At-a-glance – “I just got tired of their healthy tips”: health promotion during public health crises

Introduction

Establishing and maintaining healthy lifestyle behaviours in childhood is critical for growth, development and preventing chronic disease.^{Footnote 1} Before the COVID-19 pandemic, schools were the key setting for delivering health promotion programming to children. During the COVID-19 pandemic, countries imposed prolonged lockdowns^{Footnote 2} and school closures, leading to the collapse of school-based health promotion programming. Therefore, the responsibility for health promotion shifted to parents. In Canada, schools disseminated health promotion materials (e.g. weekly wellness emails containing healthy recipes, family-friendly activities and exercise suggestions, mindfulness practices) to parents, who were tasked with relaying the information to their children and/or implementing health promotion activities in the home environment (e.g. cooking with healthy recipes).

It is important to understand how parents perceived health promotion materials from schools and to identify strategies to increase parental engagement to facilitate health promotion during health crises. This qualitative study explored parents’ perspectives on (1) pandemic-related changes to health promotion programming, and (2) how they could be better supported in facilitating health promotion at home.

Methods

Ethics approval

The Health Research Ethics Board of the University of Alberta (Pro00061528) and participating school boards approved all study procedures.

Study design and procedures

This research is part of a multimethod study (i.e. one using complementary methodologies to achieve a common overall research goal^{Footnote 3}) that examined parents’ and children’s perceptions of the impacts of COVID-19 on elementary school children in 20 APPLE (A Project Promoting healthy Living for Everyone) Schools in western Canada. School lockdowns in Canada were implemented in March 2020 and continued into the 2020/21 school year, with remote learning replacing in-person learning for this duration. Fluctuating provincial restrictions, such as the reopening of schools in September 2020 and repeated suspensions throughout the 2020/21 school year, led to the delivery of school-based health promotion programming in an online format, with a focus on children’s mental health and psychological well-being.

We interviewed 15 parents whose children attended Grades 4 to 6 in one of the six APPLE Schools in six small and mid-sized communities (population < 15 000) in the provinces of Alberta and Manitoba, Canada, between December 2020 and February 2021.^{Footnote 4} We used purposive, snowball and convenience sampling techniques to recruit participants for 60-minute, semi-structured telephone interviews that were audio-recorded, transcribed verbatim and analyzed using thematic analysis. All participants were mothers. Participants received a CAD 30 gift card to compensate them for their time.

Results

Participants were, on average, 46 years of age and had one to four children. Most participants were above the low-income cut-off (CAD 50 000/y; 93.3%), were married or living common-law (86.6%), had at least a community or technical college education (93.4%) and had not had their (or their partner’s) employment affected by the pandemic (86.7%). Two main themes emerged from the thematic analyses: (1) “Oh my god, there’s too much in [this email]”: parents overwhelmed with health promotion materials; and (2) “We really liked that”: tips for increased parental engagement with health promotion materials.

“Oh my god, there’s too much in [this email]”: parents overwhelmed with health promotion materials

Although parents expressed concerns about the negative changes to their children’s lifestyle behaviours and mental health because of the pandemic,^{Footnote 4} most parents did not access health promotion materials made available to them. When prompted to expand on the reasons for not accessing these resources, some participants described them as intrusive (“I just want to be left alone by somebody else telling me what I have to do during my day with my kids” [Parent 4a]) or explained that they were too preoccupied with other things (Table 1, Quote 1.1). Most participants also spoke of their own pandemic-related mental health stressors, such as unexpected family circumstances, changes to routines, the inability to rely on social support networks and being overwhelmed by the pandemic (Table 1, Quotes 1.2 and 1.3). 

Table 1. Select quotes from parents of children in Grades 4 to 6 attending APPLE Schools^{Footnote a} in Alberta and Manitoba, December 2020 to February 2021, on school-based health promotion during the pandemic

Quote #	Quote
1.1	“Because we were so into what we were doing, we didn’t probably pay attention to what they were suggesting.” (Parent 2a)
1.2	“I was getting emails left, right and centre, just trying to keep up with my kids’ academics.” (Parent 6a)
1.3	“I’m going to be honest, I didn’t really read [health promotion materials], because it was this really lengthy email most of the time. […] There was almost too much stuff in it. I’d open it and I’d be like ‘Oh my god, there’s too much in it,’ and I wouldn’t even look at it.” (Parent 3a)
1.4	“I do know that [health promotion materials] came home, but to be honest, there was so much that I literally just took out the math and the spelling, and I just pushed the other stuff away because it was just too overwhelming.” (Parent 12a)
1.5	“When it’s not important it just gets skimmed over and it’s like ‘yeah, okay, whatever.’” (Parent 13a)
1.6	“Well [laughs], I’ve been having a hard time myself with the whole COVID thing ... I kind of go ‘yeah, yeah, yeah, okay.’ You know when you see something so much you just stop seeing it, or you stop caring about it.” (Parent 13a)
1.7	“I got tired of their healthy tips.” (Parent 9a)
2.1	“[Doing these quieter activities] just calms down their level of energy, definitely calms down a notch. They get along better, they aren’t so reactive to each other.” (Parent 5a)
2.2	“The teachers had phoned me just personally, ‘How are you doing, we’re just checking in.’ And they did that for the kids too, just to make sure we’re not losing our minds. They were watching out for everybody.” (Parent 4a)
2.3	“[The APPLE School Health Facilitator] was sending emails and phoning. […] She was following up and checking in with both kids. She was really great at that, actually.” (Parent 10a)
2.4	“[The school was putting together food baskets] and a lot of families really needed it. [City name] is an oil and gas town, and a military town as well, so a lot of families were already going through a lot of hardship, and then add the pandemic onto that as well. It’s really been tough for a lot of families, so [food baskets] was a really awesome thing that [the school] did.” (Parent 6a)
2.5	“We got free lunches from one of the [community centres that] provided bag lunches for all the schools in the valley, which was wonderful. I think that happened a couple of times. And then even the education assistants and teachers made pizzas and gave them out to the families. […] When we would drop off homework and pick up the new envelopes, they had pizzas for us to cook at home [, which] was really nice.” (Parent 10a)

Considering more immediate pandemic-related stressors, health promotion materials were viewed as “extra stuff” (Parent 11a) when compared to keeping up with educational requirements for school (Table 1, Quotes 1.4 and 1.5).

Some parents who accessed the resources described their loss of interest in health promotion materials from schools amidst the abundance of pandemic-related messaging from the media, work and other sources (Table 1, Quotes 1.6 and 1.7).

“We really liked that”: tips for increased parental engagement with health promotion materials

Those parents who accessed the health promotion materials found those targeting mental health and well-being particularly helpful (e.g. journalling and meditation). Indeed, mental health appeared to be a more salient concern than other lifestyle behaviours for parents during the COVID-19 pandemic.^{Footnote 4} Mindfulness “was definitely a coping strategy and something that helped identify some feelings that [the child was] having” and was easy to implement at home since the child was able to “link it to what [the child] had done in school” (Parent 5a). One parent commented that quiet activities potentially contributed to their children’s ability to better self-regulate their behaviour (Table 1, Quote 2.1). Another parent noted that schools provided reflective journals, allowing children to reflect on and process their feelings.

When probed to discuss the health promotion supports that would be helpful in future lockdowns, parents commented on the benefit of personal interaction from teachers or other school staff (e.g. school health facilitator), both for parents and children, compared to impersonal communications such as newsletters, emails and brochures (Table 1, Quotes 2.2 and 2.3).

Parents also spoke about more tangible supports to encourage healthy lifestyles for children, such as food basket distribution through collaboration between schools and community centres. This was particularly appreciated by the families affected by pandemic-related stressors such as job losses (Table 1, Quotes 2.4 and 2.5).

Parents suggested putting short health promotion materials (e.g. “a three-minute video” [Parent 13a]) on social media that are “easy to browse through at night when you have some down time” (Parent 6a); including more activities that are easy to do at home and that are engaging and competitive (“Maybe they could challenge other kids in their class or have [certain] amount of outside time and […] documenting that and what they did outside.” [Parent 1a]); and providing equipment to keep children engaged (“Skipping rope would have been awesome, ’cause my kids would have loved that” [Parent 5a]).

Discussion

We summarized parents’ perceptions of health promotion materials during the COVID-19 pandemic. Although some parents accessed and appreciated suggestions on maintaining healthy lifestyle behaviours while students were learning remotely, most were too overwhelmed to review or utilize these health promotion materials. This finding is consistent with existing research on health promotion communication during health crises,^{Footnote 5} when most parents are preoccupied with more immediate concerns (e.g. ensuring economic stability, keeping up with the educational requirements). Thus, unhealthy lifestyle behaviours of children lose their saliency, and health promotion becomes just “one more thing” placed on parents’ shoulders.

To prevent this outcome during crises, UNICEF^{Footnote 6} emphasizes the importance of schools assessing communication needs, identifying multiple communication channels (e.g. online parent conferences, phone calls, messaging groups, social media platforms and school websites) and specific frequency of communications, as well as strategies that have the biggest potential to establish and maintain parents’ engagement. As exemplified in our study, some parents expressed interest in receiving health promotion materials in an alternative format (e.g. short videos) on social media platforms. Moreover, given the perceived importance of meeting educational requirements, it might be helpful to contextualize health promotion as an important contributor to children’s academic success. For example, rather than using prescriptive language (e.g. “Your children need to eat healthy and exercise”), health promotion materials could emphasize the importance of healthy lifestyle behaviours for children’s ability to learn and concentrate better (e.g. “Healthier kids are better learners”).

Given that parents struggled to facilitate health promotion during COVID-19, it is imperative that alternative ways for health promotion delivery are sought. The partnerships and services component of the Comprehensive School Health framework^{Footnote 7} outlines that all schools should explore ways to create tighter connections with community organizations and co-create opportunities for kids to engage in healthier lifestyle behaviours, while also giving parents time to recharge and take care of their own physical and mental health needs.

While virtual delivery of programming by schools served during the acute, pre-vaccine phase of the pandemic, evidence shows that outdoor activities with added layers of protection against COVID-19 (e.g. masking, distancing), such as community walks and evening bike rides, are another safe option to keep children active.^{Footnote 8} Moreover, additional funding to ensure the distribution of equipment (e.g. skipping ropes, bubble-blowing solution, soccer balls, family games to promote positive family experiences) and food (e.g. food hampers, gift cards for groceries), as well as access to individual and family counselling and other community resources that focus on mental health and well-being are warranted in case of future lockdowns.

Conclusion

We found that most parents did not access health promotion materials during school closures due to the health crisis and associated challenges. We identified strategies to increase parental engagement in facilitating health promotion at home during health crises to keep students engaged in healthy lifestyles. Future research should investigate student outcomes of health promotion during health crises to ensure that health promotion is implemented in a meaningful and efficient way.

Acknowledgements

The authors thank the students, parents and school principals for their participation in the research. They further thank teachers and APPLE Schools staff, specifically Landra Walker, Tina Skakun and Katherine Dekker, for facilitating the research.

Funding

The Public Health Agency of Canada and other partners (more details available here) funded the APPLE Schools programming in the northern communities. This study was supported by operating funds from the Canadian Institutes of Health Research to KM and PJV (grant #172685). KM holds the Murphy Family Foundation Chair in Early Life Interventions.

Conflicts of interest

The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Authors’ contributions and statement

JD, NW, LM, PJV, KM–conceptualization. JD, LM, BAM, SS–data curation. NW, LM, BAM, SS–formal analysis. PJV, KM–funding acquisition. NW–methodology. PJV, KM–supervision. JD–project administration. JD, BAM, SS–writing–original draft. JD, NW, LM, BAM, SS, PJV, KM–writing–review & editing.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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