key: cord-1020694-he8foidz authors: Clarke, J. L.; Kipping, R.; Chambers, S.; Willis, K.; Taylor, H.; Brophy, R.; Hannam, K. J.; Simpson, S.; Langford, B. title: Impact of COVID-19 restrictions on pre-school children's eating, activity and sleep behaviours: a qualitative study date: 2020-12-03 journal: nan DOI: 10.1101/2020.12.01.20241612 sha: 74a1dd0c2d5873c77fa6a4f210e95b6c6288cebf doc_id: 1020694 cord_uid: he8foidz Background In spring 2020, the COVID-19 lockdown placed unprecedented restrictions on the behaviour and movements of the UK population. Citizens were ordered to 'stay at home', only allowed to leave their houses to buy essential supplies, attend medical appointments or exercise once a day. This qualitative study explored how 'lockdown' and its subsequent easing changed young children's everyday activities, eating and sleep habits to gain insight into the impact for health and wellbeing. Methods In summer 2020 we interviewed 20 parents of children due to start school in September 2020 (aged 3-5 years) by phone or video call to explore their experiences of lockdown and its easing. We recruited participants through nurseries and local Facebook community groups in the South West and West Midlands of England. Half the sample were from Black, Asian or Minority Ethnic backgrounds and half lived in the most deprived quintile. We analysed interviews using thematic analysis. Results Children's activity, screen time, eating, and sleep routines had some level of disruption. Parents reported children ate more snacks during lockdown, but also spent more time preparing meals and eating as a family. Most parents reported a reduction in their children's physical activity and an increase in screen time, which some linked to difficulties in getting their child to sleep. Parents sometimes expressed guilt about changes in activity, screen time and snacking over lockdown. Most felt these changes would be temporary with no lasting impact, though others worried about re-establishing healthy routines. Conclusions The spring COVID-19 lockdown negatively impacted on pre-school children's eating, activity and sleep routines. While some positive changes were reported, there were wide-spread reports of lack of routines, habits and boundaries which, at least in the short-term, were likely to have been detrimental for child health and development. Guidance and support for families during times of COVID-19 restrictions could be valuable to help them maintain healthy activity, eating, screen-time and sleeping routines to protect child health and ensure unhealthy habits are not adopted. Several rapid surveys have sought to capture the impact of COVID-19 on children and young 26 people's health and well-being. Most have focused on emotional and mental health and have often 27 targeted older children and young people, nationally and internationally [10] . Less research attention has 28 focused on younger (pre-school) children or explored the impact on health behaviours such as physical 29 activity, sedentary behaviour and dietary intake. An exception is the Co-SPYCE study [11] which surveyed 30 caregivers of 2-4 year olds. It found 26% of children had three or more hours of screen time a day, and only 31 22% were meeting the target of 180 minutes physical activity a day. Public Health Scotland developed the 32 COVID-19 Early Years Resilience and Impact Survey (CEYRIS) [12] to understand the impact on 2-7 year olds 33 in Scotland. From 11, 228 participants, eating behaviour was identified as worse by 32% of parents. There 34 were mixed responses in the CEYRIS about physical activity, with 24% of parents reporting children doing 35 more during lockdown and almost half (47%) reported less. 36 This study explored the impact of lockdown, and its easing, on pre-school (3-5 years) children 37 through qualitative interviews with parents focusing on: physical activity, sedentary behaviour, food intake 38 and sleep. Establishing healthy behaviours in the early years is important in maintaining a healthy weight 39 throughout childhood and beyond [13] . Nearly one in four UK children starting primary school are 40 overweight or obese, with rates increasing with deprivation [14] . Many children saw time in childcare 41 reduced or stop altogether [15] . Pre-school aged children require greater parental supervision than older Parents were recruited via two methods. First, we asked nurseries participating in another research 51 study [17] to disseminate study information to parents via email or social media. This included nurseries 52 from Swindon and Somerset (South West England) and Sandwell (West Midlands). Second, we posted 53 study information on local Facebook groups within these areas and Birmingham (West Midlands) to 54 increase recruitment of Black, Asian and Minority Ethnic (BAME) participants. Interested parents (n=85) 55 completed an online form to check eligibility and collect postcode (for calculation of Index of Multiple 56 Deprivation (IMD) score) and ethnicity data for sampling purposes. To provide socioeconomic and ethnic 57 diversity in the sample, sampling was weighted towards parents in the most deprived areas and those from 58 BAME populations. Twelve parents were recruited via nurseries and eight via Facebook. 59 Sampled parents were emailed the participant information sheet (PIS) and consent form. A 60 convenient time to conduct the interview was arranged with participants at least 24 hours after sending 61 study documents. All sampled parents agreed to participate, bar one who we were subsequently t unable 62 to contact. 63 Data collection 64 Semi-structured interviews were conducted by experienced qualitative researchers (JC, KW or SC) researchers to generate an initial list of codes. Codes were both deductive (generated from our topic guide 76 and research questions) and inductive (generated from interview data). Differences in coding were 77 resolved through discussion to produce an agreed coding framework. Subsequent transcripts were single-78 coded using this coding framework with further discussion to clarify or expand the framework as needed. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted December 3, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 In response, some parents created make-shift rules around food, balancing child demands with 101 wanting to provide 'healthy' snacks. Mother_4's children were allowed crisps because they went "on and 102 on at me" but then were told "to move on to the fruit bowl." Another parent made healthy snacks more 103 accessible: "I make sure there are bits and bobs cut up in the fridge. Because I know if she's going to help 104 herself to something, it's the stuff on the bottom she can reach" (Mother_5). However, some parents 105 reported giving additional 'treats' to their children to compensate for the pandemic's impact: "We were 106 feeling bad they'd missed out on so much, we were buying treats and things for them to make them feel Lockdown had other impacts on families' food behaviours. With restaurants shut, people no longer 118 ate out. Some participants also reported consuming less take-aways. For one, this was related to concerns 119 about the virus -"I didn't touch any takeaways. I did not feel comfortable to do so." (Mother_4). In 120 contrast, one parent reported eating more take-aways because "we all need something to look forward to" 121 (Mother_7). 122 Food costs 123 Several participants reported spending more on food during lockdown. Some related this to the 124 whole family now being at home, as well as increased snacking, while others felt prices increased. 125 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted December 3, 2020. ; https://doi.org/10.1101/2020.12.01.20241612 doi: medRxiv preprint their child's nursery: "It's a lot more expensive now obviously, because she was having meals [at pre-127 school]… We haven't had any kind of help from school with regard to her dinner" (Mother_8). Another 128 participant who was shielding had moved to on-line deliveries, a service unavailable at their normal 129 cheaper supermarkets: "We'd normally just go to Aldi or Lidl and be able to buy it, whereas now we've 130 been trying to do the online stuff, it's just added to our bill" (Mother_9). However, an unexpected benefit 131 of this was healthier snacking: "it's a money thing, we've not been able to buy all the junk food …The stuff 132 he can see is the fruit bowl, so that's probably improved a bit" (Mother_9). Concerns over screen time were rarely linked to lack of movement or activity. Rather Father_3 referred to "the effect of the brain becoming lazy" which he admitted was "something that is worrying perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted December 3, 2020. Generally, parents thought children's increase in snacking during lockdown was "just a temporary 211 thing" (Mother_2) and would not last once children were back at nursery or school. As Mother_5 212 acknowledged: "when she goes to school she's not going to have that opportunity to (a) steal food or (b) 213 she won't be home to be eating masses during the day". However, one parent whose child had already 214 returned to nursery acknowledged getting back into a routine was difficult: "Trying to get him to eat 215 properly once we started to go back into a routine was really hard (Mother_10). 216 Several parents wished to sustain positive changes established during lockdown, such as home-217 cooked meals and involving children in food preparation. However, as one mother noted, these changes 218 required time and would need a "conscious effort to keep doing" (Mother_14). Many talked positively 219 about returning to previous activities (e.g. swimming, gymnastics) and were pleased to see these opening 220 again. However, several admitted feeling "wary" (Father_4) about how safe these were, especially those 221 involving close contact (such as soft play). 222 Some parents expressed concerns about the impact of lockdown on their child's skills and study, with the absence of childcare, and corresponding increase in parental juggling of work and 250 household chores, it is clear how this 'need' for downtime increased for many parents. . Zecevic et al [22] showed that, in circumstances not associated with 259 lockdown, young children who receive greater parental support for physical activity were 6.3 times more 260 likely to be highly active than inactive (B = 1.44, P<.05). In our study some parents made considerable 261 efforts to keep their child physically active and thus minimise the impact of the restrictions. Many parents 262 took advantage of the permission to leave the house for exercise to keep their child active. Yet despite 263 these efforts, barriers specific to the lockdown were reported to reduce children's physical activity, mainly 264 relating to childcare and other facilities (such as playgrounds) being shut, as well as reduced contact with 265 friends and family. 266 Our study identified disruptions to normal eating habits and routines, which varied by child and family. 267 in families where free school meals were no longer available and where the pandemic impacted family 274 finances [25] . 275 Rundle et al (2020) suggested the closure of schools during this period may exacerbate childhood 276 obesity levels and increase disparities in risk of obesity for school-aged children [26] . While few parents 277 mentioned concerns about weight gain, our findings suggest there is potential for obesity prevalence in The negative impacts of COVID-19 for children living in poverty are expected to be the greatest 285 [28, 29] Our interviews sought to explore potential differences in the impact of lockdown across the 286 socioeconomic spectrum. Half our participants lived in the most deprived IMD quintile, giving insight into 287 the impact on families living in the areas of highest deprivation. We noted some differences within our 288 sample. For example, the two families without access to gardens reflected on the difficult in keeping 289 children active. In addition, families where parents were not working found it easier to engage children in 290 physical activity than where parents were working. Beyond this, however, we did not note any obvious 291 differences in narratives between those living in more or less deprived neighbourhoods. Overall, the 292 impact of lockdown on children's eating, physical activity and sedentary behaviours was felt similarly 293 across the socioeconomic spectrum. The lack of difference could be due to characteristics of the sample; 294 most families still had at least one parent in paid work and most had access to a garden. Interviews took 295 place early in the COVID-19 crisis, so we may not yet be seeing the full effect, for example with the 296 protective effect of the furlough scheme still in place. 297 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted December 3, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 This study raises the question of how parents can be supported during future lockdowns or local 298 restrictions. The most recent periods of national lockdown in England and Wales, during the autumn of 299 2020, have not been as restrictive, with childcare, schools and some workplaces open. However, there are 300 new and additional challenges: shorter, colder days, weariness of the restrictions, and increased financial 301 pressures for some families with unemployment and redundancy rates at the highest seen for three and 12 302 years respectively [30] . In addition, positive cases in a childcare or school setting can result in an entire 303 class (or 'bubble') being required to isolate for 14 days without being allowed out. The importance of 304 supporting families to maintain or increase activity for young children within the home and in accessible 305 outdoor environments becomes more prominent. Families need support to establish healthy revised 306 routines and manageable healthy rules for snacks and screen time during periods of restriction. This needs 307 to be presented in a context of supporting parents and not adding guilt or burden to parents during a 308 period of stress. As highlighted in the recent Ipsos Mori report, which included an online survey of 1,000 309 parents of 0-5s in October 2020, 70% of parents reported feeling judged by others and almost half felt this 310 negatively impacted on their mental health [31] . There is a role here for all sectors of health, social care 311 and education including health visitors, children's centres, early years providers, GPs, social services, local 312 authority public health teams and Public Health England. Further, there is a role for research with pre-313 schoolers and 2020 school starters to be expanded [32] to understand the impact on their physical and 314 social development, and particularly their risk of obesity, as they start school.  What activities has your child been doing during the coronavirus disruption?  During the time since lock-down started in March has your child been going out of your home and garden (if they have one)?  Do you think your child is currently more or less active than before the disruption?  What sitting activities has your child been doing during the coronavirus disruption? (e.g. screen time, educational activities, TV, games, social interaction)  Do you think the changes since March due to coronavirus have affected your child's sleep?  Have there been any changes in what your child has been eating because of the coronavirus disruption?  Have there been any changes to how you get your food?  Have there been any changes to how you prepare your food at home?  Overall, do you think that your child is eating more or less healthily than before the disruption? All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted December 3, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted December 3, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 Public Health England. Health matters: physical activity -prevention and management of long-term conditions New report shows scale of crisis in early years sector Characteristics of and Important Lessons from the Coronavirus Disease COVID-19) Outbreak in China: Summary of a Report of 72314 Cases from the Chinese Center for Disease Control and Prevention 5. Department of Health and Social Care How much sleep do children need? Royal College of Paediatrics and Child Health C& YPE team. COVID-19 -research studies on children and young people's views Co-SPYCE STUDY -1ST UPDATE Public Health Scotland. COVID-19 Early years resilience and impact survey Do Obese Children Become Obese Adults? A Review of the Literature Department for Education U. Coronavirus (COVID-19) attendance in educational and early years settings in England -summary of returns to 17 Prime H, Wade M, Browne DT. Risk and resilience in family well-being during the COVID-19 pandemic All rights reserved. No reuse allowed without permission. perpetuity preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted December 3, 2020. ; 17. NAP SACC (UK): Nutrition and physical activity self-assessment for childcare Applied Thematic Analysis Barriers and facilitators to young children's physical activity and sedentary behaviour: a systematic review and synthesis of qualitative literature Physical activity guidelines: UK Chief Medical Officers' report -GOV.UK [Internet Impact of the COVID-19 virus outbreak on movement and play behaviours of Canadian children and youth: A national survey Making health habitual: The psychology of "habit-formation" and general practice How are habits formed: Modelling habit formation in the real world lnstitute for Fiscal Studies: Family time use and home learning during the COVID-19 lockdown No reuse allowed without permission. perpetuity preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in COVID-19-Related School Closings and Risk of Weight Gain Among Children They must not be left behind in its aftermath Pre-publication: Priorities for the child public health response to the COVID-19 pandemic recovery in England Unemployment rate hits highest level in three years State of the Nation: Understanding Public Attitudes to The Early Years We are very grateful to all the parents who took part in the research interviews. The views expressed in this publication are those of the authors and not necessarily any of the funding bodies listed. The study was conceived by JC, RK, SC, KW, HT, RB, KH, SS and RL. JC led the study with oversight from RL and RK. Interviews were conducted by JC, SC and KW. Coding of the data was performed by JC, HT and RB.JC, RK and RL produced the first draft of the manuscript, with all other authors providing critical review and intellectual content. All authors read and approved the final manuscript.