Barriers and enablers to nutrition and physical activity in Lima, Peru: An application of the Pen-3 Cultural Model among families living in pueblos jóvenes

Abstract

Objectives

Childhood obesity is increasing in Latin America as nutrition status and economies transition. Peru is one such country with an emerging childhood obesity epidemic. The Peruvian Ministry of Health established goals for achieving reductions in overweight and obesity prevalence among children 5 years and younger by 2021. However, specific intervention strategies for achieving these goals are lacking. Culturally appropriate interventions guided by evidence-based theories are needed to address the emerging problem of overweight and obesity among young children. This study utilized the Pen-3 Model, a culture based conceptual framework to explore barriers and facilitators to healthy diet and physical activity for parents of young children in pueblos jóvenes communities.

Design

A qualitative investigation was conducted as part of a larger cross-sectional survey study of parents of three and four-year-old children at five school sites in the peri-urban slum neighborhoods of southern Lima. Parents were asked to describe barriers and facilitators of healthy diet and physical activity for their preschoolers and families. Thematic analysis guided by PEN-3 model constructs assisted in identifying emergent themes.

Results

Two domains of the Pen-3 Model guided the elucidation of barriers and facilitators of health behaviors deemed essential to healthy diet and physical activity. Parental perceptions about neighborhood safety, lack of community resources, such as parks and recreation spaces, and lack of information about appropriate serving sizes and healthy recipes were identified as barriers. Facilitators to healthy behaviors included mothers’ views on their role as nurturers, and personal values for family-centered health behaviors.

Conclusions

Parents identified specific barriers and facilitators of eating healthy and physical activity for their preschoolers and families living in resource poor areas of Peru. Health promotion professionals can utilize findings to inform the design of culturally appropriate family-based interventions in Peru’s pueblos jóvenes.

Introduction

The obesity epidemic and nutrition transition in Peru

The childhood obesity epidemic is a global public health concern disproportionately affecting children living in developing countries. One in five children worldwide are overweight or obese (Perez Rodrigo 2013), and the majority live in low and middle-income nations (de Onis et al. 2010). Moreover, the growth rate of obesity and overweight prevalence in young children is highest in low and middle-income countries (de Onis et al. 2010). One region particularly vulnerable to the global childhood obesity crisis is Latin America (The Lancet Diabetes 2014), where many countries are dealing with a dual burden of stunting, malnutrition and excess weight in children under constrained resources (Popkin 2004).

Peru is one such Latin American country undergoing a nutrition transition (Loret de Mola et al. 2014). Urbanization and globalization have contributed to changing diets, an increase in sedentary lifestyles and decreased physical activity among Peruvians living in the urbanized areas of Lima and the coast (Loret de Mola et al. 2014; Uauy et al. 2001). Obesity and overweight prevalence is rising even amongst the youngest children. In Lima, 13.1 percent of children 5 years or younger are obese or overweight (Busse and Diaz 2016). The Peruvian government recognized the excess weight crisis and in 2011 issued a National Strategic Plan with specific goals for reducing the prevalence of overweight and obesity in children under five years, however no specific action plans to achieve these goals have been developed (Salinas Castro et al. 2011). Early intervention is critical because children who are overweight or obese are more likely to become overweight or obese adults (Serdula et al. 1993), putting them at risk for both immediate and long-term deleterious health outcomes (Kelsey et al. 2014; Trevino et al. 2015; Trost et al. 2003).

Cultural and parental influences on children’s weight

Parents are one of the strongest influences on children’s weight, as they largely control opportunities for, and model, obesity preventive behaviors such as physical activity and nutrition (Baughcum et al. 2000; Birch and Fisher 1998). Although parents serve as powerful role models and gatekeepers of nutrition and physical activity opportunities, culture may moderate this influence (Cachelin and Thompson 2013). Culture can shape parents’ normative beliefs about obesity, diet, and physical activity (Caprio et al. 2008). While there is extensive literature on Hispanic parents and their perceptions about obesity prevention, much of it is focused on Mexican-Americans (Sosa 2012). Peruvian parent’s perceptions about obesity preventive behaviors have not been explored. A qualitative investigation that provides a more in-depth understanding of parental perceptions about diet, physical activity and childhood obesity is essential for the design of culturally appropriate obesity prevention interventions. This paper presents findings of a qualitative study utilizing the PEN-3 Model to determine parental perceptions about barriers and facilitators of healthy diet and physical activity for their preschoolers in Peru’s peri-urban slums. This study was part of a larger study that had two goals: (a) characterize Peruvian parents’ knowledge, attitudes and behaviors towards home-based nutrition and physical activity for their children; and (b) determine parents’ ability to correctly identify their child’s weight status.

Theoretical framework

The Pen-3 Model, originally developed to facilitate design of culturally appropriate HIV/AIDS interventions in Africa (Airhihenbuwa 1989), has been applied to a wide spectrum of public health issues. The Pen-3 includes three domains to examine and understand a health behavior within a cultural context: Cultural Identity, Relationships and Expectations, and Cultural Empowerment (Iwelunmor et al. 2014). The Cultural Identity domain is utilized to identify appropriate access points for interventions (individual, family, extended kin), therefore it was not included to analyze parental perceptions. In this study, only two of the Pen-3 domains, the Relationships and Expectations and Cultural Empowerment domains are used to explore parental perceptions of facilitators and barriers to healthy diet and physical activity among Peruvian preschool children in their home environment.

The Relationships and Expectations domain is comprised of three constructs: Perceptions, Enablers, and Nurturers. This domain encompasses the individuals’ attitudes towards a health behavior (Perceptions), the societal or structural resources (Enablers) and relationships with other individuals (Nurturers) that facilitate or hinder the health behavior of interest. The Cultural Empowerment domain explores Positive, Negative, and Existential beliefs and behaviors regarding a health problem. The Positive construct includes beliefs and practices that support healthy behaviors, Negative refers to beliefs and practices that hinder or serve as barriers to healthy behaviors, and, the Existential are culturally unique beliefs and behaviors that do not necessarily positively or negatively impact healthy behaviors. Collectively these constructs characterize attitudes and practices of intended participants regarding the health problem or behavior of interest (Iwelunmor et al. 2014).

Materials and methods

Ethical considerations

The study protocol was approved by a human ethics committee from A.B. PRIMSA, an NGO research organization in Lima, Peru, the Institutional Review Board at Florida International University in Miami, Florida (IRB Number 104889) and the Peruvian Ministry of Education district overseeing the schools in southern Lima (UGEL). A Spanish-speaking research assistant from Lima Sur was trained in study protocol and human subjects protection and assisted with all participant recruitment and school staff and parent communication.

Setting

The study was conducted in two of Lima’s more populated districts: Villa Maria del Triunfo and San Juan de Miraflores (SJM) which are pueblos jóvenes comprised of more than 690,000 residents (2018; Municipalidad). Lima Sur has the highest rate of poverty in all of Lima’s regions, with 17.7 percent of the population lacking financial resources to meet basic needs. Household income in the district is close to the national monthly minimum wage (Municipalidad).

Participants

Parents over the age of 18 who were able to speak and read Spanish, resided in Lima Sur, and had a three or four-year-old child attending one of the participating schools were invited for participation. Weight and height of the children of participants were assessed as part of the larger study, however, no anthropometric data was collected from the parents.

Instrument

The researcher developed instrument was comprised of two parts: a demographic questionnaire and two open-ended questions on barriers and facilitators to a healthy diet and physical activity. These two open-ended questions were developed using an iterative process. The lead researcher identified similar questions through a literature search. A panel of experts reviewed the questions, provided feedback and finally the original questions were modified to be linguistically appropriate for the study. The panel of experts included the partnering research organization in Peru, Peruvian maternal and child health researchers, and researchers with expertise on physical activity and nutrition in preschool children. The questionnaire, including the open-ended questions, was pilot tested in a neighboring community in Lima Sur for readability, comprehension, and appropriateness of language. Pilot-testing feedback was used to prepare the final version of the instrument upon which this study is based.

Recruitment and data collection

The UGEL region director provided a list of all licensed private and public preschool sites in SJM and Villa Maria. In November of 2016, six schools from the list were contacted and five public and private schools in the two communities agreed to participate. Schools, principals, and teachers sent informational letters about the study home to parents prior to scheduled data collection dates. Parents were recruited via convenience sampling from participating school sites during child-drop off and pick-up times. A research assistant approached parents and invited them to participate in the study. Interested parents who met inclusion criteria were consented and then completed the questionnaire at the school. Average survey completion time was 15 minutes.

Data analysis

All participant responses were transcribed verbatim into Microsoft Excel. A bilingual research assistant translated all responses into English. A second researcher cross-checked the translation to ensure accuracy. Thematic analysis was conducted by two researchers who independently read the English transcripts and identified emergent themes from participant responses. Responses were sorted into broad categorical codes. Coded responses were analyzed for emergent themes. The researchers then collaborated and assessed interrater agreement between coded responses and the emerging themes. Through a consensus process coding differences and emerging themes were reconciled. Researchers then worked cooperatively using a priori analysis to sort the emergent themes based on Pen-3 Constructs.

Results

Description of the study population

A total of 175 parents participated in the study. Demographic characteristics of the participants are presented in Table 1.

Table 1.

Demographic Characteristics of Participants, N=175.

Demographics Characteristics		n	%
Gender	Female	153	87.4
	Male	22	12.6
Age	Less than 20 years	2	1.1
	20 to 29 years	66	37.9
	30 to 39 years	83	47.7
	40 to 49 years	18	10.3
	50 years or more	5	2.7
Primary caretaker of child	Yes	170	97.1
	No	5	2.9
The person who prepares most meals	Me	130	74.3
	Spouse	17	9.7
	Grandparent	15	8.6
	Other	13	7.4

Relationships and Expectations: Perceptions

Participants described the perceptions they had about physical activity and diet for their family. Parents indicated that regular physical activity was important for themselves and their children, but also mentioned how difficult it was for them to be physically active. One parent reported, ‘playing sports improves my family’s health.’ The high value and recognition of the health benefits of PA serves as a facilitator to PA, however the parents also described a multitude of barriers they felt that made it difficult to be more active. Perceptions about neighborhood safety was the most frequently mentioned concern. Parents hesitated to send their children outside to play. One mother said, ‘In the case of playing in the street, I think it is dangerous for a child to play alone, instead he should go with someone.’ Others mentioned specific safety concerns, ‘The parks where I live are full of bad people.’ Another said, ‘There’s a lot of moto taxis around where I live that keeps the kids from being able to go out and run and be physically active,’ while another voiced a concern about feral dogs and said she would not let her young child outside to play until there were ‘no animals running along the street.’

Relationships and Expectations: Enablers

Many of the barriers parents described related to a lack of community resources in Lima Sur. Lack of access to parks and recreation spaces was mentioned as a barrier to being physically active. One mother said, ‘There are no sports and recreation places for the kids to play. The ones that exists are far away and you have to pay to enter,’ and another reiterated, ‘We don’t have parks where we can exercise.’ Others expressed their desire for recreation spaces, ‘I would like to have green areas where we can play sports and parks with bike paths.’

Parents described enablers to a healthy diet in their environment. Some parents reported that they were currently receiving information about diet and nutrition, while many more expressed the desire to receive information. One mother expressed her desire for general information about diet, ‘I would like to be informed about nutrition so I can provide a healthy diet for my son,’ while another mother specifically asked for recipes, ‘I would like to learn how to cook new, healthy recipes.’ Knowledge about correct portion sizes was an idea that came up frequently among participants. One participant said they would like to, ‘know what portion size to feed my children of different ages and what times to feed them,’ and another mother stated that she would like to, ‘know how to provide balanced diets for my family. Like, knowing the correct portion to give my daughter based on her age.’

Parents identified societal barriers to eating a healthy diet which included the advertising of unhealthy food and the local food environment. Several parents mentioned that the abundance of commercials on TV that advertised unhealthy foods made it harder for them to make healthier dietary choices. One mother complained that there were, ‘a lot of commercials and advertising for junk foods and sweets,’ while another mother felt that the commercials deliberately deceived them about the nutrition content of their products, ‘the advertising of many products is misleading.’ Another barrier repeatedly identified by the participants was the food environment in their community. One participant stated, ‘the environment we live in, the junk food is easy for us to access,’ another reiterated, ‘There’s so much junk food around us.’ Other parents talked about the street vendors selling junk foods in their community, ‘the environment where we live, the quioscos (mobile food carts) where they sell food that’s not nutritious,’ and particularly the food carts outside of the schools, ‘many times the things that make difficult (to eat healthy) are the quioscos and the goodies that they sell inside and outside the schools.’

Relationships and Expectations: Nurturers

The participants, who were predominantly mothers and the primary person responsible for preparing the food for the family, viewed themselves as the facilitators to nutrition and physical activity for their family. Mothers frequently described their role in getting their children to be active. ‘In physical activity, I would like to share more time with my son and teach him the importance of physical activity.’ Another mother said she needs to ‘take the kids to play more often.’ Another mother saw herself as the barrier to physical activity for her family, stating, ‘I myself, because I do not exercise like I should.’ While mothers generally saw themselves as the person responsible for making sure their children were active, others expressed the desire to receive help from other family members, ‘We need to go out together to play sports. I wish that my husband would go with us, because I have been going alone with my son to run.’

Similarly, mothers saw themselves as the primary person responsible for providing their families with healthy meals. Many expressed their goal of serving healthier foods, such as fruits and vegetables, to their family more often. One mother stated that she needs to ‘utilize more vegetables or salads that my children don’t like very much,’ while another stated that she felt she needed to ‘prepare nutritious meals more often per week to eat more fruits and vegetables.’ Another mother felt that her biggest nutrition challenge was the need to replace the junk food in the home with better alternatives, ‘the biggest is to provide more fruits and vegetables and less junk food.’ One mother described her role in motivating her children to eat healthier, ‘Many times the children do not want to eat healthy, but with a lot communication they understand that it is for their well-being and for their development.’

Cultural Empowerment: Negative

Additional negative beliefs and practices that participants identified were related to time constraints and screen time. Parents described their children as spending too much time watching TV or playing on a cell phone. One participant stated her children’s problem was ‘spending all day on the cell phone and not going out to play.’ Another mother complained, ‘that my children watch so many cartoons.’ In addition to excess screen time, participants described their families’ barriers to being healthy due time constraints and work schedules. One participant said, ‘As their parent, I have very little time, only Sundays, off from work.’ Parents felt their lack of free time hindered both their dietary and physical activity behaviors, ‘I am the one that works, and I can’t do more activities with them, like playing sports or other things,’ while another stated, ‘I work and am not at home with my children to have lunch together, and cook meals, and try to eat vegetables.’

Cultural Empowerment: Existential

The importance of family emerged as an existential belief expressed by the participants. Parents described physical activity not as an individual activity, but a family activity. One participant expressed her desire to, ‘go to the park, organize and have a day especially for going out together as a family’ and another said, ‘going out together on Sundays, all going to the park together, playing sports together.’ Others stated they would like to be physically active by, ‘going out and walk with my family’ or ‘exercise with my family in the fresh air.’ While family was viewed as a facilitator for physical activity, participants responded that lack of shared family meal time was a barrier to healthy eating. ‘I work and am not at home with my children to have lunch together, and cook meals, and try to eat vegetables.’ Another elaborated on the effect on her children of her absence at meal time, ‘because of my job I can’t be with my kid at lunch and make sure they finish their food.’

Discussion

This study contributes knowledge regarding Peruvian parents’ perceptions about obesity preventive behaviors for their children and families from a cultural perspective. The Pen-3 model provided a framework for organizing and making sense of reported barriers and facilitators to healthier diet and physical activity experienced by parents living in the slums of southern Lima. Results also provide insightful cultural contextualization that can inform the planning, design, implementation, and evaluation of home-based dietary and physical activity interventions aimed at curtailing Peru’s obesity epidemic.

Perceptions of diet and physical activity

Many of the perceptions that served as barriers to physical activity and nutrition among Peruvian parents reinforce findings from other Hispanic populations. Parental perceptions of neighborhood safety, lack of community resources, and the local food environment emerged as perceived barriers to engaging in healthy behaviors. Parents held negative perceptions about local traffic, crime, and stray animals, which prevented them from encouraging their families to be physically active outside. Similarly, previous studies of Latino parents of young children found that parental perceptions of neighborhood insecurity were negatively associated with parental practices encouraging physical activity in their children (O’Connor et al. 2014).

Enablers to diet and physical activity

Enablers described by parents further illustrated the barriers they faced in helping their child to eat healthy and be physically active. Parks and sports fields were deemed to be structural resources necessary for physical activity. Parents expressed frustration with the lack of free and safe parks and sports fields in their community. Although the lack of recreation spaces was self-reported, and the researcher did not conduct an assessment of the Lima Sur built environment, previous studies have shown that parental perceptions of availability of neighborhood physical activity spaces was an indicator of their families’ use of the spaces (D’Haese et al. 2015). Findings have been mixed regarding the effect of objectively measured built environment physical activity spaces versus parental perceptions of the availability of physical activity spaces on children’s physical activity levels (Burdette and Whitaker 2005). Previous studies indicate that in older children, objective measures might be a better predictor of physical activity levels (Burdette and Whitaker 2005), but a study of Latino parents of preschool children indicated that parental perceptions was a better predictor of physical activity level than objective environmental measures (Airhihenbuwa 1989). This study supports the existing evidence that Latino parental perceptions about the availability and quality of physical activity spaces are important determinants of young children’s physical activity levels.

The food environment emerged as another enabler that served as a barrier. Parents complained about the ease of access to junk food from the mobile food carts located outside the schools and throughout the neighborhoods. A few studies have examined the effect of mobile food carts on families and children’s diets. The carts were described as a common food source in low-income Latino neighborhoods, particularly for children (Sharkey et al. 2012; Tester et al. 2010; Valdez et al. 2012). Additionally, food carts were more likely to sell calorie-dense low-nutrient foods as compared to other informal food vendors and customers were more likely to come from food insecure households (Sharkey et al. 2012; Valdez et al. 2012). Findings from the study reinforce the need to further explore the effect of mobile food vendors on dietary consumption of children and families in low-income areas.

Nurturers to diet and physical activity

Several facilitators to physical activity and diet, unique to Peruvian parents, emerged from the study. Parents viewed themselves as nurturers in supporting and promoting physical activity. They described the importance of family engagement in promoting outdoor play or physical activity. Moreover, Peruvian parents’ view of physical activity as a family social outing might be one coping mechanism to overcome concerns of neighborhood safety. Another facilitator was the positive beliefs expressed by Peruvian parents related to their children’s physical inactivity. For example, Peruvian parents criticized the amount of time their children spent watching TV or on their cell phone, which is a major contrast to other Hispanic populations. While these inactive screen time behaviors offer low support for physical activity they were viewed as positive behaviors and potential learning opportunities among Mexican parents (Grzywacz et al. 2016).

Existential support for diet and physical activity

Finally, one existential finding from the study shed light on the mothers’ views of physical activity as a family, not an individual, behavior. This reflects the idea of familismo, which is described as a sense of strong family connectedness and valuing needs of the family over the needs of individuals in Latino communities (O’Connor et al. 2014). A study of Latino adolescents found that those who reported a strong sense of familismo were more likely to be physically active, however familismo was not associated with healthier BMI or eating habits (Salvy et al. 2017). Familismo was also important in a Pen-3 study of older Latino women, who expressed a desire to exercise with family members (Perez and Fleury 2018). Similarly, in our study, familismo was repeatedly mentioned in the context of physical activity but less so with dietary behaviors.

Results demonstrate the need for multi-level interventions in the peri-urban slums of Lima, Peru that include: 1) creating and maintaining safe, free-entry, family-centered, physical activity spaces and 2) developing campaigns that promote available physical activity spaces and opportunities as a “family affair” (Shaw-Ridley et al. 2013). Additionally, to address perceptions about the local food environment, policies that seek to limit the availability of inexpensive, calorie-dense food from mobile food venders may be worth consideration.

The study has several limitations. First, the convenience sampling was limited to preschool sites in the pueblo jóvenes of southern Lima, thereby limiting generalizability of the findings to the greater Lima or Peruvian population. Childhood obesity rates are higher in Lima than in other areas of Peru. Although nearly half of the population of Lima lives in poverty, and pueblos jóvenes neighborhoods in the northern and southern cones of Lima are some of the most populated districts, it is not known if childhood obesity risk varies within socio economic strata and neighborhoods of Lima. Therefore, we cannot determine if barriers to healthy eating and diet would be similar for residents of Lima outside of the pueblos jóvenes communities. Second, study participants were predominantly female, and thus the barriers described are likely those faced by mothers, and may not reflect those facing the fathers. Third, participating schools were situated in more established areas of the communities. Many pueblos jóvenes residents live along the steep mountainsides, where there is limited road access and infrastructure. Here, water is brought in by truck and costs 10–15 times piped-in water. Only one participant mentioned the high cost of the water from the truck, and most parents lived closer to the participating school sites. Thus, it is likely there are additional barriers faced by the residents living in less incorporated areas of the hillsides than those living in the more established parts of the community.

The Peruvian Ministry of Health established specific goals to reduce overweight and obesity in young children, but specific strategies to achieve them are still needed. Effective obesity reduction efforts aimed at young children must include the parents, be culturally and contextually appropriate, and address parental perceptions, nurturers, and enablers of obesity preventive behaviors. This study provides Peruvian health promotion professionals with knowledge about parental perceptions of facilitators and barriers to healthy nutrition and physical activity. Interventionists must implement these multilevel interventions to address the barriers and facilitators, especially if parents are expected to become partners in a national solution to promote sustainable home-based lifestyle behavior change for parents and their young children.