Parental Attitudes and Beliefs Surrounding Play Among Predominantly Low-Income Urban Families: A Qualitative Study

Abstract

Objective

Parents’ perceived benefits and barriers to participation in cognitively stimulating activities may help explain why income-related discrepancies in early and frequent participation in such activities exist. We sought to develop an improved understanding of attitudes and beliefs surrounding play among families who live in predominantly low-income urban communities.

Methods

Using qualitative methods, focus groups were conducted with parents of children 2 weeks to 24 months of age who attended a primary care clinic serving predominantly low-income urban communities. Discussions were recorded, transcribed verbatim, and analyzed using thematic analysis.

Results

35 parents participated in 6 focus groups. Participants were 61% female and 94% nonwhite; 71% had children who received public health insurance. Analyses revealed 7 major themes that mapped onto the Health Belief Model’s core domains of perceived need, barriers, and cues to action:1) play as important for developing parent-child relationships, 2) toy- and media-focused play as important for developmental and educational benefit, 3) lack of time due to household and work demands, 4) lack of knowledge regarding the importance of play, 5) media-related barriers, 6) need for reminders, and 7) need for ideas for play.

Conclusions

Caregivers of young children describe many important benefits of play. Yet they have misconceptions regarding use of toys and media in promoting development as well as notable barriers to participating in play, which may be opportunities for intervention. Public health programs may be more effectively implemented if they consider these attitudes to develop new or refine existing strategies for promoting parent-child learning activities.

INTRODUCTION

Converging economic, developmental, and biological studies highlight early and frequent participation in cognitively stimulating activities as one key parenting behavior central to children’s development, subsequent school readiness and overall educational achievement.¹ An example of such an activity is parent-child shared reading, which can promote a child’s early language and literacy skills.² Early childhood, specifically during ages 0–24 months, is a particularly critical period during which play can also support critical brain development and positively impact a child’s motor, language, and social-emotional development.³ Available research further suggests play can also enhance higher level executive function skills such as memory, attention, and impulse control as well as early literacy and math skills.⁴ Indeed play has been viewed as so critical to healthy child development that the United Nations Convention on the Rights of a Child deemed play as a right of every child.⁵

Theoretical models suggest that one mechanism through which play impacts childhood outcomes is through facilitation of parental sensitivity and responsiveness, key aspects of parenting behaviors central to children’s development and subsequent educational achievement.⁶ This may help explain why several studies have also demonstrated the superiority of “traditional” or physical, nonelectronic toys compared to digital, media-based toys in fostering both the quantity and quality of language exposures, fundamental factors in stimulating early language development.^7–9 Indeed a wealth of literature demonstrates the positive impact of parental involvement in a child’s play activities to promote early language, social-emotional, and school readiness skills.^10,11 Underscoring these findings are recently released clinical reports from the American Academy of Pediatrics (AAP) discouraging use of digital media-based toys and encouraging pediatricians to advocate parent-child shared play at every well child visit in the first two years.^12,13

Although the benefits of cognitively stimulating activities on a child’s development are well-established, there are significant income-related discrepancies favoring children from higher income families in the quantity and quality of time spent on these learning activities.^14,15 In addition to factors that include elevated parenting stress and decreased economic resources, the Health Belief Model (HBM) proposes that parents’ attitudes and beliefs may also explain why such disparities exist.¹⁶ According to the HBM, a parent’s likelihood of engaging in a behavior is influenced by his/her perceived need of this activity. In this way, parents are more likely to play with their child if they believe that by doing so, they will positively impact their child’s development or education. Additionally, the HBM asserts that perceived barriers and different cues to action (e.g., a reminder postcard to make a dental visit) can also impact one’s behavior.¹⁷

Pediatric and public health campaigns have long sought to reduce income-related educational inequities by encouraging key parenting behaviors, including participation in cognitively stimulating activities such as play, to improve early childhood development.¹⁸ Utilizing various modes of dissemination including primary care offices and home visits, parent-directed programs have utilized play as a modality to promote parental responsiveness and increased language exposure to positively impact early childhood social-emotional, language, and learning skills.^19–21 Although many of these programs have demonstrated improved parental outcomes, a better understanding of the attitudes and beliefs surrounding the importance of play may improve overall uptake and enhancement of key parenting behaviors.²² Further, it may direct pediatric providers in delivering more effective anticipatory guidance during a child’s first two years to ultimately enhance developmental outcomes.

The goal of our study was to inform actionable targets for pediatric and public health programs that aim to reduce income-related differences in key parenting behaviors and encourage parental participation in cognitively stimulating activities during the first two years of a child’s life. Accordingly, we utilized qualitative methodology to develop an improved understanding of attitudes and beliefs surrounding participation in cognitively stimulating activities, specifically play, among families who live in predominantly low-income urban communities.

METHODS

Recruitment and Eligibility

Given the relatively limited information regarding the attitudes and beliefs surrounding play, focus groups were conducted to develop improved insight into the beliefs and decisions surrounding parent-child play. Purposive sampling was used to recruit caregivers from predominantly low-income backgrounds whose children varied in ages and who received primary care services at a university-affiliated outpatient care clinic in the Midwest United States. As the primary health system for the state and one of the largest in the city, the facility accounts for a significant proportion of healthcare delivered to a large metropolitan city’s medically underserved population. This clinic provides pediatric care to more than 40,000 children 0 to 21 years of age annually, of whom at least 70% receive public health insurance.

Participants were eligible to participate if they had a child between 2 weeks to 24 months of age and identified themselves as the child’s primary caregiver. Individuals who were less than 18 years of age or did not speak English were excluded. Flyers were placed in the waiting and examination rooms of the clinic and interested participants called the provided telephone number whereupon a research assistant described the study and screened for eligibility. The study was designed to have at least three focus groups, of four to six participants, the minimal number we estimated could achieve saturation. To account for cancellations and no-shows, recruitment continued until 6–10 participants were scheduled for each focus group.

Study Procedures

Informed consent was obtained from all study participants prior to the start of the focus group. After receiving consent, demographic data, which included information regarding caregiver age, gender, and education, was obtained via a participant completed paper survey. An open-ended, semi-structured interview guide was developed to elicit discussions regarding attitudes and beliefs surrounding positive parenting behaviors, with a specific emphasis on play (see Appendix A). Members of the study team met consistently throughout data collection to adapt the interview guide with any new concepts raised by participants as needed. The sessions were moderated by the first author and note-taking done by an experienced graduate-level research assistant. Focus group sessions were held in a private conference room, audio-recorded and lasted approximately 90 minutes. Snacks, childcare, and $75 cash were provided for participation. Data collection continued until the research team determined thematic saturation was achieved. This study adhered to the COnsolidated criteria for REporting Qualitative research (COREQ) checklist for reporting qualitative research.^23,24 The authors’ Institutional Review Board approved this study.

Data Analysis

A summary report was completed by a member of the research team after each focus group that highlighted important ideas, comparisons from previous focus groups, and possible questions or considerations for the next focus group. Focus group audio-recordings were professionally transcribed, and then reviewed for accuracy. The transcripts were segmented in which meaningful, complete, coherent and independently understood coding units were demarcated.²⁵ A coding framework was developed utilizing both deductive and inductive methods. Prior to transcript analyses, the first author generated an initial list of provisional a priori codes based on anticipated categories from the focus group questions.²⁵ As transcripts were reviewed, additional codes emerged inductively from the data. The codebook was refined via an iterative process as transcripts were analyzed by the coding team.

Analyses were conducted with qualitative software Dedoose (Version 7.5.9). Structured guidelines for thematic analysis were followed, including identifying themes, reviewing and revising themes, and refining themes and subthemes.²⁶ A developmental and behavioral pediatrician (first author) and a doctoral clinical psychology graduate student (second author), each of whom had prior experience with qualitative analyses, independently coded all transcripts. Coders met regularly to review code applications. Discrepancies were addressed by discussion and establishing consensus on code applications, or determining whether revisions of the coding scheme were needed. Through these discussions, they also began to identify emergent themes. Once consensus was achieved on all code applications, themes were further refined through an iterative process of considering all excerpts within a given code and identifying patterns within the data, followed by considering multiple codes in tandem and identifying patterns across codes. The final stage of analysis involved corroborating previous stages by closely examining code application and identifying patterns and emergent themes to ensure that final themes were representative of data excerpts and assigned codes.²⁷

RESULTS

Participants

35 primary caregivers (henceforth referred to as “parent”) participated in the six focus groups, which ranged in size of five to nine participants. 61% of participants were female, 94% were of nonwhite race or ethnicity, and 51% were first-time parents; 71% of families reported receiving public health insurance (see Table 1).

Table 1.

Demographics of Study Sample, n = 35

	N	%
Child
Gender (female)	20	61
Child Age
0–6 months	20	57
7–12 months	3	9
13–18 months	6	17
19–24 months	6	17
First Born Child	18	51
Receives Public Health Insurance	25	71
Parent
Gender (female)	28	80
Age
18–20	1	3
21–25	7	21
26–30	10	29
31–35	12	35
36–40	4	12
Race/Ethnicity
Asian	4	11
Black/African American	20	57
Latino/Hispanic	6	17
White/Caucasian	2	6
Bi-racial	2	6
Other	1	3
Marital Status
Single	22	63
Married	13	37
Highest Education Level
High School and Below	10	29
Some College	7	21
2-Year Degree	2	6
4-Year Degree	8	24
Graduate or Postgraduate Degree	7	21

Note. Where data points were missing, percentages are calculated based on total number of available cases.

Focus Group Themes

Analyses revealed seven major themes that mapped onto the HBM’s core domains of perceived need, barriers, and cues to action. Themes describing parents’ perceived need for play included: 1) play as important for developing parent-child relationships, and 2) toy- and media-focused play as important for developmental and educational benefits. Themes describing parents’ barriers to play included: 1) lack of time due to household and work demands, 2) lack of knowledge regarding the importance of play, and 3) media-related barriers. Lastly, themes describing cues to action for play included: 1) need for reminders, and 2) need for ideas for play. Further descriptions of the themes characterizing each of the HBM domains follow.

Domain 1: Perceived Need For Play.

Parents’ perceived need for play was grounded in their sense of play as 1) important for developing parent-child relationships, and 2) toy- and media-based play as central for developmental and educational benefits.

Parents across focus groups viewed play as important for building parent-child relationships and commented specifically on the strong role of play to foster bonds between a parent and a child. They discussed their active role in play to facilitate this relationship and the satisfaction they received in eliciting a positive reaction from their child. One mother commented, “I think this age below two years, playing is the most important. It can be the main factor to show your love. Play together and show many kinds of things that make them fun, make them feel warm, feel happy, that’s a factor.”

Within the theme of developmental and educational benefits of play, parents described play as often physical in nature and commented on its importance for a child’s development in broad terms. However, when discussing how play supported specific developmental and educational domains such as motor, language, and school readiness, toys and media were referenced as the vehicle through which these benefits were imparted onto children during play. For example, one mother stated, “My daughter was 4 months old, and at 6 months old, I used to let my daughter – my daughter has an iPad- and I used to play Sesame Street in front of her every day. She’s still watching right now today, and before my daughter was 1, she knew all of her numbers and all of her letters, colors, everything, and this was before I even put her in daycare. So, you all can continue to do that. It’ll be a benefit.” Thus, while parents viewed play as imparting developmental and educational benefits, they viewed toys and media as facilitating these benefits, rather than parent-child engagement in play independent of toys or media.

Toys and media were central to parents’ understanding of the benefits of play in the specific domain of language development. Parents sought toys and media to facilitate language and speech rather their own (parental) active participation in play. One mother noted, “I would buy the toy that, like I said, [that] sings the ABC, then the one, two, three, because that’s how they learn. How to put words together, ABC, because that’s how I learned, by playing with a toy…” Parents also tended to seek out electronic toys or media that had a strong emphasis on teaching children the correct way to pronounce a sound or word. For instance, one mother said, “I recommend that toy she was talking about that teaches you how to pronounce the letters. ‘A, B, C’- If they hear it, maybe they’ll start saying it over and over again. Maybe the child will see it and know how to pronounce it the correct way, instead of [you] trying to show it to them and say, “Say ‘A.’ Say ‘red.’ Say ‘blue.’” Another mother also highlighted this point remarking, “You’re saying it, and they’re looking at you, trying to comprehend what’s coming out. Sometimes, they’re not really going to just jump on it right away, but if they get this toy that they’re so into, at least spitting out how to say “A” and “B,” and how to pronounce it the right way, it’s a little bit better on the child’s point of view.” As noted in these excerpts, parents tended to rely on toys and media for language promoting benefits, and at times juxtaposing toys and media as more effective in supporting language development relative to stand-alone parental engagement with their child.

Similarly, parents discussed play as important for a child’s learning and education, emphasizing media and toys as offering the educational benefits of play. For their children less than 2 years of age, parents focused on toys and media that contained concrete concepts such as letters and numbers and viewed these skills as critical for early learning and school readiness skills. A mother in the group expressed, “For me, I would say a toy that involves the alphabet, colors, and numbers because to me, those are the first crucial things of a kid, whether it’s 2 years old going to daycare, or 3 years old starting Head Start, those are the most crucial, important things.”

Domain 2: Barriers to Play.

Themes describing parents’ barriers to play included: 1) time for play due to household and work responsibilities, 2) knowledge regarding importance of play, and 3) media.

Parents identified numerous everyday responsibilities that prevented them from playing with their child such as cooking, cleaning, and other household tasks. Additionally, parents acknowledged distractions posed by having other children in the home as barriers to play. One mother observed, “And I think if you have another child, I think it’s maybe a little bit harder to kind of entertain both, because if they’re different ages, like the bigger guy’s not gonna wanna sit and maybe do something with the little guy, or you know what I mean?”

Many parents also commented on how being at work hindered their ability to find time or energy to play with their child once they returned home. One mother summarized these feelings by saying, “I agree with him, because I work 12 hours every day, and she go to daycare…As soon as I come through that door, ‘Mom! Mom!’ And I be so tired when I go home. Me and her dad swap. I’m first shift. When I’m coming home, he leaving out. He work from 6:00 at night to 6:00 in the morning, I’m from 6:00 in the morning to 6:00 at night, and she be so energized. I be like, ‘Ooh, honey, I’m so tired,’ but I know she needs that time and attention.” Participants described fatigue, often caused by these everyday responsibilities, as further impacting their ability to play with their child. As one mother noted, “Yeah, that sum it all up. Time just in the way of the play. There’s not enough time.”

In addition to household responsibilities, some parents mentioned that a lack of knowledge regarding the benefits of play prevented participation in play activities. One mother commented, “It’s one thing to sit back and judge or see somebody else or how they raising their kids, but you never really focus in or think about it for a second, like, “He [parent] probably didn’t learn too much.” Parents discussed how younger or first-time parents were particularly vulnerable for not having this knowledge. For example, one mother remarked, “Right, because I was 18 when I had my first child, got right out of high school, so I didn’t know what to do.”

Although parents indicated that certain television shows and cellphone/tablet applications could be beneficial for their child’s development and learning (see perceived need themes), they also recognized the challenges posed by them in terms of limiting interactions and opportunities for play. For instance, a mother said, “So it’s impressive to see the little children be able to work technology, but it can be a disturbance. But it’s like a give-and-take. In moderation. It would be great if you can just do it in moderation, and regulate the times, but sometimes the time just goes by. It just goes by.”

Some parents acknowledged that media had become a necessity to keep their child calm or entertained as one mother stated about her 6-month son, “My son, he’s 2, and I have a son that’s 6 months. My son that’s 6 months, all he wants to do is watch TV or be on the iPad. I just let him watch cartoons on the iPad all day.” Other parents noted that due to the prolonged exposure to media, their children seemed confused as to how to play. One mother emphasized, “Sometimes, I think a little too much TV is too much for kids. It’s all they know. It’s what they want. When they wake up, they’ve got the TV on, and when it’s time to play, it’s like, “Oh, what are we doing? This is new. I’m not used to this.”

Lastly, other parents discussed their own use of media, with an emphasis on social media and cellphones, as a hindrance to playing with their children. One mother in the group observed, “A lot of parents are into- so worried as to what’s going on in today’s society, or chasing a relationship. Those types of things. So, they’ll just sit on their phone and be on social media all day. Kids can burn the house down and they wouldn’t even know it.”

Domain 3: Cues to Action.

Participants expressed a need for reminders, often due to everyday demands, to prompt them to play with their child. One mother stated, “No, I think, if you compile your mind with a lot of things of what you have to do, that might be on the backburner. You might forget about, ‘Hey, he needs to play. He needs to hear my voice. He needs to hear me sing or hear me read to him.’ If you’re thinking about the housework, and the older kids, and the school forms that need to be turned in - that is a hindrance I’ve experienced with this four-month-old.”

Participants also indicated a need for ideas on how to play with their children. One mother expressed, “Because, a lot of times I think it’s hard to keep a child entertained. You have to try different things.” Another mother agreed with this difficulty stating, “Because, I think they get maybe bored or not challenged.” Additionally, parents discussed the need for ideas on how to integrate play into their daily responsibilities. For example, one mother stated, “Yeah, and there’s also an expectation – getting stuff done at the same time. So, I’m making dinner most nights as well, so how do I blend those two together and keep her occupied?”

Parents requested suggestions on activities that they could do with their child not only for their child’s benefit, but also to alleviate some of their own feelings of monotony with play activities. One father commented, “For me, sometimes, just thinking of what to do. I can get a little monotonous, so I think, ‘What do I do right now?’ If we’re singing, ‘What are we singing?’ That’s the biggest challenge right there.”

DISCUSSION

The primary aim of this study was to develop an improved understanding of parental attitudes and beliefs surrounding participation in play through focus group interviews with parents of young children attending a primary care clinic in a large urban medical center. Our study was unique in that we examined this topic through 1) qualitative methodology and 2) an emphasis on obtaining views from families from low-income, urban communities. Thematic analyses revealed several themes that mapped onto the HBM domains explaining parental perceived need for play, barriers to play, and cues to action.

Parents described play as important for promoting parent-child bonding, as well as for promoting development and learning. The perceived need for play for bonding versus play for developmental and educational skills differed in one prominent way. Play in the service of parent-child bonding was described as general interactive play between the parent and child with rare mentions of the utilization of toys or media to facilitate bonding. In contrast, play in the service of development and education was almost exclusively described as toy- or media-based play. Parents discussed play as beneficial for development and educational readiness only when an educational toy or media was involved in play, and did not discuss interactive parent-child play as promoting development or school readiness skills. Additionally, there were notable barriers which impacted parental participation in play, including household and work demands, lack of knowledge, and media barriers. Despite these barriers, parents recognized the importance of play and indicated that reminders and ideas for play would be helpful cues to action for engaging their child in play.

Implications & Future Directions

As suggested by the HBM, parental attitudes and beliefs surrounding play have important implications on if and how parents play with their child, which can subsequently influence their child’s development and subsequent educational trajectory. Our results demonstrate that families have heard the strong pediatric and public health messages emphasizing the importance of play to promote a child’s development. However, there may be important misinterpretations of this message which may help guide future public health communications and program development, a key objective of this study.

Understanding how to activate the benefits of play.

Parents in this study viewed play as an important strategy for nurturing parent-child relationships and recognized its importance in encouraging a child’s development, specifically in the areas of motor and language development. However, somewhat undermining this belief, many parents did not view their actions as impactful as electronic toys for promoting speech, language, and early learning skills. Parental reliance on electronic toys for promoting early childhood development and education is concerning. If well-intentioned parents are overly relying on electronic toys to reap the benefits of play, how may this affect their children, particularly those who are at increased risk for poorer developmental outcomes?

Although the role of toys in early development requires further investigation, theoretical models of child development suggest their impact is largely due to facilitating parent-child interactions.^7–9,28 Limited studies suggest that educational media or applications (i.e., “apps”) may have some positive impact on the acquisition of concrete literacy skills in older children. However, theoretical models of child development again suggest their impact, similar to language development, is largely driven through facilitating parent-child interactions.^29,30 Thus, by forming an overreliance on electronic toys and media to promote a child’s development, well-meaning parents may unintentionally be contributing to educational inequities through their dependence on them.

As suggested by the HBM, the fact that parents did not view stand-alone parent-child play as capable of impacting cognitive and language development suggests that they may be less likely to engage in this type of play. Addressing these beliefs to promote increased understanding of the full range of domains that parent-child play can impact will be particularly important for the growing number of national and international parent-directed programs that strive to promote parent-child interactions. Given these findings, future next steps include: (1) examining how to integrate this advice during well-child visits and potential impacts on parental attitudes and behavior will be important next steps, and (2) additional strategies on how to convey the known strengths of parental involvement for their child’s development in contrast to the limited research regarding the role of toys and apps during an already time-compressed well-child visit should also be explored.

Understanding the range of play benefits.

Parents placed a strong value on teaching their children concrete academic topics such as letters, numbers, and colors in preparation for school success. In contrast, very little discussion centered around the benefits of play with regards to executive function skills and social development, factors that have shown to also be critical for school success. As a result of these findings, future studies examining how parents view these “soft skills” in relation to their children’s later academic success m further encourage parent-child shared play. Additionally, an exploration of how these views vary by different cultures will be important to tailor pediatric anticipatory guidance for larger reach.

Addressing barriers & learning to integrate play.

Caregivers identified several everyday demands that prevented their participation in play, underscoring the need for approaches that incorporate play activities into daily routines. Given these findings, future studies should examine how parent-directed programs and pediatric providers can nudge caregivers into engaging in play activities by developing strategies on how to integrate these activities into already existing daily demands such as making dinner versus asking a parent to add an additional, although hopefully enjoyable task, to an already full day.

Limitations

There are potential limitations to our study that must be noted. The participants in our sample were recruited from a single primary care-based setting serving a largely urban, low-income population. As a result, our findings may not be relevant to other parents in other settings, such as parents receiving services through community-based clinics or other systems. However, our participants did represent a diverse sociodemographic perspective in relation to age, ethnic background, and number of children living in the home, and thus our findings may be relevant to other parent-directed programs and pediatric providers who aim to encourage cognitively stimulating activities. Additionally, the focus groups were conducted with participants who could speak English and may not reflect cultural differences in attitudes and beliefs in other non-English speaking ethnic groups. Future studies should assess variability in perspectives based upon characteristics such as gender, age, ethnicity, or household composition.

Conclusion

Parents in this study demonstrated a strong desire to encourage their child’s developmental and school readiness skills through play. However, their dependence on toys and media, in part due to every day responsibilities and stressors, may actually be inhibiting key opportunities and benefits of parent-child shared play. Pediatric and public health programs may be more effectively implemented if they consider these attitudes as they develop new or refine existing strategies for promoting key parenting behaviors that foster early childhood development.

Abbreviations:

AAP

American Academy of Pediatrics

HBM

Health Belief Model

UI Health

The University of Illinois Hospital & Health Sciences System