Received: 12 July 2019 | Revised: 30 November 2019 | Accepted: 12 December 2019 DOI: 10.1111/hex.13020 ORIG INAL RE SE ARCH PAPER Parent recommendations to support physical activity for families with young children: Results of interviews in deprived and affluent communities in South Wales (United Kingdom) Ashrafunnesa Khanom PhD1 | Bridie Angela Evans PhD1 | Rebecca Lynch MA1,2 | Emily Marchant MSc1 | Rebecca A. Hill PhD1,3 | Kelly Morgan PhD1 | Frances Rapport PhD1 | Ronan A. Lyons PhD1 | Sinead Brophy PhD1 1 Swansea University, Swansea, UK National Centre for Mental Health, Cardiff University, Cardiff, UK 2 3 Abstract Background: Physical inactivity is the fourth leading cause of mortality worldwide. Hywel Dda University Health Board, Wales, UK Early childhood is a critical period when healthy behaviours can be instilled for a Correspondence Ashrafunnesa Khanom, Swansea University Medical School, Floor 2, ILS2, Swansea University, Swansea, SA2 8PP, UK. Email: a.khanom@swansea.ac.uk affecting child and family physical activity and sought parent recommendations to future active lifestyle. We explored community, societal and environmental factors support physical activity in families with young children. Methods: We interviewed 61 parents expecting a child or with a baby ≤12 months (35 mother and father paired interviews and 26 interviews with mothers only). We Present address Frances Rapport, Macquarie University, Macquarie Park, NSW, Australia purposively sampled families for neighbourhood deprivation status (Townsend Index; Funding information Public Health Wales NHS Trust; Swansea University; NISCHR; DECIPHer; British Heart Foundation, Grant/Award Number: MR/KO23233/1; Cancer Research UK; Economic and Social Research Council; Medical Research Council; Welsh Government; Wellcome Trust Results: We identified four themes: work family-life balance; spaces for activity; 26 affluent; 35 deprived). We conducted thematic analysis of interview transcripts using Bronfenbrenner's socio-ecological framework to guide interpretation. beliefs and attitudes; and physical activity facilitators. We found that parents from deprived neighbourhoods were more likely to be underactive because of a complex web of community, social and personal factors which reduced motivation and hindered opportunity for physical activity. To increase knowledge and opportunity, respondents suggested ‘help not tell’ messages covering ‘why’, ‘how’ and ‘where’ information about physical activity, and using physical activity to support community engagement and social interaction. Conclusions: Recommendations from parents highlight effective communication about the importance of early child and family physical activity and improved community access to safe facilities and opportunities. Both parents need to be engaged in designing interventions to support greater physical activity and healthy behaviours which are relevant and achievable in individuals’ lives. KEYWORDS family activity, interventions, interview, physical activity, young children This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2020 The Authors Health Expectations Published by John Wiley & Sons Ltd Health Expectations. 2020;00:1–12. wileyonlinelibrary.com/journal/hex | 1 2 | KHANOM et Al. 1 | BAC KG RO U N D Physical inactivity is the fourth leading cause of mortality worldwide.1 Greater urbanization and development of modern technology contribute to inactivity and its associated physical and psychological health problems. 2,3 Inactivity and sedentary behaviour start from an early age and are linked to weight gain through childhood.4,5 Studies have identified early metabolic markers for high cholesterol, blood pressure and abnormal glucose metabolism in overweight children as young as five6 and early vascular lesions in overweight children as young as three.7 Many pre-schoolers (2-6 years) fail to complete the minimum daily 60 minutes of moderate-to-vigorous physical activity recommended for young children.8 Targeting interventions at early years (0-8 years) could support formation and maintenance of future health behaviours1 when physical activity can be nurtured to sustain active lifestyles.9,10 The Department of Health in the United Kingdom has produced physical activity guidelines for children from birth to 5 years of age to encourage activity in early childhood.11 Increasing whole-family physical activity could potentially re- F I G U R E 1 Bronfenbrenner's socio-ecological model. Source: Bronfenbrenner40 duce childhood obesity and improve their overall health. Poor motor framework to address the reported evidence gap in ways to enable development in infancy and early childhood is associated with re- more physically active children.42,43 In this paper, we report the duced physical activity in older children but can be improved through views of expectant parents and families with a baby ≤12 months parent-facilitated physical activity at an early age.12,13 Children's ac- concerning community, societal and environmental factors affecting tivity rates increase if one parent is active and are highest if both family physical inactivity, as this can be a time when family activ- parents are active. Children with active parents are more likely ity levels can decline. We also present parents’ recommendations to maintain activity levels through childhood.15-18 However, adults for interventions to support physical activity in families with young with dependent young children appear to be less physically active children. 14 compared to those without children.19,20 Moreover, parents21 and adults in general22,23 undervalue the importance of physical activity as a means to encouraging energy expenditure and reduce weight gain. 24,25 Interventions which focus on individuals and their families can 2 | M E TH O DS 2.1 | Setting overlook social, economic and environmental barriers to undertaking physical activity; which individuals often have little control over Parents in this qualitative study were already taking part in an ex- and can prevent them maintaining positive health behaviours. 26-31 isting birth cohort study ‘Growing Up in Wales: Environments for Young mothers from disadvantaged backgrounds are less likely to Healthy Living’44 which examined the impact of environmental in- participate in regular physical activity. 32 Children from families in fluences during gestation and post-birth on health outcomes using lower socio-economic groups have lower levels of physical activ- data linkage of routine, anonymized medical records.45 Participants ity 33,34 and higher body mass index. 35 Studies looking at parent-re- were recruited for the cohort study when they attended maternity ported barriers report lack of time,36,37 the cost of being active,36,37 appointments in hospitals and clinics. Exclusion criteria were preg- facilities within the home 36,38 and outside. 39 One way to understand how context influences parent and child nancies under the age of 16, incomplete pregnancies and mothers with serious health problems such as cancer. A detailed description health behaviours is through Bronfenbrenner's socio-ecological of study participants who were eligible to take part in the birth co- model.31,40,41 This identifies four levels of influence on a child's de- hort study has been provided elsewhere.44 velopment: the individual's immediate physical and social environment such as home and family (microsystem); the wider environment such as school (mesosystems); broader social, political and economic conditions (exosystem). These all interact to affect the beliefs and 2.2 | Qualitative study: recruitment and data collection attitudes of wider society (macrosystems; see Figure 1). This study explores the attitudes of parents across different We purposively sampled parents from the birth cohort sample of par- socio-economic groups towards physical activity and the opportu- ents according to neighbourhood deprivation using the Townsend nities available to them. We use Bronfenbrenner's socio-ecological Deprivation Index.46 AK contacted expectant mothers or mothers | KHANOM et Al. 3 with infants aged ≤12 months, face to face at antenatal clinics or by and categories were further refined and clustered into codes and telephone. AK made arrangements to interview those who agreed sub-codes concerning individual/family, community, environmen- to take part. Interviews took place in participants’ homes except for tal and societal level, using the socio-ecological model as a frame- two conducted at participants’ workplace (personal preference). A work40 (see Figure 1). These formed a codebook which was used semi-structured interview schedule was used for interviews (Table 1). by AK to code the remaining transcripts. Findings were discussed Questions concerned parents’ knowledge and views about living a in four paired analysis sessions, to ensure robustness and internal healthy lifestyle; how this influenced their current choices for family- validity.47,48 A senior qualitative researcher (FR) was also available based physical activity; barriers and facilitators to physical activity; throughout to challenge and critique analytic outputs and themes and recommendations to facilitate family physical activity. Informed as they emerged. consent was obtained before undertaking and recording the interviews, which were all carried out by AK. Interviews were conducted in English, Bengali and Urdu depending on which language was preferred 2.4 | Reporting by respondents. Parents who spoke Urdu and Bengali were included in the sample as the researcher AK was fluent in both these languages. We report results according to themes identified in the data. We The interviews ranged from 30 to 60 minutes. selected quotations to be representative of respondents’ com- Recruitment and data collection happened in parallel. Initially, ments unless otherwise stated. Quotations are identified by re- the intention was to interview mothers only. However, fathers were spondent family identification number and whether they are a present in two early interviews and it was recognized that this broad- mother or father. Further information such as deprivation status ened the discourse and enabled data capture of the whole-family of where they live and age and number of children can be found perspective, and useful detail of the dynamics between parents. in Table 2. Subsequently, AK sought to recruit fathers also. During the paired interviews, AK encouraged both participants to equally contribute to the discussion by rephrasing and directing questions to both 3 | R E S U LT S participants. We conducted 61 interviews from a potential total cohort of 819 2.3 | Data analysis families from the Growing Up in Wales study with parents: 35 with both parents and 27 with mothers only; 26 families from affluent neighbourhoods; and 35 families from deprived neighbourhoods. An inductive thematic data analysis approach was used 47 where Respondent characteristics are shown in Table 3. Four interviews theoretical perspectives are informed by the interpretation of raw were conducted with mothers only in the participant's mother data. AK, RL and EM independently reviewed anonymized inter- language (Bengali [3] and Urdu [1]) and were translated and tran- view transcripts, working with the first 20 completed interviews scribed by the researcher (AK). The remaining transcripts were to systematically code the data to draw out themes and categories transcribed by an independent transcriber. All transcripts were to illustrate emerging concepts. Through discussion, these themes cross-checked with notes taken during the interviews to ensure TA B L E 1 ance; spaces for activity; beliefs and attitudes; and physical activ- data integrity. We identified four themes: work family-life balInterview schedule for physical activity Can you describe your weekly levels of physical activity (individually and as a family)? Does anything pose a barrier to your family taking part in physical activity? ity facilitators. 3.1 | Work family-life balance Local environment and location of facilities? Beliefs, attitude, culture? Respondents reported that busy work schedules, irregular work During your childhood how physically active were you? patterns and lack of time reduced opportunities for family physical Can you identify the best way to inform or advise parents about the importance of physical activity? family unit and often sought support from each other to facilitate What sort of service or support do you look to health professionals for? What sort of families do you think will/should use or listen to advice on taking part in physical activity? activity. Many parents expressed a keen desire to be active as a family activities, recognizing value for whole-family health and well-being and also the opportunity to maintain and strengthen family bonds. However, work patterns resulted in extended periods of time when one parent was alone with one or more young Do you know of anything being done in your local area to promote physical activity? child. Often, one parent had to stay home to wait for their part- Do you have any ideas on ways to improve your local area to encourage family physical activity? deprived areas. Repeated and prolonged periods alone caring for ner to return. This was especially evident for mothers living in their children also appeared to be a bigger burden for mothers. 4 | KHANOM et Al. TA B L E 2 Identifiers for study quotes be a one to one. ..Three kids…a slight problem, you need three adults Respondent family ID Neighbourhood details 1 Mother Deprived Child aged three and child aged 4 mo 2 Mother Deprived Child aged 4 mo 6 Mother Affluent Child aged eight, six and two 7 Mother Deprived Child aged six, four and expecting child I’d like to move towards doing more things as a family like 12 Mother Affluent Child aged 6 mo [on our own]…we’ll spend longer, longer outside. If it’s 13 Mother Deprived Child aged eight and child aged 6 mo just me and X [daughter] then a lot of the time we’ll have Family details 14 Mother Deprived Child aged six and child aged 9 mo 17 Mother Deprived Child aged one (55: Mother) Being alone at home also eroded motivation to be active and to play. Arranging activities as a sole parent could be less fun as well as harder to manage. family bike rides and so it would be all of us rather than something specific to do rather than too much playing (22: Mother) Many fathers, from both types of communities, voiced dissatisfac- 18 Mother Deprived Child aged three and child aged 9 mo tion with their employment patterns because work hours reduced the 19 Mother Deprived Child aged 9 mo regular physical activity. 21 Father Deprived Child aged four and expecting child 21 Mother Deprived Child aged four and expecting child doing things and as soon as I’m home I just want to do 22 Mother Deprived Child aged two and expecting child (23: Father) 23 Father Affluent Child aged two and expecting child time they could spend with their children and limited the possibility of Because [of] my teaching, you’re limited to the holiday stuff with her The effect of employment patterns was more acute when one or both parents were working shifts or overtime for additional income, 25 Mother Affluent Child aged two and expecting child 26 Mother Affluent Expecting child 28 Father Deprived Expecting child 35 Father Affluent Child aged four and expecting child My job is different hours virtually every day… at the mo- 41 Mother Deprived Child aged eight and child aged 3 mo and then I’ve got them for about two hours before they 49 Mother Affluent Child aged four and one 55 Mother Deprived Child aged five, child aged 12 mo and expecting child 60 Father Deprived Child aged 19 mo and child aged 8 mo which was more common for those in deprived neighbourhoods. Having regular work hours enabled families to schedule activity during the week and at weekends. ment, [my partner] had the kids all day, she’d go to work go to bed… but I don’t know if the government could do anything to sort of allow us time maybe off work and things like that, whether we could spend more time with the kids (60: Father) Access to personal transport was associated with employment for They reported that it resulted in less time playing and being ac- many families. A family needed two vehicles, if one was used by the tive with their children. Sometimes this was because several adults parent travelling to work and the parent at home had one too. Families were needed to make an activity possible. Managing and super- needed a larger income to run one or two cars. Families with access vising several very young children, handling pushchairs and other to a car had more choice and opportunity to pursue physical activities equipment, was very difficult for one parent. Public facilities often for children. Access to facilities often required access to transport and required more than one adult. Parents reported feeling isolated added to the overall cost of attending such facilities. Income was a fac- and less willing or able to take their children out on their own or tor in choosing physical activities, with some respondents reporting when they had household tasks to undertake—unless it was shop- that some activity venues were too expensive to visit regularly. ping trips. Well when we went down the beach [by taxi] we ended The only thing with that [trying to go swimming as a fam- up walking back into town. But then when we go out ily] if you’ve got children under a certain age you need to we have a taxi home because the double buggy steers | KHANOM et Al. TA B L E 3 Socio-demographic data of study participants TA B L E 3 (Continued) Mother Socio-demographic characteristics of participants Number of interviews conducted 61 Parents (n) 1-1.9 y 12 2-2.9 y 13 Mother 61 3-5 y 20 Father 35 >5 y 39 Average age in years (age range of all parents in family) Mother Father 30 (20-42) 35 (21-52) 5 Father like a tank and it’s heavy because we’ve got the two of them and he’s no lightweight, so it’s easier to get a taxi home,…we’ve always got at least £10 to manage Occupation of all parents (n) to get a taxi home so [adds to the cost of being active Non-manual 16 27 Manual 17 26 Student 5 3 Not in employment 11 4 Homemaker 12 1 3.2 | Spaces for activity Higher degree 16 12 The home was identified as an important space for enabling or re- First degree 15 13 stricting physical activity. In small homes with limited floor area, chil- Diplomas in higher education 6 3 dren played in confined indoor spaces or potentially unsafe areas A/AS levels 4 3 such as steps in front of the house when there was no garden. These O/GCSE levels 14 14 children were reportedly more likely to encounter accidental injury Other 2 12 around the home. None 4 3 Unknown 0 1 Education of all parents (n) (18: Mother) [My daughter aged 2/3 has hurt herself playing in here] diving off the settee and bouncing off the fire [guard] Ethnicity of all parents (n) White (European) as a family] with her head 49 52 Welsh 47 51 Romanian 1 0 Polish A number of homes in the deprived areas had steps to the main 1 1 door. These created extra barriers to families going out to be active Ethnic minority 12 9 together, exacerbated because the parent had to manage alone when Bangladeshi 4 4 the partner was working. One mother, pregnant with her third child, African 2 1 said she felt imprisoned in her house because she could not leave with Middle Eastern 2 2 the children on her own. South East Asian 2 1 Pakistani 2 1 (18: Mother) We’ve got a double buggy and I only go out when their father’s off… …unless there’s two people I can’t get the Socio-economic status % (n) Affluent neighbourhood 43% (26) pram down the steps…but if we moved to somewhere Deprived neighbourhood 57% (35) with less steps we would probably go out a lot more (18: Mother) Number of children % (n) Expectant mother with no child 11% (7) Expectant mother > 1 child 48% (29) Mother with child ≤ 12 mo of age 41% (25) Average number of children per family (range = n) 1.7 (1-5) Average age of children (age range) 4.75 y (1 mo-18 y) Other participants living in deprived areas relied on friends and family networks to help them access spaces for safe play: ….our friends have just moved down into the new [X] Estate so we go down to see them and then we spend all day running round the garden (18: Mother) Number of children in each age category(n) <1 y 20 In contrast, children living in mostly affluent neighbourhoods were (Continues) observed by the researcher to have access to more floor space within 6 | KHANOM et Al. the home that was safe for play and physical activity. These homes A number of people perceived risks in areas where there were few also tended to have bigger gardens, which were better equipped for other people, or people they didn't trust. In parks and on cycle paths the children. and walking routes, respondents said they felt anxious for their safety and the safety of their children because these facilities were little used, …. we’ve got a massive trampoline that they’re out on every overgrown or poorly designed. These concerns were shared by parents night, you know, we’ve got a big garden that they play in in both types of communities. that, you know, they use their bikes. So I would say the children are very active, even on days when we stay at home (6: Mother) …there’s a cycle path which runs sort of from about eight miles up that direction … but as if a girl would go there on her own… Too scary! In addition, they often had access to well-maintained facilities such (26: Mother) as parks and local amenities near their homes which enabled them to be active as a family. Respondents also asked for investment in their local built environment to repair and expand existing facilities and ensure public spaces Yeah, but we’re lucky I guess for exercise ‘cause the park’s were safe and accessible for family activities. Better cycle routes and at the back of the house, so we can just walk in there, safer local parks were frequently requested as easy ways to support good fresh air, great environment, but I think if it wasn’t people's potential interest. there, if it was more difficult to get to it I think we’d be struggling …we like going out on our bikes and there doesn’t seem to (35: Father) be an awful lot of cycle paths just here… Yeah some safer places to go on a bike Overall, they were less reliant on partner support to facilitate daily (17: Mother) activities. They were also likely to have access to their own personal transport which offered greater freedom of choice in the type of activities that were offered to children. Some participants identified the need for facilities for older children and teenagers because of perceptions that they contributed to local parks being unsafe and inaccessible for young families. These I’m out at work two days a week, and the rest of the week comments were particularly prominent among respondents living in we tend to go to baby groups in the mornings, we go to deprived areas. The presence of local, safe cycle paths was reported the library and we go swimming, we do sign language and to be a strong motivator for families to engage in physical activity music and also allowed free travel in their communities. (12: Mother) …if the cycle ways were safer for us to use as a family then we’d be able to get around the city, and up to school and back and into town, and, on our bikes wouldn’t we? 3.2.1 | Safety and accessibility (49: Mother) Many respondents talked about their safety in outdoor spaces, in Access to organized activities and facilities locally was also re- addition to the physical risks in vandalized or dirty public parks. ported to be variable. Some parents commented that there were Respondents who lived in deprived areas were unhappy with the few clubs for older children in their local area and those that were condition of their local parks. They said the facilities were damaged available were often oversubscribed, further limiting opportunities. and the ground was littered with needles, scrap metal, broken glass or fouled by dogs which created safety concerns, sometimes so No, there’s nothing for them to do, no, nothing at all. Well, I badly, that the parks were unusable. think there’s a football pitch all the way up there somewhere, but there’s a lot of gypsies up there, actually, so I don’t know, I took my little boy up there on the bike and I couldn’t to be honest…I don’t think there’s any clubs round here at leave him on it, if he fell off he’d land in glass, it’s dreadful all, nothing like that, which I think they [children] need over there [local park] (41: Mother) (14: Mother) the school, they have like Fit Club and all this, but it’s We don’t go to the parks round here… Because of heroin full. I always ask them when they have space for him, and addicts… you can find needles they always say they will make sure (21: Father) (13: Mother) | KHANOM et Al. 7 Access to safe walking routes was also a concern for parents Other respondents, whose routine provided less opportunity for from both types of community. They were hesitant about walking being active, perceived activity as an additional thing to arrange, often their children to school, even though this daily routine provided a involving inconvenience or difficulty and they reduced their expecta- ready-made opportunity for physical activity. They said the walk was tions accordingly. too long, taking too much time and beyond their children's ability; traffic was too fast, and it was dangerous to cross the road with a No I don’t mind, I could walk but… you know, I don’t think pram: my daughter [three years old] can walk for 20 minutes, you know, it’s too much for her … even the school run for me is taking your life in your (1: Mother) hands, you know, because I don’t get on a pavement until I’m almost at school and it’s a single lane, wooded lane Parents’ attitudes towards physical activity also appeared to be that I’m walking around with a buggy and two other chil- strongly influenced by the quality of the environment. Some respon- dren to look after and it, that walk freaks me out a bit I dents associated beaches and countryside with an active lifestyle and consciously chose to live in these areas so they could follow an ac- must admit. So I tend to try and avoid that (6: Mother) tive way of life. The opportunity to move to such areas was primarily evident among families with higher income, suggesting inequities in choice associated with socio-economic status: 3.3 | Beliefs and attitudes I think that is one of the big factors why we moved here Parents appeared to understand the importance of physical activity, as well ‘cause we appreciate healthy lifestyle, we wanted for their children and also for their family. Although some mentioned to be by the sea, we wanted the parks it in a health context, activity was more often discussed as a time for (35: Mother). being with other people. Some parents said they enjoyed cycling as a family. While being active benefited everyone's health, doing something together appeared to be just as important for strengthening 3.4 | Physical activity facilitators the family unit. Parents asked for information to encourage physical activity, with …it’s a bonding time with you and your family and it’s messages applicable to a family which explained why physical activity keeping healthy together, you’re supporting each other’ was valuable, how to do it and where to access local opportunities. (19: Mother) Supportive and relevant messages, ‘helping’ not ‘telling’, were more likely to encourage people in place of a didactic approach which risked Community activities were seen as a positive way for adults and alienating those who found the advice hard to follow through. children of all ages to be together. By contrast, inactivity was associated with personal and community problems. You should do this, you should do that, you have to do this’. It’s great in theory, but unless you can provide ac- I think they need to give something for the older children to tually a way and a means of doing that practically, on do. And I know we bang on about youth clubs and things a day-to-day basis, I think that makes it worse, because like that, but they’re sitting there just making a menace and you’re telling them what they should be doing. But if they then they graffiti the new park things and you think, well haven’t got the ability to then do it, you’re in danger of it’s sad because this is for the younger children, not for you making them feel quite bad about themselves, and then (7: Mother) they end up with a guilt complex. It’s helping people to achieve it rather than telling them Attitudes to physical activity were affected by how much it (12: Mother) was considered a normal aspect of life. Individuals who had always been active perceived it as part of their everyday habits, rou- Respondents said it was important for people to trust, and also tinely walking or cycling and then adding other activities to that respect, the source of the information given. They wanted to know schedule. that professionals delivering messages about active living were speaking from personal experience, for the advice to have credibil- I used to do triathlon…as a young child, it would be bal- ity. Information needed to be easy to understand and convey sig- let on a Monday, swimming on a Tuesday… we do lots of nificance, for people to have confidence and be likely to respond. walking as well [as a family], but we don’t think of that as Respondents also suggested that the format and mode of message exercise do we? delivery should take into account socio-cultural behaviour and (25: Mother) preference. 8 | KHANOM et Al. …[For Asian families you need to] go to the home like the and achievable in individuals’ lives. Few physical activity-based in- way the midwife comes to the home, talks to women, at terventions have targeted both mothers and fathers of young chil- that time people may accept it, I think so. Otherwise our dren,15,49 or have focused on facilitators and barriers to parent and Asian people don’t bother with other things [and disre- child physical activity in the community.50 Engaging users to iden- gard healthy living advice] tify, design and deliver interventions is recommended to remedy (2: Mother) current unhealthy lifestyles and lack of engagement with health messages.51,52 Both parents needed to be engaged and included in discussions and information sharing around child and family physical activity. We identified barriers to family-based physical activity which align with the levels described in Bronfenbrenner's socio-ecological model.31,40 We also found that some issues cross the ecological lev- Men have just as much role nowadays with bringing up els: work patterns and income (exosystem) affect individual isolation children as women do and yeah, I suppose they need and well-being (microsystem); and the quality of built environments to put the information across to both parents, not just and neighbourhood facilities (mesosystem) was associated with so- mother and baby sessions, you know, so they need to tar- cio-economic characteristics (macrosystem).41,53,54 While higher get men…if they like watching the football… income and better quality environment enabled more physical ac(21: Mother) tivity, perceptions and attitudes were common between families in deprived and also affluent neighbourhoods. These findings are con- Respondents distrusted advertising and were wary that the media sistent with previous studies which report pressures at the exosys- misrepresented facts about physical activity. Within their localities, tem and mesosystem level of work and family life encountered by they favoured using community and social networks and encouraging parents when trying to maintain physical activity.(6,36-45,53) In par- word of mouth communication, to strengthen local connections along- ticular, we found the dynamic interplay between ecological levels side promoting community-based physical activities. Parents from reduced opportunities for physical activity for those parents living both types of neighbourhood expressed a need to connect and inte- in deprived neighbourhood. This included the cost of activities36,37 grate with their neighbours and the wider community. They suggested which limited access to transport and lack of time to accommodate community-based activities as a way to achieve this. Some ideas con- physical activity36-38 because of irregular work patterns. Irregular cerned child-focused neighbourhood events which did not appear to and variable work patterns have been shaped by the expansion of involve parents in activity. Other respondents suggested ways for a de-regulated labour market resulting in a societal change across communities to unite in physical activity by bringing parents together. the macrosystem which has affected lower socio-economic groups’ Ideas included neighbourhood charity fundraising physical activities; disproportionately.55 Indeed, parents in less affluent areas perceived community days out, bringing families together to be active; walk-to- physical activity as a luxury,54,56 and therefore, it was not a regu- school schemes to incorporate physical activity into daily routines and lar occurrence. In contrast, parents living in affluent areas reported also reduce traffic volume and pollution; activities attached to community parenting classes and childcare provision; and community gardening areas to provide family physical activity and encourage healthy eating (see also Table 3): TA B L E 4 Respondent suggestions to encourage child and family physical activity Information sharing …you’re also generating community spirit as well if people are interacting. I think that’s the best way (28: Father) 4 | D I S CU S S I O N This study provides insights into factors influencing child and familybased physical activity and includes recommendations from parents on ways to improve opportunities for family-based physical activity in the community. Their suggestions have been summarized in Table 4. We found that parents from deprived neighbourhoods are more likely to be underactive because of a complex web of community, economic, social and personal factors which block motivation and opportunity for physical activity. Respondents said both parents need to be involved in designing interventions to support greater physical activity and healthy behaviours if they are to be relevant Targeted mailings about local activities issued before school holidays Location-specific advertising of activities, focusing on community relevance Awareness raising by health professionals through pre- to post-natal networks Link with formal and informal parent and toddler networks Extending existing services Physical activity sessions at community parenting classes Route cards for local cycle paths and walks Childcare at adult activity sessions Improve lighting and cleanliness of cycle routes and walking paths More activity clubs in deprived areas Make use of school and community facilities after school hours Community activities Charity fundraising activities: cycling/walking/jogging Active family days out Walk-to-school schemes Community garden areas Youth clubs and activities for teenagers | KHANOM et Al. 9 working mostly regular hours during the week and were therefore physical activity as a means of community engagement and social able to maintain some form of regular physical activity outside the interaction to improve community cohesion. Thus, they advocated home. opportunities to engage in purposeful physical activity that accrued Obesity and other risks to adult health associated with variable benefits above and beyond the individual. Research shows that com- work patterns, as well as the disruptive effect on the mesosystems munity engagement can encourage physical activity and increase such as family routines, have been documented.57-60 Our findings perceived social cohesion.69-71 Social interaction is also a motivator reinforce evidence that shift work can limit involvement in regular for family physical activity68,72,73 and may increase participation in extra-curricular activities and general socialization in the community community physical activity.72 Our findings identified that physical for families with young children in particular when both parents were activity may also foster social interaction and this message may pro- working opposite shifts. We found one parent cannot always facil- vide the purposeful motivator for individuals who feel disengaged itate physical activity without partner or family support, which re- and isolated. duced child activity.56,61 We now need to understand how the wider Our study highlighted problems at all levels of the socio-ecolog- socio-economic context of parents’ variable employment patterns ical model (ie microsystem, mesosystem and exosystem) preventing impacts on child health and physical activity at the microsystem level parents from deprived neighbourhoods from undertaking physical and devise targeted interventions at one or more socio-ecological activity with their children. In common with people generally, they levels to facilitate improved interactions between microsystem, me- preferred to visit quality green spaces, the sea or leisure facilities, sosystem and exosystem factors. despite needing to travel a distance.74-76 Compared to those in af- Parents were not always aware of physical activities for families fluent neighbourhoods, facilities local to them were inadequate, in their local area (ie mesosystem). Interventions targeted at the exo- pushing them further afield in search of safe, accessible facilities. system level could direct health professionals to provide information However, they physically struggled to leave their homes when the on available local opportunities for physical activity and the health other parent was working, often lacked transport and were unable benefits of being active for parents with infants and toddlers. Indeed, to meet the costs. Motivation and choice were consequently dimin- parents may be more inclined to enable family physical activity if ished. Frequency of outdoor activity reduces with distance required they were aware of the importance for early motor development and to travel to suitable locations, while access to personal transport future child health at the individual microsystem level.62 However, usually increases physical activity in a choice of locations that offer Bronfenbrenner's ecological theory 42,43 would suggest that changes varied experience.77 in the mesosystem or exosystem are unlikely to be successful in iso- People with access to green spaces often exhibit better lation. Nutbeam63 states that providing information alone is unlikely health-related outcomes.78 Subsidized access to travel and ven- to change behaviour. Acceptance of public health messages is deter- ues that facilitate physical activity and more places for organized mined by the way in which individuals interpret and internalize such activities could help reduce these challenges at the mesosystem messages. This can be mediated by microsystem factors such as indi- level. Improvements to neighbourhood facilities such as parks, vidual autonomy and the ability to utilize this message, governed by paths and cycle ways could also address the reported negative contextual factors such as perception of lifestyle, level of education, perceptions.79-81 Physical activity generally increases in areas disposable income, the physical environment and available support with more sports and recreational facilities, and attractive parks at the mesosystem and exosystem level. 28,64 Health-orientated mes- and cafes. 82-84 Free outdoor recreation that is safe and attractive sages delivered at different ecological levels need to be simple, clear makes it visible within a community, positively influencing social and consistent to be effective65; explain the importance of physical and cultural attitudes towards physical activity. 83 Such a change activity, convey the type of physical activity people should do, and at the exosystemic level could bring about macro-level changes ways they can be physically active.66 Awareness raising messages which normalize physical activity and improve community cohe- can also fail to reach the target audience due to timing of interven- sion, which was a priority for parents in this study. Public spaces tions, and lack of publicity and poor practitioner support.67 Parents near to bus stations and shopping areas could encourage both par- in our study suggested ‘help not tell’ messages covering ‘why’, ‘how’ ent and child activity. Well-designed neighbourhoods also enable and ‘where’ information about physical activity. They suggested tai- more physical activity.75 loring information for fathers and minority ethnic groups and using community and social networks for dissemination. Initiatives at the exosystem and macrosystem level40 require political commitment and resources to make societal changes impact- Participants in our study who were physically active outside ing on health inequality.85,86 In the short term, interventions that can the home often mentioned enjoyment and general well-being for promote physical activity in communities include improvements in the whole family as a motivation. People who perceive a purpose in active transport, housing location, urban design and neighbourhood physical activity are more likely to take part and enjoy it at the indi- safety. 26,41,87,88 Most successful multi-component interventions can vidual microsystem level. 68 Respondents who advocated community be seen to echo Bronfenbrenner's socio-ecological theory where activities (charity bike rides, walking to school schemes) at the meso- they are delivered alongside and supported by social marketing pro- system level wanted to know their neighbours. This was particularly grammes that have raised awareness about the positive benefits of evident among respondents in deprived neighbourhoods who saw making healthy behaviour change.89 10 | 4.1 | Strengths and limitations KHANOM et Al. AU T H O R S ’ C O N T R I B U T I O N S RAL and SB designed the ‘Growing Up in Wales’ birth cohort study. The size of this study sample, which also included mothers and AK, RAH and KM were involved in the recruitment of participants fathers, is a strength of this study. Respondents came from di- to this birth cohort study. AK conceived the qualitative research verse socio-economic and cultural groups and provided a rich concept and study design and sampled participants from the birth and widespread of views. Where both parents were present, we cohort study for interview. AK developed the interview schedule were able to obtain varying perspectives on the topic. Parents with advice from SB and RAH. AK conducted all the interviews. either confirmed or contradicted a point or added detail to each AK, RL and EM analysed and interpreted the qualitative interview other's responses. However, we acknowledge that the presence data and drew up a draft document of themes. FR offered guid- of the partner could have negatively influenced some responses ance on qualitative methodology. AK drafted the manuscript with where respondents felt unable to speak freely. There was a pos- support from BAE, and all authors read and approved the final sibility of participant bias as mothers had already agreed to par- manuscript. ticipate in a birth cohort study so may have been more motivated towards healthy behaviours compared to the general population. DATA AVA I L A B I L I T Y S TAT E M E N T S However, views appeared generally consistent within socio-eco- The data that support the findings of this study are available from nomic groups, suggesting the responses concerned issues shared the corresponding author upon reasonable request. by those populations. ORCID Ashrafunnesa Khanom https://orcid.org/0000-0002-5735-6601 5 | CO N C LU S I O N Bridie Angela Evans Parents from deprived neighbourhoods experience a range of com- REFERENCES munity, social, economic and personal barriers which interact to limit 1. World Health Organisation. 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