Workshops Delivery and Participant Characteristics
Workshops were presented in French to a total of 17 participants. Characteristics of the participants are presented in Table 2. Fifteen participants (88%) were parents, of which 11 (65%) were mothers. Four children attended the workshops (3 patients and 1 sibling) of which 2 were too young to answer the questionnaire. Two participants attended to more than one workshop.
On a total of 45, 13 workshops (29%) were delivered and 32 (71%) were cancelled (Table 3). Over the 12-month implementation period (March 2018 to March 2019), 7 of the workshops delivered (69%) were held with only the facilitator, without the chef (Table 3).
Table 2. Characteristics of the workshop participants
|
All participants
n=17
|
Participants per workshop, mean (SD, range)
|
1.53
(0.52, 1-2)
|
Relationship with patient, n (%)
|
|
Mother
|
11 (65%)
|
Father
|
4 (23%)
|
Patient
|
2 (12%)
|
Participants enrolled in the VIE study, n (%)
|
10 (59%)
|
Participants who participated to more than one workshop, n (%)
|
2 (12%)
|
SD : Standard deviation
Table 3. Characteristics of the workshops as described by the facilitator in the activity report
Characteristics
|
Workshops
|
Workshops canceled, n (%)
|
32 of 45 (71%)
|
Workshops delivered, n (%)
|
13 (29%)
|
Meal fortification, n (%)
|
3 (23%)
|
Taste and preferences, n (%)
|
3 (23%)
|
Digestive side effects, n (%)
|
2 (15%)
|
Mediterranean diet, n (%)
|
1 (8%)
|
Planning economic meals, n (%)
|
4 (31%)
|
Nutritional support, n (%)
|
0 (0%)
|
Workshops delivered without the chef, n (%)
|
9 (69%)
|
Duration in minutes, mean (SD, range)
|
|
All workshops
|
51.4 (12.8, 40-90)
|
Workshops without the chef
|
45.9 (4.0, 40-50)
|
Workshops with children participants, n (%)
|
4 (31%)
|
Workshops with 100% of the messages covered, n (%)
|
7 (54%)
|
High to very high level of interest as perceived by the facilitator
|
12 (92%)
|
SD : Standard deviation
To evaluate workshop interest and barriers to participation, we surveyed the families enrolled in the VIE study (Table 4). Twenty-six families out of 31 answered the appreciation survey: one family could not be reached and 4 others dropped out of the VIE study before the survey was conducted. At the time of the survey, patients’ mean time since diagnosis was 8 months (range of 1 to 14 months) (Table 4). Because of low the participation at the workshops, data from the observation checklist were not collected.
Table 4. Demographic characteristics of families who completed the appreciation survey
|
Participants
n=26
|
Relationship with patient, n (%)
|
|
Mother
|
19 (73%)
|
Father
|
6 (23%)
|
Patient
|
1 (4%)
|
Sex of the patient, male n (%)
|
17 (65%)
|
Age of patient (years), mean (SD, range)
|
7.80 (4.99, 1.68-18.09)
|
Time since diagnosis (months), mean (SD, range)
|
7.98 (0.81, 1.63-14.23)
|
SD: Standard deviation
Evaluation of the Implementation Process
This section details the perceptions and opinions obtained from the families and the facilitator. Data were collected using the questionnaires, facilitator activity report and survey. Results are presented according to each component of the process evaluation. Each qualitative segment could have been included under more than one theme.
Procedures of the workshops’ promotion and recruitment. Three themes were identified for the recruitment component: 1) procedure description; 2) impact of recipes and; 3) availability of families. Workshops were promoted using wall posters in strategic locations in the inpatient and outpatient clinics of the Division of Hematology-Oncology. Seventy-three percent (73%) of the families interviewed were aware of the workshops (Table 5). The facilitator visited the families enrolled in the VIE study to promote the workshop of the week. Families attending the common areas were also approached. The total number of families approached during the promotion tours was not documented. The facilitator also contacted 16 of the 17 workshop participants during promotion tours. Flyers were also handed to the nurses in the outpatient clinic to encourage promotion of the workshops to families. Nurses and clinical dieticians were also notified each week.
Table 5. Preferences in the workshop themes and mode of delivery according to the appreciation survey
|
Participants
n=26
|
Interest in recipe tasting
|
18 (69%)
|
Interest in content related to foodborne infections
|
11 (42%)
|
Awareness of the workshops
|
19 (73%)
|
Awareness of the workshops via posters
|
12 (46%)
|
Preferred mode of workshop delivery
|
|
Flyers
|
4 (15%)
|
Online videos
|
18 (69%)
|
Face-to-face workshops
|
3 (12%)
|
Videoconference
|
4 (15%)
|
No best option
|
1 (4%)
|
Most useful theme
|
|
Meal fortification
|
8 (31%)
|
Changes in taste during cancer therapy
|
10 (38%)
|
Adapting diet to eating-related side effects of treatments
|
3 (12%)
|
Mediterranean diet and health
|
3 (12%)
|
Planning quick and economic meals
|
7 (27%)
|
Nutritional support
|
3 (12%)
|
Less useful theme
|
|
Meal fortification
|
0 (0%)
|
Changes in taste during cancer therapy
|
0 (0%)
|
Adapting diet to eating-related side effects of treatments
|
8 (31%)
|
Mediterranean diet and health
|
5 (19%)
|
Planning quick and economic meals
|
6 (23%)
|
Nutritional support
|
4 (15%)
|
None
|
3 (12%)
|
Barriers to participation
|
|
Nutrition not a priority
|
1 (4%)
|
Theme not related to actual child’s condition
|
16 (62%)
|
No other person could stay with the child
|
15 (58%)
|
Doctor or health professional could visit during activity
|
20 (77%)
|
Scheduled treatment or test during activity
|
22 (85%)
|
Unaware of the workshop location
|
2 (8%)
|
Too busy
|
11 (42%)
|
Other
|
17 (65%)
|
Reach. Three subthemes emerged from the reach component: 1) impact of low participation; 2) target population and; 3) characteristics of patients. The reach of the population was low as only 1 to 2 participants attended each workshop (Table 2). The facilitator reported that this caused some delivery-related difficulties and affected the possibility for participants to interact. Language had a minor impact on the workshop reach: overall, only 4 parents were unable to participate to a workshop because they did not understand or speak French.
Subthemes related to the target population and patients’ characteristics that either facilitated or challenged participation were described using observation notes and survey. Many surveyed parents reported they were cooking at home and that nutrition was a priority for them. Some mothers surveyed had professional cooking (n=3) or a dietician (n=1) education. This was not a barrier for participation but did influence participants’ interests:
(Survey) One mother reported preferring the treatment-related themes because she had professional cooking training.
Some parents mentioned that being at the hospital with their spouse would help them attend an activity. Other parents mentioned that the workshops were more relevant for their spouse, suggesting that the reach is not equivalent within a same family:
(Survey) I am not the one who cooks at home.
(Survey) My spouse is more present than me at the hospital.
Characteristics of patients also influenced parents’ participation and interests. The most stated characteristics were the child’s current health condition related to his treatment, allergies or lactose intolerance, as well as his pickiness. These conditions were mentioned as barriers for recipe tasting or for workshop participation.
Dose delivered. Three sub-themes emerged and segments were extracted almost exclusively from the activity report: 1) adaptations of the content and animation; 2) description of the key messages that were not delivered and; 3) reason for not delivering the key messages.
In 7 of the 13 workshops, all the nutritional messages were covered (54%) (Table 3). Messages related to the prevention of foodborne infections were the most omitted. The reasons for not delivering the key messages included the unreceptiveness of participants, oversight from the facilitator, participant prematurely leaving the activity and difficulties performing the recipe.
The adaptation subtheme refers to the strategies used by the facilitator to adapt the messages and animation for the audience. For example, she gave personalized advice to take into account participant’s comments and involved the children in the cooking demonstration. This did not alter the content of the messages delivered. Moreover, during one workshop, the content was adapted in order to address the parent’s questions and knowledge.
Contextual factors. Five subthemes have emerged as contextual: 1) location and material; 2) medical or nutritional characteristics of the patient; 3) Logistics and time management; 4) parental presence required elsewhere and; 5) characteristics of the target population.
Difficulties related to the physical location, equipment and noises during the culinary demonstrations were reported as challenges by the facilitator. During the promotional tour, one mother and one nurse reported that it would be more convenient if the workshops would take place on the same floor as the inpatient Division of Oncology, rather than on the floor the activity was planned (2 floors below):
(Field notes) One mother mentioned that she thought this kind of activity was very interesting and that she wanted to participate. However, she could not attend because her child was immunocompromised and she was reluctant to leave her alone. She stated that she would participate if the activity would take place on the same floor as her child’s room.
Difficulties related to logistics and time management were commonly reported by families. During the promotion tours, many parents stated that they lived far away from the hospital and would not come only to attend a workshop. In the outpatient clinic, parents reported that, when visiting the hospital, they were generally busy with appointments in the morning and wanted to leave as soon as possible. One parent mentioned:
(Field notes) [Parents] always want to leave before hitting traffic. They corroborated that this consists in the principal barrier to attend a workshop because they are otherwise interested [in participating to a workshop].
Lack of time was also a recurrent factor of the target population. Forty-two percent (42%, n=11) of the families surveyed mentioned that being too busy prevented them to participate (Table 5).
Availability and interests of parents were highly affected by patients’ medical condition (Table 5). In the survey, 77% (n=20) of parents stated that expecting a visit from a doctor or a health professional at the time of the workshop would be a barrier for participation. A scheduled test or treatment would also be a barrier for 85% (n=22). For some parents, nutritional difficulties encountered by the child were a motivation to attend, while for others, their management was rather perceived as time-consuming and as a barrier:
(Field note) A mother stated that she is, in essence, interested, but at the moment, she believes she was more helpful by helping her child by focusing on his acute nutritional challenges.
The need for the parent to be at his child’s bedside was reported in the appreciation survey as a participation barrier by 58% of families (n=15) (Table 5), regardless of the child’s age. The presence of both parents was reported as a facilitator for workshop participation. One mother stated:
(Survey) We were lucky to be both present [at the hospital] that day: it made it easier to attend the workshop. When only one parent comes [to the hospital] with the child, it is more complicated to attend a workshop [for him/her].
The contextual factors highlighted the barriers and reasons that complexify parents’ access to the workshops and helped explaining the general low attendance.
Fidelity. Four themes have emerged related to fidelity of the implementation process: 1) workshop delivery; 2) recipes; 3) minimization of the burden related to participation and; 4) impact of low participation. The workshops had a mean duration of 51 minutes (± 13 minutes, range: 40-90), which was shorter than the planned 60 minutes (Table 3). The absence of the chef in 69% of the delivered workshops led to a shorter mean duration (46 ± 4 minutes, range: 40-50).
The facilitator described some difficulties related to the message delivery in the absence of the chef. They principally referred to coordinating the delivery of nutritional messages with the recipe demonstration. Other difficulties reported were a less dynamic or fluid animation, omission of content and challenges in determining the best moment to answer participants’ questions.
Sixty-nine percent of the parents (69%, n=18) were interested in tasting the recipes (Table 5). One participant mentioned that the recipe persuaded her to come to the workshop. A recipe (one-pot mac’n’cheese) was mentioned by one mother as the main reason explaining her participation to the workshop. Some parents mentioned the pickiness of their child was a barrier to taste new recipes. However, while the majority of parents stated that tasting was enjoyable, it was not the principal incentive for participation:
(Survey) [Mother] I would have come even though there was no recipe. However, it was appealing to me.
It was essential for the research team to minimize the burden associated with participation. On occasions, the facilitator adapted the time and content in order to accommodate participants’ schedule.
Dose received. The dose received refers to the exposure and perceived utility of the intervention. In the questionnaires, 71% of participants (12/17) agreed they had acquired knowledge related to every key message (Table 6). Only 13% (2/17) stated they had acquired knowledge for less than half of the key messages. All participants (n=17) would recommend the workshops to other parents. For this component, the subthemes raised from the qualitative data were: 1) delivery mode; 2) interest and receptivity; 3) logistical and organizational context; 4) prior knowledge; 5) utility/non-utility of the workshop related to patient’s condition and; 6) workshop themes.
Table 6. Knowledge acquisition and perceived utility of the workshops according to participant questionnaires
|
Participants
n=17
|
Perception of knowledge acquisition
|
|
100% of the key messages
|
12 (71%)
|
Equal or more than 50% of the key messages
|
3 (18%)
|
Less than 50% of the key message
|
2 (12%)
|
Would recommend workshop
|
100%
|
Intent to use advices or recipes
|
100%
|
When asked about their favorite delivery format, most parents surveyed preferred short web-based video capsules (n=18, 69%, Table 5) in comparison with flyers only, face-to-face or videoconference. Families reported that videos were more appealing than written documentation because they are less time consuming and they can be watched whenever needed.
Data acquired during promotional tours or with the survey show that parents were interested in nutrition: only one parent stated that healthy eating was not his priority (Table 5). Besides, for 12 of the 13 workshops, the facilitator rated the participants’ level of interest form high to very high (Table 3). In the appreciation survey, many families expressed that workshops could be a nice distraction while being at the hospital:
(Survey) This kind of activity is very relevant to me because we are often looking for something to do in the hospital.
In general, there was interest for the activity, but the logistical barriers (e.g. having to stay with the child or living far from the hospital) limited the exposure to the intervention. No pattern in terms of the day (week or week-end) and time (morning or afternoon) of delivery or in the workshop theme was identified in relationship with attendance. Also, families’ preferences were very diverse when asked about what time of the day would be ideal to attend a workshop. However, parents stated that it was easier to attend when the child was hospitalized rather than when he was an outpatient.
The perceived utility of the workshops was influenced by parents’ prior culinary and nutritional knowledge. This was mainly related to foodborne illness prevention as 58% of participants reported not being interested by this specific content (Table 5). These parents stated they had received thorough instructions by the nursing staff and were already applying the principles at home. Conversely, other parents found that reminders of the rules for prevention of foodborne infections were helpful.
The perceived utility was influenced positively or negatively by the child’s medical condition. Some parents reported that their child could eat everything, so they did not perceive the workshops as useful. Other mentioned that their child was picky and that this was a barrier to attend. Parents’ interest towards the activity was also often related to treatment side effects:
(Field notes) One mother stated that, at the moment, her child was well and that she will consider [the workshops] if the child loses weight.
(Survey) The utility of the workshops is related to the treatment side effects and the child’s eating habits.
Thus, 62% of the parents surveyed (n=16/26, Table 5) reported that the workshop theme was not related to the child’s current condition, which was a barrier for participation. The survey showed that Changes in taste during cancer therapy, Meal fortification and Planning quick and economic meals were the most useful workshops for 38%, 31% and 27% of the parents, respectively (Table 5). Parents reported that the least useful workshops for them were Adapting diet to eating-related side effects of treatments (31%), Mediterranean diet and health (23%) and Planning quick and economic meals (19%) (Table 5). Among the families who stated that the least useful theme was Adapting diet to eating-related side effects of treatments, 25% also reported that their child did not suffer from these side effects. One mother specified that even though she did not find this theme useful, it could be for other parents.