Appetite 65 (2013) 117–124
Contents lists available at SciVerse ScienceDirect
Appetite
journal homepage: www.elsevier.com/locate/appet
Research report
Investigating parents’ food-provision behaviours via the sensitisation
method q
Simone Pettigrew ⇑, Melanie Pescud
Business School, University of Western Australia, 35 Stirling Highway, Crawley 6009, Australia
a r t i c l e
i n f o
Article history:
Received 5 August 2012
Received in revised form 11 January 2013
Accepted 1 February 2013
Available online 13 February 2013
Keywords:
Australia
Child obesity
Qualitative research methods
Introspection
Memory work
Interviews
Focus groups
Observation
a b s t r a c t
In this article, the sensitisation method is introduced as an approach suited to investigating nutritionrelated issues affecting disadvantaged families. Using a longitudinal design, sensitisation is a combination
of self-introspection, memory work, observation, individual interviews, and focus groups. The method
was applied to child obesity as experienced in low socioeconomic families to generate information about
parents’ food provision attitudes and behaviours. Data were collected in Western Australia between May
2010 and May 2011. The outcome was a large quantity of data that provided deep insight into the foodrelated experiences of parents of overweight children. The growing awareness produced by the sensitisation process also resulted in reported behavioural change in many of the study participants, thus indicating that the method may effectively constitute an intervention in its own right.
Ó 2013 Elsevier Ltd. All rights reserved.
Introduction
Child obesity is a health problem that is greatly in need of new
methodological approaches given the lack of success in preventing
and treating the condition to date (Saris & Harper, 2005). The negative consequences of the condition for individuals and populations have resulted in a large number of studies in recent years
seeking to identify contributing factors and investigate potential
prevention and treatment programs (for reviews see Birch and
Ventura (2009) and Monasta et al. (2010)). To date, however, little
progress has been made and child obesity remains at epidemic levels in many countries (Han, Lawlor, & Kimm, 2010). The trend is
most notable among children of low socioeconomic status (SES:
O’Dea and Dibley, 2010; Singh, Siahpush, & Kogan, 2010; Stamatakis, Wardle, & Cole, 2010), suggesting that health inequalities will
worsen over time unless improvements can be made to address the
situation. However, the difficulty of the task is compounded by the
q
Acknowledgements: The authors thank the parents who were part of the
research project for their commitment to the study. Conflict of interest: The authors
declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article. Funding: The authors disclosed receipt of the
following financial support for the research, authorship, and or publication of this
article: The West Australian Health Promotion Foundation (Healthway) provided
funding for the research.
⇑ Corresponding author.
E-mail address: [email protected] (S. Pettigrew).
0195-6663/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.appet.2013.02.004
problems associated with recruiting and retaining low SES participants in studies (Kleinman & Madans, 1985; Salmon, Campbell, &
Crawford, 2006; Sonne-Holm, Sorensen, Jensen, & Schnohr, 1989).
Previous research has highlighted the need to develop research
methods that can overcome parents’ concerns that their involvement in child obesity studies will reflect poorly on their parenting
practices (Pagnini, King, Booth, Wilkenfeld, & Booth, 2009). This
article describes a new qualitative research method, named
sensitisation, that was designed to address this issue by providing
parents with the opportunity to reflect on their food-related beliefs
and behaviours over an extended period of time. Featuring a
combination of existing qualitative data collection methods
incorporated into a longitudinal study design, sensitisation has
the potential to facilitate deeper access to the issues experienced
at family level that impede the provision of healthy foods.
The sensitisation method was developed and applied to generate detailed information about the barriers, motivators, and facilitators influencing low SES parents’ behaviours in relation to their
overweight children’s diets. A method was required that could
investigate parents’ thoughts and feelings at a particular point in
time and also facilitate greater understanding by sensitising the
target group to food-related issues and allowing them to (a) consider these issues over an extended period of time and (b) examine
their daily experiences in the light of this heightened awareness.
Existing data collection methods were not well-suited to this task,
resulting in the need to strategically combine a range of methods
with varying strengths and weaknesses.
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S. Pettigrew, M. Pescud / Appetite 65 (2013) 117–124
The aim of this article is to introduce the sensitisation method,
provide an account of its application to the intractable issue of
child obesity, describe its strengths and limitations, and suggest
potential other areas of application. The findings provide insight
into both the difficulties faced by low SES parents with overweight
children and the methodological challenges associated with investigating these issues.
Child obesity
Australia, the context of the present study, has among the highest rates of obesity in the developed world. Nearly two-thirds of
adults (63%) and a quarter of children (25%) are classified as either
overweight or obese (Australian Bureau of Statistics (ABS), 2012).
While these rates appear to have stabilised among children since
2008, adult rates have continued to increase (ABS, 2012). Similar
trends are apparent in the US (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Health inequalities are evident in the large disparity in
child obesity rates in Australia according to SES. The national figure
of 25% represents 8% obese and 17% overweight children. In low
SES areas, the overall rate is 32%, which is comprised of 12% obese
and 20% overweight children (ABS, 2009). By comparison, the
equivalent rates among high SES children are 19% total, 5% obese,
and 14% overweight (ABS, 2009). This state of affairs has resulted
in calls for child obesity research focused specifically on low SES
families and the factors contributing to their poorer weight outcomes (Hesketh, Waters, Green, Salmon, & Williams, 2005; O’Dea
and Dibley, 2010).
Previous work that has specifically focused on the disadvantaged has found that low SES is associated with weaker nutrition
knowledge (Parmenter, Waller, & Wardle, 2000; Rasanen et al.,
2003) and poorer diets (Boutelle, Birnbaum, Lytle, Murray, & Story,
2003; Campbell et al., 2002; Merchant, Dehghan, Behnke-Cook, &
Anand, 2007; O’Dea and Dibley, 2010). On a more positive note,
low SES parents have been found to be more desirous of nutrition
information than more affluent parents (Hart, Herriot, Bishop, &
Truby, 2003). Given these trends, there are likely to be major structural, cultural, social, and environmental factors that perpetuate
unhealthy eating patterns among the disadvantaged (Crawford &
Ball, 2002; Stewart, Makwarimba, Barnfather, Letourneau, & Neufeld, 2008; Thomas, 2006). Unfortunately, much published research under-represents disadvantaged groups, largely because of
lower response rates resulting from problems relating to illiteracy,
access, and suspicion (Kneipp, Lutz, & Means, 2009; Sonne-Holm
et al., 1989). An additional complication is that most studies of
nutrition-related attitudes and experiences are cross-sectional in
design. This does little to address the particular needs of low SES
study participants who are likely to need time to develop the rapport and trust that is required for frank disclosure (Perez, Nie, Ardern, Radhu, & Ritvo, 2011).
Where researchers seek to better understand a phenomenon
such as child obesity that has strong sociocultural and emotional
determinants, research methods are needed that can (a) access
study participants’ thoughts and feelings and the resulting behaviours; (b) analyse how these thoughts, feelings, and behaviours
change over time; and (c) incorporate consideration of relevant
environmental and logistical factors. The sensitisation method, as
outlined below, was developed to make progress towards achieving these objectives.
Introducing the sensitisation method
While individual interviews have also been used (e.g., Jackson,
Mannix, Faga, & McDonald, 2005; Lindelof, Nielsen, & Pedersen,
2010), focus groups appear to be the most common form of data
collection in the few qualitative studies that have gathered data
from parents of overweight children (for reviews see Hughes, Sherman, and Whitaker (2010) and Pocock, Trivedi, Wills, Bunn, and
Magnusson (2009)). The use of alternative data collection methods
has the potential to offer new insights to assist in developing and
implementing more effective interventions in the future. In addition, combining multiple methods has the advantage of providing
a source of triangulation that can generate a more robust interpretation than the use of individual data collection methods (Mays &
Pope, 2000). The sensitisation method is longitudinal in approach
and combines a range of data collection methods, some of which
have rarely been used in child obesity research: self-introspection,
memory work, observation, individual interviews, and focus
groups. Each of these elements offers unique and valuable contributions to the understanding of nutrition-related issues. In combination, they provide a means of appreciating the multiple factors
impacting these issues, how these factors can change in their nature and their influence over time, and how people respond to them
in different ways according to the degree to which they are sensitised to their presence.
The section to follow outlines the characteristics of each individual qualitative method within the overall sensitisation approach. The application of sensitisation to a child obesity study
focusing on low SES families is then outlined and the major methodological outcomes are reported.
Self-introspection
The complexities of real life make post-facto reporting problematic because of the sheer amount of detail that can be lost through
memory or time constraints. Self-introspection can overcome this
limitation to some degree by encouraging study participants to closely examine and report on their own thoughts about and reactions
to stimuli. The examination process involves consideration of both
‘what’ is being thought about and ‘how’ the thought is being experienced (i.e., with a positive, neutral, or negative valence) (Gould,
1995).
By engaging in on-going monitoring of their mental processes
and behaviours, individuals can progressively develop interpretations of these that they can share with others (Gould, 1995). This
process can provide unique access to thoughts and emotions as
they are experienced in a natural context (Ellis, 1991; Marti, Sackur, Sigman, & Dehaene, 2010). The primary benefit of self-introspection relative to other data collection methods is thus that it
can provide access to detailed, relevant, and immediate information over an extended period of time (Holbrook, 1998). However,
the method also has significant limitations which typically result
in self-introspection being combined with other data collection
methods. The main disadvantage is that it is a particularly subjective form of interpretation that involves individuals who lack research training attempting to make sense of their own thought
processes (Carruthers, 2010).
Memory work
Originating in feminist research, memory work involves closely
examining aspects of life that are typically taken for granted
(Thomsen & Hansen, 2009), and there is a particular emphasis on
the experience of emotions (Onyx & Small, 2001). It is similar to
self-introspection in its inclusion of informants as co-researchers
who are expected to participate in the interpretation of their
own data (Onyx & Small, 2001). In classical memory work,
informants document memory episodes that are examined individually and in group contexts, often over multiple sessions. Memory
work has been previously applied to a limited range of topics, but
most of these have been health-related. Examples include the
S. Pettigrew, M. Pescud / Appetite 65 (2013) 117–124
119
experience of physical activity (Sironen, 1994), interactions with
health providers (Feldman, 1999), and health information preferences (Oinas, 1999).
participant overload and attrition while encouraging optimal
engagement and disclosure.
Observation
The study
There are often substantial differences between what people
say they do and what they actually do (Adler & Adler, 1994). This
has resulted in cautions against relying entirely on data generated
via self-report mechanisms (Barnes, 1996; Huberman & Miles,
1994). In particular, verbal accounts alone cannot be expected to
elucidate behaviour resulting from conformity values, as the common urge to be accepted ensures that taught responses are provided by respondents (Kluckhohn, 1967). In other words, not
only are individuals taught to conform in their behaviours, they
are also taught to justify their behaviours in ways that discount
the importance of conformity pressures. Informants may also
choose to deceive researchers where they consider it appropriate
(Nachman, 1984).
Although the benefits of observation are appreciated in health
research (e.g., Shaw, 2010), it is rarely used in its pure form because of the difficulties associated with interpreting observational
data without the insights provided by other forms of data. It is
therefore typically combined with interview data and/or participant observation to permit deeper exploration of possible explanatory factors (e.g., Christensen & Grimsmo, 2008).
Sample
Individual interviews
Interviews have the advantage of being able to generate data
that can provide access to individuals’ motivations (Dichter,
1964), and they are also useful for exploring the effects of macroforces (e.g., social and cultural factors) on the thoughts and behaviours of individuals (Goodenough, 1980; Patton, 2002). Their main
disadvantages are the tendency for interviewees to exhibit a ‘presentational self’ by providing information that portrays them in a
positive light and to omit information that makes them psychologically uncomfortable (Dean & Whyte, 1958). Combining individual
interviews with other data collection methods can allow these limitations to be offset by the strengths of the other methods
(Onwuegbuzie & Leech, 2005).
Focus groups
Focus groups are especially useful for illustrating how group
consensus is achieved and supplying a source of data triangulation
when used in conjunction with other methods (Fontana & Frey,
1994; Lehoux, Poland, & Daudelin, 2006). The group dynamics that
are visible during focus groups offer a form of social data that is difficult to obtain in other ways (Calder, 1977). Despite their advantages, focus groups can be difficult to organise because of the
logistical problems associated with bringing multiple people together at the same place at the same time (Reinschmidt & Chong,
2007). They also present difficulties in terms of moderating individuals’ participation and preventing a small number of participants from dominating the group and some individuals from
failing to contribute (Fontana & Frey, 1994). They should therefore
be used carefully, especially for topics that can be uncomfortable
for people to discuss in the presence of unfamiliar others. They
are, however, acknowledged to be especially useful for exploring
health-related issues (Hughes et al., 2010; Lehoux et al., 2006).
To take advantage of the strengths of these individual data collection methods and overcome the limitations of each, they were
combined to produce a robust approach to investigating the many
and varied factors influencing child obesity. This was a complex
process that required careful consideration of issues relating to
Parents are often more appropriate targets for child obesity
interventions than children because of their critical roles as (a) role
models of food consumption and engagement in physical activity
and (b) providers of food and activity opportunities (Birch & Fisher,
1998; Moore et al., 1991). As such, parents were selected as the
sample population for the present study. Eligible parents had at
least one overweight or obese child aged 5–9 years, had a household income of less than $60,000 per annum (the national mean
gross household income was $73,300 per annum (ABS, 2008)),
and lived in a household where no-one possessed a college/university qualification. The children’s age range included the early
schooling years before children’s taste preferences become resistant to change (American Dietetic Association, 2004).
The initial recruitment plan was to involve a sample of 50 low
SES parents for a 6-month study. Reflecting the intense difficulties
that have been reported in attracting low SES individuals into previous studies, especially longitudinal studies (Blumenthal, Sung,
Coates, Williams, & Liff, 1995; Heinrichs, Bertram, Kuschel, & Hahlweg, 2005), recruitment was very challenging. Ultimately, 37 parents, almost all of whom were mothers, commenced the study
(sample profile provided in Table 1). At the end of the 6-month
period, 27 of these parents remained involved in the study. Because of the smaller starting sample and strong commitment
among many of the remaining parents at the 6-month point, the
study duration was extended to 12 months. This strategy enlarged
the data set and provided insight into relevant factors over a longer
period of time. Twenty-two parents agreed to continue for the full
year, 17 of whom were still actively involved in the study at its
completion. As shown in Table 1, while the commencing and completing samples were very similar, there were some differences in
the profiles of those choosing to continue. In particular, there was a
lower proportion of those working full time and those with male
children in the final sample relative to the commencing sample.
Data collection occurred between May 2010 and May 2011.
Parents participating in the study received remuneration for
their contributions. Monthly payments were made progressively
throughout the data collection period, averaging AU$71 per month
depending on the number of data collection episodes in which the
participant had been involved. At the end of the 12 months, participants received a summary report that outlined the major findings.
Procedure
The study was approved by the University of Western Australia
Human Research Ethics Committee. Potential participants were
sourced through a social research agency that randomly telephoned households in Perth, Western Australia. Parents who met
the eligibility criteria and expressed interest in participating in
the study were sent an information sheet containing further details
about the research process and were subsequently contacted to arrange an interview. During this first interview, participants signed
consent forms to record their agreement with the requirements of
the study and the remuneration arrangements. To commence the
sensitisation process, participants were given a list of specific issues for them to monitor and contemplate over the coming
months. These included media coverage of child obesity, food
advertising, food-related behaviours of other parents, food-related
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Table 1
Sample characteristics.
a
Category
Description
Number commencing
study (n = 37)
Number completing
study (n = 17)
Gender
Women
Men
35
2
16
1
Family structure
Dual parent families
Single parent families
14
23
6
11
Employment status
Working full time
Working part time
Parenting full time
6
7
24
1
6
10
Child gendera
Female
Male
25
14
12
1
No. of children in family
1 Child
2 Children
3 Children
4 + Children
5
17
8
7
4
13
6
3
Child weight statusa
Overweight
Obese
20
19
6
4
Total exceeds number of participants because some participants had more than one child in the age range specified for inclusion in the study.
behaviours of extended family members, and child pestering for
food products.
To meet the requirements of the sensitisation method, it was
necessary for participants to provide data regularly, but there
was considerable flexibility in the way this could be achieved. Participants were encouraged to attend at least two individual interviews and to provide fortnightly introspections. In addition, they
were advised that there would be the opportunity to attend focus
groups with other study participants. All participants had the option to attend interviews on campus or any other location of their
choice, but almost all elected to be interviewed in their homes for
convenience and to alleviate concerns relating to transport and
childcare.
The individual interview rounds were scheduled at the start,
middle, and end of the 12-month period, while member-checking
focus groups were conducted at the 6-month point to allow participants to provide input into the emerging interpretation (as per
Lincoln and Guba (1985) and Mays and Pope (2000)). The interviews and focus groups were semi-structured in nature, with discussion focusing on the foods provided to children for
consumption in the home and at school, parents’ and children’s
food preferences, family interactions during meals, and perceived
barriers to providing children with a healthy diet. In line with
the semi-structured approach, participants were able to introduce
other topics that they felt were relevant to their children’s diets.
Participants could select from a variety of introspection reporting mechanisms including email, a weblog, handwritten notes submitted in reply-paid envelopes, or a toll-free telephone message
system. The weblog enabled them to enter their own comments
and/or reply to other participants’ comments, and was monitored
daily to ensure interactions were positive and to identify any possible instances of conflict or inappropriate language usage (of
which there were none). The weblog was not password protected
because there was the potential for the need to recall a password
to constitute a barrier to its use. Frequent moderation was undertaken to address any contamination from non-participants, but this
proved to be unnecessary as there were no entries from individuals
other than those participating in the study. The provision of multiple reporting mechanisms allowed participants flexibility according to their access to technology, their preferred methods of
communication (i.e., written or verbal, independent or interactive),
their time constraints, and their physical location (e.g., at home or
elsewhere). Regular reminders were used to advise participants
when their next introspection report and/or interview were due.
The introspection reminders often contained optional issues that
the participants could consider as well as discussing any topics
of their choice. Examples of the introspection prompt issues included birthday parties, weekend activities, and treats.
Memory work was integrated into the study by asking participants to provide data relating to relevant memories that were triggered over the data collection period. During the first interview,
participants were asked to consider incorporating memory work
in their self-introspections throughout the study. During the individual interviews, participants were regularly prompted to reflect
on past experiences related to the relevant topic of conversation.
The application of memory work provided insight into the extent
to which participants’ childhood experiences factored into their
parenting practices and how aspects of the physical and social
environment might have altered in recent decades and the resulting implications for children’s diets. Although memory work was
not implemented in the strict form advocated by its originators
(i.e., individuals’ memories reported to the sample group and analysed collectively), prompting participants to access their memories on a regular basis and to apply these memories to their
contemplations of their current live experiences proved to be very
productive.
Observations were conducted in several ways. These included
(a) monitoring participants’ body language during interviews and
focus groups; (b) watching parents interact with their children in
their homes before, during, and after interviews; (c) being given
‘pantry tours’ by some participants; and (d) documenting the proximity of grocery stores and fast food outlets to participants’ homes.
In total, more than 70 h of observations were conducted across
these four areas. Detailed field notes were taken during observations to produce transcripts that could be included in the subsequent analysis process.
To ensure the study requirements were not onerous, participants could choose to vary the data provision process to suit their
needs. For example, some participants were reluctant to take on
the responsibility of submitting fortnightly introspection reports
and instead elected to undertake additional interviews or focus
groups. A group of three participants who lived in the same area
chose to participate in 10 small focus groups over the 12 months
instead of submitting introspections. These participants committed to regularly contemplate issues relating to their children’s diets
and to discuss their evolving thoughts on these issues during the
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S. Pettigrew, M. Pescud / Appetite 65 (2013) 117–124
focus groups. They thus engaged in on-going introspection, but
chose to report their thoughts in a different way. Despite the small
number attending these sessions, they were considered to be focus
groups rather than group interviews because there was considerable interaction among the participants.
Analysis
All introspections, transcripts, and field notes were progressively transcribed and imported into NVivo9 (QSR International
Pty Ltd., Australia) for coding and analysis. The use of software is
an accepted and increasingly common method of analysing qualitative data (Auld et al., 2007; Bringer, Johnston, & Brackenridge,
2006). In this instance, the sheer quantity of data generated by
the sensitisation method made computer-assisted analysis the
most feasible alternative.
Initially, a deductive coding schema was generated from the relevant literature, including behavioural models such as the Health
Belief Model (Rosenstock, 1990), the Theory of Planned Behaviour
(Ajzen, 1991), and Protection Motivation Theory (Rogers & Prentice-Dunn, 1997). This coding schema was inductively updated
with emergent codes as data analysis progressed to allow the
emerging findings to guide subsequent data collection episodes
(as per Glaser and Strauss (1967) and Strauss and Corbin (1990)).
As new codes emerged, earlier data were re-coded to ensure coverage of all relevant themes. NVivo’s sophisticated search functions
facilitated this process. Data interpretation occurred via the interrogation of individual content nodes (nodes being the storage
points for content assigned to specific codes) and the running of
text and matrix searches.
In terms of contributions to the study, the first author conceptualised the methodological approach, performed the literature review, managed the participant recruitment process, assisted with
moderating the member-checking focus groups, and developed
the paper. The second author conducted the individual interviews
and the focus groups, managed participants throughout the introspection reporting process, transcribed the interview recordings,
coded the data, and assisted in writing the paper. Both authors
analysed the coded data and collaborated on the emerging
interpretation.
Results
The methodological outcomes of the sensitisation method as
applied to child obesity research with low SES families are outlined
below. The major findings relate to the quantity and quality of data
generated and the ability of the study to produce intervention outcomes. Where participants’ words are shown to support the methodological outcomes described, they have been modified in places
for grammar. This decision was taken to preserve the participants’
dignity and increase the likelihood that their intended meaning
was conveyed to an international audience. All names used are
pseudonyms, and descriptors are provided at the end of each quote
showing the demographic characteristics of the participant and the
weight status of the focal child (represented as OW for overweight
or OB for obese).
Quantity of data
Despite a relatively small sample, the numerous data collection
methods and the longitudinal approach yielded a substantial body
of data which totalled 596,439 words. Table 2 shows the number of
data collection episodes and number of words generated from each
data collection method.
Table 2
Data summary.
Data collection method
Episodes
Words
Interviews
Focus groups
Introspections
Email
Handwritten
Weblog
Telephone
Field notes
72
12
372,404
139,769
165
51
129
9
90
38,513
13,024
19,657
5367
7705
Total
528
596,439
Quality of data
There were numerous indicators of the quality of the data obtained. First, the average length of the interviews and focus groups
increased over the course of the study. The first-round interviews
averaged 35 min in length, while the final-round interviews averaged 56 min. Similarly, the first-round introspection reports averaged 140 (weblog), 203 (handwritten), 330 (email), and 719
(phone) words, and the last-round reports averaged 154, 263,
250, and 781 words respectively. The only form of data collection
that did not exhibit an increase over time was email introspections,
with an average of 330 words in the first round and 250 words in
the final round. This overall upward trend suggests that as participants became more familiar with the study requirements and
more sensitised to the phenomenon under investigation, they were
able to consider the issues more deeply and share more information about them. This was also evident in the nature of the information provided, as shown in the following quotes from the
same participant who was willing and able to be more expansive
in her responses about children’s school lunches as the study
progressed:
Interviewer: What would typically go in your children’s
lunchboxes?
Participant: (Silence) (single mother, four children (OB), first
interview).
Interviewer: Do your children get what you would classify as
treats in their lunchboxes?
Participant: Yeah, I put sort of in a little bit of everything. They
have their fruit and they’ll have like an LCM bar and sometimes
potato chips (second interview).
I think kids should have a healthy lunch like fruit and rice
snacks that have got no sugar, salt, or artificial flavours in them.
Chicken is all right – as long as you don’t put any skin or fatty
pieces in the sandwich, it should be okay. Healthy choc milk,
like the school-approved one, are good. My kids are fussy – if
they don’t have chicken, they want spreads. It may be cheese
spread. Sometimes they won’t eat their lunch or sometimes
they just have recess. They come home with their lunch or
sometimes their fruit, but they always eat their recess (twentieth handwritten introspection).
The second indicator that the quality of the data improved over
time was that the number of personal disclosures increased, some
of which contradicted previous statements. This suggests that the
longitudinal approach, with its higher levels of rapport and trust,
was able to reach below participants’ presentational selves (Maddux, Norton, & Leary, 1988). This outcome is demonstrated in the
extracts below from one participant across two interviews conducted 12 months apart and an introspection submitted mid-way
through the data collection period. This participant initially
painted a rosy picture of food consumption and meal times in
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her home. With increasing familiarity, she felt comfortable disclosing the difficulties she encountered juggling meal preparation with
her other parenting and work responsibilities:
Participant: I’ll give them fruit every day with their lunch. They
don’t always eat it, but every night we have veggies, and they
eat them. So they are very good, they love their peas and corn.
the next time, and the next question comes up and you like pay
more attention to what’s going on. And it’s so true, when you’re
told to think about an issue, you think about it more, it’s so true.
And the questions are really good, like you think, ‘Oh man, I
haven’t even thought about that!’. Those are really good questions, yeah. That was very good, the 10 year question (married
mother, four children (OB), 3rd interview).
Interviewer: And how do dinner times go in your family?
Participant: Most stuff will get eaten. We always sit at the table
here together. It’s not usually a hassle dinner time, it’s pretty
good (married mother, two children (OB), first interview).
‘‘We rarely eat takeaways, but I do indulge in convenience foods
for the lunch boxes (eighth blog introspection)’’.
Trying to do the food is so hard. It’s like, you know, come home
and some nights it’s just like, ‘Oh God, what am I going to do?’. I
try and put the slow cooker on before I go, and then it’s such a
hassle trying to get healthy stuff, you know? And I’ve only got
Thursdays and Fridays to do all the cleaning and the shopping,
and it’s like, ‘Oh, I can’t be bothered’. So trying to pack their
lunches is a bit hard, trying to keep it healthy and easy for me
to prepare, yeah (third interview).
The third indicator of data quality was that participants reported heightened awareness of issues relating to child obesity
over the course of the study. Initially, many had difficulty identifying factors other than their own perceived laziness that were influencing their ability to feed their children well. As the study
progressed, they came to appreciate the multitude of other factors
that were likely to be relevant. In particular, the participants became more aware of elements in their environments that influenced their food provision behaviours. They were able to share
this growing realisation and explain how their lived experiences
were affected by these factors:
There are about eight takeaway joints or more on the way
home. Two Red Rooster, McDonalds, two Hungry Jacks, Chicken
Treat, Subway, a couple of fish and chip places, and it is only a
10 min drive home. I have never looked at it like that before.
And oh my God, us parents don’t stand a chance with those
odds (mother in a de facto relationship, two children (OW), fifth
blog introspection).
The use of the memory work technique was especially useful in
encouraging participants to appreciate how times have changed
since their childhood and the implications for their children’s
diets:
Often after school I will go through the drive thru and get the
children a soft serve (ice cream). I do this probably once or
twice a week. I’ve been thinking about this and how it is probably a bit much when compared to what I grew up with (married mother, six children (OW), first handwritten introspection).
Although participants could nominate any issues of personal
importance to them for their introspections, the suggested
prompts were much appreciated for their ability to stimulate
thinking and provide insight into issues that might not have been
consciously considered previously. For example, the participant
below discussed how she progressively became more sensitised
to issues relating to children’s food consumption and how she particularly appreciated an introspection prompt that asked the parents to describe what they thought their children would be like
in 10 years’ time:
I think it’s really good because it makes you think about things
that you wouldn’t normally have, really think about them. And
then you kind of carry that through into the week with you until
Intervention outcomes
The purpose of the study was to obtain information to inform
future interventions, but it quickly became apparent that the research process was yielding intervention outcomes of its own. Repeated contemplation of issues relating to children’s food
consumption appeared to result in increased awareness as noted
above, and in many cases also seemed to lead to increased confidence and behavioural change. At the root of these outcomes
was the eventual acknowledgement that their children were overweight. Despite being in a child obesity study, a majority of the
parents initially believed that their children were not overweight,
and it took some time for them to come to terms with their children’s weight status. The following mother did not explicitly
acknowledge that her daughter was overweight until her final individual interview at the end of the 12 months of data collection:
I was shocked that my daughter was over(weight). I was definitely shocked, because I would never had said that, because I
just thought it was healthy. But I think it opened my eyes – it
did open my eyes a lot, and I don’t know how else you would
word it. I must say I was very shocked my daughter was in that
category, because I always thought I’d been very careful. But
you know what? If you’re shocked, it’s kind of good too (single
mother, one birth child and two foster children (OB), third
interview).
With this realisation came the understanding that some of their
food provision practices were suboptimal:
The longer I was involved, the more I realised, because I thought
we were sort of quite healthy. The more I realized that, you
know, there are still things that we can work on, and it makes
you more aware (married mother, six children (OW), third
interview).
The required levels of contemplation appeared to increase participants’ incremental absorption of information relating to food
and diet. They reported that this increased their confidence in their
knowledge levels and ability to positively influence their children’s
health. This apparent empowerment through confidence is evident
in the following quotes where the participants expressed their
appreciation for the opportunity to think more deeply about the issues and learn new information:
I’m enjoying this study because it’s very informative, it keeps
your brain ticking over. You don’t always go into panic stations
(married mother, three children (OB), focus group).
Thank you so much for letting me participate in this study.
It has made me step back and think more about the things that
my children are eating and the long-term side effects that they can have on their lives, both good and bad (married mother,
four children (OB), third interview).
I’m learning, and also I’m sharing whatever I can share. So it has
been a very great experience, thank you (single mother, two
children (OB), focus group).
S. Pettigrew, M. Pescud / Appetite 65 (2013) 117–124
Finally, there was the suggestion that behavioural change was
occurring within the participants’ families. Participants reported
being more vigilant in monitoring and modifying their children’s
diets:
(The study) was good because it kept me aware of what I was
doing with my own children, kept me on my toes. You know,
‘‘Oh, did they get enough fibre in their diet today?’’ or ‘‘Did they
get enough vegetables?’’ Or, ‘‘God, I didn’t give them the vegetables today – I better start thinking about tomorrow what I
can do to help make up for what they missed out on.’ So yeah,
it was good in the sense that it kept me on my toes (married
mother, three children (OB), third interview).
Especially now being in the study, I’ve been more prominent
about watching what they eat and trying to add different things
into their diet, which I have actually had quite a lot of success
with, especially with my three year old (single mother, two children (OW), focus group).
Discussion
The sensitisation method encourages individuals to contemplate an issue over an extended period of time and examine their
own thoughts, motivations, and behaviours. It allows them to become ‘tuned in’ to their own behaviour and the behaviours of others with whom they associate to obtain deeper insight into the
social and environmental factors at play. In this application of
the method, a large quantity of data was generated from a relatively small sample and the quality of the data appeared to increase over time. While many of the benefits of the study are
likely to be the result of the longitudinal design, the intentional focus on sensitising participants to diet-related issues may have contributed to the increases in awareness and reported behavioural
changes that were identified.
The data generated by the sensitisation method may be richer
and more enlightening than the outputs of cross-sectional studies
that seek to understand individuals’ knowledge, attitudes, and
behaviours at a single point in time. For example, virtually all of
the many factors listed in Pocock et al.’s (2009) systematic review
of 21 qualitative studies of parental perceptions relating to child
obesity were identified in the present study. The ability of a single
study to generate findings that encompass variables represented in
numerous other studies is a notable strength. In addition to the issues identified in previous research, the present study produced
new findings. A range of erroneous nutrition beliefs that have not
been identified elsewhere were uncovered (Pescud, Pettigrew, &
Henley, 2013), and novel insights were generated relating to parents’ breakfast food choices (Pettigrew & Pescud, 2013). Further,
the chronic experience of guilt among the parents was explicated
to provide the first typology of the sources of this guilt (Pescud &
Pettigrew, 2012). The method was thus effective in contributing
to the body of knowledge relating to the beliefs and behaviours
of parents with overweight children.
The sensitisation method is likely to be applicable to related
health issues and other populations. For example, recruiting adolescents to participate in a sensitisation study on alcohol use could
generate new insights into the factors that motivate consumption
of this product. Future research is required to assess the range of
topics to which the method could be productively applied.
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