Participants
Twenty-one participants were recruited excluding one pilot interview. The average interview length was 42 minutes, ranging from 24 to 58 minutes. Professions spanned five broad groups which were: dentist, obstetrician, nurse, doctor and nutritionist. Nurses identified as either a technical nurse or licensed nurse, the latter holding more clinical responsibilities. Participant characteristics are summarised in Table 1.
Table 1 Summary of participant characteristics
Participant number
|
Age
|
Gender
|
Profession
|
Time qualified (years)
|
Age of patients (years)
|
Is a parent
|
<5
|
5-11
|
12-16
|
>16
|
1
|
20-29
|
Male
|
Dentist
|
<1
|
No
|
Yes
|
No
|
No
|
No
|
2
|
40-49
|
Female
|
Assistant Obstetrician
|
21
|
No
|
Yes
|
Yes
|
Yes
|
Yes
|
3
|
30-39
|
Male
|
Technical Nurse
|
14
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
4
|
40-49
|
Female
|
Technical Nurse
|
16
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
5
|
20-29
|
Female
|
Licensed Nurse
|
6
|
Yes
|
Yes
|
No
|
No
|
No
|
6
|
40-49
|
Male
|
Family Doctor
|
3
|
No
|
Yes
|
No
|
No
|
Yes
|
7
|
30-39
|
Female
|
Obstetrician
|
4
|
No
|
No
|
Yes
|
No
|
No
|
8
|
50-59
|
Female
|
Technical Nurse
|
31
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
9
|
50-59
|
Female
|
Surgical Doctor
|
19
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
10
|
20-29
|
Female
|
Licensed Nurse
|
<1
|
Yes
|
No
|
No
|
No
|
No
|
11
|
30-39
|
Male
|
Dental Surgeon
|
5
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
12
|
30-39
|
Female
|
Technical Nurse
|
14
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
13
|
20-29
|
Female
|
Licensed Nurse
|
1
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
14
|
30-39
|
Female
|
Licensed Nurse
|
6
|
Yes
|
No
|
No
|
No
|
Yes
|
15
|
30-39
|
Female
|
Technical Nurse
|
12
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
16
|
20-29
|
Female
|
Technical Nurse
|
<1
|
Yes
|
No
|
No
|
No
|
No
|
17
|
40-49
|
Female
|
Obstetrician
|
9
|
No
|
No
|
Yes
|
Yes
|
Yes
|
18
|
20-29
|
Female
|
Technical Nurse
|
<1
|
Yes
|
Yes
|
No
|
No
|
No
|
19
|
20-29
|
Male
|
Licensed Nurse
|
6
|
Yes
|
Yes
|
Yes
|
No
|
No
|
20
|
20-29
|
Female
|
Licensed Nutritionist
|
3
|
Yes
|
Yes
|
Yes
|
Yes
|
Yes
|
21
|
40-49
|
Female
|
Obstetrician
|
10
|
No
|
No
|
Yes
|
Yes
|
Yes
|
Findings
Eight themes were identified and were categorised according to the research objective which they best addressed. Salient points of each theme are summarised in Table 2.
Table 2 Summary of themes categorised according to the research objectives
Category 1: HCPs’ perceptions and attitudes towards childhood obesity
|
1a
|
Level of concern regarding childhood obesity
|
· Childhood obesity is not a major concern in Iquitos
· Undernutrition is a greater priority than obesity
|
1b
|
Perceived consequences of childhood obesity
|
· Long-term medical implications
· Psychological consequences, particularly in adolescents
|
Category 2: Factors which HCPs perceive to be important in the development of childhood obesity
|
2a
|
Parental factors
|
· Parents have the most influence
· Positive views of excess weight prevail
|
2b
|
Contextual factors
|
· Availability of technology, affordable healthy foods and outdoor space
· Perceived association with socioeconomic status
|
Category 3: HCPs’ perceptions of their role in childhood obesity prevention and management
|
3a
|
Educating parents about childhood obesity
|
· Addressing parental misconceptions
· Supporting the family as a whole
|
3b
|
Regular monitoring of child growth
|
· Key to recognising overweight or obese children
· Enable interventions to be initiated
|
Category 4: Barriers and facilitators in childhood obesity prevention and management
|
4a
|
Barriers and facilitators in healthcare
|
· Barrier – Lack of parental cooperation
· Facilitator – Utilising home visits
|
4b
|
Barriers and facilitators in schools
|
· Barrier – Lack of interest from teachers and parents
· Facilitator – Platform for education and government policies
|
HCPs’ perceptions and attitudes towards childhood obesity
Level of concern regarding childhood obesity
All participants discussed childhood obesity from a pathogenic perspective and associated it with negative consequences. Although many had encountered cases of overweight or obese children, the majority believed that childhood obesity was not common nor increasing in Iquitos and had a low level of concern.
“I don't think [childhood obesity] is increasing here in Iquitos, there may be cases of obesity in children, but it's not extreme” (P9 – Surgical Doctor)
This regard for childhood obesity as a lower priority was contrasted by a high level of concern for undernutrition, which was considered a more important health issue in children.
“What you see most is child undernutrition, it's more relevant. Yes, there are obese children, but the greatest percentage are undernourished” (P13 – Licensed Nurse)
Some participants believed that childhood obesity was increasing but maintained the perception that it is not currently a priority in Iquitos, a view shared by all participants. Comments on prevalence rates were often contextualised using other countries or Peru’s coastal regions to highlight that trends in Loreto were not concerning.
“In other countries, such as the United States, there is a greater index of obesity compared to Loreto. I could highlight the undernutrition in Loreto compared to other countries. There is very little obesity here” (P14 – Licensed Nurse)
“I think other places attach more importance to childhood obesity than here in Loreto. Here, […] they are definitely putting childhood obesity aside” (P20 – Licensed Nutritionist)
Perceived consequences of childhood obesity
Universally, discussions surrounding the implications of childhood obesity were approached in terms of long-term adverse health outcomes. Increased risk of diabetes and cardiovascular diseases in adulthood predominated the lists of medical consequences which were cited.
“If we don’t recognise the problem of obesity in children, in the future this will become an adult who will suffer from metabolic diseases such as diabetes mellitus, hypertension and dyslipidaemia” (P9 – Surgical Doctor)
Reports of consequences which manifested in childhood were less common and included physical problems such as “problems of their joints, […] support of their hips, their knees and their ankles” (P19 – Licensed Nurse). Bullying from peers was mentioned by several participants, with a few also recognising some psychological consequences of teasing. Mental health issues resulting from being overweight were usually raised in relation to adolescents.
“When you reach puberty, you realize that you are fat. Then come the social factors, the bullying. [Others] aggravate them because they’re fat, and that's when they first realise that they’re obese and start to become aware” (P6 – Family Doctor)
Factors which HCPs perceive to be important in the development of childhood obesity
Parental factors
The perception that parents possess the most influence in the development of childhood obesity was a pervasive theme in all discussions regarding contributing factors and prevention strategies. Parental influence was largely viewed negatively, as participants focussed on the detrimental impact of parents on their children, typically through their role in imparting unhealthy eating behaviours.
“[Childhood obesity] depends a lot on the parents because they are the ones who live with them 24 hours a day and I think we should address them first so that they can help the child too” (P13 – Licensed Nurse)
“[Responsibility is] mostly the parents’, because they must guide and educate their children properly so that later they do not suffer from disease” (P18 – Technical Nurse)
Parents were often criticised for either acting as poor role models to their children or conceding to their children’s requests for junk food.
“Here at the facility, we see that the mother brings in a bottle of sugary drink, instead of bringing something healthy” (P4 – Technical Nurse)
“[Parents] say that they feed their children [certain foods] because their children want to eat that, for example, if the child says they want to eat chocolate, then they’ll give them chocolate” (P7 – Obstetrician)
The sentiment that parents did not care and lacked awareness about obesity was commonly proposed to explain these bad practices.
“Another important factor [in childhood obesity] is the lack of awareness in parents because they just want to give [children] food but they don’t care if they are receiving the right nutrients for their body” (P7 – Obstetrician)
Notably, participants reported that there was a prevailing belief amongst parents that excess weight in children is desirable and signals health, which may account for the lack of interest in adopting healthier behaviours. HCPs perceived the lack of understanding about the pathogenicity of obesity to be widespread and a challenge to navigate.
“A lot of the time, parents think wrongly of their kids that the fatter they are, the healthier they are” (P14 –Licensed Nurse).
“It is a challenge [to understand obesity] for us as professionals, as well as for the families, because mothers think that an obese child is healthy, when in fact it’s not” (P5 – Licensed Nurse)
Although participants themselves viewed childhood obesity as a problematic health issue, one admitted that their own perception had been different previously.
“We thought [obesity] was inherited, right? If the parent is fat, then [the child is] fat too. But now, over time, studies show that weight gain in children is pathological” (P2 – Assistant Obstetrician)
In contrast to the negative attitude towards parents demonstrated in most interviews, one participant felt that parents contributed positively to child health.
“In our city, you observe […] mothers who care about their children's nutrition and enrol their children in different holiday courses such as football, volleyball, basketball, etc. to always keep them active” (P10 – Licensed Nurse)
Contextual factors
Beyond parental influences, participants raised a variety of issues which appeared to be a product of the wider context within which their patient population lived. The rainforest location of the city proved, for some participants, to be an influential factor in childhood obesity as it was thought to determine the availability of technology, affordable healthy foods and outdoor space for physical activity. Generally, the HCPs felt that Iquitos had limited access to the former two commodities whilst a few mentioned that there was a greater abundance of the latter.
Greater use of technology, such as televisions and phones, was perceived to accelerate the development of obesity in children by increasing sedentary behaviour. However, this was less of a concern in Iquitos compared to elsewhere.
“Childhood obesity here is not so common mainly because we don't have the most advanced technology yet [...] here, children are not totally focused on technology, you rarely see children with their tablets, phones or TVs, they prefer to go out and play in the streets” (P10 – Licensed Nurse)
Another location-dependent factor recounted by some participants was the high prices of fruits and vegetables. This generated a financial barrier to change according to some HCPs who empathised that eating healthier foods may incur an economic cost to families.
“Here in our region, carbohydrates are the most consumed, we don't consume fruits or vegetables. Sometimes because of the cost, it’s a little bit inaccessible” (P2 – Assistant Obstetrician)
“Parents don’t have the financial freedom to buy the right foods” (P18 – Technical Nurse)
Most reports of physical activity levels further suggest that the environment which Iquitos provides children may have protective elements.
“One of the advantages we have in Iquitos is that we don’t live in an environment with as much risk or danger as the big cities on the coast. Here, the children still go out to play, […] they have more free spaces than other cities” (P9 – Surgical Doctor)
The micro-context of the family unit was also presented as a potential factor which determined if a child became obese. Many participants associated a family’s socioeconomic status with the likelihood of developing childhood obesity.
“Economic aspects prevent you from eating healthy fruits or vegetables as they are expensive in this region” (P6 – Family Doctor)
“Financial accessibility to have video games […] makes children today remain more inactive” (P9 – Surgical Doctor)
Some believed that families of higher socioeconomic status had greater access to food and so they were more likely to have overweight children.
“People who have a little more money […] buy junk food to please the child” (P16 – Technical Nurse)
“I think [childhood obesity is common] in the middle class because it also occurs in the class that has more wealth” (P13 – Licensed Nurse)
This view was usually compounded by the perception that undernutrition was more commonly seen in families with lower socioeconomic status, which may contribute to the lay perception that having overweight children is desirable.
“[Obesity occurs] from the middle class and up and the lower group is where we attend patients with child undernutrition” (P1 – Dentist)
“The common thing you see is that the father of the family doesn’t have a job. If they don’t have a job, how are they going to feed the child” (P17 – Obstetrician)
Meanwhile, a correlation with socioeconomic status in the other direction was also posited. Some participants suggested that higher socioeconomic groups could be healthier because “they can buy better food, that's the purchasing power” (P11 – Dental Surgeon) in addition to the advantage that access to sport clubs provides for children.
“There are football, basketball and volleyball clubs. […] Within the city here we have higher, middle and lower social classes. The first two spheres allow their children to play there during holidays and within the school period” (P19 – Licensed Nurse)
Contrary to preceding views that greater wealth equates to greater consumption of junk food, the prohibitive cost of healthy food was also thought to result in similar consequences for less wealthy families.
“People here prefer to buy fast food because healthy food is expensive, they can’t buy fruits and vegetables, so they prefer to buy cheaper food although it isn’t healthy” (P7 – Obstetrician)
HCPs’ perceptions of their role in childhood obesity prevention and management
Educating parents about childhood obesity
In accordance with participants’ perceptions that parents have the most influence in childhood obesity and the pervasiveness of the “incorrect belief [that] a fat child is a healthy child” (P9 – Surgical Doctor), HCPs’ self-perception of their role predominantly focussed on educating parents as supporting the family unit was seen to be key to affecting a child’s behaviours.
“[Encouraging healthy lifestyles in children] basically consists of educating the parents, doesn't it? Making parents aware of good nutrition for their children” (P14 – Licensed Nurse)
“We are here to support them, whether it is the parent or the family […] because that is our job, to support” (P15 – Technical Nurse)
Addressing parental misconceptions was often central to the education provided by HCPs.
“We advise the family, the parents, that it’s important to understand that their child is obese. It doesn’t mean that they are healthy, because there is a culture of this misconception that a fat child is a healthy child, and that is not true” (P9 – Surgical Doctor)
Promoting healthier lifestyles directly to parents was the mainstay of attempts to address obesity concerns as responsibility to initiate change was seen to be the parents’ domain. Educating the parents to teach their children healthy practices was the preferred long-term approach as the home was viewed as the source of learned behaviours.
“Few children consume [healthy foods]. Parents don't teach them at home. Children learn from their environment, from home. We'll generally give them some ideas, some advice, but [unhealthy behaviours are] definitely from the home” (P21 – Obstetrician)
Many HCPs acknowledged that their efforts to promote healthy lifestyles had little success, but most persisted for the few patients who benefitted from their advice.
“We are here to guide the patient whether they understand or not, we are there every day to fight for the health of the whole family” (P15 – Technical Nurse)
Conversely, one participant maintained that parents lacked education, but instead preferred to address this gap by targeting education towards the children themselves.
“Unfortunately, parents aren’t interested, they aren’t educated. Or they already have the knowledge but for an adult to erase that is very difficult, it is already deeply embedded. That's why you always have to educate the little ones so, as they grow up, they will keep that knowledge” (P13 – Licensed Nurse)
Regular monitoring of child growth
Generally, participants perceived monitoring growth in children to be a core aspect of a HCP’s role. At the two healthcare centres, measurements are routinely taken for all children who attend. Nurses appeared to hold this responsibility to a greater extent than other participants.
“We, as workers, must be monitoring children whether they are obese or not […] it is our priority to keep the child healthy” (P15 – Technical Nurse)
Routine monitoring of both weight and height enabled HCPs to recognise obese or overweight children and therefore created an opportunity to initiate interventions through a referral pathway to other HCPs.
“Healthcare personnel are already dedicated to observing the weight and height of children […] Depending on their body mass they’re referred to the specialists, if they are obese, they’re automatically referred to the nutritionist so that the child can lose weight appropriately” (P15 – Technical Nurse)
Barriers and facilitators in childhood obesity prevention and management
Barriers and facilitators in healthcare
In the healthcare setting, a common barrier experienced by most participants was the lack of parental cooperation. This impacted HCPs’ ability to provide education and monitor child growth. Some felt that it was difficult to convince parents of the importance of childhood obesity because “they always stick to their own beliefs about how to raise their children” (P10 – Licensed Nurse) and thus were unlikely to comply with advice or return for further support.
“There are some parents who do follow [advice], for example, five out of ten. The rest I think throw in the towel, they give up […] so they don't come back to their appointments” (P20 – Licensed Nutritionist)
Many participants encountered difficulties explaining childhood obesity to parents due to a lack of engagement. However, none mentioned experiencing challenges related to raising the topic of obesity due to fear of stigma or offending parents.
“I do everything possible so that the patient understands me. I practically have to scare them, because here we have to scare the parents and maybe then they’ll become aware that [obesity] can happen” (P20 – Licensed Nutritionist)
Participants perceived that families only proactively consulted HCPs regarding weight concerns when they were already invested in cooperating with guidance. This included those who had encountered issues after ignoring previous healthcare advice.
“There are mothers who only come once to the consultation and leave immediately then return after a few weeks when their child's health has already become complicated” (P10 – Licensed Nurse)
Participants often praised the use of home visits to circumvent the lack of attendance at the healthcare centres. This enabled HCPs to contact families with the lowest attendance and therefore reach patients they believed to be of most concern.
“We do home visits because the barrier was coming to the [child health] appointments” (P6 – Family Doctor)
All comments on home visits were positive and many reported that this initiative was effective in terms of fulfilling their self-perceived duties in childhood obesity management and prevention which was to educate and monitor.
“Our main role is to spread information to prevent illnesses, that is why we do home visits” (P8 – Technical Nurse)
“We have to do our job which is to follow-up on what [patients] are achieving, if they are succeeding or lack support, that is why home visits are made” (P5 – Licensed Nurse)
Barriers and facilitators in schools
Overall, schools were viewed as an important source of health education for children and their parents. Some participants were part of long-standing programmes at schools to provide demonstrations regarding nutrition and portion sizes which they felt worked well.
“Last year, we worked directly with the school and were able to train teachers and parents. The best intervention has been at the school” (P21 – Obstetrician)
School-based interventions were presented as useful strategies when combined with other interventions, rather than as a stand-alone measure, as parental influences in the home remained most pertinent.
“Don’t forget that schools are the second home of our children. They spend half of their life in school. So, if we have an enhancing effect between families and schools […] we could advance a lot” (P9 – Surgical Doctor)
Initiatives in schools appeared to be led mainly by HCPs as the participants perceived that “in schools, even the teachers don't care” (P3 – Technical Nurse).
“I think that if we, as healthcare professionals, don't go to the educational institutions they forget [about obesity] so we have to constantly advocate to strengthen the link with them” (P11 – Dental Surgeon)
Therefore, schools were perceived to facilitate the HCPs’ aims by allowing them an additional platform to reach their patient population. However, the reluctant attitudes of teachers and parents still introduced barriers in this setting.
“[Schools] always call parents in to talk about how they can have a healthy lifestyle with their children […] but the parents don't go, only a minority attend, […] so even though education is provided, I think more education should be given” (P13 – Licensed Nurse)
Additionally, schools facilitated the main governmental policy that participants were aware of which centred around the introduction of healthier options at ‘kiosks’, stalls in schools where children buy lunch.
“The ministry of health implemented a policy regarding healthy kiosks where school kiosks were required to sell healthy food such as fruit and salads, not the sweets that have typically been sold there” (P9 – Surgical Doctor)
Not all participants were aware of the healthy kiosks and many felt that the government was doing very little beyond this to prevent childhood obesity, which accorded with the HCPs’ own low level of concern for the issue.
“The government is currently focusing on chronic childhood undernutrition […] the only thing being worked on [for childhood obesity] are the healthy lunches but not anything else” (P14 – Licensed Nurse)