Dairy products provide children with essential macro- and micronutrients( Reference Dror and Allen 1 ), and are unique in that they offer a high concentration of readily absorbable dietary Ca( Reference Nicklas 2 , Reference Heaney 3 ), essential for maximizing growth and peak bone mass in children. Inadequate consumption of Ca during this time can lead to lifelong health problems including an increased risk of fractures and osteoporosis( Reference Kalkwarf, Khoury and Lanphear 4 , Reference Huth, DiRienzo and Miller 5 ). Despite these benefits, the most recent Canadian national survey( 6 ) indicates that 37 % of children between 4 and 9 years of age fail to consume the recommended daily number of dairy servings (≥2 for children aged 4–8 years; ≥3 for children aged 9–10 years( 7 )). A similar pattern of underconsumption is seen in other developed countries including the USA( Reference Quann, Fulgoni and Auestad 8 ) and Australia( Reference Baird, Syrette and Hendrie 9 ). Given the potential negative outcomes associated with inadequate dairy intake and the low rates of consumption among children, it is imperative that effective intervention strategies be determined for this population.
A systematic review by Hendrie et al.( Reference Hendrie, Brindal and Baird 10 ) identified fourteen interventions aimed at increasing dairy or Ca consumption in children discretely (n 5), in the context of a healthy diet (n 8) or as part of a combined nutrition and physical activity intervention (n 6). Ten of these interventions were classified as effective, operationalized as a statistically significant increase in a dairy outcome measured either objectively (e.g. observed intake) or using dietary assessment methods (e.g. an FFQ). However, six of these effective interventions increased Ca or dairy intake through the provision of dairy products free of charge as an intervention strategy. While initially effective, providing families with free dairy products does not represent a sustainable method of promoting volitional intake, nor is it a feasible strategy to reach a large number of individuals.
Parents have been highlighted as a potential channel through which to positively impact the nutritional behaviour of children. Coined the ‘nutritional gatekeepers’, Wansink( Reference Wansink 11 ) estimated that parents control 72 % of the food eaten by their young children. This is not surprising given that parents typically control what food is purchased for the family and what meals are prepared for consumption within and outside the home. In addition, parents play a pivotal role in children’s diet through modelling. It is well known that young children learn through observation and emulation of the behaviours of their parents, especially with regard to eating habits. Cooke et al.( Reference Cooke, Wardle and Gibson 12 ) reported that parents’ fruit and vegetable consumption was a significant predictor of a child’s intake of those foods. In relation to dairy, Fisher et al.( Reference Fisher, Mitchell and Smiciklas-Wright 13 ) demonstrated that when mothers drank and served milk frequently in front of their young girls (aged 5–9 years), the girls were more likely to meet the recommended daily intake of Ca. Parental role modelling has been shown to be a more successful method of improving a child’s dietary consumption compared with more controlling tactics, such as restricting access to certain foods( Reference Scaglioni, Salvioni and Galimberti 14 ). Therefore, the direct inclusion of parents in dairy promotion interventions may present a feasible strategy through which to both increase household purchasing of dairy and promote children’s dairy consumption( Reference Hendrie, Brindal and Baird 10 , Reference Cluskey, Edlefsen and Olson 15 ).
In the context of promoting a healthy diet, Hendrie et al.( Reference Hendrie, Brindal and Baird 10 ) identified three studies that incorporated parents in the intervention design. Specifically, Evans et al.( Reference Evans, Greenwood and Thomas 16 ) focused on parents’ provision of packed lunches and reported a significant increase in dairy food consumption during school lunch. Despite this, only 60 % of children consumed the recommended intake of one portion of dairy daily during school lunch, as measured 3 months after the intervention. The other two interventions involved providing parents and children with specific dietary guidelines in an aim to decrease children’s BMI( Reference Van Horn, Obarzanek and Friedman 17 , Reference Epstein, Paluch and Beecher 18 ). Both studies reported daily increases of approximately 0·3 servings of low-fat dairy foods immediately post the interventions that lasted between 2 and 3 years; no further follow-up statistics were reported. While these findings are positive, children were not consuming sufficient dairy to meet the daily recommended intakes following the interventions.
Interestingly, none of the interventions reported by Hendrie et al.( Reference Hendrie, Brindal and Baird 10 ) specifically targeted parents’ attitudes or behaviour as a mechanism for changing their children’s dairy consumption. Instead, parents were included as a complementary social influence within intervention designs that were primarily targeted towards children. Given the evidence surrounding the impact of role modelling it is possible that directly targeting parents’ thoughts, feelings and behaviour towards dairy product purchasing and consumption could have a meaningful impact on increasing children’s dairy consumption. In an intervention aimed at increasing fruit and vegetable consumption in pre-school children, Haire-Joshu et al.( Reference Haire-Joshu, Elliott and Caito 19 ) directly targeted parents’ behaviour through education and emphasizing the importance of modelling fruit and vegetable consumption. Parents’ knowledge regarding fruit and vegetable consumption, availability of fruits and vegetables in the home, and parents’ consumption of fruits and vegetables all increased following the intervention. Most importantly, parents’ change in fruit and vegetable intake was a significant predictor of children’s change in fruit and vegetable consumption. To our knowledge, no studies have examined the impact of intervention material directly targeting parents’ dairy-associated attitudes and behaviour as the primary method of increasing consumption of dairy products in children. This is important as positive changes to dietary intake during childhood, such as ensuring adequate dairy consumption, may track into adult dietary behaviours( Reference Lien, Lytle and Klepp 20 , Reference Lytle, Seifert and Greenstein 21 ).
A framework through which to develop targeted messages is Social Cognitive Theory( Reference Bandura 22 ). Social Cognitive Theory posits that the decision to engage in a specific behaviour is influenced by three factors: (i) the outcomes expected to occur as a result of performing the behaviour (outcome expectations); (ii) the values placed on these outcomes (outcome values); and (iii) the individual’s confidence to perform the behaviour in the face of setbacks (self-regulatory efficacy). In the context of dairy consumption, individuals are more likely to consume dairy products if they believe consumption will elicit personally valued outcomes (i.e. outcome expectations) and if they are confident that they can consume dairy regardless of any potential barriers (i.e. self-regulatory efficacy).
Previous research has demonstrated the effectiveness of targeted interventions based on Social Cognitive Theory in increasing volitional dairy consumption in young women( Reference Jung, Martin Ginis and Phillips 23 ) and adults aged 30–50 years( Reference Jung, Latimer-Cheung and Bourne 24 ). Targeted interventions involve the development of material specific to a subset of the population, rather than specific to each individual, and thus have the potential to reach large numbers of people within the targeted subset at a relatively low cost. In a qualitative investigation of dairy consumption in adults aged 30–50 years, Jung et al.( Reference Jung, Mistry and Bourne 25 ) found that compared with non-parents, parents had a unique set of attitudes and consumption strategies pertaining to dairy foods. Given the distinct social and environmental situations parents encounter, it is imperative to gather information related to dairy product purchasing and consumption as it relates specifically to parents in order to develop effective targeted intervention material. With this in mind, the overall purpose of the present formative research was to: (i) ascertain how social cognitions related to dairy product consumption, for both parent and child, and purchasing behaviour manifest in parents of children aged 4–10 years; and (ii) use this information to develop novel intervention messages, specifically targeted towards parents, that could positively impact these social cognitions and the subsequent behaviour of parent and child. The study focused on parents of children aged between 4 and 10 years as the influence of parents and the home food environment significantly influences children’s dietary intake during this time( Reference Ong, Ullah and Magarey 26 , Reference Pearson, Biddle and Gorely 27 ). As children get older their dietary intake will likely be influenced by additional factors such as school, peers and social media. Given that dairy intake during childhood can have an impact on adolescent bone health( Reference Moore, Bradlee and Gao 28 ), it is key to establish adequate intake behaviours during this influential time.
Methods
Study design and procedure
Formative research provides insight into characteristics of the target population that influence choices and actions to aid in the development of effective strategies through which to promote behaviour change. These strategies are then tested with the target audience. The current study consisted of two phases. In Phase I, the exploratory phase, in-depth group interviews were conducted with parents of children who consumed both above and below the recommended daily intake of dairy( 7 ) to learn about barriers and benefits that may influence parent purchasing and consumption of dairy products, to ascertain useful strategies to ensure the purchasing and consumption of dairy products and to explore effective channels of communication. Information gleaned from Phase I was used to guide the development of draft intervention messages. These draft messages were then tested through a second round of in-depth group interviews in Phase II, the elaborative phase. Parents of children who failed to consume the recommended intake of dairy were the focus of Phase II as they represent the target group for future intervention. In-depth group interviews were considered appropriate to enable participants to generate and share ideas, encouraging dynamic and unique discussion( Reference Sparkes and Smith 29 ). The study was conducted according to the guidelines in the Declaration of Helsinki and all procedures were approved by the University of British Columbia Behavioural Ethics Committee. Written informed consent was obtained from all participants. A total of thirty participants took part in seven in-depth group interviews conducted across the two phases, specifically four in-depth interviews in Phase I and three in Phase II. Data collection ceased when no new categories emerged from the data (i.e. data saturation had been reached). All participants were recruited through online advertisements, word of mouth and posters placed in the local urban community. Phase I took place in February 2015 and Phase II in May 2015, all within the local community. A researcher experienced in moderating in-depth group interviews facilitated each group interview in the current study, while a trained research assistant took field notes to capture any non-verbal communication and group dynamics. A debrief occurred after each interview with research staff to reflexively guide future interviews. Each group interview lasted approximately 1·5 h. All group interviews were audio-taped and transcribed verbatim.
Phase I: exploratory group interviews
Two researchers with knowledge of behaviour change theories pertinent for dietary behaviour and qualitative methodology developed the semi-structured group interview guide. Questions and activities were designed to enable group discussion around barriers to and benefits of the target behaviour, and were intended to be interactive in nature. The interview guide consisted of four sections: (i) an introductory section pertaining to participants’ dairy product purchasing and consumption habits; (ii) questions exploring participants’ perceived anticipated outcomes from purchasing and consuming dairy products for themselves and their children; (iii) brainstorming activities to elicit strategies for ensuring the purchase and consumption of dairy products for parents and their children; and (iv) questions exploring preferred information delivery methods and format (see the online supplementary material for the interview guide). A brief demographic survey was administered at the beginning of each focus group. At the end of the interviews, participants were given the opportunity to raise any topics they felt had been missed and were important in relation to their families’ purchasing and consumption of dairy products.
Forty-one individuals contacted the research team to take part in the study and were screened for study eligibility. Eligibility criteria included men and women (i) with a child between 4 and 10 years of age, (ii) who had no dietary constraints for consuming dairy products themselves, (iii) whose child had no dietary constraints for consuming dairy products (e.g. vegetarian, vegan, paleo or dairy allergies) and (iv) who were able to read and write English. Individuals self-identified their gender, and their child’s dairy consumption was established using a modified version of the ‘Calcium Calculator™’ developed by the British Columbia Dairy Foundation( 30 ). The original tool assessed consumption of Ca from a comprehensive list of thirty commonly consumed dairy and non-dairy foods that are available in Canada and has been found to be a valid assessment of dietary Ca intake( Reference Hung, Hamidi and Riazantseva 31 ). In the current study, parents were asked to indicate the number of servings of the ten dairy products included in the list that their child consumed on the previous day. A serving size was explained for each product. The ten-item version of this tool has been used in previous studies to assess Ca consumption( Reference Lytle, Seifert and Greenstein 21 ).
Participants were then stratified into groups according to their self-identified gender and their child’s dairy consumption status. Dairy consumption status was classified as either meeting Canada’s daily dairy consumption guidelines (≥2 servings/d for children 4–8 years, ≥3 servings/d for children 9–10 years) or not meeting Canada’s daily dairy consumption guidelines (<2 servings/d for 4–8 years, <3 servings/d for 9–10 years). Eighteen individuals were eligible and able to attend the meeting time. Participants were mothers (n 11, mean age 37 (sd 7) years) and fathers (n 7, mean age 38 (sd 5) years) of children who were classified as under-consumers of dairy (n 10) or adequate consumers (n 8). One group interview was held with each stratified group. The majority of participants identified as exclusively white (77·8 %), married (66·7 %), had at least a college or other non-university certificate (94·5 %), worked full- or part-time (66·7 %) and had two or more children in the household (66·6 %). Participants made food purchasing decisions for the household either themselves (44·4 %) or in collaboration with their partner (50·0 %) and did the grocery shopping either themselves (38·9 %) or with their partner (44·4 %).
Phase II: elaborative group interviews
A second round of in-depth group interviews were conducted with a new group of participants to (i) further probe and discuss the findings drawn from the exploratory group interviews to ensure that data saturation had occurred and (ii) pre-test a series of draft messages developed from the information gleaned from Phase I. Participants were asked to provide feedback on message content relevance and the appropriateness of proposed delivery methods. Phase II was conducted with a new group of participants to confirm the findings revealed in Phase I and to test the draft messages exclusively with the target audience (i.e. parents of children failing to meet the recommended intake of dairy).
Fourteen individuals contacted the research team and were screened for eligibility. Eligibility criteria were the same as in Phase I, with the addition that children must be consuming less than the recommended intake of dairy. A total of twelve participants were eligible and able to attend the meeting times. These individuals were stratified into groups based on self-identified gender (mothers: n 10, mean age 38 (sd 3) years; fathers: n 2, mean age 37 (sd 1) years). Demographic characteristics for Phase II participants were similar to those of Phase I (see Table 1).
Table 1 Demographic statistics for Phase I and Phase II participants independently and for the whole sample, British Columbia, Canada, February–May 2015
CEGEP, general and vocational college.
Analyses
Given the interaction between the study objectives and our data, an abductive approach to data analysis was taken( Reference Sparkes and Smith 29 ). Using the interview guide as a framework, deductive content-based analysis was conducted in order to organize initial coding categories (e.g. barriers; benefits; strategies). Thematic analysis was then carried out to inductively explore recurring patterns within these categories. Content was further delineated into sub-themes with similar content. For information that could not be coded using the original categories, new categories were developed for important information related to the purchasing and consumption of dairy products. Data were imported into NVivo qualitative analysis software version 11 (2015; QSR International Pty, Ltd) where each transcript was analysed independently by two researchers. Once complete, the two researchers met to compare and discuss coding and categorization. Agreement rates of 90 and 91 % were reported for Phase I and II, respectively. Disagreements in coding were discussed and resolved through consensus. Results across group interviews were used to guide the development of potential intervention messages.
Message development
Information gleaned from Phase I in-depth group interviews was used to create a series of draft intervention messages. Specifically, following completion of Phase I data analyses three members of the research team engaged in a series of four brainstorming and development sessions, one each for benefits, barriers, consumption strategies for parent and child, and purchasing strategies. During these sessions, the researchers discussed the most appropriate method of delivering these messages based on the Phase I findings. The outcome of the sessions was a series of draft messages, and proposed delivery methods, to be delivered to participants in Phase II of the study for review. Participants in Phase II were asked to state (i) whether they would find the message content useful and (ii) if they would pay attention to the message. Feedback from the draft messages presented in Phase II was used to create the final intervention messages, and delivery methods, in collaboration with two behaviour change experts and a registered dietitian.
Results
Themes are presented for each of the initial coding categories, namely benefits, barriers, purchasing strategies, consumption strategies and communication methods. There was significant overlap in responses from participants from the two phases of interviews. The results are reported combining the responses from both phases, unless patterns emerged that were specific to one phase, in which case this is specified. Differences between (i) mothers and fathers and (ii) parents of children who met the recommended intake of dairy and parents of those who did not are reported where applicable. Subsequent message development is reported.
Benefits
Convenience
All mothers of children who consumed above and below the recommended intake of dairy perceived dairy products as convenient for children to consume at home or school and they could be purchased in a manner that allowed children to open and consume the product independently. One mother reported:
‘Part of it is convenience. Like I give my kids these Nano’s [yoghurt tubes] at lot. It’s easy for them to open and recycle and it’s just the right amount to give them a shot of energy at snack time.’
Taste
All parents (henceforward, ‘all parents’ refers to parents of children who consumed both above and below the recommended intake of dairy) discussed the enjoyable taste of dairy products as a benefit of consumption for both themselves and their children. Parents took comfort in knowing their children enjoyed eating dairy products, with one parent stating:
‘At school she’ll have a cheese stick, and she loves cheese.’
Cheese was the most frequently discussed dairy product regarding taste.
Overall health
Dairy products were believed to increase overall energy and aid in recovery from physical activity by all parents. As reported by one parent:
‘I remember many times that the best thing to have after you have a workout is chocolate milk. My daughter is very physically active, so I think that that helps her keep her energy up.’
In addition, all parents mentioned that dairy products were part of a well-balanced diet, contributing to overall health.
Nutritional content
All parents described the primary benefit of consuming dairy products as being their high nutritional content. Specifically, parents believed that dairy products were a good source of Ca, protein and vitamin D, aiding with bone development in children and bone maintenance in adults. For example, when discussing consuming dairy products one parent stated:
‘For my son, sometimes in the morning he doesn’t have a big appetite. So being able to get a big amount of milk and yoghurt into him is good because I know it has a good amount of protein and fat. Rather than just a piece of toast and that’s it, so I’d rather he just have that.’
All parents expressed a desire for information about how the nutritional content of dairy products compared directly with non-dairy products.
Based on these findings, message content was created that focused on providing nutritional comparisons between dairy and non-dairy products for participants to assess the benefits of dairy intake. In addition, messages highlighted the role of dairy products for maintaining overall health and emphasized the convenience of dairy products. Participants in the elaborative phase expressed a desire for messages to contain even more information pertaining to the nutritional content of dairy products, specifically Ca and protein.
Barriers
Negative health outcomes
All parents expressed concerns that dairy products were high in fat and sugar and that consuming these products could negatively impact their weight control. In addition, all parents highlighted physical sensitivity including excess gas, diarrhoea, mucus, eczema and low energy as frequent outcomes of dairy consumption for both themselves and/or their child. One parent commented:
‘He’s [child] also very phlegmy, I feel like he has a cold a lot, so the more milk he drinks, the worse it is’.
Excessive packaging and processing
For all mothers, the packaging of dairy products was a barrier to purchasing, with one mother stating:
‘I can’t stand these things [yoghurt tubes]. I can’t stand the waste of them.’
In addition, all mothers felt that there were a lot of artificial additives in many dairy products.
Contamination of dairy products
Concerns regarding the contamination of dairy products was a commonly discussed barrier to dairy product purchasing and consumption for all parents, with one parent stating:
‘I believe that pasteurizing is a big part of the problem, it’s contributing to people having sensitivities, as well as the hormones and antibiotics.’
All parents believed that regular dairy products contained hormones and antibiotics and as a result felt that buying organic products was preferable:
‘Who knows what’s going on so it’s better to just stick with the organic and not have to worry about it.’
Cost
Due to contamination concerns, all mothers and fathers of children who consumed above the recommended intake of dairy felt they should purchase organic dairy products. However, the cost of these products was a concern:
‘That’s a barrier for me is what is in dairy products that are just mainstream dairy products versus organic dairy products and can I afford organic?’
The cost of dairy products in general was also a concern and appeared to be a greater concern for all mothers as compared with fathers.
Lack of trustworthy information
All parents expressed feelings of confusion regarding the health benefits and contents of dairy products, which inhibited their purchasing and consumption. Parents discussed feeling overwhelmed by the amount of information and mistrusting the sources of much of this information. For example, one parent commented:
‘I think the whole thing’s just a little fishy [milk production]. So I’d rather stay away.’
Another participant questioned the trustworthiness of the grocery stores selling the products:
‘When you see it at the grocery store you have your doubts too because you see them at the grocery store, like at superstore, is it really that organic?’
Parents in the elaborative phase shared that despite a feeling of information saturation they desired more information pertaining to ethical and contamination issues, nutritional content and expected outcomes of dairy consumption from unbiased, trustworthy sources, in order to provide clarity. Reputable sources of information included Health Canada, local health authorities, schools, universities and health-care professionals. Information from grocery stores, Dairy Farmers of Canada or other production companies were perceived as marketing campaigns aimed at selling products, making this information untrustworthy.
Based on these findings, draft messages incorporated a series of ‘myth busters’, providing information pertaining to dairy products from sources that participants specified as trustworthy. In addition, information on the expected outcomes of consuming dairy products and ethical concerns included references to trusted sources’ websites and summaries of research articles so that participants could examine this information themselves.
Purchasing strategies
Habitual
Parents of children who met the recommended intake of dairy discussed how purchasing dairy products was largely habit, part of their regular food shop, with one parent stating:
‘I just have staples, butter, milk, cheese. Every shop we buy the staples.’
Parents of children meeting the recommended intake of dairy reported that purchasing decisions were often made based on ensuring products incorporated all food groups, as explained by one parent:
‘And I’m going to make sure at the end of the day, he’s had his protein, dairy and veggies and I’m happy. That’s how we shop so, I don’t know, I’m not always thinking of those things, that’s just not how I shop or eat, really.’
Parents of children who failed to meet the recommended intake of dairy did not discuss habitual strategies.
Bulk buy
Dairy products were commonly bought in bulk by parents of children who consumed adequate dairy as a way of ensuring constant availability for consumption within the home. Bulk purchasing was also considered possible due to the ability of dairy products to be frozen, as one parent stated:
‘We freeze a lot of cheese, I always shred it, because we have a lot of homemade pizza so I’ll be like “Yay! Shredded cheese!” and then we’ll make our little pizzas.’
Parents of children who did not meet the recommended intake of dairy did not discuss this strategy.
Comparing costs
All parents discussed comparing the cost of dairy products across different stores and making purchasing decisions based on which products were on sale. One parent highlighted the power of a sale in a comment:
‘Print advertising I don’t read. Any kind of advertising I think we’re trained to just glance over it, unless there is a sale.’
Product likeability
All parents agreed that buying products that they knew their children liked, and would therefore consume, was an essential purchasing strategy, with one parent commenting:
‘Looking at what’s not being eaten, like I got just really weird flavoured yoghurt the last shop and no one has really eaten it. Just based on taste.’
Reading labels
In addition to purchasing products based on their children’s taste preferences, mothers of children who failed to meet the recommended intake of dairy and all fathers discussed simultaneously reading food labels in an effort to buy fewer processed products:
‘Yeah, when it says artificially flavoured I tend to just stay away from it.’
Furthermore, parents sought to purchase local products from smaller companies where possible:
‘I avoid the big corporations because I don’t trust them. And, um, I try to look for smaller companies that are more ethical.’
Planned purchases
All parents discussed the importance of planning dairy purchases. Planning occurred in a variety of ways, including: (i) meal planning; (ii) making a grocery list to guide shopping; (iii) selecting products from the perimeter of the grocery store; and (iv) selecting a grocery store based on products sold and pricing. As an example, one parent stated:
‘We usually have a menu on my, like, very organized weeks.’
And another commented:
‘I shop in a few spots. I do it all, like I do Costco, to health food stores, to farmers’ market.’
Subsequent intervention messages included information on how to plan food purchases, identify healthy products in the grocery store and how to save money, for example through bulk buying products. All participants in the elaborative phase discussed that they would utilize these strategies themselves.
Consumption strategies
Balance
All parents expressed that they tried to ensure each meal was nutritionally balanced by ensuring each food group was present, rather than focusing specifically on dairy products, with one parent commenting:
‘So, it’s really about, to me, you go grocery shopping and you make sure your fridge is filled with the right portions of food, and then the rest will happen on its own.’
Supplements
Parents of children who did not meet the recommended intake of dairy discussed the use of dairy product supplements in their diets including almond milk, soya milk, broccoli and other greens, as well as tablet supplements. For example, one parent stated:
‘For calcium and stuff, we get these raw green powders that we drink every morning, just to supplement for the calcium and vitamins, it has lots of good stuff in there.’
Parents of children who met the recommended intake of dairy did not discuss the use of supplements as a consumption strategy.
Creativity
All mothers expressed that being creative with food regarding visual appearance and textures was important to ensure that children consumed a healthy diet. Concerning dairy consumption, one parent commented:
‘We used these [small yoghurt packets] but I take the tops and we put our own yoghurt into them.’
Availability and accessibility
Ensuring dairy products are always available in the house in a manner that is convenient for children to eat by themselves or that can be eaten on the go is a consumption strategy utilized by all parents. As one parent commented:
‘Yup, it’s convenient. The yoghurt tube is the easiest way to get her yoghurt, because she doesn’t waste any of it. There’s no spoon, suck on the piece of plastic.’
Autonomy
Ensuring food is available and accessible to children was important for all mothers and fathers of children who met the recommended intake of dairy, to provide children with a feeling of autonomy. Providing autonomy was believed to lead to greater engagement with food, as noted by one parent:
‘We had a little sectioned off part of the fridge, and that was “her” section. We had a glass of water in there, a glass of milk, and whatever … She was excited because she felt independent.’
Providing children with autonomy also extended to enabling children to pick their choice of product at the grocery store to assist with consumption at home. All mothers and fathers of children who did not meet the recommended intake of dairy utilized autonomy as a consumption strategy for healthy food in general.
Combining products
Parents of children who consumed adequate dairy discussed many ways of combining dairy products with other foods to ensure consumption. The most popular combinations included milk in coffee (for parents only), cereal with milk, and using milk or cheese as a cooking ingredient. One mother explained how she combines dairy products for her child:
‘Hiding it in a bit like that, in soups and things, in one-pot meals. That’s where I try to get things that he’s not necessarily crazy about. Like with smoothies.’
Parents of children who did not consume adequate dairy did not mention this strategy of combining products to bolster consumption.
Role modelling
All parents believed that role modelling was one of the most effective strategies to ensure their child consumed adequate dairy products and this belief subsequently served as a personal consumption strategy. One parent explained:
‘I think that’s how you develop being a child though, being a role model. You can feed them as healthy as you want but if they see you eat something else, then they’re going to model that later in their life, so you have to eat healthy if you’re expecting them to. There’s probably more impact on them than you know.’
Intervention messages that incorporated these strategies were presented to participants in Phase II discussions. Participants reported that they utilized some of these strategies already and would try to adopt the strategies they were not currently using. It was clear that parents wanted additional strategies on how to incorporate more dairy products into meals at home and school and suggestions on how to involve children.
Methods of communication
Parents expressed a desire for information in two distinct formats. Specifically, parents wanted messages pertaining to consumption and purchasing strategies to be fun and interactive, with an emphasis on engaging their children. Catching the attention of their children meant that parents were more likely to pay attention, as one parent stated:
‘That’s a really effective way to make me listen is through my child, because it’s something we can do together.’
Proposed methods of delivering this information included infographics, recipes that involved children, a calendar, and other novel activities to spike children’s interest.
Simultaneously, parents sought information regarding the pros and cons of dairy products to be provided in a formal manner from trusted, unbiased sources, enabling them to make informed decisions. Preferred methods of delivery for this information varied between mothers and fathers. Fathers preferred short facts, while mothers sought more in-depth information in the form of an editorial. For example, one father stated:
‘What’s going to stick with me is short, quick facts.’
Whereas one mother commented:
‘I would read it and ingest it and probably, if I was getting it from a credible source and I didn’t have to query it all the time … that’s the main way that I would be interested in this information.’
Parents believed that receiving this information in the form of a newsletter would be appropriate; however, there was some disagreement as to whether this should be sent via postal mail or electronically. Most parents concluded that mail newsletters were favourable as it enabled them to review the document at their leisure, while an email may be deleted without being read on busy days. Source credibility was of utmost importance for this information, with one parent stating:
‘For me and probably my peer group, it just needs to be from a credible source.’
As soon as parents felt that the information was coming from organizations or individuals with a vested interest to sell products, their frame of reference shifted from information sharing to advertising and the information was deemed invaluable. Parents suggested the use of a logo to remind them of the source of the information throughout the intervention messages.
Parents in Phase II agreed on the two formats of information delivery. However, they believed that the information did not have to be mutually exclusive and that by combining these two formats in one ‘bundle’, engagement of both the parent and child would be greater.
Final message development
Final message content was developed around the key themes (identified within quotation marks in the following paragraphs of the present section) identified within the Phase I and II group interviews, feedback from draft messages presented in Phase II and in collaboration with two behaviour change experts and a registered dietitian (example message content is provided in Table 2).
Table 2 Examples of the final targeted messages aimed at increasing dairy consumption in parents of children aged 4–10 years
The benefits emphasized within message content pertained predominantly to ‘nutritional content’ and ‘positive health outcomes’ associated with consumption of dairy in comparison to non-dairy products and supplemental products or tablets. The favourable ‘taste’ of dairy products was not included as this was perceived a personal preference and providing recipes that may be perceived as tasty was considered more influential on increasing dairy consumption. In addition, the benefit of ‘convenience’ was highlighted.
The identified barriers of ‘negative health outcomes’ and ‘contamination concerns’ were addressed via a series of phrases designed to contradict these beliefs, or myth busters. The myth busters included facts from sources all participants considered trustworthy and were designed to contradict negative perceptions. A registered dietitian verified the content of the myth buster phrases to ensure all information was scientifically accurate. To further address the concern of ‘lack of trustworthy information’, messages also included information on where to find trustworthy information sources, how to assess the quality of information and provided direct links to research articles.
The barriers of ‘excess packaging/processing’ and ‘cost’ were addressed through the provision of purchasing strategies such as ‘buying products in bulk’. Messages also contained strategies to assist with ‘planning purchases’, ‘reading nutrient labels’ and ‘reducing costs’. Strategies to promote child engagement with food and consumption of dairy included: (i) suggestions on how to make food easily ‘accessible’ to children; (ii) novel ideas to make food more attractive for consumption (‘creativity’); and (iii) advice on how to involve children in planning and cooking to increase ‘autonomy’.
Recipes were included to provide practical strategies on ways to ‘combine’ dairy products within meals and provide a ‘balanced’ diet. All recipes were appropriate for parents and children to make together and suggestions on which preparation activities were suitable for children were included. All recipes were tested and the nutritional value calculated using ESHA Food Processor SQL software (ESHA Research Inc., Salem, OR, USA). Messages highlighted importance of parental ‘role modelling’ and provided tips on how parents could increase their role modelling behaviour.
Overall, the message content emphasized salient benefits of dairy consumption, addressed key barriers and provided numerous practical strategies in the aim of promoting dairy product purchasing and consumption in parents and their children.
Discussion
The main purpose of the current two-phase formative research study was to explore parents’ social cognitions in relation to dairy product consumption and purchasing in order to inform content for health promotion messages and to establish parents’ preferred communication modality through which to disseminate this information. Perceived benefits of dairy product consumption were similar for both mothers and fathers of children who consumed both above and below the recommended intake of dairy. However, differences were observed in purchasing and consumption strategies utilized by parents of children who consumed adequate dairy and those who did not. Regarding preferred methods of communication, there were gender differences. Taking account of these differences, recommendations for message content and dissemination methods are provided for future public health campaign messages targeting parents as a means to modify children’s dietary behaviours.
The importance of education
Parents believed that consuming dairy products would lead to beneficial nutritional outcomes and overall health. In particular, the high Ca content in dairy was especially important to ensure adequate bone development in children and bone maintenance in adults. These findings are similar to results from Jung et al.’s study( Reference Jung, Mistry and Bourne 25 ) which revealed that adults aged 30–50 years highly value the physiological benefits from consuming dairy products. In the current study, all parents expressed a desire for more information about the physical health benefits of consuming dairy products, particularly for their child, and how the nutritional content of dairy directly compared with non-dairy products. Given that parental knowledge has been linked to engagement in practices to promote Ca intake in children( Reference Cluskey, Edlefsen and Olson 15 ) and to dairy intake in children( Reference Brett, Vanstone and Maguire 32 ), it is important that messages contain an educational component to satisfy parents’ desire for nutritional knowledge.
In addition to the positive physical outcomes associated with dairy consumption, parents perceived a number of negative physical outcomes. Specifically, excess gas, diarrhoea, mucus, eczema and low energy were believed to be associated with dairy consumption for their child and themselves. Some parents believed these physical sensitivities to dairy products could be due to contamination of dairy products with hormones and antibiotics. Contamination of dairy products was a common barrier theme for all parents and has been reported previously in adults ranging from 18 to ≥60 years of age( Reference Jung, Mistry and Bourne 25 , Reference Marcinow, Randall Simpson and Whiting 33 , Reference Mobley, Jensen and Maulding 34 ). These findings are concerning for countries with strict hormone and antibiotic use regulations by dairy farmers, such as Canada. Participants in the elaborative phase were extremely receptive to ‘myth buster’ messages as a method of dispelling misinformed beliefs but stressed the importance of information coming from credible sources.
Source credibility
A lack of trustworthy information was one of the most frequently discussed barriers to dairy consumption for parents. This finding echoes those of Jung et al. in a study of Canadian adults( Reference Jung, Mistry and Bourne 25 ). In the current study, parents reported feeling overloaded with nutritional information, but felt that the majority of this information came from non-credible, untrustworthy sources. Information provided by grocery stores and production companies was deemed untrustworthy and purely for advertising purposes. Information disseminated from health-care professionals, schools and universities (i.e. organizations that did not stand to gain a profit from their dairy consumption) were deemed trustworthy. In a meta-analysis of health communication tactics, Keller and Lehmann( Reference Keller and Lehmann 35 ) concluded that messages from sources perceived as non-reputable were not as effective as messages from sources perceived as reputable. Future health promotion messages should clearly identify the source of the information content to provide transparency and promote trust among readers.
Tips on reducing costs
A barrier specific to mothers was the cost of dairy products. It is possible that mothers are more aware of the cost of food products as they traditionally do the majority of the grocery shopping and meal preparation in the household( 36 ). The cost barrier was accentuated due to the belief that they should purchase organic dairy products for their children. Health promotion messages should provide evidence-based information on the health benefits of organic v. non-organic dairy products to enable parents to make informed decisions about purchasing organic products. Parents in the elaborative phase reported that this information was extremely informative and useful.
Not surprisingly, cost was identified as an important purchasing consideration, with all parents making purchasing decisions based on product sales. This purchasing strategy appeared to take precedent over other purchasing considerations. One purchasing strategy that was utilized by parents of children who consumed adequate dairy, and which would help to address cost concerns, was buying dairy products in bulk. Parents reported buying dairy in bulk and freezing products for consumption at a later date and to avoid spoiling. Given the importance of price for purchasing and consumption behaviours, future messages should contain practical strategies that can reduce grocery-shopping costs.
Provision of practical consumption strategies
Regarding consumption, parents of children who consumed adequate dairy discussed combining dairy products with other food items to promote consumption for themselves and their child. Mothers in particular discussed that being creative with how food was presented was a useful strategy to ensure their children consumed a healthy diet. Consumption strategies utilized by all parents included making sure dairy products were available in the home and that these products were accessible for children to consume by themselves. This strategy provided children with a sense of autonomy that parents felt was important to promote dairy consumption. Despite the number of consumption strategies identified, all parents expressed a desire for additional practical tips and techniques to promote dairy consumption such as recipes, how to make lunch-box meals appealing and ways of increasing child engagement in food and eating. As such, it is important that future health promotion messages incorporate these ‘hands-on’ suggestions in order to increase parents’ confidence to engage their children in food choices and to prepare meals containing dairy products so as to promote familial consumption.
The power of role modelling
Role modelling was identified as an effective consumption strategy for both parents and children. Parents were aware of the impact that their consumption behaviour had on their children’s consumption and this relationship was extremely important to them. The value of role modelling reported in the current study is in line with previous research which revealed that acting as a role model was exceptionally important to parents in order to ensure their children engaged in healthy behaviours, often making up for a lack of concern regarding their personal eating habits( Reference Aschemann-Witzel 37 ). Given that role modelling of healthy eating is essential in the development of long-lasting healthy nutrition behaviour in children( Reference Golan and Crow 38 ), health promotion messages should emphasize the importance of role modelling and provide suggestions on how to be a good role model.
Clarity on supplementation
Interestingly, parents of children who did not consume the recommended intake of dairy reported using supplements as a means of ensuring consumption of nutrients found within dairy products. Parents reported supplementing their diets and those of their children. It is important that parents are provided with evidence-based information related to pros and cons of supplementation v. dairy product consumption, as the nutritional profile of supplemental products will likely be different from that of dairy products. Furthermore, scientific concerns regarding the use of Ca-fortified foods and beverages have previously been highlighted( Reference Nicklas 2 ).
Channels of communication
With regard to knowledge dissemination methods, parents expressed a desire for: (i) fun and interactive materials that engaged their children, such as recipe books and calendars; and (ii) material that was adult-focused and provided factual information. Parents reported a preference for receiving this information in print rather than via email, with fathers expressing a desire for quick, easy-to-read facts and mothers seeking a more comprehensive article. Similarly, Birkett et al.( Reference Birkett, Johnson and Thompson 39 ) reported that parents had a preference for print materials in regard to nutrition education. Most importantly, information must come from a reputable, trustworthy source, such as a university or health-care provider, for the message content to be read and subsequently processed. If future public health campaigns fail to address this concern, the content of health messages will be irrelevant.
Study limitations and strengths
One limitation of conducted in-depth group interviews is that the findings may not be generalizable to the wider target population. Specifically, in the current study participants reported a high level of education, with 60 % holding a university certificate or higher. Parents with lower education levels may hold different perceptions regarding the benefits and barriers to dairy product consumption as well as different purchasing and consumption strategies. As such, future research should be conducted with parents of children with differing education levels and socio-economic status, to examine if differences do occur and to examine how these impact potential intervention messages. An inherent limitation of in-depth group interviews is that individuals may feel uncomfortable sharing their personal beliefs and may conform to the consensus of the group( Reference Krueger and Casey 40 ). To minimize these potential effects, all interviews were moderated by a researcher experienced in group moderation. The moderator began each session by informing participants that there were no right or wrong answers and that all thoughts and comments were valuable to the research. The moderator also asked participants if they had any different thoughts or feelings from those expressed by others in the group to help promote openness. In addition, interviews were coded by two raters, who displayed high inter-rater reliability. One of the strengths of the current research was the use of both exploratory and elaborative phases with two different groups of parents. The exploratory phase allowed for the examination of barriers to and benefits of purchasing and consuming dairy products, and identification of appropriate avenues of communication through which to share these messages. In the elaborative phase, social cognitions were further examined in order to confirm the findings revealed in Phase I and draft intervention messages and dissemination methods were presented to a new sample of the target audience. Directly involving the target audience in the development of health promotion messages is critical to the acceptance and success of an intervention( Reference Glanz, Rimer and Lewis 41 ).
The present study draws on the extensive value parents attach to the health of their child to in turn create a series of messages directly targeting parents in an effort to promote positive behaviour change in both parent and child. Given the high rates of dairy underconsumption among young Canadian children, these findings have implications for public health initiatives. Specifically, future public health campaigns should ensure that nutritional information, particularly dairy, is imparted to parents from reputable sources such as their child’s school or Health Canada. In addition, messages should endeavour to address the commonly held negative perceptions of dairy products, while highlighting the benefits their child could stand to gain. Public health campaigns should also provide a plethora of strategies to help parents feel confident to engage in the desired behaviour within their own home.
Future research should aim to examine the effectiveness of these intervention messages, targeted specifically towards parents as the ‘nutritional gatekeepers’, on increasing parent dairy-related behaviour and the consumption of dairy products by children.
Acknowledgements
Acknowledgements: The authors would like to thank Lindsay Burton for assistance with transcribing and coding the transcripts. Financial support: This work was supported by a grant from the Canadian Agri-Science Clusters Initiative, Dairy Research Cluster (Dairy Farmers of Canada, Agriculture and Agri-Food Canada, and Canadian Dairy Commission). The Canadian Agri-Science Clusters Initiative had no role in the design, analysis or writing of this article. Conflict of interest: None. Authorship: M.E.J. was responsible for project conception. M.E.J. and J.E.B. designed the research, developed the overall research plan, conducted the research, analysed the data, determined the content of the manuscript and collaborated on the writing. K.A.M.G. and A.B. contributed to the overall research plan and assisted with manuscript writing. All authors read and approved the final manuscript. Ethics of human subject participation: This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the University of British Columbia Behavioural Ethics Committee. Written informed consent was obtained from all subjects.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1368980017002038
