Caregiver experiences, attitudes and perceptions about feeding toddlers and preschool children in Switzerland: a qualitative study

Methodological approach, research paradigm and theoretical framework

The ontological stance of this research is a constructivist perspective. It assumes an interactive relationship between the researcher, and the participant and aims to reconstruct participants’ accounts towards a consensus [18]. It is, therefore, compatible with qualitative research methods. The Food Choice Process Model [19, 20] was used as a theoretical framework in this study and is consistent with the research paradigm.

Study population and sampling

To be consistent with the epistemological underpinnings of this study, participants were purposively sampled to vary in age, gender and income backgrounds, and to provide information pertinent to the study [21]. A national database of landline numbers was used to recruit participants by telephone (Link Qualitative AG, Lausanne). Participants were eligible to take part in the study if they were the principle caregiver of a healthy toddler or preschooler aged between 1–5y and were responsible for providing all foods and drinks on most days of the week. In addition participants were screened to ensure that they did not work in a field related to childhood health/nutrition and had not previously participated in research on the topic. Potential participants were taken through a screening questionnaire to gather demographic data and to check their eligibility for participation.

Ethics, consent and permissions

Ethical approval for this research was obtained from the Faculty of Health and Medicine Research Ethics Committee of the University of Lancaster, U.K. (November, 2013). However, no formal ethical approval was required for such a study in Switzerland.

Interviews

An in-depth interview schedule of leading questions was developed based upon the Child Feeding Questionnaire [22] starting with questions used by Sherry et al. [11] in qualitative research with caregivers of preschool children. It was adapted to include opening questions about typical meal, snack and beverage pattern in a 24 h period. It also included a section focusing specifically on beverages. The interview guide was developed in French and pilot-tested with three caregivers to ensure the questions were clear and comprehensible. Interviews were conducted in the homes of participants, during March and April, 2014, lasting approximately 60 min. Seventeen interviews were conducted. However, 2 male participants were spontaneously joined by their wives, resulting in a participant sample size of n = 19. Interviews were conducted until saturation was reached. Saturation was determined by the repetition of themes, with no new themes appearing, offering no new coding opportunities. All interviews were digitally recorded and field notes were taken during the interviews.

Questions

Interviews commenced by asking participants to describe meals and in-between-meal eating and drinking occasions on a typical day of the week, including examples of the types of foods and beverages consumed. Questions followed about their experience of feeding at mealtimes and the goals of mealtimes; their experience of foods and beverages consumed in-between meals; how they make choices about the types of foods and beverages to feed their children; how they decide upon the quantity of food and beverages to feed their children and how they decide which beverages to provide, and how to portion them.

Analysis

All recorded interview material was transcribed verbatim, into English, by a professional transcriber. Thematic Analysis (TA) was used for data analysis. TA can be applied to a wide range of theoretical frameworks [23] and was applied in an inductive manner (“bottom-up”) guided by the six-phase process described by Braun and Clarke [23]. The coding was led by one author (EJ). Two authors (AG, AB) oversaw the process and reviewed the quality of the analytical phase. The six-phase approach consists of familiarisation with the data, coding the data, searching for themes, reviewing themes, defining and naming themes, and refinement of the analytical narrative. Coding followed an inductive approach with the identified themes being strongly linked to the data themselves. Coding units were cross-checked against the theoretical framework and similarities and differences were noted. Saturation was reached with no adaptation of the coding system required for later interviews. Central organising concepts were identified in order to construct key, overarching themes [21]. AtlasTi was used to electronically review, code, and catalogue the transcripts as analysis moved through the six phases.

Participants

After providing informed consent, 19 participants, aged 20–46y (mean age = 36y) took part in the study. All resided in the Canton Vaud, in the Lausanne region of Switzerland. Caregivers either worked part-time (n =11) or full-time (n = 4) or did not work (n = 2) (Table 1).

Rules and routines

Half of the participants encouraged the child to finish their entire meal. Some caregivers rewarded children with desserts if they finished their meal. However, the remaining participants allowed children to self-regulate their food intake at meals. Rules and routines about eating in between meals followed culturally acceptable routines in Switzerland; namely the feeding of children at 10 am and 4 pm. However, when asked about snacking, the practice was largely refuted, or, associated with a particular subset of foods such as salty and sweet snack-foods.

Food and beverage portion sizes

Managing

Rules and routines may influence feeding goals and behaviours

Rules and routines were positive in their intention and reflected both European and national-level anti-obesity and healthy-eating messages [5, 6] such as encouraging regular meals, increasing fruit and vegetable consumption, limiting, or completely avoiding SSB consumption, and providing water as a beverage of choice. The setting of limits in relation to foods perceived to be unhealthy is consistent with findings from qualitative studies with caregivers of young children in the U.S., U.K. and Australia [24–26]. Nonetheless, despite displaying knowledge about good dietary behaviours, studies indicate that dietary guidelines are poorly adhered to by both adults and children in Switzerland [27, 28]. Therefore the description of rules and routines may indicate feeding goals but may not reflect actual consumption behaviours. Further research is required to understand if actual food and beverage intake patterns reflect caregiver feeding goals.

As described in the theoretical framework, rules and routines may originate through caregivers attempts to standardise the recurrent situation of meals and snacks using a classification system that can be cultural, social, or personal [29, 30]. For example, eating in-between meals was perceived negatively, but the cultural practice of feeding children in Switzerland at 10 am and 4 pm was not perceived as snacking per se. Participants described snacking as involving certain salty snacks or sweet foods. This indicates that the conceptualisation of snacking by the researcher and the participant may be different, or have cultural specificities. This requires further understanding since it may impact how HCP advice is delivered along with impacting the collection of dietary intake data.

Portioning foods vs. beverages: the tacit and the explicit

Caregivers were unsure how to provide appropriate food-portion sizes and had difficulty to explain how they estimated the appropriate food-portion size. Participants exclaimed they did not need further support/education about portion sizes. Tacit knowledge is commonly defined as that which cannot be explicated, whereas explicit knowledge follows rules and steps, and can be written down and described [31]. The use of tacit knowledge in estimating preschool children’s food portion sizes has not been previously reported in Switzerland, but has been described in studies from the U.S. Johnson et al. [32] reported two key themes about how mothers portioned meals for their children in the home-setting; (1) portion sizes differ for children who are “good” eaters and “picky” eaters; (2) mothers know the “right amounts” to serve their child. The present study supports the findings in (1) and (2). This study also agrees with previous qualitative work from the UK amongst caregivers who reported that they fed their children the amount they thought the children could eat, based on their perception of the child’s individual appetite [10, 25].

A novel finding of this study is that contrary to the description of preparing food portions, participants were able to precisely describe beverage portions, even as far as providing volume estimates for the amounts of water, tea, juice and milk consumed. This attention to the volume of liquids consumed in the early years of the child’s life—along with the fact that drinking vessels contain a scale for the estimation of volume—may be a means in which the caregiver becomes more attuned to the quantities of liquids served and consumed. This may suggest that major life events, such as having a child, may impact expertise in relation to the portioning of liquids. This is also consistent with the theoretical framework whereby Sobal et al. [30] describe the impact of major life events on the feeding behaviours. This hypothesis would require further research and may have impact for the collection of dietary intake data.

Explicit knowledge about health effects of beverages

Despite milk being consumed morning and evening by all participants, and the health benefits of milk being widely described, caregivers perceived water to be the healthiest of all beverages. This would be in agreement with public health nutrition advice in Switzerland to offer water in preference to sweetened beverages, especially when feeding young children [6, 14]. Several participants’ subjectively integrated advice of HCPs in providing fruit juice—specifically orange juice—when their child experienced constipation. A search of the literature failed to find any studies which reference this notion, nor paediatric guideline, to support this recommendation [33]. If such a recommendation has no scientific basis, then there is scope to educate HCPs. Sweetened beverages were limited, by the caregiver, if they contained “fizz” (i.e. carbonated beverages) but fruit juice was not perceived as a sweetened beverage that should be limited. Rather, the “fizziness” itself was perceived as being unhealthy. This has been reported in a previous study in Switzerland in older children and adults [34] and indicates opportunity to educate caregivers about the nature and composition of sugar sweetened beverages and their moderation in the diets of toddlers and preschoolers.

Challenges in the provision of foods and beverages

Participants described three sub- themes which impacted their ability to manage the provision of foods and beverages of their choosing, in the manner of their choosing; 1) Time to cook 2) Homemade is better and 3) Budget.

Most participants expressed issues in finding time for planning and preparing meals. This is comparable to findings from the US in which families of employed mothers have less frequent family meals, more frequent fast food for family meals, and spend less time on food preparation [35]. There may be scope to include “available time” as a factor in the development of healthy eating guidelines and in advice from HCPs.

Several participants preferred homemade food and rejected commercially produced meals. Negative attitudes towards commercially prepared meals have been reported in previous European studies [36, 37]. Homemade food has been thought of as an authentic creation of the family, and a way for the family to create meaning and identity [38]. Therefore, regardless of the nutritional quality of a meal, homemade food may be linked to creation of family identity and meaning and be the preferred option for feeding young children. Caregivers may benefit from advice on how to prepare quick, healthy, age-appropriate, family meals.

With the exception of 3 participants, all caregivers described shopping according to a budget often buying lower quality items, for example meats, due to the cost constraints. Cost can be a barrier to a high-quality, nutrient-dense and varied diet [39]. As described by one low-income participant, households may experience periods whereby the acquisition of nutrient-dense foods may not be possible for the entire family. The extent to which periods of food insecurity may occur amongst low-income families in Switzerland is not known. Recent studies in Switzerland describe how low-cost food items are comparable in nutrient composition to more costly branded items [40] but available product choice of low-cost food items is sometimes limited. The feasibility of access to a healthy diet, for low-income families in Switzerland, remains under-researched.

A qualitative study, such as this, can help to improve understanding in a way that randomized controlled trials cannot. As usual, in qualitative research, the purposively selected participants are not expected to be representative of all caregivers in Switzerland. However, this study provides an explorative overview of the caregiver experiences when feeding very young children, and makes a novel contribution to Swiss and European qualitative research in nutrition. Future research is required to confirm the study findings herein.