J Community Health DOI 10.1007/s10900-014-9945-4
ORIGINAL PAPER
Childhood Obesity Perceptions Among African American Caregivers in a Rural Georgia Community: A Mixed Methods Approach Dayna S. Alexander • Moya L. Alfonso Andrew R. Hansen
•
Springer Science+Business Media New York 2014
Abstract Given the pivotal role of African American caregiver’s perceptions of childhood obesity in rural areas, the inclusion of caregiver’s perceptions could potentially reduce childhood obesity rates. The objective of the current study was to explore childhood obesity perceptions among African Americans in a rural Georgia community. This concurrent mixed methods study utilized two theoretical frameworks: Social Cognitive Theory and Social Ecological Model. Using a convenience sample, caregivers ages 22–65 years completed a paper-based survey (n = 135) and a face-to-face interview (n = 12) to explore perceptions of obesity risk factors, health complications, weight status, built environment features, and obesity prevention approaches. Descriptive statistics were generated and a sixstep process was used for qualitative analysis. Participants commonly cited behavioral risk factors; yet, social aspects and appearance of the community were not considered contributing factors. Chronic diseases were reported as obesity health complications. Caregivers had a distorted view of their child’s weight status. In addition, analysis revealed that caregivers assessed child’s weight and height measurements by the child’s appearance or a recent doctor visit. Environmental barriers reported by caregivers included safety concerns and insufficient physical activity
D. S. Alexander M. L. Alfonso A. R. Hansen Department of Community Health Behavior and Education, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA 30460, USA D. S. Alexander (&) Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, One University Heights, CPO #2125, Asheville, NC 28804, USA e-mail: [email protected]
venues and programs. Also, caregivers conveyed parents are an imperative component of preventing obesity. Although this study found caregivers were aware of obesity risk factors, health complications, built environment features, and prevention approaches their obesity perceptions were not incorporated into school or community prevention efforts. Findings suggest that children residing in rural areas are in need of tailored efforts that address caregiver perceptions of obesity. Keywords Childhood obesity Rural health African American caregivers Perceptions
Background Childhood obesity is a public health concern resulting from unhealthy behaviors, which reinforce negative lifestyles and adverse outcomes in adulthood. In the United States, approximately 12.5 million children and adolescents ages 2–19 years are classified as obese [1]. Proportionally, African American children bear the greatest morbidity burden with 35.9 % between the ages of 2–19 years being obese [2]. Recent data confirms the prevalence of obesity among children is stabilizing, but not improving [3]. The effects of obesity on a child are numerous including physical, mental, and social [4–6]. Currently, the financial impact of obesity on the United States is estimated to be $254 billion [7]. Numerous predictors (genetics, environment, demographics, and behaviors) contribute to childhood obesity including caregiver perceptions [8–11]. The interactions of these predictors results in childhood obesity making it a multi-dimensional issue in multiple settings. Children are more likely to be obese in rural settings than urban [12–14]. African Americans are disproportionately
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affected by obesity in rural areas [15, 16]. Prior obesity studies noted families residing in rural areas are limited in prevention efforts because they do not account for rural challenges [13, 17, 18]. When rural caregivers attempt to model and maintain a healthy lifestyle for children recreational parks and facilities, grocery stores with fresh produce, and health care resources are unavailable or inaccessible [13, 17–19]. African American communities experience more barriers in their environment resulting in higher obesity rates [20–22]. However, past studies that have examined this association were subjected to small sample sizes and conducted only in urban settings. Thus, results are neither generalizable nor transferable to African Americans in rural locations. Whereas caregivers are usually underemphasized in school-based childhood obesity efforts, community-based programs are dramatically emphasized [23–25]. It is imperative to learn the perceptions of caregivers because this may provide insight into the development and implementation of culturally appropriate micro-and macro-level interventions among this target population. The purpose of this concurrent mixed methods study that employed the Social Ecological Model [26] and Social Cognitive Theory [27] was to conduct formative research on African American caregiver’s perceptions of childhood obesity in a rural community. This approach enabled the in-depth exploration of five components: risk factors, health complications, weight status, features of the built environment, and prevention efforts.
Materials and Methods Study Design The study was reviewed and approved by the Georgia Southern University Institutional Review Board and County School Board. Informed consent was obtained from participants. The study was conducted from June 2013 to November 2013. A concurrent mixed methods design was employed in this study. The methodological approach included concurrent, but separate data collection, data analysis, and interpretation of the data [28]. Equal priority was given to the quantitative and qualitative components. According to Creswell (2009), this design allowed for different, but complementary data and increased the credibility and confirmability of the results [28]. Sampling and Recruitment A convenience sample comprised of African American caregivers, 18 years of age and older, whose child attended an elementary school in rural Georgia. The school has a high population of African American students compared to
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other schools in this county and is centrally located within the county. During the study period, approximately 595 African American students were enrolled in third through fifth grades. If a parent had two or more children attending the school, the child with a higher weight status was selected. The study was presented to caregivers at an open house, invitational letters were sent home the first week of school, and informed consents and surveys were sent home the second week of school. A total of 135 completed surveys were received resulting in a 22 % response rate. All participants (n = 12) who voluntarily provided contact information were interviewed. Instrumentation No survey instrument was identified that assessed African American caregiver’s perceptions of childhood obesity; therefore, the development of the survey was guided by a 12-step instrument development process [29] based on the Social Ecological Model and Social Cognitive Theory. The survey instrument was pretested with 15 participants and piloted with 30 participants at a county health department. At a seventh grade reading level, the survey contained 59 questions using two five-point Likert scales including five sections: perceptions of risk factors, child’s weight status, features of the built environment, importance of obesity prevention strategies, and demographics. However, one five-point Likert scale was collapsed for ease of reporting in the analysis section. Evidence of reliability and validity were established through assessments of interrater reliability, internal consistency reliability (0.708–0.817), face validity, and content validity. Development of the interview guide was informed by empirical literature and the theoretical framework’s concepts. The interview guide was pretested with five parents and piloted with five parents in a county health department. The 14-item, open-ended interview guide mirrored the five sections of the survey. Trustworthiness and confirmability evidence was gathered through expert review, transcript verification, and code definitions [30–32]. Data Collection School teachers distributed the surveys to caregivers by placing survey packets in the eligible student’s backpacks. Teachers tracked the packets by using a tracking log developed by the researcher. Two rounds of follow up surveys were distributed by teachers who were instructed to randomly select every third student. Caregivers reported the child’s height and weight on the survey. The researcher collected all packets twice a week from August 2013 to November 2013. Interviews were conducted in a convenient
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location (e.g., home, school, work setting) for the caregivers and conducted until saturation was reached. The interviews lasted, on average, 30–45 min. All interviews were audiorecorded, and full transcripts were created. Data Analysis Quantitative analyses, specifically descriptive statistics, were calculated using SPSS version 21. Data were triple checked to ensure accuracy by two data coders. The Cohen’s kappa statistic range of the coders was 0.94- 1.00. Body mass index (BMI) was calculated using a BMI Calculator for Children and Teens [33]. Qualitative data was analyzed using a six step process including: (1) transcribing the interviews verbatim; (2) reading the transcript line-by-line; (3) developing codes; (4) developing themes; (5) connecting the codes and themes; and (6) interpreting the data [28]. Validation methods included member checking, rich description, and assessing intercoder agreement (100 %). Reflexivity, member checking, and an external audit were used to enhance trustworthiness and confirmability.
Results A majority (n = 135) of survey respondents (96 %) were female and aged 22–65 years. All respondents self-identified as Black or African American and resided in the targeted county. Approximately 38 % of the sample reported their highest education level as ‘‘some college’’ or an ‘‘associate degree.’’ Over half of the sample indicated having full-time (65 %) employment. Roughly 42 % reported an income below $19,000. Interviewees included female (n = 11) and male (n = 1) aged 26 to 65 years. Nearly half of the interviewees had ‘‘some college’’ or ‘‘college degree.’’ Five interviewees were unemployed and five were employed full-time. Five interviewees indicated an income below $19,000, whereas four reported an income level between $19,001 and $39,000 (Table 1). Risk Factors Survey respondents were likely to ‘‘agree’’ that parent’s eating habits (80 %), exercising habits (86 %), and lifestyle habits (94 %) influence a child’s susceptibility to obesity. Also, respondents ‘‘agreed’’ that parental obesity (42 %) is a predictor of child obesity while 40 % of respondents ‘‘disagreed’’ (Table 2). Many interviewees believed that parents were the main risk factor for childhood obesity. If they have parents that are not into fitness or not into eating right then they are not going to do it. I think the parent is your number one. It starts at home.
Regarding additional childhood obesity risk factors, survey respondents ‘‘agreed’’ that physical activity (81 %), food advertising (68 %), watching television and playing video games (60 %), and consuming high caloric foods (90 %) all contributed to obesity (Table 2). One interviewee stated, Dietary consumption is majority of the problem. Interviewees described the three stores found in their community and stated they had access to fresh fruits and vegetables, yet the produce is expensive. Interviewees also commented on the convenience of fast-food restaurants. In addition, many interviewees described the county and their community as having insufficient resources for children to be active. Interviewees had heard little about obesity in rural areas. Um not a lot honestly when you read journals, when you read articles, it doesn’t really focus on rural areas. In general, childhood obesity is a problem and kids are being affected in earlier ages by diseases that we thought were old people diseases. Conversely, survey respondents ‘‘disagreed’’ that the lack of money (50 %), poorly kept housing (53 %), and close ties of a community are risk factors of childhood obesity (33 %). However, interviewees stated that a low socioeconomic household can contribute to obese children because they cannot afford programs and activities for their children. Correspondingly, an interviewee who had an obese child stated community members are not helpful when addressing the obesity problem in the rural community. Like I said it’s a lack of networking and from surrounding areas, but I don’t think people sit up there and take heed into it is actually in their home. So I feel as though if we can get more networking out into the homes. Health Complications Most survey respondents ‘‘agreed’’ that diabetes (78 %) was a result of obesity (Table 3). Some respondents ‘‘agreed’’ asthma (44 %) and bone joint problems (61 %) were health outcomes of obesity. Respondents selected ‘‘neither’’ that if a child was obese, he/she is likely to develop cancer (45 %), be infertile (41 %), or experience irregular menstrual cycles (38 %). In addition, 58 % of survey respondents ‘‘disagreed’’ that their child’s weight status was related to any current health problems the children may have developed (Table 4). A majority of the interviewees stated diabetes, hypertension, breathing problems, and hyperlipidemia were all obesity complications.
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J Community Health Table 1 Characteristics of survey respondents (N = 135) and interview participants (N = 12) Characteristics
Survey Frequency (n)
Interview Percentage (%)
Frequency (n)
Percentage (%)
Age in years 22–25
8
5.93
26–35
78
57.78
8
66.67
36–45
34
25.19
3
25.00
46–65
15
11.11
1
8.33
129 5
96.27 3.73
11 1
91.66 8.33
0–2
57
44.88
3
25.00
3–5
64
50.39
9
66.67
6–8
6
4.72
0
Gender Female Male Children per household
0
Education Less than high school
13
9.85
1
8.33
Some high school
12
9.09
1
8.33
High school or GED
30
22.73
2
16.66
Some college or an associate degree
50
37.88
5
41.66
4 year college degree
10
7.58
1
8.33
Some graduate education or completed degree
17
12.88
2
16.66
Employment status Unemployed
20
18.87
5
33.33
Part-time Full-time
17 69
16.04 65.09
2 5
16.04 65.09
Less than $19,000
55
41.98
5
41.66
$19,001–39,000
34
25.95
4
33.33
$39,001–59,000
16
12.21
3
25.01
$59,001–74,000
4
3.05
0
0
$74,001 or more
5
3.82
0
0
Annual income
Don’t know Refuse Total
6
4.58
0
0
11
8.40
0
0
135
100.00
12
‘‘Heart attacks, high blood pressure you know cause all of that is going to lead to stroke and all that other stuff’’ or ‘‘high blood pressure, sugar [diabetes], and breathing problems.’’ Interviewees infrequently referenced social and emotional problems such as depression or bullying. Weight Status While completing the survey, caregivers were asked to choose which picture represented their child’s weight status (Fig. 1). Fifty percent reported an underweight child, 21 % a healthy weight, 17 % overweight, and 12 % obese
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(Fig. 1). Only 50 % of respondents reported their child’s height and weight on the survey. More overweight children were reported in the sample (Fig. 2). Yet, when interviewees described obesity they visualized someone much bigger than their child. ‘‘I think like real big kids’’ or ‘‘big people like real, real big.’’ Subsequently, 52 % of the respondents ‘‘disagreed’’ about being concerned about their child’s weight. Additionally, 75 % of survey respondents ‘‘disagreed’’ their child was obese when completing the survey, and 58 % ‘‘disagreed’’ that their child was overweight (Table 4). Sixty-four percent of respondents considered their child to
J Community Health Table 2 Description of childhood obesity risk factors
a
‘‘Strongly disagree’’ and ‘‘Disagree’’ and ‘‘Strongly agree’’ and ‘‘Agree’’ were collapsed for ease of interpretation
Table 3 Description of childhood obesity health complications
a
‘‘Strongly disagree’’ and ‘‘Disagree’’ and ‘‘Strongly agree’’ and ‘‘Agree’’ were collapsed for ease of interpretation
Table 4 Description of child’s weight status
Survey question number
Responses (frequency and percentages)a
3
Neither
Lack of money (1)
66 (50.00)
28 (21.21)
38 (28.79)
2.71
Lack of physical activity (2)
15 (11.37)
10 (7.58)
107 (81.06)
4.11
3
Food advertising (3)
29 (22.13)
12 (9.16)
90 (68.70)
3.74
4
Poorly kept housing (4)
69 (53.49)
34 (26.36)
26 (20.15)
2.56
6
Watching TV (5)
32 (24.42)
20 (15.27)
79 (60.30)
3.51
4
Eating foods (6)
8 (6.86)
5 (3.82)
118 (90.07)
4.26
4
Agree
Parent’s eating habits (7)
15 (11.45)
10 (7.63)
106 (80.92)
3.96
4
Parental obesity (8)
52 (40.00)
23 (17.69)
55 (42.31)
2.99
5
Parent’s exercising habits (9)
10 (7.64)
8 (6.11)
113 (86.25)
4.14
4
6 (4.62)
1 (0.77)
123 (94.61)
4.46
5
Close ties of a community (11) A problem (12)
44 (33.58) 26 (19.70)
41 (31.30) 17 (12.88)
46 (35.11) 89 (67.42)
3.03 3.65
4 3
Survey question number
Responses (frequency and percentages)a
Mean
Missing
2
Parent’s lifestyle (10)
Disagree
Neither
Asthma (13)
36 (27.07)
38 (28.57)
59 (44.36)
3.20
Diabetes (14)
16 (11.95)
13 (9.70)
105 (78.36)
3.85
1
Stroke (15)
27 (20.30)
23 (17.29)
83 (62.41)
3.52
2
Cancer (16)
55 (41.35)
60 (45.11)
18 (13.53)
2.68
2
Bone and joint problems (17)
19 (14.18)
32 (23.88)
83 (61.94)
3.61
1
Infertile (18)
53 (39.55)
56 (41.79)
25 (18.66)
2.75
1
Irregular menstrual cycles (19)
37 (27.61)
51 (38.06)
46 (34.33)
3.13
1
Mean
Missing
Survey question number
Agree
Responses frequency (percentage)a Neither
Agree
Concern about weight (21)
70 (52.24)
9 (6.72)
55 (41.05)
2.85
1
Appropriate weight (22)
36 (26.87)
12 (8.96)
86 (64.17)
3.5
1
Obese (23)
99 (75.00)
14 (10.61)
19 (14.39)
2
3
7 (5.23)
10 (7.46)
117 (87.31)
4.19
1 7
Prevent obesity (24) Parental influence (25)
‘‘Strongly disagree’’ and ‘‘Disagree’’ and ‘‘Strongly agree’’ and ‘‘Agree’’ were collapsed for ease of interpretation
Missing
Disagree
Disagree
a
Mean
8 (6.25)
13 (10.16)
107 (83.59)
4.07
My child is underweight (26)
103 (78.03)
19 (14.39)
10 (7.58)
1.94
3
My child is overweight (27)
76 (58.01)
22 (16.79)
33 (25.19)
2.41
4
Health problems (28)
78 (58.21)
43 (32.09)
13 (9.71)
2.29
1
Doctor discusses weight (29)
31 (23.31)
26 (19.55)
76 (57.14)
3.40
2
Growth chart (30)
15 (11.28)
19 (14.29)
99 (74.44)
3.87
2
Difference (31)
21 (15.67)
12 (8.96)
101 (75.37)
3.79
1
be an appropriate weight for his/her age and 78 % ‘‘disagreed’’ their child was underweight. Interviewees referred to their child as ‘‘thick’’, ‘‘solid’’, ‘‘heavy’’, ‘‘skinny’’, and ‘‘overweight’’ constructing weight status on a prior doctor visit or appearance.
I based my daughter’s height and weight with other children her height and weight as well as her activity level and her yearly physical when she goes into see her doctor.
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J Community Health Fig. 1 Visual aid of child’s weight status (Survey Question Number 20)
not provide a recommendation, did not believe this to be true, or stated parents were in denial. Built Environment
Fig. 2 Comparison of caregiver’s perceptions of child’s weight status
Eighty-three percent of respondents ‘‘agreed’’ parents influence their child’s weight, and 87 % agreed parents could prevent obesity. In most instances, survey respondents and interviewees cited their child’s doctor discusses weight status using a growth chart. A majority of survey respondents (75 %) reported understanding the difference between obesity and overweight. The interviewer asked caregivers to provide recommendations to parents for assessing their child’s weight status: interviewees could
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Survey respondents ‘‘agreed’’ parks and recreational facilities play a role in preventing childhood obesity (82 %). The county has three parks and one recreational department. However, interviewees stated that illegal activity occurred at the parks and strangers are usually present. Survey respondents ‘‘agreed’’ their child felt safe in their community (91 %) and safe communities encourage physical activity among children (82 %). In interviews, safety was contingent on where the child resided: ‘‘You know it depends on where the child is living. We have some neighborhoods that are better maintained than others’’ or ‘‘You know out here we live in the country and we don’t have any problems with anybody and gangs and stuff like that but it’s a few gangs in [name of the city] with young boys.’’ Several interviewees responded that they allowed their children to play in front of the house when they were outside. Forty-two percent of survey respondents ‘‘agreed’’ that their child having a playmate in the neighborhood could prevent obesity while 35 %
J Community Health Table 5 Description of the built environment
Survey question number
Response frequency (percentage)a Disagree
Safe in community (32)
a
‘‘Strongly disagree’’ and ‘‘Disagree’’ and ‘‘Strongly agree’’ and ‘‘Agree’’ were collapsed for ease of interpretation
Neither
Mean
Missing
Agree
4 (3.11)
7 (5.43)
118 (91.47)
4.18
6
Litter or garbage (33)
86 (66.67)
27 (20.93)
16 (12.41)
2.20
6
Stray dogs (34)
54 (34.65)
21 (16.54)
62 (48.82)
3.21
8
Not enough areas (35)
70 (53.85)
10 (7.69)
50 (38.46)
2.82
5
Traffic (36)
66 (51.16)
17 (13.18)
46 (35.66)
2.81
6
Lack of programs (37)
48 (37.80)
12 (9.45)
67 (52.76)
3.21
8
Playmate (38)
46 (35.94)
28 (21.88)
54 (42.19)
3.05
7
Present health programs (39)
68 (52.31)
40 (30.77)
22 (16.93)
2.48
5
Motivate (40)
25 (19.53)
18 (14.06)
85 (66.40)
3.54
7
Recreational facilities (41)
11 (8.46)
12 (9.23)
107 (82.31)
3.94
5
7 (5.39)
16 (12.31)
107 (82.30)
4.00
5
Communities encourage (42)
‘‘disagreed’’. A common barrier was the lack of venues and health programs in the community for their child to be active. Um if they could just get a seed planted you know reach rural communities. I think our issues are different cause we don’t have all of the resources that every other like you know if we go to [name of city] there are options everywhere you got the Y, all kind of gyms, and all kind of stuff. That’s not the case for us in rural communities. We kind of just left up to figure it out. Fifty-three percent of survey respondents ‘‘disagreed’’ there were not enough areas in the community for their child to be active (Table 5). Many interview participants commented on the limited number of activities provided by the school and recreational department. Also commenting that the expensive fees and the activities were not being targeted towards non-athletic children. Some participants stated their child participated in activities sponsored by churches. These activities were only available to children who attended the church. Nevertheless survey respondents ‘‘agreed’’ some community activities motivated their child to be physically active. Approximately 52 % of respondents ‘‘agreed’’ that the lack of community programs increases the risk of childhood obesity, whereas 37 % of respondents ‘‘disagreed’’. Fifty-two percent of survey respondents ‘‘disagreed’’ there are health programs in the community that focus on obesity. Interviewees mentioned when their child experienced health issues, they would drive to the hospital in the next county, which was a 30–45 min. In addition, the interviewees discussed access to one health department that provides preventive health services.
Prevention Strategies Eighty-five percent of survey respondents ‘‘agreed’’ schools play a role in their child developing healthy behaviors; however, 8 % of caregivers ‘‘disagreed’’ that the school can prevent childhood obesity more than they can (Table 6). Interviewees asserted the school provided a supportive environment by establishing new nutritional standards such as not offering fried chicken and ice cream and providing more vegetables and fruits to students. Several interviewees stated their children attended physical education classes twice a week and emphasized a need for more physical activity opportunities in the school. As one interviewee stated, 80 % is on the parents, and 20 % is on the school. Also, 75 % of survey respondents ‘‘disagreed’’ that their community could prevent childhood obesity more than they could. However, all interviewees stated a lack of obesity prevention efforts and community involvement among neighbors, elected officials, and organizations for their child to be active. …like I said there’s no involvement, community involvement. We have parks we got the recreational park, but it’s not like a park, park. When I was small they haven’t put anything new in it. It’s just the same thing so it’s just the same stuff they not putting any money into the growth of the community. In addition, 62 % of survey respondents ‘‘agreed’’ their child’s doctor had communicated obesity prevention strategies. Furthermore, 62 % of respondents ‘‘agreed’’ they had sufficient income to help prevent their child from becoming obese. Yet, interviewees discussed the need for
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J Community Health Table 6 Description of childhood obesity prevention strategies Survey question number
Response frequency (percentage)a Disagree
Neither
Mean
Missing
Agree
Schools (43)
11 (8.21)
9 (6.72)
114 (85.08)
3.92
1
My child’s school (44)
86 (66.15)
33 (25.38)
11 (8.46)
2.26
5
My child’s doctor (45)
25 (19.09)
24 (18.32)
82 (62.59)
3.54
4
My community (46)
100 (75.76)
28 (21.21)
4 (3.04)
2.04
3
Drink water (47)
4 (3.04)
4 (3.03)
124 (93.94)
4.31
3
Provide education (48)
2 (1.52)
15 (11.36)
115 (87.12)
4.09
3
Provide low-fat meals (49)
22 (16.80)
21 (16.03)
88 (67.18)
3.62
4
Income (50)
22 (16.42)
28 (20.90)
84 (62.69)
3.55
1
Survey question number
Limit screen time (51) After-school program (52)
Response frequency (percentage)
Mean
Missing
Not at all important
Slightly important
Somewhat important
Moderately important
Extremely important
9 (6.77) 8 (6.11)
3 (2.26) 11 (8.40)
28 (21.05) 31 (23.66)
36 (27.07) 38 (29.01)
57 (42.86) 43 (32.82)
3.96 3.74
2 4
Limit portion sizes (53)
5 (3.79)
3 (2.27)
18 (13.64)
42 (31.82)
64 (48.48)
4.18
3
Health professional (54)
10 (7.52)
10 (7.52)
23 (17.29)
41 (30.83)
49 (36.84)
3.81
2
Provide healthy snacks (55)
1 (0.75)
1 (0.75)
10 (7.52)
38 (28.57)
83 (62.41)
4.51
2
Exercise with my child (56)
2 (1.50)
2 (1.50)
9 (6.77)
39 (29.32)
81(60.90)
4.46
2
Read nutritional labels (57)
3 (2.26)
7 (5.26)
19 (14.29)
44 (33.08)
60 (45.11)
4.13
2
Limit high calorie foods (58) Community leaders (59) a
2 (1.53)
3 (2.29)
11 (8.40)
41 (31.30)
74 (56.49)
4.38
4
12 (9.02)
11 (8.27)
26 (19.55)
38 (28.57)
46 (34.59)
3.71
2
‘‘Strongly disagree’’ and ‘‘Disagree’’ and ‘‘Strongly agree’’ and ‘‘Agree’’ were collapsed for ease of interpretation
programs to target low income families because they do not have the resources to sustain a healthy lifestyle. Survey respondents ‘‘agreed’’ they encourage their child to drink water instead of sugary drinks (93 %), provide education about healthy behaviors (87 %), and provide low fat-meals to prevent obesity (67 %). Sentiments expressed by an interviewee included,
The most important to me would be the parents. The parents if they play their part everything else would pretty much fall in place.
Discussion Risk Factors
I buy a lot of fruits and stuff and vegetables and everything for the house too. So that’s what I try to do for her… she eats vegetables a lot. Caregivers were asked to rank the importance of prevention strategies (Table 6). A majority of respondents circled ‘‘extremely important’’ for limiting screen time (42 %), their child participating in an after-school program (32 %), regulating portion sizes (48 %), speaking with a health professional (36 %), providing healthy snacks (62 %), exercising with their child (60 %), reading nutritional labels (45 %), restricting energy-dense food (56 %), and facilitating discussions with community members and leaders (34 %). Most interviewees asserted that parents can prevent childhood obesity.
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Caregivers appeared to be well informed on the behavioral habits, parental influence, family obesity, and the environment as predictors of childhood obesity. Lack of money was not seen as a risk factor among survey respondents. However, interviewees contradicted the survey results stating a child from a low- income background would likely become obese because their parent(s) could not afford activity fees or healthier foods. This contradiction may have occurred because the interviewees were a self-selected sample; therefore, they may have cared more about childhood obesity and attempted to learn more risk factors of obesity. Despite the results, minority children in low-income families are disproportionately at risk for obesity and are
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not usually presented with the opportunity to participate in obesity programs [34, 35] due to their environment. Minorities tend to reside in obesogenic communities with limited access to healthy foods and recreational parks and facilities [22]. Additional studies suggest residing in a rural area and lack of access to healthy foods increases the prevalence of obese children [36, 37]. African Americans residing in rural areas are more likely to encounter these aforementioned risk factors. In the study instruments, social cohesion was designated as a risk factor. Close ties of community members and children playing with other children were examples of social cohesion. High social cohesion can have a negative impact on perpetuating unhealthy behaviors [38] and may influence coordinated action among community members [39]. Survey respondents and interviewees rebutted that social cohesion is a childhood obesity risk factor. Consequently, multiple dimensions of the social environment and structural characteristics of communities, particularly governing bodies, should be assessed in rural communities.
associated with caregiver perceptions of weight status [46]. Current study findings were consistent with the previous body of literature revealing a perception and weight status disconnect. However, study participants reported that their perceptions were influenced by a prior doctor visit and visually examining their child. In addition, findings in this study demonstrated study participants compared themselves to others to determine normal weight status. Prior research asserts that minorities’ perceptions of obesity vary because they have an inaccurate clinical definition of obesity due to a lack of communication with healthcare providers during early childhood [47] and their ability to correctly perceive themselves or others as overweight is poor [48–50]. Yet, study participants reported understanding the difference between overweight and obesity. Participants agreed they could influence their child’s weight status through diet and physical activity habits. Caregivers of different races/ethnicities who are engaged in a childhood obesity intervention have significantly greater self-efficacy to promote healthy eating and increase support of physical activity for their children [51].
Health Complications Built Environment Survey respondents were well-informed on the pulmonary, endocrine, cardiovascular, and psychological effects of childhood obesity. Interviewees stated diabetes, hyperlipidemia, hypertension, and breathing problems were associated with obesity. Interviewee’s obese family members and friends were diagnosed with these aforementioned diseases. Only a few interviewees stated depression as a health complication of obesity. Nevertheless survey respondents and interviewees were uninformed of the effects on the reproductive system and the correlation of obesity and cancer. Interviewees that commented on health effects of the reproductive system worked in the healthcare field. Although no studies were found on rural, African American caregivers’ perceptions of obesity health complications the study findings rebutted prior studies with a majority White sample [40, 41]. These studies concluded caregivers fail to recognize their child is at an increased risk for physical and mental health problems caused by obesity and overweight [40, 41]. Weight Status Regarding weight status, little agreement existed between self-reported height and weight and the visual aid (Fig. 1). Perceptions of weight status have been examined in multiple populations as it relates to race/ethnicity and culture [42, 43]. Thus, studies have shown a difference in perceptions of ideal body weight between African Americans and Whites [42–45]. Demographic factors such as educational status, socioeconomic status, and age of the child are
Caregivers encounter challenges in their rural environment when attempting to implement healthy behaviors for their children. Survey and interview participants disagreed poorly kept housing increases the risk of childhood obesity. It is important to conduct further analysis of perceptions regarding the appearance of a community because this risk factor is modifiable through the enactment of environmental and social policies [9]. Many interviewees commented on the inadequate or distant physical activity venues and programs. Moreover, perceived crime was stated as a barrier of the built environment. Caregiver concerns regarding safety of the recreational parks influenced their child’s physical activity levels. Similarly, the lack of infrastructure and physical activity facilities in rural areas has been associated with low levels of physical activity and unhealthy weight status [52]. Literature suggests that walkable communities are associated with a lower rate of obesity. A study reported parental perceptions of neighborhood characteristics such as sidewalks influences self-efficacy and body weight of a child [53]. An additional study found that children’s weight status is reduced in environments where sidewalks or trails are present and in good condition [54]. Other studies have substantiated the association between the built environment and obesity [9, 55]. No literature currently exists on African American caregivers’ perceptions and other cultural groups regarding the perceptions of the rural built environment.
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Prevention Strategies Caregivers stated parents are essential for preventing childhood obesity because they influence the child’s lifestyle habits and are more influential than the school and community setting. This finding reinforced studies that childhood obesity efforts should target caregivers and work with children at the earliest stages of child development to encourage healthy practices [56, 57]. Caregivers were well aware of prevention strategies to employ; however, making healthy lifestyle choices and seeking preventive care revolved around their contextual environment and daily routines. Interviewees stated employing preventive strategies for obesity such as ensuring their child consumes more fruits and vegetables, speaking with their child’s doctor, and exercising with their child would be effective in reducing the risk of obesity. This finding demonstrated how participant’s behavioral capability, role modeling, and selfregulation can assist in future childhood obesity efforts. With relatively few studies and interventions in the literature focused on African Americans residing in rural areas, more research is warranted to draw conclusions on behavioral constructs that are associated with childhood obesity. In addition, studies are needed on the differences between urban and rural African American caregiver perceptions on childhood obesity prevention strategies. Limitations and Strengths Study limitations included the use of convenience sample, self-report data, a low response rate despite multiple survey distributions, distribution of surveys by teachers, and two poorly worded survey questions. Despite these limitations, multiple strengths were noted, including the use of theoretically derived instruments with reliability and validity evidence, the mixed method design which allowed for mixing qualitative and quantitative data, and being the first study we are aware of that explores childhood obesity perceptions among African American caregivers in a rural community. Implications Caregivers are in a position to impact obesity risk factors, their child’s weight status, utilize features in the built environment, and implement prevention approaches. Thus, public health efforts should be designed to assist caregivers in creating and sustaining healthy lifestyles in rural communities. The caregivers in this study had accurate obesity perceptions; however, they must extend their knowledge and influence into the community setting. Assessing the target population’s perceptions prior to conducting an obesity prevention program is imperative to understand their readiness for change. The contradictions between
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survey respondents and interviewees demonstrate caregivers have misperceptions of obesity. Effective interventions should utilize community assets identified by community members to increase parental involvement in childhood obesity efforts while providing resources to alleviate the stress of engaging in new health behaviors. Identifying community based organizations and faith based organizations that would be willing to sponsor programs to educate and monitor caregiver’s behaviors can potentially promote self-efficacy in the caregiver. Moreover, establishing support groups for families of unhealthy weight children would help increase social cohesion. Finally, examining the differences and similarities between urban and rural caregivers would allow public health professionals and policymakers to create sustainable programs for caregivers while integrating the challenges of both environments. Future Research Although obesity rates are stabilizing, obesity will continue to be one of the most challenging issues that public health professionals encounter until action is taken to educate and assist caregivers. For future research purposes, conducting a longitudinal, comparison study among African American families’ lifestyles and demographics to other cultures in multiple rural areas would be necessary. This would include objectively measuring the lifestyle habits of each family member in different settings (i.e., home, school, work, and community) to gain an exhaustive view on the determinants that influence childhood obesity and effective prevention strategies in rural areas. Examining the availability and accessibility of physical activity opportunities in rural areas would be an important predictor regarding weight status among African American children. Identifying and evaluating urban interventions that could be modified for a rural setting could possibly reduce weight status. When adapting the urban interventions it would be vital to assess population characteristics (e.g., geographic location, language, socioeconomic status, and tax-base), community readiness, risk factors perceived by the target population, and the individuals who would deliver the program [58]. Thus, there are countless ideas that could be produced from the present findings of this study.
Conclusion To date, no published studies were identified that investigated caregiver perceptions of obesity among African Americans in a rural area. An understanding of these perceptions may contribute to the development of tailored and effective family-based obesity interventions for African Americans. While conclusions based on these findings
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need to be strengthened due to the convenience sample and low response rate, the findings suggest a promising approach that warrants future attention before designing and implementing a program within this context. Acknowledgments We thank the content experts (Drs. Larissa R. Brunner Huber, Robert J. McDermott, Yelena N. Tarasenko, and Ashley D. Walker) for their involvement in the survey development. We also thank Alesha Wright and Dr. Divine Offeogbu for coding assistance, Dr. Dziyana Nazaruk for assisting with interviews, Dr. Gavin T. Colquitt for conducting an external audit on the study, and Julian Strayhorn II for assistance in designing the weight status figure. Lastly, we thank the study participants, the elementary school staff, and the County School Board. This work was supported in part by the Graduate Student Organization grant (1378924576).
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ORIGINAL PAPER
Childhood Obesity Perceptions Among African American Caregivers in a Rural Georgia Community: A Mixed Methods Approach Dayna S. Alexander • Moya L. Alfonso Andrew R. Hansen
•
Springer Science+Business Media New York 2014
Abstract Given the pivotal role of African American caregiver’s perceptions of childhood obesity in rural areas, the inclusion of caregiver’s perceptions could potentially reduce childhood obesity rates. The objective of the current study was to explore childhood obesity perceptions among African Americans in a rural Georgia community. This concurrent mixed methods study utilized two theoretical frameworks: Social Cognitive Theory and Social Ecological Model. Using a convenience sample, caregivers ages 22–65 years completed a paper-based survey (n = 135) and a face-to-face interview (n = 12) to explore perceptions of obesity risk factors, health complications, weight status, built environment features, and obesity prevention approaches. Descriptive statistics were generated and a sixstep process was used for qualitative analysis. Participants commonly cited behavioral risk factors; yet, social aspects and appearance of the community were not considered contributing factors. Chronic diseases were reported as obesity health complications. Caregivers had a distorted view of their child’s weight status. In addition, analysis revealed that caregivers assessed child’s weight and height measurements by the child’s appearance or a recent doctor visit. Environmental barriers reported by caregivers included safety concerns and insufficient physical activity
D. S. Alexander M. L. Alfonso A. R. Hansen Department of Community Health Behavior and Education, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA 30460, USA D. S. Alexander (&) Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, One University Heights, CPO #2125, Asheville, NC 28804, USA e-mail: [email protected]
venues and programs. Also, caregivers conveyed parents are an imperative component of preventing obesity. Although this study found caregivers were aware of obesity risk factors, health complications, built environment features, and prevention approaches their obesity perceptions were not incorporated into school or community prevention efforts. Findings suggest that children residing in rural areas are in need of tailored efforts that address caregiver perceptions of obesity. Keywords Childhood obesity Rural health African American caregivers Perceptions
Background Childhood obesity is a public health concern resulting from unhealthy behaviors, which reinforce negative lifestyles and adverse outcomes in adulthood. In the United States, approximately 12.5 million children and adolescents ages 2–19 years are classified as obese [1]. Proportionally, African American children bear the greatest morbidity burden with 35.9 % between the ages of 2–19 years being obese [2]. Recent data confirms the prevalence of obesity among children is stabilizing, but not improving [3]. The effects of obesity on a child are numerous including physical, mental, and social [4–6]. Currently, the financial impact of obesity on the United States is estimated to be $254 billion [7]. Numerous predictors (genetics, environment, demographics, and behaviors) contribute to childhood obesity including caregiver perceptions [8–11]. The interactions of these predictors results in childhood obesity making it a multi-dimensional issue in multiple settings. Children are more likely to be obese in rural settings than urban [12–14]. African Americans are disproportionately
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affected by obesity in rural areas [15, 16]. Prior obesity studies noted families residing in rural areas are limited in prevention efforts because they do not account for rural challenges [13, 17, 18]. When rural caregivers attempt to model and maintain a healthy lifestyle for children recreational parks and facilities, grocery stores with fresh produce, and health care resources are unavailable or inaccessible [13, 17–19]. African American communities experience more barriers in their environment resulting in higher obesity rates [20–22]. However, past studies that have examined this association were subjected to small sample sizes and conducted only in urban settings. Thus, results are neither generalizable nor transferable to African Americans in rural locations. Whereas caregivers are usually underemphasized in school-based childhood obesity efforts, community-based programs are dramatically emphasized [23–25]. It is imperative to learn the perceptions of caregivers because this may provide insight into the development and implementation of culturally appropriate micro-and macro-level interventions among this target population. The purpose of this concurrent mixed methods study that employed the Social Ecological Model [26] and Social Cognitive Theory [27] was to conduct formative research on African American caregiver’s perceptions of childhood obesity in a rural community. This approach enabled the in-depth exploration of five components: risk factors, health complications, weight status, features of the built environment, and prevention efforts.
Materials and Methods Study Design The study was reviewed and approved by the Georgia Southern University Institutional Review Board and County School Board. Informed consent was obtained from participants. The study was conducted from June 2013 to November 2013. A concurrent mixed methods design was employed in this study. The methodological approach included concurrent, but separate data collection, data analysis, and interpretation of the data [28]. Equal priority was given to the quantitative and qualitative components. According to Creswell (2009), this design allowed for different, but complementary data and increased the credibility and confirmability of the results [28]. Sampling and Recruitment A convenience sample comprised of African American caregivers, 18 years of age and older, whose child attended an elementary school in rural Georgia. The school has a high population of African American students compared to
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other schools in this county and is centrally located within the county. During the study period, approximately 595 African American students were enrolled in third through fifth grades. If a parent had two or more children attending the school, the child with a higher weight status was selected. The study was presented to caregivers at an open house, invitational letters were sent home the first week of school, and informed consents and surveys were sent home the second week of school. A total of 135 completed surveys were received resulting in a 22 % response rate. All participants (n = 12) who voluntarily provided contact information were interviewed. Instrumentation No survey instrument was identified that assessed African American caregiver’s perceptions of childhood obesity; therefore, the development of the survey was guided by a 12-step instrument development process [29] based on the Social Ecological Model and Social Cognitive Theory. The survey instrument was pretested with 15 participants and piloted with 30 participants at a county health department. At a seventh grade reading level, the survey contained 59 questions using two five-point Likert scales including five sections: perceptions of risk factors, child’s weight status, features of the built environment, importance of obesity prevention strategies, and demographics. However, one five-point Likert scale was collapsed for ease of reporting in the analysis section. Evidence of reliability and validity were established through assessments of interrater reliability, internal consistency reliability (0.708–0.817), face validity, and content validity. Development of the interview guide was informed by empirical literature and the theoretical framework’s concepts. The interview guide was pretested with five parents and piloted with five parents in a county health department. The 14-item, open-ended interview guide mirrored the five sections of the survey. Trustworthiness and confirmability evidence was gathered through expert review, transcript verification, and code definitions [30–32]. Data Collection School teachers distributed the surveys to caregivers by placing survey packets in the eligible student’s backpacks. Teachers tracked the packets by using a tracking log developed by the researcher. Two rounds of follow up surveys were distributed by teachers who were instructed to randomly select every third student. Caregivers reported the child’s height and weight on the survey. The researcher collected all packets twice a week from August 2013 to November 2013. Interviews were conducted in a convenient
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location (e.g., home, school, work setting) for the caregivers and conducted until saturation was reached. The interviews lasted, on average, 30–45 min. All interviews were audiorecorded, and full transcripts were created. Data Analysis Quantitative analyses, specifically descriptive statistics, were calculated using SPSS version 21. Data were triple checked to ensure accuracy by two data coders. The Cohen’s kappa statistic range of the coders was 0.94- 1.00. Body mass index (BMI) was calculated using a BMI Calculator for Children and Teens [33]. Qualitative data was analyzed using a six step process including: (1) transcribing the interviews verbatim; (2) reading the transcript line-by-line; (3) developing codes; (4) developing themes; (5) connecting the codes and themes; and (6) interpreting the data [28]. Validation methods included member checking, rich description, and assessing intercoder agreement (100 %). Reflexivity, member checking, and an external audit were used to enhance trustworthiness and confirmability.
Results A majority (n = 135) of survey respondents (96 %) were female and aged 22–65 years. All respondents self-identified as Black or African American and resided in the targeted county. Approximately 38 % of the sample reported their highest education level as ‘‘some college’’ or an ‘‘associate degree.’’ Over half of the sample indicated having full-time (65 %) employment. Roughly 42 % reported an income below $19,000. Interviewees included female (n = 11) and male (n = 1) aged 26 to 65 years. Nearly half of the interviewees had ‘‘some college’’ or ‘‘college degree.’’ Five interviewees were unemployed and five were employed full-time. Five interviewees indicated an income below $19,000, whereas four reported an income level between $19,001 and $39,000 (Table 1). Risk Factors Survey respondents were likely to ‘‘agree’’ that parent’s eating habits (80 %), exercising habits (86 %), and lifestyle habits (94 %) influence a child’s susceptibility to obesity. Also, respondents ‘‘agreed’’ that parental obesity (42 %) is a predictor of child obesity while 40 % of respondents ‘‘disagreed’’ (Table 2). Many interviewees believed that parents were the main risk factor for childhood obesity. If they have parents that are not into fitness or not into eating right then they are not going to do it. I think the parent is your number one. It starts at home.
Regarding additional childhood obesity risk factors, survey respondents ‘‘agreed’’ that physical activity (81 %), food advertising (68 %), watching television and playing video games (60 %), and consuming high caloric foods (90 %) all contributed to obesity (Table 2). One interviewee stated, Dietary consumption is majority of the problem. Interviewees described the three stores found in their community and stated they had access to fresh fruits and vegetables, yet the produce is expensive. Interviewees also commented on the convenience of fast-food restaurants. In addition, many interviewees described the county and their community as having insufficient resources for children to be active. Interviewees had heard little about obesity in rural areas. Um not a lot honestly when you read journals, when you read articles, it doesn’t really focus on rural areas. In general, childhood obesity is a problem and kids are being affected in earlier ages by diseases that we thought were old people diseases. Conversely, survey respondents ‘‘disagreed’’ that the lack of money (50 %), poorly kept housing (53 %), and close ties of a community are risk factors of childhood obesity (33 %). However, interviewees stated that a low socioeconomic household can contribute to obese children because they cannot afford programs and activities for their children. Correspondingly, an interviewee who had an obese child stated community members are not helpful when addressing the obesity problem in the rural community. Like I said it’s a lack of networking and from surrounding areas, but I don’t think people sit up there and take heed into it is actually in their home. So I feel as though if we can get more networking out into the homes. Health Complications Most survey respondents ‘‘agreed’’ that diabetes (78 %) was a result of obesity (Table 3). Some respondents ‘‘agreed’’ asthma (44 %) and bone joint problems (61 %) were health outcomes of obesity. Respondents selected ‘‘neither’’ that if a child was obese, he/she is likely to develop cancer (45 %), be infertile (41 %), or experience irregular menstrual cycles (38 %). In addition, 58 % of survey respondents ‘‘disagreed’’ that their child’s weight status was related to any current health problems the children may have developed (Table 4). A majority of the interviewees stated diabetes, hypertension, breathing problems, and hyperlipidemia were all obesity complications.
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J Community Health Table 1 Characteristics of survey respondents (N = 135) and interview participants (N = 12) Characteristics
Survey Frequency (n)
Interview Percentage (%)
Frequency (n)
Percentage (%)
Age in years 22–25
8
5.93
26–35
78
57.78
8
66.67
36–45
34
25.19
3
25.00
46–65
15
11.11
1
8.33
129 5
96.27 3.73
11 1
91.66 8.33
0–2
57
44.88
3
25.00
3–5
64
50.39
9
66.67
6–8
6
4.72
0
Gender Female Male Children per household
0
Education Less than high school
13
9.85
1
8.33
Some high school
12
9.09
1
8.33
High school or GED
30
22.73
2
16.66
Some college or an associate degree
50
37.88
5
41.66
4 year college degree
10
7.58
1
8.33
Some graduate education or completed degree
17
12.88
2
16.66
Employment status Unemployed
20
18.87
5
33.33
Part-time Full-time
17 69
16.04 65.09
2 5
16.04 65.09
Less than $19,000
55
41.98
5
41.66
$19,001–39,000
34
25.95
4
33.33
$39,001–59,000
16
12.21
3
25.01
$59,001–74,000
4
3.05
0
0
$74,001 or more
5
3.82
0
0
Annual income
Don’t know Refuse Total
6
4.58
0
0
11
8.40
0
0
135
100.00
12
‘‘Heart attacks, high blood pressure you know cause all of that is going to lead to stroke and all that other stuff’’ or ‘‘high blood pressure, sugar [diabetes], and breathing problems.’’ Interviewees infrequently referenced social and emotional problems such as depression or bullying. Weight Status While completing the survey, caregivers were asked to choose which picture represented their child’s weight status (Fig. 1). Fifty percent reported an underweight child, 21 % a healthy weight, 17 % overweight, and 12 % obese
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(Fig. 1). Only 50 % of respondents reported their child’s height and weight on the survey. More overweight children were reported in the sample (Fig. 2). Yet, when interviewees described obesity they visualized someone much bigger than their child. ‘‘I think like real big kids’’ or ‘‘big people like real, real big.’’ Subsequently, 52 % of the respondents ‘‘disagreed’’ about being concerned about their child’s weight. Additionally, 75 % of survey respondents ‘‘disagreed’’ their child was obese when completing the survey, and 58 % ‘‘disagreed’’ that their child was overweight (Table 4). Sixty-four percent of respondents considered their child to
J Community Health Table 2 Description of childhood obesity risk factors
a
‘‘Strongly disagree’’ and ‘‘Disagree’’ and ‘‘Strongly agree’’ and ‘‘Agree’’ were collapsed for ease of interpretation
Table 3 Description of childhood obesity health complications
a
‘‘Strongly disagree’’ and ‘‘Disagree’’ and ‘‘Strongly agree’’ and ‘‘Agree’’ were collapsed for ease of interpretation
Table 4 Description of child’s weight status
Survey question number
Responses (frequency and percentages)a
3
Neither
Lack of money (1)
66 (50.00)
28 (21.21)
38 (28.79)
2.71
Lack of physical activity (2)
15 (11.37)
10 (7.58)
107 (81.06)
4.11
3
Food advertising (3)
29 (22.13)
12 (9.16)
90 (68.70)
3.74
4
Poorly kept housing (4)
69 (53.49)
34 (26.36)
26 (20.15)
2.56
6
Watching TV (5)
32 (24.42)
20 (15.27)
79 (60.30)
3.51
4
Eating foods (6)
8 (6.86)
5 (3.82)
118 (90.07)
4.26
4
Agree
Parent’s eating habits (7)
15 (11.45)
10 (7.63)
106 (80.92)
3.96
4
Parental obesity (8)
52 (40.00)
23 (17.69)
55 (42.31)
2.99
5
Parent’s exercising habits (9)
10 (7.64)
8 (6.11)
113 (86.25)
4.14
4
6 (4.62)
1 (0.77)
123 (94.61)
4.46
5
Close ties of a community (11) A problem (12)
44 (33.58) 26 (19.70)
41 (31.30) 17 (12.88)
46 (35.11) 89 (67.42)
3.03 3.65
4 3
Survey question number
Responses (frequency and percentages)a
Mean
Missing
2
Parent’s lifestyle (10)
Disagree
Neither
Asthma (13)
36 (27.07)
38 (28.57)
59 (44.36)
3.20
Diabetes (14)
16 (11.95)
13 (9.70)
105 (78.36)
3.85
1
Stroke (15)
27 (20.30)
23 (17.29)
83 (62.41)
3.52
2
Cancer (16)
55 (41.35)
60 (45.11)
18 (13.53)
2.68
2
Bone and joint problems (17)
19 (14.18)
32 (23.88)
83 (61.94)
3.61
1
Infertile (18)
53 (39.55)
56 (41.79)
25 (18.66)
2.75
1
Irregular menstrual cycles (19)
37 (27.61)
51 (38.06)
46 (34.33)
3.13
1
Mean
Missing
Survey question number
Agree
Responses frequency (percentage)a Neither
Agree
Concern about weight (21)
70 (52.24)
9 (6.72)
55 (41.05)
2.85
1
Appropriate weight (22)
36 (26.87)
12 (8.96)
86 (64.17)
3.5
1
Obese (23)
99 (75.00)
14 (10.61)
19 (14.39)
2
3
7 (5.23)
10 (7.46)
117 (87.31)
4.19
1 7
Prevent obesity (24) Parental influence (25)
‘‘Strongly disagree’’ and ‘‘Disagree’’ and ‘‘Strongly agree’’ and ‘‘Agree’’ were collapsed for ease of interpretation
Missing
Disagree
Disagree
a
Mean
8 (6.25)
13 (10.16)
107 (83.59)
4.07
My child is underweight (26)
103 (78.03)
19 (14.39)
10 (7.58)
1.94
3
My child is overweight (27)
76 (58.01)
22 (16.79)
33 (25.19)
2.41
4
Health problems (28)
78 (58.21)
43 (32.09)
13 (9.71)
2.29
1
Doctor discusses weight (29)
31 (23.31)
26 (19.55)
76 (57.14)
3.40
2
Growth chart (30)
15 (11.28)
19 (14.29)
99 (74.44)
3.87
2
Difference (31)
21 (15.67)
12 (8.96)
101 (75.37)
3.79
1
be an appropriate weight for his/her age and 78 % ‘‘disagreed’’ their child was underweight. Interviewees referred to their child as ‘‘thick’’, ‘‘solid’’, ‘‘heavy’’, ‘‘skinny’’, and ‘‘overweight’’ constructing weight status on a prior doctor visit or appearance.
I based my daughter’s height and weight with other children her height and weight as well as her activity level and her yearly physical when she goes into see her doctor.
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J Community Health Fig. 1 Visual aid of child’s weight status (Survey Question Number 20)
not provide a recommendation, did not believe this to be true, or stated parents were in denial. Built Environment
Fig. 2 Comparison of caregiver’s perceptions of child’s weight status
Eighty-three percent of respondents ‘‘agreed’’ parents influence their child’s weight, and 87 % agreed parents could prevent obesity. In most instances, survey respondents and interviewees cited their child’s doctor discusses weight status using a growth chart. A majority of survey respondents (75 %) reported understanding the difference between obesity and overweight. The interviewer asked caregivers to provide recommendations to parents for assessing their child’s weight status: interviewees could
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Survey respondents ‘‘agreed’’ parks and recreational facilities play a role in preventing childhood obesity (82 %). The county has three parks and one recreational department. However, interviewees stated that illegal activity occurred at the parks and strangers are usually present. Survey respondents ‘‘agreed’’ their child felt safe in their community (91 %) and safe communities encourage physical activity among children (82 %). In interviews, safety was contingent on where the child resided: ‘‘You know it depends on where the child is living. We have some neighborhoods that are better maintained than others’’ or ‘‘You know out here we live in the country and we don’t have any problems with anybody and gangs and stuff like that but it’s a few gangs in [name of the city] with young boys.’’ Several interviewees responded that they allowed their children to play in front of the house when they were outside. Forty-two percent of survey respondents ‘‘agreed’’ that their child having a playmate in the neighborhood could prevent obesity while 35 %
J Community Health Table 5 Description of the built environment
Survey question number
Response frequency (percentage)a Disagree
Safe in community (32)
a
‘‘Strongly disagree’’ and ‘‘Disagree’’ and ‘‘Strongly agree’’ and ‘‘Agree’’ were collapsed for ease of interpretation
Neither
Mean
Missing
Agree
4 (3.11)
7 (5.43)
118 (91.47)
4.18
6
Litter or garbage (33)
86 (66.67)
27 (20.93)
16 (12.41)
2.20
6
Stray dogs (34)
54 (34.65)
21 (16.54)
62 (48.82)
3.21
8
Not enough areas (35)
70 (53.85)
10 (7.69)
50 (38.46)
2.82
5
Traffic (36)
66 (51.16)
17 (13.18)
46 (35.66)
2.81
6
Lack of programs (37)
48 (37.80)
12 (9.45)
67 (52.76)
3.21
8
Playmate (38)
46 (35.94)
28 (21.88)
54 (42.19)
3.05
7
Present health programs (39)
68 (52.31)
40 (30.77)
22 (16.93)
2.48
5
Motivate (40)
25 (19.53)
18 (14.06)
85 (66.40)
3.54
7
Recreational facilities (41)
11 (8.46)
12 (9.23)
107 (82.31)
3.94
5
7 (5.39)
16 (12.31)
107 (82.30)
4.00
5
Communities encourage (42)
‘‘disagreed’’. A common barrier was the lack of venues and health programs in the community for their child to be active. Um if they could just get a seed planted you know reach rural communities. I think our issues are different cause we don’t have all of the resources that every other like you know if we go to [name of city] there are options everywhere you got the Y, all kind of gyms, and all kind of stuff. That’s not the case for us in rural communities. We kind of just left up to figure it out. Fifty-three percent of survey respondents ‘‘disagreed’’ there were not enough areas in the community for their child to be active (Table 5). Many interview participants commented on the limited number of activities provided by the school and recreational department. Also commenting that the expensive fees and the activities were not being targeted towards non-athletic children. Some participants stated their child participated in activities sponsored by churches. These activities were only available to children who attended the church. Nevertheless survey respondents ‘‘agreed’’ some community activities motivated their child to be physically active. Approximately 52 % of respondents ‘‘agreed’’ that the lack of community programs increases the risk of childhood obesity, whereas 37 % of respondents ‘‘disagreed’’. Fifty-two percent of survey respondents ‘‘disagreed’’ there are health programs in the community that focus on obesity. Interviewees mentioned when their child experienced health issues, they would drive to the hospital in the next county, which was a 30–45 min. In addition, the interviewees discussed access to one health department that provides preventive health services.
Prevention Strategies Eighty-five percent of survey respondents ‘‘agreed’’ schools play a role in their child developing healthy behaviors; however, 8 % of caregivers ‘‘disagreed’’ that the school can prevent childhood obesity more than they can (Table 6). Interviewees asserted the school provided a supportive environment by establishing new nutritional standards such as not offering fried chicken and ice cream and providing more vegetables and fruits to students. Several interviewees stated their children attended physical education classes twice a week and emphasized a need for more physical activity opportunities in the school. As one interviewee stated, 80 % is on the parents, and 20 % is on the school. Also, 75 % of survey respondents ‘‘disagreed’’ that their community could prevent childhood obesity more than they could. However, all interviewees stated a lack of obesity prevention efforts and community involvement among neighbors, elected officials, and organizations for their child to be active. …like I said there’s no involvement, community involvement. We have parks we got the recreational park, but it’s not like a park, park. When I was small they haven’t put anything new in it. It’s just the same thing so it’s just the same stuff they not putting any money into the growth of the community. In addition, 62 % of survey respondents ‘‘agreed’’ their child’s doctor had communicated obesity prevention strategies. Furthermore, 62 % of respondents ‘‘agreed’’ they had sufficient income to help prevent their child from becoming obese. Yet, interviewees discussed the need for
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J Community Health Table 6 Description of childhood obesity prevention strategies Survey question number
Response frequency (percentage)a Disagree
Neither
Mean
Missing
Agree
Schools (43)
11 (8.21)
9 (6.72)
114 (85.08)
3.92
1
My child’s school (44)
86 (66.15)
33 (25.38)
11 (8.46)
2.26
5
My child’s doctor (45)
25 (19.09)
24 (18.32)
82 (62.59)
3.54
4
My community (46)
100 (75.76)
28 (21.21)
4 (3.04)
2.04
3
Drink water (47)
4 (3.04)
4 (3.03)
124 (93.94)
4.31
3
Provide education (48)
2 (1.52)
15 (11.36)
115 (87.12)
4.09
3
Provide low-fat meals (49)
22 (16.80)
21 (16.03)
88 (67.18)
3.62
4
Income (50)
22 (16.42)
28 (20.90)
84 (62.69)
3.55
1
Survey question number
Limit screen time (51) After-school program (52)
Response frequency (percentage)
Mean
Missing
Not at all important
Slightly important
Somewhat important
Moderately important
Extremely important
9 (6.77) 8 (6.11)
3 (2.26) 11 (8.40)
28 (21.05) 31 (23.66)
36 (27.07) 38 (29.01)
57 (42.86) 43 (32.82)
3.96 3.74
2 4
Limit portion sizes (53)
5 (3.79)
3 (2.27)
18 (13.64)
42 (31.82)
64 (48.48)
4.18
3
Health professional (54)
10 (7.52)
10 (7.52)
23 (17.29)
41 (30.83)
49 (36.84)
3.81
2
Provide healthy snacks (55)
1 (0.75)
1 (0.75)
10 (7.52)
38 (28.57)
83 (62.41)
4.51
2
Exercise with my child (56)
2 (1.50)
2 (1.50)
9 (6.77)
39 (29.32)
81(60.90)
4.46
2
Read nutritional labels (57)
3 (2.26)
7 (5.26)
19 (14.29)
44 (33.08)
60 (45.11)
4.13
2
Limit high calorie foods (58) Community leaders (59) a
2 (1.53)
3 (2.29)
11 (8.40)
41 (31.30)
74 (56.49)
4.38
4
12 (9.02)
11 (8.27)
26 (19.55)
38 (28.57)
46 (34.59)
3.71
2
‘‘Strongly disagree’’ and ‘‘Disagree’’ and ‘‘Strongly agree’’ and ‘‘Agree’’ were collapsed for ease of interpretation
programs to target low income families because they do not have the resources to sustain a healthy lifestyle. Survey respondents ‘‘agreed’’ they encourage their child to drink water instead of sugary drinks (93 %), provide education about healthy behaviors (87 %), and provide low fat-meals to prevent obesity (67 %). Sentiments expressed by an interviewee included,
The most important to me would be the parents. The parents if they play their part everything else would pretty much fall in place.
Discussion Risk Factors
I buy a lot of fruits and stuff and vegetables and everything for the house too. So that’s what I try to do for her… she eats vegetables a lot. Caregivers were asked to rank the importance of prevention strategies (Table 6). A majority of respondents circled ‘‘extremely important’’ for limiting screen time (42 %), their child participating in an after-school program (32 %), regulating portion sizes (48 %), speaking with a health professional (36 %), providing healthy snacks (62 %), exercising with their child (60 %), reading nutritional labels (45 %), restricting energy-dense food (56 %), and facilitating discussions with community members and leaders (34 %). Most interviewees asserted that parents can prevent childhood obesity.
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Caregivers appeared to be well informed on the behavioral habits, parental influence, family obesity, and the environment as predictors of childhood obesity. Lack of money was not seen as a risk factor among survey respondents. However, interviewees contradicted the survey results stating a child from a low- income background would likely become obese because their parent(s) could not afford activity fees or healthier foods. This contradiction may have occurred because the interviewees were a self-selected sample; therefore, they may have cared more about childhood obesity and attempted to learn more risk factors of obesity. Despite the results, minority children in low-income families are disproportionately at risk for obesity and are
J Community Health
not usually presented with the opportunity to participate in obesity programs [34, 35] due to their environment. Minorities tend to reside in obesogenic communities with limited access to healthy foods and recreational parks and facilities [22]. Additional studies suggest residing in a rural area and lack of access to healthy foods increases the prevalence of obese children [36, 37]. African Americans residing in rural areas are more likely to encounter these aforementioned risk factors. In the study instruments, social cohesion was designated as a risk factor. Close ties of community members and children playing with other children were examples of social cohesion. High social cohesion can have a negative impact on perpetuating unhealthy behaviors [38] and may influence coordinated action among community members [39]. Survey respondents and interviewees rebutted that social cohesion is a childhood obesity risk factor. Consequently, multiple dimensions of the social environment and structural characteristics of communities, particularly governing bodies, should be assessed in rural communities.
associated with caregiver perceptions of weight status [46]. Current study findings were consistent with the previous body of literature revealing a perception and weight status disconnect. However, study participants reported that their perceptions were influenced by a prior doctor visit and visually examining their child. In addition, findings in this study demonstrated study participants compared themselves to others to determine normal weight status. Prior research asserts that minorities’ perceptions of obesity vary because they have an inaccurate clinical definition of obesity due to a lack of communication with healthcare providers during early childhood [47] and their ability to correctly perceive themselves or others as overweight is poor [48–50]. Yet, study participants reported understanding the difference between overweight and obesity. Participants agreed they could influence their child’s weight status through diet and physical activity habits. Caregivers of different races/ethnicities who are engaged in a childhood obesity intervention have significantly greater self-efficacy to promote healthy eating and increase support of physical activity for their children [51].
Health Complications Built Environment Survey respondents were well-informed on the pulmonary, endocrine, cardiovascular, and psychological effects of childhood obesity. Interviewees stated diabetes, hyperlipidemia, hypertension, and breathing problems were associated with obesity. Interviewee’s obese family members and friends were diagnosed with these aforementioned diseases. Only a few interviewees stated depression as a health complication of obesity. Nevertheless survey respondents and interviewees were uninformed of the effects on the reproductive system and the correlation of obesity and cancer. Interviewees that commented on health effects of the reproductive system worked in the healthcare field. Although no studies were found on rural, African American caregivers’ perceptions of obesity health complications the study findings rebutted prior studies with a majority White sample [40, 41]. These studies concluded caregivers fail to recognize their child is at an increased risk for physical and mental health problems caused by obesity and overweight [40, 41]. Weight Status Regarding weight status, little agreement existed between self-reported height and weight and the visual aid (Fig. 1). Perceptions of weight status have been examined in multiple populations as it relates to race/ethnicity and culture [42, 43]. Thus, studies have shown a difference in perceptions of ideal body weight between African Americans and Whites [42–45]. Demographic factors such as educational status, socioeconomic status, and age of the child are
Caregivers encounter challenges in their rural environment when attempting to implement healthy behaviors for their children. Survey and interview participants disagreed poorly kept housing increases the risk of childhood obesity. It is important to conduct further analysis of perceptions regarding the appearance of a community because this risk factor is modifiable through the enactment of environmental and social policies [9]. Many interviewees commented on the inadequate or distant physical activity venues and programs. Moreover, perceived crime was stated as a barrier of the built environment. Caregiver concerns regarding safety of the recreational parks influenced their child’s physical activity levels. Similarly, the lack of infrastructure and physical activity facilities in rural areas has been associated with low levels of physical activity and unhealthy weight status [52]. Literature suggests that walkable communities are associated with a lower rate of obesity. A study reported parental perceptions of neighborhood characteristics such as sidewalks influences self-efficacy and body weight of a child [53]. An additional study found that children’s weight status is reduced in environments where sidewalks or trails are present and in good condition [54]. Other studies have substantiated the association between the built environment and obesity [9, 55]. No literature currently exists on African American caregivers’ perceptions and other cultural groups regarding the perceptions of the rural built environment.
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J Community Health
Prevention Strategies Caregivers stated parents are essential for preventing childhood obesity because they influence the child’s lifestyle habits and are more influential than the school and community setting. This finding reinforced studies that childhood obesity efforts should target caregivers and work with children at the earliest stages of child development to encourage healthy practices [56, 57]. Caregivers were well aware of prevention strategies to employ; however, making healthy lifestyle choices and seeking preventive care revolved around their contextual environment and daily routines. Interviewees stated employing preventive strategies for obesity such as ensuring their child consumes more fruits and vegetables, speaking with their child’s doctor, and exercising with their child would be effective in reducing the risk of obesity. This finding demonstrated how participant’s behavioral capability, role modeling, and selfregulation can assist in future childhood obesity efforts. With relatively few studies and interventions in the literature focused on African Americans residing in rural areas, more research is warranted to draw conclusions on behavioral constructs that are associated with childhood obesity. In addition, studies are needed on the differences between urban and rural African American caregiver perceptions on childhood obesity prevention strategies. Limitations and Strengths Study limitations included the use of convenience sample, self-report data, a low response rate despite multiple survey distributions, distribution of surveys by teachers, and two poorly worded survey questions. Despite these limitations, multiple strengths were noted, including the use of theoretically derived instruments with reliability and validity evidence, the mixed method design which allowed for mixing qualitative and quantitative data, and being the first study we are aware of that explores childhood obesity perceptions among African American caregivers in a rural community. Implications Caregivers are in a position to impact obesity risk factors, their child’s weight status, utilize features in the built environment, and implement prevention approaches. Thus, public health efforts should be designed to assist caregivers in creating and sustaining healthy lifestyles in rural communities. The caregivers in this study had accurate obesity perceptions; however, they must extend their knowledge and influence into the community setting. Assessing the target population’s perceptions prior to conducting an obesity prevention program is imperative to understand their readiness for change. The contradictions between
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survey respondents and interviewees demonstrate caregivers have misperceptions of obesity. Effective interventions should utilize community assets identified by community members to increase parental involvement in childhood obesity efforts while providing resources to alleviate the stress of engaging in new health behaviors. Identifying community based organizations and faith based organizations that would be willing to sponsor programs to educate and monitor caregiver’s behaviors can potentially promote self-efficacy in the caregiver. Moreover, establishing support groups for families of unhealthy weight children would help increase social cohesion. Finally, examining the differences and similarities between urban and rural caregivers would allow public health professionals and policymakers to create sustainable programs for caregivers while integrating the challenges of both environments. Future Research Although obesity rates are stabilizing, obesity will continue to be one of the most challenging issues that public health professionals encounter until action is taken to educate and assist caregivers. For future research purposes, conducting a longitudinal, comparison study among African American families’ lifestyles and demographics to other cultures in multiple rural areas would be necessary. This would include objectively measuring the lifestyle habits of each family member in different settings (i.e., home, school, work, and community) to gain an exhaustive view on the determinants that influence childhood obesity and effective prevention strategies in rural areas. Examining the availability and accessibility of physical activity opportunities in rural areas would be an important predictor regarding weight status among African American children. Identifying and evaluating urban interventions that could be modified for a rural setting could possibly reduce weight status. When adapting the urban interventions it would be vital to assess population characteristics (e.g., geographic location, language, socioeconomic status, and tax-base), community readiness, risk factors perceived by the target population, and the individuals who would deliver the program [58]. Thus, there are countless ideas that could be produced from the present findings of this study.
Conclusion To date, no published studies were identified that investigated caregiver perceptions of obesity among African Americans in a rural area. An understanding of these perceptions may contribute to the development of tailored and effective family-based obesity interventions for African Americans. While conclusions based on these findings
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need to be strengthened due to the convenience sample and low response rate, the findings suggest a promising approach that warrants future attention before designing and implementing a program within this context. Acknowledgments We thank the content experts (Drs. Larissa R. Brunner Huber, Robert J. McDermott, Yelena N. Tarasenko, and Ashley D. Walker) for their involvement in the survey development. We also thank Alesha Wright and Dr. Divine Offeogbu for coding assistance, Dr. Dziyana Nazaruk for assisting with interviews, Dr. Gavin T. Colquitt for conducting an external audit on the study, and Julian Strayhorn II for assistance in designing the weight status figure. Lastly, we thank the study participants, the elementary school staff, and the County School Board. This work was supported in part by the Graduate Student Organization grant (1378924576).
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