The early years are a crucial time for developing healthy eating behaviours, shown to track from infancy into adulthood(Reference Emmett and Jones1,Reference Zelman2) . Currently, many children’s diets are far from optimal. From as early as around 3·5 years, intakes of fruit and vegetables do not meet national dietary guidelines for optimal health(Reference Spence, Campbell and Lioret3–5). In addition, > 90 % of Australian children from the age of 9 months exceed the upper recommended limit of discretionary foods (energy-dense, nutrient poor foods such as cakes, biscuits, chips, ice cream and sugar sweetened beverages)(Reference Spence, Campbell and Lioret3,4) . This is mirrored in other high-income countries, such as the USA(Reference Liu, Lee and Micha6). Furthermore, poor dietary outcomes are more common in children from families of low socio-economic position (SEP)(Reference Boylan, Hardy and Drayton7), even before children reach one year old(Reference Spence, Campbell and Lioret3).
A useful setting to promote healthy eating to children, regardless of SEP, is through the home environment, given the strongest correlates of child diet quality are home based(Reference Yee, Lwin and Ho8). Before children reach primary school age (around 6 years in Australia), most of a child’s food intake occurs within the home, even for children who attend long day care(Reference Bernardi, Cezaro and Fisberg9). In addition, recent evidence suggests that meals at home tend to include fewer fruits and vegetables than those provided at childcare(Reference Sisson, Kiger and Anundson10), highlighting the vast potential to improve child diets within the home setting. Family meals, where a child and caregiver eat together, are part of this home environment. Frequently engaging in family mealtimes is cross sectionally associated with optimal nutritional and developmental outcomes for children(Reference Dallacker, Hertwig and Mata11), allowing family members to come together for regular communication and parental modelling of expected behaviours. Family mealtimes present opportunities for offering and consuming healthy foods and in turn, for children to develop healthy food related behaviours. In Australia, 77 % of families with young children engage in family mealtimes most nights(Reference Litterbach, Campbell and Spence12), and families are interested in and motivated by the prospect of family meals(Reference Spence, Hesketh and Crawford13) making it an ideal context in which to promote healthy eating behaviours.
More than one-third of young children in Australia(Reference Litterbach, Campbell and Spence12), the USA(Reference Thimmig, Cabana and Bentz14) and the United Kingdom(Reference Collings, Kelly and West15) engage in screen use (television, tablets and smartphones) during mealtimes, every day. Additionally, children from families of lower SEP may be most likely to engage in mealtime screen use(Reference Avery, Anderson and McCullough16). Evidence suggests that mealtime screen use reduces opportunities for family cohesion at mealtimes(Reference Dallacker, Hertwig and Mata17), and cross-sectional(Reference Dallacker, Hertwig and Mata11) and 2-year prospective evidence(Reference Litterbach, Zheng and Campbell18) suggests that children’s diets are poorer when screens are included in family meals. Qualitative research with diverse(Reference Jordan, Hersey and McDivitt19) and low-income(Reference Bekelman, Bellows and Clark20) families has also found that many parents acknowledge mealtime screen use as not aligning with best practice eating environments and that turning the TV off would improve family communication and connection. However, this awareness does not appear to be enough to guide behaviour.
A useful framework to understand and inform behaviour change is the Capability, Opportunity, Motivation and Behaviour (COM-B) System of Behaviour Change(Reference Michie, van Stralen and West21). This theory posits that behaviour occurs through an interacting system whereby one’s capability (having the skills and knowledge to enact a behaviour) and opportunity (having access to information or equipment and relevant social and cultural norms) influence one’s motivation to enact a behaviour (thoughts and feelings towards engaging in the behaviour, such as goals, habits and emotions). The behaviour itself also has a unidirectional relationship with each of capability, opportunity and motivation(Reference Michie, van Stralen and West21).
Understanding caregivers’ capability, opportunity and motivation around mealtime screen use is important in establishing whether reducing screens at mealtimes is feasible for families, especially for families of low SEP who may experience an increased number of barriers to healthy mealtime behaviours(Reference Bekelman, Bellows and Clark20,Reference Jarrett, Bahar and Kersh22) .
Recent evidence from families of low SEP suggests that families engage in mealtime screen use to manage the difficulty of making family meals happen, to reduce picky eating(Reference Bekelman, Bellows and Clark20) and to potentially manage children’s negative emotions(Reference Domoff, Lumeng and Kaciroti23). Screen use immediately prior to mealtimes has been reported to extend into the mealtime(Reference Jarrett, Bahar and Kersh22). Large-scale interventions have employed reducing mealtime screen use as a strategy for promoting nutrition through the family meals setting in older children(Reference Fulkerson, Neumark-Sztainer and Story24) and young children(Reference Gunther, Rogers and Hopkins25). However, no studies have explored caregiver experiences of reducing mealtime screen use in families with young children, making it difficult to determine whether limiting mealtime screen use is a feasible goal for families.
Receptiveness to interventions can be enhanced by tailoring strategies to address barriers(Reference Sebastião, Galvez and Bobitt26) and aligning these with what is already understood through strength-based approaches(Reference Crawford, Ball and Cleland27). However, strategies based on researchers’ interpretations of qualitative inquiry are not always understood and translated as the participant intended. Therefore, the co-construction of ideas between researchers and participants, based upon participants’ lived experiences and researchers’ scientific knowledge(Reference Bergold and Thomas28), is a useful way to design behaviour change strategies. A co-design approach involves conducting research with participants, rather than on them, may increase acceptance and engagement(Reference Sebastião, Galvez and Bobitt26,Reference Bergold and Thomas28) and therefore has the potential to be more respectful and effective. Planning research collaboratively with members of the community impacted by the implementation of research outcomes also integrates end-user value and the planning of broader dissemination at the core of the research(Reference Goodyear-Smith, Jackson and Greenhalgh29).
Utilising the COM-B System of Behaviour Change as a framework allows for a greater understanding of how behaviour change strategies can be tailored to increase caregivers’ capability, opportunity and motivation for change and helps to identify underlying ideas, broader meanings and implications that inform behaviour change.
Therefore, this study aimed to co-design strategies tailored to the challenges of mealtimes and explore caregiver experiences of using these strategies to reduce mealtime screen use, in families of low SEP with young children.
Methods
This study reports on the second part of a two-part project. Part one was an exploratory study of mealtime screen use behaviours in 25 mothers with young children(Reference Litterbach, Laws and Zheng30). Part two, the focus of this study, involved a sub-group of participants ‘opting in’ to a motivational interviewing (MI) and strategy co-design session, followed by a brief trial period, and then a follow-up interview for each participant.
Research paradigm and reflexivity
This research project was underpinned by Constructionism. This theory is driven by a socially constructed idea of continually changing reality and the belief that our understanding of knowledge within reality is indeterminate(Reference Gubrium and Holstein31). Within Constructionism, this research used a combination of Constructivist and Critical Theory paradigms. Constructivism offers that as humans, we create truth and reality individually and together(Reference Creswell and Creswell32), supporting the use of in-depth interviews for the initial stages of this research. In addition, elements of Critical Theory were included, whereby researchers act as advocates for the participant and challenge dominant discourse and data collection methods which previously reflect the researcher as the only expert(Reference Jacobs33). This combined paradigm approach aimed to promote a respectful interchange between researcher and participant. Facilitating a sense of ownership of the research process and voice in the scientific literature for participants was important(Reference Jacobs33) whilst acknowledging that the presented interpretations were a co-creation between researcher and participants.
It is also important to acknowledge the researchers’ backgrounds given they impact the research. All researchers are qualified nutritionists and mothers. The lead researcher also having a background in Psychology, Healthy Conversation Skills(34) and extensive experience in qualitative interviewing.
Eligibility, reimbursement, consent and ethics approval
Participants were eligible if they lived in Australia, could speak and read English, were a parent or caregiver of at least one child between six months and six years of age and did not have a university degree. Criterion regarding education level was informed by previous research, which describes parental education as a proxy for family SEP(Reference Spence, Campbell and Lioret3). Additionally, maternal education is reported to be a good predictor of children’s diet and screen behaviours(Reference Cárdenas-Fuentes, Homs and Ramírez-Contreras35). A supermarket voucher ($40AUD) was provided on completion of part one, and then again for those participating in part two. Participants provided informed consent both online (recruitment) and verbally (each interview). Ethics for this study was approved by Deakin University (HEAG-H 178_2020).
Recruitment
Recruitment via social media was conducted from January to July 2021, when many Australian cities and suburbs were experiencing strict COVID-19 related lockdowns. Facebook™ advertising attracted interested caregivers to a brief online eligibility, consent and registration form using REDCap™ (V10·6·0). Participants were then contacted via email or phone to arrange a convenient time for a 45-minute interview with the researcher.
Initial interview (part one)
Twenty-five mothers completed an initial interview aimed to explore why families may use screens at mealtimes (part one, published elsewhere)(Reference Litterbach, Laws and Zheng30). At commencement, participants were informed that part way through the interview the researcher may ask the participant of their interest in participating in further related research.
Motivational interviewing and co-design (part two)
Fifteen parents were invited to continue to part two, comprising those families who engaged in any mealtime screen use and discussed an openness to change. Part two offered the opportunity to participate in an individual MI session, and to co-design strategies for reducing mealtime screen use to apply in their home. Participants were provided the option of completing the MI session immediately or, to go away and consider their interest in participating, and later scheduling a time to complete the individual MI session. Fourteen of the 15 invited mothers agreed to participate in this step, formed the sub-sample for this study and all participated in MI sessions immediately. Participants were asked to trial their co-designed strategies for three to four weeks, then recontacted and invited to discuss experiences via Zoom or telephone interview.
Data collection
Data collection focused on a co-construction of ideas and understanding between the researcher and participant(Reference Gubrium and Holstein31). Researchers acknowledge the elements of Critical Theory embedded into the methods utilised, whereby researchers worked collaboratively with participants to identify and implement their own ideas, supported by the researcher.
Motivational interviewing
All MI sessions were conducted by the lead author. After initial exploration of current behaviours (part one), participants spent 20–30 min with the researcher in exploring desired outcomes and anticipated difficulties, goal setting and planning 2–4 tailored strategies aimed to reduce mealtime screen use. This process aimed to develop behaviour change strategies through collaboration and reflection of participants’ lived experiences and researchers’ scientific knowledge. Goals were participant-led and could include the reduction of any type of screen (TV, tablet or phone use), at any meal or snack time and for any number of mealtimes across the week. A semi-structured interview script, provided in Additional file 1, was used to help guide the conversation towards study aims and to ensure goal setting was comprehensive. A SMARTER ME (SMARTER: Specific, Measurable, Achievable, Realistic, Time based, Evaluate, Reflect, ME: Motivation, End goal) goal setting plan was used as a guide(34). MI is driven by a conversational style of interviewing, which helps participants explore their own motivations around a particular behaviour and commitment to changing it(Reference Flynn36). A key aspect of MI is helping people to weigh up costs and benefits to help them move towards such change(Reference Hettema, Steele and Miller37). Participants were encouraged to identify factors influencing their family’s mealtime screen use and create a comprehensive plan. The MI and co-design session provided Problem Solving (BCT #1·2), Emotional Social Support (BCT #3·3) and Practical Social Support (BCT #3·2), as well as facilitating the development of further behaviour change techniques (BCT) according to Michie and colleagues’ BCT taxonomy(Reference Michie, Richardson and Johnston38). Mothers came up with between two and four specific strategies for their family to trial, which were summarised and emailed back to each participant following the MI and co-design session.
Trial phase and follow-up interviews
Participants were encouraged to document thoughts, feelings, ideas or changes to the planned strategies during the trial period and were offered the opportunity to contact the researcher for support during this time.
Around 3–4 weeks after the initial interview and MI, to offer enough opportunity for trialing strategies, participants were invited to complete a follow-up interview. Using the COM-B System of Behaviour Change as a framework, a semi-structured interview script allowed the researcher to map if and how the elements of COM-B were interacting to influence mealtime screen use and behaviour change(Reference Michie, van Stralen and West21). Additional file 2 outlines the follow-up interview questions, mapped to COM-B.
All interviews were recorded with permission and professionally transcribed using Digital Transcripts©. Transcripts were checked by the lead author for accuracy, annotated to include visual cues or gestures made in the video and de-identified for storage.
Analysis
Analyses were conducted by the lead author, who was also the interviewer, strengthening the credibility of the coding process alongside achieving continuity of interview techniques, persistent observation and prolonged engagement with the data(Reference Korstjens and Moser39). Analysis for this study involved an iterative process which began immediately after each interview whereby the researcher took notes about observations and musings regarding the exchange. In addition, so the researcher could frequently reflect on the research development, a continually iterated running sheet of overall thoughts pertaining to interviews, possible correlations, ideas to explore and potential questions for prospective interviews was kept. This was referred to continuously during the analysis phase.
Upon the completion of data collection phase, the transcripts, annotations and other documents about the interviews were re-read for familiarity and the separate interactions for each participant were merged into one document. Semantic level reflexive thematic analysis(Reference Braun and Clarke40) was conducted, using NVivo. Semantic level thematic analysis focuses on demonstrating patterns in surface level content (without trying to identify latent meanings), interpreting those patterns and highlighting the implications and broader meanings(Reference Patton and Patton41). To begin, the lead author inductively created codes, which grouped similar ideas within the data. Once all interviews were coded, patterns within the codes were identified and tentatively labelled. All five authors were involved in an iterative process, where codes were discussed, merged, became sub-codes and or were renamed, until the coding framework reflected the data and aligned with the aims of the study. Behaviour change strategies were identified, grouped by likeness and labelled intuitively. Finally, BCT were mapped to components of COM-B, condensed accordingly and classified using Michie and colleagues’ BCT taxonomy(Reference Michie, Richardson and Johnston38).
Results
Participants
Fourteen mothers participated in the MI session, trial period and follow-up interview (aged 29–44 years). Table 1 illustrates participant demographic characteristics. Most had completed a certificate or diploma, and ten mothers had two or more children. Nine lived in a dual-headed household, three were born in a country other than Australia and one mother was of Aboriginal descent. Most (twelve) families engaged in family meals > 5 times per week, with reported mealtime screen use varying from one meal per day to every meal (data not shown). The types of screens engaged at mealtimes varied from meal to meal and included television use, child handheld device use (individual and shared) and caregiver phone use, depending on the needs and desires of family members.
Table 1 Participant demographic characteristics
* All families had ≥ one child between the age of 6 months and 6 years.
Motivational interviewing: Mothers’ considerations when planning to make change
During the MI phase, mothers discussed perceived ideal environments for change and acknowledged that change would be most difficult outside of these environments. For example, it would be more difficult to limit mealtime screen use when their partner was not around for support, or if their child(ren) were tired or grumpy, with some reporting an anticipated lack of confidence to engage in strategies in these situations. Most mothers acknowledged the need to be prepared for their child to resist change while establishing a new routine. Table 2 shows mothers’ anticipated challenges and desired outcomes of reducing mealtime screen use, along with example quotes. In summary, while mothers anticipated a range of challenges, their desire for outcomes around connection and engagement, exposure to healthy environments and family connectedness, helped to limit these anticipated challenges. For example, some mothers were worried about how they would manage their child’s reactions to screen-free meals. These mothers expressed concern that if their child reacted negatively, mothers might feel upset or grumpy. However, mothers reported that they were motivated to stay calm and avoid yelling or getting upset at their child in order to help promote a calm and positive atmosphere.
Table 2 Mothers’ anticipated challenges and desired outcomes of reducing mealtime screen use
Motivational interviewing: Co-designed strategies (planned and engaged)
Most strategies were generated from mothers’ reflections around why they used screens at mealtimes, as well as past experiences, considering things that had or had not worked before(Reference Litterbach, Laws and Zheng30). Mothers anticipated the ways their child might respond to change and were receptive to the differing needs of their children of varying ages. These were carefully considered in planning, and strategies were tailored accordingly. Participants co-designed a wide variety of strategies, identified in Table 3. Strategies were also mapped to corresponding BCT, which encompassed broad BCT groups; 1. Goals and Planning, 3. Social Support, 7. Associations, 8. Repetition and Substitution, 10. Reward and Threat, 11. Comparison of Outcomes and 12. Antecedents. As well as each specific strategy acting as a BCT, the process of design also worked as a BCT. These included 1·2 Problem Solving; tailoring strategies to mothers’ own barriers and facilitators and planning for ways to overcome pre-empted challenges and 3·3, Social Support (emotional) and 3·2, Social Support (Practical), where the researcher supported the mothers development and ongoing implementation of such strategies(Reference Michie, Richardson and Johnston38).
Table 3 Co-designed strategies and their corresponding behaviour change techniques
* Numbered behaviour change techniques denote their alignment with Michie and colleagues’ Behaviour Change Taxonomy (v1)(Reference Michie, Richardson and Johnston38).
The most widely engaged strategies were exhibiting clear, consistent and firm expectations of mealtime screen use, modelling expected behaviours and altering the physical environment to help facilitate screen-free meals. Physical environmental change often aligned with screen type. For example, moving meal location to a dining table, kitchen bench or outside was engaged for many families aiming to reduce television use. In comparison, moving devices away from meals areas was often engaged for those families aiming to reduce handheld device use. Families with higher mealtime screen use tended to start with smaller goals, such as removing screens from one meal per pay and gradually increasing, while others who engaged in fewer screens were more likely to go ‘cold turkey’ and remove all screens at once.
Follow up interviews: Mothers’ experiences and reflections around reducing mealtime screen use
All fourteen mothers completed the second interview with thirteen implementing at least one of their co-designed strategies three times or more, over the 3–4 week trial period. All mothers discussed their reflections after the trial period. Five main themes are identified in Table 4.
Table 4 Reflections and experiences of seeking to reduce mealtime screen use
Theme one: Consistency and parenting self-efficacy
Consistency and parenting self-efficacy were identified as underpinning mothers’ capacity to enact their goals. This was expressed explicitly, such as mothers reporting that consistently engaging in screen-free meals and pushing through difficult situations without screens was vital for change. It was also expressed implicitly, such as mothers who reported sporadic changes to mealtime screen use tending to report screen-free meals as more difficult for families to adjust to, compared with those who had more consistency. Most mothers reported that they built their consistency and self-efficacy throughout the trial period.
Theme two: Changes to foods served or consumed
Changes to foods served or consumed were experienced near opposing ends of a spectrum of consistency and self-efficacy. For one mother, the quality of foods served declined at screen-free meals. She anticipated high child resistance to change, a reliance on screens to distract her child while she engaged in preparing meals and limited resilience towards removing screens in time for meals. In response, she chose easier to prepare meals which she knew were liked by her children, resulting in higher consumption of discretionary, energy dense foods during screen-free meals. Mothers who expressed high levels of parenting self-efficacy and consistency reported that children were more likely to try new foods or consume a larger variety of the foods served.
Theme three: experience exceeding expectations
Prior to the trial phase, mothers had discussed that they expected change to be difficult. Although for many, aspects of reducing mealtime screen use brought challenges, most mothers reported change to be easier than expected. In addition, the benefits anticipated by reducing mealtime screen use were exceeded by the value mothers reported to have gained from this experience.
Theme four: increased value of mealtimes
Mothers who reported they were building consistency and self-efficacy perceived an increased value of mealtimes. In addition, mothers who expressed high consistency and self-efficacy tended to perceive reducing mealtime screen use to be easier and more beneficial than anticipated, which often exceeded their expectations.
Theme five: shifting established habits
Mothers felt their child/ren had established behaviours which were difficult to change and shifting established habits took considerable effort, particularly initially. This including being more organised, more present and more engaged with children. Those reporting high consistency and resilience worked through this stage more easily. Many mothers acknowledged the importance of reducing their family’s mealtime screen use now, while their child was still young and had spent less time building habitual mealtime screen use. Those with less ingrained habits also appeared to find change easier. For example, for the two families in this study who reported not having access to a dining table, the family whose limited access had been a long-term scenario, (i.e. had been eating meals in the living room for some time), found it difficult to move mealtime location. In comparison, the family who had more recently lost access to their dining table, because of COVID-19 related remote working/learning arrangements, found moving mealtimes back to the dining table a feasible option.
Families with older children found value in engaging them for social support. Mothers reported, in part, cultural screen acceptance and abundance heavily enabled mealtime screen use. This included a learned reliance on and addiction to screen use more broadly, both in their children and themselves (for example, parent mobile phone addiction and the difficulty of ignoring phone notifications). One highly motivated single mother participated in MI and co-designed several strategies but did not participate in the trial phase of the study. However, in the follow-up interview she reported ‘I was very gung-ho on the day and my enthusiasm waned very quickly’. She reflected on her perceived low resilience and consistency, including self-reported limited capacity to cope with current life stressors (mental health and relationship challenges), family stability and mealtime routine, which limited her capacity to overcome barriers to screen-free meals.
Recommended supports and future plans
Participants were asked about resources that may have supported them to make change. Suggestions included reminders, mealtime planning tools, tips for involving children in meal preparation, managing child resistance and ways to redirect children when they ask for screens, as well as the usefulness of having partners involved in the co-design phase. All thirteen mothers who implemented strategies had plans to continue. Some reported a previous desire for reducing their mealtime screen use before beginning the study but had been unsure how to implement change.
Discussion
Using a combination of MI and co-design techniques, this qualitative study explored mothers’ perceptions and experiences of reducing mealtime screen use in families with young children, in a low SEP sample. Mothers co-designed a large number of feasible strategies in line with established BCT, tailored to the challenges of family meals and aimed at reducing mealtime screen use. Mothers’ experiences were driven by their level of consistency and self-efficacy to change and included changes to foods served or consumed and increases in the value of mealtimes. Overall, mothers found that beneficial changes were feasible and easier to enact than anticipated. Regardless, shifting established habits did require considerable effort. Almost all mothers reported successes in increasing the number of screen-free family meals and planned to maintain changes within their home, regardless of other demographic factors.
Consistent with a realist synthesis of obesity-related behaviour change interventions(Reference Enright, Allman-Farinelli and Redfern42), this study identified three specific strategies frequently used by families: increasing opportunity through altering the physical environment; role modelling healthy mealtime behaviours and exhibiting clear, consistent and firm expectations of mealtime screen use. While there was commonality among approaches taken, it was also the case that many additional BCT were used across the group. This is likely to reflect the differing challenges families seek to address and highlights the potential benefit of developing tailored intervention strategies.
One such strategy, altering the physical environment by consistently having any meals or snacks at a dining table or bench space (usually moving them from a TV or lounge area) was reported to be particularly helpful for families in reducing mealtime TV use. Previous research has identified cross-sectional associations between eating at a table and better dietary and psychosocial outcomes in children(Reference Skafida43,Reference Mak, Prynne and Cole44) . Likewise, emerging prospective evidence suggested that the relationship between children’s mealtime TV use and later intakes of discretionary foods differed by mealtime location(Reference Litterbach, Zheng and Campbell18). Families were also able to utilise meal location to set screen use boundaries and implement new mealtime expectations, such as ‘no screens at the table’. This then also offered increased opportunity through modelling. Parental modelling of expected behaviours, such as joining in on screen-free meals, was a useful strategy caregivers utilised in this study and is a well-established strategy for encouraging child behaviours(Reference Yee, Lwin and Ho8). These findings highlight the potential for nutrition promotion initiatives to encompass location of eating in nutrition messaging. However, findings also suggest that screen-free family meals might be more difficult to achieve for those with limited opportunity to alter their physical environment. Messaging should consider socio-economic implications, such as owning or having space for a dining table, so that healthy mealtimes feel achievable, regardless of family resources.
Consistent with utilising changes to the physical environment and parental modelling as potential BCT, reducing parent phone use at family meals was a key goal for many families in this study. Parental phone use at mealtimes may contribute to normalising mealtime screen use behaviours as well as distracting parents from engaging with their child. One recent survey of 298 parents of toddlers living in Norway found 40 % of parents reported using their phone at mealtimes which was associated with unhelpful feeding practices, such as applying pressure to eat, and reduced likelihood of engaging in family meals(Reference Vik, Grasaas and Polspoel45). These findings and those in the current study highlight a need for increasing caregiver awareness around the importance of screen-free meals, including limiting phones during mealtimes.
This study suggests that a reduction in use of screens at mealtimes may have nutrition trade-offs for some, which requires exploration. Screens may not only be used for behaviour management(Reference Bekelman, Bellows and Clark20) but also to facilitate the consumption of more nutrient dense foods(Reference Wenhold and Harrison46). Nonetheless, the current study suggests that some of the more difficult aspects of reducing mealtime screen use, such as the increased effort required to shift established habits, might be improved with consistent screen-free meals and increased caregiver confidence. These changes could offer potential pathways to work with these families to produce more beneficial outcomes. Longer-term trials are required to determine if reducing mealtime screen use can be sustained and the nutritional impacts of such change.
Interventions aimed at reducing family mealtime screen use in families with young children could take advantage of mothers’ high value of family meals for providing opportunities for communication, family connection and learning opportunities. In addition, even though mothers in this study were likely highly motivated to reduce their mealtime screen use, many reported that it took significant effort, especially initially. Most mothers discussed that normalising screen-free behaviours by avoiding the development of mealtime screen use habits altogether was likely to be easier than trying to reduce them later in life, which is supported by past literature(Reference Skafida43). These findings emphasise the need for promoting screen-free meals from the inception of mealtimes, opportunities for education and the design of targeted strategies that support the adoption of screen-free meals.
This is the first study to explore caregiver perceptions of reducing mealtime screen use in families with young children. Focusing on families of lower SEP has offered insight into how we might engage families from diverse backgrounds in initiatives aimed at limiting mealtime screen use. A key strength of this study was the use of MI and co-design methods. This process enabled participants to explore their own motivations and commitment to change(Reference Flynn36) and co-construct ideas based upon the participants’ lived experiences and the researchers’ scientific knowledge(Reference Bergold and Thomas28), strengthening engagement and ownership of the behaviour change process. Although it is likely some self-selection bias played a role in mothers’ pre-trial motivation levels, it appeared that MI helped to consolidate motivation by encouraging mother’s to self-identify their capability and opportunity for change.
Despite all participants being mothers and the acknowledgement that fathers are an important but missing inclusion in this research(Reference Davison, Kitos and Aftosmes-Tobio47), this study was successful in recruiting a diverse sample of motivated participants. In Australia, mothers are more often responsible for the preparation and management of meals(Reference Mehta, Booth and Coveney48). Therefore, results of this study are likely transferable to other similar family groups and highlight the potential, not only to engage culturally and socioeconomically diverse mothers in behaviour change, but in the promotion of screen-free meals. Notably, most mothers had completed a trade or diploma. Therefore, education levels were on the higher end of ‘low SEP’, within the approximately 50 % of women aged 25–34 years in Australia without a university education(49). This may limit some transferability to groups whose highest completed education levels include high school or lower. Further research could explore families with lower educational background and, where appropriate, include both caregivers’ in the process of behaviour change planning. It is also important to note that although efforts were made to confirm the accuracy of researcher interpretations with participants, recounts of participant experiences are acknowledged to be influenced by the role of the researchers in this study.
A final consideration is the timing of data collection. Given that this research was conducted during the COVID-19 pandemic, some participants were experiencing higher than usual amounts of stress and screen time. During the COVID-19 pandemic, overall screen use in Australia increased,(Reference Arundell, Veitch and Sahlqvist50) and it is possible that mothers considered screen related behaviours temporary as their family adjusted to living under lockdowns. While this may not be reflective of usual, it also shows that mothers had capacity to engage in such behaviour change, even during a challenging time.
Findings from this study could be used to inform future interventions aimed at using the family meal as a setting to promote optimal nutrition to children and families, providing acceptable suggestions to limit mealtime screen use and optimise opportunities for healthy outcomes. Embedding the promotion of screen-free meals into existing early childhood nutrition promotion initiatives may be beneficial. Many strategies were used consistently across families, regardless of the type of screens being used. For example, strategies such as parental modelling of screen-free meals, sitting to eat together (at a table, bench or mat on the floor) and getting the family invested and helping at mealtimes. These strategies may be well received by a majority of mothers and help motivate families to engage in healthy family meals. This requires testing on a larger scale.
At an individual level, this study highlights the value of early life practitioners understanding family-level barriers, to assist in making feasible recommendations around the promotion of healthy family mealtimes. While time-intensive MI sessions are unlikely feasible, their intent in this study was the generation of co-designed strategies for future testing which, at a broader scale, may offer a suite of realistic strategies practitioners could promote as part of routine, person-centred care. Furthermore, there is a need for developing and testing accessible and realistic resources for caregivers and families around ways to limit mealtime screen use.
Conclusions
This qualitative exploration of mothers’ perceptions and design of strategies around reducing mealtime screen use in families with young children has highlighted a number of feasible strategies caregivers might engage. Several strategies appear likely to be transferrable, including moving meals away from TV areas to a table or bench, having consistent expectations at mealtimes and promoting healthy mealtime behaviours through parental modelling of screen-free meals. Small, incremental changes appeared acceptable for families with high mealtime screen use. These strategies should be tested for their effectiveness in a larger sample. Finally, although reducing family mealtime screen use appeared feasible in these motivated families, it took considerable effort to implement change. This challenge highlights the importance of pre-emptive messaging and embedding the promotion of screen-free mealtimes into nutrition promotion from early in a child’s life.
Acknowledgements
The authors wish to thank the dedicated mothers who participated in this study.
Authorship
E-K.L. co-led the study design, conducted and transcribed the interviews, led development of the coding framework, performed data coding, contributed to the interpretation of data and drafted the manuscript. A.C.S. co-led the study design, contributed to developing the coding framework and interpretation of data and helped to draft the manuscript. R.L. contributed to the study design, contributed to developing the coding framework, contributed to interpretation of data and helped to draft the manuscript. M.Z. contributed to developing the coding framework, interpretation of data and helped to draft the manuscript. K.J.C. contributed to the study design, interpretation of data and helped to draft the manuscript.
Financial support
E-K.L. was supported by a Deakin University Postgraduate Research Scholarship. M.Z. was supported by Australian National Health Medical Research Council Early Career Fellowship (GNT1124283).
Conflict of interest
There are no conflicts of interest.
Ethics of human subject participation
This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by Deakin University’s Human Ethics Advisory Group Health (HEAG-H) (Approval number: HEAG-H 178_2020). Verbal informed consent was obtained from all participants. Verbal consent was witnessed and formally recorded. Informed verbal consent was witnessed and formally recorded.
The datasets used and/or analysed during the current study are not publicly available due to privacy but may be available from the corresponding author upon reasonable request.
Supplementary material
For supplementary material accompanying this paper visit https://doi.org/10.1017/S1368980023002847
Open access
