Parent experiences of empowerment: Understanding the role of parent empowerment in child health promotion

Abstract

Background:

Establishing healthy behaviors during a child’s first five years is essential for healthy growth. Parents are targeted as agents of change because they serve as primary models of behavior during this period. Although parent-focused interventions often target empowerment as a driver of change, our understanding of how parents experience the process of empowerment in the context of child health promotion remains limited.

Objective:

This qualitative study explored the process by which parents gain empowerment through participation in a health promotion intervention.

Methods:

Semi-structured interviews were conducted with 37 low-income parents who participated in Parents Connect for Healthy Living (PConnect), a 10-week empowerment-centered obesity prevention intervention. Data were analyzed using inductive-deductive thematic analysis and guided by empowerment theories.

Results:

Most parents were Hispanic/Latino (41%) and female (97%). Five themes emerged that correspond to the process by which parents gained empowerment: 1) friendships formed and relationships strengthened during PConnect, 2) parents strengthened relationships with their children and believed in their ability to parent successfully, 3) the experience of knowledge led to behavior change, 4) parents used new resources to improve family health, and 5) parents took action.

Conclusion:

Empowerment theory should be a component of health promotion programs.

Introduction

A child’s first five years¹ critically shapes their long-term growth,² development,³ and chronic disease risk.¹ During this period, parents serve as principal models of health behaviors,⁴ including, but not limited to, behaviors related to diet,⁵ physical activity,⁶ and sleep.⁷ For this reason, the most effective interventions targeting early childhood health promotion center around parents as agents of change.⁸

Within the context of parent- and larger family-centric interventions, one hypothesized driver of behavior change is that of parent empowerment,⁹ or the process wherein parents recognize control over their life situation and enact changes to promote a healthy lifestyle.^9–13 This empowerment process, conceptually grounded in Zimmerman and Christens’ Psychological Empowerment Theory,^14,15 encompasses four key components: emotional, relational, cognitive, and behavioral empowerment. In the context of child health promotion, emotional empowerment pertains to a parent’s self-perceived ability to affect change in their specific circumstance. Relational empowerment is embodied through the practice of leveraging relationships central to child health promotion. Cognitive empowerment pertains to the skills and knowledge informing health promotion behaviors and practices. Finally, behavioral empowerment comprises actions taken to promote child health. In this way, parent empowerment represents the key intersection of three well-documented positive parenting domains, including self-efficacy in child health promotion,¹⁶ knowledge about child health,^17,18 and actions taken to promote child health.^19,20 As such, it is unsurprising that the process of parental empowerment is associated with the reported adoption of healthier parenting practices²¹ critical to the development of healthy behaviors and outcomes in early childhood.

Despite mounting evidence that empowerment may be an effective mechanism of change in health promotion interventions,^22–24 our understanding of how parents experience the process of empowerment through engagement in health promotion interventions remains limited. Qualitative studies would provide the richest picture of parents’ experiences with the empowerment process in child health promotion, thereby critically informing intervention design, implementation, and evaluation design. Responding to this gap in the literature, we interviewed diverse participants of an intensive 10-session empowerment-centered parenting program (Parents Connect for Healthy Living or PConnect) implemented in Head Start, a federally funded free preschool program for low-income families in the United States. In doing so, we aimed to document and characterize the process by which parents experienced empowerment over time and assess the degree to which these experiences align with the intervention’s hypothesized theory of change (Figure 1), informed by empowerment theories^14,15,25 and the Family Ecological Model.¹⁰

Figure 1.

Communities for Healthy Living (CHL) Theory of Change²¹

Methods

Positionality Statements

We recognize that the research team’s life histories and positionalities influence all aspects of this study, including questions in the interview guide, data synthesis, and interpretation of results. To bring transparency to our work, we have chosen to outline the positionalities of the first and senior authors on this study (NG and KD) in addition to providing a brief overview of the individuals who collected the data. NG identifies has non-Hispanic White, is a native English speaker, and is a mother to two young children. NG is a doctoral candidate at Boston College, a Jesuit University, whose research focuses on improving children’s health within the context of their family. Prior to enrolling in the doctoral program, NG spent 5 years working as a medical social worker with children with chronic illnesses and their families. KD identifies as non-Hispanic White, is a native speaker of English, and is the mother of two young adult men. She is a professor and Dean of Research at Boston College. Originally from New Zealand, KD completed her PhD in human development and family studies in the United States. KD’s research over the past 20 years has focused on family-centered approaches to childhood obesity prevention in low-income communities.

Six interviewers collected data, four of which identified as non-Hispanic White, one non-Hispanic Asian, and one Hispanic/Latino. Two of the interviewers were parents. The majority of interviewers and participants were concordant in language. That is with the exception of two interviewers who collected data in their non-native language (i.e., Spanish).

Setting and Sample

PConnect is a 10-session parenting program designed by Head Start parents, for Head Start parents to improve parent and child health through empowerment. PConnect is a component of a larger childhood obesity prevention and family health promotion intervention, Communities for Healthy Living (CHL), that was implemented in Head Start programs (n = 16) in the greater Boston area from 2018–2021. PConnect was developed using community-based participatory research (CBPR) methods and aims to improve parent and child outcomes through parent empowerment.²⁶ The theory of change (Figure 1) hypothesizes that parent empowerment will lead to positive parenting practices and parent health behaviors and, in turn, improve child health outcomes.

PConnect sessions covered a variety of health-related topics, including child diet and physical activity, parental advocacy, and healthy family relationships. PConnect sessions were co-led by a Head Start parent and staff member in English, Spanish, or Chinese. Table 1 illustrates how PConnect session objectives and activities were designed to build knowledge, self-efficacy, and interpersonal skills. Each session followed the same basic structure: introduce the knowledge base for a given topic, engage in group activities and discussions to make the topic salient, and develop a plan to take action. By participating in PConnect, parents expanded their social networks, learned how to leverage relationships and community resources to promote family health.

Table 1:

PConnect sessions are informed by empowerment theories

Empowerment subdomain	PConnect session objectives	PConnect activity examples
Expansion of social networks	All sessions 1. Shared meala and group discussion to strengthen community. Session 7: Healthy Family Relationships 1. Identify healthy and unhealthy characteristics of family relationships. 2. Use communication strategies to resolve conflict with my child’s other caregivers 3. Incorporate healthy communication practices into daily life. Session 8: Neighborhoods and Social Networks 1. Define social network and identify my own. 2. Explain how social networks can be used to improve the health of children, parents, and families. Session 10: Graduation 1. Express gratitude for one another and the people who have supported me through PConnect.	All sessions 1. Parent Expert: Share and discuss parenting strategies to improve child health. Session 7: Healthy Family Relationships 1. My Family RelationSHIP: Share ideas about what makes relationships healthy. 2. Parenting Styles: Identify personal parenting styles and conflicts that arise between caregivers. Session 8: Neighborhoods and Social Networks 1. Social Networks for Health: Identify my social network and learn how it can be used to make my community healthier. 2. Committing to Leadership: Make a plan to promote healthy families in our communities. Session 10: Graduation 1. Graduation Ceremony: Receive a certificate and give thanks to those who supported me during PConnect.
Parenting efficacy	Session 2: Nutrition and Physical Activity 1. Name at least three strategies I plan to use to help my children and family with nutrition and physical activity. Session 3: Sleep and Screen Time 1. Name at least three strategies I plan to use to improve my child’s sleep and reduce their screen time. Session 5: Child Personality 1. Identify and use parenting strategies specific to my child’s personality. 2. Use positive guidance as a general parenting start for all child personalities. Session 6: Mindfulness 1. Identify ways to incorporate stress management techniques, including mindfulness, into daily life.	Session 2: Nutrition and Physical Activity 1. Parent experts: Share and discuss parenting strategies to make sure Head Start kids are eating healthy, avoiding sugary drinks, and being active. Discuss which habits are most important to their family and acknowledge how difficult it can be to enforce healthy habits. 2. Healthy Habit Station: Get hands-on experience to promote healthy nutrition and physical activity at home. Session 3: Sleep and Screen Time 1. Parent expert: Share and discuss parenting strategies to make sure Head Start kids are sleeping well and limiting screen time. Discuss which habits are most important to their family and acknowledge how difficult it can be to enforce healthy habits. 2. Creating a sleep and screen time plan: Create a plan to improve my child’s sleep ad screen habits. Session 5: Child Personality 1. Parenting toward the Big Goal: Identify parenting strategies to achieve my Big Goal that are specific to my child’s personality. 2. Positive Guidance: Learn about and plan to use positive guidance strategies. Session 6: Mindfulness 1. Stress Management and Mindfulness: Share stress management strategies and learn about mindfulness. 2. Practicing Mindfulness: Practice mindfulness exercises.
Resource Mobilization	Session 2: Nutrition and Physical Activity 1. Use resource sheets to learn about available resources. Session 3: Sleep and Screen Time 1. Use resource sheets to learn about available resources. Session 4: Goal Setting and Supporting Resources 1. Use the CHL Neighborhood Resources Map and HelpSteps.com to identify local resources. 2. Add new resources to the CHL Neighborhood Resources Map. Session 8: Neighborhoods and Social Networks 1. Describe the positive and negative effects of my neighborhood on my family’s health.	Session 2: Nutrition and Physical Activity 1. Learn about resources specific to Head Start or in the surrounding community to promote nutrition and physical activity. Session 3: Sleep and Screen Time 1. Learn about resources specific to Head Start or in the surrounding community to promote healthy sleep and screen time habits Session 4: Goal Setting and Supporting Resources 1. Learn how to identify community resources for the Healthy Habits using the CHL Neighborhood Resources Map. 2. Learn how to identify resources using HelpSteps.com. Session 8: Neighborhoods and Social Networks 1. Learn about resources in my local community.
Behavioral empowerment/advocacy	Session 9: Parent Advocacy 1. Name the steps required to advocate for something I care about. 2. Use the advocacy steps and effective communication strategies to advocate for my child. Session 10: Graduation 1. Describe new health goals for families to pursue.	Session 9: Parent Advocacy 1. Learn the definition of advocacy and see an example of a parent using the five advocacy steps to work on an issue in their neighborhood. 2. Advocacy at School: Discuss an example of a parent using the five advocacy steps to help her child in Head Start. 3. Advocacy at the doctor’s office: Create a plan to advocate for my child at the doctor’s office. Session 10: Graduation 1. Reflect on the knowledge built and consider how I will carry what I learned into the future. Discuss how I can be a health champion in my community.
Critical Awareness	Session 1: Welcome and Health Connections 1. Introduction to the socioecological model. Session 5: Child Personality 1. Identify and use parenting strategies specific to my child’s personality. 2. Use positive guidance as a general parenting strategy for all child personalities. Session 6: Mindfulness 1. Explain the importance of self-care in my own life. Session 8: Neighborhoods and Social Networks 1. Describe the positive and negative effects of my neighborhood on my family’s health. 2. Know how to make healthy changes in my neighborhood by getting involved.	Session 1: Welcome and Health Connections 1. Think about how external factors can impact family health. Discuss how this framing removes personal blame. Session 5: Child Personality 1. Identify parenting strategies to help achieve my PConnect Big Goal that are specific to my child’s personality. Session 6: Mindfulness 1. Acknowledging Our Stress: Discuss the health effects of stress. Session 8: Neighborhoods and Social Networks 1. Welcome to the Neighborhood: Identify the positive and negative effects that neighborhoods have on health. 2. Introduction to Community Involvement: Learn about government and other ways to get involved in the community.

^a.The shared meal occurred in the in-person sessions only.

PConnect was implemented as an in-person program in the spring of 2018 and 2019; due to the COVID-19 pandemic, CHL research staff adapted and implemented PConnect for a virtual setting in the 2020–2021 school year. All primary caregivers (herein described as “parents”) of children enrolled in Head Start intervention sites were eligible to participate in PConnect. Over three implementation years, 136 parents participated in PConnect, 78 in-person and 58 virtually.

Data Collection

All parents who attended sessions 8, 9, or 10 of PConnect in the spring of 2019 or 2021 were verbally invited to participate in a semi-structured interview. Parents were recruited toward the end of the program so they could adequately speak to their experiences in PConnect. Informed by empowerment theories^15,25 and the theory of change,²⁶ the interview guide included questions regarding what was valuable and challenging about participants’ experiences in PConnect, the behavior changes they focused on, reasons behind their selection, behavior change strategies that worked and did not work and how the diverse backgrounds of the parents attending the group affected their experience. While the interview guide remained nearly identical across the two years, small changes were made to the guide in 2021 to accommodate the virtual setting.

Prior to scheduling the interview, parents received an information sheet outlining the study and gave verbal consent at the start of the interview. Interviews were conducted face-to-face (in person n = 1; virtual n = 0), over the phone (in person n = 15; virtual n = 0), or over Zoom (in person n = 0; virtual n = 21), and were audio-recorded. Participants were provided with a $20 gift card to compensate them for their time. Our university’s Institutional Review Board approved all procedures.

Data Analysis

All interviews were transcribed verbatim and translated into English where necessary using a professional online transcription and translation service.²⁷ A codebook was created a priori based on empowerment theories^15,25 and the interview guide. The codebook provided operational definitions of each of the sub-constructs of empowerment outlined in the theory of change, examples of what to include and exclude, and relevant interview guide questions. Two authors (NG and EG) coded the interviews using NVivo version 11 and inductive-deductive thematic analysis²⁸ following comprehensive training by an expert in qualitative methods (RB). The applicability of the codebook to the data was tested by having the two research assistants code two interview transcripts using the codebook; one transcript from 2019 and one from 2021. The two coders then met in person to qualitatively compare results. Based on the discussion, the codebook was revised, and codes re-defined. After a second iteration of this process, no modifications were made and the codebook was finalized. The two coders then independently coded nine additional transcripts and compared results; the Kappa Coefficient for these transcripts was 0.93. One coder (NG) then coded the remaining 24 transcripts while the second coder reviewed the coding of these transcripts and discrepancies were discussed and resolved. After the initial coding process was complete, the codes with numerous references were broken down into smaller subcodes based on empowerment theories^15,25 and iterative reading of the transcripts. NG broke the coded text into smaller coding groups and a third member of the research team (AA) reviewed the re-coded texts to check for accuracy. Discrepancies were discussed until an agreement was made on which code provided an accurate depiction of the text. After careful reading of the codes, one researcher (NG) summarized the data, grouped the data into themes around empowerment sub-constructs from CHL’s theory of change, and identified illustrative quotes. The data were stratified into two groups according to the mode of participation and differences in the experience of empowerment for parents in the in-person and virtual programs were qualitatively examined. Because few noticeable differences were observed, the combined data are presented in the results section, and differences are highlighted where necessary.

Results

Sample Description

Of the 59 PConnect parent participants who were approached, 37 agreed to participate and were interviewed in English (n = 21), Spanish (n = 12), or Chinese (n = 4) by six trained members of the research team. The interviews lasted an average of 36 minutes (range 22 to 64 minutes). Sixteen parents were interviewed from the in-person and 21 from the virtual program. The majority of parents were Hispanic/Latino (41%) and female (97%) (Table 2).

Table 2:

Sample Characteristics (N=37)

	Parents Interviewed
	n (%)
	n=37
Female	36 (97%)
Race/Ethnicitya
NHb White	4 (11%)
NHb Black	10 (27%)
Hispanic/Latino	15 (41%)
NHb Asian	7 (19%)
Employment
Unemployed	14 (38%)
Other	23 (62%)
Format
In-person	16 (43%)
Virtual	21 (57%)
Language of Interview
English	21 (57%)
Spanish	12 (32%)
Chinese	4 (11%)

^a.does not add up to 100% due to missing data,

^b.NH=non-Hispanic

Themes

Five major themes were identified that outline how PConnect parents experienced the process of empowerment. Below is a description of each theme with corresponding quotes in Table 3.

Table 3:

Illustrative quotes that correspond to themes and sub-themes embedded in the relational, emotional, cognitive, and behavioral components of empowerment

Themes	Sub-Themes	Illustrative Quotes
Relational Component
Expansion of social networks: Friendships formed and relationships strengthened during PConnect	Multi-cultural group experience heightened parents’ appreciation of cultures and enhanced their learning experience	“I love the fact that there was diversity in [the] background of moms there. Not only moms from like Arab-speaking [countries], or they want a diversity in terms of language, religion, and everybody. I felt that freshness when they would share their experience. You can relate. You find something universal like all moms goes through that. I love that.” – Parent 13
		“Our thoughts and situations are different. The differences are quite significant. We have different opinions in the class and we all speak out. One said one thing, the other said something else. I think this is difficult. Because what you said may be right, but each one has their own view, everyone believes one’s view is correct. Due to cultural gap, it feels like we are arguing. One said one thing, the other said something else. The issue of cultural gap requires some separation and division.” - Parent 36
	Bidirectional support from other PConnect parents facilitated others’ empowerment and improved family health	“Mainly, it was because of the people there and how they were eager and they wanted to make a change. It just did something inside of me where I wanted to actually flush out and I wanted to stop just talking about it or thinking about it or wishing for it. Seeing how the other parents move … it just made me wanna move faster. So I think it was the encouragement that they had actually provided at that point. I started making changes as soon as the second meeting that we actually had.” – Parent 29
		“Yes, we celebrated his [my son’s] birthday and I invited two people [from PConnect] and they came to the party. So yes, we [see each other] outside of PConnect. Not all of them, but at least two of them. Actually, yesterday, I picked up her [PConnect parent] daughter because she works very early. I said ‘Don’t worry, I can pick her up.’ We always talk on WhatsApp.” – Parent 31
		“I’ve tried to share with my friends what I’ve learned about food, screen time… Children took refuge in computers or tablets. I share with the other mothers and tell them, “Try to start with half an hour less. If they watched it for two hours, now they can watch it one hour and a half. Then reducing going until you reach the time you consider necessary, they can be on the screen.” I share everything I learned with other people.” – Parent 20
Emotional Component
Parenting efficacy: Parents strengthened relationships with their children and believed in their ability to parent successfully		“[PConnect] helped me understand myself a little bit more also on my parenting techniques because I have a bit of anxiety and sometimes struggle with communication, especially with my daughter. [PConnect] helps me look at myself and try to figure out what I’m doing wrong and try to work on techniques to help myself, so I won’t stress myself out and connect with my daughter on a better level.” – Parent 22
		“It feels more better and more lighter and brighter in the home.” - Parent 29
		“There are less tantrums. Now, I try to listen to her before reprimanding her, before telling her, ‘It’s time to eat!’ Sometimes she wasn’t hungry and we would start arguing and ultimately, she wouldn’t eat. And we would end up, her with a tantrum and me upset. It’s better to talk, learn about her need.” - Parent 3
Cognitive Component
Critical awareness: The experience of knowledge led to behavior change		“I change their sleep patterns, which makes them effective for the next time, which helps them to control their emotions, to concentrate or have different benefits. I’m working with it, and I benefited from that because my child’s starting to have almost enough sleep.” – Parent 27
		“My son, a few months ago, almost fell on top of a needle—for cryin’ out loud—that was by our house. There’s lots of things and gross stuff that’s in the parks, so we were talkin’ about cleaning up the parks and understanding that it’s gonna have to be done and repeatedly because these people are just gonna repeatedly keep hangin’ there. Our children, they can’t be locked inside. They need to be outside and playin’ around.” – Parent 29
Resource mobilization: Parents used new resources to improve family health		“By participating in PConnect, I learned of some of the resources that I didn’t know [of before]. I know how I can use them and how I can choose between the more available resources for me--how I can prioritize my things.” - Parent 27
Behavioral Component
Behavioral empowerment/advocacy: Parents took action	PConnect parents practiced their advocacy skills	“I can help my community with that. I can post it around. Say if you need help or you need somebody, or you need to know something about your community, about your potholes, about parking, who do you connect to? There’s a lot of research that PConnect taught me that can help my community…If there’s something wrong with the public park that we have, there’s a number that we can contact to keep the park clean or keep it safe for the kids. Yea, I can help my community do all of that.” – Parent 2
		“Finally, they unlocked our playground after calling a million times, and submitting a million Twitter feeds. They finally unlocked our playground. That was great.” – Parent 8
	PConnect parents made changes to enhance family health	“Instead of frying, I bake now. Instead of giving her [my daughter] a white potato, I make sweet potato French fries for them. Instead of pasta, I use gluten-free pasta or quinoa, or small changes that they wouldn’t notice.” – Parent 10
		“I never walked because I have a car and it was easier to take the car to pick up my son. But once she told me [about exercise], I tried it and I started walking. I like it”– Parent 31

Relational Empowerment

Theme: Expansion of social networks: Friendships formed and relationships strengthened during PConnect

Examples of relational empowerment were readily provided by parents, without direct prompting on this topic. All parents interviewed mentioned the use of relationships built within PConnect to enhance their family’s health and well-being. References to this theme dominated the parent interviews and were categorized into two sub-themes.

Subtheme: Multi-cultural group experience heightened parents’ appreciation of cultures and enhanced their learning experience

Nearly all parents identified the benefits of participating in a parenting intervention with a culturally and linguistically diverse group of parents. Hearing different perspectives on family and child behavior also helped parents to better understand their own family and parents were able to learn parenting strategies from parents of differing cultural backgrounds. The shared experience of parenting preschool age children cut across cultures and parents felt connected by universal parenting challenges. Although the vast majority of parents thought a multicultural group experience was beneficial, one mother felt as if her voice was not heard.

Subtheme: Bidirectional support from other PConnect parents facilitated others’ empowerment and improved family health

A strong sense of group cohesion and trust was evident as parents formed friendships with other parents in PConnect. PConnect created a culture of parental vulnerability where parents benefited from open and honest communication. The reciprocal sharing of information and support provided comfort and validation to parents, as they no longer felt alone in the challenges they encountered as a parent.

The relationships formed in the in-person program were not constrained to individual PConnect sessions and appeared sustainable, as parents remained in contact with one another and continued to provide support and resources to one another in person and over messaging apps. Parents from the in-person program also intended to maintain these newly formed friendships upon the termination of PConnect. In contrast, relationships formed in the virtual program were primarily constrained to the bounds of PConnect.

There was a spillover effect of the knowledge and skills built in PConnect in both the in-person and virtual programs. Through social media and in-person interactions, parents shared health-related information and resources with their larger social network.

Emotional Empowerment

Theme: Parenting efficacy: Parents strengthened relationships with their children and believed in their ability to parent successfully

Parents’ conversations about their experiences in PConnect reflected one key element of emotional empowerment, self-efficacy. Many parents (33 of 37, 89%) reported fewer conflicts, strengthened parent-child relationships, and began to feel more confident in their role as a parent. Improved communication and listening skills enabled parents to connect with and enjoy spending time with their children. As parents reflected on their interactions with their children and actions as a parent prior to and after PConnect, it was as if the emotional state of the home environment shifted. This newfound state of calmness and peace was welcomed by both parents and children.

Cognitive Empowerment

Theme: Critical awareness: The experience of knowledge led to behavior change

Parents referenced multiple elements of cognitive empowerment. Critical awareness, the most dominant of these themes, was voiced by 32 (of 37, 86%) parents. Parents understood how individual behaviors, family routines, and the environmental context influence family health. While most parents were focused on individual or familial-level factors that influenced health (i.e., individual behaviors, family routines), a few parents noted how environmental factors (i.e., neighborhoods) also affect family health. This awareness led to behavior change. Importantly, after implementing behavior change, whether that be reducing sources of sugar in their child’s diet, improving their child’s sleep routine, or limiting their child’s screen time, parents noticed how these changes led to improved mood, energy, and/or behaviors in their children. Heightened awareness of these benefits served as a natural reinforcement for positive health behaviors.

Theme: Resource mobilization: Parents used new resources to improve family health

Resource mobilization, a second key theme within the domain of cognitive empowerment, was articulated by 21 (of 37, 57%) parents. Parents learned how to use resources that fostered family health. This was primarily channeled through the use of the Neighborhood Resources map, an electronic map that was introduced to parents during PConnect. The Neighborhood Resources map has pins that correspond to playgrounds, food pantries, social service agencies, farmer’s markets, and health services in a user’s location. Parents frequently used this map to locate age-appropriate neighborhood playgrounds and identify locations where they could acquire healthy inexpensive food (i.e., food pantries, farmer’s markets). Parents primarily used the map as well as other resources, such as 311, to enhance family health. In addition to building awareness of community resources, parents also learned how to effectively use the resources.

Behavioral Empowerment

Theme: Behavioral empowerment/advocacy: Parents took action

Behavioral empowerment was characterized by parents taking action to enhance community and family health. This theme was identified by most parents (33 of 37, 89%) and divided into two subthemes.

Subtheme: PConnect parents practiced their advocacy skills

A few parents (9 of 37, 24%) began to understand that their voices matter and were able to successfully communicate with the right people and mobilize skills into action to promote family health. Parents also expressed a desire to become more involved in their communities by volunteering in their child’s Head Start classroom and cleaning up their local park.

Subtheme: PConnect parents made changes to enhance family health

Changes made, as a result of PConnect, influenced the children’s, as well as the parents’, quality of life. Nearly all parents reported making changes to their health-related parenting practices. In addition to dietary changes, parents most frequently discussed using the skills learned in PConnect to reduce their child’s juice intake and screen time. PConnect also taught parents how to improve their health and well-being. Parents adopted healthy eating habits and learned to reduce stress. Parents began incorporating exercise into their weekly routines, many opting for walking as a mode of transportation.

Discussion

Our findings exemplify the experience of empowerment among parents who participated in CHL’s PConnect intervention. Five themes were identified that correspond to empowerment theory including 1) friendships formed and relationships strengthened during PConnect, 2) parents strengthened relationships with their children and believed in their ability to parent successfully, 3) the experience of knowledge led to behavior change, 4) parents used new resources to improve family health, and 5) parents took action. Findings support CHL’s theory of change to suggest targeting parent empowerment may be an important facilitator of health behavior change. Our findings are atypical for childhood obesity interventions, which often focus solely on measuring change in knowledge about childhood obesity-related behaviors and the behaviors themselves. The findings from our study demonstrate how parents gained control primarily through relational empowerment, but also through emotional and cognitive empowerment, to influence both familial and external factors that influence childhood obesity outcomes.

While parents experienced empowerment in a variety of ways, threaded throughout all parent interviews was an emphasis on relational empowerment. Parents built collaborative competence, the ability to work together with a diverse group of parents who participated in PConnect. Like the theoretical definition,¹⁵ parents spoke about the power of relationships. These relationships “bridged social divides”, in that they crossed cultural differences and parents noted they learned from one another’s differences.¹⁵ Further, parents gained relational empowerment by passing on their knowledge to friends outside PConnect, essentially passing on their legacy and facilitating others’ empowerment.¹⁵ Notably, the finding of relational empowerment occurred for parents who participated in PConnect in person and virtually. As outlined in our previous work, a virtual setting can promote authenticity and provide a safe space that allows parents to share personal experiences that they otherwise may have felt too ashamed to disclose in an in-person setting.²⁹

In terms of emotional empowerment, restored relationships with children and confidence in one’s ability to fulfill their role as a parent emerged as ways in which parents experienced empowerment. Aligned with the definition of parenting efficacy,³⁰ these findings extend prior qualitative work³¹ by amplifying the voices of parents, rather than providers, to indicate belief in one’s ability to parent and positive parent-child relationships are important characteristics of empowerment. This theme also speaks to the power of relationships and how positive family relationships can also be leveraged to improve family health.

Cognitive empowerment was characterized by knowledge acquisition of the root causes of child and family health. Parents gained critical awareness of what influenced health behaviors and mobilized community resources, with several sources of knowledge stemming from their social networks. Importantly, these findings demonstrate that efforts to increase empowerment amongst populations who feel less empowered to mobilize resources (i.e., low-income and Hispanic/Latino populations)³² are effective. This research also mirrors past literature identifying access to information as a salient characteristic of parent empowerment.³³ These findings, however, differ slightly from the theoretical definition,²⁵ specifically for the empowerment sub-construct critical awareness. Critical awareness refers to an in-depth understanding of how a range of factors contribute to one’s life situation, position in the world, and actions taken to gain control over their life.^25,34 While discussion of how individual behaviors influence health was present throughout parent interviews, identification of sociopolitical influences on family health and actions taken to address these influences, a key underpinning of critical awareness,^25,34 was not prominent. Critical awareness is a complex construct that requires attention to and active engagement with social issues that may, or may not, be prominent in their family’s lives.³⁵ This may be an abstract concept for parents, especially non-native English speakers, to express, or perhaps was not an important part of the empowerment process, as parents may have chosen to focus their attention on factors (i.e., individual behaviors) where they have more control.

While consideration for how sociopolitical forces shape family health was primarily absent, a few parents spoke about their experience advocating on behalf of and becoming more involved in their communities, essentially using relational empowerment to strengthen bonds with their communities. While this experience of empowerment mirrors behavioral empowerment,²⁵ few parents articulated this sub-theme. This may reflect the barriers that preclude advocacy among low-income parents who are marginalized by society.³⁶ For example, advocacy work is challenging and time-consuming.³⁷ Consistent with Maslow’s Hierarchy of Needs,³⁸ low-income parents may need to prioritize other areas of their lives, such as caregiving, housing and employment needs and responsibilities, before taking social action. Moreover, the prevalence of this sub-theme may also be underrepresented because parents were interviewed during weeks 8, 9, and 10 of PConnect while the session on advocacy occurred during week 9. Parents also made adaptive changes to their health-related parenting practices and health behaviors.

Unique to our study is the examination of how parents experience the different sub-components of empowerment. While empowerment is widely acknowledged as a multidimensional construct with distinct sub-components,^25,39 resource empowerment aside, studies have neglected to examine the different components of empowerment which have implications for intervention development. For instance, findings from our qualitative study suggest child health promotion interventions must be grounded in relational empowerment.¹⁵ Approaches to foster relational empowerment must include opportunities to develop collaborative competence and bridge social divides. In addition to facilitating positive group processes where individuals benefit from self-disclosure and group problem-solving,⁴⁰ applying relational empowerment to programs can provide parents with the opportunity to expand their social networks and build skills that allow them to work with others to achieve a common goal. When parents gain collaborative competence and the ability to bridge social divides, they may be more able to advocate, speak out and potentially gain the ability to respond to the external factors that influence their families’ lives. As interventions transition to virtual or hybrid formats, relational empowerment must be retained for the sustainability of the intervention effects.

Our findings are not without limitations. It is important to note that interviews were conducted over multiple years (2019 and 2021) with one year occurring during a global pandemic. While all interviewers received training from the same trainer, multiple interviewers conducted the interviews. Since the quality of data is dependent upon the skill set of the interviewer,⁴¹ variability in data quality, particularly across the two study years and three interview languages, may be present and bias the results. Additionally, questions in the 2019 and 2021 interview guides were slightly different making it difficult to assess if the similarities and differences identified in the experience of empowerment across the in-person and virtual formats were due to the content of the interview guide, format of delivery, or COVID-19 pandemic. Nearly half of the interviews were conducted in Spanish or Chinese, and translating them into English may have resulted in the loss of richness/meaning to the data. Furthermore, interviews were conducted during weeks 8 and beyond of PConnect. Recruiting parents for our study towards the end of PConnect may positively skew findings, as the voices of parents who dropped out of PConnect were not captured in the interviews.

Advocacy, a subtheme within the final theme, was underrepresented in the data. As previously mentioned, this may reflect the timeline of participant interviews (i.e., several participants were interviewed prior to the session on advocacy). However, underrepresentation of this subtheme may also reflect how the research team’s positionality influenced the study design. Low-income parents may more frequently adopt non-traditional approaches to creating social change (i.e., vocalizing support for their schools/communities).⁴² While these non-traditional forms of advocacy can be beneficial to family health, our interview guide and code book may not have captured these more nuanced forms of advocacy. Likewise, we acknowledge collecting qualitative data in a non-native language may make it more challenging for the interviewers to actively listen to, respond to, and/or clarify participant responses appropriately.⁴¹ Having interviewers and coders whose positionality was more closely aligned with the positionalities of the participants may have mitigated these limitations.

Conclusion

Our study has two primary implications for future intervention research aimed at improving child health. First, our study suggests that incorporating empowerment theory into child health interventions for low-income parents can generate important skill development, in addition to traditional knowledge around child health behaviors, that can potentially influence positive behavior change. Second, empowerment-informed interventions may improve the sustainability of the effects of the intervention because the knowledge and skills built are useful beyond changing parenting or child health behaviors. Empowerment can benefit parents as they navigate other aspects of their family’s lives. Therefore, our study suggests that incorporating relational, emotional, and cognitive empowerment may have a profound and lasting influence on low-income families’ health and well-being.