Health Education Research, Vol. 15, No. 5, 581-590,
October 2000
© 2000 Oxford University Press
Social–environmental influences on children's diets: results from focus groups with African-, Euro- and Mexican-American children and their parents
Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates, Houston, TX 77030,
1 Department of Behavioral Science, University of Texas M. D. Anderson Cancer Center, Houston, TX 77030 and
2 University of Houston, Houston, TX 77030, USA
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Abstract |
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Children's fruit, juice and vegetable (FJV) and fat intakes do not meet recommended guidelines. Since personal factors account for only a small percentage of the variability in children's FJV consumption, social and environmental influences were explored via focus group discussions with Grade 4–6 African-, Euro- and Mexican-American students and parents. Questions included the effects of social influences, availability and accessibility on children's FJV and low-fat food choices. Few ethnic differences were noted. A variety of low-fat items and fresh FJV (not cut-up) were available at home; older children were expected to prepare their own. Eating out occurred at least twice a week; FJV were not usual restaurant choices. Students reported some modeling by parents (more mothers) and friends (usually at lunch). Negative peer responses for eating vegetables were reported. Parents were concerned with children eating too much junk food and not enough FJV, recognized the outside influences their children received about food, and reported several methods to encourage children to eat FJV. Recommendations for future interventions are proposed.
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Introduction |
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Children's fruit, juice and vegetable (FJV) and fat intakes do not meet recommended national guidelines (Patterson et al., 1990
; Devaney et al., 1993; Domel et al., 1994), and are risk factors for the development of chronic diseases (US Department of Health and Human Services, 1988). Less than 20% of youth eat the recommended goal of 5 servings per day and mean intakes of 1.5–2.5 servings of FJV per day have been reported for US children (Murphy et al., 1990; Domel et al., 1994). Similar data on low-fat food consumption are not available.
Since there is a belief that child lifestyle behaviors are likely to become adult lifestyle behaviors (Kelder et al., 1994) and that behaviors are more malleable among children (Singer et al., 1995), dietary behavior change programs for children are needed. Understanding the influences on children's diet will lead to more effective intervention programs (Baranowski, 1997).
Eating FJV and low-fat foods must be understood in the context of relevant behavioral theory. Social Cognitive Theory and its principle of reciprocal determinism propose that behavior, the environment and personal factors interact in constant reciprocal relationships (Bandura, 1986). Two recently published studies (Domel et al., 1996; Resnicow et al., 1997a) revealed that among a battery of social cognitive personal characteristics, including self-efficacy (the confidence one has to perform a specific task), FJV preferences and outcome expectations, only FJV preferences was the dominant predictor of children's FJV consumption and accounted for only 9–13% of the variability. This lack of predictiveness for personal variables suggests that environmental factors (physical and social) are important in children's FJV consumption.
Environmental factors influencing FJV intake have been reported by African- and Euro-American students (Baranowski et al., 1993; Kirby et al., 1995): low availability at home, low accessibility at home (e.g. ready-to-eat carrot sticks in the refrigerator); and low availability at fast food restaurants. Mexican-American children were not represented in these discussions. Children's FJV consumption has been related to home FJV availability and lunch FJV consumption was related to FJV availability at elementary school cafeterias (Hearn et al., 1998). Lower fat in school lunch meals reduced children's fat intake (Parcel et al., 1989; Raizman et al., 1994). Because of differences across ethnic groups in culturally specified foods (Menotti et al., 1999; O'Doherty and Holm, 1999), there is a belief that ethnic groups differ in consumption, but the data are inconsistent (Reynolds et al., 1999; Thompson et al., 1999). Very little is known about ethnic group differences or social environmental influences on children's food consumption (Baranowski, 1997).
There is little research on parent influences on children's diets (Baranowski, 1997). Research on social modeling, social support and normative expectations for FJV and low-fat food among children is limited (Crockett and Sims, 1995; Baranowski et al., 1999). Adult role models (Birch, 1980; Birch et al., 1980; Hendy, 1998) can influence pre-school children's food intake. The literature on social influences, such as peer modeling or perceived norms, in regard to children's eating FJV or low-fat foods also is limited (Kelder et al., 1994). The literature on parent roles associated with helping elementary school age children eat healthy diets suggests we do not know much about how to help families influence children (Baranowski and Hearn, 1997). Parents provide access to foods in the home (Crockett et al., 1988), may act as models and provide encouragement/discouragement for specific eating behaviors (Olvera-Ezzell et al., 1990; Cousins et al., 1993; Baranowski, 1997). This paper presents the results from focus groups with African-, Euro- and Mexican-American students and parents to assess social–environmental influences on children's FJV and low-fat choices. From a social cognitive perspective, these groups focused on parent motivation and behavioral capability to promote children's healthy diets; the availability and accessibility of FJV and low-fat foods in children's environments; the competition provided by alternate foods in children's environments; and social influences from parents and peers (normative beliefs, perceived norms and social modeling) on children's food choices and practices. Ethnically homogenous discussion groups allowed comparison of results by ethnicity.
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Methods |
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Sample
This study was approved by the Institutional Review Board of the University of Texas M. D. Anderson Cancer Center in Houston, and parental consent and child assent were obtained. A local parochial school district agreed to participate, and the superintendent assisted with the recruitment of Grade 4–6 classrooms (9- to 12-year-old children) from three African-American schools (78 potential students), one Euro-American school (160 potential students) and two Mexican-American schools (105 potential students). All schools received Chapter 1 funding indicating attendance by low-income families. Student discussions were conducted in the classroom and lasted about 45 min; parent groups were scheduled in the evening. Participating children and parents received small gifts. Three of the authors (Euro- and African-American dietitians, and a Mexican-American psychologist) conducted the groups, which were audiotaped and then transcribed.
Question guide
Key student questions centered on the issues of availability/accessibility of FJV and low-fat foods (at home and when eating out), foods competing with FJV, and social aspects of eating FJV (e.g. modeling by parents and friends, normative beliefs, perceived norms). Parent questions targeted similar issues plus monitoring of child health and growth, and parent motivation and behavioral capability to help child eat a healthy diet. General questions were introduced; probes were used to elicit further discussions on responses and to ensure that all topics were introduced.
Data analysis
The audiotapes were transcribed and analyzed using NUD*IST qualitative software (QSR, 1997). The transcripts were coded and variable names assigned based on content. Themes associated with text passages were identified and assigned as variables. All the transcripts were then reviewed and text passages were transferred to the appropriate variable. These data were then printed and two staff members independently summarized student comments (within each variable) by grade level and ethnicity (based on school). Differences in summarization were reviewed and resolved.
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Results |
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Sample
The average size of the student focus groups was 11 students, with a range of six to 17 (Table I
). The average parent group included five parents, with a range of two to nine. Tables II and III present demographic information. The educational level of the Mexican- and African-American parents was lower than that of the Euro-American parents. Fewer African-American parents reported being married/living with a partner. No information was available for non-participants.
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Availability and accessibility
All child groups reported that a variety of fresh FJV were available in their homes. Only a few of the African-American and Euro-American children reported that the vegetables were already cut-up (i.e. accessible); parents expected children this age to prepare their own or ask for help. Parent groups confirmed the availability of a variety of fresh FJV, and some canned or frozen FJV, in the homes. Parents acknowledged the importance of accessibility: `And if you have vegetables and things cut up...but on the weekends I think I eat more healthy because I take the time to prepare the foods...on the weekends and Monday and Tuesday. By Wednesday we're eating whatever, because I've only prepared for those 2 days'. Parents in one African-American and the two Mexican-American groups reported that canned FJV were not as healthy as fresh FJV. Cost of FJV out of season and of 100% juice were the major reasons for not purchasing them and not having them available at home.
All child and parent groups reported that low-fat versions of a variety of foods were in their homes: milk, salad dressings, margarine, crackers, cheese, cookies and chips. Low-fat frozen dinners were only reported in the Euro-American groups. All groups noted that whole milk was also available in all homes for certain family members. Poor taste of low-fat foods was a major concern, particularly the fat-free versions: `It (low-fat food) doesn't have flavor to it'; `...disgusting'. Despite the poor taste of low-fat foods, most of the child groups related low-fat foods to weight control and reported that low-fat foods were good because they `didn't make you as fat as other foods'. Most parents reported that eating low-fat foods was a good habit: `It's good to watch their low fat'; `I think it's a good habit to get into because you carry these habits forever'. At least one parent in each group felt that low-fat foods were not needed unless the child had a weight problem: `I think it's all about eating a small portion'.
Parent influences
An African-American child group suggested that some parents did not make their children eat FJV and might not fix vegetables in an appetizing manner. Most child groups reported that parents expected them to finish their meals. An African-American parent group suggested that parents did not prepare FJV and have them accessible for meals. All parent groups mentioned that they felt that the lack of parent example (both their own and in general) was a reason children did not eat FJV: `I don't eat bananas and there's not any of my kids that can eat bananas'. The child groups also reported that they observed mothers eating FJV or low-fat foods only occasionally.
Most parents reported that their children were allowed to help prepare some meals, particularly breakfast, lunch and snacks. Only a few of the older children (i.e. those in Grade 6) were allowed to use stove, ovens and knives without supervision. Children from all age groups were allowed to use the microwave oven without supervision.
Peer influences
Students reported peer influence as a reason for not eating both FJV and low-fat foods. Many students reported observing friends eat fruit sometimes, usually at lunch. Most negative comments from peers were about eating vegetables, although most students said that negative comments would not affect their eating a vegetable they liked. All parent groups focused on the competition from sweets, `junk food' and `fast foods'.
TV Influence
TV commercials that promote `junk foods' and non-juice sport drinks were mentioned as influential by parents and children. Parents were concerned about new foods advertised on TV that they thought were less healthy.
Other influences (norms)
Students considered 100% orange juice as a `breakfast thing'. If given a choice, preferred beverages at all meals were soft drinks, punch drinks, sport drinks, water and milk. Parents also reported choosing preferred beverages like coffee, tea and soft drinks instead of 100% orange juice. Most of the child groups mentioned sweets, desserts and other snack foods as preferred choices instead of eating fruit at meals: `We like candy, all kids like candy more than fruit'; `We like junk food'. Parents noted that `Most of the children eat the same thing, a lot of junk food'.
The child groups preferred items like salad, baked potato, macaroni, macaroni and cheese, broccoli and cheese casserole, french fries, bread, sweets, desserts, and salty snack foods to eating vegetables. Parent groups also admitted often selecting more preferred foods like sandwiches, bread, rolls, baked potato, cottage cheese and salads instead of vegetables. Both the student and parent groups considered salads as a separate food group from vegetables.
Eating out
Most child groups reported eating out at least twice each week and being allowed to order what they wanted. Choice of restaurant was not based on FJV/low-fat availability. A few FJV were reported as occasional choices: salads, baked or mashed potatoes, corn, green beans, fruit salad, and lettuce and tomato on hamburgers; parent groups concurred. Buffets (all you can eat for a low price), coupons, reasonable prices, drive-thru windows and kid friendliness guided restaurant choice. Parents only influenced menu choice when cost was an issue; only a few parents reported that they encouraged vegetable or salad choices when eating out.
Parent monitoring of children's growth and diet
All parent groups reported that they monitored child growth and health, and reported a great concern about weight and potential problems with obesity. Parents reported some knowledge about the FJV recommendation; `...give her some at each meal, ...give one at each meal...kids mostly don't eat this', let them have `all they want'. Parents often asked what foods their child consumed during the day, and recognized the access that children had to less healthy meal and snack foods in school and elsewhere.
Parent motivation/behavioral capability to help children eat healthy diets
All parent groups reported concern about weight and obesity, recognized their role in helping children eat a healthy diet, acknowledged that most children do not eat enough FJV, and were concerned with the amount of `junk foods' their children were eating. `My kids fix a lunch, and when they come back they would still have the same lunch [in their lunchbox]. So what did they eat during school time? ...bought French fries and stuff instead of eating the bagels or fruit snacks or fruit that I prepared for them.' Most African-American and Euro-American parents encouraged their children to eat FJV, and insisted that the children try at least one bite. They admitted that using bribery to get children to eat certain foods did not work. The majority of Mexican-American parents in one group and a few African-American and Euro-American parents reported that children were required to finish all the foods on their plate. Most of the child groups reported that some parents required them to eat everything on their plates, particularly if they wanted dessert.
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Discussion |
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Availability, accessibility, TV, and peer and parent factors were reported to influence FJV and low-fat food consumption by both child and parent groups. Consistent with our earlier findings (Kirby et al., 1995
), few ethnic group differences in responses were noted for any of the questions.
FJV were reported available in all homes, similar to other results with Houston area AfricanAmerican Boy Scouts and their parents (Cullen et al., 1998), but opposite to results obtained elsewhere with Euro-American and AfricanAmerican groups (Baranowski et al., 1993; Kirby et al., 1995). FJV accessibility (e.g. cut-up vegetables or fruit ready-to-eat) appeared to be a problem when older children were in the home in that parents expected the children to fix their own. Because of the competition from convenient ready-to-eat snack foods noted by these groups, parent interventions to make FJV more accessible, even to older children, are needed.
A surprising variety of low-fat foods were reported available in all homes, regardless of ethnicity. National data indicate that children and adults consuming a low-fat diet reported eating more fat-modified foods compared with those consuming high-fat diets (below 30% kcal from fat versus above 30% kcal from fat) (Kennedy et al., 1999). Low-fat items appeared to be more acceptable to the children in this study compared with fat-free items. Further study of the type consumed and contribution of fat-modified foods to childrens' dietary patterns is warranted.
All parents recognized their role of providing foods in the home (Crockett et al., 1988), reported trying to eat healthier foods (modeling food choice and eating behaviors), providing direct encouragement for eating foods, being concerned about the amount of `junk foods' their children were eating and worrying about their children's potential weight problems. Parents offered several suggestions for getting children to eat more FJV and some parents admitted that they tried to coerce their children into finishing meals. In previous research, parents reported that providing a positive social context and improving food acceptability by adding favored foods and modifying preparation were the most frequent methods used to encourage liking for foods (Casey and Rozin, 1989). However, parents in the present study also reported using rewards to induce liking for a food, which can reduce liking of the target food (Birch, 1980; Birch et al., 1982, 1984), but has shown short-term success among pre-school children (Hendy, 1998). There is some evidence that parenting style may be related to children's eating behaviors associated with obesity (Klesges et al., 1983; Johnson and Birch, 1994). Parents who reported using a high degree of parental control over what and how much their children ate had children who showed relatively little evidence of energy regulation (Johnson and Birch, 1994). Parents appeared frustrated by their children's poor choices and eager to learn appropriate methods to encourage healthy food choices in their children. Interventions targeting specific mediating variables (e.g. socialization practices, modeling) may be appropriate.
Food choices are influenced as children enter school and enjoy more social experiences with friends (Birch, 1980). Among 12- to 16-year-old students, friends' consumption of the food significantly influenced eating `unhealthy foods' (Woodward et al., 1996). In the present focus groups, children acknowledged that certain foods (vegetables and low-fat foods) would receive negative comments from friends. Similar concerns about eating vegetables were voiced by African-American Boy Scouts (Cullen et al., 1998). Although these students said negative comments would not affect eating the food at that time, perhaps such influences would counter the availability/accessibility of FJV and low-fat choices in schools and other eating establishments and children's own preferences.
Participants also acknowledged media influences on food choices (Donkin et al., 1993). Consumption of high-fat dairy foods, snack foods and cookies increased with hours of television reported watched by a British adolescent population (Woodward et al., 1997). A Food Pyramid constructed solely from foods advertised during Saturday morning TV shows excluded the fruit and vegetable groups (Kotz and Story, 1994). In this study, students reported the influence of sports stars promoting beverages and parents noted TV's influence on their children's food choices. Both the students and parents reported that snack foods, other beverages and desserts were preferred to FJV, despite high fruit and juice preferences reported in these focus groups and in previous work with children (Domel et al., 1996). Enabling children and adults to choose FJV in addition to or in place of higher calorie competitive foods remains a challenge for future work.
Eating out was frequent, at least twice per week for the evening meal, and restaurant choice was not guided by FJV/low-fat availability. National statistics indicate that children reported eating 26% of meals and snacks away from home, accounting for 32% of food calories and 36% of calories from fat (Lin et al., 1999). Reduced availability of FJV and low-fat food on fast food menus (Greecher and Shannon, 1977; Rees, 1992) poses a barrier to consumption. Previous research found that eating out was considered a special occasion and no conditions were applied to food choices (Baranowski et al., 1993). Similar findings were obtained in this research, identifying eating out as an important area for potential intervention research.
Both parents and children reported that salads were considered a separate food group from other vegetables. This suggests that influences on salad consumption may be different from those on consumption of other variables. This is consistent with recent findings that predictiveness increases when research is focused on more narrow food groupings (Baranowski et al., 1999). Future research should focus on salad consumption separate from other vegetables. Identifying categories of naturally clustered vegetables (Rappaport et al., 1993) and assessing influences separately may be another way to advance this research.
Limitations of this research must be noted. The purpose of the focus group discussion is to explore specific topics and collect subjective data from target groups (Kreuger, 1994). Therefore, all data are self-reported and there is no way to validate the responses. This was a self-selected group of children and parents who participated in these focus groups, potentially limiting the findings to this group. Although some socioeconomic differences among the parents were identified (Tables II and III
), the nature of the discussion format does not allow differentiation of responses by socioeconomic status. Comments from all ethnic groups were remarkably similar, identifying few ethnic differences in social–environmental influences on children's eating patterns. Perhaps we involved only acculturated Mexican-Americans.
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Application |
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Eating occurs in response to many influences—physiological, personal and environmental. The data presented in this paper highlight some of the environmental factors. Understanding the factors that influence dietary behaviors should enable researchers to design effective intervention programs that target these factors. For example, parents noted the relationship between accessibility of FJV and their family's healthier food consumption patterns. Time management, menu planning and shopping practices in regard to children's FJV accessibility could be a component of dietary change interventions targeted at parents. Children could learn to identify FJV and low-fat items in various eating establishments, identify other eating establishments that provide healthier food selections and increase their own skills in simple, tasty FJV preparation.
Since perceived norms appear to be an influence, videos including appropriate role models promoting FJV and low-fat foods, thereby resetting those norms, seems appropriate. Families' and/or a community's social norms for healthy eating, e.g. FJV and low-fat selections becoming standard foods at social events, could be increased. Interventions providing food-related parenting tips are indicated to increase parent motivation and behavioral capability to help children eat more FJV and low-fat foods. Although few ethnic differences were obtained in response to these issues, interventions still need to be tailored to the surface sensitivities for specific groups (Resnicow et al., 1997b). Attention to social–environmental factors influencing children's FJV and low-fat food consumption appears to be a substantial contribution to the design of effective interventions.
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Acknowledgments |
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This material is based upon work supported by the Cooperative State Research, Education, and Extension Service, US Department of Agriculture, under agreement no. 9700578.
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References |
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Received on May 13, 1999; accepted on February 21, 2000
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