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Effect of a Parental Modeling Intervention on Parent and 1- to 5-Year-Old Children’s Physical Activity

DuBose, Katrina D.1,2; Dlugonski, Deirdre1

Translational Journal of the American College of Sports Medicine: November 1, 2018 - Volume 3 - Issue 21 - p 169–175
doi: 10.1249/TJX.0000000000000072
Original Investigation

ABSTRACT This study examined the effect an 8-wk parental modeling physical activity (PA) intervention had on parent and child PA. Twenty-six parent and young child dyads (1–5 yr) were randomized into either a PA intervention (n = 19) or a waitlist control group (n = 7) for 8 wk. The intervention group received weekly phone calls with a coach to discuss strategies to increase parent and child PA. PA was assessed by an accelerometer before and after the intervention. Time spent in sedentary behavior, light, moderate, and vigorous PA was determined using age appropriate cut points. A series of 2 (group: control–intervention) × 2 (time: pre–post) ANCOVA was run to examine the effect of the intervention on PA levels in the parents and children adjusting for wear time. Among the parents, main and interaction effects were not significant for PA levels, regardless of intensity (P > 0.05). Effect size analysis indicated the intervention group had medium reductions in sedentary behavior (d = −0.57) and increases in vigorous PA (d = 0.65), whereas parents in the control group had a small increase in sedentary behavior (d = 0.14) and medium reductions in vigorous PA (d = −0.75). Regarding the children’s data, the PA levels were similar by group and time (P > 0.05), and interaction effects were not present. Small decreases in sedentary behavior (d = −0.24), light (d = −0.23), moderate (d = −0.13), and total (d = −0.21) PA were observed in the intervention children, whereas control children had small increases in sedentary behavior (d = 0.24) and large decreases in light (d = −0.92) and moderate (d = −0.90), and total (d = −1.02) PA. Although a parental modeling PA intervention may have positive effects on parent’s and children’s PA levels, additional research is needed using a larger sample to better understand the effect this type of intervention may have on improving PA levels.

1Department of Kinesiology, East Carolina University, Greenville, NC;

2East Carolina Diabetes and Obesity Institute, East Carolina University, Greenville, NC

Address for correspondence: Katrina D. DuBose, Ph.D., Department of Kinesiology, East Carolina University, 174 Minges Coliseum, Mail Stop 559, Greenville, NC 27858 (E-mail: dubosek@ecu.edu).

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INTRODUCTION

Engaging in physical activity (PA) is not only important for adult health but also beneficial for positive child development (1). Moreover, PA and child health are two of 26 leading health indictors identified by Healthy People 2020—a national health promotion and disease prevention initiative—that affect the health and function of Americans (2). Although the U.S. government acknowledges the importance of PA in adults and children, only 50% of adults and 16.3% of youth (aged 6–19 yr) are engaging in health benefit–producing PA levels (2,3). Measurement of PA levels in children under 5 yr old is sparse; however, most studies report that preschool-aged children engage in more sedentary behavior than PA and engage in <60 min·d−1 of moderate-to-vigorous PA (MVPA) (4). Currently, adults are recommended to engage in at least 150 min·wk−1 of moderate-intensity PA or 75 min·wk−1 of vigorous-intensity PA (1). Regarding youth, the PA guidelines are for those ≥6 yr and a standard recommendation for those ≤5 yr old does not exist (1,5); however, the consensus suggests that children ≤5 yr should engage in PA for 180 min·d−1 in a mixture of light, moderate, and vigorous intensities (5).

Modeling behaviors is an important way for children to learn healthy behaviors. Parents play a crucial role in the development of their child’s lifestyle and health behaviors, especially PA (6). Children with an active parent were twice as likely to be physically active compared with children with inactive parents, and this effect was even stronger when both parents were physically active (odds ratio = 5.8, 95% confidence interval = 1.9–17.4) (7). Two reviews have examined the association between parental PA and PA among children younger than 6 yr old (8,9). Although the reviews provide inconsistent evidence for the association between parental and young child PA, the studies reviewed were limited by self-reported measures of PA. More recently, Hesketh et al. (10) used accelerometry to assess PA among 554 mothers and their preschool-aged children. The authors reported that a 10% increase in MVPA in the child occurred for every 1-min increase that occurred in the mother’s PA level (10). Further, Rebold et al. (11) had children (3–6 yr) participate in three different social conditions, PA alone, with a parent watching, or with a parent participating for 30 min over multiple days. Children accumulated 23,899 more counts when active with their parents than when the parents watched and 41,585 more counts than being active alone (P < 0.02). In addition, 80% of children reported that they would rather be active with their parent than have the parent watch them (10%) or be active alone (10%). These findings suggest that encouraging parent–child PA participation might be one successful approach for increasing PA not only in the parent but also in the child. Thus, the purpose of this study was to examine the effect an 8-wk parental modeling PA intervention had on parental and child PA levels. It was hypothesized that the intervention would increase time spent in moderate and vigorous PA, while decreasing sedentary time among parents and children.

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METHODS

Participants

Recruitment for this study occurred through advertising on workplace listservs and at local child care centers and preschools. Parents interested in participating were asked questions to determine their and their child’s eligibility for participation. Study inclusion criteria included the following: 1) the parent was ≥19 yr of age with a child 1–5 yr old, 2) the parent and the child lived in the same household, 3) the child walked as his/her primary method of movement, 4) the parent was not meeting PA recommendations, and 5) the parent was not currently pregnant or < 6 wk postpregnancy. Of the 39 parents who were screened, 32 were eligible to participate, and 26 parent–child dyads participated in the study. The main reason for ineligibility was that the parent was already meeting PA recommendations (n = 7). Of the six dyads that were eligible to participate but did not, four scheduled but did not complete the first study visit and 2 did not respond to attempts to schedule the first study visit. The study was approved by the university’s institutional review board, and written parental informed consent was obtained.

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Design

This was an 8-wk intervention study, where the participants were randomized into either an intervention or wait-list control group at a 2:1 ratio (intervention–control). A computer-generated randomization list was created by an individual not associated with the study. The participants (parents and children) completed baseline measures and wore an accelerometer for 1 wk. When the accelerometers were returned, the group placement was revealed, and intervention parents were given a notebook with intervention materials and the name and contact information of their PA coach. After an 8-wk intervention period, the participants (parents and children) returned for posttesting, which included the same measures as during the baseline period and wore an accelerometer again. Parents participating in the intervention were invited to participate in a focus group. All parents were given a $25.00 gift card upon completion of all study procedures, and those who participated in the focus group received an additional $15.00 gift card.

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Intervention

The primary goal of the intervention was to increase both parent and child PA by encouraging the parent to be a role model for their child’s behavior to increase their own PA and to increase PA with their child each week. There were two main components of this intervention—weekly newsletters and phone calls with a PA coach. Each parent was given a binder that included the weekly newsletters, a list of area parks, and suggested physical activities that a child could engage in both in and outside the house. The weekly content (newsletter and phone calls) focused on the following: PA recommendations (adult and child), goal setting, social support for PA, PA barriers, PA progression, lifestyle PA, PA motivators, and prevention of PA setbacks (see Table, Supplemental Content, Intervention material structure and time line, http://links.lww.com/TJACSM/A28). The intervention incorporated aspects of self-determination theory and motivational interviewing techniques (12,13). The constructs of autonomy, relatedness, and competence were incorporated into the educational materials/weekly phone calls (12). Every week, the following items were completed: review of last week’s goals and reasons for success and/or challenges, and new goals were developed. During the eight weekly phone calls, a PA coach used motivational interviewing techniques to facilitate a person focused and goal-oriented PA counseling session to enhance collaboration, evoke change, and develop autonomy (13). The phone calls were designed to last 20–30 min (average length: 26.5 ± 7.7 min), and at the end of the phone calls, the parents set individual PA goals and a goal to be active with the child. The PA coach assisted the parent in developing realistic goals, an action plan, and strategies to overcome barriers. During the intervention period, 121 phone calls occurred on the appropriate week, compared with 10 times when the intervention material was doubled up on because of missing a week.

The PA coaches were two females between 22 and 25 yr of age. They were trained by a researcher who has 7 yr of experience with motivational interviewing. The PA coaches completed training before the intervention and continued to receive feedback to improve their technique on a weekly basis during the intervention period. The PA coaches were provided with cues/questions to use during the weekly phone calls with the participants. These cues were specific to the weekly topics. On a weekly basis, the PA coaches’ phone calls were reviewed and scored using a checklist by the researcher. The checklist was developed by the researchers and focused on the coaches’ ability to review material, discuss weekly content, weekly goal development, use affirmations, reflections, and summaries, and the number of questions asked during the call, including open-ended and close-ended questions. Then the PA coaches received feedback regarding their motivational interviewing technique. This feedback focused on not only areas of proficiency but also areas for improvement and suggestions on how to improve those areas.

Although the PA coaches were there to help the parents increase their PA, the parents were given autonomy to set goals and develop strategies for achieving these goals. If the parent was unable to create a goal, the PA coach gave suggestions, but ultimately it was up to the parent if they wanted to do one of the suggestions given. To further encourage autonomy, the newsletters had blank space for the parent to write responses to questions related to the topic. For example, for the newsletter on social support, the different types of social support were presented, and then the parent was asked to identify what type of social support they needed and who they could ask to give them more support. Finally, the parent was asked to reflect on one of their PA barriers and brainstorm who and how that person could help support them to overcome this barrier. To help guide the discussion during the phone calls, the PA coaches used open-ended questions, affirmations, highlighted successes, and scaled questions. As a result, both the newsletters and the weekly phone calls were interactive in nature. The phone calls helped reinforce the parents’ autonomy for PA change, relate the newsletter material to their life, and develop competence for becoming more active.

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Measures

All the measurements described below were obtained baseline and postintervention for control and intervention participants.

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Anthropometrics

Parent and child height and weight were measured in duplicate, with shoes off, using a wall-mounted stadiometer (Perspective Enterprises, Portage, MI) and portable electronic scale (model # 68987; Befour Inc., Saukville, WI) to the nearest 0.1 cm and 0.5 kg, respectively. Body mass index (BMI) was calculated as kilograms per square meter. The parents were categorized as healthy weight (<25.0 kg·m−2), overweight (≥25.0 and <30.0 kg·m−2), or obese (≥30.0 kg·m−2). For children, age- and sex-adjusted BMI z-score s and percentiles were calculated, and then children were categorized as healthy weight (BMI <85th percentile), overweight (BMI ≥85th percentile, but < 95th percentile), and obese (≥95th percentile) (14).

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PA Measurement

Parents and children wore an ActiGraph accelerometer (GT3X+; ActiGraph LLC, Pensacola, FL) for seven consecutive days. The accelerometer was worn during waking hours around the waist. Accelerometer data were included in the analyses if the parents wore the monitor for at least 4 d and 8 h·d−1 (15) and if children had at least 2 d and 8 h·d−1 of wear (4). Non–wear time was defined as 60 min of consecutive zeros (15,16). For the parent’s PA data, Freedson’s cut points were used to determine the time spent in light, moderate, vigorous, and MVPA (17). Because of the wide age range of children, two different cut points were used to determine the amount of time spent in different PA intensities; cut points by Trost et al. (18) and Butte et al. (19) were used for children 1–2 and 3–5 yr old, respectively. Total PA was calculated as the sum of light, moderate, and vigorous PA.

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Focus Groups

During the posttesting visit, all intervention group parents were invited to participate in a focus group. The focus groups occurred after the intervention and posttesting had been completed. If a parent was unable to attend one of the focus group times, they were invited to participate in an individual interview in a private office space with the same researcher who conducted the focus group. The goal of the focus group was to gather participant perceptions of the intervention. Parents answered questions related to their reasons for enrolling, strengths and weaknesses of the specific intervention strategies (i.e., newsletters, phone calls with PA coach), and the short- and long-term effects of the program. Focus groups were conducted by a 35-yr-old female researcher who is trained in qualitative data collection techniques and has 10 yr of academic experience. Further, the researcher was not directly involved with either the intervention delivery or testing. Overall, 16 parents participated in an interview after the program. Because of time conflicts, four participants were interviewed individually. The remaining 12 participants participated in one of two focus groups. Individual interviews lasted an average of 21.2 ± 7.8 min, and focus group interviews lasted an average of 47.0 ± 2.0 min.

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Statistical Analysis

Means, SD, and frequencies were calculated for demographic characteristics. Differences in baseline demographic characteristics were determined by t-tests and chi-square analyses. The intention-to-treat method was used to handle missing data (four intervention dyads), where baseline values were carried forward. Multiple 2 × 2 (group–time) repeated-measures ANCOVA was used to evaluate differences in parental and child PA levels and adjusted for wear time. Effect sizes (ES; Cohen’s d) were calculated, and the values were interpreted as follows: >0.8 was a large, 0.5 was a medium, and < 0.2 was a small effect (20). SAS (version 9.3, Research Triangle, NC) was used for all analyses and the significance level was set at P < 0.05.

Focus group and individual interviews were transcribed verbatim. The qualitative data were analyzed using a general inductive approach that is useful for answering specific evaluation questions (21). The goal of this analysis was to provide information about how to refine this intervention for future iterations. As such, members of the research team initially identified the following primary objectives of the qualitative analysis: to explore participant reasons for enrolling in the intervention, to examine parent perceptions of intervention outcomes, and to identify strengths and weaknesses/areas for improvement of the intervention. Next, two members of the research team (DD and KD) coded the transcripts for themes related to the primary objectives. Discrepancies in interpretations were discussed and these perspectives are reflected in the final summary. The most important themes are presented in the results along with representative quotes.

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RESULTS

Overall, 26 parent–child dyads participated in the study, with the average age of the parents being 35.4 ± 6.0 yr and the children were 2.8 ± 1.3 yr. Most of the parents and children were Caucasian (Table 1). The majority of parents were married, had a college education or higher, worked outside the home, and the net annual household income was over $50,000 (Table 1). The average BMI was 30.2 ± 8.5 kg·m−2 for the parents, and the average BMI z-score was 0.28 ± 0.87 for the children; 76% of the children were classified as a healthy weight. The demographic characteristics for children and parents were similar between the intervention and the control groups (P > 0.05), except the intervention group had more female children than the control group (P < 0.05).

TABLE 1

TABLE 1

Table 2 shows the PA levels for the parents at baseline and postintervention. At baseline, most of the day was spent in either sedentary activities (~8.5 h·d−1) or light-intensity activities (4 h·d−1), whereas less than 20 min·d−1 was spent in MVPA. Main and interaction effects were not observed for the parent’s PA intensities because of the intervention (Table 3); however, ES analysis indicated differences between the groups. Among the control parents, small increases in sedentary behavior and moderate PA were observed (Table 2). A medium to large decrease in vigorous PA was indicated (Table 2). By contrast, ES analysis indicated that the intervention parents had medium reductions in sedentary behavior, small increases in moderate PA, and medium increases in vigorous PA.

TABLE 2

TABLE 2

TABLE 3

TABLE 3

Table 4 shows the PA levels for the children at baseline and postintervention. Like the parents, most of the children’s day was spent in either sedentary (7 h·d−1) or light-intensity activities (3.3 h·d−1), with under 60 min·d−1 of MVPA. Unlike the parents, children were meeting the guidelines of 180 min·d−1 of light, moderate, and vigorous PA. Main and intervention effects were not found for any of the children’s PA levels (Table 3). ES analysis revealed that in the control group, there was a small increase in sedentary behavior and large decreases in light, moderate, and total PA as well as MVPA (Table 4). By contrast, among the intervention children, small decreases were found for all types of PA, except vigorous PA (no change).

TABLE 4

TABLE 4

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Focus Group Interviews

Reasons for Enrolling

Parents signed up for this intervention for several reasons, but most parents highlighted a desire to increase either their own or their family’s PA. Some parents wanted to “jump start” a personal PA routine that had lapsed. Other parents were looking for ideas about how to be physically active with their child. For example, one mother stated, “I’m really good at coming up with crafts and cooking and things like that with her [daughter]. I’m super good at those kind of activities, but I fall short whenever it comes to thinking of physical ways to play with her and to be more active with her.” Finally, a few parents cited common health-related reasons for wanting to enroll in the program (e.g., lose weight and be more fit).

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Perceived Outcomes

There were three primary benefits of the intervention that were mentioned by most the parents as being helpful for becoming more physically active. First, parents had an enhanced feeling of accountability that was created primarily through the weekly phone calls with a PA coach. The following quote highlights this feeling, “What I really enjoyed about the phone calls was that accountability. Someone saying, ‘how’d you do with your goals?’ or ‘why didn’t it work out?’.” Second, parents frequently described the effect of the intervention on their perceptions about what counts as PA. After the intervention, parents understood that even small bouts of light- to moderate-intensity PA were beneficial. Here is one example of a quote that illustrates these altered perceptions about PA, “Even though sweat wasn’t pouring off of you, you were still active. You’ve only got 5 minutes of this but that’s OK because you can do something with it. It really helped to rewire my brain of how I looked at activity.” Finally, parents described gaining new ideas about physical activities that they could do with their child during the intervention. These ideas came from the list of ideas in the back of the notebook, the weekly newsletters, and discussions with the PA coach. For example, one mother said, “The activities in the back [of the binder], I know I keep going back to that, but that was just so cool to have other things, other than riding bikes or playing tag, other fun ways to be active with your kids.” Finally, one important benefit for a small group of parents was the positive effect that the intervention had on their family relationships, as evidenced by the following quote, “We’ve definitely gone outside more since starting the program. Kids are happy outside, so we’re all happier and we get along better.”

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Strengths of the Intervention

Parents emphasized several components of the intervention that were helpful for achieving the outcomes described above. Parents in this study had many positive interactions with their PA coach that helped to increase accountability, reframe views about what counts as PA, and provide ideas for new activities. One parent said this about her PA coach, “And even when we didn’t meet our goals, it wasn’t this negative thing. It was okay, you’re working, and you understand what the barriers are. She was very optimistic and very encouraging to push us toward just keep trying and being realistic.” Overall, the PA coach interactions seemed to be a well-received and critical component of the intervention. Parents also noted that the newsletters were useful for providing information about how to be active with their child. They specifically liked the newsletters because they were “not too long and not too short,” provided as hard copies, had an interactive/worksheet structure, and included stories about other parents trying to increase PA with their children. Finally, a few parents mentioned that the intervention provided opportunities for practicing self-regulatory skills (i.e., goal setting and self-monitoring) to help increase PA.

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Areas for Intervention Improvement

Parent perceptions of the program were mostly positive, but there were several suggestions for improvement that should be considered for future versions of this intervention. Although parents found the interactions with the PA coach encouraging and helpful, many reported that the calls were too long; on average, the phone calls lasted 26.5 ± 7.7 min. Parents suggested shorter, more frequent calls to enhance accountability, limiting the overlap between the newsletter and the phone call, and considering other forms of interaction (e.g., e-mail and chat). A few parents reported challenges with logging their PA throughout the intervention and suggested an electronic log or app to be able to record the PA data in the moment. Finally, some parents expressed a desire to incorporate a social aspect into the intervention (e.g., play dates at the park, Facebook page, etc.).

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DISCUSSION

This study determined the effect a parental modeling PA intervention had on parental and child PA levels. Although statistically significant changes in PA levels were not observed among either the parents or young children, the intervention may have had positive effects. Most notably was that intervention parents increased vigorous PA time and decreased sedentary behavior. Further, children in the intervention group had smaller reductions in light, moderate, MVPA, and total PA than the control children.

The results of the current study agree with reports that adults are not engaging in adequate PA levels (1); however, the young children in the current study were participating in more than 180 min of PA per day, which contrasts with what has been reported (4). The small sample size of the current study and study recruitment methods, and different cut points used could have influenced the difference in results across studies.

A paucity of family-based PA intervention studies exists in young children. This study’s results are different from those of O’Dwyer et al. (22), who reported that a 10-wk family-based intervention increased preschool-aged children’s PA levels by 4.5%–13.1%. Possible reasons for differences in results between the two studies include the shorter duration, high baseline PA levels, and younger age of children who participated in the present study. To better understand the effect family-based interventions have on young children’s PA levels additional research needs to be conducted. Specifically, conducting family-based PA interventions recruiting not only parents but also young children who are not meeting PA recommendations would be an important consideration for future research.

A novel aspect of the study is that the effect of the intervention on parent’s PA levels was also determined. Past research has focused on the ability of family-based interventions to improve children’s PA levels, but it is possible that the parent’s activity levels might also be affected. Although the results indicated changes that were not statistically significant, the changes were in the desired direction and resulted in medium reductions in sedentary time and increases in vigorous PA levels, where the control parents had no change in sedentary time and large decreases in vigorous PA levels. Future research should also examine parental changes in PA levels as the result of family-based interventions.

The qualitative data indicated that, overall, the intervention was well received by parents. One of the main reasons parents enrolled in the intervention was to learn how to be active with their child, and parents also self-reported the usefulness of the ideas for engaging in activity together that were provided in the intervention notebook. These findings suggest an awareness of the importance of engaging in PA with their young child. Future studies should educate parents about the ways they can be active with their children and measure changes in parent–child coparticipation in PA as an outcome variable. Parents also mentioned changed perceptions about what “counts” as PA. Thus, they might be engaging in shorter, more frequent bouts of activity that are difficult to recall using self-reported questionnaires. This highlights the importance of using objective measures of PA. Finally, parents noted the accountability that was created by being enrolled in the intervention and talking weekly with a PA coach. It is important to find ways to maintain accountability after the intervention ends to sustain any positive changes that occurred during the intervention.

This study has some limitations that could be used to guide future investigations. The time frame of the intervention was short, and a longer intervention duration might be needed to elicit improvements in PA levels among parents and young children. Further, the children were predominantly Caucasian, males, and already obtaining suggested PA levels, so replicating the study in a diverse sample, racially and PA levels, is warranted. Further, although the parents were given multiple resources, discussion with PA coach, newsletters, listing of area parks, and PA suggestions, to help them become more active which intervention components were the most beneficial for increasing parent–child PA, were not determined. It would be important for future research to identify the intervention component(s) necessary to promote PA increases among parents and young children. Finally, the purpose of this study was to examine the feasibility of this type of intervention; therefore, process evaluation of the intervention was not quantified. Future studies should include quantitative data determining the reach, dose, and fidelity of the intervention.

In conclusion, although an 8-wk intervention did not produce statistically significant improvements in PA levels among parent and young children, small to medium improvements in the parents’ MVPA levels were observed. In young children, the intervention may have helped maintained PA levels. Furthermore, parents were not only receptive but also enjoyed this family-based PA program. This type of intervention that includes parental modeling may be an effective strategy to produce positive effects on parents’ and young children’s PA levels.

Funding for this project was provided by a Research/Creative Activity Award, East Carolina University, to Katrina D. DuBose.

The authors acknowledge Kellie Soos, Alexandria Payton, and Keylynne Matos-Cunningham for their assistance with data collection and implementation of the intervention.

The authors do not have any conflict of interests to disclose.

The results of this study do not constitute endorsement by the American College of Sports Medicine.

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