TIME (Tools, Information, Motivation, Environment) for Health: A Multi-Level Intervention to Promote Healthy Eating in Children and their Families

Principal Investigators:

Kirk, Sara (Dalhousie University)


Molloy, David (Nova Scotia Health Promotion and Protection); Shearer, Cindy (Dalhousie University); Chircop, Andrea (Dalhousie University); Bassett, Raewyn (Dalhousie University); Abidi, Syed Sibte Raza (Dalhousie University); Alvaro, Celeste (Dalhousie University); Rehman, Laurene (Dalhousie University); Blanchard, Chris (Dalhousie University); Rainham, Daniel (Dalhousie University)  

1. The Health Problem/Issue 

Childhood obesity is a significant public health problem. It is now widely acknowledged that there is a need to provide supportive environments where children live, learn and play if we are to see a reduction in rates of obesity. Yet, there are a number of settings where food availability is not consistent with current recommendations for healthy eating. One such setting is recreational facilities. While these facilities promote health in the form of physical activity, by contrast, the nutrition environment within them is often neglected in favour of energy dense fast and processed foods that are quick to prepare, cheap to provide and profitable. Our own research from a project funded under an earlier ‘Built Environment, Obesity and Health’ competition, found that parents and youth reported being over-scheduled in ways that limited options for healthy meal preparation and that, ironically, healthy nutrition was often sacrificed due to the pressures of being involved in leisure-time physical activities. This suggests that changes in the food environment both in the family home and at recreational facilities where they go to be physically active may support healthier food choices by children and their families. 

2. The Objectives 

The objective of this project is to design, implement and evaluate a multi-level intervention aimed at, a) improving family nutrition habits and, b) incorporating a change in the built environment to increase healthy food availability. The food environment change will take place in recreational facilities where children regularly go to undertake physical activities, such as swimming. The family-level intervention will be targeted at parents of young children. We have called this project TIME, to describe the key features of the intervention - this represents Tools, Information, Motivation and the Environment. At the facility level, we will focus on evaluating the impact of existing work aimed at changing the food environment within multipurpose recreation facilities (Tools and Environment). This might include increasing the availability of healthy food choices, or activities to encourage families to purchase healthier food options. For the family-level intervention, we will give parents of children aged 5-12 years a global positioning system (GPS)-enabled smart phone that will provide: a) Information about availability of healthy food options in a timely fashion, both for preparing inside the home and for eating out (using GPS technology to provide information about healthy food options available in a given location) and b) Motivation such as personalized health messages, meal ideas and shopping hints and tips. We will use existing nutritional information that is available on the Heart and Stroke Foundation of Canada website (with permission) and tailor this for use on smart phones through a custom-built application. 

3. The Approach 

Changes directed at the food environment of recreational facilities will involve limiting the availability of unhealthy food choices and promoting the availability of healthier food choices for children and families involved in activities at these facilities. Ongoing work in Nova Scotia involves the development of a toolkit for facility directors. The exact content of the toolkit is not yet defined, but will likely include sample guidelines, suppliers, approaches, as well as implementation and evaluation strategies for making changes towards having healthy food choices in the recreation setting environment. We will work with four recreational facilities in the Halifax Regional Municipality; with the following conditions: 1) No food environment change, no intervention offered (this will act as the control site), 2) No food environment change; family level intervention only, 3) Food environment change; facility intervention only, and 4) Food environment change; facility intervention plus family level intervention. The intervention will last for six months and we will measure the impact of any changes from baseline measures at six months and 12 months. We will use sales information from facilities and grocery receipts from families to determine if the types of foods purchased are healthy or unhealthy and to see if these change as a result of the intervention. We will also do focus groups and interviews with people taking part in the study to find out what they think about ways to eat more healthily in both settings. 

4. The Unique Factors 

Our proposed project is innovative because it involves developing a multi-level intervention to modify the food environment in two key settings – the family home and recreational facilities. So far, recreational facilities have not been widely studied as settings for promoting health, other than for physical activity. In fact, these facilities may undermine healthy eating by serving foods that are not consistent with current nutrition guidelines. Further, the use of smart phones (i.e. interactive and sophisticated mobile devices) to deliver healthy eating messages is also highly innovative. Text prompts can be sent to the family, and can be personalized based on information provided by the family through a custom-designed application on the smart phone. These might include healthy recipe ideas, shopping hints and tips or motivational messages. The GPS features of smart phones means that information about a person’s location can be used to identify food retail outlets nearby that offer healthy food choices. This can therefore be incorporated into the intervention to support healthy food choices both in the family home and outside. This clearly links with our previous research, which found that families are often under time pressure around scheduled physical activity that prevents them making healthy food choices at home. We have a developed a comprehensive food environment database for Nova Scotia that can be used for this purpose. Each food retail outlet in the database that serves healthy food choices will be able to be identified and a prompt sent to the smart phone of intervention families.  

5. How the project is relevant to the objectives of the initiative 

The proposed work is highly relevant to the objectives of the Built Environment: Population Health Intervention Research initiative, addressing two of the research areas listed in the Request For Proposals – the availability of healthy food choices in recreation facilities and representing a natural experiment of a multi-level and intersectoral intervention intended to improve health through improved food behaviours. The proposed work has a number of anticipated outcomes, providing important evidence of how changes in the food environment can be encouraged across the levels of the social-ecological model to impact health. It is anticipated that families receiving the family-level intervention will demonstrate a change in family-level food purchasing behaviour, in favour of more nutritious foods. Those families who receive the facility-level intervention in addition to the family-level intervention will demonstrate a greater degree of change in favour of more nutritious foods. It is anticipated that the two levels of the intervention will also highlight key components needed to stimulate changes in the food environment of recreational facilities and within families and will further impact policy in Nova Scotia, where leading work is being conducted around modifying the food environment where children learn and play, e.g. through the Nova Scotia Food and Nutrition Policy for Public Schools. In addition, the qualitative data is expected to provide key information about how families and facility directors make decisions around food provided in these settings. Further, this work also builds on a previously funded study and directly targets one of our keys findings, which is that families are often under such time pressure around scheduled physical activity that they may not have the time to make healthy food choices at home. This direct relevance to our earlier research, along with the support we have from our key partners, clearly demonstrates the value of this work.