December 8, 2022

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Adopting and maintaining a healthy lifestyle in low SES families: How the experience of motherhood shapes responses to dietary and physical activity public health guidance | BMC Public Health

The results reported here all reflect the principle finding that motherhood influences health behaviour. We define the complex and contested nature of the motherhood-health behaviour nexus as “The Conflicted Mother”.

Table 2 The Conflicted Mother, themes and codes

Principle finding: the conflicted mother

The mothers that took part in this research were aware of healthy lifestyle advice and had a broad knowledge of dietary guidelines and the importance of a balanced diet. They were able to discuss in general terms what constituted a healthy diet. They saw it as their responsibility to provide healthy meals for their families but faced a number of challenges in doing so. As a result, their own diet often suffered. The response to physical activity guidance was more complex; they did not have enough understanding of the current guidance to make use of it to adopt healthy behaviours (particularly the nature of the recommended physical activity they should be undertaking) and questioned its applicability to their lives. Whilst diet was seen as part of the mothering role, physical activity was perceived as something separate. For some it was a further chore, a necessity to keep healthy to look after the family. The detailed results are presented under the four themes, below. The repeated nature of the interviews allowed changes in participant response over time to be noted. Overall, there was considerable consistency for each participant across the series of interviews. Even though some of the interviews were more than a year apart, the participants gave the same or similar examples to illustrate lifestyle behaviours. For some participants a healthy diet became more difficult as they went through transitions for example, when children moved from being babies to toddlers. Physical activity in the form of walking briskly, for example, became more difficult when children started walking rather than being pushed in a pram. The use of repeated interviews also allowed ideas for interventions that fitted the participants’ core identities as mothers to be explored. In the discussion they were able to talk about and challenge existing guidance and support, and offer insights that could inform further work on coproduced interventions that would have the potential to have a critical public health impact in this group.

Prioritising children and family

Mothers described how their needs were secondary to those of their families using phrases such as “being on the back burner” (Sumi, Jade and Shabnam) to refer to their needs. The mothers understood the requirement to adopt a healthy lifestyle for themselves, but had insufficient time and material resources to meet their own needs, and those of their children and partners. When they had to choose, the mothers put their families first:

“so there are days when I don’t look after myself because I’m just too tired to do that. I make sure everybody else is fed and then put myself last” Yasmine

“It’s an awareness, it’s in the back of my head that I have to eat some foods in order to keep myself healthy but it’s not no it’s not a priority. Ever since I had him [her son] it’s not been a priority ….I think that’s purely it why I don’t eat healthily because I just want something that’s quick, satisfying and then I can forget about it and get on with the day. I think that’s why I eat unhealthy” Noorie

The study participants reported struggling to manage multiple responsibilities, that they experienced conflict trying to undertake all the tasks assigned to them, or which they assigned to themselves, and as a result, they felt guilty when they failed to live up to the high standards, they had set themselves. For example, Vicki talking about not managing time to go to an exercise class:

“every time I don’t go I feel guilty and it’s all misplaced guilty you know” Vicki.

And Christine talking about how she feels when she has a Chinese takeaway meal rather than cooking the meal herself:

“Chinese um after that I feel guilty. When I ate too much. Because because it’s not my routine eating something very oily takeaway yes I feel guilty”, Christine

They experienced guilt when they perceived themselves as taking time and resources away from the family to follow a healthy lifestyle, and when they failed to follow a healthy lifestyle, because of a lack of time and resources. The participants, for the most part, felt alone in managing their responsibilities and neither expected nor received support. Some participants did have some help from their husbands, but many did not. For example, Eisha described how when she came home from hospital after the birth of her second child earlier that day she had to “stand and cook some food for me and for my family” and Jade described how she considered giving her baby to her husband to look after so that she could exercise but decided not to because “you feel guilty…. And you don’t want that feeling”. Many of the participants also reported feelings of isolation which were compounded by their lack of resources to access activities that might help them.

Challenges of putting dietary advice into practice

The mothers’ understanding of what the “good” mother should be achieving in terms of diet and physical activity both for themselves and as a role model for their children differed for the two life style behaviours, diet and physical activity. Following and providing a healthy diet was seen as an integral part of the mothering role.

“I don’t want him to be overweight or anything like that so I try I give him [her son, who had recently been weaned] lots of vegetables, I make it a bigger portion so we all have the same thing … I steam broccoli and cauliflower… I try to vary it so that he’s got a taste of everything” Lilly

The women were generally well informed about current public health guidance on healthy eating. They were familiar with the advice to eat five portions of fruit and vegetables a day. One or two participants were able to quote specific figures such as 6 g of salt being the recommended maximum daily allowance, but most spoke in general terms about wanting to increase their intake of fruit and vegetables and reduce fat, sugar and salt in the diet.

“they say eat lots, eat as many as you can vegetables there’s no limit to how many you can intake, the fruit, they did used to say five a day, then I’ve heard it seven a day … cut down on fat, cut down on sugar” Sumi

They used this dietary knowledge to set themselves targets of the type of food they should be eating and providing for their family, and felt guilty, when in their eyes, they fell short of this objective and failed to be good mothers. Despite this knowledge, their everyday tasks often prevented them from eating healthy meals, for example Sumi despite being very familiar with the current dietary recommendations said:

“I obviously end up eating something quick and easy, and then it might not be the healthier option”. Sumi

“it’s just you know mums are so busy um you know they’ve got school runs to do little one at home and it’s just so quick and easy just to put something in the oven and you know something very very quick and you know instead of standing there and doing something from scratch”. Shabnam

The mothers stated clearly in the course of the interviews that it is not lack of knowledge or ignorance of the public health guidance that prevents the women from eating a healthy diet. They are cognizant of the constant messaging as to what constitutes a healthy diet. They reported that because these messages are transmitted without the provision of appropriate tools to support them in adopting a healthy diet, that they are not always able to act on the messages and this engenders a feeling of guilt, and undermines their mothering role. In some cases, the environment in which they lived with easy access to a wide range of fast-food outlets and regular supermarket discounts on energy dense foods, together with family preferences for unhealthy choices, made their task even harder.

“my husband because when he wants to eat meat they [her children] also want to eat meat … when I have made um errr maybe um lentils then sometime my husband buy kebabs from outside and then they don’t want to eat lentils they want to eat kebabs” Naseem

They felt that all these difficulties are unacknowledged in the public health messages aimed at them as mothers.

Disconnection from physical activity guidance

In contrast to the way they took note of the dietary guidance, the mothers responded very differently to the physical activity guidance. Unlike their broad knowledge of dietary guidelines, the mothers either did not know, or understand the current physical activity guidelines and they had confused the messaging on physical activity and sedentary behaviour. As women with young children, they saw themselves as active, because they equated being busy with being physically active. They considered that because they were not sedentary, they were doing enough physical activity, and that any other official advice had limited relevance for them. They therefore did not feel that a lack of time spent on physical activity had a negative impact on their mothering role. In fact, rather than feeling remorseful about their lack of participation in physical activity, most of the participants saw taking time away from their family for individual physical activity as a selfish activity, and offered that as an explanation for not exercising.

“I think it is important but if you have time or if you like something … it’s not a priority, no”. Eva

“There’s always something that comes up and I think no … No so exercise unless it’s yeh unless it’s something you have to do or enjoy doing” Jade

“I think for some people that need that yeah I think it’s important to exercise. But some women don’t need it” Noorie

The Leisure Centres in the area where the research was carried out have crèche facilities, and the participants were aware that they could leave their children in a crèche and exercise. None of the participants however chose to do this, and most of those that talked about the crèche facilities made it clear that they saw it as their responsibility to look after their children. In their eyes the good mother does not leave her child in a crèche whilst she exercises.

“I wouldn’t have left him in a crèche to go swimming even if it was available” Fatima

“I probably wouldn’t leave her there. I’m quite a…no I’d feel really bad I’d feel bad that I’m putting her in a crèche while I’m doing something leisurely if that makes any sense. I’d feel really bad” Kirti

Moreover, some of the mothers felt it would be inappropriate to spend their limited family money and use their valuable time on what they perceived to be a selfish activity.

There were two women in the study group (Aahna and Rozina) who were regular gym users, and they had both found a way to take part in physical activity, without impacting on their family responsibilities. They talked about their participation in physical activity as something they did for the family’s benefit.

“I don’t feel like going every day. But I have to go just to keep myself fit. It is really very tiring though. Going to the gym every day. It’s very tiring.” Aahna.

“So I started exercising. That’s the reason I joined. To be healthy. I have to be healthy for her [referring to her daughter].” Rozina

Aahna and Rozina both went to the gym early in the morning before their husbands and children were awake, so the sleeping husbands had responsibility for the sleeping children, and the women returned home ready to take up the care of the family before either their husband or child woke up.

Modelling healthy behaviours

The same contrast between diet and physical activity behaviours was seen when it came to modelling healthy behaviours for their children. For many of the mothers the weaning period had been important as they wanted to introduce their children to a wide range of healthy foods particularly fruit and vegetables and many of the women had made the decision to prepare this healthy food for the whole family so that the child could see eating this food as normal.

“I do want to be a good role model to them especially when it comes to eating because I do want them to be healthy you know. I don’t want them to think it’s OK just to eat whatever you want because you have to start educating them from a young age.” Shabnam

Rozina explained how she had changed her diet because she wanted her daughter to see her eating healthy food:

“After she is born I am more conscious I want to be healthy for her. Because if I am not healthy she will ….eat whatever I eat so I try not to eat junk. That’s the reason”. Rozina.

The mothers acknowledged the difficulties in modelling a healthy diet, but thought that it was worth the effort:

“It’s not easy, it is difficult, believe me it is difficult but I make time because I know in the long run it’s healthier for my children, it’s healthier for me and my husband and I’m instilling these you know these things into my children”. Kirti

Physical activity, in contrast, was seen by the mothers as an optional activity, mainly taking place outside the home, and some of the women questioned whether it was even something they should be doing. Most, but not all the mothers, saw physical activity as outside their maternal role and therefore it was not prioritised. Some of the participants, that had very busy lives, did not think it was realistic to serve as a role model for physical activity. They acknowledged that this would be the case in an ideal world, but in their lives, they did not have the time. Christine described how she facilitates physical activity for her children rather than modelling it herself:

“They do all these things without me. Without me in the sense that my daughter she goes to swimming lessons I’m not in the pool with her. She goes to the dance classes. I take them so I think they are they get the message that it’s good to do it.” Christine

The oft repeated response by the participants of lack of time to engage in their own healthy lifestyle behaviours led to a discussion on what type of intervention the mothers would find supporting for the adoption of healthy lifestyle behaviours and realistic in the light of their busy lives.

Listening to mothers: the potential for coproduced interventions

The repeated and in-depth nature of the interviews provided the participants with an opportunity to reflect on and talk about both the reason why current lifestyle interventions are not serving them and the type of intervention, mode of delivery and support mechanisms that would be more helpful to health and wellbeing enhancement in their particular circumstances. All the ideas for interventions came from the participants in the first two interviews and were collated and shared by PW with the ten mothers who took part in the third interviews. The mothers’ ideas for interventions were based on their own experience of what had worked well for them and what had worked less well. The mothers took up ideas suggested by others (and presented to them during the interview) and developed them, again with reference to their personal experience and circumstances, so that the ideas for intervention were born of collaborative effort. The mothers provided insightful feedback on how the intervention ideas would fit in with their mothering role. They saw little need for more leaflets and educational materials to be presented to them, viewing such items as too general and not relevant, but perhaps more importantly they had little motivation to read this type of material. They were looking for information to be provided in a more engaging and practical way, tailored to their specific needs as mothers of young children. Their comments, with examples below, set out how the ideas for interventions matched their concept of motherhood and their core identity as mothers.

Meenakshi talked about the importance of interventions being for the whole family so that the mother feels supported rather than having to carry the burden alone: “I think they should encourage it more the whole family so at least the whole family hears the whole idea and at least they can work together to follow whatever it is…. so they can work together as a team”.

Jade spoke about the value of volunteers visiting the home to provide hands on practical support with the daily demands of providing for a family: “it would help as well having volunteers to help with ideas on what to have [to eat] because I think that’s the main problem that you have all this stuff in the fridge and you open it and you think I’ve got nothing to eat” Jade.

Kirti voiced the importance of information coming from somebody who had shared similar experiences and ideally in a group setting “…somebody who can guide me, talk to me, answer questions motivate me you know, same might be with other mums as well or other people” Kirti.