Participant characteristics
Seven focus groups were held among parents and four among YHCP. The average durations were 58 and 56 min for parents and YHCP, respectively. The characteristics of participating parents and YHCP are given in Table 1. The average age of parents was 38.0 years (SD 4.4, range 31–46) and the majority were female (96%). The mean number of children per parent was 2.6 (SD 1.7, range 1–7). Most of the parents had been born in the Netherlands (64%) and had received a high level of education (44%). Five YHCP dropped out because the scheduled time did not suit them. Participating YHCP were predominantly female (96%). Most of them were working as a youth physician (68%) and the largest portion in the Western part of the Netherlands (48%).
Current practice of youth healthcare regarding young children’s lifestyle
Parents
Regarding the current practice of youth healthcare regarding young children’s lifestyles, the themes that arose were: (1) screening and discussing lifestyle, and (2) advising and informing. Parents stated that their child’s lifestyle is often discussed during youth healthcare appointments and that they appreciate this. The emphasis of the conversation is usually on nutrition, but the topics of physical activity and sleep are also commonly addressed. Parents value the open-ended, non-judgmental questions asked by YHCP to start the conversation. However, when asked to clarify their preferences, parents expressed that YHCP could ask more in-depth questions, such as how much the child is eating exactly or what the vegetable intake is like. According to the parents, this may provide YHCP with a better understanding of the situation from which to offer specific advice. It may also help to break down barriers that might prevent parents from sharing their concerns if only open-ended questions are asked.
Regarding parents’ preferences for screening and discussing lifestyle:
“If a child is growing well and following the curve, then it’s basically done. But you [the YHCP] could also zoom in on what they [the children] actually eat and what the fruit and vegetable intake is like.” Parent #5.
Moreover, parents indicated that the lifestyle conversation could be more in line with their needs and family situation. Barriers to discussing lifestyle, according to parents, are the relatively few appointments offered by youth healthcare services and time constraints. Some parents put forward that not all YHCP were equally open to alternative ways of eating or upbringing.
Parents reported receiving advice and information about their child’s diet, physical activity and screen use. In general, parents were satisfied with the advice they received. However, the advice and information was also repeatedly perceived as not being very comprehensive and not giving enough guidance on what is healthy. As facilitators in informing about lifestyle by YHCP, parents reported explaining guidelines and advice and providing information material to take home.
With regard to the way information is given, parents prefer a coaching, non-strict conversation with a holistic perspective. The presence of older children in the family is a major obstacle in compliance with lifestyle advice for their young children. In the focus groups with parents with lower levels of education and migrant backgrounds, the grandparents’ views on a healthy lifestyle and a healthy weight were also noted as disturbing factor.
Regarding the perception of older family members as a barrier to complying with lifestyle advice:
“When I go on holiday to my family, they say: ‘Oh he is cute, but skinny, so sad’.” [when in fact he has a normal weight] Parent #13.
YHCP
For YHCP, the themes on the current practice of youth healthcare regarding young children’s lifestyles that arose: (1) screening and discussing lifestyle, and (2) advising and informing. YHCP indicated that the subject of lifestyle is discussed in the majority of appointments. Exceptions include appointments on indication, for example when vision or motor skills are examined only. When children are younger than one year old, lifestyle, particularly nutrition, is often addressed at the parent’s initiative. Parents may have questions themselves, and also expect talking about their child’s nutrition. After the first year of life, parents typically bring up the topic of nutrition only when they experience problems, such as the child not eating well or being a picky eater. YHCP stated that if parents do no mention lifestyle themselves, they will inquire about it as openly as possible.
Regarding the current method of screening and discussing lifestyle during a youth healthcare visit:
“Well, I basically just ask at every consultation: ‘How is the diet?’. And then we talk about that.” YHCP #5.
In addition to nutrition, YHCP may discuss with parents their children’s physical activity, screen time, sleep, as well as family stressors, parenting and parental lifestyle. Sometimes this conversation is initiated on the basis of a child’s growth curve or specific items in the electronic health record, such as supplemental vitamin D intake. Several YHCP also mentioned that tools, such as a waiting room poster that displays the number of sugar cubes in various sugar-sweetened beverages, frequently spark discussion. However, the demand-driven way of working within Dutch youth healthcare and time constraints make it sometimes challenging to discuss lifestyle with parents, especially when YHCP feel there are no “starting points”, such as unhealthy weight, for the conversation.
Regarding the absence of “starting points” to proceed with the conversation:
“So, when I ask ‘How is the diet?’, and the answer is ‘Good’, yes, then it gets difficult. Because indeed, how much further should you ask? If I see a child having overweight or obesity, then I really have a starting point for a conversation, but when I see a child with a healthy weight who is developing well, yes… Then I’ll let it go, then I won’t ask any further questions. So, I’m probably missing a lot of things.” YHCP #7.
Regarding time constraints during consultations:
“You have several things to do and this [discussing lifestyle] is just a small part of it. In that respect, I believe I absolutely miss children who may have an unhealthy diet but are otherwise healthy-weighted. But because you just have 20 minutes and there are so many things you need to give attention to, that goes wrong sometimes.” YHCP #14.
Nevertheless, when YHCP notice “red flags”, such as abnormal growth or overweight, they probe further. While it is easier to start the conversation about lifestyle in this case, YHCP find it more difficult to continue this conversation. Reasons for this are mainly parent-related: some parents may find the topic of lifestyle too sensitive, they may not be open to a conversation about it, or are unaware of the lifestyle recommendations for a specific age.
With regard to advising and informing parents about lifestyle of their children, YHCP indicated a list of facilitators and barriers. Above all, it was stated that advice or information given should be tailored to the family concerned. To facilitate this, YHCP reported that provided advice and information should be in line with the parents’ knowledge, skills, financial resources, environment, and culture. Additionally, using existing tools and information sources, such as flyers from the Dutch Nutrition Centre, and offering feasible advice was considered helpful. Most barriers were related to these facilitators. In addition, the resistance of parents to advice was also raised as a major concern.
Regarding parental resistance to lifestyle advice:
“But here again, if parents notice that their child is overweight but refuse to do anything about it, it is better to ask parents again when they begin to worry about it. (.) However, it gives me mixed feelings, because the child has no choice. (.) So, I still find that very difficult.” YHCP #16.
Requirements for a new lifestyle screening tool
Parents
The requirements that emerged from the parents were divided into requirements for themselves and for their children (Table 2; Fig. 1). Six themes were identified in terms of requirements for the parents themselves: (1) usability, (2) time investment, (3) alignment with family, (4) visual attractiveness, (5) effectiveness, and (6) child privacy. Usability mainly concerned completing the tool at a suitable place (e.g. at home or waiting room) and in a practical way (digitally or on paper). Although opinions varied on the best place and method, parents agreed that the time investment should be minimal and certainly no longer than ten minutes. To align the lifestyle screening tool with the family, parents requested that the tool be tailored to the family’s needs and values in terms of socio-economic status, skills and family culture. Parents preferred a visually appealing tool that provides an overview of a child’s lifestyle.
Regarding effectiveness and visual attractiveness:
“And that’s why I thought of a spider web, because then you can show the relationship between the different elements, and as professional you can also say: ‘Hey, I’m noticing something here’.” Parent #2.
As for effectiveness, major concerns for parents were that the purpose of the tool should be clear to them and that YHCP act upon the answers parents provide. Moreover, the tool should mainly facilitate and support the conversation with the YHCP and not be strict and patronizing. While the higher-educated parents emphasized the importance of using the tool holistically and without judgment, the parents with a lower education and/or migration background indicated that they would prefer outcomes with more direction. The use of a traffic light system, for example, in which healthy behavior is marked green and less healthy behavior orange or red, would give them guidance and motivation to improve.
Regarding outcomes with a clear direction as part of the theme ‘effectiveness’:
“Of course! When I get a warning like ‘your child can do much better’ (…), you just do your best!” Parent #14.
Some parents mentioned that a tool would have been helpful before the age of one, whereas others stated that they had more questions during toddlerhood and such a tool would therefore be more effective from the age of 12 months and older. Finally, parents considered it critical to ensure the safety of the data they would provide with the tool.
The requirement for the child comprised including relevant topics in the tool. The parents suggested nutrition, physical activity and sleep as the most relevant topics. Screen time was not mentioned.
YHCP
YHCP devised requirements for the new lifestyle screening tool for themselves, for the parents, and for the children (Table 2; Fig. 1). As for requirements for YHCP themselves, three themes were identified: (1) usability, (2) time investment, and (3) courses of action. Usability referred to several factors, including using the tool as a conversation aid, embedding it into the current working method and electronic health record, and utilizing existing tools and resources for providing advice and information. Regarding time investment, the most frequently mentioned concern for YHCP themselves was that the instrument should not lead to time loss during the appointment. Lastly, the YHCP mentioned that the tool should offer them courses for action, for example by providing a score, offering cues for the conversation or contributing to counselling.
Regarding using the tool as a conversation aid:
“Could it be a starting point for the conversation you are already having anyway, but in a certain way, from that starting point?” YHCP #2.
According to the YHCP, the requirements for the parents were subdivided into: (1) usability, (2) alignment with family, (3) attractiveness, and (4) effectiveness. YHCP expressed that the tool should have high usability for parents too, for example by enabling quick and digital completion. In addition, the YHCP above all felt that a new lifestyle screening tool should align with the family, particularly in terms of the parents’ needs, socio-economic status, skills, and culture. Other requirements for parents for the tool included it being attractive, i.e. visually appealing and not too strict or patronizing, as well as being effective, for example by increasing parents’ knowledge and awareness of their child’s lifestyle.
The overarching theme of the requirements for the children according to YHCP was effectiveness. YHCP mentioned that a new lifestyle screening tool would be effective for children if it covers relevant topics and is used at appropriate ages. Healthy and unhealthy dietary intake and physical activity were most frequently mentioned as relevant topics, but screen time, sleep and smoking also emerged. YHCP agreed that a lifestyle screening tool should be applied before lifestyle patterns become ingrained, so for example at the age of one year, or even earlier.
Overlapping and individual themes that emerged for parents, children and YHCP according to parents and YHCP
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