Eat, Learn, Grow: a digital responsive feeding support program for parents and caregivers

Eat, Learn, Grow is a targeted, brief, digital intervention designed to promote responsive feeding practices among Australian families of young children (6 months - 24 months) who experience food insecurity or economic hardship. Responsive feeding practices are those that attend to a child's cues of hunger and fullness and supports eating autonomy and self-regulation. Responsive feeding interventions have been shown to reduce fussy eating and increase fruit and vegetable intake. It is also thought to play a role in promoting healthy growth in children. Families who experience food insecurity have unique feeding challenges and experience poorer nutrition-related outcomes. Eat, Learn, Grow has been co-designed with Australian families who experience economic hardship/food insecurity. It includes a series of short digital modules that will be delivered via SMS to the parent's mobile phone and a small supplementary package of materials including a booklet, toothbrush, intervention messaging stickers and a children's storybook (Goodnight Veggies, by Diana Murray ISBN: 9781839130434). The booklet has been designed by the research team for this project and includes the project’s contact details, key intervention messaging (i.e., What is responsive feeding and why it’s important; The roles of adults and baby/child in feeding; Young children need lots of chances to try food; Supporting young children to learn about food through sensory exploration/play; The benefits of role modelling and eating together) as well as links to further information to credible sites including The Raising Children’s Network (for comprehensive government endorsed parenting support), Oral health for babies and toddlers (the Australian Dental Association), Food Allergies (nip allergies in the bub), Recipe and cooking skills (no money, no time website from the University of Newcastle). The children’s storybook is included as an activity parents can do to expand their child’s experience with food (food literacy); it tells the story of saying good night to vegetables in a garden explaining where they grow and has illustrations to support this. There are 12 digital modules, which take 3-5 minutes each to complete that will be sent out over 6 weeks to parents with the following schedule and content: Week 1: 3 lessons (M, W, F) 1. Welcome: Objective - To make contact with participants and welcome to the program Summary of contents: • Objective of this resource is to support responsive feeding (RF) • Introduce the team (Video) • Advice given is generalised; seek local CHN/GP for individualised support • Share these resources with your family 2. What is Responsive Feeding?: Objective: To become aware of the definition of responsive Summary of contents: • Responsive feeding and the key principles • Babies are born with the capacity to self regulate food intake • Adults can influence this capacity • Definition of responsive feeding and basic principle • Why use RF? • Common baby hunger signs • Common baby fullness signs 3. Responsive Feeding: What does it look like?: Objective - To reinforce the principles of RF and identify what is looks like in practice Summary of Contents: • Definition of RF • Metaphor of RF is a conversation (back and forth) • Structure to support RF • Video of hunger and fullness signs Week 2: 2 lessons (W, F) 4. Feeding Roles: Parent provides, child decides. Objective - To introduce Ellyn Satter’s Division of Responsibility in Feeding framework, identify the key components and how to apply it. Summary of Contents: • Division of responsibility can help parents navigate mealtimes • Definition of feeding roles (parent and child) under the division of responsibility • Eating is a learning process 5. Learning to eat takes time. Objective: To make parents aware that learning to eat a range of foods is a process that takes time, requires multiple exposure to foods and can regress during toddlerhood. Summary of Contents: • Babies can be enthusiastic eaters • As babies move into toddlerhood it is normal to become more cautious with foods • Acknowledge this is frustrating • Parents can help support food acceptance by offering food multiple times without pressure • Food wastage can be of concern Week 3: 2 lessons (W, F) 6. Mealtimes are about more than food. Objective: To describe what is meant by a family meal, what are the benefits of regular family meals and strategies to do them more often Summary of Contents: • Family meals don’t have to be perfect or complicated • Benefits of regular family mealtimes for parents and children, extend beyond eating • Warmth and tone of the meal is important • Strategies and tips for regular mealtimes 7. Let’s Eat Together: Role modelling. Objective: What is parental role modelling and why is it important for feeding? Summary of Contents: • What is role modelling? • Who are role models? • Why role modelling is important when it comes to children learning to eat • Acknowledgement that eating together is not always possible and some of the reasons that get in the way (i.e., not enough food, conflicting schedules) Week 4: 2 lessons (W, F) 8. Family Food Talk. Objective: To promote adults’ awareness that what they say about food and the strategies they use to get children to eat or not eat matter and can have a lasting impact on children’s eating behaviour Summary of Contents: • Food is central to many aspects of life (culture, celebrations, religion, connection) • Parents sometimes use food to control child behaviour (rewards, bribes, punishments) • What to do instead • Having a neutral approach to food 9. Learning about food away from table. Objective: To teach parents that young children explore food through their senses and that this is important to become more familiar with food and to eat variety. • Children learn about food both at the table (eating) and away from the table (playing) • Ideas presented for how to support young children’s growing experience with food • That learning about food can be messy Week 5 2 lessons (W, F) 10. Variety. Objective: To describe what is meant by food variety, why it is important, and prompt parents to include more variety Summary of Contents: • Why is variety important • 2 definitions of food variety (i.e., different foods within and between the 5 food groups) • What are the 5 food groups • Simple ways to include more variety 11. Being Creative. Objective: To share the experiences and tips for how they feed their family on a budget from the parents who codesigned the intervention. Summary of Contents: • Acknowledge that feeding the family can be expensive and challenging • Being creative with food resources and cooking can help reduce the cost and stress • What is meal planning • Collated tips & strategies from parents Week 6 Text msg (M); 1 Lesson (F) Text Message – • Include a reminder to ‘catch up’ on content • To encourage parents to catch up on any mini lessons that they haven’t yet completed • Reminder that the final ‘wrap up’ lesson is coming on Friday with the second survey 12. What’s next…Objective: To thank parents for their participation, recap the key messages, to remind them of the survey and why this is important Summary of Contents: • Reminder that these mini-lessons can be revisited whenever they like • Recap: What is RF; What are the shared feeding roles; Children need lots of chances to try foods; Learning about food happens away from the table too; Family meals are important; Being creative with food • Link to T1 survey This intervention will be piloted in a feasibility randomised control trial of 150 participants with a wait listed control group. The digital modules draw on cognitive load and social learning theories to develop the content to optimise impact. The impact will be evaluated through a baseline, 6 week and 6 month online survey including sociodemographic factors, and validated tools for the primary outcome: parent feeding practice (Feeding Practice and Structure Questionnaire) and the mediating factors measured: food insecurity (United States Department Household Food Security Survey) and household chaos and dysfunction (Confusion, Hubbub and Organisation tool). Secondary outcome measures include infant dietary variety (EPOCH-Infant dietary Q - 2 items) and process evaluation factors including satisfaction, engagement and uptake, and acceptability of the digital mode. The intervention period is 6 weeks with a 6 month follow up. Engagement and uptake will include website analytics from the learning management system used to create and deliver the modules and will include: if the module link was opened, if it was completed, if questions/quizzes/polls were completed and what the responses were. The intervention will be delivered remotely and the package will be mailed to participants. The content was developed by the research team who are dietitians with child feeding and parental feeding practice expertise and was reviewed by a committee of experts including child health nurses, dietitians, and a psychologist with parenting research experience. This research program will be coordinated from a Brisbane hub and delivered Australia wide. The pilot will run from May 2023 until adequately recruited for, it is expected that data collection will be until February 2024. The intervention content is a series of 12 short digital modules, which are web browser hosted, and includes videos, audio bites, and interactivity. The mailout package will be posted at the commencement of enrolment for the intervention group. The intervention has been designed for the target population of families with young children who experience food insecurity. The content is contextually sensitive to this experience and includes contributions by families with quotes and short story excerpts to bring families lived experience to the content and to promote practice through social learning.