Engaging families in physical activity research: a family-based focus group study

Background

Family-based interventions present a much-needed opportunity to increase children’s physical activity levels. However, little is known about how best to engage parents and their children in physical activity research. This study aimed to engage with the whole family to understand how best to recruit for, and retain participation in, physical activity research.

Methods

Families (including a ‘target’ child aged between 8 and 11 years, their parents, siblings, and others) were recruited through schools and community groups. Focus groups were conducted using a semi-structured approach (informed by a pilot session). Families were asked to order cards listing the possible benefits of, and the barriers to, being involved in physical activity research and other health promotion activities, highlighting the items they consider most relevant, and suggesting additional items. Duplicate content analysis was used to identify transcript themes and develop a coding frame.

Results

Eighty-two participants from 17 families participated, including 17 ‘target’ children (mean age 9.3 ± 1.1 years, 61.1 % female), 32 other children and 33 adults (including parents, grandparents, and older siblings). Social, health and educational benefits were cited as being key incentives for involvement in physical activity research, with emphasis on children experiencing new things, developing character, and increasing social contact (particularly for shy children). Children’s enjoyment was also given priority. The provision of child care or financial reward was not considered sufficiently appealing. Increased time commitment or scheduling difficulties were quoted as the most pertinent barriers to involvement (especially for families with several children), but parents commented these could be overcome if the potential value for children was clear.

Conclusions

Lessons learned from this work may contribute to the development of effective recruitment and retention strategies for children and their families. Making the wide range of potential benefits clear to families, providing regular feedback, and carefully considering family structure, may prove useful in achieving desired research participation. This may subsequently assist in engaging families in interventions to increase physical activity in children.

Family-based interventions present a much-needed opportunity to increase children’s physical activity levels. Parental support has been consistently and positively associated with increased physical activity in children [1], and the addition of parent education to school-based physical activity interventions has shown to be effective [2].

However, little is known about how best to engage parents and their children in physical activity promotion [3]. Recruitment rates are often not reported; a review of 23 family-based physical activity interventions was not able to include any information on recruitment compared with those eligible or invited to participate [4]. Failure to meet recruitment targets has several consequences. First, it may lead to underpowered research studies, where clinically relevant changes may appear statistically non-significant. Second, inadequate recruitment strategies may necessitate an extension of the recruitment period; which may be economically and logistically challenging. Third, it may result in recruitment of families which do not accurately represent the wider population, resulting in selection bias. Retention of families is equally difficult; in particular, children from socio-economically disadvantaged families, ethnic minorities, and those at risk of ill health, tend to drop out early [5]. The mean attrition rate (i.e., failure to complete measurement) reported in a review of child health studies was 20 % (range 0–54 %) at initial follow-up, and 32 % (range 0.59 %) for extended follow-up [5]. High attrition rates may also increase sampling bias and compromise generalizability [6].

Recent work consisting of a literature search and Delphi study presented potentially successful strategies for recruitment and retention of children in behavioural health risk factor studies [6]. Beneficial strategies reported included identifying suitable settings and tools for recruitment, eliciting support from key stakeholders/project champions, and ‘creating a study identity’. The authors of this work acknowledge, however, that their results are mainly driven by school-based intervention protocols, and may not be applicable for research conducted in other settings.

Family-focused work to date has engaged mostly with parents; soliciting their views on recruitment, content and delivery of family-based PA interventions [7–9], but none have involved all family members. For example, formative work for a recent family-based physical activity intervention included asking parents where best to advertise (schools were most commonly cited as a preferred locale for recruitment into research studies) [8] . A second study employed participatory processes to ensure parents were involved in all aspects of the intervention, including development of materials, and implementation of intervention activities [9]. However, neither of these involved other family members. To include parents, siblings, other family members, and the target children themselves, would be a novel way to explore recruitment and retention strategies. This inclusive strategy will enable participants to build on each other’s responses, and may help us to understand how family relationships facilitate or obstruct family physical activity.

The aim of this study was therefore to engage with the whole family to understand how best to recruit for, and retain participation in, family-based interventions to increase physical activity in children.

Ethics

Ethical approval for this study was granted by the Cambridge Psychology Research Ethics Committee (University of Cambridge, Application No: Pre.2013.119). All subsequent study amendments were reviewed and approved. Written (parental) consent was obtained for all participants, and child participants provided written assent.

Pilot

A pilot focus group, using a convenience sample, was conducted to refine the study protocol. All procedures from recruitment through to data analysis were tested; pilot participants provided feedback, which was then used to improve each process. Data obtained in the pilot focus group was not included in the final study sample.

Recruitment

Families (including a ‘target’ child aged between 8 and 11 years, their primary caregiver(s) (hereafter referred to as ‘parents’), siblings, and others involved in their care) were recruited through schools and community groups (e.g., scout/guide groups) in the wider Cambridgeshire area. Particular effort was made to contact schools and community groups (through which to deliver recruitment materials) that were located in areas representing all levels of socio-economic status. Initial letters and posters invited families to contact the study team to express their interest in participation. The study co-ordinator spoke with parents on the telephone, answered any questions, and obtained a postal and/or email addresses for further correspondence. Recruitment packets were then sent to families via their preferred method (i.e., postal or email), containing (i) a personalised cover letter, (ii) full study information with a list of frequently asked questions, (iii) written consent forms, and (iv) a brief data collection form. Personalised letters have been shown to elicit greater initial response [10], and therefore children’s, parent’s and sibling’s names were included in all correspondence. Once consent had been provided, appointments were scheduled to include all family members.

Data collection procedures

Basic demographic and anthropometric data (age, sex, height, and weight) of those agreeing to participate were collected using the brief data collection form.

Focus groups were conducted in participants’ homes, mostly during the evening (to ensure all family members were available to participate). A semi-structured interview approach was used. An introductory activity was used as an ‘ice-breaker; participants were asked to share their favourite physical and non-physical activities. This encouraged each family member, along with researchers, to build rapport and ensured participants felt comfortable contributing to the discussion.

Families were then asked to order cards listing the possible benefits of, and the barriers to, being involved in physical activity research. These cards were used as prompts only (developed using feedback from our pilot focus group), and were not designed to provide an exhaustive list. They were asked to highlight the items they consider most relevant, and suggest additional items. Health, social, and educational benefits were listed, as well as the provision of child care, connection with other families, and incentives. Barriers included increased time commitment and/or scheduling clashes, difficulties with transport, financial commitment, and a lack of interest or perceived benefit. Participants were asked to explain their choices (i.e., items highlighted as being of most importance), discuss conflicting opinions, and supplement the list with additional items relevant to their family. Follow-up probes were used by the facilitator (HEB) to encourage further discussion. A second researcher (AS) recorded participant responses (particularly when ordering the cards) and noted family interactions. At the end of the session, AS provided families with a summary of the discussion, offering them a chance to elaborate or add to previous answers. Two digital voice recorders were used to record the session.

Follow-up

All individual participants were provided with a £5 gift voucher and were contacted later with individual feedback on their session, and some interim results.

Data analysis

Demographic data were recorded from the participant questionnaires. The postcode of each family home was used to classify according to socio-economic deprivation. Families were ranked according to social deprivation percentile (those ranked in the higher percentiles represent families of higher socio-economic status compared with the rest of the UK) [11].

Interviews were transcribed verbatim and anonymised by an external data transcription service. Data was then analysed thematically; two members of the study team (HEB and AS) independently read transcripts to identify emerging themes and develop a coding framework [12]. Once complete, the coding frame was provisionally tested with a 10 % sample of transcripts. Discrepancies were discussed, and the coding frame refined (on the basis of both theoretical issues guiding the research questions, and salient issues arising from the transcripts) [12]. Quotations were then clustered around broader themes and these themes were merged or altered where appropriate. Additionally, observer notes (recorded during the focus groups) were coded, and a quantitative count of the ‘card order’ (i.e., the order in which facilitators and barriers were listed by participants) was noted.

All data from the focus groups was recorded and considered, but the main aim of the present analysis was to identify effective recruitment and retention strategies for engaging families in physical activity interventions. Given the complexity of family context and relationships, family case studies were also written (combining demographic information, coded interview transcripts, and observer notes). This more detailed narrative aimed to offer further insight into the potential incentives for and barriers to research participation.

Recruitment of participants to the study is depicted in Fig. 1. A total of 82 individual participants from 17 families took part (not including the pilot session). This included 17 ‘target’ children (mean age 9.3 ± 1.1 years, 61.1 % female), 32 other children (siblings) and 33 adults (including parents, grandparents, and older siblings). The median number of participants per focus group was 4 family members (range: 2–5). Self-identified ‘primary caregivers’ also provided demographic information; indicating a mean age of 44.2 ± 3.9 years. These respondents were mostly women (83.0 %). Socio-economic status (assessed from postcode) was relatively high; 89 % of families (15 families) were classified as being above the 70th percentile (and therefore of higher socio-economic status than the national average). The remaining two families were however, significantly lower; classified as above the 35th percentile, and above the 40th (Fig. 2).

Examples of flashcards used to prompt facilitators/barriers discussion

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Recruitment of participants to family focus groups

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Incentives for involvement in research

Social benefits were cited as being key incentives for involvement in physical activity research, with emphasis on children experiencing new things (even “being outdoors” (grandmother: boy, 10y) was considered beneficial), developing character, and increasing social contact. This was particularly important for parents of shy children;

Mother: boy, 9y: I think improved social skills is good, especially for shy children, I know he didn’t seem it but he can be shy sometimes so that’s quite nice to get them active and sort of connect to other people

Mother: boy, 8y: I mean the biggest thing I hope he improves is his social skills…communication with other kids…will get rid of [his] self-consciousness

Achieving “a balanced life” (mother: boy, 10y) was also important, in which children were able to appreciate a variety of different activities. Making a connection, and “fit[ting] in” (father: girl, 11y), with the wider community was also cited as being of value. For most parents, research participation being of educational benefit for their children was essential (particularly, the children finding an activity “stimulating” (mother: boy 10y));

Mother: girls, 9y and 7y: Well it makes them understand so I think that’s quite important, you know, like doing this [participating in the present study], it makes them understand why things happen so it kind of increases their educational attainment

Fun was a key consideration for both parents and children;

Mother: boy, 10y: But if there were things where it’s possible to go and enjoy it and … but if there were activities at the weekend that I thought were brilliantly pitched at their level, they would have fun, they’d learn, you know, new bowling skills and it didn’t matter if they didn’t go every week than I would be much more inclined to do it

Mother: boy, 10y: Our priority would be, ‘is it something that I genuinely think they’d enjoy?’

Families also gave priority to the perceived health outcomes of being involved in physical activity research, commenting that to be “fitter…and possibly just getting stronger” (grandmother: boy, 10y) would be of value. When asking the children what they considered to be the potential advantage of such research participation, weight loss or maintenance was commonly suggested;

Boy, 7y: The more active you are, the more weight you lose

Girl, 9y: [You would take part in physical activity research] because you don’t want to be fat!

For most multiple-parent families (or families where practical support was given by other relatives), the provision of child care was not considered to be of sufficient appeal to encourage study participation, viewed as a “useful” (mother: girl, 11y) adjunct or bonus;

Mother: boy, 10y: But it’s only childcare if it comes with some other things as well so it’s not just any old childcare

Single parents, however, saw the provision of child care as more beneficial;

Mother: boy, 9y: Providing childcare would be relevant to me ‘cos, as you know, I’m on my own

Financial incentives for participation in research were not highly valued; families commented that the opportunity to contribute to something “meaningful” was of greater worth (mother: boy, 10y). Indeed, three families declined the offer of vouchers for involvement in the focus groups themselves. The receipt of detailed feedback was suggested as an alternative impetus;

Father: boy, 10y: Being informed of outcomes, and seeing progress in your child

Barriers to involvement

Increased time commitment or scheduling difficulties were quoted as the most pertinent barriers to involvement in physical activity research. This was especially true for families with several children;

Mother: boy, 10y: If two children of different ages had to be in two places at once that would be difficult

Parents suggested that research activities should be kept outside of both working hours and extra-curricular club periods;

Mother: boy, 10y: But often school clubs finish at what, 4.30 pm, and because they don’t go to bed ‘til 8.30 pm, there’s a four hour gap and often you and your friends, you’ll be either watching TV, or on your Xbox…when actually if there was something really good to do in a sports centre that was absolutely targeted at your age that would be great

In contrast, single parents considered that providing intervention activities during working hours (when paid childcare would otherwise be required) would encourage participation. Activities requiring extensive time investment, or attendance at inconvenient times of the day, were poorly received. Some families mentioned challenges with transport, but they noted that these could be overcome if the perceived benefits of involvement were sufficient (“if there is obvious benefit” (father: boy, 10y)).

Given the potential benefit of engaging the family in physical activity promotion [1, 2, 13], understanding how best to recruit for, and retain participation in, such intervention research is essential. Work conducted to date has included either parents or children, but has not involved all members of the family [7–9]. This study was the first to do so, and included parents, children (including siblings), and, in one case, grandparents. Perceived benefits of research participation were explored, and families were able to identify the elements of a physical activity intervention that would encourage their involvement. Challenges or barriers to participation were also debated between family members.

When recruiting, making the potential benefits of research participation clear to families was deemed essential. In particular, parents perceived educational, social, and health outcomes to be most relevant (whilst children cited ‘fun’ as a primary motivation for involvement). Strong advertising materials, which succinctly outline the possible advantages of involvement (whilst still clarifying any possible risks), may be useful in increasing initial expressions of interest. This advice is mirrored in Schoeppe and colleagues’ REACH strategies, who list providing clear and simple information describing expected study benefits, as critical to effective recruitment [6].

This focus group study was innovative in the inclusion of all family members, and the thorough exploration of incentives and barriers to research participation. This study was conceived in response to calls for better understanding of how best to recruit and retain participants in family-based physical activity research [3]. However, as if to further highlight the challenging nature of such work, enrolling families into the present study was difficult (see Fig. 1). The relatively high socio-economic background of participants may limit wider application. Although every effort was made to recruit a range of families, the disproportionate wealth in Cambridge and the surrounding areas made this problematic. Future studies should target participants from low socioeconomic backgrounds to investigate whether there are unique barriers and facilitators to research participation is this ‘hard to reach’ population. To offset this potential source of bias, case studies exploring individual incentives for and barriers to research participation, were also included. The inclusion of such detailed family narrative enables further understanding of the complexity of family context.

Regular feedback on the children’s progress and performance was suggested to retain families in physical activity interventions. Given the importance of motivation in adherence to similar trials [14–20], offering regular feedback may be essential in retaining families in physical activity interventions. Additionally, parents suggested that receiving information about their children’s health and behaviour, which they may not otherwise access, would provide sufficient incentive for engagement in research. However, researchers need to be mindful that intervention efficacy is often contingent upon participants’ understanding of their own behaviour. Ensuring that inactive families are aware of their inactivity, through effective feedback strategies, may increase their motivation to change behavior, and subsequent behavior [21]. This may however have unintended consequences for an evaluation, including positive behavior change in the control group, which may lead to an inability to observe true intervention effects [22].

Single parent families may be a key target group for physical activity intervention. Observational evidence suggests that family structure is important in the physical activity levels of children; for example, girls from single parent families have reported significantly more minutes per day watching television compared with girls from two-parent families [23]. In the present study, the data provided from single parent families differed considerably from that provided by multiple-parent families, or families in which childcare was available from other relatives. Single parents saw the provision of childcare alone as a sufficient incentive for involvement; particularly, offering an intervention during working hours (when paid childcare would otherwise be required) would encourage participation. When recruiting, researchers should consider family structure, and tailor advertising materials and intervention delivery to suit the target context.

These key lessons may contribute to the development of effective recruitment and retention strategies for children and their families. Making benefits clear to families, providing regular feedback, and carefully considering family structure, may prove useful in achieving desired research participation. This may subsequently assist in engaging families in interventions to increase physical activity in children

We would also like to acknowledge the generous contribution of Dr Cornelia Guell (Career Development Fellow at MRC Epidemiology Unit) for her help interpreting the qualitative data.

Affiliations

1. MRC Epidemiology Unit and UKCRC Centre for Diet and Activity Research (CEDAR), University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Box 285, Cambridge, CB2 0QQ, UK

   • Helen Elizabeth Brown
   • , Annie Schiff
   •  & Esther M. F. van Sluijs

Corresponding author

Correspondence to Helen Elizabeth Brown.

Competing interests

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. This work was supported by the Medical Research Council [Unit Programme numbers MC_UU_12015/7], and undertaken under the auspices of the Centre for Diet and Activity Research, a UKCRC Public Health Research Centre of Excellence which is funded by the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, and the Wellcome Trust (RES-590-28-0002). This article presents independent research in which the funders had no involvement in the study design; the collection, analysis, and interpretation of data; the writing of the article; or the decision to submit the article for publication. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health or the other funders.

Authors’ contributions

EvS and HEB conceived of the study, including its design and methods. HEB and AS recruited participants, conducted data collection and performed duplicate content analysis of transcripts. HEB led interpretation of results and drafted the manuscript; all authors read and approved the final manuscript.

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