Health Promotion International Advance Access published online on January 16, 2008
Health Promotion International, doi:10.1093/heapro/dam045
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Artice |
‘If I don't like it then I can choose what I want’: Welsh school children's accounts of preference for and control over food choice
1Social Inclusion Research Unit (SIRU), University of Wales, North East Wales Institute, Plas Coch Campus Mold Road, Wrexham LL11 2AW, UK 2Cardiff Institute of Society Health and Ethics (CISHE), Cardiff University, Cardiff, Wales, UK
* Corresponding author: E-mail: e.warren{at}newi.ac.uk
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SUMMARY |
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The paper draws on qualitative data collected in focus groups with primary school pupils in years three and five (ages 7–11 years), carried out as part of a wider study evaluating the Primary School Free Breakfast Initiative in Wales. A total of 16 focus groups were carried out across eight schools to examine pupil's perceptions of food and food related behaviour. A key finding was the way in which control over choice of food and access to healthy/unhealthy food options differed between younger and older pupils across home, school and eating out settings. While older participants experienced and valued high levels of control over food choice in all three settings, this was not the case for younger participants. Pupils in year three had little choice, particularly at home and school, with other factors (such as security, structure and mealtime companionship) being more important to them than ability to choose what they ate. All participants in the study expressed a general preference for unhealthy as opposed to healthy food items, even when acknowledging health consequences and engaging in some compensatory strategies. The authors suggest that interventions should aim to educate and encourage food providers, such as parents/carers, schools, and food outlets, to produce a range of healthy options, and encourage informed food choice among children at a younger age.
Key words: children; food; choice
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INTRODUCTION |
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Concern about levels of obesity and prevention of chronic diseases has focused attention upon the dietary practices of children (Gregory et al., 2000
; Livingstone, 2005). Child lifestyle behaviours, which are likely to become adult lifestyle behaviours (Kelder et al., 1994), are formed early in life (Dennison et al., 1998) and are more malleable than adults' behaviour (Singer et al., 1995).
A range of factors influence children's food patterns. These include: sensory perception (Eertmans et al., 2001; Stroebele and De Castro, 2004); parental food practices (Wardle et al., 2005; Contento et al., 2006; Padilla-Walker, 2006); eating environments (Coon et al., 2001; Patrick and Nicklas, 2005); socio-economic position (Backett-Milburn et al., 2006; Evans et al., 2006); peer influence (Hill, 2002; Contento et al., 2006); advertising and the media (Stroebele and De Castro, 2004; Padilla-Walker, 2006); knowledge about food and nutrition (Berg et al., 2002; Hart et al., 2002); school practices (Douglas, 1998; Shepherd et al., 2006) and the wider food environment such as price and availability, retail outlets and obesogenic environments (Furst et al., 1996; Devine et al., 2003; Stroebele and De Castro, 2004).
Given such diverse influences, children's eating patterns might be best understood in the context of their lived experiences (Mayall, 1991) and through their own accounts (Mauthner et al., 1993). This is important given policy debates concerning the effectiveness of health strategies and interventions including, for example, the Welsh Network of Healthy School Schemes (HPW, 2002), breast feeding initiatives (Radford, 1998), the Welfare Food Scheme (DOH, 2007), Sure Start (Sure Start, 2007), ‘5 a day’ (Produce for Better Health Foundation, 2007) and Food Standards Agency initiatives involving food labelling (Livingstone, 2001; Postnote, 2004).
Central to any understanding from the children's perspective must be the issue of choice over food (Wardle et al., 2003a, b, 2005; EUFIC, 2005). Fruit and vegetable intake of children is often lower than the nutritionally recommended amount (Gould et al., 2006) and despite increased exposure to diet and nutrition information, when given the choice children tend to select unhealthy food options (Warwick et al., 1997; Douglas, 1998). In the absence of family regulations surrounding food, it is argued that children tend to eat more fat and sweet foods, more snacks and make less-healthy food choices (De Bourdeaudhuij, 1997). However, where parents/carers do not provide nutritionally high meals, and where they exercise a high level of control over what food is available, children have restricted access to healthy food. One solution is to encourage parents to limit unhealthy options and make healthy food more available and convenient (Koivisto Hursti, 1999; Contento et al., 2006). The provision of several healthy options for children might also go someway to addressing their desire to have personal autonomy over food choice (Hoerr et al., 2005; Shepherd et al., 2006).
While parental/carer regulation of children's food choice is encouraged, it has also been criticised (Hill, 2002). First, the more parents encourage young children to eat certain foods, the less they may be likely to do so (Birch et al., 1985). Forbidden foods may be over-consumed when children finally have access to them (Fisher and Birch, 1999; Hill, 2002). Second, where parents exert high levels of control over food, children may become less able to regulate their own intake (Johnston and Birch, 1994). Control may limit children's acceptance of a variety of foods and disrupt regulation of energy intake by altering children's responsiveness to internal cues of hunger and satiety (Birch and Fisher, 1998). If parental control does undermine children's self-regulatory abilities, this may further increase the prevalence of obesity among children.
In the spirit of understanding children's perspectives, we explore their food preferences and perceptions of control over decision making in relation to food and discuss the implications for promoting and encouraging healthy food behaviours.
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METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSFINDINGSDISCUSSIONFUNDINGREFERENCES |
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The paper draws on an evaluation of the Welsh Assembly Government's Primary School Free Breakfast Initiative, which was rolled out from September 2004 in Communities First areas (the most disadvantaged communities in Wales. It was rolled out to primary schools in non-Community First areas in September 2005. An added phase to the evaluation includes 53 schools in these areas.). The evaluation comprised a randomized control trial, involving 58 schools and a qualitative investigation of pupil perceptions about food and related behaviours. This paper draws on the qualitative data, collected during a series of focus groups in a subsample (n = 8) of participating intervention schools (n = 29).
Schools identified for inclusion in the subsample were selected to be broadly representative of the wider sample. Hence large and small schools, urban and rural schools and schools in different geographical regions of Wales were included. In order to highlight age-related differences in pupil perceptions, one focus group of year three pupils (7–8 years old) and one of year five pupils (10–11 years old) were held in each school. Following opt-out parental consent procedures, teachers were asked to select male and female pupils who they anticipated would represent the broad range of pupil experiences. In their selection, teachers were requested to exclude pupils who they anticipated would be uncomfortable with, or distressed about, participating in a focus group (although they were urged not to merely select pupils who were most vocal/well behaved). All those selected consented to take part, with six pupils (with an even-gender split where possible) in each group, giving a total sample of 48 males and 48 females. Groups were led by a facilitator and one assistant, both of whom were trained researchers. Focus groups were held in school classrooms or staffrooms.
Group discussion aimed to: highlight perceptions about healthy and unhealthy food, explore issues of preference and choice and examine a range of food related contexts. A refined version of the ‘Circle Time’ approach (Mosley, 1998) was used to stimulate group discussion. That is, photographs depicting different eating scenarios (a school cafeteria; family kitchen/dining room; family lounge with television and fast food/restaurant) were used to introduce issues which were anticipated as pertinent to participants (Ells, 2001; Walker, 2001).
Discussions were audio-taped and transcribed verbatim. Transcripts were read and reread by the research team (authors). Analysis was informed by a grounded theory, constant comparative approach, whereby emergent themes were tested against the data set and refined accordingly. Coding reliability was achieved through independent examination of the data by members of the research team.
The study was approved by Cardiff University and NEWI Research Ethics Committees and all requirements of professional ethical practise (BSA and BPS) were observed. Each participant has been allocated a four digit identifier to ensure anonymity. In order, the digits represent gender of participant (F = female and M = male), school ID (1–8), year group (3 and 5) and pupil identifier (1–6).
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FINDINGS |
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The data indicated, irrespective of age and gender, that, when allowed to choose what they ate, pupils tended to make unhealthy, rather than healthy, choices. A marked preference was evident for items such as ‘chips and sausage’ (M552), ‘crisps and biscuits’ (F455), ‘cheese burgers’ (F636) and ‘pizza and smileys’ (M555). This was despite being knowledgeable about what constitutes unhealthy food (Warwick et al., 1997
; Douglas, 1998). Participants, irrespective of age and gender, associated unhealthy food with items containing fat, sugar and salt, highlighting, for example, ‘the fat on bacon’ (M131), ‘(If) they've got sugar in they're not healthy’ (F233) and ‘in the unhealthy food there's salt and salt isn't good for you’ (F833). In the sections below, issues of food choice in relation to healthy/unhealthy foods and pupil age are explored in three settings: home, school and eating out.
Choice at home
Older pupils exercised more control over what they ate than younger pupils. In only a small minority of cases, year five participants reported parents/carers exercising constraint such as, ‘my mum says you either have a sandwich or you put it in the bin’ (F256). For the most part parents/carers were described as complying with participant food preferences:
She just asks you what you want because some of the, some of the food in the freezer I don't like and my mum, my mum might make it without knowing that I don't like it (F254).
As illustrated in the above data extract, older pupils might exercise choice in situations where the parent/guardian is ignorant of the child's preference. Equally, as illustrated in the extract below, older respondents might reject a meal prepared for the family and select an alternative for themselves:
I go home and say what are we having for dinner and she (mum) goes like ‘we are having like pasta like a salad’ and I can choose. If I don't want it, like if I don't like it, then I can choose what I want and I can have like chips and spaghetti and chips and sausage (M552).
When offering choice, it appeared that participants' parents/carers did not necessarily provide healthy options. In the account below, the year five participant rejects his mother's ‘unhealthy’ option, for an alternative unhealthy meal of his own choosing:
I ask my mother what we are having for food and she says like ‘fish fingers and chips’ and then I say ‘mum can I have something else’ and she would say ‘what do you want’, and I would say like ‘pizza and smileys (reconstituted deep-fried potato in the shape of faces.)’, and she says ‘yes’ (M555).
In a minority of cases, year five participants claimed to access food outlets outside the home, where parents/carers provided no ‘acceptable’ option, ‘if I don't like it a lot I just get a sandwich sometimes or I just go to the chippy’ (F255).
While younger participants also tended to express a preference for unhealthy food such as ‘cheese burgers’ (F636) and ‘chips’ (M631), they appeared to exercise little control over decision making in relation to what they ate. In most cases younger respondents claimed, ‘I have what my mummy gives me’ (F631) and ‘my mummy chooses at home’ (F634). Younger pupils also appeared to have less choice over what they leave, ‘your mum makes you eat it ... I don't like mushy peas and she says well eat it’ (F233). This lack of negotiation over food at home was sometimes contrasted with the choice afforded when younger pupils ate out side the home, ‘sometimes...my auntie asks, what I want and I choose myself and I sometimes choose meatballs and smiley faces’ (F634). Only a minority described having some limited choice at home, ‘sometimes I have what my mummy gives me and sometimes I choose’ (F632).
Choice at school
Older pupils also appeared to exercise more choice about what they ate at school. This was clearly linked to their preference for packed lunches rather than school dinners, because, in the words of one participant, ‘we don't like school dinners’ (M653) and:
I just don't like having school dinners, I like have packed lunch and it's better...because you get, when you are at home you get what you want for your packed lunch like food and things but when you are at school you have got to have the selection that they give you (M351).
Similar to their experiences of eating at home, parents/carers appeared to exercise little control over the nutritional content of packed lunches. Many year five pupils described how their parents/carers succumbed to their preferences regarding contents, ‘If I like the crisps I do have them’ (M352), and, like the majority of older pupils who took packed lunches in preference to having school lunches, F554 reported how her mother:
...just says ‘what do you want for packed lunch’? And then she just takes me down the shop and she will buy me something that I want (F554).
Not withstanding their preferences for unhealthy foods some year five pupil accounts were tempered by an understanding of nutritional value. Hence, some older participants introduced healthy items, such as fruit or yoghurt, into the packed lunch ‘I normally have a packet of crisps, an apple, sweets and a yoghurt’ (M452), ‘fruit and sandwiches’ (F855) and ‘I put a lump of fruit in...and I'll have like one chocolate bar or something’ (M851).
In contrast, there was a notable preference among younger pupils for school dinners. Younger pupils said they enjoyed school dinners because, they were cooked/hot/warm, ‘because they're hot’ (F835) and ‘nice and warm for you’ (F634), because of their taste and smell ‘they're nice to eat...they smell nice and taste nice’ (F636) and also, because ‘(you) get to sit by all your friends’ (M631). The importance of companionship was reiterated in the accounts of many of the younger participants, who said they enjoyed having ‘a chit chat while you're eating’ (M131), and who did not like ‘eating by myself...because I just feel like by myself’ (F234). In addition, some younger pupils intimated a preference for a ‘traditional’ type meal in contrast to one which ‘you have to eat with your fingers’ (M631).
While participant accounts suggest that most year three pupils in this study had little choice over whether they took packed lunches or ate school dinners, because, ‘your mummy chooses’ (M635), school dinners appeared to offer younger pupils more (albeit limited) choice than that associated with food prepared at home:
Eating at school you have to choose the food and eating at home your mother or father makes it without you choosing (M734).
School dinners were also, according to some younger participants, more easily disregarded than food prepared at home, ‘I sometimes leave some beans or potatoes...because I don't like the skin’ (M633) and, ‘with (the) packed lunch you have to eat all your food’ (M631). It is interesting that some younger pupils appeared more inclined to leave uneaten, food prepared at school than that prepared for them by a parent/carer, irrespective of the context in which it was consumed.
Where year five pupils took school dinners, they appeared to be more prepared to challenge what they were given:
If we don't like it we just go to the teacher and say you don't like it and then the teacher says ‘just try a little bit’ and if we say we have, then we can leave it (F153).
As was illustrated in the case of pupils who took packed lunches, accounts of those older pupils having school dinners also highlighted a tendency to opt for unhealthy items on the menu, ‘sometimes sandwiches and sometimes I have dinner but my favourite dinner from school is pizza’ (F255), and:
We go to the hall and have our dinners. They have like cabbage and beans and all that and I don't like beans or cabbage so I just go for like a chicken burger or something like that (F652).
Choice when eating out
For older participants, eating out was contrasted favourably with school dinners, because ‘in school you just got choose out of two things, (whereas) in restaurants you have got a big list’ (F556). McDonald's, which was the restaurant chain which participants cited most, was popular among some older participants because it afforded maximum choice with least formality, ‘in McDonald's you can just go up right and then you just say oh can I have...’ (M651).
While respondents generally expressed preferences for unhealthy foods, in accounts of eating out, there were several instances where older participants talked about the importance of balancing meal contents to include healthy foods. In the following extract, for example, a year five pupil justifies (unprompted) eating at a fast food chain which she associates with unhealthy food:
In McDonald's every time I have a chicken sandwich, it's got chicken, lettuce and mayonnaise on it and McDonald's is isn't the best place but they're trying to make it healthy because they sell carrot sticks and they're selling food and stuff...because lettuce is quite healthy (F252).
Similarly, a minority of older male pupils talked about offsetting the negatives associated with unhealthy food by engaging in ‘healthy’ activities. However, it appeared from these respondent accounts that the introduction of healthy items into an otherwise unhealthy meal, or engaging in healthy activity gave participants licence to eat what they chose or, in other words, make unhealthy food choices.
Because you can, I eat sometimes unhealthy food but then I do crack and I do really sporty things, so then I run all the fat off (M851).
For the younger participants, eating out was described as ‘it's nice, you get a treat’ (M633) and identified with special occasions such as ‘birthdays because I went to a restaurant for my birthday’ (F435). McDonald's was a favourite among younger participants because it was perceived as ‘good for like parties and stuff because you can always have a little party, things like burgers...and chips’ (M832). The advantage of eating out for younger participants was also notably linked the marketing strategies employed by (particular) fast food chains. Hence, when asked what they liked about McDonald's, for example, some pupils focused upon the free gifts, ‘I like the toys and there is sometimes there is a competition to colour in McDonald's’ (F532).
One reason why eating out may be different for younger pupils is because it is a context where they are allowed more choice over what they eat. When asked who got to choose what they ate out, most responded ‘me’ (F632) and ‘I do’ (M635), although one young participant described how at McDonald's her choice was constrained because ‘I am not allowed to have chicken nuggets because all of the scraps that it is made of’ (F432). Given the choice, these pupils like their older counterparts tended to opt for unhealthy food items. Hence, McDonald's was cited by many young participants as a place where they enjoyed eating out because, for example, ‘I like McDonald's cheese burgers’ (F634) and ‘the chips are nice’ (M631).
While, for some younger respondents, eating out was described as a treat or out of the ordinary, many preferred the security and familiarity of family mealtimes. For example, one participant claimed that when ‘in restaurants I barely speak at home I speak a lot’ (M633), and another year three pupil noted:
I like it at home, it's safer...you could get locked in [at McDonald's]...you could get lost (F636).
For these younger pupils the data suggest that while the prospect of having choice over food, may be perceived as positive, other priorities, such as routine and security may take precedence among this age group.
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DISCUSSION |
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A limitation of the paper is that it is based on findings from a small focus group study, in disadvantaged areas. We are unable to comment on the extent to which the findings relate to children living in more socially advantaged areas (Berg et al., 2002
; Evans et al., 2006). We are also aware that data from focus groups involving children may be influenced by competitive group dynamics, enthusiasm to contribute and influence of peer pressure (Ells, 2001; Mauthner et al., 1993). In addition, while teachers were briefed about pupil selection, we can not exclude the possibility of bias in the identification of focus group participants. Notwithstanding these caveats, pupil responses were fairly consistent within the two year groups and age associated differences in responses were maintained across groups. We also note that children's accounts of dietary behaviours should ideally be understood in relation to the perspectives and accounts of parents, carers and teachers and within the settings where they are expressed. This highlights the need for studies that compare family perspectives and which may incorporate observational methodologies that can validate dietary reports of behaviour (Arredondo et al., 2006). The study highlights the importance of choice in the construction of a healthy diet. Most children in the study, irrespective of age or gender, opted for unhealthy choices. Moreover, where there was no (or only limited) choice offered, food options were not necessarily healthier. The study findings also highlight the importance of age and context, because the level of control over food choice (and the importance attached to it) and the type of food options available differed between the younger and older age group across the different settings.
Previous research suggests that children have a high level of control over what they eat (Robinson, 2000). Many parents agree today's children have substantially more control over their food choices than they had when they were a similar age (Hill, 2002). The findings support research suggesting that older children have more control over decision making about what they eat at home than younger children (Berg et al., 2000), and this also holds for school and when eating out. At home, most older pupils dictated their choice of meal and parents were, for the most part, presented as amenable and compliant with respondent preferences for unhealthy food items.
Most year five participants took packed lunches at school in preference to school lunches. This preference was partly a function of the importance which year five pupils attached to exercising control over decision making. As with home meals, contents of the packed lunch appeared in older pupil accounts to be largely dictated by the participants. Indeed, pupils contrasted the minimal choice offered by school lunches, which provided little opportunity for negotiation, unfavourably to packed lunches. While there was evidence that some older pupils introduced ‘healthy’ items into the packed lunch, generally they opted for unhealthy choices avoiding food items which they did not like. In their accounts of eating out, some participants justified choosing particular (fast food) outlets by highlighting the availability of healthy options on the menu. Here they implied that the negative effects of unhealthy items might be offset by (or balanced with) more healthy choices. However, where reference was made to offsetting the effects of eating unhealthy food by engaging in ‘healthy’ activities, such as exercise, this appeared to give license to indulge in unhealthy choices.
Younger participants in this study appeared to exercise less control than older pupils in all three settings (but particularly at home and school). Moreover, control over decision was not perceived to be as important by younger children who seem to relinquish choice fairly unquestioningly in favour of the advantages associated with familiarity, security and structure. Certainly younger participants in this study noted a preference for cooked meals, prepared and eaten at home in the family context. While they did express a preference for unhealthy food items [see (Murphy et al., 1995)], they had limited opportunity to choose. The nutritional content of what these pupils ate was almost wholly a function of parental/carer choice and did not necessarily reflect a healthy diet.
The findings supports research which depicts (older) children as active consumers exercising choice and exerting control over what they eat (Padilla-Walker, 2006). While the participants did not talk about wider influences, such as the media, on their dietary choices, it is clear that those in the older age group constitute an attractive target for media advertising. This suggests the need for public health policy and health promotion initiatives that are tailored to different age groups and sensitive to types of food provision and opportunities for choice across settings — and that one type of intervention will not suit all (EUFIC, 2005). Our study indicates the period between years three and five as potentially important window for intervention. For example, intervention targeting younger pupils might usefully incorporate ‘companionship’ highlighted as important by our year three participants.
Given the importance which older participants attributed to control over decision making, we also suggest that children might be usefully empowered to make more informed choices at an earlier age. Parents/carers could usefully structure choice to ensure that nutritionally high items are included in any selection (Wardle et al., 2003a). Given the apparent limited choice experienced by younger participants, parents/carers as well as children might usefully be targeted further about nutrition and the importance of informed food choice. While acknowledging the importance of nutritional guidelines ‘made by children for children’, parents' perceptions should also be sought in order to determine their responsiveness to nutrition education (Hart et al., 2002). This point highlights the importance of initiatives that support positive parenting (Positive Parenting, 2006) and research into how feeding practices are adopted and implemented within families (Backett-Milburn et al., 2006).
Finally, the introduction of food choice to children at a younger age may, we suggest, facilitate more nutritionally informed food choice when they are older (and when it appears they place greater store on control over decision making). Certainly this approach may serve to offset the problems associated with parental over-regulation of food intake whereby children rebel or become less able to regulate their own intake.
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FUNDING |
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The research on which this paper is based was funded by the Welsh Assembly Government.
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ACKNOWLEDGEMENTS |
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We acknowledge gratefully the children who participated in the focus groups, their teachers and head teachers. Finally, we would like to thank support staff at SIRU and CISHE.
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