Staff perspectives on the feeding practices used in holiday clubs to promote healthy eating in disadvantaged communities

Abstract An increasing number of holiday clubs provide free meals to alleviate children's hunger during the school holidays. Holiday clubs are well‐placed to promote healthy eating among children from disadvantaged communities who may be at risk of experiencing food insecurity, but currently little is known about the feeding practices used by staff and whether these are conducive to maximising opportunities to promote healthy eating. Unlike previous research which has predominantly studied feeding practices in parent‐child dyads and childcare settings, this qualitative study explored staff perspectives on the feeding practices they use to promote healthy eating within nine UK holiday clubs working with children from disadvantaged communities. Nine individual interviews and four focus groups were completed with 27 holiday club staff during the 2019 summer holidays. Thematic analysis revealed seven feeding practice themes, including teaching about nutrition; encouraging balance and variety; modelling; involvement; non‐food rewards; restriction; and reoffering foods. The results revealed that some staff implement various positive feeding practices which align with the existing evidence‐base of feeding practices in other contexts, which is a promising finding given the current lack of information and guidance from which to draw on. However, staff also sometimes reported using maladaptive feeding practices, including overt restriction and punishment. These results emphasise the need for guidance on effective ways to implement feeding practices with children in holiday clubs. Indeed, staff demonstrated their receptivity to engaging with training resources to maximise their opportunities to promote healthy eating behaviours among children.


| INTRODUC TI ON
Holiday hunger describes families who experience or are at risk, of seasonal hunger that occurs in households when pupils are on school holidays (Long et al., 2021, p. 2). An increasing number of UK holiday clubs are providing free food to children to alleviate holiday hunger (Long et al., 2018). In addition to providing food, research suggests that holiday programmes such as the London-based 'Kitchen Social' and North-East England-based 'A day out not a handout' have numerous benefits for children and families such as promoting health and wellbeing, and social and academic attainment Defeyter, Stretesky, Sattar, & Crilley, 2018). These studies highlight that holiday clubs are a meaningful setting for enabling health-enhancing behaviours, such as engaging children in physical activity (Graham et al., 2016) and encouraging healthy eating (Connor et al., 2015;Morgan et al., 2019). Only 18% of children aged 5-15 consume the recommended minimum daily intake of fruit and vegetables (NHS Digital, 2019), and therefore encouraging healthy eating is a major public health issue (British Medical Association (BMA), 2018).
Children have an innate preference for sweet foods and aversion to sour and bitter tastes (Birch, 1999), and food preferences and aversions could explain why children scarcely consume the recommended number of fruits and vegetables (Dovey et al., 2008).
One factor known to influence children's eating behaviours is caregiver feeding practices. Feeding practices are the food-related interactions fostered between caregiver and child, which shape the child's eating behaviour (Vereecken et al., 2010), and they can be categorised as either positive or maladaptive. Positive feeding practices encourage healthy eating behaviours in children (Kaukonen et al., 2019). Examples include modelling consumption of healthy foods, involving children in food choice and preparation, and increased availability of healthy foods (DeCosta et al., 2017). Positive feeding practices are associated with positive eating behaviour outcomes such as greater enjoyment of food and lower food fussiness among children (Holley et al., 2020). Controlling feeding practices such as pressuring children to eat and restricting food are considered maladaptive practices (Johnson & Birch, 1994). Controlling feeding practices can have counterproductive effects on children's eating behaviours as they can result in selective food preferences and reduced ability to self-regulate energy intake (e.g. Mitchell et al., 2013).
Research related to feeding practices has predominantly been conducted with parent-child dyads (Lumeng et al., 2012;Moens et al., 2018).
Despite many children spending a significant proportion of their day in childcare settings (Hughes et al., 2007), research in these settings is limited in comparison. The foods served to children and the methods used to feed children in childcare settings shape children's food experiences and influence lifelong food habits which are established in children's early years (Briley & McAllaster, 2011;Nicklas et al., 2001). Holiday clubs targeting children from disadvantaged communities are also an important setting to explore staff feeding practices, as these children typically have a more limited diet (Morales & Berkowitz, 2016), consume fewer vegetables (The Food Foundation, 2020), and are at increased risk of experiencing food insecurity (Denney et al., 2018), developing obesity (Frongillo & Bernal, 2014), and experiencing eating disorders later in life (Hazzard et al., 2020). As feeding practices research has typically engaged more affluent communities, insights into the practices used with this at-risk population are vital.
UK holiday clubs create multiple opportunities to promote healthy eating among child attendees (Holley et al., 2019), including providing access to a novel range of healthy foods, developing children's confidence to try new foods, and promoting positive social experiences around food. However, as no known research has been conducted which explores the feeding practices used in holiday clubs, this qualitative study sought to explore staff perspectives on the feeding practices used in holiday clubs to promote healthy eating among children from disadvantaged communities.

What is known about this topic
• Food insecurity is rising in the UK, and this is magnified during the school holidays when children cannot access food at school.
• Children from disadvantaged communities are more likely to experience food insecurity and have a poor diet than their affluent counterparts, which has short and long-term adverse health and wellbeing outcomes.
• Holiday clubs provide free food during the school holidays to alleviate food insecurity and provide enrichment opportunities for children, making them a meaningful setting for promoting children's healthy eating behaviours.

What this paper adds
• Some holiday club staff use a variety of positive feeding practices that are conducive to promoting children's healthy eating in holiday clubs, therefore, indicating that holiday clubs have a role to play in addressing inequality.
• However, some staff reported using some maladaptive feeding practices, which should be avoided as they could negatively impact children's eating behaviours.
• Staff within holiday clubs can benefit from support including training opportunities and guidance on how to implement positive feeding practices in order to maximise opportunities to promote healthy eating and reduce inequalities.

| Participants and research setting
Participants were staff delivering holiday clubs overseen by Barnardo's and StreetGames during the 2019 school summer holidays. Barnardo's and StreetGames are UK national charities that both aim to improve the lives of children from disadvantaged communities (Barnardo's, 2021;StreetGames, 2019). Table 1 provides a breakdown of the characteristics of the nine clubs engaged in the study, including provider name, locality, funder, guidance used to inform food provision, details of food provision, venue type, target age group, approximate number and age of child attendees. Seven were funded by the Department for Education (DfE) as part of the Holiday Activity and Food (HAF) programme, and two were non-government funded. Clubs were located in London, Leicestershire, Newcastle and Coventry, and ran in various settings including community centres, sport centres and schools. Clubs were varied in the specific target age group and number of child attendees.
Some holiday clubs were located in deprived areas while others were located in more affluent areas, but all are serving disadvantaged communities within those localities. Similarly, clubs varied in the proportion of FSM eligible children attending the club, typically varying between 50% and 90% where specific data were available.
Twenty-seven club staff participated in nine interviews and four focus groups. Staff were over the age of 18 and held either a paid or voluntary role within the club.

| Recruitment and data collection
The researcher contacted the charities Barnardo's and StreetGames to request their support in recruiting holiday clubs for the study. The charities provided a list of holiday clubs to approach for recruitment which enabled the researcher to determine whether the holiday clubs met the inclusion criteria, and to recruit a purposive sample of holiday club staff to engage in the research. The club inclusion criteria were: (1) predominantly targeted primary school aged children (e.g. age 5-11 years) consistent with the age range typically targeted in other feeding practice research; (2) primarily engaged free school meals (FSM) eligible children, where FSM eligibility serves as a reliable proxy for low socioeconomic status (Taylor, 2018) and therefore increased likelihood of experiencing holiday hunger; (3) parents not attending the clubs, as this study required insights into how staff acted as caregivers in feeding children.
The lead researcher emailed the leader of each club meeting the inclusion criteria requesting permission to approach staff to participate in the study. Willing club leaders circulated participant information sheets inviting staff to participate in an interview or focus group. Club leaders then confirmed a date for the lead researcher to visit the clubs to interview willing staff. Telephone interviews were carried out with participants who were unavailable during the visit.
Before the interviews/focus groups began, staff were asked to complete a consent form and short demographics form. Interviews lasted approximately 30-40 min, and focus groups approximately 35-65 min, with between three and nine participants in each group.
Interviews/focus groups were audio recorded and facilitated by the lead researcher using a semi-structured approach to address the study aims while also enabling elaboration and clarification.
Interview questions ( Table 2) were derived from reviewing relevant literature, and through peer review from the research team.

| Data analysis
Interviews were transcribed verbatim and analysed, guided by Braun and Clarke's (2006) thematic analysis framework. Thematic analysis complements research positioned within an interpretivist paradigm (Braun & Clarke, 2006;Flick, 2015) and provides flexibility through the analysis process while also having the potential to generate a rich and detailed account of data (Braun & Clarke, 2006). NVivo software was utilised to enable the data to be organised into generated codes and themes.
The thematic analysis was conducted using a combined inductive and deductive approach. The inductive approach was adopted (Boyatzis, 1998) because there is no known literature available to draw upon on the use of feeding practices in holiday club contexts. A deductive approach was also adopted, drawing on the existing feeding practices evidence-base. Other research has adopted this hybrid approach to thematic analysis (e.g. Fereday & Muir-Cochrane, 2006).
The lead researcher (NB-Doctoral Candidate) read each transcript to become familiarised with the data. Transcripts were coded, and from there, codes were organised into an initial thematic framework. Transcripts were further coded and recoded as the coding and thematic framework evolved. Additional researchers (CH-Senior Lecturer, CM-Senior Lecturer, PB-Doctoral Candidate) performed analysis on 10% of the transcripts to ensure reliability of the analysis conducted. Team members (CH, CM) supported refinement of the thematic framework to improve its structure and robustness.

| Participant characteristics
Staff (N = 27) ranged from 19-59 years old (mean = 32.43 years) and were predominantly female and White British ( Table 3). Most staff were educated below university level, while five (19%) had nutritional qualifications, including food hygiene qualifications, nutritional advice qualifications, and a national certificate in nutrition for sport. The number of years working at the club varied greatly, as did the staff roles.

| Thematic analysis
Staff perspectives of the feeding practices used with children in holiday clubs were explored, revealing the use of numerous feeding practices (summarised in Figure 1). In addition, Table 4 identifies which feeding practices described by staff were positive and maladaptive feeding practices. We do the certificates and we put a reason why they got it. We don't just give them some certificate…

TA B L E 1 Holiday club characteristics
There's a reason why they've been amazing today.
Verbal praise was also used as a reward, which was considered an effective method for encouraging children to try healthy and unfamil-

| DISCUSS ION
This study explored staff perspectives on the feeding practices they use to promote healthy eating in holiday clubs working with children from disadvantaged communities. To our knowledge, this is the first study to explore the use of feeding practices in holiday club settings.
The findings revealed seven themes of feeding practices used, which align with the existing evidence-base of feeding practices among parent-child family dyads (e.g. Moens et al., 2018), and in group contexts such as school and childcare (e.g. Elford & Brown, 2014). Most practices used were positive feeding practices, including encouraging balance and variety, teaching about nutrition, modelling healthy eating behaviours, involving children in food choice and preparation, offering non-food rewards and reoffering foods (repeated exposure). However, sometimes maladaptive feeding practices were used, including overt restriction and punishment. Additionally, staff implemented feeding practices in various nuanced ways, resulting in typically positive feeding practices sometimes being implemented in maladaptive ways.
Staff reflected on the importance of providing healthy foods and encouraging balance and variety. This practice is supported by previous research which suggests that the increased availability of healthy foods (e.g. in the home environment) increases the likelihood of children consuming these types of foods (Campbell et al., 2007;Cullen et al., 2003), as this promotes children's healthy food choices (Nepper & Chai, 2015). Some staff also reflected their use of verbal encouragement to support children to try new and healthy foods. Encouragement and praise have been associated with increased fruit and vegetable consumption among children (Vollmer & Mobley, 2013). Staff reporting the use of these positive feeding practices provides reassuring insights that staff recognise the importance of meaningful practices that are conducive to promoting children's healthy eating behaviours.
Staff also reported using fun, subtle approaches to teach children about nutrition, such as playing games, and writing poetry and songs about vegetables. Previous research suggests using poetry during school health education lessons increases knowledge and awareness about healthy eating (Robinson et al., 2018). Similarly, staff reported involving children in food choice and preparation and using innovative approaches to modelling such as using superheroes and celebrities as models for healthy eating. Involving children in food choice and preparation is associated with greater enjoyment of food and lower food fussiness among children (Holley et al., 2020).
Similarly, modelling has been associated with increased liking and consumption of fruit and vegetables (e.g. Lowe et al., 2004). The findings, therefore, highlight that staff in holiday clubs are able to implement positive feeding practices in ways that engage and appeal to children, which is important for encouraging children's healthy eating behaviours.
Staff reported using various methods when reoffering healthy and unfamiliar foods to children. For example, some staff encouraged children to try foods through sensory exposure (e.g. experiencing food through smell and sight). This technique has been found to induce short-term decreases in food neophobia and increases in children's willingness to taste novel foods (Dazeley et al., 2012;Mustonen & Tuorila, 2010), and therefore using this technique in holiday clubs may be particularly valuable in the event that children show fussiness or reluctance to try foods being offered to them.
Staff also encouraged repeated exposure by accompanying healthy foods with other foods (e.g. dips) and by hiding unpopular foods within more popular foods. Offering dip alongside vegetables has been associated with increased vegetable consumption in preschool children (Savage et al., 2013), and qualitative studies have found that caregivers often conceal vegetables within other foods (Holley et al., 2016;Pescud & Pettigrew, 2014). Importantly, staff should utilise food concealment in conjunction with serving vegetables in identifiable forms, as this increases children's awareness and liking for vegetables (Birch et al., 1998;Birch & Marlin, 1982). Finally, staff reported presenting foods in visually appealing ways to promote consumption, which aligns with previous qualitative research with caregivers (Holley et al., 2016). Although research on the effects of food presentation on children's eating behaviour is limited and equivocal (DeCosta et al., 2017;Holley et al., 2016), it is promising that holiday club staff consider the effects that food presentation may have on children's interest and willingness to try the foods provided to them.
In this study, staff revealed the use of maladaptive feeding practices, including overt restriction. Some staff described using covert restriction by avoiding providing unhealthy foods, as well as overt restriction, by telling children not to bring unhealthy foods and removing sweets from children. The overt restriction is a form of food restriction which is noticeable to the child, which can inadvertently result in restricted foods becoming more appealing and increased consumption upon availability (e.g. Ogden, 2003;Polivy & Herman, 1985). The covert restriction is therefore recommended as by making unhealthy foods unavailable, children are not explicitly denied certain foods (Ogden et al., 2006). Staff may benefit from working with parents to avoid children bringing unhealthy foods into the club, to prevent the use of overt restriction with children.
During discussions with staff about using rewards with children, some staff demonstrated using instrumental feeding (Mason, 2015), where children are rewarded for completing desired eating behaviours (e.g. finishing foods) or punished by withholding rewards when desired behaviours are not completed (Kohn, 1993;Mason, 2015;Reitman, 1988). Instrumental feeding has been associated with negative eating behaviours among children such as overeating (Rodgers et al., 2013), snacking (Rodenburg et al., 2014), and higher weight status as young adults whose parents reported using instrumental feeding when their child was young (Puhl & Schwartz, 2003). These results indicate the importance of supporting staff on effective ways to implement rewards with children to avoid the practices be-  (Birch et al., 1987), which reduces children's ability to self-regulate their energy intake, and long-term can lead to overeating (Mitchell et al., 2013).
This qualitative study was exploratory and small scale, but provides meaningful insights as the first study to explore staff perspectives on the feeding practices used in holiday clubs supporting children from disadvantaged communities, where previous research typically engages more affluent communities. This study focuses on staff perspectives of their feeding practices and does not measure their actual use of these practices. Future research utilising methods such as mealtime observations may therefore be beneficial to explore this. Additionally, research on parent's and children's perspectives of feeding practices in holiday clubs would also provide valuable insights.
It is important to highlight that the feeding practices identified in this study were not all implemented by all staff, and that staff practices were highly variable, which again indicates the value in staff accessing training and guidance to support their work. While small sample sizes are inherent in qualitative research and therefore results may not only be generalisable to the wider population (Trochim, 2021), utilising a qualitative approach enabled this study to capture rich discussions of not only what feeding practices were used, but also how staff implemented them. Staff implemented numerous feeding practices in various nuanced ways, which resulted in some typically positive feeding practices sometimes being implemented in maladaptive ways. For example, offering non-food rewards for completing desired eating behaviours like trying new foods (a positive feeding practice) or withholding rewards if desired behaviours are not completed (a maladaptive feeding practice). This study therefore builds on the feeding practices evidence-base, as other data collection methods such as self-report questionnaires measure feeding practices more rigidly as either positive or maladaptive, while this study allowed the nuances and variations in their implementation to be uncovered and explored.
This study is the first to explore staff perspectives of the feeding practices they use when feeding children and promoting healthy eating in holiday clubs. Staff reported implementing a range of positive evidence-based feeding practices in various ways which may promote positive eating behaviours in children, which is promising given the lack of feeding practices information resources and guidance from which to draw on. However, there are aspects of staff feeding practices that were maladaptive which could have negative impacts on children's eating behaviours if not appropriately reframed. These results therefore highlight the need for guidance on effective ways to implement positive feeding practices with children in holiday clubs. Indeed, staff highlighted their receptivity to engaging in training opportunities in different methods to feed children and how to implement them, suggesting staff would likely utilise such resources upon availability. The provision of support resources can illustrate how staff can make simple adjustments to reframe their feeding practices from maladaptive to positive. For example, offering praise for the act of tasting foods rather than the aim of finishing their foods. Supporting holiday club staff to promote healthy eating by enhancing their knowledge of evidencebased feeding practices will ensure that children experiencing food insecurity are provided important opportunities to develop healthy eating behaviours. Building on this research, future research should explore what factors influence the feeding practices used in holiday clubs to identify how positive feeding practices can best be implemented in holiday clubs.

ACK N OWLED G EM ENTS
The authors would like to thank the staff at StreetGames and Barnardo's, and the holiday clubs, for facilitating participant recruitment. Thank you to the study participants for contributing their time and insights. Thank you also to Parita Bharadia for her valued contribution in the second coding during study analysis. Finally, the authors thank the School of Sport, Exercise and Health Sciences, Loughborough University, for funding this research.

CO N FLI C T O F I NTE R E S T
There are no conflicts of interest associated with this research.

AUTH O R CO NTR I B UTI O N S
All authors have substantially contributed to the design and implementation of the study as well as drafting and reviewing the manuscript. All authors have approved the final version of the manuscript and accept accountability for all aspects of the manuscript.

E TH I C A L A PPROVA L
This study received ethical approval from the Loughborough University Ethics Committee (ref: SSEHS-2543) and conforms to the ethical standards recognised by the Social Research Association "Research ethics guidance" (SRA, 2011). All study participants signed a written consent form prior to taking part in this study.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data are not available on request due to privacy/ethical restrictions (participants did not consent to data sharing).