Obesity among children and young people has been recognised as a serious and urgent challenge because of the lifelong consequences on health and wellbeing (World Health Organization [WHO], 2016). The global epidemic can be explained by a multitude of environmental factors (Soliman and Huang, 2018). However, excessive sugar intake, increased portion size, and a decline in physical activity have been playing major roles in rising rates around the world (Sahoo et al, 2015). In England it is estimated that 1 in 5 children aged 4–5 years and 1 in 3 children aged 10–11 years are overweight or obese (Department of Health [DH], 2018). Additionally, evidence suggests that the COVID-19 pandemic lockdown has made this situation worse (Surekha et al, 2021). The rise of e-learning meant an increase in screen time and sedentary lifestyle, and an increase in unhealthy snacking. This needs to be addressed or obesity will lead to profound long-term complications.
The UK government has been actively considering restrictions on advertising unhealthy foods and beverages (DH, 2018; Department of Health and Social Care, 2021). There is evidence that this could make a meaningful contribution (Mytton et al, 2020). However, food and beverage companies have been shifting their advertising spend from TV to digital media in recent years (Powell et al, 2013; Tan et al, 2018). This is likely because children in the UK spend more time online than they watch TV (Ofcom, 2016). YouTube has become increasingly popular, and school-aged children and young people are among the most prolific contributors, not just as viewers but also as producers (Neumann and Herodotou, 2020).
Children watching YouTube frequently view user-generated content in the form of vlogs (video diaries) and their degree of bonding with the vlogger predicts their time spent watching (Folkvord et al, 2019). Content of these vlogs include ‘unboxing’ videos where products such as toys are being opened, or online viral challenges (Khasawneh et al, 2019; Strangelove, 2020). Here the children perform or teach an activity, such as making slime, and then challenge their viewers to do the same. Children who vlog and attract a mass following then act as ‘influencers’ and can generate a lucrative income from companies to promote their products (Boerman and Van Reijmersdal, 2020). This includes the promotion of unhealthy food and beverage brands (Tan et al, 2018; Alruwaily et al, 2020). This way of advertising has raised concerns in that there has been a lack of moderation for this type of content which targets children (Coates et al, 2019; Castelló-Martínez and Tur-Viñes, 2020). However, this study asks whether this phenomenon could be used to encourage healthier behaviours with vlogs promoting or challenging healthy eating in their viewers.
We have known for a long time that peer groups have an important influence during middle childhood (Ladd, 1999). Perhaps more importantly, we know that peers can have an influence on lifestyle choices (Mollborn and Lawrence, 2018) such as decision-making and consumer behaviour including food consumption (Fortin and Yazbeck, 2015). This can be explained using social learning theory, which emphasises the importance of learning by observing the behaviour of perceived peer role models (Bandura and Hall, 2018). Indeed, research suggests that peer-led healthy eating interventions are very effective in influencing adolescents and perhaps more influential than adult-led intervention (Story et al, 2002). However, past peer interventions have predominantly been developed for adolescents (e.g. aged 13–16 years) and have included classroom peer-led activities.
Given both the strong influence of peers in middle childhood and the phenomenon of using digital media, this study investigated whether families with children of different ages could respond to a healthy eating educational intervention, delivered by a public health nurse, by making YouTube-style vlogs that can potentially teach and challenge their peers. It is hoped that this approach can be implemented not only as a family-based intervention but also as an intervention for primary schools if shown to be effective. This technology can be used to support learning and be an engaging classroom activity (Neumann and Herodotou, 2020). The study also aimed to evaluate whether delivering the intervention during the UKs lockdown period could encourage healthy behaviour for the whole family at home.
Method
The study was designed in two parts. In part one, the family-based healthy eating intervention is delivered and participants are asked to produce the vlog-style films in their home setting. Part two of the study aims to evaluate these films by asking viewing families to complete an online questionnaire to assess their influence and any knowledge about healthy eating they obtained. This article reports the findings of part one.
Recruitment
Families were recruited via social media. A recruitment poster, which outlined the study and provided a link to an expression of interest, was disseminated via social media. Facebook group administrators were targeted to share the poster and link in parenting closed groups. The researchers aimed to recruit a diverse range of families such as some with multiple children, different ethnic groups, same-sex parents. Therefore, the expression of interest asked the families to explain a bit about themselves and why they wanted to get involved. The researchers followed up potential families via email with more information (participant information sheet).
Parents/guardians were explicitly asked to consider all risks and consent on behalf of their child/ren in taking part. Before giving their informed consent, they were given time to read and consider the elements in the participant information sheet and they received full guidance and advice on the criteria for the vlogs to ensure privacy is promoted and the child/ren are safeguarded. Informed consent was obtained from all parents on behalf of themselves and each of their children before they took part. In this study, it is not possible to grant participants full anonymity, due to the essence of data needed to examine the influence of human behaviour on others through film. In this approach, the family acts a co-researcher in where they are asked to make an informed consent to forgo full anonymity in order to present their work to the public in part two of the study (Thomson et al, 2018). However, the researchers are aware of children's particular competencies and vulnerabilities. Therefore, the researchers also assessed the risk of anonymity, confidentiality and safeguarding of the participants in the final edited versions of the films. The final decision on what is used in part two of the study and made public was made by the researchers. This study was approved by the University of Derby College of Health, Psychology and Social Care Ethics committee.
Intervention design
The intervention was designed and delivered by a registered public health nurse (first author) to take an informative educational approach. It used interactive Q&A elements throughout to engage the families and build upon their understanding of healthy eating. It was pitched at an appropriate level for child/ren with the age range of 6–16 years. It was delivered to one family at a time via Microsoft Teams. The elements of healthy eating included: a discussion of the Eatwell Guide (Buttriss, 2016) and Change4Life recommendations (National Health Service [NHS], 2021) which included discussions about sugar and salt and health effects, smart shopping, food labels, healthy drinks, 5 a day and healthy snacks. Each session lasted approximately 1 hour and they were delivered at a time and date convenient to each family.
Creating the vlogs
After taking part in the healthy eating intervention, the families were asked to create a fun vlog-style video on their mobile devices in which they challenge peers (the viewers) to engage in the healthy eating behaviour. Families recorded their vlog on their own device during the lockdown period using props from around their own house. To give a vlog style feel, the families were given full artistic licence on what to include in the videos. However, the guidance information provided to the families also explained what a vlog is and what they should not include. Parents were given the choice whether to appear on camera or not, however, they were required to supervise any filming taking place.
Data collection
The families were asked to complete a pre-intervention online questionnaire to determine their knowledge about healthy eating. The questionnaire also collected demographic information which included children's age, parental educational level and household income. Once the families had produced their final vlog, the guardians/parents and children were invited to an online focus group. The purpose of this focus group was to explore their experiences of taking part in the intervention and to assess if they had learnt anything during the process of making the film (e.g. if it had influenced their eating behaviour). The focus group schedule included open-ended questions to meet these aims. The focus groups were carried out by the second author and held with one family at a time via Microsoft Teams.
Analysis
Data from part one was analysed using a standard thematic content analysis mapped against the aims (Braun and Clarke, 2012). Direct quotes are used to illustrate findings but the pseudonyms of the participants have been used to maintain confidentiality.
Findings
Four families consented to take part, attended the online healthy eating intervention, and produced vlogs. There were nine children in total. Three families had two children and one family had three children. Their age ranged from 3 to 17 years. The pre-intervention questionnaire asked each family what a healthy meal looked like to them. They gave examples of meals such as pizza, another stated ‘nothing deep-fried’. They all stated that they usually have a source of vegetables. They were also asked what they thought were the main things preventing a child from eating healthily. The prominent answer was their tastes were different, but it was also recognised that the family might make poor choices or quicker and easier to buy readymade food. Overall, the pre-intervention questions suggested that these children believed that they did have some understanding of what healthy eating is. The answers were used by the public health nurse to tailor the delivery of the intervention. The interventions took place during March 2021. All families engaged and responded well to the approach. The children all got a chance to engage and participate in the questions and answers. The online delivery meant that there were technical difficulties at times, but the families and public health nurse were able to adapt accordingly, and it did not affect the interventions. The families took approximately 2–3 weeks to make their films. The longest film was 6 min and the shortest 2 min. The films included the children and/or parents demonstrating how to make healthy meals with healthier alternatives. There were discussions of food groups and the effects of sugar and salt on the body. One family demonstrated how you can grow your own vegetables in an urban garden area. They all challenged the viewer to make healthy food swaps.
Focus group findings
There were three families who chose to take part in the focus group as a follow up to making the vlogs. Analysis of the three focus groups revealed four broad themes:
- Initial challenges
- Child attitude change
- Awareness for parents
- Behaviour changes.
Within each broad theme there were several substantive subthemes that are discussed below, supplemented by anonymous quotes.
Initial challenges
All participants expressed that at first, they found creating the vlogs with their families a challenge. Several reasons for this were discussed including issues with child motivation and engagement, confidence in their technology and on-screen capabilities, the time-consuming nature of making a vlog and challenges with the content and overall vision of the video. Participants discussed the lack of child motivation in two ways. Children themselves stated that they were reluctant at first to try the new and healthier options.
‘I think my challenge was when I was cooking like – the sauces and stuff, I hated all the things going into the sauces, but then obviously, if I actually tried the sauce, it tasted quite good. So, I struggled with starting off with that – that was my challenge.’
(Robert aged 13).
Whereas parents raised issues over children's motivation to start making the film.
‘You weren't super into it at first, I think once we started editing bits together and she could see like – oh, this actually is a bit – it looks quite good, then you got quite into it, didn't you?’.
(Monroe discussing their child aged 10)
This lack of motivation was explained by some parents as being down to confidence in front of the camera. In addition, all families spoke about the time-consuming nature of creating the vlogs. All stated that the full process took a lot longer than they had originally thought it would when they signed up to the study.
‘I think it was actually a bit hard to fit everything together because it was a lot of work finding the right clips and I had to talk over some of the videos on a microphone and I kept on getting it wrong when I was speaking, and I had to start again.’
(Linsey aged 10)
Some participants explained that this hard work and the time-consuming nature of the vlogs were due to the difficulties in choosing what to include and their overall vision for the vlog. One family spoke about ‘artistic differences’ between family members slowing them down, and another spoke about ensuring they ‘pitched’ it at the correct level for other children. Some spoke about the struggle of transferring their vision onto the screen.
‘I think our vision, for what we wanted didn't necessarily come across, we had big dreams that were outweighed by our prowess when it was actually editing videos.’
(Sam talking about working with their children aged 9, 13 and 16)
Despite these initial challenges, all families indicated that they were glad they took part in the study and they were very happy with their final videos and what they were able to achieve. They spoke about how they had learnt from the experience and gained both knowledge and skills.
‘Actually doing the film, was good, it was educational for them, definitely, but that was it, I think, yes, once we had made the decision and went ahead with it, it was grand, and they enjoyed doing it.’
(Shanna talking about working with their children aged 6 and 10).
Families also spoke positively about the experience in terms of how taking part allowed them some quality family time and an opportunity to do something different together.
‘It was a lot of fun, wasn't it? We all came up with the ideas and the challenge we were going to include and that was quite a nice family time.’
(Isabelle talking about working with their children aged 9, 13 and 16).
Child attitude change
Both parents and children referred to how children's attitudes had been changed by the experience of attending the session and making the vlogs. Children spoke about this attitude change in relation to trying new foods and making healthier swaps.
(Guy): ‘Yes, we learnt how much we actually love some of the different changes in the stuff – you know, that's healthy’ (Robert): ‘Yeah, it's how some of the changes can be better than we thought they would be like we thought they would be more bad I guess, but actually, they were really good’.
(Siblings aged 13 and 16)
This change in perspective and attitude was seen across children of different ages, with participants often speaking about the realisation that healthier swaps tasted better than they had previously thought.
‘I learnt that brown rice is better, and it has a lot more nutrients and that it is actually much tastier when you have it.’
(Linsey aged 10).
This was reinforced by parents, who spoke about how these changes in attitude appeared to be long-term, in that they had been maintained weeks after the videos were created.
(Sam): ‘And every night now we get them to try different stuff so, they're more open to it now, which is good’ (Isabelle): ‘So, I think they're the biggest differences that we've seen through making them [the vlogs], it kind of encouraged them to try new stuff, because they had to because we were recording. They've now taken that on in life as well, so, that's good’.
(Parents discussing change in their children aged 9, 13 and 16)
Awareness for parents
Parents themselves did not speak about their own attitude changes, instead talking about how, for them, the process was more about bringing back into their awareness knowledge and practices they already knew. They spoke about how it had made them question themselves and their practices.
‘I must admit, I've always avoided brown pasta and stuff like that, so, that was nice to rediscover, as it were…. I think it's good as a healthy reminder, you know for a lot of things, you just kind of forget as you hide behind the guise of – oh, life is getting in the way, you know’.
(Isabelle, Parent)
More specifically, these parents spoke about how the process of making the vlog with their family allowed them to talk and engage directly with their children about healthy eating, which they may not have done otherwise. They spoke about how although they generally believe themselves to be healthy eaters this process helped both children and parents work out where they could improve.
‘It was good because I think we just take it for granted that we eat vaguely healthily, it's not like a massive thing we talk about all the time, but it is always good to have that refresh and that talk about it together and work out what we're going to show because is it healthy or not healthy, or whatever.’
(Monroe, Parent)
Behavioural change
Spanning from the previous two themes (attitude change and awareness), families spoke about behavioural changes they have now made. These changes included reducing takeaways and pre-prepared foods and reducing salt intake.
(Alaiya): ‘We eat less shop foods’ (Shanna): ‘We used to get a takeaway … we actually do make our own pizza, for pizza night now, because it actually tastes as good. So, we all know there is lots of salt in foods, but I think when you become conscious of it and it's brought more to your attention, I don't really want to have it.’
(Participant aged 10 and Parent)
These changes appeared to be long-term as they had been maintained weeks after the videos were created. Families also spoke about reducing sugar intake and snacking.
‘Yes, she would just come home and have something chocolatey, as a habit after school – have something sweet, like treat yourself kind of thing. You don't do that so much now, do you? So, that has changed.’
(Monroe, Parent)
They discussed reducing portion sizes and increasing water intake too. Importantly, they began to talk about how they believed that other children viewing these videos would be influenced to make these healthy behavioural changes too. They specifically believed this would be because children are influenced by those of their own age.
‘Even the water, after we did the video, she was a lot more – okay, I'll have the water then, she would have just not had it before, she would go hours without having water unless I offered her. But yes, I think so, just seeing other people doing it of a similar age would make a big difference’
(Shanna, Parent)
Discussion
The family-based intervention involved actively engaging with the whole family for the task. There is evidence suggesting that family-based interventions targeting childhood obesity are successful in producing weight loss in the short and long term (Chai et al, 2019). In this approach, health practitioners work with parents as agents of change to support health behaviours in their children. However, by additionally asking families to create their own vlogs, it enhances the intervention and further embeds messages of healthy behaviours. It requires the whole family to collectively focus and act on healthy changes, knowing they also need to demonstrate this behaviour to others. This in turn may have contributed to their motivation or incentive to succeed in the task.
The findings of the focus group showed that children's attitudes and behaviours were changed by taking part in the study. This change in attitude is important because The Theory of Planned Behaviour (Ajzen and Fishbein, 2005) suggests that although attitudes and behaviour are not always aligned, when they are, behaviour is more likely to continue. Indeed, Conner and Norman (2021) also showed attitudes towards healthy eating could predict healthy eating behaviour years later. Therefore, our findings suggest that interventions of this type have the potential to have a long-term influence on children's eating behaviours. During the focus group, parents began to discuss how other children may be influenced to make healthier decisions by watching these vlogs. This is in line with the Social Learning Theory (Bandura, 1977) that highlights the role of observational learning and modelling. Furthermore, research into healthy eating and food choices suggests that children are influenced by peers both in their food (Kim et al, 2019) and drink choices (Kim et al, 2020) and that this only increases with age. In part two of our study, we explore this further by asking other families to watch the vlogs and assess their influence.
Study limitations
This study recruited a small selection of families available for the intervention and who were able to make the vlogs independently (during lockdown). The researchers did want to recruit families from underrepresented groups (e.g. ethnically diverse, same-sex families). This is crucial for addressing ethnic disparities in health status (Renert et al, 2013; Ash et al, 2017). However, the limitations that came with recruiting and adhering to the government restrictions meant the researchers were unable to reach out to diverse communities. The researchers also recognise that interventions such as these may widen the inequalities gap for those who do not have access to such technology.
Conclusions
This study engaged with families during lockdown to encourage healthy eating. During this challenging time for families, the online educational intervention was successfully delivered at a time that was convenient for them. Families were then asked to complete the vlogs, as a family task, in their own time. The act of creating these vlogs has shown great potential in enabling behavioural change for all family members involved. However, even without the requirement to create vlogs, this study shows great potential for health practitioners delivering interventions remotely. Practitioners can utilise tailored digital interventions to engage young people and their families effectively.
The next stage of this study is to determine whether the families who created the healthy eating vlogs can have a peer influence on the health behaviours of those viewing. You can watch the vlogs at www.derby.ac.uk (search Family Healthy Eating Vlogs).
KEY POINTS
- The study demonstrates how health-care practitioners can deliver tailored online public health interventions that engage the whole family.
- These families created digital films which showed their acquired knowledge of healthy eating and they encouraged others to make a healthy change of behaviour.
- This intervention indicated sustained behaviour change for these families. The vlogs can potentially be used to influence peers.
REFLECTIVE QUESTIONS
- How have you adapted your practice to deliver interventions during the global pandemic period? Reflect on the advantages/disadvantages of continuing any adaptations of practice post-COVID-19.
- How do you think online family-based interventions could be incorporated into your own practice? What are the risks? What would be the advantages/disadvantages?
- What are the possibilities of using interventions that incorporate peer influence within a school setting?