Abstract
This study examined the relationships among weight status (BMI), health perceptions, and psychosocial characteristics in children, parents, and parent–child dyads. A convenient sample of 114 parent–child dyads participated. All children were overweight or obese. Parents and children completed questionnaires by self-report or interview. Questionnaires included the Parenting Stress Index–Short Form (PSI), the Parents’ Stage of Change (SOC) Questionnaire, and the Pediatric Quality of Life Inventory (PedsQL). Child’s mean age was 10.34 years (s.d. = 1.87), mean BMI was 28.13 kg/m2 (s.d. = 5.46), and mean BMI z-score was 2.17 (s.d. = 0.38). Parent mean age was 37.28 years (s.d. = 12.66) and mean BMI was 34.07 kg/m2 (s.d. = 8.18). Most parents (68.5%) reported that they and their children (70.7%) were African American and many (44.3%) reported that they and their children were Hispanic. Significant correlations included: child health perceptions and child BMI (r = 0.309, P < 0.001) and parent perception of weight and parent BMI (r = 0.691, P < 0.001). For parent–child dyads, one correlation approached significance (child health perceptions and parent stage of change (r = ‒0.269, P < 0.01). Findings suggest that characteristics of parent–child dyads may be important considerations in the management of childhood obesity.
INTRODUCTION
In the United States, 34% of children aged 2–19 years are overweight or obese (1). Although recent findings suggest a “flattening” in the rate of childhood obesity, the prevalence remains high (2). Rates for childhood obesity vary by race, ethnicity, gender, and age with highest rates found among Mexican-American boys aged 6–11 years and African-American girls aged 12–19 years (1,3).
The multiple factors associated with childhood obesity include genetic predisposition, health behaviors, environmental supports, and psychosocial factors (4,5). Social risk factors (e.g., poverty, minority race/ethnicity, low parental education, and single-parent households) contribute to the social disadvantages of health and are associated with increased risk of childhood chronic conditions (6). These social risk factors may promote childhood obesity and contribute to health disparities (7,8).
A child’s social environment includes parents, family, and friends (9). Parent health behaviors, perceptions, and psychosocial characteristics are important factors associated with childhood obesity. Parents are important role models for their children as they establish family rules and routines around eating habits and physical activity (9–12). Parents’ Stage of Change (SOC) reflects their motivation or readiness to promote health behavior changes in their children (13). In the SOC model, change is described as a progression through five stages from no interest in or recognition of a need to make a change (precontemplation) through maintenance (maintaining the change for >6 months). The interim stages include contemplation (thinking about change), preparation (planning change), and action (participating in change for <6 months) (13). Parents who recognize an association between their children’s weight and negative health conditions may be more motivated to promote healthy changes than parents who do not (14,15). Rhee et al. reported that parents were more likely to be in the preparation/action stages when their children were older, when parents recognized that their children’s weight was a health problem, or when parents rated themselves as overweight (16).
Parenting stress may influence parents’ abilities to promote healthy behaviors for themselves and their children. Parenting stress includes child, parent, and situational characteristics (17). Evidence suggests that parents of children who are obese have increased stress levels compared to parents of children with typical weight (18–20).
Childhood obesity is associated with increased risk for negative physical and psychosocial health outcomes (i.e., heart disease, asthma, type 2 diabetes, low self-esteem, depression, anxiety, and weight-related distress) (21–25). Children from ethnic minority and low-income groups may be at higher risk for the negative consequences of obesity due to exposure to social risk factors (7,22,23). Children who are obese report lower health-related quality of life compared to their peers with typical weight (23,26–29). Health-related quality of life is defined as a comprehensive, multidimensional measure of a child’s function across several domains (e.g., physical, emotional, social, and school) (29).
Physical and social environmental factors that may be barriers to parents’ abilities to promote healthy behaviors in their children include time and resource constraints, limited social support, single-mother households, living in poverty, or living in neigh-borhoods characterized by danger, crime, lack of social cohesiveness, and lack of institutional resources (14,30–32). Parents living in these conditions may experience increased stress and may exhibit less effective parenting styles (e.g., punitive, inconsistent behaviors), which may be a barrier to the parent–child relationship and the parents’ abilities to promote child health (32).
A conceptual model (Figure 1) was designed to examine relationships among parent and child factors (i.e., weight status, health perceptions, and psychosocial factors) associated with childhood obesity. Relationships were hypothesized within groups (parent or child) and between groups (parent– child dyads). For the child group, we hypothesized that (i) child BMI is directly associated with child rating of weight status and inversely associated with child rating of overall health; (ii) child BMI is inversely associated with child rating of desire to be healthier and health-related quality of life (Pediatric Quality of Life Inventory (PedsQL); and (iii) PedsQL is directly associated with child’s ratings of overall health and desire to be healthier and inversely associated with child’s rating of weight status. For the parent group, we hypothesized that (i) parent BMI is directly associated with parent rating of weight status; (ii) parent BMI is inversely associated with stage of change for child’s physical activity (SOCPA) and nutrition (SOCN) habits; and directly associated with parenting stress (Parenting Stress Index–Short Form (PSI)); and (iii) PSI is directly associated with parent rating of weight status and inversely associated with SOCPA and SOCN. For the parent–child dyads, we hypothesized that (i) child BMI is directly associated with parent BMI; (ii) parent SOC for their children (SOCPA, SOCN) is inversely associated with PSI; directly associated with PedsQL; directly associated with child rating of overall health; and inversely associated with child BMI; and (iii) PSI is inversely associated with child rating of overall health; directly associated with child BMI and inversely associated with PedsQL.
Figure 1.
Conceptual model: parent–child relationships. Variables in boldface were included in the analysis of parent–child relationships.
Methods and Procedures
Participants and procedures
A convenient sample of 114 parent–child dyads was recruited from an urban outpatient pediatric practice. Child eligibility for this study was determined by chart review and primary care provider referral. Inclusion criteria for children were (i) 6–13 years old, (ii) overweight or obese, (iii) medically stable (i.e., no serious comorbidities such as hypertension, heart disease, dyslipidemia, or other symptoms of the metabolic syndrome), and (iv) proficient in English. The primary care providers’ referrals included medical clearance for child participation to ensure that children were safe to adopt healthier behaviors (increased physical activity and healthy eating habits) if information from this study motivated them to do so. Inclusion criteria for parents or primary caregivers were (i) aged ≥18 years and (ii) proficient in English. Institutional review board approval was obtained from the participating university and local children’s hospital that partnered for this study.
Parents and children were referred to the study by the child’s primary care provider during scheduled well-child visits. Research assistants trained in the study protocol were available in the primary care clinics to enroll parents and children and to administer the measures. Participating parent–child dyads completed consent and assent forms with these research assistants (also known as “health educators”). The health educators administered a battery of questionnaires to parents and children. All parents were interviewed on the SOC Questionnaire to ensure systematic administration and parent classification on their “readiness” to make changes in their child’s physical activity and nutrition habits. Parents were given the option to complete the other questionnaires by self-report or by interview (Demographic and Health Behavior Questionnaire and the PSI). Nearly all parents chose to complete these questionnaires by self-report.
Children were measured on height and weight and parents provided this information by self-report. Parents reported height and weight because of feasibility problems and burden in collecting these data in a busy pediatric clinic setting. Parent self-report was considered sufficient because parent BMI data were used primarily for descriptive purposes, not as an inclusion criterion. Evidence suggests that women underestimate their weight by 3.75–4.6 pounds, overestimate their height by 0.1–0.35 inches, and underestimate their BMI by 0.8–1.14 kg/m2 (33,34). Findings on self-reported height and weight data suggest that demographic characteristics may contribute to underestimates on weight by women who are obese and more accurate estimates on weight for women with education at or below high school level (34). The majority of parents in this study were mothers with low education levels.
Health educators administered all Demographic and Health Behavior Questionnaires for Children and half of the PedsQL Inventory by interview. Parents completed the PedsQL for their children who were ≤7 years of age as recommended in the user’s manual (35). For children between the ages of 8 and 13 years, it is recommended that children complete the PedsQL by self-report. Health educators and parents were requested to assist children in this age range if they were having difficulty completing the PedsQL independently. Thirty percent of the children aged 8–13 years completed the PedsQL by self-report, 7% completed the PedsQL with help from a parent, and 13% had parents complete the PedsQL for them. The remaining children (50%) completed the PedsQL by health educator interview. There was no significant difference on PedsQL scores based on method of administration.
Data collection sessions were conducted in the outpatient clinic area and complete data collection for parents and children was ~60–90 min.
Measures
Demographic and Health Behavior Questionnaires
Parent and child versions of this questionnaire were developed specifically for this study because there was no existing measure that included all items of interest (see Figure 1). Items on the parent questionnaire included: family structure, parent and child race and ethnicity, parent education level, parent perceptions of their own health and weight and their children’s weight, parent and child health behaviors for physical activity, sedentary behavior and fruit and vegetable consumption, and neigh-borhood environmental characteristics and zip code. Items on the child questionnaire were similar to the parent version with additional items on perceptions of health and weight, desire to be healthier and time spent in healthy behaviors at home and in school. The health behavior items for both questionnaires were from the Youth Risk Behavior Surveillance Survey (YRBSS) for high school and middle school-aged children (36,37). Some of these items also are in the Behaviour Risk Factor Surveillance Survey (BRFSS) for adults (38). The health behavior items included time spent weekly in moderate-to-vigorous physical activity for 30 min/day (parents) or 60 min/day (children), time spent daily in sedentary behaviors, and average daily fruit and vegetable consumption. The weight status and description items also are from the YRBSS and the BRFSS.
The neighborhood items on the parent questionnaire were: neighborhood safety and resources for outdoor play or physical activity. Parents reported their residential zip codes and descriptive neighborhood characteristics were obtained from local census and crime data based on zip codes (39).
BMI
BMI was calculated from child height and weight measures and parent self-reported height and weight. Children’s height was measured using a stadiometer (Road Rod 214 Portable Stadiometer; SECA, Hanover, MD) and weight was measured with a digital scale (UMO26; Tanita, Arlington Heights, IL). Instruments were calibrated before each data collection session using a standardized protocol. Child BMI percentile scores and BMI z-scores were calculated.
Parent SOC Questionnaire
Parents completed the SOC Questionnaire to determine their readiness to promote healthy changes for their children on physical activity (SOCPA) and nutrition (SOCN). The questionnaire has eight items (four each for physical activity and nutrition) and the scoring algorithm classified parents on SOC for physical activity (SOCPA) and nutrition (SOCN).
The SOC Questionnaire was developed for the study based on a similar questionnaire used in the pilot study and questionnaires published in the health behavior literature (40,41). Research evidence indicates that the SOC Questionnaire is a valid measure (40).
PSI
The PSI is a 36-item index that examines parent–child relationships and characteristics using a five-point response scale for parents to indicate level of agreement with each item (17). Outcomes from the PSI consist of a total score (PSI) and three subscale scores (parental distress, difficult child, and parent–child dysfunction). The PSI has good internal consistency, test–retest reliability, and concurrent validity (17). High scores are indicative of high levels of parenting stress. Raw scores are converted to percentile scores and scores in the 15th to 80th percentile reflect normal parenting stress levels (17).
PedsQL
The PedsQL measures health-related quality of life in children and adolescents aged 2–18 years. The inventory contains 23 items and scores may be reported as a total score (PedsQL) and/or four subscales scores (physical function, emotional function, school function, and social function). The PedsQL is both a child self-report measure and a parent proxy-report scale. Parents’ report for children ≤7 years old and children ≥8 years of age complete the PedsQL by self-report (preferred) or interview. Parents or children use a five-point scale to indicate how much of a problem each item was in the past month for the child. Raw scores are converted to scale scores with higher scores indicating better health-related quality of life (35).
Data analysis
Descriptive statistics were generated for all variables of interest including demographic characteristics (Table 1) and parent and child health perceptions and psychosocial factors (Tables 2 and 3). Spearman correlation coefficients were generated to examine hypotheses on the child and parent groups (Table 4) and for parent–child dyads (Table 5). Bonferroni corrections were calculated to adjust the α level and reduce the potential for type 1 error. There were 36 correlations generated for six variables of interest for the parent group and the child group and the α-level was set at 0.0014 to determine significance on these correlations. There were 49 correlations generated for the seven variables of interest examined for the parent–child dyads and the α-level was set at 0.00102 to determine significance on these correlations.
Table 1.
Demographic characteristics
| Variables | Child (n = 1,114) |
Parent (n = 114) |
|---|---|---|
| Parent and child characteristics, mean (s.d.) | ||
| Age (years) | 10.34 (1.87) | 37.28 (12.66) |
| BMI (kg/m2) | 28.13 (5.46) | 34.07 (8.18) |
| BMI z-score | 2.17 (0.38) | NA |
| BMI percentile score | 97.85 (2.13) | NA |
| Gender, n (%) | ||
| Female | 51 (44.5) | 103 (90.4) |
| Male | 63 (55.3) | 11 (9.6) |
| Education, n (%) | ||
| Grades | ||
| Kindergarten | 2 (2) | NA |
| 1–3 | 34 (30) | NA |
| 4–6 | 61 (53.1) | NA |
| 7–8 | 17 (15) | NA |
| Some high school | NA | 70 (61.4) |
| Some college | NA | 41 (35.7) |
| BMI weight category, n (%) | ||
| Underweight | NA | 0 |
| Healthy weight | NA | 11 (10.2) |
| Overweight | 11 (9.65) | 28 (25.9) |
| Obese | 103 (90.35) | 69 (63.9) |
| Marital status, n (%) | ||
| Single | NA | 87 (76.3) |
| Race, n (%) | ||
| African American | 65 (70.7) | 63 (68.5) |
| White | 14 (15.2) | 15 (16.3) |
| Other | 13 (14.3) | 14 (15.2) |
| Ethnicity, n (%) | ||
| Hispanic | 47 (44.3) | 45 (44.3) |
| Non-Hispanic | 59 (55.7) | 59 (56.7) |
| Neighborhood support characteristics, n (%) |
||
| Neighborhood is safe for child to play outdoors? | ||
| Yes | NA | 74 (64.9) |
| No | NA | 37 (32.5) |
| Neighborhood has places for child to play? | ||
| Yes | NA | 87 (76.3) |
| No | NA | 25 (22) |
| Neighborhood support scale | ||
| No support characteristics | NA | 11 (10) |
| One support characteristic | NA | 39 (35) |
| Two support characteristics | NA | 60 (54.5) |
| Zip codes | ||
| Total reported: 30 | ||
| Total count for 9 zip codes | 87 (76) | |
| Total count for 21 zip codes | 7 (24) | |
Table 2.
Health perceptions
| Health perceptions | n (%) |
|---|---|
| Child (n = 114) | |
| How would you rate your overall health at the present time? | |
| 1 = excellent | 27 (23.7) |
| 2 = very good | 28 (24.6) |
| 3 = good | 40 (35.1) |
| 4 = fair | 15 (13.2) |
| 5 = poor | 4 (3.5) |
| How much do you want to be healthier in your life? | |
| 1 = very much | 59 (53.2) |
| 2 = a lot | 42 (37.8) |
| 3 = somewhat | 5 (4.5) |
| 4 = a little | 5 (4.5) |
| 5 = not at all | — |
| How do you describe your weight? | |
| 1 = very underweight | 1 (0.9) |
| 2 = slightly underweight | 1 (0.9) |
| 3 = about right weight | 13 (11.6) |
| 4 = slightly overweight | 63 (56.3) |
| 5 = very overweight | 34 (30.4) |
| Parent (n = 114) | |
| How do you describe your weight? | |
| 1 = very underweight | 1 (0.9) |
| 2 = slightly underweight | 5 (4.4) |
| 3 = about right weight | 13 (11.4) |
| 4 = slightly overweight | 51 (44.7) |
| 5 = very overweight | 44 (38.6) |
| Do you think it’s important to be a certain weight to be healthy? | |
| 1 = yes | 89 (78.8) |
| 2 = no | 18 (15.9) |
| 3 = not sure | 6 (5.3) |
| Do you worry about your weight? | |
| 1 = yes | 77 (67.5) |
| 2 = no | 15 (13.2) |
| 3 = sometimes | 22 (19.3) |
| Do you worry about your child’s weight? | |
| 1 = yes | 99 (86.8) |
| 2 = no | 5 (4.4) |
| 3 = sometimes | 10 (8.8) |
| Do you think you are overweight? | |
| 1 = yes | 89 (78.1) |
| 2 = no | 25 (21.9) |
| Do you think your child is overweight? | |
| 1 = yes | 99 (86.8) |
| 2 = no | 15 (13.2) |
Table 3.
Psychosocial factors
| Psychosocial factors | Mean (s.d.) | Percentile | n (%) |
|---|---|---|---|
| Child (n = 114) | |||
| Pediatric Quality of Life (PedsQL) | |||
| Physical function | 76.57 (18.82) | ||
| Social function | 76.97 (21.25) | ||
| Emotional function | 70.05 (20.17) | ||
| School function | 70.41 (20.79) | ||
| Total score | 73.90 (15.62) | ||
| Parent (n = 114) | |||
| PSI | |||
| Parental distress (PD) | 25.3 (8.28) | 25th | |
| Parent–child dysfunctional interaction (PCDI) |
23.52 (7.21) | 70th | |
| Difficult Child (DC) | 23.52 (7.21) | 35th | |
| Total score | 57.19 (17.64) | 16th | |
| Stage of Change | |||
| Physical activity (SOCPA) | |||
| Precontemplation | 0 | ||
| Contemplation | 31 (27.2) | ||
| Preparation | 9 (7.9) | ||
| Action | 8 (7) | ||
| Maintenance | 66 (57.9) | ||
| Nutrition (SOCN) | |||
| Precontemplation | 1 (1) | ||
| Contemplation | 99 (88.4) | ||
| Preparation | 3 (2.7) | ||
| Action | 6 (5.4) | ||
| Maintenance | 3 (2.7) | ||
Table 4.
Spearman correlation matrices: child and parent
| Child | 1 | 2 | 3 | 4 | 5 | 6 | |
|---|---|---|---|---|---|---|---|
| 1. | Cage | — | |||||
| 2. | CBMI (N) | 0.421*** (114) | — | ||||
| 3. | CWS (N) | 0.244** (112) | 0.387*** (112) | — | |||
| 4. | COH (N) | 0.276** (114) | 0.309*** (114) | −0.218* (112) | — | ||
| 5. | CDH (N) | −0.164* (111) | — | ||||
| 6. | PedsQL (N) | — | |||||
|
| |||||||
| Parent | 1 | 2 | 3 | 4 | 5 | 6 | |
|
| |||||||
| 1. | Page (N) | — | |||||
| 2. | PBMI (N) | 0.264** (107) | — | ||||
| 3. | PWS (N) | 0.691*** (108) | — | ||||
| 4. | SOCPA (N) | — | |||||
| 5. | SOCN (N) | — | |||||
| 6. | PSI (N) | — | |||||
Child variables: Cage = child age; CBMI = child BMI (kg/m2); CWS = child rating of weight status; COH = child rating of overall health; CDH = child rating of desire to be healthier; PedsQL = Pediatric Quality of Life Inventory (total score). Parent variables: Page = parent age; PBMI = parent BMI; PWS = parent rating of weight status; SOCPA = parent SOC for child physical activity; SOCN = parent SOC for child nutrition; PSI = Parenting Stress Index (total score).
P < 0.05.
P < 0.01.
P < 0.001.
Table 5.
Spearman correlation matrix: parent–child dyads
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | ||
|---|---|---|---|---|---|---|---|---|
| 1. | PBMI (N) | — | ||||||
| 2. | CBMI (N) | — | ||||||
| 3. | SOCPA (N) | −0.209* (114) | — | |||||
| 4. | SOCN (N) | — | ||||||
| 5. | COH (N) | −0.269** (114) | — | |||||
| 6. | PSI (N) | 0.209* (100) | — | |||||
| 7. | PedsQL (N) | 0.205* (114) | 0.238** (100) | — |
PBMI = parent BMI (kg/m2); CBMI = child BMI (kg/m2); SOCPA = parent SOC for child physical activity; SOCN = parent SOC for child nutrition; COH = child rating of overall health; PSI = Parenting Stress Index (total score); PedsQL = Pediatric Quality of Life Inventory (total score).
P < 0.05.
P < 0.01.
P < 0.001
RESULTS
Demographic characteristics
Table 1 contains demographic information for parents, children, and neighborhood supports. Most parents and children were African Americans (68.5–70.7%) and many were Hispanic (44.3%). The majority of children (90%) and parents (63.9%) were obese. Some parents (32.5%) reported that their neighborhoods were unsafe for their children to play outdoors and some (22%) indicated there were no places in the neigh-borhood for the children to play. A neighborhood support scale and most parents (55%) reported both neighborhood supports. Additional neighborhood characteristics were identified by local census data collected at the level of participants’ zip codes (39). Thirty zip codes were reported for the 114 parent– child dyads with the majority of participants (76%) living in one of nine zip codes. Neighborhood characteristics based on these nine zip codes suggested that families lived in areas of high crime, with low educational attainment and low median household incomes (39).
Child and parent health perceptions
Descriptive data on child and parent health perceptions are reported in Table 2. The majority of children (83.3%) rated their overall health as “good to excellent” but most (91%) reported that they wanted to be healthier. Some children (30.4%) thought they were very overweight, although most (56.3%) indicated they were slightly overweight. Many parents (38.6%) said they were very overweight but more (44.7%) reported they were slightly overweight. Many parents (67.5%) were worried about their weight. Most parents (86.8%) reported that their children were overweight and they were worried about their children’s weight.
Child and parent psychosocial characteristics
Mean and percentile scores for parent and child psychosocial characteristics are reported in Table 3. The total PedsQL mean score was 73.90 (s.d.: 15.62) and the school and emotional domain scores were lower than the social and physical function domain scores reflecting higher health-related quality of life on social and physical function. The PSI total score was 57.19 (s.d.: 17.64) and subscale mean scores ranged from 23.52 (s.d.: 7.21) to 25.3 (s.d.: 8.28). All PSI scores were in the normal percentile range (15th to 80th percentile) with the parent– child dysfunctional interaction subscale in the high normal range. The SOCPA and SOCN scores were distributed across all stages of change with the majority of SOCPA scores in the maintenance stage (57.9%) and majority of SOCN scores in the contemplation stage (88.4%).
Correlations
Spearman correlation results are shown in Tables 4 and 5. For the child group (Table 4), there were three significant associations: child BMI increased with age (r = 0.421, P < 0.001), child BMI increased with increased ratings of weight status (r = 0.387, P < 0.001) and child BMI increased with decreased ratings of overall health (r = 0.309, P < 0.001). Findings on other correlations did not reach statistical significance at P < 0.0014 but did suggest potential relationships among other child variables.
Results among variables for the parent group (Table 4) revealed one significant correlation: parent BMI increased with increased ratings of weight status (PWS) (r = 0.691, P < 0.001). One other correlation was noted but it did not reach statistical significance at P < 0.0014. No significant correlations were found on parent–child variables. Results indicated that five correlations were noted but none reached significance at P < 0.00102 (Table 5).
DISCUSSION
Finding from this study confirmed the hypotheses for relationships between child BMI and health perceptions (ratings of overall health and weight status) suggesting that as BMI increases, children rate themselves as less healthy and more overweight. There were no significant relationship between child’s BMI and psychosocial factors (PedsQL and ratings of desire to be healthier) or between child’s psychosocial factors (PedsQL and ratings of desire to be healthier) and health perceptions (ratings of overall health and weight status). There was a nonsignificant relationship between child’s ratings of overall health and weight status suggesting that children perceive themselves as less healthy when they rate themselves as more overweight. Further, there were several nonsignificant but interesting correlations between child age and ratings of overall health and weight status and between child age and rating of desire to be healthier suggesting that with increased age, children perceive themselves as less healthy, heavier and they report increased desires to be healthier. These weaker correlations suggest that it may be important to examine health perceptions and psycho-social factors more closely to better understand the impact of obesity on children and to design effective interventions that address these factors. Interestingly, children in this study, on average, had lower quality of life compared to healthy children or those with chronic conditions (23,26–29). This finding suggests that effective health promotion interventions should include strategies to promote health-related quality of life for children who are overweight or obese.
Lack of significant correlations among the variables in the child group may be due to limitations in the measures resulting in skewed distributions of scores on health status, health perception, and psychosocial factors. Also, the small sample size and stringent α-level made it difficult to achieve significance in this study. A more focused study design and analysis plan may help reduce the number of tests run to determine significant relationships; however, the broad approach is appropriate for this exploratory study.
One of the hypothesized relationships was confirmed for variables in the parent group. Parent BMI was significantly and directly associated with their ratings of weight status suggesting that parents were fairly accurate in the assessment of their BMI and weight classification even though they were more likely to describe themselves as “slightly” overweight as opposed to “very” overweight when nearly two-thirds of the parents were obese. This finding suggested that parents from low-income minority groups may be aware of their weight status but may not perceive their weight as a potential health problem. The lack of other significant findings for the parent group may be due, in part, to the type of psychosocial measures used for parents (PSI, SOCPA, SOCN). For the SOC measures, parents were asked to rate their “readiness” to promote health behavior changes in their children which may not be strongly associated with their own weight status or health behaviors. Interestingly, most parents indicated that they were in the maintenance phase in promoting their children’s physical activity and the contemplation phase in promoting healthy nutrition habits for their children. The skewed distribution of scores on the SOC questionnaire may influence correlation results. Parents’ responses on this SOC questionnaire suggested that they may not have a good under-standing of “moderate-to-vigorous” physical activity since, on average, the children did not meet the recommended levels of moderate-to-vigorous physical activity.
Parenting stress levels were in the normal range although the parent–child dysfunctional interaction subscale was in the high normal range suggesting somewhat stressful parent–child interactions which may interfere with parents’ ability to promote healthy behaviors in their children and to be role models for their children. Although the PSI is a valid and reliable tool, this index may be more specific to emotional and psychosocial behavioral concerns in children rather than health behavior concerns. It may be better to choose a more health-specific measure of parenting stress in future studies.
No significant findings were found to support hypotheses for the parent–child dyads. However, there were findings that indicated weak associations between some parent and child variables which offered partial support for the hypotheses. For example, increased parent SOCPA was associated with decreased child BMI; increased child rating of overall health; and increased child health-related quality of life. Also, increases in parenting stress were associated with increases in child BMI. Again, these nonsignificant findings warrant further investigation to determine whether these relationships would be stronger in studies that use more specific measures, larger sample sizes, and fewer analyses. It is important to have a good understanding of parent and child health perceptions and psychosocial factors to design effective family-focused health promotion and weight management interventions.
Demographics and descriptive characteristics
Parents who worry or are concerned about their children’s weight status may be more inclined to make healthy changes. The majority of parents in this study indicated that they perceived their children to be overweight and they were worried about their children’s weight. This concern may have influenced parents’ stage of change classification as indicated by the SOCPA scores but not the SOCN scores. Because most parents indicated they were in contemplation for SOCN, they may benefit from interventions that promote active change such as nutrition education, training in meal preparation, shopping and cooking, and strategies to find healthy food resources in the community (e.g., farmers markets, etc.).
In this study, most parents reported that they made sure their children met the recommended levels of daily physical activity despite many families living in neighborhoods that were not safe or that did not have places for their children to be play. However, children reported, on average, that they did not meet the recommended daily levels of physical activity. The discrepancy between parent and child reports and the prevalence of obesity in the sample of children suggests that parents may try to encourage their children to be active but children may not fully adopt these behaviors. Therefore, family-focused approaches that promote family physical activity may be most effective.
The findings in this study emphasize the multidimensional factors associated with childhood obesity for children and their parents. For the sample in this study, parent demographics and health status point to family-based intervention approaches to promote health and reduce “family trends” toward obesity (9,42). Most parents indicated that their families were exposed to the social and environmental risk factors associated with obesity. Interventions to reduce or prevent childhood obesity should include strategies to enhance environmental supports and resources such as safe parks, recreation centers, and access to purchase healthy foods at a reasonable cost (43). Findings indicate that interventions should incorporate psychosocial supports to promote the parent–child relationship and enhance parenting capacities for healthy changes in themselves, their children and their family routines. Parents may need health education and behavioral strategies to promote healthy change. Family-focused programs that incorporate behavioral techniques are effective approaches to promote and sustain healthy lifestyles for children who are overweight or obese (44).
Limitations to the study have been discussed. Additionally, the sampling procedure and inclusion criteria may have introduced bias to recruitment and enrollment. Further, the exploratory nature of this study limits our ability to discuss implications and make recommendations for clinical application and interventions. Strength of this study is that the participants represent members of minority groups from underserved urban areas that are sometimes excluded from health studies despite the high prevalence of childhood obesity in these populations.
The findings contribute to the body of knowledge about parent–child psychosocial and health perception factors associated with childhood obesity. These findings may inform family-based approaches to reduce or prevent childhood obesity and to address health disparities.
ACKNOWLEDGMENTS
We greatly appreciate the support of the Primary Care Providers and medical and administrative staff at st. Christopher’s Hospital for Children and the faculty and administration at Drexel University’s College of Nursing and Health Professions. We acknowledge the project staff, consultants, and research assistants including: Dr smith, Jodi Brindisi, McKenzie Medeiros, stephanie Morano, Marie Boling, Brian Hurdle, Dr saunders, Prachi Patel, Jessica Jones, Divya Ullal, Christine Hall, and Alissa solomon. We thank our Project Manager, Rachel John. Finally and most importantly, we thank the parents and children who are the participants in this project.
This study was funded by an NIH R21 grant (Interventions for Parents of Overweight Children: −1R2 NR09852-01).
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