Effect of an Occupation-Focused Family Intervention onChange in Parents’ Time Use and Children’s BodyMass Index

Kristina Orban, Lena-Karin Erlandsson, Anna-Karin Edberg,

Jenny Onnerfalt, Kristina Thorngren-Jerneck

MeSH TERMS

� body mass index

� family health

� health promotion

� life style

� pediatric obesity

Kristina Orban, PhD, Reg OT, is Assistant Professor,

Department of Health Sciences, Faculty of Medicine, Lund

University, PO Box 157, S-221 00 Lund, Sweden; kristina.

orban@med.lu.se

Lena-Karin Erlandsson, PhD, Reg OT, is Associate

Professor, Department of Health Sciences, Lund

University, Lund, Sweden.

Anna-Karin Edberg, PhD, RN, is Professor, School of

Health and Society, Kristianstad University, Kristianstad,

Sweden.

Jenny Onnerfalt, MD, is Doctoral Student, Department

of Pediatrics, Clinical Sciences, Lund University, and

Vardalinstitutet, Swedish Institute for Health Sciences,

Lund, Sweden.

Kristina Thorngren-Jerneck, MD, PhD, is Chief

Physician, Department of Pediatrics, Clinical Sciences,

Lund University, Lund, Sweden

.

OBJECTIVE. This study explored factors related to changes in the time parents spent with their childrenwith obesity and associated decreases in children’s body mass index (BMI) z-scores after an occupation-focused

intervention.

METHOD. Parents participated in a 1-yr occupation-focused intervention to promote healthy family life-

styles. Data on 40 parents of 22 children with obesity ages 4–6 yr were collected before and after intervention

and analyzed using linear and multiple regression methods.

RESULTS. Parents increased time spent with their children by an average of 91 min/day. Parents’ finances,perceived satisfaction in daily occupations, low BMI, and mastery at inclusion were associated with increased

time spent with their children. Mothers’ subjective health and high mastery and fathers’ perceived occupational

value and education explained 67% of the variance in children’s BMI z-scores.

CONCLUSION. The results indicate important factors to consider in developing interventions that facilitateoccupational engagement and health among children with obesity and their families.

Orban, K., Erlandsson, L.-K., Edberg, A.-K., Onnerfalt, J., & Thorngren-Jerneck, K. (2014). Effect of an occupation-focused

family intervention on change in parents’ time use and children’s body mass index. American Journal of Occupational

Therapy, 68, e217–e226. http://dx.doi.org/10.5014/ajot.2014.010405

The prevalence of obesity has escalated worldwide, and the World Health

Organization (WHO; 2012) has noted that overweight or obesity is a major

risk factor for several chronic diseases. Multiple factors are associated with in-

creasing rates of childhood obesity (Brown, Kelly, & Summerbell, 2007), in-

cluding low levels of activity and high levels of sedentary behavior (Telama,

2009) and parents’ weight (Davison & Birch, 2001) and socioeconomic status

(Lissner, Johansson, Qvist, Rossner, &Wolk, 2000). Obesity is preventable (WHO,

2012), and contemporary research has found family-based lifestyle interventions

to be useful in preventing and treating childhood obesity (Golley, Magarey, Baur,

Steinbeck, & Daniels, 2007; Oude Luttikhuis et al., 2009; Reinehr, Kleber, Lass,

& Toschke, 2010; Wilfley et al., 2007).

Health care practitioners agree that it is necessary to assess family lifestyles

and support parents in establishing healthier family lifestyles (e.g., Ayoob, 2011).

However, only a few examples of effective intervention strategies with this focus

have been published (see Berge & Everts, 2011). The establishment of healthy

family lifestyles is most likely based on many factors (Golan, 2006), including

supportive environments and communities that encourage families to make

healthier choices about food and regular physical activity. From a public health

perspective, outreach to parents, who are the principal enactors of change in

childhood obesity, has been recommended as an effective approach to help them

establish proactive strategies early in their children’s lives (Nader et al., 2012).

The American Journal of Occupational Therapy e217

An occupation-focused family intervention called

Lighter Living (LiLi) was recently shown to be effective in

reducing children’s body mass index (BMI) z scores by

increasing the time family members spent together in

shared occupations in the home environment (Orban,

Edberg, Thorngren-Jerneck, Onnerfalt, & Erlandsson 2014).

During the year-long intervention, parents were encouraged

to focus on occupational engagement and reflect on their

patterns of daily occupation to identify areas they needed to

change. Parents considered the support they received in

implementing sustainable family routines to be a useful in-

gredient in the intervention. The time participating parents

spent in various daily occupations, including time spent

with their children on weekdays, increased significantly, and

children’s BMI z scores decreased significantly from referral

to the end of the intervention (Orban et al., 2014). How-

ever, not all participating parents changed the amount of

time they spent with their children, and the factors associ-

ated with changes in time use have not yet been explored.

The aim of this study was to explore factors related to

changes in the time parents spent with their children in

three areas of occupation and changes in the children’s BMI

z scores. The following research questions guided this study:

To what extent does an occupation-focused family in-

tervention effectively support parents in changing three

areas of their time use: (1) time spent with their children

preparing and eating meals, (2) time spent engaging in

physically active occupations, and (3) time spent engaging

in physically inactive occupations? To what extent does the

intervention decrease children’s BMI z scores, and what

factors are related to any decrease?

Method

Research Design

This study had an explorative and quasi-experimental design

and was part of a larger study called the Lund Overweight

and Obesity Preschool Study (LOOPS), a randomized con-

trolled trial (RCT) described in detail elsewhere (Onnerfalt

et al., 2012). The overall aim of LOOPS was to determine

whether family-based interventions aimed at parents (both

mothers and fathers) of children ages 4–6 yr with over-

weight or obesity had a long-term positive effect on the

children’s BMI. The study was approved by the Regional

Ethical Review Board, Lund University (Dnr159/2008),

and registered at ClinicalTrials.gov (NCT00916318).

Participants and Selection Procedure

Children who were overweight or obese were identified

during a regular visit to their local child health center. The

children were referred to a nearby children’s hospital,

where parents received oral and written information from

a pediatrician describing the family intervention, procedures,

and confidentiality. Inclusion criteria for the LOOPS were

that children be ages 4–6 yr, be obese, and have parents

with satisfactory ability to communicate in Swedish. The

exclusion criterion was presence of any other medical or

endocrine disorders in the child. Once informed consent

was obtained, participants were randomly assigned by

blocking them in series of 10 (randomly allocated to two

different intervention groups), stratifying them by parents’

weight (normal, overweight, or obese), and concealing

their identities in numbered envelopes.

At the time of analysis, all parents allocated to the 1-yr

LiLi intervention who provided the required time use data

and completed the intervention were included in this study,

yielding a total of 40 parents of 22 children with obesity

(Figure 1). Data on parents of 11 children who never came

to the group sessions were analyzed separately as non-

participants, and parents of 7 children who did not write

diaries throughout the entire intervention (i.e., participants

with missing diaries) were analyzed separately. Socio-

demographic characteristics at inclusion of all participants

originally assigned to the LiLi appear in Table 1.

Instruments and Data Collection

Time-Use Diaries. Parents used time–geographic diaries

(Ellegard, 1999, 2006) repeatedly during the intervention

program to record when, where, and with whom they par-

ticipated in occupations during a 24-hr period. All partici-

pating parents maintained an open diary, a small booklet

in which they recorded the time they started each new ac-

tivity during the 24 hr, the place, and the people with whom

they performed each activity. We coded participants’ time

use using a coding system of 600 general types of activities

and transformed the codes into graphs using the software

program Daily Life Version 2008 (Ellegard & Nordell,

2011). Each graph comprised 1,440 min of parent time use

(e.g., co-occupations with children were displayed by re-

cording with whom a given activity was completed). To

ensure the validity of the data collected, the parents rated on

a 5-point scale (1 5 not at all to 5 5 very well; median 5

4.6) how well each documented 24 hr represented an av-

erage day in their current lives. The reliability of the coding

was assessed through participants’ endorsement of the graph

representing each diary. Participants wrote a total of 220

diary entries (average of 6) throughout the program; all

7 days of the week were represented.

Body Mass Index. A trained registered pediatric nurse

measured the children’s weight and height in a standardized

e218 November/December 2014, Volume 68, Number 6

way at inclusion, after 6 mo, and at the end of the in-

tervention. BMI was calculated as weight (kg) divided by

height (m) squared (i.e., BMI 5 kg/m2). The terms over-weight and obesity were defined by BMI according to the

definition set out by Cole, Bellizzi, Flegal, and Dietz (2000).

We obtained BMI standard deviation scores (z scores) forage- and gender-specific reference values from reference

data for Swedish children (Karlberg, Luo, & Albertsson-

Wikland, 2001). The BMIs of both parents were mea-

sured at inclusion.

Occupational Value Instrument With Predefined Items.

The Occupational Value Instrument With Predefined

Items (OVal–pd; Eklund, Erlandsson, & Persson, 2003;

Eklund, Erlandsson, Persson, & Hagell, 2009) was ad-

ministered at the beginning and end of the intervention.

Each of the 18 items describes a separate aspect of perceivedoccupational value—that is, the experience derived from an

occupation (e.g., sense of competence or enjoyment)—in

the three dimensions of concrete value (e.g., “something

important was accomplished”), symbolic value (e.g., “it led

to other people getting in touch”), and self-reward value (e.g.,

“it was a true pleasure to do these things”). Respondents

were asked to state how frequently they had perceived these

aspects of occupational value during the past month by

choosing a response from 1 5 not at all to 4 5 very often;totals ranged from 18 to 72 points. Eklund et al. (2003)

found adequate convergent validity. Eklund et al. (2009)

demonstrated a good fit of the 18 OVal–pd items to the

Rasch model, suggesting that these items form a one-

dimensional occupational value construct, and found that

Cronbach’s a was good, at .91. Moreover, test–retest and

internal consistency reliability of an American English

version were very good (a 5 .92), and exploratory factor

analysis confirmed its structural validity (Eakman & Eklund,

2011).

Study-Specific Questionnaire. In addition, the pediatric

nurse administered a questionnaire developed specifically

for this study to participants at inclusion and after 1 yr of

intervention. The questionnaire included the Swedish

version of the Pearlin Mastery Scale (Pearlin & Schooler,

1978), the Mastery–S (Eklund, Erlandsson, & Hagell,

2012), to assess the extent to which parents felt that they

were in control of their everyday lives and able to achieve

their goals. Parents self-reported their degree of mastery

by rating seven statements on a scale ranging from 1 5strongly agree to 4 5 strongly disagree; total scores ranged

Figure 1. Flow chart of participant recruitment in the Lighter Living (LiLi) intervention.BBE 5 Better Balance Everyday (behavior-focused intervention); LOOPS 5 Lund Overweight and Obesity Preschool Study.

aReasons for not receiving the allocated LiLi intervention included parent time constraints, unavailability of child care in the evenings, difficulty traveling, parent illhealth, and failure to respond to the invitation.

The American Journal of Occupational Therapy e219

from 7 to 28 points, with higher scores indicating a

higher degree of perceived mastery. The original in-

strument has shown satisfactory psychometric properties

(Pearlin, Menaghan, Lieberman, & Mullan, 1981) and

good internal consistency (Chiesi, Galli, Primi, Innocenti

Borgi, & Bonacchi, 2013; Majer, Jason, & Olson, 2004;

Marshall & Lang, 1990). Rasch model testing of the

Mastery–S showed that the items represent a logical

continuum of the measured construct; although one item

displayed misfit, it showed acceptable reliability (Person

Separation Index 5 .70; Eklund et al., 2012).

In addition to theMastery–S, the questionnaire included

two specific questions. The first requested an overall esti-

mation of subjective health using the question “In general,

how would you evaluate your health?” Four response

alternatives ranged from 45 excellent to 15 poor. Second,overall satisfaction with daily occupations was measured

using the question, “In general, how would you evaluate

your satisfaction with your daily occupations?” Five re-

sponse alternatives ranged from 5 5 excellent to 1 5 poor.

Other Data. Sociodemographic information regarding

age, gender, marital status, education, profession, and finances

was obtained. In addition, parents’ frequency of attendance at

the targeted intervention (LiLi) and number of diary entries

written during the intervention were also recorded.

Intervention

LiLi is a 1-yr occupation-focused family intervention pro-

gram with a specific focus on facilitating healthy lifestyle

changes in families. It was inspired by the Redesigning Daily

Occupations (ReDO) program (Erlandsson, 2013), which

has proved effective in encouraging lifestyle-related changes

(Eklund & Erlandsson, 2011). LiLi takes a clearly occupation-

focused approach to child weight management that differs

from the traditional focus on dietary restriction, increased

physical activity, and child weight loss. This alternative

approach shifts the emphasis to supporting parents in

revising their lifestyles, specifically by altering everyday

routines to include more time spent in co-occupations,

improving meal routines, and encouraging physically active

Table 1. Sociodemographic Characteristics of Parents of Children Randomized to the Lighter Living Program

Characteristic Participants (n 5 40) Participants With Missing Diaries (n 5 12) Nonparticipants (n 5 22) p

Gender

Female 21 6 11

Male 19 6 11

Age, mean (SD)

Mothers 38 (5.4) 39 (5.9) 34 (5.9) .173

Fathers 40 (6.4) 40 (5.5) 35 (7.6) .155

BMI, mean (SD)

Mothers 28 (5.6) 30 (7.6) 27 (4.1) .727

Fathers 28 (4.5) 30 (6.5) 32 (5.3) .169

Marital status .672

Married or cohabiting 34 10 16

Single 6 2 6

No. of children 22 7 11 .067

1 child in household 7 2 1

2 children in household 10 3 3

3 children in household 4 0 4

4 children in household 1 2 3

Level of education .003

Compulsory school (ages 7–16 yr) 4 1 3

High school (ages 16–19 yr) 21 2 18

College or university 15 9 1

Employment status .170

Employed 33 9 12

Self-employed 4 0 4

On parental leave 1 0 1

Unemployed or on sick leave 2 3 5

Child’s gender .070

Girl 13 5 7

Boy 9 2 4

Child’s age, mean (SD) 4.9 (1.0) 4.7 (.95) 4.9 (.94) .815

Child’s BMI z score, mean (SD) 3.08 (.96) 2.88 (.82) 3.30 (.84) .485

Note. BMI 5 body mass index; SD 5 standard deviation.

e220 November/December 2014, Volume 68, Number 6

occupations in the family. These changes, in turn, are pre-

sumed have a positive impact on children’s BMI.

The LiLi intervention was standardized in a manual

(Erlandsson & Orban, 2008) outlining 12 two-hour ses-

sions based on occupational therapy theory (Scaffa, Van

Slyke, & Brownson, 2008; Wilcock, 2006) and evidence

(Clark et al., 1997, 2012; Eklund & Erlandsson, 2011).

The participants received course materials in a specially

designed folder that included information specific to each

session. A key component of the intervention is the use of

time-use diaries to provide parents with insight into their

daily routines and offer them opportunities to reflect and

focus on healthy meal preparation and on participation in

play and physically active occupations with their children.

Interveners

The LiLi programwas directed by two occupational therapists

(one of whom was the first author, Kristina Orban) ex-

perienced in family interventions and group dynamics. The

therapists administrated all sessions according to the manual;

they were blinded to group assignment, and all data collected

from parents and children before and during the intervention

were concealed.

Data Analysis

Analyses were conducted to identify and more fully un-

derstand differences among participants who completed

the intervention, participants with missing diaries, and

nonparticipants. Linear regression analyses were used to

determine parents’ self-reported time-use change in mi-

nutes in three areas of co-occupation with their children:

preparing and eating meals, engaging in physically active

occupations, and engaging in physically inactive occupations.

We selected these three areas because of their hypothesized

links to the maintenance and treatment of childhood obesity

(Davison & Birch, 2001). Standard descriptive statistics

(mean and standard deviation [SD]) were computed for

the children’s BMI z scores. Paired two-tailed t tests,

Pearson correlations, analysis of variance, and x2 tests

were used to test statistical significance, set at p < .05.

Multiple linear regression analyses were used to identify

the most systematic and statistically significant model

predicting parents’ change in time use and children’s change

in BMI z scores; thus, the dependent variables were (1)

parents’ time-use difference and (2) children’s change in

BMI z score. Parents’ time use and children’s BMI z score

data were converted to individual difference scores ac-

cording to how the data were collected throughout the

intervention. Both parents may have influenced a child’s

BMI change; therefore, the parental independent variables

entered into the models using backward selection were

occupational value difference (OVal–pd total score) during

the intervention, frequency of program attendance, and

number of diary entries written. Additional independent

variables were parents’ sense of mastery, subjective health,

satisfaction with everyday occupations, BMI, education,

and finances at inclusion. Sample size requirements were

considered, taking into account the number of inde-

pendent variables included in the regression models

(Tabachnick & Fidell, 2007); at each step, only the

variables that made significant contributions to the model

were kept. Because the sample was small, the adjusted R2

for the model was used. Data analyses were conducted

using SPSS (Version 18.0; SPSS, Inc., Chicago).

Results

At inclusion, no significant differences were found among

participants who completed the intervention, participants

with missing diaries, and nonparticipants on the variables

of parents’ age, BMI, marital and employment status,

number of children, children’s gender, or children’s BMI.

The only significant difference we found was that parents

in the nonparticipants group had significantly less edu-

cation (p 5 .003; see Table 1).

Parents’ Change in Time Use

Parents increased the time they spent with their children

by an average of 91 min per day during the intervention,

F(1, 218) 5 4.87, p 5 .028. Physically active occupa-

tions in particular increased, F(1, 218) 5 5.96, p 5 .015

(Table 2).

The regression model for change in parents’ total time

use revealed a final model that was statistically significant,

F(4, 32) 5 2.87, p 5 .038, and that explained 17.3% of

the variance (Table 3). Predictors for time-use change in

physically active occupations were number of diary en-

tries written, finances, perception of occupational values,

and low mastery at inclusion, which together accounted

for 18.5% of the variance. Predictors for time-use change

in physically inactive occupations were finances, parent

BMI at inclusion, and perception of occupational values,

which together accounted for 26.4% of the variance.

Children’s Change in BMI z Scores

No statistically significant change was observed in child-

ren’s BMI z score at the end of the intervention. How-

ever, a clinically important decrease (Kolsgaard et al.,

2011) in mean BMI z score was noted, from 3.08

(SD 5 0.96) at inclusion to 2.93 (SD 5 1.05) at the

end of the intervention. The change in mean BMI

The American Journal of Occupational Therapy e221

z score was 20.15 (SD 5 0.56), 95% confidence interval

[20.11, 0.40].

Factors associated with parent characteristics that pre-

dicted children’s change in BMI z score in a healthful di-

rection were mothers’ mastery (high) and parental subjective

health and fathers’ perceived occupational value and edu-

cation. The final model was statistically significant, F(5,

15)5 9.05, p < .001, and explained 66.8% of the variance

(Table 3).

Discussion

The results of this study indicate that a 1-yr occupation-

focused group intervention for parents may contribute to

changed time use in families and reduced BMI for children

diagnosed with obesity. This article is the first to report

that parent factors were significantly associated with changes

in how parents spent time with their children and with

children’s changed BMI z scores after the intervention.

The parents who participated in the LiLi intervention

increased the amount of time they spent with their

children, particularly time spent in physically active oc-

cupations. The number of written diary entries was a

strong predictor of time-use change in physically active

occupations. The diary method used in the LiLi program

thus constituted an important facilitator of change. The

diaries enabled parents to reflect on and identify any need

for change in the patterns of their daily occupations.

Moreover, the results indicate that four to six diary entries

written during the intervention were enough to contrib-

ute to a time-use change. Developers of future lifestyle

interventions should consider including a diary component.

Table 2. Linear Regression Analysis of Change in Time Parents (N 5 40) Spent With Children During the Intervention

OccupationFirst Diary Entry,Median (Q1–Q3)

Last Diary Entry,Median (Q1–Q3)

Mean Differenceper Day (Range) R2 p

Preparing and eating meals, min 50 (26–113) 90 (61–187) 44 (24–90) .015 .070

Engaging in physically active occupations, min 22 (0–69) 60 (22–172) 44 (9–80) .027 .015

Engaging in physically inactive occupations, min 52 (6–103) 72 (15–140) 3 (230–37) .000 .844

Total time use, min 139 (95–267) 235 (171–465) 91 (10–173) .022 .028

Note. Q1 5 first quartile; Q3 5 third quartile.

Table 3. Factors Associated With Parents’ Time-Use Change and Children’s BMI Change

Dependent Variable Final Model R2 Adjusted R2 B 95% CI p

Total time-use change .264 .173 .038

Finances 1.78 [.260, 3.29] .023

Mastery 2.148 [2.320, .023] .088

Satisfaction in daily occupations .384 [21.02, .254] .229

BMI 2.046 [2.130, .038] .271

Preparing and eating meals .143 .065 NS

Engaging in physically activeoccupations

.276 .185 .031

No. of diary entries 2.094 [2.175, .013] .025

Finances .327 [2.110, .764] .137

OVal–pd diff. .008 [2.006, .022] .261

Mastery 2.024 [2.069, .022] .297

Engaging in physically inactiveoccupations

.326 .264 .004

Finances .763 [.249, 1.27] .005

BMI 2.038 [2.067, .009] .012

OVal–pd diff. 2.020 [2.037, .003] .024

Children’s BMI change .751 .668 <.001

Fathers’ OVal–pd diff. 2.047 [2.068, 2.025] <.001

Mothers’ mastery 2.152 [2.220, 2.083] <.001

Mothers’ subjective health 2.995 [21.59, 2.395] .003

Fathers’ education 2.552 [2896, 2.209] .004

Fathers’ subjective health .610 [.188, 1.03] .008

Note. BMI 5 body mass index; CI 5 confidence interval; NS 5 not significant; OVal–pd diff. 5 difference in scores on the Occupational Value Instrument WithPredefined Items. Mean scores on independent variables entered into the regression: OVal–pd diff. (sum of concrete, symbolic, and self-reward value) at inclusion,47, and at end, 52 (p 5 .002); mean scores at inclusion: mastery, 23.7; subjective health, 3.3; satisfaction with daily occupations, 3.6; education, high school;finances, satisfied; parents’ BMI, 28; frequency of attendance at Lighter Living sessions, 7.7; number of diary entries, 6.

e222 November/December 2014, Volume 68, Number 6

Parents’ financial situation was a strong predictor of

change in time spent with children but not of changes in

children’s BMI. Parents’ sense of control (mastery), sub-

jective health, and education were stronger predictors of

children’s change in BMI than finances, a result that

contrasts with those of other studies showing that eco-

nomic disadvantage predicts child obesity (see Lissner et al.,

2000). In Sweden, paid parental leave promotes paternal

involvement irrespective of economic situation, enabling

both parents to spend time with their young children. It

also allows all parents of children up to age 8 yr to work

part time (instead of full time) if they choose. According

to the findings of this study, parents who considered their

current finances sufficient were better able to change their

time use, perhaps by spending less time at work and more

time with their children. However, our study showed

parents’ subjective health, mastery, and education to be of

greater importance than finances in facilitating a healthful

reduction in child BMI.

Lower scores in parents’ sense of mastery at inclusion

(i.e., total score of <23 on the Mastery–S) predicted

greater change in time use. Parents who perceive a lower

level of control over events and circumstances in their

everyday lives may be more motivated to change and may

benefit more from the targeted intervention.

The decreases in children’s BMI z scores after in-

tervention were not statistically significant, although they

might have been clinically important. Nowicka, Pietrobelli,

and Flodmark (2007) found similar reductions, showing

that low-intensity family therapy was useful in their clinical

setting. Other studies have reported that reductions of

0.11–1.30 in BMI z scores are clinically significant

(Epstein, Paluch, Roemmich, & Beecher, 2007; Golan,

2006), and according to Kolsgaard et al. (2011), even a

modest reduction in BMI z score after a 1-yr interventionwas associated with improvement in several cardiovascular

risk factors. Parents’ time-use change in, for instance,

physically active occupations performed with children

might have contributed to a more physically active life-

style. However, our hypothesis that changes in parents’

time use in daily occupations performed with their chil-

dren would promote children’s weight normalization was

not fully supported, even though the study results reflect

slowed weight gain. Future research should investigate

whether parental changes in time use can contribute to

children’s weight reduction in the long term.

Parent involvement seems essential to children’s weight

reduction. Our results show that increases in fathers’ per-

ceived occupational value and level of education, parents’

self-rated health, and mothers’ reports of high mastery

were predictors of a decrease in children’s BMI z scores.

This finding aligns with those of previous studies showing

that involved parents, especially fathers (Stein, Epstein,

Raynor, Kilanowski, & Paluch, 2005), are essential part-

ners in effective childhood obesity treatment programs

(Golan, 2006; West, Sanders, Cleghorn, & Davies, 2010).

A previous study investigating division of time and pa-

rental duties between mother and father (Orban, Ellegard,

Thorngren-Jerneck, & Erlandsson, 2012) showed that

fathers who were away from the family during most of

the children’s waking hours had the most constraints on

changing their time use patterns, resulting in mothers’

difficulty adjusting their own schedules, and children’s

BMI reduction was limited (Orban et al., 2014). Thus,

fathers’ cooperation in shared daily occupations with

their children could be of vital importance.

Finally, the findings of this study confirm that parent

involvement with children can be increased without re-

quiring the children to participate in the group sessions.

The changes our parents achieved in time use can be

interpreted as the result of awareness they gained through

reflection and collaboration during the occupation-focused

intervention. This interpretation is consistent with the ideas

behind the ReDO program (Erlandsson, 2013) and with

research done by Bateson (1996) and Schon (2003), who

accentuated opportunities for reflection and discussion as

a requirement for learning and change. Thus, this study

indicates that it might be just as relevant to highlight

shared family occupations in the home environment and

changes in parents’ lifestyle and that it may not be nec-

essary to focus on the children’s weight and body size in

interventions.

Limitations and Future Research

The 220 collected time-use diary entries that constituted

our primary data provided subjective data. Note, however,

that we did not inform the parents specifically that we

would be analyzing the time they spent with their children

in the three areas of occupation. This strategy provided

parents, as well as researchers, with otherwise difficult-to-

obtain insight into daily routines.

Some of the variables that predicted change were

collected using psychometrically tested instruments and a

study-specific questionnaire. Self-reported perceived per-

ceptions are highly subjective, a fact that may affect re-

liability; further studies with larger samples are needed to

confirm the results.

Because the LiLi program was one arm of an RCT,

participants were assigned (i.e., did not choose) to par-

ticipate in the occupation-focused program. Some parents

might have expected or preferred a diet-focused or

The American Journal of Occupational Therapy e223

behavior-focused intervention. For various reasons, 27.5%

of the parents randomized to LiLi decided not to par-

ticipate; younger parents and those with lower education

levels were more likely to decline. Barriers to attendance

were identified well before the first intervention session.

Attrition rates are commonly 20%–50% in child weight-

management studies (Golley et al., 2007; West et al.,

2010); the high rate of nonparticipation may threaten this

study’s transferability. Future intervention programs must

target parents’ needs more carefully and consider that dif-

ferent family types may need different strategies to ac-

complish lifestyle change. In addition, it was difficult to

recruit certain groups of parents to the RCT, such as those

belonging to various ethnic groups, same-sex parents,

parents with functional limitations, and parents of low

socioeconomic status. The fairly small and homogeneous

sample limits the generalizability of these findings.

Implications for Occupational TherapyPractice and Research

The findings presented in this study can be considered an

attempt to understand factors of importance when designing

and developing occupation-focused interventions aimed at

promoting a healthy lifestyle among children with obesity

and their families. These findings have the following im-

plications for occupational therapy practice and research:

• Supporting parents in reflecting on the way they spend

their time and engage in daily routines with their

children might lead to sustainable lifestyle change by

promoting an understanding of the relationship be-

tween time use, weight status, and well-being for the

whole family.

• Parents’ increased involvement in their children’s daily

occupations may predict positive outcomes in both

time use and child BMI.

• Interventions in routine clinical settings should help

both parents identify healthy occupational opportunities.

• Collaboration with parents using an occupation-

focused approach may be effective in interventions

aimed at facilitating normal weight development in

children.

• Clients have different resources and capacities (e.g.,

finances, subjective health) at their disposal. Practi-

tioners can identify and strengthen parental resources

to enable engagement in meaningful occupations.

• Future research needs to explore family constraints

that limit opportunities to engage in desired family

routines. The great challenge lies in identifying and

reaching out to all parents who need support to effect

changes in their daily occupations. s

Acknowledgments

The authors thank the families who participated in the

study and Anna Lindgren for statistical guidance. The

research was supported by Vardalinstitutet, Swedish In-

stitute for Health Sciences. The authors have no com-

peting financial interests to declare.

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