Barriers to Physical Activity and Healthy Eating in Children as Perceived by Low -Income Parents: A Case Study

During the past three decades the prevalence of childhood obesity has steadily increased in the United States. Causes of childhood obesity are complex and include numerous individual and environmental factors. The purpose of this study was to determine parent perceptions on the social-ecological barriers (community, school, and family) to physical activity and healthy eating, perceived specific to their children. Self-reported data gathered from a 50-item questionnaire and six focus groups were conducted with parents (n=43) enrolled in the Women, Infants, and Children (WIC) Program. Participants (16 to 67 years old) were predominately female (88.4%), Hispanic (67%), low income, and living in or near Lompoc in Santa Barbara County, CA. The social-ecological model (family, school, and community) was utilized to create focus group questions and provide recommendations as part of the Lompoc Community Health Improvement Project (2006-to-the-present). Popular community barriers for physical activity were: disconnected sidewalks, lack of safe bike routes to school, lack of recreational programming at an affordable cost, and language barriers (lack of marketing physical activity programs in Spanish). Two safety barriers involved parks; fear of injury (dilapidated equipment) and fear of gangs (violence). Common school barriers were: teachers do not lead-by-example, lack of healthy food in school cafeteria, and insufficient time for children to purchase food and eat. Family barriers included: grandparents sabotaging healthy eating environments (e


Introduction
Global changes in diet and physical activity (PA) patterns are fueling an obesity epidemic as obesity is reaching pandemic proportions throughout the world [1]. As the availability of fast, inexpensive, energy-dense foods grows and PA declines, obesity rates across all ethnic and age groups in the United States are projected to climb [2]. Notably, in the United States, the speed of the epidemic spread is alarmingly more pronounced [3,4,5] as experts estimate roughly 17% or 12.5 million American children and adolescents are obese [6]. Persistence of childhood obesity into adolescence and adulthood depends on several factors, including age of obesity onset, severity of obesity, and presence of obesity in one or both parents [7,8].
The relationship of sedentary lifestyle and poor eating habits to childhood obesity is of particular interest because of the longterm health effects. These health effects carry with them increased health care costs to the public through Medicare and Medicaid, as low-income and minority populations are at higher risk for cardiovascular disease, diabetes, obesity, and many other conditions [9]. Obesity and its consequences disproportionally affect ethnic minority populations [10,11] with those of Hispanic origin, particularly Mexican-Americans, among the groups with the highest risk [12].
In 2007-2008, Hispanic boys, aged 2-19 years, were significantly more likely to be obese than non-Hispanic white boys, and non-Hispanic black girls were significantly more likely to be obese than non-Hispanic white girls [10]. According to a recent study, U.S. economic costs of obesity in 2005 were estimated to be $190 billion spent on obesity-related healthcare expenses [13].
Popular theory suggests that the current epidemic of childhood obesity is caused by existing in a culture that encourages excessive food intake and discourages PA [14]. Specifically, excessive consumption of sugar-and fat-enriched food, lack of exercise, and excessive television viewing are positively related to weight gain [15]. Hill and Peters (1998) described the U.S. culture as an aberration, one that is conducive to obesity, and more recently, detailed how the environmental forces in our society have promoted weight gain in children. This is particularly true in low socioeconomic, single-parent households and households in which parents work full time, favoring the preparation and consumption of time-saving convenience foods [16].

Methods and Materials
The purpose of this study was to use focus group discussions to determine the perceptions of parents participating in the Women, Infants, and and coded by the three lead researchers utilizing the inductive analysis procedures outlined by Patton [29] and Thomas [30]. Results were compared and agreement was reached on the thematic coding.
Once major themes were agreed upon, an inductive process was used to list all of the possible responses for each theme utilizing the socialecological model as the framework for the codebook.
Each researcher conducted an independent second analysis consisting of reading and rereading the interview transcripts and examining the data line by line to identify potential categories prior to a team discussion. Researchers discussed coding discrepancies until consensus was reached.

Participants
Forty-three participants took part in the focus groups.
As Table 1  Thompson is that they have the baby swings you can put your baby in and swing. Uh-uh.  (1) Healthier foods tend to be priced higher (8); Lack of quality grocery stores in area (4) "Lompoc is for adults, we don't have a skate rink, so children can play, we barely have anything for children to have fun that is not at home." "We had a bowling alley but it's gone." "It's very expensive to get your child involved in some kind of a club." "The aquatic center has such limited time, it is always full." "It's the language too. It's a factor because everyone goes to the recreation center to get information but it's not in our language. I don't understand what is on the flyers." "I don't see many healthy places here, you have to go outside of town to find a Trader Joes TM." "You can go buy a loaf of bread and the pastas are a lot cheaper than fruits and vegetables."

In the School
Perceived barriers to physical activity Perceived barriers to healthy eating Funding commitment for quality physical education is low (5); School playground safety (4); Lack of motivation of school (3); Distance to school is too far to bike or walk (7); Not safe to walk to school (10) School food quality questioned (33) "I ask my daughter about P.E. and she says "she had it on Monday'... and I asked 'what happened to Wednesday?' She said, 'they didn't have enough money to have a teacher full time.'" "School is very far away." "I don't want them to walk because you never know these days, we live close to school but what I hear in the news and read in the newspaper it's not secure." "Only after school do they get a guard." "They fight kids, they assault kids." "I used to work at the school my son is at and the food is not very healthy… they give them a little pizza." "The school gives them junk food… I tell my daughter I will pack a lunch and she says 'NO'… they have Doritos TM and other things."

In the Family
Perceived barriers to physical activity Perceived barriers to healthy eating Funding commitment for healthy food is low (4); Family economics (10); Denial there is a weight problem in the family (2) Cultural custom to finish food on plate (7); Lack of nutrition education (8 ); Ease of preparing fast food (6); Preference for junk food (5) "Because of work I can't take my child to the recreation center or I can't afford to put my child in the activities." "Everything is about money, everything costs money." "When I was young, I was chubby, and everyone would say "how pretty, how pretty" but they said that because I was chubby." "We have a culture that you won't get up until your plate is empty…the bigger the plate the more food we put on it." "In our culture it's a sin to discard food." "My husband has to have soda in the house." "I don't know how to make asparagus and they are full of vitamins, only rich people make them." "It's hard to be at work all day and when you come home you are too tired to make dinner. You just put in those Hot Pockets TM."   These issues proved to be complex, and the participants themselves provided a somewhat inconsistent portrait of the role they and their families played in their children's health. For example, most of the participants had reported that they alone were responsible for choosing, buying, and/or cooking the food their family ate.
However, despite having ultimate control over the food that entered and was served in the home, they still felt that other family members often had a significant negative impact on their children's eating behaviors.
These findings underscore the complexity of the interpersonal and cultural dynamics associated with food and mealtimes [35].
Consistent with other research [36,37], participants also cited socioeconomic factors as a challenge to healthy eating; lower incomes and long working hours -particularly among the single parents of the groups -made it difficult to prepare what they perceived to be more time-consuming and costly healthy meals.
Clearly these barriers had an impact on participants' own weight status in addition to that of their children; only 22.5% had a BMI in the "Healthy" range; the rest were overweight to morbidly obese themselves. Moreover, because parent obesity status is a predictor of children's obesity [38], this represents a significant risk factor for their children that was not acknowledged in the focus group discussions. In fact, surprisingly, participants largely felt that personally they were doing "better than average" in addressing weight issues in their children.

Taking Local Action Based on Local Results
Since Such locally-based data collection, paired with tailored, data-driven community responses, represents a model approach for other communities that seek to define and address the barriers to promoting healthy lifestyles -and preventing childhood obesity -in their own populations.