Parenting style and perceptions of children’s weight among US Hispanics: a qualitative analysis

Parenting style and perceptions of children’s weight among US Hispanics: a qualitative analysis Abstract Parental perceptions of their children’s weight status may limit their willingness to participate in or acknowledge the importance of early interventions to prevent childhood obesity. This study aimed to examine potential differences in Hispanic mothers’ and fathers’ perceptions of childhood obesity, lifestyle behaviors and communication preferences to inform the development of culturally appropriate childhood obesity interventions. A qualitative study using focus groups was conducted. Groups (one for mothers and one for fathers) were composed of Hispanic parents (n = 12) with at least one girl and one boy (≤ 10 years old) who were patients at a pediatric clinic in Tennessee, USA. Thirteen major themes clustered into four categories were observed: (i) perceptions of childhood obesity/children’s weight; (ii) parenting strategies related to children’s dietary behaviors/physical activity; (iii) perceptions of what parents can do to prevent childhood obesity and (iv) parental suggestions for partnering with child care providers to address childhood obesity. Mothers appeared to be more concerned than fathers about their children’s weight. Fathers expressed more concern about the girls’ weight than boys’. Mothers were more likely than fathers to congratulate their children more often for healthy eating and physical activity. Parents collectively expressed a desire for child care providers (e.g. caregivers, teachers, medical professionals and food assistance programs coordinators) to have a caring attitude about their children, which might in turn serve as a motivating factor in talking about their children’s weight. Parental perceptions of their children’s weight and healthy lifestyle choices are of potential public health importance since they could affect parental participation in preventive interventions. childhood, obesity prevention, parental views, qualitative methods, misperception INTRODUCTION Childhood obesity is one of the biggest public health challenges the USA is facing in the 21st century, particularly among Hispanic youth. While the occurrence of childhood obesity in the US has increased overall since the 1990s (from 12.4% in 1998 to 16.9% in 2012), the disease disproportionally affects minority populations (Ogden et al., 2014). Hispanic children have higher rates of obesity than non-Hispanic whites, e.g. 16.7% versus 3.5% among ages 2 to 5 years, and 26.1% versus 13.1% among ages 6 to 11 years, respectively (Pan et al., 2012; Ogden et al., 2014). Children who are overweight and obese are more likely to become obese in adulthood, and they face an increased risk of metabolic and cardiovascular morbidities, increased health care costs and premature death (Ogden et al., 2002). In particular, obesity has been linked to type 2 diabetes, both of which are associated with an increased incidence and mortality from cancer (Gallagher and LeRoith, 2015). Current recommendations are that behavioral and clinical interventions and policies promoting healthy diets and physical activity should target children at an early age in order to effectively mitigate overweight and obesity-related health conditions later on in life (Hawkins and Law, 2006; Birch and Ventura, 2009). In order to be effective for primary and secondary prevention of childhood obesity, interventions should incorporate an integrated effort that targets multiple social systems including school, home, healthcare, childcare and the community, with parents serving a central role in the adoption and sustainability of recommended behaviors and actions. However, parental perceptions of their children’s weight status may limit their willingness to participate in and acknowledge the importance of early interventions to prevent childhood obesity. Previous studies have collectively revealed a widespread prevalence of parental misperceptions of their children’s weight status, particularly among Hispanics (Jackson et al., 1990; Baughcum et al., 2000, Myers and Vargas, 2000; Hackie and Bowles, 2007, De La et al., 2009; Rivera-Soto and Rodriguez-Figueroa, 2012). Studies have reported that these misperceptions are different for mothers compared to fathers, and parenting styles related to weight management can vary considerably depending on the child’s gender (De La et al., 2009; Rivera-Soto and Rodriguez-Figueroa, 2012). However, few studies have investigated whether mothers and fathers view boys and girls differently in regards to their weight status (Towns and D'Auria, 2009; Rivera-Soto and Rodriguez-Figueroa, 2012). This study was conducted as a precursor to the development of a of culturally appropriate childhood obesity prevention program for low-income Hispanic parents and children. The questions developed for this focus group were intended to examine key factors in obesity prevention strategies, including potential differences in Hispanic mothers’ and fathers’ perceptions of childhood obesity, lifestyle behaviors (healthy eating and physical activity habits) and communication preferences. METHODS We used qualitative research methods to gain a greater understanding of the subjective experience of study participants. In particular, we conducted focus groups to understand the role of family dynamics as they pertain to factors commonly associated with childhood obesity such as parent feeding behaviors, cultural norms and sedentary behaviors. We also aimed to identify specific parenting strategies related to parenting styles, diet and physical activity behaviors. We followed the consolidated criteria for reporting qualitative research to describe our focus groups’ semi-structured discussions within the three domains: (i) research team and reflexivity, (ii) study design and (iii) analysis and findings (Tong et al., 2007). Research team and reflexivity Personnel characteristics/relationship with participants The focus groups were conducted by a clinician researcher [MMG] with a Preventive Medicine and Public Health background. She is an experienced focus groups moderator and actively involved within the local Hispanic community, especially with issues related to childhood obesity. She is of Hispanic background herself and fluent in both English and Spanish. Study design Theoretical framework Thematic analysis was used to systematically organize data into a structured format. Participants Each group was comprised of six Hispanic mothers and fathers who were parents to at least one girl and one boy, both aged 10 years and younger (n = 12). The child’s weight status did not affect inclusion. Only one parent from a given family was included in the study. Participants were recruited from a predominantly Hispanic community using advertisements posted in a community-based pediatric clinic, and verbal informed consent was obtained prior to the start of the focus group. Setting The study protocol was approved by the Institutional Review Board at Meharry Medical College, Nashville, TN, USA. Two focus groups of available primary caregivers (one for mothers and one for fathers) were conducted between December 2013 and March 2014. Participants received a cash incentive, and a modest meal was provided during the focus group meetings. Data collection Prior to each focus group, information on sociodemographic characteristics and parenting practices was collected. Parenting practices were assessed using the Parenting Strategies for Eating and Activity Scale (PEAS). The PEAS has been validated for use in Hispanic communities as a measure of parenting strategies related to children’s dietary and activity behaviors (Larios et al., 2009). The survey consists of 26 statements with a Likert scale series of responses and a five-factor structure measuring (i) limit setting, (ii) monitoring, (iii) discipline, (iv) control and (v) reinforcement related to eating and physical activity behaviors in children (Larios et al., 2009). Since the number of statements comprising each factor is different, and since each factor’s ‘score’ depends on the number of statements, we rescaled each factor score and the overall PEAS score to a 0–100 scale to improve interpretability. Higher scores indicate a greater parental strategy (subscale) towards unhealthy eating and sedentary activity except for reinforcement. Higher scores for reinforcement indicate a greater parental congratulations for healthy eating and physical activity. The focus groups lasted approximately 2 hours and were video-audio recorded. Each session was conducted in Spanish and moderated by the study investigator and assisted by a research assistant who served as a note taker. Both were bilingual and culturally competent concerning the community from which the participants were recruited. A semi-structured interview guide (Supplementary data, Table S1) was used to facilitate the discussion, which focused on common knowledge about childhood obesity, prevention, and parenting styles, including barriers and facilitators to parental decision making related to the prevention of childhood obesity. Previous work within the target community by the researchers and a literature search guided the development of the interview guide. In addition to video-audio recording focus group discussions, the moderator and note taker recorded nonverbal gestures, themes and ideas as they emerged, and unexpected findings. Data analysis Following the focus group meetings, the moderator and note taker compared and contrasted their observations and checked for errors (Krueger, 2008). Audiotaped interviews were later transcribed verbatim and translated in English. Thematic analysis was used to identify, analyse and report themes in the data by two researchers with training in qualitative research. The transcribed data were first read and re-read several times (repeat reading), followed by a coding phase to identify information pertinent to the research questions (Braun 2006). A third researcher experienced in qualitative analyses reviewed the themes to ensure accurate coding. The last stage involved searching for themes by combining different codes that were similar or spoke to the same issues (Braun 2006). A final discussion of the results [MMG, SJG, JLS, and MS] was conducted to identify potential explanations and interpretation of the findings. Feedback from participants was not obtained. RESULTS Sociodemographic characteristics of focus groups participants are shown in Table 1. All participants were born outside of the USA. Mothers were, on average, younger than fathers (35 versus 41 years), reported fewer years living in the USA (13 versus 17 years), and used or consumed media more frequently than fathers (83.0% versus 66.7%). Parents were primarily low income with 66.7% below the 2013 poverty line and 60% participating in a food assistance program. The majority of the mothers (66.7%), however, could not estimate their annual family income. Table 1: Parents sociodemographic characteristics and average PEAS scores (n = 12) Characteristic  Mothers (n = 6)  Fathers (n = 6)  Age in years (mean)  35  41  Marital status (% married)  67  83  Years of schooling (mean)  9  10  Years living in the USA (mean)  13  17  Years living in Nashville (mean)  7  10  Family size (mean)  6  4  Children <10 years old (mean)  3  2  Boy:girl ratio (mean)  2:1  1:1  Media used at least once/week (%)  83 (Facebook, text messages, radio)  67 (Text, radio, TV, YouTube)  Annual Income <$35,000 (%)  67 did not know  67  WIC, food assistance (%)  67  50   PEAS Subscalea  Mothers (n = 6)  Fathers (n = 6)   Limits setting  93  93   Monitoring  93  69   Discipline  60  64   Control  61  56   Reinforcementb  80  35  Characteristic  Mothers (n = 6)  Fathers (n = 6)  Age in years (mean)  35  41  Marital status (% married)  67  83  Years of schooling (mean)  9  10  Years living in the USA (mean)  13  17  Years living in Nashville (mean)  7  10  Family size (mean)  6  4  Children <10 years old (mean)  3  2  Boy:girl ratio (mean)  2:1  1:1  Media used at least once/week (%)  83 (Facebook, text messages, radio)  67 (Text, radio, TV, YouTube)  Annual Income <$35,000 (%)  67 did not know  67  WIC, food assistance (%)  67  50   PEAS Subscalea  Mothers (n = 6)  Fathers (n = 6)   Limits setting  93  93   Monitoring  93  69   Discipline  60  64   Control  61  56   Reinforcementb  80  35  a The scores were converted into rates from 0 to 100. Higher scores indicate a greater parental strategy (subscale) towards unhealthy eating and sedentary activity except for reinforcement. b Higher scores indicate a greater parental congratulations for healthy eating and physical activity Both mothers and fathers had moderate-to-high scores on all of the PEAS subscales except the monitoring and reinforcement domains, in which mothers had a significantly higher scores (93 and 80) than fathers (69 and 35), respectively. This suggests that mothers are more likely than fathers to supervise unhealthy eating and sedentary activities as well as more likely to congratulate their children for healthy eating and physical activity (Table 1). The focus group analysis revealed four major themes: (i) perceptions of childhood obesity and children’s weight; (ii) parenting strategies related to children’s dietary behaviors and physical activity; (iii) perceptions of what parents can do to prevent childhood obesity and (iv) parents’ suggestions for partnering with child care providers to address childhood obesity. Supplementary data, Table S2 provides detailed information on the parents’ responses and main issues raised during the focus groups. Perceptions of childhood obesity and children’s weight Overall, mothers appeared to be more concerned than fathers about their children’s weight (Supplementary data, Table S2). However, fathers expressed more concern about the girls’ weight compared to the boys’ using the rationale that ‘boys will outgrow’ obesity. Both mothers and fathers were concerned about the emotional implications of being overweight, especially among girls. Even though parents mentioned diabetes as one of the risks associated with childhood obesity, none of them expressed concerns about the unhealthy weight among their children leading to downstream health consequences into adulthood. Mother ID2: ‘I don’t want my children to be affected emotionally because of their weight’. Father ID 3: ‘I am trying to help my daughter to lose weight because it will be hurtful to see her reach 15 y/o and be an overweight teenager and suffer for it’. Parenting strategies Limit setting and monitoring were the parental strategies that mothers reported most often (Supplementary data, Table S2). For example, one mother noted, ‘I don’t buy junk food to avoid that my children have access to it at home’ (Mother ID1). Another mother said, ‘My daughter lost 3–4 pounds because I watch closely what she eats’ (Mother ID 3). Mothers perceived fathers as being more permissive than them when it comes to parenting. Mothers also described strict parenting as someone totally ‘authoritarian’ but tended not to identify themselves as such. Although they considered the setting of some rules as important regarding healthy eating and physical activity, they were not sure about the ideal recommendations. Fathers admitted to being more permissive and less engaged with family food choices than their partners. Fathers voiced the importance of establishing house rules, and reported using ‘food treats’ as rewards for good behavior and school performance. Regarding the main barriers to healthy eating, mothers referred to costs, children’s preferences, food as a reward, lack of control over school menus, and cultural customs such as encouraging large portion size (Supplementary data, Table S2). On the other hand, fathers were more concerned about the difficulties of setting a good example for their children. Mothers reported the following barriers for physical activity: lack of access to safe parks and playgrounds, cost and children’s preferences. Conversely, fathers were more concerned about their children being teased, time constraints and use of electronic media, in addition to cost. Parental perception of role in preventing childhood obesity Both mothers and fathers acknowledged the importance of serving as role models to promote their children’s healthy lifestyle choices, but admitted to having encountered barriers, including a lack of knowledge about the right thing to do, and discrepancies between what is acceptable for adults (often fathers) compared to the overall message (in the form of rules and guidance) being sent to the children, particularly regarding healthy eating and physical activity. Mother ID4: ‘I know I should be a role model but I feel I don’t’ know how’ Father ID5: ‘I wish my children ate healthier but they just love to eat bad stuff and big portions like daddy’. Parental suggestions for partnering with healthcare providers Finally, parents collectively expressed a desire for child care providers (e.g. caregivers, teachers, medical professionals and food assistance programs coordinators) to have a caring attitude about their children, which might in turn serve as a motivating factor in talking about their children’s weight (Supplementary data, Table S2). Both mothers and fathers expressed concern regarding the manner in which weight was discussed by their healthcare provider. In some cases, providers offended them and their children or spoke about the subject in a manner that was difficult for the family to understand. Parents also expressed a desire for reassurance that the provider is doing everything possible to promote a healthy weight for their children, including the provision of the tools and education necessary for parents to help their children at home. Lastly, parents reported that they do receive information on childhood obesity from Spanish radio and television, health providers, and other parents. Mother ID6: ‘I would like to have someone who knows my child to talk to me about his/her weight in a way that I can understand’. Father ID6: ‘Someone should be able to tell me if my child needs to see the doctor before things go out of control’. DISCUSSION Our study contributes to a growing literature that suggests the importance of involving both mothers and fathers in efforts to promote and maintain healthy weight in children. The qualitative data portray some of the challenges related to parents’ perceptions and experiences in regards to childhood obesity and highlight the need for further research on how cultural norms may play a role regarding concerns versus responsibility for action to address weight management behaviors. Overall, mothers appeared to be more concerned than fathers about their children’s weight, while fathers expressed more concern about the girls’ weight compared to the boys’ (e.g. ‘boys will outgrow’ obesity). Research indicates that parenting is among the most important family-level determinant of childhood obesity (Stokols, 1996; Birch and Davison 2001; Ventura and Birch 2008). However, the prevalences of parental misperceptions of children’s weight and healthy lifestyle choices are public health concerns since they could limit parental engagement in primary and secondary interventions to prevent childhood obesity. For example, a study among Hispanic WIC participants reported that most mothers of overweight and obese preschool children misclassified their children’s weight as normal (93.6%) (Chaparro et al., 2011). Compared to parents who incorrectly categorize their overweight or obese children as being healthy weight, data show that parents who correctly recognize their children’s unhealthy weight are more likely to express concern (Moore et al., 2012) and to report intentions to positively modify family lifestyle behaviors (Park et al., 2014). Conversely, few of the existing studies have focused on Hispanic parents, a population that is difficult to engage in research studies due to a number of barriers, including English language proficiency, fears associated with immigration status and lack of familiarity with the US health care system (Escarce Jose, 2006). The various themes that emerged during focus groups provide useful information regarding the confluence of factors, including parental knowledge gaps regarding appropriate prevention/intervention strategies and parental perceptions of overweight and obesity in general that may serve as significant barriers to promoting healthy nutrition and physical activity habits in young children. Home environments play an important role in the formation of children’s dietary and physical activity related behaviors that are crucial to prevent childhood obesity (Moore et al., 1991; Birch and Fisher, 1998; Strauss and Knight, 1999; Birch and Fisher, 2000; Savage et al., 2007; Hawkins et al., 2009). Various mechanisms by which Hispanic parents, in particular, influence their children’s risk for obesity have been identified: (i) parenting style (a more indulgent parenting style is associated with greater risk for obesity) (Sherman et al., 1995; Hughes et al., 2005); (ii) parenting strategies (parents who use more monitoring, more positive reinforcement and less controlling parenting strategies have children who consume a healthier diet and are more physically active) (Arredondo et al., 2006); (iii) provision of instrumental support (more instrumental support for physical activity is associated with normal weight) (Elder et al., 2010) and (iv) modeling of health behaviors (parents and children who eat away-from-home foods at least once per week are at greater risk for being overweight/obese) (Duerksen et al., 2007; Ayala et al., 2008). The results presented in this study point to the need to engage minority and culturally diverse communities in taking a pro-active stance towards preventing childhood obesity. Although anthropometric measurements were not included in this study to establish predictors of childhood obesity, the qualitative data support the need to explore further the mechanisms described above in order to mitigate the risk of obesity among Hispanic children. For example, we found that fathers show a more indulgent parenting style compared to mothers. With regard to parenting strategies, mothers reported that they tended to use more reinforcement and monitoring but both mothers and fathers were very similar when it came to moderate controlling such as the need to establish some house rules (e.g. TV time). Moreover, both parents expressed the importance of supporting and influencing their children’s amount of physical activity, but encountered many obstacles including time constraints, cost and lack of access to safe play areas. In addition, fathers used fast food as a reward for good behavior and admitted to having difficulty modeling healthy lifestyle behaviors. Such inconsistent messages from each parent may inadvertently sabotage efforts to maintain lifestyle change in children. Finally, children’s behaviors are not only influenced by parents but also by a wide range of child care providers including school teachers, health professionals and those who work in government programs. Their direct and indirect messages ultimately shape parents knowledge about their children’s health and risk of obesity including a number of issues related to children’s daily routines such as eating patterns, physical activity and sleep. The current recommendation is that counseling should not be simply directive, but instead should provide parents knowledge about how to be effective, and aware of their own perceptions and motivations. Some of the limitations of this study include the small sample size that restrained the analysis from reaching the point of saturation and the lack of information on the child's weight status. Based on personal clinical and community experiences (MMG), participating parents and their children seemed to be representative as to cultural background pertaining to childhood obesity issues. Nonetheless, there is also a possibility that perceptions of parents who not only seek routine medical care for their children but also agree to participate in research studies might differ from those parents who do not. Additionally, information from the present pilot will be used to develop future inquiries that more explicitly address how parental perceptions of their children’s weight status may have affected the children’s weight and lifestyle behaviors. The strength of the study is the participation of parents from the target community who provided valuable information in regards to future planning for a larger pilot study of parental perceptions of children’s weight. In addition, we found that parents expectations based on child care providers (e.g. caregivers, teachers, medical professionals and food assistance programs coordinators) attitudes were deemed as crucial as a motivating factor in talking about their children’s weight. This was anticipated as a part of our interest on developing a culturally appropriate intervention involving parents, children and providers. In summary, the US childhood obesity epidemic has continued to worsened for the past three decades, particularly among minority populations. There remains a need for policies that are culturally appropriate and that target barriers to healthy eating and physical activity at the individual, family and community levels. The parents involved in our study identified important socioeconomic, cultural and health-literacy-related barriers to promoting a healthy weight status in their children. In order to effectively support parents to change their behaviors, it is necessary to empower them to take a more proactive stance in developing and encouraging the appropriate lifestyle modifications, such as limiting sedentary media activities, encouraging physical activity and delivering consistent messages about dietary needs. ETHICS APPROVAL The study protocol was approved by the Institutional Review Board at Meharry Medical College, Nashville, Tennessee, USA. SUPPLEMENTARY MATERIAL Supplementary material is available at Health Promotion International online. AUTHORS’ CONTRIBUTIONS Conception/design: Maria C. Mejia, MD, MPH; Robert S. Levine, MD; Collection/assembly of data: Maria C. Mejia de Grubb, MD, MPH; Sandra J. Gonzalez, MSSW, LCSW; Data analysis: Maria C. Mejia de Grubb, MD, MPH; Maureen Sanderson, PhD; Jason L. Salemi, PhD; Manuscript writing: Maria C. Mejia de Grubb, MD, MPH; Robert S. Levine, MD; Maureen Sanderson, PhD; Sandra J. Gonzalez, MSSW, LCSW, Jason L. Salemi, PhD; Roger J. Zoorob, MD, MPH; William Mkanta, PhD. ACKNOWLEDGEMENTS This study was conducted at Meharry Medical College, Department of Family Medicine in collaboration with the Meharry Pediatrics Clinic, Nashville, Tennessee, USA. Parts of this study were included in a poster presentation at the 143rd American Public Health Association Annual Meeting, Oct. 31 - Nov. 4, 2015, Chicago, IL. 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Parenting style and perceptions of children’s weight among US Hispanics: a qualitative analysis

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Abstract

Abstract Parental perceptions of their children’s weight status may limit their willingness to participate in or acknowledge the importance of early interventions to prevent childhood obesity. This study aimed to examine potential differences in Hispanic mothers’ and fathers’ perceptions of childhood obesity, lifestyle behaviors and communication preferences to inform the development of culturally appropriate childhood obesity interventions. A qualitative study using focus groups was conducted. Groups (one for mothers and one for fathers) were composed of Hispanic parents (n = 12) with at least one girl and one boy (≤ 10 years old) who were patients at a pediatric clinic in Tennessee, USA. Thirteen major themes clustered into four categories were observed: (i) perceptions of childhood obesity/children’s weight; (ii) parenting strategies related to children’s dietary behaviors/physical activity; (iii) perceptions of what parents can do to prevent childhood obesity and (iv) parental suggestions for partnering with child care providers to address childhood obesity. Mothers appeared to be more concerned than fathers about their children’s weight. Fathers expressed more concern about the girls’ weight than boys’. Mothers were more likely than fathers to congratulate their children more often for healthy eating and physical activity. Parents collectively expressed a desire for child care providers (e.g. caregivers, teachers, medical professionals and food assistance programs coordinators) to have a caring attitude about their children, which might in turn serve as a motivating factor in talking about their children’s weight. Parental perceptions of their children’s weight and healthy lifestyle choices are of potential public health importance since they could affect parental participation in preventive interventions. childhood, obesity prevention, parental views, qualitative methods, misperception INTRODUCTION Childhood obesity is one of the biggest public health challenges the USA is facing in the 21st century, particularly among Hispanic youth. While the occurrence of childhood obesity in the US has increased overall since the 1990s (from 12.4% in 1998 to 16.9% in 2012), the disease disproportionally affects minority populations (Ogden et al., 2014). Hispanic children have higher rates of obesity than non-Hispanic whites, e.g. 16.7% versus 3.5% among ages 2 to 5 years, and 26.1% versus 13.1% among ages 6 to 11 years, respectively (Pan et al., 2012; Ogden et al., 2014). Children who are overweight and obese are more likely to become obese in adulthood, and they face an increased risk of metabolic and cardiovascular morbidities, increased health care costs and premature death (Ogden et al., 2002). In particular, obesity has been linked to type 2 diabetes, both of which are associated with an increased incidence and mortality from cancer (Gallagher and LeRoith, 2015). Current recommendations are that behavioral and clinical interventions and policies promoting healthy diets and physical activity should target children at an early age in order to effectively mitigate overweight and obesity-related health conditions later on in life (Hawkins and Law, 2006; Birch and Ventura, 2009). In order to be effective for primary and secondary prevention of childhood obesity, interventions should incorporate an integrated effort that targets multiple social systems including school, home, healthcare, childcare and the community, with parents serving a central role in the adoption and sustainability of recommended behaviors and actions. However, parental perceptions of their children’s weight status may limit their willingness to participate in and acknowledge the importance of early interventions to prevent childhood obesity. Previous studies have collectively revealed a widespread prevalence of parental misperceptions of their children’s weight status, particularly among Hispanics (Jackson et al., 1990; Baughcum et al., 2000, Myers and Vargas, 2000; Hackie and Bowles, 2007, De La et al., 2009; Rivera-Soto and Rodriguez-Figueroa, 2012). Studies have reported that these misperceptions are different for mothers compared to fathers, and parenting styles related to weight management can vary considerably depending on the child’s gender (De La et al., 2009; Rivera-Soto and Rodriguez-Figueroa, 2012). However, few studies have investigated whether mothers and fathers view boys and girls differently in regards to their weight status (Towns and D'Auria, 2009; Rivera-Soto and Rodriguez-Figueroa, 2012). This study was conducted as a precursor to the development of a of culturally appropriate childhood obesity prevention program for low-income Hispanic parents and children. The questions developed for this focus group were intended to examine key factors in obesity prevention strategies, including potential differences in Hispanic mothers’ and fathers’ perceptions of childhood obesity, lifestyle behaviors (healthy eating and physical activity habits) and communication preferences. METHODS We used qualitative research methods to gain a greater understanding of the subjective experience of study participants. In particular, we conducted focus groups to understand the role of family dynamics as they pertain to factors commonly associated with childhood obesity such as parent feeding behaviors, cultural norms and sedentary behaviors. We also aimed to identify specific parenting strategies related to parenting styles, diet and physical activity behaviors. We followed the consolidated criteria for reporting qualitative research to describe our focus groups’ semi-structured discussions within the three domains: (i) research team and reflexivity, (ii) study design and (iii) analysis and findings (Tong et al., 2007). Research team and reflexivity Personnel characteristics/relationship with participants The focus groups were conducted by a clinician researcher [MMG] with a Preventive Medicine and Public Health background. She is an experienced focus groups moderator and actively involved within the local Hispanic community, especially with issues related to childhood obesity. She is of Hispanic background herself and fluent in both English and Spanish. Study design Theoretical framework Thematic analysis was used to systematically organize data into a structured format. Participants Each group was comprised of six Hispanic mothers and fathers who were parents to at least one girl and one boy, both aged 10 years and younger (n = 12). The child’s weight status did not affect inclusion. Only one parent from a given family was included in the study. Participants were recruited from a predominantly Hispanic community using advertisements posted in a community-based pediatric clinic, and verbal informed consent was obtained prior to the start of the focus group. Setting The study protocol was approved by the Institutional Review Board at Meharry Medical College, Nashville, TN, USA. Two focus groups of available primary caregivers (one for mothers and one for fathers) were conducted between December 2013 and March 2014. Participants received a cash incentive, and a modest meal was provided during the focus group meetings. Data collection Prior to each focus group, information on sociodemographic characteristics and parenting practices was collected. Parenting practices were assessed using the Parenting Strategies for Eating and Activity Scale (PEAS). The PEAS has been validated for use in Hispanic communities as a measure of parenting strategies related to children’s dietary and activity behaviors (Larios et al., 2009). The survey consists of 26 statements with a Likert scale series of responses and a five-factor structure measuring (i) limit setting, (ii) monitoring, (iii) discipline, (iv) control and (v) reinforcement related to eating and physical activity behaviors in children (Larios et al., 2009). Since the number of statements comprising each factor is different, and since each factor’s ‘score’ depends on the number of statements, we rescaled each factor score and the overall PEAS score to a 0–100 scale to improve interpretability. Higher scores indicate a greater parental strategy (subscale) towards unhealthy eating and sedentary activity except for reinforcement. Higher scores for reinforcement indicate a greater parental congratulations for healthy eating and physical activity. The focus groups lasted approximately 2 hours and were video-audio recorded. Each session was conducted in Spanish and moderated by the study investigator and assisted by a research assistant who served as a note taker. Both were bilingual and culturally competent concerning the community from which the participants were recruited. A semi-structured interview guide (Supplementary data, Table S1) was used to facilitate the discussion, which focused on common knowledge about childhood obesity, prevention, and parenting styles, including barriers and facilitators to parental decision making related to the prevention of childhood obesity. Previous work within the target community by the researchers and a literature search guided the development of the interview guide. In addition to video-audio recording focus group discussions, the moderator and note taker recorded nonverbal gestures, themes and ideas as they emerged, and unexpected findings. Data analysis Following the focus group meetings, the moderator and note taker compared and contrasted their observations and checked for errors (Krueger, 2008). Audiotaped interviews were later transcribed verbatim and translated in English. Thematic analysis was used to identify, analyse and report themes in the data by two researchers with training in qualitative research. The transcribed data were first read and re-read several times (repeat reading), followed by a coding phase to identify information pertinent to the research questions (Braun 2006). A third researcher experienced in qualitative analyses reviewed the themes to ensure accurate coding. The last stage involved searching for themes by combining different codes that were similar or spoke to the same issues (Braun 2006). A final discussion of the results [MMG, SJG, JLS, and MS] was conducted to identify potential explanations and interpretation of the findings. Feedback from participants was not obtained. RESULTS Sociodemographic characteristics of focus groups participants are shown in Table 1. All participants were born outside of the USA. Mothers were, on average, younger than fathers (35 versus 41 years), reported fewer years living in the USA (13 versus 17 years), and used or consumed media more frequently than fathers (83.0% versus 66.7%). Parents were primarily low income with 66.7% below the 2013 poverty line and 60% participating in a food assistance program. The majority of the mothers (66.7%), however, could not estimate their annual family income. Table 1: Parents sociodemographic characteristics and average PEAS scores (n = 12) Characteristic  Mothers (n = 6)  Fathers (n = 6)  Age in years (mean)  35  41  Marital status (% married)  67  83  Years of schooling (mean)  9  10  Years living in the USA (mean)  13  17  Years living in Nashville (mean)  7  10  Family size (mean)  6  4  Children <10 years old (mean)  3  2  Boy:girl ratio (mean)  2:1  1:1  Media used at least once/week (%)  83 (Facebook, text messages, radio)  67 (Text, radio, TV, YouTube)  Annual Income <$35,000 (%)  67 did not know  67  WIC, food assistance (%)  67  50   PEAS Subscalea  Mothers (n = 6)  Fathers (n = 6)   Limits setting  93  93   Monitoring  93  69   Discipline  60  64   Control  61  56   Reinforcementb  80  35  Characteristic  Mothers (n = 6)  Fathers (n = 6)  Age in years (mean)  35  41  Marital status (% married)  67  83  Years of schooling (mean)  9  10  Years living in the USA (mean)  13  17  Years living in Nashville (mean)  7  10  Family size (mean)  6  4  Children <10 years old (mean)  3  2  Boy:girl ratio (mean)  2:1  1:1  Media used at least once/week (%)  83 (Facebook, text messages, radio)  67 (Text, radio, TV, YouTube)  Annual Income <$35,000 (%)  67 did not know  67  WIC, food assistance (%)  67  50   PEAS Subscalea  Mothers (n = 6)  Fathers (n = 6)   Limits setting  93  93   Monitoring  93  69   Discipline  60  64   Control  61  56   Reinforcementb  80  35  a The scores were converted into rates from 0 to 100. Higher scores indicate a greater parental strategy (subscale) towards unhealthy eating and sedentary activity except for reinforcement. b Higher scores indicate a greater parental congratulations for healthy eating and physical activity Both mothers and fathers had moderate-to-high scores on all of the PEAS subscales except the monitoring and reinforcement domains, in which mothers had a significantly higher scores (93 and 80) than fathers (69 and 35), respectively. This suggests that mothers are more likely than fathers to supervise unhealthy eating and sedentary activities as well as more likely to congratulate their children for healthy eating and physical activity (Table 1). The focus group analysis revealed four major themes: (i) perceptions of childhood obesity and children’s weight; (ii) parenting strategies related to children’s dietary behaviors and physical activity; (iii) perceptions of what parents can do to prevent childhood obesity and (iv) parents’ suggestions for partnering with child care providers to address childhood obesity. Supplementary data, Table S2 provides detailed information on the parents’ responses and main issues raised during the focus groups. Perceptions of childhood obesity and children’s weight Overall, mothers appeared to be more concerned than fathers about their children’s weight (Supplementary data, Table S2). However, fathers expressed more concern about the girls’ weight compared to the boys’ using the rationale that ‘boys will outgrow’ obesity. Both mothers and fathers were concerned about the emotional implications of being overweight, especially among girls. Even though parents mentioned diabetes as one of the risks associated with childhood obesity, none of them expressed concerns about the unhealthy weight among their children leading to downstream health consequences into adulthood. Mother ID2: ‘I don’t want my children to be affected emotionally because of their weight’. Father ID 3: ‘I am trying to help my daughter to lose weight because it will be hurtful to see her reach 15 y/o and be an overweight teenager and suffer for it’. Parenting strategies Limit setting and monitoring were the parental strategies that mothers reported most often (Supplementary data, Table S2). For example, one mother noted, ‘I don’t buy junk food to avoid that my children have access to it at home’ (Mother ID1). Another mother said, ‘My daughter lost 3–4 pounds because I watch closely what she eats’ (Mother ID 3). Mothers perceived fathers as being more permissive than them when it comes to parenting. Mothers also described strict parenting as someone totally ‘authoritarian’ but tended not to identify themselves as such. Although they considered the setting of some rules as important regarding healthy eating and physical activity, they were not sure about the ideal recommendations. Fathers admitted to being more permissive and less engaged with family food choices than their partners. Fathers voiced the importance of establishing house rules, and reported using ‘food treats’ as rewards for good behavior and school performance. Regarding the main barriers to healthy eating, mothers referred to costs, children’s preferences, food as a reward, lack of control over school menus, and cultural customs such as encouraging large portion size (Supplementary data, Table S2). On the other hand, fathers were more concerned about the difficulties of setting a good example for their children. Mothers reported the following barriers for physical activity: lack of access to safe parks and playgrounds, cost and children’s preferences. Conversely, fathers were more concerned about their children being teased, time constraints and use of electronic media, in addition to cost. Parental perception of role in preventing childhood obesity Both mothers and fathers acknowledged the importance of serving as role models to promote their children’s healthy lifestyle choices, but admitted to having encountered barriers, including a lack of knowledge about the right thing to do, and discrepancies between what is acceptable for adults (often fathers) compared to the overall message (in the form of rules and guidance) being sent to the children, particularly regarding healthy eating and physical activity. Mother ID4: ‘I know I should be a role model but I feel I don’t’ know how’ Father ID5: ‘I wish my children ate healthier but they just love to eat bad stuff and big portions like daddy’. Parental suggestions for partnering with healthcare providers Finally, parents collectively expressed a desire for child care providers (e.g. caregivers, teachers, medical professionals and food assistance programs coordinators) to have a caring attitude about their children, which might in turn serve as a motivating factor in talking about their children’s weight (Supplementary data, Table S2). Both mothers and fathers expressed concern regarding the manner in which weight was discussed by their healthcare provider. In some cases, providers offended them and their children or spoke about the subject in a manner that was difficult for the family to understand. Parents also expressed a desire for reassurance that the provider is doing everything possible to promote a healthy weight for their children, including the provision of the tools and education necessary for parents to help their children at home. Lastly, parents reported that they do receive information on childhood obesity from Spanish radio and television, health providers, and other parents. Mother ID6: ‘I would like to have someone who knows my child to talk to me about his/her weight in a way that I can understand’. Father ID6: ‘Someone should be able to tell me if my child needs to see the doctor before things go out of control’. DISCUSSION Our study contributes to a growing literature that suggests the importance of involving both mothers and fathers in efforts to promote and maintain healthy weight in children. The qualitative data portray some of the challenges related to parents’ perceptions and experiences in regards to childhood obesity and highlight the need for further research on how cultural norms may play a role regarding concerns versus responsibility for action to address weight management behaviors. Overall, mothers appeared to be more concerned than fathers about their children’s weight, while fathers expressed more concern about the girls’ weight compared to the boys’ (e.g. ‘boys will outgrow’ obesity). Research indicates that parenting is among the most important family-level determinant of childhood obesity (Stokols, 1996; Birch and Davison 2001; Ventura and Birch 2008). However, the prevalences of parental misperceptions of children’s weight and healthy lifestyle choices are public health concerns since they could limit parental engagement in primary and secondary interventions to prevent childhood obesity. For example, a study among Hispanic WIC participants reported that most mothers of overweight and obese preschool children misclassified their children’s weight as normal (93.6%) (Chaparro et al., 2011). Compared to parents who incorrectly categorize their overweight or obese children as being healthy weight, data show that parents who correctly recognize their children’s unhealthy weight are more likely to express concern (Moore et al., 2012) and to report intentions to positively modify family lifestyle behaviors (Park et al., 2014). Conversely, few of the existing studies have focused on Hispanic parents, a population that is difficult to engage in research studies due to a number of barriers, including English language proficiency, fears associated with immigration status and lack of familiarity with the US health care system (Escarce Jose, 2006). The various themes that emerged during focus groups provide useful information regarding the confluence of factors, including parental knowledge gaps regarding appropriate prevention/intervention strategies and parental perceptions of overweight and obesity in general that may serve as significant barriers to promoting healthy nutrition and physical activity habits in young children. Home environments play an important role in the formation of children’s dietary and physical activity related behaviors that are crucial to prevent childhood obesity (Moore et al., 1991; Birch and Fisher, 1998; Strauss and Knight, 1999; Birch and Fisher, 2000; Savage et al., 2007; Hawkins et al., 2009). Various mechanisms by which Hispanic parents, in particular, influence their children’s risk for obesity have been identified: (i) parenting style (a more indulgent parenting style is associated with greater risk for obesity) (Sherman et al., 1995; Hughes et al., 2005); (ii) parenting strategies (parents who use more monitoring, more positive reinforcement and less controlling parenting strategies have children who consume a healthier diet and are more physically active) (Arredondo et al., 2006); (iii) provision of instrumental support (more instrumental support for physical activity is associated with normal weight) (Elder et al., 2010) and (iv) modeling of health behaviors (parents and children who eat away-from-home foods at least once per week are at greater risk for being overweight/obese) (Duerksen et al., 2007; Ayala et al., 2008). The results presented in this study point to the need to engage minority and culturally diverse communities in taking a pro-active stance towards preventing childhood obesity. Although anthropometric measurements were not included in this study to establish predictors of childhood obesity, the qualitative data support the need to explore further the mechanisms described above in order to mitigate the risk of obesity among Hispanic children. For example, we found that fathers show a more indulgent parenting style compared to mothers. With regard to parenting strategies, mothers reported that they tended to use more reinforcement and monitoring but both mothers and fathers were very similar when it came to moderate controlling such as the need to establish some house rules (e.g. TV time). Moreover, both parents expressed the importance of supporting and influencing their children’s amount of physical activity, but encountered many obstacles including time constraints, cost and lack of access to safe play areas. In addition, fathers used fast food as a reward for good behavior and admitted to having difficulty modeling healthy lifestyle behaviors. Such inconsistent messages from each parent may inadvertently sabotage efforts to maintain lifestyle change in children. Finally, children’s behaviors are not only influenced by parents but also by a wide range of child care providers including school teachers, health professionals and those who work in government programs. Their direct and indirect messages ultimately shape parents knowledge about their children’s health and risk of obesity including a number of issues related to children’s daily routines such as eating patterns, physical activity and sleep. The current recommendation is that counseling should not be simply directive, but instead should provide parents knowledge about how to be effective, and aware of their own perceptions and motivations. Some of the limitations of this study include the small sample size that restrained the analysis from reaching the point of saturation and the lack of information on the child's weight status. Based on personal clinical and community experiences (MMG), participating parents and their children seemed to be representative as to cultural background pertaining to childhood obesity issues. Nonetheless, there is also a possibility that perceptions of parents who not only seek routine medical care for their children but also agree to participate in research studies might differ from those parents who do not. Additionally, information from the present pilot will be used to develop future inquiries that more explicitly address how parental perceptions of their children’s weight status may have affected the children’s weight and lifestyle behaviors. The strength of the study is the participation of parents from the target community who provided valuable information in regards to future planning for a larger pilot study of parental perceptions of children’s weight. In addition, we found that parents expectations based on child care providers (e.g. caregivers, teachers, medical professionals and food assistance programs coordinators) attitudes were deemed as crucial as a motivating factor in talking about their children’s weight. This was anticipated as a part of our interest on developing a culturally appropriate intervention involving parents, children and providers. In summary, the US childhood obesity epidemic has continued to worsened for the past three decades, particularly among minority populations. There remains a need for policies that are culturally appropriate and that target barriers to healthy eating and physical activity at the individual, family and community levels. The parents involved in our study identified important socioeconomic, cultural and health-literacy-related barriers to promoting a healthy weight status in their children. In order to effectively support parents to change their behaviors, it is necessary to empower them to take a more proactive stance in developing and encouraging the appropriate lifestyle modifications, such as limiting sedentary media activities, encouraging physical activity and delivering consistent messages about dietary needs. ETHICS APPROVAL The study protocol was approved by the Institutional Review Board at Meharry Medical College, Nashville, Tennessee, USA. SUPPLEMENTARY MATERIAL Supplementary material is available at Health Promotion International online. AUTHORS’ CONTRIBUTIONS Conception/design: Maria C. Mejia, MD, MPH; Robert S. Levine, MD; Collection/assembly of data: Maria C. Mejia de Grubb, MD, MPH; Sandra J. Gonzalez, MSSW, LCSW; Data analysis: Maria C. Mejia de Grubb, MD, MPH; Maureen Sanderson, PhD; Jason L. Salemi, PhD; Manuscript writing: Maria C. Mejia de Grubb, MD, MPH; Robert S. Levine, MD; Maureen Sanderson, PhD; Sandra J. Gonzalez, MSSW, LCSW, Jason L. Salemi, PhD; Roger J. Zoorob, MD, MPH; William Mkanta, PhD. ACKNOWLEDGEMENTS This study was conducted at Meharry Medical College, Department of Family Medicine in collaboration with the Meharry Pediatrics Clinic, Nashville, Tennessee, USA. Parts of this study were included in a poster presentation at the 143rd American Public Health Association Annual Meeting, Oct. 31 - Nov. 4, 2015, Chicago, IL. 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Health Promotion InternationalOxford University Press

Published: Feb 1, 2018

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