Listening to pre-school children speak about health and health-promoting behaviours

Abstract

Objective:

As children become increasingly exposed to health information and education, it is important to understand how these messages affect the way children speak about health and health behaviours. Children are social agents and co-constructors of their social worlds. Exploring how pre-school children speak about health and health-promoting behaviours can help explain what children make of health messages and may help facilitate communication between children, parents and educators.

Methods:

Participants included 163 pre-school children aged 3–5 years attending childcare centres in South-East Queensland, Australia. Semi-structured interviews were used to explore how pre-school children speak about health and health behaviours. Data were analysed using thematic analysis.

Results:

Participant responses were structured as two categories. The first category was Meaning of Healthy. This category comprised four themes of eat your food (n = 74 of 145, 51%), participating in activities (n = 36, 24%), growing big and strong (n = 20, 13%) and not being sick (n = 15, 10%). The second category, How to be Healthy, comprised five themes including eat healthy food (n = 86 of 150, 57%), reduce risk (n = 31, 20%), treat illness (n = 13, 8%), be well behaved (n = 12, 8%) and do exercise (n = 8, 5%).

Conclusion:

Findings highlighted the centrality of food in how children speak about health. In comparison to the discussion of food and the importance of eating healthy food, there was limited mention of physical activity by participants as a way to be healthy. The theme reduce risk emerged from participant responses and relates to the practice of safety behaviours to prevent injury and illness. Future research needs to determine whether the emphasis children place on risk minimisation is shaping how young children speak about health and how this interaction plays out in their health behaviour.

Keywords

Health-promoting behaviour nutrition physical activity pre-school children talking about health

Introduction

Early childhood is a life stage at which a person is gradually developing an understanding of complex concepts. The concept of health has evolved to be understood as a multi-dimensional, dynamic state of well-being (Bircher, 2005). How children understand and speak about health has implications for how they will act to promote health and manage risks to their health over time (Barton, 2012; Biro and Wien, 2010; Craigie et al., 2011; Tatlow-Golden et al., 2013; Telama, 2009; Telama et al., 2005; Tinsley, 2003; Trudeau et al., 2004; Waters et al., 2011; Whitaker et al., 1997). Children are social agents and co-constructors of their social worlds and the way they talk offers fundamental insight into the information they have received regarding health and health behaviour (Normandeau et al., 1988; Tinsley, 2003). Listening to how children speak about health behaviours and how to maintain health may help explain the complexity of children’s health behaviour.

Previous research has shown that young children can understand complex information if it is presented in an appropriate way, with children as young as 3 years demonstrating the ability to construct understandings of health (Cammisa et al., 2011). A child’s developmental acquisition of health-related understandings is often explained using an individual differences perspective. Such an account suggests that personality, social and cultural variables mediate children’s understanding of health (Tinsley, 2003). Children develop their understanding of health through direct instruction, modelling and experiences within their environment. Messages about health are communicated to children both implicitly and explicitly so that they begin to learn social values around health. These understandings serve as the mental foundation to reasoning, intention and behaviour (Bartsch and Wellman, 1989; Worsley, 2002). Adults can be unaware of the ways in which children are interpreting information on health and making this information meaningful to their lives. By listening to children’s voices, it is possible to identify key values within the society of which they are a part.

Existing research presents mixed findings regarding children’s understanding of health and what they consider to be health behaviours. Much research has focused on children’s conceptions of illness or has targeted school-age children (7–12 years; Irwin et al., 2007; Natapoff, 1982; Normandeau et al., 1998; Piko and Bak, 2006). A number of studies have explored pre-school children’s knowledge and understanding of specific health behaviours, for example, food and exercise (Anthamatten et al., 2013; Harrison et al., 2015; Macdonald et al., 2005; Matheson et al., 2002; Pearce et al., 2009; Protudjer et al., 2010; Schultz and Danford, 2016). Interestingly, research that has looked broadly at this population’s understanding of health has found that children know the least about the relationship between food consumption, exercise and their health, and the most about beneficial and harmful practices in the areas of safety and hygiene (Mobley, 1996; Olvera-Ezzell et al., 1994). Pre-school children have also been found to view health as being able to participate in desired activities, being engaged and feeling good (Almqvist et al., 2006).

Much of the research investigating how children understand health and what they consider health behaviours was conducted over a decade ago (Aggleton et al., 1998; Almqvist et al., 2006; Mobley, 1996). It can be argued that how children speak about health may have shifted alongside societal changes. The field of child health has changed dramatically in recent years resulting in the adoption of new policies and interventions promoting health behaviours within childcare settings (e.g. healthy eating and active play; Wolfenden et al., 2012). Children are increasingly exposed to a variety of public health messages through media advertisements, education and promotion posters which collectively shape a child’s understanding of how to be healthy (Burrows and McCormack, 2014; Wolfenden et al., 2012). Exploring how pre-school children speak about health and health-promoting behaviours may offer insight into how children understand health, and thus help explain what children make of health messages in their ever-changing environments. This knowledge may help facilitate communication between children, parents and educators. The purpose of this study was to explore how pre-school-aged children speak about health and health behaviours.

Methods

Participants and procedure

Convenience sampling was used to recruit 163 pre-school children aged 3–5 years, from approximately 240 children attending eight childcare centres in South East Queensland, Australia. Of the 163 participants, 87 were boys (53.3%), while 76 were girls (46.6%). Participants ranged in age from 3 years, 1 month (37 months) to 5 years, 1 month (61 months; M = 48.13; Table 1). More than half of the participants’ primary carers had completed higher education (bachelors or masters degree; 56.0%). Most participants had an annual household income of AUD$145,600 or more (41.4%) or AUD$83,200–$145,599 (31.8%). Childcare centres were selected based on their geographic proximity to the research team and willingness to participate in the study. At participating centres, invitations asking parents to allow their child to take part in the study were distributed, which comprised information about the research and consent forms. Ethical approval for this project was obtained through Griffith University Human Research Ethics Committee HREC (MED/04/14/HREC).

Table 1.

Demographic characteristics of study participants (n = 163).

Variable	n (%)
Gender
Male	87 (53.3)
Female	76 (46.6)
Ethnicity^a
Caucasian	131 (82.9)
Non-Caucasian	27 (17.1)
Annual household income^b
AUD$145,600 or more	65 (41.4)
AUD$83,200–$145,599	50 (31.8)
AUD$83,199 or less	42 (26.8)
Primary carer education^c
Lower secondary school	3(1.88)
Upper secondary school	19 (12.00)
Technical and further education	48 (30.2)
Higher education (bachelors/masters)	89 (56.00)
Child age (years)
3	61 (37.4)
4	89 (54.6)
5	13 (7.9)
Child age (in months)	Mean (min, max)
	48.13 (37, 61)

Response categories were collapsed from 10 to 2 categories of non-Caucasian and Caucasian.

Response categories were collapsed from 10 categories, ranging from >145,600 to <$13,000 per annum to three categories ranging from >145,600 or more to <83,199 or less.

Response categories were collapsed from five categories, ranging from primary school to higher education to four categories ranging from lower secondary to higher education.

This investigation was part of a larger intervention study conducted to evaluate the Get Up and Grow healthy lifestyle programme for pre-school children (Wiseman et al., 2016). The qualitative component was conducted in March–April 2016 prior to the intervention being implemented. It was integrated into the main study data collection as a means to build rapport with participants and to orient participants’ thinking to health concepts prior to further data collection.

To gain an understanding of how pre-school children speak about health and health behaviours, semi-structured interviews were conducted with each participant individually. The interviews took approximately 10 minutes with each child and were conducted by a researcher within hearing distance of classroom educators. The researcher conducting interviews had extensive experience working with pre-school children and followed a set protocol with each participating child. Prior to commencing the interviews, each participant was asked verbally whether he or she would like to participate. Interviews were structured with two open-ended questions. The questions used were drawn from a previous study conducted by Calfas et al. (1991). First, each child was asked ‘Can you tell me what healthy means?’ After responding, the participant was then provided with an age-appropriate explanation, ‘Being healthy means that you can play outside, you don’t get sick and you feel good’. This definition was also drawn from the study conducted by Calfas et al. (1991) and was given to participants as a platform to allow them to tell the researcher what makes them healthy, so that they all had the same basis to respond. The participant was then asked ‘Can you tell me some things that you might do to be healthy?’ If a child did not offer a response, he or she was offered the follow-up question ‘Can you tell me what your mummy or daddy do to be healthy’. If a participant did not respond to these questions, the qualitative component of the interview ended. The qualitative component of the interview was audio-recorded with parental and participant permission.

Data analysis

Audio-recorded participant responses were transcribed into a Microsoft Word document. Children’s responses were organised under the two categories of (1) Meaning of Healthy and (2) How to be Healthy which reflects the questions asked. Data were then analysed using a thematic analysis process. Thematic analysis is an inductive analysis strategy used to identify, organise, explain and report patterns and themes within data (Braun and Clarke, 2006). Data analysis began by reading the data and noting down initial ideas. The transcripts were reviewed and open coding was used to cluster ideas under broader themes (Liamputtong, 2013). Themes were developed by segmenting and labelling text and were defined on the basis of the children’s statements (Liamputtong, 2013). The final phase of analysis involved the revision of themes, the defining and refining of themes and relating the analysis back to the research question and existing literature (Braun and Clarke, 2006). Thematic analysis was conducted and reviewed by the three authors to ensure consistency of the interpretation of data.

Results

Two main categories of response, together with representative quotes and number of responses from participants are presented below in Tables 2 and 3. The themes presented are ordered by how many children gave a response relevant to that category. Responses did not vary by gender or age; however, in some instances it was evident that the sophistication of child responses within themes increased with age. Of the participating children, 18 did not respond to question 1 and 13 did not respond to question 2 (non-responders varied by question). Table 2 presents the first category: Meaning of Healthy, including the four themes of eat your food, participating in activities, growing big and strong and not being sick. Eat your food accounted for just more than half (n = 74, 51.03%) of all responses recorded under this category. Within this theme, a number of children stated that being healthy meant ‘finishing my dinner, drinking water’ or to ‘eat your breakfast’. Other children associated health with growing big and strong and the ability to do activities such as painting and playing with toys. Children frequently characterised health as the absence of or resistance to illness, for example, children stated that being healthy meant to ‘not be sick and not have a cough’.

Table 2.

Meaning of Healthy (n = 145).

Theme	Representative quotes	Sex, age	n (%)
Eat your food	Eat food Eat your breakfast Finishing my dinner, drinking water Eat some food. Eat food every day	Male, 4 yearsFemale, 5 yearsFemale, 3 yearsMale, 5 years	74 (51.03)
Participating in activities	You can go to school You can play with cars and trucks Painting pictures	Male, 4 yearsMale, 3 yearsFemale, 4 years	36 (24.8)
Growing big and strong	Healthy means that you are big and strong I do, it means you are strong so You can swim very well You get big and strong	Female, 3 yearsFemale, 5 yearsMale, 4 years	20 (13.79)
Not being sick	You don’t get sick Not be sick Not be sick and not have a cough You keep the doctor away	Male, 3 yearsFemale, 3 yearsMale, 3 yearsFemale, 5 years	15 (10.34)

Table 3.

How to be Healthy (n = 150).

Theme	Representative quotes	Sex, age	n (%)
Eat healthy food	Eat healthy food like meat and watermelon, potato, and bread	Male, 4 years	86 (57.33)
	Drink water, eat carrots, meat and potatoes and broccoli and food	Male, 3 years
	Yes, you need to eat heaps of vegies and fruit	Female, 4 years
	Eat food that’s good you for but you can eat lollies every now and then	Female, 4 years
	Eat not to much lollies	Female, 4 years
	Eat lots of healthy food	Female, 3 years
Reduce risk	If it’s cold outside in the rain and stuff you have to wear a long shirt and stuff and it’s wet you run and you can slip	Female, 5 years	31 (20.66)
	Try to not get hurt, that’s all, stopping on my bike at the road	Female, 3 years
	Umm mummy can put my seatbelt on when I get in the car	Male, 4 years
	Strangers are not healthy and running on the concrete is not healthy, I’ll break my bones Cover your mouth	Male, 4 yearsMale, 3 years
Treat illness	I got sick so I need to drink lots of water and take my medicine	Male, 3 years	13 (8.66)
	When I was a baby I was sick. I went to the hospital. The doctors made me better strawberry medicine	Female, 4 yearsMale, 3 years
	you get needles from the doctor and have medicine and tablets	Male, 4 years
Be well behaved	Clean up your toys I help my mum clean the house and fix things with my dad	Male, 3 yearsMale, 4 years	12 (8.00)
	Be nice to my brother	Male,5 years
	You be good for Mummy	Female, 4 years
Do exercise	Mummy does exercise	Male, 4 years	8 (5.33)
	Playing, running, walking and basketball with Daddy	Male, 5 years
	Yes, um run and I exercise	Female, 5 years

With regard to participants’ understanding of How to be Healthy, five themes emerged including eat healthy food, reduce risk, treat illness, be well behaved and do exercise (Table 3). Again, the themes presented are ordered in terms of how commonly they were cited by the children. Eat healthy food emerged as the most common theme, accounting for more than half of the responses for this category (n = 86, 57.33%). Children frequently indicated that the consumption of healthy food is important to obtain good health. Children typically mentioned water, types of fruit, vegetables and meat products as food to be consumed to be healthy. The theme ‘reduce risk’ refers to the practice of safety behaviours to prevent injury and illness, for example, ‘If it’s cold outside in the rain and stuff you have to wear a long shirt and stuff and it’s wet, you run and you can slip’. Treating illness was the third theme; this included medical treatment of illness to restore health, for example, ‘I got sick so I need to drink lots of water and take my medicine’. Being well behaved was also frequently mentioned by participants; this theme refers to practices such as obeying rules, being kind and helpful to siblings, parents and friends. The final theme which was less frequently mentioned by participants as a way to maintain health was exercise or physical activity.

Discussion

How children speak about health reflects the social and environmental context in which they live and grow (Lanigan, 2011). Children are increasingly exposed to a range of health messages formulated within public health missives, television programmes and commentaries from friends, families and teachers, which collectively shape a child’s way of understanding how a healthy person looks, behaves and talks (Burrows and McCormack, 2014).

In this study, good food choices dominated how children spoke about what it meant to be healthy, contributing the most to each of the two categories and the emergence of the themes, ‘eat your food’ and ‘eat healthy food’. Research suggests that children as young as 3 years are knowledgeable about health in relation to eating (Schultz and Danford, 2016). This may be due to a prominent educational focus on the importance of a healthy diet in the home and childcare setting (Burrows and McCormack, 2014; Frerichs et al., 2016). A study conducted with school-aged children (Burrows and McCormack, 2014) found that nutritional information is readily available across young children’s private, public and institutionalised lives. These messages that children receive across contexts, often in the form of directives, may contribute to responses about food and healthy eating (Burrows and McCormack, 2014).

Participants frequently identified fruit and vegetables as examples of healthy foods and also mentioned the need to limit the intake of unhealthy foods. For example, one participant stated, ‘Eat food that’s good for you but you can eat lollies every now and then’. This supports other research that found pre-school children tend to view fruit and vegetables as healthy (Frerichs et al., 2016), and are able to classify foods as unhealthy or ‘junk’ (Schultz and Danford, 2016). These views have been potentially shaped by the combination of dominant nutrition education, which use food group–based guidelines as a framework, and marketing campaigns that focus on fruit and vegetable promotion (Frerichs et al., 2016). The extent to which eating informs how children speak about what it means to be healthy from such a young age is an important finding, as it highlights the potential benefits of persistent health messaging (Dwyer et al., 2008).

Interestingly, there was limited mention of physical activity as a health-promoting behaviour. This is consistent with previous work (Irwin et al., 2007; Lanigan, 2011) which found children were more adept at identifying healthy foods and explaining the benefits, than identifying physical activities that make their bodies healthy. The literature offers several possible explanations for this finding. A qualitative study conducted by Dwyer et al. (2008) of young children’s physical activity found that parents and educators consider children to be naturally active, requiring less physical activity promotion, which may contribute to reduced mention of physical activity as a health-promoting behaviour by children. There is evidence to suggest that conflicting messages regarding health supporting behaviours may limit the uptake of these behaviours (Lanigan, 2011). The emphasis participants placed on the importance of minimising risk and injury prevention as a health behaviour may work to contradict the encouragement of children engaging in physical activity, for example, ‘Running on the concrete is not healthy, I’ll break my bones’ (boy, 3 years).

Responses that reflected children’s emphasis on the importance of safety to maintain health were organised under the theme labelled ‘reduce risk’ which refers to the practice of behaviours to prevent injury and illness. Children’s emphasis on safety is reflected in a number of studies that seek to explain the barriers to promoting physical activity in young children in the home and childcare settings (Coleman and Dyment, 2013; Dwyer et al., 2008; Van Zandvoort et al., 2010). Given that the leading cause of child death in Australia is injury, the societal emphasis on child safety is warranted (Australian Institute of Health and Welfare: Pointer, 2014). This presents a challenge, as at a life stage in which lifestyle behaviours are developed, limiting children’s opportunities to enjoy bodily movement, may constrain their long-term participation in healthy physical activity. Further research is needed to determine which factors within a young child’s environment come together to shape how children talk about physical activity and risk.

The absence of illness was also considered a criterion of good health by participants with two themes emerging from responses including ‘treat illness’ and ‘not being sick’. Although the definition of healthy provided to participants in this study may have influenced the emergence of this theme, this finding is consistent with existing early childhood literature. Normative health education for children largely individualises health, reducing health promotion to the reduction of risk (of future illness, injury and the practice of unhealthful behaviours; Burrows and McCormack, 2014). This approach shapes children’s classification of health so as to be two-dimensional, meaning that they tend to view health and illness as two separate concepts that cannot be present at the same time (Almqvist et al., 2006).

Personal experience of injury and illness also plays a part in children’s understanding of health as the absence of illness, with participants who expressed this belief consistently referring to a past event that led them to be ‘unhealthy’, for example, ‘I got sick so I need to drink lots of water and take my medicine’. This may also help explain children’s mention of preventing illnesses such as colds and injuries (falls) as these are frequently experienced by children (Piko and Bak, 2006).

Another theme that emerged from children’s responses as a way to maintain health was the importance of being well behaved. This theme provides further evidence of the extent to which a child’s context and environment can shape how children speak about health and refers to practices such as obeying rules, being kind and helping others. Given that the definition of healthy provided to participants included the phrase ‘you feel good’, this may have contributed to the emergence of this theme. Nevertheless, the wider early childhood literature highlights the emphasis placed on children being well behaved at this age with the importance of good behaviour undoubtedly a key message reinforced across the home and childcare environments by parents and educators (Boonpleng et al., 2013; De Decker et al., 2013; Gubbels et al., 2014; Larson et al., 2011; Maybin and Woodhead, 2003). This is reflected in children’s responses, for example, ‘Clean up your toys’, ‘Be nice to my brother’ or ‘You be good for Mummy’.

Limitations

This study is subject to limitations. Participants lived in a medium-high socioeconomic community, thus it is difficult to generalise findings to other groups. Interview method was used in this study since it provided the best fit with the larger intervention study that it was part of. Although a substantial amount of information was obtained using the selected open-ended questions, the use of other complementary age-appropriate, child-friendly methods would facilitate more in-depth data in future studies (Mobley and Evashevski, 2000; Olvera-Ezzell et al., 1994). The definition of healthy provided to participants may have influenced some responses; however, the definition served as the basis for children to tell the researcher what they do to make themselves healthy and to ensure those who were unable to explain what health meant had the same basis to respond to the following questions. Finally, the fact that the research was conducted within an educational childcare setting may have biased participant responses.

Conclusion

This study explored how pre-school-aged children speak about health and health behaviours. Participant responses provided insight into how key societal values shape how children speak about important issues. Findings highlighted the centrality of food to how children speak about health. In comparison to discussion of food and the importance of eating healthy food, there was limited mention of physical activity by participants as a means to be healthy. The findings raise important questions and help identify avenues for further research to assist with the effective promotion of health in young children. Further research should seek to quantify the impact parents’ and educators’ concern for risk may have on pre-school children’s engagement in physical activity in the Australian context.

Footnotes

Acknowledgements

The authors would like to thank the children, parents and staff at the participating childcare centres for their time and involvement that allowed this research to occur.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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