Childhood is a time of rapid physical and psychosocial development and changes(Reference Baird, Jacob and Barker1). Optimal nutrition and the development of good dietary habits are crucial during this life stage as habits formed can track into adulthood(Reference Movassagh, Baxter-Jones and Kontulainen2). Unhealthy dietary behaviours have shown to affect the growth and development of children and contributed to the increasing prevalence of childhood obesity and its associated morbidities such as diabetes, CVD and disordered eating(Reference Christian and Smith3). Current literature reveals that many children globally are not meeting their recommended food and nutrient intakes(Reference Chin, Edginton, Tang and Bagchi4). Similar trends have been observed in Singapore, where diets of primary school children, aged 6–12 years old, were found to be lacking in fruits, vegetables and whole grains, and high in sodium and added sugar(Reference Brownlee, Low and Duriraju5). To curb the raising prevalence of childhood obesity in Singapore, which has increased from 11 % in 2013 to 13 % in 2017(Reference Chia6), it is crucial to understand the factors influencing the dietary behaviours among children in Singapore. Such information can help inform future health promotion programmes on improving children’s dietary behaviours.
Extensive research has shown that children’s dietary behaviours are influenced by multiple factors(Reference Krolner, Rasmussen and Brug7,Reference Sleddens, Kroeze and Kohl8) . Using socio-ecological frameworks, previous studies have examined multiple levels of influence and the interplay among these levels(Reference Scaglioni, De Cosmi and Ciappolino9). For example, on the intrapersonal level, children’s dietary choices were found to be intrinsically influenced by their knowledge, skills, taste preference and familiarity with the food(Reference Scaglioni, De Cosmi and Ciappolino9–Reference Rathi, Riddell and Worsley11). Interpersonal influences often come from children’s families(Reference Holsten, Deatrick and Kumanyika12,Reference Yee, Lwin and Ho13) and peers(Reference Ragelienė and Grønhøj14), while community influences include schools(Reference Wafa and Ghazalli15) and the physical environment (e.g. the proximity of food stores)(Reference Townshend and Lake16), while macrosystem influences include policies, media and advertisements(Reference Scaglioni, De Cosmi and Ciappolino9). However, most of these studies have largely been based on quantitative studies and reports from parents(Reference Krolner, Rasmussen and Brug7–Reference Scaglioni, De Cosmi and Ciappolino9,Reference Yee, Lwin and Ho13,Reference Ragelienė and Grønhøj14,Reference Townshend and Lake16) .
In recent years, qualitative studies conducted with children themselves have been gaining traction as responses from children have been found to be richer and more accurate than proxy reporting by parents(Reference Vereecken and Maes17,Reference Ogden and Roy-Stanley18) . Additionally, such methodology has shown to be particularly useful in revealing new knowledge about the diverse determinants of dietary behaviour and in elucidating culture-specific influences(Reference Ishak, Chin and Taib10,Reference Rathi, Riddell and Worsley19) . Research has also shown that most children aged 7 and above enjoyed providing their opinions and were able to provide accurate and useful information for informing interventions(Reference Adler, Salanterä and Zumstein-Shaha20). However, to date, studies examining perceptions of children have mostly been conducted in North America, Europe, UK and Australia(Reference Krolner, Rasmussen and Brug7,Reference Holsten, Deatrick and Kumanyika12,Reference Ogden and Roy-Stanley18) and there is a paucity of such studies in the Asian context(Reference Ishak, Chin and Taib10,Reference Rathi, Riddell and Worsley19) .
A deeper understanding of the socio-ecological influences on dietary behaviours from children themselves can help inform the development of age- and culture-appropriate dietary interventions to support sustainable behavioural change. Using a socio-ecological framework, this qualitative study aims to explore primary school children’s perspective of the socio-ecological influences on their dietary behaviours in Singapore using focus group discussions (FGD).
Methods
Study design and participants
A qualitative interpretive approach was used in this study to allow for a richer understanding of the influences on children’s dietary behaviours(Reference Elliott and Timulak21). Focus group discussions (FGD) were conducted with children as they have shown to be less intimidating to children than individual interviews and allows ideas and discussions that may not arise in individual interviews to be elicited(Reference Adler, Salanterä and Zumstein-Shaha20). This study is reported according to the Consolidated Criteria for Reporting Qualitative Research(Reference Tong, Sainsbury and Craig22).
All FGD took place between July and November 2018. Children aged 9–12 years were recruited using convenience sampling from 2 co-educational public primary schools in Singapore. This age range was chosen to better understand children’s views as this is when they start gaining more autonomy in their food decisions and a critical period for prevention and health promotion(Reference Shlafer, Hergenroeder and Emans23). As most of the primary schools in Singapore are public schools, students from public schools were selected for this study so that findings are applicable to most children. Information sheet with parental consent and child assent form was provided to 530 students in one school and 220 students in another school. Those who were interested to participate (n 64) submitted their consent and assent forms to us through their teachers (See Supplementary Figure for participant flow). Children’s demographic data were also provided by parents when consent forms were submitted.
Data collection
A semi-structured discussion guide, principally guided by the Social-Ecological Model (sem), was designed to facilitate the FGD. The discussion guide was reviewed by an experienced qualitative researcher (GK), and questions in the guide were refined after pilot-testing in a separate group of children (n 14) from each school a month before data collection commenced (see Supplementary Table for key questions asked during the FGD). Analysis of notes and memos was conducted in conjunction with data collection and thus enabled the questions in the guide to be refined iteratively(Reference Pope, Ziebland and Mays24).
Eleven focus groups were formed. These children were grouped so that the focus groups were homogenous in age (9–10 years, 11 years and 12 years) and gender at each school (see Supplementary Figure for participant flow). Such arrangement was made to reduce the variation in cognitive, linguistic, social and psychological competencies among children in the groups(Reference Adler, Salanterä and Zumstein-Shaha20). Each focus group had a median of 5 children with numbers ranging from 2 to 7. When there were more than 7 interested students in a focus group, students were selected randomly to form the group. All FGD were conducted after school hours and within the schools, in rooms with minimal noise (e.g. a classroom or discussion room in the school library). A familiar adult (teacher) was present at the initial meeting with the children, but not involved in the FGD as the presence of an authority figure may influence children’s responses during the FGD. All FGDs were conducted by MJC, who received training and guidance on the conduct of FGDs with children from an experienced qualitative researcher (GK), and an assistant moderator (GWNT or JL) who helped with notetaking and time management. There were no pre-existing relationships between the researchers and the children.
Children were informed before data collection that there would be 2 sessions of FGD – one for the influences on physical activity, while another on dietary behaviours. Ten groups attended 2 sessions of FGD, and one group attended only one session where both physical activity and dietary behaviours were discussed, due to time limitations. Data saturation was reached by the end of data collection. This article will focus on the FGD findings pertaining to dietary behaviour as findings on physical activity are reported elsewhere(Reference Tay, Chan and Kembhavi25).
Before each FGD commenced, the background of the researchers and the reasons for the study were introduced to the children. Ground rules (e.g. being respectful to others’ opinions, that there are no right or wrong answers in the discussion) were also explained to the children. To sustain their interest and attention, activities such as sorting picture cards (e.g. with images of common foods consumed by children and images of common agents of socialisation like family, friends, teachers, etc) and scenario-based questions that were relevant to the topic were incorporated into each FGD(Reference Adler, Salanterä and Zumstein-Shaha20). Each FGD lasted between 45 and 100 min. Tokens of appreciation, in the form of stationery (e.g. markers and pens) and snacks (e.g. malted beverage, fruit juice, biscuits), were given to all children at the end of each session. All FGDs were recorded using Sony UX560F digital voice recorders.
Data analysis
All audio recordings were transcribed verbatim without identifiers. Transcripts were then checked against their corresponding audio recordings and imported to NVivo (Version 12, QSR International) to organise the data. Two researchers (MJC and GWNT) conducted the analysis first deductively using the sem, and then inductively for themes in each sem level, following the thematic analysis guide by Braun and Clarke(Reference Braun and Clarke26). The researchers read the transcripts repeatedly and generated meaningful codes from the transcripts independently. These codes were then discussed between the researchers before classifying them into themes at each level of the sem. To ensure credibility, codes were deliberated between MJC, GWNT, JL and MFFC and consensus was reached after several iterations. Saturation was considered to have been achieved when no new themes were identified.
Results
Of those who consented to participate, 48 children (n 26 girls) took part in the semi-structured FGD. Their mean age was 10·8 years (sd = 0·9, range 9–12 years), and the majority of the children were Chinese (n 36), along with some Indians (n 8) and Malays (n 4). Sixteen children did not participate due to non-selection (n 10) or were not present during the FGD (n 6). Nine key themes relating to influences of children’s dietary behaviour emerged from the analysis and were classified according to the sem as shown in Fig. 1. Key quotes to illustrate each theme are presented in Table 1. This includes (1) knowledge and (2) attitudes towards healthy eating, (3) parents’, (4) peer and (5) teachers’ influences, (6) school’s education and policies, (7) incentives and environmental cues in school, (8) food accessibility in the neighbourhood and (9) health promotion advertisements. Generally, the themes that emerged were similar between boys and girls except for peer influence, which was more frequently discussed among the girls than boys. Themes were also similar across all age groups, but influence from the macrosystem level were not discussed among younger children (9–10 years old). It should also be noted that younger children tended to be more literal in their responses and provided less in-depth description and elaboration.
Key influences on children’s dietary behaviour summarised according to the socio-ecological model
Key themes and quotes from the focus group discussion data analysis on dietary behaviours
Intrapersonal influences
Knowledge of healthy eating
Most of the children demonstrated a good understanding of healthy eating and there was a consensus on the importance and benefits of healthy eating. When asked to define healthy eating, many children described foods that provide them with ‘nutrients and vitamins’, such as fruits, vegetables, carbohydrate and protein. Some mentioned limiting certain seasonings (e.g. sugar, salt and oil), as well as ‘junk’ and fast foods. When asked about the recommended amounts of fruits and vegetables one should consume, most of them were able to recall the correct portions stated on My Healthy Plate (a visual guide designed by the Singapore Health Promotion Board for creating balanced and healthy meals(27)). However, a few of them were unsure of the amounts or described the wrong portions. When asked about the importance of healthy eating, most children discussed how healthy eating helps reduce the risk of diabetes, cancer and growing ‘very fat and die’. A few of the children also alluded healthy eating to ‘grow taller and stronger’ and aesthetic reasons such as ‘smooth skin and pretty’.
Attitudes towards healthy eating
There were, however, inconsistencies between the children’s understanding of healthy eating and their corresponding attitudes. Only a few children reported that they adhered or tried to adhere to a healthy diet, while the rest of them felt that the consequences of unhealthy eating were not of immediate concern to them. Some also displayed an indifferent attitude, stating that their food choices should not be restricted, and they should be allowed the freedom to choose any food.
When it comes to food preferences, children generally value the taste of the food over their nutritional value. In most of the FGD, the children reported a preference for less healthy foods such as fast foods as they perceived these foods to be tastier than healthier foods such as vegetables, which many described as ‘tasteless’ and ‘disgusting’. Thus, when given the autonomy to make food decisions, the majority reported choosing less healthy foods and tended to exclude fruits and vegetables from their meals. Additionally, some children reported that they would consume fruits and vegetables only when they were prepared in ways that they enjoyed eating. For example, they would consume vegetables only when the vegetables were prepared in ways that masked their taste or appearances, such as vegetables that are stir-fried with chili or topped with gravy. Nevertheless, a minority reported avoiding less healthy foods as they disliked the taste of less healthy foods (e.g. ‘too sweet, too salty’ and ‘too oily’) and not because of the benefits of healthy foods.
In a few FGD, some children have showed that they were aware of the nutritional value of foods but tended to rationalise their unhealthy eating habits in various ways. These children mentioned that consuming less healthy foods was acceptable if they had done, or would be doing, some physical activity on the same day. A few claimed that eating fries were considered healthy as fries were made from potatoes, a type of root vegetable. Additionally, a few children reported that their consumption of fruits and/or vegetables tended to ‘depend on (their) mood’ or their level of satiation. For example, they would not have fruits if they felt full after their main meal.
Interpersonal influences
Parents’ influences on children’s accessibility to food and children’s attitudes and values towards food
Most children described their parents as gatekeepers to their food accessibility within, and sometimes out of, their homes. Although parents would buy unhealthy snacks when shopping for groceries, many children reported that their parents would restrict them from consuming these snacks. Some children also mentioned that their parents limit the frequency of their fast-food consumption as well. In response to these restrictions, a few children stated that they would adhere to them to appease their parents, while most found ways around these restrictions by consuming the restricted foods in secrecy. For example, purchasing snacks from convenient stores in secret and taking snacks from parent’s ‘secret stash’ of snacks without them knowing. Besides restricting less healthy foods, parents’ provision of healthy foods was also a common practice described by the children. This included preparing fruits and vegetables at home in ways that children prefer and using healthier cooking methods when preparing home meals. When eating out or buying take-outs, some parents would also ensure that vegetables were included as part of the meal.
The children’s attitudes towards food were also reported to be influenced by their parents in various ways. Some recounted that their parents would impart health knowledge to get them interested in or be more aware of the benefits of healthy eating. One child narrated that his father taught him that too much unhealthy foods will cause arteries to be ‘clogged’ and can lead to death. Others mentioned that their parents would use coercive methods, such as reprimanding or scaring them, to get them to adhere to a healthy diet. For example, telling them that worms will ‘grow’ in them if they eat too many sweets. Some of the children also expressed displeasure at their parents’ constant nudging to consume fruits and vegetables, yet not doing so themselves. The children also tended to model after their parents’ dietary and snacking behaviours, whether healthy or unhealthy. Some expressed that snacking on unhealthy snack foods together with their parents was an enjoyable experience.
Peer influence
The influence from peers was brought up in some FGD. The responses from these children suggest that some of their food choices were in part influenced by their peers, whether positively or negatively, depending on the food selection and preferences of their companions. Some children revealed that they get access to snacks from their friends at times and they would accompany their friends to patronise fast food joints or convenience stores. Conversely, some children reported that peers also encouraged them to eat healthily by persuasion, for instance, ‘nagging’ or ‘forcing’ them to finish the vegetables on their plate during recess time and assuring them that the vegetables served are palatable. Most children also appeared to perceive that fast food consumption was a norm among children, and this made them less hesitant to consuming fast foods.
Teacher’s influence during meal and snack times
Teachers were reported to have influence over the children’s food choices and behaviours through education and monitoring. Besides teaching them about healthy eating as part of the school curriculum, some children also spoke of how their teachers would monitor their fruit and vegetable intakes during recess time and the types of snacks consumed during snack time. One child also mentioned that she had changed her food choice from roti prata (a type of fried bread) to fish ball noodles for recess after heeding her teacher’s recommendations. However, they revealed that such efforts were not consistent among teachers, as some were less strict in enforcing healthy eating habits (e.g. giving children warnings but still allowing them to consume less healthy snacks in class).
Environmental influences
Health education in schools and school policies
As part of the school curriculum, children learned about healthy foods and their recommended portion sizes using My Healthy Plate(27), during physical education lessons. Besides learning about healthy eating, schools also ensured a healthy food environment through the Healthy Meals in Schools Programme which provides guidelines on the provision of healthier food options in schools(28). The children who had their meals in school were aware that fruits and vegetables were provided in all the meals sold in school. Furthermore, the children from one school mentioned that they were only allowed to bring ‘healthy’ snacks, such as fruits and wholemeal biscuits, for snack time in school. Despite the schools’ provision of healthier meals, not all children consumed the fruits and vegetables provided. Some children revealed that they would either give away the fruits and vegetables to their friends or throw them away if they were not to their liking.
Incentives and environmental cues in school
The children from one school reported that the inter-class fruits and vegetable consumption competitions organised by the school incentivised them to consume more fruits and vegetables in school. It also seemed that children from this school were more inclined towards consuming fruits and vegetables as compared with the school where such incentives were not present. However, a few children expressed that such initiatives were not sustainable, as they noticed that their peers would stop consuming fruits and vegetables when the competition ended. The children from both schools also noted the presence of posters in their schools that reminded them about healthy eating. However, despite having these posters at areas frequented by the children (e.g. the canteen), the children from one focus group observed that not many of their peers paid attention to the messages on the posters.
Food accessibility in the neighbourhood
The children also highlighted how their neighbourhood and environment around the school influenced the access that they had to various foods. For example, the proximity of fast-food chains and convenience stores to their schools, homes or even the routes that they took to get home from school allowed them easy and quick access to less healthy foods or snacks. Children from another focus group also revealed that they would purchase snacks from a convenience store ‘just across the street’ from their school.
Macrosystem influences
Health promotion advertisements
In a few focus groups, there was mention of posters containing health messages (e.g. posters from the Let’s Beat Diabetes campaign(29)) that could be found ‘everywhere in Singapore’, which reminded the children to eat healthily. Some of them mentioned picking up information about their health through advertisements on digital platforms, such as YouTube, which acted as an alternative source of health knowledge to the children outside of school. Particularly, a few children from one FGD demonstrated the lasting impression of one of the video advertisements from the Let’s Beat Diabetes campaign by re-enacting it.
Discussion
Our findings through children’s perspectives showed that the influences on their dietary behaviours were from multiple levels of the sem, separately as well as interacting across levels.
While the children in our study appeared to know the ‘hows and whys’ of healthy eating, this knowledge alone did not necessarily translate into consistent healthy dietary behaviour. The importance of health and nutrition appeared to be a low priority among the children in our study. Instead, taste and appearance preferences appeared to be pivotal influences over their food decisions. These findings match those observed in previous studies conducted with children and adolescents in other populations which showed that the taste, smell, texture, appearance, as well as their emotional attachment to foods (e.g. pleasure and disgust) were more influential on their food choices than the nutritional value of food(Reference Ishak, Chin and Taib10,Reference Rathi, Riddell and Worsley11) . It has been suggested that at this age, the concept of nutrition and diet-related diseases may be too abstract to comprehend or perceived as distant and irrelevant(Reference Doherty and Hughes30). Furthermore, enjoying the immediate gratification from consuming less healthy foods may often outweigh waiting out the long-term benefits of healthier eating(Reference Story, Neumark-Sztainer and French31). This reinforces the need to focus on the short-term benefits and effects of healthy and unhealthy eating, respectively, when messaging health promotion interventions to children, rather than the longer term health implications. To motivate healthier dietary behaviours among children, some studies that changed children’s hedonic response towards fruits and vegetables (e.g. making healthy foods fun and enjoyable or used incentives, gamified healthy eating and experiential learning) have shown promising outcomes(Reference Marty, Chambaron and Nicklaus32–Reference Appleton, Hemingway and Saulais34). Similar effects have also been reported among recent Asian studies, suggesting that such activities could be adapted to interventions targeting children in Singapore(Reference Li, Pallan and Liu35–Reference Teo, Chin and Lim37).
Despite the awareness of the low nutritional value of less healthy food, children in our study reported justifying their unhealthy eating habits based on their beliefs of certain foods (e.g. categorising fries as a vegetable) and actions (e.g. compensating unhealthy food consumption with physical activity). A possible explanation could be due to the cognitive dissonance between their knowledge and food preferences, thus resulting in the formation of beliefs to minimise this conflict and feelings of guilt when consuming less healthy foods(Reference Rabia, Knäuper and Miquelon38). Although some of these beliefs could motivate one to engage in healthy behaviours (e.g. physical activity), evidence has shown that they were often associated with poorer health outcomes among adults and adolescents(Reference Kakoschke, Kemps and Tiggemann39). Currently, there is limited research exploring this among children, further research is required to better understand children’s cognitive process and biases towards healthy and unhealthy foods and their health beliefs. These behaviours could also be due to the lack of procedural nutrition knowledge (i.e. knowing how to practice healthy eating) among children as the current knowledge students reported tended to be more declarative (i.e. knowing what healthy eating is). This highlights the importance of enhancing the procedural and declarative nutrition knowledge of children(Reference Rathi, Riddell and Worsley40).
On the interpersonal level, children in our study generally viewed parents as being quite influential in their dietary choices and frequently cited parents as the gatekeepers to the food supply at home. A range of food parenting practices have been reported by children in our study. Some of these practices have shown to help encourage healthy eating among children, while others appear to be counterproductive, such as setting restrictions on unhealthy food consumption which resulted in them eating in secrecy, as reported by children in our study. This finding is consistent with those in earlier studies which showed that the restriction of these ‘forbidden foods’ tended to increase children’s desire to consume these foods in the short-term and may contribute to dysregulated eating behaviours in the long term(Reference Rollins, Savage and Fisher41). While it is important to limit unhealthy food consumption in children, teaching children to self-regulate their food consumption by providing guidance and routines, setting limits and considering the child’s perspectives may be better alternatives(Reference Rollins, Savage and Fisher41). Our findings also highlighted the importance of parents’ role modelling on fruit and vegetable consumption as contradictory behaviours of parents could undermine children’s perceived importance of adherence to healthy eating(Reference Cooke, Chambers and Añez42). This suggests that besides enhancing parents’ skills to feed their children healthily, parents should be encouraged to recognise how influential their eating behaviour is and practice positive role modelling. Given the strong influence of parental practices on children’s dietary behaviour, and the scarcity of such research among Asian parents(Reference Quah, Syuhada and Fries43–Reference Rathi, Riddell and Worsley45), further research is warranted to understand the food parenting practices and children’s responses to them among the Asian population.
Besides parental influences, influences from school have shown to have a significant impact on children’s food choices and dietary behaviour, such as encouraging and enforcing the consumption of healthy foods like fruits and vegetables in school. Existing research has observed that children whose schools provided healthy foods and drinks tended to consume more healthy foods and have lower BMI(Reference Wafa and Ghazalli15). Hence, such policies to ensure the availability of healthy foods and drinks in schools should be continued. However, similar to a previous survey study, our findings also suggested that the provision of healthier food options in school does not necessarily increase the intake of these foods in all children as some children would still find ways to avoid eating them(Reference Bekker, Marais and Koen46). The consumption of healthier foods, such as fruits and vegetables, seemed to be primarily driven by children’s personal preferences or affect towards the food, as shown in our findings and previous study among Indian children(Reference Rathi, Riddell and Worsley47). As previously mentioned, the provision of incentives, gamifying healthy eating and experiential learning could be alternative ways to garner children’s interest(Reference Marty, Chambaron and Nicklaus32–Reference Appleton, Hemingway and Saulais34). Providing more variety of healthy foods that are prepared in a hygienic way could also help increase children’s affect towards healthy foods(Reference Rathi, Riddell and Worsley47). Apart from communication via school programmes, it is also crucial to ensure consistency in reinforcing healthy eating among teachers and across home and school as conflicting messages may confuse children and hinder their ability to make prudent dietary choices.
Peer influence has been found in previous literature to have a strong influence on children’s food acceptability and selection as children desire to seek approval from their peers and conform to the group(Reference Krolner, Rasmussen and Brug7,Reference Ragelienė and Grønhøj14) . However, the influence from peers was not frequently mentioned in our study, which is an unexpected finding. A possible explanation could be due to the limited time children spend with their friends over school meals. Unlike their Western counterparts whose school curriculum includes a 1-h lunch break, children in Singapore typically have a 30-min recess break, during which some children would spend their time playing instead of having a meal. Previous studies have also found that parents appear to be more influential to children between the ages of 10 and 14, and they may be less concerned about what their peers think(Reference Ludvigsen and Scott48). These findings suggest that more focus should be put on parents than peers in interventions among children of this age group in Singapore.
Our findings also highlighted some important influences from the environmental and macrosystem levels of the sem, such as the proximity of stores and restaurants that sell unhealthy foods and the presence of health advertisements around them. Although the presence of these stores may not directly lead children to eat less healthy foods, their easy access coupled with children’s heightened preference for these foods may encourage the consumption of such foods(Reference Townshend and Lake16). Past research suggests that modifying the built environment, such as the implementation of zoning laws to limit the number or proximity of fast-food chains and convenience stores in residential areas or near schools, could help reduce the consumption of less healthy foods among children(Reference Townshend and Lake16). However, such interventions may be difficult to achieve in Singapore as shops, schools and housing are closely nested together due to the small island size. More research is needed to explore how such health concerns and interventions can be aligned with urban planning policies in Singapore. Finally, contrary to expectations, the influence of media on encouraging less healthy food consumption was not mentioned among our participants. Instead, the use of media to encourage healthy eating was reported. This could be attributed to the effect of regulations on food advertising to children in Singapore(49), as well as the increase in health promotion advertisements in Singapore after the local Ministry of Health declared ‘War on Diabetes’ (a nationwide campaign aimed at lowering diabetes incidence rates) in 2016(29). Although our findings suggest that children did not pay heed to the messages of the health promotion posters in school, the advertisements on the online platform seemed to capture their attention. Given the high media consumption and social media usage among children in Singapore(50), future health promotion messages to target primary school children could be delivered on online platforms frequented by children.
To the best of our knowledge, this is the first study to examine children’s perspectives of the influences on their dietary behaviour in Singapore. The use of qualitative methods with children directly allowed us to gather rich data from them through their perspectives, therefore contributing to the limited but growing body of literature in Asia(Reference Ishak, Chin and Taib10,Reference Rathi, Riddell and Worsley11) and locally(Reference Quah, Syuhada and Fries43,Reference Fries, Chan and Quah44) . However, there are some limitations to be considered. One limitation of the present study is that most of the children who participated were of Chinese descent, thus their experiences may not be generalised to all primary school children in Singapore, which consists of a racial mix of Chinese, Malay and Indian children. Besides, information on the socio-economic status of the children’s families was not collected. Thus, when conducting our analysis, we were unable to elicit information on the influence of socio-economic status on the children’s dietary behaviour. Further research is warranted to explore the views of children of Indian and Malay descent, as well as the influence of socio-economic status on the influences. It should also be noted that in 3 of the focus groups there were only 2 participants instead of the recommended minimum of 4 participants per group. Despite having fewer participants, we noticed that the children had the opportunity to provide more depth and detail through their interaction with each other. As mentioned in our findings, younger children (9–10 years old) often gave more literal information and did not provide further elaboration. In such cases, the moderator had to probe using more direct questioning, which could unintentionally have resulted in the use of leading questions. Future research working with younger children could consider using more participatory-based methods, such as photovoice, drawing or storytelling(Reference Abma and Schrijver51), to elicit more in-depth responses from children of this age group.
Conclusion
Understanding the determinants of a healthy diet contributes to the foundation of effective interventions. The insights from children in this study can be used to inform the development of future lifestyle interventions and policies targeting the different levels of sem to promote healthy eating in children aged 9–12 years old. Our findings also demonstrated the value of eliciting children’s input to identify intervention gaps, suggesting that the development of interventions ‘made by children for children’ may be more well accepted by children. Although gathering data from children themselves would help in the development of a more relevant intervention, it is essential to consider the viewpoints of parents and schools, who are also important agents of socialisation in influencing children’s behaviour.
Acknowledgements
Acknowledgements: We thank the principals, teachers and children from both primary schools for their participation and contribution to this study. We would also like to thank the Ministry of Education, Singapore for their help in the recruitment of schools for this study.
Financial support:
This study was supported by the National University Health System (NUHS) Summit Research Programme Partnerships - Office of Deputy President Research and Technology, Saw Swee Hock School of Public Health and Yong Loo Lin School of Medicine, National University of Singapore (NUS). Additional funding was provided by Health Promotion Board, Singapore. All funders had no role in the design, analysis or writing of this article.
Conflict of interest:
There are no conflicts of interest.
Authorship:
This study was conceived and designed by M.J.C. and M.F-F.C. Data were collected by M.J.C., G.W.N.T. and J.L. Transcripts were checked and coded by M.J.C. and G.W.N.T. Analyses were conducted and interpreted by M.J.C., G.W.N.T. and M.F-F.C. with guidance from G.K. The figure was prepared by M.J.C. The manuscript was drafted by M.J.C. and M.F-F. C., with input from G.W.N.T., G.K., S.A.R., H.N., C.L., M.C.W. and F.M. All authors reviewed and approved the final draft of the manuscript.
Ethics of human subject participation:
This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the National University of Singapore’s Institutional Review board (reference number: S-18-087). Approval was also obtained from the Ministry of Education, Singapore to approach schools for participant recruitment (reference number: RQ17-18(02)). Informed written consent was obtained from the parents or caregivers of all participants. In addition, participants gave their verbal assent prior to the start of every focus group discussion, which was witnessed and recorded.
Supplementary material
For supplementary materials referred to in this article, please visit https://doi.org/10.1017/S1368980022000404
Open access
