Family functioning, parental psychological distress ...

Health Promotion International, Vol. 26 No. 3 doi:10.1093/heapro/daq054 Advance Access published 16 August, 2010

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Family functioning, parental psychological distress, child behavioural problems, socio-economic disadvantage and fruit and vegetable consumption among 4 –12 year-old Victorians, Australia A. M. N. RENZAHO 1*, S. KUMANYIKA 2 and K. L. TUCKER 3,4 1

SUMMARY The aim of this analysis was to assess relationships between family functioning, parental psychological distress, child behaviour difficulties and fruit and vegetable (F&V) consumption among 4 –12-year-old children in Victoria, Australia. We used the 2006 Victorian Child’s Health and wellbeing data set that included 3370 randomly selected primary caregivers of 4 –12-year-old children interviewed between October 2005 and March 2006. Behavioural problems were measured using the Strengths and Difficulties Questionnaire; level of family functioning was measured using the McMaster Family Assessment Device –General Functioning Scale and parental psychological distress was measured using the Kessler-6 scale. The mean number of servings consumed per day was 2.2 (95% CI: 2.1, 2.3) for fruit and 2.0 (95% CI: 1.9, 2.1) for vegetables. The proportion of children meeting the minimum daily age-specific recommendation was 87.8%

(95% CI: 86.4, 89.1%) for fruit and 36.5% (95% CI: 34.5, 38.5) for vegetables. Children with behaviour difficulties, low levels of prosocial behaviours and from poorly functioning households consumed fewer servings of F&V than children who did not experience any environment stressors or behavioural problems. Although parental psychological distress was not associated with fruit intake, daughters of parents who reported higher levels of psychological distress consumed fewer servings of vegetables than daughters of parents who reported lower levels of psychological distress. Child behavioural problems and family functioning and to some extent parental psychological distress were associated with F&V consumption. Programmes aimed at promoting F&V consumption in children should target those families with children experiencing behavioural problems or poorly functioning households

Key words: fruit and vegetable consumption; psychological distress; family functioning; prosocial behaviours

BACKGROUND Chronic diseases, including diseases of the heart and circulatory system and cancer, constitute major leading causes of death in most highincome countries such as Australia (Australian

Bureau of Statistics, 2009), the USA (Kochanek et al., 2004), the UK (Allender et al., 2007) and countries in rapid economic transition (Murray and Lopez, 1997). Available evidence suggests that a diet high in fruit and vegetables (F&V) is associated with decreased risk of certain cancers 263

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WHO Collaborating Centre for Obesity Prevention, Deakin University, 221 Burwood High Way, Burwood 3125, Victoria, Australia 2School of Medicine, University of Pennsylvania, Philadelphia, USA 3 Bouve College of Health Sciences, Northeastern University, Boston, MA, USA and 4USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA *Corresponding author. E-mail: [email protected]

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A. M. N. Renzaho et al.

significantly associated with higher intakes of leafy green vegetables and fresh fruit among adolescents. The purpose of this study was to assess the influence of family functioning, parental psychological distress and child behavioural problems on F&V consumption among children in Victoria. We hypothesized that (i) socioeconomic disadvantage would be associated with low F&V consumption; and that after controlling for confounding factors, (ii) poor family functioning, parental psychological distress and child behaviour difficulties would be associated with low F&V consumption and (iii) child prosocial behaviours would be positively associated with F&V intake.

METHODS Study design, recruitment and interview procedures Analyses were conducted using data for children in the state of Victoria in South-Eastern Australia, taken from the 2006 Victorian Child’s Health and Wellbeing (VCHW) data set (Department of Human Services, 2007). The VCHW data set was derived from a state-wide cross-sectional telephone survey that was commissioned by the Victorian Department of Education and Early Childhood Development between October 2005 and March 2006. The survey included 5000 randomly selected primary caregivers of 0–12-year-old children. The analysis sample used here included 3370 (67.4%) 4– 12-year-old children and their respective care givers (girls ¼ 1625 or 48.2%; boys ¼ 1745 or 51.8%), with complete data. Data pertaining to child F&V consumption (the dependent variable), family characteristics and family environment stressors as reported by the child’s parent or guardian (the independent variables), formed the focus of this paper. The study was approved by the Deakin University Human Ethics Committee. Using computer-based random digit dialling, participants were randomly selected using a sample of telephone numbers generated at the regional level and stratified by area of residence. With the stratified random sampling, selected households with only one child aged 1,3 years were automatically included in the database of research volunteers to be contacted via phone.


and reduced morbidity and mortality from heart disease, suggesting that low F&V intake contributes to the burden of cardiovascular diseases and cancer (Ness and Powles, 1997; Van Duyn and Pivonka, 2000; Reddy and Katan, 2004; World Cancer Research Fund and American Institute for Cancer Research, 2007). Consequently, expert panels have recommended increases in F&V consumption as a preventive measure for chronic diseases (Joint WHO/FAO Expert Consultation, 2003; World Cancer Research Fund and American Institute for Cancer Research, 2007). Health promotion programmes geared towards increasing F&V intake focus on strategies such as social marketing, printed brochures and other educational materials (Havas et al., 1998; Marcus et al., 2001). Several studies have examined barriers to F&V consumption, including social and economic inequalities such as low socio-economic status, disadvantage associated with ethnic minority status, family and neighbourhood access to fresh F&V, affordability, individual behaviours and attitudes and personal factors such as lack of self-efficacy (Kratt et al., 2000; Siega-Riz and Popkin, 2001; Renzaho and Burns, 2006; Yeh et al., 2008). Lifelong F&V consumption patterns may be established during childhood, and childhood F&V consumption may influence disease risks in adulthood (Nicklas et al., 2001; Maynard et al., 2003; Ness et al., 2005). Influences on children’s F&V consumption are, therefore, of particular interest for informing the design of related health promotion interventions (Pearson et al., 2009). Few studies have considered how psychological or behavioural factors at the household level could negatively impact on children’s F&V consumption. Household characteristics are affected by parental mental wellbeing (Brody et al., 1994) and family functioning (Tiffin et al., 2007). Fewer family resources have been found to lead to depression and decreased optimism in both parents which, in turn, is associated with the disruption of parental co-caregiving support and with conflict (Brody et al., 1994). Oddy et al. (2009) and Ambrosini et al. (2009) found that poorer behaviour in early adolescence was associated with a diet high in red and processed meats, takeaway foods, confectionary and refined foods, and that a healthier diet was associated with better family functioning. Higher positive behavioural scores were

Family functioning, parental psychological distress and F&V consumption

Children in single-eligible child households were automatically selected to be the subject of the interview and in the case of a household having more than one eligible child, the computer programme randomly selected one child to be included in the study. Telephone calls were made throughout the day and evenings on both weekdays and weekends, with a maximum of six call attempts in order to establish initial contact with a household. Once contact was established, up to nine additional calls were made to secure participant involvement and to confirm a suitable interview time (Department of Human Services, 2007). The interview lasted 2 –3 min. The data were collected by 28 trained interviewers.

Family environment stressors The family environment stressors included level of family functioning, child behaviour difficulty and parental psychological distress. Level of family functioning was measured using McMaster Family Assessment Device–General

Functioning Scale (Miller et al., 1985). The scale included 12 items (e.g. in times of crisis we can turn to each other for support), scored on a 1–4 scale (1 ¼ strongly agree; 4 ¼ strongly disagree), with a Cronbach alpha of 0.89 in this study. The standardized scores (min ¼ 1, max ¼ 3.92) were then categorized into healthy (score 2.0) and poor (score .2) family functioning (Miller et al., 1985). Child behaviour difficulty was measured using the Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997, 2001). The SDQ has been used to describe child behaviours, emotions and relationships (Goodman, 1997, 2001). The SDQ contains 25 items and five clinical scales: emotional symptoms (e.g. the child has many worries or often seems worried), peer relationship problems (e.g. the child is rather solitary or prefers to play alone), hyperactivity/inattention (e.g. the child is restless, overactive, cannot stay still for long), conduct problems (the child often loses his/her temper) and prosocial behaviour (positive behaviours, e.g. the child is considerate of other people’s feelings). The items for each clinical scale were answered on a 3-point Likert scale (0 ¼ not true, 1 ¼ somewhat true and 2 ¼ certainly true). Summing the scores from emotional, peer relations, hyperactivity and conduct subscales provided the total child behaviour difficulties score (Goodman, 1997; Goodman, 2001) (min ¼ 0, max ¼ 32; Cronbach alpha ¼ 0.801 in this study). The prosocial subscale consists of five items that depict child behaviours in terms of consideration of others, sharing personal belongings with other children, helping another child who is hurt or upset, being kind to younger children and volunteering to help others such as parents or teachers. Scores range between 0 (anti-social) and 10 (prosocial behaviour). Parental psychological distress was measured with the Kessler-6 (K-6) (Kessler et al., 2002), which consists of six items (Cronbach alpha ¼ 0.782 in this study) that ask parents or guardians about negative emotional states experienced in the 4 weeks prior to interview (e.g. in the last 4 weeks, about how often did you feel nervous?) and scored on a 5-point scale (1 ¼ none of the time to 5 ¼ all of the time). Potential confounding factors Considered confounding factors included the child’s age (What is the child’s date of birth?)


Study variables F&V consumption Parents or care givers were asked to report their children’s F&V consumption patterns. Children’s fruit consumption was measured following the Australian Guide to Healthy Eating (National Health and Medical Research Council, 2003) and included the following questions: ‘How many serves of fruit does your child usually eat each day?’ For children’s vegetable consumption the question was: ‘How many serves of vegetables does (child) usually eat each day?’ A serving of fruit was considered to be one medium piece (e.g. apple, orange, banana, mango, mandarin, pear), two small pieces of fruit (e.g. apricots, kiwi, plum, figs), one cup of diced or canned fruit or one serve of dried fruit (four dried apricots or 1 1/2 tablespoons sultanas) (National Health and Medical Research Council, 2003). A serving of vegetables was considered to be half a cup of cooked vegetables or one cup of salad vegetables (National Health and Medical Research Council, 2003). Seven cases for fruit consumption and eight cases for vegetable consumption were excluded from the analysis because they had missing or extreme values, or were coded as ‘do not know’ or ‘refused to answer.’

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Data analysis All analyses were conducted using Stata Version 10 (Stata Corporation, TX, USA). The reported number of servings of F&V was dichotomized by minimum daily recommendations (meeting recommendations versus not meeting minimum recommendations) using age-specific cut-off points proposed by the Australian Guide to Healthy Eating (National Health and Medical Research Council, 2003). For fruit consumption, the recommendations are: at least one serve per day for children aged 4– 7 years and 8–11 years and at least three serves per day for children age 12 years or older. For daily vegetable consumption, the recommendations are: at least two serves per day for children aged 4–7 years, at least three serves per day for children aged 8– 11 years and at least four serves per day for children aged 12 years or older. Relationships between two categorical variables were examined by chi-square test. T-test and oneway ANOVA were

used to compare means between two and three or more groups, respectively. Relationships between the number of servings of F&V consumed per day and family environment stressors were assessed using multivariate linear regression. For each dependent variable (i.e. number of servings of fruit consumed per day and number of servings of vegetable consumed per day), four different models were developed in which a different family environment stressor (i.e. child behaviour difficulties, child prosocial behaviour, levels of family functioning or parental psychological stress) was considered as a predictor. In each model we controlled for potential confounding factors as previously described (i.e. household income level, parental educational attainment, child age and gender, food security, financial stress, social support and parental language use at home). We also adjusted each model for sampling weights to account for a lone child having a greater probability of selection than a child from a household with more than one eligible child, and households with more than one telephone line having an increased probability of selection over households with only one telephone line.

RESULTS Sample characteristics The analysis sample included 3370 children. The responding parent or guardian’s country of birth was mostly Australia (81.4%), with relatively small numbers of immigrants from each of several regions (Table 1). Only 372 households (12.3) reported speaking a language other than English at home and 93% of these responding parents or guardians were born outside of Australia. Six per cent of the sample reported food shortages during the past 12 months and 5% reported lacking a source of social support during an emergency.

Fruit consumption Approximately 2.1% (95% CI: 1.4, 2.6%) of 4– 12-year-old children were not eating any fruit. The mean number of servings of fruit consumed per day was 2.2 (95% CI: 2.1, 2.3). More than half of the sample (59.4% of 4 –7-year-old children, 56.9% of 8–11-year-old children and 53.2% of 12-year-old children) ate two to three


and gender (1 ¼ boy; 0 ¼ girl), household income level (1 ¼ less than $20 000; 3 ¼ $20 000–$39 000; 4 ¼ $40 000–$59 000; 5 ¼ $60 000–$79 000; 6 ¼ $80 000 and over); parental educational level (0 ¼ high school or less; 1 ¼ tertiary or further education), family structure (couple versus single parent household), parents’ language use at home (English only versus a language other than English), food security, financial stress and social support. In this study, food security was measured using the following single item. ‘In the last 12 months, were there times that you ran out of food and could not afford to buy more?’ For financial stress, the question was: ‘Could you raise $2000 within 2 days in an emergency?’ Social support was assessed using the following item: ‘Could one of your relatives or friends care for you or your children in an emergency?’ These questions were answered ‘Yes’ or ‘No’. These retained confounding variables are known to be directly associated with F&V consumption. For example, F&V consumption among children has been positively associated with household income, parental educational levels and social support; being a girl and younger age (Gibson et al., 1998; Kamphuis et al., 2006; Talvia et al., 2006; Bere et al., 2008; Pearson et al., 2009) as well as adequate food security and low financial stress (Tingay et al., 2003; Kamphuis et al., 2006; Alaimo et al., 2008).


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Table 1: Demographic characteristics of the study sample and their relationship to F&V intake Girls

Boys

Fruit n (%)

b

Vegetables p-value

b

p-value

n (%)

b

Vegetables p-value

b

p-value

675 (39) 849 (49) 221 (12)

Ref 20.131 20.245

0.137 0.032

Ref 0.259 0.442

0.000 0.000

206 (13) 316 (19) 340 (21) 309 (19) 455 (28)

Ref 0.03 20.197 20.128 20.088

0.883 0.300 0.500 0.643

Ref 0.123 0.014 0.093 0.126

0.359 0.928 0.533 0.399

817 (47)

Ref

926 (53)

0.215

1405 (81) 338 (19)

Ref 0.008

Ref

0.195

0.007

Ref

20.171

0.265

0.114

0.348

1638 (94) 107 (6)

Ref 0.29

0.465

Ref 0.217

0.206

94 (5) 1634 (95)

Ref 0.034

0.834

Ref 0.007

0.963

239 (14) 1467 (86)

Ref 0.331

0.019

Ref 0.222

0.031

1522 (87) 220 (13)

Ref 20.037

0.742

Ref 20.422

0.000

LOTE, language other than English.

servings of fruit per day (Figure 1A). Approximately 89% (95% CI: 87.2, 91.1) of girls and 86.4% (95% CI: 84.6, 88.3) of boys ( p , 0.01) met the minimum recommendations for fruit intake. The majority of children up to the age of 11 years consumed the recommended amount of fruit (95.8%, 95% CI: 94.7, 96.9% for 4– 7 years old; 95.0%, 95% CI: 93.7 and 96.3% for 8 –11 years), but the proportion was significantly lower among children aged 12 years (28.0%, 95% CI 22.7, 33.2%, p , 0.001) (Figure 1B). The regression model containing all the socio-demographic and economic variables (controlling for each other) (Table 1), grouped by gender, revealed that girls who consumed fewer servings of fruit per day were more likely to be older (b ¼ 20.264, 95% CI: 20.474,

20.057) and from a sole parent family (b ¼ 20.257, 95% CI: 20.501, 20.014). Language spoken at home, household income, parental educational level, household food insecurity, financial stress and social support were not associated with fruit intake among girls. Unlike with girls, parental education and financial stress were associated with the consumption of fruit among boys. Less financial stress was associated with greater fruit intake, with boys from households that could raise $2000 within 2 days in an emergency eating more servings of fruit per day (b ¼ 0.331; 95% CI: 0.054, 0.608) than those from households that could not. Similarly, parental educational attainment was positively associated with fruit intake among boys, with boys whose parents had tertiary education (b ¼ 0.215, 95% CI: 0.056, 0.375) eating


Age group 4– 7 years 623 (38) Ref Ref 8– 11 years 779 (48) 0.047 0.600 0.173 0.022 12 years 223 (14) 20.264 0.013 0.165 0.132 Income ($) ,20 000 172 (12) Ref Ref 20 000–39 000 270 (18) 0.242 0.094 0.026 0.859 40 000–59 000 305 (20) 0.122 0.408 20.066 0.682 60 000–79 000 281 (19) 0.091 0.547 20.054 0.737 80 000 460 (31) 0.074 0.619 20.062 0.688 Parental educational attainment High school or 796 (49) Ref Ref less Tertiary/further 828 (51) 0.121 0.128 0.152 0.032 education Family structure Couple parent 1312 (81) Ref Ref family Sole parent 310 (19) 20.257 0.038 20.114 0.386 family Household ran out of food in the past 12 months No 1521 (94) Ref Ref Yes 101 (6) 0.057 0.743 0.44 0.012 Have relatives/friends who can care for the family in an emergency No 68 (4) Ref Ref Yes 1549 (96) 20.112 0.669 0.01 0.955 Could you raise $2000 within 2 days in an emergency No 217 (14) Ref Ref Yes 1364 (86) 0.072 0.531 0.159 0.118 Parents’ language spoken at home English only 1417 (87) Ref Ref LOTE 206 (13) 0.107 0.360 20.362 0.001

Fruit

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more servings of fruit per day than boys whose parents had only secondary education level or less. Boys who consumed fewer servings of fruit per day were also more likely to be older (b ¼ 20.245, 95% CI: 20.469, 20.021). No relationship was found between fruit intake among boys and household income level, household food insecurity, social support, family structure or language spoken at home. The effect of family environment stressors on fruit consumption among children, after adjusting for confounders, was evident (Table 2). With the exception of parental psychological distress and hyperactivity/inattention, girls with

emotional symptoms (b ¼ 20.064, p , 0.01), conduct problems (b ¼ 20.066, p , 0.05) and peer relationship problems (b ¼ 20.065, p , 0.05) or from poorly functioning households (b ¼ 20.291, p , 0.01) consumed fewer servings of fruit per day than girls who did not experience these environmental stressors or behavioural problems. In addition, girls with high levels of prosocial behaviours ate more servings of fruit per day than girls with low levels of prosocial behaviours (b ¼ 0.069, p , 0.05). Boys with emotional symptoms (b ¼ 20.054, p , 0.05) or from poorly functioning families (b ¼ 20.349, p , 0.01) consumed fewer


Fig. 1: (A) Serves of fruit eaten per day by age group (n ¼ 3363) and (B) proportion of children meeting age-specific minimum recommendations for fruit.

Table 2: Relationships between family environment stressors and number of F&V servings consumed by the boys and girls per day Number of serves of fruit consumed per day Adjusteda

Unadjusted

p-value b (95% CI)

20.019) 0.032) 0.034) 20.009) 0.003)

0.003 0.474 0.763 0.018 0.109

20.054 (20.095, 20.012) 20.012 (20.063, 0.040) 0.007 (20.023, 0.038) 20.044 (20.094, 0.006) 20.010 (20.025, 0.006)

0.011 0.657 0.632 0.085 0.208

20.021 20.029 20.007 20.038 20.011

0.047 (0.006, 0.087) 20.432 (20.602, 20.261) 20.009 (20.037, 0.019)

0.025 0.000 0.511

0.068 (0.026, 0.110) 20.349 (20.537, 20.160) 20.004 (20.031, 0.023)

0.001 0.000 0.792

20.059 (20.101, 20.061 (20.116, 20.011 (20.045, 20.063 (20.118, 20.019 (20.036,

20.016) 20.005) 0.023) 20.007) 20.003)

0.007 0.033 0.510 0.028 0.022

20.064 (20.112, 20.015) 20.066 (20.126, 20.006) 20.003 (20.040, 0.033) 20.065 (20.128, 20.002) 20.018 (20.037, 0.001)

0.010 0.032 0.852 0.043 0.057

20.044 20.030 20.013 20.035 20.016

0.068 (0.014, 0.122) 20.300 (20.493, 20.107) 20.011 (20.033, 0.011)

0.014 0.002 0.341

0.069 (0.009, 0.129) 20.291 (20.502, 20.080) 20.015 (20.039, 0.009)

0.025 0.007 0.227

(20.059, (20.074, (20.035, (20.081, (20.025,

p-value b (95% CI)

0.018) 0.015) 0.021) 0.004) 0.002)

(20.054, (20.059, (20.034, (20.076, (20.023,

p-value

0.297 0.196 0.635 0.079 0.097

20.014 20.013 20.005 20.033 20.009

0.043 (0.005, 0.082) 20.314 (20.474, 20.154) 20.009 (20.030, 0.013)

0.028 0.000 0.422

0.054 (0.014, 0.093) 20.241 (20.416, 20.066) 0.000 2(0.021, 0.021)

0.008 0.007 0.992

(20.079, (20.078, (20.041, (20.081, (20.029,

20.009) 0.018) 0.015) 0.011) 20.003)

0.013 0.223 0.367 0.134 0.019

20.050 20.027 20.017 20.033 20.017

(20.088, (20.082, (20.047, (20.085, (20.032,

20.012) 0.027) 0.012) 0.019) 20.003)

0.010 0.323 0.239 0.215 0.021

0.045 (20.004, 0.093) 20.221 (20.378, 20.064) 20.023 (20.043, 20.003)

0.069 0.006 0.024

0.055 (0.003, 0.107) 20.228 (20.392, 20.063) 20.027 (20.046, 20.008)

0.038 0.007 0.006

0.025) 0.033) 0.024) 0.01) 0.005)

0.483 0.579 0.730 0.135 0.220

Adjusted for household income, family structure, child age and gender, parental educational level, language spoken at home, financial stress, food security and social support.

269


a

20.059 (20.098, 20.018 (20.068, 0.004 (20.025, 20.054 (20.098, 20.012 (20.027,

p-value b (95% CI)

Adjusteda

Unadjusted


b (95% CI) Boys Child’s behaviour difficulties Emotional symptoms Conduct problems Hyperactivity/inattention Peer relationship problems Total behaviour difficulties scores Prosocial behaviour scores Family functioning score Parental psychological distress Girls Child’s behaviour difficulties Emotional symptoms Conduct problems Hyperactivity/inattention Peer relationship problems Total behaviour difficulties scores Prosocial behaviour scores Family functioning score Parental psychological distress

Number of serves of vegetables consumed per day

270


servings of fruit per day than boys who did not experience these environment stressors or emotional problems. Boys with high levels of prosocial behaviours ate more servings of fruit per day than boys with low levels of prosocial behaviours (b ¼ 0.068, p , 0.01).

Fig. 2: (A) Serves of vegetables eaten per day by age group; (n ¼ 3363) and (B) proportion of children meeting age-specific minimum recommendations for vegetable.


Vegetable consumption The proportion of 4–12-year-old children not eating any vegetable was 2.1% (95% CI: 1.5, 2.8%). The mean number of servings of vegetables consumed per day was 2.0 (95% CI 1.9, 2.1). Fewer than 15% across all age groups consumed fewer than four or more servings of vegetables per day (Figure 2A). A total of 45.9% (95% CI: 42.9, 48.9) of girls and 44.9% (95% CI: 42.1, 47.8) of boys met the minimum recommendations for vegetable intake. However,

consumption of the recommended number of servings of vegetables each day was most common among 4–7-year-old children (73.7%, 95% CI: 71.2, 76.2% for 4–7 years; 28.6%, 95% CI: 25.9, 31.4% for 8–11 years and 11.6%, 95%CI: 8.1, 15.0% for 12 years, p , 0.001). Among girls, vegetable consumption was positively associated with age up to 11 years, with girls aged 8– 11 years (b ¼ 0.173; 95% CI: 0.025, 0.321) eating more servings of vegetables than those in the 4–7-year age bracket. Girls from households that spoke a language other than English ate fewer servings of vegetable (b ¼ 20.362; 95% CI: 20.572, 20.151) than those from household that spoke English only. There was a positive relationship between vegetable consumption among girls and parental educational attainment (b ¼ 0.152, 95% CI: 0.013, 0.291). Girls from households that had


DISCUSSION To our knowledge, this is the first study to examine relationships between F&V consumption among 4–12-year-old children and household environment stressors such as parental mental health, family functioning and the child conduct problems. Firstly, the hypothesis that socio-economic disadvantage would be associated with low levels of F&V consumption was partially supported. The effects of parental educational attainment, level of household food insecurity, financial stress, language spoken at home and age were evident. Family income was not related to child’s F&V intakes in this sample. However, higher parental education was associated with higher F&V intakes in boys and with higher vegetable intakes in girls. It is possible that when income is controlled, better educated parents may be more aware of the importance and health benefits of F&V consumption and more likely to provide F&V to their children or model eating them (Pearson et al., 2009). Our findings suggest that income itself is not necessarily the limiting factor. In terms of financial stress, the household’s ability to raise $2000 within 2 days in an emergency was positively associated with F&V intake among boys, whereas running out of food in the last 12 months preceding the survey was positively associated with vegetable intake among girls. Pearson et al. (2009) in their systematic review examining determinants of F&V in children, noted some inconsistent patterns. They reported that fruit availability was positively associated with children’s fruit intake in five samples, but accessibility of fruit was inversely associated with fruit consumption in children in one, and unrelated to fruit consumption in two studies. Availability of vegetables was positively associated with children’s vegetable consumption in six samples and unrelated to consumption in three samples. However, they did not indicate how they defined food accessibility and availability. It is not clear whether their findings relate to both physical and economic access to food or whether food availability encompasses physical availability of food through own production and reserves, purchasing or food handouts. Our findings on the relationship between food insecurity and F&V intake contradict those reported by Dave et al. (2009). The authors found that higher rates of food


run out of food in the past 12 months preceding the survey consumed more servings of vegetables per day than those from households that did not (b ¼ 0.440; 95% CI: 0.098, 0.781). Vegetable consumption among girls was not associated with household income level, family structure, social support or financial stress. Among boys, vegetable consumption was positively associated with age, with boys aged 8 –11 years (b ¼ 0.259; 95% CI: 0.116, 0.403) and 12 years (b ¼ 0.442; 95% CI: 0.199, 0.684) consuming more servings of vegetables than those in the 4–7-year age bracket. There was a positive relationship between vegetable consumption among boys and parental educational attainment (b ¼ 0.195, 95% CI: 0.053, 0.337). Less financial stress was associated with greater vegetable intake, with boys from households that could raise $2000 within 2 days in an emergency eating more servings of vegetables per day (b ¼ 0.222; 95% CI: 0.021, 0.424) than those from households that could not. Boys from households that spoke a language other than English ate fewer servings of vegetables (b ¼ 0.422; 95% CI: 20.604, 20.239) than those from household that spoke English only. Vegetable consumption among boys was not associated with household income level, household food insecurity, social support or family structure. The effect of family environment stressors on vegetable consumption among children was also evident, after adjusting for confounders (Table 2). Girls with behavioural difficulties (b ¼ 20.017, p , 0.05), emotional symptoms (b ¼ 20.050, p , 0.05) and from households functioning poorly (b ¼ 20.228, p , 0.01) or with parental psychological distress (b ¼ 20.027, p , 0.01) consumed fewer servings of vegetables per day than girls who did not experience any environment stressors or behavioural problems. In addition, girls with high levels of prosocial behaviours ate more servings of vegetables per day than girls with low levels of prosocial behaviours (b ¼ 0.055, p , 0.05). Boys from households with poor family functioning (b ¼ 20.245, p , 0.01) consumed fewer servings of vegetables per day than boys from households functioning adequately. Effects of behavioural problems and parental psychological distress were not statistically significant. Boys with high levels of prosocial behaviours ate more servings of vegetables per day than boys with low levels of prosocial behaviours (b ¼ 0.054, p , 0.01).

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was among Hispanic children in the USA and is hardly a direct comparison. Further studies are required to shed light on this finding. In addition, unlike the study by Riediger et al. (2007), we found that household income level and social support did not have any effect on F&V consumption among children. Secondly, the hypothesis that poor family functioning would be associated with low levels of child F&V consumption was supported for both boys and girls. Studies examining the relationship between level of family functioning and F&V intake among children are few. In one, Kintner et al. (1981) examined the relationship between dysfunctional family environments and family member food intakes. Family functioning was measured using the Rudolf Moos Family Environment Scale, which includes 10 subscales: cohesion, expressiveness, conflict, independence, achievement orientation, intellectual-cultural orientation, activerecreational orientation, moral-religious emphasis, organization and control. They found that associations between overall family functioning and F&V intake were small and non-significant. Only family cohesion (whether family members helped and supported each other) was associated with F&V intake. However, this study did not specifically focus on children. It is, therefore, not surprising that our findings related to family functioning do not support their findings. In our study, poor family functioning was associated with inadequate F&V intake among children (both boys and girls). Family functioning was measured using the McMaster Family Assessment Device – General Functioning Scale (Miller et al., 1985). Using the same measure of family functioning, Ambrosini et al. (2009) reported similar findings that the consumption of a healthy diet was associated with better family functioning among adolescents. Thirdly, the hypothesis that child prosocial behaviours would be positively associated with F&V consumption was supported for both boys and girls, but the hypothesis that child behavior problems would be associated with low F&V consumption was generally supported for girls but less so for boys, and only with respect to their fruit intake. These findings mirror those reported by Oddy et al. (2009) indicating poorer diets among adolescents with poorer behaviour. They found that improved behavioural scores were significantly associated with higher intakes of leafy green vegetables and fresh fruit among


insecurity were associated with lower fruit and vegetable intake among 5–12-year-old Hispanic children in the USA. These contradictory findings could be due to measurement-related differences. The concept of food security incorporates four pillars: food availability (own production or commercial stocks), food access (financial and physical access to food), food utilization (the ability to use, store and process food available) and asset creation (capital assets: human, natural, financial, social and physical to produce to sustain the food supply) (Renzaho, 2002; Renzaho and Mellor, 2010). It is possible that issues related to food access and availability and food utilization do not always reflect participants’ answer to the single item ‘In the last 12 months, were there times that you ran out of food and could not afford to buy more?’ Hence, the single-item proxy measure of food insecurity may not capture the multiple factors that underscore the complex relationship between food insecurity and fruit consumption, thus limiting interpretability of the findings. In a study examining the impact of socioeconomic and demographic factors among Canadian adolescents Riediger et al. (2007) found that 15–19-year-old children reported eating F&V less frequently than their 12 – 14-year-old counterparts. In that study, household education and income each, independently, had significant positive associations with F&V consumption, and adolescents living in homes with only one parent reported a significantly lower frequency of intake, compared with adolescents living with two parents. Consistent with their findings, we found that inadequate fruit intake was associated with older age and being from a single parent-headed household among girls; and with older age and lower parental educational attainment among boys. Vegetable consumption was positively associated with age, English language use at home and parental educational attainment among boys; and with age, parental education and English use at home among girls. Although nationally representative samples that measure ‘language use at home’ and F&V consumption among children are lacking, findings from among migrant populations provide a different picture. For example, our findings contradict those reported by Dave et al. (2009) suggesting that higher rates of English use at home (a surrogate measure of acculturation) were associated with lower F&V intake at home. However, Dave et al.s’ study


STRENGTHS AND LIMITATIONS The strengths of this study include its large sample size and carefully standardized measurements, which substantially increase precision. A weakness of the VCHWS is under-representation of non-English speaking households. The survey was not designed to specifically report on culturally and linguistically diverse communities. All interviews were conducted in English and a reasonable level of English was required to complete the survey, ruling out a significant proportion of those who could not speak English. It is also possible that responses of respondents for whom English was not their usual language at home were of lesser quality, due to their differential understanding of or cultural perspective on certain questions. Although the scales used to measure family functioning, child behaviour difficulties and parental psychological distress have been found to have good psychometric properties and had high internal reliability in our sample, extensive factor-analysis was not conducted. The questions used to measure the number of F&V servings consumed by the child per day may have underestimated children’s F&V intake, either due to day-to-day and season-to-season variations in type and amount of F&V consumed, or due to limitations in the proxy-report

( parents/guardians reporting children’s F&V intake).

CONCLUSION The findings from this study highlight the importance of family environment factors in shaping children’s F&V consumption. Child behavioural problems and family functioning and to some extent parental psychological distress were associated with F&V consumption. Programmes aimed at promoting F&V consumption in children should consider the family environment and target those families with children experiencing behavioural problems or poorly functioning households.

ACKNOWLEDGEMENTS We acknowledge the support of the Department of Education and Early Childhood Development in granting access to the data set and extracting the relevant data for analysis. The views expressed in this paper are those of the authors and do not necessarily reflect the views of the Department of Education and Early Childhood Development.

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