Ti

tle:

Children’s views (aged 9-10) about healthy eating:

Comparing two exploratory case studies (to

tackle/address childhood obesity).

Au

thor:

Khajik

Sirob Yaqob

Da

te:

September

2013

Ins

titution:

1

The Westminster Institute of Education at Oxford

Brookes University;

ʻThis dissertation is submitted in partial fulfilment

of the requirements governing the award of the

Master of Arts in Childhood Studies’.

Statement of

originality

This Dissertation is an original piece of work which

is made available for photocopying and for

interlibrary loan, with permission of the Head of

School of Education.

Signed………………………………………………………….

2

Acknowledgments

Many thanks in particular to Professor Debra McGregor for her

help and support in the evolution of this project. I am

grateful for teachers and children from the Primary school

group and local Church cohort who gave so freely of their

time. Also, I would like to express appreciation to Georgina

Glenny, Nick Swarbrick and James Bird for their assistance in

the field work without whom this project would be

insurmountable.

Abstract:

This research study was designed to explore children’s (aged

9-10) beliefs about healthy eating and what they manage to eat

healthily. It was exploratory to the way that two different

groups of children conceptualized healthy eating to compare

between them. One was at a primary school cohort and another

at a local Church group. The same questionnaire comprised of

3

14 questions was administered to children in both cohorts with

the twenty-six year 9 and 10 participants to explore how they

perceived healthy eating. Total number of children (aged 9-10)

was 26, 19 at primary school group and 7 at local Church

cohort. Both cohorts were from the same ethnicity (whitish-

British), age, gender and low-middle socioeconomic states and

different level of education of parents.

Overall, findings from primary school age group were somewhat

concerning of such a school which has been already committed

to a healthy eating policy. Although children at primary

school age group were more likely to make healthy food choices

than those of the local Church group, (77.3% vs. 47.1%) 71%

favour to eat unhealthy foods. Other concerning finding

included, the indications that 26.3% of children at the

primary school group as compared to 28.5% of those in the

local Church group thought that pasta is made from cheese and

14.2% of children at local Church cohort believed that pasta

is made from meat. 10.5% of children at primary school cohort

perceived that egg is made from Cow and 5.2% believed that

Crisps is made from plastics. The results also suggest that

children in both cohorts had a different gender food

preference for the same quality of food they favoured. Rather

surprising findings were misconceptions of healthy and

unhealthy breakfast in both cohorts. 100% of children in the

local Church group as compared to 36.8% of those at primary

school cohort had knowledge of healthy eating from their

parents. Although findings from such a small sample is not

generalizable, results suggest that children had differences

4

in their understanding of healthy eating in both cohorts and

redirection of policy and practice in the school is required.

Key Words: children’s, beliefs, healthy eating, childhood

obesity, questionnaire, local Church group, primary school

cohort, exploratory comparative research study, two case

studies.

Contents

1.0

Introduction………………………………………………………………………….............

..... 9

2.0 Literature review………………………………………………………………………. 13

2.1 Mothers´ perceptions of obesity in their

children……………………… 13

2.1.1 Factors that raised maternal concerns

about childhood obesity.. 14

2.1.2 Maternal views of contributing

factors……………… 14

2.2 Men’s understandings of obesity…………………………………. 14

2.3 Children’s understandings about their own and

other bodies’ health…. 15

5

2.4 Cognition development and relation to healthy

eating………………. 18

2.5 The relevance of breakfast………………………………………………………….

21

2.5.1 Breakfast habits through the

world…………………………………. 22

2.5.2 Food choices for

breakfast……………………………………………….. 22

2.5.3 Children’s views on what represents a

healthy breakfast…. 23

2.5.4 What is a Balanced Breakfast Model?

…………………………….. 24

2.6 Fruits and vegetables (FV) consumption,

attitudes and beliefs towards FV

And peer/parent/teacher influences on

children’s FV attitudes…… 25

2.7 Children’s diets and relation to behaviour and

performance…………. 27

2.8 Children’s views about food

origin………………………………………………… 30

6

2.9 Children’s views on foods and consumption of

selected food groups… 30

2.10 Gender differences in food

preferences………………………………………… 31

3.0 Research design and

methodology………………………………………………… 32

3.1 Development of the

question…………………………………………………… 32

3.2 Rationale for this research

question………………………………………… 33

3.3 Quantitative vs. Qualitative

research……………………………………….. 33

3.3.1 Advantages and disadvantages of

a questionnaire survey….. 34

3.3.2 Advantages of interviewing and

issues for consideration…. 35

3.3.3 Shaping a case

study…………………………………………………………. 36

3.3.4 Issues to consider when

undertaking a case study…………… 39

7

3.3.5 Types of case

study…………………………………………………………… 40

4.0 Ethics………………………………………………………………………………………………. 40

5.0 Fieldwork period……………………………………………………………………………..

42

5.1 The participating school (first

group/cohort)………………………. 42

5.1.1 The local Church group (second

case study group/cohort)… 45

5.2 Data

collection……………………………………………………………………… 46

6. Data analysis………………………………………………………………………………………

47

6.1 Results of the questionnaire

survey for children………………… 47

6.2 Descriptive data and

findings………………………………………………… 47

6.2.1 Children’s responses to the

question regarding the definition of

Healthy eating (Q1)

………………………………………………………… 47

8

6.2.2 Source of knowledge for children

about healthy eating (Q2)… 49

6.2.3 Children’s knowledge regarding

healthy snack box contents

(Q3)

…………………………………………………………… 50

6.2.4 Matters children considered when

choosing food (Q4)……. 51

6.2.5 Children’s least and most

favorite food choices (Q5) ... 53

6.2.6 Children’s understandings

regarding “5 a day” (Q6)……… 56

6.2.7 Responses of children in both

groups about the question “Why

do you think calcium is an important part of your

diet”? (Q7)… 57

6.2.8 Children’s understandings of

fish as a healthy diet (Q8)……… 58

6.2.9 Children’s beliefs about fresh

fruits and vegetables as a healthy

9

Diet (Q9)

……………………………………………………………. 59

6.2.10 Children’s views regarding

water as an important part of a

Healthy diet (Q10)

…………………………………………… 60

6.2.11 Children’s knowledge regarding

a healthy person (Q11)… 62

6.2.12 Children’s perceptions about

food origin (Q12)…………. 63

6.2.13 Children’s habits of taking

breakfast (Q13)…………………. 65

6.2.14 Children’s knowledge of

healthier food choices (Q14)……. 69

7. Discussion………………………………………….. 72

7.1 Matters for consideration in choosing

food by children (Q4)…….. 72

7.2 Gender food preferences (Q5)……………………………

74

10

7.3 Children’s knowledge regarding healthy

person (Q11)…… 76

7.4 Children’s understandings about food

origin (Q12)………… 77

7.5 Children’s habits of eating breakfast

(Q13)……………… 78

7.6 Children’s knowledge of healthier food

choices (Q14)………. 80

7.7 Source of knowledge for children about

healthy eating (Q2)…. 81

8. Limitations………………………… 82

9. Conclusions ……………………………… 83

9.1 Conclusion of study of primary school

cohort……………………………. 84

9.2 Conclusion of survey of local Church

group……………………………….. 86

References………………….. 88

11

Appendices ………………………………………….. 104

Appendix 1: Letter to parents………………. 104

Appendix 2: Letter to head………………….. 105

Appendix 3: Ethical Approval Form ………. 106

Appendix 4: Questionnaire administered to cohort 1 &

2….. 111

Appendix 5: Cover letter for questionnaire ……….. 112

Appendix 6: Interview questions (devised in

preparation for school based research)……… 114

Appendix 7: Revised questionnaire (in light of

research findings)….. 116

Appendix 8: A (research informed) example Healthy

Eating policy for primary school……………. 117

Appendix 9: Tentative suggestions for guidelines that

parents should pay attention to (School or general

guidance)…….. 120

Appendix 10: More suggestions for shaping my

dissertation…………………. 122

12

1.0 Introduction

As a qualified general practitioner, I have long been

concerned with general health issues and notoriously concerned

with children’s (aged 9-10) perception of healthy eating. My

apprehension is increasing as a result of rising incidence of

childhood obesity and type 2 diabetes. Globally, 10% of all

children and 43 million children under 5 years are either

overweight or obese (Livingstone, 2013). This statistic

indicates there is a 60 % increase in childhood obesity over

two decades. My motivation to study this, therefore, I

intended to do this research study to explore children’s views

of healthy eating and to manage their misconceptions with the

appropriate education promotion of healthy eating in the

primary school. Also to make children further appreciate the13

dangers of childhood obesity through exploration and support

of their understandings about healthy eating.

However, my main challenges lay in reconciling my different

roles as a health practitioner, future teacher and educational

researcher. As a general practitioner, I already had some

experience of paediatric food and nutrition practices, but I

wanted better understand children’s views to promote healthy

eating education programs in primary schools. As a future

health educator, I wished to support staff in their teaching

about healthy eating education who in turn can improve child's

knowledge about healthy food; and finally, as an educational

researcher, I wanted to benefit the academic community by

contributing to the scholarly debate on this topic.

Obesity is defined as “abnormal or excessive fat accumulation

that might have a negative impact on health” (WHO, 2013).

Livingstone (2013) stated that Body Mass Index (BMI) as a

person’s weight in kilograms divided by the square of his

height in meters (kg/m2). A BMI greater than or equal to 25

is overweight and a BMI greater than or equal to 30 is obese.

Childhood obesity is defined as a BMI exceeding the 85th or the

95th percentiles (Reilly et al., 2003). BMI is an international

standardized way of defining of obesity in children, and it is

a simple index of weight for height often used to classify

obesity and overweight in adults (Livingstone, 2013).

Furthermore, BMI for children is gender and age specific as

BMI varies dramatically with age and sex as body fat changes

with growth and maturity. Therefore, to measure BMI in

14

different age and sex, specific growth reference charts are

needed. For instance, those produced by WHO, International

Obesity Task Force (IOTF), the U.S. Centres for Disease

Control and Prevention (CDC), and the British 1990 Growth

Reference (UK90) Standards. However, at different ages these

criteria give somewhat various estimates of overweight and

obesity prevalence. So, when we consider the lack of

nationally representatives’ surveys that measured heights and

weights of children over time, there is really an issue to get

a good handle of the prevalence of childhood obesity.

According to Livingstone (2013), childhood obesity is one of

the serious public health challenges in the 21st century

because of the negative impacts of childhood obesity on

childhood mental and physical health. For instance, very young

children are aware of the negative views hold by the society

in addition to poor self-esteem, depression, teasing and

discrimination by peers and the psychological impact of

childhood obesity might persist into adulthood. Also, the most

serious complication of childhood obesity is type 2 diabetes

which might result in obese middle age adults and early

dementia. Once childhood obesity is established, obesity is

notoriously difficult to treat. Nevertheless, childhood

obesity and its associated co-morbidities are largely

preventable. Obesity is the result of a complex interplay of

several factors; genetic, environmental (lifestyle and

dietary), cultural, socioeconomic and psychological factors.

Livingstone (2013) stated that childhood obesity is a real

issue as approximately 30% of obese children and 70% of obese15

adolescents will go on to become obese adults. Girls are more

likely to be affected than boys. The longer a child remains

obese beyond 3 years old the more likely that obesity will

persist into adulthood. Also, childhood obesity appears to

result in premature disability and premature death. Possibly

by 2020, worldwide, 9% of all preschool children

(approximately 60 million children) will be obese; if no

significant intervention is done. However, according to the

International Association for the study of obesity (IASO,

2012) the highest Prevalence of childhood obesity is in the

USA and this is followed by the UK and Australia (IASO, world

map of childhood obesity, 2012). Globally, the rates of

obesity are increasing in all countries and till late 1970s

the rates were static and started to increase in the early

1980s (Livingstone, 2013).

Recently, Jack Johnson (2013) stressed that the NCMP (National

Childhood Measurement Program) worryingly show that across

Oxford county 7% of children (aged 4-5) and almost 16% of

children (10-11) are clinically obese.

In Livingstone (2013) terms, Obesity is a result of chronic

imbalance between energy we ingest and energy we expend and

over 100 variables might impact directly or indirectly on

energy balance. Also, Gibney (2012) suggested that:

“If we give obesity a biological complexity score of 100, then cancer will score

10 and chronic heart diseases will score 1”.

Therefore, it is evident that, an unbalanced diet, low fruit

and vegetables and low physical activity, can lead to

16

childhood obesity, abnormal behaviour and low school

performances (Wheelock, 2007, p. 17).

Paquette (2005, p. S15) suggested, however, that it is

necessary to better appreciate the public’s perceptions of

healthy eating to assess how people interpret and use health

promotion messages in their daily life. This is essential to

develop successful healthy interventions. Others (Lupton and

Chapman, 1995; Lupton, 1996; Nestle, 2002; van Dillen et al.,

2003) assured that many components of foods must be studied to

determine their healthy value, e.g., type of fat. This is as a

consequence of evolution in nutritional science over the last

century which increased the complexity of the definition of

healthy foods. Consequently, people gather information on food

and nutrition from health professionals, television, food

labels and manufactures. They have to well understand the

advantages of this information and how to apply it in their

everyday life.

According to Paquette (2005, p. 15) perceptions of healthy

eating are defined as “the public’s (children, adolescents and

adults) and health professional understandings, meanings,

views, attitudes and beliefs about healthy eating, eating for

health and healthy foods”. The public’s perceptions of healthy

eating deemed to be heavily influenced by dietary guidance,

which recommend fruit and vegetables, meat, limitation of fat,

salt and sugar, variety, moderation, fresh and balanced food

(Health Canada, 1990, 1992; Paquette, 2005, p. 16).

17

Also, healthy eating is “the consumption of a wide variety of

fresh fruit, vegetables, legumes, whole grain cereal food and

protein-rich food” (Worsley and Crawford 2004). This is

suggested by the Australian guide to Healthy Eating (Smith et

al., 1998) and The Australian Dietary Guidelines for Children

and Adolescents (NHMRC, 2003). Healthy eating is significant

for children’s growth and development and to achieve their

best educational potential (NHMRC, 2003; Journal of the

American Dietic Association, 1999, pp. 93-101). Furthermore,

food preference and eating habits established in childhood

often persist into adulthood; children are appropriate target

group to positively influence dietary habits (Nu et al., 1996;

Skinner et al., 2002; Nicklas et al., 2004). Food Preference

is a vital predictor of children’s food intake (Nu et al.,

1996; Perez-Rodrigo et al., 2003; Bere and Klepp, 2005). For

instance, children have an uncertain lower preference for

vegetables than fruit (Edwards and Hartwell, 2002; Perez-

Rodrigo et al., 2003).

Particularly, my remit focused on exploring how do children

(aged 9-10) understand healthy eating, and what they do to

attain that? I tried to develop a project that would encompass

evidence of effectiveness from all of these areas and that

could be piloted in a primary school. It was my intention

therefore that, through undertaking this area of work as a

research project, I would be able to demonstrate year 5 and 6

children’s awareness about healthy eating in a school based-

setting. Consequently inform the participant school about the

18

research outcomes and to employ them for the educational

welfare of the involved school.

Nevertheless, this study follows the following structure:

1. A review of literature relating to perception, healthy

eating, children, school-based setting, favourite food,

cognition development, attitudes and beliefs, fresh

fruits and vegetables, eating 5 a day, water, healthy

person, food origin, healthy breakfast, healthy choices

and decisions, food and gender preferences, behaviour and

performance, that informed my decision to undertake this

research field and determines the context within which

the study was ordered.

2. A synopsis of my research methodology, demonstrating the

rationale for my choices, including the discipline upon

which I am describing, the paradigm adopted, and research

methods selected.

3. A field work, an account of the steps involved throughout

the project, so that others could replicate my work, if

desired.

4. An analysis and discussion of the findings of the

research project. These are presented in chapters based

on data collection methods; but address issues raised in

the research approach such as a quite two small samples

of children (aged 9-10) were collected, just 26, from two

different groups. One from a primary school cohort and

one from a local Church group.

19

5. A conclusion, examining the wider implications for this

survey and implications for policy in school working and

for practice need to change.

2.0 Literature review

2.1 Mothers’ perception of obesity in their children:

Childhood obesity occurs within the context of the family life

and especially mothers are implicated in the rapid growth of

the prevalence of childhood obesity (Golan and Crow, 2004).

Usually mothers (Baughcum et al, 2000) influence the nature,

quality and quantity of food available to their children. They

are shaping the food related to their children’s attitudes and

behaviours, and create the family mealtime environment and

influence ceremonies around eating (Gable and Lutz, 2000;

Hodges, 2003; Golan and Crow, 2004). Furthermore, Myers and

Vargas (2000) found that only 20% of sampled mothers were

aware of overweight in their preschool children. Similarly,

(Baughcum et al, 2000) found that 35% of 200 of socially

deprived parents of preschool children were unable to identify

overweight in their preschool children.

2.11 Factors that raised maternal concerns about

childhood obesity:

Various factors might increase maternal awareness about their

children overweight, such as when their children could no

longer fit into age appropriate clothing. Other events that

20

triggered concerns like negative comments from relatives and

friends, and realizing their child in a class photo. Also,

acknowledging their child was larger than their peers were, or

being told that their child was outside percentile charts by a

paediatrician (Jackson et al., 2005).

2.12 Maternal views of contributing factors:

Some mothers believe that certain contributing factors might

contribute to childhood obesity such as family or cultural

factors, inactive lifestyle, not drinking enough water or

inadequate food chewing, genetics and slow metabolism

(Jackson, 2005). Others believe that a large infant is a

healthy infant and therefore, this is an indication of

successful mothering (Baugheum, 1998). According to (Jackson

et al., 2005), some mothers think that kids consume more than

their siblings, and they suffer lack of self-control where

food is available.

Moreover the contribution and support of parents is important

for any future intervention to prevent and manage childhood

obesity (Jackson, 2005). However, (Myers and Vargus, 2000)

indicated that it might be difficult for the paediatricians

themselves to identify childhood obesity and this is an area

to be addressed if families are to be assisted successfully.

2.2 Men’s understandings of obesity:

Weaver et al., (2008) stated that when the word obesity is

used in everyday language it does have different meaning to

the word clinical obesity. Obese people were described by men

21

ages 25-40 years old as being fat with a central obvious

distribution of the excess weight, and words like round or the

balloon are used (Weaver et al., 2008). Furthermore, others

define obesity as somebody being overweight, and not

necessarily unfit, but struggle with their breathing and

movement. For instance, men who had a BMI>25 described feeling

comfortable with how they look. Another example, men with BMI

of 36 thinks it is unhealthy to be too thin particularly in

women (Weaver et al, 2008).

(Weaver et al, 2008) found that men understand that health

issues appear because of being very heavy and that people with

high BMI could be strong and healthy. Besides, men are aware

of the complexity of issues related to weight and fitness. For

example, people of the same weight, normal or otherwise, can

have very unlike fitness levels and therefore different in

terms of health. Likewise, men realize the positive value of

physical exercise on wellbeing and they think that exercise

can counteract the ill impacts of an unhealthy diet.

Additionally, (Weaver et al, 2008) suggested that men

understand constitutes of healthy diet and many men prefer to

eat healthy eating. There was an awareness regarding policy

intervention to promote healthy eating campaigns. For example,

most men described a sensible approach to healthy eating such

as mentioning 5 portions of fruit and vegetables a day. Also,

they included references to brown rice, brown bread, avoiding

high fat, salt, sugar, and processed foods.

22

2.3 Children’s understanding about their own and

other bodies’ health:

According to Burrows (2007) primary and secondary school

students emphasized that food and exercise, across all school

settings, were expressed as vital approaches for getting

healthy apart from year group, socioeconomic context and

ethnicity. Eating fresh fruit and vegetables with good

exercise can make positive changes to one’s health status.

Primary school kids believe that eating fruit and vegetables

and/or running are the key provisions for a healthy future,

whereas older children understand health strategy is keeping

away from junk food, fizzy drink and fatty food, regular

physical exercise and eating smaller portions of food. Girls

deemed to be more aware of their health than boys and they try

to change what they eat and drink. Therefore, such gender

difference, explain the relative increase in the number of

young women in the secondary level thinking about changing

diet and exercise to minimize stress created by unhealthy diet

in the adolescent age (Drewery and Bird, 2004; Evans et al.,

2006; Wright et al., 2006).

Many children can make judgments about healthy persons simply

by looking at a person. Consequently, fitness, non-fatness,

health with size, shape, and weight, and indications that

one’s capacity to run, together with what they eat, may be

responsible for the way they look and therefore their health

(Burrows, 2007). Young children (aged 9-10) are keen to draw

these kinds of links between health and corporeal markers.

23

This notion that health can, in a sense, be read off the body

is deemed to be crucial, particularly, for physical educators’

revision (Crawford, 1980; Tinning, 1985; Shilling, 1993;

Markula, 1997).

According to Burrows (2007) some children think that being

healthy is that the state of being not too thin and not too

fat, but rather, just right. They believe that being too thin

means ill-health and they point to a main focus on obesity as

an indicator of poor health. They, also, understand that

genetics play a confounding role in the potential afforded to

people to become slim or thin or just born big or little,

therefore, not everyone is equally positioned to become the

ideal (Kirk and Colquhoun, 1989). Likewise, some children

trying out the recommended food and exercise portions and

letting out that these practices made little disparity to

their weight or size provoked a questioning of the value of

particular health essentials. For others, this understanding

that they were doing the right thing and those bodily changes

were still not taking place. This made them more concerned

about their health and their capacity to make healthy changes

in their own lives. Thus, the imperatives to eat 5 a day or

push play for 60 minutes do not essentially yield parallel

outcomes across diverse populations or even for persons within

the same household.

However, Burrows (2007) stated that skilled senior students

(aged 10-11) think that skinny people might eat junk food and

do not exercise, this does not mean that skinny people are

healthier than fat people. Also, senior children suggested24

that when kids are eating and exercising right and trying to

be healthy, they are still considered unhealthy by others.

This is because, as others suggested, their body does not

match the normative outcome of the imperatives-that is a slim

body. While, the younger children (aged 9-10) do not have

similar skills and/or experience to draw on to challenge these

consistent ideas. The senior children are more able to reject

the imperatives, stick up for their own health status, and

competently build plans to ward off other people's judgments

of their health and/or weight. This might be a developmental

phenomenon or an occasion of more attention for children in

elementary and secondary schools to providing them with

opportunities to critique orthodoxies (Gillespie and McBain,

2003; Drewery and Bird, 2004).

Moreover, a research study by Burrows (2007) revealed that

gender and age are potentially essential shaping influences on

how young children think about their own bodies and health.

This study conducted with four New Zealand schools, two

secondary and two primary, 795 students were involved in this

study to explore how the participants think and understand

their own health and that of the others. On time, “I feel good

about my body”, asked participants to choose between one of

three options, always, sometimes or rarely. Regarding

secondary school response, 67% of year 11 students responded

sometimes or rarely as compared to only 44% of the primary

school children. Also, senior girls were the most likely to

rarely feel good about their bodies. Roughly, 48% senior males

always feel good about their bodies while just 27% of the

25

girls did. Among junior children, 61% of boys always feel good

about their bodies as opposed to 51% of girls.

These findings yields marked differences in girls’ and boys’

responses and also points to links between advancing age and

increased body dissatisfaction. A marked gender and age-

related differences were clear when participants asked if they

feel happy with their current weight, and if they need to get

thinner. For example, 52% senior children boys have been

always happy with their weight as opposed to 30% of girls.

Also, 30% of boys in secondary school responded “yes” they

need to get thinner compared to 62% of girls saying “yes”. In

primary school children, just 4% gender difference responses

were derived (38% boys and 42% girls).

2.4 Cognition development and relation to healthy

eating:

A cognitive development model with four consecutive stages

developed by Jean Piaget include: sensory-motor period (0-2

years), pre-operational stage (2-7 years), concrete

operational stage (7-11 years) and the formal operational

stage (11-15 years). Along these stages, children’s thoughts

change from concrete to abstract as they grow and develop.

Children become more independent; they develop better

knowledge capacity and become more able to resolve their own

problems with better awareness for details (Delfos et al.,

2003; Flavell and Piaget, 1963; Rodder-John 1999 and Shaffer,

2003). Contento (1981) found that, children in the pre-

operational stage were unable to distinguish between food and

26

snacks, whereas those in the concrete operational stage did.

Pre-operational children thought that the ingested food did

not change in the body after being consumed. Concrete

operational children believed that food was changed by some

means in the stomach. The Pre-operational children could

refer to foods that were healthy, but they could not explain

why. Concrete operational children could tell or made the

correct connection that food made someone strong, grow and

healthy, but they could not explain why or how this occurred.

Bahn et al., (1989) stressed that, in both pre-operational and

concrete operational children, they concentrated mainly on the

quality and feature of the brand, for instance, liking the

taste or the colour of the package when they were

distinguishing the brands. Concerning preference, concrete-

operational children focused more on cognitively based

attributes, such as healthiness and adultness, than pre-

operational children. Besides, the thought of food rejection

based on distaste, danger and inappropriateness, is in line

with the growth of the child and the idea of contamination

appear gradual between the ages of 3.5 years and 12 years

(Fallon et al., 1984; Rozin et al., 1986).

However, there is a gradual emergence of different classes of

food rejections as child grown-up. Very young children of 1-

2.5 years old accept almost all kinds of edible and inedible

substances. The first rejection category to appear is

distaste; disliked products are eliminated. Secondly,

rejections based on danger appear. This means that products

are rejected because unenthusiastic consequences of ingestion27

are likely. The third refusal group is based on the idea of

what something is or where it comes from (ideational). This

class can be split into disgust, and unworthiness. Disgust

means that the association with the food product is unwilling,

whereas inappropriateness means that the food product is not

considered to be a food. It is not until the age of 7 that

children differentiate between disgust and inappropriateness

(Fallon et al., 1984; Rozin et al., 1986 and Zeinstra et al;

2007).

Others (Fallon et al., 1984; Rozin et al., 1986) suggested

that, the idea of contamination appears gradually between ages

of 3.5 and 12 years. A food is contaminated when even a trace

amount of a disgusting or inappropriate product has been or is

present in the food. This development of food rejection is in

line with the growth of the child. Also, between the ages of 2

and 7 (Rozin et al., 1986 and Delfos, 2003) children become

more independent eaters and they have to learn which foods is

edible and which foods are not.

Furthermore, the ideas children have about specific nutrients

can determine their taste, their eagerness to taste and their

whole eating experience (Oram, 1994). Consequently, these

different thoughts, perceptions and decision strategies may

significantly impact on interventions aimed at changing food

preferences and intake. Because most current approaches have

not been effective in establishing long term changes in fruit

and vegetable consumption, cognitive development may be a

promising field for achieving such changes (Zeinstra et al;

2007). Such information is crucial to know how the differences28

in cognitive development relate to children’s perceptions of

healthy eating, therefore; on the basis of the cognitive

development theories, it is expected that the number of

cognitions about healthy eating will increase as the child

matures and that these cognitions will increase in complexity

and abstraction.

In (Zeinstra et al; 2007) terms young children focus on

appearance and texture, whereas older children focus on taste

aspects. Comparable results were found by (Rose et al., 2004)

with sensory preference for meat. Others, (Szczesniak, 1972

and Oram, 1994) suggested that, for 6-7 year old children,

mouth feel characteristics were most imperative for liking,

whereas in 10-11 year old children flavour and smell were most

significant. The reduced significance of textural attributes

is due to the child's development of their teeth and jaws, and

texture is vital for disliking and liking products among the

youngest children's age groups. (Zeinstra et al; 2007) stated

that, young children could not identify the specific taste of

the product but they could tell whether they liked or dislike

the taste of the product. This study in line with the study of

Liem et al., (2004) where 4 year old children failed to

differentiate sweetness intensities during discrimination

tests but could point to their favoured solution.

(Roedder-john, 1999; Valkenburg and Cantor, 2001) found that

preoperational children focus on the most exceptional

attributes that catch the eye, whereas older children use more

functional and underlying characteristics. One characteristic

of cognitive development is a raise in the level of concept29

(Flavell and Piaget, 1963; Delfos et al., 2003). This increase

was seen in children’s improved perceptions of health and the

basic tastes, the shift in classification from concrete groups

to abstract categories, the increase of abstract relations,

and more conceptual arguments concerning healthiness. Roos

(2002) and (Zeinstra et al; 2007) stated that 9-11 year old

kids could make healthy food choices, and this is confirmed by

(Hart et al., 2002) where food nutrient and food-health links

were used between 7-11 year old children as an explanation for

the healthiness of food.

Likewise, parents play an important role in the nutrition

behaviour of children and they employ different patterns

depending on the age of the child (Fisher and Birch, 1999;

Hart et al., 2002; Bourcieret al., 2003; Wardle et al., 2005).

According to (Flavell and Piaget, 1963; Roedder-John, 1999;

and Delfos, 2003) parents use food deals or instrumental

rewarding because it is a concrete strategy for the child, for

example, (“if you eat your vegetables, you will get a candy”).

This food deal was more frequently reported by younger

children (7-8 years) compared to older children (10-11 years).

In the oldest age group, children are less egocentric, and the

instrumental rewarding appears to fit their cognitive

capacities. They have a better understanding of value, and

they can understand another’s perspective. The above subjects

are crucial to understand how cognitive development and

preferences are linked. Therefore, difference in cognitive

development are reflected in changes in attribute importance

in relation to liking and disliking foods, in children’s

30

understanding of, and reasoning about, health, and in the

child-reported parental use of strategies.

2.5 The relevance of breakfast:

In exploring the significance of breakfast, it is relevant to

find an acceptable and a unifying definition for breakfast.

Breakfast is defined as the first meal of the day, eaten

before or at the start of the daily activities within two

hours of waking, typically no later than 10:00 am, and of

caloric level between 20% and 35% of total daily energy needs

(Timlin and Pereira, 2007). Through various physiological

mechanisms, breakfast skipping might result in up-regulation

of appetite, worse overall dietary quality, and a leading

cause of obesity, diabetes and cardiovascular diseases. Also,

increased meal frequency is associated with metabolic changes

improving risk factors for chronic diseases, and reduce

appetite and energy intake (Speechly and Buffenstein, 1999;

Speechly et al., 1999) and (Farshchi et al., 2004; Farshchi et

al., 2005). Such metabolic changes are primarily related to

breakfast composition, namely high-carbohydrate, low-glycemic

index and fibre-rich foods. Consequently, regular breakfast

consumption is associated with lower risk of chronic diseases

(Pereira et al., 1998; Liese et al., 2003).

Recently, in a study involved primary and secondary school

children, BBC news (2013), stressed that “an alarming number

of children do not eat breakfast each morning” and the numbers

skipping breakfast is increasing with age. Nevertheless, 8% of

elementary children had not breakfast on that morning of the

31

research. This increased almost to a quarter (24%) of 11-14

years old and almost a third (32%) of 14-16 years old.

(Nicklas et al., 1998; Kleemola et al., 1999) suggested that

regular breakfast eaters have higher diet quality including

increased consumption of fibre, calcium, vitamin A and C,

riboflavin, zinc, iron and decreased uptake of calories, fat

and cholesterol). For children, breakfast consumption is

associated with education and better school performance

(Pollitt and Mathews, 1988; Vaisman et al., 1996; Murphy et

al., 1998). Also, breakfast has positive effects on cognitive

development and induces better academic achievement (Dye et

al., 2000). Conversely, skipping breakfast is linked with

difficulty in issue solving, short-term memory, attention, and

episodic memory in children (Pollitt et al., 1983; Vaisman et

al., 1996; Wesnes et al., 2003). According to (Giovannini et

al., 2010), therefore, recommendations to encourage regular

breakfast consumption in children include:

- Using diverse kinds of foods to support positive

experiences and learned preferences

- Teach parents to act as role models

- Hearten family breakfast attended by all family members;

- Maintenance a balance of nutrients within the day, and

within breakfast meals during the week.

2.5.1 Breakfast habits through the world:

Traditional breakfast habits usually were more viewed as a

sort of optimistic, moralizing, “good start of the day,” than

correlated to a specific scientific matter (Agostoni and32

Brighenti., 2010). In USA and Europe, 10-30% children and

adolescent are skipping breakfast, according to revision of 47

observational studies on breakfast habits (Rampersaud et al.,

2005). Although regular breakfast consumption is associated

with positive health benefits, children are more likely to

miss out breakfast than any other meal (Timlin and Pereira,

2007).

2.5.2 Food choices for breakfast:

Hanson and Chen (2007) stated that the demographic and

socioeconomic background of children and adolescents is an

objective determinant, unrelated to subjective perceptions and

taste, and deeply affect the quality of diet. However, there

are subjective situations more difficult to be quantified, for

instance 12% of total 699 thirteen-year-olds in an Australian

survey, skipped breakfast. The only statistical variable was

the gender with girls skipping at over three times the rate of

males. The reasons given for skipping breakfast were, not

being hungry in the morning, lack of time, dissatisfied with

their body shape and they have been on a diet. Therefore,

skipping breakfast in such case was just a matter of

individual choice (Shaw, 1998).

2.5.3 Children’s views on what represents a healthy

breakfast:

According to personal knowledge, thoughts and family

background, a subjective individual perception and attitudes

towards breakfast has been explored (Berg et al., 2003). This

33

study was to identify what do children think about good

breakfast (healthy vs. tasty), usual personal and parental

habits, and parents’ choices for their children breakfast

(normative breakfast). For instance, for the judgment on milk

with different fat content, there was little disagreement

between the concepts of delicious, normative, usual and

healthy compared to the broad difference between the same

concepts considering bread with varying fibre content for

example, high fibre bread and breakfast cereals are perceived

as healthy. Accordingly, parents have an essential role in

influencing breakfast choices via norms and by controlling the

availability of foods, and often children make breakfast

choices in agreement with their parents’ wishes. This suggests

that family correlates of breakfast consumption among children

and adolescents are essential to support positive breakfast

habits (Agostoni and Brighenti., 2010).

Additionally, children’s awareness on parental emphasis on

what is a good breakfast is a significant determinant (Cheng

et al., 2008; Tapper et al., 2008). Pearson et al (2009)

recognized an inverse association between socioeconomic

deprivation and skipping breakfast or consumption of an

unhealthy breakfast. Therefore, parents act as positive role

models for their children by targeting their own dietary

behaviours. Also, family structure and socio-demographic

context is necessary when designing programs to endorse

healthy breakfast habits. Touching on the relation between the

frequency of feeding breakfast and overweight, Fabritius and

Rasmussen (2008) found that frequent consumption of breakfast

34

is less protective against obesity among schoolchildren from

low socioeconomic background compared to those from higher

places. Thus, a positive parental model is a better method for

improving a child's diet than attempts at dietary control and

restriction (Scaglioni et al., (2008). Withal, as Liem et al

(2004) suggested that stronger parental control rules are

linked to a lower consumption of simple sugars in controlled

meals, and are associated with favourite for more sugary

beverages in less restricted positions.

2.5.4 What is a Balanced Breakfast Model?

According to Agostoni and Brighenti (2010) a balance breakfast

model should follow three indications:

1- To include a sufficient amount of carbohydrates,

preferably deriving from fiber-rich low-GI sources

2- To be consistent with the local dietary habits to

maintain the daily and periodical dietary allowances and

balance of micronutrient distribution;

3- To present a limited energy expenditure (ED).

A breakfast including three food items, such as a source of

milk and milk derived products (preferably low fat), cereals

(preferably whole, unrefined), and fruit (preferably fresh

fruit or natural juices with no added sugar to prevent an

increase of ED) generally meet these indications. Other

models, mainly salty breakfast models, present noticeable

imbalances of micronutrients, with high protein, high fat food

items providing lower amounts of fiber and slowly absorbed

carbohydrates, if not a marked shift in the average35

composition of the other meals of the daily diet is

implemented.

A low-GI breakfast is followed by reducing energy intake at

lunch compared with a high-GI breakfast and mainly restricted

to boys (Henry et al., 2007). This is due to enhanced fat

oxidation during physical activity after the low GI compared

to high GI test meals (Stevenson et al., 2005; 2006).

Furthermore, lower GI breakfast is associated with better

cognitive functioning in children (Wesnes et al., 2003;

Mahoney et al., 2005; Ingwersen et al., 2007). Low GI

carbohydrates have a negative impact on cognitive performance

including attention, memory, concentration, and the ability to

perform tasks through various mechanisms (Glisenan et al.,

2009). Therefore, taken together these potential benefits of a

low GI breakfast deem to indicate that this could represent an

overall positive factor to be considered as a supplementary

indicator of balance for the children’s breakfast.

2.6 Fruits and vegetables (FV) consumption, attitudes

and beliefs towards FV, and peer/parent/teacher

influence on children’s FV attitudes:

FV are fundamental elements of the perception of healthy

eating (Paquette, 2005). Eating more FV could lead to a

reduction in the consumption of high-fat, energy dense foods,

although is no direct linkage between increased FV consumption

and obesity prevalence (Gortmakeret al., 1999; Slusser et al.,

2007). FV are essential sources of a broad range of nutrients,

and it is evident that FV can prevent cardiovascular disease,

36

diabetes and some cancers (Nishida et al., 2003). Moreover, FV

can protect the child against asthma (Antova et al., 2003).

Despite the increasing evidence about the positive effects of

FV, according to the Youth Risk Behaviour Surveillance System

(YRBSS, 2007), only 20% of high school students eat five or

more FV daily (Eaton et al., 2008), and less than one fourth

among younger children consume the recommended amounts (Field

et al., 2003). According to (BBC NEWS, 2013), (77%) of primary

school children and (88%) of secondary pupils realize that

people must eat five portions of fruits and vegetables a day.

Nevertheless, 67% of primary children and 81% of secondary

pupils eat less than 5 a day.

Furthermore, (BBC NEWS, 2013) revealed that the associations

with risk of type 2 diabetes are different among individual

fruits, and greater consumption of specific whole fruits,

especially blueberries, grapes, and apples, is significantly

associated with a lower risk of type 2 diabetes, whereas

increase consumption of fruit juices has the opposite

association.

Others, (Prelip et al., 2006) revealed a slight increase in FV

consumption with no significant change in positive attitudes

towards FV, for both intervention and control groups. In this

study, there was an increase in fruit consumption from pre-

test to post-test for both the intervention and control

schools, and smaller increase in vegetable consumption in both

schools. Regardless, the FV consumption for this population

was well below the recommended 5 servings of FV a day. This

37

study (using hybrid model), a total of 1528 year 3, year 4 and

year 6 participants were included. The number of involved

primary schools was 12; nine of them were selected randomly,

as intervention schools, and 3 as control schools. A cross

sectional pre-test and post-test design was to assess the

impact of the intervention. Children completed questionnaires

to evaluate attitudes, beliefs, and behaviours at the

beginning of the school year for baseline data collection and

again at the end of the school year for post test data

collection.

The hybrid model is an accurate school based intervention

program, in which elements are planned at a district level and

then the individual schools and the teachers decide what,

when, and how to use it (Prelip et al., 2011). Moreover, the

teachers have a central potential role in affecting children’s

FV attitudes and behaviours as they were more likely to be

viewed as influential nutrition messengers and they may impart

healthy eating messages to children in the school (Prelip et

al., 2011). Therefore, I found this might be interesting to

explore with children (please see question 2, 4, 8, 9 and 10

in my questionnaire). Such questions are included specifically

to explore how year 5 and year 6 children know about healthy

eating, how they decide when choosing what to eat, and why

they think that water, fish, calcium, and fresh FV are

essential for their health.

Concerning positive influences at home about consuming FV,

there was a slight increase in the intervention group (Prelip

et al., 2006). Others (Baranowski et al., 2000 and Anderson et38

al., 2005) have documented similar findings. The latter

studies have noted the challenge of involving parents in

school-based nutrition plans and the difficulty of these

projects on impacting home consumption practices.

Consequently, the students might take this information and

positive attitudes home to their families, and this would

increase parental knowledge and attitudes towards the

importance of consuming FV for themselves, and their children

(Prelip et al., 2006). Therefore, a more structural approach;

specific homework activities engaging students with their

parents might have a greater impact on parental influence.

This might be possible only with families that value what is

happening in schools. Also, a decrease in peer influence on

children’s attitudes towards FV is much higher in the control

groups, this influence could operate through modelling, shared

activities and eating patterns.

2.7 Children’s diets and relation to behaviour and

performance:

The World Health Organization (WHO) emphasized that ” young

people who develop healthy eating habits early in life are

more likely to keep those habits as they mature, and to reduce

their future risk of chronic diseases such as cardiovascular

disease, high blood pressure, stroke, cancer, non-insulin-

dependent diabetes and osteoporosis” (Council of Europe, 2005,

p. 29).

The concept of fish as “brain food” is a shining example of

elderly wives tales passed along generations, have linked diet

39

to behaviour and performance, and is logically reliable

(Wheelock, 2007, p. 145). According to Rogers (2001), fish oil

is the primary source of omega-3 fatty acids; these acids act

as a mood stabilizer, and are advantageous in depression,

schizophrenia, dementia and aggressive and violent behaviour.

Ruxton (2004) stated that, in a number of major multinational

studies, high annual fish consumption has been associated with

lower prevalence of major depression, or higher self-reports

of mental health condition. For example, in North America and

Many European countries, the association between fish intake

and the mental status is confirmed by an increase prevalence

of reported depression in these areas. This is due to reduced

intake of fish oils (high in omega 3 fatty acids) and

increased use of vegetable oils (high in omega 6 fatty acids).

Moreover, Ruxton (2004) assured that, increasing intake of

omega-3 fatty acids are linked to potential positive health

effects related to cardiovascular disease, arthritis, brain

development and function. The omega-3 and omega-6 fatty acids

are the most plentiful in the brain cell membrane. They

increase the fluidity of neuronal membrane for neuronal

synapses essential for efficient synapses transduction.

Therefore, highly unsaturated long chain fatty acid

consumption might negatively affect mood and behaviour by

direct effect on neuronal function.

However, oily fish and seafood are rich with omega-3 fatty

acids needed by the brain while omega-6 fatty acids are more

abundant in vegetable oils, meat and dairy products. ADHD,

dyslexia, Autism and dyspraxia affect up to 20% of school age40

children and this is due to reduction in certain highly

unsaturated fatty acids (Richardson, 2003). For example, those

with ADHD have lower plasma level of omega-3 fatty acids

compared with normal children (Ruxton, 2004). Furthermore, as

Richardson (2003) suggested that, omega-3 fatty acids might

have a therapeutic effect in such mental illnesses. In

children with developmental coordination disorder, they showed

steps forward regarding the decrease in ADHD-type symptoms,

and improvement in reading and spelling (Richardson, 2003 and

Montgomery, 2005). Thus, supplementation of malnourished

children with vitamins and minerals, plus omega-3 fatty acids,

result in more than 30% decreases in antisocial behaviour

(Wheelock, 2007, p. 150).

Links have also been established pertaining to individual

nutrients, for instance, iodine supply is well recognized to

affect psychomotor and cognitive function. Therefore, eating

foods rich in iodine such as fish can protect individuals

against hypothyroidism, poor learning, ADHD and loss of memory

(Anderson and Zimmerman, 2010). Besides, in 2 years old

children with iron deficiency anaemia, lack of cognition,

attention and motivation is prominent and iron therapy has a

consistent therapeutic effect (Ruff et al, 1996 and Wheelock,

2007, p. 150). Foods rich in iron include red meat, liver,

lentils, and fruit and vegetables. Also, Mac Evilly and Kelly

(2001) suggested that, low selenium intake is associated with

greater incidence of depression and other negative mood

states. Selenium is abundant in brazil nuts, kidney, liver and

shellfish. Furthermore, thiamine and folat, as B vitamins, are

41

highly plentiful in junk food, have anti-depressive effects

(Rogers, 2001). Using certain additives such as artificial

colorants, artificial sweeteners and preservatives might lead

to ADHD (Wheelock, 2007, p. 151).

Also, the imbalance of protein and carbohydrates consumed in a

meal can negatively influence brain serotonin hormone which is

involved in the modulation of mood and behaviour. This might

lead to depression, aggression and impulsivity (Rogers, 2001).

For instance, feeling less depressed and better reaction times

are associated with carbohydrate rich/protein poor diet

(Markus et al., 1998 and Markus et al., 2000).

The brain, therefore, is sensitive to short term fluctuations

in glucose supply which is derived from the metabolism of

carbohydrates in the diet. Therefore, maintaining normal blood

glucose level is essential as glucose is needed for the

metabolism of serotonin and linked to memory, attention and

arithmetic ability (Blundell et al., 2003 and Bellisle, 2004).

However, it is evident that, child’s poor behaviour is the

consequence of eating specific food ingredients (Van de

Weyner, 2006). In particular, malnourished students had

significant improvement in behaviour after been included in a

free school breakfast program, and they showed improvements in

almost all tasks, especially in their math grades, reading and

social science (Woroby and Woroby, 1999). For instance, the

Dudes program (Tapper et al., 2003), is a healthy eating

program, which combined the peer modelling (the Food Dudes

cartoon characters in videos) and the rewards, is a successful

42

way to increase children’s consumption of fruit and

vegetables.

Therefore, children, in the primary schools, showed increase

percentage from 4% to 100% and from 1% to 87% for fruit and

vegetable consumption respectively (Wheelock, 2007, p. 193).

Such outcomes were achieved for at least six months (100% of

children were still eating fruit and 58% ate vegetables). So,

the mere presence of fruit and vegetables in the home is not

sufficient to endorse consumption and to maintain the

behavioural learning principles. Such program is regarded as

an excellent British initiative to raise children to eat at

least five helpings of fruit and vegetables daily.

Traditionally, Eastern medicine has used foods to bring about

changes in behaviour, mood and thought processes, recent

evidence suggests that diets can alter brain chemistry,

behaviour and cognitive ability (Mac Evilly and Kelly, 2001;

Blundell et al., 2003). The brain is sensitive to metabolic

changes associated with the form of meals and fasting, linked

to adequate glucose supply to the brain, and also long term

nutritional status (Bellisle, 2004). This is more significant

for children in their stage of growth and development as these

varieties might cause immediate or long term positive or

negative effects.

2.8 Children’s views about food origin:

BBC NEWS (2013) stated that nearly a third (32%) of UK primary

children deems that cheese is made from plants and 25% believe

fish fingers come from chicken or pigs. The British Nutrition43

Foundation (BNF) stated that about 10% of secondary school

pupils consider that tomatoes grow underground. This was large

survey, in which, 27,500 children (aged 5-16) were questioned

in June, 2013. Also, the survey explored ambiguity about the

source of staples such as pasta and bread among younger

pupils, with about a third of 5-8 years old believing that

they are made from meat, and 19% did not understand that

potatoes grew underground, with 10% thinking they grew on

bushes or trees.

Consequently, Roy Ballam, education program manager at BNF

called for a national agenda and management for food and

nutrition education across the UK, “especially at a time when

levels of obesity are soaring”. The study, created to coincide

with the BNFʼs healthy eating week, in which, 3000 UK schools

have signed up. Mr Ballam said aims “to begin the process of

re-engaging children with the origins of food, nutrition and

cooking, so that they grow up with a fuller understanding of

how food reaches them and what a healthy diet and lifestyle

consist of”.

2.9 Children’s views on foods and consumption of

selected food groups:

It is essential (Sharifah et al., 2013, p. 132) to assess

children’s views on foods which may influence their food

options depending on their own cultural eating patterns and

nutrient availability in their own culture. This is

significant as the information obtained might be helpful for

planning the related intervention and development of a dietary

44

assessment method and aid. For example, food frequency

questionnaire and food photographs of children. The children’s

food choice is crucial as it becomes one of the determinants

of their nutrient intake, which later can influence their

growth and maturation. Their food choices in the early stage

of life have a high possibility to be carried through into

adult life.

Zaini et al (2005) suggested that snacks and fast food

consumption can lead to childhood obesity. Furthermore,

dietary fibre might act as a protective element against

childhood overweight, as it affects food intake, digestion and

absorption of nutrients and carbohydrate metabolism (Ali et

al., 1982). Authoritative sources of dietary fiber include

fruit and vegetables, cereal and cereal products, legumes and

other whole-grain products. Besides dietary fibre, (Skinner et

al., 1999; Carruth et al., 2001) stated that dairy products

have serious potential effects on body weight in babies, and

it is important to distinguish what type of food groups really

consume by children. This is fundamental to develop

interventions to encourage them to make better health choices

and decrease the risk for chronic disease.

Moreover, children taking cereals for breakfast usually have a

lower body mass index (BMI) and lower cholesterol than those

who eat non-cereal breakfast foods. This is because breakfast

cereal is lower in fat and higher in fibre than non-breakfast

cereal and can be protective against childhood obesity

(Resnicow, 1991 and Williams, 1995).

45

Sharifah et al (2013) found that most of the (7-9 years old)

children like food because of the taste. Other reasons include

the nutrient value of the food and the attractive feature of

the food such as a nice smell and the food's texture, for

instance the crispiness. Others (Olson et al., 1981; Ricketts,

1997; Pѐrez-Rodrigo et al., 2003; Molaison et al., 2005) have

shown that the taste of food was the major limiting factor

related to consumption and regarded as a significant

determinant of children’s food choice. However, for non-

favourite food, some children dislike some types of foods when

they recognize that the food is unhealthy, for instance,

sweets as they know it can cause tooth aches or they dislike

fish as it holds heaps of bones (p. 135).

2.10 Gender Differences in Food Preferences:

The food service organizations are offered the opportunity to

look at their current offerings and policies to move towards

plummeting fat and sugar options with increasing fruit and

vegetable selections. Therefore, the food service staff should

be asking” What will kids eat?” while assessing current

policies and services (Caine-Bish and Scheule, 2009). Certain

factors are connected to food preference such as age, gender,

culture and the socioeconomic state (Logue and Smith, 1986;

Drewnowski, 1997; Turrell, 1998; Lytle et al., 2000; Wansink

et al., 2003; Westenhoefer and Cooke, 2005; Caine-Bish and

Scheule, 2007). Accordingly, it is essential to understand the

influence of these factors on children’s food preferences to

46

help develop healthy and successful menus (Caine-Bish and

Scheule, 2009).

Caine-Bish and Scheule, (2009) suggested that the food

preferences of children and adolescents varies between genders

as well as gender differences differ between primary, middle

and high school students. Thus, differences in gender and the

combination of gender and grade level are crucial to fully

appreciate children’s food preferences within the school

setting. For instance, boys as compared to the girls, have a

greater preference for pork, beef and fish in the primary

school. On the other hand, it is uncertain why the boys in

particular are less favourable to these foods in the middle

school level. Regarding girls, as compared to the boys, have a

greater preference for fruit and vegetables, sweets and

starches. However, in adult women they choose comfort foods

such as ice-cream and chocolate.

Moreover, (Caine-Bish and Scheule, 2007; Guthrie et al., 2006)

suggested that children’s food preferences can predict the

food children choose, but many of children’s top choices are

foods high in fat, sugar and calories when asked their

preferences. There are, however, many healthier food choices

that children also prefer such as grapes, strawberries and low

fat milk. Also, not only males and females would prefer

different foods, but these food preferences would change based

on their grade level with an indistinct reason.

3. Research design and methodology:

47

3.1 Development of the question:

An initial proposal question made an attempt to identify the

focus of my planned interventions, especially in terms of

establishing a clear link between the specific research

question and the related methods of date collection, an issue

I have struggled with for quite a few months. After

discussions and further thought, the question was developed

and in many respects broadened to explore the views, beliefs,

attitudes, and understandings of children (aged 9-10) about

healthy eating.

3.2 Rationale for this research question:

The question is highly topical with the high prevalence of

childhood obesity among primary school children in the UK,

coupled with the government’s agenda to reduce children’s

overweight. A number of recent national policy documents

(Livingstone, 2013; Gibney, 2012; Wheelock, 2007; Paquette,

2005; NHMRC, 2003) have stated the increasing prevalence and

the risks of childhood obesity. This makes explicit reference

to the significance of exploring children’s views about

healthy eating, with particular attention being paid to year 5

and 6 children in the primary school. However, based on

literature review, many aspects of perception of healthy

eating are closely related to the main research question.

These include how children know about healthy eating, the

influence of parents, teachers on their food choices, gender

differences and food preferences, and their views about food

origin. Moreover, the goal of this research question is to

48

explore children’s understanding about particular food groups,

and why they like certain food groups and they dislike others.

I will endeavour to explore the misconceptions in food

knowledge including the fundamental elements of healthy eating

in children (aged 9-10) in primary school.

3.3 Quantitative vs. Qualitative research:

Biggam, (2008) suggested that quantitative refers to research

that is concerned with assessing the extent of something, for

instance, the success rate of dissertation students in the USA

school of medicine. It could be more complicated than just

gaining simple quantitative information. It can involve

calculating, for pension and personal insurance purposes, the

possibility of dying before retirement for those in a given

profession (p. 86). Whereas, qualitative research links to in

depth exploratory studies, for example, why students choose a

certain module to study where the opportunity for quality

responses exists.

To explore a particular matter in depth, it is common to mix

and match both qualitative and quantitative methods,

therefore, quantitative research answers the how questions,

whereas the why questions are left to qualitative research

(Myers, 1997).

3.3.1 Advantages and disadvantages of a questionnaire

survey:

I chose to undertake a questionnaire for a number of reasons.

Menter et al., (2011, pp. 105-107) provide a list of several

49

characteristics of a questionnaire, which I will now briefly

discuss in more detail to explain why I felt this was the

appropriate method for my project:

- The need to collect large amounts of data within a

relatively short period of time.

- Although questionnaires are not essentially easy to

design, they can be easily administered.

- They can be used to explore beliefs, attitudes, views and

past behaviours. Therefore, they are flexible and a wide

range of information can be collected, although

flexibility is more a feature of an interview as once

written a questionnaire is fixed.

- Due to the focus provided by standardized questions,

there is an economy in data collection and time is not

spent on peripheral questions.

- Both closed questions, for rapid data analysis and open

questions that are more complex to analyze, can be used.

- Survey questionnaire does make larger samples possible,

and statistical techniques.

Conversely, here are some of the disadvantages of

questionnaires:

- Questionnaires, particularly self-administered ones,

could be quite challenging especially for younger

children with dyslexia. Also, writing at a level they

understand but does not confuse them is a challenge.

- It is not possible to follow up answers within

questionnaires (as we could in an interview). Therefore,

50

the responses we get are constrained by the decisions we

have made about the design of the questionnaire.

- It is relatively a mechanistic form of data gathering as

we cannot guess how confidently the respondents are

interpreting the questions and responding to them.

- They depend on the individuals’ honesty, motivation,

memory and ability to respond.

- Errors due to non-response and misinterpretation might

occur, although the subjects identified in a survey are

often a random sample. Therefore, people who choose to

respond to the survey might be different from those who

do not respond, and this can bias the findings.

Therefore, it may be easier for (9-10 years) older

children to give honest answers through an anonymous

questionnaire rather than through class discussion or

focus group where they have to look the researcher in the

eye (Menter et al., 2011, p. 106). However, children

might not feel obliged then to answer for instance

knowing the person might ʻpersuade´ the participants to

respond.

3.3.2 Advantages of interviewing and issues for

consideration:

Because of the flexible nature of the method and the

limitations can be addressed with careful planning by

complementing the approach with other methods. Also,

interviewing is responsive and can read body language and

other behaviours in response to questions. (Menter et al.,51

2011, p. 127-128) have stated many advantages of interviewing

and these include:

1. Interviewees can ask for explanation which is helpful to

collect more accurate information or might help to

realize the question need refining.

2. Interviewees can shape the research and highlight

relevant issues.

3. Interviewees can be helpful to appreciate more about the

factors influencing actions and attitudes.

4. Interviewees can provide their own views in their own

terminology. This is helpful to understand the meanings,

underpinning people’s actions and illuminate their

attitudes and rationale.

5. Because of the interactive environment of the interview,

the researcher can adapt the questions to suit responses

and gain greater insights.

However, (Menter et al., 2011, p. 128), there are certain

matters of interviewing should be considered and these

include:

1. Interviewing could be a time consuming method and costly

because of the time taken to conduct interviews and

analyze the information.

2. Sensitive topics can be difficult to discuss face to face

because of the socially interactive nature of the

interview. Therefore, it can both improve but also hamper

the gathering of information.

52

3. Differences in the level of detail across the interviews

and the interpretation of questions by the informants

might appear. This is occurring when the interviews are

conducted by more than one interviewer, each may ask

questions differently.

4. In certain cases, for example, if the researcher is

interested in a more complete understanding of a

particular issue, he might need to compare a range of

interviewees’ accounts and also triangulate with other

methods such as observation and document analysis.

5. Interviewing needs, like focus groups, skill and

awareness on behalf of the interviewer to avoid

influencing the interviewee.

3.3.3 Shaping a case study:

The chosen approach is an exploratory study that is also

comparative in nature between two different cohorts. In this

study, I am dealing with two case studies, one is the local

Church group and one is the primary school cohort, each has a

different context and background. The project has become an

opportunistic comparative case study because it focuses on the

specific instance to explore children’s views about healthy

eating of a bounded system (a department) (Cohen et al. 2007,

p. 253) and aims to provide an in-depth description focussing

on the processes involved, rather than emphasizing the final

outcomes. In Yin’s (2003) terms, it is an exploratory case

study which will aim to present “a complete exploration of a

phenomenon within its context” (p. 5).

53

This survey was administered in one primary school in west of

the Oxfordshire / UK and in one local Catholic Church in the

centre of Oxford in June 2013. Only children (aged 9-10) were

selected because younger children might find some of the

questions difficult to understand or answer on their own while

older children would be expected to be busily preparing for

the entrance examination for the secondary schools.

Nevertheless, I chose to undertake a comparative case study

for a number of rationales, children (aged 9-10), one group in

the primary school and one outside the school (social

grouping). Cohen et al., (2000, p. 182) state a list of

hallmarks of a case study, which I will now briefly consider

in more detail to elucidate the reason beyond choosing this

method:

1. ʻThe researcher is essentially involved in the case´. This was always a

concern. As already discussed, my involvement in this

research was certain. Issues of power and bias therefore

needed to be considered from the outset. I intended to

undertake both the questionnaire and interviewing the

children as focus groups. However, the school I had

arranged to go and interview children in was able to

facilitate my request as head´s permission was obtained

and enough time was available. All the interviews

questions and schedule were prepared and were ready for

processing with the children (Appendix 6).

2. ʻCase study highlights on individual actors or group of actors, and searches

for understanding their perceptions of events´. I wanted to choose a

research design where all concerned had an input into54

the project and where their understanding of the event

could contribute heavily to the outcomes, recommendation

and sustainability of the project. Furthermore, I wanted

to undertake a project that was strongly based in the

reality of school, therefore reflecting the experiences

of those involved, who were necessary to live with the

project in its entirety.

3. ʻIt is concerned with a rich and vivid description of events relevant to the

case´. It was crucial that any research undertaken could be

reachable to as many various audiences as possible:

health promotion specialist, teachers, parents, local

government officers, and so forth. As a result, it

deemed significant to choose a research method that was

inclusive for everyone, regardless of prior research

experience, and that was presented in everyday terms,

free from jargon and professional language. Choosing a

design that included a full description of the

experience as part of the research in everyday language,

reflected the many decisions that were made throughout

the process, and that detailed their influence upon the

research, seemed ideal.

4. ʻIt combines a description of events with the analysis of them´. As stated

above, this was relevant to the multi-faceted audience

that this research was aimed at.

5. ʻIt provides a sequential narrative of events imperative to the case´. As

detailed above, the research needed to be accessible to

everyone. However, it also compulsory to be influential

enough to be scrutinized by many, in particular if

55

favourable outcomes or recommendations were to be

followed up in the future.

6. ʻAn effort is made to depict the richness of the case in writing up the report´.

From the outset, I was uncertain as to what the outcome of

this study would be. Therefore, in order to capture as

much as possible, I wanted to use as many different data

collection methods as was feasibly possible. Also, for

others involved to be able to suggest and contribute

data collection methods that they believed appropriate

and felt comfortable with. However, with so many

different forms of data collection planned, I needed to

adopt a research design where all of these dissimilar

findings could be communicated. I afterwards found out

that many various styles of data collection were

certainly preferable in case studies, but it was this

initial aim of portraying the affluence of the

experience which made me enthusiastic to use it.

3.3.4 Issues to consider when undertaking a case

study:

Having made the decision to undertake an exploratory

comparative two case studies, there were a number of

characteristics of good case study design that I needed to

deem. Robson (2002) summarizes these briefly and I adhered to

all of these when planning my research design. More crucially

however, and worthy of discussion here, I felt was

necessitated to address some of the inherent weakness

56

concurrent with this form of flexible design; those of

validity and reliability.

- Validity

The accuracy of findings in fixed or quantitative designs is

usually ensured by direct replication. If an independent

investigator can confirm a finding, then it is said to be

valid. The difficulty with flexible research designs is that

identical circumstances cannot often easily be replicated. The

way to resolve this, according to Robson (2002) is to reframe

the terminology and consider ʻbeing accurate, or true, or

correctʼ (p. 170). He states that question asking, good,

listening, adaptiveness, and a grasp of the situation and a

lack of bias, (i.e. Good scientific rigor), are methods that

can be used to overcome this. These are issues I needed to

consider in my research study. ʻBeing prepared to trace the

route by which you came to your interpretation (Mason, 1996

cited in Robson, 2002 p. 171) is another approach to do this.

This was a key way that I wanted to work and so I felt sure

that I could ensure validity. I also considered the threats to

validity: description, interpretation and theory (Robson,

2002), and sought to minimize these in my research design.

-Reliability

57

ʻIn qualitative research reliability can be regarded as a fit

between what the researchers record as data and what really

occurs in the natural setting that is being researched, for

instance, the degree of accuracy and comprehensiveness of

coverageʼ (Bogdan and Biklen, 1992 cited in Cohen et al.,

2000. P. 119). As I mentioned already, my original intention

was to interview children as well as doing questionnaire.

However, due to unforeseen circumstances, and despite

preparatory discussions, the interviews were not possible to

undertake as the school that agreed to participate was so busy

and there was no enough time to undertake this study. I

intended to invite few colleagues to also become researchers,

this might make the findings more reliable as we compare and

discuss what happened. Although this cannot guarantee

reliability as they might produce completely different

findings from the same observation.

Therefore, I decided to ensure that my colleagues and I agreed

in advance the reliability of the instruments of research we

chose to use and that there were enough of them to ensure

triangulation occurred. Triangulation, plus a sufficient

number of records would hopefully prove the project findings

reliable, for instance, ensuring that there are enough

children involved in the project to ensure that the techniques

used were reliable.

3.3.5 Types of case study:

Having considered the specific issues relating to the use of

case studies and satisfied myself that this was still the most

58

appropriate form of research design for my project, I then had

to decide which type of case study to undertake. As I already

discussed, I decided to do a two exploratory comparative case

studies. A case study was described as a ʻsmall-scale version

of the real thing, a try-out of what you proposeʼ and an

opportunity to ʻlearn on the jobʼ (Robson, 2002, p. 185). An

exploratory case study is a pilot to other studies or research

questions (Basit, 2010, p. 20). Indeed, Cohen et al., (2000)

stated that exploratory case studies can actually be used

solely to generate hypothesis for larger scale research forms.

However, case studies are quick to state that this is not a

reason to devalue or disregard this type of case study as a

valid research form or to reduce it to a mere ʻpreliminaryʼ to

other studies. I was keen that my project be purposeful in its

own right, despite its dual role of also being the pilot for

further work, if only to provide ʻon-the-spotʼ satisfaction

and gratification to the school staff involved.

4. Ethics:

An essential characteristic of any research project that I

have not yet discussed clearly is ethics. Bell (1999) cites a

useful quote from Blaxter et al (1996, P.39) that succinctly

summarizes the key issues of research ethics:

ʻResearch ethics are to be comprehensible regarding the nature

of the agreement you have entered into with your research

subjects or contacts. This is why contracts can be a useful

recommendation. Ethical research involves getting the informed

consent of those that you are going to interview, question,59

observe, or take materials from. It involves reaching

agreements concerning the uses of this data, and how its

analysis will be reported and disseminated. And it is about

keeping to such agreements when they have been reached. ʼ

I considered the need for a kind of contract between myself,

as a qualified general practitioner, and the school to clarify

some of the above. I also considered the question ʻwho might

be harmed by my research? ʼ in order to generate some ʻworst-

caseʼ scenarios. I felt that by pre-emptying potential

problems, I could guarantee that the ethics contract addressed

theses issues sufficiently. Initially, it felt awkward to

think in such negative terms as someone being ʻharmedʼ by my

research, particularly with the way the project had positively

developed, the keenness that there was for the project from

all parties.

Moreover, throughout my research, I continued to be open to

both children and staff about the scope of my research study.

I intended to seek the reasonably informed consent (Cohen et

al. 2007, p. 53) of all participants including the children in

the local primary school. It assured for the participating

children that they are free to discontinue their contribution

in the project at any time without injustice to them. As I

discussed already, my original intention was to interview

children inside the school as timing and location may affect

the responses. Therefore, interview questions were arranged to

ask for the children (Appendix 6). I planned to use pseudonyms

to protect the identities of those involved. Also, respondents

to questionnaires were ensured anonymity and interviewees who60

require it were granted confidentiality (Cohen et al. 2007, p.

64). I was also aiming to show interviews records to

participants so that accounts can be checked for accuracy and

if necessary amended. Ethical approval was obtained from the

university-wide Ethics Committee at Oxford Brookes University

prior to the commencement of the study (Appendix 3). I

intended to obtain a written consent from each student’s

parent prior to his/her participation in the study.

Basit (2010, p. 56), stated that ʻsome of the most intractable

ethical problems arise from conflicts among principles and the

necessity of trading one against the other. Therefore, the

balancing of such principles in real situations is the

eventual ethical actʼ (House 1993, p. 168). I considered also

in my research to have a responsibility to meet the

requirements and to rigor (Gorard, 2003). For instance,

experimental design might be the most ethical approachable to

obtain a specific research question even where it is more

risky than other less appropriate design. (p. 173).

Furthermore, as (Basit, 2010) suggested, in my research study,

to be so gentle with the children, their gender, race, social

class, disability, ethnicity and so forth are considered when

interacting with them. The use of sexist and racist language

was avoided. We tried to create a non-hierarchical

relationship with the participants and dress appropriately for

the fieldwork (Basit, 1995).

5. Fieldwork period

61

Questionnaires (comprised of 14 questions) for children (aged

9-10) were distributed to one local primary school between 22nd

and 23rd of July 2013. Also, questionnaires were distributed to

children of the same age in a local Church group one week

later. Completed questionnaires of the children were returned

and collected via one of the teaching staff working in the

same school. Similarly, questionnaire from the local Church

group were collected via one of the Brookes staff on the 29th

of July. Both data are separately analyzed as different

background and context might influence the findings of the

research.

5.1 The participating school (first

group/cohort).

Background

The school has four grades, junior, voluntary controlled

school in the west of Oxford, Stanton Harcourt that currently

has 78 boys and girls aged range between 4-11 years on roll.

The selection of the school was opportunistic. After the

(other) school that had initially agreed to participate, for

unforeseen and unknown reasons, withdraw, there arose an

opportunity for a tutor at Brookes, who taught in the local

school to administer the questionnaire on my behalf. The

teacher there checked the questionnaire and administered it on

my behalf.

However, most of the children are from low-middle

socioeconomic state. A recent Ofsted report (2008) stated that

62

most pupils of this much smaller than average village school

are from a White British Background. The proportion of pupils

with learning difficulties and disabilities is well below

average but with increasing numbers of pupils with speech and

language problems. Numbers of pupils in each year group are

small and vary significantly from year to year. A voluntary

management committee provides a popular after-school club. The

school has achieved Healthy Schools, Eco, Active mark and

BECTA Computing Awards.

According to Ofsted report (2008), the spiritual, moral,

social and cultural development of pupils is outstanding. It

plays a significant part in their personal development and

sense of well-being. They are quick to celebrate the

achievements of others as well as their own and have a well-

developed concern for the welfare of each other.

The school is very active in village life, helping pupils

develop a strong sense of their place in the community. Their

understanding of values and beliefs in other communities

however is less well developed. The Eco club and school

council give pupils responsibilities and encourages them to

contribute to the life of the school. The Eco club, for

example, is developing in pupils a strong awareness of care

for the environment. Pupils demonstrate excellent attitudes to

learning. They have a willingness to learn which shows in the

ways they are keen to contribute to lessons, willing to take

responsibilities and eagerly take part in class discussions.

Relationships are very good and pupils say they feel safe and

confident in approaching adults for help. Their behaviour is63

excellent. They have a very good sense of a healthy lifestyle

and readily take opportunities for additional exercise at

break-times. Social skills are developed very well through

paired and group working and pupils are encouraged to become

independent in their learning.

As mentioned above, the school was already committed to

becoming a ʻHealthySchoolʼ and welcomed this research study. A

teacher working in the school was responsible for steering the

study and passing the questionnaire to the children.

Eating Environment

The school provides a safe and healthy eating environment for

pupils, staff and visitors having lunch at midday in the

school. All children are required to sit at a table for at

least 20 minutes, in order to eat their lunch. Children are

encouraged and are given the time, to try to eat most of the

food provided either by school or home. Lunchtime supervisors

or a member of staff will help any children who have any

concerns. Children help to clear up afterwards on a Rota

basis, wiping tablecloths and sweeping floors. Teachers were

the key decision maker in lunch choices, followed by parents.

The school reported nutritional value and food safety as their

top two considerations for choosing food for lunch, consistent

with parents’ wishes.

Healthy Eating Policy 64

The school agrees that healthy eating is crucial for school

education and children’s development, and has developed its

healthy eating policy. Where policy existed, it focused

primarily on school lunch followed by snacks to make explicit

the values and guidelines that underpin every aspect of food

culture in the school. Moreover, to ensure that our children

receive consistent and coherent messages about food and its

role in their long-term health in order to meet the outcomes

of the Every Child Matters legislation.

School l unches

The weekly menu is on display for the children and parents in

the assembly hall, in class areas, on the school notice board

as well as on the school web site. The menus are sent home to

parents when each new set of menus is introduced. The school

listens to the children’s opinions on the menu and adapt the

menu accordingly. All of our menus meet the new nutritional

requirements for school meals.

Free School Meals

The school recognizes the particular value of school meals to

children from low income families. The system for free school

meals is actively promoted to parents by the school and a non-

discriminatory process is emphasized.

5.1.1 The local Church group (second case study

group/cohort).

65

A supportive staff at Brookes offered an opportunistic way to

gather some empirical data for my study, so despite the good

intentions and all my plans and preparation, this was a

fallback situation. The nature of the participating cohort is

described below as these factors need to be taken into account

when interpreting the findings. However, the local Church is

the Catholic Church and is located in the centre of Oxford.

Most of the children (aged 9-10) attended this Church drawn

from nearby primary schools and they were all of whitish

British ethnicity. The children are from low- middle

socioeconomic states and most of their parents were educated

with high qualification and some of them are working in the

university.

Children (aged 9-10) were meeting in the Church on a usual

Sunday morning and all were students in the primary school.

However, I tried my utmost to get the acceptable number of

participants for my research study, and undertake both

qualitative and quantitative research methodologies. This was

my original intention and plan, and the interview questions

were all arranged in advance (Appendix 6). However, despite of

previously preliminary discussions and due to unexpected

circumstances, the interviews were not possible.

5.2 Data collection

One teacher working in the same participating school

distributed the student questionnaire to year 5 and year 6

children (aged 9-10) in one local primary school on the Friday

afternoon in June, 2013. Some of the children’s parents were

66

available and they indicated a willingness for their children

to participate in this study. The students were asked to

complete the self-administered questionnaire in a school

during a classroom session. A quite two small samples were

collected, just 26, from two different resources. One sample

from a local primary school and another was from a local

Church group. Regarding primary school cohort, no time limit

was given; the children spent about 10-15 minutes to complete

answering the questionnaire. The teacher had to clarify a few

questions and answer responses; but no direction was given in

response. The number of children was 19 in this local school,

year 5 and 6 pupils in the class (aged 9 – 10). Most of the

children (18) were either at level 4 or 5 of the national

curriculum and one child was at level 3.

The second cohort that responded to the questionnaires was

children in a local Church group in which ten questionnaires

were administered at the end of meeting, which is regular once

weekly meeting. This sample was regarded as a purposive sample

as needed responses are required for this study. A member of

Brooke’s staff first introduced himself to the children and

their teacher in the Church. He tried to explain the aim of

this research study for the children and their teacher who

were happy and welcomed the notion of the survey. The member

of Brooke’s staff administered 10 questionnaires to the

children and he was in attendance when the children filled out

the questionnaires, but did not interpret the questions for

the children, who were motivated and focussed, although one

child did not complete the whole exercise. Seven were

67

returned. Of these, two were completed by children whose

parents read with them and helped them to answer the

questions. One parent declined to let his child join the group

and answer the questions, but gave no reason for his

decision. 

6. Data analysis

Descriptive statistics were used to summarize the findings of

the study and they were reported in percentages, means, and

histograms, wherever appropriate. Some percentages in the

descriptive figures might not add up to the total or 100%

because of rounding. Moreover, the sample bases for each

question might vary due to the missing answers.

6.1. Results of Questionnaire Survey for Children

A total of 46 copies of questionnaires (Appendix 4) were

administered, 36 questionnaires were administered (only 19

were returned) to children in the primary school by one

teacher. The questionnaire for the primary school group was

administered in 19th of July and collected 5 days later. Also,

10 questionnaires were administered on Sunday 28th of July to

the local Church group by one member of Brooke’s staff (only 7

were returned) and collected on Monday 29th of July 2013. A

total of 26 copies of completed questionnaire was collected

with a response rate of 92.3 % for both case studies. Of the

questionnaires, two questionnaires were not fully completed

and all were used for data analysis.

6.2 Descriptive data and Findings

68

All the data from questions of the children’s questionnaires

in the study were presented in tables, graphs, histograms, and

I will write a paragraph to explain each graph findings for

both participating groups separately.

6.2.1 Children’s responses to the question regarding

the definition of healthy eating (Q1)

Question 1 was “what does healthy eating mean to you?”

Children (aged 9-10) were asked to choose only one answer

among four options (a, b, c, and d), in which the choice (d)

was the best answer. Option (d) referred to “Healthy eating

means eating a balanced diet with good physical activity” was

the closest option for healthy eating. Other options that were

definitely not healthy eating were a) Eating more food b) Food

with high salt, sugar and fat and c) Too many calories. The

goal of this question was to explore how children do (aged 9-

10) understand and perceive the meaning of healthy eating.

Consequently, Table 1 show the number and percentage of

children correctly answered the question regarding “What does

healthy eating mean to you?” (Q1). Among the local Church

group (6 responses and one missing answer), percentage of

correct answers was 85.7% while it was 94.7% for the primary

school cohort (one missing answer among 19). The mean and SD

(standard deviation) for both case studies were 6.5, 0.70 and

18.5, 0.70 respectively. In general, an understanding of

children in both cohorts regarding the meaning of healthy

eating was very good. These responses (for example not 100%)

mean that perhaps the question was not as well clear as it

69

could have been. Therefore, For instance, the more testing the

options for this question could be a) having a healthy

appetite b) eating all foods with a healthy label on it c)

eating a balanced diet d) eating enough but not too much.

Furthermore, range of interpretations of healthy eating would

have been better explored if children were interviewed and

their correct answers had been followed up (Appendix 6).

6.2.2 Source of knowledge for children about healthy

eating (Q2)

Question 2 was “How do you know what healthy eating is?”

Children (aged 9-10) were asked to choose options correct for

them among four choices (a, b, c, and d). The aim of this

question was to explore children’s source of knowledge about

70

healthy eating. The options were: a) Television adverts b)

Parents told you c) Food labels/packaging d) Schools and

teachers. However, some children did not respond to only one

question, so all responses were presented as totals to provide

cumulative scores for each option.

The maximum proportion of children (100%) at local Church

group considered their parents as the main source of knowledge

for them of healthy eating as opposed to 36.8% of primary

school cohort. Also, 71.4% of children at local Church cohort

stated that they had knowledge from their schools and teachers

as compared to 36.8% at the primary school cohort. Conversely,

the highest percentage of children (42.1%) at primary school

group considered having knowledge of healthy eating from food

labels and packaging as compared to (0%) at the local Church

group. Although Television adverts were the lowest proportion

among the given options, the percentage was higher in the

local Church group (14.2%) than that at the primary school

cohort (5.2%) (Chart 1)

Such quite differences in findings between two cohorts might

suggest that parents at local Church group might do care of

their children more than those in primary school group. Or

schools of local Church cohort might have a better healthy

eating policy than those in primary school cohort. Therefore,

follow up these findings might be advantageous to further

explore the influence of parents, schools and teachers on

children’s understandings concerning source of knowledge of

healthy eating (Appendix 6).

71

6.2.3. Children’s knowledge regarding healthy snack

box contents (Q3)

Question 3 was “which of the options below is the healthiest

snack box content?” Children (aged 9-10) were asked to choose

only one answer among four options (a, b, c, and d), in which

the choice (d) was the correct answer. Option (d) referred to

“Fresh fruit and vegetables, pure water, cheese, egg and brown

bread”. The goal of this question was to explore children’s

(aged 9-10) knowledge about healthy snack box contents to find

out their views of each of these food items.

72

85.7% of children at local Church cohort (6 responses and one

missing answer) and 94.7% in the primary school group (one

missing answer among 19) correctly answered this question. The

mean for both groups were 6.5 and 18.5 respectively. In

general, the major perception of the healthiest snack box

contents as fresh fruits and vegetables, pure water, cheese,

egg and brown bread in both groups was very good (Table 2).

Other options were not healthy and these include a) White

bread, ice cream, fatty chicken b) Fizzy drink, sausages,

crisps, canned fruit and vegetable. However, more information

could have been obtained from the children in both groups if

they were interviewed. For instance, to explore their views of

each of these options of foods and why do they think each of

these contents in option (d) is healthy? (Appendix 6)

73

6.2.4 Matters children considered when choosing food

(Q4)

Question 4 was “When choosing what to eat, how do you decide?”

Children (aged 9-10) were asked to choose options correct for

them among five choices (a, b, c, d, and e). The aim of this

question was to explore what do children consider when they

decide to eat. The options were: a) Taste b) Appearance of

food c) Parents recommended for me d) Cost and e)

Choice/available.

All responses of children in the first and the second case

studies were accumulated and presented as accumulative totals.

The utmost percentage of children (85.7%) at local Church

group considered the taste as a main concern when choosing

food, whereas choice/availability was the priority of children

at primary school cohort (26%). Also, 21% of children at

primary school cohort concerned the appearance of food when

choosing what to eat as compared to (0%) at the local Church

group. Furthermore, 28.5% of children at local Church cohort

stated that their parents recommended food for them when

choosing food as opposed to 15.7% of primary school cohort. No

one (0%) of children considered the cost as a matter when they

decided to eat in both groups (Chart 2)

Accordingly, these options could be further explored and the

children’s responses could be followed up by interviewing such

participants, For instance, to find out why they consider

taste and choice available as a priority in the first and

74

second case studies respectively. Also, do children in primary

school cohort did not think that taste is important? Or the

question might have been phrased better for example, what do

you consider in your mind when choosing food? (Appendix 6)

6.2.5 Children’s least and most favourite food

choices (Q5.1 and Q5.2)

75

Q5 comprised of two parts; the first part (Q5.1) was what your

five favourite foods to eat are? And the second part was

(Q5.2); do you think each of these foods is healthy? The aim

of this query was to explore children’s (aged 9-10) five

favourite foods and to find out the gender differences among

them concerning the foods they favour. Children were asked to

mention the names of five foods they prefer to eat as the most

and least favourite food choices. In both groups, children

stated that Chocolate, Apple, Cucumber, Salad and Bananas as

their most five favourite foods, whereas Sweets, Chips,

Crisps, Chicken, and Fish as their least five favourite food

choices. These foods were the most common foods mentioned by

children in both cohorts.

In local Church group, findings showed a marked gender

difference regarding the children’s favourite food choices, in

which, (75%) of the girls had more preference than boys (25%).

Conversely, children in the primary school cohort, Boys (47%)

had more preference for these foods than girls (26%). In this

group, we had two missing answers (one boy and one girl).

Moreover, 57% of children in the local Church group as

compared to 42% of primary school cohort considered each of

these foods as healthy. Whereas, 71% of the children of the

primary school group considered their favourite foods as

unhealthy in comparison to 0% of those at local Church cohort

(Chart 3a and 3b) .

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However, in Q5.1 it is uncertain whether the children had

mentioned their five favourite foods as the most to least

preferable foods or not? And why they prefer these foods more

than others? Did they really understand the question?

Furthermore, in the interview we could find out why they

considered some of their favourite foods as healthy and

considered the others as unhealthy? Also, as shown in Chart

3a, a marked gender difference of food preferences in both

case studies is worth of exploration to further follow up by

interviewing children in both groups.

Therefore, Q5 could have been further refined for instance, we

can ask the children what are your most and least five

favourite foods to eat? Which foods are healthy and which are

not? Why do you eat unhealthy foods? And what do we have to

suggest if all their favorite foods were unhealthy? For

instance, looking for the core reasons beyond that as a

discussion with their parents, their teachers and schools

might be helpful (Appendix 6).

6.2.6 Children’s understandings regarding “5 a day”

(Q6)

Question 6 was “what do you think 5 a day is?” Children (aged

9-10) were given four options (a, b, c, and d), in which the

choice (d) was the best answer among three other confusing

answers. Option (d) referred to “Five portions of fruits and

vegetables”. The goal of this question was to explore what

children (aged 9-10) think about 5 a day.

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Accordingly, 57.1% of children in the local Church group as

compared to 89.4% of primary school cohort correctly thought

that “5 a day” means five portions of fruits and vegetables.

Also, 14.2% of children in the local Church group as opposed

to 5% in the primary school cohort perceived that “5 a day”

means five portions of fruits and five portions of vegetables.

No one (0%) in both groups thought that 5 a day mean five

portions of fruits and one portion of vegetables. Whereas, 5%

of children in the primary school and no one (0%) thought that

5 a day mean five portions of fruits and two portions of

vegetables. (Chart4)

Further information could have been explored if children were

interviewed. For instance, do you eat five portions of fruit

and vegetables a day? And why? (Appendix 6)

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6.2.7 Responses of children in both groups about the

question “why do you think calcium is an important

part of your diet” (Q7)

Question 7 was “why do you think calcium in an important part

of your diet?” Children (aged 9-10) were asked to choose only

one answer among four options (a, b, c, and d), in which the

choice (d) was the correct answer. Option (d) referred to

“Build strong and healthy teeth and bones”. The goal of this

question was to explore children (aged 9-10) thoughts about

calcium as an important part of their diet.

85.7% of children at local Church group and 94.7% of primary

school cohort correctly answered this question. The mean for

both groups were 6.5 and 18.5 respectively. In general, the

major understanding of children about calcium as a crucial

element to build healthy bones and teeth was very good (Table

3). Also, more information could have been explored if

children were interviewed. For instance, do you know other

types of vitamins and elements which you think are healthy?

And how do you know that calcium is healthy? (Appendix 6)

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6.2.8 Children’s understandings of fish as a healthy

diet (Q8)

Question 8 was “why do you think fish is part of a healthy

diet?” Children (aged 9-10) were asked to choose only one

answer among four options (a, b, c, and d), in which the

choice (d) was the best answer. Option (d) referred to “Low in

fat, source of phosphorus for bones and brain and other body

systems”. The goal of this question was to explore why

children (aged 9-10) thought that fish as an important part of

their diet.

78.9% of children at primary school cohort and 42.8% at local

Church group correctly answered this question (option d).

Regarding local Church cohort, 42.8% is rather low as compared

to 85.7% of their knowledge about calcium. Whereas, 21% of

children in the local Church group as compared to 42.8% of

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primary school cohort stated that their parents recommended

fish for them as a healthy diet (Chart 5).

Again Q8 could be better refined as “why do you think fish is

an important part of a healthy diet? How often do you eat fish

per week/month, and the role of parents in educating their

children about fish as an important part of a healthy diet?

Therefore, these questions could have been explored further by

interviewing children and exploring their views about other

options a) My parents told me that fish is important b) Full

of fat c) Good for vision (Appendix 6)

6.2.9 Children’s beliefs about fresh fruits and

vegetables as a healthy diet (Q9)

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Question 9 was “why do you think fresh fruits and vegetables

are an important part of a healthy diet?”

Children (aged 9-10) were asked to choose only one answer

among four options (a, b, c, and d), in which the choice (d)

was the correct answer. Option (d) referred to “Source of

essential vitamins and minerals”. Other options were a) Have

beautiful colors b) Taste is good c) Always available at home.

The goal of this question was to explore why children (aged 9-

10) thought that fresh fruits and vegetables are healthy diet.

57.1% of children at local Church group and 94.7% of primary

school cohort correctly answered this question. The mean for

both local Church group and primary school cohort were 5.5 and

18.5 respectively (Table 4).

This question could have been improved such as why do you

think fresh fruits and vegetables are a significant part of a

healthy diet? And why do you think fresh is better than canned

or frozen fruits and vegetables? Which is better to eat and

why? And why do people often do not eat the fresh version?

(Appendix 6)

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6.2.10 Children’s views regarding water as an

important part of a healthy diet (Q10)

Question 10 was “Why do you think water is an important part

of a healthy diet?”

Children (aged9-10) were asked to choose options correct for

them among four choices (a, b, c, and d). The aim of this

question was to explore why children think that water is an

important part of a healthy diet. The options were: a) I used

to drink water with the diet b) 60% of the body fluids is

composed of water c) Water is good for hair growth d) Water

give nutrients to the body cells and flush toxins through the

body. All responses of children in both case studies were

presented as accumulative totals.

28.5% of children in the local Church cohort used to drink

water with the diet as opposed to 5.2% in the primary school

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group. 28.5% at local Church group thought that 60% of the

body fluids are composed of water as compared to 31.5% at

primary school cohort. Furthermore, 57.1% of children at local

Church group perceived that water gives nutrients to the body

cells and flush toxins through the body as compared to 68.4%

at primary school cohort. No one (0%) of children thought that

water is good for hair growth in both groups (Chart 6).

However, further children’s thoughts of water as an important

part of a healthy diet could have been identified by

interviewing them. For instance, how much water do you drink

daily? And why do you think it is healthy? (Appendix 6)

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6.2.11 Children’s knowledge regarding a healthy

person (Q11)

Question 11 was “How do you know if a person is healthy?”

Children (aged 9-10) were asked to choose options correct for

them among four choices (a, b, c, and d). The aim of this

question was to explore the children’s thoughts of a healthy

person. The options were: a) They are fit, fast and skinny b)

They look healthy not big or fat c) Good shape, no signs of

diseases, infections or obesity, and d) They are not

overweight, they do exercise, do not smoke. All responses of

children in both case studies were presented as accumulative

totals (Chart 7).

71% of children in the local Church group and 5.2% of children

at primary school cohort considered that a healthy person

looks fit, fast and skinny. Whereas, 57% of children local

Church group and only 5.2% of children at primary school

group, thought that a healthy person looks healthy not big and

fat. Moreover, 29% of children in the local Church group as

opposed to 42% of children at primary school cohort viewed

that a healthy person has good shape, no signs of diseases,

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infections or obesity. Also, children in the both groups

relatively agreed with their understandings that a healthy

person is not overweight, do exercise and do not smoke with

57% and 58% in the first and second case studies respectively

(Chart 7).

Accordingly, the findings revealed a big difference of

children’s views in both cohorts concerning this question.

This difference perhaps could be due to the influence of their

parents, teachers and schools on their knowledge of a healthy

person. Therefore, this could have been explored further by

interviewing children in both groups. For instance, “Do you

think someone’s size or shape has anything to do with their

health?” Also, some important characteristics of a healthy

person could have been given as open questions. For instance,

fit, not overweight, good shape and signs of diseases or

infections (Appendix 6).

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6.2.12 Children’s perceptions about food origin (Q12)

Q12 was “What do you think these foods are made from?”

children were given 6 options of different foods and were

asked to choose the appropriate choice that they think the

food is made from. Next to each food item where one correct

answer and 2 wrong answers, and the children were asked to

choose only one answer among them. The 6 different kinds of

foods were a) Cheese b) Eggs c) Burgers d) Pasta e) Crisps f)

Yoghurt. The goal of this question was to explore children’s

views of food origin.

28.5% of children at local Church group thought that pasta is

made from cheese and 14.2% believed that pasta is made from

meat. Others, 85.7% correctly answered that cheese is made

from milk, 85.7% eggs from chicken, 85.7% burgers from beef,

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42.8% pasta from cereal, 71.4% crisps from potatoes, and 71.4%

yoghurt from milk (Table 5)

Also, 10.5% of children at primary school cohort perceived

that eggs are made from Cow, 26.3% thought that pasta is made

from cheese, and 5.2% stated that crisps are made from

plastic. Others, 94.7% correctly answered that cheese is made

from milk, 82.3% eggs from chicken, 84.2% burgers from beef,

47.3% pasta from cereal, 78.9% crisps from potatoes, and 73.6%

yoghurt from milk (Table 5). These findings revealed

children’s confusion in this small sample of children in both

groups which indicate a partial understanding of children

regarding food origin.

However, further exploration of children’s knowledge of food

origin could be maintained by interviewing them and following

up their answers to the questionnaire. For instance, “Do you

think potatoes or tomatoes grow under or above the ground?”

(Appendix 6)

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6.2.13 Children’s habits of taking breakfast (Q13)

Question 13 comprised of two parts, the first (Q13.1) was

“Have you had your breakfast today?” with yes and no options.

Also, children were given choices of food items in case they

had their breakfast on the day of the survey. These food items

were a) Egg b) Cereal c) Milk d) Bread/Toast and e) Orange

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juice. Moreover, children were given a big box in case they

want to mention other food items. The second part of this

question (Q13.2) was to find out whether the children think

that their breakfast was healthy or not.

71% of children at local Church group reported that they had

breakfast on the day of research study as opposed to 89% of

primary school cohort. 29% of children at local Church group

did not answer to this question as opposed to 5% in the

primary school group (Chart 8a and 8b). Only 5.2% of children

at primary school cohort have not taken breakfast on the day

of research study (Chart 8b).

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As shown in Chart 9, cereal was the utmost among food items

that had been consumed by the local Church group 42.8% as

compared to 47% in the primary school group on the day of the

survey. In the local Church group no one (0%) had consumed egg

on the day of survey as compared to (5.2%) at primary school

cohort. 21% of children in the local Church cohort had other

foods or drinks such as yoghurt, fruit, water, hot dogs, and

fresh fruit. Both groups had milk on the day of research with

(14.2%) and (15.7%) for the local Church group and the primary

school group respectively. Furthermore, 28.5% of children had

bread/toast in the local Church group as opposed to only

(5.2%) in the primary school cohort. Only (5.2%) of children

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at primary school cohort had orange juice as compared to

(14.2%) at the local Church group.

However, certain questions were relevant to explore such as

“Do children think that cereal is healthy or unhealthy? Are

they aware of cereal high in sugar? Therefore, it is relevant

to explore that by interviewing children and following up

their answers (Appendix 6).

Additionally, in the local Church group, 57.1% of boys and

14.2% of girls perceived their own breakfast as healthy, and

no one stated their breakfast as unhealthy. Whereas, at

primary school cohort, one boy (5.2%) perceived his breakfast93

as mostly healthy breakfast, 31.5% girls and 26.3% boys

thought it was healthy. Only 2 boys (10.5%) and 2 girls

(10.5%) perceived their breakfast as unhealthy breakfast

(Table 6).

Therefore, it is worthy to explore why some of the children

thought their breakfast was healthy and others perceived their

breakfast as unhealthy by interviewing them and following up

their answers (Appendix 6).

6.2.14 Children’s Knowledge of healthier food choices

(Q14)

Q14 composed of 8 questions (a to h), each question had two

options, one is healthy and one is unhealthy. The aim of this94

question was to find out whether children (aged 9-10) could

make healthy food choices and could differentiate between

healthy and unhealthy food and drink options. This special

question was presented in texts and pictures to make it

attractive for children to understand this question.

Children’s were given four pairs of foods or drinks and asked

to choose the relatively healthier choices among each pair. In

local Church groups, in general, knowledge of healthy food

choices was bad (mean number of correct answers was 1.5 out of

4). Only (47.1%) could identify correctly the relatively

healthier choices among the four pairs of foods or drinks. Two

children (29%) chose both fresh and fried fruits and

vegetables as healthy foods; one child (14%) considered both

food low and high in fat as healthy, two (29%) stated that

both food low and high in salt is healthy, one (14%) chose

both boiled and fried potatoes as healthy foods, and one (14%)

regarded both brown and white bread are healthy choices

(Chart10a).

In the other cohort, at primary school group, in general,

knowledge of healthy food choices was good and better than

those at the local Church group (mean number of correct

answers was 3 out of 4. About (77.3%) could identify correctly

the relatively healthier choices among the four pairs of foods

or drinks. (24%) chose fried fruits and vegetables as healthy

foods; (6%) considered both food low and high in fat as

healthy, (24%) stated that both food low and high in salt are

healthy, (12%) considered both food low and high on sugar is

healthy, (12%) thought that both boiled and fried potatoes are95

healthy foods, and (18%) considered both brown and white bread

are healthy choices (Chart 10b).

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Moreover, a marked gender differences concerning healthy food

choices in both groups were explored in this study. In primary

school group, boys (53%) were more likely to make healthier

choices than girls (47%). Conversely, girls (57%) were higher

than boys (43%) in the local Church group in making healthier

choices (Table 7). This was again worthy to explore by

interviewing children in both cohorts (Appendix 6).

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7. Discussion

Having reviewed the literatures concerned with healthy eating

and childhood obesity, and after the data results have been

presented for both cohorts, I will now highlight my discussion

for each group separately. This is because each group has a

different context and background which might influence the

research findings. Therefore, I will epitomize each group’s

findings independently so that I can argue the main

interesting issues that could be managed to address childhood

obesity and to promote healthy eating.

Findings from the current study showed lots of misconceptions

of children’s views of healthy eating; the following themes of

perceptions need to be further investigated: most importantly,

1. Matters children considered when choosing what to eat, 2.

Gender food preferences, 3. Children’s thoughts regarding a

healthy person, 4. Children’s views on Food origin, 5.

Children’s habits of taking breakfast, 6. Children’s thoughts

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concerning healthier food choices, and 7. Source of knowledge

for children about healthy eating. I will identify and explore

each theme independently for each participating group to

epitomize children’s misconception explored in the results of

this research study.

7.1. Matters for consideration in choosing food by

children (Q4)

As I mentioned already, for this question, all responses of

children both cohorts were presented as accumulative totals.

The utmost proportion of children 85.7% at local Church group

considered the taste as a priority when choosing food as

compared to 26% at primary school cohort. In the primary

school group, (21%) of the children concerned the appearance

of food when choosing food as compared to (0%) of the local

Church cohort. Also, among the local Church group 28.5% stated

that their parents recommended food for them as opposed to

15.7% of the primary school cohort. No one (0%) considered the

cost as a matter when they decided to eat in both groups

(Chart 2).

These findings are similar to those revealed by a large cross-

sectional study in Hong Kong (DOH, 2008), despite of the

difference in cultures, socioeconomic state, ethnicity, eating

environment and quality of foods.

Moreover, our findings clearly support the cognitive

development theory which has already been mentioned in the

literature review (chapter2. 4). As we are dealing with

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children in the concrete operational stage of development

(aged 9-10), accordingly, and as Bahn et al., (1989)

suggested, concrete operational children concentrate mainly on

the quality and characteristic of the brand, for instance,

liking the taste or the colour of the package when they were

distinguishing the brands. Young children focus on appearance

and texture, whereas older children focus on taste aspects

(Zeinstra et al; 2007).

Additionally, our findings support what already had been

suggested by Sharifa et al (2013) who found that most of the

(7-9 years old) children like food because of the taste. Also,

(Olson et al., 1981; Ricketts, 1997; Pѐrez-Rodrigo et al.,

2003; Molaison et al., 2005) have shown that the taste of food

was the major limiting factor related to consumption and

regarded as a significant determinant of children’s food

choice. Furthermore, for non-favourite food, some children

dislike some types of foods when they know that the food is

unhealthy, for instance, sweets as they know it can cause

tooth aches or they dislike fish as it contains lots of bones

(p. 135).

However, these findings are worthy to explore to find out and

follow up children’s answers such as why you prioritize taste

when choosing food, a food with taste nice is it healthy? What

about the influence of your parents on your choice, and do

they make healthy choices for their children, and how much do

children care about the appearance of food and cost? I

believe that such different children’s views could be better

100

explored by interviewing them in this critical stage of

cognitive development (Appendix 6).

Besides taste, in both groups, a surprising finding in our

study was the clear influence of the parent on children’s

decisions when choosing food. In this small sample study,

28.5% of children in the local Church group stated that their

parents recommended food for them in comparison to 15.7% of

primary school cohort. As I mentioned already, in the concrete

operational stage, children are less egocentric, and the

instrumental rewarding appears to fit their cognitive

capacities, although we did not measure the cognitive

development. Also, children have a better understanding of

value, and they can see another’s perspective, they are more

independent and self confident than younger age children

(Flavell and Piaget, 1963; Roedder-John, 1999; and Delfos,

2003). Therefore, it is relevant to explore the reasons beyond

the influence of parents on children’s decisions, in this

particular age group, when choosing food in both cohorts. For

instance, the child might have a loss of appetite or might

have abnormal growth and development (Appendix 6).

7.2 Gender food preferences (Q5)

Children in both groups had common most and least five

favourite foods. Most favourite foods were Chocolate, Apple,

Cucumber, Salad and Bananas, while the least favourite foods

were Sweets, Chips, Crisps, Chicken and Fish. As shown in

Chart 3a, the findings revealed a marked gender difference

regarding children’s five favourite food choices. That is, at

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the local Church group, 75% of girls had more preference than

boys (25%). Conversely, at the primary school cohort, Boys 47%

had more preference for these foods as opposed to 26% of

girls.

Moreover, 57% of children in the local Church cohort,

considered each of these foods as healthy as opposed to 42% of

the primary school cohort. Despite of 71% of children at the

primary school cohort considered their five favourites as

unhealthy; they considered such foods as their favourite foods

(Chart 3b).

In local Church groups, children foods such as Pizza, Crisps,

Chicken, Chocolate, Sweets, Cake but not Fruit cake, Orange

juice, Bananas, Biscuits, Kiwi, Beef, Cucumber, Apple and

Pepper were their favourite foods. Among seven children, four

children (2 boys and 2 girls) considered each of these foods

as healthy, and three children did not answer this question (Q

5.2).

Children at the primary school cohort stated foods such as

bananas, Salad, Apple, Pasta, Pizza, pork noodles, Ice cream,

Strawberries and Chocolate, Potatoes, Carrot, Sausage, Meat,

Hotdogs, Fish, Chips, Olives, Rose berries, Cheese and Sweets

as their favourite foods. In this group, we had two missing

answers. Among 19 children in the primary school group, two

children did not answer this question (Q 5.2), 5 children

regarded these foods as healthy and 12 children considered

these foods as unhealthy.

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However, these findings were similar to those revealed by the

department of health (DOH, 2008).

Also, boys as compared to girls, in both groups, had a greater

preference for pork, beef and fish. Whereas, girls preferred

fruit and vegetables, sweets and comfort foods such as ice-

cream and chocolate more than boys in both cohorts.

Despite of similarity of these findings to what had been

already highlighted in the literature review (Chapter 2.10),

each group of children had a different gender preference for

the same quality of food they favoured. 75% of girls at the

local Church cohort had more preference for their five

favourite foods than boys 25% as opposed to 47% boys and 26%

girls at the primary school group. This is worthy to explore

by interviewing children of different genders in both groups

to find out why they had different gender food preferences,

although they shared similar factors such as age, gender,

socioeconomic state, ethnicity and culture.

As already mentioned, such factors are connected to food

preference (Logue and Smith, 1986; Drewnowski, 1997; Turrell,

1998; Lytle et al., 2000; Wansink et al., 2003; Westenhoefer

and Cooke, 2005; Caine-Bish and Scheule, 2007). Accordingly,

it is essential to understand the influence of these factors

on children’s food preferences to help develop healthy and

successful menus (Caine-Bish and Scheule, 2009). Moreover, the

level of education of the parents is worthy to explore by

interviewing parents. However, I potentially arranged some of

the questions that were my original intention to ask children

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to further explore and follow up the influence of their

parents and other factors on their gender preferences

(Appendix 6).

However, it was uncertain how did the children appreciate this

question? Did they consider each of their favourite foods as

healthy or unhealthy? This is relevant to find out why did

they perceive some of their favourite foods as healthy and

others as unhealthy? And if certain food was unhealthy, why

did they favour it? This finding again is worthy to explore

and follow up to further understand why in both cohorts

children had different gender food preferences which are

against studies revealed in the literature review (Chapter

2.10). Also, further research study is needed to confirm our

findings.

7.3 Children’s knowledge regarding a healthy person

(Q11)

71% of children in the local Church group thought that a

healthy person looks fit, fast and skinny as opposed to only

5.2% of children at the primary school cohort. Whereas, 57% of

children in the local Church group thought that a healthy

person looks healthy not big and fat as compared to 5.2% of

the primary school cohort. Also, 29% of children in the local

Church group perceived that a healthy person has good shape,

no signs of diseases, infections or obesity in comparison to

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42% of the primary school group. Moreover, children in the

both groups relatively agree with that a healthy person is not

overweight, do exercise and do not smoke with 57% and 58% in

the first and second cohorts respectively (Chart 7).

Our findings support what had been already explained in the

literature review (Chapter 2.3). Accordingly, same age groups

from different contexts and background had various perceptions

of their health and others bodies’ health. These results were

similar to those found by Burrows (2007).

Certain question such as “Do you think someone’s size or shape

has anything to do with their health?” and gender

differentiation responses, are worthy to explore. For

instance, they might refer on their understandings that some

people are just born big or little. As they perceived that

genetic factors play a confounding role in the possibilities

afforded to people to become slim or thin (Kirk and Colquhoun,

1989). Such findings could have been further explored by

interviewing children (Appendix 6).

As shown in Chart 7, children’s responses represent a

conflation of fitness with non-fatness, health with size,

shape, and weight. These findings also were indications that

one’s capacity to run, together with what they eat, may be

responsible for the way they look and therefore their health.

This notion that health can, in a sense, be read off the body

is well reconsidered in physical education literature

(Crawford, 1980; Tinning, 1985; Shilling, 1993; Markula,

1997). However, this preoccupation with appearance as an

105

indicator of health is largely regarded as the preserve of

adults. The findings also indicate that children (aged 9-10)

are ready and willing to draw these kinds of links between

health and corporeal indicators as an important insight

particularly for physical educators (Burrows, 2007).

7.4 Children’s understandings about food origin (Q12)

28.5% of children at local Church cohort believed that pasta

is made from cheese and 14.2% thought that pasta is made from

meat. These results revealed children’s confusion in this

small sample of children which indicate a partial

understanding of children of food origin. Therefore, further

education about healthy eating and food origin is compulsory

for children in this group. However, 85.7% correctly answered

that cheese is made from milk, 85.7% eggs from chicken, 85.7%

burgers from beef, 42.8% pasta from cereal, 71.4% crisps from

potatoes, and 71.4% yoghurt from milk (Table 5)

In the other cohort study, 10.5% of the children of the

primary school group perceived that eggs are made from Cow,

26.3% thought that pasta is made from cheese, and 5.2% viewed

that crisps are made from plastic. These results again

revealed children’s confusion in this small sample of children

which indicate a partial understanding of children about food

origin. However, 94.7% correctly answered that cheese is made

from milk, 82.3% eggs from chicken, 84.2% burgers from beef,

47.3% pasta from cereal, 78.9% crisps from potatoes, and 73.6%

yoghurt from milk (Table 5) These findings support what had106

been previously acknowledged in the literature review (Chapter

2.8).

Moreover, the findings in this study have been similar to

those recently published by BBC NEWS (2013). However, further

exploration of children’s knowledge of food origin could have

been maintained by interviewing them. For instance, “Do you

think potatoes grow under or above the ground?” and “Have you

ever been on a farm visit?” Or do they really understand what

is plastic? Or it is the question needs to be refined?

(Appendix 6)

Again, the percentages of these findings, as compared to the

small sample of children in both cohorts, are relatively

worrying. Therefore, the data suggest that teaching children

about healthy eating and food origin must be promoted and more

focussed than before, and the policy and practice should be

re-directed. The aim must be to “start the process of re-

engaging children with the origins of food, nutrition and

cooking, so that they grow up with a fuller understanding of

how food reaches them and what a healthy diet and lifestyle

consist of” (BBC NEWS, 2013). Also, it is essential for

children to visit farms to be physically active as part of a

healthy lifestyle in addition to healthy eating.

7.5 Children’s habits of eating breakfast (Q13)

As shown in Chart 8a and 8b, 71% of children in the local

Church group had breakfast on the day of survey as opposed to

and 89% of the primary school cohort (Q13.1). Only 5.2% of the

local Church group skipped breakfast on the day of the survey.107

Besides having breakfast, Chart 9 revealed that cereal was the

highest among food items that had been consumed by the local

Church group (42.8%) and the primary school group (47%) on the

day of the survey. This is, as mentioned already, useful for

children to have a lower body mass index (BMI) and lower

cholesterol than those who eat non-cereal breakfast foods.

This is because breakfast cereal is lower in fat and higher in

fibre than non-breakfast cereal and can be protective against

childhood obesity (Resnicow, 1991 and Williams, 1995).

Although not all cereal is healthy because it might contain

high sugar and this is again worthy to find out and discuss by

interviewing children. Also the relevance of milk, egg, bread

an orange juice as a healthy breakfast, and to further explore

why some of the children in both cohorts had certain foods in

their breakfast such as yoghurt, fruit, water, hot dogs, and

fresh fruits and do they think each of these are healthy?

(Appendix 6)

Furthermore, in the local Church group, 57.1% of boys and

14.2% of girls perceived their own breakfast as healthy, and

no one stated unhealthy breakfast. Whereas, in primary school

group, one boy (5.2%) perceived his breakfast as mostly

healthy breakfast, 31.5% girls and 26.3% boys thought it was

healthy. Only 2 boys (10.5%) and 2 girls (10.5%) perceived

their breakfast as unhealthy breakfast (Table 6).

However, 71% of children at local Church group and 89% in the

primary school group stated that they had a healthy breakfast.

They were more likely to mention a large number of healthier

food options such as yoghurt, fresh fruit and vegetables than108

those who have not had breakfast or had skipped breakfast.

These findings are similar to those revealed by the Department

of Health (DH, 2008). Also our findings support what have been

already mentioned in the literature review (Chapter 2.5). For

instance, as (Nicklas et al., 1998; Kleemola et al., 1999)

suggested that regular breakfast eaters have higher diet

quality including increased consumption of fiber, calcium,

vitamin A and C, riboflavin, zinc, iron and decreased intake

of calories, fat and cholesterol).

For children, breakfast consumption is associated with

education and better school performance (Pollitt and Mathews,

1988; Vaisman et al., 1996; Murphy et al., 1998). Also,

breakfast has positive effects on cognitive development and

induces better academic achievement (Dye et al., 2000).

Conversely, skipping breakfast is linked with difficulty in

issue solving, short-term memory, attention, and episodic

memory in children (Pollitt et al., 1983; Vaisman et al.,

1996; Wesnes et al., 2003).

Again, all these issues are commendable to explore by

interviewing children in both groups. For instance, why do you

think breakfast is relevant for your health? Why do you think

your breakfast is healthy or unhealthy? Do you feel better

(more aware) in the class when you already had your breakfast?

(Appendix 6)

Moreover, it is valuable to explore the essential role of

parents in influencing breakfast choices for their children

who often make breakfast choices in agreement with their

109

parents’ wishes (Agostoni and Brighenti., 2010). Also to

explore a probable reason for skipping breakfast such as: not

being hungry in the morning, lack of time, dissatisfied with

their body shape, or being on diet particularly in girls.

7.6 Children’s Knowledge of healthier food choices

(Q14)

Our findings in Chart 10a and 10b showed that in a local

Church cohort, in general, children’s knowledge of healthy

food choices was bad (mean number of correct answers was (1.5

out of 4). Only (47.1%) could identify correctly the

relatively healthier choices among the four pairs of foods or

drinks. Whereas, among primary school group, children’s

knowledge of healthy food choices was good (mean number of

correct answers was 3 out of 4). About (77.3%) could identify

correctly the relatively healthier choices among the four

pairs of foods or drinks.

Therefore, children of the primary school group were more

likely to make healthier choices than those of the local

Church group (77.3% vs 47.1%). These findings support what had

already been mentioned in the literature review (Chapter 2.9).

However, a marked gender differences concerning healthy

choices in both groups were explored in this study. In primary

school group, boys (53%) were more likely to make healthier

choices than girls (47%). Conversely, girls (57%) were higher

than boys (43%) in making healthier choices (Table 7). These

findings were relatively similar to those found in (DH, 2008).

110

Also, children should be aware of that the associations with

risk of type 2 diabetes are different among individual fruits.

This means that a greater consumption of specific whole

fruits, particularly blueberries, grapes, and apples, is

significantly associated with a lower risk of type 2 diabetes,

whereas increase consumption of fruit juices has the opposite

association (BBC NEWS, 2013).

Moreover, by interviewing children and following up their

responses, we might explore the major limiting factor related

to food consumption and regarded as a significant determinant

of children’s food choice (Appendix 6). For instance, the

taste of the food as suggested by Olson et al (1981),

Ricketts, (1997), Pѐrez-Rodrigo et al (2003) and Molaison et

al (2005).

However, as (Zaini et al (2005) suggested that for non-

favourite food, some children dislike some types of foods when

they know that the food is unhealthy, for instance, sweets as

they know it can cause tooth aches or they dislike fish as it

contains lots of bones (p. 135). Also, as I mentioned already,

this question has a significant correlation with gender,

murders children considered when choosing food as well as

children's food preferences.

7.7 Source of knowledge for children about healthy

eating (Q2)

The maximum percentage of children 100% at local Church group

considered their parents as the main source of knowledge of

111

healthy eating and 71.4% thought that schools and teachers

were the second source. Whereas, in the primary school only

36.8% of children had their knowledge of healthy eating from

their parents and also 36.8% had from their schools and

teachers. Conversely, the highest percentage of children

(42.1%) at primary school children's group considered having

knowledge of healthy eating from food labels and packaging

whereas no one considered this source among the local Church

cohort. Also, Television adverts were the lowest proportion

among the first (14.2%) and the second (5.2%) cohorts

respectively (Chart1). These findings clearly support what

have been already mentioned in the literature review (Chapter

2.6).

These findings support the notion of influence of parents by

sending healthy eating messages to their children (Paquette,

2005). The reason might be because of that most of children in

the local Church group had qualified and educated parents.

Therefore, it is worthy to find out and follow up children’s

responses among both groups possibly by interviewing the

children, their parents and their teachers (Appendix 6).

8. Limitations

There are certain limitations in this study that should be

acknowledged; data from this study were collected using self-

administered questionnaire. Children in the primary school

group completed the questionnaire under the supervision of

teachers in a classroom setting, Whereas, those in the local

Church group did that as a social grouping in the weekly

112

Sunday meeting under the supervision of one of the Brookes’

members. Therefore, it is possible that some children might

provide socially acceptable answers that did not reflect their

true perceptions of healthy eating.

Moreover, for the purpose of reliability of this study, this

study would have been more accurate if the administered

questionnaire were cross-checked with the background

information including, the class number, gender and date of

birth for both groups. Accordingly, only the matched

questionnaire should be used to assess the associations among

the findings from the children in both groups and the school

and Church they were attending.

Concerning the primary school group, only year 5 and year 6

(aged 9-10) were included in this study. It could be argued

that they might not represent the entire primary school

population. Although data were collected in two different

settings, one school in the west of Oxford and One local

Church group in the centre of Oxford, children’s food

preferences reported in this research were likely to reflect

local and regional food preferences. Additionally, food

preferences were not measured in relationship to the

preparation or the source of the food, which may have had an

impact in the decrease in many food preferences demonstrated

in children of both sexes. It is unknown, if when rating

preferences, children reported preferences in relationship to

the food in general or the food as served at school or home.

113

Another limitation is that a small number of children

participated in this research study; therefore it is not easy

to generalize to a larger or broader population. Further

research is needed to confirm our findings.

However, several different actions were taken in this study to

ensure reliability and validity. I used to accept systematic

procedures for data collection, data handling and data

analysis. The fact that children in both cohorts were assured

that there were no wrong answers and that we did not finish

their responses for them supports validity. Major topics,

confusing and conflicting data, the analyses and

interpretations were discussed with my supervisor (Professor

Debra McGregor). Furthermore, the comparison of our findings

with other results in the literature strengthens evidence. I

have been very careful with the interpretation and I am

confident that the findings were an accurate reflection of

what the children said.

Despite these limitations, the study provided useful

information on two cohorts with two different context and

background concerning children’s knowledge, attitudes and

practices of healthy eating and the existing nutritional

environment among both case studies. The results generated

will have significant reference value for future planning of

healthy eating promotion programs in both school and local

Church groups.

As a novice researcher learning how to be systematic in the

searching for and the then synthesis of research, has proved

114

hard but an invaluable skill to develop. This was the first

piece of self-directed academic work undertaken and many

lessons have been learned along the way from my supervisor.

9. Conclusions

The insights of healthy eating continue to be a relatively

unsolved matter Because of two reasons. First, the polysemy of

“Healthy eating” has not been recognized in the past and

second reason is because of the complexity of the issue

(Gustafsson and Sidenvall, 2002). Yet, if perceptions were

found to be comparatively homogeneous across studies in varied

developed countries, age groups, genders and socioeconomic

states, more research need to be conducted to authenticate

this finding (Paquette, 2005).

Because of each cohort findings were analyzed, presented and

discussed separately, and because of that each cohort had

different context and background, therefore, each group needs

a distinct conclusion.

9.1 Conclusion of study of primary school cohort

The main confusing questions for children in this group were

Q2, Q4, Q5, Q12, Q13 and Q14. Although the school had a

healthy eating policy, maximum percentage of children (42. 1%)

stated that they had knowledge of healthy eating from food

labels and only 36.8% had their knowledge from schools and

teachers. The highest proportion 26% of children depends on

choice/availability when choosing food and no role of parents

in sending healthy eating messages was evident. A very

115

surprising finding was, although children in primary school

cohort knew that their food was unhealthy, 71% favor it. This

indicates that they had a lack of information on healthy

eating and redirection of policy and practice in the school is

compulsory. These findings were alarming of a school which has

been already committed to a healthy eating policy and had a

good sense of a healthy lifestyle (Ofsted report, 2008).

Moreover, 26.3% thought that pasta is made from cheese, 10.5%

perceived that egg is made from Caw and 5.2% believed that

Crisps is made from plastics. These findings proved that

children in the primary school cohort had a partial

understanding of knowledge of food origin. Therefore, it might

be useful for the school to sign up for the BNF´s Healthy

Eating Week program which aims “to start the process of re-

engaging children with the origins of food, nutrition and

cooking, so that they grow up with a fuller understanding of

how food reaches them and what a healthy diet and lifestyle

consist of” (BBC NEWS, 2013).

Despite of that all options given for having breakfast were

healthy, 21% of children in this group thought that their

breakfast was unhealthy (Q13). This means they had

misconceptions of which food is healthy or not which need

further efforts to be undertaken by the school. For instance,

free school breakfast programs could be added to the school

health policy and teaching children about healthy breakfast is

a good step forward. In addition, children viewed a lack of

knowledge of making healthy choices. 24% thought that fresh vs

fried fruits and vegetables, 6% believed that food low vs high116

in fat, 12% believed that food low vs sugar, 24% thought that

food low vs high in salt, 12% perceived that boiled v's fried

potatoes and 18% brown vs white bread were healthy choices.

The above analysis of children’s responses in the primary

school group, and as suggested by Burrows (2007) recommends

that there is much for physical educators to attend to

pedagogically and personally in relation to health and

physical education in schools. These findings point to a need

to equip children with strategies for making sense of both the

contradictory and normative information they are presented

with. They also need the cognitive apparatus to weigh up the

implications for themselves and others of adopting particular

health practices and the resources. This is to examine the

potential disjuncture between recommended strategies and the

embodied effects of these at the level of the individual.

Furthermore, the school provides a unique opportunity for

preventing childhood obesity and children spend a large

proportion of their time in school settings, in which children

can receive information on proper healthy eating (Elder et

al., 2010).

Moreover, food preferences differed between genders in the

primary school group. Menu offerings need to reflect the

changing preferences of children with respect to gender and

dietary recommendations for health. This school that plans

similar menus for both genders may want a look more closely at

preferences by gender and have choices that satisfy both

genders. Insight into the food preferences reported by

children (aged 9-10) with regard to gender is valuable117

information which might be used to improve the diets of

primary school children while developing lifelong healthy

eating. Also, preference data might be helpful with school

menu planning to create worthy nutrition education programs

that parallel changes being completed in the school food

service (NATALIE et al., 2009). Therefore, a greater

understanding of the implications of food quality or product

brand on the preferences and consumption of children in the

school setting also should be explored.

Additionally, the present study revealed that the children’s

preferences of food depend on several factors such as taste,

parents, schools and teachers. The involvement and support of

parents is essential to the success of any intervention aimed

at the prevention and management of overweight or obesity in

young children (Jackson et al., 2005). Therefore, in order to

promote healthy food to children the food manufacture should

produce healthier foods with good taste and an attractive

presentation which is child-friendly. Parents and teachers

should educate the children about healthier food choices, as

they might be interested in food after they know the

nutritional value of the food. Also, it is very essential to

promote the intake of fruits and vegetables, at home and

school, as snacks because they do satisfy the appetite and

they are nutritious.

Therefore, school data necessitate further efforts to be

undertaken to promote children’s awareness of healthy eating

campaigns, support of the healthy eating promotion in school,

and participation in any healthy eating activity organized by118

their school could have positive impacts on children’s views

about their healthy eating knowledge and eating habits.

Furthermore, the participating school can get benefit from a

Balanced Breakfast Model (Chapter 2.5.4) to promote eating a

healthy breakfast for their children. Thus, the food service

staff should be asking “What will kids eat?” while assessing

current policies and services (Caine-Bish and Scheule, 2009).

For future studies, it is recommended to interview children,

parents, teachers, and school canteen operators to gather

better information about the availability of foods in the

school and home environment and the children’s food choices in

both settings.

However, making suggestions about policy for schools and

guidance for parents to tackle/address obesity through

heightening healthy eating awareness is essential and could be

helpful also to further shape my dissertation (Appendix 8, 9

and 10).

9.2 Conclusion of survey of local Church group

As I mentioned already, most of the children’s parents in this

group were educated with high qualification, therefore this

might be the reason that children were very good at answering

questions Q1, Q2, Q3, Q7, and Q8.

However, certain issues were concerning particularly Q9, Q10,

Q12, and Q14 in this group need addressing to perhaps avoid

childhood obesity. Only 57% of children in this group

perceived that fresh fruit and vegetables are healthy because

119

they are sources of essential vitamins and minerals (Q9). This

percentage was low as compared to such a very small sample of

children (only 7 in number). A high proportion of children

(28%) in this cohort used to drink water with diet and thought

this was a healthy. Only 57% viewed that water is an important

part of a healthy diet because it is nutritious and antitoxic.

Also, 42.7% of children revealed partial understanding of food

origin (Q12).

Moreover, children had difficulty to make healthy choices

among certain foods such as fresh vs fried fruits (57%) and

vegetables, food low and high in fat (57%), sugar (57%) and

salt (57%), and boiled and fried potatoes (42.8%). All these

findings revealed that there were areas of partial

understanding or misconception of children in this group that

is essential to be addressed and tackled to help to avoid

childhood obesity.

However, we could have had more exploration of children’s

views in this cohort, if they had been interviewed (Appendix

6).

120

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Appendices

Appendix 1: letter to parents

Dear parents,

Childhood obesity puts children at risk of developing seriousillnesses. As a result of unhealthy diet and inactivelifestyle, we are seeing an alarming increase in childhoodobesity, i.e., almost one in five primary school children areoverweight in 2013. In addition many studies regardingchildren’s perception about healthy eating revealed children’sconfusion and misconception. For instance, cheese is made fromplants, Pasta is made from meet and crisps are made fromplastic (BBC News, June, 2013).

Therefore, I am conducting a research into Children’s ideasabout healthy eating. I would like to give your children aquestionnaire to fill in to find out what they think aboutHealthy Eating. It will take about 20 minutes for them toanswer the questions. No disadvantages or risks of taking partin this study, just time. Your child is invited to participateand complete a questionnaire to record his/her views about

142

healthy eating. The ultimate goal of this research project isto explore how do year six children make healthy choices? Howdo they think when they decide to eat? What food do theyprefer to eat and why? What does healthy eating mean to them?These are few examples involved in the questionnaire. Thisresearch project is part of my MA Childhood Studies Course atOxford Brookes University/school of education. This researchstudy will be conducted in anonymity and collected informationwill be restricted to the researcher, my supervisor and thehead teacher of the participating school. It will not affectthe academic performance or internal assessment of your child.If you have any concerns please contact my supervisor ProfDebra McGregor, McGregor@brookes.ac.uk, Professor in Education(Learning and Developing Pedagogy), School of Education,Faculty of Humanities and Social Sciences, Harcourt HillCampus, Oxford Brookes University, OX2 9AT, Tel : 01865488355. My contact details are: Khajik Yaqob,12007086@brookes.ac.uk, student in School of Education,Faculty of Humanities and Social Sciences, Harcourt HillCampus, Oxford Brookes University, OX4 2NS, Mobile no:07753353598.

Thank you for your time,

Date 10/07/2013

Appendix 2: Letter to head teacher

Dear head teacher of St, Josephs Catholic Primary School,

I am Khajik Yaqob/ studying the MA Childhood Studies course. Iam studying for a Master degree in Oxford Brookes University/

143

school of education. I am conducting research into Children’sideas about healthy eating. I would like to give your childrena questionnaire to fill in to find out what they think aboutHealthy Eating. This is supported by focus group interviews. Iwould bring in a questionnaire for the year 6 to complete. Itwill take about 20 minutes for them to answer the questions.No disadvantages or risks of taking part in this study, justtime. I sincerely hope that you can help me to carry out thequestionnaire to year six children in your school.

A copy of the results/findings of the research will be sent tothe Head of the participating school. A full copy of thethesis will be available to borrow on request. The research ispart of the Master’s program in the Faculty of Humanities andSocial Sciences at Oxford Brookes University. Thisdissertation will be submitted to achieve that degree/award.If you have any concerns please contact my supervisor ProfDebra McGregor, McGregor@brookes.ac.uk, Professor in Education(Learning and Developing Pedagogy), School of Education,Faculty of Humanities and Social Sciences, Harcourt HillCampus, Oxford Brookes University, OX2 9AT, Tel : 01865488355. My contact details are: Khajik Yaqob,12007086@brookes.ac.uk, student in School of Education,Faculty of Humanities and Social Sciences, Harcourt HillCampus, Oxford Brookes University, OX4 2NS, Mobile no:07753353598.

Thank you for your time

10/07/2013

144

Appendix 3: Ethical approval form

Faculty of Humanities and Social Sciences Faculty Ethics form HSS.E2

Application for ethics approval for a research project

involving human participants

Undergraduates and Foundation Degree Students:

Before completing this form, the ethics review checklist (school form

HSS.E1) should have been completed to establish whether this additional

application for ethics approval is required. If ethics approval is

required, you should complete this form, sign it and submit it to the

Faculty Research Ethics Officer, Maggie Wilson at mvwilson@brookes.ac.uk. A

decision form, E3 will then be returned to you by e-mail.

Master’s Students:

You should complete this form before you start your project and submit it

to your supervisor.

If he or she is unable to sign it at this stage, the form will be referred

to the Faculty Research Ethics Officer, as above, who may seek further

information and clarification from you. A decision form, E3, will then be

returned to you by e-mail.

145

All students should refer to the University Code of Practice on Ethical

Standards for Research involving Human Participants, available at

www.brookes.ac.uk/res/ethics and Faculty guidelines, which are included in

the relevant on-line module or course handbook. You should bind a copy of

the approved form in your final project or dissertation submission.

1. Name of Principal

Investigator (Student):

Khajik Yaqob

E-mail address:

12007086@brookes.ac.uk

2. Name of Supervisor and e-

mail address: Prof

Debra McGregor

dmcgregor@brookes.ac.uk

3. Working Project Title: To

explore year 6 children’s

views about healthy eating

and what they do to eat

healthily?

4. Project Type (please

specify course and give

module number):

Master’s

project

146

Master’s

dissertation

P70899 Undergraduat

e project:

Undergraduat

e

dissertation

:Foundation

degree

project:

5. Background to and rationale

of proposed research:

The rationale of this research

project is to explore how do

children (aged 9-10) think about and

understand healthy eating, to

address Childhood obesity. As it is

evident that, unbalanced diet with

low fruit and vegetables plus low

physical activity, can lead to

childhood obesity, abnormal

behaviour and low school

performances. Moreover, obesity can

be associated with shorter life

expectancy. For instance, a 16 year

old girl with obesity, she has just

6 years to live because of her

unhealthy diet. Also, a 4 year old

girl with obesity gets bullied.

Therefore, healthy eating can

147

prevent cardiovascular disease, some

cancers and it can protect the child

against asthma. I would bring in a

questionnaire for year 6 children to

fill in to find out how they

understand healthy eating.

6. ‘Gatekeeper’ permission

If you are conducting your

research within an

organization external to

Brookes, such as a school

or company, has permission

has been obtained?

Attach a copy of the letter

or e-mail giving permission

Yes.

7 Methods of data collection:

Attach a copy of your draft

questionnaire, interview

schedule or observation

guidelines

The methodology includes

questionnaire plus focus group

interviews.

8 Participants involved in

the research:

Include the target number,

age range, source and

method of recruitment and

Only year 6 (9-10) children will be

involved as participants in this

research. The target number is 46.

This research will be recruited to

the head teacher in St. Josephs

Catholic Primary School Mrs. Tomkys

148

location of the research Sue in Headington, Headley Way, Ox3

7SX, Oxfordshire, Oxford.

9 Are participants in a

dependent relationship) as

an unequal power

relationship) with the

researcher?

If yes, what steps will you

take to ensure that

participation is entirely

voluntary and is not

influenced by this

relationship?

No

10

.

Potential benefits of the

proposed research:

The head teacher can see the results

of my study and use them to inform

what the school might do about

healthy eating.

11 Potential adverse effects

of the proposed research

and steps to be taken to

deal with them:

These are defined as risks

greater than those

encountered during normal

day to day interactions and

could include possible

psychological stress or

No disadvantages, just time.

149

anxiety

12

.

Plan for obtaining informed

consent:

Please attach copy of your

participant information

sheet and consent form

(Note consent forms are not

needed for questionnaires)

Done

13

.

Steps to be taken to ensure

confidentiality of data:

Outline steps to be taken

to ensure confidentiality,

privacy and anonymity of

data during collection and

publication of data

1- I will use pseudonyms to

protect the identities of

those involved.

2- Respondents to questionnaires

are ensured anonymity and

interviewees who require it

will be granted

confidentiality.

3- Interviews with the dealing

with the child and the school

will be re identified before

the application.

4- All data will be destroyed

once the dissertation has been

completed. In the meanwhile,

only myself as a researcher,

the head teacher and my

supervisor will see the data.

150

14 Debriefing and/or feedback

to participants

What debriefing and support

will participants receive

after the research?

How will the findings of

the research be made

available to them?

A copy of the findings/ results of

the research will be sent to the

Head of the participating school. A

full copy of the thesis will be

available to borrow on request.

15 Data storage and security

How will you ensure safe

data storage during

fieldwork and after

publication?

All the data collected will be

stored and kept in one of the

pathway protective system and this

will be checked with my supervisor

to ensure safety of the collected

data during field work and after

publication.

All materials submitted will be treated confidentially.

I have read and understood the University’s Code of Practice on Ethical

Standards for Research involving Human Participants

Signe

d:

Principal

Investigator

/Student

Khajik Yaqob

Signe Supervisor

151

d:

Prof Debra

McGregor

Date: /06/2013

Appendix 4 Sample of a questionnaire administered to

both groups

152

153

Appendix 5: Participant´s information sheet

OXFORD BROOKES UNIVERSITY

WESTMINSTER INSTITUTE OF EDUCATION

Harcourt Hill,

Oxford

OX2 9AT DATE: 24 June 2013

Direct Line for Supervisor: 01865 488355

Name: Debra McGregor

Email: McGregor@brookes.ac.uk

Researcher’s name: Khajik S. Yaqob

Student No.: 12007086

Email: 12007086@brookes.ac.uk

MA IN CHILDHOOD STUDIES: How do year 6 children think about and understand

Healthy Eating?

Covering letter for questionnaire

I am Khajik Yaqob/ studying the MA Childhood Studies course. Iam studying for a Master degree in Oxford Brookes University/school of education. I am conducting research into Children’sideas about healthy eating. I would like to give your childrena questionnaire to fill in to find out what they think aboutHealthy Eating. This is supported by focus group interviews.It is up to you to decide whether or not to take part. If youdo decide to take part you will be given this informationsheet to keep. If you decide to take part you are still freeto withdraw at any time and without giving a reason. Bychoosing to either take part or not take part in this studywill have no impact on children’s marks. I would bring in aquestionnaire for the year 6 to complete. It will take about20 minutes for them to answer the questions. No disadvantages

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or risks of taking part in this study, just time. You can seethe results of my study and use them to inform what the schoolmight do about healthy eating. All data will be destroyed oncethe dissertation has been completed. In the meantime, onlyyourself as a head, myself as a researcher, and my supervisorwill see the data. Please inform me about which class can beavailable to fill in the year 6 questionnaire (date and time).A copy of the results/findings of the research will be sent tothe Head of the participating school. A full copy of thethesis will be available to borrow on request. The research ispart of the Master’s program in the Faculty of Humanities andSocial Sciences at Oxford Brookes University. Thisdissertation will be submitted to achieve that degree/award.If you have any concerns please contact my supervisor ProfDebra McGregor, McGregor@brookes.ac.uk, Professor in Education(Learning and Developing Pedagogy), School of Education,Faculty of Humanities and Social Sciences, Harcourt HillCampus, Oxford Brookes University, OX2 9AT, Tel : 01865488355. My contact details are: KhajikYaqob,12007086@brookes.ac.uk, student in School of Education,Faculty of Humanities and Social Sciences, Harcourt HillCampus, Oxford Brookes University, OX4 2NS, Mobile no:07753353598.

Thank you for your time

24/06/2013

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Appendix 6: Interview questions for children in local

Church cohort and primary school group.

1. What does a healthy lifestyle mean to you?

2. Do you think healthy eating is enough for a person to

live healthily?

3. What do you think of exercise and physical activity?

4. Why do you think it is difficult (the barriers) to

achieve healthy eating?

5. Why you should eat healthy food?

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6. Do your parents often tell you about healthy eating? What

about your teachers? Was that helpful? How?

7. Do you think that your parents and school could help you

to further understand about healthy eating? How?

8. What do you think about Fresh fruit and vegetables, pure

water, cheese, egg and brown bread? Why do you think each

of these foods is significant to eat?

9. Do you have any of these foods in your snack box? And

Why?

10. Why do you think white bread, ice cream, fatty

chicken, fizzy drink, sausages, crisps, canned fruit and

vegetables are not so healthy? Do you think each of them

is good to eat?

11. Why you consider the taste when choosing foods?

What do you think about the appearance of food? Cost? And

Why?

12. What are you most and least five favorite foods to

eat? And do you think each of these foods is healthy? And

Why? And why you prefer to eat unhealthy foods? Or you

might have to eat unhealthy foods for certain reasons?

13. Do you eat five portions of fruits and vegetables a

day? And why you should eat 5 portions a day?

14. What other vitamins and minerals are healthy to eat?

Why? Which foods would you find them in? Why is it

healthy to eat calcium?

15. Do you like to eat fish and why? Do you think fish

is rich of calcium? And do you know which vitamin is

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essential for vision? Do you know other foods which are

rich of calcium?

16. Do you think fresh is better than canned or frozen

fruits and vegetables? Which is better to eat and why?

And why do people often do not eat the fresh version?

17. How much water do you drink daily? And why do you

think it is healthy?

18. Do you think someone’s size or shape has anything

to do with their health?

19. Do you think potatoes and tomatoes grow under or

above the ground? And have you ever been on a farm visit?

Did you enjoy it? And why? Do you feel more active there?

Is that worthy for you?

20. Do you think that cereal is healthy or unhealthy?

Are you aware of cereal high in sugar? And why you like

to eat cereal? Do you think you are eating a healthy or

an unhealthy breakfast? And why?

21. Do you think boys or girls that are better in

making healthier food choices? And why? And how do you

know you eat a healthy diet?

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Appendix 7: A revised questionnaire (in light of

research findings).

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Appendix 8:

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A (research informed) example Healthy Eating policy

for primary school cohort

Findings from primary school cohort were somewhat concerningof such a school which has been already committed a healthyeating policy, therefore, I would suggest a new healthy eatingpolicy for this school that could be helpful to promote andincrease children’s knowledge and awareness about healthyeating and consequently to help addressing childhood obesity.

The policy below illustrates the participating new school’scommitment to promoting healthy eating across the schoolenvironment, including teaching and the classroom, the schoolorganization, food service and the wider family community. Itwill outline a summary of the actions the school night committo achieve in the future.

The school might contribute to improving the nutrition anddecreasing the risk of lifestyle disease in our children bypromoting healthy eating and food variety in a positive way,not only in the classroom, but across the whole schoolcommunity/environment.

The following areas have been identified as the most importantfor the school to focus on:

Teachers and Curriculum School organization and Food service Parent Education

Teaching and the CurriculumWhat should the school do?

Run a curriculum on aspects of healthy eating and livingat each year level

Incorporate topics on nutrition, Childhood obesity andhealthy eating into a range of learning areas 

Undertake a whole school focus during our designatedhealthy eating week in Term 1 each year

Teachers act as role models for healthy eating

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The plan aims to: Give teachers the opportunity to update their own

knowledge of healthy food, nutrition and Childhoodobesity

Investigate further curriculum ideas and topics toinclude at each year level

Make greater use of the school market as a curriculumresource

Have Junior School Council focus some of their activitiesaround healthy living concepts

School Organization and Food Service What the school might do:

Allot eating time in class ( 25-30 minutes) Designate an allocated eating area at the junior school

for children to finish eating Year 5 and 6 children have a fruit/vegetable snack around

10.15 in class (approximately mid way point before11.35am lunch break)

Encourage and allow water bottles in class and ifpossible to provide free clean tap water in the school

Ban fizzy drinks in children’s school lunches and in theschool’s canteen

Designate and encourage water breaks during PE and sportsessions

Contact parents of children who are not supplied withlunch and if necessary provide students with food fromthe staffroom

Offer a variety of healthy food and seasonalfruit/vegetables at Before and After School Care

Offer low nutritional food on whole school hot food daysonce a term only

Free school breakfast programs should be available in thenew school healthy policy and teaching children abouthealthy breakfast is absolutely a good step forward.Furthermore, the participating school can get benefitfrom a Balanced Breakfast Model (Chapter 2.5.4) topromote eating a healthy breakfast for their children.

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Thus, the food service staff should be asking “What willkids eat?” while assessing current policies and services

Menu offerings need to reflect the changing preferencesof children with respect to gender and dietaryrecommendations for health. This school that planssimilar menus for both genders may want a look moreclosely at preferences by gender and have choices thatsatisfy both genders. Insight into the food preferencesreported by children (aged 9-10) with regard to gender isvaluable information which might be used to improve thediets of primary school children while developinglifelong healthy eating. Also, preference data might behelpful with school menu planning to create worthynutrition education programs that parallel changes beingcompleted in the school food service. Therefore, agreater understanding of the implications of food qualityor product brand on the preferences and consumption ofchildren in the school setting also should be explored

Also the plan aims to: Introduce across the school rubbish free lunches once a

term with an emphasis on healthy eating Look at alternative fundraising options not based on low

nutritional food Investigate healthy alternatives for whole school special

hot food days Provide vegetable seeds for children to take home and

grow, then return grown vegetable to school for show andtell

Family and CommunityThe goal is to:

Promote healthy eating to families via the weeklynewsletter if possible

Inform parents of the Healthy Eating Week viathe newsletter, email, post or call

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Discourage parents from providing foods of minimalnutritional value in school lunches via informationnights and the newsletter 

An expression of interest should be placed in the FreeFruit Friday program for the junior school students

Utilize the school nurse to give informative talks toprep parents on nutrition, healthy eating and Childhoodobesity

Also to: Conduct information sessions for parents on healthy

eating practices and Childhood obesity focusing onhealthy lunchboxes and after school snacks

Include tips, simple recipes and ideas in the newsletterfor families to adopt at home if they wish

Conduct information sessions for parents on topics ofinterest related to healthy lifestyle, food origin andChildhood obesity

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Appendix 9: Tentative suggestions for guidelines that

parents should pay attention to (School or general

guidance).

1. Also, making suggestions about guidance for parents to

tackle/address childhood obesity through heightening

healthy eating awareness is crucial and could be

supportive. Parents, teachers and cooks in the school

need further education of healthy eating as they were the

key decision maker of food choices and they should be

more aware of healthy eating, healthy lifestyle, food

origin, and making healthy choices. Also, parents at home

could help and support their children by passing healthy

eating messages to promote their children’s knowledge of

healthy eating.

2. Parents should participate, if possible, in every healthy

eating promotion program arranged by their children’s

school and to share their ideas with each other and with

the teachers and cooks. This could be helpful to maintain

a good healthy menu for their children. Particularly, as

mentioned already, the school menus are sent home to

parents when each new set of menus is introduced. Also,

the school should listen to the children’s opinions on

the menu and adapt the menu accordingly, and the menus

must meet the new nutritional requirements for school

meals.

3. Parents could give valuable information about their

children’s favorite foods to school and teachers, what do

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they children often like or dislike eating at home, and

this might be changeable as the child grows and develops.

Accordingly, certain menus could be arranged and prepared

in school and considering the gender differences as well.

4. Parents should care about their children’s foods by

keeping in touch with their teachers and school and they

should continue informing the school about any new

condition that might happen to their children. For

instance, if the child has any medical problem such as an

allergy to specific types of foods or certain foods might

the child be not allowed to eat to avoid any future

eating complication.

5. Also, the level of education of parents has an effective

role to promote children’s knowledge and awareness about

healthy eating. It was evident in this study that parents

of children in the local Church group had a more crucial

role than those in primary school cohort by sending their

children healthy eating messages that helped them to

correctly answer the questionnaire. Therefore, parents of

children in primary school should be more aware of

healthy eating and all the issues related and to create a

healthy eating environment at home to help their children

to further understand about healthy eating and childhood

obesity.

6. Certain recommendations to encourage regular breakfast

consumption in children include:

- Using diverse kinds of foods to support positive

experiences and learned preferences

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- Teach parents to act as role models

- Hearten family breakfast attended by all family members;

- Maintenance a balance of nutrients within the day, and

within breakfast meals during the week.

7- Finally and very recently parents and families of obese

children could have benefited from a new health service

and the scheme (Reach 4 Health Program) which has been

launched on the 6th of Sept. 2013 to help combat the

growing issue of Childhood obesity in Oxford (Oxford

Journal, 2013). Such scheme is commissioned by

Oxfordshire County Council and delivered by the trust´s

School Health Nursing service, is in direct response to

a seven year long National Childhood Measurement Program

(NCMP). Therefore, parents are set to benefit from the

scheme, which is a free weight management service for

children (aged 4-16), as it offers ongoing support to

help families make healthy changes to their lifestyles.

Moreover, the scheme is said to have an emphasis on

having fun and will include group sessions with

activities, as well as one to one support. The focus of

this ten week program will be on making healthy lifestyle

changes including healthy eating and activity and ongoing

support will be given via text and telephone once the

sessions have finished and via the all year round

activity drop-sessions, which will be held countywide.

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Appendix 10: Reflections on ways my thesis could have

been improved.

1. As I mentioned already, self administered questionnaire

plus interviewing children in the local Church group and

primary school cohort might be the future goal for someone

who wishes to replicate or develop this research study.

2. Larger numbers and more age groups of children (not only

aged 9-10) could be included next to represent the entire

population in primary school population. Also, different

ethnicity and children from different socioeconomic status

might have various findings and conclusions.

3. Because of the goal of this research study was to explore

children’s views about healthy eating and to make

suggestions about Childhood obesity, therefore, I think the

next study should include interviewing obese children of

different age and gender to find out what and how they

think about healthy eating. This is my future intention of

my PhD degree which aims to explore further children’s

beliefs about healthy eating to help to address Childhood

obesity.

4. My future intention is to progress this study, perhaps in

my home country (Iraq, Kurdistan) to find out how do

children (aged 9-10) think about healthy eating. Also, it

is interesting to consider the religion, culture, time, and

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food preferences, source of food and food availability, and

ethnicity and then comparing both studies could be a step

forward to further understand children’s thoughts about

healthy eating.

5. I hope to develop and improve my research study as a future

step for my PhD degree in Paediatrics and child health in

the UK, in particular, overweight and obese children (aged

9-10). The goal will be to explore obese children’s views

of healthy eating and Childhood obesity as well as the

incidence and prevalence of overweight and obese children

in the UK specifically in Oxford. This future study will be

explored and action research study to deal with real obese

children, assessing their weights and BMI. Also, trying to

explore the reasons of childhood obesity in each case and

what kinds of food do they eat.

6. However, more studies are needed to confirm the findings of

this research study.

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