Healthy Happy Family Eating: An investigation into the effectiveness of interventions aimed at improving family eating behaviours

Unhealthy eating in children is a widespread problem, associated with poor cognitive and physical development. Increasingly, evidence indicates that poor eating habits in children track into adulthood. Parents’ feeding practices are consistently found to predict children’s eating behaviours and many interventions have been developed to target parents as the main agents of change in family eating interventions. However, parents cite time, stress and convenience as barriers both to implementing positive feeding practices and to participating in healthy eating intervention studies. The research described in this thesis sought to investigate the effectiveness of interventions aimed at improving family eating behaviours, with a particular focus on enjoyment and stress reduction. The first paper is a comprehensive Systematic Review of family eating interventions delivered in the family home. The Review found that, in order to be effective, interventions should be robustly theory and evidence driven as well as engaging and burden-free for parents. The second paper describes the detailed development of a healthy eating intervention, the Healthy Happy Family Eating programme, which was delivered online and emphasised implementing enjoyable mealtimes. The design of a Randomised Controlled Trial is described in the subsequent three chapters. These describe measure selection and design, including the third paper which identifies the lack of and reports the design of a parental feeding goal measure; a report of the trial itself (the fourth paper) and supplementary analyses and information about the trial. Throughout these studies, attention is given to parents’ goals, motivations and engagement. Collectively, the studies indicate that future intervention studies should prioritise stress-reduction at mealtimes as well as paying careful attention to the theory and evidence base; parents’ preferences for the type of help they receive with their children’s eating should be given more attention, as well as their feeding goals and the potential conflicts between these

Tailoring persuasive health games to gamer type

Persuasive games are an effective approach for motivating health behavior, and recent years have seen an increase in games designed for changing human behaviors or attitudes. However, these games are limited in two major ways: first, they are not based on theories of what motivates healthy behavior change. This makes it difficult to evaluate why a persuasive approach works. Second, most persuasive games treat players as a monolithic group. As an attempt to resolve these weaknesses, we conducted a large-scale survey of 642 gamers' eating habits and their associated determinants of healthy behavior to understand how health behavior relates to gamer type. We developed seven different models of healthy eating behavior for the gamer types identified by BrainHex. We then explored the differences between the models and created two approaches for effective persuasive game design based on our results. The first is a one-size-fits-all approach that will motivate the majority of the population, while not demotivating any players. The second is a personalized approach that will best motivate a particular type of gamer. Finally, to make our approaches actionable in persuasive game design, we map common game mechanics to the determinants of healthy behavior

Targeting parents for childhood weight management: development of a theory-driven and user-centered healthy eating app

Background: The proliferation of health promotion apps along with mobile phones' array of features supporting health behavior change offers a new and innovative approach to childhood weight management. However, despite the critical role parents play in children's weight related behaviors, few industry-led apps aimed at childhood weight management target parents. Furthermore, industry-led apps have been shown to lack a basis in behavior change theory and evidence. Equally important remains the issue of how to maximize users' engagement with mobile health (mHealth) interventions where there is growing consensus that inputs from the commercial app industry and the target population should be an integral part of the development process. Objective: The aim of this study is to systematically design and develop a theory and evidence-driven, user-centered healthy eating app targeting parents for childhood weight management, and clearly document this for the research and app development community. Methods: The Behavior Change Wheel (BCW) framework, a theoretically-based approach for intervention development, along with a user-centered design (UCD) philosophy and collaboration with the commercial app industry, guided the development process. Current evidence, along with a series of 9 focus groups (total of 46 participants) comprised of family weight management case workers, parents with overweight and healthy weight children aged 5-11 years, and consultation with experts, provided data to inform the app development. Thematic analysis of focus groups helped to extract information related to relevant theoretical, user-centered, and technological components to underpin the design and development of the app. Results: Inputs from parents and experts working in the area of childhood weight management helped to identify the main target behavior: to help parents provide appropriate food portion sizes for their children. To achieve this target behavior, the behavioral diagnosis revealed the need for eliciting change in parents' capability, motivation, and opportunity in 10-associated Theoretical Domains Framework (TDF) domains. Of the 9 possible intervention functions, 6 were selected to bring about this change which guided the selection of 21 behavior change techniques. Parents' preferences for healthy eating app features revolved around four main themes (app features, time saving and convenience, aesthetics, and gamification) whereupon a criterion was applied to guide the selection on which preferences should be integrated into the design of the app. Collaboration with the app company helped to build on users' preferences for elements of gamification such as points, quizzes, and levels to optimize user engagement. Feedback from parents on interactive mock-ups helped to inform the final development of the prototype app. Conclusions: Here, we fully explicate a systematic approach applied in the development of a family-oriented, healthy eating health promotion app grounded in theory and evidence, and balanced with users' preferences to help maximize its engagement with the target population

What practices do parents perceive as effective or ineffective in promoting a healthy diet, physical activity, and less sitting in children : parent focus groups

Background: To support parents in improving the health of their young children, examples of effective parenting practices for a healthy diet, physical activity (PA) and sedentary behavior (SB) are needed. This study explores perceived effective and ineffective parenting practices in difficult situations concerning raising healthy children and investigates their relationship with Self-Determination Theory (SDT) and Social Cognitive Theory (SCT). The current study is formative work to inform the content of a randomized controlled trial. Methods: Four focus groups were conducted between June and October 2012 at worksites during lunch break. A total of 21 unrelated parents of primary schoolchildren (6 fathers, 15 mothers) participated. A short written questionnaire introduced typical difficult situations derived from parental anecdotal reports, concerning healthy diet, PA and SB. These situations formed the backbone for the subsequent focus group discussion. In October 2012, discussions were audio-recorded and analyzed in Nvivo to identify key response items using thematic analysis. Results: Parents experienced explaining why the child should behave healthily, monitoring, being consistent, offering alternatives, reacting empathetically, modeling, motivating, increasing intrinsic value and availability, and using time-out as effective practices, whereas anger was considered ineffective. Opinions were mixed about the effectiveness of giving as much freedom as possible, obliging, rewarding and punishing, and setting rules and agreements. Parenting practices were consistent with principles from both SDT and SCT. Conclusions: Parents identified numerous perceived effective practices to respond to their child's health-related behavior. Since many of them coincide with the evidence base and the success of a parenting program depends upon the degree to which parents' concerns and motivations are integrated into the program design, important opportunities are created for future intervention programs

The importance of parents and teachers as stakeholders in school-based healthy eating programs

Schools have a crucial role for promoting and establishing healthy behaviors early in the life-course. In recent years, a substantial effort and resources have been invested in attempts to change the 'food culture' in schools in westernized societies. Large school-based programs which promote healthy eating often utilize an ecological model for instigating behavior change amongst school children. An ecological model is a set of comprehensive intervention strategies that target a multitude of factors which influence the eating practices of children in the school setting. The cultural issues that necessitate these healthy eating programs mean that interventions are not without challenges to their application and effectiveness particularly as they rely on collaboration between stakeholders: teachers, parents, public health practitioners, policy makers and more. The stakeholder input and relations are key parts of planning, implementing and evaluating complex health promotion and education programs in schools. This commentary will outline the importance of considering both teachers and parents as influencing agents or 'enablers' in the process of creating change in this context. Parental perceptions and teachers’ insights are critical for underpinning intervention feasibility, acceptability and performance. Their perceptions and understandings can provide ground-level and highly applicable expertise and importantly motivate children in the school environment. The philosophical principles behind parent and teacher integration into formal program evaluation are discussed, providing a theoretical basis for program evaluation. Recommendations are made for policy makers, researchers and professional evaluation experts’ to consider and integrate these stakeholders in future programs

Effectiveness of a Faith-placed Cardiovascular Health Promotion Intervention for Rural Adults

Introduction: Cardiovascular disease (CVD) is the leading cause of mortality in the US. Further, rural US adults experience disproportionately high CVD prevalence and mortality compared to non-rural. Cardiovascular risk-reduction interventions for rural adults have shown short-term effectiveness, but long-term maintenance of outcomes remains a challenge. Faith organizations offer promise as collaborative partners for translating evidence-based interventions to reduce CVD. Methods: We adapted and implemented a collaborative, faith-placed, CVD risk-reduction intervention in rural Illinois. We used a quasi-experimental, pre-post design to compare changes in dietary and physical activity among participants. Intervention components included Heart Smart for Women (HSFW), an evidence-based program implemented weekly for 12 weeks followed by Heart Smart Maintenance (HSM), implemented monthly for two years. Participants engaged in HSFW only, HSM only, or both. We used regression and generalized estimating equations models to examine changes in outcomes after one year. Results: Among participants who completed both baseline and one-year surveys (n = 131), HSFW+HSM participants had significantly higher vegetable consumption (p = .007) and combined fruit/vegetable consumption (p = .01) compared to the HSM-only group at one year. We found no differences in physical activity. Conclusion: Improving and maintaining CVD-risk behaviors is a persistent challenge in rural populations. Advancing research to improve our understanding of effective translation of CVD risk-reduction interventions in rural populations is critical

Goal-directed visual attention drives health goal priming: an eye-tracking experiment

Objective: Several lab and field experiments have shown that goal priming interventions can be highly effective in promoting healthy food choices. Less is known, however, about the mechanisms by which goal priming affects food choice. This experiment tested the hypothesis that goal priming affects food choices through changes in visual attention. Specifically, it was hypothesized that priming with the dieting goal steers attention toward goal-relevant, low energy food products, which, in turn, increases the likelihood of choosing these products. Methods: In this eye-tracking experiment, 125 participants chose between high and low energy food products in a realistic online supermarket task while their eye movements were recorded with an eye-tracker. One group was primed with a health and dieting goal, a second group was exposed to a control prime, and a third group was exposed to no prime at all. Results: The health goal prime increased low energy food choices and decreased high energy food choices. Furthermore, the health goal prime resulted in proportionally longer total dwell times on low energy food products, and this effect mediated the goal priming effect on choices. Conclusions: The findings suggest that the effect of priming on consumer choice may originate from an increase in attention for prime-congruent items. This study supports the effectiveness of health goal priming interventions in promoting healthy eating and opens up directions for research on other behavioral interventions that steer attention toward healthy foods

Methods for the thematic synthesis of qualitative research in systematic reviews

<p>Abstract</p> <p>Background</p> <p>There is a growing recognition of the value of synthesising qualitative research in the evidence base in order to facilitate effective and appropriate health care. In response to this, methods for undertaking these syntheses are currently being developed. Thematic analysis is a method that is often used to analyse data in primary qualitative research. This paper reports on the use of this type of analysis in systematic reviews to bring together and integrate the findings of multiple qualitative studies.</p> <p>Methods</p> <p>We describe thematic synthesis, outline several steps for its conduct and illustrate the process and outcome of this approach using a completed review of health promotion research. Thematic synthesis has three stages: the coding of text 'line-by-line'; the development of 'descriptive themes'; and the generation of 'analytical themes'. While the development of descriptive themes remains 'close' to the primary studies, the analytical themes represent a stage of interpretation whereby the reviewers 'go beyond' the primary studies and generate new interpretive constructs, explanations or hypotheses. The use of computer software can facilitate this method of synthesis; detailed guidance is given on how this can be achieved.</p> <p>Results</p> <p>We used thematic synthesis to combine the studies of children's views and identified key themes to explore in the intervention studies. Most interventions were based in school and often combined learning about health benefits with 'hands-on' experience. The studies of children's views suggested that fruit and vegetables should be treated in different ways, and that messages should not focus on health warnings. Interventions that were in line with these suggestions tended to be more effective. Thematic synthesis enabled us to stay 'close' to the results of the primary studies, synthesising them in a transparent way, and facilitating the explicit production of new concepts and hypotheses.</p> <p>Conclusion</p> <p>We compare thematic synthesis to other methods for the synthesis of qualitative research, discussing issues of context and rigour. Thematic synthesis is presented as a tried and tested method that preserves an explicit and transparent link between conclusions and the text of primary studies; as such it preserves principles that have traditionally been important to systematic reviewing.</p

The Application of the Theory of Planned Behaviour to Diet in Carers of People with an Intellectual Disability

Background - The utility of the theory of planned behaviour (TPB) in predicting the intentions of care staff to encourage healthy eating behaviour in those they supported was examined. Method - A quantitative, within-participant, questionnaire based design was used with 112 carers to assess the performance of two TPB models. The first contained the variables: attitude, subjective norm and perceived behavioural control. The second had additional variables of self efficacy and self identity. Results - Model 1 accounted for 31% of the variance with all three variables being significant predictors. Adding variables increased the overall predictive power of the model by 4%, but resulted in a reduction in the predictive power of the individual variables. Conclusion - The results suggests the TPB is a useful model for predicting carer intentions in relation to the diet of those they support, with their perceptions of the attitudes of others towards healthy eating being a key influential factor. Ways in which this may inform interventions to improve the overall health of people with intellectual disabilities are discussed

Diet behaviour among young people in transition to adulthood (18–25 year olds) : a mixed method study

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