Barriers to increasing physical activity and limiting small screen recreation among obese children
Article Outline
- Summary
- Introduction
- Methods
- Results
- Discussion
- Implications for research and practice
- Conflict of interest
- Acknowledgements
- References
- Copyright
Summary
Objective
To investigate the barriers to increasing physical activity and limiting small screen recreation time among obese children.
Design
Qualitative study using a case study design incorporating focus groups and interviews with parents and pair interviews with children.
Participants
Nine obese children (age range 5–12 years) and their parents.
Methods
Parents participated in focus groups followed by individual interviews to explain their perceptions of the barriers their child faced in spending more time participating in physical activity and less time in small screen recreation. Children took part in pair interviews to identify their barriers. Parents and children also discussed strategies to promote physical activity and limit small screen recreation time.
Results
A wide range of barriers were identified. These included family dynamics, lack of social support, the physical environment and perceived competence. Parents were unable to identify strategies to overcome these barriers.
Conclusion and implications
Among obese children and their parents, there are an array of barriers to increasing physical activity and limiting small screen recreation. Parents believe that they know what they have to do to overcome many of these barriers but they are unaware of the actions they need to take.
Keywords: Qualitative research, Case study, Overweight, Child, Physical and sedentary activities
Introduction
Pediatric overweight and obesity, which affects approximately 10% of children worldwide [1], has been described as an epidemic and perhaps as one of the most pressing threats to the health of children and families in developed countries [1]. It is strongly associated with physical and psychosocial health consequences [1], [2] prompting calls for more effective prevention and treatment efforts to curb the current and increasing prevalence [3]. Traditionally, interventions have targeted dietary modification, physical activity, time spent in small screen recreation and parenting skills, with most of these only having, at best, modest success in preventing unhealthy weight gain [4]. While it has been established that dietary behaviours, physical activity and some sedentary behaviours influence obesity [5], determinants studies have largely focused on establishing what aspects of these behaviours are associated with obesity. For example, a review conducted by Davison and Birch showed that there are a number of physical activity factors influencing a child's weight including age, gender, fitness levels, parental and peers activity patterns, parent encouragement of activity, parental weight status, socioeconomic status, crime rates and neighbourhood safety, and school physical education programs [6]. In relation to sedentary behaviours, research has shown that gender, parental viewing patterns, monitoring of small screen recreation, socioeconomic status, ethnicity and access to sedentary activities are all related to a child's weight status [6]. Less is known, however, about how these behaviours, and the context in which they occur, exert their influence on obese children. Such information is more appropriately gathered from qualitative studies.
The purpose of this study was to qualitatively examine barriers to physical activity and small screen recreation among families with obese children. Although it is acknowledged that dietary patterns is a key behaviour influencing child obesity, only physical activity and small screen recreation behaviours (watching TV or videos/DVDs, computer games and internet activities) were examined in this study. It is important that parents and children have strategies in order to adopt healthy weight-related behaviours. Without having a range of strategies to draw on, barriers are much harder to overcome. Therefore, a further purpose was to understand what strategies parents and children were aware of to overcome any perceived barriers.
Methods
Design and participants
A case study research design was used to explore the social and environmental contexts in which physical activity and small screen recreation occurred among obese children. 14 children and their parents were invited to participate in the study with 10 consenting. One family dropped out because their son was in hospital for an unrelated illness. The convenience sample consisted of nine obese children and their parents from the Illawarra region of New South Wales, Australia (population 0.4M). The demographic characteristics of the children and their parents are displayed in Table 1. Participants were volunteers who were ineligible to participate in a diet and physical activity intervention being conducted in the region for obese children aged between 5 and 9 years. Reasons for ineligibility included extreme obesity (BMI z score
>4SD) which accounted for 2 participants and being outside the age parameters of the study (7 participants). Families were contacted and invited to participate and parental consent and child assent were obtained. The research was approved by the University of Wollongong Human Research Ethics Committee.
Table 1. Characteristics of children and parents.
| Characteristic | No. of participants |
|---|---|
| Children | |
| Boys | 6 |
| Girls | 3 |
| Age | |
| 5 years | 2 |
| 10 years | 6 |
| 12 years | 1 |
| Family | |
| Single parent | 2 |
| Siblings | |
| Siblings | 8 |
| No siblings | 1 |
| Parents | |
| Focus group | 5 familiesa |
| Males | 3 |
| Female | 4 |
| Families not attending focus group | 4a |
| Individual interviews | 9 families |
| Male | 2 |
| Female | 10 |
| Overweight/obese | |
| Parents | 7b |
| Siblings | 0b |
| Cultural background of families | |
| English speaking | 9 |
| Occupation of parents | |
| Banking (hours 9am to 5pm) | 1 |
| Real estate (hours 9am to 5pm) | 1 |
| Sales (hours 9am to 5pm) | 4 |
| School teacher (hours 9am to 4pm) | 3 |
| Construction (hours 7am to 3pm) | 1 |
| Administration (hours 9am to 5pm) | 3 |
| Retail (part-time) | 2 |
| Unemployed | 1 |
aBoth parents from two families attended the focus groups while parents from four families could not attend these. |
bBased on observational data. |
Procedures
A parent questionnaire was initially used to identify the physical activity and sedentary behaviours participation of these children [7]. This questionnaire consisted of an extended checklist of 30 physical activities. For each item in the checklist, parents were asked to circle yes or no, indicating whether their child participated in that activity during a typical week (Monday to Friday) and during a typical weekend (Saturday and Sunday). “Typical week” was defined as being during the current school term, excluding school holidays. If they circled yes, parents were asked to report the frequency of the activity and the total time their child spent in that activity. This questionnaire has established validity and reliability [8].
Two focus groups were then conducted, each approximately 1h in duration. The focus group interviews discussed issues that emerged from the questionnaire, including the amount of time spent in small screen recreation and types of physical activities in which children participated. After transcribing and analysing each focus group interview, questions were prepared for individual interviews with parents. These questions evolved from the themes and issues that arose during the focus group interviews and from responses by each parent. For those four parents who did not participate in focus group interviews, questions were developed from analysing and interpreting the results of their questionnaire. Each of the nine individual interviews with parents was from 2 to 4h in duration. After individually interviewing parents, existing interview questions were refined for each child and new questions developed relating to the responses provided by the child's parents. Child interviews were conducted in pairs to help children feel relaxed and allow them to appreciate that other children were confronted with similar challenges to themselves. Children were paired according to their age, gender and interests. Four pair interviews and one individual interview were conducted with children, with each interview approximately 45min in duration.
Both focus group interviews with parents and pair interviews with children took place at the local University campus and the individual interviews with parents took place at each family's home. With the permission of the participants, all focus group interviews were recorded on videotapes and individual and pair interviews on audiotapes and transcribed within 48h. This allowed the interviewer to concentrate on the non-verbal gestures of the interviewee, assisting in the interpretation of the interviews.
Data analysis
Physical activity and small screen recreation behaviours included in the questionnaire were divided into a number of categories in order to analyse the time spent in different types of activities and to determine the proportion of time spent in these activities. This provided the opportunity to gain a richer understanding of the barriers children were facing. Time spent was calculated for the following modes of physical activity: non-organised and organised sports, physical education and school sport, transportation and domestic/household chores. Sedentary activities were also divided into smaller categories for more comprehensive analysis and interpretation to take place. Only small screen recreation was used in interviews and focus groups as this appeared to be the main type of sedentary activity these children participated in and the one which has been found to influence child obesity [9].
Each transcript was examined to identify and label the phenomenon that was being described. While reading and rereading the transcripts, the researcher looked for patterns and common themes which became the basis for initial codes [10], [11].
Codes were compared and contrasted across the data and larger themes were established. A separate file was established for each theme, with all data relating to each theme placed in the file. Each family were colour coded, to easily identify the applicable themes.
To ensure data were both credible and reliable, a number of methods were used. Prolonged engagement took place, allowing the participants to develop a trusting relationship with the researcher [12]. This also allowed for a deeper understanding of the phenomenon under investigation to be obtained. Data were triangulated by utilising a variety of data collection methods, including questionnaires and three types of interviews, focus groups, parent (individual) and child (pair) [12]. This was to follow-up on responses in each method of data collection as a formal checking procedure. In the form of peer debriefing, data were shared with colleagues who were experienced in qualitative studies with children. To ensure intercoder reliability, an independent researcher coded the data separately to the researcher and 92% consistency was achieved between the two sets of codes.
Results
Domain 1: perceived physical activity barriers
Theme 1.
Family dynamics: Family dynamics and composition were perceived by all parents and children as a major barrier to increasing participation in physical activity. Those families in broken homes said that different rules in each house and not having a partner to share household duties made it difficult to promote activity.
“I think with me and his mum being separated his perception of himself is a bit down. I mean lately he's sorta felt like he's hopeless and says that he's not good at anything. I think that might have an effect on him wanting to get outside and play.” (Parent)
Parents and children stated that they believed they lacked the time to schedule physical activity into their day-to-day lives, as they were too busy. Household chores were thought to limit the time parents had available to participate in physical activity with their child.Theme 2.
Lack of social support: Most parents indicated that a lack of friends was a barrier to their child's participation in physical activity.
“She hasn’t got a friend you know? She's only got her brother and sister to go outside and play with.” (Parent)
Those children who had close friends stated that their friends did not enjoy participating in physical activity, making it difficult to be physically active, as they wanted to spend time with their friends. Playing with siblings was often not an option as their interests and abilities differed considerably.
“When they (friends) go to their sports that stops me from playing a bit because I don’t like playing on my own, my brothers play stupid games and Dad is usually at work and Mum is always doing Mum stuff.” (Child)
Theme 3.The physical environment: Weather was perceived to be an issue as parents acknowledged that their child lacked motivation when it was cold, rainy and dark outside. Australian conditions are not conducive to outdoor activities when the weather is inclement. Working parents faced the challenge of not getting home until it was dark, especially in winter, leaving little time for outdoor physical activity. Having a small backyard was also a dilemma for a number of families who indicated that there was not enough space to participate in physical activity.
“Well when we moved here he was only two and he didn’t have a weight problem before we moved here…they used to always be in the backyard and now because he doesn’t have that option of having a big backyard he’ll say ‘I’ll watch a movie instead’ or he’ll sit in his room instead.” (Parent)
Parents expressed that they felt that safety concerns limited the places they would allow their child to play. Lack of available facilities was a problem for families living in isolated areas, restricting the activities in which they could participate.Theme 4.
Perceived competence: All parents indicated that their child had a low self-perception of their athletic competence and would often quit activities if they perceived they were not as skilled as their peers. Children agreed and explained that because they lacked confidence in their ability and were not as skilled as their friends, they would avoid taking part in physical activity.
“I actually try and hurt myself so that next time I do PE at school I don’t have to do it…I’ve got scars and bruises all over me pretty bad.” (Child)
Domain 2: perceived barriers to decreasing small screen recreation
The perceived barriers to both increasing physical activity and limiting small screen recreation were consistent, fitting under similar themes.Theme 1.
Family dynamics: An absence of rules relating to the time children were allowed to spend in small screen recreation activities was seen as a barrier. Different rules in split houses were a problem and children also identified lack of discipline as even when their small screen recreation time was restricted, they would continue to participate in such activities.
“I’ve got rules but when he goes to his mum's he can sit up as late as he wants and watch what he wants.” (Parent)
Similar to physical activity, lack of energy and time were perceived barriers identified by all parents. This resulted in parents being more inclined to use television as a proxy-babysitter. Children concurred as they felt that the long hours their parents worked led to an increase in small screen recreation as it restricted the outdoor activities they could participate in without parental supervision.Theme 2.
Lack of social support: The need for constant social support was highlighted by parents and children.
“She goes on the computer here when we’re inside doing things. She won’t go outside on her own. She's gotta have someone with her.” (Parent)
A lack of active friends was also raised, with parents explaining that when other children visited, they only wanted to play computer games. Some children stated that the lack of focused attention they received from parents led them to participate in extra small screen recreation as they could do so by themselves.
“Some of my friends like playing outside but most of the time my friends like to play the Play Station cause I have some good games.” (Child)
Theme 3.The physical environment: Perceived safety concerns led parents to direct children to participate in “quiet” activities when both parents were busy with household chores.
“I just wish I could say off you go but I can’t. I mean I did as a child. But if she goes on her bike, she's not allowed to leave this street… So I think that stops more activities that she would do but I just can’t do it. And I don’t make the time maybe.” (Parent)
Poor weather conditions were thought to make it difficult to limit time spent in small screen recreation, with some parents worried about their children catching a cold. Parents also suggested that their child would be more active if they did not have a television in their bedroom.Theme 4.
Child characteristics: Children's enjoyment of small screen recreation activities was perceived to be another barrier. Children indicated they liked these activities because they were good at them and found them easier than physical activity.
“It's something he knows how to do. He gets up and pushes two buttons (on the Play station) and he's off.” (Parent)
Children also indicated that lack of energy, laziness and boredom were barriers to reducing the amount of time they spent in these activities.
“When you just can’t be bothered to play outside you think oh well I’ll just watch TV or play the computer or go grab my book and go out on the porch and read.” (Child)
Domain 3: strategies to increase physical activity
Although they found it difficult, parents and children identified some actions they could take to increase participation in physical activity. Choosing activities suited to their child's needs, interests and abilities and selecting a variety of activities were suggested. Others indicated that involving the entire family, making more time for physical activity by prioritising, and increasing parental encouragement by participating in activities with their children may help.
“I think maybe we need to really try and make time. It's too easy to say it's cold or I’m tired or I’ve gotta go and do this. I think we just really need to for her sake bite the bullet and say this is what we’re going to do.” (Parent)
Some children explained that if they finished their chores and homework faster, they might have more time available to participate in physical activity and it would not be dark and cold.
“I could do a little bit of homework each day so then I have about 2hours to play outside and I wouldn’t have to do as much homework as I do normally.” (Child)
Domain 4: strategies to decrease sedentary behaviours
Parents and children also had difficulty in suggesting strategies to overcome perceived barriers to reducing small screen recreation.
“I don’t know what else you can do, I mean you can’t do somersaults in the lounge room.” (Parent)
Some suggestions included developing rules or a roster system to limit time spent in small screen recreation or allocate time to physical activity, which would limit the time available for small screen recreation.
“We tried scheduling and that didn’t work. He was only allowed to watch TV after 6 at night. He’d go outside for like 10minutes then sneak in through the side and go into his bedroom.” (Parent)
Parents said that removing the television from their child's room would significantly reduce the time they spent in this activity.
Discussion
The purpose of this study was to qualitatively examine the perceived physical activity and small screen recreation barriers obese children and their families faced. A second purpose was to determine participants’ knowledge of strategies to overcome these perceived barriers.
Consistent with previous research, physical difficulties were thought to be a barrier to increasing physical activity, in particular low cardiorespiratory fitness [13], [14], poor fundamental movement skill proficiency [15], [16], and limitations in performing some daily living activities [17] such as getting up off the floor and out of a seat. Because these problems influence children's physical activity, these difficulties may be part of the cycle that perpetuates the accumulation of excess body weight in children. The finding that perceived physical competence is a barrier to participation has been found in prior studies [16], [18]. Research indicates that children with higher perceived physical competence are more active [19] and physically fit [19], [20]. This may deter the children in this current study, who may be more likely to participate in activities that they are good at and are safe, which may be more sedentary in nature.
Consistent with findings among non-overweight children [21], family dynamics were perceived to be barriers to increasing time in physical activity. All the children in this study were either the eldest child or an only child. The eldest children felt they did not receive as much attention as their younger siblings. Similar to other studies [22], [23], [24], all parents felt they were time-poor, working long hours and spending more time with younger siblings, leaving minimal time to be active with their older children. This resulted in using small screen recreation as a proxy-babysitter, a finding consistent with prior studies [25].
Similar to previous studies [26], a lack of rules around time spent in small screen recreation was thought to be a barrier to reducing the time spent in these activities. The busy lives of parents or a breakdown in parental authority may explain why rules may not be present and/or enforced. Not surprisingly, parents also felt that having a television in their child's room was a barrier, which has been previously reported [22], [27]. It exerts its influence through making it easier to select sedentary behaviours over physical activities.
Social support was felt to influence the physical activity and small screen recreation behaviours of the children in this study. Consistent with previous research, a lack of friends to participate in physical activity with [28] and low activity levels of parents [22], [24], [29] were barriers to being more active. Obese children find it harder to make and keep friends [28] and without siblings or friends, the responsibility falls with their parents. Many parents in this study, however, were not active themselves and did not encourage their child or participate with them. This perceived barrier was also evident in small screen recreation and possibly reflects a reciprocal relationship; that is, since obese children find it more difficult to make friends [28] and often have inactive parents [30], they resort to participating in activities designed for one person, which are often sedentary in nature.
Consistent with prior research, small backyards [23], [24], lack of finances [23], [29], lack of facilities [31] and safety [32] were all perceived to be barriers to increasing physical activity. Having a small backyard limited the amount of physical activity the children could do at home, especially when their parents restricted where the children were allowed to go for safety reasons. The backyard may be the only safe environment for physical activity. Due to increasing concerns about stranger danger [33], [34], [35] and traffic [36], parents are less likely to allow their child to play on the streets of their local neighbourhood. Similar to the findings of Davison and Birch [6], access to recreational facilities was believed to be a barrier as urban sprawl has led to greater distances to such facilities from the home. Parents also felt that limited finances made it difficult to access these facilities due to the cost involved (travel to and from venue, registration fees, and uniform costs), posing a further barrier to participation.
Parents and children found it challenging to identify strategies to increasing participation in physical activity. Many parents felt that they were powerless when it came to changing weight-related behaviours as they all explained that they knew “what to do but not how to do it”. First, these parents may have tried a number of things to help their child in the past but lost confidence when these strategies failed. Second, they grew up in a different generation and may have found it difficult to relate to the environment in which their child was growing up. Incidental physical activity appeared to be far more integrated into everyday life when the parents in the study were children because there were not as many safety concerns [27]. However, in contemporary society physical activity often needs to be planned for children.
Like physical activity strategies, parents and children found it difficult to identify strategies they could implement to reduce sedentary behaviours. Decreasing the time spent in sedentary activities may not have been an issue for these parents when they were children as there were not as many competing demands on their leisure time. Also, sedentary activities may have become the norm in these families’ households and it is often difficult to change behaviours that have become well established.
These findings need to be understood in the context of the following limitations of the study. Only nine obese children and their parents who had contacted the Child Obesity Research Centre at Wollongong University to be involved in a weight-management program were included in this study. This study was also limited geographically to the Illawarra region of New South Wales, Australia. As such, due to this small data set, the results of this study cannot be generalised to all obese children. The families involved in this study were of a convenience sample as they had previously inquired about a community-based weight-management program. Although they did not take part in the program, they had inquired because they were aware they had a child who was obese and therefore wanted to do something to change their unhealthy weight-related behaviours. While interviewing the children and parents, it is quite possible, although unlikely, that they had already implemented changes to their behaviours.
Implications for research and practice
As the pediatric obesity epidemic continues to increase in Australia and worldwide, research needs to focus on the most effective prevention and treatment practices. Gaining a better understanding as to why families find it challenging to adopt healthy weight-related behaviours, in particular promoting physical activity and limiting small screen recreation is imperative. Interventions which are directed towards reducing barriers to being more active and less sedentary may be an effective approach. This study helps to identify the importance of working closely with obese children and their parents in identifying potential intervention points which may enhance the success of treatment programs.
Conflict of interest
There are no conflicts of interest.
Acknowledgements
The present study was supported by the Australian Council for Health, Physical Education and Recreation (ACHPER). The authors would like to thank the Child Obesity Research Centre as well as the participants of the present study.
References
- . Obesity in children and young people: a crisis in public health. The International Association for the Study of Obesity. 2004;5:4–85
- . Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine. 1997;337:869–873
- . Trends in the prevalence of overweight and obesity among Australian children and adolescents, 1985–1997–2004. Obesity. 2007;15:1089–1095
- . Interventions for treating obesity in children (Review). Cochrane Database of Systematic Reviews. 2003;3
- . What do parents and preschool staff tell us about young children's physical activity: a qualitative study. International Journal of Behavioral Nutrition and Physical Activity. 2008;5:
- . Childhood overweight: a contextual model and recommendations for future research. Obesity Reviews. 2001;2:159–171
- . Reliability and validity of physical activity questionnaires for children: the Children's Leisure Activities Study Survey. Pediatric Exercise Science. 2004;16:64–78
- . The Children's Leisure Activities Study (CLASS): summary report. Melbourne: Deakin University; 2004;
- . Reducing children's television to prevent obesity: a randomized controlled trial. Journal of American Medical Association. 1999;282:1561–1567
- . Introduction to research methods in education. Melbourne: Longman Cheshire; 1990;
- . Research and the teacher: a qualitative introduction to school-based research. 2nd ed.. New York: Routledge; 1995;
- . Trustworthiness of think-aloud protocols in the study of translation processes. International Journal of Applied Lingustics. 2004;14:301–313
- . Association of somatotype and body composition to physical performance in 7–12-year-old girls. The Journal of Sports Medicine and Physical Fitness. 1980;20:189–198
- . Quantification of the influence of the body fat content on selected physical performance variables in adolescent boys. Irish Journal of Medicine and Science. 1988;157:383–384
- . Relationships between body composition and fundamental movement skills among children and adolescents. Research Quarterly for Exercise and Sport. 2004;75:238–247
- . Actual and perceived physical competence in overweight and nonoverweight children. Pediatric Exercise Science. 2004;16:15–24
- . The biomechanics of adiposity—structural and functional limitations of obesity and implications for movement. Obesity Reviews. 2002;3:35–43
- . Obesity and risk of low self-esteem: a state wide survey of Australian children. Pediatrics. 2006;118:2481–2487
- . Construct validity of physical self-description questionnaire responses: relations to external criteria. Journal of Sport and Exercise Psychology. 1996;18:111–131
- . Achievement goal profiles in school physical education: differences in self-determination, sport ability beliefs, and physical activity. British Journal of Educational Psychology. 2002;72:433–445
- . Developing health messages: qualitative studies with children, parents and teachers help identify communications opportunities for healthful lifestyles and the prevention of obesity. Journal of American Dietetic Association. 2003;3:721–728
- . Body mass index and parent-reported self-esteem in elementary school children: evidence for a causal relationship. International Journal of Obesity. 2004;28:1233–1237
- . Overweight children's barriers to and support for physical activity. Obesity Research. 2003;11:238–246
- . A review of correlates of physical activity of children and adolescents. Medicine and Science in Sports and Exercise. 2000;32:963–975
- . Television viewing and television in bedroom associated with overweight risk among low-income preschool children. Pediatrics. 2002;109:1028–1036
- . Television viewing habits associated with obesity risk factors: a survey of Melbourne schoolchildren. Medical Journal of Australia. 2006;184:64–67
- . Preventing childhood obesity. Nutrition Today. 2004;39:194–200
- . Social, educational, and psychological correlates of weight status in adolescents. Obesity Research. 2001;9:32–42
- . Children's perceptions of TV and health behavior effects. Journal of Nursing Scholarship. 2002;34:289–294
- . Food and activity preferences in children of lean and obese parents. International Journal of Obesity. 2001;25:971–977
- . The importance of play in promoting healthy child development and maintaining strong parent–child bonds. Pediatrics. 2007;119:182–191
- . Motivating kids in physical activity. The President's Council on Physical Fitness and Sports Research Digest. 2000;3:1–8
- Morris J, Wang F, Lilja L. School children's travel patterns—a look back and a way forward. 24th Australasian Transport Research Forum. Hobart; 2001.
- . Perceptions of local neighbourhood environments and their relationship to childhood overweight and obesity. International Journal of Obesity. 2004;1–6
- . ‘My son's a bit dizzy.’ ‘My wife's a bit soft’: gender, children, and cultures of parenting. Gender, Place and Culture. 1997;4:37–62
- . One false move.…: a study of children's independent mobility. London: PSI Publishing; 1990;
PII: S1871-403X(09)00058-1
doi:10.1016/j.orcp.2009.07.004
Crown Copyright © 2009. Published by Elsevier Inc. All rights reserved.
