Saintuya Dashdondog PHD THESIS

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Examining the food environment and nutrition practices in

Title preschool settings in Ireland
Author(s) Dashdondog, Saintuya
Publication 2021-09-07
Date
Publisher NUI Galway
Item record http://hdl.handle.net/10379/16907
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Examining the food environment and nutrition
practices in preschool settings in Ireland
Saintuya Dashdondog
MD, Master of Public Health
Thesis submitted for the Degree of Doctor of Philosophy
Supervisor: Dr Colette Kelly
Discipline of Health Promotion
School of Health Sciences
College of Medicine, Nursing and Health Sciences
National University of Ireland Galway
January 2021
Table of Contents
Author’s Declaration .................................................................................................................. vi
Funding ....................................................................................................................................... vii
Acknowledgements ................................................................................................................... viii
Abstract ........................................................................................................................................ x
List of Tables .............................................................................................................................. xii
List of Figures ........................................................................................................................... xiii
List of Abbreviations ................................................................................................................ xiv
List of Appendices ..................................................................................................................... xv
CHAPTER 1: INTRODUCTION .............................................................................................. 1
1.1 Background ............................................................................................................................. 1
1.2 Purpose and significance of the study .................................................................................... 3
1.3 General aim and research objectives of the thesis .................................................................. 5
1.4 Thesis Outline ......................................................................................................................... 6
CHAPTER 2: LITERATURE REVIEW .................................................................................. 9
2.1 Chapter overview .................................................................................................................... 9
2.2 Introduction ............................................................................................................................ 9
2.2.1 Importance of adequate nutrition and prevention of malnutrition in early childhood......... 9
2.2.3 Common nutritional issues of preschool-aged children .............................................. 13
2.2.4 Current nutritional status of Irish preschool children .................................................. 17
2.3 Determinants of eating patterns in (preschool-aged) children.............................................. 20
2.3.1 The Preschool Child .................................................................................................... 24
2.3.2 The Caregiver .............................................................................................................. 27
2.3.3 The Environment ......................................................................................................... 36
2.4 Barriers, challenges and interventions to promote nutrition best practices .......................... 47
2.4.1 Provider characteristics ............................................................................................... 49
2.4.2 Childcare providers’ training needs ............................................................................ 51
2.4.3 Challenges to food provision....................................................................................... 54
2.4.4 Parents’ involvement ................................................................................................... 56
2.4.5 Healthy eating policies ................................................................................................ 58
2.5 Nutrition-related research in early care setting in Ireland .................................................... 59
2.6 Regulatory background and recent developments in the early years sector in Ireland ........ 63
2.7 A settings approach to health promotion: theoretical foundation for the study ................... 76
2.7.1 Settings approach to health promotion in preschool setting ....................................... 79
2.8 Conclusion ............................................................................................................................ 81
CHAPTER 3: RESEARCH METHODOLOGY .................................................................... 83
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3.1 Chapter overview .................................................................................................................. 83
3.2 Research approach ................................................................................................................ 83
3.2.1 Rationale for a mixed methods design ........................................................................ 83
3.2.2 Qualitative research approach ..................................................................................... 84
3.2.3 Quantitative methods................................................................................................... 85
3.3 Epistemological approach .................................................................................................... 86
3.4 Mixed method research design and methodological issues for present study ...................... 88
3.5 Methods and tools................................................................................................................. 93
3.5.1 Observation method .................................................................................................... 93
3.5.2 Semi-structured interviews .......................................................................................... 96
3.5.3 Document reviews ....................................................................................................... 98
3.5.4 Preschool Manager Questionnaire .............................................................................. 99
3.6 Participatory approach in research ....................................................................................... 99
3.6.1 Participatory approach in research with children ...................................................... 100
3.6.2 Research methods involving very young children .................................................... 102
3.6.3 Creative and visual research methods with children ................................................. 104
3.6.4 Development of creative research tools for use with preschool children ................. 106
3.7 Data analysis ....................................................................................................................... 109
3.7.1 Document analysis .................................................................................................... 110
3.7.2 Thematic analysis of interview data .......................................................................... 111
3.7.3 Analysis of observation data ..................................................................................... 113
3.7.4 Analysis of preschool manager questionnaires ......................................................... 113
3.7.5 Children’s workshops: merging four types of data and thematic analysis ................ 114
3.8 Integration of mixed data in the present study ................................................................... 114
3.9 Strategies to ensure methodological rigour ........................................................................ 117
3.10 Sampling and recruitment................................................................................................. 121
3.10.1 Sampling approach and procedures......................................................................... 121
3.10.2 Sample size .............................................................................................................. 122
3.10.3 Preschool recruitment .............................................................................................. 125
3.11 Ethical considerations ....................................................................................................... 126
4.1 Chapter overview ................................................................................................................ 128
4.2 Background and study’s research objectives ...................................................................... 129
4.3 Data collection procedures ................................................................................................. 132
4.3.1 Preschool setting assessment tools ............................................................................ 132
4.3.2 Review of preschool documents related to nutrition ................................................. 133
4.3.3 Observation of preschool food environment and practices ....................................... 134
4.3.4 Qualitative interviews with preschool staff ............................................................... 136
4.3.5 Preschool Manager Questionnaire ............................................................................ 136
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4.4 Results ................................................................................................................................ 137
4.4.1 Theme 1: Preschool teachers’ nurturing role ............................................................ 141
4.4.2 Theme 2: Positive mealtime practices ....................................................................... 142
4.4.3 Theme 3: An unsupportive nutrition environment .................................................... 146
4.4.4 Theme 4: A need for further nutrition training ......................................................... 148
4.4.5 Theme 5: Limited scope to change nutrition practices ............................................. 150
4.4.6 Theme 6: Families’ poor food habits influence preschool efforts ............................ 151
4.4.7 Barriers and facilitators for promoting healthy eating in preschool setting .............. 151
4.5 Discussion........................................................................................................................... 153
4.6 Strengths and limitations .................................................................................................... 166
4.7 Conclusion .......................................................................................................................... 167
CHAPTER 5: STUDY 2 - USING CREATIVE RESEARCH ............................................ 169
METHOD TO EXPLORE PRESCHOOL CHILDREN’S FOOD ..................................... 169
5.1 Chapter Overview ............................................................................................................... 169
5.3 Children’s workshops ......................................................................................................... 171
5.3.1 Game-based activity with food toys .......................................................................... 174
5.3.2 Discussion of vignettes with children ....................................................................... 176
5.3.3 Drawings of food by children.................................................................................... 176
5.4 Results ................................................................................................................................ 179
5.4.1 Theme 1: Sensory appeal of food .............................................................................. 179
5.4.2 Theme 2: Emotions associated with food ................................................................. 181
5.4.3 Theme 3: Family and social influences ..................................................................... 182
5.4.4 Theme 4: Healthy food is “good for you!” ............................................................... 182
5.4.5 Theme 5: Internal and external cues to eat ................................................................ 184
5.4.6 Theme 6: Variety and exposure to food .................................................................... 184
5.4.7 Use of creative methods with preschool children ..................................................... 187
5.5 Discussion........................................................................................................................... 187
5.6 Strengths, limitations and challenges ................................................................................. 196
5.7 Conclusion .......................................................................................................................... 198
CHAPTER 6: STUDY 3 – PARENTS’ PERCEPTIONS ON PRESCHOOLERS’
NUTRITION AND PARENT-STAFF COMMUNICATION ............................................. 199
6.1 Chapter Overview ............................................................................................................... 199
6.3 Data collection procedures ................................................................................................. 202
6.3.1 Qualitative interviews with parents ........................................................................... 202
6.3.2 Qualitative interviews with preschool staff ............................................................... 203
6.3.3 Observation ............................................................................................................... 203
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6.3.4 Document review ...................................................................................................... 204
6.4 Results ................................................................................................................................ 204
6.4.1 Theme 1: Feeding challenges: food environments inside and outside the home ...... 205
6.4.2 Theme 2: Parental desire for knowledge including feeding strategies ...................... 210
6.4.3 Theme 3: Lack of clear communication between parents and preschool staff ......... 213
6.4.4 Observation of parent-staff communication .............................................................. 217
6.5 Discussion........................................................................................................................... 219
6.6 Study’s limitations and strengths........................................................................................ 228
6.7 Conclusion .......................................................................................................................... 229
CHAPTER 7: GENERAL DISCUSSION AND CONCLUSIONS ..................................... 230
7.1 Chapter overview ................................................................................................................ 230
7.2 Addressing the study’s aims ............................................................................................... 230
7.3 Summary of studies and key findings................................................................................. 231
7.4 Study findings and the Settings approach........................................................................... 234
7.5 Implications for policy and practice ................................................................................... 244
7.6 Study’s strengths and challenges ........................................................................................ 246
7.7 Recommendations for future research ................................................................................ 246
7.8 Conclusions ........................................................................................................................ 247
Reference List .......................................................................................................................... 249
Appendices ............................................................................................................................... 316
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Author’s Declaration
I declare/certify that, except where acknowledged, all parts of this thesis were
undertaken by myself. The information contained in this thesis has not been
used to obtain a degree in this, or another University.
______________________
Saintuya Dashdondog
vi
Funding
PhD research was funded by the Hardiman Research Scholarship awarded to
Saintuya Dashdondog in 2015 through the Structured PhD in Health Promotion
Research, National University of Ireland, Galway
vii
Acknowledgements
I am very grateful to the School of Health Sciences and the Discipline of Health
Promotion at the National University of Ireland, Galway for providing me with
the opportunity to undertake this doctoral thesis and for the Hardiman Research
Scholarship for providing funding to make this research possible.
I would like to express my profound gratitude to my supervisor Dr Colette

Kelly for her expertise, guidance, patience and continuous encouragement
during this PhD journey as well as for her insightful comments and invaluable
feedback on numerous drafts during the writing of this doctorate thesis. Dr
Kelly always motivated me to work harder and the knowledge and experience I
have gained from her expertise over the past several years helped in my
development as a research scholar. I admire her deeply and I consider myself to
be very fortunate to work with her.
I am sincerely grateful to my GRC members, Prof Saoirse Nic Gabhainn, Dr

Michal Molco and Dr Sheila Garrity, for their guidance through the course of
my PhD. Their expert feedback and constructive criticism during the committee
meetings significantly contributed to my research. I would like also to thank the
Health Promotion Discipline staff for their kindness and support. Especially, I
would like to thank my fellow PhD students for their friendship, support and
sharing PhD worries and successes which made this PhD journey so much
easier.
I wish to express my sincere thanks to preschool managers who gave me

permission to conduct my research in their settings and to all staff, children and
their families who agreed to participate in the studies. The time and effort they
granted are greatly appreciated and I hope I have accurately and respectfully
represented their views.
Thank you to my family and friends, I could not have accomplished this
without your love and support. Father, Mother, Sara, Onon, my pastor Helen
Freeburn, and Paul, thank you for your unending love, understanding, patience,
viii
and encouragement throughout the entire process of completion of this thesis.
I would like to say special thanks to my dear friends who helped me so many
times by minding my children when I needed time to attend trainings, lectures
and conferences. Aiga, Angela, Bernie and Gerry, Brid and Maire, Hiyam,
Huyen and Hung, your kindness and generosity are invaluable.
And to my children, Eva and Daniel, for your unfailing and unconditional love
that gave me inspiration and strength to go through this journey to the finish
line, thank you.
ix
Abstract
Background: As early years care settings contribute significantly to children’s

nutrient intake and acquisition of long-term dietary habits, a health-promoting
preschool setting can be an important intermediate for encouraging and supporting
healthy eating habits. With recent increase in investment in the early years care
sector by the Irish Government, it is timely to review the food environment and
related processes within preschools to ensure best practice in promoting healthy
food and diets to preschoolers. Understanding nutrition-related processes in the
preschool setting and the determinants and context in which they occur is an
important prerequisite for targeted and effective changes to support healthy eating
in the preschool setting.
Aims: Using a settings approach this thesis aims to explore the factors influencing
the food environment and nutrition practices in Irish preschool settings by: 1)
examining preschool nutrition policies, mealtime practices, and the food
environment; 2) identifying staff perceptions and behaviours related to food and
nutrition in preschools; 3) exploring very young children’s perceptions about
healthy eating and their food preferences; 4) examining parent views and
perceptions related to food and nutrition for preschoolers; and 5) exploring
barriers and opportunities for promoting healthy nutrition in preschools.
Methods: Purposive sampling was used and 10 preschools with different services
and approaches to food provision were recruited. All stakeholders involved in
promoting and feeding preschool children were involved, including children
(n=64), staff (n=10) and parents (n=10). A mixed method research design was
used including observation, document review, questionnaires and semi-structured
interviews with caregivers and parents. Creative and visual methods were used
with children. Inductive thematic analysis was conducted using NVivoPro11.
Findings: Study 1 revealed that preschool staff demonstrated their motivation to

educate children and provide them with nutritious and balanced food and several
positive nutrition practices were observed. However, the findings also revealed a
lack of effective healthy eating policies leading to an unsupportive nutrition
environment and a lack of staff training on nutrition. Importantly, staff could not
x
see any scope to change nutrition practices. Finally, perception of families’ poor
food habits and parental attitudes created challenges in the implementation of
healthy eating practices at preschools. Study 2 demonstrated that creative research
methods with very young children provide meaningful data. Children described
the sensory appeal of food and expressed their emotions in response to foods.
Family and social influences clearly influenced their food preferences and their
knowledge of healthy food was evident. Children as young as age 3 years
recognise internal cues of hunger and satiety and can self-regulate food intake,
however this ability is determined by environmental factors. The findings also
show that children prefer a variety of food. Study 3 illustrates the challenges faced
by parents when feeding their children, related to child preferences and external
food environmental factors. While parents expressed the need for nutrition-related
information from preschools, inadequate communication between parents and staff
hindered collaboration between these two settings to support children’s healthy
eating. Therefore, the study’s findings indicate a need to improve communication
between staff and parents, active invitation of parents to participate in preschools,
creating opportunities for parental nutrition training, and greater parental
involvement in preschool nutrition practices.
Conclusion: This research provides a holistic picture of the complex processes

occurring within the socio-ecological system related to preschool nutrition and
provides a comprehensive account of nutrition-related determinants and a
conceptual map illustrating the relationships between them. The study identified
barriers and facilitators to promoting healthy eating in the Irish preschool setting
at four levels (individual, organisational, community and policy) and outlined key
action areas (the need for changing the organisational culture in preschools,
conducting nutrition and capacity-building training for all stakeholders and
improving staff-parent communication and parental involvement) which can be
used to direct the development of future interventions to improve nutrition in
young children via contextually relevant changes within available resources.
xi
List of Tables
Chapter 3: Research Methodology
Table 3.1. Summary of the research studies
Chapter 4: Study 1 - Examining Preschool Food Practices
Table 4.1. Document review procedures
Table 4.2. Observations of preschool mealtimes
Table 4.3. Characteristics of participating preschools
Table 4.4. Characteristics of preschool staff participants
Table 4.5. Summary of preschool mealtime practices
Table 4.6. Barriers and facilitators for promoting healthy eating in

preschool setting at various levels
Chapter 5: Study 2 - Using Creative Research Method to Explore Preschool

Children’s Food Preferences and Perceptions
Table 5.1. Topic guide for workshops with very young children
Table 5.2. Food toys provided to children
Table 5.3. Vignettes
Table 5.4. Children’s most common food preferences
Table 5.5. Examples of quotes from children’s discussion and drawings

to support the themes
Chapter 6: Study 3 – Parents’ Perceptions on Preschoolers’ Nutrition and

Parent-Staff Communication
Table 6.1. Study 3 participants characteristics
Table 6.2. Observation of nutrition-related communication between

parents and preschool staff
xii
List of Figures
Chapter 2. Literature Review
Figure 2.1. Ecological framework of food choice and eating behaviour

(Story et al., 2008)
Figure 2.2. The 6 transformational goals for achieving the 5 national

outcomes within the Better Outcomes Brighter Futures: National Policy
Framework for Children and Young People in Ireland 2014-2020
(Department of Children and Youth Affairs, 2014)
Figure 3.1. The Procedural Diagram of convergent parallel dominant

mixed method design for present study
Chapter 5: Study 2 - Using Creative Research Method to Explore

Preschool Children’s Food Preferences and Perceptions
Figure 5.1. Game-based activity – ‘making’ a favourite dinner
Figure 5.2. Examples of drawings of food by children
Chapter 7: General Discussion and Conclusions
Figure 7.1. Setting-based Conceptual Map of reciprocal relationships

related to preschool children’s food and nutrition
Figure 7.2. Applying the Ottawa Charter’s 5 Action Areas for Health
Promotion to nutrition-related issues in the preschool setting
xiii
List of Abbreviations
BMI Body Mass Index
CFP Controlling Feeding Practices
ELC Early Learning and Care
EBRB Energy Balance Related Behaviours
EFSA European Food Safety Authority
HEP Healthy Eating Policy
HSE Health Service Executive
RDA Recommended Daily Allowance
SAC School-Age Childcare
SES Socio-Economic Status
SFP Supportive Feeding Practices
WHO World Health Organization
xiv
List of Appendices
Appendix 1 Ethics Committee Approval Letter and Statement of Compliance
Appendix 2 Preschool Recruitment Letter
Appendix 3 Participant Information Sheet
Appendix 4 Letter Inviting Parents for Their Child to Participate in the Project
Appendix 5 Parent Information Sheet on Children’s Workshop
Appendix 6 Parent Consent Form for a Child
Appendix 7 Child Information Sheet and Child Consent Form (3-5 Years)
Appendix 8 Parent Interview Invitation Letter
Appendix 9 Parent Consent Form
Appendix 10 Questionnaire on Participant’s Socio-demographic Data
Appendix 11 Preschool Observation Tool
Appendix 12 Document Review Guide
Appendix 13 Preschool Manager Questionnaire
Appendix 14 Topic Guide for Semi-structured Interviews with Preschool Staff
Appendix 15 Topic Guide for Semi-Structured Interviews with Parents
Appendix 16 Protocol for Managing Distress
Appendix 17 Characteristics of Study Participants
Appendix 18 Summary of Observations, Document Review and Manager

Questionnaire Data
Appendix 19 Characteristics of parent participants
Appendix 20 Observation Tool for Staff-Parent Nutrition-Related Interactions
xv
Chapter 1: Introduction
CHAPTER 1: INTRODUCTION
1.1 Background
Poor eating habits, including inadequate intake of vegetables, fruit, and

milk, and eating too many high-calorie snacks play a role in childhood
malnutrition, particularly childhood obesity (Gupta et al., 2012; Kuźbicka &
Rachoń, 2013; Labyak et al., 2019). Childhood obesity is one of the most serious
public health concerns associated with increased risk for adverse health
consequences and obesity in adulthood (Sahoo et al., 2015). As such, health in the
earliest years lays the groundwork for lifelong well-being and, therefore, focusing
health promotion efforts on children in the first 5 years of life can provide
important strategies for reducing the population-level burden of disease (Mistry et
al., 2012). Globally, in 2019 the number of overweight or obese children under the
age of five was estimated to be over 38 million (WHO, 2020). The projected
increase in the number of overweight children under five is estimated to be 70
million by 2050 if the current trend remains unchanged (WHO, 2012). In response
to growing obesity levels active efforts have been made to develop dietary
guidelines by international and national bodies (US DHHS and USDA, 2015;
HSE, 2016; EFSA, 2017), however low adherence to recommendations on child
nutrition has been observed (Banfield et al., 2016; O'Connor et al., 2020; Rosi et
al., 2020).
In Ireland, the rates of obesity increased 10-fold among Irish boys between
1975 and 2016 and 9-fold among Irish girls (NCD Risk Factor Collaboration,
2017). The levels are much higher in disadvantaged groups with rates 6-7%
higher in schools in the most deprived areas compared to the national average
(Bell-Serrat et al., 2017). Levels of excess weight in Irish schoolchildren are
stabilising but remain high with at least one in five children overweight or obese
(Bell-Serrat et al., 2017). There is less data available on overweight and obesity
rates among preschool-aged children, however, the latest data reported in 2011 by
the Growing Up in Ireland study indicated 25% of Irish three-year-olds as being
overweight and/or obese (Growing Up in Ireland, 2012). According to the
national survey of preschool-aged children (Irish Universities Nutrition Alliance,
1
2012), neither healthy dietary patterns nor nutrient requirements were met by the
majority of children.
At a time when other Western countries are experiencing reducing birth
rates, Ireland’s population of children and young people is growing. In 2011,
Ireland had the highest birth rate in the EU (16.3%) and the highest proportion of
young people aged between 0-14 (21.6%) (European Commission, 2013). The
estimated total population of children and young people (aged 0-24 years) in
Ireland is 1.55 million, or 34% of the total population (Department of Children
and Youth Affairs, 2019a). This represents an increase of 6% since 2002, with the
greatest growth in the 0-4 age group which saw an increase of 32% over the same
period (Department of Children and Youth Affairs, 2019a). This is combined with
a continuous decline in death rate for under-5s in Ireland (United Nations,
Department of Economic and Social Affairs, Population Division, 2019).
Therefore, providing important health and development opportunities and support
to this group of population becomes a priority. The Government of Ireland
therefore turned its efforts toward supporting the early years sector by developing
important policy documents including the most recent National Early Years
Strategy 2019-2028 “First 5 – The Whole of Government Strategy for Babies,
Young Children and Their Families” (Department of Children and Youth Affairs,
2019a) along with a significant expansion of early learning and care (ELC) sector
in recent years. About 96% of preschool children have accessed the National
Childcare Scheme, a two-year free universal preschool programme, with
approximately 181,123 children availing of these services in 2017-2018, a 23%
increase on the previous year (Department of Children and Youth Affairs, 2018),
while in 2018/2019, the total number of children enrolled in ELC was
approximately 206,301 nationally (Pobal, 2019). These changes reduced the
number of 4 year olds in primary school significantly because of the increase in
the number of children attending early care settings (Department of Children and
Youth Affairs, 2019b).
However, public health concern has been expressed regarding the
nutritional quality and amount of food served, and the food environment in the
early care setting in Ireland (Johnston Molloy et al., 2013). In addition, high
prevalence of overweight and obesity in children of preschool age (Growing Up in
2
Ireland, 2012) indicates a missed opportunity for healthy eating interventions in

the early care setting.
1.2 Purpose and significance of the study
Preschool years are sensitive period when sensory, motor and experiential
learning occurs across multiple and varied contexts (Meriem et al., 2020; Ventura
& Worobey, 2013). Furthermore, as significant cognitive developmental changes
occur during the preschool years, young children start to learn key concepts and
begin to relate to their environment (Baskale et al., 2009). Studies support the
notion that children's acceptance of foods is shaped by their experience with those
foods and their preferences are associated with social contexts and the
physiological effects of consumption (Savage et al., 2007). Research shows that
eating habits established in early life are likely to remain stable (Glavin et al.,
2014; Pesch et al., 2020; Sahoo et al., 2015), therefore establishing healthy eating
habits early on is essential. With this in mind, recent research evidence in the area
of preschool nutrition suggests that the potential of a preschool as a health
promoting setting for influencing children’s food choice at an early age should be
more widely recognised and utilised (Chambers, 2017; Mikkelsen et al., 2014).
Systematic reviews of healthy eating and obesity prevention interventions,
randomised controlled trials on nutrition education in childcare settings, and
preschool nutrition interventions demonstrated their impact on dietary behaviour
of preschool-aged children, such as increased fruit and vegetable consumption and
low-fat dairy intake, increase in nutrition-related knowledge and self-regulation of
food intake, and decrease in body mass index (Mikkelsen et al., 2014; Nguyen,
2019; Williams et al., 2014). In the context of public health promotion
opportunities, an additional pathway for children to develop healthy eating
behaviours, especially when the home eating environment is suboptimal, should
be provided (Jones-Taylor, 2015; Liu et al., 2016; van de Kolk et al., 2020). The
childcare setting is regarded as promising for the implementation of interventions
to promote child healthy energy balance-related behaviours (van de Kolk et al.,
2020).
Thus, as preschools contribute significantly to children’s nutritional intake
and acquisition of dietary habits, a setting-based health promotion approach can
3
be an important intermediate to promoting healthy eating. Therefore, in order to

develop effective programmes and policies to promote healthy eating in preschool
children, understanding current food and nutrition-related processes occurring in
the preschool setting is essential. However, there is scant recent literature
examining the food environment and nutrition practices in the Irish preschool
setting, particularly there is no qualitative research on the nutrition environment in
preschool settings in Ireland. A few studies exploring preschool nutrition in
Ireland conducted a decade ago were focused on quantitative assessment
(Jennings et al., 2011; Johnston Molloy et al., 2013; Molloy et al 2011). However,
qualitative approach can employ unique tools and techniques that may help to
elucidate and explain the underlying contexts and processes within the phenomena
of interest. Therefore, given the dearth of studies in the field of nutrition and
healthy eating in preschools, this study aims to obtain an in-depth understanding
of the food environment in preschools and examine influences and determinants
of preschool nutrition and healthy eating behaviours. In particular, the study
sought to assess preschool food environment and food practices and explore staff,
children and their parents’ knowledge, beliefs, perceptions and behaviours
towards food and healthy nutrition. Indeed, this is the first study of its kind in
Ireland to conduct in-depth qualitative interviews with preschool staff and parents
of children attending Irish preschool settings on nutrition-related issues. It is also
the first study in Ireland to explore data from preschool staff and parents on issues
related to nutrition and healthy eating.
The present study has also explored preschool children’s perceptions about
food and healthy eating and factors that influence their food preferences. To
procure meaningful data from very young children the study used a participatory
approach and creative methods and reported their methodological, ethical and
pragmatic challenges and the findings.
Furthermore, the present study investigates the preschool food
environment and nutrition practices from a health promotion perspective using
settings approach, which is grounded in socio-ecological model of health
promotion and informed by systems approach. Taking a settings approach to
health promotion means examining and addressing the contexts within which
people live, work, and play and making these the object of inquiry and
intervention as well as the needs and capacities of people to be found in different
4
settings (Poland et al., 2009). In addition, since young children’s dietary intake
and eating behaviours are influenced within various settings, or micro-systems,
looking at the preschool setting and home settings as ‘open systems’ in a socio-
ecological model of health highlights the importance of the multi-setting
approach, as it targets the preschool, home, and community settings. A systems
approach can provide additional information by incorporating interactions and
communication within and between the settings (Naaldenberg et al., 2009).
Systems approach helps to examine how different micro-settings interact with
each other in regard to nutrition practices in the preschool setting.
Developing a comprehensive understanding of the nutrition-related
determinants and processes in the preschool setting is a critical first step in
developing targeted evidence-based healthy eating initiatives in this setting. The
insights gained from this research can be instrumental for designing tailored
solutions and planning practical aspects of future health promotion interventions
to support healthy eating behaviour in the preschool setting.
1.3 General aim and research objectives of the thesis
This thesis addresses the following research aim:

To comprehensively explore the food environment and nutrition practices in
preschool settings in Ireland.
To address the aim of this study the following research objectives were identified:
• To examine preschool nutrition policies, mealtime practices, and the food

environment.
• To identify staff perceptions and behaviours related to food and nutrition in

preschools.
• To contribute to the research literature in very young children’s perceptions

about healthy eating and their food preferences by giving voice to preschool
children.
• To examine parent views and perceptions related to food and nutrition for
preschoolers.
• To examine preschool staff and parent communication for promoting healthy

eating in preschool children.
• To explore barriers and opportunities for promoting healthy nutrition in

preschools.
5
Guided by above research objectives this study attempts to answer the

following questions:
• What are current nutrition policies and practices in preschools?
• How do preschool staff experience and manage food and mealtimes in their
services?
• How do staff perceive their role in promoting children’s healthy diets?
• What are preschool children’s food preferences and their perceptions about
food and healthy eating?
• Can creative research methods procure meaningful data from very young
children?
• What are parent’s views and perceptions related to food and nutrition for their
preschool aged children?
• What is the nutrition-related relationship and is there communication between

preschool staff and parents for promoting healthy eating for preschool
children?
• What are the needs, challenges, barriers and opportunities for promoting
healthy nutrition in preschools?
The present study sought to understand the meaning of participants’

experiences within the everyday reality of preschool food-related routines and
processes as well as explore perceptions of multiple participants related to food
and nutrition to answer the research questions posed in this study using multiple
qualitatively-driven mixed methods. Therefore, whilst using multiple data sources
in this study sought to provide a breadth of data, together they enabled an in-depth
understanding of the food environment and nutrition-related practices in
preschools.
1.4 Thesis Outline
The document consists of seven chapters briefly outlined below.

Chapter 1 presents an introduction to the research project, briefly describes
the context of Ireland’s early care sector, and outlines the overall aim and
objectives of this PhD study. Chapter 2 presents the literature review highlighting
the importance of a socio-ecological approach to understanding the influences on
6
preschool children’s nutrition. The chapter summarises the extant literature on the
nutritional issues of preschool-aged children and preschool nutrition practices.
The determinants of eating patterns in preschool-aged children are reviewed in the
context of early childhood within the theoretical constructs of the family and
environmental influences. Further, the regulatory background and recent
developments in the early years sector in Ireland are described. The chapter
concludes by reviewing the settings-based health promotion approach which is the
theoretical foundation of the study.
Chapter 3 describes the methodological approaches used in three studies
comprising this PhD research, including research design, rationale for choice of
methods and tools, data analysis, participant recruitment, and ethical
considerations.
Chapter 4 (Study 1) explores the food environment and nutrition practices
in ten preschools that participated in the study using a mixed-method approach.
The study investigates how preschool staff experience and manage food and
mealtimes in their services and how staff perceive their role in promoting
children’s healthy diets. The chapter begins with a detailed description of the data
collection procedures using multiple methods. Then findings from thematic
analysis of combined data are presented followed by a discussion of findings in
relation to previous research.
Chapter 5 (Study 2) provides a detailed description of the children’s
workshops using creative and visual methods to explore 64 preschool children’s
perceptions of food and healthy eating. These developmentally appropriate and
child-friendly methods aided in giving voice to very young children and helped
them to express their understanding about food and healthy eating and their food
preferences and share about their food experiences. Findings are then discussed in
the context of previous research, and methodological, ethical and pragmatic
challenges are considered.
Chapter 6 (Study 3) explores parents’ perceptions about nutrition and
healthy eating and how they relate to their food parenting practices. The study
explores various factors that influence parents’ efforts to shape their children’s
diets. The study investigates the current nutrition-related relationship between
preschool staff and parents. The chapter concludes with a discussion of the
findings in relation to previous research.
7
Finally, Chapter 7 wraps up the study’s findings and presents the study
conclusions. Summary of key findings and details how the objectives were
achieved are presented. Further, discussion of the findings in relation to previous
research and settings-based health promotion approach are presented. Findings
from each study are integrated and summarised in a Conceptual Map in the
context of socio-ecological and settings-based health promotion approaches which
underpinned this research. Conceptualizing the findings and mapping the
determinants that influence preschool nutrition and exploring potential pathways
for behavioural and organisational change highlight possible interventions that are
more likely to initiate change in the current nutritional status quo in Irish
preschools. In addition, strengths and limitations of the studies are discussed and
recommendations are made for practice and future research. The chapter
concludes with sharing the final thoughts on the study.
8
Chapter 2: Literature Review
CHAPTER 2: LITERATURE REVIEW
2.1 Chapter overview
This chapter reviews the current literature with the aim of providing an
insight into the topics relevant to the study’s objectives and research questions and
provide a rationale for the study. The chapter begins with highlighting the
importance of adequate nutrition and prevention of malnutrition in young
children. Then the review outlines the nutritional requirements and health related
issues specific to children of preschool age both worldwide and in Ireland. Next,
the evidence of the determinants and influences on food choice and eating
behaviours in preschool-aged children is reviewed followed by examination of the
existing practices and interventions in early years care settings related to food and
nutrition. Individual determinants and factors related to the immediate and wider
environment will be discussed. Furthermore, the regulatory background and
recent developments in the early years sector in Ireland are described. Finally, a
settings approach to health promotion which was used as a theoretical foundation
for the study is presented. The chapter concludes with a summary of the review.
2.2 Introduction
2.2.1 Importance of adequate nutrition and prevention of

malnutrition in early childhood
A World Health Organization review concluded that the early years of life are
the most effective for interventions to reverse the effects of child malnutrition
(Victora et al., 2010). Malnutrition refers to deficiencies, excesses, or imbalances
in a person’s intake of energy and/or nutrients. The term malnutrition addresses 3
broad groups of conditions:
• micronutrient-related malnutrition, which includes micronutrient deficiencies
(a lack of important vitamins and minerals) or micronutrient excess;
• over-nutrition, which includes overweight, obesity and diet-related non-
communicable diseases (such as heart disease, stroke, diabetes and some
cancers);
9
• under-nutrition, which includes wasting (low weight-for-height), stunting (low

height-for-age) and underweight (low weight-for-age).
While malnutrition can affect people at any age, young children tend to be
among those most at risk and can suffer the most damaging and far-reaching
effects. Early years are a period of vulnerability for several reasons. Growth rates
are highest in early childhood and nutritional demands are higher, given body
size, than at any other stage of a child’s life (Phillips & Shonkoff, 2000).
Inadequate dietary intake of macro- and micronutrients affects the body’s ability
to maintain and generate tissue and even moderate nutrient deficiency can lead to
serious adverse effects on various functions of the body (UNICEF, 2019). Early
childhood under-nutrition manifests in a series of symptoms including slow linear
growth, reduced physical and mental competencies due to delayed motor,
cognitive and behavioural development, immunodeficiency, morbidity and
mortality (Kim et al., 2019).
Young children are also vulnerable due to immature immune systems.
Inadequate dietary intake of macro- and micronutrients, reduces the body’s ability
to fight infection; in turn, infection impedes the metabolic processes contributing
to child growth. Infections, particularly diarrheal diseases, are recognised to cause
poor appetite in children and metabolic and clinical disturbances that lead to poor
nutrient utilisation (UNICEF, 2010). This “synergism” of multiple deficiencies
exacerbates many problems associated with malnutrition (Schrimshaw &
SanGiovanni, 1997). Micronutrient deficiencies can also occur with over-nutrition
when excess calorie consumption occurs but intake of vitamins and minerals are
lacking due to reliance on energy-dense, nutrient-poor foods, such as high fat,
high sugar snacks (UNICEF, 2010). Children with excess body fat are at risk of
developing a metabolic syndrome and, as a consequence, later in life they have an
increased likelihood of being overweight and developing associated chronic
diseases such as cardiovascular disease, diabetes and cancer, and to suffer from
mental health issues (Haddad, 2013; Kim et al., 2019; World Bank, 2013).
Of particular importance is the fact that nutrient deficiencies can affect
child brain development at a structural and biochemical level such as the brain’s
macrostructure (e.g. development of brain areas such as the hippocampus),
microstructure (e.g. myelination of neurons), and level and operation of
10
neurotransmitters (e.g. dopamine levels or receptor numbers), all of which can

have an impact on cognitive development (Bryan et al., 2004; Wachs, 2000). This
critical brain development occurring in young children has long-term effects on
cognitive functioning and the impact of malnutrition in early life is largely
irreversible (Benton, 2008; Dauncey, 2015; De Souza et al., 2011; Oi & Haas,
2019). Although by 2 years of age the brain is about 80% and by 6 years is 95%
of its final size, the gray matter continues to thicken, a process that peaks around
puberty, meaning that brain development continues from early childhood
through adolescence, therefore poor nutrition can have a negative impact on
brain development (Benton, 2008). Evidence shows that school performance of
undernourished children is below potential (Ahmad et al., 2018; Dominguez et al.,
2018; Sunny et al., 2018). Therefore, inadequate dietary intake and micronutrient
deficits during this period have long-term effects on health, educational
attainment and productivity in adulthood (Smith & Haddad, 2015). Poor health
and lower work capacity in adulthood are associated with poor economic
outcomes and directly associated with reduced quality of life, reduced
productivity, and, to society the cost of providing health services (Hoddinott et al.,
2013).
An additional reason for the vulnerability of young children is that they are
less able to make their needs known and are more vulnerable to the effects of poor
food parenting. Poor food parenting (feeding styles and feeding practices) is
recognised to negatively impact the nutritional status of young children (Haszard
et al., 2019; Shloim et al., 2015). Poor food parenting includes uninvolved,
indulgent and authoritarian styles of food parenting that use coercive, emotional,
instrumental, permissive, and other adverse feeding practices. These practices will
be described in more detail later in this chapter.
2.2.2 Nutritional requirements of preschool-aged children
Good nutrition is defined as the intake of an adequate and well-balanced

diet to support the body’s dietary and energy needs and is a cornerstone for good
health throughout life (WHO, 2018). An adequate diet means a sufficient quantity
and quality of non-contaminated and nutritionally healthy food to meet the normal
daily requirements for a person’s size, age and general health and well-being. A
11
well-balanced diet contains adequate proportions of food groups such as

carbohydrates, fats, proteins, and fluids along with the recommended daily
allowances of all essential minerals, vitamins, and health-promoting substances
(Leitzmann, 2009). Nutrition is vital not only in human growth and development
but also in the prevention and treatment of disease. Nutrition is also fundamental
to the maintenance of good mental health and functionality.
Nutrition for children is based on similar principles as nutrition for adults.
Children, however, need different amounts of specific nutrients at different ages
and, among them, preschool-aged children have unique dietary needs. Preschool
children’s diets require special care and planning for several reasons: the need for
energy and protein is high relative to the child’s size; the stomach capacity is
small so children are not able to eat large quantities of food; young children
usually have very high physical activity levels; and, although appetite can
fluctuate throughout day, the range of foods a child is inclined to eat can be
limited (Birch & Fisher, 1995). Therefore, it is imperative that the nutritional
needs of children are met, and there is a correct balance between the types and
amount of foods eaten.
Preschool years are a unique period when independence increases and
gross and fine motor skills are mastered. They are also increasingly developing
cognitive and social skills such as autonomy and reasoning along with increasing
communication skills. These developmental advancements allow preschoolers to
feed themselves and verbally express their food preferences and needs. Preschool
children also develop the ability to observe and explore the world around them
and practice cause-and-effect relationships which are imperative to learning and
acquiring new food habits. Taste preferences continue to develop through the
preschool years, therefore, the types and amounts of food, including the amounts
of sugar and sodium in food, can shape future taste preferences of a child, having
lasting effects on the child’s eating habits (Birch, 1998; Rollins et al., 2010;
Skinner et al., 2002). Preschool-aged children make many diet-related transitions
during this time such as incorporating various new foods into their diet and
acquiring dietary habits. During this time children may become resistant to trying
new foods or choosing to eat only a handful of favorite foods (Cashdan 1994;
Grimm et al., 2014). Therefore, a nutrient-dense high-quality diet for young
children helps to provide sufficient energy and nutrients to promote healthy
12
growth and development, to achieve and maintain a healthy weight, and to

promote immediate and long-term health (Story et al., 2006). To ensure that
young children eat healthful and adequate food, a careful consideration of portion
sizes and providing a balanced diet that contains all necessary macro- and
micronutrients is essential.
Macro- and micronutrient requirements of preschool-aged children

In addition to feeding young children the appropriate amount of food, the
proper amounts of each of the food groups should be included in their diets as
preschool-aged children have high nutritional requirements relative to their size.
According to the Scientific Opinion on Nutrient Requirements and Dietary Intakes
of Infants and Young Children in the European Union by the EFSA, preschoolers
need between 459 and 583 kcals a day depending on their age and gender (EFSA,
2013). Girls aged 3 to <5 years require 79kcal/kg body weight per day
(kcal/kg/day) and girls 5 to <6 years require 78kcal/kg/day while boys aged 3 to
<6 years require 78kcal/kg/day (EFSA, 2013). Children cannot eat large quantities
at one sitting so priority needs to be given to energy dense and non-bulky
nutritious foods such as red meat, fish, poultry and dairy products. To achieve
nutritional requirements preschool-aged children should be given foods from each
of the four main food groups every day: 1) Fruit and vegetables; 2) Cereals,
breads and potatoes; 3) Milk and other dairy products; 4) Meat, fish, eggs, beans,
legumes. An average serving size for a 3-5 year old child should be approximately
one-quarter to one-third the size of an adult portion. Water and milk are the only
suitable drinks for children, and preschoolers should be consuming approximately
one pint (17- 20oz) of cow’s milk daily (low-fat milk is suitable over two years of
age) (AHA, 2018). Fortified milk products are one of several means to increase
essential micronutrient intakes in young children with inadequate or at risk of
inadequate status of these nutrients (EFSA, 2013).
2.2.3 Common nutritional issues of preschool-aged children
In the past several decades a term ‘double burden of malnutrition’, defined

as the co-existence of under- and over-nutrition, has been attributed to changes in
eating behaviours and food choices. Adding the third type of malnutrition,
micronutrient deficiencies, brings in a term ‘triple burden of malnutrition’. For
13
higher income countries, there has been an orderly transition from problems of
under-nutrition such as underweight, stunting and micronutrient deficiency
diseases to problems of over-nutrition, such as overweight, obesity and diet-
related non-communicable chronic diseases such as diabetes, high blood pressure
and coronary heart disease (Haddad et al., 2013). This shift resulted from an
increase in amount of food consumed and a reliance on processed food (Monteiro,
2009; Monteiro et al., 2007, 2011; Pingali et al., 2019).
Under-nutrition
Poverty, food insecurity, lack of education, heavy burden of infectious
diseases, and poor hygiene and sanitation are factors responsible for child under-
nutrition in both developed and developing countries. According to the most
recent UNICEF report, under-nutrition was estimated to be linked to 45% of all
deaths among children under 5 years old, which accounts for 3.1 million children
worldwide (UNICEF, 2019). These deaths mostly occur in low- and middle-
income countries. Although the global prevalence of stunting among children
under 5 years old has decreased by 10.1% from 165.8 million in 2012, still, 149
million or 21.9% were stunted and 49.5 million or 7.3% wasted in 2018 with
Africa and Asia bearing the greatest share of all forms of malnutrition (UNICEF,
2019). These figures indicate that overall progress of improving nutritional status
of young children is insufficient.
In developed countries, such as countries in Europe, America and
Australia, nutrient imbalances observed among preschool-aged children include
low intakes of poly- and mono-unsaturated fatty acids, dietary fibre- and calcium-
rich foods, and high intakes of sugar and sodium (Eldridge et al., 2019;
Huysentruyt et al., 2016; National Institute for Public Health and the
Environment, 2008; Public Health England, 2014; Sette, 2011; Stephen et al.,
2017; Zhou et al., 2012). The available data from recent nationally representative
surveys in several European countries on the intakes of nutrients in young
children from age 12 months through early childhood show that young children’s
diets do not meet the national dietary guidelines, including in the UK (Public
Health England, 2014), the Netherlands (National Institute for Public Health and
the Environment, 2008), Belgium (Huysentruyt, 2016), and Italy (Sette et al.,
2011). The most recent report from the US National Health and Nutrition
14
Examination Survey related to young children’s dietary intake revealed that

although dietary quality improved slightly over the years, total energy intake
increased, as did added sugars and excess juice consumption (CDC, 2018).
Consumption of vegetables is still low and, while fruit intake has slightly
increased compared to previous years, approximately 60% of children are
consuming below the recommended intake for fruits, and 93% of children
consuming below the recommended intake for vegetables (Stage et al., 2019; Kim
et al., 2014).
Micronutrient deficiency
Micronutrient deficiency, also termed as ‘hidden hunger’ affects millions
of preschool-aged children worldwide. This term refers to a chronic lack of
vitamins and minerals, which is not immediately apparent and which can exist for
a long time before clinical signs of malnutrition become obvious (Biesalski,
2013). The four most common micronutrient deficiencies include those of iron,
iodine, vitamin A, and zinc (UNICEF, 2019). About 12% of deaths among under-
5-years old children are attributed to the deficiency of these four micronutrients
(Ahmed et al., 2012). Micronutrient deficiencies can be equally found in both the
developed world as well as in the developing world, and their current rate of
growth in the developed world gives cause for concern. Growing evidence from
intake surveys in Western countries such as the USA, Canada, Germany, France,
Great Britain and many others indicates that a sufficient intake is not being
achieved in some micronutrients, according to recommendations using
recommended daily allowances (RDAs) as reference (Biesalski, 2013). For
example, biochemical evidence of a poor status of iron and vitamin D in young
children confirms the low intakes of these micronutrients in this age group in
Europe (Akkermans et al., 2016; Carroll et al., 2014; Cashman et al., 2016;
Eussen et al., 2015), the USA (Eldridge et al., 2019) and Australia (Zhou et al.,
2012). Iodine and essential fatty amino acids intakes are also sub-optimal and
need attention to ensure appropriate supply of these micronutrients in young
children (EFSA, 2013).
Over-nutrition and obesity

Poor nutrition is one of the leading causes of obesity in childhood
(Lobstein et al., 2015). As young children prefer foods with higher energy density
15
due to the positive physiological consequences that they provide in relation to

satiety and energy input (Birch, 1998), there is extensive evidence that diets of
preschool-aged children contain high levels of saturated fat and sugar and are low
in dietary fibre (Butte et al., 2010; Fox et al., 2010, Lobstein et al., 2015). This
aspect, combined with higher micronutrient requirements when compared to
preschool-aged children’s energy needs makes this age group vulnerable to the
development of obesity and micronutrient deficiency (Butte et al., 2010),
predisposing to a condition of ‘triple burden of malnutrition’ highlighted above.
Overweight and obese children are likely to stay obese into adulthood (Nicklaus et
al., 2004; Mita et al., 2015). It has been suggested that there are certain critical
periods in childhood that can predict persistence of obesity. Preschool years are
one of these critical periods. Body mass index (BMI) increases in the first year of
life, decreases in toddler years and then increases again at around 6 years of age, a
period known as adiposity rebound. Longitudinal studies suggest that children
whose BMI increased before 5.5 years of age (a period known as ‘early adiposity
rebound’) are more likely to be obese later in life than other children (Rolland-
Cachera et al., 1984; Siervogel et al., 1991). Children who are overweight or
obese as preschoolers are 4 times as likely as normal-weight children to be
overweight or obese as adults (National Obesity Observatory, 2009).
In 2018, 40.1 million children aged 5 years and younger were affected by
childhood overweight worldwide (FAO, 2019). Compared to estimates in 2000,
there were 10 million more overweight children in 2016 (WHO, 2018).
Furthermore, the global prevalence of overweight among children under 5 years
old has increased from 5.5% in 2012 to 5.9% in 2018 (FAO, 2019). In Europe, the
prevalence of childhood overweight and obesity remains high. A study by Ahrens
and colleagues (2014) examined the prevalence of overweight and obesity of
18,501 children aged 2-10 years in eight European countries. The highest
prevalence of overweight and obesity was observed in Italy (42.4%), Cyprus
(23.4%) and Spain (21.2%), whereas the lowest prevalence was observed in
Belgium (9.4%) and Sweden (11.0%). Overall, 7% of the study sample was
classified as obese and 12.8% as overweight. These high rates of overweight and
obesity in European children, given the tracking of body weight from childhood to
adult age and its health consequences, represents a major public health concern
(Ahrens et al., 2014). More specifically to preschool age, The ToyBox Study
16
(Katsarou et al., 2018) reported the prevalence of overweight and obesity of

preschool-aged children in six European countries as 20.6% in Greece, 15.2% in
Bulgaria, 14.8% in Spain, 12.7% in Poland, 11.4% in Belgium and 10.0% in
Germany. These findings could be attributed to a large extent to the unhealthier
energy balance related behaviours reported in the Southern/Eastern European
ToyBox-study cohorts, with these populations having the lowest diet quality, the
lowest levels of physical activity and the highest levels of sedentary time (De
Craemer et al., 2015; Pinket et al., 2016).
The morbidity associated with childhood obesity, its economic
implications for the families and burden on health systems are significant (GBD
2015 Obesity Collaborators, 2017). Obese children are also at increased risk of
suffering from several psychological problems including low self-esteem and
depression (Dehghan et al., 2005). Obese children more likely to develop chronic
diseases such as diabetes, cardiovascular diseases and cancer in later years which
are associated with an increased risk of morbidity, disability and premature
mortality (Reilly & Kelly, 2011).
2.2.4 Current nutritional status of Irish preschool children
Over the last decades, it appears that Irish children’s diets are becoming
more nutritionally adequate and getting closer to meeting the national nutritional
recommendations. However, this improvement, in some respects, is a shift from
under-nutrition towards over-nutrition, with increased consumption of foods that
are higher in added sugars and fats and an overall increase in energy intakes. The
National Preschool Nutrition Survey (NPNS) 2010–2011 (IUNA, n.d.) was
carried out by the Irish Universities Nutrition Alliance to establish databases of
habitual food and drink consumption in representative samples of Irish children
aged 1–4. Weighed 4-day food records were used to collect food intake data from
parents of 500 preschool children. The NPNS was designed to be representative of
the population in Ireland with respect to age, gender, residential location and
socioeconomic status; however the survey sample was of higher socio-economic
status than the general population. Nevertheless, food and nutrient intakes and
body weight measurements were similar across the socio-economic status groups.
The NPNS showed the main sources of energy and macronutrients for Irish
17
preschool-aged children. While the proportion of total energy from milk/formula

decreased with age (from 29% at age 1 year old as the most important source of
energy) it remained an important contributor to energy (11%) at age 4 years.
Other important contributors to energy intake in 1-4 year olds were meat (10-
13%), breakfast cereals (8-9%), fruit and fruit juices (8-9%), yoghurts (4-7%),
bread (6-11%), and biscuits and cakes (6-8%). The proportion of energy from
bread, meat, and biscuits and cakes increased, and the proportion from yoghurt
decreased with increasing age. The contribution of confectionery to energy intake
increased from 1% in 1-year-olds to 4-5% in 3-4 year olds. For all ages, beverages
(excluding fruit juices and milk/formula) contributed 1-2% to energy intakes.
Walton and colleagues (2017) used the NPNS to estimate energy and nutrient
intakes across ages 1-4 and compliance with the most recent nutrient
recommendations and dietary reference values available from EFSA (EFSA,
2013). The researchers found that Irish preschool-aged children have generally
adequate intakes of carbohydrates 48–50% energy (E), protein (15–16%E), total
fat (32–34%E), dietary fibre (2.5 g MJ−1), α‐linolenic acid (0.45%E), and most
micronutrients which were in good compliance with dietary recommendations.
However, intakes of long chain polyunsaturated fatty acids (LC-PUFAs) (65–80
mg) were low and significant proportions of children had below the estimated
average requirement intakes of vitamin D and iron. Small proportions of children
with intakes exceeding the upper level for retinol, folic acid, zinc, copper and
iodine, were unlikely to give rise to adverse health effects. Mean intakes of free
sugars (12%E) and salt (3.1 g day−1) exceeded recommendations and increased
with age. The salt intakes also exceeded the Food Safety Authority of Ireland’s
daily salt intake targets of 2g for 1-3 year olds and 3g for 4 year olds. The mean
intake of saturated fat (15%E) decreased with age. By the age of 4 years, patterns
established for intakes of salt, saturated fat and free sugars were unfavourable and
similar to those observed in the diets of older children. The need for further
research to identify dietary strategies that improve the quality of the diet in young
children, particularly in relation to excess of saturated fat, free sugars and salt, as
well as inadequacy of iron, vitamin D and LC-PUFAs, is clear.
The findings from the NPNS showed that, although the majority (77%) of
2-4 year old children had a healthy weight, 23% of these children were defined as
overweight or obese, among which 27% of 2-year-olds, 32% of 3 year olds and
18
8% of 4 year olds were classified as overweight or obese. Such fluctuations reflect

the rapid changes in BMI that occur during growth and development of young
children and may reflect the ‘adiposity rebound’ theory which is a characteristic
of this age according to some researchers (Rolland-Cachera et al., 1984; Siervogel
et al., 1991) and indicate that by 4 years of age, most Irish children were within
the normal weight ranges. Similar to these findings, a much larger national
representative study, Growing Up in Ireland, showed that 24% of Irish 3-year old
children were either overweight or obese.
Growing Up in Ireland is a national longitudinal study which began in
2008/09 and initially involved 11,100 children in its Infant Cohort (9-month-olds).
The Infant Cohort followed the infants from age of 9 months (Wave 1) to 3 years
(Wave 2 in 2011), 5 years (Wave 3 in 2013) and 7-8 years old (Wave 4 in 2016).
The families were re-interviewed in 2011 in Wave 2 (n=8,000) and findings
showed that, although the majority of children had a healthy weight, by age of 3
years 19% were overweight and 5% were obese meaning that 24% or almost one
in four children had a BMI beyond the range that is considered healthy.
The findings from Wave 3 in 2013 (n=5,344) showed that by age 5 years
children’s overweight and obesity rates dropped slightly to 20% due to a drop
among those who were overweight (15%), however, obesity remained at 5%. Girls
were more likely to be overweight (17% compared to 13%) and obese (6%
compared to 5%) than boys. Children who were not overweight at age 3 years
were very likely to remain so at age 5 years (91%) while 39% of overweight 3
year olds were still overweight at age 5. There was considerable movement within
this group as many children had moved to the not-overweight category (50%) and
11% had become obese. The findings on children’s diet showed that an average 5
year old consumed just over 1,500 kcals a day and, boys consumed marginally
more calories than girls. There was a graduated relationship between energy
intake and household income. On average, children in lower income families had
significantly higher, or 23% more, energy intake per day than those children in the
highest income families.
The findings of the next and latest Wave 4 Infant Cohort study at
children’s age of 7-8 years (n=5,344), carried out in 2016, showed that although
the overweight rates had further decreased to 15%, the obesity rates remain the
19
same 5% as at age 3- and 5-years, showing that the overweight and obesity rates
still remain high among young children in Ireland.
Of particular interest is that children from less advantaged households are
shorter on average than those from professional and managerial households and
remain so at all ages. Their rapid weight gain is therefore disproportionate to their
growth in height, leading to higher BMI scores and a higher risk of overweight
and obesity long-term. This relationship was observed by both household class
and the highest education of the primary caregiver. Whereas 4% of 3 year olds
from professional/managerial households or whose parents had a higher level of
education were classified as obese, this figure was 9% among those whose parents
had never worked or had lower education levels. This pattern remained for all
study ages. Thus, inequalities in the risk of overweight and obesity associated
with socio-economic background begin early and are already established by the
age of 3 (Growing Up in Ireland, 2012).
These findings from the Growing Up in Ireland study show that, in
general, Irish preschool-aged children were reported to be in a good health and to
be developing positively between birth and 5 years of age. However, while some
overweight and obese children regain a healthy weight during these five years,
most remain at an unhealthy weight. There were relationships between socio-
economic factors (income, social class and mother’s level of education) and the
daily energy intake, the amount of structured and unstructured play, and amount
of children’s screen-time. These factors were also associated with overweight and
obesity. The study highlights the importance of social determinants of health as it
suggests that poor diets associated with low family income are also associated
with poor nutritional status leading to malnutrition and increased risk of
overweight and obesity in young children that may persist into later childhood.
2.3 Determinants of eating patterns in (preschool-aged) children
Food choices and eating patterns have a potential to impact on nutritional

status and health (Melaku et al., 2019; Scarborough et al., 2019). The range of
factors influencing the food choices and eating behaviours is diverse and dynamic.
According to the Food Choice Model (Falk et al., 1996; Furst et al., 1996,
Connors et al., 2001), biological, psychological, behavioural, economic,
20
sociocultural, and environmental influences and their interplay across various

contexts are all involved in developing and influencing food choices among
adults. Overall, people are assumed to construct food choices in a variety of ways
by actively considering food choice possibilities and exercising their personal
agency in perceiving, defining, conceptualising, managing, and enacting food
choices (Sobal et al., 2006). In other words, people create their own personal
systems for making food choices as they move through the life course (Sobal et
al., 2006; 2009). These personal systems are not stable and are malleable during a
person's lifetime and the foundation for healthy food habits can be created in early
childhood (Anzman-Frasca et al., 2018; Hursti, 1999). Young children shape their
unique and personal food choice and behaviours by interacting with the
environment (Laureati & Pagliarini, 2019).
Conceptual models and theories of food choice

Various other conceptual food choice models (e.g. Six C’s Ecological
Model by Harrison et al., 2011; Model of Community Nutrition Environments by
Glanz et al., 2005; Framework of determinants of physical activity and eating
behaviour by Wetter et al., 2009) aim to explain the differences in children’s food
choice and dietary behaviours and they incorporate multiple determinants into
different levels of influence on behaviour, such as intra- and interpersonal,
community, organisational and policy levels. The food choice models help to
conceptualise the complexity of contexts and influences that impact a child’s
individual eating patterns (Dufour et al., 2012; Glanz et al., 2005; Lytle, 2009;
Story et al., 2008; USDA & DHHS, 2010). For example, Story and colleagues
(2008) proposed an ecological framework illustrating four broad levels of
influence that interact, both directly and indirectly, to impact eating behaviours:
these include individual, social environment, physical environment, and macro-
level environments (Figure 2.1).
21
Figure 2.1. Ecological framework of food choice and eating behaviour

(Story et al., 2008)
These multiple influences on dietary behaviours are grouped into two major
levels:
• Individual-level factors include cognitions, behaviours, and biological and

demographic factors. These individual factors can impact food choices
through characteristics such as motivations, self-efficacy, outcome
expectations, and behavioural capability.
• Environmental contexts related to eating behaviours include:
− social environments - includes interactions with family, friends, peers, and
others in the community and may impact food choices through mechanisms
such as role modelling, social support, and social norms.
− physical environments - includes the multiple settings where people eat or
procure food such as the home, work sites, schools, restaurants, and
supermarkets. The physical settings within the community influence which
22
foods are available to eat and impact barriers and opportunities that facilitate
or hinder healthy eating.
− macro-level environments - these factors play a more distal and indirect role
but have a substantial and powerful effect on what people eat. Macro-level
factors operating within the larger society include food marketing, social
norms, food production and distribution systems, agriculture policies, and
economic price structures.
Brofenbrenner’s Ecological Systems Theory of Child Development
defines five complex ‘layers’ or environmental systems which form children’s
environment and directly or indirectly influence their development
(Brofenbrenner, 1979). The theory presents an ecological approach to children's
relationships within family, communities and the wider society and
interrelationships within and between the systems. Brofenbrenner theorised that as
children grow, their physical and cognitive abilities mature, which allows them to
participate more actively in their physical and social environment, which, in turn,
enhances their learning of the world surrounding them. Based on this theory, it
can be assumed that most preschool-aged children’s food and nutritional
knowledge is acquired through direct experiences with food in their homes within
their ‘micro-system’. As children grow in awareness of their environments the
interaction within those environments becomes more complex, for example the
interrelationship between the home and childcare environment, described as a
‘meso-system’ (Brofenbrenner, 1979). Most child development research considers
the concordance within the meso-system of home and childcare setting to be
beneficial for child development (Gerritsen et al., 2018). However, at times this
concordance is not always preferable if, for example, a high-quality childcare
service is providing positive experiences or quality food that is not available
within the home (Gerritsen et al., 2018). Gubbels and colleagues (2014)
emphasised the importance of, firstly, moving from research that is limited to
examining separate ‘micro-systems’, e.g. focusing on the influence of either
childcare or home influences, which, in reality, interact with each other in
influencing children’s eating behaviours, to more a comprehensive approach that
takes into account the ‘meso-systems’ created by interactions between the home
and early care setting. Secondly, Gubbels and colleagues (2014) advised to
consider another important moderating factor within this ‘meso-system’ - the
23
influence of the child itself - that has mostly been overlooked in past research.
Children should be seen as active agents, shaping and interpreting their
environment and their individual characteristics might influence how well they
can adapt to the environment. Brofenbrenner later has renamed the “ecological
systems theory of development” to “bio-ecological systems theory of
development” to emphasise that a child’s own biology is a primary environment
fueling his or her development (Bronfenbrenner & Morris, 2007). In line with this,
the bio-ecological approach highlights the importance of synergy between
individuals and their environment. Therefore, Gubbels and colleagues state that
more studies are required that explore the ‘meso-system’ to further elucidate the
effect of environments on child nutrition and eating behaviours (Gubbels et al.,
2014; 2018).
In relation to a young child and in view of Brofenbrenner’s bio-ecological
model and many food choice models available, the child, the caregiver and the
food environment are the key influences on children’s eating patterns. Research on
each of these topics, specific to pre-school children will be discussed in the
following three sections below.
2.3.1 The Preschool Child
Innate factors influencing child food preferences

While dietary quality and food patterns in the early years of life are
usually determined by parents and other primary caregivers and peers, the food
acceptance by a child is influenced not only by the parental feeding practices and
social influences, but also in part by the child’s genetic and biological
predispositions (Breen et al., 2006; Falciglia & Norton, 1994; Fildes et al., 2014),
the intrinsic temperamental traits and personality (Bergmeier et al., 2014; Holley
et al., 2020; Kaukonen et al., 2019; Rogers & Blissett, 2019), age and
developmental stage (Cashdan, 1994; Mennella et al., 2014; McFarlane & Pliner,
1997), and child’s health (Milano et al., 2019). For example, heightened sensory
sensitivities related to the taste, texture or smell of food are common in picky
eaters (Farrow & Coulthard, 2012; Nederkoorn et al., 2015). Numerous studies
provided evidence for genetic influences on taste preferences and heritability for
food preferences and findings suggest that there is a high heritability for some
24
foods, particularly vegetables, fruit and protein and moderate-to-low heritability

for starches, snacks and dairy (Breen et al., 2006; Falciglia & Norton, 1994;
Fildes et al., 2014). Research has identified several genes related to individual
differences in sweet (Fushan et al., 2009), umami (Shigemura et al., 2009), and
bitter (Bufe et al., 2005) taste perception. Certain food behaviours, such as faster
eating, are heritable and relate to higher body mass (Llewellyn et al., 2008). Other
innate factors such as personality traits including sensation seeking (Zuckerman,
1979), trait anxiety (Galloway et al., 2003, Loewen & Pliner, 1999), surgency
(Kaukonen et al., 2019), openness (McCrae et al., 2002), emotionality and
shyness versus sociability and activity (Pliner & Loewen, 1997), and neuroticism
(Steptoe et al., 1995) have shown to influence acceptance of food, food choices
and eating behaviour. Furthermore, child’s temperament may influence parental
feeding practices. For example, parents may overfeed more distressed children
(Stifter et al., 2011), or use more pressuring feeding practices with more
unsociable children (Blissett & Farrow, 2007). In addition, it was found that
genetic variations contribute to individual differences in satiety responsiveness
among infants and children and can be modifiable with behavioural interventions
(Burgess & Faith, 2018).
Influence of taste on a child’s food acceptance

Taste is consistently reported as a major influence on food behaviour of
young children. Some taste preferences and aversions, such as liking for sweet,
salty and umami and disliking for bitter, are innate (Beauchamp & Mennella,
2011; Ganchrow, et al., 1983; Maller & Desor, 1973; Steiner, 1979) and had been
evolved to differentiate beneficial calorie- and protein-dense foods from
potentially harmful substances as a critical system to ensure human survival
(Negri et al., 2012; Scott, 1992). Indeed, very young children have heightened
preferences for sweet-tasting and greater rejection of bitter-tasting foods which
differ markedly from adults (Negri et al., 2012; Nicklaus et al., 2019).
Clearly, food likes and dislikes of young children are influenced by these
innate preferences.
25
Food neophobia
Furthermore, when a child begins to transition from breast milk to the
adapted adult diet of their culture, they do not readily accept new foods.
According to Kalat and Rozin (1973), the neophobia, or rejection of novel foods,
can be viewed as an adaptive response, protecting an individual from potential
poisonous substances. There is evidence that neophobia increases sharply as a
child becomes more mobile, reaching a peak between 2 and 6 years of age
(Addessi et al., 2005; Cooke et al., 2003; Kral, 2018) which corresponds to the
stage of cognitive development when children attempt to categorise foods and
make decisions on whether they are safe to consume (Harris, 2008). This
developmental stage leads children to give preference to familiar foods (Wardle et
al., 2003) and refuse a variety of nutritious foods which poses the risk of
consuming an inadequate diet. However, research shows that the expression of
these biological tendencies in young children can be modified by early food
experiences. Kalat and Rozin (1973) argued that reduction in neophobia and,
therefore, increases in intake of and preference for, initially novel foods can be
attained by achieving “learned safety” through repeated exposure to new foods in
the absence of negative gastrointestinal consequences. On the contrary, when a
food is eaten and gastrointestinal illness follows, a learned aversion to the food
can result from only one pairing of the food with illness, and that food is
subsequently avoided or rejected (Andresen et al., 1990).
Early food preference learning

As only few food likes are innate, food preferences are learned, essentially
during the first years of life (Schwartz et al., 2011). Furthermore, children’s food
preferences could be modified by a range of social and environmental factors and,
in fact, numerous intervention studies have been carried out in different countries
trying to shape children’s food preferences through various interventions and
educational programmes (Başkale & Bahar, 2011; Cason, 2001; Lambrinou et al.,
2019). Children may accept and learn to prefer novel or disliked foods with a
regular and repeated exposure combined with positive feeding practices (Anzman-
Frasca et al., 2012; Caton et al., 2013; Wardle et al., 2003). A recent systematic
review on early food preference learning conducted by Anzman-Frasca et al.
(2018) advocates that caregivers should practice repeated exposure of young
26
children to a variety of healthy foods from a very early age, including the prenatal
and early postnatal periods and through the introduction to complementary foods,
which have all been shown to have the potential to assist with food acceptance
and intake to support young children’s consumption of healthy foods.
2.3.2 The Caregiver
Family influence on food habits

Taste and other sensory perceptions of flavour are developed very early in
life (Beauchamp & Mennella, 2011). Many flavours in the maternal diet appear to
be present in amniotic fluid and breast milk and influence future food acceptance
and food preferences (Mennella et al., 2001; Beauchamp & Mennella, 2011;
Savage et al., 2007). With increasing age, the influence of a number of factors,
such as social interaction and food environment, continue to shape children’s food
preferences and eating behaviours. After a child is born, the social context in
which a child’s eating patterns develop becomes important because the eating
behaviour of people in that environment serves as a model as the child grows
older (De Wit et al., 2015). It is believed that the shaping of food habits takes
place in the home, and the family is widely recognised as being significant in food
decisions. A concept of a 'gatekeeper' was introduced by Lewin (1943) and
defined as a person who takes the main responsibility for food provision and
preparation. Lewin emphasised that it is important to study the characteristics of
the gatekeeper in order to understand the factors influencing their food choices as
these largely determine which foods are made available to the children in their
care. Studies indicate that parent-child diets are related with one another (Ashby-
Thompson, 2019; Fisk et al., 2011; Lipsky et al., 2019; Marshall et al., 2014;
Raynor et al., 2011; Robson et al., 2016; Skinner et al., 2002; Vollmer et al.,
2015). The findings from the Framingham Children’s longitudinal study
demonstrated a direct relationship between parental eating habits and preferences
and their preschool child’s diet (Oliveria et al., 1992). The study showed that
children with both parents eating high amounts of saturated fatty acids were 5.5
times more likely to be eating a high amount of saturated fatty acids than children
in families in which neither parent was consuming such a diet. The early dietary
27
experiences in home set the stage for later food choices and life-long food habits
(Nicklaus & Remy, 2013).
Food parenting: feeding styles and feeding practices

Feeding styles are thought to follow the general behavioural construct of
parenting styles: authoritative, authoritarian, indulgent, and uninvolved. These
have often been based on at least two dimensions of parent-child interaction:
demandingness (how much control and supervision parents exercise) and
responsiveness (involvement, warmth and acceptance in response to their
children's needs). In the feeding domain, demandingness refers to how much the
parent encourages eating and responsiveness refers to how the parents encourage
eating, that is, in a responsive or nonresponsive way (Hughes et al., 2005).
Therefore, feeding style is an attitude and emotional context parents can create
around food and eating. According to experts (Hughes et al., 2005; Shloim et al.,
2015), four feeding styles can be mainly defined as:
• Authoritarian feeding style, represented mostly by parents who can be
highly controlling with little sensitivity towards the child (high
demandingness and low responsiveness); this feeding style has been most
studied and includes coercion, restriction, reward and punishment and other
controlling feeding practices.
• Authoritative feeding style, represented mostly by parents who have
reasonable nutritional expectations and sensitivity towards the child’s
nutritional needs (corresponding to high demandingness and high
responsiveness of parenting style); this feeding style includes discussion,
negotiations, and reasoning, providing rationales, and praising the child for
eating the desired food.
• Indulgent or permissive feeding style, represented mostly by highly
responsive parents who provide little structure (low demandingness and high
responsiveness), such as low parental control over the child’s eating while
letting the child eat whatever he/she wants.
• Uninvolved feeding style, represented mostly by parents who have a
tendency to not care what their children eat and/or those who cannot provide
structure (low demandingness and low responsiveness).
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An example of an authoritative feeding style could be a parent actively

encouraging their child to eat but achieving this through supportive behaviours
including rules explained in a sensitive way whereas a parent with
an authoritarian feeding style sets strict rules with little regard for their child’s
preferences. An authoritative parenting and feeding style is generally associated
with the most positive child outcomes and a more positive home food
environment (Johnson et al., 2012).
Feeding practices, on the other hand, are the specific behaviours that
parents use to get their children to eat and include restriction, pressure to eat,
monitoring, making food accessible or limiting access to food, emotional and
instrumental feeding and other practices (Gevers, et al., 2014). Both feeding styles
and practices have been associated with factors relating to children’s nutrition
such as children’s eating habits and weight status. The feeding styles that parents
adopt may influence their choice of feeding practices or the outcomes of these
practices (Collins et al., 2014; Larsen et al., 2015; Stang & Loth, 2011). For
example, authoritative parenting was associated with parental monitoring of child
food intake. A permissive parenting style was inversely related to monitoring of
child dietary intake (Collins et al., 2014). A parental pressure to eat, which is a
feeding practice to force their children to eat more, was found to create negative
feelings to the pressured foods while using food as a reward and restrictive
feeding, a parental restriction of their child’s access to food, was found to increase
the child’s preference for the restricted food (Gregory et al., 2010; Fries & Van
der Horst, 2019, Savage et al., 2007).
The latest systematic review by Shloim and colleagues (2015) concludes
that parental feeding practices are significantly associated with child’s weight
status. The review found that children whose mothers followed an indulgent or
uninvolved parenting style at baseline were more likely to become overweight
later on than children of authoritarian or authoritative mothers. Parental restricting
and pressuring practices have been associated with higher and lower weight in
children, respectively, in longitudinal studies (Afonso et al., 2016; Derks et al.,
2017; Jansen et al., 2014). It was suggested that both practices weaken child’s
natural ability to self-regulate energy intake with opposing effects on later weight
(Haszard et al., 2019). Similarly, emotional feeding practice, which is use of food
as a means of comforting and rewarding a child, e.g. offering food in response
29
to the child being fussy, bored or upset, is thought to disrupt a child's energy self-
regulatory abilities by ignoring satiety cues and encouraging eating in the absence
of hunger (Birch et al., 2003) resulting in overeating and gaining excess body
mass (Fisher & Birch, 1999). Emotional feeding used by mothers was associated
with a significantly higher risk of overweight at both 3.5 years and 5 years of age
(by 19%–28%, respectively), with a stronger effect on children who were not
overweight as toddlers, while ‘restriction for health’ (limiting the consumption of
less healthy food by the child) was a predictor of a lower risk for overweight at 5
years of age (Haszard et al., 2019). Using food as reward, or rewarding positive
child behaviour with food, which is a form of an instrumental feeding practice,
was found to be positively associated with child body weight in a study by
Marshall et al (2011). However, ambiguous findings, mostly demonstrating lack
of associations were demonstrated by cross-sectional studies that examined the
association between parental monitoring of child’s food intake (cautiously
keeping track of what children eat) and child’s weight (Gubbels et al., 2011;
Webber et al., 2010).
In addition, the review by Shloim and colleagues (2015) underlined the
importance of considering child characteristics when exploring associations
between parenting feeding practices and child eating behaviour and body weight.
This is important as there is evidence of bi-directional associations between
parental feeding practices and child’s nutritional and body weight outcomes,
parental feeding practices being a cause or consequence of child weight status
(Afonso et al., 2016; Eichler et al., 2019; Webber et al., 2010). A longitudinal
cohort study of 1512 parents with their children aged 2 to 12 years found that
while higher child body mass index predicted more restrictive feeding, lower child
body mass index predicted higher parental pressure to eat (Eichler et al., 2019).
Self-regulation of energy intake in young children

Young children have been found to accurately regulate their energy intake
by adjusting their food intake in response to changes in the energy density of the
food consumed to maintain a relatively constant total energy intake across the
changes in energy density (Birch & Deysher, 1985; Lipps & Deysher, 1986). For
example, a child who ate a light breakfast most probably will compensate this low
intake at lunch or at dinner. However, controlling feeding practices such as
30
pressuring, instrumental, emotional, and restricting feeding (Carper et al., 2000;

Christensen, 2019; Herle et al., 2018; Mason, 2015; Ozdemir & Bilgiç, 2018;
Savage et al., 2007; Steinsbekk et al., 2018) and social influences such as peer
modeling (O'Connell et al., 2012) may weaken children’s focus on internal cues
of hunger and satiety thus reducing self-regulation of eating (Hughes & Frazier-
Wood, 2016) and increase fussiness (Fries & Van der Horst, 2019). These, in
turn, may increase the risk of a child having an inadequate diet and malnutrition.
Previous research demonstrates that in a supportive, structured environment and
when treated in a developmentally appropriate manner, most children can
recognise and respond to their own appetite signals and can adjust their dietary
intake throughout the day (Johnson, 2000). Therefore, interventions that aim to
instil responsive feeding practices into caregiver–child interactions that directs
caregiver attention to child’s hunger and fullness cues; and encourages child’s
autonomy and self-efficacy are important.
Preschool children's ability to self-regulate and their weight status

A recent randomised controlled trial showed that self-regulation training
among preschool children may be an effective means of limiting caloric intake
and could protect preschoolers against the obesogenic environment (Rhee et al.,
2019). However, another randomised controlled trial that examined preschool
children's ability to self-regulate their energy intake showed that children with
higher weight status were unable to self-regulate their energy intake when faced
with increase or decrease of energy density of the foods consumed over a longer
period of time (Smethers et al., 2019). The study assessed children’s response to
changing their dietary energy density over 5 days, a period likely long enough for
compensatory behaviour. The study found that increasing or decreasing the
energy density of several foods per day leads to sustained changes (either increase
or decrease) in the energy intake of preschool children. Children with a higher
weight status had greater amounts of over-consumption when served higher-
energy-dense foods and of under-consumption when served lower-energy-dense
foods compared to children with a lower weight status. Similar findings were
demonstrated in another recent randomised controlled trial where children who
were overweight or obese in the control group consumed more energy than
children with a healthy weight (Rhee et al., 2019) as well as in past studies where
31
children’s eating self-regulation was associated with their weight status (Hughes
et al., 2015). To explain this weakened self-regulation in overweight children it
was suggested that, evolutionally, there is a greater predisposition towards
stronger adjustment to energy deficits than to energy surfeits as a protective
mechanism during periods of food shortage rather than food abundance (Poppitt
& Prentice, 1996). In today’s eating environment, energy surfeits are encouraged
by a variety of readily available high-energy-dense foods, constant snacking,
increased fast-food consumption, and larger portion sizes (Blundell, 2018;
Livingstone & Pourshahidi, 2014). As these findings contradict the suggestion
that preschool children's regulatory systems can be relied upon to adjust intake in
response to energy imbalances, it is therefore, important to create an optimal
feeding environment in both home and early care settings to encourage
developing and sustaining self-regulatory eating behaviours in young children
through responsive feeding practices (McCrickerd, 2018). As suggested by
Johnson (2000), one strategy to enable parents and caregivers to do so is to help
them to recognise their responsibilities of acting as role models of healthful eating
and acknowledge children’s capabilities of eating self-regulation.
Parents’ characteristics and home food environment
It has been documented that alongside parental feeding practices the home
food environment plays an important role in children’s dietary intake. This
environment is shaped by parental socio-economic factors such as, family income,
parental education and employment status. Other factors, such as cost of food,
influence what is available in the home.
Parental nutrition knowledge and home food environment

Various cross-sectional and longitudinal studies have shown that
nutritional knowledge of parents or other caregivers and the home food
environment are associated with children’s dietary quality (Haire-Joshu et al.,
2008; Knowlden et al., 2015; Peters et al., 2012; Williams et al., 2014; Wyse et
al., 2015). Indeed, the availability of healthful foods at home was found to be
more consistently related to healthy food intake in children compared to parenting
feeding practices (Couch et al., 2014). In general, children tend to prefer eating
foods, regardless if they are healthy or not, that are readily available in the home
32
and served most often (Sirasa et al., 2019). Given that parents are the main
gatekeepers and primary educators, parental nutritional knowledge is related to
the food made available and offered to children at home, thus influencing the
children’s food preferences (Mura Paroche et al., 2017). Evidence suggests that,
particularly, mothers’ nutrition knowledge and home food availability are directly
and independently associated with children’s food intakes. For example,
Campbell and colleagues’ study (2013) showed that home food availability
mediated the association between mother’s nutrition knowledge and children’s
intake of fruits and vegetables, salty foods and sweetened beverages.
In a recent study by Boles and colleagues (2019), home food availability
was found to positively and significantly associate with dietary intake for a broad
range of foods ranging from healthy and less healthy foods among preschool-aged
children after controlling for demographic, location and weight status. Moreover,
school children’s fruit and vegetable intake was increased when these foods were
not only available but also provided in accessible locations (e.g. easy for the child
to reach), in accessible sizes and ready to eat (e.g. apple wedges, carrot sticks)
(Baranowski et al., 1999). On the contrary, poor parental nutrition knowledge was
found to contribute to increased availability and accessibility of unhealthy food at
home (Birch & Davison, 2001), greater consumption of energy-dense and
nutritionally poor foods including unhealthy snacks, fast food, sweetened
beverages and fried food (Hu et al., 2010; Lin et al., 2016; Vitolo et al., 2010) and
associated with adult assistance during meals and playing or watching television
during dinner (Sirasa et al., 2019). Vitolo and colleagues (2010) reported positive
relationships of increased nutritional knowledge of family or caregivers with
healthy aspects (increased consumption of vegetables and fruits, and greater
variety in the intervention group than in control group) and inverse relationship
for unhealthy aspect (the cholesterol level was lower in the intervention group
than in control group).
Socioeconomic status and home food environment

Home food availability is associated with socioeconomic characteristics of
the family. It is documented in various studies that cost is a major influence on
food purchases (Darmon & Drewnowski, 2015; Fulgoni & Drewnowski, 2019)
and, since lower socioeconomic groups are likely to have less disposable income,
33
it's likely that more unhealthy foods are favoured compared to healthier and often
more expensive foods (Hardcastle & Blake, 2016). In addition, low parental
education levels and lower socioeconomic status have been associated with poor
child diet quality (Damen et al., 2019; Desbouys et al., 2019; Gevers et al., 2016;
van Ansem et al., 2014a) and increased child obesity (Paes et al., 2015). However,
Østbye and colleagues (2012) observed a moderating effect of mothers’ low
socioeconomic status, low education and unemployment status on home food
environment on child dietary intake: families with frequent family meal where the
mother was less educated and unemployed exhibited higher child intake of
unhealthy food. Although these findings contradicted the existing evidence about
the association between family meals and healthful eating practices, authors
suggest that it may be explained by the fact that these families’ meals comprised
generally unhealthy foods such as fast food and sugar-sweetened beverages. This
is in line with recent evidence in the literature (Terry et al., 2017; van Ansem et
al., 2014b). Terry and colleagues (2017) found that children in those families that
perceived fruits and vegetable being too costly, particularly in low-income
households, reported greater consumption of unhealthy foods. Van Ansem and
colleagues (2014b) examined the association between maternal education and
unhealthy eating behaviour and found that children of mothers with a low
educational level were found to consume more sugar-sweetened beverages than
those of mothers with a high education level, while children of mothers with an
intermediate educational level were found to consume more snacks than those of
mothers with a high education level. On the other hand, maternal employment
status and working hours were found to affect children’s healthy lifestyles and the
family food environment to varying degrees. For example, studies found a
positive association between maternal working hours and intakes of sweetened
drinks and fast food (Bauer et al., 2012; Datar et al., 2014; Gevers et al., 2015),
with lack of time being the most plausible explanation, as working mothers may
have less time to prepare healthy meals (Datar et al., 2014) or monitor their
child’s dietary intake (Gubbels et al., 2011).
Parental role modelling

Further, positive associations were found for role modelling and food
availability within the surrounding environment and children's healthy food
34
consumption (Gibson et al., 1998; Sirasa et al., 2019; Wang et al., 2013). For
example, children's confectionery consumption was predicted by the mother's
liking for confectionery and predictors of children's fruit intake was related to
mothers’ frequency of fruit consumption (Gibson et al., 1998), while the
availability of chips and sweets in a child's home and parental inappropriate
modelling of eating were associated with an increased risk for consumption of fats
and sweets by children (Wang et al., 2013). In low income group, role modelling
of healthy eating behaviours increased the healthy food intakes among children of
less educated and unemployed mothers. The authors argue that possible
explanation may be that there may be less food available in general, including
unhealthy food, thus decreasing the access to unhealthy foods, especially
sweetened beverages, in homes with low-educated mothers who do not work
(Terry et al., 2017). Another possible explanation to these findings, according to
the authors, may be that mothers who are not working outside the home may be
able to spend more time with their children, and therefore have more opportunities
to role model healthy and unhealthy eating (van Ansem et al., 2014a).
A recent systematic review of multiple modifiable family and community
factors influencing the eating behaviours of preschool-aged children across low
and middle-income countries conducted by Sirasa and colleagues (2019) reported
the influence of family and community factors (household food availability,
nutritional knowledge of family or caregivers, family income, and food
availability within the surrounding environment) on child eating behaviour
outcomes. Both positive (for protein rich foods, green leafy vegetables and fruit)
and negative (for cereals) associations were observed between the household food
budget and children's healthy food consumption (Mascie-Taylor et al., 2010). The
review found positive consistent associations for nutritional knowledge of the
family or caregivers with healthy food consumption and micronutrient intake. In
particular, maternal nutritional knowledge was strongly related to children's
healthy food consumption. This is consistent with conclusions of the previous
review based on qualitative evidence (Paes et al., 2015). When parents and
caregivers are educated about child nutrition, importance of nutrition, nutrient
requirements of a child and how to nourish their children properly, they can apply
this knowledge in feeding their child (Sirasa et al., 2019). Therefore, a focus on
nutrition education that expands parents’ understanding of what foods to buy,
35
prepare and serve is imperative for promoting healthy eating or discouraging

unhealthy eating in preschool-aged children. Interventions to increase nutrition
knowledge in mothers in low-income households have been associated with
healthier diets (lower in fat and higher in fresh fruits and vegetables) (da Costa
Louzada et al., 2012; Vitolo et al., 2010).
2.3.3 The Environment
As preschool-aged children start interacting with their wider environment,

both physical (e.g. attending settings other than the home setting) and social
(interacting with persons outside the family), various contextual factors can
influence their diet. Wider environmental contexts can also influence preschool
children’s dietary habits. As they age, interactions outside the home and with
more people will increase their exposure to different foods. Whilst food
preferences develop throughout the life cycle, it has been shown that
environmental factors are strongly associated with overcoming innate or genetic
predispositions for food preferences (Nicklaus, 2009; Nicklaus et al., 2004). For
example, individuals acquire preferences for coffee and tea that have a bitter taste
through learned positive reinforcement, i.e. stimulation elicited by caffeine or
influenced by social contexts (Ong et al., 2018). Previous research indicated that
social factors related to eating behaviours of peers and adults outside the family
are significant in the development of food preferences and eating behaviours in
young children. Moreover, the social aspect of eating together outside the home
can also play a positive role on preschool children’s food preferences and intake
(Birch et al., 2007; Birch, 1999). As food choice and consumption are commonly
connected to social interactions (Higgs & Thomas, 2016), social norms (Hang et
al., 2019; Higgs et al., 2019) and social contexts (Laureati & Pagliarini,
2019; Poelman & Steenhuis, 2019), food consumption has implications that go
beyond merely obtaining nutrients and energy needed for life sustenance. As
social modeling emerges early in life and remains stable across development
(Cruwys et al., 2015), young children learn which foods are palatable by
observing other people eating (Marty et al., 2018). A study by DeJesus et al.
(2018), which examined how social information affects preschool-aged children’s
perception of taste, found that social messages play a powerful role in guiding
children's consumption and perception of foods. In this study, 5-6 year old
36
children consumed more of a food described as popular with other children than a
food that was described as unpopular with other children, even though the two
foods were identical.
The role of socio-cultural environment in food choice and eating behaviours
As family processes are inevitably embedded in larger cultural and
sociopolitical contexts (Fiese & Bost, 2016), socio-cultural values may influence
child-feeding styles and practices (Tovar et al., 2012). For example, the use of
more controlling feeding practices by Chinese-American parents is associated
with the use of the authoritarian parenting style which is perceived as an
expression of caring parenting in Chinese culture, in contrast to its perception in
Western culture as of low warmth and caring (Huang et al., 2012).
Taking an example from immigrant families, families often change their
dietary habits in order to assimilate to a new culture (Guendelman et al., 2011;
Van Hook et al., 2016). While immigrant families may maintain culinary practices
from their countries of origin to preserve their cultural practices (Best 2017), they
also incorporate new foods into their diets (Azar et al., 2013) and their dietary
habits and behaviours may change due to unavailability of ethnic ingredients,
economic status, having less time for household chores and family life due to
work demands, and influence of school food services (Villegas et al., 2018). Same
as their parents, children may face a range of food options and varying pressures
when confronting the realities of a new culture (Tovar et al., 2012). In school,
children of immigrants may face strong social pressure to acculturate and conform
to mainstream norms because classmates monitor what they eat and being
different can lead to bullying (Dondero et al., 2019). Parents’ and children’s
different experiences in a new cultural context and cultural influences due to their
upbringing can bring pressures on food parenting practices (Villegas et al., 2018).
In a qualitative study conducted by Villegas and colleagues (2018), parents of
preschoolers described the challenges of trying to get their children to eat
traditional foods and healthier options and indicated that the new food preferences
of their children, resulting from exposure to new environments, caused conflicts
and often led to giving in to their children’s desires. The researchers suggest that
discussing and supplying strategies to incorporate traditional meals into
preschoolers’ diet or to create new traditional meals, integrating healthy food
options from multiple cultural backgrounds, could alleviate these challenges.
37
Dondero and colleagues (2019) argue that social institutions shape the
dietary assimilation of immigrant children in the form of food acculturation. They
found that high social pressure to acculturate and highly standardised food menus
in schools lead to higher food acculturation during school meals than home meals.
On the other hand, school meals are predominantly healthy, due to high
government regulation of nutritional quality, and are often healthier relative to
home meals. However, the authors argue that schools may still indirectly affect
unhealthy food acculturation by influencing children’s food preferences through
exposure to peers’ unhealthy eating or directly through unhealthy foods in schools
(Dondero et al., 2019).
Early care setting environment
While families are primarily responsible for helping children establish

healthy eating behaviours, many preschool-aged children in high-income
countries spend a substantial amount of time in child care settings making this
setting ideal for implementing nutrition-related interventions (Story et al., 2006).
For most children, the early care setting is the first opportunity to experience an
institutional environment. Children are faced with social, emotional, behavioural
and other changes that arise during this transition (Belkowitz, 2019) and
challenged to adapt to new environments (Graziano et al., 2007), which is vital for
their social and academic competence (Denham et al., 2012). The food served at
the childcare setting and mealtime practices can be different from those in the
home. As preschool years are formative, the nutrition related environmental and
caregiver influences that children are exposed to at a childcare setting can have a
lasting impact (Chambers, 2017; Mita et al., 2015). Given that a majority of
preschool-aged children attend early care settings, these are important places to
implement interventions to address food insecurity, hunger and malnutrition (Loth
et al., 2019), provide an opportunity to improve or buffer preferences and
behaviours learned at home (Gerritsen et al., 2018) and influence long-term health
outcomes among young children (Janssen et al., 2005; Singh et al., 2008). Early
care settings may provide an additional pathway for children to consume healthy
diets if the home eating environment is suboptimal. This could be particularly
important for children from socio-economically disadvantaged families (Jones-
38
Taylor, 2015; Liu et al., 2016). Furthermore, in the context of public health
promotion opportunities, early care settings could be an influential place to
provide nutrition education and promote healthy eating behaviours in young
children. All children who attend early care settings could be exposed to both
structured nutrition education activities and health-promoting mealtime
experiences where supportive feeding practices are instilled. Supportive feeding
practices include caregivers sitting with children during mealtimes, role modeling
healthy eating behaviours, encouraging children to try new foods, and addressing
children’s hunger cues (Peterson & Kristi Wilkerson, 2019). Furthermore,
mealtimes could offer the opportunities to interact with their peers and be a time
for learning and socialisation by constructing a community of peers and
caregivers through sharing information, stories or food (Harte et al., 2019).
In childcare settings, since childcare providers have a primary care role
which includes providing for the nutritional needs of children in their care, their
position as authority figures and positive role models is particularly important for
young children. Employing supportive feeding practices, such as enthusiastic
teacher modelling, providing adequate portion sizes when serving food or using
family style meal service, and other practices, has been associated with many
positive child outcomes including greater acceptance of novel and healthful foods
and social, emotional and fine motor skill development (Gerritsen et al., 2018;
Larson et al., 2011; Kharofa et al., 2016; Ward et al., 2015). However, previous
studies reported lack of educators’ training in nutrition and health education,
inadequate nutrition-related childcare policies, and food provision challenges
(Lehto et al., 2019; Yoong et al., 2017). Tackling the challenges and barriers and
establishing supportive nutrition environment, the early care settings could
harness their unique potential in shaping children’s dietary intake and eating
behaviours and benefit immensely to many nutrition-related outcomes in
preschool-aged children (Larson et al., 2011).
39
Child care policy: an avenue for implementing nutrition

standards
Preschool nutrition policies and standards

Regulatory framework and evidence-based guidelines for childcare
practice which aim to support childcare providers in achieving the national
standards that define high-quality childcare are essential. National standards for
nutritional requirements in childcare settings allow for consistency in curriculum,
nutrition education of childcare providers, training cooks, accreditation system
and evaluation of compliance with government regulations across childcare
services.
There is evidence that national childcare policy-based contexts could

impact providers’ feeding practices. For example, in the USA, a positive effect
occurred on beverages served in childcare settings after enactment of state and
federal beverage policies (Ritchie et al., 2015). Another example of national
childcare nutrition policy’s impact on preschool food practices is related to Head
Start, a federally funded preschool programme in the USA, which primarily
serves children with low-income minority backgrounds and those at increased risk
for childhood obesity (Peterson & Kristi Wilkerson, 2019). Head Start is
considered a leader in promoting healthy eating for young children in early care
settings (Benjamin-Neelon, 2018). As federally funded programmes, Head Start
childcare centres are expected to follow federally regulated meals, policies, and
procedures. The programmes are guided by Nutrition-related Performance
Standards that require programmes to implement developmentally appropriate
child feeding practices, provide nutrition education, and healthy meals and snacks.
Head Start educators are encouraged to promote healthy eating behaviours among
children by using supportive feeding practices (SFPs). Thus, as these federal
standards require Head Start providers to use SFPs, there is an increased
compliance of Head Start providers to healthful nutrition practices. Furthermore,
researchers found that Head Start programmes were more likely to implement
SFPs and provide healthy foods compared to non-Head Start programmes (Dev et
al., 2013). Additionally, childcare providers can participate in the Child and
Adults Care Food Program (CACFP), another federally-funded programme that
provides financial reimbursement for nutritious foods and beverages to childcare
40
programmes who serve low-income children (USDA, 2020). However, compare

to Head Start, CACFP lack standards regarding providers’ feeding practices and,
therefore, there are variations in the fidelity with which the CACFP implement
supportive feeding practices (Sisson et al., 2019). This lack of federal regulations
means that compliance with best practices is optional and any burden associated
with compliance is assumed by childcare providers themselves (Loth et al., 2019).
A policy impact can also be seen from the next example. In 2016, a revision of US
federal standards occurred resulting in removal of the family style meal service
requirement, a key strategy for implementing SFPs in childcare settings (Bandy et
al., 2019). Consequently, individual Head Start programmes can since then choose
whether or not to participate in family style meal service based on the needs of
their programme. Studies indicate that Head Start programmes without family
style meal service were less likely to implement SFPs and have policies in place
to support these efforts, compared to programmes that did use this style of service
(Bandy et al., 2019) due to perceptions of food wastage, or that family style meal
service will require more time and create a mess (Dev et al., 2014).
National nutrition guidelines for preschools

Studies show that, currently, national nutrition guidelines for early care
have room for improvement in different countries. A study has been conducted in
three high-income countries, the UK, Australia, and Sweden, characterised with
various approaches to school meal regulation and standard setting at the regional
and national level, from entirely centralised (Sweden) to entirely federal
(Australia), and from highly standardised (Sweden) to highly varied (UK) (Lucas
et al., 2017). The study reviewed and compared the school meal policies in
preschool and primary school settings and found that action in preschool services
generally lags behind schools, and policies tend to lack enforceability and routine
monitoring by government and there are poor rates of adherence. In addition, they
found that the wording of national standards for food and drinks to be ‘nutritious
and appropriate’ was too vague to be enforceable. There are no national policies
for packed lunches in the UK, although it is estimated that between 39% and 49%
of preschool settings use packed lunches only. The study suggests that consistent
policies, strong incentives for compliance, systematic monitoring, and an
acknowledgement of the broader school eating environment, including home
41
provided meals, would be beneficial for improvement of the current situation. In

addition, the study emphasised the importance of broader public health, health
promotion and political action to improve preschool and school food
environments.
Similarly, another study that interviewed Australian childcare providers on
resources they used to support the provision of nutritious food and the promotion
of healthy eating within the early care setting, has shown that that the guidelines
were not used by most educators (Wallace et al., 2017). Forty eight childcare
providers were asked specifically about the Australian Dietary Guidelines and the
Get Up & Grow guidelines, the resources prescribed by the National Quality
Standards to guide the provision of nutritious and varied food, and responses
showed that the majority of providers reported having never heard of Get Up &
Grow guidelines and only few participants actually reported using the resources.
Likewise, only half of participants were aware of the Australian Dietary
Guidelines while only several participants reported actual use, and few were
aware of a major review to include specific recommendations for children aged 2-
4 years (Wallace et al., 2017). The reasons given by participants were dietary
recommendation being too general and difficult to implement. The study indicated
that there is no accompanying training to guide the implementation of these
resources in early care settings thus leading to under-utilisation of the translation
of evidence-based information into practice.
In addition, as food and nutrition guidelines for preschools are not
mandatory in many countries, including Ireland, methods to encourage the
provision of nutritious food in this setting must be investigated, implemented and
evaluated and further research in this field is required (Johnston Molloy, 2013;
Wolfenden et al., 2016). Furthermore, research to date shows that there is a need
to examine implementation of national guidelines through qualitative analysis of
everyday mealtime activities to gain greater understanding of the relationship
between childcare policy and organisational contexts and nutrition practices
occurring in early care setting, however, research in this area is scarce (Harte,
2019).
42
Preschool food practices
Until recently, the emphasis on creating healthy food environments for

children was placed predominantly in school settings. Research examining the
food environment in early care settings has been extremely limited along with
little intervention research on changing the childcare food environment (Story,
2008; Larson et al., 2011). However, as early care settings are increasingly seen as
having a great potential for childhood obesity prevention by shaping dietary
intake and development of healthy eating behaviours in young children, a greater
interest in this domain emerged. Consequently, over the past decade, a body of
nutrition research, has been carried out in early care settings. However, studies
have mainly focused on the quantitative parameters such as nutritional quality of
food and beverages served in childcare settings (Benjamin Neelon et al., 2012)
and mealtime routines (Sigman-Grant et al., 2008a) while research on the
mealtime practices, feeding behaviour of childcare practitioners and children’s
food preferences, in other words, qualitative data that may help to reveal and
explain the underlying processes and contexts that have led to quantitative
findings has been relatively limited (Nanney et al., 2016; Fallon et al., 2018; Mita
et al., 2015).
Influence of childcare setting on children’s weight status

Centre-based early care has the potential to provide an optimal nutrition
environment that may decrease the effects of exposure to obesogenic risk factors
found at home or elsewhere (Alberdi et al., 2016). However, formal childcare use
has been associated with an increased risk of overweight throughout childhood
(Benjamin et al., 2009; Geoffroy et al., 2013). A systematic review that examined
the association between childcare and risk of childhood overweight and obesity in
children aged 5 years and under found that, compared to parental care, children
who attended centre-based child care had higher odds of being overweight or
obese during childhood (Alberdi et al., 2016). The review found that age of
initiation in care, type of care and hours spent in care are all positively associated
with weight gain and adiposity among children (Neelon et al., 2015; Geoffroy et
al., 2013; Gubbels et al., 2010). However, the evidence is equivocal with some
studies finding a protective effect of attending preschool settings through the
decreased exposure to obesogenic risk factors found at home and the increase in
43
healthy behaviours (Flores & Lin, 2013; Koleilat et al., 2012) and other studies
finding no association between formal childcare and childhood overweight and
obesity (Koleilat et al., 2012; O’Brien et al., 2007; Zahir et al., 2013). The review
authors suggest that differences in the quality or irregularities in the
implementation of health-promoting policies and regulations of childcare centres
might explain variability in results (Alberdi et al., 2016). Similar mixed results by
type of care or subpopulation analyses were found by another review by Swyden
and colleagues (2017). More recently, Chambers (2017) examined these reviews,
particularly the studies related to association between UK childcare and
overweight and obesity, and concluded that more research is needed to examine
the impact of formal childcare on children’s weight status and dietary behaviours
as there have been recent introduction of statutory and voluntary guidance in early
care and it is possible that these initiatives are actually helping to reduce the risk
of excess weight gain during the early years. This illustrates the need for more up-
to-date data on children and the preschool nutrition/food environment.
Influence of childcare setting on children’s dietary intake

Studies have shown that early care policies and their social and physical
environments influence child dietary intake (Anundson et al., 2018; Erinosho et
al., 2011; Gubbels et al., 2010; Kharofa et al., 2016; Lessard & Breck, 2015;
Sisson et al., 2016), however, there is great variation in quality of health-
promoting practices and policies in early care settings (Swyden et al., 2017;
Schwartz et al., 2015; Benjamin Neelon et al., 2012). Recent studies show that
childcare services both nationally and internationally do not provide foods
consistent with dietary guidelines (Bell et al., 2015; Benjamin Neelon et al., 2012;
Grady et al., 2018; Jennings et al., 2011; Molloy et al., 2014; Seward et al., 2017).
A 2016 report on childcare licensing regulations found that only 20% of US early
care centres fully met ‘healthy weight practice’ regulations (Federal Interagency
Forum on Child & Family Studies (US), 2017). Multiple studies found that the
majority of childcare centres serve foods high in sugar, sodium and fat, do not
provide the recommended number of servings of vegetables, fruits and whole
grains, and access to water is inadequate (Bussell et al., 2018; Grady et al., 2018;
Yoong et al., 2017). Despite the potential for childcare environments to have
44
beneficial effects on nutrition, current practices do not appear to be optimal

(Chambers, 2017; Daniels, 2013).
Supportive nutrition practices

Much of the recent research findings draw attention to the importance of
supportive nutrition practices, such as responsive feeding in the development of
healthy eating behaviours and prevention of childhood obesity. Efforts to identify
effective mealtime practices that develop healthful habits and improve children's
dietary intake have been undertaken and evidence-informed nutrition best
practices have been suggested from dietary guidelines of several high-income
countries (Department of Health of Australia, 2013; US Department of Health and
Human Services, 2016; Children’s Food Trust, 2012; Tysoe & Wilson, 2010).
Systematic reviews (Ward et al., 2015) and cross-sectional and intervention
studies (Battista et al., 2014; Gerritsen et al., 2018; Kharofa et al., 2016; Ward et
al., 2017) also illustrated the benefits of these practices. Recommended best
practices related to childcare caregivers’ behaviours at mealtimes include (1)
serving family style meals and allowing children to control the amount of food
they eat; (2) not using food as a reward or punishment; (3) sitting with children at
meals, (4) eating the same foods as children and use of positive modelling; (5)
informally talking with children about healthy foods; (6) encouraging children to
try new or less preferred foods; (7) promoting self-regulation, e.g. helping
children determine if they are still hungry before serving seconds; (8) providing
easy access to drinking water and encouraging water consumption; and (9)
providing nutrition education to children.
Family style meal service

Family style meal service (FSMS) is widely regarded as one of the
recommended best practices at child care setting and has been associated with
numerous benefits (Dev et al., 2014; Kharofa et al., 2016; Lynch & Batal 2011;
Mita et al., 2015). When delivering FSMS, caregivers’ sitting with children at the
same table and eating the same food enables them to teach (e.g. skills and
nutrition), demonstrate table manners, initiate and model socialisation skills (e.g.
share food, take turns), and prevent accidents and choking (Sigman-Grant et al.,
2008a). In addition, having FSMS allows opportunities for enthusiastic modelling
of healthy eating (i.e. promoting healthy food while and after eating it), which was
45
reported to be effective in trying and accepting new foods by children (Hendy &
Raudenbush, 2000). It has been reported that young children gain many benefits
by participation in FSMS, such as: 1) children learn cooperation and social skills
as they practice patience by sharing, passing platters, taking turns, waiting, and
using appropriate language and manners; 2) it helps develop language skills as
they engage in conversations, make up stories or discuss current events relevant to
their age group; 3) FSMS expands fine motor skills as children serve themselves,
learn to hold flatware, and pour their own beverages; 4) children learn
mathematical skills, including spatial relationships, e.g. sorting and counting the
flatware, setting the table, or placing the chairs; 5) dining together deepens
relationships and friendships in a relaxed atmosphere where children can focus on
one another without outside distractions (Dev et al., 2014; Kharofa et al., 2016;
Locchetta et al., 2017; Lynch & Batal 2011; Mita et al., 2015).
Implementation of supportive nutrition practices

Recent studies and national reports carried out mainly in the USA,
Australia, and several European countries suggest variability in the
implementation of supportive nutrition practices (Ward et al., 2017; Gubbels et
al., 2015; Dev et al., 2014; Sisson et al., 2012; Lanigan, 2012; Sigman-Grant et
al., 2011, 2008; Ramsay et al., 2010; Gable & Lutz, 2001). Some studies reported
effective implementation of supportive nutrition practices such as serving more
fruits and vegetables, improving access to water and using family style meal
service as well as positive outcomes such as children’s increased willingness to
try new foods and improving children’s self-regulation skills (Anundson et al.,
2018; Dev et al., 2014; Kharofa et al., 2016; Lynch & Batal 2011; McKee et al.,
2020; Mita et al., 2015; Whiteside-Mansell et al., 2019). However other studies
found low implementation rates (Erinosho et al., 2012; Fallon et al., 2018). For
example, Fallon and colleagues (2018) found that preschool teachers’ self-
reported feeding practices were not consistent with observations of their feeding
practices. For example, 83% of the teachers reported always enthusiastically role
modelling, but only 48% were actually observed role modelling. Although further
development is warranted for the measurement instrument used in this study, the
findings showed that the agreement between observed and self-reported
behaviours was generally high for controlling feeding practices, but low for
46
healthful feeding practices. The researchers concluded that having clear policies
within child care settings that discourage certain feeding practices may help
teachers to engage in more healthful feeding practices as opposed to focusing on
the more controlling ones. A study conducted in 314 childcare centres in
Oklahoma, USA, found that although the centres reported nutrition best practices
such as staff joining children at the table most of the time, staff rarely eating
different foods in view of children, visible self-serve or availability of water, and
regular informal communication about healthy eating, they needed to improve
several other practices which included helping children determine whether they
are still hungry, non-food holiday celebrations with non-food treats, and having
toys and books that encourage healthy eating (Sisson et al., 2012). Likewise, a
recent USA study reported that introducing a ‘healthy celebration policy’ was a
major challenge that triggered the strongest negative reactions, especially from
parents, and was a policy that required an extra effort to maintain (McKee et al.,
2020).
2.4 Barriers, challenges and interventions to promote nutrition

best practices
A number of studies report the presence of barriers and facilitators that

contribute to the variability in implementation of supportive nutrition practices
(Finch et al., 2019; Grady et al., 2018; Lehto et al., 2019; Moore et al., 2005; Ray
et al., 2016; Seward, et al., 2017; Wolfenden et al., 2016). Most recently, Seward
and colleagues (2017) conducted a systematic review of the factors influencing
the implementation of dietary guidelines regarding food provision in centre-based
childcare services using the Theoretical Domain Framework (TDF) that consists
of 14 theoretical domains synthesized from 33 behaviour change theories and 84
theoretical constructs in a single framework (Cane, 2012). The factors (barriers
and facilitators) which influence the implementation of dietary menu guidelines
were extracted from 12 included studies, six qualitative and six quantitative, and
assigned to the relevant TDF domains. The review findings showed that, in
qualitative studies, the TDF domains most frequently identified as barriers to
implementation of dietary guidelines were ‘social influences’ (e.g. staff
perceptions of what foods children liked or disliked); ‘environmental context and
47
resources’ (e.g. insufficient menu planning tools and resources; insufficient time);
‘knowledge’ (e.g. staff have limited general nutrition knowledge and poor
knowledge of the menu dietary guidelines); ‘beliefs about capabilities’ (e.g. food
service staff lack confidence in their kitchen math skills and cooking skills) and
‘beliefs about consequences’ (e.g. the impact of menu changes on food budget;
increased food wastage as a result of menu changes). The TDF domains most
frequently identified as facilitators were ‘environmental context and resources’
(e.g. the availability of sample menus; the service creating a supportive
environment by enforcing nutrition policies and role modelling healthy eating
behaviours); ‘social influences’ (e.g. staff communicating and collaborating; well
established social networks to share information), ‘skills’ (e.g. highly trained and
skilled staff for menu planning) and ‘goals’ (e.g. planning menus in advance;
making a gradual transition to serving healthier foods; planning strategies to
contain food costs as a result of menu changes). From remaining six quantitative
studies, the TDF domains most frequently identified as barriers to implementation
of dietary guidelines were ‘environmental context and resources’; ‘social
influences’ and ‘skills’; and ‘knowledge’, while the most frequently TDF domains
identified as facilitators that enable services' implementation of the menu dietary
guidelines were ‘environmental context and resources’, ‘social influences’ and
‘skills’ (Seward et al., 2017). Overall, the review identified that ‘environmental
context and resources’ and ‘social influences’ were each the most common
domains within which barriers and facilitators to the implementation of menu
dietary guidelines were identified by centre-based childcare services. It was noted
that qualitative studies included in the review identified a greater number of TDF
domains as barriers or facilitators, compared to quantitative studies. The authors
reckoned that this discrepancy between qualitative and quantitative findings
suggests that quantitative studies may have overlooked many important factors
influencing guideline implementation in this setting. The factors identified in
Seward et al. (2017)’s review are in line with findings from previous studies that
examined factors influencing the implementation of nutrition policies and healthy
eating practices in childcare setting, which reported many environmental and
policy factors, such as a lack of suitable resources, support from service
management or parents, and a lack of training, knowledge and skills, as barriers to
the implementation of supportive nutrition policies and practices (Finch et al.,
48
2019; Grady et al., 2018; Lehto et al., 2019; Moore et al., 2005; Ray et al., 2016;
Wolfenden et al., 2016).
Based on current literature that identified numerous barriers and
challenges to implementation of supportive nutrition practices in childcare setting,
the barriers and challenges related to the present PhD study can be grouped as
follows: 1) childcare provider characteristics; 2) training needs of providers; 3)
food provision; 4) parent involvement; and 5) healthy eating policies. These are
described in detail in the following sections.
2.4.1 Provider characteristics
For young children, childcare providers hold a special position of authority

as role models, including for eating behaviours (Hughes et al., 2007). Studies have
explored the factors that contribute to variability in childcare providers’ feeding
practices (Seward et al., 2017; Swindle et al., 2016). Provider-level characteristics
that have been shown to influence feeding practices are as follows: providers’
personal food preferences and limited self-efficacy for handling children’s
negative preferences toward healthy food (Bandy et al., 2019; Peterson & Kristi
Wilkerson, 2019); race and ethnicity (Dev et al., 2014; Gans et al., 2019; Huang et
al., 2012); level of education (Freedman and Alvarez, 2010; Miguel-Berges et al.,
2017); providers’ own weight status and concerns about losing weight (Dev et al.,
2014; Tovar et al., 2017); health concerns (Benjamin Neelon et al., 2011;
Erinosho et a, 2012); their nutrition beliefs, attitudes and perceptions about
healthy eating (Cooper & Contento, 2019); and providers’ sense of responsibility
for feeding children and concern about children’s weight (Dev et al., 2014). These
provider characteristics may impact the ability to be positive role models and
engage children in health promoting activities. For example, providers who
reported being concerned about children's weight, being responsible for feeding
children and had an authoritarian feeding style were more likely to pressure
children to eat, restrict intake, and control food intake to decrease or maintain
children's weight (Dev et al., 2014). Providers with non-White race, who were
trying to lose weight, and who perceived nutrition as important in their own diet
were more likely to use restrictive feeding practices (Dev et al., 2014). In
addition, it was noted that despite receiving nutrition training some providers’
concern about food scarcity in children’s homes may override any training they
49
have had about avoiding controlling feeding practices. For example, studies show
that providers who work with children from food insecure households often
address their concern regarding food insecurity by buying extra food, giving food
to families to take home, and determining children’s portion sizes (Gooze et al.,
2012) as well as feeding children more on Mondays and Fridays (Gooze et al.,
2012; Sigman-Grant et al., 2008b). Providers’ ethnicity, education level, and type
of childcare (centre-based versus family-based) were significant predictors of
reported mealtime practices, including insisting children finish their meals before
leaving the table, not allowing children to eat less than they thought they should
be eating and making children eat foods they thought were good for them.
Specifically, Hispanic providers, providers with less education, and providers in
family-based childcare settings were less likely to engage in best practices
(Freedman & Alvarez, 2010). White Caucasian providers reported themselves as
less likely to sit with children and promote healthful foods than teachers of other
races or ethnicities (Cooper & Contento, 2019). The food portions served to
preschool children was reported to be influenced by their teachers and was
associated with greater energy intake by children. For example, children’s self-
selected portions at preschool were related to the portions their teachers served to
them (McCrickerd et al., 2017). The research suggests that caregivers can
influence children’s food intake directly through the size of the portions they
serve and indirectly by imparting their own portion size norms, which children
learn about over time. Both could result in children becoming more accustomed to
eating larger portions than they need (McCrickerd, 2018). In recent studies,
personal food preferences of childcare providers were cited as the biggest
challenge to engage in supportive feeding practices with children (Peterson &
Kristi Wilkerson, 2019; Swindle & Phelps, 2019). Providers reported that they
found healthy food non-appealing and were challenged to model healthy eating to
children and instead they pretended to eat the food, cut up their food into small
pieces, told children their physician told them not to eat it, and allowed their plate
to sit in front of them without eating it (Swindle & Phelps, 2019). In addition,
during mealtimes, providers consumed food brought from outside, which did not
meet childcare nutrition guidelines (Peterson & Kristi Wilkerson, 2019).
50
A multidisciplinary USA expert consensus on priorities for obesity

prevention research in early care highlighted the need to address providers’ own
personal and health challenges (Ward et al., 2013). Given the diversity of
childcare provider characteristics it was suggested that intervention programmes
should tailor efforts to their population of providers (Ward et al., 2013). For
example, perceived importance of nutrition in their own diet and interest in losing
weight may be ways to engage providers in nutrition education that focuses on
feeding practices (Dev et al., 2014). This way, equipping the providers with
resources to help maintain a healthy weight and life-style for themselves, without
transferring the practice of restricting food intake to children in their care (Dev et
al., 2014; Tovar et al., 2017) may be of benefit to both providers and children
involved in interventions for promotion of healthy eating and enhancing food
environment in childcare settings. Given the key role that childcare providers play
in shaping preschoolers’ eating behaviours, understanding the providers’
challenges and enabling factors is critical for developing targeted nutrition-related
interventions that can better support feeding practices (Anundson et al., 2018). A
greater understanding of the barriers is needed through exploring the views of
childcare providers on positive meal environment and their role as a positive
model and perceived barriers. To improve teachers’ use of these mealtime
practices, it was suggested that teachers’ actual practices (e.g. observational
study) as well as their perceived barriers associated with these key operations
should be investigated (Mita et al., 2015).
2.4.2 Childcare providers’ training needs
Childcare providers may use undesirable feeding practices due to a lack of

training on how to consistently implement mealtime guidelines, policies and
nutrition best practices (Sigman-Grant et al., 2011). For example, a study
involving 568 childcare centres in the USA found that staff members were
significantly less likely to receive training in child feeding than in nutrition or
child development (Sigman-Grant et al., 2008a) although it is one of the essential
day-to-day activities for preschool staff. Past research has shown that information
that caregivers give children about food and nutrition sometimes is inaccurate,
51
developmentally inappropriate or ineffective (GolMohamadi et al., 2015; Ramsay

et al., 2010; Sigman-Grant et al., 2008a).
Previous studies demonstrate the feasibility and positive impact of
mealtime conversations to deliver nutrition education, model healthy eating,
repeated exposure to healthy foods, support self-regulation, and promote healthy
eating in preschoolers (Dev et al., 2017; GolMohamadi et al., 2015; Ramsay et al.,
2013; Ramsay et al., 2017). However, due to a lack of knowledge and confidence
as effective role models (Ramsay et al., 2013, 2010), the implementation of
supportive mealtime practices is not always effective. Moreover, non-responsive
verbal comments during mealtimes are common practice and include asking
children if they wanted more food or if they were finished eating, telling children
to take, try, eat, or finish food, and praising children for eating without
referencing their internal cues (Dev et al., 2017). McBride and Dev (2014)
proposed an innovative approach designed to reduce caregiver controlling and
restrictive feeding in childcare settings by encouraging children’s attention to
satiety cues. The authors recommend training caregivers to use internal verbal
comments when talking to children during mealtimes. For instance, rather than
asking non-internal verbal comments “Are you done?” asking questions “Are you
full?” or “If you are hungry, you can have some more” can help children pay
attention to their internal signals of hunger and fullness. In addition to changing
the questions caregivers ask, other suggestions include teaching children
vocabulary to express their hunger and fullness signals (such as rumbling in
tummies) and discuss them, modelling and talking about their own feelings of
fullness; respecting children’s cues once expressed to help preschool children to
maintain their ability to self-regulate energy intake. In support of these
recommendations, a study conducted by Lanigan and colleagues (2019)
demonstrated that using a combination of child-centred nutrition phrases with
repeated exposure increased consumption of healthful foods by 3-6 year old
children, especially novel foods that children may typically refuse, compared with
repeated exposure alone. In this study, during the 6-week intervention preschool
children were given developmentally appropriate, accurate nutrition information
to help to understand how a food may benefit them and were offered to taste food,
which resulted in significantly greater consumption (P=.003) of that food
compared to the children who were engaged in general non−food related
52
conversation. This study supports the importance of mealtime conversations and

the potential benefit of consistent developmentally appropriate food-related
messages. Therefore, developing training for providers that focuses on using
responsive feeding practices can be a feasible and low-cost approach that can help
promote healthful eating in preschool-aged children (McCrickerd et al., 2018;
Johnson, 2000; Lanigan et al., 2019; McBride & Dev, 2014;).
To date, various local, state, and national training programmes aim to
deliver knowledge, skill-based lessons, and practical tips to providers related to
improving the nutrition environment in their childcare setting. Loth and
colleagues (2019) found that centre-based childcare providers participating in
federal, state and other nutrition training programmes, adhered to more nutrition
and physical activity best practices than those not involved in those training
opportunities. Several other studies reported favourable results in improvement of
overall nutrition environment with the delivery of providers’ training and
technical assistance (Neelon et al., 2014; Hollar et al., 2018; Lyn et al., 2013;
Smith et al., 2017; Sigman-Grant et al., 2011; Ward et al., 2008). For example,
Benjamin Neelon and colleagues (2014) reported significant improvements in
providers’ nutrition behaviours and reduction in the centres’ provisions of high-
sugar, high-salt and fatty foods, while Smith and colleagues (2017) found
significant improvements in the provision of whole grains and low fat foods,
provider nutrition behaviours, and nutrition environment following nutrition
training of providers. Likewise, Hollar and colleagues (2018) and Lyn and
colleagues (2014) found significant improvements in the nutrition environment,
nutrition training and education, and nutrition policies in the participating
childcare centres. Lyn and colleagues (2014) and Sigman-Grant and colleagues
(2011) reported that the delivery of training and technical assistance from a
nutrition professional, which included providing nutrition education materials and
printable resources for activities, was reported to be the most helpful support for
learning and adopting nutrition guidelines. A 3-year longitudinal study following
12,000 preschool children in seven kindergartens in Thailand examined the effect
of teacher nutrition education on children’s over-nutrition and obesity rates and
reported that the prevalence of obesity in children significantly decreased at the
end of the intervention only in those schools which had received teacher education
(Ratanachu-ek & Moungnoi, 2008). The ToyBox study, a successful multinational
53
early childhood obesity prevention programme aimed to promote healthy food and
active play for children aged 4–6 years across six European countries (Belgium,
Bulgaria, Germany, Greece, Poland and Spain), prioritised providers' training as a
critical element in creating and maintaining a health-promoting nutrition
environment (Payr et al., 2014). ToyBox nutrition trainings were designed to
enable providers not only increase their knowledge and develop skills but also
change their attitudes and habits, as well as enhance self-efficacy to empower
them to set environmental changes and to adapt the ToyBox programme to meet
any changing circumstances without sacrificing the programme principles (Payr et
al., 2014).
2.4.3 Challenges to food provision
National nutrition guidelines require early care services to provide

children with an adequate variety and amount of foods that both satisfy their
appetite and contribute to their nutrient intake. However, as mentioned earlier in
this chapter, recent systematic review (Seward et al., 2017) that described the
factors (barriers and facilitators) influencing the implementation of dietary
guidelines regarding food provision in centre-based childcare services, using the
theoretical domain framework, found that the implementation of dietary
guidelines is suboptimal. The review identified that ‘environmental context and
resources’ and ‘social influences’ were the most frequently reported factors that
impact the implementation of dietary guidelines and recommended menu content
in centre-based childcare services. The review reported that because implementing
new guidelines require an increase in food budget expenses by necessitating the
acquisition of new foods, cooking tools, recipes and up-skilling of staff, these
were perceived as barriers. In addition, providers reported insufficient menu
planning tools and resources and insufficient time. The providers believed or
experienced that children do not like the new, healthy foods which results in food
wastage. Other barriers in ‘knowledge’ (e.g. staff have limited general nutrition
knowledge and poor knowledge of the sector menu dietary guidelines) and
‘beliefs about capabilities’ domains (e.g. food service staff lack confidence in
their kitchen math skills and cooking skills) were reported (Seward et al., 2017).
On the other hand, the facilitators to overcome these barriers were identified as
strengthening relationship with food vendors and experienced cooks and using
54
pre-tested recipes as a means of assistance or support. In this systematic review,

qualitative studies identified a greater number of domains as barriers or
facilitators, compared to quantitative studies, suggesting that quantitative studies
may have overlooked many important factors influencing guideline
implementation in childcare setting.
A recent Australian study involved 202 cooks responsible for menu
planning and examined barriers and enablers to implementation of dietary
guidelines in early care settings (Grady et al., 2018). The study found that studies
reported low implementation of guidelines related to meat, vegetables, and
discretionary foods (high in energy, fat, sugar, and/or salt), and that none of the
childcare services included in the review were compliant across all food groups.
These findings were consistent with findings from the systematic review (Seward
et al., 2017) and international studies (Bell et al., 2015; Maalouf et al., 2013;
Yoong et al., 2014) that implementation of dietary guidelines is challenging and
highlight the need for strategies to support dietary guideline implementation. The
study confirmed the previous findings that a perceived cost of providing healthier
options, perceived lack of resources, training materials, vague nutrition guidelines
as well as a lack of understanding of how to apply dietary guidelines, were
perceived as barriers to implementation. Most services employed a cook with
limited or no training in cooking, food service, or menu planning (Grady et al.,
2018). Implementing strategies to overcome barriers such as the provision of
resources and professional development opportunities, will likely require
investment by governmental and childcare accreditation agencies responsible for
providing oversight of childcare service operational standards (Seward et al.,
2017) as well as community engagement (Stephens & Oberholtzer, 2018).
Community engagement - Farm to Preschool initiative

One example of a community programme to address the implementation
barriers and increase the quality of childcare setting is a Farm to Preschool
initiative which is a part of a wider Farm to School movement in the USA (NFSN,
2019). Farm to Preschool is a set of activities and strategies that include the use of
fresh locally grown and seasonal foods, gardening opportunities, and food-based
learning activities such as cooking lessons and farm-field trips. These activities
change traditional food purchasing and education practices and enhance the
55
quality of preschool menus and educational experience, rendering an engaging

way to teach nutrition and encourage children to eat fruits and vegetables. A 2016
systematic review analysed 14 Farm to Preschool intervention studies and
identified types of farm-to-preschool activities, motivations, needs, challenges and
barriers to implementation and documented the results of the National Farm to
Preschool Survey. The farm-to-preschool intervention and survey outcomes
included an increase in children's preference for and consumption of produce,
increased willingness to try new fruits and vegetable, increased knowledge of
food origins, positive reactions from both parents and teachers, and positive
changes in parent behaviour, including increased local food consumption at home
(Hoffman et al., 2017). In general, from wider Farm to School programmes’
experience it was demonstrated that these programmes offer many benefits to
students, schools, local farmers, and entire communities (Tonti, 2017). These
activities also increase community connections by promoting local commerce and
opening new markets to small- and medium-sized farms, thus promoting
significant financial benefits for both schools and local producers. For example,
direct school-to-farm procurement often brings down the transaction costs for
both schools and farmers (Conner et al., 2012; Izumi et al., 2010). On the other
hand, small local producers have an incentive to perform responsibly in order to
continue to take advantage of schools' market opportunities (Ahearn, 2012).
Additionally, several studies reported positive nutritional outcomes when children
grow fruit and vegetables, and prepare, cook or bake food in childcare setting
(Dawson et al., 2013; DeCosta et al., 2017; Gerritsen et al., 2018; Hersch et al.,
2014; McKee et al., 2020).
2.4.4 Parents’ involvement
Families play a critical role in the implementation of wellness policies in

childcare centres (McKee et al., 2020). Within the ecological framework
perspective (Bronfenbrenner et al., 1999), the determinants of behaviour are a
complex interplay between elements within the environment and they influence
not only the behaviour of interest but also each other, and it is their combined
influence that determines human behaviour, forming a complex system (Gubbels
et al., 2014). In line with this, settings such as the home and childcare setting
interact with each other in influencing children’s eating behaviour and weight
56
status. In other words, the influence of the childcare environment depends on what
happens at home, and vice versa (Gubbels et al., 2018). Recent qualitative
research indicates that these interactions are important, particularly
communication between childcare providers and parents and mutual support in
promoting healthy eating behaviours (Dev et al., 2017; Garcia et al., 2018; McKee
et al., 2020; Mena, 2019). However, inconsistency between home and childcare
setting is hypothesised to have negative effects on child outcomes (Gubbels et al.,
2018). Previous research found that many childcare centres face barriers with
effective communication with parents (Dev et al., 2017; Johnson et al., 2013;
McKee et al., 2020)These barriers include poor parental motivation and lack of
parental engagement (Hakyemez-Paul et al., 2018; Lyn et al., 2014), providers’
limited time and challenges of communicating with parents (Dev et al., 2017;
Hakyemez-Paul et al., 2018; Johnson et al., 2013), parents offering unhealthy
foods and providers reporting their concern that parents are not receptive to
nutrition education materials (Dev et al., 2017). Parental beliefs and attitudes were
also commonly mentioned as a barrier for promoting healthy nutrition in childcare
(Gerritsen et al., 2018; Hirsch et al., 2016; O’Malley, 2019). For example, in a
study by Dev and colleagues (2016) some providers reported that they had to
pressure children to eat due to negative parental response if their children did not
eat while in child care. On the other hand, childcare providers take on the role
they can play to influence parents regarding children’s nutrition by giving
information and advice, however, they are cautious about not offending the
parents (Johnson et al., 2013). In line with this, Hennink-Kaminski and colleagues
(2018) argue that careful communication is needed to avoid triggering feelings of
guilt among parents and perceptions of superiority among providers. Parents
recognise that childcare practices influence the home situation and child’s
behaviour at home, both positively and negatively (Baumgartner & McBride,
2009; Mena et al., 2015). Parents also actively sought parenting advice from
childcare workers (Johnson et al., 2013; Lloyd-Williams et al., 2011).
To overcome barriers and encourage more effective communication
between childcare providers and parents, various strategies have been proposed.
Examples include childcare providers offering a demonstration of food
preparation techniques; providing parents with recipes, menus, and nutrition
newsletters; and communicating with parents on a one-to-one basis about their
57
children’s eating and nutrition (Johnson et al., 2013); and suggestions from
parents to use written communication, such as staff providing parents with daily
written information on what child ate or not or a daily sheet with a checklist of
eating issues, a parent handbook containing preschool’s food policies, or a
calendar of meals (Johnson et al., 2013). An effective strategy, in a study of
communication barriers between child care providers and parents (Dev et al.,
2017), was having a formal system-wide policy, which helped directors be more
confident when communicating with parents. Providers reported that it was easier
for them to communicate about the new system-wide practices to parents than it
would have been if they were making policy changes as a single centre.
Some efforts have been undertaken to engage the community and families
in improving the quality of child care they received. For example, in the USA,
licensed childcare programmes can volunteer to be rated by Parent Aware
Program, a Minnesota’s voluntary Quality Rating and Improvement System,
which assesses childcare programmes based on their participation in and
commitment to on-going trainings, adherence to a range of childcare best
practices, improvement of nutrition and physical activity environments, and
commitment to maintaining daily activities that help children learn and grow
appropriately (Loth et al., 2019). As an incentive, providers who engage in the
Parent Aware evaluation process are provided with free education, coaching and
training opportunities as well as scholarship opportunities. In addition, higher
ratings can be used by providers as a marketing tool to attract families looking for
a childcare provider (www.parentaware.org). A recent study shows that Parent
Aware and engagement in training were positively associated with adherence to
nutrition practices in both childcare service and family home setting, and with
adherence to physical activity practices in family homes (Loth et al., 2019).
2.4.5 Healthy eating policies
A healthy eating policy for childcare service is a document that defines the
activities that enable implementation of national nutrition guidelines such as
providing healthy meals, snacks and beverages for children and applying
developmentally appropriate health-promoting child feeding practices. Healthy
eating policies can help set clear expectations for childcare providers and can
serve as a means through which centres may be held accountable for their
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practices. In addition, routinely communicating it to staff and parents is

evidenced to be beneficial to support the implementation of healthy eating
policy in childcare setting (Dev et al., 2017; Loth et al., 2019). Research findings
show that, in preschools that served snacks, the practice of serving biscuits as a
snack was significantly higher in the absence of a healthy eating policy (n=16;
84.2%). Conversely, in preschools where snacks were provided by parents (n=21),
providers of preschools with a healthy eating policy (n=13) had better
communication with parents regarding appropriate snack provision and were more
likely to advise parents on healthier snacks (P=0.047) than the preschools without
healthy eating policy (Jennings et al., 2011).
Furthermore, research shows that unless policies are written, policy
communication, implementation, compliance, and enforcement may be
compromised (Falbe et al., 2011). Numerous studies show that having written
nutrition polices have demonstrated benefit in facilitating supportive feeding
environments in childcare setting (Lyn et al., 2013; Sigman-Grant et al., 2011;
Smith et al., 2017) and improving some eating behaviours of preschool children
(Kakietek et al., 2014; Lehto et al., 2019) and staff (Neelon et al., 2014). For
example, Lehto and colleagues (2019) found that having many written food
policies in preschool setting was associated with a higher intake of vegetables (p =
0.01) and fibre (p = 0.03) among the children. Similarly, caregivers were observed
modelling healthy dietary behaviours more frequently at centres that had written
policies about staff discouraging unhealthy foods for meals and snacks and having
informal nutrition talks with children at meals, compared with caregivers at
centres without such policies (Erinosho et al., 2012).
2.5 Nutrition-related research in early care setting in Ireland
In Ireland, the two most recent studies that assessed food-related services
in early care settings have identified areas for improvement in regards to
preschool nutrition practices and food environment (Jennings et al., 2011;
Johnston Molloy, 2013).
In the first study, conducted in preschools in the North West of Dublin,

Jennings and colleagues (2011) conducted a telephone questionnaire completed
by 54 preschool managers to examine preschool dietary practices, food provision
59
and the association between these and preschool size. The nutritional training
attendance and preschool staff nutritional training needs, possession of the Food
and Nutrition Guidelines for Preschool Services (the Guidelines) and having a
healthy eating policy were also investigated. The study demonstrated inadequacies
in healthy eating policy enforcement, menu planning, meal time practices, and
nutritional training for childcare staff. The results showed that 20 (37%)
preschools did not have a written healthy eating policy; attendance at nutritional
training was reported by 40 (74%) preschools; and possession of the Guidelines
by 40 (74%) preschools. Inappropriate beverages were served to children aged 1–
5 years in 43 (80%) preschools and snacks in 37 (69%) preschools, respectively.
Only 2 preschools served juice with meals, diluted to the recommended strength
of one part juice to four or five parts water (Department of Health and Children,
2004). However, unexpected results were also found such as a greater incidence
of serving biscuits with possession of the Guidelines (P=0.008) and inappropriate
beaker introduction in preschools with a healthy eating policy (P=0.032). The
authors also found that vague nutritional regulations and non-mandatory
guidelines have resulted in variability in healthy eating policies, many of which
were not enforced, and possession of the Guidelines did not consistently result in
their use. The study highlighted the need for nutritional training of preschool
managers and identified barriers to the provision of effective training, including
poor baseline nutritional knowledge of staff, low familiarity with and use of the
Guidelines, high staff turnover and limited staff and parental involvement in
dietary practices (e.g. in policy and menu development). Preschool managers’
perceived nutritional issues and training needs included the need for provision of
appropriate preschool nutritional resources, particularly related to nutritional
education and health promotion (n=18, 33%) and general healthy eating (n=11,
20%), the need for parental education (n=29, 54%), while half of managers (n=27)
expressed concerns regarding menu planning and requested menu planning
support and practical ideas for meals and snacks. Jennings and colleagues (2011)
concluded that a clear and detailed written policy is vital for enabling optimum
nutritional practices and the policy can be used to substantiate nutritional practices
when issues arise.
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The second study, the Healthy Incentive for Preschools Project (HIP),
which took place in 58 preschools of three midland counties in Ireland in 2008-
2012, aimed at developing a validated nutrition- and health-related evaluation tool
and an education information resource for preschools, and determining whether
their use can promote improved food service and nutrition and physical activity
practices in this setting (Molloy et al., 2011; Johnston Molloy, 2013). Preschools
were divided into two randomised training groups: ‘manager-trained’ and
‘manager-and-staff-trained’ and pre- and 6-9 months post-intervention data was
collected using survey, preschool managers’ self-assessment questionnaire and
direct observation. Data collected through direct observation (food and fluid
provision, physical activity, outdoor time, staff practices and availability of
nutrition and health resources) were recorded during one full-day spent in each
preschool both pre- and post-intervention, using a specifically developed and
validated Preschool Health Promotion Activity Scored Evaluation Form. Post-
intervention, self-assessment data were also collected using the same evaluation
tool.
The study assessed ‘whole school’ policy on nutrition and physical activity
and the food environment and showed the lack of a health promoting food
environment. Observation revealed that meals tend to be rushed with children
being told to hurry up, cleaning taking place, and children leaving the table and
being allowed to play while other children were still eating. Pre-intervention
results showed that preschools in the majority of cases did not practice supportive
feeding practices. For example, in ‘manager-trained’ group (24 preschools), 88%
of preschools did not provide family style food service, 42% did not allow
adequate time for meals or snacks, 13% did not allow self-service and 92% did
not provide adequate age-appropriate eating and drinking utensils for infants and
children. Lack of nutrition policies and inadequate portion sizes were also
observed, resulting in public health concern regarding nutritional quality and
amount of food served (Johnston Molloy et al., 2013).
The training intervention consisted of a one-hour individual face-to-face
training session with each preschool manager in both ‘manager-trained’ and
‘manager-and-staff-trained’ groups by a research dietician and an additional 1.5-
hour long structured staff information session delivered to all staff members by
the research dietician in the ‘manager-and-staff-trained’ group. During the
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training session for preschool managers the Preschool Education Resource Pack
was introduced to each manager, and each best practice criterion on the Preschool
Health Promotion Activity Scored Evaluation Form was outlined and discussed.
In addition, each manager was provided with their individualised ‘written
feedback record’ from the pre-intervention assessment. Each observation on this
record and the suggested strategies for improvement were discussed with the
manager.
Post-intervention results showed that the nutrition education of managers
and stuff almost doubled the ‘best practice’ score of participating services,
resulting in significant improvement in nutrition- and health-related practice in all
areas evaluated: environment, food service, meals and snacks. It is worth noting
that a larger proportion of preschools (21%) in the ‘manager-trained’ group
attained a ‘best practice’ score than in the ‘manager-and-staff-trained’ group,
suggesting that the positive role of leadership may have had an impact. Overall, it
was found that ‘manager-trained’ nutrition education was equally effective as
training both managers and staff. Given the additional costs needed for providing
staff training by the Health Service Executive and the challenges related to
releasing staff for training from preschools, this finding proved the cost-
effectiveness of the ‘manager only’ training (Molloy et al., 2015). This study was
one of only few studies in Ireland that included a nutrition intervention in
preschool setting with training preschool staff and pre- and post-training
assessment. The study concluded that as the Food and Nutrition Guidelines for
Preschools are not mandatory, methods to encourage the provision of nutritious
food in this setting must be investigated, implemented and evaluated and further
research in this field is required (Johnston Molloy, 2013; Wolfenden et al., 2016).
The need for further research

While these quantitative studies identified important factors such as the
organisational characteristics and staff behaviours and practices that influenced
the implementation of nutrition guidelines in Irish centre-based childcare services,
they were conducted long time ago and many policy and regulatory changes took
place in the early care sector since then. The studies’ findings indicate the need
for further research to better understand the influence of these factors not only on
62
the implementation of nutrition guidelines but also on promoting healthy eating

behaviours in preschool children.
The studies identified important barriers to healthy eating in preschools
including families’ poor nutritional knowledge and dietary habits and highlighted
the importance of parental involvement in preschool nutrition. However, the
studies did not address issues related to the context of such a situation and did not
explore in-depth the relationship between staff and parents in promoting healthy
eating among children. Furthermore, although these studies identified several
barriers to implementation of nutrition guidelines, none of the studies explored the
existing or potential facilitators for improvement of the preschool nutrition
environment and nutrition practices. Understanding of both barriers and
facilitators to promoting healthy eating in the preschool setting would be a
valuable contribution to inform a more effective and efficient design of future
nutrition interventions in this setting. Finally, these studies assessed the nutrition
knowledge and perceptions of only preschool staff and did not explore
perceptions of other key stakeholders – children and parents.
As the studies concluded, methods to encourage the provision of nutritious
food in the preschool setting must be further investigated, implemented and
evaluated and, therefore, more research in this field is required (Jennings et al.,
2011; Johnston Molloy, 2013).
2.6 Regulatory background and recent developments in the early

years sector in Ireland
The Early Care Regulatory framework
Governmental agencies
In Ireland, the regulation and inspection of early care services is
provided by law, specifically by the Child Care Act 1991. Specifics about the
regulation of childcare services are set out in the Child Care Act 1991 (Early
Years Services Regulations 2016). These Regulations set down the standards of
health, safety and welfare that must be in place before early care services can
be provided. Overall, the Department of Children, Equality, Disability,
Integration and Youth (DCEDIY) has responsibility for these Regulations and
for developing policy in the early care sector in Ireland. DCEDIY manages and
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coordinates the childcare strategy in each county and city area through its local
agents, comprising 30 City and County Childcare Committees (CCCs). CCCs
support the implementation of early education and childcare programmes at local
level by providing information, delivering professional development training and
mentoring on quality practice, and meeting statutory regulations as well as
providing guidance for families on sourcing quality early years’ services and
accessing various capital programmes. Pobal, a not-for-profit company that
manages programmes on behalf of the Irish Government and the EU, funds CCCs
and oversees their work and provides development supports. DCEDIY, Pobal and
the CCCs also work collaboratively via a case management process to ensure that
any contracted services experiencing challenges are closely supported. CCCs are
often the first point of contact for service providers and parents in relation to early
childhood care and education initiatives such as the national childcare funding
programmes and the national quality and curriculum frameworks, Síolta and
Aistear.
Síolta and Aistear

Early years services are assessed and accredited through Síolta, the
National Quality Framework for Early Childhood Education, which was first
published in 2006 and is managed by the Department of Education. Síolta
established 12 Principles, 16 Quality standards and 75 Components that all early
childcare settings should meet when providing a quality service and includes a
self-assessment Quality Assurance Programme. The latter indicators of quality of
an early childcare setting, the Components of Quality, provide quality indicators
for all practitioners in implementing Síolta and relate directly to the Standards and
act to break them down into more focused and specific parts (www.siolta.ie)). The
operation of Síolta is closely linked with Aistear, the national Early Childhood
Curriculum Framework developed in 2009 for the education and care of children
from birth to six years in Ireland under the National Council for Curriculum and
Assessment. The Framework uses four interconnected themes to describe the
content of children's learning and development: Well-being, Identity and
Belonging, Communicating, and Exploring and Thinking.
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Non-governmental organisations
There are several non-governmental, not-for-profit and voluntary
organisations in Ireland that are involved in promoting health, including healthy
nutrition, in early care services. One of the key organisations is Early Childhood
Ireland, the largest national member-based organisation in the early years sector
with 3,800 childcare members, representing almost 75% of childcare service
provision in the country. The organisation supports over 20,000 early childhood
educators and 100,000 children and their families through preschool, afterschool,
and full-day care provision nationwide and represents their interests and needs.
The focus of Early Childhood Ireland's work has concentrated on providing
pedagogical and governance leadership, continuous professional training, advice
and support, support for new developments and legislative compliance,
networking, and lobbying to support members in the provision of quality services
in early years settings and afterschools (www.earlycholdhoodireland.ie).
Another leading organisation involved in early years sector in Ireland is
the National Childhood Network (NCN), a non-profit organisation that supports
the attainment of high quality standards in both early childhood and afterschool
services and provides a broad range of supports to the sector through information
provision, training, professional development, on-site mentoring, risk assessment
and collaborative working with other agencies on the island of Ireland
(www.ncn.ie). The NCN operates at local, regional, cross-border and national
levels with both voluntary and statutory agencies.
In consideration of food safety, Safefood is an all-island implementation
body set up under the British-Irish Agreement with a general remit to promote
awareness and knowledge of food safety and nutrition issues on the island of
Ireland. Safefood is actively involved in tackling obesity and other nutrition
related issues on an all-island basis through cooperation and collaboration with
key nutrition stakeholders on the island of Ireland.
Food and nutrition guidance for preschools
Provision of food and nutrition in preschool service (early learning and

care setting for children under six years of age) in Ireland is regulated by several
governmental bodies such as Department of Health, Health Service Executive
(HSE) and Tusla, a state Child and Family Agency responsible for improving
65
wellbeing and outcomes for children. According to the national Childcare

(Preschool Services) Regulations 2006, preschool providers must ensure that
children are given regular drinks and food in adequate quantities for their needs,
in consultation with parents where concerns exist. In addition, under the Child
Care Act 1991 (Early Years Services) Regulations 2016 (2016), a registered
provider should ensure that adequate and suitable, nutritious and varied food and
drink is available for each preschool child attending the preschool service. The
Department of Health (2004) released the Food and Nutrition Guidelines for
Preschool Services with the following guidance on food and beverages to be
provided by the preschool service, which is also reflected in Tusla’s Regulation
22 ‘Food and Drink’:
• Children in day care for more than 5 hours per session (full-day care)
Offer at least two meals (one hot) and two snacks, for example – breakfast,
snack, lunch and snack. If children are there for a long day, an evening meal
may also need to be provided.
• Children in day care for up to 5 hours maximum per session (part-
time day care)
Offer at least two meals and one snack, for example – breakfast, snack and
lunch. It is not necessary to have a hot meal; however, the meal should include
at least one serving from each food shelf on the food pyramid.
• Children in day care for up to 3.5 hours per session (sessional and
half-sessional preschool service)
Offer one meal and one snack – for example snack and lunch or breakfast and
snack.
Clean and safe drinking water is available and accessible to children at all
times.
The Health Service Executive, which is the implementing agency of the

Department of Health in charge of management and delivery of health and
personal social services, is responsible for operation of these requirements of
statutory compliance with regulations on food and drinks served at preschools and
inspection of preschool services (including preschools, play groups, nurseries,
crèches, day-care and other similar services looking after more than 3 preschool
66
children) under the Child Care (Preschool) Regulations 2006. There are
Preschool Services or Preschool Inspection Teams in each of the HSE's 32 Local
Health Offices nationwide that administer these functions at local level.
Additionally, at local level, the Community Nutrition and Dietetic Services are
involved in promotion of healthy nutrition in communities and working with early
care service providers on issues related to nutrition in preschool settings.
In addition, the Child Care Act 1991 (Early Years Services) Regulations
2016 gives Tusla the authority to assess compliance with the regulations which
promotes the care, safety and wellbeing of children attending early years services.
The preschool service providers are required to register with Tusla and take all
reasonable measures to safeguard the health, safety and welfare of preschool
children attending their service. Tusla’s Early Years (Preschool) Inspectorate is
the independent statutory regulator of early years services in Ireland and is
responsible for regulation and inspection of food provision and mealtimes in the
preschool settings. In the Tusla’s Inspection Tool, the Regulation 19-1(a) ‘Eating
and drinking’ is related to nutrition and it states that a registered preschool
provider should ensure promotion of healthy food, availability of snacks and
drinking water; supervision and timing of feeding; encouragement of self-feeding
if appropriate; availability of menus and availability of age-appropriate feeding
equipment; and encouragement of children’s choices (Early Childhood Ireland,
2017). However, the Tusla Inspection Tool does not outline mealtimes and other
preschool nutrition practices as an assessable standard for accreditation and the
national standards for food and drinks are vaguely stated as ‘to be nutritious and
appropriate’. In addition, there is a limited literature in Ireland to reflect
observation of mealtime practices or qualitative research to comment upon the
effectiveness of the implementation of national standards.
The Food and Nutrition Guidelines for Preschool Services (Department of
Health and Children, 2004) were developed by the Department of Health and
Children in 2004 to provide practical information to early care settings on a varied
and healthy diet for children from 0 to 5 years of age in the context of promoting
health and the Child Care Regulations 1996. The Guidelines cover a range of
nutrition-related issues such as food safety and preparation, suggestions for food
variety for meals, snacks and beverages, serving sizes, food allergies and special
food needs, ideas for activities with children to help them in developing positive
67
attitudes to eating and physical activity, an outline of healthy eating policy, and a
list of local nutrition-related contacts. A new Food Pyramid for children aged 1-4
years was published in 2020 and was included in the Guidelines. The Preschool
Guidelines are intended as a standard resource for preschool managers and
Preschool Inspection Teams. They can also be used for in-service training of
preschool workers. A new Nutrition Standards for Preschool Meals are currently
under development in Ireland. A ‘3-Week Menu Plan - A Resource for
Preschools’ was developed by the Health Service Executive in 2004 (HSE, 2004)
and was devised as a practical tool to support preschool services to implement the
recommendations of the Food and Nutrition Guidelines for Preschool Services by
providing ideas for healthy menus, including suggestions for specific dietary
needs. ‘Serving Size Guide for Preschools’ was developed by Safefood which
provides visual guides for different types of foods (starchy, protein, dairy foods,
fruits and vegetables, composite foods, and desserts). The guide has illustrations
that show what a serving size of a selection of foods in the ‘3-Week Menu Plan’
and a number of other everyday foods looks like when served on a plate
(Safefood, n.d.). In addition, in collaboration with Early Childhood Ireland
(www.ncn.ie), Safefood developed Little Bites, an online resource for early
childcare providers that delivers information and advice on healthy eating, food
safety and hygiene, food allergens, portion sizes for preschool-aged children and
other food and nutrition related issues. One example is “Sally and Sammy” stories
for small children that aim to increase a child’s experience of healthy food from
an early age and encourage a positive attitude towards a healthy diet. The stories
are downloadable or can be watched online and followed by questions to facilitate
discussions with children about food topics.
A template policy on healthy eating with guidelines

The Irish national nutrition guidelines provide a template policy on healthy
eating with guidelines (Tusla, n.d.) to aid the development of a healthy eating
policy by individual early care services. According to this template, the policy
must include the core elements set out in the Tusla Quality and Regulatory
Framework Policy on Healthy Eating (www.tusla.ie) and be comprised of the
following main parts:
• Policy Statement - outlines the principles, values and the purpose of the policy;
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• Procedures & Practices - outlines the specific steps and/or guidance to be

followed in order to implement the policy;
• Communication Plan (for staff & families);
• Supporting Documents such as legislation and policy documents
The guidelines advise that a healthy eating policy related to preschool-aged

children should include the following core elements:
• It is available and communicated to all parents and guardians.

• It sets out how sufficient, suitable and nutritious food and drink are available
to each child depending on their age, development and needs, covering
information about:
o specific dietary requirements;
o appropriate serving size;
o the food and drinks children bring to the service;
o availability of drinking water at all times;
o availability of weekly menu plans adhering to meals, snacks and
drinks.
• It states that the menu be displayed in the service and that it includes a wide
variety of healthy foods.
• It states that any changes in the menu are noted, and any foods that are
substituted are of equal nutrient value.
• It states that the main meal must include appropriate servings of protein,
starch, dairy, vegetables and iron.
• It states that parents and guardians are informed if their child has not eaten
well.
• It details that staff sit with children during meal or snack time and encourage
good eating habits.
• It describes how food is safely stored, prepared and served.
• It states the requirements when outside catering companies are used.
• It describes how birthday parties and special occasions are celebrated.
• Specific dietary requests are managed, for example – hypersensitivities,
religious requirements, and so on.
69
While, generally, nutrition guidelines provide templates or models of a

childcare nutrition policy, each childcare setting has its own unique set of
circumstances (e.g. varying levels of autonomy, budget and available resources,
various sources of support, staff training level, etc.), and thus there is often a need
to adjust the common aspects of the nutrition policy to fit the needs of the
individual childcare setting.
Recent reforms and strategies
The governmental reforms in early care sector

Despite recent important advancements in the early years sector, Ireland
invests approximately 0.2% GDP in the early years sector (Department of
Children and Youth Affairs, 2018). This is significantly below the OECD average
of 0.8% GDP and the UNICEF international benchmark of 1% GDP while leading
countries in this area (such as the Nordic countries) invest between 1.2% and
1.9% GDP in the sector (OECD, 2015a). In the meantime, Ireland has been
among the countries with the highest childcare fees in the world. In 2015, the
gross costs of full-day childcare represented 54% of the average wage in Ireland
for a 2-year-old in full-day care, double the OECD average of 27% and 23% of
EU countries (OECD, 2015b).
However, with increasing recognition of the importance of childhood as a
foundation of health and wellbeing throughout all life stages, a series of important
governmental reforms and initiatives have been rolling out in Ireland for the past
two decades, particularly in recent years. In 2000, a ten-year National Children’s
Strategy, Our Children – Their Lives (2000-2010) was launched as the first
strategic statement by the Government of Ireland that children’s lives required a
coherent and common approach across policy domains. The strategy was an
innovative step in Irish policy making, being Ireland’s first ever national
children’s strategy and one of the first globally. Its specific focus on children and
its commitment to children as participants in the policy-making process marked it
out as an important milestone in changing attitudes towards children in Ireland.
As part of the national strategy, several governmental initiatives such as the Equal
Opportunity Childcare Programme (2000-2006) and the National Childcare
Strategy (2006-2010) were implemented with key objectives to improve
70
availability of childcare and further develop the childcare infrastructure to meet

the needs of children and their parents for quality early childhood care. To
implement the strategy, a major investment programme in childcare infrastructure,
the National Childcare Investment Programme (2006 – 2010) was introduced,
with €575 million allocated to this five-year programme, including €358 million
for capital investment, with the creation of 25,000 new childcare places and
establishment of County and City Childcare Committees (Children’s Rights
Alliance, 2011). The Government decided to create the dedicated Department and,
in June 2011, the Department of Children and Youth Affairs was established. The
first national children’s strategy was followed by the second strategy - Better
Outcomes, Brighter Futures: National Policy Framework for Children and Young
People (Department of Children and Youth Affairs, 2014) which set out the
Government’s agenda and priorities in relation to children and young people aged
under 25 years over the period 2014-2020 (Figure 2.2). This national framework
represents a new ‘whole-of-Government’ effort to improve outcomes for children
and young people that recognises the shared responsibility of achieving these
results. The framework endorses a cross-governmental approach, in line with the
goals of Healthy Ireland, the National Framework for Improved Health and
Wellbeing 2013-2025 (Healthy Ireland, 2019), to seek to improve all aspects of
health and wellbeing and to reduce risk-taking behaviour in children, with a
particular focus on promoting healthy behaviours and positive mental health and
in disrupting the emergence of poor outcomes such as diet-related non-
communicable diseases arising from childhood overweight and obesity.
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Figure 2.2 The 6 transformational goals for achieving the 5 national outcomes
within the Better Outcomes Brighter Futures: National Policy Framework for
Children and Young People in Ireland 2014-2020 (Department of Children and
Youth Affairs, 2014)
One of the key strategies to achieve Better Outcomes, Brighter Futures

Framework’s aims is the focus on ‘Quality services’. This focus warrants the
government investment in children being more outcomes-driven and informed by
national and international evidence on the effectiveness of expenditure on child-
related services and resource allocation within services based on evidence of both
need and effectiveness. In other words, the Framework seeks to promote a shift in
policy toward earlier intervention and to ensure the provision of quality early
years services and interventions aimed at promoting best outcomes for children.
This could be achieved through commitments made to continue to raise the
quality of early care and education (Department of Children and Youth Affairs,
2018).
“First 5” - the National Early Years Strategy

The Framework was followed by several key strategic documents and
policies including Ireland’s first national early years strategy - First 5: A Whole-
of-Government Strategy for Babies, Young Children and their Families 2019-
2028 - launched in November 2018. This strategy, also called the National Early
72
Years Strategy, is a major milestone in policy development for the youngest

members of society and it is Ireland’s first ever national strategy that focuses on
the early childhood, from birth to age five, and covers all aspects of children’s
lives. The strategy takes up for the first time a joined-up cross-governmental
approach to the issue of supporting children and their families during the early
years.
The Strategy adopted the term Early Learning and Care (ELC) to define:
“any regulated arrangement that provides education and care from birth to
compulsory primary school age – regardless of the setting, funding, opening hours
or programme content – and includes centre and family day-care; privately and
publicly funded provision; preschool and pre-primary provision.” (p.26). ELC
includes centre-based ELC and regulated home-based ELC but excludes
grandparental care and the early years of primary school. This term has been
chosen as it recognises the inseparability of learning and care as high-quality care
includes learning, and high-quality learning is dependent on care. The term ELC
was proposed with an assumption that it can be broadly understood by all,
ensuring that the nature and value of this work continues to gain wider
recognition.
The National Early Years Strategy sets out a range of programmes and
initiatives for families, communities, health services, and ELC services among
others. This ten-year plan (2019-2028) sets out the early childhood system
infrastructure that needs to be established or strengthened to embed and sustain
these new developments. One of the plan’s important components is a reform of
the Early Learning and Care system, including a new funding model to further
improve affordability, accessibility and quality of early care services. Measures
include introducing the new National Childcare Scheme, moving progressively
towards a graduate-led professional ELC workforce and the extension of
regulations and supports to all paid child-minders and school-age childcare
services.
The ECCE and other targeted programmes

The Irish Government provided approximately €260 million in 2015 to
ELC and SAC (School-Age Childcare) (Department of Children and Youth
Affairs, 2015). The majority of this funding (i.e. approximately €246 million) was
73
directed towards three programmes, which aim to improve accessibility,

affordability and quality of ELC services. These targeted programmes – the Early
Childhood Care and Education (ECCE) Programme, the Community Childcare
Subvention (CCS) Programme, and the Training and Employment Childcare
(TEC) Programme were funded by the DCYA and supported provision for more
than 100,000 children each year (Department of Children and Youth Affairs,
2015). The latter two programmes are currently in the process of being replaced
by the new National Childcare Scheme. The remaining €14 million funded all
CCCs, the national voluntary childcare organisations, and various early care
quality development and training initiatives and grants (Department of Children
and Youth Affairs, 2015).
Total public investment on ELC was €574 million in 2019 (Department of
Children and Youth Affairs, 2019a). This represents a significant increase – of
more than 116% - since 2015 (Department of Children and Youth Affairs, 2018).
However, despite budget increases for ELC (and school-age childcare), the
proportion of national budget allocation to ELC is low compared to other
developed countries. Per capita investment in ELC is considerably lower than
investment in primary education. Under the First 5 Strategy, the then Minister for
Children and Youth Affairs Dr. Katherine Zappone announced plans to at least
double investment in ELC over the next decade (Department of Children and
Youth Affairs, 2019c).
There are a number of main aims of the Government’s current investment
in early years and the following ELC system reforms led by the Department of
Children and Youth Affairs have been introduced in the recent years:
• Promotion of optimal development for all children is important,
therefore, narrowing the gap in attainment between children of different socio-
economic backgrounds can be achieved through the provision of quality ELC
services. This aim has been pursued through the Early Childhood Care and
Education (ECCE) programme by introducing a universal one-year free
preschool programme in 2011, which was extended to two years in September
2018, available to all eligible children before starting primary school.
• Parents’ opportunity to participate in the workplace provides an
important protective factor against child poverty and related child outcomes. To
74
address this aim, the targeted childcare scheme (TEC) enabled parents to prepare
for a return to paid employment by participating in training, education and other
activation measures by providing subsidised childcare places. On the other hand,
parents on a low paid employment avail of reduced childcare costs at participating
ELC services (CCS).
The National Childcare Scheme

In March 2019, the new National Childcare Scheme (NCS) was
introduced and commenced in October 2019. The new Scheme is the first ever
statutory entitlement to financial support for childcare (under Childcare Support
Act 2018 (Payment of Financial Support) Regulations) that is currently replacing
all previous targeted programmes with a single, streamlined and user-friendly
scheme and will include “wrap-around‟ care for preschool and school-age
children. Parents can apply online directly to the Scheme for financial support,
meaning providers will no longer need to manage parental paperwork in order to
apply for subsidies. The Scheme has started to operate under a single system to
ensure streamlined administration for childcare providers and establish a flexible
and future-focused platform to invest in ELC and SAC (Department of Children
and Youth Affairs, 2019d). There are two types of supports available under NCS
(1) a universal subsidy, available for all families with children aged 24 weeks – 36
months (or until the child qualifies for the ECCE programme, if later) and (2) an
income-assessed subsidy, payable for children from 24 weeks to 15 years of age
who are using childcare services with any participating Tusla registered service
(Department of Children and Youth Affairs, 2019d).
Other planned future developments in early years sector in Ireland include
reviews of the operating and inspection systems; a review of the universal
preschool programme and preparation of legislation to place it on a statutory
footing; regulation of child-minders; development of a New Funding
Model, which will provide additional resources to services which meet key
indicators of quality and affordability; and a doubling of public investment in
ELC over the decade (Department of Children and Youth Affairs, 2019a)
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2.7 A settings approach to health promotion: theoretical

foundation for the study
The World Health Organization's 1986 Ottawa Charter for Health

Promotion defines health promotion as ‘the process of enabling people to increase
control over, and to improve their health’ that articulates core values of equity,
participation and empowerment (WHO, 1986). The Charter proposed a
framework of three strategies: 1) advocacy for favourable conditions for health; 2)
enabling all people to reach their full health potential; and 3) mediating between
different interests in society for the pursuit of health) and Five Areas of Action:
• Building healthy public policy, at all sectors and levels of government;

• Creating supportive environments, to improve living and working
conditions;
• Strengthening community action in priority setting and in strategies;
• Developing personal skills, through education for health and life skills;
• Reorienting health services towards health promotion (WHO, 2009).
‘Creating supportive environments’ has been identified as one of five key
strategies for health promotion and is defined as developing physical and/or social
environments in ways which support health and protect against physical hazards
and socially and psychologically damaging practices. This can be done by
changing physical or social environments, by organisational change, or by
offering additional infrastructure, programmes or services. Physical environments
encompass the natural and built environments, and the social environment
incorporates the psycho-social and cultural environments, the activities and
relationships of the people in the setting and the influences on their interactions.
Steps to create supportive environments can be taken by individuals, community
groups, organisations and governments and can take place at structural, social and
personal levels (Ottawa Conference Report, 1986; Nutbeam & Harris,
1995; WHO, 1998).
The Ottawa Charter emphasised the health promoting role of the setting:
“Health is created and lived by people within the settings of their everyday life;
where they learn, love, work and play” (Ottawa Conference Report, 1986). The
settings approach has featured prominently in subsequent international health
promotion conferences. The Sundsvall Statement of 1992 called for the creation
76
of supportive environments with a focus on settings for health. In 1997, the

Jakarta Declaration emphasised the value of settings which “represent the
organisational base of the infrastructure required for health promotion” (p. 4) and
“offer practical opportunities for implementation of comprehensive strategies”
(WHO, 1997, p. 2). In 2016, the Shanghai Declaration stressed the importance of
the local level and the local environment on everyday life of communities. It
noted two important factors to support promotion of health: local leadership and
citizen engagement in settings (WHO, 2016).
Health promotion has adopted the idea of settings as a strategic way of
implementing programmes aimed at encouraging health-enhancing environments
(WHO, 1991). A key factor behind the increased theoretical and strategic interest
in the settings approach has been the ecological perspective of health promotion
with reduced focus on single health problems and risk factors towards a more
holistic view and with the intent to develop supportive contexts within the places
where people live their lives. The settings are viewed not simply as culturally and
socially defined locations in space and time but also as “arenas of sustained
interaction, with pre-existing structures, policies, characteristics, institutional
values, and both formal and informal sanctions on behaviour” (Green et al., 2000,
p. 23). Dooris and colleagues (2007) suggested that the settings approach reflects
an ecological model of health promotion, implying that multiple factors influence
health – intrapersonal, interpersonal, institutional, community and policy. The
synergy of the public health and health education with various social and
behavioural sciences and other multi-disciplinary influences resulted in socio-
ecological conceptualisation of health promotion that offers a wider range of
actions, beyond individual behaviour change toward systems and policy level
approaches (Green et al., 1996). These, in turn, form the foundation of the settings
approach to health promotion practice (Green et al., 2000). Thus, the settings
approach allows to expand the boundary, within which a problem is being
addressed, to open up new opportunities to lever change and, therefore, offers
health promotion the conceptual base for pursuing practice across a significantly
broader canvas (Fleming & Baldwin, 2020; Whitelaw et al., 2001). Another
important foundation in modern health promotion has been the ‘salutogenesis’
approach (Kickbusch, 2003; Lindström & Eriksson 2006; Eriksson & Lindström,
2008), which raised the focus on peoples' health-related resources rather than risk
77
factors for a disease and underlined peoples' empowerment and sense of

coherence.
Furthermore, settings are also a part of ‘systems-thinking’ approach to
prevention (Fleming & Baldwin, 2020; Gubbels et al., 2014), which sees settings-
based health promotion as much more than using settings as mere vehicle or a
venue to access people for implementation of individualistic health education
activity (Bloch et al., 2014) or a set of fragmented interventions at multiple levels
(LaMontagne et al., 2006). Informed by systems perspective, the settings approach
views settings as complex, dynamic and open systems that interact with other
systems and the wider environment and suggest that “the healthfulness of a
particular setting and well-being of its participants are jointly influenced by
multiple aspects of its physical environment…and its social environment” (Best et
al., 2003, p. 170). Systems thinking emerged through a critique of reductionism
that assumed that phenomena are best understood by breaking them down into
parts, and then studying the parts in terms of cause and effect. In contrast, systems
thinking assumes that the world is systemic and the parts are interrelated, and thus
that meaningful understanding comes from building up whole pictures of the
system (Best et al., 2003). A systems approach is concerned about a deeper
understanding about how complex processes within the system work and
interactions between its components. Thus, the various actors, context,
circumstances and environment of a system play an important role in systems
thinking. Using systems thinking in health promotion means attention for
interactions, and facilitating mutual learning among the actors and, ultimately,
innovation that brings about the desired change in the system. As processes in
which the system’s structure, meanings and power relations play an important role
to foster learning and innovations, insight into the system and its current situation
are necessary (Naaldenberg et al., 2009).
Dooris (2006) examined the settings approach as a sociological model,
where complex systems are integrated, interrelated, interdependent, and
interconnected with different elements and noted that each setting is an open
system that is part of a greater whole. He presented change as being developed
and managed within that whole, value-based system, that combines “organisation
development with high visibility projects, to balance top-down commitment with
bottom-up stakeholder engagement, and to ensure that initiatives are driven by
78
both public health and ‘core business’ agendas” (Dooris, 2006, p.56). In 2009,
Poland and colleagues proposed a comprehensive analytical framework with a
series of critical questions to help in understanding and analysing setting’s
context, changing settings within that context, and build knowledge development
and knowledge translation to create positive, sustainable change. This analytical
framework was developed to assist in the planning, implementation, and analysis
of health promotion interventions that use a settings approach—working on, with,
and through the settings in which people live, work, and play (Poland et al.,
2009).
Lastly, the settings approach focuses on the whole organisational change
(Grossman & Scala, 1993) and ‘whole system thinking’ (Pratt et al., 2005). Paton
and colleagues (2005) emphasised that the distinctiveness of the settings approach
lies in its prioritisation of organisation development and systems theory to plan,
stimulate and implement appropriate change.
Today, the concept of setting represents a fundamental aspect of health
promotion practice evidenced by various settings being used to facilitate the
improvement of public health throughout the world. Settings approach defines the
channels for enabling and reinforcing the setting’s health-related behaviour,
collaborate and creating supportive environments by recognising its particular
needs in the physical, social, and organisational environment (Fleming &
Baldwin, 2020).
2.7.1 Settings approach to health promotion in preschool setting
This PhD study intended to fill a gap in the current literature by

developing a comprehensive understanding of the nutrition environment and
practices in preschool settings in Ireland, by using the settings approach.
According to Poland and colleagues (2009), as mentioned earlier, a
comprehensive analytical framework aids in understanding and analysing the
setting, which the present study was engaged in, in order to bring about tailored
and sustainable change. To understand a setting, in this study a preschool setting,
an effort needs to be made to define the physical, social, and organisational
environment in order to contextualise the environment of the setting. The physical
environment includes both the natural (e.g. outdoor air, soil, climate, natural
resources and other geographic characteristics of the preschool’s location) and
79
built environments (e.g. man-made infrastructures such as the preschool building

and classrooms with their materials and contents). The social environment
includes activities and interactions of the people in the preschool setting such as
children, preschool staff, children’s families, and wider community. The
organisational environment of the preschool includes the preschool manager, the
local childcare committee, and higher governance structures responsible for
funding, policy, and regulations. In addition, every preschool classroom has its
governance and accountability level, vested in the teacher who is responsible for
the children in the room setting. In addition to formal regulations, policies and
procedures, the unwritten rules or the sociocultural norms and values also build
the social environment. Parent-preschool staff relations are another source of
interaction and influence in the preschool setting, through their health-supporting
roles.
Globally, there is a strong support for schools as settings for health
promotion. Health-promoting schools are seen as enablers for the development of
healthy lifestyles and behaviours and emphasise the value of collaboration and
linkages between schools and home. However, to date, policies associated with
setting-based health promotion have not been as prevalent within the early
childhood sector (Hayden, 2006; Gubbels et al., 2014; Mistry et al., 2012).
Nevertheless, many childcare centres have been performing many of the strategies
and activities associated with health promotion, which are mainly attributed to
indicators of quality of childcare (Hayden, 2006; Lambrinou et al., 2019; Peñalvo
et al., 2015; Messiah et al., 2017; Shin et al., 2019; van de Kolk et al., 2020). This
shows that early childhood services have the potential to be health promoting
settings and, therefore, the setting-based interventions that undertake a
comprehensive approach to improving child health as encouraged by other health
promotion frameworks (e.g. health promoting schools framework) should be
adopted by a preschool setting (Chambers, 2017; Mikkelsen et al., 2014).
The present study aimed to understand a setting as it is defined and
understood by the people who ‘learn, work and play’ in it. Analysis of the context
of the setting could contribute to understanding the current needs, challenges and
opportunities for creating supportive environments for healthy nutrition of
preschool children. Moreover, the capacity within the setting needs to be
80
identified. Therefore, evidence-based knowledge provides the foundation to

ensure change is effective and sustainable.
Given the dearth of available research in preschool setting in Ireland, the
recent changes in policy and regulatory aspects in ELC in Ireland and the need for
more qualitative research in this sector, the aim of the present PhD study is to
develop understanding of the preschool setting nutrition environment using the
settings approach, and documenting and sharing the process. The study will
contribute to the knowledge base for on-going and future work in early care in
Ireland and beyond.
2.8 Conclusion
This review of the current published literature has highlighted the

importance of optimal nutrition for preschool-aged children and the role of
nutrition-related practices and processes both at home and early learning and care
settings in development of children’s eating behaviours. As the development of
food preferences begins at conception and continues throughout life involving a
complex interplay of biological tendencies and environmental influences,
understanding and consideration of these processes and determinants from
ecological and life course perspectives is important. Caregivers use a variety of
feeding strategies to influence children’s food intake, which have the potential to
affect, both directly and indirectly, the type, amount, and preference of foods
consumed, and a range of eating behaviours. With many children now being cared
for and educated in early learning care settings, the food environment and
nutrition practices in these settings play a critical role in children’s dietary intake
and the development of eating habits and behaviour. Therefore, effective
implementation of nutrition guidelines and using evidence-based supportive
feeding practices is important to ensure adequate and health-promoting dietary
intake by preschool children.
Nutrition-related research in early care setting in Ireland has been limited
to few quantitative studies which identified important factors such as
organisational characteristics and staff behaviours and practices that influenced
the implementation of nutrition guidelines in Irish childcare services, however
many policy and regulatory changes have taken place in the early care sector since
81
then. The past studies’ findings indicate the need for further research to better
understand the influence of these factors not only on the implementation of
nutrition guidelines but also on promoting healthy eating behaviours in preschool
children and the social as well as the environmental context in which nutrition
behaviours occur. In recent years, recognising the importance of early childhood
as a foundation of health and wellbeing for all life stages, several important
reforms have been rolled out in the early care sector in Ireland. However, in order
to implement the sector’s national nutrition guidelines and initiatives more
effectively, evidence-based knowledge of the early care setting’s current state is
needed. Therefore, the present PhD study set out to develop a comprehensive
understanding of the nutrition environment and practices in preschool settings in
Ireland using the Settings approach to health promotion, which views the
preschool setting as a complex, dynamic and open system that interacts with other
systems and the wider environment.
Review of current literature aided in a contextual understanding of the
nutrition-related practices, processes and influences in early childcare settings
from multiple perspectives and informed the development of a mixed-method
study presented in this PhD thesis.
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CHAPTER 3: RESEARCH METHODOLOGY
This chapter presents the research design and methodology applied in the
study. The chapter includes justification for the research approach, the methods
selected for the study, sampling procedures, and the approach to analysis of the
data. The ethical issues that are pertinent to the study are also described.
3.2 Research approach
A mixed methods approach, with an emphasis on a qualitative research

approach (i.e. qualitatively-driven mixed method approach), was used in this
study due to limited in-depth knowledge of the food environment and feeding
practices in preschool settings and because of the complex nature of the setting.
Mixed methods research is a type of research in which elements of qualitative and
quantitative research approaches (e. g., use of qualitative and quantitative
viewpoints, data collection, analysis, inference techniques) are combined in a
single study or series of studies for the broad purposes of breadth and depth of
understanding and corroboration (Johnson et al., 2007).
3.2.1 Rationale for a mixed methods design
The present study aimed to understand the nutrition-related processes and

practices taking place in the preschool setting. The research objectives include
exploring how preschool staff experience and manage food and mealtimes in their
services and how they perceive their role in promoting children’s healthy diets;
food-related perceptions of preschool staff, children and parents; caregivers’
communication for promoting healthy eating for preschool children; and the
needs, challenges and opportunities for promoting healthy nutrition in preschools.
These research questions are predominately qualitative in nature and could be
investigated using qualitative research methods. However, the behaviours of
interest also inherently occur in the physical environment and organisational
context of the preschool setting. As defined in the literature, the effect that
internal system processes and structures have on observed activities is mediated
by a number of human, sociocultural, and organisational factors, collectively
83
referred to as context (Griffin, 2007). Therefore, the situational opportunities and

constraints that affect the occurrence and meaning of organisational activities
need to be taken into consideration when investigating why behaviours occur
(Griffin, 2007; Johns, 2006). As such, quantitative research can provide formal
objective information about the preschool setting, including its organisational
structure and the food environment. In addition, quantitative methods can assist
with quantifying nutrition behaviours, and considered together with the qualitative
results obtained from interviews, to assess if they match actual occurrence of the
behaviours.
Therefore, combining both an in-depth qualitative approach with objective
contextual findings of quantitative approaches mixed methods research can be
used to produce a rigourous and credible source of data (McBride et al., 2018),
thereby enhancing the quality of the overall data collected (Creswell & Creswell,
2017). Thus, in order to achieve breadth and depth of understanding of the
preschool nutrition processes this study adopted a mixed methods approach by
combining elements of qualitative and quantitative research in the research
process.
Using multiple methods in a mixed method research design allows gaining
a more holistic understanding of the phenomenon of interest (Jick, 1979). As
suggested by (Creswell & Creswell, 2017), using multiple methods ensures that
data on participants’ expressed views (e.g. data from interviews) are
complemented with data on relevant actual life occurrences and environments
(e.g. observation), thus strengthening the study’s validity. In addition, while Yin
(2014) suggests the purpose of using multiple sources is to identify ‘convergence’
of findings, Stake (1995) advises that it assists in identifying ‘divergence’ of
findings, which, according to Jick (1979), can lead to an enriched explanation of
the issue under research. The point at which the findings converge or diverge is
seen to represent reality (Jack & Raturi, 2006).
3.2.2 Qualitative research approach
Due to the qualitative nature of the research questions in this study, a

qualitative approach played a dominant role. In the context of food practices and
preschool children, a qualitative approach provides an insight into knowledge,
beliefs and motivations that underpin feeding and eating behaviours and the
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relationship between caregivers that may not be captured using quantitative

measures.
Qualitative research is a process of inquiry that seeks to gain insights into
underlying reasons and patterns within social phenomena (Merriam & Grenier,
2019) by learning about people’s everyday experiences in their natural setting
(Mason, 2017). A qualitative approach is rooted in naturalistic and constructivist
research philosophies, where reality is viewed as constantly changing, as opposed
to being fixed and directly measurable, as in quantitative approaches. In
qualitative approaches, reality is thought to be a product of social processes and
can only be understood indirectly through people’s interpretation (Kyngäs et al.,
2020). Qualitative research approaches are particularly useful when there is no or
limited understanding of a complex phenomenon which cannot be described
through objective measurements or numbers, if current knowledge is unstructured
or fragmented, or when a new perspective is sought (Kyngäs et al., 2020).
Qualitative inquiry effectively addresses sensitive or personal issues,
intricate or nebulous topics, and contextually-sensitive issues. By the same token,
qualitative research can help to obtain meaningful information from hard-to-reach
or underserved populations such as children of all ages, subcultures, and deviant
groups (Roller & Lavrakas, 2015). Finally, good quality qualitative research can
deliver a meaningful understanding of people’s experiences and perspectives in
the context of the setting in which they occur and its strength is in providing
understanding of processes, context, nuance and diversity in today’s increasingly
complex contemporary social world (Kyngäs et al., 2020; Mason, 2017). As
qualitative research usually aims to reflect the diversity of views on the studied
phenomenon within a given population, it can be, therefore, a useful tool for
informing the design of effective interventions tailored to a given population's
own needs and contextual conditions (Crabtree & Miller, 1999; Dixon-Woods et
al., 2001).
3.2.3 Quantitative methods
In qualitatively-driven mixed method research design a supplementary

quantitative phase was included to quantify the extent to which attitudes or
behaviours, which were explored in a qualitative phase, occur (Mason, 2006).
Mason (2006) argues that supplementary quantitative studies not only serve to
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validate findings, but also open our perspective to the multi-dimensionality of

lived experience. When the qualitative and quantitative phases are used to expand
on one another, the qualitative study explores meanings while the quantitative
study provides credibility to the qualitative outcomes and enhances the integrity
of the findings (Harrison & Reilly, 2011).
The qualitative approach in this study was supplemented by the use of an
observation tool and a preschool manager questionnaire, which yielded
quantitative data (e.g. assisted in quantifying nutrition behaviours and the food
environment) that helped to expand the understanding of preschool nutrition
processes and the sociocultural context of the setting.
3.3 Epistemological approach
To address potential convergent and divergent data on perspectives of

diverse participants (staff, parents and children), this study adopted a pragmatic
constructivist approach. Given that in this study three different perspectives are
involved in a feeding/health relationship, it is important to note that a
constructivist approach assumes that individuals within a family or a relationship
construct their own realities which may be similar or different from the realities
perceived by other family members (Zartler, 2010). According to constructivism,
humans create rather than ascertain knowledge (Karnaze, 2013) while a major
underpinning of pragmatist epistemology is that knowledge is always based on
experience and that knowledge is not a reality but rather it is constructed with a
purpose to better manage one’s existence and to take part in the world (Goldkuhl,
2012; Morgan, 2014). Karnaze (2013) argues that if researchers abandon
foundationalist notion of the quest for absolute truth, they might welcome the
pragmatic (constructivist) prospect of increasing the repertoire of useful
predictions about human behaviour and experience. As such, pragmatist
researchers acknowledge the value of both convergence and divergence data. As
Karnaze (2013) argues, any divergence of findings does not necessarily indicate
failure, as findings in one knowledge domain may simply conform to assumptive
networks and constructs of that domain and not conform with another domain.
Furthermore, Cromwell (2010) said, “When we assume that different knowledge
domains rely on different assumptive structures, we enable ourselves to ask new
and different questions” (p. 9). Asking new and different questions, and thus
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having more data points to draw from, can in theory help one better prepare for a
variety of life experiences (Karnaze, 2013). Dillon et al. (2000) affirm that
meaning is inseparable from human experience and needs and is dependent upon
context.
As a research paradigm, pragmatism orients itself toward solving practical
problems in the “real world” (Creswell & Plano Clark, 2007, pp. 20-28; Dewey,
1925; Rorty, 1999). Dewey in Dillon (2000) suggests that a pragmatist would
identify genuine problems that are part of actual social situations, and once the
problem is identified and the dimensions are clearly defined, the researcher should
investigate the problem from various perspectives, depending on the purpose or
objective of the inquiry. Since pragmatists believe that the process of acquiring
knowledge is a continuum rather than two opposing and mutually exclusive poles
of either objectivity and subjectivity (Goles & Hirschheim 2000), pragmatism
embraces the two extremes and, therefore, offers a flexible and more reflexive
approach to research design (Feilzer, 2010; Morgan, 2007). Thus, a pragmatic
approach allows the possibility of choosing the appropriate research methods from
the wide range of qualitative and/or quantitative methods and any combination of
them such as multiple methods and/or mixed methods and this pluralism is its
strength. Thus, ultimately, it is the researcher who makes the choices and decides
which research question is important and what methodology is the most
appropriate to address the research question (Kaushik & Walsh, 2019; Morgan,
2007; Feilzer, 2010).
Pragmatism, therefore, is considered the “philosophical partner for the
mixed methods approach” (Denscombe 2008, p. 273). Pragmatism does not reject
the differences between positivism and constructivism as approaches to research,
but focuses on their characteristic approaches to inquiry (Morgan, 2014).
Pragmatism emphasises creating shared meaning and joint action, and this
emphasis points to the underlying belief in complementarity when combining
quantitative and qualitative approaches in mixed method research (Shannon-
Baker, 2016).
Therefore, while a constructivist approach and perspectives from different
stakeholders underpin this study, quantitative tools can be drawn upon when they
are considered useful for supporting the overall programme of research. As a
quantitative observation tool and a questionnaire were used to collect data in
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preschools, in this study, these tools offered an additional perspective rather than
contradicting or overriding participant’s subjective perspectives gathered by
qualitative methods.
3.4 Mixed method research design and methodological issues for

present study
This mixed method PhD study was comprised of three studies which were
preceded by a pilot phase. An overview of the aims, methods and samples for
each study is shown in Table 3.1.
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Table 3.1. Summary of the research studies
Study Research aim Research approaches, methods and tools Study sample Timeframe
Pilot Evaluate the feasibility of the approach Qualitative approach: semi-structured Preschool staff (n=1); May 2017
phase intended to be used in the study and to interviews with preschool staff and parents Preschool children (n=5);
pre-test the research instruments. and creative and visual methods with Parents of preschool children (n=3).
children (toys, stories and drawings by
children).
Study Examine preschool food environment, Mixed method approach using multiple -Preschools (n=10) in Galway City May –
1 food-related practices, and beliefs and methods: with different services and types of October
perceptions of preschool staff to gain -Participant observation; food provision: full-day (n=4) and 2017
deeper insights into food-related issues -Semi-structured interviews; part-time/sessional community
and processes in the preschool setting. -Document review; preschools (n=6);
-Preschool manager questionnaire. -Preschool staff (n=10).
Study 1) Elicit very young children’s Participatory approach using interactive Preschool children (n=64) aged 3-5 May –
2 perceptions of food, healthy eating and creative and visual methods. years attending preschool settings October
their food preferences. Children’s workshops (n=18) involving: in Galway City. 2017
2) Develop and use creative methods for -Toys and game-based activity;
very young children and examine its -Stories/vignettes;
methodological challenges. -Drawings by children.
Study 1) Explore parents’ knowledge and Mixed method approach using - Parents (n=10) of 3-5 year old May –
3 perceptions of preschoolers’ nutrition. -Semi-structured interviews with parents and children attending preschool October
2) Examine preschool staff and parent preschool staff; settings in Galway City; 2017
communication for promoting -Direct observation; - Preschool staff (n=10).
healthy eating in preschool children. -Document review.
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A synergistic approach to mixed methods research draws on the strengths of

both types of approaches, going beyond the limitations of a single approach, thus
rendering opportunities to provide more comprehensive answers to research questions
(Creswell & Creswell, 2017). However, the full value of mixed methods research may
be realised only if effective integration of qualitative and quantitative data strategies is
applied (Creswell, 2014; Creswell & Plano Clark, 2017; Plano Clark et al., 2010).
Integration, which is a systematic process by which quantitative and qualitative
approaches are brought together in a study (Creswell, 2014), provides a more complete
and synergistic utilisation of data (McBride et al., 2018) and can be performed at one
or more stages in the process of research (Cresswel & Creswell, 2017; Creswell &
Plano Clark, 2017; Fetters et al., 2013).
The timing of data collection, priority given to research approaches within the
study design, and integration of qualitative and quantitative data are described in this
section.
Timing of data collection
A convergent parallel (also called concurrent triangulation design) mixed

method design was considered the most appropriate design for this study as it allowed
to integrate qualitative findings with quantitative results to develop a more complete
understanding of preschool nutrition-related processes and practices. The main purpose
of the convergent design is “to obtain different but complementary data on the same
topic” (Morse 1991, p. 122). In convergent parallel design both quantitative and
qualitative data are collected simultaneously, therefore it has several advantages such
as cost- and time-efficiency in data collection, independent data analysis with using
discrete quantitative or qualitative techniques, and it is an intuitive process (Creswell &
Plano Clark, 2017). This type of design also has a number of challenges due to
methodological and interpretation complexities when combining datasets with different
types of data (Tashakkori & Creswell 2007). Therefore, a thorough and systematic
approach of combining and integrating data is necessary to overcome these challenges
and obtain a meaningful outcome.
Priority of research approaches within the study
With respect to addressing the research questions, the design and the analytical
framework guiding the data integration (Moseholm & Fetters, 2017) can represent the
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emphasis of the mixed method research on whether both qualitative and quantitative
phases of the study have approximately equal emphasis (i.e. equal status), or whether
one component has significantly higher priority than does the other phase (i.e.
dominant status) (Leech & Onwuegbuzie, 2009). In the present study, as the research
questions were more of qualitative nature, the mixed methods research was weighed
more towards qualitative approach, i.e. was “qualitatively-driven” (Johnson et al.,
2007). A qualitative dominant or ‘qualitatively driven’ mixed methods research relies
on a qualitative, constructivist view of the research process, while concurrently
recognizing that the addition of quantitative data and approaches are likely to benefit to
this study (Johnson et al., 2007). According to a notation system developed by Morse
in 1991, if the prioritisation is given to qualitative data over quantitative data with
concurrent data collection, the notation is QUAL + quan (Morse, 2016).
Integration of qualitative and quantitative data in this study was performed at
multiple stages: at the design level, the methods level and the interpretation and
reporting level. The diagram below (Figure 3.1) illustrates the stages and levels of data
design, collection, analysis and interpretation used in this study. The integration of
mixed data is described in detail in the ‘Data Analysis’ section of this chapter.
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Figure 3.1. The Procedural Diagram of convergent parallel dominant mixed method design for present study.
AT DESIGN LEVEL QUAL & QUANT DATA COLLECTION AND AT METHODS LEVEL AT INTERPRETATION &
ANALYSES REPORTING LEVEL
ARE CONDUCTED SEPARATELY
QUALITATIVE
DATA COLLECTION DATA ANALYSIS
Procedures Procedures
Interviews with staff & parents Inductive Procedures
Procedures Studies 1,3 thematic analysis Procedures Integrating through narrative
Matching the questions Children’s workshops Study 2 Studies 1,2,3 Merging (by weaving - Study 1, 2 &
in qualitative tools with Document review Study 1,3 the QUAL & QUAN contiguous - Study 3
the questions in Product Product databases approaches)
quantitative tools Audio records, photograpfs of Themes The two databases are brought Considering how merged results
Studies 1,2,3 ‘dinners’, children’s drawings, Studies 1,2,3 together for comparison give better understanding of
field notes, reflective notes and analysis preschool food environment and
Studies 1,2,3 Studies 1,2,3 nutrition practices
INTEGRATION INTEGRATION INTEGRATION
QUANTITATIVE
Product DATA COLLECTION DATA ANALYSIS Product Product
Convergent parallel, Procedures Procedures Comparison of perceptions with Report
QUAL dominant Observation Study 1,3 Descriptive statistics, measurements of behaviour to Studies 1,2,3
mixed method design Children’s workshops Study 2 Counts determine the extent to which
Studies 1,2,3 Manager questionnaire Study 1 Studies 1,2,3 the two forms of data confirm,
contradict or expand each other
Product Product Studies 1,2,3
Number of nutrition Numbers & frequency
behaviours observed/stated of nutrition behaviours,
Studies 1,2,3 number/types of
liked/disliked foods
Studies 1,2,3
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3.5 Methods and tools
The following methods and tools were used in this multiple mixed method
study:
3.5.1 Observation method
Observing and studying people in their natural environment helps

researchers to unearth crucial information that would be concealed in self-report
data retrieved from interviews or focus groups (Zhao & Ji, 2014). Gold (1958)
identified four roles that an observer can adopt: the “complete observer”, the
“complete participant”, the “observer-as-participant”, and the” participant-as-
observer”, defined by the degree of involvement of a researcher in the lives of
informants. Among these four types the "observer-as-participant" and
"participant-as-observer" roles are the ones that satisfy the ethical requirement of
informed consent.
Observation of the preschool environment in the present study, including
daily activities in the classrooms and during meal and snack times, enabled the
researcher to immerse in the preschool setting. Throughout the observations the
researcher’s general position was “observer-as-participant” (Gold, 1958). In the
role of the “observer-as-participant” the identity of the researcher is revealed to
informants, however, the researcher is expected to maintain their professional
distance and remain “strongly research oriented” allowing adequate observation
and recording of data (Adler & Adler, 1994, p. 380). As the role of the “observer-
as-participant” is less interrogative and usually involves one-visit interviews
(Baker, 2006), it allowed observing the environment and activities relevant to the
research question in a limited time-frame and with the consent of the participants
(Merriam & Tisdell, 2015). Observation occurred before the interviews and
facilitated the researcher’s understanding of participants’ perspectives shared
during the interviews. One major advantage of the “observer-as-participant” role
is that it enables researchers to detach themselves emotionally from the people
being studied so that they can record, analyse and evaluate data objectively and
accurately (Schwartz & Schwartz, 1955). However, as Duch and Rasmussen
(2020) argue, the researcher has to balance between different positions of
familiarity and distance during observation. The authors refer to Bourdieu and
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Wacquant (1996, p. 234) who describe that the researcher needs to have the
necessary analytical distance with the concept of participant objectification, which
means breaking with one’s deep and unconscious feelings of solidarity with the
research object, acknowledging this being extremely difficult, since such feelings
are often what made one venture into the theme in the first instance (Duch &
Rasmussen, 2020). In this study, the researcher developed and used a Preschool
Observation Tool, a comprehensive observation checklist as a tool to assist in
maintaining the objectivity as an observer as well as capturing and recording all
possible relevant aspects of preschool food environment and nutrition practices as
a holistic process, not only from a food-related perspective, but also from social
and health-promoting perspectives and personal experiences and behaviours of
both children and preschool staff.
Review of food environment observations tools
A review of published literature showed that, currently, appropriate

observation tools to assess nutrition-related environments in childcare settings are
limited (Ward et al., 2013) and include two assessment tools - the Environment
and Policy Assessment and Observation (EPAO) instrument (Ward, 2008) and the
Wellness Childcare Assessment Tool (WellCCAT) (Henderson et al., 2011).
The EPAO is a modification of a childcare self-assessment tool into a tool
that is executed by objective, trained field observers through direct observation
and document review (Ward, 2008). It is an intensive, day-long environmental
observation tool consisting of 102 items that measures several domains, including
types of foods served to children, staff mealtime interactions, physical activity and
sedentary opportunities, staff support, and the physical environment. It also
includes a document review of menus, handbooks, training documents, curricula,
policies, and a playground safety check. While the EPAO has many merits, it is
resource-intensive, requiring a full-day of observation and thorough document
review. The instrument's validity and reliability are established (Benjamin et al.,
2007), however, it was originally designed to assist childcare staff to evaluate
their own facility's nutrition and physical activity environment and identify areas
of improvement and may not be suitable for studying the role of environmental
factors across multiple childcare centres (Henderson et al., 2011). The second
instrument, WellCCAT, was developed by the Rudd Center for Food Policy and
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Obesity, Yale University. A part of this tool is the Nutrition and Physical Activity
Environment Assessment Survey, which is a self-administered childcare director
survey to quantitatively assess four areas of the nutrition and physical activity
environment of childcare centres in preschools serving low-income families:
centre policies, practices related to the social environment, physical environment,
and nutrition quality (Henderson et al., 2011). The tool was modified and
validated to allow researchers to study environmental factors across a large
number of childcare centres. Henderson and colleagues (2011) validated the
survey against other measures such as the Director Interview Tool, the Direct
Observation Tool, and the Preschool Menu Rating Tool and found adequate
criterion validity with strongest agreement for items assessing the childcare
policies and the nutrition environment.
In Ireland, Molloy and colleagues (2014) developed and validated the
nutrition and health related assessment and evaluation tool for the Healthy
Incentive for Preschools Project (described in the literature review in Chapter 2).
The tool assesses preschool nutrition environment, food provision and practices
for weaning and weaned children. A score can be assigned: ‘Participated’,
‘Bronze’, ‘Silver’, ‘Gold’ or ‘Platinum’ category therefore serving as a
motivational tool as well.
Based on the preschool nutrition themes prevalent in the theoretical and
research literature and informed by the review of existing quantitative observation
tools designed to evaluate the nutrition environment in childcare settings
described above, a Preschool Observation Tool (Appendix 11) was developed for
this study. The Preschool Observation Tool was designed as a checklist to assess
the preschool environment, with open-ended sections to record the behaviours
observed and the researchers’ reflections. The following main sections were
included in the Preschool Observation Tool: food provision, eating environment,
meal and snack time practices, interactions between preschool staff and children
during meal and snack times, presence of visual images and materials (such as
posters, books, toys and materials for food related play, etc.), use of food and
nutrition related resources during activities and presence of nutrition related
themes in the activities (Appendix 11).
Before the observation began and throughout the data collection, the
researcher engaged in informal conversations with preschool staff and children to
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build a rapport and reduce the communication barrier. The emphasis was given to
inform the preschool staff about the aim of the study and the confidentiality of
data collected. Importance was given to maintaining the balance between
observation and participation by not becoming involved in the daily activities in a
preschool setting.
3.5.2 Semi-structured interviews
A semi-structured interview is a type of qualitative interview that

combines a set of open questions or themes identified in advance (also called
interview guide) with the opportunity for the interviewer to pursue new themes
that might arise in the course of the interview thus offering flexibility (Cannold,
2001). On the other hand, semi-structured interviews can provide reliable,
comparable qualitative data (Cohen & Crabtree, 2006) as the use of pre-
determined questions provide uniformity that would aid in comprehensive
qualitative analysis.
The key advantage of a qualitative interview approach over other forms of
interviewing is that the interviewer is able to gather complex, in-depth data that is
not as easily obtained through questionnaires or structured interview approaches
(Esterberg, 2002; Gill et al., 2008). In addition, for qualitative interviews,
researchers need fewer participants to gather useful and relevant insights. Other
advantages of qualitative interviews that are pertinent to this PhD study are
perspective assessment (gathering not only factual but also emotional data and
non-verbal cues), collection of first-person data (participants use their own words
and share their own perspectives), and collection of honest feedback (Gill et al.,
2008). The disadvantage of qualitative interviews is that they can be costly and
time-consuming (Akbayrak, 2000). Other drawbacks include reliance on
respondents’ accuracy and possible emotional strain (Esterberg, 2002), researcher
skill, including careful consideration of the interview guide and avoiding leading
questions (Roulston & Choi, 2018).
Since the perceptions and experiences of preschool staff and parents
related to food and nutrition in preschools were of interest, and to achieve in-
depth understanding of these aspects and understand the challenges and needs
they face, individual semi-structured interviews were selected as the most
appropriate research method. In addition, for practical reasons it would be
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difficult to gather together preschool staff from different preschools or groups of

parents at the same time for group discussions; therefore, individual interviews
were deemed most suitable. Individual interviews also allow for sensitive topics to
be discussed without the worry or influence of others. In the present study, using
semi-structured interviews with preschool staff and parents allowed an
interviewee to speak freely and openly while the interview topic guides helped the
researcher to focus the interviews on the topics of interest. During interviews, a
conversation-style technique was employed which allowed the conversation to be
spontaneous and personalised thus helping the exploration of each participants’
opinions, beliefs and perceptions on topics of interest. In addition, probing
questions were asked to clarify responses or to explore new perspectives, when
appropriate.
Topic guides for interviews and a pilot phase
Topic guides were developed for semi-structured interviews with

preschool staff and parents and to guide the children’s workshops in order to
obtain information that provides rich qualitative data while allowing the
conversation with participants to be spontaneous and personalised to gain a more
in-depth understanding of the topics discussed. The topic guides were piloted
prior to data collection for the main study.
A Topic guide for semi-structured interviews with preschool staff
(Appendix 14) was developed based on the literature review, research questions
and previous experience in childcare settings. The main topics included were staff
perception of healthy eating and related knowledge, their perceived role in
providing healthy foods; their attitude and behaviours during mealtimes,
relationships with children’s families, and the barriers and facilitators they face
around healthy eating at preschools. The topic guide was piloted with a preschool
teacher who had nine years of experience in a preschool setting. Based on the
pilot interview the order of topics was changed.
A Topic guide was developed for semi-structured interviews with parents
(Appendix 15) and included topics about parents’ attitudes and behaviours
towards their child’s nutrition and food environment at home, parents’ knowledge
and perceptions of healthy nutrition, and the facilitators and barriers they perceive
towards healthy eating at home and at preschool. The topic guide was piloted with
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three parents of preschool aged children. The topics were reviewed and the order
of topics was changed. In addition, in the topic about barriers to healthy eating,
the question on income and purchase ability was changed to be broad rather than
specifically about family income.
A Topic guide for children’s workshops with questions to be asked from
each individual child was also developed (Table 5.2 in Chapter 5). The guide
included topics on children’s food preferences, socio-cultural factors that promote
children’s healthy eating, the behavioural capabilities of children, children’s
perceptions about ‘healthy’ and ‘less healthy’ foods, and their views about food in
their homes and in a preschool setting. The topic guide was piloted with five, 4
year old children. During the pilot workshop with children, clarifications were
sought on how children described food, thus minor changes were made to the
guide. These changes included rephrasing some questions to make them more
understandable to young children and including the words that very young
children use in everyday life. In addition, clarifications on children’s everyday
food-related vocabulary were made during interviews with preschool teachers and
parents to make certain that all procedures were child-friendly and easily
understood by very young children.
3.5.3 Document reviews
Document analysis is a research method for collecting, reviewing,

interrogating and analysing various forms of written ‘text’ as a primary source of
research data (O’Leary, 2014). As a research method, document review and
analysis is often used in combination with other qualitative research methods to
validate and corroborate data obtained during the study. Documents can provide
background and supplementary research data, are accessible and a reliable source
of data since they are commonplace and obtaining and analysing them is time-
and cost-efficient. Furthermore, documents are stable, “non-reactive” data
sources, meaning that they can be read and reviewed multiple times and remain
unchanged by the researcher’s influence or research process (Bowen, 2009, p. 31).
Documents are helpful in contextualizing one’s research within its subject or
field; in other words, documents provide data on the context within which
research participants operate (Bowen, 2009).
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In this study, preschool nutrition documents provided background and

context to the preschool nutrition practices and were used to corroborate data
collected during staff interviews and observation. The documents that were
reviewed and analysed included: preschool healthy eating policies; staff
handbooks, menus (in full-day-care preschools); packed lunch guidelines (in
sessional preschools), written communication with parents on food, nutrition and
meal times (e.g. parent handbooks), if present. A record of whether preschools
had Food and Nutrition Guidelines for Preschool Services (Department of Health
and Children, 2004) in their possession was also taken. The document review data
was collected using the Document Review Guide (Appendix 12) and field notes.
3.5.4 Preschool Manager Questionnaire
The Preschool Manager Questionnaire (Appendix 13) was adapted from

the Director Interview Tool of the Yale Rudd Center for Food Policy and Obesity,
which consisted of questions regarding nutrition and physical activity in childcare
services. The Preschool Manager Questionnaire used in this study retained only
the questions related to food and nutrition and included questions on: 1) food
provision; 2) nutrition guidelines and policies; 3) communication with parents on
nutritional issues; 4) eating environment and behaviour; 5) staff training; and 6)
barriers and supports.
3.6 Participatory approach in research
An important part of this PhD study was using participatory approach and
creative methods with preschool children, which was employed in Study 2 to
explore children’s food preferences and perceptions. This section describes
participatory approach in research and particularly in research with very young
children.
Participatory research is defined as systematic inquiry, with the
collaboration of those affected by the issue being studied, for purposes of
education and taking action or effecting change (Green et al., 1995). The
fundamental principle of participatory research is that it is research ‘with’ rather
than ‘on’ people (Reason & Heron, 1986) by treating people as ‘research
participants’ rather than ‘research subjects’ thus attempting to change power
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relations in the various stages of the research and to ensure that research is owned
and controlled not only by researchers, but also by research participants (Cornwall
& Jewkes, 1995). It is a people-centred ‘bottom-up’ approach in the sense that the
process of critical inquiry is informed by and responds to the experiences and
needs of people involved (Israel et al., 1998).
The primary aim of participatory research is to give members of
(marginalised) groups a voice, or to enable them to make their voices heard.
Blackburn and Holland (1998) stated that participation is making efforts to create
such conditions which would contribute to empowerment of those members and
groups of the society, who have little control in the oversight of powers
determining their life, whose views are seldom sought, and whose voices are
rarely heard. Normally, these groups have little opportunity to articulate, justify,
and assert their interests. This allows understanding of social reality from ordinary
people’s perspectives and experiences, provides a deeper understanding of the
dimensions that usually are not identified through the conventional approaches,
which in turn might increase the relevance, applicability and delivery of research
findings to address problems of daily life (Tadevosyan & Schoenhuth, 1997).
Cornwall and Jewkes (1995) argue that the key element of participatory
research lies not in methods but in the attitudes of researchers, which in turn
determine how, by and for who research is conceptualised and conducted based
on the basic principles of openness, communication, and the appropriateness of
the method to the subject under study.
3.6.1 Participatory approach in research with children
A realisation of children as social actors in their own right and agents in

their own worlds provided the momentum to propel agendas towards research
‘with’ rather than ‘on’ children (Jones, 2004; Mason & Hood, 2011). Recognising
children’s participatory rights, it has been advocated that research about child
welfare should include attention to children’s opinions and their accounts of their
own experiences that are significant to them (Hill, 1997; Mason & Danby, 2011).
Thinking about children as a social group with limited power and influence links
with the argument that research should give due weight to the views of those who
are commonly oppressed or marginalised (Punch, 2002; Suarez‐Balcazar, 2020).
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Interest in accessing children’s perspectives and views has been prompted

by official endorsement and widespread acceptance of the United Nations
Declaration on the Rights of the Child (UNCRC) (UNICEF, 1989). Articles 12
and 13 of the UNCRC require that children should be informed, involved and
consulted about all decisions that affect their lives. In response to changing
perspectives on children’s status in society, involvement of children as
participants and co-researchers is rapidly gaining credence (Kellet, 2014).
However, despite many initiatives and the policy emphasis given to increased
children’s participation and consultation, much participatory research, due to its
challenges, is still adult-led, adult-designed and conceived from an adult
perspective, which is likely to miss key aspects of children’s lives (Kleine, 2016).
Nevertheless, the increasing acknowledgement of children's agency in
social research has had an important influence on research methodology,
particularly on qualitative methods of inquiry. Kellett (2005) noted that child-led
research can bring benefits of better and richer data, as children are able to
provide a richness that can never be tapped by adults because it is inherent in
children's own experience and understanding of their worlds and ‘subcultures’ in
which they have a unique ‘insider’ perspective that is critical to understanding of
children’s worlds. Children observe with different eyes, ask different questions -
they ask questions that adults do not even think of - have different concerns and
have immediate access to peer culture where adults are outsiders, and all this can
offer valuable insights and original contributions to knowledge (Kellet, 2010).
Christensen and Prout (2002) observe that the success of research with young
children lies in ‘watching, listening to, reflecting and engaging in conversation;
seeking to enter the child's world in just a small way’. The authors advocate for
‘ethical symmetry’ by ‘engaging with the local cultures of communication among
children, paying attention to the social actions of children, their use of language
and the meanings they put into words, notions and actions’ (p. 483). Therefore,
using a combination of communication skills, including different types of
questions, reflexion, flexibility and sensitivity to communication styles of
individual children, can be effective in research with children (Fratter, 1996).
In Article 12, the UN Committee on the Rights of the Child emphasises
that all children, and not just older children or articulate children, have the right to
participate, that they should be supported to do so and that their views should be
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weighed seriously in decision-making (Tisdall, 2015). Vandenhole et al (2015)

state that a child should be presumed to have the capacity to form a view. The
right to express a view has no age threshold and a child need not have
comprehensive knowledge to be considered capable. Verbal communication and
non-verbal communication should be recognised as expressing a view. In
addition, children should be supported to participate and they should be able to
express their views ‘freely’, without being unduly influenced or pressured
(Vandenhole et al., 2015) Ebrahim and Muthukrishna (2005) emphasise that, as
children articulate their views and opinions in various ways, it is appropriate to
use different and creative techniques to enable children to share their knowledge.
They found, after careful observation of the way in which children presented their
knowledge in particular contexts, that with children under four, it was appropriate
to select participatory techniques such as talking, playing, acting and singing.
Molina et al. (2009) stated that appropriate research tools are important for
participatory research with children and found that child-friendly participatory
research is most successful when: a) Cultural norms and the age range of
participants shape the research design; b) Research methods are focused on
having fun; c) Activities are carried out in small groups, so that individual
children feel confident enough to participate; d) Methods are iterative, allowing
children themselves to shape and change them; e) Researcher intervention is
limited to an explanation of the tool or method, and f) A mix of oral, visual, and
written activities is used. These practices help children to express their
perceptions, experiences, vulnerabilities, and capacities.
3.6.2 Research methods involving very young children
Preschool children are in preoperational stage of cognitive development

according to Piaget (1930). During this stage (age 2 through 7 years) young children
are able to think about things symbolically and learn to use words and pictures to
represent objects. Children at this stage tend to be egocentric and struggle to see
things from the perspective of others. While they are getting better with language and
thinking, they still tend to think about things in very concrete terms. They also often
struggle with understanding the idea of constancy. At this stage, children
understand the difference between past and future (Grant & Suddendorf, 2011),
engage in make-believe and learn through pretend play (Jaggy et al., 2020). But
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their thinking is based on intuition and still not completely logical. According to
Inhelder and Piaget (1964), the preoperational child is perceptually oriented and
often classifies on the basis of how things look or how they are used. Therefore,
Piaget’s followers (Isaacs, 1974; Lavatelli, 1970) have emphasised the importance
of activity-based teaching strategies that encourage interaction with real-world
objects. Piagetan theory argues that preoperational children cannot yet grasp more
complex concepts such as cause-and-effect and comparison. However, other
researchers have challenged Piaget in respect to causality. Gelman (1978)
concluded that even at the age of 3 or 4 years, children associate cause with effect
and make accurate predictions based on causal principles. As cognitive
developmental psychology has moved forward from Piaget’s theory, age-related
development is now replaced by development of executive functions such as
working memory, initiation of a task or activity, self-monitoring, etc. (Bauer &
Booth, 2019). What is evident is that in general, preschool-aged children do not
have the communication skills required to express detailed and complex
explanations or rationale for their thoughts or actions (Matthews et al., 2018,
Smith et al., 2003). In addition, preschool children have limited literacy skills and
so open-ended questions are usually used and non-verbal communication has
particular relevance for research with young children. Whatever strategy is
employed, it is crucial for the technique to align with the cognitive and
communication capabilities specific to preschool children, including brief
attention span, limited verbal skills, and lack of fine motor skills (Popper & Kroll,
2004).
Taking into consideration these developmental and educational
characteristics of preschool aged children, creative and visuals research tools were
developed for this study that incorporated tasks appropriate to the children's
cognitive level of development. For example, given children’s limited test-taking
skills, open-ended questions were used to determine children’s food perceptions
and food preferences rather than asking them to select a food that belonged to one
of the food groups or that had other predetermined characteristics. It was
hypothesised that preschoolers’ knowledge about foods and nutrition could be
examined if the materials and tasks were appropriate to the children’s
developmental stage.
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3.6.3 Creative and visual research methods with children
Participatory, creative and task-based approaches came to early

prominence in the field of childhood studies (James et al., 1998) and are
increasingly coming to dominate research (Clark & Richards, 2017). Central to all
creative and participatory methods is that research with children must take into
account the multiple voices of children who express their views in different ways
(Edwards et al., 1998). This includes not only verbal language forms but also
drawing, painting, music, dance, drama, clay, and wire, to name a few. The term
‘hundred languages of children’ refers to the many ways that children have of
expressing themselves and originates from a poem of the same name by Italian
pedagogist Loris Malaguzzi (1987). This idea is a foundation of the Reggio
Emilia approach to early education (Edwards et al., 1998; 2012; Rinaldi, 2006), or
‘pedagogy of listening’ (Rinaldi, 2006, p. 64). Carefully listening to children's
ideas enhances the possibility of learning how children think and how they both
question and develop a relationship with reality. Reggio teachers provide children
with different avenues for thinking, revising, constructing, negotiating, developing
and symbolically expressing their thoughts and feelings thereby helping children
to search for meaning and understanding in what they do, what they encounter,
and what they experience.
The Reggio Emilia approach makes children’s voices visible and therefore
offers many possibilities for researchers who desire to work with children and
educators in a collaborative and participatory manner (Clark & Moss, 2001;
Einarsdóttir, 2005; Harcourt et al., 2011; Harcourt & Einarsdóttir, 2011). One of
the projects that reflected the Reggio Emilia’s ‘pedagogy of listening’ is the
Mosaic approach developed by Clark and Moss (2001) to investigate the daily
experiences of young children in early childcare settings that enables children in
the early stages of language development a variety of possibilities, verbal and
non-verbal, to describe their environment. Other creative and visual methods with
young children include use of stickers, smiley faces and puppets (Gray & Winter,
2011), photo supported interviews (Einarsdóttir, 2014), draw-and-write technique
(Angell et al., 2014), and the use of emoji (Fane et al., 2018) and drawing,
painting and using pre-cut pictures to create a new picture (Nyberg, 2019). These
studies are valuable by limiting adult input and bias and validating the capabilities
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of very young children. In nutrition domain, the visual methods that were used in
previous research to explore preschool children’s food perceptions and define
children’s understanding of relations between food and healthy eating include
various food classification and meal-construction tasks such as images of foods in
colour photographs or pictures of food (Holub & Musher-Eizenman, 2010;
Nguyen, 2007; Varela & Salvador, 2014), an illustrated storybook (Tatlow-
Golden et al., 2013), and food models (Holub & Musher-Eizenman, 2010;
Harrison et al., 2016).
In the present study, the creative and visual methods, and research tools in
particular, were developed based on the participatory approach underlying these
studies. Overall, the food toys for the present study were chosen to be the most
suitable research tools for several reasons: 1) the topic of the research was focused
on young children’s food preferences and perceptions about food, therefore, toy
replicas of food items were (a) easy to identify by very young children, (b)
appropriate to be used as a reference to a specific food, c) suitable to play with
and share among participants; and 2) food toys were easy to obtain and were
suitable for the study budget.
Visual methods
Creative visual methods are useful for engaging children in joint
knowledge production, as literacy is not required, and help children to participate
in research in an active way (Kleine et al., 2016). The value of using creative
methods with young children is that they enable them to reflect on their
experiences and allow children time to think and build ideas in stages rather than
having to give an immediate response (Brooks, 2009; Leigh, 2020). This is
important as children have not yet mastered structured thought of adults (Smith et
al., 2003). Although visual data may be difficult to analyse, if paired with spoken
feedback from children, such data can convey in-depth information (Søndergaard
& Reventlow, 2019). Visual methods can be particularly useful with children who
have received little education as they de-prioritise verbal communication. For
example, thematic drawing was used with 175 Ugandan street children by asking
them open questions which allowed them to draw scenarios of living on streets
that were most significant to them. Following the drawing exercise, they were
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offered the opportunity to explain their pictures to other participants (Biggeri &
Anich, 2009, in Kleine et al., 2016).
In summary, children differ in their age, level of articulacy and
extroversion, cultural and religious background, as well as in the urban or rural
environments they grow up and live in, and the degree of adult support or care
they receive. These differences will affect the methods that children as active
participants prefer to use. Therefore, researchers who embark themselves in
research with children need to give careful consideration to who they want to
engage with in the research and how, what positive change for the children might
emerge from the research, and how children can be empowered to play a part in
bringing this change about (Kleine et al., 2016).
This was the intention of in Study 2 where the creative method approach
was underpinned by the principles of participatory research. However it is
difficult to actively involve very young children in the research process in its
entirety. Nevertheless, through respect for children’s opinions and perspectives
this research gave the children power through their active engagement and input
in the research process.
3.6.4 Development of creative research tools for use with

preschool children
As children vary in their dispositions, abilities, experiences, and

preferences, a key feature of present study was providing children with a choice of
ways they could actively participate. The careful selection of tasks was to enable
them to have opportunities to express their views using ways in which they were
comfortable. Given the age range of participants (3-5 years old), having fun was a
priority, as well as activities appropriate for small groups that still enable
individual children to participate. The choice of research tools was informed by
creative, visual, narrative, and participatory research methods that have been used
with young children to elicit their understanding of health, well-being and their
environment. The approaches and tools were reviewed and, considering
preschoolers’ cognitive and language abilities and the goal to include all children
who wanted to participate, not one but three research tools were deemed
necessary to meet the study objectives. Thus, three interactive research tools - a
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mix of visual (vignettes and drawings) and game-based activities (meal-creation

game), which were complemented with discussions - were developed and used
during the children’s workshops. The following three sections describe the tools
that were used in the study.
Game-based activity with food toys

Play is essential for children’s learning and development (Ginsburg, 2007;
Goldstein, 2012; Kernan, 2007). Children learn societal roles, norms, and values
within their sociocultural contexts (Roopnarine at al., 1998) and during play
children recreate the specificities of their social and cultural environment in a
personally meaningful way (Corsaro, 1993; Gosso, 2010), while at the same time
the sociocultural environment shapes children's play in its unique way (Bloch,
1989; Erickson, 1963; Schwartzman, 2012; Vygotsky, 1977). Lynch (2012) found
that children play with toys that represent foods realistically and grasp their
connection to real foods while research on grocery-shopping role-play with toy
products has proven valid for assessing various aspects of different types of food
purchasing and consumption schemas among children ages 2-6 (Sutherland et al.,
2008).
In this study, a game-based activity was designed to enable children to
express through play their understanding and perceptions about food, their eating
behaviours, and food related experiences. Children were given a range of food
toys (n=122) that covered common food types (Table 5.1 in Chapter 5). The
familiarity with food items in the food set was previously pre-tested with children
in the pilot phase.
Discussion of vignettes with children
Stories are one of the most fundamental ways of communication and they
do not just develop children’s literacy, they convey values, beliefs, attitudes and
social norms which shape children’s perspectives about their world (Albers,
2016). Given children’s interest in stories, the use of narrative methodology has
included stories told to and by children in which data are collected, analysed and
reported. In this study, a narrative lens was integrated into the research process by
inclusion of children’s accounts of their food experiences through the use of short
stories (Hill, 1997; Crafter et al., 2015). Vignettes are short stories, descriptions,
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pictures or scenarios about hypothetical characters in specified circumstances, to

whose situations the interviewee is invited to respond to elicit participants’
perceptions, beliefs and attitudes (Crafter et al., 2015; Finch, 1987; Hill, 1997;
Hughes, 1998). Vignettes make responding to questionnaires an interesting and
enjoyable process because vignettes are based on the approach of telling a story
(Barter & Renold, 1999, p.25). The advantage of using vignettes for data
collection from both adults and children is that they allow participants to express
their opinions and judgements on sensitive topics in a less personal and
threatening way (Hughes, 1998), allowing them to control whether they disclose
and discuss personal information (Barter & Reynold, 2004).
Four vignettes used in this study were designed to reflect the situations and
stories that were familiar to children and described child characters, their food
preferences and their behaviours in various situations to elicit different
dimensions of children’s food perceptions. Two short stories were read out to
children that described child characters in situations related to ‘healthy eating’ and
‘less healthy eating’. Given young children’s short attention span, an additional
two vignettes contained a picture of a character and one sentence that described
the characters who were ‘feeling full’ and ‘eating disliked foods” to elicit other
dimensions of children’s food experiences.
Drawings of food by children
Using children’s drawings as a data-gathering method has many

advantages, as it provides the children with an opportunity to express their views
and perceptions in a creative way while engaging in an activity that is familiar to
them and fun (Dockett & Perry, 2005; McWhirter, 2014). This activity was
considered especially important to gather data from very young children who can
have limited vocabulary. In this study, and at the end of the workshop children
were given sheets of paper and asked to draw pictures of food they liked and
disliked.
These different creative methods facilitated children’s engagement and
provided them with opportunities to express their perceptions and share
experiences in a variety ways. Discussions about the drawings, games and
vignettes were integrated throughout each of the activities. Children were
provided with opportunities and prompts to talk about their own experiences
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during the discussion of the stories, when they explained their drawings of food,
and while discussing their food preferences during the game.
3.7 Data analysis
Through the triangulation of interviews, preschool manager

questionnaires, observation, document review data, and the data from children’s
workshops, a rich, comprehensive description of the preschool food environment
and nutrition processes was uncovered. As convergent parallel design was
employed in this mixed method study, first, qualitative and quantitative data were
collected simultaneously and then analysed separately, followed with integration
of these data.
When analysing the qualitative and quantitative data, firstly, the food-
related documents were reviewed to gain a contextual understanding of preschool
operations. Secondly, the data gathered from the interviews with preschool staff
and parents were thematically analysed. Whilst data collection was carried out in
each participating preschool at the same time for all three studies, the data were
segmented for in-depth analysis for each study. Two separate data sets were
created for analyses in Study 1 and Study 3 and these data sets were analysed
separately. The analysis of data obtained from the children’s workshops in Study
2 involved merging four types of data and conducting inductive thematic analysis.
In Study 1 and Study 3, the data from thematic analyses were supplemented with
the data obtained through observation and document review. In Study 1, in
addition, the data from manager’s questionnaire were added. Detailed reflective
field notes were taken throughout the data collection phase.
These methods allowed capturing the holistic picture of the nutrition-
related issues by viewing the daily reality of the preschool environment through
multiple lenses. The semi-structured interviews and children’s workshops elicited
perceptions and experiences of preschool staff, children and parents related to
food and nutrition in preschools to achieve in-depth understanding of these
aspects and understand the challenges and needs they face, while the document
review provided context and legal background to the preschool nutrition practices.
The observation allowed an objective assessment of the nutrition environment,
practices and activities and the manager questionnaire provided additional
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information on preschools’ policies, mealtime practices as well as barriers and

needs of the participating preschools.
3.7.1 Document analysis
The nutrition-related preschool documents were analysed to gain

understanding of the legal and organisational context in which the preschool’s
nutritional practices were carried out. Document analysis is a systematic
procedure for reviewing or evaluating documents, both printed and electronic, to
answer specific research questions (O'Leary, 2017). Similar to other methods of
analysis in qualitative research, document analysis requires repeated review,
examination, and interpretation of the data in order to gain meaning and empirical
knowledge of the construct being studied (O'Leary, 2017; Rapley, 2007).
The document analysis in this study involved finding, selecting, reviewing,
assessing and synthesising data contained in documents. Therefore, the analytic
procedures undertaken included a) determining the relevance of documents to the
research problem and purpose; b) ascertaining the documents fit the the
conceptual framework of the study (e.g. setting approach); c) determining the
purpose of each document, the source of information contained in the document,
the context in which it was produced, and the intended audience; d) confirming
the authenticity, credibility, accuracy, and representativeness of the selected
documents; e) existence (e.g. presence or absence of the Food and Nutrition
Guidelines for Preschool Services or healthy eating policy) and accessibility of
documents; and f) usefulness of documents (e.g. how or whether healthy eating
policies or menus were used in preschool day-to-day nutrition practices).
Further, the documents were assessed for completeness, in the sense of
being comprehensive (covering the topic of interest completely or broadly, e.g. if
there is a packed lunch section in the healthy eating policy) or selective (covering
only some aspects of the topic) and whether the documents are even (balanced) or
uneven (containing great detail on some aspects of the subject and little or nothing
on other aspects). Identifying these characteristics in documents is important
because absence, sparseness, or incompleteness of documents may help to gain
insights about the phenomena under study or the people involved. For example, it
may suggest that certain matters have been given little attention or that certain
voices have not been heard (Bowen, 2009). In that sense, the document analysis
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not only provided contextual data for the present study but was also instrumental
in triangulating multiple-method data. For example, information contained in
preschool nutrition-related documents provided ideas for asking additional,
probing questions during interviews and also suggested situations or practices that
needed to be observed in preschools.
The document analysis was a complementary analysis in support of
triangulation and the thematic analysis (Braun & Clarke, 2006), which was based
on an inductive approach aimed to identify patterns and discovering concepts in
the data. The thematic analysis data were supplemented with the documentary
data (text extracts and field notes). Then the codes from interview transcripts,
observational data and documentary data were synthesised, so that themes would
emerge across all three sets of data.
As document analysis should work towards addressing the research
questions in insightful ways, a referral to the research objectives was implemented
throughout the document analysis.
3.7.2 Thematic analysis of interview data
The semi-structured interviews with preschool staff, parents and children

were transcribed verbatim from the audio files and checked for accuracy after
transcription, and the observation notes were typed by the researcher. Then the
interview transcripts were read several times to gain familiarity with the data.
Interview data from all stakeholders were treated separately in the initial analysis
stage.
The data were imported into, coded and analysed using NVivo Pro 11
software. An open (unrestricted) coding was performed and subthemes and
themes were identified. The thematic analysis and theme generation in this study
was guided by Braun and Clarke’s (2019) principles of reflexive thematic
analysis. Thematic analysis is a method for identifying, analysing and reporting
patterns (themes) within data. Thematic analysis differs from other analytic
methods that seek to describe patterns across qualitative data by its flexibility as it
is not constrained by a requirement to adhere to any pre-existing theoretical
framework. Through its theoretical freedom, thematic analysis provides a flexible
and useful research tool, which can potentially provide a rich and detailed, yet
complex, account of data (Braun & Clarke, 2006). During the thematic analysis
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phase in this study themes were identified from subthemes and subthemes were
developed from codes using an inductive approach, where the themes identified
are strongly linked to the data themselves (Patton, 1990). Coding quality in
reflexive thematic analysis stems not from consensus between coders, but from
depth of engagement with the data and situated, reflexive interpretation. In such
interpretation the relevance of the theme to the research question and the quality
of the theme are critically important (Braun & Clarke 2006, 2012). In line with the
epistemological approach in the thesis, thematic analysis in all studies was carried
out from a constructionist perspective which posits that there are multiple
knowledges, rather than a single truth or reality (Braun & Clarke, 2013). It was
acknowledged that different participants - parents, staff and children - may have
different perceptions, understandings and experiences.
Braun and Clarke (2016) present an approach to thematic analysis that
meaning is not inherent or self-evident in data but a result of the researcher’s
contextual and theoretically embedded interpretation of data – in short, that
meaning requires interpretation or, in other words, meaning is generated or
constructed rather than discovered from data. From this perspective, the meaning
generated from the data is about the quality of data collected – their richness,
depth, diversity and complexity, as opposed to the quantity of data collected or
frequency of the codes identified (Braun & Clarke, 2019; Fusch & Ness 2015). In
this regard, the concept of information power proposed by Malterud and
colleagues (2016), which argues that high quality data, regardless of its size, is
sufficient if it gives new insights that contribute substantially to or challenge
current understandings, becomes relevant.
A balance between methodologically sound technique and ensuring
flexibility in making active choices about the particular form of thematic analysis
used is important. Therefore, guided by these principles of thematic analysis by
Braun and Clarke (2006, 2019), data analysis in this study involved moving
through the following six steps of thematic analysis: 1) Becoming familiar with
the data by checking the verbatim transcripts back aganst the original audio
recordings for ‘accuracy’; and rigourous and thorough reading and reflecting on
the transcripts and reflective notes. At this stage, an initial list of interesting ideas
in the data was generated; 2) Generating initial codes by identifying interesting
aspects in the data items that may form the basis of repeated patterns (themes)
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across the data set and organising the data into meaningful groups (codes); the
inductive ‘data-driven’ coding of each actual data extract (quote) from the entire
data set was performed; 3) Creating initial themes by interpretative analysis of
the data – examining all quotes associated with each code and organizing codes
into subthemes and further into themes; 4) Reviewing and refining themes by
examining all codes and quotes associated with a theme in detail, combining
several themes into one theme, separating themes and eliminating themes; 5)
Defining and naming themes by defining the essence of each theme; and 6)
Producing the report. A second researcher (supervisor) reviewed the coding
scheme and themes as they were developed, and differences in themes generated
were discussed and reconciled and a list of final themes and representative quotes
were agreed.
3.7.3 Analysis of observation data
Following the Preschool Observation Tool the researcher looked at

occurrences of events and participants’ behaviours in the data to calculate the
frequency of food-related practices and behaviours. These practice and behaviour
frequencies were used to assess the extent of occurrences of food behaviours and
the extent of variation or similarity of food- and nutrition-related practices and
behaviours among the participating preschools. The observation data
supplemented the data gathered by other methods to gain a more comprehensive
understanding of preschool food environment and nutrition-related practices.
3.7.4 Analysis of preschool manager questionnaires
The frequencies of managers’ responses were calculated and data obtained

through this method provided additional quantitative information on preschools’
policies, mealtime practices as well as barriers and needs of the participating
preschools. The data from questionnaires were triangulated with the data obtained
through semi-structured interviews, observations and document review.
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3.7.5 Children’s workshops: merging four types of data and

thematic analysis
Four types of data (toys, vignettes, drawings, and discussions) were

collected, merged, coded, and analyzed. The discussions with children during the
workshop activities were tape-recorded and transcribed verbatim by the
researcher. Field notes taken during data collection were also transcribed and
included in analysis and were used throughout the analytic process to record and
reflect on the researcher’s observations. The interview transcripts, notes on the
children’s drawings, and field notes were read several times to gain familiarity
with the data. Inductive thematic analysis of all combined data (transcripts of
discussions from games and vignettes, field notes, and notes on drawings) was
conducted (Braun & Clarke, 2006). Sub-themes were identified from the codes,
and themes were agreed followed by refinement and naming themes and sub-
themes. The codes, sub-themes, themes, and representative quotes were discussed
and debated and agreed upon. NVivo Pro11 software was used to manage data.
The results are presented using the vernacular, as this is how children expressed
their views and this way their responses are better contextualised.
3.8 Integration of mixed data in the present study
Integration of qualitative and quantitative data in this study was performed

at multiple stages: at the design level, the methods level and the interpretation and
reporting level (See the diagram in Figure 3.1).
Integration at Design level – through convergent parallel design

Convergent parallel design was adopted for this study and the two types
of data were collected separately - qualitative data were collected through semi-
structured interviews with preschool staff and parents, children’s workshops and
document review. Quantitative data were derived from observations and manager
questionnaires. Within the convergent parallel design, the “matching” approach
was used which involves intentionally designing data collection instruments to
have related items such that both instruments will elucidate data about the same
phenomena or variables. Particularly, this involves matching qualitative questions
with questions in quantitative instruments (Creswell, 2015a, 2015b; Fetters et al.,
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2013). For example, questions in the semi-structured interview guides were

developed with the questions in the observation guide and manager questionnaire
in mind.
Integration at Methods level – through merging

After purposefully matching the questions in qualitative instruments with
those in quantitative instruments during the study design stage, integration
through merging method (the two databases are brought together for comparison
and analysis) followed. Firstly, the analyses of the quantitative and qualitative
data were conducted separately but in parallel. For the qualitative analysis,
inductive thematic analysis was conducted. For the quantitative analysis,
descriptive statistics of the number and frequency of food-related behaviours of
staff and parents were calculated. Secondly, different merging approaches were
used to enhance interpretation of the integrated quantitative and qualitative data in
this convergent study (Fetters et al., 2013): 1) comparing the quantitative and
qualitative findings after separate analyses of the quantitative and qualitative data
collected; and 2) analysing on a theme-by-theme basis by linking related
qualitative themes and quantitative variables. During the integration process, as
the items on the qualitative interview guides and on the observation guides were
developed in tandem, the codes in the coding procedure during the thematic
analysis were similarly developed based on the data obtained through the
interviews and the observation. As additional themes emerged, codes to capture
these were added. These methodological procedures facilitated thematic searches
of the transcripts from the qualitative interviews about preschool food
environment and nutrition practices that could be matched and merged with the
observational data and manager questionnaire responses (Fetters et al., 2013).
The outcome of merging and comparing the qualitative data and
quantitative data at this level was the understanding whether the databases
converge, complement, conflict, or diverge (Creswell, 2015b; Fetters et al., 2013).
In this study, the integration of the quantitative and qualitative data resulted in
an expansion of understanding about the preschool nutrition processes: the
qualitative findings provided information about the study participants’ food-
related perceptions and experiences, while quantitative data illustrated the types of
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behaviours practiced and frequency of the behaviours among the study

participants.
Integration at Interpretation and Reporting level – through narrative approach

using weaving and contiguous methods of narrative integration
As the quantitative and the qualitative data have been structured in a
format based on thematic relevance to allow merging, higher order integration
interpretation was needed. For this, a narrative approach that synthesizes and
describes the quantitative and qualitative results thematically was used in the final
report. In Studies 1 and 2, the results from the quantitative and qualitative data
were integrated using a weaving approach where the results are connected to each
other thematically, and the qualitative and quantitative data weave back and forth
around similar themes or concepts (Fetters et al., 2013).The qualitative data were
given priority at the stage of interpretation (Johnson et al., 2007). The narrative
provided comparisons of the findings from the qualitative interviews on nutrition
practices that were supported by the results from the quantitative data obtained
through observation and manager questionnaire.
In Study 3, in which the preschool staff-parent communication patterns
were explored, a contiguous type of narrative integration was used that is -
presentation of findings within a single report, but the qualitative and quantitative
findings are reported in different sections (Fetters et al., 2013).
Through obtaining the outcomes of integration of mixed data at
Interpretation and Reporting level the following purposes of using mixed methods
approach were achieved in this study (Greene et al., 1989; Schoonenboom &
Johnson, 2017; Venkatesh et al., 2013):
• triangulation (e.g. several results from different methods (e.g. interviews,
observation, manager questionnaire) corresponded and converged; observed
nutrition practices corroborated with the results of the interviews; the results of
document reviews corresponded to the nutrition practices at preschools, etc.).
This outcome is described in more detail in the next section ‘Strategies to
ensure methodological rigour’).
• expansion (e.g. the findings from several sources of data diverged and
expanded insights of nutrition-related processes in the preschool setting by
addressing different aspects of these processes);
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• complementarity (e.g. the results from observations of preschool food

environment helped to enhance the understanding about occurrence of certain
nutrition-related activities; the results from the interviews clarified several
aspects of observed nutrition practices; observed nutrition practices illustrated
the results of the interviews, etc.)
3.9 Strategies to ensure methodological rigour
In order to achieve good quality research, strategies ensuring the study’s

rigour need to be in place. Since, in this qualitatively-driven mixed method study,
simple mathematical procedures of counting numbers and frequencies were used
in the quantitative phase, the methodological rigour is more pertinent to the
qualitative phase of the study. Four criteria proposed by Lincoln and Guba (1985),
credibility, dependability, confirmability and transferability, formed the
framework for determining the rigour of the qualitative research. A number of
strategies were undertaken in the present study to ensure that the analyses were
rigourous and met these criteria.
Credibility refers to the value and believability of the findings and
involves two processes: conducting the research in a believable manner and being
able to demonstrate credibility. In the present study, triangulation of multiple
qualitative and quantitative methods and peer review/debriefing enhanced the
credibility. Triangulation is defined as a research methods strategy to ensure that
the data, analysis, and conclusions of a research study are as comprehensive and
accurate as possible (Moon et al., 2019) by seeking at least three ways of
verifying or corroborating a particular event, description, or fact being reported by
a study (Patton, 2015). It enables multiple perspectives to be brought together as a
“means of widening or deepening understanding of a subject through the
combination of multiple readings” and thus increases confidence in the
conclusions (Lewis et al., 2003, p. 275). Completeness of data was pursued with
gathering multiple perspectives from various sources so that as complete a picture
as possible of the phenomena of interest is portrayed. Each approach to gathering
data (qualitative interviews, document review, observation and questionnaire)
employed in Study 1 and 3 had specific advantages that, when used together,
maximised the potential for in-depth insight and more complete understanding of
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findings and their context (Casey & Murphy, 2009; Fenech Adami & Kiger,
2005). In addition, by triangulating data, the study findings were corroborated
across data to reduce the impact of potential biases that can exist in a single
method and thus increase the validity of data. The convergence or agreement
between several methods "…enhances our belief that the results are valid and not
a methodological artefact" (Bouchard, 1976, p. 268), which is also called
‘convergent validation’ (Jick, 1979). However, where divergent results emerge,
alternative, and likely more complex, explanations are generated, in other words,
in seeking explanations for divergent results, the researcher may uncover
unexpected results or unseen contextual factors (Jick, 1979). In this study,
triangulation allowed for unpredicted and interesting findings that were not
considered previously. This will be presented further in the Results and
Discussion sections of Chapter 4 (Study 1). In Study 2, which explored preschool
children’s food preferences and perceptions about food and healthy eating,
triangulation of diverse sources of data gave a more complete picture of children’s
food-related perspectives than would have been given by a single data source.
Triangulation of four types of data (toys, stories, drawings, and discussions), in
effect, countered the challenges of collecting data from very young children.
In addition, to enhance the credibility, regular debriefing meetings were
carried out in this study between the researcher and the supervisor. Discussions of
the study’s research process, including research design, methods and tools used in
the study, analysis methods, and research findings, were carried out for the
purpose of recording researcher’s thoughts, decisions and activities. The
supervisor and the members of the Graduate Research Committee provided expert
feedback and advice to enhance the researcher’s developing ideas and
understanding of the data, analysis process, and interpretation of findings.
Transferability refers to whether or not particular findings can be
transferred to another similar context or situation, while still preserving the
meanings and inferences from the completed study. To determine transferability,
the researcher is required to provide a thick, detailed description of the original
context of the research so that judgements can be made by readers to make
informed decisions about the transferability of the findings to their specific
contexts (Koch, 1994). Rich and thorough descriptions of the research process,
including epistemological and theoretical underpinning and methodological
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considerations detailing the sampling and recruitment procedures are presented in

the current chapter. In addition, a detailed description of the data collection
procedures and presentation of the findings, with verbatim quotes and description
of themes are reported in Chapters 4, 5, and 6 of this thesis.
Dependability in qualitative research is often compared to the concept of
reliability in quantitative research and refers to how stable the data are and
whether the research process is consistent, logical, transparent and clearly
documented (Long & Johnson, 2000; Ulin et al., 2012). Confirmability refers to
the neutrality and accuracy of the data, and is closely linked to dependability – the
processes for establishing both are similar (Houghton et al., 2013). Rigour can be
achieved by an audit trail, which is recording a detailed account of the research
methods and decisions made throughout the process to provide a rationale for the
methodological and interpretative judgements of the researcher. Koch (1994)
believed that while readers may not share a researcher’s interpretation, they
should nonetheless be able to discern the means by which it has been reached. A
detailed description of the qualitative methodology of this study is provided in
several sections of the current chapter.
Finally, in most qualitative research, the researcher is considered a part of
the research instrument (Rodgers & Cowles, 1993). Therefore, the credibility of a
study rests on the research procedures implemented and the self-awareness of the
researcher throughout the research process, at the same time acknowledging the
experiences and values of the researcher which are inseparable from the research
process (Ulin et al., 2012). Related to confirmability is awareness of distinction
between the researcher’s own individual views and those of the study informants.
This distinction can be achieved through an audit trail as well as continuous
critique and self-appraisal by the researcher, through the use of reflexive notes
and materials gathered during the research process (Ulin et al., 2012). In this
study, on-going reflexive notes were kept about the study progress reflecting my
personal views, thoughts and insights, and interpretations in relation to research
tool development, data collection, analysis, coding process and the researcher’s
perceptions about the study’s themes that emerged as the research was
undertaken. The reflexive notes were used iteratively as an additional data source
for memo-construction and peer and supervisory review and debrief. Furthermore,
it is important to reflect on the researcher’s identity, experiences and values,
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assumptions and reactions and bias and how these factors might influence the
research findings.
I obtained an M.D. degree in internal medicine in Irkutsk, Russia,
however, I grew interested in disease prevention which upon graduation led me to
work in the public health field, specifically for the Ministry of Health of
Mongolia. I went on to study further and completed a master’s programme in
public health with concentration in social and behavioural sciences and
community health at State University of New York at Albany, NY, USA. This
qualification opened up opportunities to work as a community health educator in
early care settings in two countries, Mexico and Mongolia for several years where
I gained invaluable experiences of working with young children and became
aware of the importance of the childcare environment on children’s health and
well-being. Following this, I had the opportunity to manage a non-governmental
organisation in public health related to food safety and nutrition in Mongolia.
These experiences in the field of public health and health promotion, particularly
related to children and nutrition, along with being a mother of two preschool-aged
children at the time, had further led me to develop a keen interest in research in
the area of children’s health and well-being, and specifically in young children’s
nutrition. I was fortunate to be awarded a Hardiman Research Scholarship and
accepted into the Structured PhD Programme in Health Promotion at the National
University of Ireland, Galway. As a mixed method researcher, I conform to a
pragmatic approach to the research process acknowledging the value in both the
quantitative and qualitative research paradigms as, I believe, that combining these
approaches can enhance the overall quality of research (Morgan, 2014; Shannon-
Baker, 2016). During this structured PhD study, consultations and discussions
with my academic mentors and attending national and international conferences
and events related to the field of my study further advanced my knowledge and
experiences. A researcher’s reflexive stance requires to scrutinise his or her
research experience, decisions, and interpretations, the way the researcher
conducts research, relates to the research participants and represents them in
written reports’ and it requires to enter into a collaborative, non-hierarchical
relationship of reciprocity with participants where meaning and power is mutually
negotiated (Charmaz, 2005, 2006; Dowling, 2006). I recognise that my past
professional experience in public health and my present position as a doctoral
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student in health promotion, influenced my thinking and acting. Acknowledging

the value of participatory research I recognise the value the participants, both
children and adults, can bring to the research process. During the course of this
PhD study I acknowledged the validity of each participant’s statements respecting
their ability and its value to create knowledge stemming from their personal
experiences and identify solutions for problems arising from these experiences. I
carefully maintained a democratic approach with all participants during my
inquiry through conducting interviews with preschool staff and parents and
children’s workshops in an interactive, respectful manner that encouraged
participants’ input, ensuring that participants were fully involved during the
inquiry process, and confirming during discussions with participants my
understanding of their views and perceptions. Finally, as a parent of young
children, I could understand, identify with and empathise with the experiences of
caregivers, however, as a researcher I needed to maintain an appropriate balance
between familiarity and professional distance to distinguish my own views,
beliefs and experiences from those of study participants to eliminate any bias
when analysing and interpreting the data (Duch & Rasmussen, 2020).
3.10 Sampling and recruitment
This section will describe the recruitment process and the rationale for
choosing the study’s sample and sample size.
3.10.1 Sampling approach and procedures
The selection of an appropriate sampling method depends upon the aim of

the study. Qualitative researchers typically engage in purposive sampling which
was also used in the present study. Patton (2002) defines purposive sampling, also
known as judgmental, selective, or subjective sampling, as a method that
deliberately choses the study subjects who can provide rich information due to
their particular characteristics. It is a non-random technique that does not need
underlying theories or a set number of subjects. Simply put, the researcher decides
what needs to be known and sets out to find people who can and are willing to
provide the information by virtue of knowledge or experience (Bernard 2002,
Lewis & Sheppard 2006). Purposive sampling is widely used in qualitative
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research for the identification and selection of information-rich cases for the most
effective use of limited resources (Patton, 2002).
Purposive sampling was used in this study to select and recruit preschools.
In order to achieve a mix of socio-economic background among the study
participants the following three sample frames were used:
1. Community crèches/preschools - were recruited to reach the families who
avail of community crèches as they are typically in receipt of social welfare
payment or of low income. A community childcare facility is managed by a
voluntary management committee. These types of facilities give preference to
families on lower incomes, supporting parents in returning to work or
education. In community preschools the subsidised childcare is provided with
costs based on a sliding scale, according to the family income.
2. Other/private preschools - in private childcare facilities, the main income is
derived from parents’ fees. However, both community and private childcare
facilities operate the government-funded ECCE, a scheme that provides two
years of free ECCE for all children of preschool age. In addition, since
September 2017 all existing subsidy schemes (other than ECCE Scheme)
have been merged into the ‘Affordable Childcare Scheme’ and have been
opened to private preschool services available to families who meet the
criteria, making all types of childcare more accessible to all families.
Therefore, children from families with a mix of socio-economic background
could be attending private preschool settings.
3. Preschools that are located in disadvantaged areas of Galway City were
identified based on the Pobal HP Deprivation Index (Pobal, 2016). These
areas include Ballybane, Ballinfoyle, Bohermore, Doughiska, Lough Atalia,
Mervue, Newcastle, Shantalla and Westside. The rationale was that families
living in these areas of disadvantage would choose the childcare settings
within easy access to their homes and local to their community.
3.10.2 Sample size
A sample size in qualitative research is a much debated issue (Boddy,

2016; Blairie, 2018; Braun & Clarke, 2020; Sim et al., 2018a). Some experts in
qualitative research methodology believe that the issue of an appropriate sample
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size in qualitative research is only really answerable within the context and
scientific paradigm of the research being conducted (Boddy, 2016; O’Reilly &
Parker, 2013; Sandleowski, 1995; Sim et al., 2018b). Others state that in research
that employs an inquiry built on iterative process of knowledge co-production by
researcher and participants, particularly in research employing a constructivist
approach, it is practically impossible to determine sample size in advance
(Blaikie, 2018; Braun & Clarke, 2019). However, there are considerable pressures
to estimate and justify a sample size prior to research commencing, for example
for a research proposal, ethics or funding purposes. Moreover, Patton (2002)
recommends “that qualitative sampling designs specify minimum samples based
on expected reasonable coverage of the phenomenon given the purpose of the
study and stakeholder interests.” (p. 246). Therefore, determining an adequate
sample size in a qualitative study depends on a combination of interpretative,
positional, and pragmatic judgment, the latter being formed and limited by the
time and resources available to the researcher (Boddy, 2016; Blaikie, 2018; Braun
& Clarke, 2019; O’Reilly & Parker, 2012; Sandleowski, 1995; Sim et al., 2018a).
Thus as Sandelowski (1995) points out “ sample size … is ultimately a matter of
judgement and experience such as evaluating the quality of the information
collected against the uses to which it will be put, the particular research method
and sampling strategy employed, and the research product intended " (p. 183).
In studies that use interviews as primary source of data, a sample size is
often justified on the basis of interviewing participants until ‘data saturation’ is
reached referring to the point in data collection when no new findings, concepts or
problems were evident in the data (Glaser & Strauss, 2017). However, there is no
agreed method of establishing when data saturation has been reached. Braun and
Clarke (2019) reason that it is difficult if not impossible to predict the ‘data
saturation point’ in advance when the analysis is inductive and, therefore,
determining sample size in advance is challenging. The authors argue that data
saturation is not the only, or indeed the best, rationale for sample size in this type
of research and suggest that various intersecting aspects needs to be considered
when determining the sample size: the breadth and focus of the research question;
the methods and modes of data collection to be used; diversity within the sample
population; likely experiential or perspectival diversity in the data; the demands
placed on participants; the depth of data likely generated from each participant or
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data item; the expectations of the local context including discipline; the scope and
purpose of the project; the pragmatic constraints of the project; and the analytic
goals and purpose of their thematic analysis.
On the other hand, Malteraud and colleagues (2016) proposed the concept
of “information power” to guide adequate sample size for qualitative studies. The
authors argue that for an exploratory study, researchers do not try to achieve to
describe all aspects of the phenomenon of interest completely and are usually
satisfied when a study offers new insights that contribute substantially to or
challenge current understandings. The model indicates that this can be obtained
even with a sample of a few participants, provided that the sample holds sufficient
information power. Similarly, Boddy (2016) argues that as qualitative research
often concerns developing a depth of understanding rather than a breadth,
particularly when undertaken with a constructivist approach to research, a small
sample size (as small as a single research participant) can be of importance and
can generate great insight. In this regard, sample adequacy, data quality, and
variability of relevant events are often more important than the number of
participants. Thus, an initial approximation of sample size is necessary for
planning, while the adequacy of the final sample size must be evaluated
continuously during the research process. Likewise, Braun and Clarke (2019)
consider information power as a useful alternative to data saturation ‘for thinking
around justifications for sample size in reflexive thematic analysis, both actually
and pragmatically’. They suggest that researchers should be constantly reviewing
data quality during the data collection, recognising that sample size alone is not
the only factor at play, and make a decision about the final sample size, shaped by
the adequacy and richness of the data for addressing the research question.
In the present study, it was deliberated that the data collected from ten
preschools would hold sufficient ‘information power’ to address the research
questions. The consideration of multiple perspectives from different types of
participants allowed for information-rich data and deeper and richer findings from
a small sample (Silverman, 2011), while using mixed method design helped to
triangulate the findings.
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3.10.3 Preschool recruitment
After consultation with members of Galway Childcare Committee

(GCCC) a list of all childcare settings offering a preschool service in Galway City
was obtained from the GCCC website https://www.galwaychildcare.com/.
Initially, in order to address the study’s research questions and achieve a mix of
socio-economic background of the participants, the selection criteria for
preschools were:
a) Full-day care services (both community and private) with food prepared on the
premises and served to children;
b) Part-time/sessional community preschools; and
c) Preschools located in disadvantaged areas.
Based on availability of these types of services in Galway City an initial
approximation of sample size necessary for planning the data collection was 18
preschools which met one or more of the above named criteria – 10 full-day and 8
part-time/sessional preschools. Galway City was chosen for data collection
because the researcher could travel to the preschools by public transport within a
reasonable timeframe and with available resources. The research question and
related methodology did not require sampling from other counties in Ireland.
To answer the research questions posed in this study, the focus was
initially on full-day care services where food was prepared on the premises and
served to children. Thus, ten full-day care preschools, both community and private
services, located in disadvantaged areas of Galway city were contacted first. The
letters to preschool managers (Appendix 2) inviting them to participate in the
study and the Participant Information Sheet (Appendix 3) were sent out by post
followed by visits to the premises to see if they had any questions or needed
additional information about the study. Four preschools were recruited at that
point. Recruitment of private full-day preschools was challenging as some
managers were hesitant to take part despite efforts to emphasise the importance
and confidentiality of the research study. Nevertheless, fewer preschools were
recruited (n=4) than initially planned and another round of invitations was sent out
to 8 part-time/sessional community crèches where food was not served on the
premises but provided by children’s parents. Six out of 8 preschools of this type
were recruited in the second round. While food is not prepared on site, nutrition
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policies still apply to lunch boxes and carer’s assistance at mealtimes impacts on
food behaviours. In sum, out of 18 preschools invited to participate in the study 10
preschools agreed to take part (response rate 56%). After preschool managers
provided consent to take part, recruitment letters to parents including the Letter
Inviting Parents for Their Child to Participate in the Project (Appendix 4), Parent
Information Sheet on Children’s Workshop (Appendix 5), Child Information
Sheet and Consent Form (Appendix 7) and active Parental Consent Forms
(Appendix 6) were administered by preschool staff or placed in the children’s
bags. Active parental consent forms were collected by preschool managers.
Seventy one children whose parents signed the consent forms were recruited
(response rate 29%). To recruit parents who gave consent for their children to
participate in workshops, invitation letters to parents (Appendix 8) and parent
consent form (Appendix 9) were administered by preschool staff or placed in the
children’s bags. The response rate of parents to participate in the interview was
14%.
3.11 Ethical considerations
Ethical approval for the study was granted by the Research Ethics
Committee of the National University of Ireland, Galway (Appendix 1).
The researcher obtained Garda vetting clearance prior to contacting the
preschools for recruitment of participants. When conducting research with
children in this study, ‘Children First: National Guidelines for the Protection and
Welfare of Children’ (Department of Children and Youth Affairs, 2017) were
followed. Active Parental Consent Forms (Appendix 6) were obtained from each
child’s parent. Parents were asked to read and discuss with their child the Child
Information Sheet and Consent Form (Appendix 7) prior to the workshops.
Children’s assent and permission to audio-record the workshops were obtained
before the data collection. Children were informed that they can withdraw from
the activities at any stage and were free to ask questions at any time. Throughout
the children’s workshops the researcher observed the non-verbal cues children use
to communicate their assent or dissent. This included using a sense of ‘ethical
radar’ as described by Skanfors (2009) sensing when children have discomfort or
disinterest that is presented apart from their verbal or body language.
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Other ethical issues considered in this study were confidentiality,

anonymity and the risk of emotional distress to participants. Several strategies to
address these concerns were applied throughout the data collection. The
confidentiality and anonymity issues were explained in the Participant
Information Sheet (Appendix 3). In addition, prior to the interviews participants
were verbally assured that the participation is voluntary and that they could
withdraw from the study at any time, and that responses would be made
anonymous. As data was collected using interviews with preschool staff and
parents who interact daily, maintaining confidentially was particularly important.
To address this, interviews were conducted in a separate room or outside of the
preschool. Anonymity of the participants was ensured by assigning specific
participant numbers and pseudonyms to avoid identifying participants by name. In
relation to distress, in the event of participant becoming upset as a result of the
interview process, a protocol for managing distress (Appendix 16) was prepared.
All collected data were stored securely and treated confidentially. In
addition, in compliance with the Data Protection Acts 1988-2018 and the
European General Data Protection Regulation (GDPR) in its processing of
Personal Data and Special Categories of Personal Data and to ensure privacy and
give greater control to participants over their personal information, the study data
were kept in a safe place and the participants had a right to access the data or ask
for it be erased if they wish so. Upon the completion of the study the transcribed
data and hardcopies of signed consent forms will be kept separately in a locked
filing cabinet in the possession of the supervisor and retained in accordance with
NUI Galway Research Ethics guidelines for five years and be destroyed
thereafter.
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Chapter 4: Preschool Nutrition Practices and Staff Perceptions
CHAPTER 4: STUDY 1 - EXAMINING PRESCHOOL FOOD

PRACTICES
The purpose of health promotion is to positively influence health and well-

being of individuals and communities as well as the living and working conditions
that influence their health by developing individual, institutional, community and
systemic strategies to improve health, knowledge, attitudes, skills and behaviour.
The settings are viewed not merely as culturally and socially defined locations in
space and time but also as “arenas of sustained interaction, with pre-existing
structures, policies, characteristics, institutional values, and both formal and
informal sanctions on behaviour” (Green et al., 2000, p. 23). Furthermore, settings
are also a part of ‘systems-thinking’ or systems approach to prevention (Fleming
& Baldwin, 2020). The systems approach sees settings (e.g. preschools) as
ecological systems in themselves, and that the effectiveness of health promotion
practice can be improved with better understanding of the systemic characteristics
of the settings such as their interactions and dynamic complexity (Tseng &
Seidman, 2007). The aim of this study (Study 1) was to investigate the
characteristics of the preschool nutrition environment, how preschool staff
experience and manage food and mealtimes in their services, how they perceive
their role in promoting a healthy diet and to explore their food-related perceptions
and beliefs. First, a brief overview of relevant literature and the legal background
of the early years sector in Ireland is provided, followed by description of the data
collection process (Chapter 3 provided the methods for choice of tools used in this
study). Then the findings based on integrated interpretation of merged qualitative
(thematic analysis of interviews with preschool staff and document analysis) and
quantitative results (observation and the manager questionnaires) are presented.
Following this, the results are discussed in relation to the current literature and
recommendations for future research and practice are provided. Finally, the
study’s strengths and limitations are described.
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4.2 Background and study’s research objectives
Early childhood is seen as a formative period and a critical time for

interventions to help children in developing positive attitudes toward (healthy)
food and establishing healthy behaviour patterns (Paes et al., 2015). As early
years care settings contribute significantly to children’s nutrient intake and
acquisition of dietary habits; knowledge, skills and behaviours of children,
parents, and caregivers can be targeted in these settings. In addition, childcare
settings can provide cost-effective opportunities to promote healthy eating habits
in preschoolers by reaching more children at the same time (Mills et al., 2014).
Studies with successful implementation of healthy eating interventions in early
years care settings such as the ToyBox study (Lambrinou et al., 2019), Si!
Program (Peñalvo et al., 2015), Healthy Caregivers-Healthy Children study
(Messiah et al., 2017), and NAPSACC (Shin et al., 2019) demonstrated the
effectiveness of evidence-based best practices that promote modelling of positive
behaviours, creating childcare environments that promote healthy diets, and
simultaneously targeting factors at the family and childcare levels. However,
research carried out in a number of countries such as Australia, Canada, the USA,
and several European countries to examine early years care centres as a setting for
promoting healthy nutrition has identified numerous areas for improvement in
food environment and nutrition practices in this setting (Byrd-Williams et al.,
2017; Ward et al., 2017; Gubbels et al., 2015; Dev et al., 2014; Sisson et al., 2012;
Lanigan, 2012; Elliasen et al., 2011; Sigman-Grant et al., 2011, 2008; Ramsay et
al., 2010; Gable & Lutz, 2001).
Recent systematic reviews reported that the most effective interventions
to promote optimal nutrition in early years care settings were multi-component
and multi-level targeting childcare setting’s policy, environmental, and
individual-level determinants of healthy eating behaviours and focused on
capacity-building of caregivers, parents and children (Ling et al., 2016;
Matwiejczyk et al., 2018; Mikkelsen et al., 2014; Sisson et al., 2016; Ward et al.,
2017; Wolfenden et al., 2016). Furthermore, Jackson and colleagues (2006)
reviewed evidence of effectiveness of health promotion strategies in relation to
action areas of the Ottawa Charter's on Health Promotion, such as building
healthy public policy, creating supportive environments, strengthening
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community action and developing personal skills. They concluded the action areas
‘need to act in conjunction with each other and certain supporting actions to be
effective’ (p. 82) and that interventions using multiple strategies at multiple levels
and sectors are most effective. However, it has been noted that although
successful when delivered by experts, the more comprehensive the intervention,
the more it may affect its feasibility and may not be replicated when delivered
by end-users, e.g. early years care provides (Matwiejczyk et al., 2018).
Likewise, Ward and colleagues (2016) found an inverse relationship between
comprehensiveness and positive outcomes. Matwiejczyk and colleagues (2018),
in their umbrella review argue that, therefore, the translation of research
evidence into practice warrants further qualitative exploration of
implementation drivers and barriers with end-users to understand the local
context and ensure the sustainability of change.
In Ireland, there has been a recent significant expansion to
preschool services nationally. Since the Early Childhood Care and Education
(ECCE) Scheme, a universal government-funded free childcare programme for
children of preschool age delivered through both private and community (not-for-
profit) childcare providers, was introduced in 2010, a significantly greater number
of children have been attending early care settings. Over the past several years,
about 96% of preschool children have accessed the National Childcare Scheme
with an average of 25 hours per week spent in childcare (Central Statistics Office,
2017). In addition, there are various national childcare programmes that support
parents on a low income to avail of reduced childcare costs at participating
community childcare services thus rendering more affordable and accessible
childcare (Department of Children and Youth Affairs, 2017a, 2017b).
Coupled with the increase in preschool services came a rise in
employment in these settings. It is estimated that in 2019 approximately 30,775
staff worked in the ELC/SAC sector, of whom 26,882 (87%) worked directly with
children. This is an increase of 4% on the previous year, and represents a higher
overall increase than the number of children enrolled (2%). This indicates that the
number of staff in the sector is growing faster than the number of children
enrolled. Sixty six percent of staff who directly work with children are employed
in private childcare services and 59% of staff working directly with children care
for children aged 3-5 years old (Pobal, 2019).
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In parallel, an increase in preschool teacher degree and training

programmes evolved in Ireland. Quality and Qualifications Ireland (QQI) is
responsible for developing, promoting and maintaining the Irish NFQ (National
Framework of Qualifications), a 10-level national certification entity. The
Childcare Legislation (2016) requires all childcare workers to hold a minimum of
a QQI Level 5 Major Award in Childcare (NFQ Level 5) before they are allowed
to work in a registered childcare setting. However, to benefit from ECCE Scheme
subsidies, the service Room Leader must hold at least a QQI Level 6 Major
Award in Childcare (NFQ Level 6) (Quality and Qualifications Ireland, n.d). In
2019, 94% of staff had a qualification NFQ Level 5 or higher, within which the
proportion of staff with NFQ Level 6 or higher was 67% (Pobal, 2019). However,
the minimum requirement for staff to be employed as a preschool teacher does not
require comprehensive nutrition knowledge. The QQI Childcare Level 5 course
curriculum includes two nutrition-related topics, specifically nutritional needs of
young children and balanced menus for young children, as part of the Child
Health and Wellbeing module (5N1765). An optional Nutrition module (5N2006)
is offered as an elective module which includes basic training in becoming
familiar with and evaluation of the composition and nutritional content of food;
understanding the relationship between health and nutrition; interpreting current
dietary information (e.g. food labelling) and recommendations; examining eating
habits; and becoming familiar with the nutritional needs of different groups of
people. The QQI Childcare Level 6 and higher course curriculums do not include
topics on nutrition and healthy eating. At present, nutrition legislation for
preschools is lacking, although the Food and Nutrition Guidelines for Preschool
Services developed in 2004 (Department of Health and Children, 2004; Child
Care Act 1991 (Early Years Services) Regulations 2016) highlight the need to
provide nutritious and varied food and drinks for every child attending preschool
service. Accordingly, a new Food Pyramid for young children was developed in
2020 (HSE, 2020). However, current research focused on nutrition in early years
settings in Ireland has been very limited and only a small number of initiatives
aiming at changing nutrition environments in childcare settings have been
implemented to date (National Childhood Network, 2018).
The evidence base on positive nutrition practices in preschools and related
implementation challenges have been reported (Matwiejczyk et al., 2018).
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However, in Ireland there has been a lack of in-depth research and thus
understanding of the processes and practices around food service in preschool
settings. Given the significant change in the early years context in Ireland and the
need to promote healthy nutrition among preschool-aged children, this study
sought to comprehensively explore the preschool food environment and beliefs
and perceptions of preschool staff to gain deeper insights into food-related
practices and policies in the preschool setting. These data can help to understand
the current status quo and the extent of change needed to promote and support
healthy eating in the preschool setting. Therefore, three key research questions
were addressed in this study:
1. How do preschool staff experience and manage food and mealtimes in

their services?
2. How do staff perceive their role in promoting children’s healthy diets?
3. What are the barriers and facilitators to promote healthy eating in the
preschool setting?
In accordance with the research objectives the current study employed a

mixed methods research design with an emphasis on a qualitative approach.
Purposive sampling was used to recruit preschools with different services and thus
types of food provision. The study aimed to achieve a mix in socio-economic
background, thus community preschools and day care services located in
disadvantaged areas in the West of Ireland were selected. A total of ten preschools
took part in the study including full-day-care (n=4) and sessional community
preschools (n=6). Full details on sampling were described in Chapter 3.
4.3 Data collection procedures
Data for this study were collected from each of the 10 preschools using
predominately qualitative methods (semi-structured staff interviews and review of
preschool nutrition documents), supplemented with quantitative tools (Preschool
Observation Tool and Preschool Manager Questionnaire).
4.3.1 Preschool setting assessment tools
Guided by the review of existing preschool assessment instruments

designed to evaluate the nutrition environment in childcare settings such as: a) the
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Environment and Policy Assessment and Observation (EPAO) Tool (Ward et al.,
2008); b) WellCCAT tools (Henderson et al., 2011); and c) the Preschool
Assessment Tool and Health Promotion Activity Scored Evaluation Form
(Johnston Molloy et al., 2013), the following qualitative and quantitative
assessment tools were developed for this study:
1. Preschool Observation Tool (Appendix 11);
2. Document Review Guide (Appendix 12);
3. Preschool Manager Questionnaire (Appendix 13).
4. Topic guide for interviews with preschool staff (Appendix 14);
4.3.2 Review of preschool documents related to nutrition
Preschool nutrition documents provided background and context to the

preschool nutrition practices and helped to develop the staff interviews and were
used to contextualise data collected during staff interviews. The Document
Review Guide (Appendix 12) aided data collection. The documents that were
reviewed included: preschool healthy eating policies (HEPs); parent handbooks,
menus (in full-day-care preschools); packed lunch guidelines (in sessional
preschools), written communication with parents on food, nutrition and mealtimes
(e.g. notes for parents on children’s food intake, leaflets with nutrition information
for parents, etc.), if present (Table 4.1). A record of whether preschools had Food
and Nutrition Guidelines for Preschool Services (Department of Health and
Children, 2004) in their possession was also taken.
Discussions with the preschool managers assisted in the identification of
documents and other textual artefacts relevant to nutrition activities in the
preschools. By reviewing the documents the researcher was able to get insights
into how these documents were used: where they were located and whether they
were easily accessible for use (e.g. office areas, computer, in the entry foyer,
hallways, walls, information boards, in classrooms, other children’s activity areas,
the kitchens, dining areas, storage areas, etc.), and how the documents were
communicated to staff, parents and children. The document review data were
collected using the Document Review Guide (Appendix 13).
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Table 4.1. Document review procedures
Documents Documents Data analysed (when accessed)

Reviewed sourced
Food and Nutrition 8 Presence, location, usage and mode of

Guidelines for Preschools communication to staff and parents
Healthy eating policy 7 Location; contents: comprehensiveness,

completeness, whether the policy
content is balanced or uneven, usage and
mode of communication to staff and
parents
Menus 4 Menu cycle (weekly, monthly, etc.);

menu variety; adherence to the Food and
Dietary Guidelines for Preschool
Services; the number, types and
frequency of meals; presence of detailed
information about food (e.g. fat content
of milk, portion sizes, etc.)
Packed lunch policy 0 Location; contents: comprehensiveness,

completeness, usage
Packed lunch guidelines 1 Comprehensiveness and completeness;

mode of communication to parents
Staff handbooks 0 Location, comprehensiveness, usage
Parent handbooks 3 Presence, comprehensiveness,

communication mode (printed on paper,
through email, etc.)
4.3.3 Observation of preschool food environment and practices
This method enabled the researcher to observe the environment and

activities relevant to the research questions in a limited time-frame. In each
preschool, observations were carried out for 3-5 hours on two consecutive days
and an additional 3rd day in one full-day-care and one sessional community
preschool. This allowed the researcher an opportunity to be familiar with the
food-related environment and daily activities and observe the daily routine in and
around mealtimes. Mealtime observation in preschools included breakfast, main
meal (lunch), and morning and afternoon snack times. In full-day-care preschools
it also included observation of kitchen and dining facilities and plating and
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serving food by staff and fluids to/by children. In sessional preschools the main
meal, and both morning and afternoon sessions were observed in each preschool.
A total of 58 mealtime occasions were observed over 2-3 days in each of
ten preschools. In total, 19 mealtimes were observed in full-day-care preschools
and 39 mealtimes were observed in sessional community preschools. Observed
mealtimes consisted of breakfast (n=1), morning snack (n=15), main meal (n=22),
and afternoon snack (n=20) (Table 4.2).
Table 4.2. Observations of preschool mealtimes
Number of observations
Mealtimes Day 1 Day 2 Day 3
Preschool type Full-day Sessional Full-day Sessional Full-day Sessional
Total
Breakfast - - - - 1 - 1
Snack (AM) - 6 1 6 1 1 15
Main meal 4 6 4 6 1 1 22
Snack (PM) 4 6 3 6 - 1 20
Total* 8 18 8 18 3 3 58
*n=preschools 4 6 4 6 1 1
Since the researcher had been present at each preschool (for recruitment
and familiarisation with preschools purposes) prior to the observational data
collection phase, children and staff were familiar with the researcher’s presence.
The researcher positioned herself as “observer-as-participant” (Gold, 1958), and
thus helped staff if required, but refrained from initiating interactions with study
participants.
The observation of the preschool food environment was guided by the
Preschool Observation Tool (Appendix 11) and data were collected using
observation sheets and field notes. The Preschool Observation Tool included an
outline of different aspects of the food-related environment, and activities and
interactions during mealtimes such as meal and snack time practices, children’s
eating and preschool staff feeding attitudes and behaviours, presence of food-
related visual images and materials, and food-related classroom activities. An
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open-ended section enabled a record of field notes and reflections. Observing

mealtimes helped the researcher to gather contextual information, such as
adherence to current healthy eating guidelines, actual practices and behaviours of
staff and children during mealtimes, the atmosphere during mealtimes, children’s
food preferences, as well as parent choice of packed lunch boxes. While the
Observation tool was completed during observation, reflexive notes were written
down as near as possible to the time the observation was conducted to ensure
accurate recall while minimising possible self-consciousness of participants and
the Hawthorne effect (McCambridge et al., 2014).
4.3.4 Qualitative interviews with preschool staff
Face-to-face qualitative semi-structured interviews were conducted with

one staff member from each of ten participating preschools. The study only
included staff who have been employed in each preschool for more than one year.
The interviews were carried out in preschools at a time convenient to staff in order
not to interrupt planned activities. The interviews lasted 20 to 40 minutes and
were carried out in a separate room or the manager’s office, except for one
interview. Interviews started with thanking the participants for agreeing to be
interviewed, giving a brief description of the aims of the study, assuring of the
confidentiality of the data gathered during the interview, and obtaining consent to
audiotape the interview. The Topic guide for interviews with preschool staff
(Appendix 14) aided the type and flow of questions.
4.3.5 Preschool Manager Questionnaire
Preschool managers (n=8; including 4 full-day-care and 4 sessional

community) completed questions (Appendix 13) on: 1) food provision; 2)
nutrition guidelines and policies; 3) communication with parents; 4) eating
environment and behaviour; 5) staff training; and 6) barriers and supports to
promoting healthy nutrition in preschools. Two managers did not complete the
questionnaire stating busy work schedule.
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4.4 Results
In total ten preschools with different types of service and food provision
participated in the study (Table 4.3).
Characteristics of participating preschools
Full-day-care preschools
Full-day-care preschools had a separate kitchen area where food was stored
and prepared. In private preschools food was purchased and prepared by the
managers while in the community preschool food was purchased by the manager
and a designated cook prepared the food.
Sessional community preschools

All six preschools of this type of service were not-for-profit community
preschools.
Table 4.3. Characteristics of participating preschools

Type of Pre- Ownership No. of Type of food provision
service School type children
in the
service
Full-day- 1 Community 38 Food service from preschool (3 meals, 2
care snacks)
2 Private 25 Food service from preschool (3 meals, 2
snacks)
snacks)
snacks)
Sessional/ 5 Separate 18 Packed lunch from home
Community 6 entity 21 Packed lunch from home
7 Located in 21 Packed lunch from home. Snacks from

a primary preschool
8 school 26 Packed lunch from home
9 Building 25 Packed lunch from home
10 26 Packed lunch from a food catering
service
The participants were six preschool managers and four teachers. All ten
participants were female, employed full-time at the preschool, cared for children
between ages 3 to 5 years, and were engaged in daily mealtimes with the children.
The participants’ work experience as preschool teachers ranged from 2 to 14
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years. Nine out of ten participants had an advanced qualification of QQI Level 6
with one studying for QQI Level 7 (Table 4.4).
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Table 4.4. Characteristics of preschool staff participants

Preschools 1 2 3 4 5 6 7 8 9 10
FD FD FD FD PT/S PT/S PT/S PT/S PT/S PT/S
Type of service
Ownership Comm Private Private Private Comm Comm Comm Comm Comm Comm
Staff position, Teacher Manager Manager Manager Teacher Teacher Teacher Manager Manager Manager
number/gender 1/F 1/F 1/F 1/F 1/F 1/F 1/F 1/F 1/F 1/F
Staff years of experience 5 14 11 9 2 3 3 9 7 6

Staff qualification (QQI) Level 5 Level 6 Level 6 Level 6 Level 6 Level 6 Level 6 Level 6 Level 6 Level 6
No. of child participants 2 11 5 8 13 9 4 5 2 5
Age range of children 3-4 3-5 3-4 3-5 3-4 3-4 3-5 4 3-4 3-4
(years)
Note: FD=Full-day-care preschool; PT/S= Part-time/sessional preschool; Comm=community; F=Female.
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The results of the study were attained by analysing the data gathered from
the interviews with preschool staff (thematic analysis) and contextualising it with
the data obtained through observation, document review and manager
questionnaires (See Appendix 18 – Summary of observation, document review
and manager questionnaire). These data were combined for analysis using
merging method (at Methods level), which resulted in more comprehensive and
rich data from which the findings were drawn. The data then were reported on a
theme-by-theme basis using weaving method of narrative approach of mixed data
integration (at Interpretation and Reporting level).
After the mixed data integration at Interpretation and Reporting level, the
themes and subthemes were analysed to identify the barriers and facilitators for
promoting healthy eating in preschool settings. Barriers were defined as factors
that limit or restrict the implementation of healthy eating practices in the
preschool setting. Facilitators were defined as factors that enable the
implementation of healthy eating practices in the preschool setting. A multilevel
approach to examining factors that facilitate or impede the success of best practice
implementation proposed by Grol and Wensing (2004) was used. The
themes/subthemes were mapped into a four-level framework (see Table 4.6)
adapted from the Grol and Wensing’s six-level framework, which describes how
barriers and facilitators can be identified, categorised and used for the
development of tailor-based implementation strategies to facilitate desired change.
Grol and Wensing’s 6-level framework included two healthcare-related levels,
namely ‘innovation in health care’ and ‘patient’ levels, which were excluded from
this study’s framework.
The results of analysis of observation, document review and manager
questionnaire indicated that seven preschools had written HEP, 5 of which
displayed it on the notice board and 3 provided it in the parent handbook. No
preschool had a written policy on packed lunches from home but advice on
packed lunch content was given verbally to parents in all preschools except one
sessional community preschool. In full-day services, menu plans were either on 3
or 4 weekly rotations. Menu planning was organised by the manager in 5 of the
preschools, with teachers involved in 2 preschools and parents involved in just 1
preschool (Appendix 18).
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Analysis of the integrated mixed data identified the following six major
themes: 1) Preschool teachers’ nurturing role; 2) Positive mealtime practices; 3)
An unsupportive nutrition environment; 4) A need for further nutrition training; 5)
Limited scope to change nutrition practices; and 6) Families’ poor food habits
influence preschool efforts.
4.4.1 Theme 1: Preschool teachers’ nurturing role
The staff in all participating preschools expressed a desire to provide

adequate amounts of nutritious and appropriate food to children acknowledging its
importance for optimal growth and development of preschool children:
“I think it’s very important to give proper nutritious warm meals and to
make the menus, to adapt the menus for the time of the year as well. Like
in the winter time they need warm food, good nutritious food, it’s good for
their brain, it’s good for their learning, it good, you know, every part of
their day.” (Full-day, community).
All full-day preschool staff expressed a desire to “cook from scratch” with fresh
ingredients, “the kind of things that we can make ourselves”.
All participants described the importance of their role in providing healthy

food to children in their care:
“Very important. I feel that parents don’t have time, you know, to give
them the right meal, so here we supply the dinner that would be
substantial.” (Full-day, private);
“I think it’s very important [healthy eating], I think it keeps children

healthy, it gives them more energy, especially for day-care because they
are here from 8 in the morning till the evening time, so we are looking for
different foods that give them energy as well as the foods that they enjoy.”
(Full-day, private).
Another role the participants described was educating children about

healthy eating and about food in general:
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“…we kind of do a circle time and sometimes we go down the kitchen and
we talk about what we have in the refrigerator, pictures we have seen or
things like that.”(Full-day, community);
“We discuss the colour, the taste, the texture. Oh they are happy to talk
about those foods, you know, what they have in their lunch boxes. There’s
always every day a discussion going on, yeah.” (Sessional, community);
“We do a lot… in our classroom… and we read a lot about healthy food,
nutrition… ehm… we would have discussions about what they like to eat,
what is good for them, you know, what they can only have on special
occasions or treats, if we have a party.” (Full-day, community);
“… especially when we see fruits or vegetables, we always talk about it.

We show it to other kids… especially if they have something new …
something they don’t know, then we always talk about it. ….” (Sessional,
community).
Consistent with this data staff were observed talking to children during
mealtimes regarding healthy food choices in most preschools: “Yogurt is good for
your bones” (Sessional, community); “The apple is a fruit and makes you strong,
it gives you energy” (Full-day, private). Observation of activities with children
showed that staff in all preschools read books to children about food and nutrition
while in two community preschools (one full-day-care and one sessional) weekly
nutrition-related education activities were carried out with children (e.g. naming
food by colour, texture and taste). However, there were few food-related books
present in classrooms. Toy kitchens were present in most preschools with food
toys in all preschools and children engaged in ‘cooking’ and ‘eating’ related play.
4.4.2 Theme 2: Positive mealtime practices
Supportive mealtime practices
While a mix of classroom or dining areas were used for mealtimes across
the preschools, this did not impact on the dining experience. The mealtime
routines appeared to be well-established and children seemed to know what to
expect at mealtimes, which facilitated carrying out meal and snack times in a
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relaxed yet efficient manner. Before each meal and snack time, children were
directed to wash their hands, taking turns under staff supervision in the bathroom.
While children washed their hands, staff set tables with cutlery. Children were
divided into groups with a maximum of six-seven children and were seated at
tables.
In full-day-care services staff put pre-plated food on the tables. Children’s

specific dietary needs (e.g. religious beliefs) were acknowledged and the children
were served different foods, where appropriate. Staff sat with the children most of
the time, occasionally getting up to help children if needed. Staff did not eat the
same food as children and did not eat in front of the children at any time. Children
sometimes asked for second helpings or staff asked them if they wanted ‘seconds’
after they finished their plates. Most of the staff asked children if they want to eat
more, but did not ask if they were hungry before serving a second serving. A
drink, mostly water, was poured in plastic cups and served to children with food.
The size and type of utensils and cutlery used by children was appropriate for the
children’s age. During the morning and afternoon snack times children sat at the
tables and were served snacks and water.
In sessional preschools meal and snack times occurred in classrooms.
Children ate the food and drink they brought in their lunch boxes. Staff sat with
them, however, in this type of service staff moved from table to table more often
helping children open their lunch boxes and bottles if needed.
A gentle and supportive approach to eating

In general, the atmosphere during meal and snack times was calm and
relaxed in all preschools. Gentle encouragement of eating was practiced across all
preschools and children were not rushed to finish their food.
”We give the children adequate time to eat their food; we don’t allow to
rush them. Ehm… some children do eat faster, and if they do it constantly,
we kind of encourage them to eat a bit slower because it’s better if they eat
slower and chew the food properly and digest it. So we would never rush a
child, never ever, and we would encourage them to eat as much as they
can until they feel full.” (Full-day, community).
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In most preschools, children who finished eating were allowed to go to the

play area in the classroom and play. In sessional preschools, if children were not
eating their food they were asked to try an alternative option in their lunch boxes
(“You don’t want your sandwich? Then don’t you want to try this tasty yogurt?”)
or they put the uneaten food back into the child’s lunch box to bring it back home.
Positive peer modelling was an influential factor that encouraged children

to eat and staff used it as leverage to encourage children to eat:
“Children, I find, eat much better in a group. … and they often kinda start
“I’m not hungry” or “I don’t want to eat it”. So they may eat slowly in the
beginning and, if you leave them, they copy when they see someone gets
praise “Well done!”, “Do you want some more?”, “That was very
good!”… ehm… Yeah, they do, they do follow others.” (Full-day, private).
During meal and snack times, the majority of staff talked to children about
different non-food topics and about food or contents of children’s lunch boxes and
benefits of healthy eating, however most of the children did not talk to each other
during mealtimes. Children were praised for eating new foods and were
encouraged to share their thoughts and feelings about foods. Using food as a
reward or punishment was not observed in any of the participating preschools,
while some providers encouraged children to eat savoury food before eating non-
savoury food (e.g. sandwich before banana or yogurt).
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Table 4.5. Summary of preschool mealtime practices

(preschools n=10)
Mealtimes Yes (n) No (n)
Were age appropriate feeding and drinking utensils available for children? 10 0
Were children able to eat as much or as little as they want to? 10 0
Did at least one staff sit with children during lunch? 10 0
Were there appropriate seats for providers so to enable them to sit with 0 10
children?
Did all children wait to eat until all have plates of food/lunchbox? 6 4
Did staff consume the same food as children? 0 10
Did staff eat and/or drink less healthy foods in front of children? 0 10
Was adequate time allocated to feeding times? 10 0
Were children allowed to leave the table before all children are finished eating? 7 3
Did cleaning of dishes begin before all children are finished eating? 2 8
Did children participate in meal (laying cutlery, serving, cleaning up etc.)? 0 10
Interactions between preschool staff and children during mealtimes Yes (n) No (n)
Were mealtimes carried out in a positive and relaxed atmosphere? 10 0
Were children actively encouraged to feed themselves? 10 0
Were children allowed to eat at their own pace or are they told to hurry and 10 0
helped to eat to speed up the process?
Did staff serve children seconds without being asked for more by the child (see 0 10
an empty plate and add food without request by child)?
Did staff encourage children to eat new and less preferred foods? 10 0
Did staff praise children when they eat all their food? 10 0
Was food and nutrition discussed at a mealtime? 9 1
Did staff talk with children about healthy/unhealthy foods? 8 2
Did staff teach children nutrition and/or food concepts? 2 8
Did staff use food as a reward and/or was food withheld as a punishment? 0 10
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4.4.3 Theme 3: An unsupportive nutrition environment
Policies and guidelines are lacking

The review of food-related documents revealed that most of the preschools
(8 out of 10) owned a copy of the Food and Nutrition Guidelines for Preschool
Services (2004). The ‘3-Week Menu guide’ was owned by only one full-day-care
preschool (community preschool) out of four participating full-day-care
preschools. In sessional preschools, written healthy eating policies were present in
all but one preschool and were displayed on notice boards. In one sessional
preschool the HEP was incorporated into the ‘Health’ section of the general
school policy. In full-day-care preschools, two out of three private preschools did
not have a written HEP.
HEPs varied in format and content and mostly consisted of a one-page
document outlining the types of food provided, mealtimes, food allergies, food
preparation, and food hygiene and safety. The detailed descriptions of food
practices, such as food served during celebrations, guidance on second helpings,
using food as a reward or punishment, were absent in HEPs. All preschools
reported that they did not have a policy on food brought from home for meals and
snacks. Only one sessional community preschool had written guidelines on
packed lunch contents as a short list of food that parents can or cannot provide in
the lunch box. Staff in the rest of the participating preschools, both full-day-care
and sessional, reported that guidelines were given to parents verbally.
Staff handbooks were not available in any of participating preschools.
Parent handbooks were used in three (one full-day-care community and two
sessional community) preschools, which consisted of a booklet containing
information about the preschool’s general policy, including nutrition and HEPs.
Written communication with parents consisting of notes on paper about a child’s
food intake was practiced in two preschools, in others it was done verbally.
There was a lack of visual materials displayed in the preschools related to
nutrition and healthy eating. Only one community preschool had an image of the
Healthy Eating Pyramid displayed on the wall. Some posters related to hand
hygiene and food safety were present in the kitchen, common areas and
bathrooms.
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Challenges in planning menus and snacks

All full-day-care preschools had 3 or 4-week menu plans which they either
displayed on the information board or handed to parents. Although preschool staff
in all participating preschools expressed their desire to provide children with a
balanced and healthy diet, some of the managers of private preschools described
menu planning as a challenge:
“Yeah but we talk about it with girls, because they are supervising them and
giving them the food and might have a look and you know, ‘they are not
eating that so change to something else’ or ‘they have had that for a while
now’ and we change around, you know. Whatever the girls would say, I
would go with them.” (Full-day, private).
Ideas for snacks were a particular challenge for all private preschools. “… I
can say at the sandwich time in the afternoon it’s a difficult one to come up with
different ideas.” (Full-day, private). Another private preschool manager was
concerned that store-bought snacks children usually like are unhealthy and “full of
additives and things” and expressed their desire to provide children with more
healthy, freshly prepared snacks:
“I suppose [we need to be] more efficient in making up more healthier

snacks… and variety as well, you know, a healthy variety for children in
the evening that they will eat. You could be trying different things but they
don’t eat them.” (Full-day, private).
Water provision is inadequate

Water provision in all preschools appeared to be inadequate and the
promotion of water consumption was not evident. Water was served to children at
meal and snack times and also on demand in all preschools. There were jugs of
water visible in classrooms in three out of four full-day-care preschools and in
four out of six sessional preschools, while in one sessional preschool water was
provided from an adult-accessible faucet in the teacher’s room and in the rest of
the preschools water jugs were located in the kitchen. Even though water was
available for children throughout the day, the accessibility of water was
inadequate. In one of the full-day-care preschools a staff member stated that
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“…the water is in a jug…They can have water any time”, but added that children
cannot get water themselves because “the jag is too heavy for them”. This
incongruity was also observed in the majority of preschools.
In all participating preschools neither verbal nor modelling of water
consumption was observed: none of the staff asked children if they were thirsty or
if they wanted to drink water between meal or snack times and none of the
children asked for water between meal and snack times; none of the preschool
staff were observed drinking water in front of children. In only one preschool
(community full-day-care) the practice of giving water to every child after
physical activity in the outdoor play area was observed.
Finally no stickers or posters encouraging regular consumption of drinking
water were visible in any preschool.
4.4.4 Theme 4: A need for further nutrition training
Variation in nutrition knowledge

The concept of healthy food differed between staff: some of the
participants described healthy food in very broad and general terms (“Ehm…
healthy food is the food which contains a lot of vitamins, minerals, nutritious
things which gives nutrition to our body …” (Sessional, community) while, in
contrast, some of them described specific food groups (“Yeah I suppose fruits and
veg and salads… and obviously… just to say, and if you are cooking chicken to
have chicken fillets… that type of thing” (Sessional, community). Others believed
a diet was healthy “as long as you have potato, meat and veg” (Full-day, private).
Some participants, however, defined healthy food in a more comprehensive way
and described variety, balance, and moderation:
“Well, sugar… you should keep the sugar content in food to a minimum
and the different types of fats, the healthy fats in foods and always have
portions sizes… your biggest portion should be vegetables and your
carbohydrates and your protein, meats, you know, keep it of that
size…yeah...” (Full-day, private).
However, gluten-free bread was also described as ‘healthy’: ”I think we

tend to eat an awful lot of bread in Ireland, you know maybe we should be more
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educated in eating maybe gluten-free and… you know… and the better bread.”
(Full-day, private).
None of the participants described nutrition with respect to the needs of
preschool aged children, appropriate portion sizes for different types of foods, or
the importance of providing nutrient-dense foods. On the contrary, they expressed
challenges in defining portions sizes appropriate for preschool aged children and
their interest in information about it. Other challenges involved concerns by
preschool managers on how long a mealtime should last and they were interested
and eager for more nutrition information relevant to preschool children.
The sources of information described by staff varied but did not focus on
evidence-based resources and their knowledge reflected this. For example, the
Internet, television, and “listening to other people” were the most common
sources of information. Some participants mentioned leaflets or booklets they
received from public health authorities, however, none of them mentioned State
resources on food and nutrition specifically developed for early childcare
providers in Ireland.
Desire for nutrition training

The perception of access to on-going nutrition training for preschool
teachers varied among the staff with some participants mentioning information
and training provided by public health authorities and some being unaware of
training opportunities. Majority of participants expressed that nutrition-related
training they were provided with as part of childcare provider qualification was
insufficient. They recalled the nutrition-related training received as part of QQI
Level 5 course, “Levels 5 and 6 they do [a module] on healthy eating so you kind
of have an idea.” (Sessional, community), but many could not remember the
detail. One of the providers said that no training was provided during two years of
her employment as childcare staff while others described occasional training on
healthy nutrition with the incentive of getting three paid days off work in the year.
The need for nutrition training was expressed by all participants. “…it
could be like a little mandatory training for all of us just to talk about food and a
little certificate maybe, we can bring that training, that practice to parents, you
know, to speak to parents.” (Sessional, community). The themes prioritised by
preschool staff were training on the nutritional content of different foods; portion
149
sizes; appropriate duration of mealtimes; practical ideas for food provision; and
ideas for new recipes, especially healthy snacks.
Differences between community and private preschools in staff training and

children’s nutrition education
Although staff perception of their role in providing nutritious food to
children was the same in both community and private preschools, there was a
clear disparity across childcare settings in terms of access to training and
awareness of resources for early childcare providers. Community preschools have
more access to information and training conducted by public health authorities,
compared to private preschools. A private preschool manager reported that
educational opportunities are limited to occasional “information evenings” and
that there is no “proper training in nutrition” available, training was out-dated
“it’s been a good few years ago” and expressed interest in such opportunities.
This was also reflected in their descriptions of challenges in finding healthy meal
and snack ideas and appropriate portion sizes. It was evident from interviews that
staff in private preschools were less aware of the available resources compared to
staff in community preschools.
Data illustrate that community preschools engaged in more educational
activities with children on topics related to food and nutrition than private
preschools. Food education activities were carried out regularly, e.g. weekly, in
some sessional community preschools. For example, books about children from
other countries, the food eaten in that country and showing pictures of children
eating different types of food were used by community preschools but not private
preschools.
4.4.5 Theme 5: Limited scope to change nutrition practices
Although several challenges were expressed by staff regarding preschool

nutrition practices, changes to practice seemed impossible for some providers.
Limited time in sessional settings was offered as a reason: “You see... we only
have for 3 hours [and] there could be no changes because they are only here
having snack and having lunch box, it’s all they have…” (Sessional, community).
In a full-day-care setting, the staff did not perceive change was needed: “I don’t
think there’s something [to change], no…I don’t see what else, how we could
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incorporate [changes] in what’s already there” (Full-time, community). In

addition, some providers perceived that their opinions on preschool practices are
not taken into consideration. For example, staff expressed a concern that they
were being given contradicting instructions by inspectors and other authorities on
child feeding practices without taking staff experience and opinion into account.
4.4.6 Theme 6: Families’ poor food habits influence preschool

efforts
Preschool staff reported challenges in the implementation of healthy eating

practices when poor food habits at home prevailed. The latter was also perceived
as the reason children did not eat food prepared in preschool (in full-day-care
preschools ): “You could be trying different things but they don’t eat them” (Full-
day, private); “);“I think everything goes back to parents, you know… you see,
they constantly bring something unhealthy” (Sessional, community). Dental
problems among the children, caused by “letting her drink Coke every day" were
also described. “We had many conversations with lots of parents to tell them they
can’t do it [bring inappropriate foods] and it takes 5-10 times before they
eventually get the message” (Sessional, community). Preschool staff also
perceived that family eating habits were represented by the contents of children’s
lunch boxes:
“In one family, if they generally eat good food, their children bring it here,
so you could see exactly which child, you know, what… like…eh… what
kitchen they have, what kind of food they have at home… You can see it.”
(Sessional, community).
4.4.7 Barriers and facilitators for promoting healthy eating in

preschool setting
Table 4.7 below details the barriers and facilitators for promoting healthy
eating in preschool setting at various levels – individual, organisational,
community, and policy levels.
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Table 4.6. Barriers and facilitators for promoting healthy eating in preschool setting at various levels
Level Barriers Facilitators
Individual • Inadequate knowledge of staff about nutrition and healthy eating; nutritional needs • Staff awareness and recognition of their important role in:
of preschool-aged children; portions sizes, etc.
o providing children with adequate amounts of balanced
• Inadequate knowledge in planning preschool menus and snacks and cost-effective and nutritious food;
food sourcing and meal preparation
o educating children about food and healthy eating
• Low awareness of nutrition information resources available for preschool
• Use of positive meal practices
providers
• Staff interest to learn/attend training on nutrition and
• Lack of training in nutrition, healthy eating, child feeding, and information on best
healthy eating and child feeding
practices in preschool nutrition
• Staff openness and willingness to improve their service
• Lack of staff ‘voice’ and participation in decision making
• Staff perception of limited scope to change preschool practices and low work
engagement
Organisational • Healthy eating policies are too general and include items related mainly to food • Leadership (openness and interest of preschool managers to
(preschool setting) served at preschool, excluding food brought from home.
promote healthy eating at preschools, (e.g. efforts to
• Absence of healthy eating policy for packed lunches
provide children with freshly cooked food and healthy
• No family style food service
snacks, etc.)
• Inadequate water accessibility to children
• Lack of educational activities with children on food and healthy eating.
Social/community • Poor food habits of families • Staff interest in better communication with parents about
healthy eating
Policy/economy/ • Lack of formal continuous training of preschool providers on nutrition, healthy • Increased recognition of ELC (Early Learning and Care)
societal eating, and positive feeding practices that led to recent reforms and developments and increased
funding for early care sector
• Vague nutritional regulations for early care sector
• Non‐mandatory food and nutrition guidelines for preschools
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4.5 Discussion
The current study sought to assess the preschool food environment by

exploring 1) how preschool staff experience and manage food and mealtimes
in their services; 2) how staff perceive their role in promoting children’s
healthy diet; and 3) the barriers and facilitators to promote healthy eating in
the preschool setting. This mixed method study provided comprehensive and
rich in-depth information regarding various factors influencing the food
habits of preschool children. Although lacking adequate HEPs and guidelines,
staff were engaged in several supportive mealtime practices. Participants
demonstrated their motivation to provide children with nutritious and
balanced food and recognition of their role in educating preschool children
about food and healthy eating. However, additional evidence-based training
of staff in child feeding, nutrition and healthy eating, and communication
with families, particularly for providers working in private preschools, is
needed along with improving familiarity with available nutrition information
resources. The study revealed staff’s low sense of ownership and
participation in decision making. An important perceived barrier for
promoting healthy eating in the preschool setting was families’ poor diets and
nutrition attitudes.
The preschool nutrition-related policies and practices take place in the
context of national dietary guidelines that direct preschool staff in providing
adequate and balanced nutrition to children in their care. A clear and
comprehensive written HEP, which specifies the rules and practices for
promoting and supporting healthy eating behaviours and a supportive food
environment, and reflects the agreement on healthy eating practices between
the preschool and parents, is recommended (Department of Health and
Children, 2004). The present study’s findings showed that although most of
the participating preschools had a written healthy eating policy, the policies
appeared to be too general and weak and were not consistent with the spirit
and guidance of the Food and Nutrition Guidelines for Preschool Services
(2004). In addition, possession of the Guidelines did not consistently result in
their use since adhering to these standards is voluntary in Ireland. These
findings are in line with the previous study conducted in Ireland by Jennings
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and colleagues (2011) that highlighted that the guidelines were not actively
enforced and variability existed in HEPs. Internationally, similar findings
have been reported that the implementation of dietary guidelines presents
challenge in early childhood education centres with the most frequently stated
barriers and drivers pertaining to the environmental context and resources
(Grady et al., 2018; Seward et al., 2017; Wolfenden et al., 2016). Research
evidence suggests that resource development and incorporating skill
development and role modelling strategies into professional development
may facilitate improvements in guideline implementation (Seward et al.,
2017). Lucas et al. (2017) in their systematic review of preschool and school
policies, regulations, their implementation and impact on diet in three high-
income countries found that preschool policies tend to lack enforceability.
The authors conclude that policies need to have clear standards, systems for
monitoring compliance and reach, acknowledge the whole school eating
environment including home provided meals and, furthermore, involve
broader public health and political actions in order to improve preschool food
environment.
Further work is needed in Ireland in implementing the national
policies on preschool nutrition. In addition, there are no national policies for
packed lunches in Ireland. The present study revealed that none of the
preschools had a packed lunch policy and only one preschool had a one-page
document with a short list of allowed/restricted foods. Although staff reported
giving recommendations to parents on which foods to include or restrict in
lunch boxes, this was done verbally. Due to lack of policy and clear
guidelines on content of packed lunches and a lack of effective ways to
communicating them to parents, there appears to be incongruence between
the preschool HEP and the food brought from home, thus impacting on
children’s dietary intake. A systematic review and meta-analysis of
effectiveness of lunchbox interventions on improving the foods and
beverages packed and consumed by children at childcare setting and school
by Nathan et al. (2019) found that, globally, foods provided by parents for
consumption in childcare settings are not in line with dietary guidelines. The
review found that, although the impact of lunchbox interventions was mixed,
there was encouraging evidence that improved provision of vegetables
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packed for children also led to increased vegetable consumption. The review
concluded that further research and interventions to improve the nutritional
contents of lunch boxes are warranted; particularly greater attention should be
paid to the barriers to removing unhealthy foods from lunch boxes which may
include addressing parents’ concerns regarding time, cost or food safety
(Hawthorne et al., 2018). In the present study, the findings suggest that a
detailed written HEP that includes clear recommendations for packed lunches
and more active strategies by preschool staff when communicating with
parents may facilitate preschools to implement healthy nutrition practices.
More research is needed to examine the content of packed lunches in Irish
preschools to evaluate and build an evidence base to guide the development
and implementation of effective lunchbox interventions.
Results of this study showed that finding ideas for nutritious and
varied meals and snacks was a challenge for managers of private full-day-care
preschools. In an attempt to come up with new ideas for meals, staff, and in
some cases parents, were involved in menu planning, which is a positive and
consultative practice likely to produce positive outcomes in terms of food
eaten and enjoyed (Harte, 2019). However, this also revealed that the
managers did not avail of the resources available for childcare providers such
as 3-Week Menu Plan developed by the Health Service Executive in 2004
(Health Service Executive, 2004). The Menu Plan was devised as a practical
tool to support preschool services to implement the recommendations of the
National Food and Nutrition Guidelines for Preschool Services. The 3-Week
Menu Plan includes portion sizes of the meals which, among other resources,
could also have been a guide for the private preschool managers participated
in this study who had a challenge of defining serving sizes for preschool-aged
children. However, the 2004 3-Week Menu Plan is out-dated as it was
developed almost two decades ago.
Research literature suggests that childcare providers need support
at all levels and alternative ways to support them have been suggested. One
such way, for example, in our era of digital communication, could be a social
support through online discussion forums that could render a good
opportunity to connect with other providers and share solutions to challenges
and information including recipes, however, it would be enhanced if a
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professional mediates and contributes to discussions to ensure that

information and tips shared are science and evidence-based (Lynch & Batal,
2011).
Current regulations necessitate the provision of regular drinks in
adequate quantities for children’s needs, and the availability of potable
drinking water to children at all times (Department of Health and Children,
2004). However, water promotion was low and provision of water was
observed to be inadequate in most participating preschools. This is consistent
with findings of previous studies that indicated the similar problems with
adequacy of potable water provision to preschool children (Middleton et al.,
2013; Patel & Hampton, 2011). In a study involved 40 preschools, water was
available in most classrooms (84%) but was only adult accessible in over half
of those classrooms and verbal prompts for children to drink water were few
(Middleton et al., 2013). In the present study, it was evident that there was a
need to change water provision practices and use more appropriate, child-
friendly water dispensing equipment (e.g. water dispensers) that would enable
children to easily access water and self-serve it at any time. Children are at
greater risk for dehydration than adults because they have a greater surface-
to-mass ratio, allowing for greater water losses from the skin. Children differ
from adults in total body water content. Additionally, children have different
thirst sensitivities and body cooling mechanisms than adults, thus they do not
always recognise that they are thirsty, and, if they are not encouraged and
reminded, they may forget to drink (D’Anci et al., 2006). Data reported by
Bar‐David et al. (2005) indicate negative effects on cognition induced by
even mild dehydration in children. Therefore, encouragement of children’s
water intake, especially during and after physical activity, should be increased
while helping children focus on internal thirst cues that may help them self-
regulate consumption (Ramsay et al., 2010). Furthermore, as young children
are dependent upon caregivers for provision of fluids, preschool staff need to
be educated about the importance of hydration in young children and
adequate provision of water to them.
During mealtimes several good practices were described in staff
interviews as well as observed in participating preschools such as giving
children adequate time to eat their food and not rushing them, using age-
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appropriate cutlery and utensils, gently encouraging children to eat, and using
lots of opportunities to discuss different types of food and its benefits.
However, none of the preschools practiced family style food service. Staff
sitting with children at the same table and eating the same food enables adults
to teach (e.g. skills and nutrition), demonstrate table manners, initiate
socialisation skills (e.g. share food, take turns), and prevent accidents and
choking (Sigman-Grant et al., 2008a). In addition, not having family style
dining diminished the opportunities for enthusiastic modelling (i.e. promoting
food while eating it), which was reported to be effective in trying and
accepting new foods by children (Ward et al., 2015; Mikkelsen et al., 2014).
Nevertheless, all participating staff were observed to use various ways to
gently encourage children to eat their food.
One of the perceived barriers to implementing preschools’ HEPs was
preschool staff perception that children’s families’ poor nutritional habits
undermine staff efforts for implementing healthy eating practices in the
preschool setting. However, staff holding parents responsible for their child’s
poor eating habits may be a ‘get-out’ from dealing with challenges related to
communication with families on nutrition topics or, possibly, a sense of any
change the preschool makes will be offset by families may serve as an
impediment for staff engagement and proactive behaviour. Similarly, a recent
study showed that previous unsuccessful attempts to engage parents in
childcare health promotion activities have left teachers, particularly in centres
with low parental engagement, feeling discouraged (Luecking et al., 2020). In
another study by McSweeney et al. (2016), staff, although reported that they
believed parents needed help and educating about their children’s health, they
were unable to define how it would be best delivered. Previous research
suggested that to support preschool staff in engaging in effective
communication and collaboration with families, on-going professional
development strategies, such as training and coaching, particularly in
communication with parents, are needed (Forry et al., 2011). Communication
is explored and discussed in more depth in Study 3, Chapter 6 of this thesis.
The above findings demonstrated staff desire to ensure children eat
their food, whether it was prepared at preschool or brought from home in a
lunch box. Understanding childcare providers’ perceptions and beliefs
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regarding their role in children’s healthy eating is an essential component of

childcare-based healthy eating initiatives (Sisson et al., 2017; McSweeney et
al., 2016). The present study’s findings showed that preschool staff perceive
the importance of educating children about healthy eating, yet they recognise
the need to enhance their own knowledge. The findings demonstrated that
staff knowledge of healthy eating was insufficient and seemed to be based
mostly on their personal experiences. Similar findings were described in other
studies that found that preschool teachers’ (n = 386) nutrition knowledge,
particularly in regard to basic nutrition recommendations (servings,
food/beverage choices, and portion sizes), was lacking with common
knowledge barriers being lack of staff training, confidence, and resources
(Rapson et al., 2020). It has also been suggested that providing specific
training for preschool directors and addressing food quality may further
improve teachers’ nutrition-related attitudes, beliefs, and practices (Cooper &
Contento, 2019). In this PhD study, this was particularly evident in staff
working in private preschools. Therefore, since preschool staff daily
responsibilities involve educating children and promoting healthy behaviours,
fulfilling this role should be based on knowledge gained in formal accredited
training in nutrition and healthy eating and not relying solely on their
personal knowledge, common sense and enthusiasm. In addition, it was
observed that staff need training in child feeding practices during mealtimes
(e.g. teaching children how to self-serve, helping them focus on internal cues
of hunger and satiety to self-regulate food intake, acting as role models by
eating the same or new food, teaching children how to prevent choking,
teaching table manners, etc.). This finding is corroborated by a study
involving 568 childcare centres in the US which found that staff were
substantially less likely to receive training in child feeding than in nutrition or
child development (Sigman-Grant et al., 2008a) although it is one of the
essential day-to-day activities of preschool staff. The findings also suggest
that the basic training that preschool staff receive as part of their minimum
qualification QQI Level 5 training has been diluted over the years, and does
not equip them with the necessary skills, demonstrating the need for
continuous professional development (CPD). Given that currently in Ireland
there is no formal CPD for preschool providers in nutrition and healthy food
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provision, nor the legislation to enforce such training (Johnston Molloy,

2011), it is not surprising that most participants expressed interest in
mandatory training in this area.
Furthermore, the current study highlighted the need for nutrition
training for preschool staff in private childcare settings. Inclusion of both for-
profit private and community non-for-profit types of childcare services in this
study allowed observing the differences in staff nutrition knowledge,
awareness of information sources available, and in their training needs. It was
noted that community preschools receive more information and access to
nutritional training opportunities from public health authorities. In contrast,
the staff in private preschools appeared to be less involved in training and
thus demonstrated less knowledge on healthy food and nutrition. Private
practitioners were also less aware of and therefore availed less of the
educational resources available to them. In the meantime, recent expansion of
childcare services in Ireland through ECCE (two-year universal free childcare
programme) and introducing the new Affordable Childcare Scheme towards
the cost of childcare in both community and private childcare settings, allows
more children to attend private childcare settings, which traditionally were
not accessible to low-income families. Increasing attendance of private
preschools implies a potentially larger influence of this type of childcare
setting on children’s dietary intake.
At present, ECCE programme receives by far the largest proportion of
government funding in the early years sector (Early Childhood Ireland, 2016).
However, although ECCE has been a positive and welcome initiative in Irish
childcare, this has come at the expense of the non-ECCE services in terms of
focus, investment and the consequent financial viability of non-ECCE
childcare services, including privately-owned year-round full-day-care
services (Early Childhood Ireland, 2016). Thus, private preschools, as means
of maintaining their viability, increasingly shift toward adopting ECCE
model, which offers part-time and sessional services to eligible children. In
2019, 77% of services offered the ECCE programme nationally were private
and 23% were community (European Commission, 2019). Although, as an
incentive, an enhanced funding grant to support staff in gaining qualifications
and higher capitation payments are provided to childcare centres where staff
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have a QQI Level 6 (European Commission, 2019), these are insufficient to

cover for the wages that private services have to pay to highly qualified staff
holding QQI Level 6 and higher. Six out of ten staff earned below the living
wage rate in 2019. Meanwhile, less than half (46%) of staff worked more
than 30 hours per week (Pobal, 2019). Thus, a concern has been expressed
that due to increased part-time employment and thus lower income, attracting
and retaining highly qualified staff capable of delivering quality care and
education to children will become increasingly difficult as many private
childcare services are not in a position to pay adequate salaries to a more
qualified staff (Early Childhood Ireland, 2016). The relationship between
wages and qualifications is not linear. While newer staff are likely to have
higher qualifications and higher wages, they also have less experience and,
therefore, are likely to earn less than those working longer in the sector. In the
meantime, the sector has a high annual staff turnover rate of 23.4% with over
4 in 10 services reported having at least one staff member left the service in
12 months. In 2018/19 out of total number of staff who left service, 93% had
an NFQ Level 5 or above (Pobal, 2019). These indicators show that
improvement of terms and conditions of employment in early care sector are
warranted. In the meantime, provision of childcare staff, regardless of their
level of qualification, particularly staff currently employed by private
childcare providers, with continuing training, including nutrition training that
enables them to fulfil their role as promoters of healthy eating as well as their
nurturing role, should be implemented as a priority.
The current study revealed a discordant finding that although
preschool teachers pointed out several challenges in their food practices, they
perceived no change was needed in their preschool. Previous research studied
preschool staff workplace-related issues such as work climate and job-related
well-being and primarily described staff interest in voicing their opinions and
participation in decision-making (Granziera & Perera, 2019; Hewett & La
Paro, 2020; Hur et al., 2016; Saunders, 2018; Wells, 2017). In contrast, the
present study found a lack of motivation of preschool staff and their
perception of a limited scope to make changes in the childcare setting, which
are topics that are under-researched, particularly in the context of preschool
nutrition. More research is required to fully understand the factors leading to
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low motivation and proactive behaviours in the preschool setting and how
these can be overcome. In the present study, it is hypothesised that a lack of
voicing their opinion towards work-related improvements, particularly
mealtime practices, may have been caused by lack of training and thus
awareness about local or international best practices in early years care.
Another possible reason may be a lack of interest in changing their work
environment due to lack of opportunities to participate in decision making at
their workplace and low motivation due to lack of an incentive system and
recognition at workplace. The core principles of health promotion is
empowerment, a way of working to enable people to gain greater control over
decisions and actions affecting their health determinants, and participation
where people take an active part in decision making (WHO, 1986). Research
in employee voice and participation in decision-making points to numerous
benefits of same to both employees and organisations. Campbell Pickford et
al. (2016) argue that enhancing feeling of ownership in employees by
involving them in organisational decision-making increases employees’
working motivation and commitment. This is particularly important in
settings with high staff turnover such as the early care setting. According to
Elele and Fields (2010), employees most often have more complete
knowledge of their work than senior staff, therefore decisions made in
consultation with employees are made with more information, as
demonstrated in the present study when preschool managers involved staff
members in menu planning. Employees who are involved in decision-making
subsequently are better equipped to implement such decisions.
According to health promotion perspective, a work setting is
recognised as a complex sociocultural environment that can influence health
and well-being of people who live and work in it (WHO, 1991). Furthermore,
people’s perceptions of control over their environment and over their personal
circumstances (Wells, 2017) are equally important. In the present study, the
lack of proactive behaviour of preschool staff for making changes at work
could be explained by low intrinsic motivation. Proactive behaviour is
defined as involving in active and self-starting approach to work, taking
initiative in improving current circumstances, and actively creating
environmental change (Bateman & Crant, 1993; Frese et al., 1997). It was
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found that employee’s job resources (e.g. job control, job complexity,
participation in decision making, feedback and social support) increase
intrinsic motivation and, through increase in work engagement, boost
proactive behaviour at work or job performance (Hawkes et al., 2017;
Salanova & Schaufeli, 2008). Thus, it was argued that these positive
outcomes may be fostered by appropriate workplace changes, particularly by
increasing or enhancing job resources. Applying to the present study, a
continuous quality-assured training programme in best preschool nutrition
practices aimed at increasing levels of preschool teachers’ skills and efficacy
might result in increasing staff work engagement. Research on continuous
improvement in workplace indicates that improving training effectiveness and
organisational support makes employees feel more capable to participate in
the organisation’s continuous improvement activities, feel more empowered
to improve their workplace and increases their job satisfaction (Jurburg et al.,
2016). Likewise, preschool teachers’ increased sense of efficacy has been
associated with teachers’ higher sense of community, that is teachers’
perceptions of staff collaboration and consistent opportunities to participate in
decision-making, highlights the importance of workplace climate for
preschool teachers (Guo et al., 2011; Hewett & La Paro, 2020).
Previous research indicates that the childcare manager has a central
role in creating and maintaining workplace climate that supports teachers in
order to positively influence a teachers’ increased commitment and
engagement in work as well as have a tremendous influence on whether a
positive changes to workplace will take place (Cooper & Contento, 2019;
Fullan, 2007; Saunders, 2018). Preschool teachers who perceived their leader
as providing feedback, guidance, opportunities for professional growth and
being generally knowledgeable about children’s growth and development
reported higher commitment to their job (Saunders, 2018). In study by
Johnston Molloy (2013) where a training on best practices in preschool
nutrition involved two randomised training groups (‘manager-trained’ and
‘manager-and-staff-trained’) a larger proportion of preschools in the
‘manager-trained’ group attained a best practice score than in the ‘manager-
and-staff-trained’ group, suggesting the positive role of leadership.
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On the other hand, focusing only on intrinsic motivation is not a

practical or even feasible strategy. Total motivation is a function of external
plus internal motivation (Fang et al., 2013). Although various theories debate
that extrinsic rewards (e.g. reward system, pay raise, incentives, benefits)
have different effects on intrinsic motivation (negative, positive and neutral),
if extrinsic reward is appropriately implemented and attests and increases
employee’s sense of competence, then the extrinsic reward enhances intrinsic
motivation (Fang et al., 2013). In early care sector, current low pay and status
of staff act as disincentive to their extrinsic motivation (Government of
Ireland, 2019). However, the Irish Government’s capacity to directly
influence wages and working conditions of the sector is constrained by the
fact that the Government is not the employer. ELC and SAC services are
owned and managed by a combination of independent centre-based providers,
of which 74% are private and 26% are community-based (Pobal, 2019). The
Minister for Children and Youth Affairs has called for the ELC sector to
pursue a Sectoral Employment Order through the Workplace Relations
Commission/Labour Court and has expressed her Department’s willingness to
cooperate with such a process (Government of Ireland, 2019). Currently, the
Workforce Development Plan and a new Funding Model for ELC/SAC have
been under development since 2019. Both reform initiatives will be informed
by an inclusive consultation from all stakeholders (Early Childhood Ireland,
2020) and should take into consideration the findings from this research and
recommendations related to the need for further and continuous training of
staff for promotion of healthy eating in the preschool setting.
The present study’s finding of preschool staff perception of a limited
scope to change nutrition practices reveals possible underlying issues related
to staff motivation and work engagement, which are related to larger system-
dependent factors influencing the preschool setting such as regulation of
terms and conditions of employment in ELC sector and workforce
development. Therefore, the issues revealed by this research need to be
addressed from systems approach perspective, at multiple levels – individual,
organisational, community and policy levels to allow the system-wide
solutions. To aid this process, this study identified the barriers and facilitators
for promoting healthy eating in the preschool setting. Identifying the barriers
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(factors that limit or restrict the implementation of healthy eating practices) is

instrumental for understanding what changes are required to improve the
current food environment and nutrition practices in the preschool setting and
serve as a starting point for developing actions toward change. Recognizing
the facilitators (factors that enable the implementation of healthy eating
practices in the preschool setting) will help in building on existing positive
structures and practices that will enable more efficient implementation of
future interventions. The barriers and facilitators were categorised into four
levels of their influence - individual, organisational, community and policy
levels.
At the individual level, the barriers such as inadequate nutrition
knowledge of staff, low awareness of existing nutrition information resources
and lack of staff voice for preschool nutrition changes show that staff who are
directly involved in provision of food and nutrition practices are not
adequately equipped with appropriate knowledge and practical skills to
implement HEPs. On the other hand, such positive attitudes of preschool staff
as recognition of their important role as nurturers and educators and interest
in advancing their knowledge could act as facilitators for further training.
Making parallel with research on implementation of children’s health
promotion or preventive programmes, it is important to understand
organisational capacity (Wandersman et al., 2008) and the characteristics of
‘implementers’ (i.e. those responsible for the implementation of a practice or
intervention) that support or prohibit successful implementation processes
(Durlak & DuPre, 2008). Considering the increasing diversity in social and
cultural contexts in today’s preschool settings, the staff will increasingly be
working in complex and changing contexts in their daily practices, which
constitutes their professional competence (OECD, 2006; Urban et al., 2012).
Thus, “becoming a competent practitioner is the result of a continuous
learning process: a process through which one’s own practices and beliefs are
constantly questioned in relation to changing contexts” (Urban et al., 2012, p.
35). Therefore, this study suggests that increasing preschool staff sense of
self-efficacy and competence in promoting healthy eating in their settings
through continuous training that provides up-to-date information on nutrition,
healthy eating and best nutrition practices and facilitates skills development
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and professional growth, should be given a priority. Professional growth is

defined as a continuous learning process that encompasses personal and
professional growth (Council of the European Union, 2009) provided through
workshops, encouraging collaboration, allotting time for preschool staff to
engage in learning opportunities outside of their preschool, and providing
guidance and reference materials (Bloom, 2010).
At the organisational level, developing preschool teachers’
professional competence is related to the workplace climate and
organisational structure. Competences in fact evolve constantly from
individuals to the group and vice versa, improving the organisation as a
whole (Urban et al., 2012). At this level, leadership is important in many
respects, for example, in terms of setting priorities, establishing work climate,
offering incentives, and managing the overall process of preschool settings’
practices and could act as important facilitator. This study found that
preschool managers are interested in promoting healthy eating at preschools,
however, they lack training, particularly private providers, leading to lack of
comprehensive and effective HEPs and challenges in menu planning,
unsupportive food environment, and teachers’ low participation in decision
making. The study suggests that preschool providers’ training should include
training preschool managers in effective leadership skills for creating
supportive work climate in the preschool setting that maximises preschool
staff commitment and engagement, satisfaction, and quality of work through
both fostering their intrinsic motivation and using effective extrinsic reward
system. This is particularly applicable to privately-owned preschools where
the service owners are responsible for establishing staff salaries and wages.
Valuing work of all staff at preschool and recognising their contributions,
opportunities should be provided for staff to express their voice in decision-
making wherever appropriate and possible (Saunders, 2018). A healthy,
motivated and well-qualified workforce is vital to sustainable functioning of
the preschool setting and, ultimately, to the quality of care provided to
preschool children, including health-promoting nutrition practices.
At the community level, the main barrier appears to be a lack of
effective communication between staff and parents leading to perception by
staff that families’ poor dietary habits undermine preschool efforts to teach
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children healthy eating behaviours. Although preschools have policies

advocating healthy practices within the preschool setting, there are challenges
in communicating them to parents. Therefore, a notable opportunity for
improving nutrition of preschool children attending childcare settings
appeared to be improved communication between staff and parents and
fostering parental engagement with staff in promoting healthy eating
behaviours in children.
At the policy level, although significant progress has been made
towards strengthening the early care sector in recent years, vague early care
service regulations, particularly preschool nutrition regulation, and
insufficient workforce capacity building mechanisms related to preschool
nutrition, act as barriers and leave room for further regulatory improvements
and more effective use of government-allotted resources (e.g. allocating them
in the sector’s priority areas). Without addressing such priority issues as the
low pay and poor conditions in the sector as well as supporting sustainable
business models for childcare provision by private childcare settings it will be
difficult for the Government to achieve its own policy goals to expand and
optimise the childcare sector (Early Childhood Ireland, 2016).
In summary, most barriers are found at the organisational level, which
are inevitably interrelated with barriers at individual and community levels.
The main facilitator is the recognition by preschool staff of their key role in
promoting healthy eating among children in their care and their interest in
further training and working together with families. However, the most
impactful factors for change to take place are situated at policy level. In
conclusion, identifying the barriers and facilitators for promoting healthy
eating in the preschool setting improves understanding of the underlying
mechanisms and inter-related issues which may hinder or support preschool
settings to develop effective healthy eating policies and cultures.
4.6 Strengths and limitations
This study was explorative and therefore has its limitations. Particularly,
the participants’ sensitivity about discussing issues regarding their work
environment might be a limitation and it was addressed by ensuring the
anonymity of participants and confidentiality of data. While efforts were
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made to keep the researcher’s influence in the setting minimal, being a

participant observer had the potential to influence some aspects of mealtimes.
Providers may have altered behaviour in the presence of the study observer
due to social desirability bias (McCambridge et al., 2014). In addition,
mealtime behaviours were determined by observation of meal and snack
times during 2-3 days and may or may not be typical of other days. The
strength of this study is applying multi-method mixed method design which
allowed a holistic and in-depth exploration of factors that influence preschool
nutrition. Another strength of this study is that triangulation allowed for
unpredicted and interesting findings, namely preschool staff perception that
no changes in preschool practices are needed although several challenges
were expressed about nutrition service and feeding practices. This confirms
Jick’s (1979) argument that in triangulation where divergent results emerge,
alternative, and likely more complex, explanations are generated, in other
words, in seeking explanations for divergent results, the researcher may
uncover unexpected results or unseen contextual factors.
4.7 Conclusion
The study’ findings revealed that preschool staff are interested in

providing children with nutritious and balanced food and educating them
about healthy eating and several positive nutrition practices were observed.
However, preschools lack effective and practical healthy eating policies that
could aid in implementing national nutrition guidelines for preschools while
there is an inconsistency in the use of the existing healthy eating policies
resulting in an unsupportive nutrition environment. Therefore, there appears
to be a dichotomy between preschool staff desire to provide healthy food to
children in their care and their limited knowledge of how to implement it.
Moreover, staff expressed a desire for nutrition training yet staff cannot
envisage how to make changes in their settings to improve mealtime
practices. To reconcile these findings the study suggests providing preschool
staff with in-depth training in nutrition, healthy eating and child feeding as
well as improving organisational climate, better recognition and support of
staff contribution in the workplace and effective use of both intrinsic and
extrinsic incentives. For example, better recognition and involvement in
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decision-making may enhance staff sense of self-efficacy and ownership,

which in turn may empower them for enhanced work engagement and
increase their work performance. Another important finding is that educating
staff in private childcare setting is particularly important due to recent
increases in attendance at this type of settings in Ireland. The added value of
the present study is in identifying the barriers and facilitators for promoting
healthy nutrition in the preschool setting at individual, organisational,
community, and policy levels. Knowing the factors that might facilitate or
mitigate the success of future interventions is important for further research
and practice.
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Chapter 5: Preschool Children’s Food Prefeences and Perceptions
CHAPTER 5: STUDY 2 - USING CREATIVE RESEARCH

METHOD TO EXPLORE PRESCHOOL CHILDREN’S FOOD
PREFERENCES AND PERCEPTIONS
5.1 Chapter Overview
Adopting a participatory approach to studying young children’s perspectives

means viewing the children as competent social actors in their own right. Acknowledging
that children should be informed, involved and consulted about all decisions that affect
their lives, the aim of this study (Study 2) is to use creative methods to explore preschool
children’s food preferences and how very young children perceive food and healthy
eating. First, an introduction to the study is provided, followed by a review of relevant
literature and an outline of the research questions for this study. Next, the process of data
collection using creative and visual methods with preschool children is described.
Following this, the findings based on thematic analysis of merged data collected with
four tools (game-based activity with toys, short stories/vignettes, drawings and
discussions) are presented. Finally, the findings are discussed in relation to the current
literature and recommendations for future research and practice are provided. Ethical and
methodological challenges faced when carrying out research with very young children
are also discussed.
As outlined in Chapter 1, preschool years are a critical period for growth and
development and dietary habits formed at this age may persist in later years (Birch et al.,
2007; Glavin et al., 2014; Reilly & Kelly, 2011; Sahoo et al., 2015). Interventions to
improve dietary habits among preschoolers are plentiful (Ling et al., 2016; Matwiejczyk
et al., 2018; Mikkelsen et al., 2014; Sisson et al., 2016; Ward et al., 2017; Wolfenden et
al., 2020), yet these have not considered the perspective of very young children, in part
because there are limited data on how very young children perceive food and healthy
eating (Dial & Musher-Eizenman, 2019). Previous research suggests that children have a
basic understanding of the names and categories for common foods and the origins of
food (Harrison et al., 2016; Holub & Musher-Eizenman, 2010; Lafraire et al., 2016a;
Nguyen et al., 2011; Rioux et al., 2018; Tatlow-Golden et al., 2013; Varela & Salvador,
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2014), and a basic understanding about the relation of food to health (Dial & Musher-
Eizenman, 2019; Hays et al., 2001; Mobley, 1996; Schultz & Danford, 2016). For
example, by age 3-4 years children have the ability to classify foods as healthy or
unhealthy (Girgis & Nguyen, 2018; Nguyen & McCullough, 2009) and report that eating
healthy foods helps the body grow (Slaughter & Ting, 2010; Tatlow-Golden et al., 2013).
Despite their basic knowledge and skills, children are not passive actors in their
immediate food environment (Calderon et al., 2016; Henry & Borzekowski, 2011; Kraak
et al., 2006; Wingert, et al 2014). The food options that parents and schools provide are
significantly influenced by children’s food preferences (Holsten et al., 2012;
O’Dougherty et al., 2006). Past research has shown parents yielding to preschool-aged
children’s food purchase requests 48% to 59% of the time (Calderon et al., 2016; Ebster
et al., 2009; O’Dougherty et al., 2006). In the US it was estimated that children influence
household purchases at a rate of $500 billion annually (Kraak et al., 2006). Indeed,
preschool children’s food preferences are one of the most important factors influencing
their food choices (Anzman-Frasca et al., 2018; Henry & Borzekowski, 2011; Nekitsing
et al., 2018; Nguyen et al., 2015). Therefore, preschool children’s diets are determined
by a combination of children’s increasing autonomy and agency and caregivers’ control
resulting in a “co-construction of choice” (Bassett et al., 2008; Holsten et al., 2012;
Walsh, 2012). In this regard, it is important to understand children’s perspective of their
food, dietary choices and of their food environment(s).
Giving children a voice in processes that affect their lives involves
acknowledgement of children’s competence and capacity to understand and act upon
their world (Freeman & Mathison, 2009). The children’s rights movement and
sociological perspectives on children as social actors, view children as capable and
knowledgeable experts of their own lives, who are able to communicate their own views,
with the right to be respected and heard (Corsaro, 1997; James, 2009; James & Prout,
1990; Moran-Ellis, 2013; Thomas & O’Kane, 2000; UNICEF, 1989). However,
involving very young children in research requires consideration of language and
cognitive competence. The solution may lie in creative methods which can actively
engage children and enable them to express what they like to eat and what they know
about a given food-related topic, taking into account the developmental stage of children
(DeJesus et al., 2018; Wiseman et al., 2018; Zeinstra et al., 2007). There is some research
involving young children in tasks such as food classification and meal-construction tasks
using images of foods (Holub & Musher-Eizenman, 2010; Nguyen, 2007; Varela &
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Salvador, 2014) and food models (Holub & Musher-Eizenman, 2010; Harrison et al.,
2016). Yet, research with very young children is limited due to a dearth of
developmentally-tailored methods, which this study set out to address. The present study
is the first study in Ireland, that we know of, that uses a range of creative methods with
very young children to explore food preferences and perception of foods.
Recognising the rights of the child and informed by a participatory approach
(Chevalier & Buckles, 2013), the aim of this study was, first, to elicit very young
children’s food preferences and perceptions of (healthy) food using creative methods
and, secondly, to document the methodological process in developing creative methods
for use with very young children. The research questions for this study are:
1. What are preschool children’s food preferences?
2. How do preschool-aged children perceive food (healthy and unhealthy food)?
3. What factors influence preschool children’s food preferences?
4. Can creative research methods procure meaningful data from very young
children?
5.3 Children’s workshops
The researcher was introduced to children by preschool teachers and spent time at
preschools to become familiar with and to children and their food environment.
Children’s workshops were carried out in each preschool setting with small groups of
between 2-5 children. When there were more than 5 children participating in a preschool,
multiple workshops were conducted. This was to ensure the maximum number of
children in any one workshop was 5. Children with parental consent were brought to a
quiet area on-site and seated at the same table. Information about the study was presented
to children in an age-appropriate manner; children’s questions were answered, and assent
for participation and audio recording was obtained. The researcher has several years
experience working in preschool settings in two different countries and is therefore very
experienced in working with very young children. To build rapport with children, the
researcher began by discussing their friendships and family. Then the researcher asked
children if they would like to play a game with food toys. After the game-based activity
with toys, the researcher showed pictures on the vignettes, and read an accompanying
short story to stimulate discussion. At the end, the researcher invited children to draw
pictures. A Topic guide (Table 5.2) was used to ensure children were asked similar
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questions whilst still allowing the conversation to be spontaneous and personalised to

gain an understanding of a child’s perspective. The questions in the topic guide were
asked throughout the three activities (games with toys, discussing the vignettes and
drawings). Depending on the child’s response or lack of response to a question, the
researcher rephrased and repeated questions. As appropriate, the researcher asked
clarifying questions, e.g. ‘What do you mean by…?’ or probing questions e.g. ‘Have you
tried [X food] before?’ to understand a child’s perception about food and healthy eating.
To ensure the children were comfortable and at ease the researcher sometimes asked the
child to express themselves with body movements. The latter was not used as a data
collection tool. All workshop activities were audio recorded.
In this study, terms such as ‘healthy’ (foods that can be eaten any time) and ‘less
healthy’ (foods that can be eaten sometimes) were used.
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Table 5.1. Topic guide for workshops with very young children*
Topic of interest Questions used during workshops Complimentary questions used: drawing,
toys, stories/vignettes or movement
Warm up/ice breaker Tell me your name? How old are you? What is your favourite Will you draw yourself for me? Do you want to draw me?
questions toy? Do you have brothers or sisters?
Food likes What is your favourite food/fruit/drink/snack? Show me what foods you like to eat. Make your favourite dinner from these toys. Draw
Why do you like it? What do you like about it? me your favourite food.
Food dislikes What food/fruit/drink/snack do you not like to eat? Show me what foods you don’t like to eat.
Tell me why you don’t like it? Draw me the food(s) that you don’t like.
What don’t you like about it? Vignette1 and Vignette 4.
Socio-cultural factors Do you like eating with other children/your friends/your family? Show me how you eat your lunch/dinner.
that influence food choice Do you like to try new foods?
What new food have you recently tried?
Appetite/satiety Do you eat when your tummy is full? Why? -Vignette 3.
Healthy eating Which food(s) do you think is good for you to stay healthy? Why -Show me what food you need to eat if you want to be strong and smart?
do you think so? What does eating this food(s) do to your body? -Show me how you feel when you are healthy.
What happens when you eat fruits and vegetables? -Show me what body movements you can do when you are healthy and strong.
-Vignette 1 (healthy food vs liked food).
Less healthful foods Which food do you think is not so good for your body if you eat it -Show me the food that is not so good for your body if you eat it too much/too often.
too much/too often? Why do you think so? -Vignette 2.
Foods at preschool What food/snack do you like to eat at your preschool?/ What is -Show/draw me your favourite food here at your preschool.
your favourite food here? What kind of food/snack do you eat
here at preschool? Is it the same as you eat at home?
Foods at home What is your favourite food at home? Draw me your favourite food that you eat at home.
Where do you like prefer to eat, here or at home? Why?
Who cooks the food for you?
*Questions were not asked in this order but were used throughout the workshops/during activities
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5.3.1 Game-based activity with food toys
Children were given a range of food toys (n=122) that covered

common food types (Table 5.1).
Table 5.2. Food toys provided to children
Food category Food item
Vegetables Aubergine, broccoli, carrots, chilli pepper, cucumber, green beans,

lettuce, peas, potatoes, sweet corn (canned), tomato
Fruits Apple, banana, grapes, mandarin, pineapple, strawberry,

watermelon
Meats Beef steak, boiled egg, burger, fish, fried chicken leg/wings, fried
egg, sausage, whole grilled chicken
Dairy Cheese, ice-cream
Grains Biscuits/cookies, white bread, croissant, pasta, popcorn
Beverages Milk, chocolate milk, fizzy/soft drink, grape juice, orange juice
Oils/condiments Cooking oil, ketchup, mustard
Sweets Boiled sweets, jellies
Other Hamburger, pizza, French fries/potato chips
The food toys were placed on the table and children were invited to
play a ‘favourite dinner game’. While children were playing with toys, the
researcher approached each individual child and asked each child to ‘make’ their
favourite dinner from any of the foods available. During the game, while a child
was choosing toys to create his or her ‘favourite dinner’, the researcher asked the
child about the chosen food items, the reason why a child chose it, what qualities
of the food were liked by a child and why. Therefore, the discussions were child-
led and the choice of toys, which represented the child’s preference (Figure 5.1),
directed the discussions. The questions about the ‘dinner’ creations were
complemented by other questions about their food likes and dislikes, about
‘healthy’ and ‘less healthy foods’, foods eaten at home and at preschool and
frequency of consumption. During the activity children played with the toys and
shared or exchanged toys while playing.
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Figure 5.1. Game-based activity – ‘making’ a favourite dinner
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5.3.2 Discussion of vignettes with children
After the game-based activity with food toys all children in the group
were shown pictures of children as characters of vignettes printed on a laminated
A5 coloured paper. Four vignettes were read out to children that described the
child characters, their food preferences and their behaviours in various situations
such as ‘healthy eating’, ‘less healthy eating’, ‘moderation when eating’, and
‘how children feel when eating a food they dislike’ (Table 5.3). The vignettes
and the characters were integrated throughout the discussions during this activity
and children were provided with opportunities and prompts to talk about their
own experiences.
Table 5.3. Vignettes

Vignette content Questions
Vignette 1
Hello, I’m Katie, I am 5 years old and I What do you think: does she
live with my mummy and my little still need to eat them?
brother. My mummy says that peas are Why do you think so?
good for me and I will become stronger if
I eat them, but I don’t like them.
Vignette 2
Hi, my name is Brian, I’m 4 years old. I What do you think, is it good
like to go to [name of a fast-food or bad if he eats at [name of a
restaurant] and eat hamburger, chips, fast-food restaurant] every
and have a fizzy drink. But we don’t go day?
there often. Why do you think so?
Vignette 3
This boy ate too much. How do you think he feels after
eating so much?
Why do you think so?
Vignette 4
This boy doesn’t like broccoli. Why do you think he doesn’t
like it?
5.3.3 Drawings of food by children
At the end of the workshop, followed the discussion of the vignettes,

children were given sheets of paper and asked to draw pictures of food they
liked and disliked. Children sat in groups at the table, which they were familiar
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and comfortable with at preschool, but with enough distance to prevent children
copying from each other (Cammisa et al., 2011). While they were drawing, the
researcher sat with the children to encourage children to draw the food they liked
or disliked and to ameliorate children influencing each other. Then the
researcher sat next to each child and discussed the individual drawings with each
child. Children described to the researcher their drawings: they named what they
drew and explained why they liked or disliked the food they drew. Children’s
explanations were written down by the researcher on the paper next to the
child’s drawing (Figure 5.2).
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Figure 5.2. Examples of drawings of food by children
Food likes, Girl,4 Food likes, Boy, 3
Food dislikes, Boy,4 Food dislikes, Girl, 3
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5.4 Results
Ten preschools took part including full-day care (n=4) and part-
time/sessional care community preschools (n=6). Seventy one children whose
parents signed the consent forms were recruited, however, 7 children did not
participate in the study (5 children were absent on the days when data were
collected and 2 children were sleeping during the activities). Therefore, 64
children participated in the study. Participants ranged in age from 3 years, 2
months to 5 years, 8 months and 95% of participants were 4 years of age and
younger. The sample consisted of 42 girls and 22 boys.
As described in Chapter 3 data from the workshops were transcribed
and analysed using thematic analysis. Counts of food preferences were also
calculated to provide an overview of specific food preferences.
Children’s food preferences
Children’s food preferences collected through different creative

methods (toy-based games, vignettes and drawings) comprised mostly of
fruits, vegetables, meats, bread/grains, sweets, chips and pizza (Table 5.4). In
general, the number of foods that children liked was greater than the foods
they disliked. Chicken was the most popular food chosen by children,
followed by sausage, strawberry, carrots and fish.
Results of thematic analysis of workshops
Six themes were identified that describe and explain children’s food
perceptions and preferences. These themes are 1) Sensory appeal of food; 2)
Emotions associated with food; 3) Family and social influences; 4) Healthy
food is “good for you!”; 5) Internal and external cues to eat; 6) Variety and
exposure to food. Examples of children’s quotes relative to each theme are
included below with further examples available in Table 5.5.
5.4.1 Theme 1: Sensory appeal of food
The sensory aspect of food played a dominant role in how children

described food and explained their preferences. All children described senses
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relating to taste, smell, sight, sound and touch. While playing, children were
‘eating’ the ‘food’,
Table 5.4. Children’s most common food preferences
Food Number of children Number of children who

who like the food dislike the food
Fruits
Strawberry 23 3
Banana 19 3
Grapes 18 0
Apple 10 0
Watermelon 8 0
Pineapple 7 0
Vegetables
Carrots 22 4
Broccoli 14 14
Tomato 13 7
Potatoes 8 1
Lettuce 8 6
Meats/Protein-rich foods
Chicken 31 4
Sausage 28 1
Fish 22 11
Eggs 20 3
Meat (beef) 12 2
Grains
Bread 14 1
Pasta 9 1
Popcorn 9 0
Toast 6 0
Other foods
Chips 21 2
Pizza 12 1
Ketchup 9 0
Hamburger 3 0
Sweet food
Ice-cream 18 0
Cookies/biscuits 13 0
Cake/cupcakes 8 0
Sweet/Candy 4 0
Beverages
Fizzy drink/soft drink 9 0
Juice 8 0
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smelling it and even biting it. Taste was the most frequent sensory aspect
described and was characterised as “yummy”, “yummy for my tummy”, “I
like how it tastes”, “delicious”, or “yucky”, “don’t like the taste of it”. Other
sensory aspects of food such as touch and sound were also described by
children, e.g. “crunchy”, “juicy”, “gooey”, “fizzy”, and “squishy”.
Ciaran, age 4: [grabs lettuce] Lettuce!

Researcher: Lettuce? Oh, why do you like it?
Ciaran: Because you tear them apart.
Researcher: You tear them apart? It’s fun?
Ciaran: Yeah.
Some children gave importance to the colour of food when explaining their
food likes: “[I like it] because it’s red, it’s red in colour [tomatoes] - Boy,
aged 4; “Because it’s brown” [chicken]; - Boy, aged 3; “It’s green [lettuce] -
Boy, aged 3, “Because… because it’s purple and because it’s green”
[grapes] - Boy, aged 4; “Because it has green in it and I don’t like green
colour” [broccoli] – Girl, aged 4.
5.4.2 Theme 2: Emotions associated with food
Children’s feelings and emotions associated with eating certain foods

were very evident while discussing the toys chosen by children and in their
drawings. Emotions such as feeling good, happy, sad or proud were
articulated by children: “[I like] strawberry – it feels good when eating it” -
Boy, aged 3; “Sometimes I eat it, when I eat it I smile.” [lettuce] - Girl, aged
4; “Fish fingers, because they have fish in them, makes you happy”- – Girl,
aged 4.
[Oliver grabs fish]
Researcher: Do you like fish?
Oliver, age 4: [nods].
Researcher: Why do you like fish, Oliver?
Oliver: It’s delicious. I like big fish.
Researcher: You like big fish.
Oliver: [with pride] My Daddy caught a big fish!
Researcher: Oh your Daddy caught a big fish! Ooh! Was it delicious?
Oliver: [nods].
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5.4.3 Theme 3: Family and social influences
Many children referred to their family, predominately their parents,

both during conversations and through their drawings. Parents had a major
influence on their food preferences: “Because my mum said eat my egg”
[egg] - Girl, aged 4; “Because my Mummy and Daddy give me” [sandwich]-
Girl, aged 4; and food they disliked: “My mummy drinks a lot and got sick”
[Coke] - Boy, aged 4., “Because they are made of pig and my Mummy said
‘No’” [sausages] Girl, aged 4; “Because I don’t like it because my Mummy
doesn’t cook it” [fish] – Boy, aged 3. Familiarity with food also influenced
children’s food preferences. Many children expressed their likes of foods
based on their everyday experiences with these foods: “[I like it] because I
always eat it” [egg] - Boy, aged 4; “Because I put it on my chips” [ketchup] -
Girl, aged 4.
During playtime with the toys children recreated the food practices
they observe or partake in at home. They ‘peeled carrots’, ‘chopped’, ‘cut’,
made ‘cupcakes’ and ‘sandwiches’, and mixed different foods to make
familiar food combinations. Children often described these processes while
playing with toys: “I’m gonna eat my carrot. Peel my carrot, peel-peel my
carrot, peel my carrot!”- Boy, aged 5, singing.
Foods eaten by children when dining outside the home were described
and fast food outlets were predominantly mentioned (“[I like it] because they
are in XXX, there are chips and sausages there”- Girl, aged 3). These were
popular fast food establishments in Ireland illustrating that food brands and
outlets are familiar to preschool children.
5.4.4 Theme 4: Healthy food is “good for you!”
In general, children were more willing to talk about food they

considered as ‘healthy’ food than ‘less healthy’ food and the number of foods
that children thought were ‘healthy’ were greater that the foods they labelled
as ‘less healthy’. Children associated ‘healthy’ foods with being ‘nice food’
and ‘goodness’. Healthy food was described as something that makes them
‘big’ and ‘strong’ and ‘is good for you’, ‘makes you grow’:
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[Lia grabs a broccoli].

Researcher: Ok, broccoli. Why did you choose broccoli?
Lia, age 5: Because I like it.
Researcher: And why do you like it, Lia?
Lia: Because it’s healthy for you.
Researcher: It’s healthy for you? What do you mean by healthy?
[Lia is thinking].
Researcher: Why is it healthy for you?
Lia: Because it will make you big and strong.
Fruits and vegetables were mostly ‘healthy’ food while fewer children
referred to sweetened drinks and chips as ‘less healthy’ food. On the other
hand, their food dislikes were categorised as ‘less healthy’ foods and were
mostly associated with ‘not growing’, being ‘small’ and becoming ‘weaker’
or ‘sick’. The discussion of Vignette 2 with three children is shown below to
illustrate the dynamics of the conversation with very young children:
Researcher: And my question for you: what do you think, is it good or bad if
he eats at [fast food restaurant] every day?
Nathan, age 3: Not [shaking his head].
Researcher: It’s not good? Why do you think it’s not good?
Sally, age 4, and Nathan: It’s a bad thing!
Researcher: It’s a bad thing?
Both children: [nodding their heads].
Nathan: There he has a fizzy drink.
Researcher: Mhm. What do they do to you if you eat them?
Nathan: They won’t let you grow and do anything. It does make you be
small.
Researcher: Uh, Ok. And you, Sally, what do you think, is it good or bad?
Sally: Bad.
Researcher: Why do you think so?
Sally: Because then he gets sick.
However, although the majority of children had some idea about

‘healthy’ or ‘less healthy’ foods, they could not elaborate further on how
these foods affect health. Some children described food as “bad”, “...
because you won’t grow” [white bread] and could articulate what a healthier
alternative could be (“It should be brown” [bread]- Girl, aged 4). Others
described it as ‘bad’ without giving a reason “Popcorn bad. …But they are
yummy!” – Boy, aged 5.
Children learned about healthy eating mostly from their parents with
some influence evident from their preschool (“Because it’s bad for you, sugar
cake. My Mummy told me that some cakes don’t have sugar” – Girl, aged 4;
“Because my Mummy said I will be big” [egg] – Girl, aged 3; “Because my
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Mum said [it is healthy]” [strawberry] – Girl, aged 3; “My teacher told me
they are nice” [tomatoes] – Boy, aged 4).
5.4.5 Theme 5: Internal and external cues to eat
During the games and stories children described feelings of hunger

and fullness and described how such feelings explain why some children did
not eat their vegetables “because she is not hungry enough” - Boy, aged 3.
When discussing the vignette in which a ‘girl’ does not like the taste of peas,
but her mother says she will get stronger if she eats them, children explained
that the girl might dislike peas, not because of the taste, but because she is not
hungry enough to eat it.
However, other children described how they finish all their food, and
this makes them stronger. Children’s conversations disclosed the ‘Eat all your
food/clean your plate’ narrative: “I finish all my food” - Girl, aged 4; “I eat
all my lunch and I grow stronger” - Boy, aged 3. Children gave these
answers with a sense of pride.
5.4.6 Theme 6: Variety and exposure to food
Children were excited to see such a variety of ‘foods’ in front of them

and to choose any ‘food’ they liked, “I like this… and this... yummy!… and
this!” Children played with the ‘food’ and demonstrated their knowledge of
how to prepare it in different ways, e.g. ‘sandwich man’, “I can have it in
different ways” [egg] - Girl, aged 4. Children’s preference for variety was
evident: “I like different [foods]”- Boy, aged 5, “get sick of burgers and
chips” - Boy, aged 3. Children explained that boredom and repeated exposure
(“maybe he eats it every day” – Boy, aged 3) may prevent children from
liking certain foods. Similarly, children shared their experiences of trying
new foods: “I kind of like them. I didn’t like eggs but now like them” – Girl,
aged 5.
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Table 5.5. Examples of quotes from children’s discussion and drawings to support the themes
Sensory appeal of food
Taste “Because they are so delicious!” [grapes] Girl, aged 4
“Because I like taste (leafy taste), like a leaf on a tree.”[broccoli] Boy, aged 5
“Because they are yummy… and have a wiggly tail!” [fish] Boy, aged 4
“Because I don’t like spicy, but sometimes I eat it.” [onion] Girl, aged 3
“Don’t like taste, it’s good for me but still I don’t like it.” [onion] - Boy, aged 5
“It makes my tongue hot” [spicy chicken] – Girl, aged 3
Smell “It smells yummy and buttery, my Dad puts butter on it.” [toast] Girl, aged 4
“I don’t like smell and taste”. [all peppers] Boy, aged 5
“Because I don’t like smell of them. I don’t like taste of them.” [peas] Girl, aged 3
Sight/appearance/colour “I like yellow bits inside it.” [egg] - Boy, aged 5
“I don’t like taste; I don’t like black spots on it.” [banana] - Boy, aged 5
“I like it because I like how it looks.” [broccoli] Boy, aged 4
“Because I don’t like black bits inside.” [mushroom] Boy, aged 5
Touch/texture “Because it’s yummy, because it’s crunchy.” [cookies] Boy, aged 3
“Because it’s mushy and yucky.” [avocado] Boy, aged 3
“Because they are gooey. Sometimes teachers give us bananas.” [banana] Girl, aged 4
“Because you tear them apart.” [lettuce] Boy, aged 4
Emotions associated with food

Positive and negative emotions “You get happy”[fish] Girl aged 4
“Because it’s good for eating, it feels good when eating it.” [strawberry] Boy, aged 3
“I don’t like it because it made me sick” [fish] Girl, aged 4
“My dad caught a big fish!” Boy, aged 3
Family and social influences
Family “Because my Mummy makes it for me” [fish] Girl, aged 4.
“Because Mummy cooks it and Daddy puts it on a sandwich and on my plate” [cabbage] Girl, aged 4.
“Because my Mummy likes it” [fish] - Girl, aged 4.
“Because my Mummy and my Daddy give me [sausage, tomato, lettuce] – Girl, aged 4
Familiarity with food “Because they go on the toast” [beans] Girl, aged 4.
“Because it’s mashed and we have it for dinner” [potato] Girl, aged 5
“Because I eat chicken every day” [chicken] Girl, aged 4
“Because I like it. My Mummy buys milk from the shop” [milk] Girl, aged 4
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Food outside home “Chippies from XXX [fast-food restaurant], love the taste.” Boy, aged 5
“Because my mummy and I went to XXX, we went to XXX and got chicken.” Girl, aged 4
“Because I got it in XXX.” [chicken] Girl, aged 4
“Because they are at XXX.” [French fries] - Girl, aged 4.
Feeling ‘good’ about food choices
‘Healthy’ food “Blueberries makes you big and strong.” Girl, aged 3
“Oh because fish is healthy for your teeth too, like grapes.” Girl, aged 5
“Because it tastes nicely, it tastes very watery and water is healthy for you” [pasta] Girl, aged 5
“Makes me better, stronger. I feel much better because it’s healthy” [honey] Boy, aged 5
“You grow” [fruits and vegetables] Girl, aged 4
“I will be strong because I have the biggest strawberry!” Boy, aged 3
“That makes you very strong! It makes you grow”. [fruits Boy, aged 4
‘Less healthy’ food “He will not get strong” [about a child who doesn’t like broccoli]. Girl, aged 3
“He will have a drink and drink will break his teeth.” Girl, aged 4
“Because you get sick.” [explaining why it’s bad to eat too many biscuits] Girl, aged 4
“His belly will be that big! [shows with his arms a big belly, about ‘less healthy’ food] Boy, aged 4
“I don’t eat them a lot because they have sugar and salt” [chips] Girl, aged 4
Internal versus external cues to eat
Acknowledging internal cues “I know I feel full when I’m full…” Girl, aged 3
“I just say I had enough. [when full] Boy, aged 3
“Stop eating” [when full] Girl, aged 3
“Because she is not hungry” [to eat peas] Boy, aged 4
Variety and exposure to food
Liking a variety of foods “I like different” [food] Boy, aged 5
“I like various fish.” Girl, aged 3
Trying new food “When last time they made me eat chicken. I tried, it was really nice.“ Girl, aged 4
“I tried new foods before… like I tried… I really tried carrots before and they were really-really good.” Girl,
aged 3
“I tried cupcakes and they were nice and I like eating them.“ Girl, aged 3
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5.4.7 Use of creative methods with preschool children
The workshops enabled high levels of engagement from the children

producing data to answer the research questions. The children were at
different stages of cognitive and physical development and thus differed in
their ability to express themselves. The use of questions, art, stories/vignettes
and games provided opportunities for each child to contribute to the
workshops in a way that suited their capabilities and interests. Thus different
creative methods facilitated gathering information from children in a variety
of ways. Most children contributed in a meaningful way, however, the
youngest children could not explain why they choose a particular food or why
they liked or disliked certain foods. Children often answered by stating:
“Because I like it”, “I don’t know” or “I like all foods”. Moreover, the
youngest children were less able to express whether food was ‘healthy’ or
‘less healthy’ compared to the older children. For example, 27 out of 32
three-year-olds had difficulty describing a food as ‘healthy’ or ‘less healthy’,
while only 9 out of 29 four-year-olds needed clarifying questions. As
anticipated and based on researcher experience, questions were phrased in
different ways and/or repeated throughout the workshop activities to ensure
clarity in what children said, except for the oldest children who did not need
additional time or questions to clarify their responses.
Overall, creative and visual methods enabled participation, especially
among younger children, by facilitating interaction between the researcher
and children and enabling sharing of experiences and perceptions. Each
creative and visual method added a specific dimension to the data and more
meaningful data were produced that would not have been achieved with a
single method.
5.5 Discussion
The aim of this study was to gain an understanding of very young

children’s food preferences, perceptions of (healthy) food and influencing
factors using creative research methods suitable for this age group. The
multiple methods used provided each child with various opportunities to talk,
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demonstrate or illustrate their food experiences and preferences. The findings

present six main themes that give insight into children’s food preferences and
perceptions.
The data illustrate several important factors that influence children’s
food preferences and food choice. Consistent with previous research on
young children’s food preferences this study showed that sensory appeal
plays a major role in determining children’s food preferences. Children have
a natural tendency to prefer sweet or salty, energy-rich foods (Birch & Fisher,
1995) and this was reflected in the children’s responses. In addition to taste,
participants also mentioned many non-taste qualities of food when describing
their food preferences. The findings resonate with Dazeley’s and colleagues
(2015) notion that children engage with food using not only their taste but
also food’s non-taste sensory modalities such as smell, sight (appearance of
food), hearing (the name of the food or sound it makes while chewing), and
touch (feeling the texture in one’s hands or mouth). Furthermore, appearance,
taste and texture were reported to be the most important reasons for lack of
children’s fruit and vegetable consumption (Dovey et al., 2012; Zeinstra et
al., 2010). On the other hand, it was reported that playing with food and
feeling the texture of a food with hands increases preschool-aged children’s
acceptance of food with the same texture (Nederkoorn et al., 2018). As
Matheson (2002) described, preschool-aged children classify food primarily
based on its concrete, easily observed physical characteristics including
colour or shape rather than more abstract criteria such as food groups. The
findings of this study support this work and more recent findings that
interventions to increase knowledge and experience of foods should include
listening, seeing, touching, and smelling food in addition to tasting it
(Coulthard et al., 2017a, 2017b; Nekitsing et al., 2018; Zucker et al., 2015).
Thus, since liking various taste and non-taste attributes of food predicts
young children’s food choices, emphasizing the “nice” taste, colour, sound,
etc. of healthy foods and providing children with healthy foods they like
could be efficient strategies to promote healthy eating habits in children
(Marty et al., 2018; Nekitsing et al., 2018).
Another theme evident from the data is emotions associated with food.
Research on preschool children’s food-related emotions has mainly focused
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on emotional eating, such as over- or under-eating in response to negative

emotions, and its association with parental feeding practices (Blissett et al.,
2019; Herle et al., 2017; Powell et al., 2017). Very limited research about
food-elicited emotions, particularly using a qualitative approach, has been
conducted with preschool children to date (Alsulami et al., 2020), possibly
due to challenges in interviewing children younger than 4 years old whose
linguistic abilities and knowledge of emotion words are limited (Bosacki &
Moore, 2004). The present study used creative and visual methods that
allowed children to talk freely about their food perceptions and provided a
novel outcome that associations between food and emotions, both positive
and negative, are evident in children as young as 3 years of age. Research
indicates that children's acceptance of foods that have less intrinsic hedonic
appeal, such as vegetables, are shaped by their experience with those foods
including physiological consequences and social contexts (Johnson, 2016;
Savage et al., 2007). Furthermore, a recent study conducted by Alsulami
(2020) to help children to recognise six basic food-related emotions using
Food and Children’s Emotions (FACE) Picture Book and semi-structured
interviews, found that preschool children based their food-related emotions
with past eating experiences and not solely the food characteristics. This
suggests that children learn to prefer foods associated with positive contexts
and dislike foods presented in negative ones. The present study revealed that
several children, including 3 year olds, expressed their emotions in relation to
their food preferences and it was evident that their emotions were associated
with past experiences with food, which should be considered when
developing interventions for very young children. Therefore, it is likely that
the social and emotional atmosphere during eating is important in children’s
food-related decisions and results from this study (Study 2) supports the call
for more research on food-related emotions in preschool-aged children
(Alsulami et al., 2020).
An important aspect of associative learning during young children’s
food experiences is seen through family and social influences. Higgs and
Thomas (2016) argue that social influences on eating are powerful and
pervasive. The present study highlights the central role of parents in
acquisition of eating habits of preschool children, which is in line with other
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studies (Gibson et al., 2020; Savage et al., 2007; Scaglioni et al., 2018;
Skouteris et al., 2012a, 2012b). Familiarity with food was another factor
influencing the participants’ food preferences. This finding is supported by
studies of preschool children's food acceptance which indicated that repeated
opportunities to taste unfamiliar foods results in increased liking and
consumption (Aldridge et al., 2009; Coulthard, 2017a). According to Cooke
(2007), children like what they know and they eat what they like, thus
children’s experiences with food strongly influence their preferences and
intake. Therefore, caregivers (parents and preschool educators) play a critical
role in determining which kinds of foods will become familiar to their
children. Indeed, children who from the earliest age have plentiful
opportunities to sample a variety of healthy foods appear to have healthier
diets throughout childhood (De Cosmi et al., 2017; Nicklaus & Remy, 2013;
Nicklaus, 2016).
Children’s understanding about ‘healthy’ and ‘less healthy’ foods was
limited, especially in the youngest children; however, most of the children
could show a rudimentary understanding of this concept. The vignettes which
elicited children’s views and perceptions about ‘healthy’ and ‘less healthy’
foods were discussed with children after the game-based activity with toys as
the researcher was conscious not to influence children’s responses with
wording used in the vignettes (e.g. ‘good for me’, ‘become stronger’, etc.). In
line with previous research on young children’s knowledge about healthy and
unhealthy foods (Nguyen et al., 2011; Tatlow-Golden et al., 2013), this study
found that preschool children were better able to identify ‘healthy’ foods
compared to ‘less healthy’ foods. Conversations with children, especially
discussions of the vignettes provided insight into the types of foods that
children consider healthy and unhealthy. Similar to existing work (Holub &
Musher-Eizenman, 2010; Tatlow-Golden et al., 2013), children associated
‘healthy’ and ‘less healthy’ foods with their own personal preferences. For
example, many children stated that a food was ‘healthy’ because they liked it
or ‘less healthy’ because they did not. Similarly, in a study by Sigman-Grant
and colleagues (2014), when children were presented with statements
regarding health (e.g. “A healthy food is good for you”), most children
associated the term “good for you” with taste rather than health, suggesting
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that preschool children may have difficulty in articulating the reasoning

behind their food choices (Lanigan, 2011). In support of work by Tatlow-
Golden et al. (2013), our findings, that 3 year olds were less able than 4 year
olds to express whether food was healthy or unhealthy, corroborate their
assumption that understanding of health and nutrition concepts start to
develop by the age of 4 years. Research shows that by age 4 years, children
appropriately apply the evaluative categories of healthy and unhealthy foods
to a variety of different foods (Lafraire et al., 2016b; Nguyen, 2008). By the
same age, children selectively use these evaluative categories of healthy and
unhealthy foods and can generalise or extend information that they learn
about one food, particularly its potential impact on the human body, to
another food that belongs to the same evaluative category. This is an
important ability and may be related to children’s own health and well-being
as they make decisions about what foods to eat. Furthermore, when health is
presented in a strategic, intentional language using simple concepts that are
easy to understand, combined with repetitive activities that address
familiarisation, associative, and observational learning strategies, this
provides a concrete understanding of the relationship between health and food
and helps children use their knowledge about health and the verbal
information to guide their decisions about food (Birch & Anzman, 2010;
Nguyen et al., 2011; Sigman-Grant et al., 2014). In support of Mikkelsen and
colleagues (2014) suggestion that there is a need to teach children about
health as children with increased health knowledge about food might be able
to more readily apply their knowledge to their own food behaviours and food
choices, this study (Study 2) corroborates that children begin to show signs of
understanding the reasoning behind these classifications by age 4 years.
Therefore, these findings may be used to develop an age-appropriate nutrition
education programme.
Another important finding in this study was that preschool children
demonstrated their capability to recognise internal and external cues to eat.
However, some of the children demonstrated willingness to eat food beyond
their satiety level as they perceived that ‘eating all food on the plate’ was
praiseworthy. This is concerning as children can be offered large quantities of
food, which, as evidence suggests, they can and will eat, overriding their
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satiety cues. For example, children as young as 5 years eat more when they
are served or shown large portions of food and beverages (Norton et al.,
2015; Orlet Fisher et al., 2003; Reale et al., 2019, Aerts & Smits, 2018). This
study’s findings are in line with evidence that although young children are
highly capable of self-regulation of their energy intake, the extent to which
they exercise this ability is determined by environmental conditions (Birch &
Fisher, 1995; Hughes & Frazier-Wood 2016; McCrickerd, 2018). In addition,
when children are forced to eat foods usually perceived to be ‘good for them’
this can produce dislikes for these very foods (Birch & Fisher, 1995; Boots et
al., 2019). Likewise, if children are given the instrumental benefit of a food
(when the food is presented as instrumental to being healthy, i.e., “makes you
strong”), it has a negative effect on its consumption as children assume that
food which offers instrumental benefits would be less tasty (Maimaran &
Fishbach, 2014). Therefore, this study suggests that serving the appropriate
amounts of food to young children and letting them eat until they are satisfied
are important messages for preschool staff and parents. Removing ‘value’ to
eating (e.g. praising a child for eating the food or enforcing the ‘good for you’
message) is also important to communicate to staff and parents. Interventions
promoting healthful eating among preschool children should consider the role
of appetite, feelings of satiety and hunger and encourage children’s self-
regulation of food intake. Haines and colleagues (2019) concluded that
autonomy, support and structure are important feeding practices in early years
which are associated with better outcomes for children's eating habits than
more coercive practices, e.g. food restriction and pressure to eat. Structured
practices (environments that provide accessibility of healthful foods and
encourage child competence, e.g. regular mealtimes and caregiver modelling
of healthy eating) are linked to healthier eating in children from preschool age
through to adolescence, while autonomy support practices (providing
encouragement and praise to foster a child's ability to self-regulate their
eating without excessive control) are associated more with healthier eating in
children under seven years of age than in older children (Vaughn et al., 2016;
Vollmer & Mobley, 2013; Yee et al., 2017). In this context, feeding strategies
that are responsive to hunger and satiety and encourage children's attention
toward these cues and support their self-regulation should be promoted.
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Finally, children clearly expressed their preference for variety in foods

they eat. This finding contrasts much of the existing research that preschool
children have varying levels of food fussiness and picky eating and the
majority of them do not tend to try new foods at this age (Brown & Perrin,
2020; Patel et al., 2020). However, while presently there is little evidence on
whether preschool children hold food variety-seeking preferences (Ahl &
Dunham, 2020), Ahl and Dunham (2020) in their quantitative study observed
a variety-seeking behaviour in the food domain in 5- and 6-year-olds, but not
3- and 4 year olds and explained it by the fact that younger children were not
asked to reason about this behaviour. The present study employed a
qualitative approach and found that younger preschoolers (aged 3-4 years)
undoubtedly prefer a variety of foods while expressing boredom from
repeatedly consuming the same food. This finding is encouraging since food
variety contributes to children’s nutritional diversity and adequacy of the diet
(Steyn et al., 2006; Roe et al., 2013). In addition, a higher dietary variety
among young children such as less fussiness is linked with a higher general
enjoyment and interest in food (Vilela et al., 2018). However, as this study is
exploratory in nature and its generalizability is limited, larger scale studies
are needed to investigate variety-seeking behaviours of preschool children
and the ways to support them. Research evidence to date suggests that the
more foods children are exposed to from the early age, the more new foods
they accept later in childhood and the more variable their diet (De Cosmi et
al., 2017; Nicklaus, 2016). Studies have documented that availability and
accessibility of healthful foods such as fruits and vegetables and water have
been linked to increased consumption of these products among children (Ding
et al., 2012; Lahlou et al., 2015; Wyse et al., 2011). Therefore, creating an
environment where a variety of nutritious foods are readily available,
appealing, and easily accessible may provide an opportunity to encourage
children to acquire healthy eating habits. Based on this study’s findings,
changing the narrative to one where preschool-aged children value and
appreciate variety from one where they are all considered ‘fussy’ or ‘picky’
eaters may empower families and caregivers to introduce new foods in their
home and preschool settings.
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Use of creative methods with young children

This study employed a novel approach of using not one but a
combination of creative and visual interactive research tools in one study to
elicit perspectives of very young children on food and healthy eating.
Previous research related to nutritional knowledge in preschool children using
visual methods involved colour photographs (Holub & Musher‐Eizenman,
2010; Nguyen et al., 2015), an illustrated story book (Tatlow-Golden et al.,
2013), drawings (Nyberg, 2019) or food models (Harrison et al., 2016),
supplemented with either interviews or questionnaires with children and/or
their caregivers and/or observations, and showed their effectiveness. In this
study, reflecting on the participatory workshops with children demonstrated
advantages associated with the combined use of toys, stories/vignettes, and
drawings by allowing a variety of different ‘voices’ which provided space for
children to express their own feelings and beliefs towards different kinds of
food and their food preferences; explanations being offered from the
children’s point of view; and children having control of the situation during
games with toys and drawings. Using a combination of multiple creative and
visual methods ensured the responses from children were captured, what
would otherwise not be achieved in full due to inherent limitations in
cognitive and language abilities of children of this age group.
The game-based activity was a useful tool to gather data while the
children were actively involved in play and shared mealtime practices from
home in particular. The interaction between the children and the researcher
enhanced data collection over observation alone or paired interactions
between the researcher and each child. When presented with a variety of food
toys, preschool children were able to create their preferred ‘meals’ and they
were engaged in pretend play, imitating the routines and food practices they
had experienced at home, indicating that through imaginary interactions with
food, children demonstrate their understanding of food practices learned from
their real social environments (Matheson et al., 2002). This finding is in line
with Bronfenbrenner’s hypothesis that children’s perceptions of their
environment shape their behaviour (Bronfenbrenner, 1979) and with prior
research indicating that the eating context is important in forming children’s
food behaviours (Gibson et al., 2020; Savage et al., 2007; Scaglioni et al.,
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2018; Skouteris, 2012a). Previous studies that used meal creation tasks
demonstrated that this play-based method with preschool children is a
valuable tool for research and teaching which could provide insights into
what are children’s perceptions and what they are learning from their social
environments about food and eating (Harrison et al., 2016; Matheson et al.,
2002). Therefore, it is suggested that nutrition education programmes that
build on children’s everyday experiences and using hands-on teaching
methods with food would be more effective and meaningful in shaping their
behaviour than based on abstract nutrition concepts, e.g. their understanding
of food groups (Harrison et al., 2016; Matheson et al., 2002).
The vignettes enabled the researcher to grab children’s attention, keep
their interest in the topic and were useful in eliciting children’s perceptions
about food by allowing them to express their opinions in an indirect way. The
disadvantage of using a story or a vignette is the risk that the scenarios would
not have the same meaning to children as to adults (Spratt, 2001). In this
study, however, a vignette served as a starting point for discussion and
children would shift to their own experiences in the course of discussions.
The study’s findings showed that preschool-aged children are capable of
providing important insights into their daily lives and food experiences.
However, some children struggled to describe their thoughts or provided one-
word answers. At the same time, the researcher tried to be reflexive being
aware that helping children to express themselves without leading a child is
key (Irwin & Johnson, 2005). Likewise, Vandenhole et al. (2015) emphasised
that children should be supported to participate and they should be able to
express their views ‘freely’, without being unduly influenced or pressured.
Finally, children’s drawings provided children with a tool to tell their
own story in an imaginative and creative way, which is often part of
children’s everyday lives. This method was particularly important tool for
gathering data from those children who had difficulty to express themselves
during other activities. Several children declined to take part in discussions
but they enthusiastically made drawings and willingly explained what they
had drawn and why. While visual data may be challenging to interpret, when
combined with spoken feedback from children, these data add further
dimension to the data (Angell et al., 2015; Eldén, 2012; Nyberg, 2019).
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5.6 Strengths, limitations and challenges
It was anticipated that the volume and depth of data from very
young children would not be as plentiful as that expected from older children
or adults. While this held true the process of collecting data worked well and
the research questions were addressed. Asking children the same or similar
questions using different tools, e.g. food likes or dislikes, countered the
challenges of collecting data from very young children and children’s
accounts were verified. Triangulation of diverse sources of data gave a more
complete picture of children’s food-related perspectives than would have
been given by a single data source. Reflection on the participatory workshops
with very young children illuminated advantages to using a combination of
toys, vignettes, drawings and discussions. The strength of this study was the
use of a variety of different approaches to ensure children’s responses could
be captured, which allowed space for children to express their own feelings
and beliefs towards different kinds of food and their food preferences.
Children had control of the situation while engaged in toy-based games and
other activities and they openly described their pictures and food choices.
Therefore, although it is challenging to adhere to participatory research with
very young children, creative methods minimised the power relationship
between the adult researcher and child. Through respect for children’s
opinions and perspectives, this research gave the children power through their
active engagement and input in the research process. Indeed, the novel
outcome of this study is that a combination of creative methods did produce
meaningful data from very young children and can enable others to engage
with very young children in matters likely to affect them.
However, this study has some limitations such as the broad age
range (3-5 years) of children, given the developmental milestones: cognitive,
motor and physical changes that occur during this timeframe. To help the
youngest children to express themselves, additional questions were needed to
understand the reasons behind children’s answers. During game-based
activities children easily identified foods they liked but not as easily the foods
they did not like. The range of ‘less healthy’ food toys may have been limited
or were unfamiliar to children because these foods were not available in their
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home or preschool. Therefore, to counteract this possibility children were

asked to draw the foods they both like and dislike.
While playing the food game children expressed themselves verbally
and non-verbally, acted and interacted with each other, thus non-verbal
communication (e.g. body language, facial expression, tone of voice) was
important. The researcher adapted to the children’s needs by changing facial
expression, voice and body position and slowed down to establish a rapport
with a child. Further work on the use of non-verbal communication as a
research tool with preschool children would be useful. Challenges also
include interpretation of ambiguous responses (i.e. ‘I like it because I like it’)
due to very young children’s limited capability to elaborate, explain or
articulate some of the reasons behind their food choices.
In addition, it is important that the researcher’s interpretation and thus
description of the findings accurately reflects the children’s responses (James,
2007). Ideally the children should be consulted further about the
interpretations of the findings by the researcher (Shaw et al., 2011).
In this study questions related to ‘healthy’ and ‘less healthy’ foods
were formulated in such a way that foods can be ‘good’ or ‘bad’ for your
health depending on how much and how often it is consumed. Previous
studies have used the terms ‘good’ or ‘bad’ food and have asked children to
categorise foods into ‘good’ or ‘bad’ (Hart et al., 2002; Thompson et al.,
2011). However, careful consideration needs to be given to the language used
in research about food with young children. Though not evident from
children’s responses in this study, the potential association between ‘bad’ and
‘good’ food and bad and good behaviour, respectively needs consideration. It
is imperative that children do not learn or believe that they themselves are
good or bad by consuming certain foods. Thus, the terms used to teach
children about healthy and unhealthy diets needs careful consideration to
prevent such associations emerging. If such beliefs are learnt, moral
judgements could extend to other children or be internalised by the child; thus
the language used when designing and delivering strategies and interventions
to improve dietary habits needs careful thought.
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5.7 Conclusion
The study adds to the literature on preschoolers’ nutrition perspectives

of food and healthy eating by applying a novel approach of using a mix of
multiple creative and visual methods which empowered children to actively
participate and share their experiences, food perceptions and food
preferences. The findings of this study highlighted diverse influences on
children’s food preferences and provided more information and insights in the
factors influencing preschool children’s perceptions about food and healthy
eating that may be translated into interventions for promotion of healthy
eating in young children.
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Chapter 6: Parents’ Perceptions and Parent-staff Communication
CHAPTER 6: STUDY 3 – PARENTS’ PERCEPTIONS ON

PRESCHOOLERS’ NUTRITION AND PARENT-STAFF
COMMUNICATION
6.1 Chapter Overview
Multiple perspectives are important to gain a holistic picture of the

complex determinants that influence preschool nutrition. The previous
chapters included perceptions from preschool staff and children while this
chapter will focus on parents of preschool children. Since relationship
between home and preschool is key for children’s well-being at this
developmental stage, the present study also explores the relationship between
staff and families in respect to food in preschools. Study 3 aimed to explore
parents’ knowledge and perceptions of nutrition, particularly preschool
nutrition, and to investigate the relationship patterns between preschool staff
and parents. First, a brief introduction and overview of relevant literature is
provided. Following this, data collection procedures are described. Then the
findings based on thematic analysis of 10 interviews with parents of
preschool children and 10 interviews with preschool staff, observation of
nutrition-related communication between staff and parents and document
reviews are presented. Finally, the results are discussed in relation to the
current literature, recommendations for future research and practice are
provided, and the study’s strengths and limitations are presented.
Given that preschool-aged children rely on family and other

caregivers for food provision, their parents and caregivers and the various
environments to which children are exposed are the most important
contributing factors to developing young children’s dietary behaviours. With
the family being the primary social setting influencing young children,
parents shape young children’s eating behaviours through food parenting
practices, such as controlling the availability and accessibility of foods and
modelling eating behaviours (Vaughn et al., 2016). Therefore, there are
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opportunities for applying strategies that focus on the impact of caregivers on

children’s diet and eating behaviours (Nguyen, 2019; Pocock et al., 2010;
Ventura & Birch; 2008). Parental involvement in general has been recognised
as an important requisite to a successful early intervention (Smith & Zaslow,
1995) and therefore, in the past two decades, parental involvement in various
forms has been included in many early childhood intervention programmes.
Depending on the goals and the context of a particular programme, family
involvement varied, focusing either on parents or parent-child relationships
(Borgonovi & Montt, 2012; Hilado et al., 2011). These nutrition interventions
usually focus on improving parenting skills, developing positive parent-child
relationships, providing social and emotional support to family members,
involving parents in programme policy-making and operations, and assisting
parents in gaining access to community resources (Hilado et al., 2011;
Mehdizadeh et al., 2020; Walch et al., 2020). However, parents’ perception
about preschool food, nutritional needs of and preparing food for preschool-
aged children is lacking from this body of research. These data are needed to
better inform healthy eating intervention designs. In addition, parental
perspectives and perceptions about nutrition can inform professionals and
communities who support families in promoting healthy eating.
As children across socio-economic backgrounds may not experience
optimal nutrition environments at home (Larson et al., 2011; Robson et al.,
2015), early care settings may provide an opportunity to improve or support
positive eating behaviours (Davison et al., 2013). Studies have found that
parents provide healthier meals for their children when childcare providers
share nutrition information with families (Gupta et al., 2005; Sellers et al.,
2005). The development of children’s healthy eating behaviours and food
intake patterns, therefore, depends on communication and information
sharing between caregivers and, optimally, on ‘synergism of feeding practices
among their various caregivers’ (Johnson et al., 2013, p. 559) to ensure
consistency between environments. Evidence suggests this communication
between providers and parents can serve as a link between the home and
childcare environment (Shpancer, 2002). However, parents and early care
providers may not be communicating effectively and working coherently to
ensure optimal nutrition of children in their care (Gerritsen et al., 2018;
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McGrath, 2007). Therefore, strategies for effective communication, policy

and environmental changes were recommended for fostering a respectful
relationship and building a bridge between providers and parents to improve
communication about children’s nutrition and health (Dev et al., 2017). A
recent study by Gerritsen and colleagues (2018) explored adherence to
recommended nutrition-related behaviours (RNB) within the home and
centre-based childcare in a large sample of preschool children and examined
the prevalence and congruence of RNB in home and early care services. The
study found a lack of congruence between home and childcare service
behaviours suggesting that health-promotion messages may not be effectively
communicated to families. The study concluded that further research is
needed on the barriers childcare staff face in effective communication with
parents to ensure consistency in healthy nutrition behaviours across home and
childcare settings (Gerritsen et al., 2018).
Recently, the Irish Government has undertaken important reforms in
sectors related to children’s health and well-being, particularly early
childhood. The previous Minister for Children and Youth Affairs Dr.
Zappone highlighted that experts, including children themselves, recognise
the essential role played by families in nurturing healthy child development,
and that is why strengthening families is at the heart of the “First 5: A Whole-
of-Government Strategy for Babies, Young Children and Their Families"
(Department of Children and Youth Affairs, 2019). First 5 developed a new
national model of parenting supports, with an aim to streamline and improve
existing parenting supports and include high-quality information and
guidance for parents to promote healthy behaviours and maintain strong
parent-child relationships, making it more accessible to all families for the
first time. Yet, parents’ and childcare providers’ perspectives on what
supports and hinders communication between parents and providers are
needed in Ireland. To the author’s knowledge, research exploring parents’
perceptions on preschool child nutrition and parents and childcare providers’
perspectives regarding communication about preschool children’s nutrition
has not been published in Ireland. Therefore, the current study objectives are
to:
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1. Explore parents’ knowledge and perceptions about preschoolers’

nutrition;
2. Explore the communication strategies for promoting healthy eating in
preschool children between staff and parents;
3. To examine the needs and opportunities for effective communication
between staff and parents, specific to promoting healthy eating among
preschool children.
6.3 Data collection procedures
To address the research objectives the current study applied a mixed

method research design using semi-structured interviews, direct observation
and document review. The study aimed to achieve a mix in socio-economic
background, thus community preschools and early care services located in
disadvantaged areas in the West of Ireland were selected using purposive
sampling. Ten preschools with different services and types of food provision
including full-day-care (n=4) and sessional community preschools (n=6) and
a total of 20 participants (parents=10 and preschool staff=10) were recruited
for the study. Preschools were enrolled through invitation letters posted to
managers (Appendix 2) and follow-up phone calls and visits to preschools.
To recruit parents, invitation letters to parents (Appendix 8) and parent
consent form (Appendix 9) were administered by preschool staff or placed in
the children’s bags.
6.3.1 Qualitative interviews with parents
Face-to-face semi-structured interviews were conducted with parents

of preschool children attending the participating preschools. To ensure
confidentiality and encourage participants to speak freely, all interviews were
conducted either in a separate room in the preschool at child pick up time or
in a place outside the preschool after drop-off time. The interviews lasted 16
to 44 minutes and were audio recorded. Interviews started with thanking the
parents for agreeing to participate, giving a brief review of the aims of the
study, assuring them of the confidentiality of the data gathered, and obtaining
consent to audiotape the interview. The parent was asked to sign a Parent
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Consent Form (Appendix 9) and answer a short questionnaire on participant’s

socio-demographic background (Appendix 10).
The interview was guided by the topic guide for parents interviews
(Appendix 15). The main topics discussed were typical meal times at the
family home; parent’s perception of healthy eating and related knowledge;
parents’ attitude toward healthy eating and the food environment at home;
and parents’ behaviours during meal times including the challenges they face
around mealtimes at home. Parents’ perceptions about preschool food and
nutrition practices were also explored in addition to parents’ perceptions
about food-related communication with preschool staff. When appropriate,
probing questions were asked to clarify responses or to explore new
perspectives. At the end of the interviews, parents were thanked for
participating in the study and asked if they had any questions or additional
thoughts they were willing to share which were not covered in the interview.
The parents were given the opportunity to request information about the
findings of the study.
6.3.2 Qualitative interviews with preschool staff
One-to-one semi-structured interviews conducted with ten preschool

staff are described in detail in Chapter 4. The main topics included were staff
perception of healthy eating and related knowledge, their role in providing
healthy foods; their attitude and behaviours during mealtimes, relationships
with children’s families, and the barriers and facilitators they face around
healthy eating at preschools. The data specific to relationships with parents
about food and other related behaviours were analysed together with the data
from parent interviews and are described in this chapter. In addition, the
results of review of preschool documents pertinent to staff-parent
communication are presented in this chapter.
6.3.3 Observation
In each preschool, observations of parent-preschool staff interactions

were carried out during child pick up times on two consecutive days in all
preschools and an additional 3rd day in one full-day-care and one sessional
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community preschool. Thus a total of 22 occasions of observation data were

collected between each participating parent and preschool staff. In total, 9
interactions were observed in full-day-care preschools and 13 interactions
were observed in sessional community preschools. During the observations
the researcher observed from within the room where the interactions occurred
but remained on the outer edges of the room and did not interact with staff,
parents or children. An Observation Tool for staff-parent nutrition-related
interactions was used to collect observation data (Appendix 20). In addition,
reflection notes that sought to capture different aspects of food and nutrition-
related interactions between parents and preschool staff, including topics
discussed and participant responses, were taken immediately after the
observations were carried out (see Table 6.2 in this chapter).
6.3.4 Document review
The documents that were reviewed and analysed in this study included:
preschool healthy eating policies; packed lunch guidelines, written
communication with parents on food, nutrition and meal times (e.g. parent
handbooks, paper notes), if present.
6.4 Results
A total of ten preschools participated in the study including full-day-

care (n=4) and sessional community preschools (n=6). The participants were
10 preschool staff and 10 parents of children attending the participating
preschools (Table 6.1). Seventy one parents who gave consent for their
preschool children to participate in Study 2 were invited to take part in Study
3, however, only ten parents agreed to participate in the study (response rate
14%). All ten parents were female, married, with an average age 29 (SD 4.1)
years; 7 parents were working full-time and 3 parents were not working
outside the home; 4 parents were mothers of children attending full-day-care
preschools and 6 were mothers of children attending sessional preschools.
The number of children in each family ranged from 1-3. Six mothers were in
receipt of social welfare (Appendix 19). Preschool staff who participated in
the study were preschool managers (n=6) and teachers (n=4).
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Table 6.1. Study 3 participants characteristics

Preschool type Participants
Staff Parents
Manager Teacher Employed Not
employed
Full-day-care 3 1 3 1
Community sessional 3 3 4 2
Total 10 10
The inductive thematic analysis of the data identified three main themes and
these included: 1) Feeding challenges: food environments inside and outside
the home; 2) Parental desire for knowledge including feeding strategies; and
3) Miscommunication between parents and preschool staff.
6.4.1 Theme 1: Feeding challenges: food environments inside

and outside the home
All parents viewed nutrition as key to their children’s healthy growth

and development and a vital component of their health-related behaviours.: “I
think healthy food is very important” (Mother of 3 year old, sessional
preschool); “[we should] keep emphasising the message [to children] that
healthy food helps us to be healthy and strong (Mother of 4 year old, full-
day-care); “… eating healthy will help them [children] in the long-run”
(Mother of 4 year old, sessional).
All parents were keen to provide healthy and nutritious foods to their
preschool children by “preparing home-made meals”, “trying to eat fresh
vegetables at home” and “getting [the child] to try new foods”. Parents
reported that most meals per week were eaten at home (mainly dinner), with
an average of one meal every two weeks eaten out in a restaurant, mostly in
fast-food outlets.
Parents encountered challenges in providing their children with
healthful diets and wanted more resources to prepare nutritious meals: “I
need more information, more time to prepare food, and more money!”
(Mother of 4 year old, sessional); “I wish nutritious foods [were] more
affordable and more acceptable…” (Mother of 4 year old, full-day-care); The
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most common challenges that parents faced were lack of effective food
parenting skills when dealing with their children’s ‘fussy eating’, lack of time
to prepare healthy meals and outside influences on their children’s diets,
which are described in the subthemes below.
Mealtime challenges and strategies

All parents described at least one issue related to their child’s ‘fussy
eating’ “Oh she is a very fussy eater“ (Mother of 3 year old, full-day-care);
“I’d love him to be not so fussy…, so I don’t have to cook separately for
him…”, accommodating their child’s food preferences to ensure their child
ate, and a desire to reduce food-related conflicts. For example, accounts of
children eating only specific foods every day led parents to feel helpless and
thus to give in to their child’s preferences. Strategies described by parents
included “I have to kind of always push my son to eat, finish his food”
(Mother of 4 year old, sessional), “It’s difficult to make her eat vegetables, I
don’t even try anymore… even if I force her, she screams!” (Mother of 3 year
old, sessional); “If she doesn’t want it, she will try it and she will spit it”
(Mother of 4 year old, sessional). Most parents expressed frustration about
their children’s fussy eating behaviours while some believed that it was a
temporary behaviour: “I think it’s their age when they are fussy eaters. I’m
not too worried and hope he will grow out of it” (Mother of 4 year old,
sessional).
Parents discussed other challenges related to feeding practices:
“She wants me to feed her, because sometimes I tell her just go and to
eat [the snack] but she doesn’t eat it and when I give it to her, she eats
it. I don’t know what’s the problem… I don’t know what to do” (Mother
of 4 year old, sessional).
Parents try to use different strategies, mostly controlling feeding

practices, in an attempt to increase their children’s consumption of healthy
foods: “They have to at least try everything. Particularly my daughter, she
doesn’t like meat that much, but she has to have a certain amount of spoon-
fulls before she can leave the table” (Mother of 3 year old, full-day-care).
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Parents commonly used food as a reward or as a negotiation tool

because it was the only thing that worked most of the time, although they
perceived it as an inappropriate tactic: “… we promise them that we give them
a dessert, if they try at least…” (Mother of 4 year old, full-day-care);
“Sometimes I have to tell him that he needs to finish his food if he wants to
eat dessert. I know you are not supposed to, but I do it anyway… because it
works!” (Mother of 4 year old, sessional); “I guess we have to, to be honest,
use it [food] as a reward. I’m conscious of that and trying not to do it too
much… but it works…” (Mother of 5 year old, full-day-care). One parent said
she uses food as a punishment: “Sometimes I just try to insist. I say ‘I’ll
punish you, we are not having sweets after and we are not going out’”.
Parental time constraints

Many parents reported that there is not enough time in their busy
lifestyles to cook healthy food at home as they often feel tired after work or
are busy with household chores:
“I think sometimes that if I was home all the time, the meals would be
amazing, but you know when you are under pressure of time, you don’t
have energy and… so you end up just, you know, reheating fish fingers
and boiling pasta because it’s just the easiest thing and you know that
they’ll eat it and you just do that. But if I had more time I would prefer
meals more cook myself and try to be more creative. Yeah… lack of time…
definitely a challenge.” (Mother of 4 year old, sessional).
“Sometimes I don’t have enough time to make a whole salad, I just do rice
quickly, the vegetables, the meat. Quick, quick, quick! And for a salad I
just pick the fastest things” (Mother of 4 year old, sessional).
Parents reported that that they give convenience foods (e.g. chicken nuggets,
pizza, fish fingers) to their children because of lack of time to cook meals
from scratch.
External food environments and influences
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In trying to shape their children's eating patterns, mothers believed that

their efforts to improve their children's diet were challenged by the influences
outside of home, such as other family members, friends and the wider
environment such as schools, restaurants and supermarkets.
“I think I can control what’s inside, but I’m concerned about other
people’s influence. I find it difficult if someone calls to visit and they
come with chocolate bars and you are thinking ‘Hmm, oh no, please
don’t bring them in! You know… so it’s kind of outside influence and
for them [children] learning to say ‘No’ to treat food”. So, when they
[children] are outside the house, I find it difficult.” (Mother of 4 year
old, full-day-care).
Other caregivers, such as grandparents, often interfered with the mother’s

sense of control and mothers found it difficult to keep the children’s home
diet consistent due to grandparents often offering treat foods to children.
“You are trying to give them healthy food, no sweets. And then you
leave them with their grandparents and they give them whatever... they
are quite bad really! Since my son was two [years old] they would give
him sweets. He never had sweets [before] and he didn’t realise it was
food, but they kind of shove it at him even if he doesn’t need it, you
know, and not asking for it. And that’s the reason he likes sweets so
much now... But then, you know, you don’t want to offend them and it’s
very difficult.” (Mother of 4 year old, sessional preschool).
“Yeah… and it’s a difficult one because they [grandparents] are older
and they have their own beliefs and, even if you kind of say something,
they still prefer their old ways, ‘Well, I raised four kids and they turned
out fine”, you know. They might not be very willing to change.”
(Mother of 4 year old, sessional preschool).
Many parents believed that the wider environment, such as restaurants,

supermarkets and even schools, are unsupportive of healthy eating habits. For
example, mothers complained that when they go to a restaurant to have
dinner, there are special ‘kid’s menus’ or ‘kid’s meals’ that usually contain
unhealthy food.
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“… it was a lovely restaurant and they had, you know, for kids they
have a kids’ menu, which drives me crazy because sausage’n’chips,
nuggets’n’chips… yeah.. sausage and chicken nuggets, a burger,
pizza… and it’s the same price!.. You know, if I pay for a dinner I
would get a proper dinner! You know, I can make you a sausage and
chips [at home] if you want! Yeah… And a coke... ooh… I just think…
But it is what … kids expect… you know. I don’t know why, yeah.”
(Mother of 4 year old, full-day-care).
“...Before he wouldn’t eat chips but now he’s kinda forced on it

because they are everywhere, anywhere we go to a restaurant there are
chips.” (Mother of 4 year old, sessional).
Some of the parents expressed their frustration that preschools can be a

place from where children can get confusing messages due to parents of other
children not following healthy eating policies and rules or due to schools not
having a clear and comprehensive healthy eating policy:
“Like one friend of her [daughter] brings a donut to school every day…
and another child brings marshmallows every day. And another boy got
in trouble taking some of his marshmallows. That’s not fair to the child
to be exposed to those marshmallows every day because then they
become a forbidden fruit and that’s very difficult. They are very good at
talking about healthy food [at preschool], they are [children] learning
about it, but just in practice, in reality, are their parents following that?
It makes more challenging for you when others aren’t.” (Mother of 4
year old, full-day-care).
In general, parents were aware of the external factors negatively influenced

their children’s diets and dietary habits, however they felt that they had
limited control over managing them.
“It should be coming from all levels… Like you go to a supermarket and
they have these sweets saying ‘sugar-free’ and kids asking for it.... So it’s
all kind of mixed messages from everywhere, isn’t it?” (Mother of 4 year
old, full-day-care)
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6.4.2 Theme 2: Parental desire for knowledge including

feeding strategies
Practical advice is needed

All parents expressed their interest in learning more about healthy
eating. In general, most parents had basic nutrition knowledge but none of the
parents were familiar with the nutrition needs and issues related specifically
to preschool-aged children. The most frequently used source of nutrition
information was the Internet followed by family and work, however, the
Internet was mostly used for searching for recipes. Parents described ‘a lot of
information out there’ but the information was often contradictory so it was
better to ‘use common sense’ and ‘think of a balance’. Parents also reported
that they would seek information on child nutrition and health only when
there was a problem: “If I was really worried, I would be looking for
information. But because I am not that worried, I haven’t looked into it too
much” (Mother of 3 year old, sessional); “If I had a real concern about my
children, I would go to that trouble, you know, emotionally or behaviour-
wise…” (Mother of 4 year old, full-day-care). None of the participants
mentioned any nutrition information courses or training that they took part in.
While parents expressed interest in training on nutrition issues; they voiced
concerns about the appropriateness of the content of the training and interest
in practical tips. For example, one parent stated:
“So I think what would be good is a practical information on how you

are actually going to get them to eat it! I think that would be really
good. Because there is a lot of information about healthy eating, but it’s
just a matter of how to get them to eat it, for example you give them
chicken and vegs, but they want to eat only pancakes, so how you are
going to get them eat vegs? I think that would be important, you know”.
Similarly, some parents wanted advice on how to deal with daily issues they
encounter when feeding their children:
“Yeah, we have leaflets through the door and things like that. Ehm…
but it’s always quite… probably would be very basic level… like food
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pyramids and things like that. It’s important, don’t get me wrong, but
you know maybe more tips on dealing with fussy eating, more tips to
encourage new foods and… would be very helpful..” (Mother of 5 year
old, full-day-care),
“Yeah…sometimes I want to know how much meat or vegetable she

needs to eat every day…” (Mother of 3 year old, sessional).
While parents described the difficulties in feeding their children, they

also had suggestions for coping and possible solutions. For example, when
parents expressed their desire to diversify the food they cook at home, they
said that they could “learn easy and quick recipes” or “at least try to present
food in different ways”. Therefore, there appears to be a contradiction
between information they perceive they need and implementing ideas they
already have.
Meal planning and cooking skills

Several parents expressed their concern that their children prefer
eating snacks rather than eating meals. They articulated their own lack of
knowledge on how to manage it and expressed their interest in learning how
to ensure their children eat nutritious meals instead of wanting to eat snacks
all day. In addition, younger mothers mentioned their lack of cooking skills
and that having children has motivated them to learn how to cook healthy
meals. Most parents described how they do not plan their meals in advance
and are interested in learning about meal planning skills: “Sometimes I don’t
know what to cook, I never plan what to cook… maybe if I do… this maybe
can help me make healthy foods.” (Mother of 3 year old, sessional). Several
parents suggested that planning meals would be a good way to eat healthy
and save money and that they need to improve their meal planning skills. For
example, one mother stated:
“…you know things like that when you can say ‘You have this for lunch
and then this for dinner’, for example you can have a roast chicken on
Sunday and chicken sandwich on Monday using the leftover chicken
from Sunday. You know, thinking like that how you can… just
manage… that would help with money, time and all of that. And make
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sure you have variety with just changing little things”. (Mother of 4
year old, full-day-care).
Other topics that parents were interested in were practical tips on ideas for
packed school lunches. One mother said:
“Yeah, training on healthy school lunches would be nice as well,
something that I would look online as well, just to get ideas what to put
in school lunch, you know. Because it could be challenging just the way
it is now… to find something practical for them to eat” (Mother of 4
year old, sessional preschool).
Many parents expressed their interest in increasing the variety of meals

cooked at home and cooking different or new foods, especially new flavours
that were not eaten by their preschool children, but find it challenging to do:
“I feel kind of I always cook the same food. But when you have kids, I
think you are afraid to cook something new because you put all those
ingredients and cook and spent so much time and what you get is ‘I
don’t like it’. And you are like ‘Arrhhh!’ So, what I would like [to
learn] is simple menus…” (Mother of 4 year old, full-day-care).
Another challenge raised consistently by parents was finding ideas for

cooking meals at home; “It’s hard to find ideas. You are tired, and they are
hungry and you are hungry, and you just can’t think” (Mother of 5 year old,
full-day-care). In general, therefore, parents were interested in learning easy,
quick and child-friendly recipes to save time and have their children eat a
variety of foods.
Parents indicated that preschools would be the most trusted source of
information and suggested that organising training at preschool would be
most helpful:
“The best is when information comes from the school, then we really
look at it. For example, my other daughter [primary school pupil] goes
to this information sessions called Food Dudes where they try different
foods, fruits and vegetables, so this is kind of broadened what we would
give them as a lunch at school. So, when the information comes from
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schools, I would say we listen more. …Yeah, it would be really helpful,

it would be something I would try, you know.” (Mother of 4 year old,
sessional preschool).
None of the participants, neither preschool staff nor parents, described

on-going nutrition-related activities involving parents and staff.
6.4.3 Theme 3: Lack of clear communication between parents

and preschool staff
Challenges in sharing nutrition information

Both preschool staff and parents were motivated to communicate with
each other about children’s food habits. Preschool staff expressed their
interest in sharing knowledge on nutrition topics that they would acquire as
part of childcare provider training, “… training about nutritious food… we
can bring that training, that practice to parents, you know, to speak to
parents.” (Teacher, sessional). Preschool staff emphasised the importance of
engaging in discussion with parents as an opportunity to better understand
their approaches to child feeding. Staff also perceived that conversations with
parents would be a good way to help to support healthy eating in both the
preschool and at home. However, due to the busyness of parents, providers
felt that involving parents in training, especially gathering parents as a group,
would be challenging:
“Yeah that would be a good idea [to organise training for parents]. But
it’s like if you get people to come to it… but yeah, certainly.” (Manager,
sessional).
Some working mothers expressed their alienation from workshops

because they are working full-time:
“My problem is that, as I work full-time, I find that a lot of these

workshops for parents are run during school hours or during my
working hours. And I always felt alienated for that reason and felt that
workshops for parents don’t take into account the working parents. So,
perhaps, if it was an evening thing, then it would work. I know that even
the stuff on child behaviour and other things that they put out there I
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would be interested in all those things but the time would be an issue
for me.” (Mother of 4 year old, full-day-care).
While timing of workshops was identified as a challenge, meeting parents

individually was suggested by staff, while parents suggested getting together
to share their own experiences might be useful: “…parents could get together
and share their ideas on what they tried to give their kids in their school
lunches and discuss what worked and what didn’t. That would be a great
idea.” (Mother of 4 year old, sessional).
Parents cited busyness of the staff at the pick-up time as a hindrance to

sharing nutrition information:
“I don’t know how much they ate unless I ask. And when you pick them
at the crèche, there’s so much going on, so you don’t think to ask what
they ate, you just assume they ate, you know, but maybe they didn’t eat
or didn’t like it… yeah…” (Mother of 4 year old, full-day-care).
“They would [tell about child’s food intake], but access to the teachers
when I pick her up is not easy. If I pushed, if I was insistent about it,
I’m sure they will be able to tell me or leave me a note every day, but
it’s not what I’m concerned about because if [child’s name] is hungry,
she [the child] would tell me about it.” (Mother of 3 year old, full-day-
care).
On the other hand, several staff reported that parents were too busy to talk to
staff when picking up their children. One preschool ensures two staff
members are available at pick up time to enable communication with parents
and “a really good partnership” with parents was described (Teacher,
sessional).
The challenges in offering advice while not offending families was also
evident:
“I think sometimes, if they come from disadvantaged areas, they
merely feel like it’s a personal attack if you advise them, so you have to
be very careful, you know, in the way that you word it… you know… as
to not insult them. You know… as to not insult what they have [in the
lunch box].” (Teacher, sessional).
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Miscommunication between parents and preschool staff

During the interviews, preschool staff and parents reported that in-
person conversation during drop-off and pick-up times was the primary
method of communication between staff and parents (n=10), followed by
over the phone (n=9), text messaging (n=8) and email (n=8). Parent
handbooks were used in three (one full-day-care community and two
sessional community) preschools, which consisted of a booklet containing
information about the preschool’s general policy, including nutrition and
HEPs. Written communication with parents consisting of notes about a
child’s food intake was practiced in two preschools, in others it was done
verbally. The majority of parents attending sessional preschools reported
seeking advice from preschool staff about healthy foods and beverages for
their child, primarily about the lunch box content (n=5 out of six parents
whose children attended sessional preschools).
In full-day-care preschools, most parents considered the nutritional
quality of the menus provided at preschools appropriate and said that ‘it
seems to be healthy’ and ‘well-balanced’. However, some parents reported
insufficient written communication on the content of preschool menus to
parents:
“They haven’t sent the menu lately [by email]. They sent it a couple of
times but it doesn’t seem to be consistent, so I usually know because
other children would be eating it so I can see what they are eating or I
ask [the child’s name] and she describes it to me and I understand what
it is, so I don’t always know.” (Mother of 4 year old, full-day-care).
Communication between staff and parents varied among the

participating preschools and communication type and patterns were described
differently by staff and parents. On one hand, parents expressed
dissatisfaction with daily verbal information about their child’s food intake as
they wanted to plan meals at home and ensure their children’s diet was
adequate:
“I do worry what she eats for dinner at school. But there is a change over
in the staff so I don’t know what she ate or how much she ate, they don’t
give that information. So, when I ask, it’s always a different girl in the
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room that is looking after her than it was when I talked to in the morning
and when she had dinner. So it’s difficult to know how much she has eaten,
so they can say to me there was a shepherd’s pie for dinner, but I actually
wouldn’t know if she ate enough of that.” (Mother of 4 year old, full-day-
care).
In sessional preschools, where parents provide packed lunches, an

issue frequently mentioned by staff was parents’ low compliance with
preschool healthy eating practices and recommendations and packing
unhealthy food in children’s lunch boxes.
“We’ve told parents not to bring unhealthy lunches … Some parents

would be ok and they wouldn’t send it again, with other parents it
would take 10 times. One particular parent would say his wife is doing
it and we would tell please tell your wife not to do it, but it happens
again… so messages were not coming across, I think.” (Manager,
sessional).
“We say that we need to be compliant with the regulations of the

preschool. So would need to talk to some parents quite a lot before they
get the message. Other parents… you could tell them and they would
not bring it in, but then later for some reason there’s a biscuit in their
bag… It’s like with children, you need to repeat, repeat, and repeat“.
(Manager, sessional).
However, on the other hand, parents voiced that they often struggled with
ideas on what healthy foods could be packed for children’s lunches. Parents
often felt frustrated that preschools provide a list of foods which are not
recommended to bring to preschool, but not suggestions on what to bring in
packed lunches.
“When they start school, they give kind of information on what not to give
them for lunch, you know, not to give breakfast bars and stuff like that.
Ehm… but it was like a list of ‘don’t give this’ for their lunch, but they
didn’t actually have ‘what to give’ list, what you supposed to give, and it
would be helpful for parents because parents might give those things…
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[otherwise], they are like ‘What am I supposed to give then?’” (Mother of

4 year old, sessional).
Indeed, it appears that staff provide only general recommendations for packed
lunch contents:
“We do try to promote [healthy eating] and we tell them about healthy
lunches in the beginning of the school term, you know kinda, please try to
pack as much [healthy food] as you can and bring a healthy lunch, but I
still don’t think that deters them from pulling in the convenience food in
their lunch boxes” (Manager, sessional).
6.4.4 Observation of parent-staff communication
Direct observation of interactions between preschool staff and parents

occurring in preschool setting revealed that child nutrition-related
communication was infrequent. Consistent with parents’ and staff accounts,
the main interaction between providers and parents occurred during drop-off
and pick-up times when some parents inquired about child’s food intake
during the day in order to decide which foods and how much food to serve to
their children at home.
Drop-off time
At drop-off times parents and children were met and greeted by staff
and, after taking coats off in a changing room, children were brought to the
classroom. Most working parents seemed to be in a hurry to drop off their
children to go to work. If a parent and a child arrived late than or during
breakfast, the interaction was brief and a child was brought to the breakfast
table. Due to parents being in a hurry, there was limited time for parent-staff
communication during the drop-off time.
Pick-up time
At pick-up time, generally, the situation was more stress-free and
parents were more relaxed and open to communication than at drop-off time.
However, it seemed to be a busier time for staff. When parents arrived, staff
would inform the child and bring the child to the parents or, sometimes,
parents would observe or take part in the child’s activity for a short time. In
some cases parents would prefer to leave quickly. Often staff would give
217
drawings or crafts made by a child to a parent to bring home. In many cases,

staff were busy bringing children to their parents while looking after other
children and communicating with parents at the same time. Some staff
actively communicated with the child and their parent during the drop-off
situation, while others did not. In general, interactions between parents and
staff consisted of a few minutes of friendly conversation centred around the
child’s well-being, things a child did at preschool and occasionally food and
nutrition-related issues. When food was discussed, the most frequent topic
was a child’s food intake followed by the contents of the lunch box. Only on
one occasion a parent asked for nutrition advice. The nutrition-related
communication is presented in Table 6.2 and illustrates that parents and staff
did not always or often discuss food and nutrition during opportunistic times.
Table 6.2. Observation of nutrition-related communication between

parents and preschool staff
Type of Full-day-care Sessional To

preschool tal
Parent 1 2 3 4 5 6 7 8 9 10
Days of observation
Days 1 2 1 2 1 2 1 2 3 1 2 1 2 1 2 1 2 1 2 1 2 3 22
Discussed
child’s food √ √ √ √ √ √ √ √ √ √ √ 11
intake
Discussed the
contents of _ _ _ _ _ _ _ _ _ √ √ √ √ √ √ √ √ 8
lunch box
Staff actively
communicated
with the child √ √ √ √ √ √ √ √ √ √ √ √ √ 13
and their
parent
Parent asked
nutrition- √ 1
related
question
Staff conveyed
nutrition √ 1
educational
message
Parent asked
questions √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ 18
about child’s
general well-
being
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6.5 Discussion
The objectives of this study were to explore parents’ knowledge and

perceptions of preschool-aged children’s nutrition, explore the patterns of
preschool staff-parent relationship about children’s nutritional issues and to
identify needs and opportunities to support effective communication for
promoting healthy nutrition in preschool children.
Feeding is an essential part of parenting young children, yet various
positive food parenting skills are needed for shaping and maintaining
children's optimal nutritional status and healthy eating habits and ensure their
overall well-being (Fries & Van der Horst, 2019; Hughes et al., 2005; Savage
et al., 2007). Findings from Study 2 of this research project indicate that
preschool children's food preferences and perceptions are influenced by
familiarity with foods and parental modelling, supporting the importance of
positive food parenting. Evidence shows that better food parenting practices
at age 4 were associated with children’s healthy dietary behaviours at age 5
(Nguyen, 2019). According to food parenting constructs outlined by Vaughn
et al. (2016), positive food parenting practices include provision of optimal
structure in the food environment (rules and limits; monitoring; meal and
snack routines/scheduling; atmosphere of meals; no distractions; family
presence; modelling; food availability; food accessibility; and food
preparation) and autonomy support (reasoning/nutrition education; child
involvement; encouragement and praise; guided choices; and negotiation).
However, developing and maintaining positive food parenting skills is
challenging (Fries & Van der Horst, 2019). Parents in this study expressed
their concern about lacking knowledge on effective food parenting skills
when dealing with their children’s resistance to eating healthy food. The
study revealed several possible explanations for parents’ difficulties. Parents’
nutrition knowledge was generally limited, however the problem with
establishing healthy eating practices and routines in the home environment, in
other words, both structure and autonomy support, was a greater problem.
Parents’ lack of positive food parenting skills, parental daily life demands and
work schedules, and managing influences of external food environment on
children’s eating habits were among the challenges faced by parents in this
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study. These are common problems highlighted in other research on parents

of young children (Dev et al., 2017; Eli et al., 2016; Morin et al., 2013). The
use of controlling and permissive feeding practices by parents in this study
driven by their concern over making sure their children eat a sufficient
amount of food is similar to findings reported by previous studies (Loth et al.,
2018; Wolstenholme et al., 2019). Catering to children’s food preferences and
helping children to eat eased parental concerns over ensuring children’s
sufficient food intake. However, limiting the choice of foods to the ones that
children prefer can limit exposure to healthy and/or new foods (Savage et al.,
2007).
Time constraints were an important issue raised by most parents,
especially by working parents in this study. It was evident that busy daily life
and work schedules interfered with the ability of parents to create and
maintain healthy food environments. Similar to these findings, studies
reported competing daily demands and work schedules of parents with
preschool children as barriers to establishing routines that promoted healthy
eating habits (Devine et al., 2006; Penilla et al., 2017). A study by Morin et
al. (2013) examined the associations between the perception of self-efficacy
related to meal management and food coping strategies among working
parents with preschool children using a self-administered questionnaire. The
study found that high self-efficacy among working parents was associated
with planning a menu for the upcoming week, preparation of healthy meals
with only few ingredients on hand, and preparation of meals in advance,
which are home-based food strategies. Low self-efficacy was linked to
adoption of ‘away from home’ food strategies such as eating in fast-food
restaurants. Similarly, parents in the present study reported resorting to take-
away or convenience foods as a way of coping with a lack of time or energy
to cook food at home. Furthermore, due to time constraints the working
parents in this study voiced their concern of not being able to attend
training/information events conducted at educational settings because of
conflicting schedules. Therefore, strategies to improve the nutrition-related
communication between parents and preschool staff need to take into
consideration the context of parents’ daily life demands and responsibilities.
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On the other hand, in this study, there appears to be an inconsistency

between parents’ perception of lacking effective food parenting skills and
their reports of various practical solutions they use to cope with everyday
challenges of feeding young children. The possible explanation of this
dichotomy might be parents’ lack of confidence in their current knowledge
and low perceived self-efficacy. Research exploring the role of parental and
other caregivers’ self-confidence in practicing responsive feeding is limited
and need further investigation (Almaatani et al., 2017). The possible factors
influencing parental self-confidence in feeding their young children include
parents’ past experiences, family and social relationships, knowledge and
beliefs about food and feeding, and the responses of their children to their
feeding practices. For example, parents who had positive feeding experiences
as children, felt confident in their role as parents and in feeding their children
(Almaatani et al., 2017). The present study suggests that supporting parents in
developing skills and enhancing their confidence and self-efficacy for
effective food parenting could be beneficial. For example, organising
nutrition sessions for parents can serve not only for training of parents but
also as parental knowledge–sharing events that enable them to share their
everyday challenges and personal experiences of feeding their young
children, while sharing their own coping strategies with other parents may
enhance confidence in their own food parenting.
External food environmental influences on children’s eating habits
were cited as significant factors on children’s dietary habits in this study. It
was clear that parents’ efforts for ensuring good nutrition and shaping healthy
eating habits in children were likely to be undermined by influences from
other people such as other family members, especially grandparents, friends,
and the food served or sold outside the home. These competitive outside
influences that young children are exposed to on a daily basis may have a
significant impact on children’s food preferences and dietary choices
(Cruwys et al., 2015; Farrow, 2014; Osei-Assibey et al., 2012). The evidence
has shown that this issue can be addressed through the inclusion of the wider
family in nutrition interventions with the purpose of involving not only the
primary caregivers but also other family members in nutrition education and
encouraging reinforcement of key health concepts at home and within the
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extended family (Eli et al., 2016). The wider community interventions are
also warranted. Health-promoting interventions in restaurants (Ayala et al.,
2016; Crixell et al., 2014) and marketing approaches in supermarkets that
promote healthful food choices (Bucher et al., 2016) could have the potential
of supporting what is taught in schools regarding healthy eating behaviours
and require a system-wide health promotion interventions and inter-sectoral
collaboration. Overall, these findings highlight the complexity of factors that
can influence child’s feeding environment and need to be addressed
comprehensively.
While positive food parenting and home food environment are a
starting point for acquiring healthy eating habits, childcare settings provide
further opportunities for development of health-promoting behaviours and
self-regulation in children. The role of early years care and education has
evolved along with understanding of early childhood - from supporting
women’s workforce participation, compensatory programme for children with
special needs, and school readiness programmes – into a setting that has
become a facilitator of knowledge, skills, attitudes, and relationships around
children (Haiden, 2006). Thus preschool settings have a potential to become
significant players in health promotion within their communities. This role
represents an expanded focus of early childhood settings from being child-
centred to being family and community-centred (Haiden, 2006). Preschool
settings have a unique position to serve as a health-promoting setting for
families and a local community because they are easily accessible to parents
of young children and can offer effective outreach to the local community as
well. Therefore, to facilitate transfer of nutrition information between
preschool and home to support and promote healthy eating behaviours in
young children, communication is important. Furthermore, effective
communication can establish staff-parent partnerships to reinforce similar and
consistent opportunities for a healthy diet across two settings (Johnson et al.,
2013; McGrath, 2007). However, the present study revealed
miscommunication between parents and preschool staff although both sets of
caregivers recognise the importance of supporting healthy eating behaviours
in young children. The study’s findings showed that the information needed
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by parents was not provided by staff and practical advice on what food to
provide to preschool children was missing.
While preschool staff reported a lack of parental support, parents not
accepting or not following rules, parents serving unhealthy food at home, and
parents lacking health education, the need to support families was evident.
The findings showed that parents need support in preparing healthy food at
home, healthy lunch box choices, and effective food parenting skills. For
example, parents expressed the need for practical nutrition-related
information from preschools, specifically ideas for healthy foods they can
pack for their children’s lunches. The possible reason for this problem could
be an absence of a written lunch box policy in preschools, as staff gave verbal
recommendations to parents on lunch box contents. Therefore, written
communication with clear information about food choices that are both
recommended and restricted for children’s packed lunches could be one of
the ways to facilitate the implementation of information on healthy food
choices. However, as reported in findings from the Europe-wide Toybox
Study, simply providing parents with knowledge and information is not
adequate for change (Summerbell et al., 2012). Since unhealthy food and
‘treats’ are so abundant, available and integrated in daily contemporary life
and part of food culture, enforcing preschool healthy eating policies and
promoting positive health behaviours to families of young children is
challenging (McSweeney et al., 2016). Family-friendly healthy eating
strategies and activities (e.g. using nudge theory) need to be developed and
delivered by preschool settings in a manner that is sensitive to parents’
concerns (McSweeney et al., 2016). A systematic review of types of healthy
eating interventions in preschools concluded that in order to develop a
healthy eating intervention involving preschool children and their families, it
is recommended that both staff and parents should be involved in the design
of the intervention, with appropriate training and support given (Nixon et al.,
2012).
Other factors that hindered effective communication revealed in this
study were busyness of both parents and preschool staff during drop off and
pick up time. Parents did not engage in frequent nutrition communication
with preschool staff and, if they did, the topic of conversation was mostly
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centred around general well-being of a child. These findings are similar to

childcare providers’ reports in a study by Dev and colleagues (2017) that
parents were willing to discuss food issues such as food allergies but were
less likely to discuss nutrition-related topics such as healthy food offerings to
children. Therefore, the current study’s findings suggest that there is a need
for enhancing or intensifying nutrition-related communication between both
home and preschool settings to allow the continuity of care between the
settings. This is consistent with previous studies that have examined factors
related to child nutrition communication between parents and child care
providers (Johnson et al., 2013; McGrath, 2007). The present study took a
broader, health promotion stance to explore the current nutrition-related
processes occurring in the preschool setting. Health promotion is described
as: ‘a comprehensive social and political process; it not only embraces actions
directed at strengthening the skills and capabilities of individuals, but also
actions directed towards changing social, environmental and economic
conditions so as to alleviate their impact on public and individual health’
(Nutbeam, 1998, p. 351). Therefore, the present study suggests that if
preschools assume a position of health-promotion agents towards the families
they serve, this will empower and encourage the staff to more actively
communicate with and, moreover, engage the families in promotion of
healthy eating in preschools.
However, the current study found low engagement of parents in
preschool activities related to promotion of healthy eating habits, e.g.
preschool menu planning. The findings showed that, although preschool staff
acknowledged the importance of communicating with parents and wanted to
work with parents to promote healthy eating behaviours in young children,
parents had limited participation in preschool activities, particularly in those
related to preschool nutrition and the food environment. Similar to these
findings, McGrath (2007) argues that although both parents and staff desire
what is healthiest for children, agreement on best practice or even knowledge
about children’s food intake over the course of a day, may not be shared
between them. Research shows that involvement of parents in preschool
activities can promote better communication and partnerships between
parents and preschool providers (McGrath, 2007) and, the other way around,
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parent-provider partnership is a key component in increasing family

engagement (Lyn et al., 2014; McKelvey et al., 2013). Applying it to the
present study, better communication (e.g. about children’s food intake at
preschool) could enhance parents’ satisfaction with the preschool food
environment and practices in meeting the nutritional needs of their children,
and, in its turn, may help to improve relationships between preschool staff
and parents. As a starting point, staff can provide information (e.g. leaflets or
newsletters) and actively invite and involve parents in preschool’s nutrition-
related activities such as menu planning, cooking events, etc. For example,
parents, when engaged effectively, may participate in menu development and
act as advocates of good nutrition in the preschool setting (Larson et al.,
2011; Ward et al., 2017). The implication is that those parents who are not
interested in participating in preschool activities will not have the opportunity
to be heard. A model of the parental involvement process developed by
Hoover-Dempsey and Sandler (1995) suggests that parents' decision to
become involved in children's education are based on several constructs:
drawn from their own beliefs and experiences, such as (a) parent's
construction of their role in the child's life, (b) parents’ sense of efficacy for
helping their child succeed in school; as well as on other constructs growing
out of environmental demands and opportunities such as the general
invitations, demands, and opportunities for parental involvement presented by
both the child and the child's school (Hoover-Dempsey & Sandler, 1995).
Therefore, this model shows the importance of creating inclusive and
welcoming environments for parents in preschools that are responsive to the
diverse communities they serve. The current study’s findings indicate a clear
need to improve communication between preschool staff and parents and
create the opportunities for parental involvement in healthful nutrition
practices occurring in preschools. The results of a recent comparative case
study between high and low parental engagement childcare centres to identify
the factors influencing parents’ engagement in the ‘Healthy Me Healthy We’
health promotion campaign indicate that centres’ organisational
characteristics influenced parent engagement with health promotion efforts
(Luecking et al., 2020). High engagement centres presented a culture that
prioritised collaborating with parents and identifying new or different ways
225
for families to be involved. Low engagement centres expressed the feeling

like a “babysitting service” and wanting more parent engagement, yet their
efforts to involve parents comprised of one-way delivery of information
rather than invitations or actions to promote collaboration.
In the present PhD study, Study 1 revealed low work engagement and
lack of proactive behaviour in preschool staff due to staff perception of
limited scope to change the nutrition practices in preschools. This lack of
proactive work behaviour in staff may extend to low engagement in actively
working towards building relationships with parents. Furthermore, staff’s lack
of knowledge on how to communicate without offending parents, and
perception of limited time for communication with parents, appear to be
significant barriers in effective communication with parents. Thus, the
present study suggests that overall lack of motivating organisational structure
and processes in preschools to support relationships and shared power
between staff and parents could be an important barrier to supporting parents’
engagement with nutrition-related health-promoting efforts. Although
preschools serve a community with diverse social and cultural backgrounds,
it appears that preschool staff and parents do not frequently share information
about their needs, challenges or circumstances within which the families live.
Preschools’ approach to get more familiar with families’ culture,
circumstances, home environment and beliefs regarding health and nutrition
can help staff personalise communication with families (Slater et al., 2010).
This might be especially important for the migrant families or families whose
cultural background is different from that of the dominant society. These
families are often unable to access support from close relatives and need
knowledge about the services and supports available in the community and
opportunities to share their concerns (Hayden, et al., 2005). All families need
to feel empowered to take part in activities that could help them to develop
the resources to address their health and well-being needs. In this regard,
preschool settings can serve as health-promoting settings which they can rely
on for information and support. The settings approach to health promotion is
seen as a strategic way of implementing programmes aimed at encouraging
health-enhancing environments which address social determinants, increase
social capital and create opportunities for partnerships to foster health and
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well-being through awareness raising, support, developing trust between

people and engaging in activities of mutual benefit and of benefit to the
broader community (Baum, 1999). These could be fostered by the health-
promoting preschools through organizing more time for parents and staff to
interact, implementing effective information exchange procedures (including
using digital technologies), and encouraging parents to seek child nutrition
information from preschools. For instance, parents were interested in learning
easy and child-friendly recipes, positive child feeding strategies, meal
planning skills and appropriate portion sizes for their preschool-aged
children. Building on the needs of parents, staff can provide tailored
information (e.g. leaflets or newsletters) or organise training sessions for
parents on the topics of parents’ interests. This will require providing
technical support and training for staff on healthy nutrition and on fostering
their relations with parents (McGrath, 2007). This will also require better
communication with families to accommodate the appropriate time for
trainings.
In addition, identifying strategies that are perceived by parents as less
burdensome could be a practical solution. For example, with growth in
internet and smartphone use, digital technologies may provide the potential to
disseminate nutrition information to parents and facilitate communication
between preschool staff and parents (Zarnowiecki et al., 2020). There are
many early years care software available today for use for staff-parent
communication about a child’s day at preschool to share notices, events,
reminders, policies and messages and as a documentation tool using digital
daily sheets with meals, naps, activities, etc. (e.g. Himama, Brightwheels,
Tadpoles, Childpath.ie, etc.) and mobile applications such as Kaymbu,
Kangarootime, etc. The advantages of using these digital tools could be
improving family engagement with preschools and building family trust by
supporting transparency and visibility of child’s development and learning.
The study’s positive findings that could be leveraged upon for
improving two-way communication between parents and staff are mutual
interest in working together and parents’ being receptive to information
coming from preschools. Relationships between childcare providers and
parents were named a key precursor for parent engagement, signifying that
227
processes that initiate and nurture these relationships are important for
achieving the ultimate goal of engaging parents (Luecking et al., 2020). As
Elicker and colleagues (1997) proposed, in order to establish effective
partnerships between childcare providers and parents several relationship
characteristics such as mutual trust or confidence, frequent and open
communication, and respecting each individual’s share of competency or
knowledge are essential. Capitalising on these relationship characteristics
could be a starting point for parent-staff partnerships in preschools settings in
Ireland.
6.6 Study’s limitations and strengths
A limitation of this study is the low response rate from parents and the
relatively small sample size. However, the consideration of multiple
perspectives from different types of participants allowed for information-rich
data and deeper and richer findings, while using a mixed method design
helped to triangulate the findings. The observation of parent-staff interactions
may have been too short in duration for capturing the patterns of interactions.
However, to the author’s knowledge, this is the first study to explore
perceptions of parents of children attending preschool settings in Ireland and
to gain insights about parent-staff relationships and communication on
nutrition-related issues and findings from this study can inform future
targeted preschool setting-based interventions. The strength of this study is
the inclusion of parents and preschool staff as informants. Specific barriers
that were identified in this study would allow future research efforts to take
into consideration these factors when designing and implementing further
research and health-promoting programmes that include both childcare
providers and parents. The findings of this study warrant identifying effective
strategies that can be embedded and implemented in preschool settings to
facilitate staff and parents to work together to support healthy eating habits
among preschool children.
228
6.7 Conclusion
The current study’s findings suggest that there is a need to educate

parents on effective food parenting practices and meal-planning strategies,
especially when parents expressed their interest in such education. There is
also a need for improvement in communication between home and preschool
settings to promote parent-staff collaboration to effectively address children’s
nutrition-related concerns (e.g. promoting healthy eating behaviours) and
allow the continuity of care between the settings. In order to develop
solutions for increasing two-way communication and greater parental
engagement, specifically with nutrition-related health promoting practices,
the organisational context of preschool settings should be assessed and
restructured. The changes should include creating and maintaining mutual
trust, active and frequent communication and responsive relationships
between preschool staff and families, as well as preschool culture
(environment and attitudes) that actively invite parents to participate.
To achieve these goals, this study suggests that preschools require
embracing the role of a health-promoting setting that serves as a healthy
setting for all stakeholders – staff, children, families and the local community.
The view of childcare settings as health-promoting settings empowers and
encourages early childhood providers to acknowledge their responsibility as
health promotion agents and actively communicate with families to facilitate
a more active role for parents and community in the process of health
promotion (Hayden & Mcdonald, 2000).
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CHAPTER 7: GENERAL DISCUSSION AND CONCLUSIONS
In this final chapter of the thesis, a summary of key findings from the
three studies is presented in relation to the aims of this thesis. Further, an
integrated discussion of the studies’ findings in relation to a settings approach
to health promotion is presented and a conceptual map is described. Further,
implications for policy and practice are described followed by the study’s
strengths and limitations and recommendations for future research. The
chapter ends with drawing overall conclusions.
7.2 Addressing the study’s aims
The goal of the present study was to research the preschool setting as
it is defined and understood by the people who ‘learn, work and play’ in it
(Ottawa Conference Report, 1986). By observing and analysing the
participants’ perceptions and the context of the setting this study attempted to
identify the current needs, challenges and opportunities for creating
supportive environments to enable healthy nutrition for preschool children.
The research aims were to explore the food environment and nutrition
practices and understand the meaning of multiple participants’ experiences
within the everyday reality of preschool food-related routines and processes.
To achieve these aims the following research questions were posed in this
study:
1. What are current nutrition policies and practices in preschools (Study
1)?
2. How do preschool staff experience and manage food and mealtimes in

their services? (Study 1)
3. How do preschool staff perceive their role in promoting children’s

healthy diets? (Study1)
4. What are preschool children’s food preferences and their perceptions

about food and healthy eating? (Study 2)
5. Can creative research methods procure meaningful data from very

young children? (Study 2)
230
6. What are parent’s views and perceptions related to food and nutrition
for their preschool aged children? (Study 3)
7. Is there a relationship between preschool staff and parents for

promoting healthy eating for preschool children? (Study 3)
8. What are the needs, challenges, barriers and facilitators for promoting
healthy nutrition in preschools? (Studies 1, 2 and 3).
A multi-modal analysis of observational data, review of preschool

nutrition documents, preschool manager questionnaires, qualitative interviews
with preschool staff and parents, and children’s workshops facilitated
construction and refinement of interpretive themes which shaped the study
findings. Documenting and sharing these findings of evidence-based
knowledge provides the foundation for targeted interventions and to ensure
change is effective and sustainable.
7.3 Summary of studies and key findings
Three studies were carried out at ten preschools with different types of
service and food provision and with a mix of socio-economic background
among the study participants.
Attaining a holistic picture of the complex nutrition-related processes
occurring in preschool was pursued by gathering data from multiple
perspectives and from various sources. As a result, the study obtained rich in-
depth data regarding various factors influencing nutrition of preschool-aged
children attending early years care settings in Ireland. In particular, this
research has identified the opportunities in childcare settings to provide better
support for healthy eating at preschool settings and highlighted the needs,
challenges, barriers and facilitators to support healthy eating environments in
preschools.
Study 1 assessed preschool food environment and food practices and
explored staff knowledge, beliefs, perceptions and behaviours toward healthy
nutrition. The findings revealed that preschools lack robust and practical
healthy eating policies that could aid in implementing national nutrition
guidelines for preschools while there is an inconsistency in the use of existing
healthy eating policies resulting in an unsupportive nutrition environment.
231
Nevertheless, preschool providers demonstrated their motivation to provide

children with nutritious and balanced food and educate them about healthy
eating and several positive nutrition practices were observed. The childcare
providers’ recognition of their role in promoting healthy eating in children
and its potential impact on children’s health is key in preschool staff capacity
building (Bell et al., 2010). However, providers felt they were lacking in
nutrition training and expressed willingness to enhance their nutrition
knowledge. Educating staff in private childcare settings is particularly
important due to recent increases in attendance at these type of settings in
Ireland. The results indicate that preschool staff want more in-depth training
in nutrition covering topics such as the nutritional content of different foods;
portion sizes; appropriate duration of mealtimes; practical ideas for food
provision; and ideas for new recipes, especially healthy snacks. Findings from
interviews with study participants revealed convergence with findings from
analysis of nutrition-related documents and observation of the preschool food
environment and practices. However, unexpected findings were also revealed.
Preschool staff believed that a change in preschool nutrition practices was not
possible, mainly due to limited time in sessional settings. This result may be
underpinned by organisational context, including culture and leadership that
is not conducive to change, leading to low work motivation among preschool
staff. Finally, perception of families’ poor food habits and parental attitudes
created perceived challenges in the implementation of healthy eating practices
at preschools.
The latter finding corroborates with Study 3 findings. Parents,
although giving great importance to nutrition, are lacking nutrition
knowledge, particularly on portions sizes suitable for preschool-aged children
and nutrient content of foods. Parents identified numerous challenges in
providing nutritious food, specifically, child feeding challenges, time
constraints and external food environment influences. Parents also expressed
their concern about lacking knowledge on effective food parenting skills and
a keen interest in nutrition-related education. Therefore, it is evident that
there is a need to up-skill parents on positive and effective food parenting
practices. While parents expressed the need for nutrition-related information
from providers, inadequate and ineffective communication between parents
232
and preschool providers hampered a working relationship to support healthy

diets in children. In addition, parents were only minimally involved in
preschool nutrition activities. Therefore, the study’s findings indicate a need
for effective communication between staff and parents, active invitation of
parents to participate in preschools, creating opportunities for parental
nutrition training, and greater parental involvement in preschool nutrition
practices. A partnership between parents and staff could support healthy
eating habits in both preschool and home settings. For this purpose, the
organisational context of preschool settings needs further exploration.
Study 2 explored the perspectives of preschool children by giving
them voice to express their food preferences and their perceptions on food
and healthy eating. The creative research methods used in this study provided
meaningful data that adds to the literature on the types and usefulness of such
tools. It also provides justification for future work to expand and explore on
research approaches that actively involve young children rather than relying
on their caregivers.
Preschool children's food preferences and perceptions are influenced
by familiarity with foods and parental modelling. In addition, the sensory
appeal of food and emotions associated with food play a major role in
determining children’s food preferences. Understanding the concept of
healthy or unhealthy food begins in the preschool years corroborating with
the recommendations in the current literature that early, positive, and repeated
experiences with healthy foods are important for promoting healthy eating
among preschool children. This study showed that children as young as three
years of age recognise internal cues of hunger and satiety and self-regulate
food intake, however this ability is determined by environmental factors. The
study’s findings support the notion that feeding strategies should focus on
encouraging non-coercive food practices and helping children to exercise
self-regulation of food intake. Furthermore, the study’s findings show that
preschool children, including the youngest 3 year olds, prefer a variety of
food. As most parents report finding foods that children will eat as
challenging, the knowledge that preschool children like variety and choice in
foods may empower them to offer different foods and meals at mealtimes.
The study’s findings suggest that this can be combined with interventions in
233
preschools with inclusion of both taste and non-taste sensory elements to

familiarise children with a variety of healthy foods to promote acceptance of
novel foods and healthy eating in young children.
7.4 Study findings and the Settings approach
The study aimed to develop understanding of the preschool nutrition

environment and practices using the settings approach. Dooris and colleagues
(2007) suggested that the settings approach reflects an ecological model of
health promotion, is informed by systems thinking, and focuses on whole
organisation change through multiple interconnected interventions to improve
health and enhance productivity. As health promotion regularly addresses
complex issues, addressing them is also complex and requires action on many
levels (Fleming & Baldwin, 2020). In the present study, a preschool setting is
seen as a part of an ecological system that involves understanding the natural
dynamic within it. Fleming and Baldwin (2020) characterised this dynamic as
how different levels interact with each other, how public health problems are
generated and sustained as an outcome of the dynamic interactions among the
parts of a larger complex system; and how an intervention will bring about
systems-level change.
A review by Gubbels et al. (2014) indicated that studies using
traditional models that focus on either environmental or personal
determinants of behaviour fail to examine the interaction between
environmental types as well as between micro-systems in the field of
behavioural nutrition and physical activity. For example, studies into
determinants of children’s energy balance-related behaviours (EBRBs) have
almost exclusively been limited to examination of separate ‘micro-
environments’, e.g. focusing on the influence of either childcare or home
influences (Gubbels et al., 2014). Likewise, some socio-ecological
frameworks, although containing an integrated approach, but due to their
linearity, do not fully reflect the dynamic and reciprocal nature of the
multiple environments influencing children’s EBRBs (Mistry et al., 2012).
Larson and colleagues’ (2011) review of studies on environmental
determinants of EBRBs at childcare showed that the majority of the existing
234
studies reported on either child behaviour or the childcare environment,

failing to examine the association between both. The effectiveness of existing
interventions focusing on single determinants of health behaviour at childcare
may be limited by the moderating influences of other factors not taken into
account. Gubbels et al. (2014) argue that even though there is a growing
recognition of the multivariate and multilevel structure of determinants of
behaviour, the analysis often stops at listing or merely integrating these
determinants. For example, various studies attempted to apply an ecological
view by examining integrated multilevel lists of contributors to childhood
obesity (Boonpleng et al., 2013; Davison et al., 2013; Hawkins et al., 2009).
However, as authors noted, “integration is not synonymous to interaction.
The relationships between these contributors are often ignored in these
studies. By doing so, they disregard the assumption of interaction between
behavioural determinants that is right at the core of a true ecological
perspective…” (Gubbels et al., 2014, p.2). The authors concluded that
empirical studies operationalizing a true ecological view on EBRBs at
childcare settings, especially regarding dietary behaviour, are scarce and
studies are needed that integrate potential determinants at the environmental
level and the individual levels’ and examine interaction within and between
environments in order to move the field forward (Gubbels et al., 2014).
The present study illustrates the position of the preschool child and
the child’s nutrition within a dynamic embedded system of multiple inter-
related levels of influence that interact with and influence each other. Figure
7.1 integrates the findings from each study culminating in a Conceptual Map
of relationships and interactions within and between the settings in socio-
ecological systems that influence preschool food environment and nutrition
practices. The Conceptual Map illustrates the reciprocal relationships within
micro-systems (preschool staff and children or children and families) and
between micro-systems, or meso-systems, (preschool and home settings) and
the wider macro-systems (e.g. governed by local and national health and
nutrition-related authorities/the government). Building on the work of
Bronfenbrenner and other social–ecological models (Brofenbrenner, 1979;
Gubbels et al., 2014; Story et al., 2008), the Conceptual Map represents how
staff, children and their families’ nutrition-related perceptions, beliefs,
235
behaviours and practices are inter-related, interact and mutually influenced in

the context of the overarching systems. Furthermore, the Conceptual Map
(Figure 7.1) indicates the areas of action that need to be undertaken to
improve the food environment and nutrition practices in the preschool setting.
236
NATIONAL HEALTH POLICY
NATIONALNATIONAL
CHILDCHILD
POLICY
POLICY
NUTRITION POLICIES, NUTRITION AGENCIES
NUTRITION TRAINING
HEALTHY EATING POLICY
Communication GUIDELINES Communication
PRESCHOOL SETTING HOME SETTING
Preschool teachers’ role as a Healthy eating is important to
nurturer and provider of food parents and they recognise they
Figure 7.1.
Setting-based Conceptual Map knowledge;
PRESCHOOL SETTING Inclusion of parents in food- need more food parenting
HOME SETTINGskills;
of reciprocal relationships related activities in preschool;
related to preschool children’s Mealtime practices are positive nutrition education of parents Families’ food habits are poor
food and nutrition (supportive feeding practices; (e.g. time constraints, social
gentle and encouraging approach); influences);
Study’s findings Provision of a variety of healthy foods, supportive
feeding practices, water promotion,
Study’s nutrition education of children
recommendations
for improvement of CHILDREN
food environment and FACTORS INFLUENCING FOOD PREFERENCES AND PERCEPTIONS:
nutrition practices in familiarity with food; parental modelling; food variety;
preschool setting sensory appeal and emotions associated with food;
self-regulation of food intake
Parents’
An unsupportive nutrition
environment (lack of healthy eating
policies; challenges in menu Parents’ involvement, e.g., Inadequate and ineffective
planning; no water promotion); input into healthy eating communication between parents
policies and menus and staff
Limited scope to change nutrition
practices.
SOCIETAL AND SOCIAL INFLUENCES
EFFECTIVE COMMUNICATION
237
Within the preschool micro-system, preschool exerts influence on

children in the setting within which children live and participate in nutrition
activities while, in their turn, children exert their influence on the micro-
system’s operations. A similar pattern is seen in the family micro-system
where both children and parents mutually influence the food behaviours. The
present study’s findings indicate that familiarity with food and parental
modelling are key determinants of children’s food preferences and food
consumption, while children’s food preferences and perceptions influence the
caregivers’ food practices. Therefore, educating staff and parents on how to
be more encouraging and exhibit behaviours that lead to an increase in intake
of a variety of healthful foods would prove a useful component of a nutrition
intervention. The barriers to improving preschool nutrition identified at this
level are inadequate knowledge of staff about nutrition, healthy eating and
planning preschool menus, low awareness of available nutrition information
resources, staff perception of limited scope to change nutrition practices and
low work engagement. These barriers could be overcome with capitalising on
several existing facilitators including staff recognition of their important role
in promoting healthy eating behaviours in children and staff willingness to
further their nutrition education. Therefore, in addition to nutrition training,
enhancing staff sense of ownership and participation in preschool-level
decision making is needed to increase staff work engagement and to
maximise their involvement in improving preschool nutrition practices.
Preschool-level policy and leadership may also be an important factor in
determining beliefs and practices of preschool staff (Cooper & Contento,
2019). In family micro-systems, a lack of parental knowledge of nutrition and
effective parenting practices could be addressed by improving relationship
and communication with preschool staff and greater involvement in preschool
nutrition policies and activities.
At the meso-system level, frequent, active and effective
communication is essential to build relationships between staff and parents to
facilitate sharing of nutrition information between the preschool and home
and, furthermore, establish parent-staff partnerships to reinforce similar and
consistent opportunities for a healthy diet across settings (Johnson et al.,
2013; McGrath, 2007). Leverage could be gained from mutual interest in
238
working together and parents’ being receptive to information coming from

preschools. In addition, involving staff and parents in development and
revision of preschool healthy eating policies and menus may promote more
sustainable change in preschool nutrition practices.
Relating and interpreting the findings at these two levels, the present
research enables to see the nutrition-related processes occurring in the
preschool setting in a more holistic manner as this shows that many
components and processes are interconnected and mutually influence each
other. The study’s findings suggest that preschools’ organisational context
that is unconducive to change, lack of staff nutrition training and parents’
insufficient nutritional knowledge (which together are influenced by wider
system levels) lead to ineffective communication between staff and parents.
Moreover, parents’ lack of nutritional knowledge and poor dietary habits
predispose staff to place the blame on parents for children’s poor eating
habits as staff perceived that it interferes with their health promoting work.
Furthermore, staff perception of limited scope for change and low motivation
to communicate with families, on one hand, and complaints of parents for
inadequate nutrition information coming from preschools, on the other, lead
to missed opportunity to enhance nutritional knowledge of parents. This
miscommunication between preschool staff and families leads to less
collaboration in teaching children healthy eating behaviours. In addition, due
to insufficient nutrition and child feeding knowledge, both sets of caregivers
have challenges in implementing and maintaining supportive child feeding
practices at both settings. For example, caregivers do not duly acknowledge
children's positive capabilities such as children's ability to self-regulate their
food intake and their preference for food variety and, therefore, do not
adequately support and promote these positive eating behaviours in children.
Nevertheless, the present study has also revealed positive findings that can be
built upon in future preschool setting based nutrition-related health promotion
work – both staff and parents’ desire to further their nutrition knowledge and
improve communication in order to promote healthy eating behaviours in
preschool children.
The Conceptual Map (Figure 7.1) illustrates that it is important to
target not only preschool staff who are responsible for ensuring that preschool
239
children are consuming adequate and healthful foods but also multiple
influences that are impacting or have a potential to impact preschool food
environment and nutrition practices such as preschool children themselves
and their families, health and nutrition professionals, the wider community,
and the environment and policy level factors. Since all these determinants
contribute to the preschool setting’s context and operations, they need to be
taken into account for preschool nutrition interventions to be effective.
Particularly, the changes that are made at the macro-system or policy level
are likely to have the greatest impact. The study findings indicate that, in
order to address the current needs and challenges faced by preschool staff and
parents at both micro- and meso-system levels, several changes are needed to
be implemented at the macro-system level. At present, vague preschool
nutrition regulations, insufficient nutrition training for preschool staff, and
staff poor terms and conditions of employment, particularly in private
preschools, act, among other influences, as macro-system level barriers to
promotion of healthy nutrition in preschools. Capitalising on recent increased
recognition and therefore funding of the ELC sector as the greatest facilitator
at this level, some of the proposed changes include introducing systematic,
on-going quality-assured training on nutrition and feeding practices which
delivers evidence-based and up-to-date information to preschool providers
and families; revision of current guidelines for healthy eating policies for
preschools; and developing and implementing the initiatives for supporting
effective involvement, engagement and communication within and between
all levels of socio-ecological system related to preschool nutrition. These
require more effective use of government-allotted resources by allocating
them in the sector’s priority areas, including preschool nutrition-related
initiatives.
This study’ findings highlight the complexity of determinants
influencing food environment and nutrition practices in the preschool setting,
therefore suggesting that action and collaboration is needed from stakeholders
at all levels (e.g. government, ELC sector, preschools, academia, families).
WHO describes this notion of collaboration as follows: health promotion has
come to represent a unifying concept for those who recognise the need for
change in the ways and conditions of living in order to promote health. Health
240
promotion represents a mediating strategy between people and their

environments, synthesising personal choice and social responsibility for
health to create a healthier future (WHO, 1984). For example, collaboration
between health promotion professionals, researchers and policy makers is
needed for a concerted effort for developing more comprehensive evidence-
based healthy eating policies, and the implementation of such policies. In
addition, a combined approach to include administrative, structural,
organisation development and behavioural strategies need to be applied that
will involve advocating for increased funding or re-orienting the use of
existing funds for improvement of current nutrition practices in the preschool
setting in Ireland.
In practical terms, the activities suggested in the Conceptual Map
include reshaping policies and environments, developing personal
competencies, bringing about sustainable change through inclusive
participation and building partnerships, and thus developing empowerment
and ownership of change throughout the setting and between settings. These
activities reflect the principles underpinning Five Areas of Action for Health
Promotion identified by the Ottawa Charter (WHO, 1986). The Diagram in
Figure 7.2 illustrates how these action areas could be applied in future
interventions or programmes for promotion of healthy eating in the preschool
setting based on the findings from the present study.
241
Figure 7.2. Applying the Creating supportive

Ottawa Charter’s 5 Action environments
Areas for Health Promotion Re-shaping preschool
to nutrition-related issues in nutrition environment
the preschool setting and practices;
organisational change
Micro-systems
PRESCHOOL HOME
Strengthening
Developing personal skills CHILDREN
Staff's supportive feeding
community action
Children’s food preferences
practices, nutrition Effective communication
and perceptions
education of staff, children, between families and
Preschool staff’s Feeding challenges preschool staff, improving
parents at home and social
nurturing role; inclusion and involvement
Positive mealtime influences;
practices; an Parental need for
unsupportive sharing knowledge
nutrition; and feeding
environment; Need strategies;
for further nutrition Ineffective
training; Limited communication
scope to change between parents
nutrition practices. and preschool staff.
Meso-system
Building healthy public policy Revision of

Healthy Eating Policy (HEP) guidelines;
Re-orienting health services
greater support of implementation of toward Health promotion
existing HEP guidelines; formal accredited Strengthening partnerships Macro-system
staff training; sector-wide changes for with health/nutrition and
improving T/C of employment; effective other specialists
funding and resource allocation
242
One of the Charter's strengths is that its action areas form an

interlinked conceptual framework where the action areas are interactive and
interdependent processes acting in mutually contributing and reinforcing
ways. Engagement with multiple action areas increases the likelihood of
achievement within each action area (Fry & Zask, 2017). This
interdependence between the Charter's action areas suggests that applying
most if not all of the five action areas is likely to increase effectiveness and
overall benefits of a programme if they are mutually supportive (Jackson et
al., 2006; Saan & Wise, 2011).
The present study has investigated the individual, setting and
community components of this ‘whole’ interrelated system and identified
current barriers and facilitators for promoting healthy eating in the preschool
setting. To achieve viable outcomes, it is important to consider pragmatic
concerns of the setting and use flexible and realistic strategies that are built
on the setting’s existing structures and practices and tailored to the setting’s
priorities and specific circumstances (St Leger, 1997; Whitelaw et al., 2001).
This also requires using negotiation and interaction between the system’s
components to achieve the ‘whole organisation change’ (Grossman & Scala,
1993; Ham & Hill, 1995; Paton et al., 2005). In the present study, using the
settings approach, which is based on ‘whole system thinking’ (Pratt et al.,
2005) and focused on ‘whole organisation change’ (Grossman & Scala,
1993), helps to recognise the settings’ actual needs and challenges in its
physical, social, and organisational environment. This way the preschool
setting is viewed as a potential environment for delivering health-promoting
interventions with a range of possible actions and potential channels for
enabling and reinforcing the preschool setting’s nutrition-related practices
supported by the setting’s current strengths and opportunities. From this
perspective, therefore, the concept of a preschool setting as an optimal health
promotion setting for supporting healthy eating behaviours and practices is
supported by this study, the preschool setting being the epicentre of the
change.
243
7.5 Implications for policy and practice
The socio-ecological conceptualisation of nutrition-related

processes in the preschool setting developed in this study suggests a wider
range of health promotion actions, beyond individual behaviour change
toward systems and policy level approaches, thus representing the settings
approach within health promotion practice. A settings approach that
involves system thinking could potentially have a greater influence
through multiple interconnected interventions to promote and enhance
healthy nutrition behaviours in the preschool setting.
This research is one of the first steps to provide evidence for in-
depth understanding of nutrition-related processes in Irish preschool
settings. The present study fulfilled the need to understand determinants of
preschool nutrition at individual, setting, and community levels which are
basic components of a socio-ecological system related to nutrition in the
preschool setting. This information will ultimately form the building
blocks of a systemic approach to improving and promoting healthy eating
in preschools at all levels. In addition to this, considering the interplay of
determinants and their relationships to one another adds to the depth of
understanding of barriers and opportunities currently present in the
preschool setting, ultimately supporting future intervention development in
this area. Identifying the evidence-based determinants of preschool
nutrition environment and practices in this study allows for development
of targeted interventions aimed at increasing consumption of adequate
healthful diets and promoting healthy eating habits in preschool children,
which not only ensures addressing barriers and facilitators to healthful
nutrition behaviours but also as efficient as possible use of time and
resources.
The following priorities and recommendations can be made based
upon the findings of this research and are outlined below:
• Comprehensive and practical healthy eating policies are needed for

preschools that address the current needs and challenges in providing
children with optimal nutrition while in childcare.
244
• Policies need updating to incorporate best practices, such as family

style meal service.
• Specific guidelines on packed lunches for preschools in Ireland are

needed.
• Written communication on food(s) that are recommended or not

allowed for children’s packed lunches should be developed between
preschool staff and families.
• Formal, systematic, and accredited nutrition training for childcare

providers as part of on-going professional development should be
introduced. Training should include practical skills related to child
feeding, menu/snack planning, and effective communication.
• To enhance two-way communication between parents and preschool

staff a range of initiatives, using both bottom-up and top-down and
collaborative approaches, are required. Frequent and open
communication between providers and families based on mutual
respect for each other’s competency or knowledge and creating a
welcoming environment for families should be encouraged.
• The study findings indicate that future nutrition interventions

implemented in the preschool setting should be based on a systems
approach and involve parents to enhance positive parenting practices,
including positive food parenting, to promote the continuity of care
between the two settings and to increase the preschool-based healthy
eating interventions’ effectiveness and sustainability.
• The study’s findings suggest that nutrition interventions with preschool

children as well as regular classroom nutrition education activities
should include both taste and non-taste sensory elements to familiarise
children with a variety of healthy foods to promote acceptance of
novel foods and healthy eating in preschool children.
245
7.6 Study’s strengths and challenges
The strength of this study is the consideration of multiple

perspectives from different types of participants and applying multi-
method mixed method design which allowed a holistic exploration of
factors that influence preschool nutrition. An additional strength of this
study is that using a mixed method design helped to triangulate the
findings and allowed for information-rich data and deeper and richer
findings. Triangulation also allowed for unpredicted and interesting
findings that were not considered previously. However, the integration of
findings obtained from various sources and through multiple research
methods was challenging, therefore a number of strategies were
undertaken to ensure that the analyses were rigorous and met the criteria of
credibility, transferability, dependability and confirmability.
7.7 Recommendations for future research
Recommendations for future research based upon the findings of

this research are:
• As the study’s findings show the importance of the regulatory
background in the Irish preschool setting, future studies should include
the perspectives of policymakers, administrators and other
representatives from governmental and non-governmental
organisations that regulate and inspect childcare settings.
• Findings from this study emphasise the value in taking a bottom-up

and collaborative approach with preschool staff. Participatory action
research with preschool staff to improve the food environment and
nutrition practices in preschool setting is needed. This approach could
promote staff sense of ownership and participation in preschool-level
decision making while also enhancing staff compliance with future
programme interventions or changes to current practices.
• Further research on organisational structure and work climate in the

preschool setting and their effect on staff attitude toward work and
participation in preschool-level decision making is needed.
246
• Since family style meal service (FSMS) is widely recommended as a

best practice for feeding children in preschool settings due to its many
benefits, its use and effectiveness in practice in the Irish context needs
to be investigated.
• Ethnographic studies to explore children’s mealtimes in Irish preschool

settings are warranted to more fully understand influences on staff
feeding strategies and children’s eating behaviours and further explore
the agency of all participants during mealtimes.
• Further research on the use of creative research methods with

preschool-aged children is needed.
• Research on effective ways that could facilitate staff and parents to

work together to support child healthy eating habits among preschool-
aged children is needed.
• This study did not explore other influences on preschool and home
settings, for example the influence of health or nutrition professionals,
on nutrition knowledge and feeding practices of preschool staff and
parents, therefore these need to be further investigated.
7.8 Conclusions
This research explored the food environment and nutrition

practices using a qualitatively-driven mixed method approach and is the
first of its kind to be applied to the preschool setting in Ireland. The study
has provided a holistic picture of the complexity of the nutrition-related
processes in Irish preschool settings. Although interventions using
multiple strategies at multiple levels and sectors are most effective, the
knowledge of the local context and implementation drivers and barriers is
critical for their feasibility and sustainability. Therefore, identifying and
understanding the barriers and facilitators for promoting healthy eating in
the preschool setting at a local level is an important prerequisite for
making sustainable changes. The study findings highlight the need for
nutrition training for preschool providers as part of on-going professional
247
development. The findings highlight that the importance of the nutrition

education’s role should be enhanced and valued, which could lead to a
more effective home-preschool relationship. This research emphasises the
need to identify effective ways for enhancing two-way communication
between preschool staff and families and creating the opportunities for
greater parental involvement in preschool nutrition practices in order to
improve coherence and consistency of feeding practices of all caregivers,
to support preschool children’s optimal diets and healthy eating habits.
The Map developed for this study presents the conceptualisation of
nutrition-related processes currently occurring in the preschool setting to
help understand the complex interplay between the determinants within
the socio-ecological system related to preschool child’s nutrition. The
Conceptual Map outlines key action steps/areas within the framework and
the underlying empirical evidence. It may therefore guide the design of
future nutrition intervention studies targeting preschool settings by
ensuring that evidence-based determinants are being targeted with the aim
of increasing their effectiveness and overall impact and inform
investments in early childhood programmes and policies.
248
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Appendices
Appendices
Appendix 1:
Ethics Committee Approval Letter and Statement of Compliance
316
Appendices
317
Appendices
Appendix 2:
Preschool Recruitment Letter
Saintuya Dashdondog
Health Promotion
NUI Galway
University Rd
Dear _______________,
My name is Saintuya Dashdondog. I am a PhD student at NUI Galway, under the supervision
of Dr. Colette Kelly (Lecturer in Health Promotion and Registered Nutritionist) and I am
studying what influences preschool children’s eating habits.
I would like to invite you and the children in your care to take part in my project. I would
really appreciate engaging in some fun and interactive workshops with children in your
preschool. I would also like to interview you or a member of your staff and some of the
children’s parents. The information sheet I have attached explains what my research is
about, exactly what is involved, and how your staff, children, and parents at your preschool
will benefit from taking part.
If you have any further questions in relation to the project, please do not hesitate to contact
me at the contact details below. In addition, I am happy to discuss alternative ways of
running the project in your preschool if you have any ideas of how we could do things
differently to make it work best for you. I will follow this letter up with a phone call next
week to see if you are interested in participation and answer any questions you may have.
I greatly appreciate your time spent reading this letter and I am looking forward to talking to
you further.
Kindest regards,
Saintuya Dashdondog
Email: [email protected]
Phone: 0899671435
Supervisor: Dr. Colette Kelly
Email: colette. [email protected]
Phone: 091493186
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Appendix 3:
Participant Information Sheet
PARTICIPANT INFORMATION SHEET
A Research project investigating determinants of eating patterns among preschool children
Introduction
I would like to invite you to participate in this project, which is intended to explore the nutrition
environment in preschool. I am interested to know your opinions about the food practices at
preschool.
Why am I doing the project?
The project is part of my PhD programme at NUI, Galway. It is hoped that the project could help us
to understand children’s eating patterns and explore ways to improve them.
What will you have to do if you agree to take part?
1. We will arrange a time to meet, which is convenient for you and in a place
convenient to you.
2. There will be one, single interview with myself during which I will ask you questions
regarding your views about food practices at the preschool. The interview is
expected to last approximately 30 minutes and is a one-off event.
3. I would be interested in looking at your preschool’s nutrition policies and observing
the meal times at your preschool.
4. I would like to invite the children in your care to take part in a workshop to explore
their perceptions about food and nutrition.
5. Parents of children attending your preschool who give their consent to participate in
the study will be invited for interviews which will contain questions about food
practices in children’s homes.
6. It will take total 2 days for two hours each day of study activities at your preschool.
7. When I have completed the study I will produce a summary of the findings which I
will be more than happy to send you, if you are interested.
Will your participation in the project remain confidential?
If you agree to take part, your name, names of other participants, and the name of the preschool will
not be disclosed to other parties. All data collected will be kept strictly confidential and used for
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research purposes only. The interview will be recorded on audio tape which will be destroyed at the
end of the study. You can be assured that if you take part in the project your name and the name of
the preschool will not be used in publications.
What are the advantages of taking part?
You may find the project interesting and enjoy answering questions regarding mealtime practices at
preschool. You will be provided with a list of relevant services and resources that may be of benefit.
The interactive workshop will be fun and enjoyable for children and they may learn more about
healthy eating by participating. Once the study is finished it could help us to understand children’s
eating patterns and explore ways to improve them. If you would like a copy of the findings please
email me on [email protected].
Are there any disadvantages of taking part?
It could be that you are not comfortable talking about food practices at preschool.
Do you have to take part in the study?
No, your participation in this project is entirely voluntary. You are not obliged to take part, you have
been approached as a member of the preschool staff with a view that you might be interested in
taking part; this does not mean you have to. If you do not wish to take part you do not have to give a
reason and you will not be contacted again. Similarly, if you do agree to participate, you are free to
withdraw at any time during the project if you change your mind.
Who do you contact for more information or if you have concerns?
If you have any questions, concerns or complaints about the study at any stage, you can contact:
Saintuya Dashdondog – Researcher Dr. Colette Kelly – Lecturer

Tel: Tel:
Email: [email protected] Email: [email protected]
What happens now?
I will call you to discuss any questions before you decide. If you are interested in taking part in the
study we can arrange to meet at a time that is convenient for you. I can then visit and hold the
interview.
Thank you for taking time to read this Information sheet and please do not hesitate to contact me if
you need further information.
Kind regards,
Saintuya Dashdondog
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About the researcher
List of useful services and resources:
www.safefood.eu (Factsheets and advice)
www.healthpromotion.ie (Factsheets and advice)
Hello, my name is www.childfeedingguide.co.uk (Child feeding guide)

Saintuya. I work at the National
University of Ireland Galway. I am www.tusla.ie (Family support services)
doing a project on what preschool www.indi.ie (Irish Nutrition and Dietetic Institute)
staff and children and their parents
think about food and mealtimes. I
would like you and children in your
care to help me with the project by
taking part in an interview and fun-
Email Saintuya with any questions:
filled workshop for children. [email protected]
If you have any concerns about this study and

wish to contact someone in confidence, you may
contact:
The Chairperson of the NUI Galway Research

Ethics Committee, c/o Office of the Vice
President for Research, NUI Galway,
[email protected]
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Appendix 4:
Letter Inviting Parents for Their Child to Participate in the Project
LETTER INVITING PARENTS FOR THEIR CHILD TO PARTICIPATE IN THE PROJECT
Saintuya Dashdondog
NUI Galway
University Rd
Galway
Dear Parent,
I am writing to invite your child to take part in my research project about food and
nutrition at preschool. If you accept this invitation, your child will participate in some
games and activities at the preschool to explore their thoughts and ideas about food and
nutrition. The session with children will be fun and enjoyable and they may learn more
about healthy eating by participating.
I have enclosed the information sheet so you can read more details about the activities I
have planned for the children. I will be in contact again over the next week or so to
confirm whether or not you would like your child to participate.
Kind regards,
Saintuya
Phone:

Phone:
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Appendix 5:
Parent Information Sheet on Children’s Workshop
PARENT INFORMATION SHEET ON CHILDREN’S WORKSHOP
A Research project investigating determinants of eating patterns among preschool children
Introduction
I would like to invite your child to participate in this project, which is intended to explore the
nutrition environment of preschool children. I am interested to know children’s thoughts and ideas
about food and nutrition.
Why am I doing the project?
The project is part of my PhD programme at NUI Galway. It is hoped that the project could help us to
understand children’s eating patterns and explore ways to improve them.
What will we talk about?
Things I would like to talk about with your child are their opinions and beliefs about the things they
eat, their food likes and dislikes and the way they eat.
What will you have to do if you agree to take part?
Return the Parent Consent Form to the preschool so that I know you are interested.
1. There will be an interactive workshop (games and activities) for children at the preschool which is
expected to last no longer than an hour and is a one-off event.
2. When I have completed the study I will produce a summary of the findings. If you would like a
copy of the findings please email me on [email protected].
Will your participation in the project remain confidential?
If you agree to take part, the name of your child will not be disclosed to other parties. All data
collected will be kept strictly confidential and used for research purposes only. The answers will be
recorded on audio tape which will be destroyed at the end of the study. You can be assured that if
your child takes part in the project his or her name and the name of the preschool will not be used in
any material related to the study findings.
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What are the advantages of taking part?
The workshop activities will be fun and enjoyable for children, including interactive and art-based
activities. The activities will be delivered in a manner allowing children to critically think about an
issue and offer their own solutions. In addition, children may learn more about healthy eating by
participating. Once the study is finished it could help us to understand children’s eating patterns and
explore ways to improve them. You will receive a report, if interested.
Are there any disadvantages of taking part?
It could be that the child is not comfortable talking about the food practices at preschool or at home.
Does your child have to take part in the study?
No, the participation of your child in this project is entirely voluntary. If you do not wish your child to
take part you do not have to give a reason and you will not be contacted again. Similarly, if you do
agree to participate, you are free to withdraw your child’s participation at any time during the
project if you change your mind. Children can also decline to participate if they wish. Any children
who do not have parental consent will not feel left out and can still participate in the activities,
however their responses will not be included in the project’s data.
Who do you contact for more information or if you have concerns?
If you have any questions, concerns or complaints about the study at any stage, you can contact:
Saintuya Dashdondog – Researcher Dr. Colette Kelly – Lecturer

Tel: Tel:
Email: [email protected] Email: [email protected]
What happens now?
If you are interested in your child taking part in the study you are asked to complete the attached
consent form and return it to preschool. Once I have received the consent form I will ask your child’s
assent to participate.
Thank you for taking time to read this Information sheet and please do not hesitate to contact me if
you need further information.
Kind regards,
Saintuya Dashdondog
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About the researcher
List of useful services and resources:

Kind regards,
www.safefood.eu (Factsheets and advice)
www.healthpromotion.ie (Factsheets and advice)

Saintuya Dashdondog
Hello, my name is www.childfeedingguide.co.uk (Child feeding guide)
Saintuya. I work at the National
University of Ireland Galway. I am www.tusla.ie (Family support services)
doing a project on what children and www.indi.ie (Irish Nutrition and Dietetic Institute)
their parents think about food and
mealtimes. I would like your child to
help me with the project by taking
part in a fun-filled workshop at the
preschool.
Email Saintuya with any questions:
[email protected]
If you have any concerns about this study and

wish to contact someone in confidence, you may
contact:
The Chairperson of the NUI Galway Research

Ethics Committee, c/o Office of the Vice
President for Research, NUI Galway,
[email protected].
325
Appendices
Appendix 6:
Parent Consent Form for a Child
Project: “Determinants of eating patterns among preschool children”

Researcher: Saintuya Dashdondog
Centre: School of Health Sciences, NUI Galway
PARENT CONSENT FORM: CHILD INTERVIEW
Please circle:
I confirm that I have read the information sheet for the above study Yes No
and have had the opportunity to ask questions
I am satisfied that I understand the information provided and have Yes No

had enough time to consider the information as well as any risks
and benefits associated with taking part
I agree for my child to be observed by a researcher and asked Yes No

questions
I understand that my child’s participation is voluntary, he/she will Yes No

be given the option to take part, and can withdraw at any time,
without giving any reason and without our legal rights being
affected.
I agree for my child, if he/she wishes, to take part in an interview Yes No

at school as part of this project.
Name of Child: ____________________
Signed: __________________________ Date:

(Parent/Guardian) ____/____/____
Researcher: ______________________ Date:

____/____/____
1 copy for parent, 1 copy for researcher
Contact:
Saintuya Dashdondog,
School of Health Sciences, NUI Galway
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Appendices
Appendix 7:
Child Information Sheet and Child Consent Form (3-5 Years)
CHILD INFORMATION SHEET AND CONSENT FORM
(Note: This will be read by a parent to a child and discussed with a child prior to the interview)
Project: Determinants of eating patterns among preschool children
Hi, my name is Saintuya. I work at the National

University of Ireland Galway. I am doing a
project on what children think about eating. I
would like you and your friends to tell me about
the food you eat at preschool. Would you like to
help?
❖ If you would like to help me with the project, I will come to your preschool to talk
with you about food and eating. If you like, we can also do some drawing and
games.
❖ I will have a tape-recorder so that I can remember what we talked about later. But
don’t worry – everything will be kept private. Your name will not be used, so no-one
will know you took part.
❖ Hopefully you will have fun! We might learn something new. Maybe the project will
help other children and families in the future.
❖ If you feel annoyed or upset while chatting to me, you can stop any time. You can
talk to me or a teacher in your preschool about how you are feeling, or just do
something else instead like reading a book or drawing a picture.
❖ If you have any questions about the project, please ask your teacher, or ask me next
time I am in your preschool. I am looking forward to chatting to you and the other
children in your class!
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Appendix 8:
Parent Interview Invitation Letter
PARENT INTERVIEW INVITATION LETTER

Saintuya Dashdondog
NUI Galway
University Rd
Galway
Dear Parent,
I am writing to thank you for accepting the invitation for your child to participate in my
research project “Determinants of eating patterns among preschool children”.
I would also like to invite you to come and talk to me about your thoughts and opinions of
your child eating habits at preschool and in the home, and what you think about any
support or advice that you may have received or would like to receive to improve children’s
nutrition.
I have enclosed the information sheet so you can read more details about the interview. I
understand the limited time that parents have, and the difficulties involved with organising
childcare. I would be happy to meet you in your child’s preschool, at the NUI Galway School
of Health Sciences, or in your home, whichever is most suitable for you. Please contact me
at [email protected] to arrange a meeting place and time. I will be in contact
again over the next week or so to confirm whether or not you would like to participate.
I look forward to meeting you and talking to you further.
Kind regards,
Saintuya
Phone:
Phone:
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Appendix 9:
Parent Consent Form
Project: “Determinants of eating patterns among preschool children”

Researcher: Saintuya Dashdondog
Centre: School of Health Sciences, NUI Galway
PARENT CONSENT FORM
(To be completed with the researcher at the beginning of the interview)
Please circle:
I confirm that I have read the information sheet for the above study Yes No
and have had the opportunity to ask questions
I am satisfied that I understand the information provided and have Yes No

had enough time to consider the information as well as any risks
and benefits associated with taking part
I understand that my participation is voluntary and that I am free to Yes No

withdraw at any time, without giving any reason, without my legal
rights being affected
I agree to participate in an interview as part of the above study Yes No
Name: ________________ Signed: _________________ Date:

(Parent/Guardian) ____/____/____
Name: ________________ Signed: _________________ Date:

(Researcher) ____/____/____
1 copy for participant, 1 copy for researcher
Contact:
Saintuya Dashdondog,
School of Health Sciences, NUI Galway

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Appendices
Appendix 10:
Short questionnaire on participant’s socio-demographic data
QUESTIONNAIRE FOR PARENTS
1. GENDER FEMALE  MALE 
2. AGE 20-30  31-40  41-50  51-60


3. EDUCATION PRIMARY 
SECONDARY 
COLLEGE/UNIVERSITY 
POSTGRADUATE DEGREE 
4. DO YOU HAVE A YES  NO 

MEDICAL CARD?
5. NUMBER OF 
CHILDREN
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Appendix 11:
Preschool Observation Tool
Preschool Code No. __________________

Date ____________
Mealtime: Breakfast______ AM snack______ Lunch______ PM snack_______
Observation of mealtimes
How was meal served?
□ Family style
□ Delivered and served in prepared portions
□ Delivered in bulk and portioned by staff
□ Provided from home in a lunchbox, bag or other container
□ Was food offered to children consistent with the menu of the day?
□ Were age-appropriate feeding and drinking utensils available for of children?
□ Did staff offer an appropriate amount of food for children to eat?
□ Were children able to eat as much or as little as they want to?
□ Did staff serve children seconds without being asked for more by the child (see an empty
plate and add food without request by child)?
□ Did at least one staff sit with children during lunch?
□ Were there appropriate seats for providers so to enable them to sit with children?
□ Did all children wait to eat until all have plates of food?
□ Did staff consume the same food as children?
□ Did staff eat and/or drink less healthy foods in front of children?
If yes, what? ______________________________________________________________
_________________________________________________________________________
□ Was adequate time allocated to feeding times?
If not, how was it? _________________________________________________________
_________________________________________________________________________
□ Were children allowed to leave the table before all children are finished eating?
□ Did cleaning of dishes begin before all children are finished eating?
□ Did children participate in meal (laying cutlery, serving, cleaning up etc.)?
If yes, how? _______________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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Interactions between preschool staff and children during mealtimes

□ Were mealtimes carried out in a positive and relaxed atmosphere?
If not, how was it? __________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
□ Were children actively encouraged to feed themselves?
□ Were children allowed to eat at their own pace or are they told to hurry and helped to eat to
speed up the process? If not, how was it done?_____________________________________
___________________________________________________________________________
___________________________________________________________________________
□ When children eat less than half of a meal, did staff ask if they are full before removing
their plate? _________________________________________________________________
How was it? ________________________________________________________________
___________________________________________________________________________
□ When children request for seconds, did staff ask them if they are still hungry before serving
more food? ________________________________________________________________
How did staff behave? ________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
□ Did staff encourage children to eat new and less preferred foods?
If yes, how? ________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
□ Did staff praise children when they eat all their food?
□ Was food and nutrition discussed at a mealtime?
If yes, what? ________________________________________________________________
___________________________________________________________________________
□ Did staff talk with children about healthy/unhealthy foods?
If yes, what? ________________________________________________________________
___________________________________________________________________________
□ Did staff teach children nutrition and/or food concepts?
If yes, what? ________________________________________________________________
___________________________________________________________________________
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□ Did staff use food as a reward and/or was food withheld as a punishment?
If yes, how? ________________________________________________________________
___________________________________________________________________________
□ Did children refuse to eat food and, if yes, how was it handled by the staff?
___________________________________________________________________________
___________________________________________________________________________
□ What actions if any do staff take when food brought from home does not meet nutritional
standards?
___________________________________________________________________________
___________________________________________________________________________
Observation of drinking water access and consumption

□ Was drinking water for children available during mealtimes?
□ Was there a visible jug/bottle of water at a water station in each preschool room?
□ Was drinking water easily accessible to children to serve themselves?
□ Did staff ask children if they were thirsty between meal and snack times?
□ Did staff offer drinks to children between meal and snack times?
□ Did children ask for water between meal and snack times?
□ Did staff model drinking water?
Notes: ___________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Observation of preschool physical environment
Images in the environment
□ Were any posters, pictures or displayed books about nutrition present in the classroom?
If yes, what? ______________________________________________________________
□ Were food-related education materials visible in hallways and corridors?
If yes, what? ______________________________________________________________
□ Were any posters, pictures or stickers about nutrition present in the hallways or other areas?
If yes, what? ______________________________________________________________
□ Were there stickers and posters encouraging hand washing visible in all rooms?
_________________________________________________________________________
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□ Were there stickers or posters encouraging regular consumption of drinking

water/encouraging staff to offer water to children between meals and snacks?
If yes, what? ______________________________________________________________
_________________________________________________________________________
Books
□ Were there books related to food/nutrition/healthy eating in classrooms?
If yes, what? ______________________________________________________________
□ Did the books present accurate images and information?
If yes, what? ______________________________________________________________
_________________________________________________________________________
□ Were there other printed materials related to food/nutrition/healthy eating in classrooms?
If yes, what? _______________________________________________________________
□ What other food and nutrition related resources were present in classroom?
_________________________________________________________________________
_________________________________________________________________________
Play and toys
□ Were there food related toys in classrooms (e.g. food-shaped toys, toy kitchen, cookware,
utensils)? If yes, what? ______________________________________________________
________________________________________________________________________
□ Did children play with food-related toys (e.g. cooking, dining, dramatic play)?
If yes, how? _______________________________________________________________
_________________________________________________________________________
Children’s classroom activities
□ Were nutrition related themes present in classroom activities?
If yes, what? ______________________________________________________________
□ Was any formal nutrition education for children observed?
If yes, what? ______________________________________________________________
□ Were food-related activities consistent with nutrition education and health promotion?
□ What food-related activities were observed? ____________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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Appendices
Appendix 12:
Document Review Guide
Preschool Code No. __________________

Date ____________
Healthy eating policy

1. Is there a written healthy eating policy at preschool? Yes □ No □
2. If yes, how long has it been in place
___________________________________________
3. Are all staff aware of policy? Yes □ No □
4. Is there a policy visible anywhere? Yes □ No □
5. If yes; where is it visible? ___________________________________________________
6. Is there a policy on snacks? Yes □ No □
7. If yes, what is it?
________________________________________________________________________
8. Is there a policy on packed lunches brought from home? Yes □ No □
9. If yes, what is it?
________________________________________________________________________
________________________________________________________________________
10. Is there a specific policy on celebration days? Yes □ No □
11. Who was involved in developing policy? -
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
12. Were parents involved? Yes □ No □
If yes, how were they involved? _________________________________________________
________________________________________________________________________
________________________________________________________________________
13. Is any information given to parents on policy? Yes □ No □
If yes, how is information given? ________________________________________________
________________________________________________________________________
________________________________________________________________________
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Appendices
14. Did the policy specify how the preschool will engage parents on wellness/health/nutrition
goals? Yes □ No □
How? _____________________________________________________________________
__________________________________________________________________________
15. Did the policy specify a plan for evaluating or assessing nutrition policy? Yes □ No □
16. Did the policy specify a plan for revisiting the nutrition policy? Yes □ No □
Nutrition information resources:

1. Resources used in preschool ________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. Staff attended healthy eating training Yes □ No □ Don’t know
If yes, which training? ________________________________________________________
___________________________________________________________________________
Copy of Food & Nutrition Guidelines Yes □ No □ Don’t know □
If yes, where is it kept? ________________________________________________________
3. Are other staff aware of guidelines Yes □ No □ Don’t know □
4. Is there ‘3-Week Menu Resource’ on premises? Yes □ No □ Don’t know □
5. If yes, where is it kept? _____________________________________________________
Menu (for full-dare-care preschools)

1. Is there a written menu for preschool-aged children? Yes □ No □
2. How many weeks in length is menu cycle? 1 week□ 2 week□ 3 week□ 4 week□
Other□ _________________________________________________________________
3. Who was involved in menu development? _____________________________________
__________________________________________________________________________
4. Were parents involved in menu development? Yes □ No □ Don’t know □
If yes, how? ________________________________________________________________
__________________________________________________________________________
5. Are menus displayed for parents to see? Yes □ No □ Don’t know □
Where? ___________________________________________________________________
6. Are parents informed daily of foods eaten? Yes □ No □ Don’t know □
7. If yes, how is this done? ____________________________________________________
___________________________________________________________________________
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8. Was food offered to children appropriate to the child’s age and development, including a
wide variety of nutritious foods consistent with the Dietary Guidelines?
___________________________________________________________________________
___________________________________________________________________________
Written communication documents

1. Were there written communication with parents on food and nutrition? Yes □ No □
If yes, what? ________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
2. Does preschool provide nutrition or health information for parents? Yes □ No □
If yes, how? ________________________________________________________________
___________________________________________________________________________
3. Did preschool provide instructions on how to contact the preschool regarding concerns,
complaints, or suggestions? Yes □ No □
If yes, how? ________________________________________________________________
__________________________________________________________________________
4. Did the preschool provide nutrition or health information for parents? Yes □ No □
If yes, what? _____________________________________________________________
________________________________________________________________________
________________________________________________________________________
How? __________________________________________________________________
________________________________________________________________________
5. Did the preschool provide parents with referrals for health and/or nutrition-related
resources? Yes □ No □
If yes, how? _______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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Appendix 13:
Preschool Manager Questionnaire
Selected parts of the ‘Center Director Interview Tool’ of the Rudd Center for Policy and
Obesity, Yale University, were used in the Preschool Manager Questionnaire.
Available at: http://uconnruddcenter.org/files/Pdfs/ChildCareDirectorInterview_2016.pdf
338
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340
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341
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342
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343
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344
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345
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346
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Appendix 14:
Topic guide for semi-structured interviews with preschool staff
1. What are their attitudes/behaviours toward healthy eating

• Can you tell me what happens during a typical mealtime?
• Some children eat at different paces. What do you do about it?
• What do you do if a child doesn’t eat their food?
• What do you think about using food as a reward or as a punishment?
• Do you think there is adequate time allowed to feeding times and why? How much time
does it take for mealtimes, typically?
• Do you discuss food with children at mealtimes and if yes what do you talk about?
• What do children talk about when food is discussed?
2. What are preschool staff beliefs and perceptions about healthy nutrition
How important to you is healthy eating in general and in preschool. Why?
• What do you think is your role in providing healthy foods/nutrition to preschool?
• Do you think that the preschool’s menu contains healthy food? (If the answer is ‘Yes’:
Why do you think so? If the answer is ‘No’: What would you change in the menu?)
• Do you have anything else you would like to discuss or any questions you would like to
ask?
3. What is their knowledge of healthy nutrition

• Which food do you think would best describe a healthy food?
• Do you know of any nutrition and health issues for children of preschool age?
• Where do you get information about healthy eating?
• Did you or do you get training on nutrition at preschool?
• What would be the best way for you to get information about nutrition (books, media,
professionals, workplace training, etc.)?
4. What are the barriers for promoting healthy eating at preschool?

• What do you think needs to be changed in preschools and why?
• What one change would you like to see around mealtimes/food provision in preschools?
• What do you like or not like about…?
• What challenges do you encounter during meal/snack times?
• Do you encounter any challenges or difficulties from parents/families?
5. What are the facilitators of healthy eating?

• What do you think helps children to eat healthy foods served at preschool? (e.g. fruits,
vegetables)
• Is there any other way you would like to do to help children to eat healthy foods? What
do you think might help to improve nutrition at preschool (information, resources, food
availability, policies/management)?
ask?
348
Appendices
Appendix 15:
Topic guide for semi-structured interviews with parents
1. What are parents’ attitudes/behaviours toward their child’s nutrition and food
environment at home
• How old is your child? Do you have more children? What are ages?
• Do you have any concerns about your child’s eating behaviour or growth?
• How would you describe your child’s appetite?
• Which meals do you usually eat each day? How many snacks?
• We all are living such busy lives, especially parents of young children. Do you have times
when you skip meals?
• Are there any foods you won’t eat? If so, which ones and why ?
• Can you tell me what happens during a typical meal time in your home?
• How much time does it take for meal times, typically?
• What do you talk about during a meal? Do you discuss food with children at meal times
and if yes what do you talk about? What do/es children/child talk about when food is
discussed?
• What do you do if your child doesn't eat their food/certain food?
• What do you think about using food as a reward or as a punishment?
• Do you like to cook?/Do you enjoy cooking? Would you prefer to have take-away foods
or convenience foods when you are busy? How often do you have them?
• How often children have parties and what do they eat at the parties?
• Do you have any concerns about the food served to your child when he/she is away from
home?
• Do you think that the preschool's menu contains healthy food? (If answer is ‘Yes’, why
do you think so? If ‘No’, what would you change in the menu?)
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2. What are parents’ knowledge and perceptions on healthy nutrition
• Which food do you feel would best describe a healthy food?
• How important to you is eating healthy and why?
If a parent has other children:
• When you prepare food for your children, do you do anything different for your
preschooler than for other children or for yourself?
If a parent has no other children:
• When you prepare food for your children, do you do anything different for your
preschooler than for yourself?
• Where do you get information about healthy nutrition?
• Did you or do you get training on nutrition at preschool?
• Is there anything you wanted to know about nutrition/any topic in nutrition you are
interested in and wanted to know more about?
• At the end of this study I’m hoping to be able to come up with recommendations
about healthy eating for pre-schoolers. If I was to tell you the information about
healthy nutrition, how you think I should do it, what would be the best way?
• What would be the best way for you to get information about nutrition (books, media,
professionals, workplace training, etc.)?
3. What are the barriers to healthy eating?
• What do you think needs to be changed in your household diet and why?
• What changes would you like to make in the way you eat?
• What do you like or not like about...?
• What challenges do you encounter during meal/snack times?
• Would you agree with the impression that healthy food is more expensive?
If “Yes” – Is healthy food something you budget for/plan for?
If “No” – Where do you usually buy food?
350
Appendices
• Do you encounter any challenges or difficulties from preschool regarding your child’s
nutrition?
4. What are the facilitators of healthy eating?
• What do you think helps your child/children to eat healthy foods at home (e.g. fruits,
vegetables)
• Is there any other way you would like to do it to help your child to eat healthy foods?
(following an expression of opinion)
• What food does the father (or your partner) like to eat? Does he cook as well?
• What do you think might help to improve your family nutrition (information, resources,
food availability, policies/management)?
ask?
351
Appendices
Appendix 16:
Protocol for managing distress
DISTRESS PROTOCOL FOR QUALITATIVE DATA COLLECTION
Distress Protocol 1 – for participant: The protocol for managing distress in the context of a
research focus group /interview. (Professor Carol Haigh & Gary Witham Department of
Nursing MMU Review date 2015)
•A participant indicates they are experiencing a high level of

stress or emotional distress OR
• exhibits behaviours suggestive that the discussion/interview
Distress is too stressful such as uncontrolled crying, shaking etc.
• Stop the discussion/interview

• Researcher/s will offer immediate support
Stage 1 • Assess mental status: Tell me what thoughts you are having?
Response Tell me what you are feeling right now? Do you feel you are
able to go on about your day? Do you feel safe?
• If participant feels able to carry on; resume

interview/discussion
Review • If participant is unable to carry on Go to stage 2
• Remove participant from discussion and accompany to quiet area or

discontinue interview
• Encourage the participant to contact their GP or mental health provider
OR
Stage 2 • Offer, with participant consent, for a member of the research team to
Response do so OR
• With participant consent contact a member of the health care team
treating them at for further advice/support
• Follow participant up with courtesy call (if participant consents) OR

• Encourage the participant to call either if he/she experiences increased
Follow up distress in the hours/days following the focus group
352
Appendices
Distress Protocol 2 – for researcher: The protocol for managing distress in the context of a
research focus group /interview management. McCosker,H Barnard, A Gerber, R (2001).
Undertaking Sensitive Research: Issues and Strategies for Meeting the Safety Needs of All.
Forum: Qualitative Social Research, 2(1)
• The researcher should consider the potential

physical and psychological impact on the researcher
of the participants description of life experiences
• The researcher should consider how many
Pre-data interviews could be undertaken in a week
collection • The researcher should be aware of the potential for
emotional exhaustion
• If the topic potentially sensitive/distressing data

collection to be undertaken by two members of the
research team •
• Regular scheduled debriefing sessions with a
Data named member of the research team
collection • May be encouraged to journal their thoughts and
stage feelings which may then become part of fieldwork
notes in some research approaches
• Is alerted prior to transcription review of potentially

"challenging" or "difficult" interviews
• Has regular scheduled debriefing sessions with a
Analysis named member of the research team
• Encourage the researcher to access a research

mentor if he/she experiences increased distress in
the hours/days following transcription
Follow up
353
Appendices
Appendix 17:
Characteristics of Study Participants
Preschool 1 2 3 4 5 6 7 8 9 10
Type of service FD FD FD FD PT/S PT/S PT/S PT/S PT/S PT/S
Ownership Comm Private Private Private Comm Comm Comm Comm Comm Comm
Type of Food service Food service Food service Food service Packed lunch Packed Packed Packed Packed Packed
food provision (3 meals, (3 meals, (3 meals, (3 meals, from home, lunch from lunch from lunch from lunch from lunch from a
2 snacks) 2 snacks) 2 snacks) 2 snacks) snacks from home home home home food service
preschool provider
Staff position, Teacher Manager Manager Manager Teacher Teacher Teacher Manager Manager Manager
number/gender 1/F 1/F 1/F 1/F 1/F 1/F 1/F 1/F 1/F 1/F
Staff years of 5 14 11 9 2 3 3 9 7 6
experience
Staff qualification Level 5 Level 6 Level 6 Level 6 Level 6, Level 6 Level 6 Level 6 Level 6 Level 6
(QQI)
No. of child 2 11 5 8 13 9 4 5 2 5
participants
Age range of children 3-4 3-5 3-4 3-5 3-4 3-4 3-5 4 3-4 3-4
(years)
No. of parent 2/F 0 2/F 1/F 1/F 1/F 1/F 2/F 0 0
participants
Age range of parents 31-40 n/a 20-30 31-40 31-40 20-30 20-30 20-30 n/a n/a
31-40 31-40 20-30
Parent’s education Secondary n/a Secondary Postgrad Undergrad Undergrad Postgrad Undergrad n/a n/a
level Postgrad Secondary Secondary
Number of children in 2 n/a 2 3 3 1 1 1 n/a n/a
family 2 1 2
In receipt of social Yes n/a Yes No Yes Yes No Yes n/a n/a
welfare No Yes No
Note: FD=Full-day-care preschool; PT/S= Part-time/sessional preschool; Comm=community; F=Female.
354
Appendices
Appendix 18:
Summary of observation, document review and manager questionnaire
Preschools 1 2 3 4 5 6 7 8 9 10
Type of service FD FD FD FD PT/S PT/S PT/S PT/S PT/S PT/S
Ownership Community Private Private Private Community Community Community Community Community Community
Type of Food service Food service Food Food service Packed lunch from Packed Packed lunch Packed lunch Packed lunch Packed lunch
food provision service home. Snacks from lunch from from home from home from home from a food
preschool home catering service
Preschool documents
Written healthy Present Present Absent Absent Present Absent Present Present Present as part Present
eating (HE) of general
policy school policy
Dissemination of Parent handbook Displayed on N/A N/A Displayed on N/A Displayed on Displayed on Given in parent Given in parent
HE policy to & displayed on notice board notice board notice board notice board handbook handbook
parents notice board
Policy on packed None None None None None None None None None None
lunches from Advice given Advice given Advice Advice Advice given Advice Advice given Advice given One-page list of Advice given
home verbally verbally given given verbally given verbally verbally allowed/not verbally
verbally verbally verbally allowed foods
Menu 4-week 4-week 4-week 3-week N/A N/A N/A N/A N/A N/A
Menu planning Manager, Manager, Manager Manager Manager N/A N/A N/A N/A Food catering
teachers, parents teachers service
Communication With parents on None None None With parents on None None None None None
with parents children’s food children’s food
intake intake
Nutrition or Newsletters, None None None Occasional None Occasional Newsletters, None None
health info. for leaflets leaflets leaflets leaflets
parents
355
Appendices
Food-related images and learning materials
Nutrition-related Hallways & None None None Hallways & None Present in the Present in the None None
images classrooms classrooms classrooms classrooms
Food-related In classrooms None None None In classrooms In In classrooms In classrooms None None
education classrooms
materials/books
Food toys & Toy kitchen; Toy kitchen; Toy Toy kitchen; Toy kitchen; Toy kitchen; Toy kitchen; No toy kitchen No toy kitchen No toy kitchen
materials children play with children play kitchen; children play children play with children play children play present, present, present,
food toys, role with food children with food food toys, role with food with food children play children play children play
play toys, role play play with toys, role play toys, role toys, role play with food toys, with food toys, with food toys,
toys, role play play role play role play role play
play
Food-related Weekly food Reading Reading Reading Reading books, Reading Reading Weekly food Reading books, Reading books,
activities with theme activities; books, games books, books, games with food books, books, games theme activities; games with food games with food
children reading books; with food toys games with games with toys games with with food toys reading books; toys toys
games with food food toys food toys food toys games with food
toys toys
Drinking water
Drinking water Jugs with water in Jugs with Jugs with Jugs with Jugs with water in Jugs with Jugs with Jugs with water Adult-accessible Jugs with water
accessibility for the classroom water in the water in water in the the classroom water in the water in the in the classroom tap water in the in the kitchen
children classroom the kitchen classroom classroom classroom kitchen
Images None None None None None None None None None None
encouraging
regular
consumption of
drinking water
Note: FD=Full-day-care preschool; PT/S= Part-time/sessional preschool
356
Appendices
Appendix 19:
Characteristics of parent participants
TYPE OF OWNERSHIP TYPE OF NO. OF AGE RANGE OF PARENT’S NUMBER OF IN RECEIPT OF

PRESCHOOL FOOD PARENT PARENTS EDUCATION LEVEL CHILDREN IN SOCIAL
SERVICE PROVISION PARTICIPANTS WELFARE
/GENDER Parent Parent Parent Parent Family Family Parent Parent
1 2 1 2 1 2 1 2
Full-day-care Community Food service 2/Female 31-40 31-40 Secondary Post- 2 2 Yes No
(3 meals, graduate
2 snacks)
Full-day-care Private Food service 2/Female 20-30 31-40 Secondary Secondary 2 1 Yes Yes
(3 meals,
2 snacks)
Full-day-care Private Food service 1/Female 20-30 - Post- - 3 - No -
(3 meals, graduate
2 snacks)
Part-time/ Community Packed lunch 1/Female 31-40 - Under- - 3 - Yes -
sessional from home, Graduate
snacks from
preschool
Part-time/ Community Packed lunch 1/Female 20-30 - Under- - 1 - Yes -
sessional from home graduate
Part-time/ Community Packed lunch 1/Female 20-30 - Post- - 1 - No -

Part-time/ Community Packed lunch 2/Female 20-30 20-30 Under- Secondary 1 2 Yes No
357
Appendices
Appendix 20:
Observation tool for staff-parent nutrition-related interactions
Preschool type OBSERVATION OF STAFF PARENT

NUTRITION-RELATED INTERACTIONS
Interactions Days of observation
1 2 3
Discussed child’s
food intake
Discussed the
contents of lunch
box
Staff actively
communicated with
the child and their
parent
Parent asked
nutrition-related
question
Staff conveyed
nutrition
educational message
Parent asked
questions about
child’s general well-
being
358

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Examining the food environment and nutrition practices in

Author(s) Dashdondog, Saintuya

Publisher NUI Galway

Item record http://hdl.handle.net/10379/16907

MD, Master of Public Health

Thesis submitted for the Degree of Doctor of Philosophy

Supervisor: Dr Colette Kelly

Discipline of Health Promotion

School of Health Sciences

College of Medicine, Nursing and Health Sciences

National University of Ireland Galway

used to obtain a degree in this, or another University.

PhD research was funded by the Hardiman Research Scholarship awarded to

Saintuya Dashdondog in 2015 through the Structured PhD in Health Promotion

Research, National University of Ireland, Galway

I would like to express my profound gratitude to my supervisor Dr Colette

I am sincerely grateful to my GRC members, Prof Saoirse Nic Gabhainn, Dr

I wish to express my sincere thanks to preschool managers who gave me

Background: As early years care settings contribute significantly to children’s

Findings: Study 1 revealed that preschool staff demonstrated their motivation to

Conclusion: This research provides a holistic picture of the complex processes

Chapter 3: Research Methodology

Table 3.1. Summary of the research studies

Chapter 4: Study 1 - Examining Preschool Food Practices

Table 4.1. Document review procedures

Table 4.2. Observations of preschool mealtimes

Table 4.3. Characteristics of participating preschools

Table 4.4. Characteristics of preschool staff participants

Table 4.5. Summary of preschool mealtime practices

Table 4.6. Barriers and facilitators for promoting healthy eating in

Chapter 5: Study 2 - Using Creative Research Method to Explore Preschool

Table 5.2. Food toys provided to children

Table 5.3. Vignettes

Table 5.4. Children’s most common food preferences

Table 5.5. Examples of quotes from children’s discussion and drawings

Chapter 6: Study 3 – Parents’ Perceptions on Preschoolers’ Nutrition and

Table 6.1. Study 3 participants characteristics

Table 6.2. Observation of nutrition-related communication between

Chapter 2. Literature Review

Figure 2.1. Ecological framework of food choice and eating behaviour

Figure 2.2. The 6 transformational goals for achieving the 5 national

Chapter 3: Research Methodology

Figure 3.1. The Procedural Diagram of convergent parallel dominant

Chapter 5: Study 2 - Using Creative Research Method to Explore

Figure 5.1. Game-based activity – ‘making’ a favourite dinner

Figure 5.2. Examples of drawings of food by children

Chapter 7: General Discussion and Conclusions

Figure 7.1. Setting-based Conceptual Map of reciprocal relationships

BMI Body Mass Index

CFP Controlling Feeding Practices

ELC Early Learning and Care

EBRB Energy Balance Related Behaviours

EFSA European Food Safety Authority

HEP Healthy Eating Policy

HSE Health Service Executive

RDA Recommended Daily Allowance

SAC School-Age Childcare