Examining the Relationship Between Parental Stress and Girls’ and Boys’ Physical Activity Among Racially/Ethnically Diverse and Immigrant/Refugee Populations

Abstract

Given the high prevalence of overweight/obesity and the low prevalence of engaging in physical activity in children, it is important to identify barriers that impede child physical activity. One potential barrier is parental stress. The current study examined the association between parental stress levels and girls’ and boys’ moderate to vigorous physical activity (MVPA). Children ages 5–7 years old and their families (n=150) from six racial/ethnic groups (n=25 each African American, Hispanic, Hmong, Native American, Somali, White families) were recruited for the Family Matters mixed-methods study in 2015 through primary care clinics in Minneapolis and St. Paul, MN. Two in-home visits were carried out with families ten days apart for data collection, with an eight-day observational period in between where children wore accelerometers. Higher parental stress levels were associated with fewer minutes of MVPA in girls (p<0.05) compared to boys. On average, girls with a parent reporting a stress rating of ten engage in 24 minutes less physical activity per day than a girl with a parent with a stress rating of one. Results suggest that parental stress may reduce girls’ engagement in physical activity. Implications of these results include targeting parental stress and coping skills in future physical activity interventions. In addition, when addressing child physical activity in health care visits with parents and daughters, providers may want to focus their anticipatory guidance on parental stress and coping skills in addition to providing resources to help parents manage stress.

INTRODUCTION

Research indicates that engaging in regular physical activity is associated with improved mental and physical health for children, such as decreased risk for cardiovascular and metabolic disease, lower overweight/obesity, and decreased depression and anxiety.^1–5 However, the overall prevalence of engaging in physical activity is low for children^6–8 and the prevalence of childhood obesity continues to be high.^9–11 Furthermore, there are disparities in both engaging in physical activity and childhood obesity for children from racially/ethnically and socioeconomically diverse backgrounds.^8,12–14

Prior research has suggested that parenting practices such as modeling physical activity, engaging in physical activity with the child, or supporting child physical activity may promote child engagement in higher levels of physical activity.^15–20 However, there are often barriers to parents being able to engage in these parenting practices. One such barrier is stress. There is a large body of research indicating that elevated levels of stress contribute to parent’s own weight status, ability to engage in physical activity, and disordered eating behaviors.^21–25 However, very little is known about whether parental stress levels are associated with child physical activity levels, especially in younger children.^26–28 In addition, prior research suggests that girls engage in fewer hours of physical activity than boys and may be more susceptible to parent mood or stress levels compared to boys.²⁹ Furthermore, there are limited studies examining parental stress and child physical activity levels with diverse participants, including immigrant/refugee populations, thus studies are needed to understand these associations better.^27,28,30

The main aim of the current study is to examine the association between parental stress and physical activity among girls and boys ages 5–7 in a racially/ethnically diverse and immigrant/refugee population. Our main hypothesis is that higher parental stress levels will be associated with lower levels of physical activity in girls relative to boys.

METHODS

Data for the current study are from Family Matters³¹ a 5-year incremental (Phase I = 2014–2016.; Phase II = 2017–2019), mixed-methods (e.g., video-recorded tasks, ecological momentary assessment (EMA), interviews, surveys) longitudinal study designed to identify novel risk and protective factors for childhood obesity in the home environments of racially/ethnically diverse and primarily low-income children. In-depth details regarding both Phases of the Family Matters study have been published elsewhere.³¹

Data in the current study are from Phase I of the Family Matters study. The University of Minnesota’s Institutional Review Board Human Subjects Committee approved all protocols used in both phases of the Family Matters study.

Recruitment and Eligibility Criteria

Eligible children (n = 150) and their families were recruited from the Minneapolis/St. Paul, MN area between 2015–2016 via a letter sent to them by their family physician. Children were eligible to participate in the study if they were between the ages of 5–7 years old, had a sibling between the ages of 2–12 years old living in the same home, lived with their parent/primary guardian more than 50% of the time, shared at least one meal/day with the parent/primary guardian, and were from one of six racial/ethnic groups (African American, American Indian, Hispanic/Latino, Hmong, Somali, and White). Children ages 5–7 were intentionally recruited for this study because at this age they start to become more independent from their parents with regard to health behaviors, given they are at school and in other settings as much, or more often, than the home environment.³¹ Table 1 shows demographics of the analytic sample of boys and girls.

Table 1:

Demographics of the Analytic Sample

	Boys (n=79)	Girls (n=67)
Average daily MVPA (minutes)	55.59 (18.91)	44.45 (18.15)***
Self-reported parental stress (rating from 1 to 10)	4.28 (2.63)	3.51 (2.43)*
Race
Caucasian	19	14
Black	13	19
Hispanic	19	15
Hmong	18	16
Native American	16	18
Somali	15	18
Household income
<$20,000	38	28
$20,000–$34,999	30	45*
$35,000+	32	27
Parent born in the US	61	52
High exposure to violence in neighborhood (sum of 6 items>12)	15	4**
Child obese (BMI≥95th percentile)	25	31
Child age (years)	6.43 (0.81)	6.38 (0.78)
Number of siblings	2.24 (1.22)	2.40 (1.68)

Mean (SD) or % reported.

^***p<0.01;

^**p<0.05;

^*p<0.10 Asterisks indicate statistically significant difference between boys and girls.

Study carried out in 2015 in Minneapolis/St. Paul, MN

Procedures and Data Collection

A 10-day in-home observation was conducted with each family, including two in-home visits and an 8-day direct observational period in between home visits. A full description of the Phase I measures (i.e., video-recorded family task, EMA, dietary recalls, acccelerometry, built environment audit, home food inventory, qualitative interview) are described elsewhere.³¹ Parents filled out the online surveys prior to research team members scheduling an in-home data collection visit. During the first home visit, the parent and the child were instructed on accelerometer placement and both were asked to wear it on the right hip for eight consecutive days. The child’s height and weight were also measured in duplicate on a portable digital scale (Seca 869 model) and a portable stadiometer (Seca 217 model). All study materials were translated into Spanish, Somali, and Hmong and bilingual staff were available at all home visits, allowing families to participate in their preferred language. For the current study, online parent surveys and child accelerometry data were utilized.

Measures

Parental Stress.

Parental stress was measured using an adapted version of a self-report survey item validated in prior studies.^30,31 Parents were asked, “On a scale of 1 to 10, with 1 being not stressed at all and 10 being very stressed, how would you rate your average level of stress in the past 30 days?”.

Child Physical Activity.

Child physical activity levels were measured using an accelerometer (Actigraph GT1M model, Fort Walton Beach, FL, 2010). Children wore the accelerometer over an 8-day observation period. Standardized re-wear protocol from previous research was followed (i.e., minimum – 4 days; 1 weekend, 3 weekdays; 8 waking hrs./day).³¹ Accelerometers were set to collect data in 15 second epochs (i.e., time-sampling intervals). Sedentary, light, moderate, and vigorous physical activity classifications were set in ActiGraph software using metabolic equivalent (MET) cut points for children ages 5–8. Moderate or vigorous physical activity (MVPA) in minutes was classified when counts per minute exceeded 2,296 counts per minute. The average daily time spent in MVPA per day was calculated for all observation days; this variable captures the average number of minutes in a day (for the 8-day observation window) that the study child was involved in MVPA.

Confounding Variables.

Child weight status, race/ethnicity, household income, exposure to violence in the neighborhood, and parent foreign born status were included in the regression models as controls for factors that may be correlated with both parental stress and physical activity in this sample of diverse households. Objectively measured child height and weight were used to create a child BMI percentile measure, based on Center for Disease Control guidelines. Child race/ethnicity (i.e., White, Black, Hispanic, Hmong, Native American, Somali), household income (<$20,000; $20,000-$34,999; >$35,000), age, number of siblings, and parent born in the United States (Yes; No) were collected via parent self-report via an online survey. An exposure to violence in the neighborhood variable was also created. Parents were asked on scale from 1 (never) to 4 (many times) how often in the past year they had been awakened to the noise of police or an ambulance, awakened to the noise of gunshots, seen someone get arrested, seen drug deals, seen someone beaten or stabbed, and seen someone get shot. The six responses were summed (alpha = 0.82) and had a theoretical range between 6 and 24, with higher scores indicating higher exposure to violence. Notably, an indicator variable was created for sums greater than 12 to indicate high exposure to violence in the neighborhood. Tests for multicollinearity indicated none (average variance inflation factor for boys of 2.00 and for girls of 2.55).

Statistical Analysis

A scatter plot and linear regression model were used to examine the relationship between MVPA and parent stress. The scatter plot shows unadjusted results whereas the regression model includes the confounding variables listed above and the 95% confidence intervals were created using standard errors adjusted for intra-cluster correlations among participants recruited at the same clinic. Of the 150 participants recruited, three were excluded from the analysis sample because they did not complete the minimum accelerometry protocol (i.e., minimum – 4 days; 1 weekend, 3 weekdays; 8 waking hrs./day) and one participant was excluded because they did not complete the online survey. Given that prior studies suggest that girls engage in less physical activity than boys,²⁹ all analyses were stratified by sex (boys (n=79) and girls (n=67).

RESULTS

Parental Stress, Physical Activity, and Child Sex

Figure 1 demonstrates that there was a negative relationship between self-reported parental stress and minutes of engaging in MVPA for both girls and boys. Scatterplot results indicated that parents who rated their stress levels higher tended to have children who engaged in less physical activity on average. In addition, the girls’ line of best fit was lower and steeper than the boys’ line of best fit indicating that girls engaged in less physical activity than boys on average and that the unadjusted relationship between parent’s stress and child physical activity was more pronounced for girls than boys.

Figure 1: Unadjusted relationship between Average Daily MVPA (minutes) and Parental stress ratings (Boys and Girls).

Study carried out in 2015 in Minneapolis/St. Paul, MN

Each gray dot represents a parent-son pair and each black dot represents a parent-daughter pair; the y-axis is the average daily MVPA and the x-axis is self-reported parental stress. The gray line fits the boys’ scatter plot and the black line fits the girls’ scatter plot.

Adjusted regression results indicated a significant relationship between higher levels of self-reported parental stress and fewer minutes of engaging in daily MVPA for girls, but not for boys (Table 2). That is, girls engaged in almost three minutes less of MVPA per day for every one-point increase of stress reported by the parent, after adjusting for race/ethnicity, household income, parent foreign born status, neighborhood safety, and child weight status (p < 0.01). Furthermore, the magnitude of this relationship was noteworthy. On average, a girl with a parent reporting a stress rating of ten would engage in 24 minutes less MVPA per day than a girl with a parent with a stress rating of one (the average daily MVPA for the sample of girls is 44 minutes). This magnitude is similar to living in a neighborhood with high exposure to violence (19 minutes less MVPA per day (p<0.01) compared to living in a neighborhood with low exposure to violence).

Table 2:

Relationship Between Parental Stress and Physical Activity by Child’s Gender Dependent Variable: Child’s Average Daily MVPA (mins)

	Boys (n = 79)	Girls (n = 67)
Self-reported parental stress rating	−1.49	−2.71***
	(−3.91, 0.93)	(−4.01, −1.40)
Black	14.43	1.14
(ref=White)	(−14.80, 43.66)	(−19.04, 21.32)
Hispanic	18.02**	−18.54**
	(3.99, 32.04)	(−33.10, −3.99)
Hmong	2.21	−20.83*
	(−9.43, 13.85)	(−42.16, 0.49)
Native American	7.53	−1.17
	(−5.16, 20.22)	(−14.42, 12.07)
Somali	5.35	−16.83
	(−7.75, 18.46)	(−40.64, 6.98)
Household income <$20,000	−10.93	6.81
(ref= >$35,000)	(−25.39, 3.52)	(−7.68, 21.30)
Household income $20,000–$34,999	−9.82	−2.86
	(−24.67, 5.03)	(−15.38, 9.66)
Parent born in the US	3.93	−17.97
	(−14.65, 22.52)	(−42.11, 6.17)
High exposure to violence in neighborhood	1.96	−18.73***
	(−9.71, 13.63)	(−27.85, −9.60)
Child obese (BMI>=95th percentile)	−4.92	−7.95
	(−25.10, 15.25)	(−19.08, 3.18)
Child’s age	−0.62	−2.08
	(−4.53, 3.29)	(−6.87, 2.70)
Number of siblings	−1.08	2.68
	(−3.36, 1.21)	(−2.79, 8.14)
Constant	66.36***	82.06***
	(31.95, 100.77)	(48.45, 115.67)
R-squared	0.21	0.33

Each column displays results from a separate linear regression. Coefficients and 95% confidence interval created using standard errors adjusted for intra-cluster correlations among participants recruited at the same clinic are presented. Example interpretation: As parental stress ratings rise by one unit, girls average daily MVPA falls by 2.71 minutes, holding constant race/ethnicity, income, foreign-born status, neighborhood violence, child weight status, age, and number of siblings.

^***p<0.01;

^**p<0.05;

^*p<0.10.

Study carried out in 2015 in Minneapolis/St. Paul, MN

Results showed that boys engaged in one and one half minutes less MVPA per day on average for every one-point increase of stress reported by the parent; however, this relationship was not statistically significant.

DISCUSSION

Study findings indicate that there was a significant relationship between parental stress levels and girls’ MVPA, but not boys’ MVPA. Our results support prior findings in the field showing associations between maternal mental health and child physical activity levels.^26–28 Findings from the current study also extend previous studies by showing the relationship between parental stress and child MVPA exists for younger children, in a racially/ethnically diverse and immigrant/refugee sample, and for girls more than boys.

Overall, our findings suggest that one potential barrier to children engaging in MVPA is parental stress. This finding makes intuitive sense in that when parents feel stressed they are probably less likely to engage in parental promoters of physical activity found in prior studies,^15–17,20 such as parental modeling of physical activity, engaging in physical activity with their child, or supporting children in physical activity. Future research would benefit from examining whether parental stress moderates the relationship between parental promoters of physical activity and child physical activity.

In addition, our study findings indicating associations between parental stress and reduced levels of physical activity in girls is a new finding and may suggest that girls are more susceptible to parent stress than boys. This finding is important to investigate further to better understand whether stress levels have a different emotional impact on girls compared to boys or whether parental stress produces a differential effect in parents such that they engage in less parental promoters of physical activity with girls relative to boys.

There were both strengths and limitations of the current study. One of the study strengths included being able to examine parent stress with child physical activity among young children from diverse households and to control for important potential confounders (i.e., weight status, income, foreign born status, violence in the neighborhood), which has not been done in prior studies. In addition, analyses were pre-stratified to allow for examining results by sex. Another strength is that this study utilized accelerometry, which provides an objective measure of habitual activity that is not dependent on self-report. One limitation of the study is that parental stress was measured via self-report, which is prone to social desirability bias. However, this seems unlikely since this was a cross-sectional study and not an intervention, where participants are expected to change certain behaviors. Another limitation inherent in cross-sectional studies is temporality; thus, we cannot infer causal relationships among the variables investigated in this study and careful extrapolation of the results is warranted. In addition, although all EMA survey items in the current study were adapted from existing validated survey measures, they have not been validated for EMA. Furthermore, while this sample did include racially/ethnically diverse populations the sample size precluded ability to examine whether there were differences in the relationship between parental stress and child physical activity by race/ethnicity. Future research is needed with larger samples to examine the association between race/ethnicity, parental stress, and child health promotion to ensure issues of equity are at the forefront of the conversation.

CONCLUSIONS

Study results found that parental stress levels were associated with fewer minutes of MVPA in girls ages 5–7 but not for boys. There are potential implications of these study findings for future research, interventions, and health care providers. First, it is important for future research to replicate our findings, given the small sample size. In addition, future research should examine whether our study findings showing differences between girls and boys are driven by biological sex or gender (i.e., socio-cultural factors). Second, it may be important to intentionally include parental stress as a factor of relevance to address with regard to child physical activity interventions. For example, when developing interventions that aim to increase physical activity in girls, it may be important to target parental stress and coping skills in addition to parenting practices such as modeling physical activity. Third, when health care providers give anticipatory guidance to parents regarding child physical activity, it may be important for providers to include parental stress as an important factor to address with parents and children, particularly with girls, and to provide parents with additional resources to help them manage stress. Thus, this may result in parents having more capacity to facilitate direct and/or indirect opportunities for their children to engage in physical activity in the face of stress.