Hearty Lives (Liverpool): a case study-based evaluation of a project designed to promote healthy eating and lifestyles in looked after young people

Abstract

This article discusses the growing body of evidence on the importance of health for looked after children and young people and evaluates a project, Hearty Lives (Liverpool), designed to produce positive results. Unhealthy weight and lifestyles are significant issues for young people in care, whether living at home with parents under the supervision of social services, with foster carers or in residential homes, as there is a close relationship between food, nutrition and family connectedness. Following the principles of Appreciative Inquiry, the evaluation uses a case study approach to explore the learning and experiences of those involved in the intervention. The learning gained provides useful insights for practitioners and organisations who are interested in developing similar projects elsewhere.

Keywords

Young people in care looked after children nutrition health and well-being

Background

Causes and health implications of obesity

The fundamental cause of obesity and unhealthy weight is an energy imbalance between calories consumed and calories expended. Changes in dietary and physical activity patterns are often the result of environmental and societal developments. Globally, there has been an increased intake of energy-dense foods that are high in fat and sugar. Alongside this, physical activity has decreased due to increasingly sedentary lifestyles (World Health Organization, 2017). A well-established body of evidence indicates that obese people are at increased risk of multiple and significant poor health outcomes, diseases and health conditions (Centre for Disease Control, 2017). According to the UK’s Public Health Outcomes Framework (Public Health England, 2013), healthy weight is a key outcome targeted for improvement in both children and adults.

The association between unhealthy weight, poverty and deprivation

A multitude of factors contribute to increasing levels of obesity in England, among them: buying food with high levels of fat and sugar, lack of exercise and poverty-related deprivation of basic material assets considered necessities (Public Health England, 2013). Conrad and Capewell (2012) and Wilsher and colleagues (2016) highlight the associations between deprivation and rates of childhood overweight and obesity, based on the 2007–2010 National Child Measurement Programme Data in England. In such circumstances, families may make pragmatic choices, buying cheaper, less healthy foods because more balanced alternatives are too expensive. Families may also have limited knowledge of the health risks associated with their current lifestyle. In addition, access to green spaces, exercise and sports facilities may be restricted by limited availability locally and lack of transport facilities. The consequent risks of early death and morbidity due to diseases such as diabetes and coronary heart disease in later life are clear. In addition to increased future risks, children who have an unhealthy weight may experience breathing difficulties, increased risk of fractures, hypertension and early markers of cardiovascular disease, insulin resistance and psychological effects (World Health Organization, 2017).

Obesity and unhealthy eating as a specific issue for looked after children

The adverse experiences that most looked after children will have undergone are highly likely to compound the effect of other determinants of poor health like economic deprivation. The city of Liverpool has seen a steady and significant reduction in the extent of deprivation in the last decade. At the same time, it remains within the top five of England’s most deprived local authorities on the 2015 index of multiple deprivation and ranks within the top 10 in relation to income deprivation affecting children (Liverpool City Council, 2015).

In 2011, Croft and Frith found that almost one-quarter of looked after children had an unhealthy weight or were obese. Being in care did not help to resolve the problem and did not prevent children from becoming overweight. Hadfield and Preece (2008) also found high rates of obesity among looked after children and that many actually gained weight during their time in care. While obesity and poor diet are increasingly a cause for concern for all young people, many come into care with a poor nutritional status. For most of us, food carries with it a symbolic association with love, emotional warmth, comfort, nurture and emotional attachment to caregivers. Children who have had early experiences of abuse or neglect often have related food anxieties, so a key concern for them may be: Will food, love, nurture and comfort be consistently provided or unpredictably withheld?

In the statutory guidance Promoting the Health and Wellbeing of Looked-after Children (Department for Education and Department of Health and Social Care, 2015), there is a requirement for local authorities to ensure that every child they look after has an up-to-date individual health plan as part of an overall care plan. This should incorporate mental health and emotional well-being as well as physical health, and the care planning framework should include a focus on promoting health and improving health outcomes. The role of social workers in supporting foster carers or staff in children’s homes to promote the child’s physical and emotional health on a day-to-day basis is also highlighted.

In a rapid review of the literature, Baker (2015) found that young people leaving care voiced concerns that the experience of leaving care had a detrimental effect on their health and that plans to support their transition to independence tended to emphasise housing, financial support and education over health and well-being. It is therefore important that healthy lifestyles are established before young people reach this point and, where necessary, interventions to promote healthier living are incorporated into transition planning.

The Hearty Lives (Liverpool) project

The Hearty Lives (Liverpool) project was launched in the autumn of 2013 and ran until July 2016. It was supported through a partnership between the British Heart Foundation, Liverpool City Council and Liverpool Health Equalities Group (a social enterprise alliance delivering practical, evidence-based programmes that seek to tackle the root causes of health inequalities). Liverpool Health Equalities Group managed the project but a range of other stakeholder groups made essential contributions, for example, by assisting with the recruitment of children and their carers and by providing venues for events or facilitating activities. These included the local Children in Care Council, several residential children’s homes, children’s and community centres, library, parks and leisure services, community and voluntary sector organisations, a city farm, Liverpool Community Health and Everton in the Community (the charity wing of a premier league football club).

Shepherd and colleagues (2006) carried out a systematic review of research on barriers and facilitators to healthy eating in young people (11‒16 years) which included a focus on both non-intervention and intervention-based research. The review considered wider determinants of health, community and society level interventions. Seven outcome evaluations and eight studies of young people’s views were scrutinised. The researchers concluded that the effectiveness of the interventions was mixed, with improvements in knowledge and healthy eating but differences according to gender. Barriers included poor school meal provision and ease of access to, the relative cheapness of and personal taste preferences for fast food. Friends and teachers were not considered to be particularly important sources of information. Facilitators included support from family, wider availability of healthy foods and motivation to change. The authors concluded that there were significant gaps in the evaluation of interventions and that the effectiveness of increasing the availability of affordable healthy food in the public and private spaces occupied by young people needed to be assessed.

The British Medical Association (BMA) publication, Food for Thought: Promoting healthy diets among children and young people (BMA, 2015), explores how the majority of children and adults in the UK are not following dietary guidance, which might be compounded by adverse childhood experiences. Significant factors include: the developmental environment before birth and during infancy and its relationship to food environments in later life; the knowledge of parents and carers about what constitutes a healthy diet; and family skills for dietary planning and food purchases, storage, preparation and cooking. The report includes a call to action to initiate a range of comprehensive measures to promote healthier diets among children and young people, including education and health promotion initiatives that ensure that they (and their parents and carers) have the right knowledge to make informed choices.

The ethos underpinning the Hearty Lives initiative was that food is at the very heart of all aspects of care. Family meals are associated with a more healthful dietary intake (Berge, et al., 2012). Food and its nutritional content affect young people’s health and well-being and the relationship between learning to cook and having opportunities to do so are associated with better nutritional indicators, improved mental health and stronger family connections in young people (Utter, et al., 2016). Emotional attachments and parent–child relationships have their roots in feeding interactions during infancy (Ainsworth and Tracy, 1972). Adolescent perceptions of low parental connectedness, communication and caring are associated with unhealthy weight control as well as poor mental health and self-esteem (Ackard, et al., 2006).

The aims of Hearty Lives (Liverpool) were to work with looked after 11‒17-year-olds and their carers, particularly targeting those in foster care and residential homes. By working in partnership with the project manager, they and their carers would have an opportunity to devise the most effective methods of supporting healthier lifestyles among the children and young people. It was hoped that the provision of health information, appropriate support and training in food preparation, buying food on a limited budget and making informed choices about their diet would also help them to make a successful transition to independent living as they progressed towards adulthood.

Activities offered through the Hearty Lives (Liverpool) project

Two-hundred-and-ten young people and carers participated in the activities and events provided during the three-year project.

These included:

cook and taste courses for kinship groups, carers and staff in residential settings;

food growing workshops for families and carers;

one-to-one cooking workshops for young people and their foster carers;

sports sessions and gym activities;

walk leader and bike leader courses;

family fun days and taster sessions;

a ‘love your heart’ walk and other walking groups;

active ability and ‘make a move’ training and events and workshops at a local professional football club;

nutrition champions and ‘train the trainer’ courses to enable experienced carers to become champions of the project.

The most popular activities, attracting 10 or more participants, included cook and taste courses, active ability and make a move training, the nutrition champions and food growing courses. Cycling Sundays and bike leader courses were less well attended.

Evaluation

The evaluation of the Hearty Lives (Liverpool) project had the following aims:

to understand looked after young people’s views and experiences surrounding food, including healthy eating and food in the context of social relationships;

to gain greater insight into carers’ views and experiences surrounding food, in terms of both providing healthy eating opportunities for children and young people in their care and the challenges associated with doing this;

to explore how key stakeholders experienced the project’s aim to increase their understanding of impact and outcomes in terms of changes to young people’s diets, physical activity levels and well-being;

to inform potential future work and interventions to promote healthy eating and nutrition in looked after children and young people.

Methods

The design of the evaluation project followed an Appreciative Inquiry (AI) approach to gauge the strengths, successes and potential of the Hearty Lives project by illuminating the perspectives of its stakeholders. The aim of this model is to use people’s experiences and imaginations to show what works, to identify the positive core of the work and to establish what they really care about. Enabling people to share their stories and understandings means that they participate in the development of the project and are inspired to bring out the best in themselves, thereby leading to positive change and development (Bushe, 2013; Cooperrider and Whitney, 2001; Pawson and Tilley, 1997).

Data were collected during the summer of 2016. An initial focus group and a series of interviews explored the experiences and perceived benefits of participating in the programme from the perspectives both of the project manager and a sample of participants. Case study methods of collecting and presenting data enable the systematic production of examples that contribute to the understanding of a phenomenon and the knowledge of a discipline (Flyvbjerg, 2006). In this evaluation the project itself becomes a case study, triangulating the reflections of the project manager with individual case studies of the young people and carers involved. Interviews included a focus on healthy lifestyles, physical activity and food and nutrition experiences before, during and after engagement in the programme.

Ethical approval was given by the Liverpool John Moores University Ethics Committee.

The focus group as a starting point

A focus group involving young people from the Liverpool Children in Care Council was convened to establish a baseline understanding of the level of knowledge and healthy lifestyle challenges of looked after young people in Liverpool who had not been involved in the Hearty Lives project. Seven (three female and four male aged between 13 and 19) attended. A participation worker supported them throughout to ensure that everyone was engaged on an equal footing. Craft materials were used to construct a collage representing what healthy eating and healthy lifestyles meant to them. This formed the basis of further exploration and discussion through semi-structured questions. The benefits of making data collection fun for participants include focusing attention and encouraging reflexivity, supporting inclusivity and enabling the exploration of sensitive topics (Colucci, 2008).

Interview-based case studies

Four face-to-face interviews were conducted with the Hearty Lives (Liverpool) project manager, a Hearty Lives champion (who was also a foster carer), one foster carer (interviewed alone) who had been involved in project activities and a foster carer and the 15-year-old boy in her care (interviewed together) who had also taken part in these.

Interviewees were invited to reflect on their experiences by responding to a series of open, semi-structured interview questions and prompts. Face-to-face interviews were audio-recorded and responses were summarised in the short case studies presented in the findings section of this report.

It is widely acknowledged that it is good practice in qualitative research to return the transcripts of interviews to participants to give them the opportunity to confirm that they are authentic, trustworthy and valid, and that they are a true representation of their intended meaning (Golafshani, 2003; Shenton, 2004). The participants had the opportunity to make any corrections they felt were necessary and confirmed accurate representation.

Interpretation of findings

Interpretation of the data involved a process of thematic analysis – a method of identifying, analysing and reporting patterns in the data flexibly (Braun and Clarke, 2006; Miles and Huberman, 1994).

Findings from the focus group with young people from the Children in Care Council

The young people who took part in the focus group constructed a collage representing their individual concepts of healthy eating and healthy lifestyles. This illustrated ‘healthy eating plates’, an ideal (balanced) Sunday lunch comprising fruit, vegetables, protein, carbohydrates, fat and sugar, dairy products, and words such as ‘body’ and ‘keep fit’ and ‘lifestyle’. This formed the basis of further discussion and exploration. The participants expressed embedded concepts of keeping fit, exercise and eating a balanced diet and rated their knowledge of healthy eating between seven and one on a scale of one to 10, acknowledging that food was ‘important’ to them. They described enjoying cooking and preparing foods and trying out new recipes such as spaghetti bolognese, mac and cheese, chicken korma, Fanta chicken and Sunday roast.

Their ideas came from a range of sources: campaigns on television and social media (‘everybody is talking about dieting, healthy foods such as smoothies and looking good’) and magazine images and library books. Most of the young people engaged in physical activities, such as trampolining at a local park, performance and dance at school or college. Some had experienced theoretical and practical sessions on nutrition and cooking in school or when healthy lifestyles were part of a healthy eating week. One young man had developed an interest through undertaking a food hygiene course while in custody. This influenced his current eating and shopping habits and generated aspirations to become a chef. But most significantly, the young people stressed that a key influence on their eating and lifestyle was parenting and family.

The focus group participants said they had limited finances to spend on healthy activities. They tended to get exercise by ‘walking around town with friends’ as ‘City Bikes’ are too expensive to hire (they would use them if they were accessible at an affordable cost). Things that made healthy eating and lifestyles difficult included the comparatively high cost of healthy foods compared to convenience alternatives and having to shop more often as weekly allowances mean budgeting constraints. They said that frozen fruit and vegetables did not taste as nice and healthy options in school and college were ‘unimaginative’ and ‘unappetising’.

The young people demonstrated their enthusiasm to learn more. They said they would value activities that enable them to learn more about nutrition and healthy lifestyles, food preparation, trying out a wider range of appetising healthy recipes, exposure to a variety of exercise including adventure sports and outdoor activities, dance and performing arts, Zumba and fitness classes, and team games such as basketball, netball and volleyball. Free swimming and access to bikes would be especially popular.

Excerpts from the interview-based case studies

The project manager’s aspirations and learning from the project

The project manager explained that her role was to establish and co-ordinate the Hearty Lives (Liverpool) project. Interventions were designed to enable carers to provide healthier environments for the 11- to 17-year-olds they looked after, thereby improving their eating habits, physical activity levels and other aspects of health. This would reduce longer-term risk of cardiovascular disease. Key collaborators were public health and residential care teams within the local authority, the charitable wing of Everton football club, the leading local youth association, looked after children nurses, foster carers and the young people themselves. Engaging families and identifying champions from the beginning enabled them to contribute to shaping and promoting interventions. A ‘train the trainer’ course for foster carers was developed as it was important that outcomes were sustainable. A resource pack to explore food in the context of physical and mental health was also produced and made available as hard copy and online.

The project manager reflected that building rapport with children and young people can be challenging, particularly when they are likely to have many professionals in their lives and may not always find it easy to trust others. Taking time and providing opportunities to have fun and meet others before focusing on health and nutrition can be a helpful motivator.

She said that the main successes were raising awareness that food and nutrition are an important part of safeguarding and care of children and young people, and identified numerous learning points:

As a nutritionist, she extended her understanding to recognise the wider impact of food on mental health and well-being.

Food may represent power and control to looked after children and young people with a consequent impact on their behaviour.

Foster carers are passionate about providing the best possible support for the children and young people in their care, but face daily challenges as there is a gap in their training when it comes to nutrition and heathy lifestyles.

There is an important opportunity to work pro-actively with the first carer or residential placements that looked after children experience to promote healthy eating and a healthy lifestyle.

One foster carer’s perspective

Foster carer (1) had been involved in the first day of the ‘cook and taste’ course provided by the project. She had really enjoyed the experience. She had a young person on placement with her and invited her to join her on the remainder of the six-week course. The young person declined to be interviewed but was happy for the carer to share her experiences. She had been well looked after in foster care from the age of three but became homeless within six weeks of leaving care at 18. The carer provided a subsequent two-year placement to support her transition to independent living. This included helping her to develop life skills, cooking, cleaning and managing money.

The foster carer had always tried to provide a ‘healthy plate’ for her family and was keen to introduce the young person to ingredients she had not even heard of before such as fresh tuna, sea bass, spinach and barley soup. They enjoyed the course and together followed up their shared interest at home. During the course, foster carers and young people participated in the preparation and cooking of meals, with the young people encouraged to take the lead. They kept hold of all of the recipes in a folder so that they were able to use them later on. Some of the most memorable recipes included familiar meals, but substituted healthier ingredients for those previously used, such as using sweet potato to make a healthy cottage pie and using cauliflower and broccoli to compliment curries instead of rice – a ‘big success’ and now a weekly favourite. The course also ‘Gave you food for thought when out shopping’ (taking a list and checking food labels). This has taught her to check salt and sugar content and not to assume that ‘dearest is always the best’.

The foster carer recognised the value of focusing on practical skills, complementing other mandatory courses such as safeguarding and record-keeping. Change has been very positive as a result: the young person she looked after is now studying at university and has a part-time job in the food industry. What the foster carer valued most was meeting other foster carers, having the opportunity to talk and benefit from peer support and sharing experiences in confidence.

The perspectives of foster carer (2) and the 15-year-old young man in her care

Local foster carer (2) and the 15-year-old young man in her care chose to share their experiences together. They became involved in Hearty Lives (Liverpool) when offered the opportunity to do some cooking and fitness training. The young man was particularly interested in football, baseball, swimming and a range of other activities on offer through the charity wing of the football club (Everton in the Community). He chose football skills training sessions which increased his confidence and led to him playing in a local team. Since being involved in the project, he has been inspired to join a kickboxing club nearer to home and he now takes a younger child placed with the same family to play football in a local Sunday league.

The young man attended a six-week cooking course at the project with his foster carer. The most memorable recipes for them were a meat-free curry, kedgeree using healthy alternatives to haddock and making garlic bread avoiding the use of butter. The young people and carers on the course were encouraged to be actively involved and there were different alternatives each week so that there was an opportunity for everyone to participate. Learning about portion size and what constitutes a ‘healthy plate’ encouraged them to cut down a lot at home and they now have a more balanced range of food groups such as vegetables, meat and potatoes and have reduced salt intake.

They acknowledge that the changes they have made have been hard but beneficial. Getting to sample food they had cooked was an important motivator, as was having a choice; for example, choosing a main meal and a pudding and then making a healthier version. The young man has lost over six kilograms in weight since attending the course and is enthusiastic about taking more exercise. He confirms that it has made him feel ‘good’ and he now has more self-confidence and is becoming generally more active.

When he is not playing football, he attends school and is also thinking of the day when he leaves care and what he will cook for himself. As his family’s cultural heritage is African, food is not just important from a nutritional perspective. He is visited once a month by his aunt and together they enjoy cooking traditional food from their own country. This enables him to maintain his cultural heritage and connect with his early upbringing. He says it is ‘so different to English food’ and is considering a possible future career in catering.

The reflections of a Hearty Lives champion

The Hearty Lives (Liverpool) champion was a foster carer who wanted to learn more to complement her background and qualifications in sport, health and well-being education. She found the course to be ‘one of the best I have done’. Positive elements for her included:

opportunity to share experiences and ‘network’ with other foster carers;

learning new things that she had not previously considered;

re-igniting her passion for health and well-being;

researching more herself;

thinking more holistically;

recognising that in addition to diet, a range of factors such as lifestyle, genetics, psychology and gender affects nutrition.

Becoming a foster carer made her more aware of the relationship between food and the experiences and behaviours of the young people in her care, for example, why a child was ‘rummaging for food’. She feels that more should be done to raise awareness of how food can be central to building up trust with looked after children. Food may represent the only consistency they have as well as being a trigger for particular behaviours. She would recommend that awareness of these issues becomes part of mandatory training for foster carers: ‘I feel that there is so much more that can and should be done.’

She also feels strongly that children attending contact centres for supervised meetings with parents should have access to a kitchen where parents and children can be encouraged to prepare food together in a realistic setting instead of being treated to sweets or burgers.

She recognises that her involvement has had a significant impact on her life as well as the lives of the young people in her care. Examples include visits to a farm, where there was opportunity to participate in ‘cook and taste’ activities and buy products from the farm shop, and getting involved in the ‘bike leader’s’ course which increased her confidence in safely taking groups of children out on planned bike rides.

As a project champion, she helped to develop a ‘food in care’ resource. This takes into consideration national recommendations, eating patterns, psychology and behaviour and supports the delivery of a ‘train the trainer’ course using examples from the ‘real life’ experiences of other carers. Play activities using a toy kitchen were vehicles to explore food hoarding, motivations, smells and behavioural triggers as well as some of the visible biological consequences of poor nutrition. Further resources included posters, books, cards, budgeting games and leaflets. She says that she is now more aware of daily nutritional recommendations, has bought books and a blender/juicer machine and invested in a bigger fridge to house more fresh fruit and vegetables with frozen alternatives as a standby. During the summer holidays, she and the children in her care joined a gym and took a more structured approach to exercise, incorporating bike rides and daily dog walks:

I have just looked holistically at our lifestyle and made changes where I can… in the summer I bought a t-shirt and it said, ‘Make things happen’… I honestly think Hearty Lives (Liverpool) makes things happen by looking more holistically at health.

Discussion, conclusions and implications for practice

In health and social care research, qualitative methodologies aim to explore complex phenomena encountered by service providers, policy makers and service users (Baxter and Jack, 2008; Holloway, 1997). Nutrition and healthy lifestyles are well recognised as global public health issues and as factors in poorer health outcomes throughout the life course. There is an increasing body of evidence which recognises that for looked after children, the challenges to healthy living are compounded by adverse life events, early experiences of family and parenting, the effects of social deprivation and poverty and the relationship between feeding, parent‒child interactions and attachment. Food’s symbolic association with love, emotional warmth, comfort and nurture may be particularly problematic for them. This does not appear to diminish and may well be exacerbated when young people enter care (Baker, 2015; BMA, 2015).

The well-established evidence base highlighting the importance of food, nutrition, healthy lifestyles and well-being for looked after young people is supported by the views and experiences of the practitioners, young people and carers involved in the evaluation of the Hearty Lives (Liverpool) project. The focus group indicates that looked after children have a clear interest in food, nutrition and healthy lifestyles. They recognised the emotional, cultural and behavioural aspects of food and would value the opportunity to benefit from a project of the kind described.

This evaluation shared a similar goal to other qualitative approaches in seeking to arrive at an understanding of a particular phenomenon from the perspective of those who experience it (Baxter and Jack, 2008; Miles and Huberman, 1994). By giving voice to all those involved, the research process illustrated how the project team endeavoured to collaborate with all the stakeholders and service users and involve them throughout the development and delivery of the project.

So what were the outcomes of the discussion?

Understanding the importance of food, nutrition and healthy lifestyles for looked after children and young people

The findings from the evaluation supported the established literature on the importance of food and nutrition for looked after young people. Although they were not involved in the project, those who took part in the focus group demonstrated that they already had plenty of knowledge about keeping fit, exercise and eating a balanced diet. What made healthy eating and lifestyles difficult was that they had limited finances to spend on healthy activities, so they recognised that projects like Hearty Lives (Liverpool) would be a useful and important intervention for them.

Foster carers also clearly perceived the importance of promoting nutrition, healthy eating and lifestyles for the young people in their care. They highlighted the symbolic importance and emotional significance of food for looked after children. Foster carer (1), for example, explained that because food is symbolic of love, when you take young people shopping they are often disappointed that you cannot fill the trolley with everything they want. She explained that they have to learn that you only have your ‘small purse’ with you and you need to put some things back. It can be hard to know how to handle this. She described looking after a boy who had suffered serious neglect and had to forage for food in bins. For several weeks after coming into her care, he slept on the landing outside her bedroom door to make sure that she would make him breakfast when she got up.

A flexible approach and being mindful of what food represents to the young person was an important consideration. Presentation of food and formal family mealtimes were also seen as essential, possibly because they relate to a young person’s own need to be presentable and accepted.

The interview with foster carer (2) and the young person in her care highlighted the cultural significance of food and how this can help young people to maintain a connection with their family and cultural heritage.

Aspirations, challenges and successes of the Hearty Lives (Liverpool) project

The project’s main goal was to design an intervention programme that would improve the health, nutrition and well-being of looked after young people and their carers. Intervention sessions focusing on food and physical activity led to improvements in family lifestyle, although it is impossible to generalise from such a small number of children and young people participating in a single project. However, the number of families who were engaged in the more popular activities suggests that the project achieved a considerable reach into the target population. The fact that some of the activities struggled to recruit more than a few participants suggests the benefits of extensive service-user consultation at the start.

The foster carers and young people involved had hoped to extend their practical cooking skills and increase their awareness of food, nutrition and health. Through working on the group activities and sharing experiences, they also recognised that there were some value-added elements to their participation. For the young people, these included increased confidence and self-esteem and a greater awareness of the relationship between physical health and nutrition, whereas for the foster carers the main gain was a greater understanding of the relationship between children's mental health and behaviour.

The main successes of the project were raising awareness that food and nutrition are an important part of safeguarding and the care of looked after young people. The engagement from the beginning of families and Hearty Lives champions enabled them to contribute to shaping and promoting interventions. The project filled a gap for carers by developing bespoke training and a web-based resource pack to explore food in the wider context of physical and mental health. Over 100 already busy families were engaged in different activities over the three years of the project. A small organisation could not have achieved this on its own, so a key factor was establishing successful partnerships with 15 different organisations with which they shared their goals and encouraging them to be actively involved in the project’s delivery.

Positive outcomes as a result of the Hearty Lives (Liverpool) project

The reflections of the participants suggest a number of sustained positive outcomes following their involvement. The young people become more confident and better prepared to undergo the transition to independent living. Some developed career aspirations as a result of their developing understanding of food, nutrition and cooking. The foster carers said they had made sustained changes to their family shopping, eating and cooking habits and had incorporated healthier recipes into regular family meals as a result of their understanding of the relationship between food, nutrition, exercise and the well-being of the young people they look after. This also had a positive impact on the whole family as their involvement often extended to increasing the whole family's engagement in physical activity and seeking a healthier weight.

Recommendations to practitioners and service providers

The foster carers and young people involved in the evaluation advocated that similar interventions to those provided through Hearty Lives (Liverpool) should be accessible to all looked after children and the carers, practitioners and professionals who support them.

Most importantly, food, nutrition and lifestyle need to be embedded into health plans and case reviews. Providing opportunities for looked after children to take part in interventions similar to those that proved to be engaging, popular and effective during the Hearty Lives project should also be considered. Participants in the evaluation also valued the opportunity to use their own experiences to contribute to future service developments.

The following recommendations may be useful to professionals, service providers and policy developers interested in this area:

Make awareness of nutrition, food and healthy lifestyles part of mandatory training for all those who care for looked after children, including foster carers and birth parents, especially when there are safeguarding concerns about neglect.

In health planning and reviews, a focus on food, drink and physical activity should be included and maintained. Foster carers and significant others should record children’s food, drink and physical exercise routines. Records should include likes, dislikes, meal times, quantities (especially important for toddlers and babies), allergies, religious requirements and habits and behavioural triggers (if known).

Recognise that a child’s first placement provides an opportunity to explore what food means to them and to establish healthier lifestyles. Share the information when the child moves on. Food may represent the only consistency in the child’s life, so the structure of their eating and drinking patterns could help with their transitions. Healthy eating and lifestyles could also become the focus of positive experiences shared by looked after children, young people and their parents during contact sessions.

All looked after children and young people should have access to activities that support their own learning about food, drink, physical activity, health and well-being. Collaboration between agencies could enable a holistic and sustainable approach. Where financial barriers are a concern, consider how bikes and other health promoting activities can be made accessible.

Limitations

The authors acknowledge that the perspectives on the benefits of being involved in the Hearty Lives (Liverpool) project are limited to the views and experiences of two foster carers and one young person who had engaged in the activities offered despite the fact that over 200 people took part in the project. In addition, those involved in the evaluation were recruited by the project manager. Therefore the views expressed cannot be assumed to represent everyone who was a beneficiary, as those with negative experiences may no longer be in contact with the project or may have been less likely to volunteer to be interviewed.

Footnotes

Acknowledgements

The authors would like to thank the staff and young people of the Liverpool Children in Care Council, the Hearty Lives champion, foster carers and the young person who shared his experience of being involved in Hearty Lives (Liverpool), the Project Manager, the Chief Executive of the Health Equalities Group and the commissioners of the evaluation at Merseyside Youth Association and Liverpool City Council.

Nicholas Medforth is Programme Leader for the Advanced Paediatric Practitioner programme at Liverpool John Moores University (LMJU). He also teaches on the BA (Hons) Health and Social Care for Individuals, Families and Communities and works as a self-employed Advocate for Children and Young People on behalf of Liverpool City Council.

James Evans is Programme Manager for Social Work, Health and Social Care Counselling and Psychotherapy and IAPT (Adult Improving Access to Psychological Therapies), LMJU.

Melanie Hills is a Senior Lecturer in social work at the Faculty of Education, Health and Community, LMJU.

Hannah Madden is a PhD student at the Institute of Public Health, LMJU.

Jane Oyston is a research assistant within the public health and wellbeing team at the Institute of Public Health, LMJU.

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