Abstract
OBJECTIVE
Generate and test parents’ understanding of values and associated reason statements to encourage effective food parenting practices.
METHODS
This study was cross-sectional. Sixteen parents from different ethnic groups (African American, White and Hispanic) living with their 3–5 year old child were recruited. Interested parents were directed to a website where they provided screening information and informed consent. Two types of telephone interviews were employed: semi-structured intensive interviews and cognitive interviews.
RESULTS
The most common core values identified in the semi-structured interview were religion/spirituality, family, and health, which appeared invariant across parent ethnicity. Parent responses to cognitive interviews enabled rephrasing of statements that were not well understood; the list of values was increased; and reason statements were added to cover the spectrum cited by parents.
CONCLUSIONS AND IMPLICATIONS
Values and reasons statements will be used to tailor intrinsic motivational messages for effective food parenting practices.
Keywords: values, reasons, vegetables, parenting practices, self determination theory
INTRODUCTION
Diets rich in vegetables can reduce the risk of cardiovascular disease (1, 2), diabetes (3) and some cancers (4–6). Children’s vegetable consumption is below recommended levels (7, 8). My Pyramid recommended that 2–5 year old children consume 3 servings or 1–1½ cups of vegetables per day (9). However, the 1999–2002 National Health and Nutrition Examination Survey indicated 78% of 2–5 year old children were not meeting this recommendation (10).
Parents influence their children’s eating habits in many ways, including food parenting practices (11). Parenting practices are parenting behaviors intended to influence their child’s behavior in a specific context (12), such as feeding. Some intervention programs that attempted to engage parents to help promote healthy dietary intake among children showed positive effects in children’s vegetable consumption (13–17). Programs that teach food parenting practices (18) could be effective in encouraging children to eat more vegetables. A key issue is how to motivate parents to adopt and use effective food parenting practices.
Self Determination Theory (19) posits motivation as the strongest factor driving behavior. Motivation can be intrinsic (for the joy of doing the behavior) or extrinsic (to please someone else). Intrinsically motivated behavior tends to be sustained for a longer time than extrinsically motivated behavior, which also requires continued pressure or reinforcement (e.g. a prize, good grades) to be sustained (19). Self Determination Theory further posits that meeting three basic psychological needs moves people toward intrinsic motivation: [1] competence (self-efficacy, ability to successfully perform the behavior), [2] autonomy (independence to choose the behavior, control over the behavior), and [3] relatedness (concordance with personal beliefs and deeply held values). When these needs are met, an individual moves towards intrinsic motivation.
Relatedness explains how core values (personal beliefs that guide a person’s behavior (20), e.g. some people value “being responsible”) compel decisions to engage in a behavior. Core values play different roles in people’s lives. Individuals make everyday and long-term decisions and establish goals based on their values (20). Core values linked to specific behaviors have been used to successfully promote behavior change (21–23). Reasons are statements that relate values to particular behaviors (24), e.g. a parent who values “being responsible” may reason: “I serve my child vegetables because it shows I am a responsible parent”. Motivational messages to increase fruit and vegetable consumption were tailored to personal values using reasons statements (25). Motivating parents to develop food parenting skills through motivational messages connected to their values offers promise for improving vegetable consumption in young children. This study identified parent’s core values and associated reasons, and evaluated parents’ understanding of these values and associated reasons to encourage their child to eat vegetables.
METHODS
SAMPLE AND RECRUITMENT
Participants were recruited via flyers posted throughout the Texas Medical Center in Houston, Texas, online announcements on the Baylor College of Medicine and the Children’s Nutrition Research Center (CNRC) web sites, and contacts with families listed in the research volunteer database of the CNRC. Inclusionary criteria were being a parent or guardian of a 3–5 year old living in the home and being the primary food caregiver. Exclusionary criteria were the 3–5 year old child having a medical condition that influenced their diet. To assess ethnic differences an ethnically diverse group (African American, Hispanic, and White) was recruited. Interested parents were directed to a website where they provided screening information and online informed consent. Those who agreed to participate completed a survey that asked their ethnicity, gender, child age and gender, household income, highest level of education in household, primary food caregiver, and any disease or condition that affected their child’s food intake patterns. Parents who met the requirements were contacted by staff and invited to participate in one or both interviews. Verbal permission was obtained to record the telephone conversation. In exchange for their participation, parents received $20 per interview. This study was approved by the Baylor College of Medicine Institutional Review Board.
PROCEDURES
Two types of telephone interviews were employed: semi-structured intensive interviews (to explore parents’ understanding of the concept of “values” and their self selection of important values: Interview I) (26) and cognitive interviews (to test understanding of the items: Interview II) (27). Interview I included 12 open-ended questions, structured follow-up prompts, and unstructured probes. This manuscript only presents responses to the question “Tell me what the 3 most important values are for you?” and the follow up question, “How would your child eating more vegetables help you be/achieve the value?” To ensure parents understood what we were asking, an introduction with the definition of the term “value” was given (Think about the ideas that guide the decisions you make in your life. These ideas are sometimes called “values”…). If participants had trouble with the question an example was given.
Interview II evaluated comprehension of a preexisting list of values and their reasons statements. This involved mailing a list of 10 values and reasons statements (24) and by telephone, assessing comprehension and completeness. The list of values was adapted from a list of 30 values and corresponding reasons statements used in a serious video game for children 9 to 11 years old, reflecting the authors’ judgments about which were most applicable to having children eat vegetables. For Interview II, the meaning of “values” was asked (What does the word “values” mean to you?). If the parents were not clear of the meaning, then a standard definition was given. All interviews were conducted by trained interviewers between December 2008 and February 2009.
DATA ANALYSIS
Audio-recordings were transcribed verbatim. Transcripts were checked against audio-recordings by interviewers to ensure accuracy and completeness. All interviews were imported to NVivo software (QSR NVivo 8.0, 2008, Doncaster, Victoria, Australia). Responses were identified on the transcripts and classified by question using the interview guide as a framework; codes were derived as the classification proceeded, for example under the question What does having a healthy child mean to you? the responses were coded into the following emerging themes: emotionally healing, lack of physical illness, to have a healthy lifestyle, to be well nourished, and importance of having a healthy child. One of the authors conducted the preliminary coding, which was independently reviewed by another co-author. Discrepancies were resolved by consensus between the two coders. Further discrepancies were resolved by consensus among the investigators.
RESULTS
Table 1 presents the characteristics of the participants. Sixteen parents met study eligibility criteria and completed the phone interview. Ten parents completed Parts I and II interviews; 5 completed only Part I; and 1 completed just Part II. For Part I, 5 self identified as African-American (all female), 5 as Hispanic (4 female, 1 male), and 5 as non-Hispanic White (4 female, 1 male). For Part II, 4 were African American, 3 Hispanics (one male), 3 White and 1 female Asian (Table 1).
Table 1.
Demographic Characteristics of Participants in Both Interviews
| Characteristic | n (%) |
|---|---|
| Total | 16 (100)* |
| Interview 1 | 15 (100)* |
| Interview 2 | 11 (100)* |
| Child Gender | |
| Male | 6 (37.5) |
| Female | 10 (62.5) |
| Parent Gender | |
| Male | 2 (12.5) |
| Female | 14 (87.5) |
| Age (years) | |
| 3 | 5 (31.25) |
| 4 | 5 (31.25) |
| 5 | 6 (37.5) |
| Race/Ethnicity | |
| White | 5 (31.2) |
| African American | 5 (31.2) |
| Hispanic | 5 (31.2) |
| Asian or Other | 1 (6.25) |
| Married status | |
| Married | 13 (81.2) |
| Single | 2 (12.5) |
| Divorce, separated or widowed | 1 (6.2) |
| Household Income | |
| <$30,000 | 3 (18.8) |
| $30,000–$60,000 | 6 (37.5) |
| >$60,000 | 7 (43.8) |
| Employed | |
| Yes | 10 (62.5) |
| No | 6 (37.5) |
| Highest Household Education | |
| HS Graduate or less | 2 (12.4) |
| Some college/technical school | 5 (31.2) |
| College graduate | 5 (31.2) |
| Post graduate | 4 (25) |
Ten parents completed Parts I and II interviews, 5 completed only Part I; and 1 completed just Part II. The n is presented by total of participants and by total of participants for each interview.
Part I. Parent’s values and reasons to have their child eat more vegetables
The most common values were religion/spirituality, family, and health. Other values were education, honesty and doing the right thing (Table 2). The values identified with more mentions by the parents were invariant across parent ethnicity.
Table 2.
Parents’ (n=15) most frequently cited “ most important values” by race/ethnicity, Interview 1.
| Values | Number of mentions | Race/Ethnicity |
|---|---|---|
| Religion/Spirituality | 11 | AA= 5, H= 3, W=3 |
| Family | 6 | AA= 2, H= 2, W=2 |
| Health | 5 | AA= 1, H= 4 |
| Education | 3 | AA= 1, H= 2 |
| Honesty | 3 | AA= 1, H= 1, W=1 |
| Doing the right | 3 | AA= 1, H= 1, W=1 |
AA= African American
H= Hispanic
W= White
Among parents who reported religion/spirituality as a value, some stated that their child eating more vegetables would benefit their child’s body, which should be treated as a temple. For example, “… in the Bible it says that our bodies are a temple, we are to respect them and use them, as a vehicle to do God’s work, by eating more vegetables it keeps your body healthy, shows respect for your body and allows you to carry out that work” (White parent).
Parents also indicated that when a child eats what the parent tells them to, the child was following religious teachings, like obedience and trust of parent. One person associated eating vegetables with a good source of energy for her child to go to church: “It would make her feel good. I guess it would make… her spirits high … if she’s healthy and feeling good then … she may be more willing to go to church…to help others, that kind of thing” (African American parent).
A parent who mentioned family as an important value explained that having their family and child eat vegetables was important because it provided social support to eat healthy and make good decisions for the family; another mentioned that the family provided confidence to eat healthy: “… it’ll help them be healthier on their own. … Their decision making would be a lot better other than choosing the sugar or choosing chips all the time”(Hispanic parent); while another mentioned how different family members can be role models to improve vegetable consumption.
All parents were able to relate how their child eating vegetables would help them to achieve the “healthy child” value: “… I believe strongly that eating healthfully, including eating more vegetables is an important part of keeping my child healthy” (White parent). Some parents identified components of the vegetables like vitamins and minerals that help children grow healthy and be fit. Others mentioned how eating vegetables would help their child think more clearly: “… when you eat healthy food, certain types of vegetables they boost the, I guess endorphins in your brain are to think better versus the sluggish foods, the slower foods that carbohydrates and sugars and, so, I guess it’ll help you with the brain and then healthy, you know” (Hispanic parent).
One parent mentioned that if her child ate vegetables they would recover from illness faster. Another commented that eating vegetables gave her child the energy they needed. For example: “The nutritious attribute of getting the vitamins and minerals and all of that from the vegetables and how it really aids into being a healthier person … give them the energy that they need” (African American parent).
Part II. Cognitive testing of values and reasons for encouraging their children to eat vegetables
All the parents had heard of the word ‘values’. When asked to define values they reported “things you hold important,” “a set of guidelines,” “ideas about how things should work in life,” “things you deem important,” and “setting standards for my family.”
Three values in the original list were not understood by some of the parents: having a sense of accomplishment, having an attractive child, and pleasing others. “Having a sense of accomplishment” was difficult to comprehend for 1 parent. Rewording it as “making a contribution” enhanced comprehension. “Having an attractive child” raised concerns by 6 parents because it was not considered a value, but a physical characteristic. Rewording as “Having a wholesome child” enhanced acceptability (Table 3). “Pleasing others” was understood by all, but not endorsed by 2 parents because they felt this had a negative connotation: when it means doing things for others without consideration of one’s own judgment about what to do. This value, however, was not reworded since 9 parents endorsed it.
Table 3.
Values tested and corresponding reason s tatements as clarification from second interview.
| Value | Reason statements | |
|---|---|---|
| Having a Healthy Child. | Encouraging my child to eat vegetables helps my child to be healthy because it helps… |
|
| Pleasing others. | Encouraging my child to eat vegetables helps me please others because it shows… |
|
| Being respected by others. | Encouraging my child to eat vegetables helps me be respected by others because it shows… |
|
| Being spiritual. | Encouraging my child to eat vegetables makes me feel spiritual because it… |
|
| Being responsible. | Encouraging my child to eat vegetables shows I am responsible by… |
|
| Standing up for your beliefs. | Encouraging my child to eat vegetables shows I stand up for my beliefs because it: |
|
| Having a wholesome child.* | Encouraging my child to eat vegetables makes my child wholesome because it… |
|
| Being a role model. | Encouraging my child to eat vegetables makes me a role model because it is a good example for… |
|
| Having self-respect. | Encouraging my child to eat vegetables gives me self-respect because it makes me feel… |
|
| Making a contribution. * | Encouraging my child to eat vegetables gives me a sense of accomplishment because it… |
|
| Being honest and fair. ** | Encouraging my child to eat vegetables shows I am honest and fair because it… |
|
| Having a child who respects authority. ** | Encouraging my child to eat vegetables helps my child that respect authority because it: |
|
Value Revised
Value Added
Some parents suggested other values like, “being honest and fair,” which was defined by parents as being truthful and treating people as you wanted to be treated; and “respecting authority”, defined as respecting people who are responsible. These values were added to the list. “Having leadership” and “growing intellectually (education)” were mentioned, but not added to the list, because parents had difficulty relating corresponding reasons to encourage their child to eat vegetables. As a result, 12 values were included in the revised list (see Table 3 at Ancilliary material website). Multiple reasons statements were generated for each value since parents had different reasons for linking a value to their child eating more vegetables (see Table 3 at Ancilliary material website).
Although a few participants had initial difficulty relating some of the values and their reason statements with encouraging their child to eat vegetables, most parents agreed with them. When asked if some values should be removed, parents suggested to leave them since the reason statements clarified the relationships. Some reasons were reworded, deleted or added based on parents’ feedback (see Table 3 at Ancilliary material website).
DISCUSSION
Values and related reasons statements represent Self Determination Theory specified constructs that enhance a parent’s motivation to perform a behavior (i.e., psychological need of relatedness), in this case encouraging their child to eat vegetables. This study explored parents’ values and reasons (Interview I) for having their child eat vegetables, and generated a list of values with parent endorsement. Conducting cognitive interviews (Interview II) enabled rephrasing of statements, increased the list of values, and created additional reason statements. This important formative research should help avoid potential misinterpretations of the statements and enhance their comprehension, appeal, and acceptability. With the list of values and their reasons statements, we will create corresponding motivational messages that will be given to the parents in strategic phases of a video game, such as during goal setting. Parents will choose a value before playing the video game which targets vegetable consumption. At the end of setting a parenting goal, a motivational message (based on this selected reason statement) will be provided. These tailored messages should increase the likelihood of parents utilizing effective food parenting practices in real life.
One limitation of this study was the small sample size, but theoretical saturation (28) was reached; therefore, it is not likely additional information would have been obtained with a larger sample. The study was limited to mostly female participants with internet access; a lower income population with no access to internet and fathers were underrepresented; thus generalizability is limited. Interviews were conducted in only one geographic area which may also limit generalizability; further testing should be done in all these groups. Interviews used self reported information which are also limited.
IMPLICATIONS FOR RESEARCH AND PRACTICE
Tailored motivational messages that encourage effective food parenting practices based on parents’ core values should meet the relational needs of the parents, thereby increasing the likelihood of performance of the desired parenting behaviors. Having parents select personal values and related reasons for encouraging their child to eat vegetables should expand the procedures for enhancing behavior change. Enhancing effective food parenting practices could have an impact on children’s diet. Health care professionals and nutrition educators could use videogames as a tool to train parents in changing their parenting practices. This tool could reach large numbers of parents in an enjoyable and effective way. Future research needs to address these issues.
ACKNOWLEDGEMENTS
This research was primarily funded by a grant from the United States National Institute of Health and Human Development (HD058175). This work is also a publication funded in part with federal funds from the the United States Department of Agriculture (USDA/ARS) under Cooperative Agreement No. 58-6250-6001. The contents of this publication do not necessarily reflect the views or policies of the USDA, nor does mention of trade names, commercial products, or organizations imply endorsement from the U.S. government.
Footnotes
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ANCILLARY MATERIAL
Table 3.Values tested and corresponding reason statements as clarification from second interview.
Contributor Information
Alicia Beltran, Department of Pediatrics, Children's Nutrition Research Center, Baylor College of Medicine, 1100 Bates Street, Houston, TX 77030, USA. Phone: 713-798-0503, Fax: 713-798-7098, abeltran@bcm.edu.
Melanie D Hingle, Department of Nutritional Sciences, University of Arizona, 1177 E 4th Street, Shantz Bldg Room 309, Tucson, AZ 85721, hinglem@email.arizona.edu.
Jessica Knesek, Department of Pediatrics, Children’s Nutrition Research Center, Baylor College of Medicine, Bates Street, Houston, TX 77030, USA. Phone: 713-798-0503, Fax: 713-798-7190 knesek@bcm.edu.
Teresia O’Connor, Department of Pediatrics, Children's Nutrition Research Center, Baylor College of Medicine, 1100 Bates Street, Houston, TX 77030, USA. Phone: 713-798-6782, Fax: 713-798-7098, teresiao@bcm.edu.
Janice Baranowski, Department of Pediatrics, Children's Nutrition Research Center, Baylor College of Medicine, 1100 Bates Street, Houston, TX 77030, USA. Phone: 713-798-6762, Fax: 713-798-7098, jbaranow@bcm.tmc.edu.
Debbe Thompson, Assistant Professor of Pediatrics, Children's Nutrition Research Center, Baylor College of Medicine, 1100 Bates Street, Houston, TX 77030, USA. Phone: 713-798-7076, Fax: 713-798-7098, dit@bcm.tmc.edu.
Tom Baranowski, Department of Pediatrics, Children's Nutrition Research Center, Baylor College of Medicine, 1100 Bates Street, Houston, TX 77030, USA. Phone: 713-798-6762, Fax: 713-798-7098, tbaranow@bcm.tmc.edu.
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