Social Ecological Barriers for Healthy Eating of Obese Children and Their Caregivers in Low-income Families in South Korea

ABSTRACT

In this qualitative study, the focus is on healthy eating in children from low-income families who visit a Community Child Care center (CCC) in South Korea. Barriers for healthy eating were identified using focus group interviews with low-income overweight and obese children and their caregivers and applying a social ecological model as well as the framework analysis for qualitative data. The need for theory- and evidence-based health promotion interventions is indicated, at the level of the family, but also at the level of collaboration among all stakeholders, as well as multi-level policy changes.

KEYWORDS:

• Feeding behavior
• focus group interview
• health status disparities
• pediatric obesity
• social ecological model

Introduction

Childhood obesity is an increasing health problem in South Korea, as it is worldwide (World Health Organization (WHO) 2012). Childhood obesity often results in adulthood obesity, with an increased risk of chronic metabolic and cardiovascular health problems such as hyperlipidemia and hypertension (Faienza et al. 2016). Moreover, childhood obesity negatively affects physical growth and development, as well as psychological development such as self-esteem and quality of life (Rankin et al. 2016).

The increase in overweight and obesity in developed countries with high-income contexts like the UK is highest in lower socioeconomic groups (El-Sayed, Scarborough, and Galea 2012). Kim et al. (2011) report the body mass index (BMI) among low-income group children shows significantly higher than their counterpart and the proportion of overweight and obese girl from low-income families is significantly higher than that in the general population in South Korea. He explains these children grow up in more vulnerable environments, e.g., absence of parents who are both working, poor social support, and fewer resources to solve physical and psychological problems caused by obesity.

In previous studies in South Korea on prevention and management of childhood obesity, causes were identified, effectiveness of planned prevention and management interventions was shown, and implementation of those interventions was described in other populations, after careful tailoring (Kim et al. 2014). However, not in low-income families and in general, studies on interventions targeting low-income families are scarce (Waters et al. 2014). Environmental influences are shown to be important in children’s health and are therefore essential in child health promotion (Riesch et al. 2013). Children’s direct environment is the family, especially the parents: parents shape the food and meal environment through food availability and accessibility, and the timing and frequency of meals (Silventoinen et al. 2010). However, also studies on the role of the parents in managing children’s eating behaviors are scarce (McPhie et al. 2014).

In the current study, the focus is on children from low-income families who visit a Community Child Care center (CCC) in South Korea. The CCC centers are an after-school program for low-income children promoting health, growth and development. CCC centers provide welfare services, including protection, education, culture, emotional support and community linkage, to low-income families, and serve as a complement to the role of the family (Park, Baek, and Im 2018). Of all these services, “feeding and snacking” was the service rated as providing the highest level of assistance, and were a priority for parents and children in deciding to use the CCC center (Suh and Rho 2013).

The research question of this study is: What are the individual and environmental barriers (from the children and primary caregivers' point of view) that hinder the promotion of healthy eating among overweight and obese children from low-income families who visit the CCC centers in South Korea? The outcomes of this study will feed into the development of future interventions for childhood obesity prevention.

Materials & methods

Study design

Because of the limited available data related to the research question, this study applies a qualitative approach. A focus group interview – as defined as a carefully planned group discussion designed to obtain perceptions on a defined area of interest in a permissive, non-threatening environment (Adler, Salanterä, and Zumstein-Shaha 2019) was chosen. McLeroy’s social ecological model was adopted as the conceptual framework (Golden et al. 2015; McLeroy et al. 1988), serving as an overall guide for constructing interview questions, analyzing the data and presenting the outcomes. In this study, intrapersonal factors relate to the child’s characteristics, interpersonal factors to family members’ characteristics, organizational factors to CCC centers’ characteristics, and community and policy factors to characteristics that encompass all levels.

Participants

Participants were overweight and obese children from low-income families attending CCC centers, and their primary caregivers. With support of the associations of the CCC centers, we sent the invitation letter to service providers of 20 centers in the community. Then, they individually contacted caregivers with overweight and obese children. The children and caregivers wishing to participate in the interview voluntarily were selected.

Four focus groups were executed, two with children (two groups of five) and two with the primary caregivers (two groups of seven). Krueger and Casey (2014) suggest the ideal size of a focus group for noncommercial topic is five to eight participants. The data reached theoretical saturation and no new information was found during the final interview. In other words, no further data and new insights in final interview were found on the barriers to healthy eating at home, school, and CCC that obese children and caregivers perceived, which are the topics of this interview.

The children were 7–12 years old, 6 boys and 4 girls, and 6 lower-grade (1–3) and 4 higher-grade (4–6). The mean BMI of the children was 24.26 kg/m2, with 3 children overweight and 7 obese, based on the 2007 Korean National Growth Chart (Korea Centers for Disease Control and Prevention 2007). The mean time they had been at the CCC centers was 16 months, 1.32 years.

Of the 14 primary caregivers, the mean age was 45.93 years, 12 were mothers and 2 were grandmothers. Their mean BMI was 27.37 kg/m2, with 2 normal weight, 5 overweight, 4 obese and 3 extreme obese, based on the BMI classification for Asians (World Health Organization (WHO) 2000). Regarding educational level, 1 was elementary school graduate, 2 were middle-school graduates, 10 were high-school graduates and 1 a university graduate.

Data collection

The study was approved by the Institutional Ethics Review Board of the first author’s university, 2016–08-003-001. Data were collected in September 2016. Participating children and caregivers were informed about purpose and theme of the study, and the schedule, place and method of data collection. Preceding each interview, the researcher explained the process, the recording for data collection, the confidentiality of the participants’ statements and the anonymity of the reporting. Written informed consent was obtained from all participants; for the children's’ participation, additional caregivers’ consent was obtained. Prior to the interview, participants filled out a questionnaire on general characteristics: age, gender, weight and length, education.

The group interviews were led by a moderator who was experienced in conducting focus group interviews and who had enough knowledge about childhood obesity and CCC centers. The children’s focus group lasted one hour; the caregivers’ focus group lasted two hours. The interview consisted of a series of open-ended questions related to individual and environmental barriers for obesity management, at home and at the school and CCC center, e.g., for children: “What foods and beverages are most of the time available at home, school, and CCC?”; e.g., for caregivers: “What factors facilitate/limit your child to eat healthy or unhealthy at home, school, and CCC?” These questions were partly derived from previous studies reporting on comparable social ecological approaches (Haerens et al. 2009; Kim et al. 2019). The moderator intervened so that dominant talkers did not lead the interview. In particular, in child interviews, the lower grades were given an opportunity to respond evenly so that the discussion was not led by the upper grade children. Please see the full topic lists in Appendix A (for children) and Appendix B (for caregivers).

The environment of the interview site and the nonverbal behaviors of the participants were observed and recorded by an assistant-moderator. A small gift (e.g., gift card and stationery) was presented to the participants after completion of the interview.

Data analysis

A verbatim description of each interview was created. The framework analysis (Ritchie and Spencer 2002) was applied to answer questions about, in this case: examining the reasons for, or causes of, what exists (diagnostic) and appraising the effectiveness of what exists (evaluative). The framework analysis consists of five key stages: familiarization, identifying a thematic framework, indexing, charting, and mapping & interpretation. Three researchers repeatedly read and independently analyzed all transcripts and listened to recording files, looking for conceptualizations (familiarization, identifying a thematic framework). Outcomes were compared between researchers and differences were reviewed by a fourth researcher to reach agreement. In this next step, the data were abstracted into a matrix in line with the social ecological model to arrange themes. Quotes were selected that expressed the themes (indexing and charting). Finally, the outcomes were fully reviewed and a figure using the social ecological model was created showing the relationships among the themes (mapping & interpretation). To increase the validity and transparency of the outcomes, two primary caregivers from the caregivers’ focus group were asked to verify whether the outcomes corresponded to the intent of the participants.

Results

The framework analysis resulted in eight themes, two intrapersonal barriers for the child, three interpersonal barriers from the caregivers and family, two organizational barriers at the CCC center, and one community barrier; see Figure 1.

Figure 1. Social ecological model of barriers for health eating

Theme 1 – intrapersonal barrier: difficulty with self-regulation of food – child

Participating children expressed difficulty in controlling the speed or amount of food intake.

My eating habit was that I eat a lot and quickly. (Child)

My mom said, if I get angry (I can’t control myself), I eat a lot, and that’s why I am fat. (Child)

Theme 2 – intrapersonal barrier: lack of awareness and low-risk perception of obesity – child

Caregivers stated that their children have wrong ideas about obesity and lack awareness of the seriousness of obesity.

To be honest, no matter how much I tell them to be on a diet, it’s no use. They have to realize for themselves, but they are too young to understand the seriousness. (Primary caregiver)

My kids are a little plump. They think that their chubby body will serve as taller body as they grow up. (Primary caregiver)

Children continue to eat without realizing the seriousness of obesity, because people around them say chubby body will grow into taller body. (Primary caregiver)

Theme 3 – interpersonal barrier: food preferences of family members – home

The primary caregivers reported that the children are frequently exposed to an environment that leads to obesity because primary caregivers and siblings prefer high-calorie foods.

It is hard to manage my child’s diet because his older brother always orders food like fried chicken when it is meal time for him and leaves pop drinks around the house. (Primary caregiver)

My child and I, we are mutual victims. We are both too fond of meat and delivery foods. (Primary caregiver)

Theme 4 – interpersonal barrier: lack of attention to healthy food from primary caregiver – home

The lack of attention from primary caregiver due to work–family balance consisted of five sub-themes:

4.a. Preference for high-calories instant foods

Primary caregivers reported that they usually buy foods that could be cooked easily because of their busy daily lives. Children also stated they often eat instant food that they can cook themselves.

I eat ramen once a week because I can cook it myself. (Child)

Ramen is an easy solution when I’m not sure whether the leftover rice will be enough. If the kids agree to eating ramen, I suggest to them to eat rice with ramen because it is the easy way for me. (Primary caregiver)

I usually buy frozen foods, such as pasta, that I can quickly cook and offer. (Primary caregiver)

4.b. Lack of consistent management

Primary caregivers reported that they taught their children to eat foods slowly but also tend to rush them when they were pressed for time.

I tell my kids to eat slowly and with manners instead of devouring. But then, I find myself saying “Come on, Hurry up. Hurry up.” (Primary caregiver)

I end up forcing them to hurry up because I am late for work. (Primary caregiver)

4.c. Uninvolved parenting

Primary caregivers reported that it is difficult to manage children’s meals while they are working, and they leave their children unattended after they finished work.

My child eats as much as she wants when I am at work, and then she says she is hungry again when it’s around 10 o’clock. (Primary caregiver)

By the time I get home, I’m tired and don’t want to be bothered with anything. I’ve become lazy. (Primary caregiver)

4.d. Avoiding conflict with children

The primary caregivers expressed that they are tired of fighting with their children and try to avoid conflict by letting the children do what they want. Even when they knew such behavior is unacceptable.

My child is upset if I don’t give him food when he asks for it. Even though it’s close to 11 o’clock, he is whining and crying for food refusing to go to bed. I become so stressed that I just end up giving him food. (Primary caregiver)

As I grow older, I don’t want to be bothered with anything. Besides, I don’t want to fight with the kids. (Primary caregiver)

4.e. Compensation for feeling sorry

Primary caregivers stated that they feel upset and sorry for neglecting their children and consequently end up giving food to their children when they ask for it to compensate for their negligence.

I feel sorry I had to work all the time when my child was a baby. So, when he asks for something to eat, I tend to serve foods or buy instant foods. (Primary caregiver)

The child needs her mom and dad while studying and I feel sorry, as a grandmother, that I can’t fulfill that role. I feel so sorry when I look at him sleeping that I find myself wanting to feed him all the time. She likes curry rice very much, you know. If he says “Grandma, I didn’t have enough dinner,” I end up giving him food because I feel bad. (Primary caregiver).

Theme 5 – interpersonal barrier: high dependency on food prices – home

The primary caregivers reported that they tended to choose cheaper food ingredients rather than ingredients with a high nutritional value when shopping for groceries.

Chickens are not that expensive. So, I usually add some potato and make stir-fried chicken or make whole chicken soup. The kids enjoy this simple chicken dish so much that they don’t even eat kimchi. (Primary caregiver)

To be honest, I end up buying cheap foods. If my child likes them, I stock up on foods, such as ham and chicken, when they are on sale even when there’s not enough time to eat them before the date expires. Chickens are not that expensive, you know. (Primary caregiver).

Theme 6 – organizational barrier: frequent replacement of cooking staff – CCC center

In general, the participants were highly satisfied with the quality of meals and the guidance on snacks provided by service providers at the centers. However, they reported that they were worried about the children’s nutritional intake when the cooker was replaced.

When the cooker is replaced at the center, my child makes a fuss about being hungry. (Primary caregiver)

The regular cooker was sick for a while, and the substitute prepared the ingredients in such large pieces that they were too big for the children. (Primary caregiver).

In addition, the primary caregivers expressed expectations for their children to have balanced meals at the centers.

Perhaps I’m being greedy, but I would like my child to have a good meal at least when he is at the center, because I am so busy. (Primary caregiver)

Theme 7 – Organizational barrier: lack of adequate education on healthy eating – CCC center

CCC centers typically provide safety education, but they do not provide adequate education on healthy eating.

My center did not teach me about proper eating habits. (child)

Interviewer: What is healthy food, did not you learn this?

No, I have not learned about anythings. (Child)

Furthermore, the participants expected opportunity to learn about healthy eating.

We learned about drug abuse, prevention of getting lost, and natural disasters such as earthquakes. But we never learned about foods. I want to learn a lot about things like good food. (Child)

If I make some points about foods to the kids, for instance that the pop drinks contain caffeine and are fattening, they listen to me and cut down on them gradually. (Primary caregiver)

Theme 8 – community and policy barrier: exposure to four full meals a day – home/ccc center/school

There were concerns regarding the situation that children were exposed to eating four full meals a day. They concerned that increased accessibility to food or meals leads to becoming obese. In addition, they mentioned that shared interest and management were necessary among Home-CCC centers-School (community) to strengthen the connectivity to manage healthy eating.

My child doesn’t care much for snacks. But he will eat four meals a day. He eats lunch at school and eats another meal in between. He also eats at the CCC center. In the evening, when he comes back from his hapkido lesson, he says he is hungry again. And so, he eats another meal before he goes to bed. (Primary caregiver)

She won’t eat breakfast and only eats a little bit of her meal at school and the center because she has to eat her vegetables. And so, she goes hungry all day, then comes home and tries to eat three meals at once for dinner. (Primary caregiver)

Discussion

In this study, barriers for healthy eating were identified using focus group interviews with low-income overweight and obese children and their caregivers, and applying a social ecological model as well as the framework analysis for qualitative data. The analysis resulted in eight themes reflecting eight barriers: two intrapersonal barriers for the child, three interpersonal barriers from the caregivers and family, two organizational barriers at the CCC center, and one community barrier.

Intrapersonal barriers

For the children, the intrapersonal level barriers were: (1) difficulty with self-regulation of food and (2) lack of awareness and low-risk perception of obesity. These findings are consistent with earlier studies on determinants of eating behavior of adolescents indicating the influence of self-regulation (Kalavana, Maes, and De Gucht 2010), support from peers (Stephens et al. 2011), motivation (Mokhtari et al. 2017) and knowledge and attitudes (Taylor, Evers, and McKenna 2005). In this group of low-income children, the determinants, such as knowledge, risk perception and self-regulation, may be comparable; however, the strength of the influence may be different.

Interpersonal barriers

For the caregivers and families, the interpersonal barriers were: (3) food preferences of family members, (4) lack of attention to healthy food from primary caregiver, and (5) high dependency on food prices. The lack of attention to healthy food was further divided into five subthemes: preference for high-calorie food, lack of consistent management, uninvolved parenting, avoiding conflict with children, and compensation for feeling sorry.

Family members’ preferences for high-calorie food negatively influenced children’s healthy eating habits. As parents and family members act as role models in children’s eating behaviors (Yee, Lwin, and Ho 2017), tailored nutritional education for both children and the entire family is necessary to instill healthy eating habits in these children.

The focus of this study was on overweight and obese children living in low-income households. Currently, most Korean low-income families have a shortage of time for parents to spend with their children and have difficulty managing their children’s behavior due to parents’ long working hours for a double-income. Parents often purchase instant food that children can easily cook rather than provide food made with healthy ingredients and adequate cooking methods, which they perceive as an obstacle to healthy eating habits of their children. This is consistent with a study of low-income families that recognized the type and amount of food consumed by children as the cause of obesity (Danford et al. 2015). Again, interventions to improve the family diet should involve both parents and their children.

Primary caregivers neglected the management of healthy eating habits for their overweight and obese children due to mental and physical fatigue caused by long hours at work. Moreover, they allowed these children to do what they wanted to avoid conflicts. Distinguishing the parenting and feeding styles according to the degree of responsiveness and demandingness, this can be interpreted as showing neglectful & uninvolved and permissive & indulgent styles. In their review, Vollmer and Mobley (2013) found a consistent relationship between an indulgent feeding style and a permissive parenting style with higher obesity risk for the child. In addition, Tovar et al.’s (2012) showed that a low demanding/high responsive feeding style is associated with higher child weight status in diverse immigrant populations. Primary caregivers of low-income families should be educated on effective methods of parenting and feeding styles.

Compensation for feeling sorry reflects parents’ guilt for neglecting their children and, as a consequence, providing food preferred by their obese children. These results are similar to a qualitative study of parents of Australian low-income families reporting that participants provided snacks to show love and affection to the child (Pescud and Pettigrew 2014). However, using food as a sign of reward or affection can cause a child to overeat and use food as an emotional crutch (Turrell and Kavanagh 2006). Health professionals should encourage primary caregivers to identify and practice ways in which they can use other types of rewards.

Caregivers indicate that they are highly dependent of food prices. In another setting, Dammann and Smith (2009) reported that low-income women would like to drink regularly and consume healthy foods (e.g., fresh fruits and vegetables); however, such foods were perceived as unaffordable. Dammann and Smith (2009) suggest that changes at the policy level should be considered to increase affordability and accessibility of healthful food for low-income families, and nutrition interventions may educate low-income families on inexpensive, healthful eating.

Organizational barriers

For the CCC center, the organizational barriers were: (6) frequent replacement of cooking staff, and (7) lack of adequate education on healthy eating.

The first identified barrier was associated with the frequent replacements of cooking staff. In reality, 55.7% of the CCC centers have no staff dedicated to cooking service, and most use external personnel, such as volunteers, even though cooking staff are stationed in the center (Kwon 2011). Therefore, cooking staff changes frequently. Moreover, it is difficult to make formal nutritional education mandatory. The Child Welfare Act stipulates that a nutritionist should be employed, but only if there are more than 50 children in the CCC center, which is extremely rare (Kim and Do 2016). The obesity rate in low-income school-aged children attending CCC is 20.3%, which is two times higher than general school-aged children in South Korea (10.1%; Jang 2019). Again, changes at the policy level should be considered, to guarantee placement of cooking staff at CCC centers.

The participants also perceived the lack of structured nutritional education for caregivers and children as factor that interfered with the formation of healthy eating habits. Currently, the programs of the CCC centers are divided into areas of protection, education, culture, emotional support, and community linkage. Programs related to feeding are included in the protection area, but not in education, and therefore relate only to provide meals and eating etiquette education (Korea Ministry of Health and Welfare 2015). As a result, healthy eating habits receive significantly lower attention than other areas (accident prevention, disease prevention, mental health, personal hygiene) in health-promoting interventions in the CCC centers (Park 2018). There are examples of effective school-based interventions to provide access to fresh fruits & vegetables and nutrition education to low-income children and their families (Sharma et al. 2015). Comparable nutritional education interventions, provided by CCC centers, might play an important role in the lives of children of low-income families.

Community and policy barriers

The last barrier is in fact a multi-level barrier and therefore positioned at the community level: (8) exposure to four full meals a day.

Caregivers were concerned that the meal system at the CCC centers in combination with the meals at home naturally exposed children to four meals a day. They recognized a lack of connectivity between home, school and center as well as their own role in this, but emphasized the need for linkage between homes, schools, and CCC centers in managing children’s eating habits. Other areas have recognized the need for multifaceted and collaborative interventions that link families, communities, and primary care centers to prevent children’s obesity in low-income families (Sherwood et al. 2013). In South Korea, there is a need for a guideline for the joint management of obese children’s eating habits between homes, schools, and CCC centers, and for a program for sharing information easily on children’s dietary life.

Strengths and limitations

The strength of this study is the specific and detailed description of the environmental barriers that affect the eating habits of low-income South Korean children, using qualitative research methods. Noteworthy barriers are that caregivers offer food as compensation for feeling sorry or have a high dependency on food prices due to their economic status. These are typical characteristics of low-income families in South Korea. A limitation of this study, due to its qualitative nature, is that the results were drawn from a small number of children and caregivers who used CCC centers in a metropolitan area. The findings might be confirmed in a larger quantitative study. Nevertheless, this study makes a contribution in the given context, as the demand is increasing for after-school care of low-income family’s children to alleviate health inequality.

Conclusion

This study identified social ecological barriers for healthy eating of obese children and their caregivers in low-income families in South Korea. Primary caregivers, such as parents and family members, are in need of theory- and evidence-based health promotion interventions (Eldredge et al. 2016) to increase risk perception in combination with self-regulatory skills in these children. They are also in need of interventions teaching them to act as better role models and master effective methods of parenting and feeding styles as well as effective ways in which they can use other types of rewards than unhealthy food and snacks. Evidence-based nutritional education interventions for both children and family, provided by CCC centers, might play an important role in the lives of children of low-income families.

Next to health promotion interventions targeting behavior change, the identified barriers can only be effectively brought down by policy changes. Theory- and evidence-based interventions at the policy level (Eldredge et al. 2016) should be considered to increase affordability and accessibility of healthful food for low-income families, to guarantee placement of cooking staff at CCC centers, and to promote information sharing and joint management of obese children’s eating habits between homes, schools, and CCC centers.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP) [No. 2015R1C1A1A01052892].

Appendix A.

FGI Questions for Children

Talk about your dietary habits.

At Home

Preferences

1. What do you usually eat and drink when you are at home?

Availability

2. What foods and beverages are most of the time available at home?

Rules

3. What foods and beverages are you not allowed eating at home? Then, what foods and beverages are you obliged eating at home?

At School

Preferences

4. What do you usually eat and drink when you are at school?

Availability

1. What foods and beverages are most of the time available at school?

2. How about meal services at school?

3. What snacks and drinks do you often use on your way home from school?

Rules

8. What foods and beverages are you not allowed eating at school? Then, what foods and beverages are you obliged eating at school?

Education

9. What lessons do you get about foods and beverages?

At Community Child Care center (CCC)

Preferences

10. What do you usually eat and drink when you are at CCC?

Availability

1. What foods and beverages are most of the time available at CCC?

2. How about meal services at CCC?

3. What snacks and drinks do you often use on your way home from CCC?

Rules

14. What foods and beverages are you not allowed eating at CCC? Then, what foods and beverages are you obliged eating at CCC?

Education

15. What lessons do you get about foods and beverages?

Appendix B.

FGI Questions for Caregivers

At Home

Availability

1. Which food products or beverages are most of the time available at your home?

Barriers/facilitating factors

2. What factors facilitate/limit your child to eat healthy or unhealthy at home?

Rules

3. Are there any rules regarding the consumption of foods and beverages at home?

Shopping

4. Which factors influence what food items are bought in your household?

Factors that induce behavioral change

5. Think back during the past month. Did you change your child‘s diet in any way? Then, what factors motivated you to make these changes?

Motivation for behavioral change

Suppose your child is not eating healthy … …

6. What would motivate you to change your child’s diet?

At School

Barrier/Facilitating factors

7. What factors determine what your child eats at school?

Role of the school

8. What do you think about the role of the school in promoting healthy eating in young children?

Food Policy: rules and availability

9. Describe the food policies at your child’s school

At CCC

Barrier/Facilitating factors

10. What factors determine what your child eats at CCC?

Role of the CCC

11. What do you think about the role of the CCC in promoting healthy eating in young children?

Food Policy: rules and availability

12. Describe the food policies at your child’s CCC.