Shared Intelligence: Hey! Report by Pinnacle Graphic Design

Shared Intelligence

Evaluation of the HEY! Programme A report for Danone Nutricia Early Life Nutrition

September 2015

Shared Intelligence

Acknowledgements We would like to thank members of staff from the childrenâ&#x20AC;&#x2122;s centresâ&#x20AC;&#x2122; organisations delivering HEY! for their help with setting up case study visits, focus groups and interviews as well as for their time and hospitality. Our special thanks to all the parents who shared their experiences and views of HEY! with us during focus groups and interviews. Thanks also to Ann Evans and Harriet Morton from Danone Nutricia Early Life Nutrition (Danone), and Janet Solla and Helen Baker at the Community Health and Learning Foundation (CHLF) for the information and support they have provided. The analysis and views expressed are those of Shared Intelligence and should not be interpreted as the views of Danone or its partner organisations.

Evaluation of the HEY! Programme

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Shared Intelligence

Index

Executive Summary

Introduction

Methodology

Design and development of HEY!

Delivering HEY!

The impact of HEY!

Sustaining behavioural change

Case Studies

Conclusions

Recommendations

Appendix A

Appendix B

Appendix C

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Shared Intelligence

Executive Summary Background

Design and delivery of HEY!

Healthy Eating for Young Children (HEY!) is an Early Years community health improvement project led by Danone Nutricia Early Life Nutrition (Danone). The ambition for HEY! is to improve the health outcomes and life chances of local children aged one to three years by engaging their parents in healthy eating and Skills for Life learning. This reflects Danone’s global mission and core purpose of ‘bringing health through food to as many people as possible … because nourishing early life today really matters for tomorrow’.

The HEY! programme is delivered over seven weeks and covers topics such as budgeting, food safety, portion sizes and cooking skills through interactive and practical learning, with LLN skills embedded in the resources. HEY! was endorsed by the RSPH in 2013 and course participants can earn a RSPH Level 1 Award in Health Improvement, equivalent to two learning credits at Level 1 on the Qualifications and Credit Framework (QCF). The evaluation showed that:

●● The partnership between Danone, Wiltshire HEY! is based on a body of evidence that shows County Council, 4Children and the CHLF was that childhood obesity is linked to parents’ eating habits. Recent research by the University of Exeter, essential to design and develop HEY! as an published in the International Journal of Obesity in evidence-based, accredited programme to April 2015, discovered that the rise in obesity among address childhood obesity and promote healthy very young children has been largely restricted to eating. the minority with obese parents. The research data suggest that ‘parenting is the fundamental influence ●● The resources developed enabled HEY! to on weight gain in the early years, whereas more address its health improvement aims through an general (peer-group) influences take over later on…. embedded learning approach to address parents’ and public health strategies may need to be tailored Skills for Life needs and improve their knowledge accordingly’. about healthy eating. Research demonstrates that families living in the ●● Most HEY! courses target vulnerable or socially most disadvantaged communities are often those deprived parents, which meets local authority who have the worst health outcomes because they priorities and needs that have been identified by face the most challenges in managing their health the children’s centres. and wellbeing. A lack of language, literacy and numeracy skills is one of the major contributing ●● HEY! adds value to centres’ offer but finding factors to this. For this reason, HEY! took an the resources to staff the courses and crèche embedded learning approach by delivering health provision is becoming more of a challenge due messages through skills for life learning. to local authority budget cuts. The project was initiated in 2011 and created in partnership with Danone, Wiltshire County Council, ●● Tutors are positive about the ‘Train the Trainers’ 4Children and the Community Health and Learning session and value the resources – particularly the Foundation (CHLF). Following a successful pilot, HEY! Diary, which is attractive and easy to use. 70 HEY! courses have been run at children’s centres across the UK. ●● These have contributed to HEY! courses going well. The group working helps learning This independent evaluation of HEY! by Shared about healthy eating and parenting. The main Intelligence has assessed: challenge has been engaging parents in a way that promotes regular attendance and prevents ●● Change in parents’ and children’s healthy eating drop-out. behaviours as a result of HEY!; ●● Whether and how this behaviour change is sustained after the end of a course: ●● What works well in enabling behaviour change through HEY!; and ●● The sustainability of the HEY! model to ensure quality and credibility. Evaluation of the HEY! Programme

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All figures are up to July 2015

Who is providing HEY!?

Where has HEY! been delivered?

As of July 2015, there are seven provider organisations running HEY! courses. They are: ●● 4Children ●● Spurgeons ●● Action for Children ●● Barnardo’s ●● Independent Children’s Centre ●● Buckinghamshire County Council ●● Leicestershire County Council

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Impact of HEY! Data were collected from 90 parents who had filled in ‘before course’ and ‘after course’ monitoring forms. The evaluation utilised a range of indicators – about increases in fruit and vegetable intake and increases in physical exercise which relate to the Public Health Outcomes Framework. Also measured were improvements in health literacy, budgeting and cooking skills, as well as confidence and self-esteem to capture the impact of the programme. Analysis of the monitoring data up to April 2015 showed significant increases in parents’ knowledge and this greater awareness translated into positive behaviour change. The graphic below (‘Impact of HEY!’) sets out some of the evidence of the impacts the course had.

Evaluation of the HEY! Programme

These impacts are related to parents’ enjoyment of HEY! – particularly the social aspects of being part of a group, and the cooking and practical exercises – with most parents saying that they would have liked more cooking and recipe ideas. The only thing to which there was a more mixed response is ‘the paperwork’ – echoing tutors’ comments that some parents found the accreditation difficult. However, while it was a challenge for some parents, this was often outweighed by the boost to self-esteem from gaining a qualification from the course.

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Sustaining behaviour change

Conclusions and recommendations

The real test of HEY! is whether healthy eating behaviour change is sustained after a course. We spoke to a sample of 22 parents from seven courses to explore this and found that behaviour change was continuing at 6-8 weeks after the HEY! course. We found that parents were all:

We conclude that the Danone HEY! course is having a substantial impact on healthy eating and healthy lifestyles for parents and their young children. This impact is largely due to the design of HEY! and the resources in place for the delivery of HEY! – which children’s centres, tutors and parents have greeted enthusiastically.

●● Reducing portion sizes; ●● Swapping to healthier foods; ●● Cooking ‘from fresh’; ●● Using a greater variety of foods for their children; and

We recommend that Danone and its partners build on the success of HEY! to maximise and sustain its impact by continuing to take actions to: ●● Increase retention and reduce drop-out of course participants;

●● Most parents were sitting down with their children to eat at regular mealtimes.

●● Explore ways to increase engagement and sustain the positive impacts of the course beyond the seven week HEY! programme; and

And the sustained impact of HEY! was over and above changes in healthy eating:

●● Sustain and increase capacity for centres to run HEY! courses.

●● Parents became interested in health more generally – and had taken up physical exercise; ●● HEY! improved their confidence and relationships with their partners and children; ●● With some parents signing up for other courses – including at the children’s centres.

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Shared Intelligence

1 Introduction The HEY! programme 1.1 Healthy Eating for Young Children (HEY!) is an Early Years community health improvement project led by Danone Nutricia Early Life Nutrition (Danone). Danone’s ambition is for HEY! is to improve the health outcomes and life chances of local children aged one to three years, by engaging their parents in healthy eating and Skills for Life learning. This ambition is in line with their global mission ‘bringing health through food to as many people as possible’ and their core purpose, ‘…because nourishing early life today really matters for tomorrow.’ 1.2 The HEY! project was initiated in 2011 and created in partnership with Danone, Wiltshire County Council, 4Children and the Community Health and Learning Foundation (CHLF). Four pilot courses – each running for three hours a week for seven weeks – were delivered through children’s centres to a total of 41 parents by Spring 2013. Following a positive evaluation of the pilot by CHLF, the HEY! programme has been rolled out across the country. 1.3 HEY! courses now run throughout the UK. Forty three courses had been delivered by the end of 2014, with a further 27 having started by July 2015. So far, over 614 parents have participated in HEY!

Evaluating HEY! 1.4 Danone commissioned Shared Intelligence to undertake an independent external evaluation of the HEY! programme in December 2014. The evaluation is assessed: ●● Change in parents’ and children’s healthy eating behaviours as a result of HEY! This includes moves to swapping to healthier food options as well as cooking fresh food on a budget; ●● Whether and how this behaviour change is sustained for at least six to eight weeks after the end of a course and becomes part of day-to-day living: ●● What works well in enabling sustained behaviour change through HEY! (e.g. signposting and referral routes, strong relationships between professionals) and what are the challenges and how these have been overcome; and ●● The sustainability of the HEY! model in a way that ensures quality and credibility. 1.5 We have explored these questions by using a realist evaluation approach, which asks the question “what works well (and not so well), for whom, why and in what circumstances”. This type of approach takes account of the specific design of HEY! as a community-based health programme, the target groups of parents and the range of children’s centres from which HEY! is delivered. 1.6 Our mix of methods including quantitative analysis of the questionnaires that participants’ filled in before and after each course, qualitative fieldwork visits to children’s centres to speak with tutors and parents, and telephone interviews with stakeholders in the partner organisations involved in HEY! We also interviewed a sample of parents at six to eight weeks after the end of their HEY! course to explore whether and how they were continuing to make positive changes in relation to healthy eating for them and their children.

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Structure of report 1.7 Following this introduction the report covers: ●● Methodology – describing our evaluation framework and data collection methods; ●● Design and development of HEY! – using partners’ experiences and perspectives to identify key processes in designing and developing HEY! through a partnership, including how opportunities were grasped and challenges overcome; ●● Delivery of HEY! – identifying key features of the HEY! materials and how the programme is delivered using feedback from tutors and other stakeholders; ●● Impact of HEY! on parents and their children from monitoring data and in their own words; ●● Sustaining behavioural change – with evidence of how parents are continuing to make positive changes in healthy eating continuing after the end of the HEY! course. ●● Case studies – five examples of the impacts of HEY! and ongoing behavioural change. ●● Conclusions and recommendations – bringing all these findings together at the end of the report to develop some conclusions and recommendations for the sustainability of HEY!

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Shared Intelligence

2 Methodology Evaluation framework 2.1 This evaluation of the HEY! programme aimed to assess evidence on the impact of HEY! on parents’ and their children’s healthy eating and wider health improvements. It also explored the learning that has been generated about HEY! as a distinctive community health improvement project so we understand what aspects of HEY! make it particularly successful – and which may warrant further development – so it can be sustained and replicated in a variety of contexts. 2.2 Specifically the evaluation was designed to capture: ●● Sustained change in parents’ and children’s behaviour as a result of HEY! including: –– Direct impacts from the programme including moves to healthy eating (e.g. 5 a day, less sugar and salt), meal planning and budgeting for shopping, and using cooking skills to prepare fresh food; –– Indirect impacts such as better communication between parents and children; improved health literacy/awareness of healthy behaviour resulting in, for example, engagement in physical activity; and an increase in confidence, which could lead to further learning, seeking work and/ or participation in community groups; and –– Sustained behavioural change which continues for at least six to eight weeks after the end of a course and becomes part of daily living (e.g. moving from snacking to eating regularly at a table, reduced portion sizes as ‘normal’). ●● How well key aspects of HEY! have worked (e.g. signposting and referral routes from professionals in local authority and voluntary sectors) including: –– Identifying the enablers and success factors for strong interdisciplinary relationships and referrals and how these can be built upon; –– Learning from the barriers and challenges to these linkages working effectively and how these have been overcome; and ●● The sustainability of the HEY! model in a way that ensures quality and credibility through: –– Its distinctive approach of ‘Train the Trainers’ for a peer learning approach to health literacy; –– Danone’s growing reputation and credibility; –– Comparison of HEY! against similar programmes; and –– Evidence of the HEY! approach being embedded in public health programmes through local authorities and the charity sector. 2.3 We have used a realist evaluation methodology1 based on a ‘theory of change’ to capture the impacts and learning generated through by HEY! This approach is particularly useful for evaluating complex community programmes such as HEY! which takes a holistic and flexible approach to achieving a bundle of outcomes associated with ‘healthy eating and wider health improvements’ for a target group of often vulnerable parents and their young children living on low incomes2. 2.4 This holistic type of programme means that formal attribution is extremely difficult to prove so realistic evaluation focuses instead on finding out about ‘what works (and doesn’t work so well) for whom, why and in what circumstances’, to learn about the contribution that inputs and processes 1 2

See Pawson R. & Tilley N. (1997) “Realistic Evaluation” London: Sage Publications See, for example, Coote, A. et.al. (2004) Building knowledge about complex, community-based initiatives. London. Kings Fund

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(partnership working, delivery arrangements, resources, etc.) make to impacts. This methodology also enables us to capture the pathways that participants travel along towards impacts. In HEY! as in other behavioural change programmes, first engaging the participants and then increasing participants’ health literacy (including through knowledge, awareness etc.) as well as their self-esteem, confidence and motivation are key to achieving changes in healthy eating and wider health improvements, and can be considered as outcomes in their own right. 2.5 Our evaluation framework, based on this ‘theory of is shown’ in figure 2.1.

Figure 2.1 HEY! Theory of Change

engagement

knowledge

IMPACTS

skills

behaviours

Increased capacity Training the trainers

To use resources/ deliver HEY!

And build capacity in children’s centres

Contribution to improving health outcomes and life chances of young children

OUTCOMES

Sustained behavioural change in healthy eating/living

Commitment/uptake by children’s centres

HEY! developed by DBN/WCC/CHLF/A4C partnership

Need for community approach to improve health and tackle childhood obesity

PROGRAMME

LEARNING

Measuring change 2.6 The theory of change illustrates why it is important that the evaluation uses a bundle of indicators to measure the difference HEY! is making over the course of the programme and beyond. This approach also helps us understand the contribution of changes such as health literacy makes to healthy eating and wider health improvements and so tests out the design of HEY! 2.7 The indicators used to assess outcomes and impacts from HEY! include: Impacts on healthy eating and wider health improvement ●● Consumption of portions of fruit and vegetables per week (target = 5)3 ●● Toddler’s consumption of portions of fruit and vegetables a week ●● Days per week spent exercising moderately for at least half an hour (target = 150 minutes per week)4 ●● Days per week toddler engaged in exercise

3 4

Target from Public Health Outcomes Framework 2015 Target from Public Health Outcomes Framework 2015

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Increased knowledge and awareness ●● Understanding of healthy eating ●● Knowing how to exercise ●● Increase in cooking skills ●● Believe it’s possible to eat healthily on a budget/low income Positive behavioural change ●● Shopping to a budget ●● Reading food labels ●● Eating with family/at a table ●● Cooking food ‘from fresh’ Other positive changes ●● Increased confidence and self-esteem ●● Improved family relationships ●● Participation in learning activities

Data collection 2.8 We have taken a ‘mixed methods approach’ to evaluating HEY! which combines a rigorous analysis of the quantitative course monitoring data on parents’ progress with qualitative focus groups and interviews with the partner organisations responsible for developing and delivering the HEY! programme, the tutors running the courses, and the parents themselves – during, at the end of, and six to eight weeks after they have completed a course. 2.9 Specifically our data collection has included: ●● Secondary data analysis of course ‘before and after’ monitoring information on and feedback collected by CHLF from parents and tutors on all courses that finished by December 2014 (43 courses); ●● Background briefings or interviews with six individuals in Danone, CHLF, 4Children and other partner/delivery organisations.

Table 2.1 – Stakeholder Interviews Role

Organisation

Consultant in Public Health

Wiltshire County Council

Children’s Service Manager

Spurgeons

Cluster Manager

4Children

Deputy Head of Children’s Centres

4Children

Children’s Centre Coordinator

Leicestershire County Council

Director

Community Health and Learning Foundation

2.10 Case study visits and tutor interviews at nine children’s centres running HEY! covering a range of locations and organisations.

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Table 2.2 – Children’s centres visited Area

Organisations

Children’s centre

Leicestershire

LCC

Barwell

Leicestershire

LCC

Coalville

Leicestershire

LCC

Melton

Wiltshire

Barnardo’s

Corsham

Wiltshire

Spurgeons

Clearbury

Gloucestershire

4Children

Stow on the Wold

Gloucestershire

4Children

Bartongate

Gloucestershire

4Children

Cirencester

Stockton-on-Tees

4Children

Thornaby

●● Focus groups and longitudinal interviews with 24 parents from seven HEY! courses (and drawing on five other parents’ written feedback forms, which were discussed with tutors from one other course). These included follow up interviews with/information from 22 parents to discuss sustained behaviour six to eight weeks after the end of the course. A summary of participant interviews is shown in Appendix A.5 ●● Light touch review of similar programmes in England to identify the distinctive features of HEY!

Analysis 2.11 We have brought together (or ‘triangulated’) the quantitative data analysis and the qualitative interview data to address the evaluation questions in paragraph 2.2 above. Our findings are presented in this report. 2.12 We have also used a sample of interviews with parents to produce five real but anonymised case studies to illustrate how HEY! has improved their physical and emotional health and that of their children. These show how parents and their families have changed to and sustained healthy behaviours following HEY! and the ongoing positive impact these are having on them.

5 High drop-out rates from most of the children’s centres that we had planned to visit in December 2014 – January 2015 meant that we were unable to speak to as many parents as hoped and that we had to visit other centres in February 2015 where courses had only recently started.

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Shared Intelligence

3 Design and development of HEY! 3.1 The HEY! project was initiated in 2011 and created through a partnership of Danone, Wiltshire County Council, 4Children and the Community Health and Learning Foundation (CHLF). This partnership approach between private, public and voluntary organisations has been essential to the successful HEY! pilot and the roll out of HEY! across the country since then.

A partnership approach ●● The partnership between Danone, Wiltshire County Council, 4Children and the Community Health and Learning Foundation (CHLF) was essential to design and develop HEY! as an evidence-based, accredited programme to address childhood obesity and promote healthy eating; ●● The resources developed by CHLF enable HEY! to address its health improvement aims through an embedded learning approach to address parents’ Skills for Life needs and improve their knowledge about healthy eating. 3.2 Danone approached Wiltshire County Council (WCC) with the idea of sponsoring an Early Years community health improvement project in Wiltshire – where their UK Headquarters is based – as part of their pro-active approach to corporate social responsibility (CSR). The HEY! programme appealed to WCC as a way to address childhood obesity and promote healthy eating – both priorities within the council’s ‘Reducing Child Poverty Strategy’. Given the budgetary pressures the council was experiencing, a partnership with Danone would also bring in external, private finance to address these policy priorities. 3.3 The rationale for HEY! is based on a body of evidence that shows that childhood obesity is linked to parents’ eating habits6. This was confirmed by recent research by the University of Exeter7, published in the International Journal of Obesity in April 2015, which discovered that the rise in obesity among very young children has been largely restricted to the minority with obese parents. The research data suggest that ‘parenting is the fundamental influence on weight gain in the early years, whereas more general (peer-group) influences take over later on….and public health strategies may need to be tailored accordingly’. 3.4 The Director of Public Health (DPH) was keen on encouraging the children’s centres they commissioned to use HEY! as an evidence-based programme using ‘tried and tested’ materials and delivery methods. As a result the partnership was expanded to include 4Children, which ran the majority of the children’s centres in Wiltshire, and CHLF, which brought experience in health literacy and delivering community-based health and wellbeing programmes using their nationally evaluated Skilled for Health resources8 as well as developing and delivering ‘train the trainers’ sessions for community-based healthy eating initiatives. “Open and frank conversations with Danone were very important as there were ‘little p politics’ about working with them” (Stakeholder interview) 3.5 The partners were aware of some concerns about Danone making formula milk, which could have been seen as being endorsed by the council and potentially undermining the council’s breast feeding strategy. In addition, some children’s centres run by organisations other than 4Children were concerned about losing their UNICEF baby-friendly accreditation because of Danone’s involvement. 6 See for example http://www.sheffield.ac.uk/polopoly_fs/1.145074!/file/How-do-parents-child-feeding-behaviours-influence-childweight.-Implications-for-childhood-obesity-policy.pdf 7 http://www.nature.com/ijo/journal/vaop/naam/abs/ijo201568a.html 8 http://www.healthyfe.org.uk/content/evaluation-skilled-health-programme

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3.6 The partners worked together to develop a ‘Memorandum of Understanding’ (MoU). This laid out the joint commitment to HEY! as an evidence-based, high quality programme and tackled the formula milk issue through some agreed protocols such as by targeting HEY! to parents with children of one or older (so they would not be breast feeding) and limiting the use of Danone branding in the HEY! resources. “The partnership [to set up HEY!] worked well. If there are issues, there is dialogue” (Stakeholder interview) 3.7 The HEY! resources were designed by CHLF and are unique in that they enable HEY! to address its health improvement aims through an embedded learning approach9. This means that HEY! addresses parents’ Skills for Life needs, at the same time as improving their knowledge about healthy eating which maximises the impact of both.

Piloting and rolling out HEY! 3.8 HEY! was piloted in four 4Children’s centres in Wiltshire between late 2011 and early 2013. The impact of this pilot was evaluated by CHLF in 2013. This was based on feedback from 41 participants on the four pilot courses as well as from partners during the programme and found that: ●● There were measurable outcomes for the parents as a result of their participation in the HEY! pilot project in: Increased knowledge about health, positive health behaviour change, enjoyment of the course, and social impact; ●● There had also been a key business impact for Danone in employee engagement, relationships with stakeholders and benchmarking; and ●● Evidence of an impact on CHLF through helping to achieve organisational vision, mission, aims and objectives, enabling CHLF to develop a tailored Health Literacy course, gaining the recognition of Royal Society for Public Health (RSPH) for HEY!, and developing of stakeholder relationships. 3.9 On the strength of successful feedback from the pilot, Danone agreed to continue to sponsor the HEY! programme, which it wanted to roll-out geographically and through a wider range of organisations who run children’s centres. The children’s centres send outreach and/or family workers on a CHLF run ‘Train the Trainers’ course to learn how to use the HEY! resources (session plans and HEY! Diary workbook) to deliver the seven week course. The centres also provide crèche support for the two hours ‘parents’ learning time’, which is preceded or followed by up to an hour during which parents and children have lunch together. Danone provides £200 per course for consumables and equipment.

So that the resources are health themed with language, literacy and numeracy skills development embedded within them.

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Figure 3.1 – HEY! Course outline

3.10 In April 2013, HEY! was accredited by the Royal Society of Public Health (RSPH) as part of their Corporate Responsibility scheme. Participants on HEY! have had the option to be accredited with the RSPH Level 1 Award in Health Improvement since the second two pilot courses. 3.11 Six HEY! courses ran during 2013 following the pilot. Five of these were run by 4Children – three in Wiltshire and two in Gloucestershire (with one run by an independent provider in Wiltshire). 4Children tried to start HEY! courses in other areas but came up against the concerns about children centres losing their UNICEF baby-friendly accreditation by the local authorities and/or NHS Trusts involved. This was also a problem for other organisations running children’s centres in Wiltshire, such as Spurgeons, although this has since been resolved. 3.12 Thirty seven HEY! courses were run in 2014: 4Children expanded provision in Wiltshire and Gloucestershire and started running courses in areas as far apart as Stockton-on-Tees and Essex. Leicestershire County Council started running courses in its Surestart Children’s Centres and Barnardo’s ran courses in Wiltshire and Dorset. Despite delays caused by sorting out the baby formula milk issue and trained staff then leaving, Spurgeons started running courses in Wiltshire in 2015. Action for Children joined as a provider in Dorset and existing providers all continued and/or increased provision. By March 2015, 51 HEY! courses had been run or have started as shown below. Eleven more courses were planned to start in April 2015.

Table 3.1 – HEY! Courses 2014 4Children

Barnardo’s

Wiltshire

Gloucestershire

Dorset

Local Authority

Spurgeons

Action for Children

Total 11 8

Leicestershire

3 4

Stockton-on-Tees

Plymouth

Essex

Norfolk

Bedfordshire

Buckinghamshire Total 2014

1 26

Evaluation of the HEY! Programme

1 –

–

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Table 3.2 – HEY! Courses completed, in progress and planned by April 2015 4Children Wiltshire

Gloucestershire

Barnardo’s

Local Authority

Spurgeons

Action for Children

Total 5 2

Dorset

Leicestershire

1 3

Stockton-on-Tees

–

Plymouth

–

Essex Norfolk

Bedfordshire

Buckinghamshire Total 2015

1 6

1 2

Opportunities and challenges for children’s centres ●● Fifty one HEY! courses had been run in children’s centres across the UK by March 2015 – involving over 400 parents and their children; ●● Most HEY! courses target vulnerable or socially deprived parents, which meets local authority priorities and needs that have been identified by the children’s centres; ●● This puts a heavy responsibility on centre staff to plan and prepare HEY! sessions and encourage attendance through ‘active outreach’; ●● HEY! adds value to centres’ offer but finding the resources to staff the courses and crèche provision is becoming more of a challenge due to local authority budget cuts. 3.13 Courses are generally targeted to vulnerable or socially deprived parents in line with local authorities’ priorities and the needs of parents using children’s centres. In addition, some courses have been targeted at a specific group of parents. The course at Bartongate 4Children’s Centre in Gloucester was tailored to the needs of very young parents living nearby in warden-supported housing association accommodation. The children’s centre worked closely with the housing association to set up the course and ran the first two sessions at its premises. By the third session the six parents on the course were confident enough to move across to the children’s centre to complete the course. 3.14 The course at Cobden Surestart Children’s Centre In Loughborough took a ‘whole family approach’ to give consistent messages and be most effective, particularly with teenagers who could be influenced by peer pressure and undermine parents’ learning and younger children’s behaviours. The course took place in the early evenings so all the family could attend, with younger children cared for in the crèche, while the eight parents (including two couples) and five older children took part in the HEY! learning before the families then ate a ‘proper dinner’ together at the end of each session. The materials for this course were adapted to make sessions very interactive to engage both the older children and the parents, a number of whom needed help with literacy and English language. “Teen parents, lone parents and military families – many of these could benefit from HEY! which offers a non-threatening, useful, practical course to help parents go home with the confidence to cook” (Stakeholder interview)

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3.15 This flexibility, while still working to standard, evidence-based materials and practice, is one of the strengths of HEY! This has helped positive relationships develop with local professionals and volunteers in supporting HEY! and referring parents to the courses as they are seen as relevant to parents already using the centres and/or known to other professionals such as key workers or health visitors. Spurgeons now sends out a referral pack to inform other professionals – health visitors, midwives, Homestart workers, social workers – who and how to refer to HEY! 3.16 There is widespread recognition that targeting provision to vulnerable parents puts a heavy responsibility on professionals. In several centres, family workers and outreach staff play an active role in encouraging attendance at HEY! sessions – through phoning up the parents to check they are coming along to going to collect them. This is on top of the time to not only run the three-hour session but plan and prepare for it as well – often another two to three hours of staff time. 3.17 The organisations running HEY! courses are pleased to do so as they think that HEY! complements their aims and priorities, offers an extra activity for parents who use their centre and has a good structure with high quality materials and training for tutors. Some children’s centre staff also compared HEY! favourably to other children’s healthy eating programmes. (Our review of similar programmes is summarised in Appendix B.) “HEY! compares well to other professional partnerships…particularly in relation to CHLF…their materials, timeliness and professionalism” (Stakeholder interview) 3.18 However, several of the organisations have explained that finding the resources to staff the HEY! courses, as well as fund crèche provision and other expenses, is becoming more of a challenge as cuts to local authority budgets start to really bite. This is a particular problem for the council-run centres in Leicestershire given the cuts that have been announced for 2015/16. Other organisations, such as Spurgeons, have reported an increase in staff turnover due to the uncertainty of future funding as fixed-term local authority contracts come to an end and are re-tendered. 3.19 The reputation of HEY! has grown during the two years since the pilot and the programme is starting to become embedded in local authorities’ Public Health and Children Services provision. However, the sustainability of HEY! could be vulnerable to further reductions in local authority budgets. We recommend approaches to reduce this risk and maximise the effectiveness of HEY! at the end of this report.

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Shared Intelligence

4 Delivering HEY! 4.1 This section draws from three main sources: ●● Feedback from the ‘Train the Trainers’ questionnaire (14 responses) ●● Tutor feedback forms – on delivering HEY! (seven responses) ●● Interviews with tutors at children’s centres (9 interviews with 12 tutors10) 4.2 It captures the key issues around delivering the HEY! course, including the value of the initial ‘Train the Trainers’ sessions, the resources for HEY!, and finally some reflections on delivering the course.

Train the Trainers ●● Tutors are positive about the ‘Train the Trainers’ session; ●● Tutors like the resources and consider the session well planned and useful; ●● Some tutors would have liked more time for training. 4.3 All of the tutors attended a ‘Train the Trainers’ workshop from CHLF. From our interviews with tutors, the feedback on this session was broadly positive. The session was described by one participant as “really interesting”, while another praised CHLF, saying “they really knew what they were talking about”. 4.4 Similarly, from the feedback forms gathered from the ‘Train the Trainer’ sessions, there was a strong view from tutors that the training was well planned and delivered and that the resources provided were excellent. Tutors felt that the items on the training agenda of most benefit were around portion sizes and the practical activities such as cooking and shopping. 4.5 There were a few comments on the feedback forms from tutors on how the session could have been improved. The most common suggestion was that the agenda was quite packed and there was a lot to take in over the time available – an issue that was reflected in the interviews conducted with tutors. A few tutors felt the ‘Train the Trainers’ session had been too short, with one suggesting the training “would have been better over two days”. 4.6 More specifically, a number of tutors felt there hadn’t been enough in the training on delivering the accreditation, with one tutor stating “…I am experienced in delivering courses, but not in delivering an accreditation”. This became apparent to CHLF following early training sessions and subsequent ‘Train the Trainers’ were revised to bring in more of a focus on the accreditation. 4.7 A few tutors interviewed expressed the view that there are limits to what could be learned at the ‘Train the Trainers’ session. As one tutor said: “you only learn when you do it [deliver the course]”. Similarly, several tutors reported increased confidence with the material, either after the first weeks of the course or when delivering the course for a second time. 4.8 Most tutors seemed comfortable tailoring the course to the group and felt this flexibility had been expressly advocated at the ‘Train the Trainers’ session. However, a small number disagreed, with one tutor saying the training was “quite strict on the message” and another reported feeling “a bit under pressure” to deliver the course as in the materials.

10 Some courses are run by more than one tutor.

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Resources for HEY! ●● The tutors value having the Danone HEY! course resources; ●● The diary is welcomed as attractive and easy to use; ●● Accreditation is important for parents’ self-esteem but does not always align well with the other material; ●● Funding from Danone is appreciated but can be quite tight for some centres and/or target groups. 4.9 As above, feedback forms from the ‘Train the Trainers’ workshop included specific praise for the quality of the materials. This was broadly consistent with our interviews with tutors. Tutors praised the tutor pack, the diary and course material. However, problems were encountered with the accreditation.

Diary/workbook 4.10 In particular, the highly visual style of the Diary was commended. One tutor stated that she felt there was a good mix of materials for different learning styles. Tutors found this was reflected in participants’ enjoyment: “they enjoy doing the diary: the games, the pull-outs, the colour”. Overall, the tutors found the diary “simple” and “easy” for participants to use. “The diaries are amazing … they get to keep and use it … the visual element is good, nicely laid out and brightly coloured”. (Tutor – Stockton-on-Tees)

Tutor packs 4.11 Tutors also valued having their tutor packs. “What is also good, my folder – the course syllabus. It is really detailed in terms of what to cover in each session.” (Tutor – Gloucestershire) 4.12 Tutors thought the packs made delivery much easier and the level of detail was praised: “It is really detailed in terms of what to cover in each session.” As one tutor mentioned, the benefit of having the material was that “we don’t have to write the course ourselves”.

Accreditation 4.13 Tutors valued the accreditation as an important component of the course and explained that, although it was voluntary, it gave most parents a feeling of achievement and self-esteem. However, a majority of tutors also experienced practical problems when carrying out the accreditation exercises. 4.14 The issue most frequently cited was with the order of the document and exercises, which meant “you have to go back and forth”. This led to participants feeling they were having to answer the same questions again and was potentially demotivating. Tutors also pinpointed difficulties with some of the language; specifically where seemingly small differences in the text of the question left participants feeling that the exercises were repetitive – and in some instances, duplicated those in the diary, which could be confusing for them.

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4.15 From early feedback received around these issues, CHLF revised the language of the course material to ensure the accreditation is pitched at an appropriate level. However, since the accreditation is RSPH approved, CHLF have stressed that there are limits to the extent this can be changed.

Leaflet 4.16 A few tutors commented on the leaflet for advertising the HEY! course. They did not consider this to be as effective as it could be for showcasing what the course could offer: “[from the leaflet alone] people don’t realise how valuable the course is”. In one centre, the tutors said they were considering putting on an information session before the course to give parents a chance to find out more about it. 4.17 A question was also raised by a couple of tutors as to whether centres could design their own leaflet (for instance including pictures from previous courses to illustrate the enjoyable elements). CHLF reported that this is possible, but the tutors who raised this as an issue (and other staff from their centres) were unsure if it was allowed.

Funding 4.18 Most tutors felt the funding for delivering the HEY! course (a £200 grant from Danone) was sufficient to meet the costs of the course, such as the meals and the course shopping session. As the grant is not designed to include crèche facilities, this meant it was important the children’s centre was able to resource a crèche. 4.19 Tutors were largely appreciative of the funding: “We are so tight with funding. To have the resources and the planning in place, it would be foolish not to take it up.” (Tutor – Leicestershire) 4.20 Although many courses were running with relatively low numbers of parents, where numbers were high or any additional costs were incurred (such as for cooking equipment for the course and/or parents to take home), funding could present more of a challenge. One tutor mentioned such a situation, and said the children’s centre had covered the shortfall: “It depends on the course but at [Centre] we were feeding six families with an evening meal each week and providing taxis to get people to and from the centre. The centre had to pick up these costs…” (Tutor – Leicestreshire)

Reflections on running HEY! ●● Tutors felt the HEY! courses they delivered had gone well; ●● Group working is very beneficial, encouraging participants to share and open up; ●● Tutors thought the mix of parents having ‘learning time’ away from their children and eating with their children in the group lunch worked well; ●● The main challenges were around preventing drop-out and low attendance; ●● Tutors commented on HEY! having impacts over and above healthy eating – in confidence, parenting, health and interest in using the children’s centre.

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4.21 Overall, most tutors felt the course had gone well and that they had been able to observe significant impacts on participants. The main problem tutors experienced in delivering the course was attracting and retaining participants. In general there was a high level of dropout, although tutors suggested this is not uncommon when working with young and often vulnerable parents, and especially when courses are targeted at particular groups.

What went well? 4.22 From the tutors’ perspective, one of the most positive aspects of the course was developing the group dynamic and encouraging participants to engage in discussion based on the course material, but sometimes going off “tangent”. They considered this was important for building trust with participants; getting parents to think about issues around healthy eating and healthy lifestyles; and when going off topic, covering sensitive issues, important to a healthy lifestyle (e.g. relationships or dealing with anger). “Young parents needed time to engage [with the course, tutor, each other]…Then they really engaged and learned.” (Tutor – Gloucesterhsire) 4.23 The format was another crucial aspect of the course for a number of the tutors we interviewed. By both giving parents time away from their children for learning and to have discussions with other parents, and then also bringing them together as a group to have a meal together, the course format was recognised as effective in achieving a range of objectives, which covered parenting and communication skills as well as healthy eating. “Eating together as families was very important – as well as eating healthily. They set the tables as family tables, which encouraged them to eat and talk together. They laughed together – there was no TV and no mobiles [to distract them].” (Tutor – Leicestershire) 4.24 Tutors often felt participants had made substantial changes to their lifestyles, such as switching to a healthier diet and cooking more from scratch, and that the course had increased confidence of participants, around healthy lifestyles and more generally. 4.25 For some tutors, HEY! represented valuable experience delivering a course and in particular to parents they may not have had much prior contact with. As such, course tutors reported that delivering HEY! assisted in their own knowledge and practice, both in terms of knowledge about healthy lifestyles and by giving an insight into the lives of their clients.

What went less well? 4.26 One of the key issues was attendance. Data in section 5 of this report shows that typically less than half of participants finished the course. However, most tutors identified this as typical of courses run through children’s centres and part of the challenge of working with parents, especially those in the most difficult circumstances. “Attendance has been an issue...By definition, this group has other challenges – or hectic lives – and as a result people have missed sessions.” (Tutor – Wiltshire) 4.27 Although this was a frequent problem – and probably the main challenge faced in delivering HEY! – the severity and reasons seemed to depend on a number of factors. ●● Recruitment method – According to some tutors ‘compelling’ people to attend (for example via a referral from a health visitor) does not work as well as explaining what the course is about and trying to capture the interest of participants. As one tutor, who had run multiple courses with different experiences regarding dropout, argued: the “the key is wanting to come”. Evaluation of the HEY! Programme

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●● Previous engagement – recruitment was made easier if the tutors had already worked with parents on HEY! - often as an outreach worker – so they knew them and understood their needs and circumstances. One tutor phoned participants before each session and said “If I know them [parents on HEY!] I know how far I can push them [to come to the course each week]”. ●● Geography – In more rural locations the relatively low population density and limited public transport emerged as barriers to attendance. ●● Participant skill level – Some participants, especially those with less academic skills, could be discouraged by the accreditation and written diary exercises. Some tutors had counteracted this effect by emphasising the practical elements of the course up front over the accreditation or the more difficult exercises. As one commented “We couldn’t push the parents – it was too much like school. So we did more cooking and shopping up front”. 4.28 There were successes where specific groups had been targeted, rather than recruited openly, as for the course for very young parents in supported housing. It was clear in this case that the tutors made an additional effort to build the confidence of this group, particularly by starting the course in the supported housing facilities before moving it to the children’s centre once participants were comfortable. 4.29 Having the appropriate facilities, including crèche and kitchen facilities, was also crucial in being able to run the course effectively. Where these facilities were not available, or were of lower quality/ duration, this seemed to impact negatively on delivery. For instance, several tutors commented on the importance of having a crèche as critical to the success of HEY!. Although all courses were supported by a crèche, some children’s centres were only able to provide this at specific times which had limited the length of each session.

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Shared Intelligence

5 The impact of HEY! 5.1 At both the first and last sessions of the HEY! course, participants were issued with a short questionnaire ‘Knowing about Health’ which explored knowledge and habits with regard to healthy eating, lifestyle, food budgeting, safety and storage. By March 2015, there was a total of 161 participants recorded on the HEY! roll out database (from 32 courses which had been completed and submitted before and after questionnaires by March 2015). 5.2 Ninety of these participants completed a questionnaire both at the start and the end of the course (a response rate of 56%) and these have been used as our longitudinal sample for analysis. These responses have been analysed and the results of this analysis presented below. Data was analysed by area/course, however, this showed very little variation, and so the results are not disaggregated by course or area but presented for the total responses received. Full results are shown in Appendix C. 5.3 From the analysis of the data from the sample of 90 parents who completed before and after questionnaires, we have found significant changes in parents’ knowledge and behaviour in relation to healthy eating and wider health improvements. These are presented below using a basket of indicators across a number of outcomes as discussed in Chapter 2. Quotations from our interviews with parents at the end of the course are used to illustrate key themes that emerge from the findings.

Impact on healthy eating and wider health improvements ●● Over the HEY! course, there was a significant rise of 61% in parents eating ‘5 a day’ fruit and vegetables – with a corresponding decrease of 55% still eating less than ‘3 a day’; ●● Toddlers also moved to eating more fruit and vegetables; ●● There was a significant 27% increase in parents who exercised for ½ hour at least 5 days a week – with a 42% increase in those exercising more than 3 days a week. The number of parents who took no exercise dropped from 22 at the start of the course to just 3 by the end. 5.4 The basket of indicators used to measure the impact of HEY! on participants includes two quantitative indicators based on those from the Public Health Outcomes Framework 2015: i.e. proportion of adults eating at least 5 portions of fruit and vegetables a day; and proportion of adults achieving at least 150 minutes of physical activity per week. 5.5 Changes in these indicators were measured through questions in the before and after course questionnaires. Respondents were asked to report how many pieces of fruit and vegetables they and their toddler ate ‘yesterday’ and for how many days in the previous week they and their toddler engaged in physical activity. (Specific questions and responses are detailed in Appendix C.) 5.6 At the end of the course 21 respondents (out of 87) indicated that they ate 5 or more pieces of fruit and vegetables in the day compared to only six at the start of the course, a significant increase of 61%11 . There was also a significant reduction (55%) in the number of respondents eating less than 3 pieces of fruit and vegetables in the day falling from 53 at the start to 24 at the end of the course. The biggest shift or ‘distance travelled’ was by the 21 parents who ate 1 or 2 pieces of fruit and vegetables a day at the start of the course to 3 or 4 by the end of the course as shown in Figure 5.1 and Table 5.1 below.

11 Results that are identified as significant show a statistically significant difference at 95% confidence level.

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Figure 5.1 – Yesterday how many pieces of fruit and vegetables did you eat? (numbers of respondents) Start

End

45 number of respondents

40 35 30 25 20 15 10 5 0

1 or 2

3 or 4

6 or more

N/S

Table 5.1 – Changes in fruit and vegetable consumption by individual parents (numbers of respondents) Course Start

Course End 0

1 or 2

3 or 4

1 or 2

3 or 4

N/S

Total 15

N/S Total

5.7 There was an increase of 43% in the numbers of respondents who stated their toddler ate 5 or more pieces of fruit and vegetables in the day (from 21 at start of course to 37 at end of course). A reduction of 63% was seen in the number of respondents whose toddler ate less than 3 pieces of fruit and vegetables in the day (from 30 at start of course to 11 at end of course). “[I am putting] more vegetables on the kids’ plates...for the kids with all meals”. (Parent – Wiltshire) 5.8 The largest shifts were seen in those toddlers who previously ate 1 or 2 portions of fruit and vegetables a day to 3 or 4 a day and from 3 or 4 to five fruit and vegetables a day. These results are shown in Figure 5.2 and table 5.2 below.

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Figure 5.2 – Yesterday, how many pieces of fruit and vegetables did your toddler eat? (numbers of respondents ) Start

End

40 number of respondents

35 30 25 20 15 10 5 0

1 or 2

3 or 4

6 or more

N/S

Table 5.2 – Changes in fruit and vegetable consumption by individual toddlers (numbers of respondents) Course Start

Course End 0

1 or 2

3 or 4

N/S

Total 3

3 or 4

N/S Total

5.9 HEY! has also had an impact on positive changes in physical activity although these are not as great as for changes in eating. This may reflect the fact that physical activity is not the primary aim of the course although it is an indicator of healthy living more generally. Respondents were asked to consider “last week” and identify both how often they exercised for at least half an hour so that they had to breathe more heavily and also how often their toddler did any exercise. 5.10 There was a significant 27% increase in parents who exercised for half an hour at least 5 days a week – with a 42% increase in those exercising more than 3 days a week (26 at start to 37 at end of course). The number of parents who took no exercise dropped from 22 at the start of the course to just 3 by the end.

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Figure 5.3 – In the last week how often did you exercise for at least half an hour so that you had to breathe more heavily? (numbers of respondents) Start

End

number of respondents

Never

On 1 day On 2 days On 3 days On 4 days On 5 days On 6 days On 7 days

N/S

5.11 With regard to their toddlers, their parents reported relatively frequent exercise at the start of the course (around half did physical exercise every day) so there was less room for improvement. However, there was a 36% reduction in the number of respondents stating their toddler exercised less than 3 days in the week (from 14 at the start to nine at the end of the course) and a 17 % increase in the numbers whose toddler exercised for more than 3 days in the week (52 at start to 61 at end of course).

Figure 5.4 – In the last week how often did your toddler do any physical exercise? (numbers) Start

End

number of respondents

50 40 30 20 10 0

Never

On 1 day On 2 days On 3 days On 4 days On 5 days On 6 days On 7 days

N/S

5.12 The data suggest that these important changes to parents’ eating and exercise habits have come about as a result of improved health literacy which has enabled a better understanding of a healthy lifestyle and diet, as reported below.

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Impact on understanding of Healthy Lifestyle and Diet ●● Following the HEY! course, 98% of parents said they knew how to eat and drink healthily – compared with 66% at the start; ●● 93% said they knew how to exercise – up from 77% at the start; ●● By the end of the HEY! course, 96% of parents knew how much of each type of food they should be eating to have a healthy, balanced diet – three times more than at the beginning; ●● 88% of parents thought it was possible to eat healthily on a small budget – more than double that before the HEY! course (42%). 5.13 Overall respondents had a greater knowledge of how to eat healthily and exercise at the end of the course compared to at the start. “[I’m] more aware now of healthy eating.” (Parent – Gloucestershire) 5.14 On beginning the course many participants were unsure about aspects of a healthy lifestyle as shown below. However, at the end of the course there was a 32 percentage point increase in the respondents who said that they knew how to eat and drink healthily and a 16 point increase in those who knew how to exercise. Knowledge with regard to healthy eating was poorer than knowledge around exercise at the start of the course.

Table 5.3 – do you know how to eat and drink healthily? (% of respondents) Key Theme

Yes

Maybe

Course Start

65.5

2.4

32.1

Course End

97.6

2.4

Table 5.4 – do you know how to exercise? (% of respondents) Key Theme

Yes

Maybe

Course Start

77.4

7.1

15.5

Course End

92.9

1.2

6.0

5.15 Participants were also asked if they knew what they and their toddler needed to lead a healthy lifestyle. Prior to undertaking the course the majority of respondents (84%) stated that they knew either quite a lot or a bit – although very few (14%) felt that their knowledge was complete with regard to themselves. Responses were similar when parents were asked about their toddlers. (Detailed figures are displayed in the charts included at Appendix C.) 5.16 However, on completion of the course there was a 38 percentage point increase in those who felt they had a complete knowledge with regard to themselves (from 14% at start to 52% at end of course) and a 40 point increase with regard to their toddler (from 17% at the start to 57% at end of the course). By corollary, there was a significant decrease in those responding that they only knew ‘a bit’, with 39 and 35 point decreases for themselves and their toddler respectively. “[I] try to give her [daughter] more fruit, give her some peas and carrots with her meal.” (Parent – Leicestershire)

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5.17 More telling are the responses from participants on their knowledge around specific food groups and how they make up a healthy diet. At the start of the course over 50% of respondents thought they knew only a bit about the five food groups and how much of each they should be eating to have a healthy, balanced diet with very few (4%). having a complete knowledge about this At the end of the course however, 96% of respondents said they either knew completely or quite a lot about how much of each type of food they should be eating to have a healthy, balanced diet.

Figure 5.5 – Do you know how much of each type of food you should be eating to have a healthy, balanced diet (% of respondents) End

Start

Not at all

A bit

Quite a lot

Completely 0

30 % respondents

5.18 HEY! has also had an impact on parents’ knowledge about purchasing healthy food with an increase of 42 percentage points in their confidence about shopping for healthy eating and cooking over the duration of the course. At the start of the course only 8% of respondents stated that they always felt confident in knowing what to buy to cook healthy, balanced meals. This proportion rose to 50% by the end of the course. “Budgeting £5 for me and [daughter] to eat, it was amazing how much you could get for a fiver.” (Parent – Gloucestershire) 5.19 Perhaps even more important, there was a doubling in the number of respondents thinking it is possible to always or most of the time to eat healthily on a small budget to 88% at the end of the course, and a 46 point reduction (from 58% to 12%) in those thinking it was never or only sometimes possible to do this, as shown in Table 5.5. This change in attitudes may represent the removal of a powerful barrier to adopting healthy eating behaviour.

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Figure 5.6 – Do you think it is possible to eat healthily on a small budget? (% of respondents) Start

End Never

Sometimes

Most of the time

Always 0

% respondents

Impact on behaviour change Shopping and budgeting ●● By the end of the HEY! course, 78% of parents said they were making a shopping list either all or most of the time – nearly twice those at the start; ●● 76% of parents reported keeping their bill within budget all or most of the time. 5.20 Shopping and budgeting for healthy food on a budget was part of the HEY! course content and the data shows a positive, significant change in shopping practices over the duration of the course. At the start of the course 24% of parents never made a shopping list and 24% never kept their bill within a specific budget, whereas at the end 78% were making a list either all or most of the time and 76% were keeping their bill within budget all or most of the time. These findings and the related behaviour changes discussed below are detailed in Appendix C. 5.21 Other changes explored with regard to healthy shopping practices included comparing prices and checking food labels. Responses showed that there was a 29 percentage point increase in respondents who were regularly comparing prices by the end of the course (55% compared to 29% at the start). At the end of the course respondents were also more likely to – always or most of the time – check the labels on food before purchase (76%) compared to 66% at the start of the course responding that they never or only sometimes did this. “The week about the use-by dates and best before, finding out more about that was helpful as well.” (Parent – Gloucestershire)

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Eating at home ●● By the end of the HEY! course 43% of parents said that they always sat at a table as a family compared with 28% at the start of the course; ●● The proportion of parents who involve their toddler in food preparation and similar activities nearly trebled, from 21% to 61%; ●● And there was a noticeable rise in parents eating more than ‘5 a day’ fruit and vegetables – with very few still eating less than ‘3 a day’. 5.22 Respondents were asked questions about their behaviour at home with their toddler. In terms of eating together at the table as a family 43% of respondents stated at the end of the course that they always sat at a table compared with 28% at the start of the course, and those who stated they never sat at the table fell from 24% at the start of the course to zero by the end. 5.23 At the start of the course only 21% of respondents were regularly participating in food based activities (e.g. food preparation, food play) at home with their toddler, which increased to 61% by the end of the course. There was a similar increase in those responding that they felt confident either most or all of the time in undertaking physical activities with their toddler.

Figure 5.7 – Do you undertake food-based activities at home with your toddler? (numbers of respondents) End

Start

Never

Sometimes

Most of the time

Always 0

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Figure 5.8 – Do you feel confident doing physical activities with your toddler? (numbers of respondents) End

Start

Never

Sometimes

Most of the time

Always 0

20 30 number of respondents

Enjoyment and learning ●● The most enjoyable aspects of HEY! for parents were the social aspects of being part of a group; ●● Parents also enjoyed the cooking and practical exercises; ●● The only thing that some parents didn’t enjoy was the paperwork; ●● The only things they would have liked more of was cooking and recipe ideas. 5.24 To test the design of HEY! and understand what aspects of the course encourage learning, respondents were also asked a number of open text questions before and after the course, about what they had expected from the course, what they had and hadn’t enjoyed about the course and what they gained from the course in terms of learning and skills. Individuals’ responses were analysed to identify key themes, with the number of respondents expressing a view within each theme being recorded. “We have changed our lifestyles, we have learnt more about diet, and there is something at the end to look forward to. It has made me feel it is something worth doing.” (Parent – Gloucestershire) 5.25 The most common themes raised by respondents are shown in Table 5.5 below. This shows that the aspect that most respondents enjoyed was the social benefits from being part of a group with almost half of all those responding stating this. The next most enjoyable aspects reported were around the practical cooking elements and learning about healthy eating. Other specific aspects mentioned were learning about portion control, labelling and shopping for food on a budget.

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Table 5.5 – what did you enjoy [about HEY!]? Key Theme

Number of responses

Group/company/social aspect of course

Learning about healthy eating

Cooking

Learning about food budgeting

Learning about food labelling

Learning about portion sizes

Sharing (meal) with children

“I’ve lost weight and feel better with a clearer mind from eating better.” (Parent – Leicestershire) 5.26 Most respondents stated that they liked everything about the course and there was nothing that they didn’t enjoy. The main aspect of the course which there was a more mixed response was ‘the paperwork’ with comments around there being too much of it, it being confusing and repetitive. These views echo tutors’ comments that some parents found the accreditation difficult although this was often outweighed by the boost to self-esteem from gaining a qualification from the course. “Some of the questions are exactly the same as the one before”. (Parent – Gloucestershire) 5.27 A few respondents said they didn’t enjoy not having the opportunity to do enough cooking, specifically of hot food on some courses. (This was probably due to recognised problems with cooking facilities in a couple of centres). There were also a few concerns about childcare arrangements, for example, where the location of the crèche was not felt to be appropriate.

Table 5.6 – What did you not enjoy? Key Theme

Number of responses

Paperwork

Childcare arrangements

Not enough cooking

5.28 In terms of learning expectations at the beginning of the HEY! course, the majority of respondents wanted to learn about healthy eating and cooking and how to have a healthy lifestyle generally. Portion sizes and the need to better understand them was also something a number of individuals highlighted as a priority – even at the start of the course before the importance of these had been covered. A thematic summary of responses are summarised in Table 5.7 below.

Table 5.7 – What would you like to learn? (pre-course) Key Theme

Number of responses

Healthy eating/cooking

Healthy lifestyle

Portion sizes

Budget (cooking/food shopping on)

Exercise (how much)

Labelling

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5.29 By the end of the course it appears that individuals’ learning expectations were broadly met with much of the learning gained matching the needs identified by parents at the start of the course. Although exercise was not identified as a priority by many parents at the start of the course and how to store food appropriately was not identified as a priority at all, both of these aspects were highlighted as areas of learning by respondents. 5.30 It is noticeable that the aspects of the course individuals had most enjoyed were also the ones which they had learnt about (e.g. healthy eating, cooking and portion sizes).

Table 5.8 – What have you learnt? (post-course) Key Theme

Number of responses

Healthy eating/cooking

Healthy lifestyle

Portion sizes

Exercise

Budget (cooking/food shopping on)

Labelling

Food storage

5.31 Other open text questions focused on what more individuals would like to learn and the improvements they felt they had made as a result of the course. Of those who responded to this question almost all indicated that they would have liked to learn to do more practical cooking and to get more recipes and ideas for meals, especially for their children. 5.32 In terms of improvements they had made as a result of HEY! responses were quite specific to the individual but indicated behavioural changes for a healthier lifestyle, through for example: cooking healthier meals; exercising more; improving portion sizes; better understanding of labelling; more planning of meals; and cutting out unhealthy habits such as smoking and fizzy juice. Some also indicated measurable changes such as weight loss. A further change, welcomed by many, was that they were now planning and eating meals as a family which they hadn’t ever done before.

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Shared Intelligence

6 Sustaining behavioural change 6.1 This section uses the follow up interviews with parents to assess the extent to which behavioural change by the end of the HEY! course had continued six to eight weeks after the course and whether it was becoming part of day-to-day living for parents and their families.

What changes continued? ●● Follow up interviews showed parents’ behaviour change was continuing – at around six weeks after HEY!; ●● These parents had reduced portion sizes, swapped to healthier foods, were cooking from fresh and using a greater variety of foods. 6.2 The types of behavioural changes that parents described in the follow up interviews reinforced our findings from the analysis of the ‘before and after’ monitoring data and illustrated how these changes were being made and the impact they had on parents and their families. 6.3 All 22 parents who we interviewed or had feedback from at six to eight weeks12 after the course had finished were making the following changes: ●● Reduction in portion sizes for parents and children ●● Swapping to healthier foods ●● More cooking of fresh foods ●● More variety of foods for children 6.4 Most parents also made some changes to how they budgeted and/or shopped for food, although this varied a lot and included using a meal planner, reading food labels to compare brands on price and nutrition, and sticking to a weekly budget. 6.5 Many of the parents had also made other changes over and above eating more healthily. These included moving to regular mealtimes when they talked more with their children and taking more exercise, often with their children. We look at each of these changes in turn.

Reduction in portion sizes 6.6 Discussions with parents at the end of the HEY! courses showed they had readily absorbed information about portion sizes. Many had said they were shocked by how much over the recommended amounts they were giving their children. One tutor explained how young, first-time parents could become concerned that their children were not eating enough and overfed them as a result. “Some parents were anxious about whether their children had had enough to eat [because they left some of their food] but were giving them too much. HEY! helped them understand the size of a young child’s stomach (size of a fist) and gave them reassurance that 6-7 mouthfuls [of solids at a feed] is ok.” (Tutor – Gloucestershire)

12 The parents from the courses in Cirencester and Downton courses were interviewed about four weeks after the course finished as these courses didn’t start until February 2015.

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6.7 The practical guidelines given by tutors were easy to remember and acted like a mantra for many parents so that healthy measures of food became a habit. “I used to do too much pasta – now I measure it out. I use two and a half handfuls [of pasta] for us both – me and my daughter – now.” (Parent – Leicestershire)

Swapping to healthier foods 6.8 The awareness about eating healthier foods, in particular five portions of fruit and vegetables a day, and reducing intake of salt and sugar has led parents to make permanent ‘swaps’ in the food and drink they consume. Parents frequently described how they had substituted fruit and vegetables for sugary snacks during the day with one parent from Stockton-on-Tees explaining how she had taken to changing the balance between food groups in the meals she served, for instance serving less cheese and fatty foods in favour of healthier options. “I make chicken wraps but not just with mayo like before HEY! …now with cucumber, lettuce and tomato.” (Parent – Leicestershire)

“I do more veg with them to help fill them up more, rather than them eating junk.” (Parent – Wiltshire) 6.9 A number of parents had also just cut down on sugar and /or salt in food and drinks. Several had swapped fizzy drinks for water. “I’ve stopped putting sugar in cereal and changed from two spoons of sugar to one in tea. Two spoons tastes too sugary now.” (Parent – Leicestershire)

More cooking of fresh foods 6.10 Every parent we spoke to had continued cooking fresh foods since the HEY! course. There was a real feeling of being able to cook meals from scratch and parents valued the skills they’d learnt to do this. Most parents would have liked more cooking as part of HEY! and a number were looking for cooking courses they could join to “learn some new recipes”. 6.11 Parents were cooking or preparing dishes they had learnt at HEY! such as casseroles and fajitas, which were very popular and could be varied to suit tastes as foods were available. “I’ve cooked from fresh much more since HEY! Chilli con carne, lamb casserole, fresh foods in [pre-prepared] sauce.” (Parent – Leicestershire) 6.12 Some parents were also trying out new ideas and enjoying experimenting with healthy food. “[I cook] things like ratatouille – that was all right – my grandma gives me ideas. Also just putting different vegetables together like in a pot and with pasta.” (Parent – Leicestershire)

“I can do Toad in the Hole now. It is much cheaper than the microwave version. I can also do the Shepherd’s Pie, I can pack it with veg. On the course it says there are ways of getting veg in such as filling Shepherd’s Pie up with veg.” (Parent – Wiltshire)

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6.13 It was clear that this increase in cooking represented a permanent change in behaviour with parents explaining how they had made a corresponding reduction in buying takeaways and ready-made foods. Several explained how this made them feel healthier as well as saving money.

More variety of foods for children 6.14 A parent from Stockton-on-Tees explained how, following HEY! She had introduced a wider variety of foods into her children’s diet including oranges, bananas and apples which they hadn’t previously eaten as well as trying new meals. “I tried new foods with my children as part of the course, and now give them pitta breads filled with vegetables such as raw peppers.” (Parent – Stockton-on-Tees)

“We had kind of got into a rut…it got to the point where we would be doing the exact same meals on the same night. That doesn’t benefit the kid: he knows exactly what is in front of him, so you can’t really have a conversation about food.” (Parent – Gloucestershire) 6.15 Other parents had moved towards making food for their toddlers from scratch by mashing or cutting up the same food as the parents ate, for their children. 6.16 A couple of parents said that although their children didn’t always take to new food straight away, they tried it for up to 15 times, as recommended on the HEY! course, which usually proved effective.

Meal planning, budgeting and shopping 6.17 Parents had changed their approach to meal planning, budgeting and shopping in different ways but all stressed how they had developed ‘new routines’ which seemed to bode well for sustaining behavioural change. 6.18 For a number of parents this involved introducing a meal planner. This has helped in a number of ways: making shopping easier as parents now know what they need; but also allowing parents to plan ahead, sometimes cooking at the start of the week and defrosting meals on the day. Meal planning is also a route into budgeting, as parents resist buying items they don’t need, and can help save money. “I never buy ‘3 for 2’ as I don’t use it ... If [the price of] my list goes higher than the budget I’ve got then I leave it until next week unless it is urgent I’ve saved lots of money since changing my shopping routine.” (Parent – Stockton-on-Tees)

“I know what food we are having all week, rather than wasting food… I think I’ve saved over £30 maybe £40 a week.” (Parent – Gloucestershire)

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Outcomes for parents and children ●● Following the HEY! course, parents were sitting down with their children to eat at regular mealtimes; ●● Parents became interested in health more generally – which led to them taking up physical exercise; ●● HEY! Also improved their confidence and relationships with their partners and children. ●● With some parents signing up for other courses – including at the children’s centres.

Other changes in behaviour 6.19 Several parents had made quite major changes to when and how they ate meals following the experience of sitting down with their children to eat lunch on the HEY! course. Parents explained that before going on HEY! they often used to snack throughout the day and if they did sit down to eat it was usually on the settee watching television. Now, several of them had bought – or planned to buy – a dining table and chairs and had started eating with their children at regular times, which had improved communication between parents and children and their children’s eating habits. “We’re eating as a family more since HEY! and make the time to eat together.” (Parent – Leicestershire)

“You do notice changes straight away, how they [children] are at meal times, how they are with cutlery. [My son] is not throwing around his food so much and he is sitting on his bottom…It’s more of a family thing.” (Parent – Wiltshire) 6.20 Most parents had made some changes to the amount of exercise taken by themselves and their children. Sometimes this was because HEY! had helped them develop a better understanding of the relationship between calories eaten and calories used and wanted to lose weight. Overall, HEY! had got them interested in health more generally and they realised that physical exercise as well as eating healthily was important. “It’s not just about eating healthily it’s about exercise too... [health is] not all physical it’s mental and emotional as well.” (Parent – Stockton-on-Tees)

“More walking with the dog we’ve got, swimming once a week with the kids. We never used to do a lot of exercise.” (Parent – Gloucestershire) 6.21 Parents invariably made the link between the changes they had made – and were continuing to make – since the HEY! Course and their overall health and wellbeing. “I feel a lot better. I’ve been losing weight, which is good.” (Parent – Gloucestershire)

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6.22 As a result of eating more healthily parents commented that they: ●● Had more energy; ●● Felt less stressed; ●● Had lost weight and felt better for it; ●● Noticed an improvement in their skin with less acne; ●● Had more confidence; and ●● Had better relationships with their partners and children. “I talk to her [child] all the time anyway, but talking in the group made me realise I wasn’t being a silly person by talking to someone who doesn’t talk back.” (Parent – Gloucestershire) 6.23 A number of parents found they had enjoyed learning and cooking and had joined other courses at the children’s centres. For a number of parents the HEY! course changed their perception of the children’s centre and of the support available. “I signed up for another course at another centre closer to where I live: a general parenting course. We are doing that. Really interesting little things you don’t think about.” (Parent – Gloucestershire)

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Shared Intelligence

7 Case Studies HEY! Ashley “HEY! has changed my eating habits. My key worker got me on HEY! and it helped it coming just before Christmas so I could make a fresh start, a new year’s resolution. We still have some treats but we feel much better in ourselves” Ashley had recently moved to Leicestershire with her husband and two small children and felt isolated away from family and friends. She was introduced to the HEY! course – as well as a parenting group – at the children’s centre near where she lives. Ashley says HEY! made her really look at what she ate and make a lot of changes such as reducing sugar and salt – not easy as she works in a fast food café with burgers and fizzy drinks freely available. “Before HEY! I used to have three or four coffees a day and three or four Red Bulls and full sugar Cokes. Now I have one coffee three times a week and water with sugar free squash. At work I have cup-a-soups and savoury crackers and bottled water – not burgers and chips. I’m not bloated now and have lost two stone”. Ashley explains that she eats less and more slowly since HEY! and knows when she’s full. Her husband does most of the cooking and has changed to making healthier – and smaller – meals following HEY! Ashley has started to do more cooking and now buys less ready-made and processed food. “We make wraps now using 50/50 bread as we like Mexican food. We cook chicken breasts and haddock fillet and add vegetables and seasoning – then you know what’s in it”. Not only has Ashley moved to healthier options for food and drinks and started cooking more, she and her family have changed their eating habits, which has brought them closer together. A big change was buying a dining table and chairs so they could eat together in the kitchen instead of on their laps in the living room, which means their toddler doesn’t play with his food or wander off any more. “We have breakfast with the kids now – and enjoy each other’s company”. This led to cooking for special occasions – like Christmas and the Chinese New Year, which their toddler was learning about at pre-school. “It’s better for our marriage – doing things together. We’ve done a Valentine’s Day meal and Pancake Day for the first time in 3 years”. Ashley has learnt that healthy eating helps mental as well as physical health and sees eating as part of a healthy lifestyle. She’s made other changes to her lifestyle including reducing her hours at work to shorter shifts and feels much better for it. “I’m sleeping much better now – there’s less stress but it’s the diet as well – less coffee and so on”. “The last 6 months of 2014 – with HEY! and the parenting course – have made a massive impact on me today”

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HEY! Jen “It is just comfy to sit in front of the TV, especially when the little one isn’t in the mood for eating, but making the point that meal time is probably going to be good in the long run” Jen came to a HEY! course in Gloucestershire with her friend Lucy as they wanted to do something together and it was hard to find something with crèche facilities. Jen hadn’t been aware of the activities taking place at the children’s centre before and found out through an email from the course tutor. For Jen the course was interesting because she wanted to learn more about what to feed her son and also the “budgeting side was a draw”. Jen felt she had learnt a lot. The course helped her understand the “the exact nutritional value of things”, including how much salt and sugar foods have. She would look at food labels before, but wasn’t sure what was ‘ok’. She also found the eat-well plate useful since it tells you “what a meal should look like”. Jen felt she had made a number of changes following the HEY! course. This includes being more aware of the nutritional value of different foods and making meals more balanced by including more vegetables. Jen said that at the start of the course she was “a real salt monster”, but that over time she stopped using it for her son and herself: “I stopped putting it in food for him [her son] and it got less and less from there.” The course has helped Jen to budget better. This can be difficult, since it is just Jen and her son. HEY! helped her understand how to use something like a pack of mince and make it last. However, she is also more aware now that the cheapest option might not be the best for you. Jen is also making more of an effort to eat meals with her son at the table. She did this sometimes before, but because although “It is easy to go back in front of the TV”, “learning the importance has really made me make an effort to go back and sit at the table with him.” Jen is also being more physically active and making sure her and her son “do something every day”. Another woman on the course had mentioned the exercise app, ‘Couch to 5k’. At first Jen thought this was “impossible”, but now “I feel a lot better, and I started running”. The course has also been important for Jen’s confidence. Knowing more about healthy lifestyles means “It is more in my mind rather than just winging it”. She also felt the course was a chance to open up and discuss some “mum stuff that otherwise we might struggle with”. It has also made her feel more confident about the children’s centre. She has been offered counselling from the children’s centre and whereas before she “had been putting it off, because I thought it was a judgement about me as a parent”, “doing the course and seeing the people at the children’s centre has given me the confidence to accept the help”. “[It’s about] Giving him [her son] the right kind of starting blocks. So he has a healthy future, without thinking about it.”

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HEY! Lyndsey “I’ll never look back … [the HEY! course] has definitely changed my family’s life” Lyndsey attended the HEY! course twice. Lyndsey completed the HEY! course in Gloucestershire and enjoyed it so much that she asked if she could be involved again so as to review the course content and to act as a helper in the sessions. Lyndsey first heard about the course through participation in other adult education courses run by the children’s centre. Attending the course for a second time, Lyndsey was enthusiastic about what can be achieved. She shared her learning with other participants, for instance advising other participants about the advantages of steaming vegetables instead of boiling and also revealing that she has begun using a slow cooker to prepare many of her meals. The HEY! course helped Lyndsey to consider a wide range of changes she can make to help her and her family live more healthily. She is enthusiastic and determined about what she can achieve: “I’ve got loads of ideas of what I want to do. I’ve been keeping to it.” This includes eating more fruit and vegetables. For example, she said “we’re starting to eat quite a lot of fruit as a family... We’ve been sticking to our five a day.” She has also taken to “steaming vegetables regularly now.” Another important change is around portion sizes. She found out from HEY! that she used to give her daughter “an adult’s size” portion. Lyndsey said they were also cutting down on salt and sugar significantly. One of the biggest differences that Lyndsey has noticed as a result of these changes is that her daughter has lost weight and her children overall are less ‘hyper’. “My daughter has lost a stone and is feeling more confident now. She feels better in herself”. Lyndsey revealed that previously her daughter “lost a lot of selfconfidence” and “She was bullied because of [her weight]”. Moreover her daughter “wants to exercise more now. She seems to have more energy.” Both her children are less ‘hyper’, which Lyndsey thinks is because she has cut down on things like sugar. According to Lyndsey this is “really helping” her as a parent. Lyndsey has also started using a weekly food planner and “I know what food we are having all week, rather than wasting food.” She has involved her eldest child in the food planner. Doing this has really helped her financially, and she thinks she has “saved over £30, maybe £40 a week”. “Once I got into it, I found it quite easy – once I changed the habit.”

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HEY! Jane “Before I was like no, no…but now I think they [courses at children’s centre] are quite good. They are free; and on this one I learnt something from the book and also from talking. You learn more from other people’s opinions.” Jane enjoyed the HEY! course in Wiltshire, particularly meeting as a group and “getting advice from other people”. She learned a lot from the course, including what there is in some foods and drinks, such as the sugar in fizzy drinks and Fromage Frais; more about shopping, including where to get her fruit and vegetables; and food planning. Jane felt she has been able to make a range of changes for her children to give them a healthier lifestyle. This includes adding more vegetables to meals rather than letting her children snack on unhealthy foods: “I do more vegetables with them to help fill them up more, rather than them eating junk.” Jane felt there were good tips in the course for encouraging children to eat more vegetables, such as making dips (e.g. hummus) or adding more vegetables to a freshly prepared meal. Jane is now checking food labels more closely and knows what to look for - “I also label checked before, but now I look to see how much fat and sugar there is”. Jane has started cooking more herself and experimenting more with cooking, she said “doing the course has made me want to do more.” She found cooking from scratch better because it is both healthier and less expensive. Jane has made other changes that have helped her save money. The course made her more aware that buying loose fruit and vegetables can be cheaper, “Onions, for example, loose they are so much cheaper.” Jane goes to the local market now to buy most of her fruit and vegetables. She also freezes more food, because “I can save money as well, because my husband can have that for his lunch at work.” Jane is more aware of the benefits of exercise, particularly for her children “Doing exercise… is good for them, their mental side. The course pushed me to do it.” Now her son is taking swimming lessons again and her daughter has started dance lessons. She thinks this helps because “they get to let off some steam.” Jane thought it was difficult to make some of the healthy eating changes for herself because she is so busy, but felt the course had made a big difference to the way she feels, “I don’t know how to word it: I’m socialising more. Normally I just keep myself to myself.” Doing the course also made Jane think more about what she wants to do in the future and she will soon start doing her NVQs for care. She had been planning this before, but after the course she arranged a meeting with the careers advisor through the children’s centre. “I just thought: I’m making loads of changes, I may as well do this.” “Before the course I wasn’t in top gear. More like third gear. After the course I am more up for challenges.”

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HEY! Brooke “I was a ‘binge eater … now I’m not picking anymore ... no crisps or chocolate bars - only set meals instead” Brooke came to a HEY! course in Teesside with her friend Chloe as they like doing courses at the children’s centre – and are already involved other groups that are run there. Two months after the course finished, she has changed her family’s eating habits quite radically. Brooke was amazed at what counted as healthy portion sizes and realised that she had been giving her children “one day’s worth of food in one meal” but since the HEY! course has reduced the amount that she gives her children to “little and often”, with snacks of fruit and vegetables or yoghurts in between meals if they are still hungry. The biggest change for Brooke has been starting to eat regular meals. She described herself as having been a ‘binge eater’ in the past, having almost nothing to eat during the day and then “getting through six or seven chocolate bars and several packets of crisps on a night” but since HEY! her behaviour has changed completely, starting with eating breakfast regularly. She has noticed having more energy through the day and though she sometimes still buys snacks for her children, she does not touch them herself and does not crave them. Talking about how her cooking habits have changed, Brooke, who often cooks with Chloe for their families, has begun cooking from scratch with fresh vegetables and freezing meals, rather than using ready-made sauces from a jar. She says she was a fussy eater but has had the opportunity to try new foods “including some Quorn which was on offer and the children liked”. Brooke and Chloe have taken to ‘make your own’ style meals – putting wraps, chicken, salad and vegetables on the table – and preparing and eating these with their children once a week. Brooke already set herself a budget for the weekly shop before HEY! although she says she can be “a bit of an impulsive shopper”. The course has made Brooke realise how ’expensive’ and often less healthy branded goods are: “own-brand mini shredded wheats contain less sugar than the branded ones so even when they are on offer, I still buy own-brand”. Brooke thinks the course has made her think about health generally, including having enough exercise, although she finds it difficult to get out with the children in the winter. She has made plans to begin swimming in the near future and has taken to playing more with the children who have been using the Nintendo Wii as a way of getting some physical activity – with Brooke and Chloe joining in. “I set myself a weekly challenge to do so many minutes of exercise … I’ve taken to dancing and jumping around with the kids”

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Shared Intelligence

8 Conclusions HEY! results in behavioural change 8.1 Our evaluation of the HEY! programme has shown that it has led to increasing parents’ knowledge (e.g. about healthy eating, food labels) and skills (e.g. cooking fresh food, budgeting) which has led to noticeable changes in theirs and their children’s behaviours. 8.2 The behavioural change includes eating more healthily – more fruit and vegetables (5 a day) and less sugar and salt, reducing portion sizes, cooking fresh food instead of take-aways and ready-made meals, and sitting down to eat with their children at regular meal times. 8.3 What’s more, there is evidence that these changes are being sustained. All of the 22 parents that we followed up several weeks after the course finished said that they were: Reducing portion sizes for parents and children; Swapping to healthier foods; cooking more fresh foods; and introducing more variety of foods for their children. 8.4 Some of the parents said they had taken up meal planning and/or budgeting which had altered their shopping habits and helped them save money. Others have increased the amount of exercise they and their toddlers have and feel better for it. 8.5 The impact of these changes on parents and their young children is far reaching. By continuing to make healthy changes to their lives they: Have more energy; Feel less stressed; Have lost weight and feet better for it; Have noticed an improvement in their skin; Have more confidence; and Have better relationships with their partners and children.

A distinctive programme 8.6 HEY! includes a number of key aspects that have been important in encouraging and sustaining behavioural change for parents and young children. 8.7 One of these is the way that HEY! has a clear purpose – to improve the health outcomes and life chances of young children. This influenced the design of the programme and how it has been targeted towards vulnerable or isolated parents and those living in deprived areas. 8.8 The partnership approach that was used to design and develop HEY! has also been instrumental in getting the programme adopted by children’s centres run by a range of public sector and voluntary organisations across England. Specifically, the partnership brought together the mission and resources of Danone and the public health policy interests of Wiltshire County Council – with the skills and experience of the Community Health and Learning Programme and 4Children in delivering peer learning programmes and working with parents and young children respectively. 8.9 This produced an evidence-based programme with high quality resources and materials, which were important considerations for Public Health at Wiltshire County Council. It also met the requirements of organisations running children’s centres by complementing their existing provision. 8.10 HEY! works well because of the commitment by the children’s centres and their staff to deliver the courses. Although the £200 per course provided by Danone is very welcome, the children’s centres have to provide staff time and crèche facilities. The quality of the staff input and childcare arrangements clearly affect parents’ engagement with the course. 8.11 The involvement of the children’s centres has not only produced positive outcomes for parents on the HEY! course but also for their staff who have benefited from the peer learning approach through increasing their understanding of healthy eating and skills in delivering learning.

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8.12 These findings support the ‘Theory of Change’ for HEY! which we introduced in Chapter 2 and repeat below as Figure 7.1. This shows how the design of the programme first enables parents to engage with the course – and then uses the resources to increase their knowledge and skills, which in turn leads to behaviour change. The design of the course – embedding health literacy and Skills for Life in the content and its delivery by trained tutors – is important for the motivation needed for parents to sustain this change for them and their children. In time, the healthier eating and wider health improvements brought about by the behavioural changes should lead to the original purpose of HEY! – to lead to improved health outcomes and life chances for young children.

Figure 7.1 HEY! Theory of Change

engagement

knowledge

IMPACTS

skills

behaviours

Increased capacity Training the trainers

To use resources/ deliver HEY!

And build capacity in children’s centres

Contribution to improving health outcomes and life chances of young children

OUTCOMES

Sustained behavioural change in healthy eating/living

Commitment/uptake by children’s centres

HEY! developed by DBN/WCC/CHLF/A4C partnership

Need for community approach to improve health and tackle childhood obesity

PROGRAMME

LEARNING

Sustainability of the HEY! model 8.13 The distinctive approach of HEY! especially through the partnership between private, public and voluntary organisations and ‘Training the Trainers’ for a peer learning approach to health literacy has generated sustained behavioural change for parents and their young children. At the same time the exposure to and appreciation of this approach has enhanced Danone’s reputation and credibility. 8.14 Partners’ experiences and our light-touch benchmarking review of similar programmes show that HEY! compares well with these. Feedback from children’s centres and local authority Public Health and Children’s Services departments has been positive. However, the current levels of local authority financial cuts may mean that it is becoming more difficult both to maintain the quality of HEY! – with possible consequences for parent numbers and engagement – and to embed HEY! in mainstream provision. 8.15 We suggest that this has implications for how HEY! continues to be rolled-out. Thought should be given to increasing the national profile of HEY! – including by publishing the results of this evaluation widely – and reflecting on the current delivery model to maximise the investments that have been made in staff training across and between local authority areas. This could include developing a network of HEY! trained children’s centre workers who could deliver HEY! in a wider range of settings such as schools and community centres.

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Shared Intelligence

9 Recommendations 9.1 This evaluation has found that the Danone HEY! course is having a significant and sustained impact on healthy eating and healthy lifestyles more generally, both for parents and their young children. This impact is largely due to the design of HEY! and the resources in place for the delivery of HEY! – which children’s centres, tutors and parents have greeted enthusiastically. 9.2 Our evaluation has considered the learning from HEY! as well as its impact. We have used this to make a series of recommendations, which are intended to help Danone and its partners to build on the success of HEY! to date to maximise its impact and ensure this is as widespread and long-lasting as possible. 9.3 We therefore recommend that Danone works with its partners to address three broad areas: ●● Increase retention and reduce tackle drop out of course participants: –– Encourage tutors that have successfully attracted and retained participants to share tips and strategies with other centres. –– Encourage children’s centres to use this knowledge exchange to evaluate and ‘market’ the course locally. –– Develop the ‘Train the Trainers’ session as an opportunity to explore and share good practice on increasing retention and marketing HEY! –– Explore the opportunities for developing an online community of HEY! tutors to share good practice (see below). ●● Explore ways to increase engagement and sustain the positive impacts of the course beyond the seven week HEY! programme: –– Respond to the high level of parents’ enthusiasm for HEY! by exploring the scope for engagement beyond the course. –– Explore a Facebook community as an appropriate channel to catalyse and maintain this enthusiasm. Material for this could include simple messages from the HEY! course, giving ideas for recipes and healthy living tips (e.g. activities for rainy days). –– The platform would also provide an opportunity for parents to share experiences (e.g. pictures of meals made). Building on the ethos of openness and communication that developed in many HEY! courses. ●● Sustain and increase capacity for centres to run HEY! courses: –– Maximise the investment in HEY! by reducing the risk that skills and capacity to run HEY! courses are lost through staff turnover in children’s centres and/or increasing financial pressures which may restrict centres’ activities. –– Enable tutors to have access to an online community of sharing and good practice that would provide peer support and increase the capacity for delivery of HEY! courses. –– Explore hosting this on a platform other than Facebook (which is difficult for tutors to access for ‘work’), involving tutors themselves in its design and implementation. –– Consider running HEY! in partnership with a wider range of venues, including primary schools and community centres.

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Shared Intelligence

Appendix A â&#x20AC;&#x201C; Participant interviews Location

Area

Parent

Leicestershire

Barwell

Leicestershire

In-course FG/ interview

End-of-course FG/interview

Follow up

Barwell

Leicestershire

Coalville

Leicestershire

Coalville

Leicestershire

Coalville

Wiltshire

Corsham

Wiltshire

Corsham

Wiltshire

Corsham

Wiltshire

Corsham

Wiltshire

Downton

Wiltshire

Downton

Gloucestershire

Stow on the Wold

Gloucestershire

Stow on the Wold

Gloucestershire

Stow on the Wold

Gloucestershire

Bartongate

Gloucestershire

Bartongate

Gloucestershire

Bartongate

Gloucestershire

Bartongate

Gloucestershire

Bartongate

Gloucestershire

Cirencester

Gloucestershire

Cirencester

Gloucestershire

Cirencester

Gloucestershire

Cirencester

Gloucestershire

Cirencester

Gloucestershire

Cirencester

Gloucestershire

Cirencester

Stockton-on-Tees

Thornaby

Stockton-on-Tees

Thornaby

Stockton-on-Tees

Thornaby

P P

Key: P - done, m â&#x20AC;&#x201C; discussion with tutors using written feedback from parents

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Shared Intelligence

Appendix B – Benchmarking review Benchmarking Summary A light touch review and benchmarking exercise was undertaken to explore other courses/programmes available throughout the UK which were focused on promoting healthy eating and lifestyle among children and their parents. Generally the benchmarking exercise has identified very few courses which are specifically targeted at parents of toddlers. The majority of funded programmes appear to be focused on maternal and infant nutrition or nursery/primary school aged/older children. Other wider programmes were also identified which did have an element of work with parents and young children but again these were not specifically and only directed at the parent and toddler group. Searches have identified the following courses/programmes of most relevance from which the below key findings have been drawn: ●● HENRY – Health Exercise Nutrition for the Really Young – nationwide – trains health and community practitioners to work more sensitively and effectively with parents of babies and pre-school children around obesity and lifestyle concerns. Underpinned by the Family Partnership Model, reflective practice and solution-focused techniques, it offers face-to-face training and e-learning. ●● Fighting Fit Tots – England – 11 weekly parent and toddler physical activity sessions, followed by a parent/carer healthy lifestyle workshop – was modelled on The MEND Programme, a successful community-based obesity intervention for school-aged children – recruitment criteria were based on the children’s age, body mass index and parental obesity status, then extended to all due to poor take up. ●● Family Health Initiative – Northern Ireland – a healthy lifestyle prevention programme for families with a child under 5 years – 8 weekly sessions where parents learn how to be active as a family, what is in food and how to be a positive role model. ●● PhunkyFoods – England – early years and primary school programme of healthy lifestyle curriculum activities, lesson plans and resources and staff training – focuses on helping schools/ Early Years settings to deliver a whole-settings approach to healthy lifestyles and to engage with all children, and their families, in promoting tangible health behaviour changes. ●● Fun Time Cooking with Kids – Dundee – a class which encourages children to get involved in cooking with parents – sessions look at healthy savoury and sweet recipes and activities that children between the ages of 2 to 5 can actively get involved with, including preparing food and tasting the final product. ●● Roots to Confidence Course – Dunbartonshire – facilitated by Women’s Aid, and focusing on mums with young children provided a series of skills workshops around cookery and healthy eating and gardening. ●● Home-Start MAJIK – West of Scotland – recruits and train volunteers to support families in the community, particularly those with a child under 5, using a whole family approach, volunteers help mums living on benefits by demonstrating how to cook wholesome good old fashioned food from scratch – “cooking fun foods for young children with a variety of textures and colours, involving the family”. ●● Confidence To Cook – North East Highland – courses targeted at parents and carers of pre-school children – aim to encourage parents and carers to adopt a healthier diet by developing confidence in shopping, food preparation and cookery skills.

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●● Range of school and community programmes focused on parents and/or children together with web-based resources (some linked to programme activity) such as Infant and Toddler Programme, Eat Well Keep Well, Live Well NHS Choices, Food4Life, Jamie Oliver Food Foundation. ●● Range of guidelines and supports available to practitioners to prevent obesity in young children. Main findings are: ●● A lot of courses have a stronger practical element with more emphasis on developing actual cooking skills with accreditation tied to these elements e.g. food hygiene, food preparation. ●● Budgeting/money saving element of programmes currently receiving a lot of emphasis. ●● Many have activity for the children linked to the activity being undertaken by the parents e.g. messy food play, shopping play, physical activity games etc. ●● Opportunity to share meals with children really appreciated and valued. ●● Like to get involved in preparation of food. ●● Opportunity to socialise, get support from other parents is a real positive. ●● Main changes noted tend to be around small to moderate changes in the food bought, prepared and ate and increasing levels of physical activity. ●● Main changes to diets involved decreasing the amount of unhealthy foods and increasing the amount of healthy food, with focus on better understanding information labels on the products in the shops, cutting out unhealthy choices, eating regular meals and snacking less, cooking fresh food and eating fewer pre-prepared meals. ●● Feedback from courses indicates improved confidence levels and improved understanding of what constitutes a healthy lifestyle. ●● Number of evaluations find that while the messages around healthy eating/lifestyles do get through, making the sustained, practical changes are more challenging to achieve. ●● Do acknowledge the benefits of early intervention and of a holistic, family-based approach. ●● Lot of parents need support of a family worker/key worker to participate and sustain changes. ●● Uptake and attendance can be unsatisfactory due to issues such as poor parental perception of child weight status, commitment issues, and limited staff capacity for outreach work. ●● Targeting of individuals seems to have some positive impact but not when individuals feel coerced into participating. ●● Small changes can have huge impacts e.g. shifting to drinking water from fizzy drinks, eating less takeaways. ●● May be wider impact (although difficult to quantify) as participants pass information on to wider family etc. ●● Courses tend to have a positive effect both personally and professionally on the practitioners involved. ●● There is limited evidence of any large-scale long-term studies of the type required to ascertain if there is the desired impact on young children’s lifestyles and risk of obesity.

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Appendix C â&#x20AC;&#x201C; Questionnaire results Before and after HEY! Course Questionnaire Results (%â&#x20AC;Żrespondents) 1. Do you know what you need to lead a healthy lifestyle? Completely

Quite a lot

A bit

Not at all

Start

14.4

43.3

41.1

1.1

End

52.2

45.6

2.2

0.0

Start

End Not at all

A bit

Quite a lot

Completely 0

30 % respondents

2. Do you know what your toddler needs to lead a healthy lifestyle? Completely

Quite a lot

A bit

Not at all

Start

16.7

45.6

35.6

2.2

End

56.7

42.2

1.1

0.0

End

Start

Not at all

A bit

Quite a lot

Completely 0

Evaluation of the HEY! Programme

30 % respondents

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3. Do you know what the 5 food groups are? Completely

Quite a lot

A bit

Not at all

Start

17.8

23.3

50.0

8.9

End

65.6

31.1

3.3

0.0

End

Start

Not at all

A bit

Quite a lot

Completely 0

30 40 % respondents

4. Do you know how much of each food you should be eating to have a healthy balanced diet? Completely

Quite a lot

A bit

Not at all

Start

4.4

25.6

52.2

17.8

End

54.4

41.1

4.4

0.0

End

Start

Not at all

A bit

Quite a lot

Completely 0

Evaluation of the HEY! Programme

30 % respondents

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5. Do you know how to get the best value for money at the supermarket? Completely

Quite a lot

A bit

Not at all

Start

14.6

34.8

32.6

18.0

End

59.6

34.8

5.6

0.0

End

Start

Not at all

A bit

Quite a lot

Completely 0

30 % respondents

6. Do you make a shopping list when you go food shopping? Always

Most of the time

Sometimes

Never

Start

17.8

25.6

32.2

24.4

End

36.7

41.1

16.7

0.0

End

Start

Never

Sometimes

Most of the time

Always 0

% respondents

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7. Do you keep the shopping bill within a certain budget? Always

Most of the time

Sometimes

Never

Start

15.6

34.4

25.6

24.4

End

44.4

31.1

17.8

0.0

End

Start

Never

Sometimes

Most of the time

Always 0

% respondents

8. Do you compare the price of different products in the supermarket when you are shopping? Always

Most of the time

Sometimes

Never

Start

26.7

27.8

30.0

15.6

End

54.4

30.0

11.1

0.0

End

Start

Never

Sometimes

Most of the time

Always 0

Evaluation of the HEY! Programme

30 % respondents

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9. Do you check labels on foods before you buy them? Always

Most of the time

Sometimes

Never

Start

17.8

16.7

30.0

35.6

End

35.6

41.1

15.6

0.0

End

Start

Never

Sometimes

Most of the time

Always 0

% respondents

10. Do you buy the same things every week? Always

Most of the time

Sometimes

Never

Start

7.8

45.6

40.0

6.7

End

17.8

40.0

36.7

0.0

End

Start

Never

Sometimes

Most of the time

Always 0

% respondents

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11. Do you eat together at the table as a family? Always

Most of the time

Sometimes

Never

Start

27.8

21.1

26.7

24.4

End

43.3

24.4

21.1

0.0

End

Start

Never

Sometimes

Most of the time

Always 0

% respondents

12. Do you feel confident about knowing what to buy to cook healthy, balanced meals? Always

Most of the time

Sometimes

Never

Start

7.8

35.6

45.6

11.1

End

50.0

34.4

14.4

0.0

End

Start

Never

Sometimes

Most of the time

Always 0

% respondents

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13. Do you do food based activities at home with your toddler? Always

Most of the time

Sometimes

Never

Start

3.4

18.0

41.6

37.1

End

29.2

31.5

29.2

0.0

End

Start

Never

Sometimes

Most of the time

Always 0

% respondents

14. Do you feel confident doing physical activities with your toddler? Always

Most of the Time

Sometimes

Never

Start

25.8

34.8

30.3

9.0

End

44.9

37.1

15.7

0.0

End

Start

Never

Sometimes

Most of the time

Always 0

% respondents

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15. Do you think it is possible to eat healthily on a small budget? Always

Most of the time

Sometimes

Never

Start

11.1

31.1

46.7

11.1

End

41.1

46.7

12.2

0.0

End

Start

Never

Sometimes

Most of the time

Always 0

% respondents

16(i).Do you know how to eat and drink healthily? Yes

Maybe

Start

77.4

7.1

15.5

End

92.9

1.2

6.0

Start

100

End

number of respondents

Yes

Evaluation of the HEY! Programme

Maybe

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16 (ii).Do you know how to exercise? Yes

Maybe

Start

65.5

2.4

32.1

End

97.6

2.4

0.0

Start

100

End

90 number of respondents

80 70 60 50 40 30 20 10 0

Yes

Maybe

17. Yesterday how many pieces of fruit and vegetables did you eat? 0

1 or 2

3 or 4

6 or more

N/S

Start

17.2

43.7

32.2

2.3

4.6

0.0

End

6.9

20.7

48.3

18.4

5.8

0.0

Start

End

45 number of respondents

40 35 30 25 20 15 10 5 0

1 or 2

Evaluation of the HEY! Programme

3 or 4

6 or more

N/S

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Course Start

Course End 0

1 or 2

3 or 4

1 or 2

3 or 4

N/S

Total 15

N/S Total

18. Yesterday how many pieces of fruit and vegetables did your toddler eat? 0

1 or 2

3 or 4

6 or more

N/S

Start

3.4

30.7

42.0

14.8

9.1

0.0

End

1.1

11.4

44.3

26.1

15.9

1.1

Start

End

40 number of respondents

35 30 25 20 15 10 5 0

1 or 2

Course Start

1 or 2

3 or 4

6 or more

N/S

Course End

1 or 2

3 or 4

N/S

Total 3

3 or 4

N/S Total

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19. In the last week, how often did you exercise for at least half an hour so that you had to breathe more heavily? Never

On 1 day

On 2 days

On 3 days

On 4 days

On 5 days

On 6 days

On 7 days

N/S

Start

24.7

14.6

13.5

19.1

5.6

7.9

2.2

12.4

0.0

End

3.4

16.9

15.7

22.5

12.4

6.7

7.9

14.6

0.0

End

Start

number of respondents

Never

On 1 day On 2 days On 3 days On 4 days On 5 days On 6 days On 7 days

N/S

Course Start

Course End Never

Never

n/s

Total 22

3 4 5+

N/S Total

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20. In the last week, how often did your toddler do any physical exercise? For example. Playing in the park, bouncing on a trampoline, dancing, running, swimming? Never

On 1 day

On 2 days

On 3 days

On 4 days

On 5 days

On 6 days

On 7 days

N/S

Start

3.4

2.2

10.1

20.2

7.9

13.5

2.2

38.2

2.2

End

2.2

5.6

15.7

7.9

9.0

5.6

50.6

1.1

Start

End

number of respondents

50 40 30 20 10 0

Never

Course Start

Never

On 1 day On 2 days On 3 days On 4 days On 5 days On 6 days On 7 days

Course End

4 1

n/s

Total

N/S

N/S â&#x20AC;&#x192;

Total

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