Community Stakeholders' Perceptions of Major Factors Influencing Childhood Obesity, the Feasibility of Programs Addressing Childhood Obesity, and Persisting Gaps

Stakeholders' perception of factors influencing adoption of a pediatric weight management intervention: a qualitative study

Background

Childhood obesity is highly prevalent in the United States and disproportionately impacts communities of color and low-income populations; these disparities have worsened during the COVID-19 pandemic. Adoption of effective pediatric weight management interventions (PWMIs) that have been evaluated among low-income diverse populations is needed. The Healthy Weight Clinic PWMI, a package co-developed by the American Academy of Pediatrics and Massachusetts General Hospital, helps health centers establish multidisciplinary Healthy Weight Clinics based on previous randomized controlled trials which demonstrated effectiveness. We sought to identify the factors influencing successful adoption of this PWMI and understand adaptations needed prior to implementation in new sites.

Methods

We interviewed 20 stakeholders, 10 from two health centers in Mississippi where the Healthy Weight Clinic PWMI will be piloted (pre-implementation sites) and 10 from health centers that have previously implemented it (sites in maintenance stages). Separate interview guides informed by the Consolidated Framework for Implementation Research (CFIR) were developed for the pre-implementation sites and those in maintenance stages, including questions related to adaptations of the PWMI in response to the COVID-19 pandemic. Qualitative data analysis was conducted using directed content analysis based on CFIR constructs. Adaptations in response to the pandemic were categorized using Framework for Reporting Adaptations and Modifications-Expanded (FRAME).

Results

In pre-implementation sites, an inner setting facilitator mentioned was a positive learning climate. Characteristics of individuals that can facilitate adoption include staff willingness to learn, valuing evidence-based care for childhood obesity, and culturally and weight-sensitive staff. In terms of patient needs and resources (outer setting), social drivers of health are barriers to adoption, but creative solutions were suggested to mitigate these. Other facilitators related to the intervention included its multidisciplinary model and adaptability. Similar themes were elicited from sites in maintenance stages; adaptations brought on by the pandemic, such as telehealth visits and content modification to align with distancing guidelines and the effects of social isolation were also described.

Conclusion

Understanding the factors influencing adoption of an evidence-based PWMI informs necessary adaptations and implementation strategies required to facilitate nationwide dissemination of PWMIs, with the goal of reaching the populations most at-risk.

Teachers’ Resources to Support School Lunch: Professional Development Is Warranted

In the United States, many children who come from low-income backgrounds and experience food insecurity do not take and eat school lunch, despite it being a nutritious meal. Teachers could play a role in encouraging students’ consumption of school lunch; however, teachers in America are traditionally uninvolved in the lunch period. The purpose of this research was to understand the resources kindergarten through twelfth grade (K-12) teachers need to encourage students to take and eat school lunch. Two data collection workshops and semi-structured follow-up interviews were conducted with K-12 teachers. The workshops and interviews were recorded, transcribed, and analyzed for salient themes. Ten teachers participated in the workshops and six teachers participated in the follow-up interviews. In general, teachers believe school meals are essential for students’ focus and behavior in the classroom. However, to encourage students to take and eat school lunch, teachers need support and resources. From the workshops and interviews, three themes emerged: (1) improvements in the food quality; (2) school community support; and (3) professional development. The data suggests professional development is the greatest resource teachers need, as professional development can enhance teachers’ motivation to advocate for better food quality and engage school community support. Greater teacher involvement in school lunch could lay the groundwork for future healthier generations.

Exploring primary school years interactions around child weight: A qualitative meta-synthesis of school staff, parent, and child views and experiences

Interactions about children's weight and weight-related behaviors occur from an early stage in school settings between various stakeholders and are often intended to facilitate weight-related behavioral change in children and/or families. This meta-synthesis (PROSPERO - CRD42019133231) aimed to investigate stakeholder reported experiences and challenges of these encounters. Studies were eligible if they included school stakeholders (teaching or nonteaching staff, parents, caregivers, or children), explored communication topics related to child obesity (weight, diet or activity), were conducted within an early school setting (primary school stage or international equivalent), and used qualitative methods. Database searches conducted March-July 2019 (updated November 2020) identified 40 studies (2324 participants) from seven countries. Included studies were assessed for quality using the Critical Appraisal Skills Programme. Using inductive thematic analysis, we identified four core themes across this database: (1) "conversation characteristics and consequences," (2) "missing components," (3) "avoiding stigma," and (4) "school responsibilities." Overall, stakeholders recognized that schools are well-positioned to provide positive influential messages about childhood obesity and reported that discussions on this topic do occur in early school settings but that stakeholders find them difficult, complex, and lack the necessary skills to deliver the nonjudgmental, consistent, and tailored support that they desire.

Perception of School Committee Members (SCMs) on Factors Contributing to Overweight and Obesity Among High School Students in Kiribati: A Qualitative Study

Background

Schools are vital settings for overweight and obesity prevention among children and adolescents. School Committee Members (SCMs) are crucial assets to engaging students with overweight and obesity prevention programs. This study aimed to determine factors contributing to overweight and obesity among high school students in Kiribati through the perception of SCMs.

Methods

This prospective qualitative study was conducted in four randomly selected senior high schools in South Tarawa, Kiribati, from August to November 2020. With a purposive selection of 20 SCMs employed at the four high schools, both male and female participants consented to participate in the study. A semi-structured open-ended questionnaire was used for data collection using focus group discussions (FGDs). Data were transcribed and analyzed using the thematic analysis method.

Results

Twenty participants were involved in FGDs with equal number of SCMs (n = 5) who attended FGDs for each school and 45% of them were female participants. Six themes were identified, namely, knowledge, behaviors, perceived status toward overweight and obesity, perceived action benefits, perceived barriers to practices, and proposed strategies to overweight and obesity prevention. These themes reveal that SCMs have a broad understanding and skill set for overweight and obesity causes and effects. However, the aptitude alone is not enough to prevent the occurrence, and thus, proposed feasible plans were voiced for responsible stakeholders to include in policy developments for overweight and obesity prevention.

Conclusion

This study recognized that the knowledge-behavior gap is the main reason behind the failure in preventative strategic approaches among adolescents. As role models to students, SCMs and their schools should team up in implementing the public health policies and building mutual awareness and understanding with students and other specialist stakeholders for a more momentous and viable impact.

Rethinking sustainability in childhood obesity prevention interventions: learning from South Australia's Obesity Prevention and Lifestyle (OPAL) Programme

Increases in childhood obesity have occurred across a relatively short time-period, yet childhood obesity prevention is a longer-term game. Programmes have only identified population-level changes after 12 years of on-the-ground activity [Romon et al.]. Community stakeholders can impact the success of public health interventions [Ganter et al.; Lee et al.] and they have been identified as a critical success factor for programme sustainability [Schell et al.]. Qualitative research with stakeholders (n = 59) provides their insights and understandings of the sustainability of OPAL, a South Australian childhood obesity prevention programme. Stakeholders identified activities that they thought contributed to improved sustainability of action such as embedding obesity prevention into organizational policy and plans; and installation of infrastructure within communities to modify physical environments. In contrast, there was little appetite for sustaining OPAL or other formulations of a childhood obesity prevention programme. This research has implications for planning and implementation of community-based childhood obesity prevention initiatives when considering the balance of the portfolio of activities for implementation.

Child Health Behaviour and Parent Priorities for a School-Based Healthy Lifestyle Programme

OBJECTIVE

The purpose of this study was to characterise parents' concerns for their children's health behaviours and perceptions of motivators and barriers to positive child health behaviour change, and to determine associations between motivators and barriers and parents' priorities for a school-based healthy lifestyle programme.

DESIGN

Cross-sectional study of 46 parents who had completed an un-validated survey distributed during school-wide events.

SETTING

School for children aged 5-14 years in The Bronx, New York City, USA.

METHODS

Wilcoxon Rank Sum tests compared motivators and barriers to positive child health behaviour change by heath behaviour concern; Spearman's correlation measured associations between motivators and barriers and programme priorities.

RESULTS

Parents concerned about child weight significantly ranked keeping up with others and decreasing clothing size as motivators, while parents concerned about child food choices significantly ranked improving food choices and decreasing BMI and clothing size as motivators. Food-, play-, and self-esteem-related motivators were associated with nutrition education (r_s ≥ .41, p ≤ .01), physical activity classes (r_s ≥ .29, p ≤ .04) and child involvement in programme decision-making (r_s ≥ .43, p ≤ .01) priorities. Consistency-, child resistance-, and home rules-related barriers were associated with nutrition education (r_s ≥ .37, p=.02), physical activity classes (r_s ≥ .32, p = .02), and child involvement (r_s ≥ .40, p ≤ .02) priorities.

CONCLUSIONS

Despite the study sample size, selection bias, and generalisability limitations, prioritising nutrition, physical activity and child involvement in programme decision-making may enhance parent support for school-based healthy lifestyle programmes.

Canadian after-school care providers' perceived role promoting healthy lifestyles: a focused ethnography

BACKGROUND

After-school care programs have garnered interest in recent years as the hours of 3:00-6:00 p.m. are an opportune time for children to engage in healthy behaviours, specifically healthy eating and physical activity. Care providers are major influencers within the after-school care setting, impacting health promoting opportunities for children. However, little is known regarding the role care providers play in health promotion interventions in the after-school care setting, specifically those using comprehensive approaches. The purpose of this research was to explore care providers' role and experience promoting healthy eating and physical activity through the after-school care health promotion intervention School's Out … Let's Move (SOLMo). SOLMo was guided by the evidence-based comprehensive school health framework. SOLMo had two main goals: [1] to serve a healthy snack with vegetable or fruit, and milk or water as the drink; [2] to include 30 min of moderate to vigorous physical activity. The intervention included resources and coaching for care providers to promote healthy eating and physical activity for children and took place in four after-school sites over a six-month period. Three of four sites were located in a school. The primary researcher was engaged with the sites over 22-months.

METHODS

This research was guided by the qualitative method focused ethnography. Semi-structured interviews with care providers (n = 13) taking part in SOLMo were conducted. Participant observation was included as part of data generation to further understand care provider roles. Latent content analysis was utilized iteratively and concurrently throughout data generation.

RESULTS

Overall, care providers were supportive of promoting health behaviours in the after-school setting. Through analysis, five themes and eight subthemes emerged related to care providers' role and experience promoting healthy eating and physical activity through SOLMo: 1) enhanced awareness; 2) improved programming; 3) strong relationships; 4) collaborative approach; and 5) role tension.

CONCLUSIONS

As major influencers, care providers play a crucial role in promoting healthy lifestyle behaviours for children. This research provides valuable insight into this role and the implementation of comprehensive health promotion approaches in the after-school setting. Findings contribute to the implementation knowledge base and help inform the promotion of healthy lifestyle behaviours for children.

Community engagement strategy for healthy diet in urban community: A phenomenological study

Unhealthy diet is the risk factors for non-communicable diseases with limited intervention in Indonesia. Environmental change interventions are known to be effective in encouraging changes in healthy diet. However, community engagement is needed to ensure the adoption of the behaviour. This study seeks to identify the strategy to engage urban community in healthy diet intervention. Qualitative research with phenomenological approach was conducted in Yogyakarta, Indonesia. Samples were selected among citizens of Yogyakarta city with the age range from 19 yr old to 65 yr old. The informants consist of lay persons, cadres and stakeholders. Data from 87 respondents were collected through 7 focus group discussions and 2 in-depth interviews. Strategies to engage community in healthy eating interventions consists of 3 main themes: i) intervention’s characteristics, ii) information characteristics and iii) the information channel. The intervention’s expected characteristics are aimed at various ages, using family approach through stakeholder support and collaboration and by increasing cadre’s capacity and providing opportunity to manage funding. Information characteristics are accessible, valid, up to date and personal. Information can be disseminated through virtual and non-virtual media. Community engagement strategies in healthy eating interventions should be segmented, strengthening the role of family and easily accessible.

Indicators of Readiness and Capacity for Implementation of Healthy Eating Strategies in Child Care Settings Serving Low-Income Children

OBJECTIVE

Identify factors perceived to influence implementation of healthy eating policy, systems, and environmental strategies (PSEs) in child care settings serving low-income children.

DESIGN

This mixed-methods study, conducted in 2015-2016, used semi-structured interviews (n = 18), focus groups (n = 23), and an expert panel.

PARTICIPANTS

Public health (n = 11) and Supplemental Nutrition Assistance Program-Education practitioners (n = 9) and community residents (n = 174) from 9 counties in Ohio. Expert panelists (n = 10) had experience implementing PSEs in child care settings.

PHENOMENON OF INTEREST

Implementation factors influencing healthy eating PSEs in child care settings.

ANALYSIS

Qualitative thematic analysis of 41 transcripts using a grounded theory approach. Indicators for each theme were operationalized. Consensus feedback from an expert panel weighted themes and indicators based on perceived importance for implementation.

RESULTS

Identified themes relevant to implementation of PSEs included (1) organizational and practitioner capacity, (2) child care capacity, (3) networks and relationships, and (4) community resources and motivations. Nineteen indicators related to the 4 themes were identified and weighted.

CONCLUSIONS AND IMPLICATIONS

Findings highlighted key factors within domains of influence and informed the operationalization of the indicators and the development of an assessment tool. The assessment tool is designed to tailor PSE implementation to the realities of different child care settings.

Process Evaluation and Lessons Learned From Engaging Local Policymakers in the B'More Healthy Communities for Kids Trial

Partnerships linking researchers to the policymaking process can be effective in increasing communication and supporting health policy. However, these policy partnerships rarely conduct process evaluation. The Policy Working Group (Policy WG) was the policy-level intervention of the multilevel B'More Healthy Communities for Kids (BHCK) trial. The group sought to align interests of local policymakers, inform local food and nutrition policy, introduce policymakers to a new simulation modeling, and sustain intervention levels of BHCK. We conducted an evaluation on the Policy WG between July 2013 and May 2016. We evaluated process indicators for reach, dose-delivered, and fidelity and developed a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The policy intervention was implemented with high reach and dose-delivered. Fidelity measures improved from moderate to nearly high over time. The number of health-related issues on policymakers' agenda increased from 50% in the first 2 years to 150% of the high standard in Year 3. SWOT analysis integrated a stakeholder feedback survey to consider areas of strength, weakness, opportunity, and threats. Although the fidelity of the modeling was low at 37% of the high standard, stakeholders indicated that the simulation modeling should be a primary purpose for policy intervention. Results demonstrate that process evaluation and SWOT analysis is useful for tracking the progress of policy interventions in multilevel trials and can be used to monitor the progress of building partnerships with policymakers.

Perceived Barriers and Facilitators to Healthy Eating and School Lunch Meals among Adolescents: A Qualitative Study

OBJECTIVES

We explored how perceived barriers and facilitators influence healthy eating and investigated the acceptability of changes to school lunch meals among adolescents after implementation of the Healthy, Hunger-Free Kids Act of 2010.

METHODS

We conducted 8 focus groups with adolescents (N = 64) at 3 South Los Angeles high schools. Data collection instruments included a semi-structured guide and questionnaire. Two researchers independently coded transcripts.

RESULTS

Most participants believed fruits and vegetables were available in their community and reported high relative cost, poor quality, and lack of motivation as barriers to consumption. Many said school meals were an important source of healthy food and were aware of recent changes to the school lunch program. A primary facilitator to eating school lunches was access to fresh food items (eg, a salad bar). Perceived barriers included long cafeteria lines, time constraints, lack of variety, and limited quantities of preferred items. Adolescents viewed off-campus food establishments near the school as competition to school meals.

CONCLUSIONS

Our findings suggest the need to measure perceived and actual barriers to healthy eating among adolescents and to examine the effect of these barriers on dietary behavior. We provide programmatic and policy recommendations.

The relationship between community nutritionists’ use of policy, systems and environmental strategies to prevent obesity and its determinants depends on networking

Objective

To apply the Theory of Planned Behaviour to examine the relationship between the constructs of background factors and beliefs towards using policy, systems and environmental (PSE) strategies and reported use of PSE strategies to prevent obesity by a group of professional nutrition educators.

Design

Cross-sectional study using self-reported survey.

Setting

Cooperative Extension in New York, USA.

Subjects

Nutrition educators (n58); survey response rate 100 %.

Results

Nutrition educators’ reported use of PSE strategies to prevent obesity were positively associated with background factors of their community networking and number of staff they managed, their belief of other people’s expectations of them to make PSE changes and the belief that their communities were ready to use PSE strategies; and negatively associated with their belief that individual-level factors contributed to obesity. The relationships among these variables were complicated and their use of PSE strategies occurred only when they utilized their professional networks at a moderately high level (above mean of 5·3 on a scale of 1–7), given that their community was also ready to use PSE strategies.

Conclusions

Nutrition educators’ use of PSE strategies depends on several internal and external factors. Community networking needs to be emphasized as one of the most significant factors contributing to nutrition educators’ work in this area. Organizational and community support should be in place in order to facilitate nutrition educators’ effective use of PSE strategies.