Abstract
Background
This paper describes the formative research undertaken to explore challenges of low-income parents of 3–5 year olds to inform a parent-focused life skills-based intervention to prevent obesity in preschool-aged children.
Methods
Forty parents completed surveys, 30 parents participated in focus groups, and five community stakeholders participated in individual interviews. In each data mode, participants were asked to prioritize a list of challenges centered on parenting, family care, and self-care. Survey data were analyzed descriptively using SAS, while focus groups and interviews were analyzed for emerging themes using ATLAS.ti.
Results
Parents reported needing strategies for managing children’s behavior around picky eating, limits/boundaries, tantrums, and routines. Challenges with child behavior management were compounded by parents’ inability to find affordable fun family activities outside the home, and difficulties in communicating childrearing expectations to co-parents/relatives who assisted with childcare. Added to these were other competing priorities (e.g., financial) that led to the neglect of self, including the inability to find ‘me’ time, build relationships, and care for one’s health.
Conclusions
Interventions that address parenting, family care and self-care challenges of low-income parents may enhance resilience and support positive changes that can promote healthy development in children, including obesity prevention.
Keywords: low-income, preschool-aged children, childhood obesity, parenting, family, self-care
BACKGROUND
Childhood obesity is a significant health problem in the U.S., with greater prevalence among lower-income children (Ogden et al., 2016). Poor dietary intakes and physical inactivity are modifiable behaviors that contribute to childhood obesity (Kumar & Kelly, 2017). At home, parents influence children’s diet and physical activity (PA) behaviors through foods made available, role-modeling, and practices such as their child feeding styles, encouragement of active play, and control of children’s media use (Hesketh, Lakshman, & van Sluijs, 2017; Skouteris et al., 2011). For low-income parents providing home environments that support healthful diet and PA in children can be challenging, given their limited resources (Chang, Nitzke, Guilford, Adair, & Hazard, 2008; Kelly & Patterson, 2006).
Low-income parents are likely to be female, single, and unemployed, or they may hold multiple jobs that limit the time available to care for and feed their children healthy meals (Chang et al., 2008; Tach, Mincy, & Edin, 2010). Lack of time hinders low-income parents from spending quality time with their children, increasing the use of electronic media as “babysitters” to keep children safely occupied, thus, reducing children’s PA (Taveras, Hohman, Price, Gortmaker, & Sonneville, 2009). Lack of social support is another barrier to positive parenting that leaves low-income parents “feeling overwhelmed or burned out going through their daily routines and losing social interaction with others as a result” (Birkett, Johnson, Thompson, & Oberg, 2004; Chang et al., 2008). Depression, lack of health insurance, addiction, and abuse are other stressors of low-income parents that make it difficult to prioritize healthy eating and PA (Lent, Petrovic, Swanson, & Olson, 2009; Seccombe, 2002). The burdens and responsibilities of low-income parents can have negative effects on their psychosocial well-being and ability to provide home environments that support healthy weight in children (Luster & Kain, 1987; Pinderhughes, Dodge, Bates, Pettit, & Zelli, 2000).
Prior childhood obesity prevention interventions have targeted parents and demonstrated mixed results in terms of their effects on children’s diet, PA, and weight, thus, prompting the call for novel approaches that promote resilience in low-income families to support healthy child weight (Sigman-Grant, Hayes, VanBrackle, & Fiese, 2015; Sleddens et al., 2011). In this paper, we propose enhancing parents’ life skills as an approach to promote resilience in low-income families. The life skills approach enhances individuals’ cognitive skills for analyzing and using information, personal skills for managing self, and interpersonal skills for communicating and interacting effectively with others (UNICEF, 2017), which can be a challenge for low-income parents given their multiple stressors. The life skills approach has been applied in interventions with adolescents and shown to be effective in preventing risky behaviors such as smoking, drug use, and alcohol use (Botvin, Eng, & Williams, 1980; Botvin & Griffin, 2002, 2004). Because risky behaviors and childhood obesity share common contributors (e.g., psychosocial, familial), researchers suggest applying interventions that have been successful in reducing risky behaviors as models to prevent childhood obesity (Sakuma, Riggs, & Pentz, 2012), hence our reason for proposing to use the life skills approach with parents to prevent childhood obesity. We focus on parents (as opposed to children) because of the critical role they play in shaping children’s healthy weight behaviors in the preschool years (ages three-five).
This paper describes the formative work undertaken to prioritize the needs, concerns, and challenges of low-income parents to inform THRIVE (Transforming Human Relationships into Valuable Experiences) for Health, a parent-focused life skills-based intervention to prevent obesity in preschool-aged children. Specifically, we applied Davison and Birch’s Contextual Model on Childhood Overweight (Davison & Birch, 2001), which is based on the Ecological Systems Theory (Bronfenbrenner, 1979), to identify parental/family factors (e.g., parenting practices, family preference for PA, parental weight-related characteristics) and child-level factors (child food preferences, PA, and sedentary behaviors) upon which to intervene to promote healthy weight in preschool-aged children from low-income families.
METHODS
Participants
Data were collected from March-July 2015. Participants were 70 low-income parents of three-five year old children and five community stakeholders from rural and urban North Carolina. Parents were recruited from community locations, including public libraries, Head Start centers, Women, Infants, and Children (WIC) program offices, bus/train stations, and laundromats. Eligible parents had to be the primary caregiver of a three-five year old child and low-income, as defined by federal poverty guidelines (US Department of Health and Human Services, 2015) and/or participation in federal social assistance programs. Stakeholders were persons who occupied leadership positions (e.g., nutrition director) at community organizations that provide social services to low-income families. This study was approved by the Institutional Review Board at the University of North Carolina at Chapel Hill.
Data Collection
Data were collected via quantitative parent surveys, parent focus group discussions, and stakeholder interviews (Table 1). In each data mode, participants were asked to prioritize a list of challenges centered on parenting, family care, and self–care. This list of challenges was informed by an initial literature review and individual interviews with 10 low-income mothers of preschool-aged children, to identify facilitators and barriers to positive parenting and healthy eating and PA in low-income families. The 10 mothers were recruited from community locations including public libraries, community health centers, laundromats, and bus/train stations.
Table 1.
Description of the three modes used in collecting data from parents (n=70) and community stakeholders (n=5) in this study
| Data Mode | Description | Participants | Timeline for Data Collection |
|---|---|---|---|
| Parent survey on challenges | Brief survey assessing parenting, family care, and self-care challenges. | 40 low-income parents of 3–5 year olds. | March to July 2015 |
| Parent focus group discussions | Four 90-minute focus groups to delve in-depth into parenting, family care, and self-care challenges. | 30 low-income parents of 3–5 year olds. | April to July 2015 |
| Community stakeholder interviews | In-person interviews to understand from stakeholders’ perspectives, parenting, family care, and self-care challenges of low-income parents. | 5 community stakeholders | April to July 2015 |
Parent Survey on Challenges
We developed a brief survey that was administered in-person to 40 parents. The survey included a list of 12 parenting challenges, seven challenges related to family care, and 16 challenges related to self-care (Table 2). In each category, parents were asked to select the top three challenges they considered to be of utmost priority to address in an intervention program. Parents could write in their response if a specific challenge they experienced was not on the survey. Parents completed a demographic survey and each received a $20 incentive.
Table 2.
Parenting, family care, and self-care challenges that were assessed in this study
| Challenge Category | Challenges Assessed: |
|---|---|
| Parenting | • Creating smooth morning or bedtime routines |
| • Setting limits and boundaries for children | |
| • Managing a child’s behavior | |
| • Getting a child to do what one wants | |
| • Communicating expectations to children | |
| • How to say “no” to one’s child | |
| • Getting a picky eater to eat a variety of foods | |
| • Foods that are good for a child | |
| • Getting children to be physically active | |
| • Reducing the amount of time children spend watching TV or using other electronic devices like iPads, and video games | |
| • Affordable activities (e.g., museums, play spaces) one can do with children | |
| • Finding other resources to care for children when childcare is needed | |
| • Other (specify) | |
| Family Care | • Communicating with a co-parent on how to manage and care for one’s child |
| • Communicating with other family members on how to manage and care for one’s child | |
| • Creating family time | |
| • Affordable activities to do as a family | |
| • Providing healthy family meals on a tight budget | |
| • Eating healthy together as a family | |
| • Being physically activity as a family | |
| • Other (specify) | |
| Self-Care | • Managing finances and living on a budget |
| • Managing time effectively given all of one’s obligations | |
| • Taking care of oneself | |
| • Simple and affordable things to do during “me” time | |
| • Managing stress | |
| • Eating healthy | |
| • How to exercise more | |
| • How to sleep more | |
| • Managing one’s health better | |
| • Career development and counseling (e.g., how to find a job) | |
| • Increased education opportunities (e.g., returning to school, taking GED) | |
| • How to access health care resources | |
| • How to access parenting support resources in one’s community | |
| • Communicating one’s needs or expectations to spouse, partner, or co-parent | |
| • Communicating one’s needs and expectations to other extended family | |
| • Communicating one’s expectations and feelings to others | |
| • Building a support network of other parents whom one can relate with | |
| • Other (specify) |
Parent Focus Group Discussions
Thirty parents participated in focus group discussions that were moderated by two team members with extensive qualitative research experience. One moderator led group discussions, while the other observed and asked clarifying questions as needed. During group discussions, each parent was provided with a paper packet containing the list of 12 parenting challenges, seven family care challenges, and 16 self-care challenges, and asked to select the top three in each category that they considered to be of utmost priority to address in an intervention (Table 2). Participants could write in their response if a challenge they experienced was not included on the list. Flip charts that mirrored the paper packets were posted in the room. Upon completing their individual packets, each participant received nine sticky dots to place on the flip charts, next to the same challenge topics they had selected in their paper packets, an approach that has been used in other health promotion and disease prevention studies (Gittelsohn et al., 2010; Summers et al., 2013). The moderator tallied participants’ responses, and using a semi-structured focus group guide, asked questions and used prompts to elicit rich discussions around the three topics with the most votes in each challenge category. Four focus groups were conducted, each lasting about 90 minutes. Participants completed a demographic survey; child-care, refreshments, and incentives ($40 per participant) were provided.
Community Stakeholder Interviews
Five community stakeholders participated in individual interviews that were moderated by two team members. Following the same format as the parent focus groups, the interviewers provided each stakeholder with a paper packet containing the list of challenges around parenting, family care, and self-care. Stakeholders were asked to vote for the top three topics in each category that they perceived to be the most pressing needs of low-income parents from their experience working with such families. Thereafter, the interviewers used a semi-structured interview guide to gain in-depth understanding of stakeholders’ challenge selections. Each interview lasted about 60 minutes, and stakeholders received non-monetary incentives.
Data Analysis
Survey data were analyzed descriptively in SAS (version 9.3, Cary, North Carolina). All focus groups and interviews were digitally recorded and transcribed verbatim. Four team members (NLB, MV, RT, JCA) discussed the resulting transcripts and objectives of the formative work to develop a codebook. Subsequently, one co-author created an index of thematic codes that was independently reviewed and verified by other team members. To ensure consistency in coding and assignment of the coded data to priority themes/categories, each transcript was independently coded by two team members using ATLAS.ti (version 1.0.46, Berlin, Germany). The team met to discuss discrepancies in the application of thematic codes, and areas of disagreement were resolved by consensus. Text pertaining to each code was summarized in a report that presented findings for each theme using illustrative quotes. Due to space constraints, this paper describes the top two challenges reported in each data mode.
RESULTS
Parent Demographics
Table 3 describes demographic characteristics of the 70 parents, of which most (91%) were female, 46%, African-American, and 51% had completed high school/GED. A higher proportion of parents who completed the survey on challenges were younger, ages 18–30, compared to parents in the focus groups (60% versus 43%).
Table 3.
Demographic characteristics of parent participants by mode of data collection
| All Parents (n=70) |
Survey on Challenges (n=40 parents) |
Focus Groups (n=30 parents) |
||||
|---|---|---|---|---|---|---|
| n | (%) | n | (%) | n | (%) | |
| Gender | ||||||
| Female | 63 | (90) | 35 | (88) | 28 | (94) |
| Male | 7 | (10) | 5 | (13) | 2 | (7) |
| Age (years) | ||||||
| 18–30 | 37 | (53) | 24 | (60) | 13 | (43) |
| 31–40 | 23 | (33) | 12 | (30) | 11 | (37) |
| 41–50 | 7 | (10) | 2 | (5) | 5 | (17) |
| 51+ | 1 | (1) | 1 | (3) | 0 | (0) |
| Marital Status | ||||||
| Married | 22 | (31) | 16 | (40) | 6 | (20) |
| Living as married | 7 | (10) | 4 | (10) | 3 | (10) |
| Divorced/Separated | 7 | (10) | 5 | (12) | 2 | (7) |
| Single, never married | 34 | (49) | 15 | (37) | 19 | (63) |
| Race/Ethnicity | ||||||
| African-American | 28 | (40) | 9 | (23) | 19 | (63) |
| White | 21 | (30) | 12 | (30) | 9 | (30) |
| Other | 19 | (27) | 17 | (43) | 2 | (7) |
| Household Income | ||||||
| <$25,000 | 46 | (66) | 26 | (65) | 20 | (67) |
| $25–50,000 | 21 | (30) | 13 | (33) | 8 | (27) |
| >$50,000 | 3 | (4) | 1 | (3) | 2 | (7) |
| Highest level of education | ||||||
| Less than high school | 14 | (20) | 11 | (28) | 3 | (10) |
| High school | 36 | (51) | 18 | (45) | 18 | (60) |
| Associate’s degree | 12 | (17) | 7 | (18) | 5 | (17) |
| Bachelor’s degree | 5 | (7) | 3 | (8) | 2 | (7) |
| Master's degree or higher | 3 | (4) | 1 | (3) | 2 | (7) |
| Employment Status | ||||||
| Employed | 27 | (38) | 17 | (43) | 10 | (33) |
| Unemployed | 24 | (34) | 11 | (8) | 13 | (43) |
| Homemaker | 10 | (14) | 8 | (20) | 2 | (7) |
| Student | 4 | (6) | 3 | (8) | 1 | (3) |
| Disabled/Other | 5 | (7) | 1 | (3) | 4 | (13) |
| Self-Rating of Health | ||||||
| Excellent | 13 | (18) | 8 | (20) | 5 | (17) |
| Very Good | 20 | (29) | 10 | (25) | 10 | (33) |
| Good | 30 | (49) | 16 | (40) | 14 | (47) |
| Fair | 17 | (24) | 16 | (40) | 1 | (3) |
Results from the Parent Survey on Challenges
The top parenting challenges reported on the parent survey on challenges were related to, “getting a picky eater to eat a variety of foods” and “setting limits/boundaries for children” (Table 4). The top family care challenges centered on “communicating with a co-parent or other family members about childrearing” and “finding affordable family activities”. The top self-care challenges reported were managing “finances” and “time effectively”.
Table 4.
The two challenges voted on as being of utmost priority to address around parenting, family care, and self-care: Findings from the parent surveys and focus groups, and stakeholder interviews
| Parent surveys | Focus groups | Stakeholder interviews | |
|---|---|---|---|
| n=40 parents | n=30 parents, 4 focus groups | n=5 stakeholders | |
| ‘yes’ votes (number reporting) | ‘yes’ votes (number reporting) | ‘yes’ votes (number reporting) | |
| Parenting challenges: | |||
| Getting a picky eater to eat a variety of foods | yes (25 of 40) | -- | -- |
| Setting limits and boundaries | yes (15 of 40) | -- | yes (3 of 5) |
| Managing a child’s behavior | -- | yes (11 of 30) | yes (3 of 5) |
| Creating smooth morning or bedtime routines | -- | yes (11 of 30) | -- |
| Family care challenges: | |||
| Communicating with co-parents | yes (21 of 40) | yes (11 of 30) | yes (3 of 5) |
| Communicating with extended family | -- | yes (9 of 30) | -- |
| Findings affordable family activities | yes (19 of 40) | -- | |
| Eating healthy together as a family | -- | -- | yes (4 of 5) |
| Self-care challenges: | |||
| Managing finances | yes (16 of 40) | yes (17 of 30) | yes (4 of 5) |
| Managing one’s time | yes (13 of 40) | -- | -- |
| Managing stress | -- | -- | yes (4 of 5) |
| Caring for me | -- | yes (20 of 30) | -- |
(--) denotes topics that were not voted as being the top two in terms of challenges around parenting, family care, and self-care in each mode of data collection.
Results from Parent Focus Group Discussions
Parenting challenges reported in the parent focus groups centered on “managing children’s behavior” and “creating smooth routines” (Table 4). Parents referred to managing children’s behavior as “getting them to do what you need them to do,” and included de-escalating tantrums and providing appropriate reinforcements/consequences for misbehavior. Parents agreed that creating smooth routines was essential, but expressed frustrations when managing multiple children of different ages, and situations where children shared their time between dual households (e.g., with a grandparent or separated parent). One parent explained:
“And then, because kids, especially three-five, they need different routines and structure. So, it can’t be completely different one weekend, or two weekends a month. ‘I’m at dad’s and I can just go crazy’, and then when I get them back it takes me three days to get them back and adjusted, just to drop them off (again). The mornings and bedtime is just a disaster.”
Avoiding stress-inducing tantrums/meltdowns resulted in deviations from set routines. One parent said this often happened after a long workday:
“At first it’s like, look, we’re not doing this. But then I always give in, it’s late and I’ve been on my feet all day, and I got too much else, and we end up doing it anyways. So I think I’m defeating the purpose.”
Family care challenges reported centered on communicating with a “co-parent” and “other extended family” about childrearing. Parents lamented that their inability to communicate childrearing expectations to a co-parent/relative made it increasingly difficult to enforce consistent rules, discipline, and routines. Having differing childrearing views from a co-parent/older relative (grandparent) also posed challenges. Parents associated communication challenges with not receiving needed support from immediate family, and several reported feeling overwhelmed by parenting responsibilities. One parent described:
“…my family members always have something to say. They don’t like to help a lot but they have a whole lot to say. Especially like when I’m like at the house, and my momma’s out, she’s taking care of business and stuff and I have the kids, and she’s like ‘well, why won’t you do this with them, and why won’t you do that with them?’ And I’ll be like, ‘wait, wait, hold on, I’m babysitting, not you. I didn’t hear you volunteer to babysit.’ That’s always been my problem with my family members…you can’t talk to them and they don’t help.”
Most parents agreed that compromises were important to maintain healthy relationships and stated that their communication approach with a co-parent/relative was driven by their desire to be role-models for children.
Self-care challenges most often cited were “caring for self” and “managing one’s finances”. Parents discussed challenges in finding “me time” amidst competing priorities. They described self-care as having a break from parenting responsibilities, being able to do something nice for oneself (enjoy a walk in the mall alone), establishing friendships/relationships, spending quality time with family, managing stress, and taking care of one’s mental health (depression). Many parents emphasized the need for self-care without feeling guilty about taking that time for oneself and described this as a prerequisite for taking good care of one’s children. One parent described this dilemma with an analogy:
“Cause you have to take care of you first, before you can take care of anybody else. Yeah! When you say you’re up in the air, and the plane is getting ready to go down or whatever you’re told you to put on your mask first. Because you can’t take care of you… put on your mask first, and then put on your kid’s mask. Because you can’t take care of your kids if you’re not ok. So that’s what they say in airplanes. So it feels selfish, but it’s right.”
In regard to managing finances, parents described mental calculations that occurred when trying to stretch their limited income to cover personal/family needs. One parent said:
“…So I’m like, ok I got $20. I can get $5 worth of gas. I can go to the store and get like a $7 pack of diapers…you know and, and I can get me a pack of cigarettes and it’ll last me a couple days, which I need… Try to ration out $20 a day. If you budget it right it’ll take you a long way, but it’s real and it needs to cover everyone.”
Parents expressed frustration at the high-cost of children/family activities. Their inability to say “no” when children asked to buy things, not having the time needed to plan ahead and save, and difficulties in staying organized enough to create financial plans were cited as challenges to managing finances.
Results from Community Stakeholder Interviews
Stakeholders perceived that parenting challenges of low-income parents centered on “setting limits/boundaries” and “managing children’s behavior” (Table 4). Stakeholders said parents often found it difficult to set rules/boundaries for children, and this was usually related to time mismanagement and other competing priorities. “They have so much chaos in their lives, it’s hard to get anything else in their schedules,” reported one stakeholder. Given their family circumstances, stakeholders perceived most parents often found it easier to let children do as they wished, instead of saying “no” and setting limits. Further, stakeholders perceived that parents would benefit from receiving additional support and skills for managing children’s behavior at home and in public, especially because most parents seemed to struggle with using positive parenting styles to control misbehavior. One stakeholder said:
“I’ve just observed that they tend to really struggle with controlling the kids in an appropriate way. They use threats, they often hit the kids…, and it doesn’t help. I mean the kids keep on screaming and yelling and hollering. … I see the same thing in the grocery store where parents are screaming and hollering and the kids are yelling and I just know like, as a parent myself that, that doesn’t work.”
Family care challenges that emerged from the stakeholder interviews centered on “healthy eating” and “communicating childrearing expectations to a co-parent”. Stakeholders perceived that juggling personal/family responsibilities including, multiple jobs, employment search, and career development (schooling) left low-income parents with limited time to prepare healthy meals. Thus, parents often reverted to fast food, as buying healthy foods proved to be expensive and time consuming. One stakeholder said:
“…I think a lot of parents express not having enough time…, between work and having to do this or do that, a lot of times they pick a lot of fast food, or either do a lot of convenient-type foods. Then also too, a lot of times are trying to feed their kids healthy but it’s hard when you have no time or money… and they base it on what they like, even if they know it’s not healthy, but it’s not easy and they have a lot on their plates already.”
In describing family care challenges associated with communicating childrearing expectations to a co-parent, stakeholders perceived this challenge as being influenced by tradition/culture. “We do what dad wants,” or “my mom has always done it this way,” stakeholders said, and perceived that parents often felt uncomfortable doing things differently from a co-parent, especially when they relied on a co-parent to assist with childcare:
“…they usually say, well, my mom gives him this when I’m at work. Caregivers are a lot of time, family members, when they’re at work or not around. You know, this is what they do. Even if that parent is really wanting the child to be healthy, so a lot of times, we have to figure out strategies to get everybody else on board.”
Self-care challenges that emerged from the stakeholder interviews were managing “stress” and “finances”. Stakeholders felt that for low-income parents, these two self-care challenges were intertwined:
“I don’t know if they realize what the problem is, they just know that they feel overwhelmed, and it’s stress, and it always goes back to number one, finances. They just lead to a lot of stress, your financial situation…, and then they don’t have any coping strategies for the stress.”
Stakeholders said, having multiple responsibilities and limited finances forced parents to choose between providing for their family’s basic needs, engaging in fun family activities, or seeking mental health services to alleviate stress. “One of the things I notice with our families is that they live in the moment, they live in the day”, observed one stakeholder. Consequently, parents did not focus or plan for things down the road, stakeholders perceived. In their role as providers of social services, stakeholders felt that it was difficult to talk with parents about food/nutrition, especially if parents’ were more concerned about paying bills:
“…so for their own budget, they live day to day, week to week…. I see a lot of really sad stories of people who are losing their apartments, losing their houses, losing their jobs, and it’s hard, because I think that completely takes away from their ability to take care of their kid. Because, I mean we have people come in to talk to us for nutrition, and then I find out that they’re losing their apartment. How can I talk to them about eating healthy, if you have no place to live?”
DISCUSSION
This paper describes the formative work undertaken to explore the needs of low-income parents to inform a parent-focused life skills-based intervention to promote healthy weight gain in preschool-aged children. The study is limited by the selection of a convenience sample from North Carolina that included few men and no teen parents. Another limitation is that questions on the parent survey and list of challenges were not previously tested to ensure that they could be comprehended by low literate persons. However, positive aspects of the study include the recruitment of a racial and ethnically diverse sample from rural and urban areas, inclusion of multiple individuals’ perspectives (parents, stakeholders), and use of a mixed methods approach that allowed us to delve deeper to understand challenges reported.
Findings from the survey on challenges and focus groups suggest that healthy eating and PA behaviors that support healthy weight in children may not be priority issues for low-income parents. While stakeholders perceived healthy eating to be a challenge for low-income families, most parents did not report this as challenging. Overall, parents reported needing strategies to manage children’s behavior. Parents’ inability to juggle child behavior management with other competing priorities (e.g., financial, work, school) was cited by parents and stakeholders as a reason for using punitive disciplinary strategies or ignoring and allowing children to do as they pleased. Similarly, other studies have found that having limited finances diminishes parents’ capacity for supportive, consistent, and involved parenting (McLoyd, 1990), which in turn, leads to behavioral problems, poor cognition, and poor emotional health in children (Lempers, Clark-Lempers, & Simons, 1989; McLeod & Shanahan, 1993; McLoyd, 1990, 1998).
Parental challenges with managing children’s behavior were often compounded by their inability to find affordable, fun activities for children outside of the home and difficulties in communicating childrearing expectations to a co-parent/relative. Lack of social support, having differing childrearing views, and tradition/cultural beliefs also impacted communication between co-parents or with relatives. Communication is critical for healthy family functioning (Schrodt, Witt, & Messersmith, 2008). As indicated by parents in this study, communication is key to ensuring that children receive consistent rules, discipline, and routines. Other studies have found that children are less likely to exhibit behavioral problems when parents communicate with each other (Linker, Stolberg, & Green, 1999; Schrodt & Ledbetter, 2007).
Self-care was reported as being a challenge for parents in this study. Their inability to juggle child behavior management, family care challenges, and other competing priorities often resulted in the neglect of self-care that impacted parents’ physical, social, and emotional well-being, and ability to save or plan for the future. Self-care, parents emphasized, was critical to providing the best care for one’s family.
While some of the challenges around parenting, family care, and self-care reported by parents in this study may not be directly related to childhood obesity prevention, it is important to note that most have been implicated as risk factors for adverse experiences (e.g., violence, abuse, neglect) in early childhood, but when addressed, can build resilience in families (Centers for Disease Control, 2017; Seccombe, 2002). Prior interventions that have applied resilience theory with at-risk individuals (e.g., military families affected by combat stress, families affected by maternal depression) have demonstrated positive effects on health outcomes including distress, emotion regulation, enhanced coping strategies(Lester et al., 2012; Steinhardt & Dolbier, 2008; Valdez, Mills, Barrueco, Leis, & Riley, 2011). In stressful situations, such as those experienced by low-income families, resilience develops from having a cohesive family unit, positive outlook, financial management strategies, support networks, family communication strategies, shared recreation, routines and rituals, flexibility, and spirituality (Black & Lobo, 2008; Orthner, Jones-Sanpei, & Williamson, 2004), but most of these protective factors were reported as challenges by parents in this study. In a recent review, Sigman-Grant et al. called for researchers to deviate from the traditional approaches to childhood obesity prevention that focus on changing diet and PA, and instead, focus on promoting resilience in low-income families as a means of supporting healthy weight development in children (Sigman-Grant et al., 2015). This formative research is a step in that direction; the findings provide insight about parental, family, and child-level factors that need to be addressed in low-income families to promote resilience in parents and support positive changes at home that can promote healthy weight behaviors in children. Findings will be used to inform THRIVE for Health, a resilience-focused intervention that will provide low-income parents with life skills to support healthy weight in preschool-aged children.
CONCLUSIONS
This study provides important information that can help public health practitioners better understand the challenges of low-income families that need to be addressed to support healthy weight development in children, and inform future studies to promote healthy weight behaviors in early childhood.
ACKNOWLEDGMENTS
The authors would like to thank Miss. Emma Armstrong-Carter who assisted with data collection, and the families and key stakeholders who provided valuable feedback.
FUNDING SOURCES
This study was supported by funds from a Junior Faculty Development Award received from the University of North Carolina at Chapel Hill (UNC), and a Career Development Award received from the National Institutes of Health/National Cancer Institute (K01 CA172498–01).
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