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Parents seek trustworthy information online to promote healthy eating for their toddlers. Such information must be perceived as relevant and easy to implement and use.
The objectives of this study were to conduct a process evaluation of the electronic health (eHealth) intervention (Food4toddlers) targeting food environment, parental feeding practices, and toddlers’ diet and to examine possible differences in these areas according to education and family composition.
A 2-armed randomized controlled trial, including 298 parent–toddler dyads from Norway, was conducted in 2017. In total, 148 parents in the intervention group received access to an intervention website for 6 months. Data on website usage were retrieved from the learning management platform used (NEO). Participants’ satisfaction with the intervention was asked for in a postintervention questionnaire. Chi-square and
Most participants were mothers (144/148, 97.2%), lived in two-adult households (148/148, 100%), and were born in Norway (132/148, 89.1%). Mean parental age was 31.5 years (SD 4.2). More than 87.8% (129/147) had a university education degree and 56.5% (83/147) had over 4 years of university education. Most (128/148, 86.5%) intervention participants entered the website at least once (mean days of access 7.4 [SD 7.1]). Most parents reported the website as appropriate to the child’s age (71/83, 86%) and self-explanatory (79/83, 95%) and appreciated the interface (52/83, 63%) and layout (46/83, 55%). In total, 61% (51/83) stated that they learned something new from the intervention. Parents with over 4 years of university education and in 1-child households used the intervention website more than those with 4 years or less of university education (8.4 vs 5.9 days in total,
The Food4toddlers intervention website was found to be relevant by most participants in the intervention group, although usage of the website differed according to educational level and family composition. For eHealth interventions to be effective, intervention materials such as websites must be used by the target group. Our results highlight the need to include users from different groups when developing interventions.
ISRCTN Registry ISRCTN92980420; http://www.isrctn.com/ISRCTN92980420
A healthy diet is fundamental to preschoolers’ health and development, for which parents are responsible. A high proportion of parents feel insecure and seek advice regarding food parenting practices via different sources [
Mobile health (mHealth) and eHealth interventions are gaining popularity, as such interventions have the potential to reach a large target group, can easily be adapted to new groups, are available 24/7, and can be cost-effective [
A few other studies have reported on parental use and satisfaction of eHealth interventions targeting young children. One is the Early Food for Future health study, in which Helle et al [
We have previously developed and evaluated the effect of a dietary eHealth intervention called Food4toddlers in a randomized controlled trial, targeting parents of 12-18-month-old children [
Food4toddlers is a randomized controlled trial, aiming to promote healthy dietary habits among toddlers [
Eligible individuals were parents of children born between June 2016 and May 2017. The parents had to be literate in Norwegian. Of the 404 recruited parents, 298 (73.8%) filled in more than half of the baseline questionnaire which was the minimum requirement to be randomized into either the control or intervention group (n=148). Postintervention, at child age 18 months (follow-up 1), 220 participants completed all or parts of the questionnaire, with 99 of these from the intervention group. Details of the recruitment strategy, the development of the intervention, and the randomized trial are described in the study protocol [
The intervention group had 6 months of access to the Food4toddlers website which comprised 4 main elements: (1) lessons (n=22) on how to provide healthy food and create a healthy eating environment for the toddler, (2) recipes, (3) a discussion forum, and (4) basic information about food and beverages (called
In this paper, we present the following elements from the process evaluation: (1) the exposure or usage of the intervention, (2) parental satisfaction with the intervention, and (3) parental perception of learning something new from the intervention. To assess the exposure or usage of the website we used data automatically registered by the Learning Management System NEO. NEO is a platform for managing digital classroom activities and tracking student achievement. It has an intuitive design, making it easy to obtain access to information. The user data were manually retrieved from NEO. The data accessible were (1) number of days the participants accessed the website, (2) the use of the 22
In addition to the automatically registered information on participant’s use of the website, we used data from the postintervention questionnaires. The intervention group responded to questions about the use and satisfaction of the intervention’s website at follow-up 1 (end of intervention). Parents were asked how many of the recipes they had tried, with response alternatives
Parents’ height and weight were self-reported. For their child, measures recorded at the health care centers were reported if available. The participants reported their age and their child’s age at baseline. Further, they reported the number of persons in the household in 2 different questions: (1) number of adults and (2) number of children. They also reported county of residence and marital status (married, partnered, single, divorced/separated, widow/er, or other). The number of children in the household was dichotomized into those with 1-child households and those with more than 1 child in the household. Participants also reported on their level of education (primary school or less, primary schools plus 1 year of further education, high school, vocational school, upper secondary school or less, college/university [≤4 years], college/university [>4 years], other, and do not know). Only 18 persons were categorized with no higher education, which is a low number when doing subanalyses; therefore, we dichotomized the education variable as presented above. Consequently, the comparisons in this study were between parents with more than 4 years and those with 4 years or less of education, and between parents with 1-child households and those with more children in the household.
Means with standard deviations for continuous variables and frequencies and percentages for categorical variables were reported. The chi-square tests were used to test potential differences in the perceived value of the intervention between the 2 education groups and according to the number of children in the household. Independent sample
The data set supporting the conclusions of this article will be available in the UiA Open Research repository.
The characteristics of the participants included in the intervention are summarized in
Baseline characteristics of parents and toddlers in the intervention group (N=148).
Characteristic | Intervention group | |
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Mother/father (n) | 144/4 |
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Age (year), mean (SD) | 31.5 (4.4)a |
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Height (cm), mean (SD) | 169 (6.0) |
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Weight (kg), mean (SD) | 70.8 (14.3) |
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BMI (kg/m2), mean (SD) | 24.9 (4.6) |
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Two-adult householdb, n (%) | 148 (100) |
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Total number of household members, mean (SD) | 3.6 (1.0) |
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Born in Norway, n (%) | 132 (89.1) |
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Less than college/university (≤4 years), n (%) | 64 (43.5) |
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College/university (>4 years), n (%) | 83 (56.4) |
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Northern Norway, n (%) | 8 (5.4) |
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Central Norway, n (%) | 16 (10.8) |
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Western Norway, n (%) | 34 (22.9) |
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Southern Norway, n (%) | 24 (16.2) |
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Eastern Norway (including Oslo), n (%) | 66 (44.5) |
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Age (months), mean (SD) | 10.9 (1.3) |
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Child’s sex: Female, n (%) | 69 (46.6) |
aOne missing case in this variable.
bLive together with the other parent.
All 148 persons in the intervention group were included in the analyses based on data retrieved from NEO, including 1 person that first got access to the intervention and then decided to quit and 2 participants that did not get access mistakenly (all 3 with no access data). From the NEO data we found that 13.5% (20/148) of parents in the intervention group did not enter the website at any point (
In the intervention group, 99/148 (66.9%) participants answered at least parts of the questionnaire at follow-up 1. However, only 83/148 (56.1%) participants answered the last questions in the questionnaire that concerned the website use. When evaluating the use of the individual components on the website, most participants in the intervention group reported having used
Participants’ use of the intervention website and recipes tried.
Intervention usea | Value | |
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Did not enter, n (%) | 20 (13.5) |
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Days of access, mean (SD); min-max | 7.4 (7.1); 0-32 |
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Finalized lessons, mean (SD); min-max | 8.0 (7.6); 0-22 |
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None, n (%) | 8 (10) |
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None, but was inspired, n (%) | 27 (33) |
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1-5, n (%) | 38 (46) |
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6-10, n (%) | 9 (11) |
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11 or more, n (%) | 1 (1) |
aData were retrieved from the Food4toddlers website. One participant got access to the intervention but decided to quit. Two did not get access to the intervention mistakenly. These 3 are included in the reported numbers.
bQuestions answered at follow-up 1 (postintervention at child age 18 months).
Participants with more than 4 years of university education accessed the website for significantly more days than those with a lower educational level (
Comparison of website use between education groups (N=147) and between 1-child and >1 child households (N=148).
Analyzed component | ≤4 years of university educationa (N=64) | >4 years of university educationa (N=83) | Household with 1 childc (N=86) | Household with >1 childc (N=62) | ||
Days of access in total, mean (SD) | 5.9 (6.8) | 8.4 (7.2) | .04 | 8.3 (7.8) | 5.8 (5.7) | .04 |
Number of lessons finished, mean (SD) | 6.6 (7.3) | 9.1 (7.7) | <.05 | 8.9 (7.8) | 6.7 (7.2) | .09 |
aParents were divided based on educational level into those with 4 years or less of university education and those with more than 4 years of university education.
bIndependent sample
cAsked about how many children were included in the household, divided into 1 child versus more children.
When asked about what part of the intervention website the participants found to be most useful, 43% (36/83) were most satisfied with the recipes, whereas 31% (26/83) valued the modules as the most useful part of the intervention. Participants also reported to which degree they agreed with different statements regarding how they found the intervention website. The majority of the participants agreed that the website content applied to their child’s age (71/83, 86%) and that the texts were easy to understand (79/83, 95%). Most parents in the intervention group reported that they appreciated the interface (52/83, 63%) and layout (46/83, 55%). We also asked to which degree the participants valued the recipes and films. In total, 83% (62/75) found the recipes easy to follow, and 80% (60/75) found them easy to adjust to the whole family. Only 32% (24/75) found the films posted on the intervention website useful. There were no significant differences in how the intervention website and the recipes were valued between those with more than 4 years of university education and those with a lower educational level (data not shown).
There was low activity in the discussion forum including in the learning platform. The most active participant posed questions and responded 5 times, whereas 7 other participants posed a single question during the period when they had access to the forum. The first author (MR) of this paper responded to all questions.
In total, 61% (51/83) reported that they learned something new from the intervention website (
Perceived acquisition of new knowledge among parents in the intervention group according to educational level and number of children in the household, through response to the prompt "Think of the Food4toddlers website in total, and indicate how strongly do you agree/disagree with the statement
Statement | All |
≤4 years of university educationa (N=33) | >4 years of university educationa (N=50) | One-child householdb (N=52) | >1 child in householdb (N=31) | ||
Agree, n (%) | 51 (61) | 17 (52) | 34 (68) | —c | 35 (67) | 16 (52) | —c |
Indifferent, n (%) | 21 (25) | 13 (39) | 8 (16) | —c | 12 (23) | 9 (29) | —c |
Disagree, n (%) | 11 (13) | 3 (9) | 8 (16) | .05 | 5 (10) | 6 (19) | .30 |
aParents were divided based on educational level into those with 4 years or less of higher-level education and those with more than 4 years of higher-level education.
bParents reported how many children were included in the household, divided into 1 child versus more children.
cNot applicable.
Most parents today use the internet to obtain information relevant to their child’s health [
Although the participants rated the recipes as the most important part of the intervention, they did not find the films made for the recipes as useful as the other components. This may indicate that written recipes might be sufficient for use, or that our produced films did not quite suit the target group. Few participants used the discussion forum which was a part of the website. It might be that parents discuss in other online forums and that our forum seemed new and different, or of no need. Using a closed Facebook group, which is a common discussion forum type, might have increased the activity in the discussions. This is supported by a study by Boswell and collaborators [
A total of 13.5% (20/148) of parents who had access to the intervention website did not enter it at any point, which is higher than what is observed in other studies. The Swedish MINISTOP study had a very high website visitor rate [
There were differences in website use between education groups and between those with 1 or more children in the household. It is somewhat surprising that those with the highest education spent more time using the website, and also that there is a borderline difference in whether they found that they had learned something new from the website, with results in favor of the more educated parents. Taki and collaborators [
It was not surprising that those with more children in the household, and thereby more experience in feeding toddlers and potentially less time available, spent less time on the intervention than those in 1-child households. This is in line with what Taki et al [
We obtained objective information about parental access to the intervention from the learning management system (NEO). This means we did not need to solely rely on participants’ self-reported responses to the postintervention questions, which is a clear strength of this study. When interpreting the effect results of this intervention, it is a clear strength that a detailed process evaluation has been conducted.
The participants in our study had a substantially higher educational level compared with national figures [
Few previous eHealth interventions focusing on diet have reported data from process evaluations, including parental usage and satisfaction with the intervention, as is the case with this study. We found that most participants used the intervention website during the intervention period, and that they found it relevant and useful. Parents with more than 4 years of university education used and learned more from this intervention than those with a lower educational level. Our findings highlight the utmost importance of including users from different groups when developing eHealth interventions and may inform future interventions to take particular care in matching intervention content to different educational and socioeconomic groups’ needs.
CONSORT-eHEALTH checklist (V 1.6.1).
electronic health
mobile health
The authors thank the participants. This study is funded by the University of Agder. The financial contributor was not involved in designing the study, collection, analyses, and interpretation of data or in writing the manuscript.
FNV, ERH, and NCØ initiated and designed the study. ERH, FNV, NCØ, and MR developed the intervention. MR, ACM, FNV, MR, WVL, ERH, and NCØ initiated and developed the paper. MR performed the data collection supervised by ERH, FNV, and NCØ. MR and NCØ analyzed and drafted the first version of the paper. All authors gave substantial input to the paper. All authors contributed to, read, and approved the final version of this paper.
None declared.