Abstract
Childhood obesity has recently been reported as a growing problem in low- and middle-income countries. One potential prevention strategy is to apply effective obesity prevention approaches from the United States and/or other Western countries into programs that can be implemented in developing countries such as India. The purpose of this study was to explore Indian students’ perceptions of social–contextual factors related to obesity and whether they perceived a role for school-based obesity prevention. This study was conducted as a first step in a model to translate interventions from one culture to another. A total of 183 fourth- and fifth-grade students of middle socioeconomic status participated in focus group discussions. Analyses were guided by the essential principles of qualitative research and informed by social cognitive and social ecological theories. Results yielded five relevant themes: (a) student health behavior knowledge, (b) parental influence on health behavior, (c) school influence on health behavior, (d) media influence on health behavior, and (e) contexts for health promotion intervention. We found that students had moderate knowledge related to health behaviors (i.e., food intake and physical activity); that parents, schools, and the media are all important contributors to healthy and unhealthy behavior; and that schools can play an important role in the prevention of obesity. Results suggest that Indian middle socioeconomic status students are already moderately aware of the health benefits to nutritious food intake and physical activity, but parents, schools, and the media can influence unhealthy behaviors.
Introduction
Childhood overweight and obesity are rising global health challenges that pose serious risks to physical and psychosocial development (Kelishadi, 2007; Spruijt-Metz, 2011; World Health Organization, 2005). Once considered a problem solely in developed countries, overweight and obesity are now highly prevalent in low-middle and upper-middle income countries, including Mexico, China, Brazil, and India, where undernutrition has traditionally been of greater public health concern (Caballero, 2007; Spruijt-Metz, 2011). In a recent review of studies published from 1950 to 2007, Kelishadi (2007) compared data on prevalence of overweight and obesity among children living in developing countries. Countries such as India, China, and Mexico were found to have comparable rates of overweight and obesity in children and adolescents with a range of 15% to 20% (Kelishadi, 2007). However, a more recent review by Gupta, Goel, Shah, and Misra (2012) concluded that the rates of obesity in children increased drastically over the past three to four decades in the aforementioned developing countries. The study concluded that the rates of childhood obesity could range from 20% to 40% in countries such as Mexico, Brazil, China, and India because of socioeconomic factors, sedentary lifestyles, false beliefs about nutrition, marketing by transnational food companies, and poor facilities for physical activity (Gupta et al., 2012).
An interesting feature about childhood obesity in developing countries is that higher socioeconomic status and affluence may lead to increase in prevalence of obesity, contrary to the findings in developed countries where affluence is associated with reduced prevalence of childhood obesity. The urban middle- and high-income group children in developing countries are more vulnerable to overweight and obesity because of a rapidly emerging Western lifestyle influence (Doak, Adair, Bentley, Fengying, & Popkin, 2002; Kelishadi, 2007; Sharma, Sharma, & Mathur, 2007). For example, India has a substantial population of youth in the lower and middle income group and rates of obesity and overweight in this group appear to be approaching those found in industrialized nations (Gupta et al., 2012; Wang, Chen, Shaikh, & Mathur, 2009). According to various prevalence estimates, childhood overweight and obesity in India range from 3% to 24% (Kelishadi, 2007; Midha, Nath, Kumari, Rao, & Pandey, 2012). As a result, public health officials in India and prominent professional health organizations (e.g., Indian Academy of Pediatrics) are calling for cost-effective measures to prevent overweight and obesity (Bhave, Bavdekar, & Otiv, 2004; Singh, Reddy, & Prabhakaran, 2011; Wang et al., 2009).
Given the alarming rise in prevalence of childhood overweight and obesity in developing countries, one potential prevention strategy is to apply effective obesity prevention approaches from the United States and/or other Western countries into programs that can be implemented in developing countries such as India. Perry, Stigler, Arora, and Reddy (2008) recommend a five-stage process for the translation of prevention from the United States to countries such as India where the first step is to develop a conceptual behavioral intervention model which is followed by ensuring the appropriateness of the model for Indian youth. These steps are followed by developing intervention strategies that modify factors in the intervention model, implementing the adapted program, and conducting a process and outcome evaluation. Riggs and colleagues have developed and tested a conceptual model of school-based obesity prevention in which childhood self-regulation and executive function (those neurocognitive processes responsible for self-regulated decision making; Riggs, Huh, Chou, Spruijt-Metz, & Pentz, 2012; Riggs, Spruijt-Metz, Chou, & Pentz, 2012), as well as parental monitoring, modeling, and communication are important factors in healthy decision making.
The aforementioned model contends that many fourth- through sixth-grade youth are knowledgeable about unhealthy behaviors (e.g., high-sugar/high-fat food and physical inactivity/sedentary behavior), but that due in part to still developing executive function skills, have difficulty (a) regulating strong motivational drives to consume unhealthy food and (b) planning and organizing opportunities for physical activity. Additionally, because of the important role of the family and school context in the lives of young people, youth often lack the control over opportunities for healthy food intake and physical activity. This conceptual model informed the development of a school-based intervention, Pathways to Health (Pathways), which targets as mediators to healthy food intake and physical activity, self-regulation, and executive function in fourth- to sixth-grade children as well as monitoring, modeling, and communication skills among their parents (Riggs, Kobayakawa-Sakuma, & Pentz, 2007).
The current study resulted from a dialogue among researchers at the University of Southern California, University of Texas School of Public Health, and HRIDAY (Health Related Information and Dissemination Amongst Youth), a nongovernmental organization in New Delhi, India, regarding evidence-based strategies for obesity prevention. Emerging from these discussions, a strategy was agreed on in which the ultimate goal was to test the efficacy of the Pathways curriculum as implemented in Indian schools. In keeping with Perry et al.’s (2008) Step 2 in prevention translation, the first phase of the study was to explore the appropriateness of Riggs and colleagues’ conceptual model of obesity prevention in Indian schools by conducting focus groups among Indian youth in New Delhi, India.
The intent of the focus groups was to identify (a) community perceptions of the risk and protective factors contributing to the obesity problem in India and (b) whether Indian students perceive schools as having a role in the prevention of obesity. Protocols were approved by the institutional review boards at the University of Southern California, University of Texas, and in India.
Method
Participants
Convenience sampling was used to identify five private schools in New Delhi, India, to randomly select two classes each from Grades 4 and 5 (because these are the first two grades in which the Pathways curriculum is implemented in the United States). New Delhi is the capital city of India and is highly cosmopolitan in nature with representation of middle-class individuals from all over the country. Migrants from all places in the country live in this city and their children go to local schools adding to the diversity of the sample. Participants were 183 children (92 boys and 91girls, aged 9-11 years). Each group contained approximately 8 to 10 participants.
Data Collection
Focus groups were conducted in schools by a moderator and note taker from HRIDAY, during regularly scheduled class time, as per the convenience of the school authorities. Staff were trained for 8 hours, which culminated in participating in a mock focus group using the focus group guide prepared for the current study investigators based on the principal research objectives. The HRIDAY research team also made several visits to contact, recruit, confirm focus group dates, and establish rapport with teachers and students which facilitated discussion during the focus groups. Focus groups were conducted bilingually where participants used normal conversational Hindi or English as per their convenience. The moderator first described the purpose and procedures of the focus group to the participants. The note taker was responsible for audiotaping the discussion and taking notes. Moderators took additional notes of any nonverbal communication (e.g., gestures) in the course of discussion. Each focus group lasted approximately 40 to 60 minutes.
Focus Group Questions
Selection of the focus group questions were guided by social cognitive and social ecological theories and prior research on obesity in North America and from the Pathways program (i.e., schools; Bandura, 1977; Riggs, Huh, et al., 2012; Riggs, Spruijt-Metz, et al., 2012). Selected theories and research suggest that both intrapersonal and social contextual factors predict risk and protective factors related to obesity, including food intake, physical activity, and sedentary behavior. The focus groups sought, in part, to explore whether these risk and protective factors were relevant to youth in India and whether schools, as one important social context, are perceived as having a role in obesity prevention. Table 1 provides a list of questions discussed in the focus groups relevant to the conceptual model of Pathways.
Focus Group Questions Relevant to Pathways Conceptual Model
Data Analysis
Data were analyzed using the essential principles of qualitative research (Miles & Huberman, 1994; Strauss & Corbin, 2008). The first analytic step was for individual moderators to transcribe the audiotapes verbatim after each focus group was conducted. From these transcripts, moderators prepared an account of each focus group, providing order to the information. This was aided by contextualizing and integrating the responses that included verbal and nonverbal communication, whispering, and simultaneous group interaction. In addition, note takers prepared an individual account of the discussion based on their notes. The transcribed tapes were checked against the notes of the note takers and then translated into English. This ensured the reliability of the data used for analyses. All transcripts were independently reviewed by members of the research team at HRIDAY as well as the Universities of Southern California and Texas to identify recurrent themes across individuals and groups to minimize the subjectivity and establish validity. Following transcription, each transcript was reviewed and a number of themes, relating to factors under investigation, were identified. The main themes to emerge, reported in the results section, were related to various perceptions on obesity prevention, which was expected given the nature of the topic guide. Transcripts were then reviewed again for any quotes that fitted into one of the previously identified categories. As the analysis progressed, the process of transferring quotes was dependent on how each quote could add to the explanatory power of the relevant category. Once completed, categories were reexamined to assess how well the quotes within each category fitted together. Each transcript was then reassessed to identify any relevant quotes, originally missed, that could add to any of the categories.
Results
The results were organized into themes that related to Pathways intervention model. These themes included (a) student health behavior knowledge, (b) parental influence on health behavior, (c) school influence on health behavior, (d) media influence on health behavior, and (e) contexts for health promotion intervention. Results are presented under each theme as they correspond to questions asked (Figure 1).
Salient Themes From Focus Groups
Knowledge
Overall, students were very knowledgeable regarding the health consequences of energy-dense, nutrient-poor food (i.e., junk/snack food), fruit and vegetable intake, and physical activity. They could easily distinguish between healthy and unhealthy food. Students shared that fruits and vegetables provide energy, “glow in the face,” and “keeps us healthy.” Other statements regarding fruit and vegetable intake included “fruits and vegetables contain carbohydrates, fiber which prevents constipation and protects us from diseases.” Sample statements regarding unhealthy food included “is not good for our health as it causes diarrhea” and “raises cholesterol and makes us fat,” and “We should avoid eating burgers . . . as (they) contain more fat and cheese.” Students shared that physical activity increases concentration on studies, makes them active, and helps in building stamina. One student stated that “physical activity helps us in keeping healthy and happy.”
Families’ Influence
Students perceived their parents as playing a major role in influencing their food intake and physical activity in both positive and negative ways. Most students stated that their mothers provide homemade non-nutritious food (e.g., traditional Indian fried patties and breads), including “Western” foods such as French fries, pizzas, hamburgers, and pasta, which they admitted were readily consumed. Others commented that parental employment affected meal preparation as captured by one student stating that “my mother is working so usually I don’t have my breakfast; I have my tiffin (light meal) in the recess.” Other students commonly stated that parents stress moderation of unhealthy food intake. One student stated that her mother “has fixed a day that on Friday, I can have chips.” Others stated that they were allowed to have “junk food (only) in parties.” Finally, some students stated that grandparents and other family members influence food intake, primarily in a negative way as grandparents can often “spoil” them with energy-dense, nutrient-poor foods.
When asked what parents can do to help promote their health, students responded that they would be open to direct parental action such as parents including more fruits and vegetables in their meals, avoid giving them pocket money, which they often spent on unhealthy snacks, and having parents “not bringing junk food like pizza to home and (instead) force us to eat fruits and vegetables.” To encourage physical activity some students suggested restrictions on screen time (e.g., TV and computers) where others felt that parents could serve as positive role models for encouraging physical activity as indicated by one student commenting that parents should “force their children for cycling and they also do cycling.” Finally, some students felt that parents could advocate for healthier food options within schools by writing notes to get fruits and vegetables added to school canteens (a place where students can purchase and consume snacks during school hours).
School Influence
Students provided very concrete suggestions for how schools could promote physical health, not all being feasible, reflecting the students’ developmental stages. Among the less feasible suggestions included that teachers search every students’ tiffin for quality of food, prohibit youth to buy snack food from the canteen, or even completely close down the school canteen. However, a number of more plausible suggestions were also provided including that schools replace junk food from the canteen with fruits and vegetables, provide more time for active play and dance, and require physical activity during currently existing physical activity periods. An example of the latter was articulated by one student stating that “schools should make (it) compulsory to play in games period.”
Media and Technology Influence on Health Behavior
Although not included in the Pathways conceptual model, a theme emerged regarding the influence of the media on youth health behavior. Here, most students shared that they received information about healthy behavior from television programs such as the Discovery Channel, Animal Planet, and the news. However, unhealthy messages conveyed through television advertising were viewed as counteracting these healthy messages as indicated by one student stating that television advertising “force(s) us to take junk food.” Also, several students mentioned the emerging utilization of technology, computers, academic and social use of media. They also perceived that their generation has a lot of sedentary time because of technology.
Contexts for Health Behavior Intervention
Consistent with the Pathways conceptual model, youth considered health promotion to be a multicontextual challenge, with a role for schools, families, and neighborhoods in promoting physical health. When asked who should be involved in health promotion efforts, youth stated that children, peers, parents and grandparents, teachers, and principals should all be involved, and that “if required, separate groups can be formed for children or mothers.” Suggestions for school-based approaches to health promotion included presentations of movies, poems, poster boards/banners/advertisements, cartoons, and skits; debates or quiz competitions; and summer camps. When asked when these activities should be carried out, students responded that they could be organized weekly to once a month during free periods or assembly time.
Discussion
The main objective of the focus groups was to inform a cultural adaptation of the Pathways curriculum into an obesity prevention curriculum that can potentially be implemented for youth in India. This qualitative research was an important first step in understanding Indian youths’ knowledge and perceptions of the increasing obesity problem and its prevention, particularly in the absence of prior empirical research. The results suggest that four of the five emergent themes are relevant to the Pathways conceptual model.
Knowledge-Based Intervention Strategies
As anticipated, participants were knowledgeable regarding the health effects of snack food intake, fruit and vegetable intake, and physical activity. This is consistent with the Pathways conceptual model and other Western research suggesting that higher socioeconomic status youth are conscious of how food intake and physical activity affects health (Hart, Bishop, & Truby, 2002). Therefore, current findings do not support prevention efforts with a sole focus on promoting knowledge acquisition. Rather, a dual focus on promoting individual skill development and supporting important social contexts surrounding youth may be more effective. In addition, because a lot of “junk” or “nonnutritious food” might be cultural and indigent, students should be educated to increase their awareness about the content of daily foods relevant to their cultures and households.
Obesity as a Multicontextual Problem With a Multicontextual Solution That Includes Families and Schools
The youth also recognized that obesity is a multicontextual problem, which requires a multicontextual solution. Families were seen as critical influences in whether or not youth participate in healthy or unhealthy behaviors. In addition to the parental influences on health behavior often seen in “Western” studies, grandparents appear to play a major role, at least in the consumption of energy-dense, nutrient-poor foods.
Students stated that schools play both positive and negative roles in promoting health. Many students commented on the unhealthy nature of school snack availability and lack of opportunities for physical activity. Although students provided a number of recommendations for school-based prevention activities (e.g., student presentations, teacher advocacy, and teacher monitoring of student health behaviors), health promotion curricula such as Pathways were not mentioned. Prior to any adaptation of Pathways, students’ experience with school-based health promotion curricula should be explored to determine whether students simply have not had previous experience with school-based curricula, and are therefore not aware of this mode of health promotion content delivery, or whether students have had previous experience with school-based curricula that has not been positive.
The Role of the Media in Health Behavior
Although students were not directly queried about the influence of the media on obesity, probing questions led to the emergence of a theme of the effect of the media on health, and subsequently the potential of media to serve as a context for health promotion efforts. As a result, a future adaptation of the Pathways curriculum should consider a media/advocacy component (Perry, Stigler, Arora, & Reddy, 2009).
Students were directly asked about personal strategies for the consumption of healthy food and participation in physical activity, but no theme emerged regarding personal behavioral action plans. When asked what children can do to eat healthier food, a small number of youth responded that they simply avoid unhealthy food. However, the infrequent and nonspecific nature of these responses did not warrant a theme. A lack of an emergent theme related to personal factors related to health behavior may reflect the developmental stage of these fourth- and fifth-grade youth; that is, parents and teachers may maintain strict control over the food intake and opportunities physical activity of their children at this age. It may also represent an opportunity to promote youth perceptions of personal capacity to engage in healthy decision making through a program such as Pathways. However, if a program like Pathways has to be used, it should account for the vast socioeconomic and cultural differences between students as India has several dialects, castes, and subcultures; factors that could influence dietary practice of youth in the country.
Potential limitations of this study deserve review. First, our study was cross-sectional and observational in nature. No cause and effect conclusions can be drawn from these results. Though we tried to capture many perceptions, it is still possible that other unmeasured variables could affect the perceptions of students drawn through convenience sampling. The sample was drawn from private schools in New Delhi. Even though students in New Delhi come from all over the country, our sample might not be truly representative of Indian student population. This could be a potential threat to external validity of the findings. In addition, the monothematic nature of the study questions may have caused some students to think about the topic in a unique manner. If so, these limitations could be a threat to the internal validity of the findings. Finally, the information sought in this study was obtained through self-reported perceptions and behaviors which could have led to socially desirable responses.
Conclusions
The focus groups provided important insights into the perceptions of students in India on several aspects concerning knowledge of the contributors to obesity and the social contexts important to obesity prevention. Both the overlap and differences between the focus group findings and Pathways conceptual model will inform a culturally appropriate adaptation of the Pathways curriculum. Specifically, a Pathways curriculum implemented in India will likely retain its focus on enhancing protective factors in families and schools, although more information is needed regarding the effectiveness of school-based curricula as an obesity prevention delivery mechanism. Previous successes in the translating school-based tobacco prevention curricula (Perry et al., 2009) provide some optimism that obesity prevention curricula may be effective. In addition to family and school-based components, current findings suggest that additional focus on the media may be warranted to address the deleterious effect of advertising on unhealthy food intake.
There was a significant overlap between focus group results and Pathways model. There is a reasonable rationale for practitioners and researchers in lower middle and upper middle income countries to move forward and develop strategies to address obesity in youth and modify factors in the intervention model as applied to youth in India (i.e., Perry et al., 2008, Step 3). The findings of the study can help inform future health promotion campaigns with family and school oriented, tailored, and culturally sensitive interventions for healthy eating and physical activity in youth of low and middle income countries.