School nurses’ use of motivational interviewing as a method for health promoting conversations with parents of primary school children

Sammanfattning: School nurses in Sweden have an important task to promote healthy behaviours in children through regular health conversations with parents and children. Nonetheless, there are no evidence-based methods in Sweden for health conversations focusing on parenting practices and promotion of healthy behaviours for school aged children. Motivational Interviewing (MI) is a person-centred conversational technique that has been shown to be effective for behaviour change in adults. Valid and reliable procedures for estimating practitioners’ MI competence helps us understand potential intervention effects. However, MI competence in health promoting situations has rarely been studied, and practitioners’ and participants’ experiences of MI are often overlooked. A Healthy School Start Plus (HSSP) is a health promoting family support programme with four components, of which MI given to parents is one. HSSP was carried out in primary schools in disadvantaged areas in and around Stockholm, Sweden from November 2017 to April 2018 as a universal intervention targeting parents. Families of 353 children (aged 5-7 years) from 17 schools participated in the HSSP trial. This thesis used data from the seven intervention schools where school nurses had conducted the MI sessions with parents. The overall aims of this doctoral thesis were to evaluate school nurses’ MI performance and potential to positively influence child behaviour through health promoting conversations with parents, as well as to explore school nurses’ and parents’ experiences of delivering and participating in MI sessions. This thesis includes four studies: Study I explored parents’ thoughts regarding their normal weight children’s food and physical activity behaviours as expressed during health conversations with the school nurse. This study applied a qualitative explorative inductive study design using sampled data with a maximum variation from the seven intervention schools. Parents focus the conversation in five specific areas when discussing their children’s food and physical activity behaviours: 1) children’s personality and preferences; 2) beliefs of what constitutes healthy behaviours for children and possible consequences; 3) thoughts around parents’ responsibility and strategies; 4) how parents interact with their children around food and physical activity; and 5) contextual circumstances for promoting healthy behaviours. Study II aimed to investigate if parents’ feeding practices differ in relation to child weight status. This cross-sectional study used baseline data from both intervention and control schools. Results showed that parents of normal weight children had higher scores on Pressuring to eat than parents of children with overweight or obesity, whereas parents of children with overweight or obesity scored higher on Restriction for health and weight control when compared to parents of children with normal weight. Study III explored if objective ratings of the quality of school nurses’ MI were associated with change in children’s food intake and physical activity behaviours. We also wanted to investigate if the child’s adherence to recommended behaviours at baseline was of importance for behaviour change. This study applied a before–after uncontrolled study design and data were obtained from the seven intervention schools. Objectively assessed MI competence did not reach established quality standards and was not associated with child behaviour change in the whole group. However, when considering child adherence to recommended behaviours at baseline, some of the global scores were significantly associated with improved food and physical activity behaviours. Study IV explored school nurses’ and parents’ perceptions of delivering and participating in the MI sessions and attempted to illustrate how objective and subjective ratings of the MI sessions resonate with school nurses’ and parents’ perceptions of the same MI sessions. This study applied a mixed-methods study design (QUAL+QUANT) using both interview questions and quantitative data. Results suggest that school nurses’ MI performances were rated and perceived as valuable and family-centred by both school nurses and parents. Parents had left the meeting feeling motivated and empowered to promote their children’s healthy behaviours. Nonetheless, school nurses were critical of their own MI technical performance. In sum, the health promoting conversations were overall appreciated and perceived as respectful by both parents and school nurses, and school nurses found MI brought a more equal power balance to the health conversation. Some feeding practices differed between parents of children different weight status. Parents of children with normal weight expressed thoughts and sought support from the school nurse regarding five specific areas. Conclusions drawn from this thesis can be used for further developing school nurses’ health promoting conversations aimed at parenting practices fostering healthy child behaviours. Future studies should focus on further development of MI techniques to be used in health promotion and of methods for evaluating MI competence in the context of universal health promotion.