provide a scientific foundation for future interventions. The ENrG-framework developed by
      • Kremers S.P.J.
      • de Bruijn G.-J.
      • Visscher T.L.S.
      • van Mechelen W.
      • de Vries N.K.
      • Brug J.
      Environmental influences on energy balance-related behaviors: A dual-process view.
      was used as inspiration to study where personal and environmental perceptions regarding parenting and the role of the environment may interact.

      Recruitment and participation

      Three primary schools located in two different neighbourhoods with increased levels of childhood overweight and obesity of the city Zwolle (
      • De Jong E.
      • Schokker D.F.
      • Visscher T.L.
      • Seidell J.C.
      • Renders C.M.
      Behavioural and socio-demographic characteristics of Dutch neighbourhoods with high prevalence of childhood obesity.
      ) were invited to participate between February and September 2019, and they all agreed to participate. The neighbourhoods with an increased level of childhood overweight and obesity were by postal code derived form a larger study, from which 4000 children in the city Zwolle participated (
      • De Jong E.
      • Schokker D.F.
      • Visscher T.L.
      • Seidell J.C.
      • Renders C.M.
      Behavioural and socio-demographic characteristics of Dutch neighbourhoods with high prevalence of childhood obesity.
      ). The selection of the schools was not chosen by identity, however, the identity of the schools were divided into two public elementary schools and one Protestant-Christian school. The number of children ranged from 324 to 369 per school. Parents whose children attend these schools were invited by means of a notice in the newsletter of the school one week prior to conducting the interviews, without revealing that the main interest of the interview was health behaviour. Parents were told that the purpose of the study was to investigate what parents consider to be important in the education of children in order to inform professionals. These advanced notices consisted of the purpose of the interviews, and the presence of researchers during the day when parents have their periodical conversation with the teacher to discuss their children's progress and well-being. On the day of the interviews, the researchers TV (Male, PhD, associate professor research group Healthy Cities), IB (Female, MD, researcher research group Healthy Cities), JK (Male, MSc, researcher research group Healthy Cities) invited parents to participate in face-to-face interviews. All parents were invited to participate irrespective of overweight and/or obesity children. Health behaviour and overweight and/or obesity were not mentioned in the invitations. It is therefore unlikely that parents from children with overweight and/or obesity were preselected or excluded. The researchers were introduced to the participants as researchers of the research group Healthy Cities, Windesheim University of Applied Sciences. Prior to the study commencement, no relationship was established between the researchers and the participants.
      Approximately 1 of 4 parents refused to participate. The reasons for refusing to participate varied among participants. Reasons for refusing were: busy, children were home alone, other priorities. Three researchers conducted the interviews at the primary school and were practicing the interview in advanced, to diminish differentials in results. All researchers were trained in collecting and analysing qualitative data, within the research group Healthy Cities. The interviews took place in separate rooms, quietly and the interviews were not disturbed by others. The duration of the interviews ranged from 15 to 20 min. Confidentiality of results were promised, and informed consents were signed by the respondent and researcher. One respondent with sub-optimal Dutch language skills refused to provide written consent, however, she approved orally and participated in the entire interview. Due to the low risk characteristics of this study, no approval by a human research ethics committee has been given.

      Procedures and data collection

      The interview guide was based on previous research of
      • Baarda P.D.
      • Golombek M.
      • Veenstra A.
      Opvoedingsidealen van ouders.
      and
      • Kremers S.P.J.
      • de Bruijn G.-J.
      • Visscher T.L.S.
      • van Mechelen W.
      • de Vries N.K.
      • Brug J.
      Environmental influences on energy balance-related behaviors: A dual-process view.
      .
      • Baarda P.D.
      • Golombek M.
      • Veenstra A.
      Opvoedingsidealen van ouders.
      investigated in a quantitative study the parental ideals of parents in families.
      • Kremers S.P.J.
      • de Bruijn G.-J.
      • Visscher T.L.S.
      • van Mechelen W.
      • de Vries N.K.
      • Brug J.
      Environmental influences on energy balance-related behaviors: A dual-process view.
      developed the EnRG framework to gain insight into environmental factors which directly or indirectly influence health behaviour. Prior to the current study, the interview guide was pretested and discussed among the researchers and with two parents of primary schoolchildren, other but comparable than those participated in this study. The pre-test was preformed to demonstrate validity and was considered to be feasible for the study population. Therefore, the ideals as a result of the study of
      • Baarda P.D.
      • Golombek M.
      • Veenstra A.
      Opvoedingsidealen van ouders.
      and the EnRG framework were the underlying basis of the topics used in this study and to underwrite the individual component and the environmental context.
      The interview guide was subdivided into three parts: participants' characteristics and family composition, the priority of parental goals in parenting, and the influence of environmental factors on health behaviour of children. After identifying participants characteristics, participants were asked as an open-ended question to formulate their top three priority goals in parenting. The self-formulated goals were supplemented with 15 predetermined goals according to
      • Baarda P.D.
      • Golombek M.
      • Veenstra A.
      Opvoedingsidealen van ouders.
      including one goal related to a healthy lifestyle (Table 1). An example of a predetermined goal includes “I think it is important for my child to learn what a healthy lifestyle is” The participants were asked to rank the goals on paper in a three-column scheme: very important, less important, least important. Five goals could be placed in each column, in decreasing order of importance. Exploratory questions were asked to find discover why a goal was considered to be the first important goal in parenting. Subsequently, the link was made with a healthy lifestyle, whereby the researcher indicated the goal “I think it is important for my child to learn what a healthy lifestyle is” on the three-column scheme. Participants were asked to provide an explanation of the chosen ranking for the goal “I think it is important for my child to learn what a healthy lifestyle is”, and how health behaviour is applied in daily life.
      Table 115 pre-determined goals which were randomly submitted to the respondents.
      DutchEnglish
      Ik vind het belangrijk dat mijn kind …I think it is important that my child …
      … leert wat een gezonde leefstijl is… learns about a healthy lifestyle
      … rekening houdt met anderen… has consideration for others
      … zelfstandig leert zijn… learns to be independent
      … trots is op zichzelf… is proud of themselves
      … leert omgaan met tegenslagen… learns to handle setbacks
      … om kan gaan met geld… learns to handle money
      … leergierig en nieuwsgierig is… is inquisitive and curious
      … zichzelf kan vermaken… is able to enjoy themselves
      … voor zichzelf op leert komen… learns to stand up for itself
      … leert omgaan met vaste tijden en een dagritme… learns how to deal with fixed times and a day rhythm
      … goede resultaten behaald op school… achieves good results at school
      … zich verantwoordelijk voelt voor de dingen die hij/zij doet… feels responsible for the things he / she does
      … gebruik maakt van zijn/haar fantasie en creativiteit… makes use of his / her imagination and creativity
      … goede manieren heeft… has good manners
      … gehoorzaam is… is obedient
      The last part of the interview guide focused on healthy behaviour in family as well as school setting, to identify the importance of school environmental determinants in developing a healthy lifestyle of children. The questions with regard to the school environment consisted of statements, in which the participant could indicate to what extent he or she agreed: strongly agree, agree, neutral, disagree, strongly disagree (E.g. “The teacher has an important role in the development of a healthy lifestyle of your child”). An explanation of the choice was requested. In addition, statements were also presented about the role of the physical school environment, the availability of fruit served at school and the role the school nurse and the general practitioner (GP), i.e. the healthcare professionals. Additional quotations were recorded in the interview guide by taking written field notes during the interview. Audio or visual recording were not been carried out. Data saturation was discussed per school cluster among the researchers TV, IB and JK. Researchers agree upon a high level of saturation since the last few interviews per school did not provide more arguments to the data, and most arguments had been discussed by parents from all three schools. No repeated interviews have been carried out and transcripts were not returned to participants.

      Data analysis

      Data from the interview guide was analysed in a systematic way according to the thematic analysis approach, which aimed at identifying the retuning predefined themes (
      • Braun V.
      • Clarke V.
      Using thematic analysis in psychology.
      ). The predefined themes were used as starting point in the analysis: top three parenting goals, the priority of a healthy lifestyle in parenting, and the role of environmental factors in supporting a healthy lifestyle in parenting. First, themes mentioned in parents' top three goals in parenting were open coded and labelled (JK) to identify reoccurring themes. Second, selective coding was performed to establish healthy lifestyle related goals in parenting and were, based on parents' top 15, divided into three categories. The categories were labelled as: very important when a healthy lifestyle was categorized by parents in the top five, less important when categorized from 6 to 10, and least important when categorized from 11 to 15. Third, explanatory quotes and fieldnotes given by participants were added to these categories. Finally, an abstract of the interviews was sent to the newspaper of the schools and participants were invited to provide feedback on the results afterwards. The explanatory quotes and fieldnotes were checked during the interview. No participant had additional comments or quotes to the abstract of the interviews. Coding was checked independently by two researchers (TV, IB). Consensus was reached among the researchers.
      Qualitative data was inductively analysed with Excel. Demographic variables age, gender, ethnicity, education and family composition acquired from the interview guide were analysed with SPSS (version 25, IBM, New York, United States). According to
      • Lincoln Y.S.
      Naturalistic inquiry.
      , sample size was guided by the criteria of informational redundancy. Data saturation was discussed among the researchers and no new information was elicited by sampling more respondents.

      Results

      Participants characteristics and family composition

      A total of 63 semi-structured interviews were conducted with parents of primary schoolchildren. A total of 35 interviews were conducted with the mother only, 13 with only the father and 15 with both parents. The mean age of participating mothers and fathers was 37 and 39 years, respectively. All participating families had together 148 children, with an average of 2.3 child(ren) per family (minimum 1, maximum 5). Boys and girls were approximately equally divided (n = 70; 47% versus n = 78; 53%). The mean age of the children in families varied between 4 months and 25 years (average: 7.7 years). Table 2 provides an overview of the sociodemographic characteristics.
      Table 2Overview of the sociodemographic characteristics.
      VariablesSpecification
      Respondents (Parents)Father n (%)13 (21%)
      Mother n (%)35 (55%)
      Father and mother n (%)15 (24%)
      Father (n = 28)Mother (n = 50)
      Age (mean ± SD)39.3 ± 6.236.9 ± 6.9
      EthnicityWestern2341
      Non-western02
      Dual nationality57
      EducationPrimary school15
      Secondary school914
      Pre-vocational education34
      Higher professional education / university education1526
      Other01
      WorkweekParttime2232
      Fulltime68
      Non010
      Children's characteristicsBoys n (%)70 (47%)
      Girls n (%)78 (53%)
      Age (mean ± SD)7.8 ± 3.9
      Family characteristicsMarried / cohabiting40 (64%)
      Separated / divorced12 (19%)
      Other11 (17%)

      Themes

      In line with the study aim, parents' perception towards health behaviour promotion in parenting are presented first by describing the top three parenting goals and second to identify the importance of health behaviour in parenting. Finally, parents' perception of environmental determinants at school which influences a healthy lifestyle of children are presented.

      Top three self-mentioned parenting goals

      When parents were asked to report their top three priorities in parenting, most often mentioned goals were feeling happy, being healthy, being respectful to others, being proud of himself, and I think it is important for my child to participate in the society. In 8 of the 63 interviews (13%) healthy behaviour was mentioned in the top three self-formulated goals. In these 8 cases, parents reported that health has an important role in their family, varied from physically to mental health, having a steady day and night rhythm, participating in sports activities and having balanced healthy diet.‘My child needs to be healthy and fit. Goes to bed on time, participate in sports, doesn't eat too much candies and eats fruits.’(Mother, 103)
      Happiness’ (n = 16; 25%) and ‘Being respectful to others’ (n = 6; 10%) were mentioned as the most important goals in parenting, respectively. One respondent mentioned that happiness can be identified as a tenet of having a healthy life, which includes everything that a child needs in parenting. Besides that, being respectful to others was mentioned as a key element in parenting as well, since children need to know their position as compared to others in the society.Happiness: ‘I think it is important that my child is happy, that is the basis for everything. It is a summary of everything if the child is happy.’(Mother, 318)Respectful: ‘Our child must know that we are the father, mother, teacher and sir. He must be aware of this.’(Both, 201)

      The priority of a healthy lifestyle in parenting

      Since parents were asked to rank the self-reported goals in combination with the preselected goals in a three column scheme, the goal “I think it is important for my child to learn what a healthy lifestyle is.” was categorized in the column ‘most important’ 15 times (24%), and 4 times in the top of the column (6%). For example, parents who mentioned a healthy lifestyle as most important goal in parenting, which can be seen as a principle foundation, was explained as follows:‘As a family, we think everything is important. Being able to stand up for yourself is also being proud of yourself. It is all related to each other. Being healthy is really the most important thing, that is the basis, everything is connected with each other.’(Both, 306)
      The presence of chronic diseases related to a unhealthy lifestyle in the family is a reason for parents to prioritize and indicate a healthy lifestyle as an important factor in parenting of their children, evidenced by the following explanation of a parent who categorized a healthy lifestyle in the column ‘most important’:‘After becoming a mother, you have noticed how important it is to be healthy, for example healthy food, if you eat healthy you also feel much better. There is diabetes mellitus (DM) in both families, partner already has DM, so healthy living and healthy food are extra important to give to the children.’(Mother, 103)
      Parents (n = 2; 3%) who have any experience with chronic diseases in their family, were more likely to identify a healthy lifestyle in parenting as important.
      In 32 of the 63 interviews (51%), parents categorized healthy lifestyle as less important in parenting and gave different explanations of these categorization. In general, parents indicated health-related behaviour as a routine in parenting, or as a base of their religion and own beliefs. Additionally, parents mentioned that children are too young to focus on healthy lifestyle.‘You will learn to live a healthy lifestyle when you get older. I think that a child nowadays has to learn to be independent is more important than focusing on a healthy lifestyle. A healthy lifestyle comes more naturally, more automatically. This is also educated to the children at school.’(Mother, 101)‘Eating healthy is part of our (Christian) religion. Start your day with a very good breakfast, in the evening we eat less, no alcohol. We do not exaggerate, we search for a good balance.’(Mother, 205)
      Parents experienced difficulties in dealing with social pressure and influence with regard to a healthy lifestyle and personal preferences of parents has an influence on parenting. A single parent mentioned the preference of a certain lifestyle which is not dependent on others, but it is his own personal preferences in parenting.‘Health is important but nowadays there is enormous pressure. You can't give children anything. As a parent, you must be able to decide in your own parenting style.’(Mother, 329)‘[…] Being loyal to your own system. Our ancestors were completely carnivorous. Parents should immerse themselves there.’(Father, 216)

      The role of the school environment in supporting a healthy lifestyle in parenting

      Almost all participants indicated the environment as an important factor in supporting a healthy lifestyle of children, i.e. school and parents. In addition, the government and sport canteens are indicated as important stakeholders as well, to create a healthy environment for children. To understand parents' perceptions towards environmental factors related to a healthy lifestyle at school, parents were presented with several statements. These statements consisted of the role of the elementary school teacher, the role of the physical school environment, the role of served fruit at school and the role of the school nurse and the GP, i.e. the healthcare professional.
      The elementary school teacher was indicated by parents (n = 42; 67%) as an important role model in developing a healthy lifestyle of their children.‘The teacher sees my child every day. They take a lot from the teacher, they are role models’(Mother, 311)
      Despite these positive quotes, the reverse side indicate that the responsibility of supporting a health behaviour in parenting falls to parents.‘[…] Of course, the teacher does have a signalling role when children behave unhealthy, but the parents have the first responsible in supporting a healthy lifestyle.’(Mother, 318)
      Almost all parents (n = 55; 87%) considered the physical school environment as an important factor in challenging children to exercise.‘[…] The schoolyard must be sufficiently challenging to be able to play and sufficient playground equipment must be offered, such as bicycles.’(Father, 102)
      On the other hand, few parents who disagree with this statement indicated that the time of playing outside is too short and may not have a distinctive capability between children who behave healthily or not.‘The school environment is not relevant. They can play outside, it's healthy, but they only play for one hour.’(Mother, 318)‘[…] if you are healthy, you start exercising more. Playground equipment does not have a distinctive character between unhealthy and healthy children.’(Father, 216)
      A total of 54 parents (86%) think that fruit served at school contributes positively to the healthy lifestyle of children. Children are introduced to different variations of fruits.‘That free fruit is served at school is great! It has several reasons: First, unhealthy things are cheaper than fruit. Second, the child is introduced to different kind of fruit, other than home. A third reason is that free fruits at school is an advantage for lower income families. Finally, it works as a group pressure, absolutely: the child in the environment eats fruit, then the rest will also eat fruit. You have a conversation about fruit at school.’(Mother, 305)
      Slightly less than 10% of the parents (n = 6) do not agree with this statement, due to the fact that they give fruit themselves in their children's lunchbox.‘You can better use your subsidy money in a different way. If it is free, the children will not learn from it. Give the responsibility to your child: ‘You can make your own choices, it is your own body. Even when brushing your teeth.’(Mother, 205)
      More than half of the parents (n = 33; 52%) who were interviewed disagree with the statement that a healthcare professional, e.g. school nurses and GPs, has an important role in developing a healthy lifestyle of children. For example:‘We never see them. We don't know what they do. It is childish how they communicate. Patronizing. It does not meet the needs and wishes of the parents.’(Both, 327)
      Some parents only think that a nurse should act if there is something problematic with their child or children.‘Only when something is wrong, you go to the nurse. If you want to encourage healthy behaviour through the nurse, then something must be wrong in the first place.’(Both, 308)
      One of the parents was delighted that a nurse was present at school one time, to identify and detect overweight in her own child.‘[…] the school nurse is able to give advice about physical activity, they are able to identify a child's physical condition. This can be important for especially our children.’(Father, 331)

      Discussion

      To our best knowledge, this is the first study focusing on parents' perception of health behaviour promotion in parenting of Dutch primary schoolchildren. The results indicate that parents perceive health behaviour promotion as an important aspect of their parenting role. However, health promotion is not equally identified as a priority in parenting. Families where health behaviour is not literally identified as a primary goal in parenting, indicate that health behaviour is a routine in daily life. However, taking health behaviour into account as a daily routine does not mean that it has a prominent role in parenting.
      Parents indicated to have expectations of school- and healthcare professionals, although health care professionals' roles are not clear for most parents, while the majority of parents mentioned that school professionals have an important contributing role in discussing health behaviour with children and in health promotion in general. This is in line with previous research, which suggests a positive relationship between families and healthcare professionals, despite difficulties in discussing overweight and obesity related issues experienced by healthcare professionals (
      • Farnesi B.C.
      • Ball G.D.C.
      • Newton A.S.
      Family–health professional relations in pediatric weight management: An integrative review.
      ).
      The teacher and the school environment were mentioned by parents as important key factors in developing a healthy lifestyle for children. This is in line with the Dutch educational policy, since the Dutch education system, the National Institute for Public Health and the Environment (Dutch: RIVM) and social organizations have a joint responsibility in developing programs stimulating to educate health, signalling health problems, designing the physical environment (e.g. the schoolyard) as well as integrating policy regarding health promotion in the school system (). Additionally, previous research has shown that parents and school staff have a key role in pre-vocational school-based health promotions (
      • Ridder M.A.M.
      • Visscher T.L.S.
      • Hirasing R.A.
      • Seidell J.C.
      • Renders C.M.
      Dutch teachers and parents about overweight prevention in pre-vocational schools.
      ), due to their pedagogical responsibility. According to the parents participating in this study, teachers have an important contributing role in discussing health behaviour with children. These findings are in line with previous research of
      • Snelling A.
      • Ernst J.
      • Irvine Belson S.
      Teachers as role models in solving childhood obesity.
      , suggesting that a teacher is a role model to positively impact students' health outcomes. However, teachers need professional education to effectively provide health education and well-being in their classroom (
      • Snelling A.
      • Ernst J.
      • Irvine Belson S.
      Teachers as role models in solving childhood obesity.
      ). To conclude, both teachers and parents have a shared responsibility to actively pay attention to healthy lifestyle of children.
      A few parents who participated in the study believed that a healthcare professional (e.g. school nurses and GPs) could play a signalling role in identifying overweight in primary schoolchildren. This is in line with previous research of
      • Schalkwijk A.A.
      • Bot S.D.
      • de Vries L.
      • Westerman M.J.
      • Nijpels G.
      • Elders P.J.
      Perspectives of obese children and their parents on lifestyle behavior change: A qualitative study.
      . However, the parents in our study also indicated that it is unclear what school nurses and GPs' proceedings are. These healthcare professionals are not seen as the key stakeholders to promote health behaviour successfully in parenting. Thus, promoting health behaviour through healthcare professionals is complex. A similar conclusion was reached by
      • Farnesi B.C.
      • Ball G.D.C.
      • Newton A.S.
      Family–health professional relations in pediatric weight management: An integrative review.
      , a systematic review indicating difficulties in making health behaviour negotiable between health professionals and parents. Additionally, parents are unaware of the position of healthcare professionals promoting healthy lifestyles of their children. Parents mentioned not being aware of the school nurses' activities and, according to these parents, they do not see a healthcare professional very often. A number of parents have never seen a school nurse. In order to create a more comprehensive role for healthcare professionals, the study of
      • Philips N.
      • Sioen I.
      • Michels N.
      • Sleddens E.
      • De Henauw S.
      The influence of parenting style on health related behavior of children: Findings from the ChiBS study.
      suggest that healthcare professionals should positively encourage parents in applying more structure and behaviour control in parenting. Therefore, school nurses should make clear what kind of role they could have in parenting for instance providing information to parents about healthy lifestyle and should actively inform parents about their occupation.
      The objectively measured ranking of prioritizing healthy lifestyle is a key strength of this study. Participants were blinded for the main topic of this study, addressing the priority of healthy lifestyle in comparison to other goals in daily life, to avoid socially desirable answers in ranking the goals. Another strength of this study is the high participation rate (approximately 75%) of participants, those who have been collected from three (100% participation rate) different primary schools in Zwolle city. Further data collection was not necessary when all researchers indicated data saturation. Therefore, data can be generalized to a broader perspective of primary schools in the Netherlands.
      To understand both the personal and environmental perceptions regarding parenting, the ENrG framework was used for inspiration (
      • Kremers S.P.J.
      • de Bruijn G.-J.
      • Visscher T.L.S.
      • van Mechelen W.
      • de Vries N.K.
      • Brug J.
      Environmental influences on energy balance-related behaviors: A dual-process view.
      ). Keeping the ENrG framework in mind, the interviews have revealed that personal perceptions regarding parenting and perceptions regarding the environment are both valuable topics to discuss when supporting parents in their health promotion efforts towards children. However, further work is certainly required to disentangle how these perceptions regarding personal and environmental determinants interact.

      Practice implications

      Further research is necessary to gain insight into the thoughts of parents related to health behaviour as a self-evident part of parenting and child education in daily life. Parents mentioned health behaviour as an element in daily upbringing of their children. However, we experienced difficulties among parents making entirely clear what this means to them. With respect to the children, healthcare professionals should verbally pay attention and invest in a proper patient caregiver relationship, to inform and create a better understanding of healthy behaviour (
      • Stuij M.
      • van Maarschalkerweerd P.E.A.
      • Seidell J.C.
      • Halberstadt J.
      • Dedding C.
      Youth perspectives on weight-related words used by healthcare professionals: A qualitative study.
      ). A reasonable approach to tackle these issues could be to give healthcare professionals the opportunity to discuss the goals in parenting. Although conducted with Dutch parents, these findings could have implications for actions in other societies as well.

      Limitations

      In a single case, it seemed that parents responded in a socially desired manner when the researchers asked to explain the role of health behaviour in parenting. The response given by participants in this case could have been checked among children and teachers, and may have resulted in more valid data. We did not choose to do so in order to prevent issues regarding confidentiality. Hence, the results in our study are valuable input for future focus group interviews to discuss health behaviour, in which parents, children as well as teachers should participate. Moreover, in daily practice, healthcare professionals should focus on parents, teachers and children, to interactively discuss health behaviour.
      We did not explicitly focus on the social background of the parents associated with health behaviour in advance, but the participating primary schools were located in low SES neighbourhoods in Zwolle. However, the relatively high educational level of parents suggest a relatively high socio-economic background of participating respondents. Further research and prevention actions should make more effort to approach low SES parents to gain insight into the health inequalities between low and high SES parents. Adding a demographic item on education would therefore be helpful.

      Conclusions

      The results of the present study showed the parental perception towards health behaviour in families of Dutch primary schoolchildren. Even in case parents do not indicate health behaviour as a priority in parenting, they mentioned health behaviour as a self-evident key element in daily life. The majority of parents attribute an important role to school for health promoting activities. And, we found indication that healthcare professionals, i.e. the school nurse and the GP, have a need to improve their role in health promotion in collaboration with school staff and based on a better understanding of underlying thoughts of parents and school staff regarding health behaviour.

      Data availability statement

      The authors confirm that the data supporting the findings of this study are available within the article. The interview guide and explanatory notes are available from the corresponding author on reasonable request.

      Funding statement

      This study received no external funding.

      Ethics approval statement

      Ethics approval was not required for this study.

      Participant consent statement

      Participating parents signed an informed consent. One participant approved orally, due to sub-optimal language skills.

      Permission to reproduce material from other sources

      No permission to reproduce material from other sources was necessary.

      Declaration of Competing Interest

      No potential conflict of interest was reported by the authors.

      Acknowledgments

      We are sincerely thankful to the parents and schools for their participation in this study.

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