The aim of the present study was to gather qualitative data regarding healthy eating particularly in relation to enabling and influencing factors, barriers and knowledge in both children and adults (parents and teachers) from schools within the CHANGE! programme to provide important population-specific evidence to inform intervention design. The results provide important information to inform the design of the CHANGE! intervention, and build upon the limited body of literature that has utilized the pen-profiling method of data-analysis. The advantages of the pen-profiling technique, i.e. the capacity to comprehensively review a large data-set aligned with a well accepted theoretical model, whilst removing the likelihood of data being skewed by dominating interview participants, have been documented elsewhere
. In the present study pen-profiling has again presented the results of this study in a simple, accessible, yet informative manner though unlike previous research using both adult and child data and a range of group interview sizes (3–5 children, 2–8 adults).
The study findings indicate that children and adults had a generally sound knowledge of the constituents of a balanced diet with high awareness of the importance of fruit and vegetable (FV). These data suggest that knowledge related to diet composition was not a barrier per se to healthy eating within the population group studied but more specific knowledge especially in terms of dairy foods may be required. Previous research evidence is aligned with children’s awareness of healthy food but children’s intake of FV is still below the World Health Organization (WHO) target of 400 g per day
. Keyte et al.
 showed a median of 2 portions of FV intake with schools engaged with the UK Primary School National Healthy Schools Programme compared to only 1 portion per day for other schools. This indicates that whilst health campaigns can improve intake further work is needed to reach WHO and national recommendations. With respect to the specificity of the health benefits of FV, children’s knowledge is lacking
 which may continue into adulthood
. In the present study in regard to dairy products children’s emerging themes displayed an incomplete understanding, e.g.:
“It can kill you if you have too much dairy”
Dietary reference values for fat intake for children aged 10–11 in the UK are 35% of total energy intake
 with a recommendation to consume some milk and dairy products. This has implications for intervention design and is suggestive of the need for clear information about how to adopt a healthy diet and translate knowledge into practice, rather than a sole focuss on the benefits or constituents of a healthy diet through typical educative based means.
The important role parents play in children’s eating behaviours and food intake was evident from the children and adults’ pen profiles, both in terms of barriers to, and the child as a change-agent for healthy eating. The role of parent’s contributions to children’s eating behavior has been noted previously as multifaceted and complex
[23, 24]; but can be separated into overt and covert control
[25, 26]. Overt control includes monitoring and regulating children’s eating behavior, and was evident in this study, for example, children not being allowed to leave the table before eating vegetables, and through restriction of dietary fat and chocolate (Figure
3). This overt control can be counterproductive leading to increased portion sizes
, dietary restraint and disinhibition
[28, 29], and is implicated in overeating and overweight
[30, 31]. However, overt control also has a positive relationship with healthy snacking, fruit and vegetable intake, and reduced intake of energy dense foods
. Examples of covert control emerging from the focus groups included reducing access to sweets in the home (Figure
4), a practice associated with a decrease in unhealthy snacking
 and an increase in FV intake
. Parental control practices therefore can influence both positive and negative eating behavior but more research is needed in this area to fully understand the complex relationships between families and eating behavior.
The pen profiles also revealed parental support and encouragement of healthy behavior by educating children to make healthy choices whilst shopping, enhancing choice through tasting FV, and encouraging interaction with health education at schools (Figure
4). Family support can protect adolescents against unhealthy choices
 and parents have been shown to be supportive of interventions on health and well-being at schools
. Pen profiles suggest schools are providing (some) health education and parents are generally supportive :
"Child: “And they encourage like in school they encourage us to eat healthy stuff”."
Adult: “They had a well-being day at school. They had loads of stalls and different organizations in. They do try to educate people”
The interaction of parents, children, schools and health is a complex issue and research in this area remains in its infancy. However, previous research
 has shown that 9–10 year old school children are receptive to interventions and small behavior changes and motivational practices for families may be possible. Indeed, Watson et al.,
 showed improvements in BMI in children were related to adult changes in BMI suggesting a strong interaction of family behavior. Future interventions should investigate these interactions in more detail and how they may shape the future well-being of children. Clearly, an intervention targeting improvements in diet must include some targeted family or parental component, and raises the possibility of family orientated home-school link tasks or parental engagement sessions as possible mechanisms to positively influence the parental role upon food intake.
The emerging themes relating to barriers to healthy eating showed that external drivers such as advertising, the preferred sensory experience of “unhealthy” foods, and food being used as a reward may play a role in preventing healthy eating, in particular FV consumption (Figures
6). The sensory experience of FV consumption, including taste, smell and appearance, has shown a consistent relationship with fruit intake with the taste of vegetables presenting the major barrier
[20, 37]. Krølner et al.
 highlighted that the sensory experience can influence willingness to consume FV; with vegetables described as bitter, and the taste of unhealthy food preferred. The present study data are in agreement with children preferring the taste and visual experience of chocolate, pizza, and chips (Figures
6), which is in line with previous evidence that suggests children prefer the taste of unhealthy foods over healthy foods.
 The sensory experience of FV has been shown to be related to children’s sensitivity to taste and smell and more gradual approaches to introduce FV into the diet have been suggested
. Furthermore, introducing a variety of healthful foods and exposure can encourage greater intake
 however, repeated attempts by parents to encourage intake of specific foods can lead to frustration and parents may eventually may stop trying
 and thus limiting children’s choice of FV.
The practice of showing children pictures of FV has been shown to increase intake and variety of fruit, however this had no effect on vegetable intake
. This suggests visual exposure may be a beneficial potential strategy for children with respect to fruit but not vegetables. However, sensory based nutrition interventions are still in their infancy
 and further scientific evidence with well-designed studies with an emphasis on longer term monitoring are warranted.
Product marketing, via the TV in particular, was highlighted by both adults and children in the present study (Figures
6) with parents showing concern with their children’s desire for “rubbish food”. TV viewing has been shown to positively correlate with BMI in children
 and that children watching adverts relating to “junk food” had a more positive attitude towards this type of food
Other barriers to healthy eating were identified through themes linked with convenience with children stating:
“I just eat anything that is in the fridge”
While parents’ themes were based on money, time, and tiredness (Figure
6, N.B. the term ‘shattered’ refers to tiredness). A previous study of mothers’ perceptions with respect to healthy eating showed that key themes were time, money and convenience were reasons for not eating healthy. Specifically, mothers were aware of public health messages on healthy eating however they were not confident of making changes to improve diet
. Future interventions should respect the limitations of household finances and perceived time constraints that may in turn prevent adoption of a healthy lifestyle of parents, and encourage motivation in parents through involvement.
A number of strengths are apparent in the present study. Firstly, by including participants from varied socio-economic backgrounds, known to be important in health-related behaviours, the findings may be applied across socio-economic groups. Furthermore, the relatively large sample size, whilst using the pen-profiling technique further advances the literature using this methodology. Triangulating data between parents, children and teachers decreased the risk of misinterpretation of data, and also improves the credibility, dependability and transferability of the findings. Furthermore, the key messages from this study will be used to inform and shape the healthy eating component of the CHANGE! intervention, ensuring the intervention is specific to the target population.
In terms of limitations, participation bias may have impacted upon results, with 37% of children invited to take part refusing to participate, despite this the majority of those invited consented to participate and represented a range of socio-economic backgrounds.