Voorstel JOGG-aanpak 2022-2026 - Voorstel.pdf

............................................................................127 Presence of peers............................................................................................................................128 Neighborhood.................................................................................................................................130 Media education .............................................................................................................................131 Leisure...........................................................................................................................................132 Methodology ........................................................................................................................................134 Dataset .............................................................................................................................................134 Measures ..........................................................................................................................................134 Healthy lifestyle ..............................................................................................................................134 Social

environment..........................................................................................................................135 Control variables ............................................................................................................................136 Analyses ...........................................................................................................................................137 Ethical considerations .......................................................................................................................138

Qualitative methods..............................................................................................................................139 Interviews with parents.....................................................................................................................139 Selection and recruitment ................................................................................................................139 Data collection ...............................................................................................................................140 Experts interviews ............................................................................................................................141 Selection and recruitment ................................................................................................................141 Data collection ...............................................................................................................................141 Analyses ...........................................................................................................................................142 Reliability and validity......................................................................................................................142 Ethical considerations

.......................................................................................................................143 Results .................................................................................................................................................143 Quantitative results ..............................................................................................................................143 State of the social environment and healthy lifestyles.........................................................................144 Healthy lifestyle and presence of peers ..............................................................................................145 Healthy lifestyle and neighborhood ...................................................................................................145 Healthy lifestyle and media education ...............................................................................................146 Healthy lifestyle and leisure ..............................................................................................................147 Qualitative results ................................................................................................................................148 Interviews with

parents.....................................................................................................................148 Healthy lifestyles.............................................................................................................................148 Social environment..........................................................................................................................149 Healthy lifestyle and social environment ...........................................................................................150 Role of the municipality ...................................................................................................................150 Differences and similarities .............................................................................................................151 Expert interviews..............................................................................................................................151 Healthy lifestyles.............................................................................................................................151 Social environments ........................................................................................................................152

Greenery........................................................................................................................................152 Role of the municipality ...................................................................................................................152 Conclusion ...........................................................................................................................................153 Discussion ............................................................................................................................................154 Implications......................................................................................................................................155 Limitations .......................................................................................................................................155 Suggestions for future research .........................................................................................................156 Policy advice.........................................................................................................................................157 References............................................................................................................................................158

Appendices...........................................................................................................................................163 Appendix 1. Information letter..........................................................................................................163 Appendix 2. Informed consent ..........................................................................................................165 Appendix 3. Interview questions .......................................................................................................166

Appendix 4. ......................................................................................................................................170 Appendix 5. ......................................................................................................................................170 Appendix 6. ......................................................................................................................................171 Appendix 7. ......................................................................................................................................172 Appendix 8. ......................................................................................................................................172 Appendix 9. ......................................................................................................................................175

Foreword Before you lies the Master’s thesis about the relationship between the social environments and healthy lifestyles of children aged 4-12. This study has been written in the context of graduating from the Master’s program ‘Sociology: Contemporary Social Problems’ at Utrecht University. This research was undertaken at the request of the municipality of Alblasserdam, where I did my internship for the past 5 months. Next to conducting this research, I have spent my time working together with the team ‘social development’, where I got the chance to learn a lot about the organization and the corresponding work and where I got to develop myself into a professional in the field of policy advice. I would like to thank my thesis supervisor Mathijs Kros for the guidance and support during this process. Additionally, I would like to thank my internship supervisors Laure Ter Stege and Sjors Hendriks, for helping me content-wise in writing my thesis. Furthermore, I also wish to thank all participants, without whose cooperation I would not have been able to conduct the qualitative part of this study. I would also like to thank the staff of GGD zhz, that trusted me enough to let me use their dataset.

Lastly, I want to thank all my colleagues from the municipality of Alblasserdam, who warmly welcomed me into the organization and were always ready to answer my questions or help me whenever needed.

I hope you enjoy reading this thesis.

Jasmijn Koutstaal Papendrecht, 22nd of June 2022

Ethical Statement Both quantitative and qualitative parts of this study were applied for ethical approval in advance of the analyses. The secondary data analysis of this study was applied for ethical approval by the Ethics Review Board of the Faculty of Social Sciences (FERB) of Utrecht University. The approval was permitted on the 6th of April 2022 under the number 22-0793. Regarding the qualitative part of the study, two types of ethical approval were permitted by the Ethics Review Board, before the start of the interviews. Confirmation of the approval for the conduction of the interviews was granted on the 16th of March, 2022 with the reference number 22-0682. Additionally, for the recording of the interviews the approval was confirmed on the 21st of March, 2022 with the reference number 22-0684.

Introduction Currently, the notion of the importance of a healthy lifestyle for children is getting spread more and more around the globe (e.g. Lloyd & Wyatt, 2015) However, the research of Teuscher et al. (2015) states that, despite the increased focus on health promotion in society, most lifestyle programs have limited effects. Additionally, the research of Gerards et al. (2013) describes that the prevalence of overweight children and obesity in children is increasing worldwide, and also in the Netherlands. This implies that there might be a lot to gain regarding the lifestyle aspects of the intake of sweet drinks and water. Furthermore, concerning the sleeping habits of children in the Netherlands, an increasing number of children do not meet the age-specific recommended hours of sleep (Komrij et al., 2021). Recent developments concerning the Covid-19 pandemic have shown that the social environments might also not be as healthy as desired. ‘Public health directors worried about the effects of the quarantine policy on youth’ reads a recent article regarding this topic (GGD GHOR, 2022). ‘Mental well-being of pupils under pressure’ reads another (Vos & Hetebrij, 2021). These articles show the increasing worries about the social effects of the lockdowns of Covid-19 on children.

Children are suffering from a lack of social contact and they can’t play sports (Vos & Hetebrij, 2021). The pandemic hereby clearly confirms the importance of socialization opportunities and the social environments around children and, furthermore, suggests that the social environments of children nowadays might need some attention. This is relevant as multiple researchers have shown that the two concepts are related, as the social environment of children is an important predictor of a healthy lifestyle (Ståhl et al., 2001;

Kimbro & Denney, 2013). This all points towards the importance of investigating the current state of both the healthy lifestyles and the social environments of children, as they are both essential for children’s outcomes concerning health and well-being (Rosenbaum & Blum, 2015). Therefore, this thesis will look into the relationship between these two concepts.

Scope The concept of social environments lacks a universal definition as it is a broad concept that consists of many aspects that influence children’s behavior and outcomes in multiple ways. In this research, social environments are defined as the microsystems around children, as described by Bronfenbrenner (1979). This commonly used definition concerns the immediate environment of children that closely interact with the child, such as the neighborhood and peers (Onwuegbuzie et al., 2013). For this study, aspects of this microsystem of Dutch children, and children specifically from Alblasserdam, aged 4-12 are investigated. This age group was chosen due to their reachability for the qualitative part of this research as there are only primary schools in Alblasserdam. Four aspects will together represent the social environment in this study, which are inspired by aspects of Bronfenbrenner’s microsystem (1979) that are specifically relevant for children aged 4-12, as they are things that children of this age-group encounter daily. Additionally, the topics of interest for the municipality of Alblasserdam were considered. This leads to a focus on the presence of peers, neighborhood, media education, and leisure. Shortly summarized, the aspect of the presence of peers regards the availability of social contacts.

Furthermore, the aspect of neighborhood concerns whether or not a neighborhood is safe and child-friendly. The aspect of media education covers whether parents talk to their children about their media use and rules regarding media use. Lastly, leisure regards the different activities that occupy a child’s leisure time, which for this research entail reading, gaming, and social media use. Whether or not the social environments of children will be considered healthy depends on how a child scores on these aspects. The concept of a healthy lifestyle is something that scholars more or less agree on concerning a definition, which entails a lifestyle that improves people’s health and well-being. In this research, the focus will be on the following aspects of a healthy lifestyle namely, sleeping patterns, intake of sweet drinks, and water consumption as research shows their importance for a healthy lifestyle (González-Gross et al., 2008; Aranceta et al., 2003).

Existing literature Multiple researchers have already investigated the relationship between the two concepts, and there seems to be a consensus that the social environment of children is an important predictor as it can influence their lifestyles in multiple ways. First of all, the findings of Leonenko et al. (2019) show that children that participate in certain activities in their leisure time have better physical health. Furthermore, the research of Veitch et al. (2012) shows that neighborhood factors such as social trust and cohesion are related to a lower BMI in children. Additionally, Mustafaoğlu and his colleagues (2018) show that when children inappropriately use technology, this can cause obesity and physical inactivity. Lastly, research by Ståhl (2001) shows the effect that peers can have, as they found that social relations and social support can influence health behavior.

The gap in the literature These studies illustrate a gap in the literature, as they all focus on the effect of one specific aspect of the social environment on a specific part of lifestyles. However, there does not seem to be an overarching framework about how social environments influence the lifestyles of children, therefore the underlying mechanism remains unknown. Therefore, this thesis aims to investigate the mechanisms behind these potential relations and thereby hopefully contribute to such an overarching framework. Additionally, there seems to be a lack of consensus about which specific aspects of the social environment are important for a healthy lifestyle and in which way. Furthermore, there is also insufficient information available about the current state of the social environments and healthy lifestyles of children. Lastly, existing literature fails to provide a clear answer to how policy can contribute to a more healthy lifestyle and social environment for children.

Research questions Therefore this thesis aims to investigate the social environment and healthy lifestyles of children to be able to improve them. The first goal is to investigate the current state of the social environments and lifestyles of children. This leads to the first research question: ‘To what extent are the social environments and lifestyles of children aged 4-12 in the

Netherlands healthy?’. Furthermore, another goal of this study is to test the relationship between the two topics. In addition, we want to investigate potential differences in the effects of different aspects of the social environment. That leads to another set of research questions: ‘To what extent does the social environment of children aged 4-12 in the Netherlands influence their lifestyles?’ and ‘Which aspects of the social environment are most important for achieving a healthy lifestyle for children aged 4-12?’. Based on the answers to these questions, the last goal is to provide policy advice on how the (local) governments can contribute to making the social environments and lifestyles of children more healthy. That leads us to the policy question, namely ‘In which way can policy contribute to a healthy social environment and lifestyle for children aged 4-12 in the Netherlands?’.

Relevance These questions are societally relevant to investigate as when it becomes apparent how to achieve healthy social environments and lifestyles, society can try to provide this to children. That could lead to better outcomes for these children in terms of health and well-being. Since the social environment and healthy lifestyles do not only have short-term effects but can also influence outcomes later in life, for example regarding health (Evans et al., 2008; Szyf, M., 2011) they might thereby increase the contribution that these children will provide to society. In addition, this study is also scientifically relevant as it can help figure out which aspects of the social environment matter for healthy lifestyles for children, which can provide new insights and recommendations for future research. Lastly, this study can extend the knowledge on these two topics by investigating multiple aspects and thereby also provide more clarity about their association. This study is also practically relevant, as the mixedmethod approach can provide quality advice on how to contribute toward more healthy social environments and lifestyles for children. This study can thus provide organizations with valuable guidelines on how to approach these two topics and make them more manageable.

Municipality of Alblasserdam Although this thesis is of value to multiple parties, it is specifically targeted at the municipality of Alblasserdam. This municipality is currently increasingly concerned with the social and physical environment of children which is apparent from its vision to be ‘Fit and green’ and the collaboration with JOGG. JOGG (Jongeren op gezond gewicht) is an

organization attempting to make the social and physical environments of children more healthy and thereby make children’s lifestyles healthier, which is in line with the vision of the municipality. This is specifically relevant for Alblasserdam as there is a lot to gain concerning healthy lifestyles in Alblasserdam, visible in the 55 percent of the adult population in Alblasserdam that was overweight in 2016, which is above the national average (GGDzhz). Therefore, the children must achieve healthier lifestyles to prevent these high numbers in the future to reduce health care costs and improve levels of well-being. As the collaboration with JOGG is in the early stages, information regarding how to approach the situation in Alblasserdam can be valuable. Therefore, the policy advice will be specifically aimed at the municipality of Alblasserdam.

Research design To make this research relevant for both the municipality of Alblasserdam and for a broader audience, the focus will be on the situation in the Netherlands in general, with an additional case study about Alblasserdam. This will be executed using a mixed-method approach. Firstly, the current situation in the Netherlands will be investigated using existing quantitative data. Additionally, to research the specific state of affairs in Alblasserdam, qualitative data will be collected with the aim to dive deeper into the topics and answer questions that cannot be answered with the quantitative data. This will be done by conducting semi-structured interviews with the parents of children aged 4-12 years. As these interviews seemingly only paint part of the picture as they were fairly positive, experts’ opinions were also included.

Theory Healthy social environments We start by outlining some thoughts about the social environment of children, which in this study consists of the presence of peers, neighborhood, media education, and leisure. Because what exactly makes a social environment of a child healthy? As earlier mentioned there is no clear definition that is universally agreed on. However, McNeill et al. (2006) explain that the social environment influences people’s behavior in multiple ways. Such as by shaping people’s norms, providing opportunities to engage in certain behavior, enforcing patterns of social control, placing constraints on people’s choices, and producing or reducing stress. Therefore, a healthy social environment can be seen as one that reduces stress and provides opportunities for healthy behaviors, such as relaxation and meeting people. Research by Ståhl

et al. (2001) additionally states that a healthy environment includes social support from friends and family. Concerning existing literature, it seems like a healthy social environment for children is a concept that is rarely researched on its own. Therefore, the earlier given definition of social environments will be applied to classify them as healthy or unhealthy. This entails that whether a social environment will be considered healthy in this research depends on whether the scores on the four individual aspects are healthy. This raises the question of when these specific aspects can be considered healthy, which will be discussed later on.

Healthy lifestyles As briefly discussed, a healthy lifestyle for children entails one that improves their health and well-being. Multiple aspects are associated with such a lifestyle, such as healthy eating habits and a healthy sleeping schedule (González-Gross et al., 2008). Furthermore, research shows that a healthy lifestyle for children is dependent on multiple factors, such as the way mealtime is structured, and families’ physical activities (Cason-Wilkerson et al., 2015). This, therefore, shows that a healthy lifestyle is dynamic, it can easily change if other factors change. As earlier mentioned, in this study lifestyle will be measured by sleeping habits, intake of sweet drinks, and the water consumption of a child. Hereby, the healthier the sleeping pattern, the fewer sweet drinks, and the higher the water consumption, the healthier the lifestyle will be considered. There is not a large body of research about the current state of the lifestyles of children. However, as discussed in the introduction, some pieces of literature suggest that there is much to gain regarding healthy lifestyles for children. For example as an increasing number of children do not meet their recommended hours of sleep (Komrij et al., 2021). This leads to the expectation that regarding the lifestyles of children in the Netherlands, there is room to make them healthier.

Healthy social environments and healthy lifestyles We now approach the question of how a healthy lifestyle for children can be achieved. One of the factors that might have a positive relationship with a healthy lifestyle for children is a healthy social environment. The Socio-Ecological Model (Robinson, 2008) can provide insights into this relationship. This model includes the interpersonal level, or the social

environment, which contains processes such as social traditions, role expectations, and the culture which impact health behavior, such as eating habits. For example, acknowledgment and respect for a young person’s dietary goals can be considered supportive, while peer pressure can challenge youngsters to maintain a lifestyle change (Lang et al., 2021). Additionally, this level includes patterns that occur within families and peer groups. These groups and processes impact health behavior because they provide the individual with support, role definition, and social identity. Concerning improving health behavior, this theory states that health promotion programs focused on behavioral change through education or other strategies on the intrapersonal level neglect the social and environmental context in which these behaviors occur and are reinforced. Therefore, this theory suggests that improving the healthy lifestyles of children calls for interventions that target multiple aspects of the social environment (Robinson, 2008). This implies that the focus on multiple aspects of the social environment is important, to promote a healthy lifestyle for children as best as possible. It also shows that this theory argues that a healthy social environment is crucial for a healthy lifestyle for children.

There is also existing literature about the relationship between the social environment and healthy lifestyles for children. Robinson (2008) tested the earlier described SocioEcological Model and found that seven out of eight studies included in his review show that the social environment influenced the food choice of individuals. More specifically, results show that the social environment in general influenced dietary choices and health behavior by providing opportunities, contexts, and meanings for dietary choices. In addition, Veitch et al. (2012) found that a more positive social environment relates to a lower BMI, and thereby more healthy eating and drinking habits, for children. More generally, Dulin (2007) found that the social environment can promote or deter people’s well-being and health. Hereby, scholars seem to agree that the social environment is an important factor in achieving a healthy lifestyle for children. Taken together, the discussed theory and corresponding literature lead to the expectation that a healthy social environment can positively influence the lifestyles of children, which will be investigated by the quantitative and qualitative analyses. We will now turn to the relationship between the individual aspects of the social environment and a healthy lifestyle for children.

Presence of peers The first aspect of the social environment is the ‘presence of peers’, which solely entails whether or not children have peers present in their environment. The effect that peers, in general, can have on the lifestyle of children is something that has already been largely explored by existing literature. However, the effect that merely the presence of peers in the environment, not including the interactions with those peers, can have is less researched. Social Facilitation theory (Ward et al., 2016) can be applied to the relationship between the presence of peers and the lifestyle of children. This theory argues that the presence of others can influence the behavior of people. For example, research shows that adults eat more in presence of others than when they are alone, therefore dietary choices might be less healthy in the presence of peers (De Castro, 1993). Research by Ward et al. (2016) suggests that even though this theory is commonly applied to adults, it can also be applied to children. The mechanism behind social facilitation is still unclear, however, there are some suggestions. De Castro (1993) argues that social facilitation might happen through what he calls producing disinhibition, which entails that the presence of another person makes an individual more relaxed.

This, in turn, ensures that there is less of a brake on the behavior of this individual, therefore there are fewer constraints on his/her behavior. For example, eating with peers leads to a greater level of calmness which makes the individual free of constraints on eating. For the drinking behavior of children, this suggests that children would feel free to drink whatever they enjoy, which for children usually entails sugary drinks (Mennella et al., 2012). Therefore, this theory suggests that the presence of peers leads to less healthy drinking habits for children. However, the theory does not seem to particularly apply to sleeping patterns for children. Some researchers have already tested the influence that the presence of peers may have on the lifestyle choices of children. First of all, the research of Salvy et al. (2007) investigates the effect of peer presence on the dietary intake of children aged 6-10 years old that are overweight and children that are not. The results show that children who are overweight eat less when they are in the presence of peers, while children who are not overweight eat more when peers are present, suggesting an effect of peer modeling. These results show a clear effect of the presence of peers on dietary choices, which for children that are not overweight relates to less healthy eating habits (Salvy et al., 2007).

Furthermore, the research of Larson & Story (2009) specifically looked into the relationship between the social environment and the intake of soft drinks in children. Their results showed that the dietary

choices of children, including the consumption of soft drinks of individuals are influenced by the presence of their peers. This influence however depends on the social norms regarding dietary choices. As, according to Larson & Story’s (2009) study, soft drinks are one of the most consumed drinks in schools, one could assume that the social norms regarding drinking habits are drinking soft drinks. This suggests that the presence of peers leads to children feeling the need to follow the social norm and thus relates to less healthy drinking habits for children. The research of Godsell & White (2019) investigated the influence of peers on the sleeping behavior of 13- and 14-year old’s. Their results show that the children admitted that they felt that peers influence their sleep behavior, as they spend their nights communicating with their peers via their mobile phones. The research of Vaughn et al. (2015) showed that even for children of 4 years old, peer relations influenced their sleeping habits, as a higher peer acceptance relates to sleep duration for these children. These two studies show a clear effect of peers on the sleeping patterns of children, however, these entail interactions with peers, not just the presence of peers. Unfortunately, there does not seem to be literature regarding the relationship between the mere presence of peers and sleeping habits.

These theories and research clearly show that the presence of peers can affect the lifestyle choices that children make. With regards to merely the presence of peers, the literature and theories do not point towards a specific relation with sleeping patterns. Regarding the presence of peers and drinking habits, the literature and theory suggest that the presence of peers leads to less healthy dietary choices, which includes a higher consumption of soft drinks. This leads to the following hypothesis: H1.

The presence of peers relates to less healthy drinking habits for children.

Neighborhood The second aspect of the social environment is ‘the neighborhood’, which can be considered positive or healthy when the neighborhood is child-friendly. The relation between the neighborhood and a healthy lifestyle for children is something that has also already been partially explored by theory and research. First of all, Bronfenbrenner’s Ecological Systems theory (1998) can be applied to this relation. This theory argues that the relationships within the microsystems, or social environments, are bi-directional. This entails that the child is

influenced by things in their immediate environment, such as the neighborhood, but the child in turn can also influence their neighborhood. Bronfenbrenner argues that the environment, including the neighborhood, of children is capable of changing the beliefs and actions of a child (Guy-Evans, 2020). In the case of sleeping habits, this entails that the neighborhood can provide resources, such as safety and quietness, to help children sleep properly. Regarding drinking habits, the neighborhood can influence choices by store options that are available in the neighborhood. Therefore, according to the Ecological Systems Theory, the environment can influence the health behavior of children by the resources it does or does not provide (Holt et al., 2009). A few researchers already investigated the effect that neighborhoods can have on the lifestyles of children, regarding drinking habits and sleeping patterns. The study by Holt et al. (2009) shows that children in neighborhoods with, among other things, high access to healthy supermarkets, parks, and playgrounds tend to have healthier diets, including healthier drinking habits. This can be explained by the fact that people in neighborhoods with more such healthy stores have more opportunities to go there and purchase healthy foods and drinks. Veugelers et al.

(2008) researched the relationship between characteristics of the neighborhood and eating habits. Their results show that children in neighborhoods with access to supermarkets with reasonably priced fresh produce have healthier eating habits and were less likely to be overweight. This finding was explained through the opportunity that certain neighborhoods do or do not provide, which leads to different health behaviors. Lastly, the research of Marco et al. (2012) looked into the relationship between neighborhood environment and sleep patterns of young adolescents. Their results reveal that some neighborhood factors are associated with problematic sleep patterns for young adolescents, such as insufficient school-night sleep. There are multiple factors involved in this relation. For example, poorer neighborhood conditions lead to children going to bed later in the night. Additionally, children in neighborhoods with lower social-economic status have been found to have a lower sleep quality, possibly due to neighborhood noise and lightning. Furthermore, feelings of unsafety in the surrounding environment can interfere with the sleeping habits of children. Therefore, in multiple ways, an unsafe and not child-friendly neighborhood leads to less healthy sleeping habits.

Overall, the theories and literature seem to agree that a safe and child-friendly neighborhood promotes a healthy lifestyle for children, by providing these children the needed resources to

achieve this lifestyle. The literature clearly points to this effect for both drinking habits and sleeping habits. This leads to the second set of hypotheses: H2a.

A child-friendly neighborhood relates to more healthy drinking habits for children.

H2b.

A child-friendly neighborhood relates to more healthy sleeping habits for children.

Media education The third aspect of the social environment is the ‘media education’ provided by the parents. This is considered healthy if parents have rules about the media use of their child and if they are engaged in the media use of their child through supervision. The relationship between media education and healthy lifestyles for children is something that remains largely unexplored by theory and research. There are, however, some pieces of literature that can provide some sort of indication. The research of Bickham et al. (2015) shows in this regard that rules about media use are associated with lower levels of depression symptoms in children. The mechanism behind this relationship is not confirmed, but there is a possibility that these types of rules indicate parental involvement which is known to be protective against depression in children. This already provides an indication of a positive effect of media education on the well-being of children. Furthermore, findings from the research of van den Eijnden et al. (2021) indicate that strict rules about media use predict better quality of sleep for children. This possibly has to do with limiting the opportunities that these children have to engage in social media before going to bed and thereby increasing the time children sleep. Additionally, the research of Rosen et al.

(2014) investigated the relationship between technology and eating habits among children and teenagers. Their results point to the importance of parents setting limits and boundaries for their children regarding media use. The idea behind this is that parents can hereby provide opportunities to children to engage in other more healthy activities and habits to do that do not include screens. Furthermore, other scholars also confirm the importance of media education (Reid Chassiakos et al., 2016: Łuszczki et al.,2021), however, they only researched this concept in relation to the effects of media education. For example, Łuszczki et al. (2021) show that the use of media and smartphones for children let to poor sleep and less healthy eating habits, as it leads to fewer hours of sleep and lower sleep quality. As a solution to this problem, they argued for more media education, as appropriate parental control can restrict media use and thereby counter the negative consequences of media.

Despite media education by parents not being a common topic of interest for researchers, the existing literature shows that media education does promote more healthy choices for children. All findings taken together do suggest that this is also the case for dietary choices and sleeping patterns. Therefore, the expectation is that media education associates with healthier drinking- and sleeping habits for children. This leads to the following set of hypotheses: H3a.

Media education relates to more healthy drinking habits for children.

H3b.

Media education relates to more healthy sleeping habits for children.

Leisure The last aspect of the social environment is the activities that occupy the leisure time of children. This study includes the activities social media, gaming, and reading. Hereby, social media use and gaming are considered to be unhealthy ways of spending leisure. Rosen et al. (2014) found in this regard that media and technology use, such as social media and gaming, predicts ill-being in children. They argue that general screen activities, regardless of the number of hours, predict poor health outcomes, such as unhealthy dietary habits and physical inactivity. The reason behind this is that children tend to consume more calories while using technology, such as gaming, and such activities can, furthermore, replace physical activities. Reading in general, however, is considered to have a positive effect on children. HorowitzKraus & Hutton’s (2018) research shows in this regard that reading is important for a healthy brain- and language development for children, indicating that reading is a healthy way of spending leisure. They also confirmed that screen time, in general, harms the development of children, as it relates to lower cognitive control and language development.

Based on these insights, the leisure time of children will be considered healthy when a child spends their leisure time reading and considered less healthy when a child consumes video games or uses social media. The possible effect that these different ways of spending leisure time can have on the lifestyles of children is something that is not yet as largely explored by theory and research as some of the earlier discussed aspects. There are however some studies that are relevant to this relationship. The research of Maksniemi et al. (2022) looked into the relationship between active social media use and the sleeping habits of children. They found that for young

adolescents social media use is associated with delayed bedtime. For middle and late adolescents, social media use is related to emotional exhaustion. The mechanism behind this relationship is that the time spent using social media reduces the time that children sleep and thereby increases psychological problems. Furthermore, the research of Brambilla et al. (2017) looked into the sleeping habits of children aged 1-14 in relation to reading and the usage of video devices. Their results show that reading before bedtime does not associate with sleeping habits. However, the results do show that using video devices before going to sleep leads to less optimal sleep for children, for example sleeping lightly. A possible mechanism behind this is the light exposure from video devices in combination with the suppression of melatonin production. Mak & Fancourt (2020) looked into the relationship between reading for pleasure in childhood and outcomes in terms of healthy lifestyle behavior in adolescence. They found that reading at age eleven is associated with higher levels of fruit consumption at age fourteen. A possible explanation for this relation is that reading is associated with a better school performance, which relates to a higher chance of being informed on health-related matters. This in turn can increase the chance of healthy life choices.

Therefore, it seems like reading for pleasure is a positive predictor of healthy lifestyle choices. In addition, Turel et al. (2017) found that for children video gaming leads to increased consumption of sweet drinks. More specifically, the results showed that children tend to drink more sweet drinks while they are playing video games.

Therefore the existing literature does point towards a positive relationship between more healthy ways of spending leisure time and healthy lifestyle choices of children. In this regard, the literature shows that playing video games leads to increased consumption of sweet drinks, while reading is associated with healthier drinking habits. This leads to hypothesis 4a. The research also clearly shows that social media and gaming relate to less healthy sleeping habits, this leads to the expectation that a healthier way of spending leisure leads to healthier sleeping habits, see hypothesis 4b. H4a.

A healthier way of spending leisure time relates to healthier drinking habits.

H4b.

A healthier way of spending leisure time relates to healthier sleeping habits.

When looking at the individual aspects of the social environments of children, it is possible that they differ in the way and the extent to which they influence the lifestyle of children.

Existing literature does not have a clear answer to this. Whether or not this might be the case will be investigated through the qualitative part of this study.

Methodology As aforementioned, this study uses a mixed-methods approach, meaning that it contains both quantitative and qualitative data. As these two different forms of data require different methods of analysis, their methods will be discussed separately and in sequence. First of all, the quantitative methods concerning the dataset will be discussed, after which the qualitative methods regarding the interviews with the parents and experts will be discussed.

Quantitative methods Dataset For the quantitative part of this study, data will be used from the Kindmonitor 2017 from the GDD Zuid-Holland Zuid (GGD zhz, 2017). The Kindmonitor is a questionnaire for parents which includes all sorts of questions about their child and its environment. The dataset contains the age groups 0-4 and 4-12, but for this research, only the part concerning the age group of 4-12 was used as the target group for this study is children in primary school. This part of the data contains 4.850 participants. 48.7% of the children of the participants are girls while 51.3% are boys. The data includes children from the age of 4 to 12, with each age being approximately evenly represented. The reach of this questionnaire contains 15 towns in the area of Zuid-Holland Zuid, including Alblasserdam. More specifically, of the 4.850 participants, 299 are from Alblasserdam. Furthermore, all questionnaires took place between September 2017 and December 2017. Regarding the recruitment, 16.000 parents of children aged 0-12 in the area of Zuid-Holland Zuid were invited to participate in the research. The participants did not get paid for participating in the questionnaire.

Measures Healthy lifestyle In order to answer the research questions, several key concepts need to be operationalized. First of all, a healthy lifestyle for children will be measured using multiple variables in the

dataset concerning lifestyle. The first question is: ‘Do you have a set bedtime for your child?’, with the answer categories 0 (no) and 1 (yes). The other questions are: ‘How many days a week does your child drink sugary drinks?’, ‘How many glasses of sugary drinks does your child drink on those days?’, ‘How many days a week does your child drink water or tea without sugar?’, and ‘How many glasses of water or tea without sugar does your child drink on those days?’. These four questions have answer categories ranging from 1 (very little) to 8 (very much). The two questions concerning the consumption of sweet drinks have a Spearman’s correlation of .56 (p <.001), meaning that their correlation is high enough to be merged into a scale. Therefore, they were recoded and merged together based on their mean scores to one scale about sweet drinks, ranging from 1 (large consumption of sweet drinks) to 8 (little consumption of sweet drinks). The same was done for the two questions regarding water consumption, which have a Spearman’s correlation of .634 (p <.001). Based on their means, they were merged into a scale ranging from 1 (little consumption of water) to 8 (large consumption of water). As the correlation between the variables for sweet drinks, water, and bedtime is low, they cannot be merged into one scale that includes all three facets of a healthy lifestyle.

Therefore, these three will be separately used in the analyses.

Social environment Furthermore, the social environment will be measured using the four aspects that together represent the social environment in this study.

Presence of peers The first aspect of the social environment regarding the presence of peers will be measured by the following statement included in the dataset: ‘There are too few friends for my child to play with outside’. The answer categories for this question range from 1 (low presence of peers) to 3 (high presence of peers).

Neighborhood The second aspect of the social environment, the neighborhood, will be measured by a variable in the dataset that specifically concerns the child-friendliness of a neighborhood. Namely, ‘How child-friendly is the neighborhood in which you live?’, which answer

categories range from 1 (very child-friendly) to 4 (not child-friendly). This was recoded to a higher score meaning a higher degree of child-friendliness.

Media education The third aspect of the social environment, media education is measured by five questions in the dataset regarding this topic. The first question is: ‘Do you have rules and agreements with your child about the number of hours that your child can use a computer, laptop, or mobile phone to surf the Internet, play games, or watch TV?’, with the answer options 1 (yes) and 2 (no). As this variable is binary, it could not be merged into a scale with other variables. Therefore, it will be used separately. The other four questions are: ‘Do you know which sites your child visits on the Internet?’, ‘Do you always know who your child is chatting or texting with?’, ‘Do you watch your child when he/she is on the internet?’, ‘Do you talk to your child about what he/she sees on the internet?’. The answer scales of these questions reach from 1 (always) to 4 (mostly not), with an additional answer category of 5 (not (yet) applicable). The last four questions will be merged into a scale of parental supervision with a Cronbach’s alpha of .729 reaching from 1 (low media education) to 4 (high media education). Therefore, this aspect of the social environment entails two measures, the question about the rules concerning media use and the scale regarding parental supervision.

Leisure The last aspect of the social environment, leisure, is measured using three questions concerning leisure activities in the dataset. The first question is: ‘How often does your child read by himself (outside school hours)?’, with the answer categories ranging from 1 (every day), 2 (a few times a week) to 3 (never). The other two questions are: ‘Does your child use social media?’, and ‘Does your child play video games?’, which could be answered by 0 (no), 1 (yes), and 2 (I don’t know), of which the score 2 (I don’t know) was coded as missing. These three variables were recoded so that a higher score means more healthy spending of the leisure time. For social media and video games, this entails the answer categories 0 (yes), and 1 (no). As these three variables were not highly intercorrelated, they cannot be merged into one scale. Therefore, they will be used separately.

Control variables Next to the dependent and independent variables, this study also includes a few control variables. These are age, educational attainment of parents, gender, and parenting difficulty. Age is measured by the question ‘What is the age of your child?’, with the answer options ranging from 4 to 12. The education of parents is measured by the question ‘What was the highest completed education of you and your partner?’, with 1 being ‘low educated’ and 3 being ‘highly educated’. Gender of the child is measured by the question ‘Is your child a boy or a girl?’, with 1 ‘boy’ and 2 ‘girl’. These three variables are included as control variables as they are potential confounders in the expected associations. Lastly, parenting difficulty is measured by the question ‘How do you experience raising your child?’, with the answer categories ranging from 1 ‘very easy’ to 5 ‘very hard’. This variable is included as a control variable as the expectation is that parents that find raising their child difficult can affect the outcomes of their children with regards to lifestyle and social environment. For example, Sadeh et al. (2010) found in this regard that parental difficulty, such as setting limits, relates to sleep problems for children.

Even though the effect of parenting difficulty on other lifestyle behaviors might not have been researched yet, it can’t be ruled out that the effect is in fact present. Therefore, parenting difficulty will be included as a fourth control variable.

All missing values on the earlier discussed measures were excluded. In total, the selection of the aforementioned variables leads to a sample consisting of 3853 participants. See Table 3 for the descriptive statistics of all concepts included in this research.

Analyses To test the hypotheses and thereby answer the research questions, statistical analyses will be conducted using the program SPSS. In advance of the analyses, the variables of interest were tested for multicollinearity. Concerning the analyses, linear regression analyses will be used for the analyses including the consumption of water and sweet drinks. Furthermore, as the variable bedtime is binary, the analyses with bedtime as the dependent variable will be executed using logistic regressions. For every analysis, the regression coefficient or odds ratio and the significance level will be presented. Furthermore, for the linear regressions, the tvalue and the degrees of freedom will be displayed.

To assess the first hypothesis regarding the relationship between the presence of peers and a healthy lifestyle, two regressions will be conducted, one including sweet drinks and the other including water as dependent variables, and the presence of peers as the independent variable. To test the second set of hypotheses concerning the association between the neighborhood and healthy lifestyles, there will be three regressions conducted, this time including the three variables about healthy lifestyles as the dependent variable and neighborhood as the independent variable. Hereby the regression with bedtime as the dependent variable will be logistic and the other two regressions will be linear. Likewise, for the third set of hypotheses about the relation between media education and healthy lifestyles, three regressions will be conducted with the three variables concerning healthy lifestyles as the dependent variable and media education as the independent variable, with the analysis for bedtime being logistic. To test the fourth set of hypotheses regarding the relationship between leisure and healthy lifestyles, another set of three regression analyses will be conducted with the healthy lifestyle variables as the dependent variable and leisure as the independent variable. Again, the analysis including bedtime as the dependent variable will be logistic.

Lastly, to test whether the found effects of the analyses mentioned above will hold, all four aspects of the social environment will be put into the analyses together. Entailing one multiple regression analysis for sweet drinks and one for water, and a logistic regression for bedtime. Hereby, the aspects of a healthy lifestyle are the dependent variables, and the presence of peers, neighborhood, media education, and leisure are the independent variables. An overview of all variables and the accompanying hypotheses can be found in Figure 1. Furthermore, every analysis will firstly be run with the control variables age, education attainment of parents, gender, and parenting difficulty, to rule out the effects of these potential confounders.

Ethical considerations Potential participants received an invitation letter which, among other things, included information about the goal of the interview, how privacy issues are handled, and whom to reach in case of questions. Furthermore, the questionnaire itself also included a paragraph regarding the freedom to skip questions if respondents felt uncomfortable answering them.

Figure 1.

Path model of all variables and accompanying hypotheses

Qualitative methods To be able to dive deeper into the two topics of interest, this study also entails a qualitative part, which can help to paint the picture behind the quantitative numbers. Therefore, five parents of children aged 4-12 in Alblasserdam were interviewed. As the input of the parents on its own seemed surprisingly positive, the choice was made to also include expert interviews. The aim is that this will bring another perspective and, furthermore, reduce the potential selection bias. The methods of these two types of interviews will firstly be discussed in sequence, after which the joint analyses and the ethical considerations will be discussed.

Interviews with parents Selection and recruitment Concerning the interviews of the parents of the children in Alblasserdam aged 4-12, the recruitment took place via the schools of their children. All the primary schools in Alblasserdam were firstly introduced to this study via a short introduction in a recurring meeting with all primary schools in Alblasserdam and the municipality. A few weeks later, the directors of the schools got contacted via e-mail asking if they could share an information letter with the target group (see Appendix 1 for the information letter). Via the contact details included in the information letter, the parents could inform the researcher of their willingness to participate in the interviews. Hereafter, appointments were made via e-mail with the parents. In total, five parents were interviewed, whose children go to four different schools and all live in different neighborhoods. See Table 1 for the description of the participants.

Table 1. Description semi-structured interviews with parents Participant Gender

Age child

Gender child

Neighborhood

School

1

Male

7

Girl

De Dijk

Het Kompas

2

Female

10

Girl

Schrijversbuurt Het Kompas

12

Boy

Schrijversbuurt Special education

3

Female

12

Boy

Souburgh

Beukelmanschool

4

Female

4

Boy

Centrum

Beukelmanschool

6

Boy

Centrum

Beukelmanschool

4

Boy

Bloemenbuurt

t’ Nokkenwiel

5

Female

Data collection As some people might not feel comfortable meeting in person due to the pandemic, the participants were offered the possibility of both an online and offline version of the interview. All participants chose to meet in person. On average the interviews lasted approximately 45 minutes, with some interviews being longer than others. The interview questions were made

based on the questionnaire of the earlier mentioned dataset of the Kindmonitor, the website of JOGG, as well as the theoretical framework of this study. See Appendix 3 for an overview of the main interview questions. To provide sufficient space for in-depth and follow-up questions, the interviews took place in a semi-structured manner. Therefore, the content of the interviews differed slightly per interview, depending on the course of the interview. After the interviews were completed, they were transcribed, after which the recordings were deleted. The interviews took place from March-April 2022.

Experts interviews Selection and recruitment After the interviews with the parents took place, the input that the parents provided seemed surprisingly positive. This could be due to participants answering in a socially desirable manner. However, it also leads to the suspicion that it might be the case that mostly parents that are engaged with their child and their lifestyle tend to react to these types of invitations. Therefore, it is possible that these interviews largely include cases in which everything is going very well, but do not cover the more ‘problematic’ cases concerning lifestyles and social environments. Luckily, Alblasserdam knows multiple organizations and experts that are engaged with children and youths in Alblasserdam. Three organizations were chosen, which all in a very different way frequently interact with the target group. The first organization is ‘Jongerenwerk’, which aims to be present where children are and tries to support children by organizing fun activities but also activities surrounding prevention, for example concerning drug use. The second organization is the ‘ABC-team’, which organizes cultural and sportrelated activities for multiple age groups, including children aged 4-12. Lastly, two experts from the organization ‘Jeugdteams’ were interviewed together in the third and last interview.

Their organization supports families that voluntarily ask for help by helping these families solve their problems or by referring them to other specialists. They were all interviewed as the expectation is that they have relevant experience with our target group, see Table 2 for an overview. Table 2. Description semi-structured interviews with experts Participant