Development of a health promotion action with mothers aiming to support a healthy start in life for children using Participatory Action Research

ABSTRACT

Health inequalities arise already during the first thousand days of a child’s life. Participatory action research (PAR) is a promising approach, addressing adverse contexts that impact health inequalities. This article describes the experience of mothers involved in a PAR process to develop a health promotion action that supports both children’s and mothers’ health. It also describes the experiences of mothers who attended the developed action and trainers who facilitated it. The PAR process resulted in the development of a sustained action called Mama’s World Exercise Club aimed at promoting the health of mothers and their children. Results showed that the PAR process empowered the mothers and gave them a sense of pride at playing a useful role in their community. The developed action was highly valued by other mothers in the neighbourhood and widely implemented. These positive results can be ascribed to the strong collaboration between the researchers and the mothers, and the willingness of local stakeholders to support the action. Future studies should investigate if the results of this study sustain over a longer period of time and improve health outcomes of children and mothers in the long run.

KEYWORDS:

• co-creation
• participatory action research
• empowerment
• first thousand days
• health inequalities
• health promotion action

1. Introduction

The first thousand days of a child’s life are known as a period in which the foundations for healthy growth and development are established (Pearce et al., 2010; Pietrobelli & Agosti, 2017; Woo Baidal et al., 2016; Wopereis et al., 2014). A growing body of evidence shows that early exposure to an adverse environment has wide-ranging and long-lasting negative effects on health, and supports the conclusion that health inequalities arise within the first thousand days of a child’s life (Moore et al., 2017; Pietrobelli & Agosti, 2017; Scholte et al., 2015). The reasons for these health inequalities are multifactorial, reflecting an interaction between various factors such as cultural identity, lifestyle behaviours, and the physical, economic and sociocultural environment (Karakochuk et al., 2017). Several studies in Western countries have shown, for example, that childhood obesity is more prevalent in relatively low-income households in comparison with higher-income households (Brophy et al., 2009; Heppe et al., 2013; Steenkamer et al., 2021; van Rossem et al., 2010). Numerous Dutch studies have also shown that pre-school children with a migration background have a higher risk of developing childhood obesity than children of Dutch origin (de Wilde et al., 2018; Heppe et al., 2013; M. L. A. de Hoog et al., 2011; M. L. de Hoog et al., 2011; Sirkka et al., 2021). Growing up in a family with a lower SEP has also negative effects on emotional, behavioural, educational, and employment outcomes, while also increasing risk for psychiatric disorders, substance use, and criminal behaviour in adulthood (Cerutti et al., 2021; Galama & van Kippersluis, 2018)

Although there is growing recognition of the importance of intervening during the early stages of a child’s life, interventions do not always achieve the anticipated effects (Abma et al., 2019; Marmot, 2013). An important reason for this lack of effectiveness is that the target group is not actively involved in the development and implementation of interventions, which are therefore not sufficiently targeted towards the needs of a particular group. Various studies show that interventions which have been co-created with parents are more likely to align with their needs and wishes, and lead to more acceptable and appropriate interventions (Ganann, 2013; Noergaard et al., 2016; Wagemakers et al., 2010). Participatory Action Research (PAR) has been proven to enhance the interactive and collective participation of individuals in practical improvements that affect their daily lives (Baum, 2016; Cornwall & Jewkes, 1995; Ganann, 2013) and to contribute to feelings of empowerment (Abma et al., 2019). One study that used a PAR approach highlighted the importance of working closely with parents in order to ensure the effectiveness and acceptability of an intervention, and underlined that the parents who participated considered themselves to be a meaningful source of information and were therefore highly engaged in peer-to-peer education (Ball et al., 2021). Engaging parents as co-designers can also raise their awareness of health issues, increasing the likelihood of them making changes in their situation (Gorard & See, 2013; Jurkowski et al., 2013; Kim et al., 2018). For instance, a Danish study aimed at improving a neonatal intensive care unit and making it more father-friendly showed that the collaboration with new fathers and mothers led to credible and constructive local changes in health services (Noergaard et al., 2016).

However, reaching and collaborating with the parents of young children from disadvantaged neighbourhoods is a difficult task, as reflected in the scarcity of papers detailing the use of a participatory approach specifically targeted towards this group (Noergaard et al., 2016; Shen et al., 2017). In addition, despite the growing interest in designing interventions that involve active participation and strong collaboration with parents, explicit guidance on how to actually put such a process into practice is still limited (Martin et al., 2020; Shen et al., 2017; van de Kolk et al., 2019). This study therefore aims to describe: (1) the process of engaging parents in developing a health promotion action that reflects their needs and daily realities during the first thousand days of a child’s life (description of the PAR process) and (2) to acquire insights into how they experienced the process of PAR (evaluation of the PAR process). Additionally, the experiences of mothers who participated in the health promotion action and trainers facilitating the action will also be studied (3; evaluation of the action itself). The results of this study could provide approaches for how to actively engage parents with young children in health research and suggest how a PAR approach could be employed to develop a feasible and sustainable collective action based on parental experience and knowledge.

2. Methods

2.1. Study design

This study is part of the Food4Smiles research project, which aims to promote the healthy growth and development of children during the first thousand days of life (www.food4smiles.nl). The research area for the study is recognized as a relatively low-income and multi-ethnic neighbourhood in Amsterdam, the Netherlands. Dutch, Moroccans and Turks are the largest ethnic groups in the neighbourhood (34.3%, 20.9% and 12.9%, respectively). The neighbourhood is predominantly composed by social housing, which attracts more low-income residents than neighbourhoods with other types of housing (Petrović et al., 2018, 2022). As a result of the increasing spatial concentrations of people with low income in this residential areas, the local government identified the neighbourhood as one of the “focus districts” of Amsterdam, with regard to the prevention of multiple health problems (e.g., childhood obesity, depression) as well as socioeconomic problems (e.g., poverty, low literacy, unemployment) (Municipality of Amsterdam, 2020). The neighbourhood is inhabited by 157.964 people and the population of the neighbourhood includes more families and children than other neighbourhoods in Amsterdam. Of the people in the neighbourhood, 25% are under the age of 17 years, 5% are under the age of 3 years, and 20% of them are growing up in a poor household (an income up to 120% of the Dutch minimum standard and capital below the social welfare limit) (Amsterdam, 2020; Municipality of Amsterdam, 2020; Amsterdam Healthy Weight Programmen, 2017). The neighbourhood is next to economic and housing aspects, also less better-off of in terms of the availability and accessibility to public health services and facilities (Petrović et al., 2022).

Most existing activities and programmes in the neighbourhood, which aim to support the health of young children, are based on top-down approaches, and focus mainly on parents with school-aged children. Therefore, the existing activities do not always fit the daily reality and needs of the parents with younger children (Bektas et al., 2020). Besides, the few activities that are available for very young children, are very crowed and have long waiting lists. Therefore, a PAR approach was used to engage parents and to develop a tailored health promotion action that reflects the parents’ needs (Abma et al., 2019). We adopted core elements of PAR that involved exploring parents’ needs collaboratively, co-producing new knowledge, and describing and designing a concrete action in order to achieve interactive and collective parental participation (Baum, 2016).

2.2. Recruitment and respondents

In line with the participatory nature of the project and the COVID−19 restrictions on group size, we aimed to create a small group consisting of up to 10 participating parents. Between August and September 2020, we invited parents to take part in the action group through social media (Facebook, Instagram), and using flyers and posters which were placed in various healthcare settings, playgroups and community centres. Parents were also approached personally at playgroups by the principal researcher. Parents were considered eligible for participation if they had at least one child in the first thousand days, lived in the neighbourhood selected for the study and had a sufficient command of Dutch. All of the participants who signed up for the action group were mothers and in the rest of this paper we will therefore use the term “mothers” to refer to the participants, and the term “action group” to refer to the co-creation group.

A total of 14 mothers signed up to participate in the first meeting, but 6 of them decided not to participate in the study before the first session took place. The reasons for their withdrawal were difficulty in planning (n = 3), worries about COVID−19 infection (n = 2) and a lack of motivation (n = 1). This left 8 mothers who agreed to take part in the action group, all of whom attended the first two online sessions. Two mothers ended their participation after the second session. Four mothers participated in all 8 group sessions, while two mothers attended 6 and 7 sessions, respectively. See Appendix A for an overview of the study flow chart for recruitment.

The mean age of the mothers was 30.5 years old, with a range of 25–42 years. The mothers came from a range of ethnic backgrounds, including Moroccan, Turkish, Dutch and Iraqi, but all of them were born and raised in the Netherlands. Four mothers had a high educational level and four mothers were middle educated. Two were first-time mothers, while six already had several children. Three of the mothers had school-aged children. One mother was also pregnant during the study.

2.3. Online PAR process

Overall, 8 online group sessions of between 60–90 minutes each were organized and facilitated over a five-month period (December 2020 – April 2021). All of the sessions were due to take place in person, but as a result of the COVID−19 restrictions announced two days before the first session, we decided to switch from face-to-face meetings to online sessions. The video-conferencing programme Zoom was used to organize the online group sessions. The sessions were recorded and transcribed verbatim with the consent of the mothers. To better coordinate the arrangements with the mothers, the sessions were facilitated by the principal researcher (GB), who lived in the neighbourhood and was familiar with the target group. She was assisted by a researcher (FB) with experience of conducting PAR. In consultation with the mothers, we decided to make an appointment once every two weeks on Monday mornings during school hours, to allow greater flexibility for mothers with school-aged children. We also decided to restrict the meetings to an hour if possible and 90 minutes at most; the mothers indicated that meetings of more than 90 minutes were not compatible with caring for a young child.

Based on an outline, the online sessions were guided by the wish to generate: 1) detailed knowledge of mothers’ experiences and needs regarding a healthy growth and development of their child in the first thousand days; 2) new inspiration and action ideas for the healthy growth and development of children in the first thousand days. The researchers were not engaged as co-participants in order to exclude their own thoughts, beliefs and values, and to ensure that they did not hierarchy their knowledge ahead of the experience and knowledge of the mothers (Boxall & Beresford, 2013; Rose, 2009). The researchers only facilitated a learning platform for the mothers and had therefore no influence on the knowledge production, which could have supported active participation and shared learning, since mothers were not overwhelmed by the knowledge and views of an academician (Beresford et al., 2013; Rose, 2009). While the PAR process had a defined start and end, it did not progress in a linear fashion. We followed an iterative process, which is characterized by its multiple cycles of diagnosis, action, measurement, and reflection. See Figure 1 for the followed PAR process. Additionally, an overview of the content and activities of the 8 sessions is given in Table I.

Figure 1. Iterative and reflexive process of the PAR with mothers.

Table I. Description of the content and activities of the 8 sessions.

Session	Aim of the session	Content and activities
1 and 2	Sharing experiences, exploring and prioritising themes	The mothers were introduced to each other and were given the opportunity to share their experiences with relation to the healthy development, growth and lifestyle of children during the first thousand days. Experiences were elicited using the question: ‘What associations do you have when you think about healthy growth during the first thousand days, taking this neighbourhood into account?’ First, each of the mothers wrote down words or factors that they associated with healthy growth in the first thousand days in order to instigate a discussion. These individual associations were then discussed in the group and the mothers shared their experiences. The mothers were asked to rank the factors in order of importance and then vote for one of the factors. The two with the most votes were then selected as the basis for development.
3 and 4	Generating ideas for action	The mothers were asked to think about actions regarding the two factors using the question: ‘Imagine that you are the major of Amsterdam, which action would you undertake to improve the problem?’ Ideas for actions were explored in two groups during break-out sessions. The researchers were not present during these sessions to give the mothers a greater sense of freedom and control. Each break-out group presented their ideas for potential actions and these were then discussed in a plenary session.
5 and 6	Conceptualising the action	The mothers reflected on all the ideas for potential actions and were asked to prioritise them and choose one to develop in greater detail. They were challenged to conceptualise the action and come up with a concrete action plan containing details of the action and agreements on how to put it into action. Collectively, they explored what was needed to set up the action, as well as defining its target group, frequency and the format of it.
7 and 8	Co-creation and discussing practical issues	The mothers discussed practical issues relating to the action such as resources, possible recruitment strategies and how to facilitate the action. We also discussed the various ways in which the mothers wanted to be involved in the action, their roles in making it happen and their contributions as regards recruitment.

2.4. Evaluation

Subsequent to the PAR process, interviews were held with the mothers who participated in the PAR process (n = 6) to gain insights into their experiences of the PAR process (see also Appendix A). The two mothers who only took part in the first two sessions and decided to stop participating were not interviewed. The interviews with the mothers took between 30 and 45 minutes. An interview guide was used, encompassing their expectations of the action group, experiences of the group sessions, the mothers’ thoughts and feelings about their personal contribution during the PAR process and the action. See Appendix B for an overview of the interview topics.

In order to evaluate the action itself, 13 mothers who regularly attended the action were approached for an interview and 9 agreed to participate. These mothers were not involved in the PAR process itself. The two trainers who facilitated the action were also interviewed in order to obtain a richer and more detailed understanding of how the action was perceived by the mothers. The interviews lasted between 35 and 90 minutes. See Appendix C for an overview of the topics. Due to the impact of the COVID−19 pandemic, all interviews were conducted by telephone. In addition to the interviews, participatory observations took place over 7 two-hour sessions. After each observation, field notes on the observations were made which included the activities of mothers, and interactions and conversations with and/or between mothers and trainers.

2.5. Consent and ethical considerations

All participants were informed about the aim of the study, either verbally and/or through an information letter. The participants signed an informed consent statement agreeing to be recorded and were informed that their data would be processed anonymously (i.e., any identifying characteristics from their individual data would be removed). The Medical Ethical Committee of Amsterdam UMC (VUmc location) decided that the study was not subject to the Medical Research (Human Subjects) Act and approval was waived on this basis (approval number IRB00002991).

2.6. Data analysis

The summarizes of the interviews were sent to all the mothers of the action group in order to check if they recognized their expressions and experiences. The mothers were also given the option to be involved in the analysis of the data. One mother inclined to help the researcher with the data analysis. This mother was also actively involved in the needs assessment phase of this project (Bektas et al., 2020, 2021). Other mothers were not willing to be engaged, because this step was too time consuming.

All the transcripts of the PAR sessions and interviews were coded and analysed by the principal researcher (GB). Value coding was used to analyse and code the values, attitudes, feelings, experiences, reactions and beliefs that represent the experiences and perspectives of the mothers (Patton, 2002). Thematic content analysis was used to analyse the interviews, with the aim of being as open as possible to the experiences and perspectives of the mothers (Clarke & Braun, 2016; Patton, 2002). First, the data was read and marked to identify recurring themes and then coded into categories. The codes were checked by a mother from the action group, who was also regularly consulted about whether mothers’ expressions had been interpreted correctly. After the axial coding process, the categories were abstracted into themes that reflected the variety of experiences of the mothers involved in the PAR group and the action.

3. Results

Since the aim of this study was twofold, we will begin by outlining the PAR process of the development of the health promotion action (3.1). This will be followed by an evaluation of the action itself, based on the experiences of the mothers and the two trainers who participated in the action. (3.2).

3.1. Perceived factors that influence the healthy growth and development of children

The mothers mentioned several factors specific to their neighbourhood which affect the healthy growth and development of their children. They underlined the importance of breastfeeding, healthy food intake and the social wellbeing of the children as important aspects of healthy growth and development. The mothers also highlighted the priority of good motor skills for their child, as this improves muscle development and helps the children engage in physical activity, which in turn makes them healthier. They also stressed the negative effect on their children’s health of screen time and child-oriented marketing of unhealthy foods. The mothers also highlighted their own physical, mental and social wellbeing as an important factor in the healthy growth and development of their child. For themselves, they acknowledged the importance of healthy eating and physical activity but above all they underlined the importance of feeling less stressed and being able to relax mentally. They explained that the stress, insecurity and feelings of depression they sometimes experienced had an influence on their children. As one mother explained, It’s also about the mental health of the mother … having a child can be quite tough, with things like sleepless nights, insecurity, and there is a lot of information, also corrupted information. Everyone has an opinion, there might be tension in the family or you feel alone, or a bit down. Any number of things can overwhelm you as a mother, and if you’re not feeling well or a bit vulnerable or maybe lonely… that also affects the wellbeing of your child. – (M1-AG).

Two themes were chosen as most important for promoting the healthy growth and development of children during the first thousand days: the physical and mental health of mothers (4 votes) and the physical activity of children (4 votes).

3.1.1. The physical and mental health of mothers

The mothers recognized that a healthy mother results in healthier children and they expressed their support for an action that can improve a mother’s physical and mental health, especially during the first few months after childbirth. The mothers recognized that many women are vulnerable after giving birth because their life changes significantly, as does their body and their hormone levels. They noticed that, especially in the first three to six months after childbirth, most mothers are homebound, which can lead to feelings of loneliness or social isolation. In the words of one mother: I think that less attention is paid to the health of the mother. After giving birth many mothers find themselves at a low point. They have just had a baby, their lives have been turned upside down. And there’s not much you can do with a three-month-old baby. So the mother is homebound for three or six months. She can’t do much, many mothers isolate themselves in that period. – (M1-AG).

Some mothers underlined the positive aspect of physical activity on mental wellbeing and pointed out that mothers need activities or places where they can not only be physically active after giving birth but can also meet other mothers who are in the same circumstances. However, there are few existing options for mothers with very young children to participate in these kind of activities. As one mother said, It’s also important that the mother has a chance to get out of the house. Being physically active is also good for your mental health, but you have less motivation to go for a walk outside, especially when it’s raining. And you can’t go to the gym because you can’t bring your child with you. It’s impossible to arrange a babysitter every time you want to go out somewhere. – (M4-AG).

3.1.2. Physical activity of children

The mothers indicated that being healthy starts in the neighbourhood, which means that children should be able to play outside, but they experienced their neighbourhood as unsafe due to loitering by young adults and heavy traffic. As a result, they generally regarded physical activity among children of this generation as low. The mothers also explained that their current housing situation gives children less space to move freely. One mother said, It would probably have a positive effect on the child’s and the mother’s health if there were opportunities for physical activity and socialising. The children spend a lot of time at home, and we live in small houses. So you want to do something outside, but sometimes it can feel unsafe because of all the young people hanging around. – (M6-AG).

The mothers also noted that there are very few suitable playgrounds in their neighbourhood. They found that the playground equipment is mainly designed for older children and less inviting for families with babies or toddlers. They indicated that if playgrounds were equipped with more apparatus for younger children, it would make them more inclusive for children of different ages: Look at the playgrounds! Is there anything designed for babies or toddlers? All the equipment is for children from the age of 5 or 6. You have one or two places with a baby swing and that’s all. And they are spread throughout the district, so you can’t get there on foot. – (M3-AG).

They were also in favour of having indoor or outdoor activities for very young children with an extra focus on physical activity. They thought that this would stimulate the motor skills and development of the children, resulting in higher levels of physical activity at an early age. In the words of one mother: “I think there are very few activities for toddlers. The playgroups focus more on singing or painting … it would be helpful if they focused more on physical activity. Because toddler gym classes are very expensive.” – (M7-AG).

3.1.3. The mothers′ ideas for health promotion actions

The mothers came up with several ideas for actions to reduce mental stress among mothers and encourage physical activity among both mothers and children. These included:

• Social activities to encourage mothers to get out of the house, meet other mums in similar circumstances and increase togetherness. These might take the form of sports activities or an informal “coffee group”, where they could do some exercise, relax and socialize. The mothers noted that the social activity should have adequate facilities, such as a private place for breastfeeding or a babysitter to provide added support and comfort for the mothers.

• A local online platform to provide information about healthy growth and development in the first thousand days of a child’s life (e.g., nutrition, common baby ailments). They suggested that this should be an interactive platform where parents can find reliable information and educate themselves, but can also exchange tips with other parents. In addition, mothers noted that many parents did not make use of existing baby activities in the neighbourhood as they were unaware of their existence. They believed it would be helpful for parents to have an overview of all activities in the neighbourhood and suggested that this online platform should also provide information on local activities aimed at young children.

• Regular free or low-cost indoor physical activities for babies or toddlers in the neighbourhood, differentiated by age: for example, baby gym for crawling babies and toddler gym for children who are able to walk and run around;

• An attractive walking path for babies or toddlers at a public outdoor playground which challenges their sensory and motor skills. The mothers favoured a baby-friendly playground, as this would meet multiple needs. A safe and attractive public playground for babies and toddlers would support the physical activity of both babies and mothers, increase opportunities to socialize with peers and be accessible to everyone.

3.1.4. Conceptualising the action: Mama’s World Exercise Club

As they set about prioritizing their ideas, the mothers concluded that building a baby-friendly playground would be a long-term process that was also beyond their power. They also indicated that, although there was a genuine need for an online platform, it would not give the mothers the opportunity for socializing or mental relaxation. At the end of the prioritization process, the mothers redefined their priorities and combined two ideas to come up with an exercise club for mothers and their babies/toddlers under the supervision of trainers who also supported social interaction between mothers.

The aim of the exercise club was threefold. While mothers wanted to work on their own physical activity and health (1), they also wanted to improve the physical activity and health of their child (2). And additionally, they wanted to create a place where they could meet other mothers as an incentive to get out of the house after childbirth and a way to access social support and a local network (3): “It should be a place where they can meet, socialise and exercise without any worries. They should be able to bring the baby to the club and maybe do some integrated exercises with the baby, like baby-wearing exercises.” – (M1-AG). The mothers also indicated that the exercise club should provide childcare for mothers who also have older pre-school children, so that they could leave them with a childcare professional and enjoy exercising and socializing in a carefree setting, secure in the knowledge that their child is being well looked after.

Once the mothers had arrived at the concept for the action, they brainstormed about the practical details of the exercise club, such as the name, the target group and how frequently it should be held. They came up with the name “Mama’s World Exercise Club” and decided that it would be a weekly activity. The target group for the action was defined as mothers with children aged between 0 and 12 months, since they thought that this was a crucial period during which women found themselves spending the most time alone at home: “When a baby starts moving around it’s easier for women to take them out or go to a playground. In particular, it’s the period before children can walk when women are inactive and housebound.” – (M2-AG). In agreement with the researchers, the mothers decided that the exercise club sessions should last for 60 minutes with a margin of 40 minutes for exercise and 20 minutes for socializing.

In addition, the researchers consulted their network of stakeholders to find suitable locations. Following this orientation phase, the mothers worked with the researchers to evaluate the options for locations and jointly decided to approach a women’s centre with a strong focus on emancipation and attracting women from diverse cultural backgrounds. The centre already had a gym and childcare facilities, making it a suitable location for an exercise club. The mothers wanted the researchers to approach the centre and take care of the necessary communication and organizational tasks, as this would be too demanding and time-consuming for mothers looking after a young child. The team at the women’s centre was enthusiastic about the idea and agreed to become a partner, as the action was in line with their ideal of women’s emancipation. They offered the location and their childcare service for free and their staff became involved in promoting the action in order to recruit mothers. The researchers kept the mothers informed about the progress and developments at all the stages and asked whether they had feedback or other input. Together with the researchers, the mothers were also actively involved in selecting the trainers who would be engaged to facilitate the exercise club. Finally, the mothers in the action group provided input for the text and the layout of the flyer, which the researchers designed to promote the action and recruit mothers. And the mothers promoted the action on their own social media accounts and actively recruited participants for the action.

3.1.5. Mothers’ experiences and reflection on the PAR process

The mothers’ reasons for participating in the action group in the first place was to have a positive impact on the health of young children in their neighbourhood, since they felt that local children were growing up in an unhealthy and disenabling environment. The mothers also mentioned that they wanted to be of value to other mothers in their community by addressing their problems or giving voice to their needs and wishes: I wanted to do something meaningful for the children, and especially for the mothers here. I can see that there isn’t much in the way of activities for them. That’s something I experience myself. And so I wanted to do something about it and thought this would be a good action to participate in. – (M3-AG). One of the mothers explained that she participated in the action group because she had heard about previous activities by this research project and believed that this action would lead to a concrete and sustainable activity in the neighbourhood.

All of the mothers were positive about the collaboration process, although some said that it was a drawn out process that took up a lot of their time. The mothers also reported a good team spirit within the group, even though the sessions took place online. They explained that they found it very useful and informative to conceptualize an action through dialogue and sharing experiences in a small group of mothers with the supervision and guidance of facilitators: “It was very interesting and educational to realise that you can get something concrete out of just talking and sharing experiences with each other, something that’s possible and actually achievable in real life!” – (M4-AG). All of the mothers indicated that they were given enough opportunity to contribute their own experiences and ideas, and felt that they had control over the process. As time went on, the mothers felt themselves becoming more responsible for the process and the action, which made them feel more confident and empowered them to make a success of things. As one mother said, “At first it was vague and felt like a dream, but after a while I had more faith that it would be a real project. You gave us the space and the freedom we needed. We even had the chance to vote and choose the theme that was important for us. You actually listened to us and guided us where needed. As a result, I really feel like it’s my action!” – (M1-AG).

In addition, the mothers said that they were very proud of the result and thought that there was a real need for an action like this in their neighbourhood. They also believed that other mothers in the neighbourhood would appreciate the action they had developed and make use of it: I think mothers will think that it’s a really good action, because everyone who has given birth knows that on the day you give birth your life stops. Your child comes first. And then it’s nice to have a place where as a mother you are the centre of attention as well. So I think this is needed and they will appreciate it. – (M3-AG).

Some mothers said it was also valuable for them personally, since the action meets their own needs: “I am glad that the theme of mothers” health was chosen over children’s health. The child’s health is also important of course, but there are already activities for that in the neighbourhood. And I believe that if a mother is healthy, then this will influence her child’s health. And it’s also great that I have the chance to participate in the action myself. That’s really wonderful.’ (M1-AG). Although all of the mothers felt a sense of ownership for the idea and the action, some were more eager than others to promote it and recruit mothers from the neighbourhood by telling them that it was their idea: “I tell everyone I know and share it on social media. I tell them that I’ve been involved in setting it up. And some mothers I recommend it to have thanked me for making this happen for them. That’s when I know we have achieved our goal and I am proud to have contributed to it.” – (M5-AG).

3.2. Evaluation of the Mama’s world exercise club

The reports by facilitators and the vast majority of participating mothers were generally positive about the exercise club. This section provides an account of the views of the trainers and the experiences of the mothers who participated in the action.

3.2.1. Views of the trainers at Mama’s world exercise club

According to the trainers who facilitate the exercise club, the action attracts mothers from diverse age groups and sociocultural backgrounds, as well as a mix of first-time mothers and mothers with two or more children. They said that the diversity in the group might be explained by the fact that the mothers recruited the participants through their personal network, but also by the fact that the activities are offered free of charge. They also mentioned the location as a factor in encouraging group diversity and reaching more vulnerable mothers: We think that the location facilitates group diversity. It’s a place that already organises activities for women, such as sewing or language courses. That makes it a soft-entry activity. So we have mothers who migrated to the Netherlands recently and who come from different sociocultural backgrounds and education levels. We have also noticed that we are attracting more vulnerable mothers. By “vulnerable” we mean mothers who don’t have a social network and who struggle to find their way in the complex healthcare system.

The trainers found that the diversity of the group had both positive and negative effects on the activities. They noted that the diverse cultural backgrounds inspired mothers to learn from each other’s experiences, knowledge, traditions and cultures: “It’s beautiful to see them learning from each other. We have one mother who showed us how to relax a baby using massage. It’s was common in her culture and it’s something we all benefited from.” But the trainers also recognized that language could impede the social aspects of the action and believed it would be helpful to have a separate group for mothers who have only recently arrived in the Netherlands and have yet to master the language.

3.2.2. Mothers’ experiences of Mama’s world exercise club

The main reasons given by mothers for attending the exercise club were to improve their physical fitness, get in shape and meet other mothers. The chance to exercise together with their baby/toddler and being able to leave their older children with childcare staff was highly valued by the mothers: If it wasn’t for the option of leaving my older daughter at the childcare facility, I wouldn’t be able to come. That’s a real luxury and it shows that the club has been set up by mothers: only mothers take things like that into account. I like also the idea of doing an activity together with your child, because it shows that having children doesn’t mean you can’t do anything anymore. – (M1-MW). Many mothers said that after participating in the club, they exercised more regularly as part of their everyday lives and even did exercises in public places: “I do certain chair-based pelvic floor exercises from our training when I’m travelling on public transport. They are very easy to do yet I still have the feeling that I’m exercising.” – (M3-MW).

The mothers also appreciated the format of the exercise club, with its mix of physical activity and conversation: The combination of physical activity interspersed with small talks on a range of topics is really good. Because after childbirth your fitness isn’t great and the conversations are ideal for catching your breath. We learn also how to exercise properly and safely, and not to put a strain on our bodies. – (M5-MW). Some mothers said also that they found the conversations very useful, because discussing the struggles associated with motherhood, childcare, relationships or wellbeing as a mother helped reassure them and gave them a sense of feeling supported by their peers: “We discuss a whole range of things, such as complaints after childbirth and we focus on caring for ourselves as mothers. But we talk also about taboo topics like incontinence or changes in the husband-wife relationship, and it helps to hear that everyone is facing similar problems. I felt ashamed to discuss this kind of thing openly with others, but now I know I’m not the only one. I also learnt to train my bladder, so I experience less urine leakage, and now I feel stronger and more confident.” – (M9-MW).

The mothers were also positive about the cultural diversity of the group and the mix of first-time and experienced mothers, as these things enabled them to learn from each other’s experiences or traditions: There are mothers with 2–3 children and I learn a lot from their experiences. And it helps me to learn about the system and traditions here, because I came to the Netherlands when I was older and still don’t know everything. – (M4-MW).

4. Discussion

The aim of this study was to describe the PAR process of a health promotion action designed to stimulate the healthy growth and development of children in the first thousand days. The main findings showed that the mothers’ primary focus when thinking about a health promotion action was on their own wellbeing rather than an action only targeting their child’s health. Mothers underlined the importance of their own mental health and wellbeing during the first thousand days of their child’s life as being closely related to the health of their child. They stressed how essential it was to have social interaction and to be physically active during this period. The PAR process resulted in the development of the Mama’s World Exercise Club, an action designed to promote physical, social and mental health of mothers and their children. The mothers indicated that the PAR process helped give them a sense of pride at serving a useful purpose for their community and peers. We observed a growing sense of empowerment among the mothers as they felt themselves becoming more confident and responsible for the action, which strengthened their sense of ownership. The action was welcomed and highly valued by other mothers in the neighbourhood, who have participated in the action, and reflected the realities of their everyday lives. It met their needs, provided practical information on improving physical fitness and health after childbirth and gave them the feeling that they were not alone.

The principal aim of this study was to develop an action “with” mothers instead of “for” them. The issues they perceived as seriously impacting the healthy growth and development of their children were many and varied, including marketing strategies for unhealthy foods as well as social or environmental issues (e.g., housing, safety and infrastructure). Although our aim was to develop a health promotion action to address their children’s health, the mothers identified their own health as the main priority. They believed that if they were mentally and physically healthy, their child would also be healthy. Similar results were recently found in another Dutch study, which found that parental priorities for improving family health were reducing chronic stress for parents and being able to “relax mentally” (Wink et al., 2021). Indeed, evidence show that poor maternal physical and mental well-being—during pregnancy or up to 15 months from childbirth—are interrelated to both child’s physical and mental health measured by general health, presence of chronic health conditions (Ahmad et al., 2021). Recent studies suggest that initiatives aiming to improve maternal physical and mental health would not only improve child health, but also the resilience and well-being, and will minimize the development of or the intergenerational transmission of adverse health (Ahmad et al., 2021; Parsons et al., 2021).

The mothers in our study perceived physical activity as being good for their health, but also as a way to relax, spend time outdoors and foster social relations. This is in line with another study, in which the participants ranked social relations as the most important element for health and identified physical activity as a way of improving their health and socializing with other people (de Jong et al., 2020). By focusing on the mother’s needs they emphasized existing, compelling issues in their daily lives and the reality of the world around them, and this probably enhanced their engagement and commitment. Another possible explanation for the commitment in our study is the pre-existing relationship between the researchers and the mothers, as almost all of them were already familiar with the broader research project thanks to its earlier activities in the neighbourhood (Bektas et al., 2021). The majority of the mothers were therefore willing to work in close collaboration in the belief that their ideas for the action would actually be executed. This explanation is also supported in the literature, where building a relationship of trust is essential in engaging people and forming sustainable partnerships (Abma et al., 2019; Research ICfPH: Position Paper 5: Empowerment and Participatory Health Researchn, 2021).

The core principle of PAR is to maximize participation by those whose lives are the subject of or affected by the intervention. The ladder of participation is a well-known paradigm to describe gradations of participation, with informing as the lowest level of participation and citizen control as the highest and ideal level of participation (Arnstein, 1969). The highest level of participation includes involving participants in all stages of the process, with the strongest possible emphasis on participants setting their own agenda and carrying out actions with limited support from “outside facilitators”. Reflecting on our process, participation encompassed the mothers sharing their experiences and perspectives in order to create new understanding and plans for action, but they needed help from group facilitators to conceptualize and execute their idea. Although we encouraged the mothers to play a more active role in the communication and partnership with local organizations, they were reluctant to get involved in these areas due to lack of time. This is not surprising in light of the fact that the first years of motherhood are known to be a challenging and overwhelming phase in which mothers have very little time for themselves (Noergaard et al., 2016; Nyström & Ohrling, 2004). Previous studies using PAR already highlighted the need for a certain flexibility in the timing and frequency of sessions, and the provision of childcare (Shen et al., 2017). There is also a growing recognition that it is not always possible to achieve the desired levels of participation in a PAR process (Research ICfPH, 2013, 2020), and that researchers should acknowledge and respect various levels and types of participant involvement and be aware that participants may not be comfortable with, or wish to be involved in all levels of dissemination (Chevalier & Buckles, 2019; Israel et al., 2010).

Shared ownership is another core principle of PAR (Abma et al., 2019) and is of paramount importance in empowering communities (Research ICfPH: Position Paper 5: Empowerment and Participatory Health Researchn, 2021). We observed that the PAR process helped the mothers to become more confident and feel empowered to take action in their own neighbourhood and community, as also shown in previous studies (Groot & Abma, 2020; Jurkowski et al., 2013; Kim et al., 2018). As the process progressed, the mothers felt more and more responsible for the process and the action, and this increasing sense of ownership also made them feel proud. This feeling was shared by other mothers from the community, who participated in the action, as evidenced by their feedback that only mothers would think of providing childcare for older children. The exercise club has since been scaled up and is currently running at three different locations in Amsterdam. Social welfare organizations have adopted the activity and they secured the human and financial resources needed to run the programme by offering their locations for free and involving their staff and volunteers. They meet also the costs for the trainers and childcare. These welfare organizations are paid by the local municipality. It is known that involving local stakeholders and organizations and creating a sense of shared ownership is essential to setting up structures for sustained actions (Research ICfPH 2013, 2020). However, in order to enable the mothers of the neighbourhood to advocate for their needs it is important to consult them regularly during the process of upscaling and execution of the activity or to involve them in an advisory or sounding board (Dedding et al., 2022). In our study, the choice to base the action at an activity centre for women aided both the publicity for and participation in the action, since the centre already catered for women from diverse backgrounds. Involving the staff at the centre from the conceptualization phase of the action resulted in close collaboration and an equitable partnership, which contributed to an even greater sense of shared ownership.

4.1. Strengths and limitations

One of the strengths of this study is that it adds valuable insights to the scant literature on how to conduct PAR studies with mothers of children during the first thousand days of life, a period in which many mothers report feeling overwhelmed. The study also enriches our understanding of the opportunities and challenges at stake. The composition of the group, which was evenly distributed as regards educational background, was also a strength of the study. A mother with a higher education background was able to offer support and guidance to mothers with a lower level of education when it came to the more abstract parts of the PAR process, such as conceptualizing the idea. The mothers with a lower level of education provided valuable input on the day-to-day problems and realities relating to limited financial resources and lack of access to services, and this input proved to be enlightening for the mothers with a higher education background. Another important strength is that the principal researcher was known to almost all of the mothers, since she was a resident of the neighbourhood being studied. This helped build reciprocal and trusting relationships with the mothers and made it easier to create an open communicative atmosphere that encouraged the mothers to share their concerns and passions. However, this could also be seen as a limitation, as a sense of familiarity could also be more conducive to eliciting socially desirable answers.

One limitation is the impact of COVID−19 restrictions on the study, which meant that the PAR sessions had to be organized online. This limited the use of creative methods such as photography, filmmaking or drawing, which are known to provide a fertile context for shared learning and change processes that grow impact (Nguyen, 2018). Another limitation is that the data was not independently coded by two researchers due to time constraints. However, the coding schemes were checked by one of the mothers from the action group, who was also consulted about whether the mothers’ statements had been interpreted correctly. With her help we managed to provide a more accurate representation of the mothers’ input, opinions and feelings.

5. Conclusion

This study centred on the development of a health promotion action to stimulate healthy growth and development in the first thousand days of the lives of children in a relatively low-income neighbourhood. This action, which was implemented and evaluated in co-creation with mothers from the neighbourhood, resulted in the development of Mama’s World Exercise Club in response to the needs and interests of other local mothers. The mothers in the action group indicated that the PAR process empowered them and gave them a sense of ownership, as well as the fulfilment of serving a useful purpose for their community and their peers. The action they developed was highly valued by other mothers in the neighbourhood who participated in the action and reflected the realities of their daily lives. The action was widely implemented so much so that it has already been implemented in three new locations. These positive results can be ascribed to the strong collaboration between the researchers and the participating mothers, and the willingness of local stakeholders to support the action. Future studies should investigate if the results of this study sustain over a longer period of time and improve health outcomes of children and mothers in the long run.

Author contributions

GB and FB conceptualised and designed the project. JCS and SCD helped supervise the project. GB and FB coordinated and performed the data collection. GB wrote the manuscript. SCD and JCS interpreted the data and provided critical input and feedback on the manuscript. All of the authors read and approved the final manuscript.

Ethics approval and consent to participate

This study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Medical Ethical Committee of Amsterdam UMC (VUmc location) in 2018 (2018.229). Reference number: IRB00002991. Written informed consent for participating in the study was obtained from all participants involved in the interviews and the action-group sessions.

Availability of data and materials

The qualitative datasets generated and/or analysed during the current study are not publicly available, as the data contains information that could compromise research participant privacy/consent. However, the data are available from the principal researcher G. Bektas ([email protected]) on reasonable request, and subject to approval by the research committee of Amsterdam UMC (VUmc location).

Acknowledgments

The results of this project represent a collaborative interpretation of the collective wisdom of the mothers from the action group, and would not have been possible without their support and participation. We would therefore like to thank each and every mother who generously shared her time, experience and effort for the purposes of this project. In particular, we wish to thank one of the mothers, Tuba Arslan, for her invaluable feedback and input during the analyses, and for acting as one of the readers of the paper.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This study was funded by the Fred Foundation.

Notes on contributors

Gülcan Bektas

Gülcan Bektas is a PhD candidate in the Youth & Lifestyle section of the Department of Health Sciences at Vrije Universiteit Amsterdam’s Faculty of Science. Her educational background is in health sciences and her research areas include early childhood, lifestyle, health promotion, participatory health research, healthcare services and parental education.

Femke Boelsma

Femke Boelsma is a junior researcher in the Youth & Lifestyle section of the Department of Health Sciences at Vrije Universiteit Amsterdam’s Faculty of Science. Her educational background is in cultural and social anthropology and her research areas include participatory action research, health promotion, early childhood and healthcare services.

Jacob C. Seidell

Jacob C. Seidell is a professor in the Youth & Lifestyle section of the Department of Health Sciences at Vrije Universiteit Amsterdam’s Faculty of Science. His educational background is in nutrition and public health, and he holds a PhD in human nutrition. He is head of the section Youth & Lifestyle and co-director of Sarphati Amsterdam, an organisation in which multidisciplinary teams work on prevention and care solutions for the young people of Amsterdam.

S. Coosje Dijkstra

S. Coosje Dijkstra is an assistant professor in the Youth & Lifestyle section of the Department of Health Sciences at Vrije Universiteit Amsterdam’s Faculty of Science and at the Amsterdam Public Health Research Institute. She brings her background as a nutritionist and epidemiologist to bear in a wide range of research projects aimed at reducing socioeconomic inequalities in dietary intake, dietary behaviour and the food environment of childhood and adolescence.

Appendix A.

Study flow chart of the PAR process and evaluation

short-legendFigure A1.

Appendix B.

Interview guide on how the mothers experienced the PAR process

Table

Reason for participation: Why did you sign up for this project? Do you often participate in projects in your own neighbourhood? If not, why now? What were your expectations about the project? General: How much did you enjoy participating in this project? Which aspect of the sessions appealed to you most? And least? What did you think of the duration of the meetings (too long, too short to have a proper discussion, or just right)? What did you think of the duration of the project (length in terms of weeks/months; was the two-week interval between sessions good or too long)? How did you like participating in the sessions online? What could we have done differently or better? The chosen theme/idea What did you think of the theme that was chosen? Do you think it’s a theme that many young mothers find important? Why/why not? What did you think of the idea for the action? What do you think mums in the neighbourhood are going to think of this idea? Group process How did you think the group conversations went? What did you think of the brainstorming session in a separate virtual room? Did you enjoy it? What was the atmosphere like during this session? Did you feel that you had enough opportunity to express your experiences and ideas? Why/why not? What do you feel you have been able to contribute to the group? How did you experience the contact with the other mothers? Did you get to know the other participants in the group? Was there a team spirit within the group? Why/why not? Other What, if anything, did you learn from the meetings? Did you hear new things? What did you think of the moderators? Are there things we could do better?

Appendix C.

Interview guide on how the mothers experienced the Mama’s World Exercise Club

Table

Why did you attend the Mama’s World Exercise Club? What was the reason for your attendance? What appealed to you most? What is your experience of the exercise sessions and what do you think of the activities during these sessions? What do you think of the combination of exercise and socializing at the club? What does the exercise club offer you? What have you learned from the exercise club? Which elements or aspects have you adopted in your home setting or tried out at home? Which activity did you like the most? Which activity was most informative and/or useful and why? What do you think about providing information on physical and mental health during the sessions and discussing these topics? What do you think of the trainers? What is your experience of meeting other mothers with children in the same age group during the sessions? Did the exercise club contribute to or expand your network of mothers? Did you already know mothers at the exercise club? Have you also met new mothers? Do you talk to or have conversations with the mothers after the exercise club? What topics do you talk about? Would you recommend the exercise club to other mothers? If so, why? What do you think of the childcare provided for older children? What do you think of the location (accessibility, the gym)? How important is it to you that the activity is offered free of charge? Would you be willing to pay for this service and if so, how much? Would you still come to the club if you had to pay for it? Can you think of anything else that should be provided at these sessions? What could be improved? Was there anything you missed at the sessions?