Including the voices of children and young people in health policy development: An Irish perspective

Abstract

Objective:

This paper presents findings of a qualitative study which explored children and young people’s understanding of health and the factors that contribute, or act as barriers, to healthy lifestyles. Views were elicited from consultations with children and young people as part of the process for the development of a National Obesity Policy in Ireland.

Design:

Child participatory methodology was used which prioritised the voice of the child in policy making.

Methods:

Two consultations were held – one with 48 children between the ages of 8 and 12 and the other with 34 young people aged 13–17 years. The consultations utilised qualitative participatory methodology which prioritised the voices of children and young people in policy making. A diverse range of methodological tools (e.g. ‘lifelines’, ‘body maps’, world café workshops) were used to collect data and optimise levels of participant engagement. Qualitative visual and written data produced during the consultations was then subjected to thematic analysis.

Results:

Children and young people’s constructions of health and healthy lifestyles are multifaceted. Participants in the consultation appeared well informed as to the general factors which contribute to healthy and unhealthy lifestyles. There were notable differences of emphasis related to age, with the older age group engaging more with issues relating to mental health and peer relationships, while younger children focused more on balanced diet and exercise.

Conclusion:

Findings from this consultation suggest that children’s constructions of health, and their understandings of the factors that impact health, are complex and often go beyond medical constructions of the meaning of health. The consultation informed the development of the new National Obesity Policy in a number of ways, including specific actions in relation to the development of a whole school healthy lifestyles programme, developing a health and well-being model for early childhood services, and providing clinical services specifically for children.

Keywords

Child participation healthy lifestyle Ireland obesity policy making

Introduction

The issue of personal health carries great social and economic significance, particularly as the cost of treating obesity and related conditions continues to rise (Reeve and Bell, 2009). However, there is a dearth of published research eliciting children’s views and experiences of everyday eating and physical activity practices and giving them a voice to influence both policy and practice in these areas (Stankov et al., 2012). Moreover, young people are now exposed to multiple and sometimes conflicting health messages, from the Internet, television, schools and health professionals, and it is therefore important to understand how they interpret and apply these messages to their own lives.

Recent research recognises the importance of consulting young people themselves in the development of health policies and initiatives which affect them (Ott et al., 2011). Children, like other members of society, have a stake in debates about body size, and their ideas about health and other aspects of their lives are increasingly seen as valid contributions to the development of social policy (Rees et al., 2009). Giving children a voice in how policies and services are developed promotes citizenship and active inclusion of children and enables them to learn that they can make a difference and influence what happens in their environment (Wyness, 2012). Policy development addressing the priorities of children, as discussed by them in consultations, could be viewed as child-proofed and child-informed policy (Horgan, 2017). As well as leading to more effective policies and better services, research and policy-making that involves children actively in debate and decision-making can provide them with experiences of collective work and create a culture of shared responsibility and mutual trust (Alderson, 2008).

To date, very little research has been carried out in Ireland on children and young people’s perceptions on health and healthy lifestyles. Arguably, the need for such research has never been greater, with recent figures indicating that at least one in five Irish children are now overweight or obese (Bel-Serrat et al., 2017). It was against this back-drop that we were asked to undertake research to inform the development of the National Obesity Policy. Although the study was commissioned in relation to obesity, the remit went beyond this, to include children and young people’s constructions of health and healthy lifestyles. The current study makes an important contribution to the Irish literature on perceptions of healthy lifestyles and also provides the basis for comparison with international studies, which are outlined in the following section.

Children’s perceptions of health and healthy lifestyles

International studies suggest that children’s constructions of health, and their understandings of the factors that impact on health, are multifaceted. In one US-based study, for example, researchers found that the range of definitions of ‘healthy’ and ‘unhealthy’ invoked by children was ‘surprisingly broad’, encompassing not only illness and proper nutrition, but also environmental health, mental health, cleanliness and other meanings (Reeve and Bell, 2009). UK-based research (Reeve and Bell, 2009) which looked at 9- to 10-year-old children’s views on the factors which influence health, reported that the two largest categories of factors implicated in health were diet and exercise/sport, followed by hygiene, not smoking and getting enough sleep. A wide range of other health factors were mentioned including personal/family resources (e.g. having a nice home), community resources (hospitals), environmental factors (e.g. sun, trees) and accessing health care services. Factors seen as contributing to ill-health included smoking, poor diet (e.g. eating fast foods), environmental problems and violence. Similarly, research on primary school children’s views on health found that while food and exercise were the largest categories of response, children also stressed the social aspects of being healthy – ‘having a home, having a family and friends, playing and working hard, as well as environmental health’ (Wetton and McWhirter, 1998: 246). Moreover, children’s understanding of health was not limited to physical aspects but included mental and emotional health. The authors note that the children’s words and images revealed ‘the wealth of children’s knowledge’, which often ‘matched and went beyond narrow, adult, medical constructions of the meaning of health’ (Wetton and McWhirter, 1998: 246). Similarly, Mouratidi et al. (2016) in a study analysing 5- to 11-year-old Greek children’s perceptions of illness and health through their drawings, found that health is represented mainly as a psychosocial phenomenon rather than bio-medical.

While much of the research outlined above was conducted with children up to the age of 12, a number of studies have also looked at adolescents’ views on health and health problems. A US-based study conducted focus groups with adolescents to elicit their views on health and the implications for policy (Ott et al., 2011). The findings emerging from this study illustrate the importance of consulting young people in the formation of policies which concern them, particularly as certain policy approaches appear to be at odds with adolescents’ experiences. The authors note, for example, that while policy makers focus on depression and anxiety as individual pathologies requiring greater access to treatment, young people saw mental health issues in terms of an interaction between the individual and his or her environment (e.g. stress caused by juggling school and work) (Ott et al., 2011). Other US-based research mapped the views of adolescents, parents and health care workers on what they considered to be the most important health problems affecting adolescents and how these might be addressed (Ewan et al., 2016). Sexually transmitted infections (STIs) and obesity were identified as being most important, concerns also raised by similar US based research (Ott et al., 2011). Although obesity and STIs are distinct diagnoses clinically, there appeared to be a significant overlap in the ways in which stakeholders perceived that the two issues could be addressed, for example, through education, support systems and community involvement.

A number of studies have explored young people’s views on what constitutes healthy eating, the factors which influence their choice of food, and the barriers and facilitators to healthy eating. International research suggests that children and young people are generally well informed about the health value of different foods, though they are less aware of the importance of having a balanced diet. Research carried out with 106 children in Northern Ireland and England found that the term ‘healthy eating’ was almost invariably associated with fruit, vegetables and salads (McKinley et al., 2005). Virtually all the focus group participants felt that they could improve their eating habits and were able to make a number of suggestions on how to achieve this, including changing cooking methods; cutting down on sweets, take-away foods and fatty foods; and eating more fruit and vegetables. There was also some mention of balance and variety, though in the main children had a tendency to categorise foods as either ‘good’ or ‘bad’, ‘healthy’ or ‘unhealthy’. Research with young people attending second level schools in Ireland¹ found a similar dichotomy between ‘good’ and ‘bad’ foods – the concept of each foodstuff contributing to an overall balance appeared to be limited (Stevenson et al., 2007).

Research consistently shows that knowledge about nutrition and healthy eating does not always translate into healthy eating behaviour (Brown et al., 2000; Hesketh et al., 2005; Shepherd et al., 2006; Stevenson et al., 2007; Trew et al., 2005). Personal preference is a far more powerful determinant of food choice. In focus groups conducted with young people in Ireland, for example, one study found that while they had a good knowledge of what is healthy, nutritional knowledge was not the central motivation for food choice (Stevenson et al., 2007). Other research with Irish children and adolescents also found that food preferences (as opposed to perceived nutritional value) were consistently identified as a major influence on food choices (Fitzgerald et al., 2010). Most young people reported a marked preference for unhealthy food, despite demonstrating a clear understanding of what it means to eat healthily (Fitzgerald et al., 2010).

The barriers to healthy eating identified in various studies with young people are notably consistent and include: a lack of choice and poor availability of healthy meals at school (Hesketh et al., 2005; McKinley et al., 2005; Shepherd et al., 2006), healthy foods sometimes being more expensive (McKinley et al., 2005; Shepherd et al., 2006), wide availability of fast foods (Shepherd et al., 2006), taste preferences for fast foods (Fitzgerald et al., 2010; Stevenson et al., 2007), unhealthy food being well packaged and promoted (Hesketh et al., 2005; McKinley et al., 2005), perceived blandness or unpleasant taste of healthy foods (Stevenson et al., 2007), the use of snacks and fast foods as ‘treats’ by parents, teachers and other adults (Stevenson et al., 2007), a lack of sense of urgency about personal health in relation to other concerns (Neumark-Sztainer et al., 1999), contradictory and inconsistent messages and social pressures (Hesketh et al., 2005; Stevenson et al., 2007).

Methods

The data presented in this article derives from two consultations with children and young people which were held as part of the process for the development of a National Obesity Policy (Department of Health, 2016) in Ireland. The consultations were organised by the Department of Children and Youth Affairs (DCYA). In all, 48 children (8–12) were recruited by the DCYA from primary schools through the Irish Primary Principals’ Network (IPPN), while 34 young people (13–17) were recruited by the DCYA from the 31 Comhairle na nÓg (local youth councils) throughout the country. Considerable focus was placed on ensuring the participation of a balanced representation of children and young people from socio-economic, gender, ethnic and geographic perspectives. Following initial contact with schools and Comhairle na nÓg, an information sheet which included information on the purpose of the study, a letter of invitation, parental consent form and child/young person assent form were sent to all prospective participants 3 weeks before the event, with a stamped envelope for return of consent and assent forms. The information leaflet outlined the aims of the study and the uses to which the data would be put in child/young person friendly language. A closing date for receipt of signed consent and assent forms was included in the letter. The children and young people travelled from across Ireland to a central location in Dublin to participate in the consultations.

The consultations with children took place over one day and utilised qualitative participatory methodology, which prioritised the voices of children and young people in policy making. In line with this approach, there were at least six adult facilitators who were experienced in child and youth participatory methods in attendance at each consultation. Participatory methods recognise children’s capacities and allow children to share their perspectives and be actively involved in decision-making (Kellett, 2013). Drawing on a diverse range of methodological tools (e.g. ‘lifelines’ ‘body maps’), we sought to optimise levels of participant engagement and the quality and depth of data gathered.

The consultations with children (7–12) began with an exercise during which participants were divided into small groups (7–9) and completed a lifeline identifying contributors and obstacles to a healthy lifestyle. The lifeline was a long rectangular mat with a river shape depicted on it divided into two life stages (0–5/6–12), reflecting their own age range. The lifeline method has been used in research with children aimed at gathering information on the child’s life history – in particular important transitions and events in the child’s life. It enables the incorporation of some of the advantages of a qualitative longitudinal study in a research setting where it is not possible to follow children’s lives for a longer period of time (Pirskanen et al., 2015). This exercise was followed by a body mapping exercise. Diagrams which represent the whole body were drawn by children on large sheets of paper on the ground. Working in small groups (of 7–9), the children were asked to think about: ‘What are the things that make this child healthy?’ and to write their ideas onto the body map. By using children’s own visual representations of their bodies as a starting point from which to explore particular healthy lifestyle issues, body mapping facilitated a less directive interviewing style than would otherwise be possible. The final stage of the consultation with children involved the use of placemats. Here, the children worked in groups on floor placemats, each of which were divided into three sections: at home; at school; and in your area. The children were asked to think about ‘How can we make this child healthier?’ in each of these contexts of their lives. At the end of the consultations, the researchers collected all the of floor placemats. The consultations produced a large volume of written data from the placemats and various participatory exercises the children and young people were involved in. In addition, there were illustrations and drawing from the younger children. The visual and written data were compiled by the researchers and subject to thematic analysis.

The consultation with young people (13–17) took place over one day and involved two main stages: lifelines followed by world café workshops. Participants completed a lifeline identical to that completed by the children but with their lifeline depicting (0–5/6–12/13–17 years) reflecting their life experience to date. In the second session, young people engaged in a World Café method² workshop seeking to obtain more detail on five key topics they identified earlier. The five topics identified were as follows: Parents and Family; Bullying; Stress, Society and Peer Pressure; Magazines, Social Media and Photo Shopping; and finally Eating Disorders. Five topic zones were created: each group worked on one topic that they had identified in the lifeline session. A large square placemat was placed on each table, and participants were asked to start working from the inner circle. Each group once they had completed working on the placemat then rotated across the other topic zones so that they had an opportunity to engage with all five issues. Finally, both children and young people voted on the top issues of importance.

The consultations were all subject to standard ethical guidance and procedures for consultation and research with children. Ethical approval was obtained from the Social Research Ethics committee at University College Cork. Informed assent forms were obtained from the children and young people and informed consent forms were obtained from their parents/guardians. The key ethical issues arising through this research were those of ensuring that any sensitive issues arising relating to individual children and young people were anonymised. A strict policy of confidentiality and anonymity was adhered to throughout the consultation process. Because this was group-based data gathering, all those taking part undertook to preserve the confidentiality of others. Child protection issues were fully addressed both prior to, during and after the consultation process. The assent forms completed by children and young people included the following tick box: ‘I understand that all information gathered will be kept private unless I am in danger’. All facilitators were briefed as to the need to be aware of any child protection concerns which may present during the discussions with the children and young people. At the end of each consultation, once the children and young people had left, a debriefing was conducted with all facilitators at which there was some discussion as to any child protection concerns. In both cases, there were none. All of the DCYA facilitators are very skilled and experienced in participatory work with children and young people and are police vetted.

Findings from the consultations with children and young people

Both cohorts identified similar themes including food and eating behaviours, physical activity, school, body image and family during the consultations, though there were notable differences in terms of emphasis. For example, bullying and mental health was the focus of detailed discussion for the young people, while it was mentioned only a few times by the children. Similarly, the correlation between sleep and healthy lifestyles was a common theme for the children, but this issue was only briefly addressed by the young people.

Food and eating behaviours

The importance of healthy eating was a recurring theme, particularly for the children in the consultation. Children voted healthy food choices such as eating more fruit and vegetables as the most important contributor to a healthy lifestyle. While issues related to body image received the highest numbers of votes from the young people in the study, the availability of healthy food also received a number of votes. In general, children and young people appeared well informed about key health messages such as ‘eating five a day’, drinking water, avoiding junk food and getting sufficient sleep and exercise. In relation to what might help with healthy lifestyles, young people identified ‘easy access to health food stores’, fewer fast food restaurants and healthier foods in school canteens. Children and young people identified barriers to a healthy lifestyle as junk food and fast food, some of the children were also critical of the perceived higher costs of healthy foods and the low cost of ready-made meals and lack of education about healthy eating. These findings are similar to those of a number of national and international studies which indicate that children are generally well informed about the health value of different foods, they could identify healthy and unhealthy foods and they had some awareness of the nutrients contributing to foods being more or less healthy (Fitzgerald et al., 2010; Hesketh et al., 2005; McKinley et al., 2005).

Sleep

While the young people only briefly referred to sleep as an issue, the children identified getting sufficient sleep as a significant contributor to overall health. Some of the children pointed to specific sleep habits and public health messages such as getting 10–12 hours per night, going to bed early, making a bedtime schedule and not watching television before going to bed. On the other hand, sleeping too much and sleeping at particular times of the day (e.g. ‘during the day’; ‘in the middle of the day’) were also identified as being problematic. At the time of the consultation, Safefood³ was running a public information campaign on the importance of sleep for children’s health which may have impacted on the children’s views of sleep.⁴ The importance of sleep for general health and well-being has been widely recognised in the international literature. Chen et al. (2008) in a meta-analysis of research found that sleep plays an important role in children’s health and short sleep duration can increase the risk of childhood obesity.

Physical activity

The children and young people identified a range of physical activities which they associated with a healthy lifestyle. Specifically, they suggested that children need regular and daily exercise and that children should be exposed to different types of sports and a variety of activities. Children and young people mentioned specific facilities, for example, swimming pools, gyms, cycle lanes, and skate parks, which were important for a healthy lifestyle. They also highlighted the importance of fresh air and outdoor play and access to playgrounds for children. Location was seen as a significant variable when considering young people’s level of engagement in physical activity, and there was restricted access to facilities in rural areas. Obstacles to a healthy lifestyle related to exercise included not participating in a sport, being lazy and using technology for leisure. The children mentioned the perceived link between screen-time usage and unhealthy lifestyles. Information technology was discussed (mainly by the older group) in negative terms as promoting sedentary lifestyles. Other obstacles included not learning how to cycle, not getting outside, bad weather, staying in your room all day and ‘getting lifts everywhere’. Previous research has highlighted the importance of physical activities. For example, the longitudinal Growing Up in Ireland study found a significant relationship between levels of physical exercise and sedentarism and the risk of developing childhood obesity (Layte and McCrory, 2011).

Personal attributes, body image and self-perception

The children identified what might be described as personal attributes or states of mind contributing to well-being, for example, ‘positive thinking’, having confidence, ‘stamina’, ‘endurance’ ‘imagination’, ‘being nice to others’ and so on. The young people were concerned with issues of self-perception and how others saw them – particularly in relation to body image. The portrayal of ‘unrealistic body images’ in magazines was seen as ‘intimidating for teens’ and was voted as the top barrier to a healthy lifestyle by young people. Concerns around body image were also linked to wider issues, including peer pressure, the media and societal expectations. The findings from the consultation suggest that young people, when asked about healthy lifestyles, are concerned with issues relating to mental health and emotional well-being. Dissatisfaction over appearance and body size can lead to low self-esteem, unhealthy lifestyle choices and eating disorders. The media and advertising was implicated in projecting an unrealistic and (for most people) unobtainable body image, particularly where images of celebrities and models are photo shopped to alter their body size.

One of the notable findings of the research is that while young people identified eating disorders such as bulimia and anorexia as a significant problem, the issue of obesity was rarely mentioned in the course of the consultation by either children or young people. Linked to this young people mentioned that judging people can lead to eating disorders: ‘people judge other people on the way they look which causes eating disorders’. Participants described the frustration and disappointment associated with trying to alter their appearance or body size, and how this can lead to extreme measures. Some examples of this mentioned during the consultation by the young people included taking steroids and protein shakes to be bulkier and to achieve a certain body shape or starving oneself to be thinner. They also discussed this issue in relation to eating disorders and highlighted the negative impact of crash diets and smoking to lose weight. Similar to other consultations with children and young people, young people’s understanding of health was not limited to physical aspects but included mental and emotional health, having a positive self-concept and a sense of belonging and support (Wetton and McWhirter, 1998).

Family and friends

Positive and negative aspects of family and relationships were identified by both cohorts. Family and relationships were seen as important for mental health and emotional well-being (e.g. love, support, someone to confide in etc.) but also for physical health (e.g. parental food choice) and the provision of material resources (‘nice home’). Children also mentioned the importance of having ‘family time’ in helping them lead a healthy lifestyle. However, during the consultations some young people also said that they felt under pressure to meet parental expectations or worry that they are a disappointment to their parents; comments here included, ‘feeling sense of stress to please parents as the perfect student’; ‘pressure of previous family members’ school results’. These findings suggest that families can also be a source of stress and anxiety for children and young people. Related to this, lack of communication with parents was seen as a central issue for some young people who felt that they were not being heard at home or that their opinions were not valued there.

While the influence of parents was most frequently mentioned, siblings and grandparents were acknowledged in some responses. Pets were also identified as a positive influence, and there were numerous drawings on one of the body maps of cats and dogs, which signify their importance to children.

For children in particular, parents and families were seen as playing a key role in either promoting or limiting access to healthy foods. Specifically, children spoke about parents providing healthy food and making homemade meals together as a family, setting rules about eating, guidance on food and reminding children to exercise. Healthy parents were seen as providing positive examples. This reflects other research identifying parents as one of the main influences when it comes to shaping their children’s decisions in relation to healthy eating (Watkins and Jones, 2015). Previous research with children and young people also suggests that parents play a key role in determining the types of foods which children eat (Fitzgerald et al., 2010). Elsewhere, healthy eating is often associated with parents and the home, while ‘fast food’ is associated with eating out with friends and other social situations (Shepherd et al., 2006).

School

School emerged as an important site for promoting as well as inhibiting healthy lifestyles. Recurring themes identified included school food, bullying within school, workload and exam pressures leading to stress and anxiety. As one young person pointed out, there is ‘too much pressure to get points to fulfil the career you want and the Leaving Cert [exam] is a big reason for stress, young people are depressed, stressed and under way too much pressure’. Schools can embody a number of contradictions: for example, teaching healthy eating habits while selling unhealthy foods in canteens and vending machines, and providing supports around stress (e.g. school counsellors) while also being a major source of stress in young peoples’ lives in terms of workloads and exams, peer pressure and so on. Furthermore, opportunities for physical exercise may be limited both by time constraints and obstacles imposed by the school system such as too much homework which restricted time for play outside; heavy school bags which made walking to school difficult; not enough teachers or facilities for Physical Education (PE) and strict rules that do not allow running or playing in the school yard. Specifically, in relation to physical exercise in school the children suggested that each school should have facilities such as football pitches with ‘proper nets’, a playground, a gym, longer school playtime and after-school activities. Young people identified school PE as ‘helping with a healthy lifestyle’. However, they were generally critical of the options available to them in this class. Several participants clearly objected to being ‘forced’ to do PE in school, feeling that it should not be a compulsory subject within the school curriculum while some felt self-conscious or embarrassed about their appearance while changing clothes and taking part. They noted the lack of choice in PE, with few alternatives to team sports, and the failure to cater for other interests. Competitiveness in PE can also be a source of peer pressure and bullying, as one participant pointed out: ‘people make fun of you for not being as good as others’. Our findings here resonate with previous research (Curtis, 2008) which found that school-based PE may be experienced as challenging for children who are over-weight, ‘they feel they are under surveillance and may be teased or bullied and the requirement to participate in school-based PE can exacerbate young people’s vulnerability within the school environment’ (p. 413).

Local area and local community

Children mentioned a number of issues related to their local area as influencing healthy lifestyles. These issues included the physical environment such as access to trees, wildlife and biodiversity. Also mentioned were local places to visit with friends such as the library and park. Specifically, in relation to negative influences on a healthy lifestyle the children discussed unsafe or unhospitable environments for children (e.g. noise, smoking, lighting fires, cars near where children play) while others relate negative aspects related to the availability and marketing of unhealthy foods in community settings (e.g. vending machines in sports centres). A number of issues raised by children and young people also reflect our increasingly sedentary lifestyles, for example, being driven everywhere. Similarly, previous research indicates that aspects of the local environment (such as a lack of variety between different playgrounds, uninteresting playground equipment, concerns about safety) can discourage children’s physical activity (Hesketh et al., 2005). There is increasing evidence supporting the use of community-based approaches to promote healthy-lifestyles for children. The authors of a recent study on a school-based intervention to promote a healthy lifestyle, which involved multi-level strategies aimed at the home and family, school and wider community, concluded that adopting a holistic education approach was central to the effectiveness of the intervention (Piana et al., 2017).

Listening to children and young people

Young people identified listening to children and young people as an enabler of healthy lifestyles. The children also identified not listening to the child as a barrier to a healthy lifestyle. Findings from the consultations suggest that while families can be supportive, they can also be a source of stress and anxiety for children and young people when they felt that they were not being listened to. Young people recognised the importance of voice for the holistic well-being of children and young people which echoes previous findings that children become frustrated when they were not listened to by adults, including parents and teachers (Kirby et al., 2003). Recent research in Ireland by Horgan et al. (2015) found that although home was the most facilitative of their voice across the spaces of home, school and community, nonetheless children and young people expressed frustration at parents not listening to them and cited examples of tokenistic practices related to their participation at home. Participation of children and young people in everyday life contributes to their well-being (The Children’s Society, 2012) and fosters a sense of value and self-worth (Davey, 2010).

Conclusion

Children and young people’s constructions of health and healthy lifestyles are multifaceted. Children and young people who were involved in the consultations appear to be well informed as to the general factors which contribute to healthy and unhealthy lifestyles. Healthy lifestyles are often associated with having supportive families and friendship groups, a good balance between school work and leisure, and positive personal attributes including self-esteem, confidence and motivation. Participants’ multi-faceted understanding of health was not limited to physical aspects but included mental and emotional health. There were some differences of emphasis related to age, with the older age group engaging more with issues relating to mental health and peer relationships, while younger children focused more on balanced diet and exercise. While the results are consistent with previous international research, which found that young people are aware of different facets of health, there are also some notable differences. For example, there was no discussion of sexual health, a theme which features prominently in studies with American teenagers (Ewan et al., 2016; Ott et al., 2011). Possible reasons are that these young people do not see sexual health as being a significant area of health or are not concerned with sexual health problems (e.g. STIs). But this may also be a product of cultural norms and the research methodology, that is, an unwillingness to discuss sexual health, particularly in such a public forum with a mixed group, both in terms of gender (male and female) and age (adults and young people). Another notable difference to the US research is that the young people in these consultations identified medical conditions associated with under-eating (anorexia, bulimia) rather than with overeating (overweight and obesity). Obesity was mentioned only a few times and did not lead to further discussion. On the other hand, under-eating disorders were one of the main topics of discussion.

Another key finding of the consultation is that young people see health as being influenced not only by personal choices, but by broader contextual issues, including family and friends, schools, the physical environment, community settings and wider societal issues. Consistent with earlier studies, participants in this study did not regard stress or unhealthy eating as ‘individual pathologies’ (Reeve and Bell, 2009). For example, eating behaviour was linked not only to individual food preferences but also to parental choice, peer influence, availability of healthy foods in school and in the community, the cost of healthy eating, and strong advertising of junk foods to children. Similarly, stress was linked to factors in the home, school and society more generally (e.g. pressure to conform to expectations around body image and pressure of exams). The multiplicity of factors influencing children and young people’s healthy lifestyles suggests that health promotion interventions need to go beyond the personal level, where they are often focused, to address wider influences on health identified above.

Policy implications

The consultations with children and young people informed the Irish Obesity Policy and Action Plan 2016–2025 (Department of Health, 2016) in a number of ways. The views of participants assisted in the overall approach of the policy and in particular in relation to the importance of the family, the environment, schooling, health services and other determinants of health. Specific actions included in the policy which were informed by the views of children and young people included those in relation to whole school healthy lifestyles programme; developing a health and wellbeing model for early childhood services; provision of potable water in schools; reducing the obesogenic environment and providing clinical services specifically for children. Policymaking is one of the most challenging arenas in which children’s participation rights are implemented and there is limited literature on children’s participation in public-decision-making processes (Perry- Hazan, 2016). Our paper provides an example of a consultation process which facilitated children and young people contribution to public health policy formation in Ireland. The resultant policy actions development by the Irish Department of Health acknowledge the children and young people’s complex and multifaceted constructions of health which they expressed during the consultation process and are embedded as specific actions in the Obesity Policy and Action Plan 2016-2025.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This consultation was funded by the Department of Health, Ireland.

Notes

ORCID iD

Shirley Martin

References

Alderson

(2008) Young Children’s Rights: Exploring Beliefs, Principles and Practice. London: Jessica Kingsley.

Bel-Serrat

Heinen

Murrin

et al . (2017) The Childhood Obesity Surveillance Initiative (COSI) in the Republic of Ireland: Findings from 2008, 2010, 2012 and 2015. Dublin: Health Service Executive.

Brown

McIlveen

Strugnell

(2000) Nutritional awareness and food preferences of young consumers. Nutrition & Food Science 30(5): 230–235.

Chen

Beydoun

Wang

(2008) Is sleep duration associated with childhood obesity? A systematic review and meta-analysis. Obesity 16(2): 265–274.

Curtis

(2008) The experiences of young people with obesity in secondary school: Some implications for the healthy school agenda. Health & Social Care in the Community 16: 410–418.

Davey

(2010) Children’s Participation in Decision-Making: A Summary Report on Progress Made Up to 2010. London: Participation Works.

Department of Health (2016) A Healthy Weight for Ireland, Obesity Policy and Action Plan 2016-2025. Dublin: Department of Health.

Ewan

McLinden

Biro

et al . (2016) Mapping the views of adolescent health stakeholders. Journal of Adolescent Health 58: 24–32.

Fallon

Connaughton

(2016) Using a world café to explore new spaces and new models for front line services: A case study from the Irish university library sector. New Review of Academic Librarianship 22: 43–59.

10.

Fitzgerald

Heary

Nixon

et al . (2010) Factors influencing the food choices of Irish children and adolescents: A qualitative investigation. Health Promotion International 25(3): 289–298.

11.

Hesketh

Waters

Green

et al . (2005) Healthy eating, activity and obesity prevention: A qualitative study of parent and child perceptions in Australia. Health Promotion International 20(1): 19–26.

12.

Horgan

(2017) Consultations with children and young people and their impact on policy in Ireland. Social Inclusion 5: 104–112.

13.

Horgan

Forde

Martin

et al . (2015) Children and Young People’s Experiences of Participation in Decision-Making at Home, in Schools and in Their Communities. Dublin.

14.

Kellett

(2013) Research methods with young children: Extending the canvas. In: O’Riordan

Horgan

Martin

(eds) Early Childhoods in the Global South: Local and International Contexts. Oxford: Peter Lang, pp. 221–234.

15.

Kirby

Lanyon

Cronin

et al . (2003) Building a Culture of Participation: Involving Children and Young People in Policy, Service Planning, Delivery and Evaluation. London: Department of Education and Skills.

16.

Layte

McCrory

(2011) Growing Up in Ireland Overweight and Obesity among Nine Year Olds. Dublin: ESRI/DCYA.

17.

McKinley

Lowis

Robson

et al . (2005) It’s good to talk: Children’s views on food and nutrition. European Journal of Clinical Nutrition 59: 542–551.

18.

Mouratidi

Bonoti

Leondari

(2016) Children’s perceptions of illness and health: An analysis of drawings. Health Education Journal 75(4): 434–447.

19.

Neumark-Sztainer

Story

Perry

et al . (1999) Factors influencing food choices of adolescents: Findings from focus-group discussions with adolescents. Journal of the American Dietetic Association 99(8): 929–934.

20.

Ott

Rosenbergr

McBride

et al . (2011) How do adolescents view health? Implications for state health policy. Journal of Adolescent Health 48: 398–403.

21.

Perry-Hazan

(2016) Children’s participation in national policymaking: ‘You’re so adorable, adorable, adorable! I’m speechless; so much fun!’. Children and Youth Services Review 67: 105–111.

22.

Piana

Ranucci

Buratta

et al . (2017) An innovative school-based intervention to promote healthy lifestyles. Health Education Journal 76(6): 716–729.

23.

Pirskanen

Jokinen

Kallinen

et al . (2015) Researching children’s multiple family relations: Social network maps and life-lines as methods. Qualitative Sociology Review 11(4): 50–69.

24.

Rees

Oliver

Woodman

et al . (2009) Children’s Views about Obesity, Body Size, Shape and Weight: A Systematic Review. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London.

25.

Reeve

Bell

(2009) Children’s self-documentation and understanding of the concepts ‘healthy’ and ‘unhealthy. International Journal of Science Education 31(14): 1953–1974.

26.

Shepherd

Harden

Rees

et al . (2006) Young people and healthy eating: A systematic review of research on barriers and facilitators. Health Education Research 21(2): 239–257.

27.

Stankov

Olds

Cargo

(2012) Overweight and obese adolescents: What turns them off physical activity? International Journal of Behavioral Nutrition and Physical Activity 9(1): 53. DOI: 10.1186/1479-5868-9-53.

28.

Stevenson

Doherty

Barnett

et al . (2007) Adolescents’ views of food and eating: Identifying barriers to healthy eating. Journal of Adolescence 30: 417–434.

29.

The Children’s Society (2012) The Good Childhood Report 2012: A Review of Our Children’s Well-Being. London: The Children’s Society.

30.

Trew

Barnett

Stevenson

et al . (2005) Young People and Food: Adolescent Dietary Beliefs and Understandings. Dublin: Safefood.

31.

Watkins

Jones

(2015) Reducing adult obesity in childhood: Parental influence on the food choices of children. Health Education Journal 74(4): 473–484.

32.

Wetton

McWhirter

(1998) Images and curriculum development in health education. In: Prosser

(ed.) Image Based Research: A Source Book for Qualitative Researchers. Brighton: Falmer, pp. 263–283.

33.

Wyness

(2012) Children’s participation and intergenerational dialogue: Bringing adults back into the analysis. Childhood 20(4): 429–442.