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Abstract

Aim:

The purpose of this study was to explore perceptions, facilitators, and barriers to healthy eating behaviors among parents of primary school-aged children.

Methods:

A purposive sampling design was used to select parents of primary school children from four different communities in north-east Trinidad. They were recruited via the school system with letters containing the research purpose and background. Four focus group sessions were conducted between May and June 2013. Each focus group had an average of five participants and lasted for approximately 60 min. The participants were asked to define healthy eating, identify healthy foods, and describe their concerns regarding healthy eating. The interview questions were developed and validated by the research team members. The data were transcribed and analyzed for themes.

Results:

Twenty-three (N = 23) parents (78% female and 22% male) participated in the study. The participants define healthy foods as vegetables, starchy foods, porridge, tea, fiber, and foods low in fat. Parents also acknowledged that food cost, availability, parent’s inability to influence children to consume fruits and vegetables, and social barriers are some major challenges impeding healthy eating.

Conclusion:

Our study demonstrates that several barriers exist to healthy eating among primary school children in Trinidad. Community health professionals, school teachers, dietitians, and nutritionists need to play a more prominent role in teaching children and parents about the benefits of healthy eating. Future studies need to address the barriers to healthy eating. This might help to reduce the growing obesity prevalence in Trinidad.

Keywords

Childhood obesity parents healthy eating Trinidad and Tobago

Introduction

Childhood obesity continues to be a major public health concern in Trinidad and Tobago. Research has shown 24% of children (5–18 years old) in Trinidad and Tobago are overweight or obese.¹ These children may be at risk of long- and short-term health consequences. Studies show that a rapid nutrition transition, change in dietary food preferences, and increased importation of processed foods are associated with this transformation in body composition.^2–3 Processed foods are less nutrient dense and high in calories. Intervention researchers have recommended several strategies for engaging parents and for reducing the intake of convenient and fast foods.⁴ According to the ecological model,⁵ parents are usually the most influential people in children’s lives. Thus, parents can significantly impact children’s eating habits and food decisions.

Numerous obesity interventions have been conducted within the school and home environment that focused on positive behavior change. Interventions include improving healthy eating habits and increasing physical activity.⁴ In 2009, the Ministry of Health, Trinidad and Tobago, developed a draft National School Health policy that focused on broad categories, such as healthy lifestyles, safe school environment, nutrition, and physical activity. In 2012, the Ministry of Health implemented the Fight the Fat campaign, which targeted school-aged children, adults, and the public. The campaign promoted activities, such as wellness camps, screening caravans, healthy recipe competitions, national nutrition quizzes, and workout-sessions.

Although these initiatives have been implemented, there are no data or evaluations on positive health outcomes. The complexity of factors influencing obesity is well documented and obesity is one of the fastest growing noncommunicable diseases globally.^6,7 The trend is expected to increase by the year 2030 in both adults and children.⁸ In the Caribbean, specifically Trinidad and Tobago, little is known about parents’ perceptions of healthy eating. Therefore, the purpose of this study was to explore the perceptions, facilitators, and barriers to healthy eating among parents of primary school children in north-east Trinidad.

Methods

Study setting and participants

This study was conducted in Trinidad and Tobago, a twin-island country in the Caribbean. The country occupies approximately 5128 square miles and has a population of 1,356,633. According to the Central Statistical Office of Trinidad and Tobago, the ethnic and racial population includes 40% Indian (South Asian), 37.5% African, 20.5% mixed, 1.2% other, and 0.8% unspecified. The country’s primary sources of employment are agriculture (3.8%), manufacturing, mining, and quarrying (12.8%), construction and utilities (20.4%), and services (62.9%). The country has experienced a great decline in agriculture since the late 1970s and offshore oil and gas drilling dominate the economy. Therefore, the country imports foods (processed and unprocessed) from different countries.

The study was part of a broader multidisciplinary project dealing with food and nutrition security in the Caribbean Community (CARICOM).⁹ The primary goal of the project was to improve nutrition and health outcomes of CARICOM populations through an integrated, gender-sensitive, and environmentally sustainable approach to food and nutrition security. A purposive sampling design was adopted to recruit parents from north-east Trinidad. Eligible participants had to be participating in the CARICOM food security project and have at least one child between the ages of 5 and 9 years old attending any of the selected schools. Permission for this study was obtained from the Ministry of Health Research Ethics Committee, Trinidad and Tobago.

The sample comprised 23 (N = 23) participants (15 women and 8 men), with most being of a mixed ethnicity. The majority of participants were within the age group of 27 to 35 years, married, had completed a secondary school education, and were employed in skilled or unskilled jobs. Monthly family incomes ranged between TT$1,000.00 and TT$5,000. Table 1 provides detailed information about the participants’ demographic characteristics.

Table 1.

Particiants’ demographic characteristics.

Demographic characteristics	N = 23	Percentage
Sex
Female	18	78.3
Male	5	21.7
Age
26–35	14	60.87
36–45	7	30.4
>45	2	8.7
Marital status
Married	13	56.5
Single	7	30.4
Divorced	2	8.7
Widowed	1	4.3
Ethnicity
African	7	30.4
East Indian	5	21.7
Mixed	11	47.8
Education
Primary	9	39.1
Secondary	12	52.2
Post-secondary	1	4.3
College or university	1	4.3
Employment
Employed	13	56.5
Unemployed	10	43.4
Monthly income (TT$)
<1000	8	34.8
1001–3500	3	13.04
3501–5000	1	4.3
>5000	1	4.3

Procedure

A qualitative approach was used to understand parents’ perception of healthy eating. In this study, a parent is defined as a father or mother. Between May and June 2013, we conducted five focus group sessions. Before the focus group sessions, written consent was obtained from all participants. Eligible participants were asked to complete an application form, which was used as a screening tool and an instrument for demographic data.

The focus group guide (questionnaire) consisted of 11 questions developed by the research team members through prior literature review and health-expert opinions (Table 2). All questions were validated, and pilot tested with community members surrounding the Maracas Roman Catholic Primary School, who were not involved in the study. Most questions were directed toward healthy eating issues, as participants were asked to define healthy eating, explain how parents made healthy eating choices, and discuss their concerns about factors impacting healthy eating.

Table 2.

Focus group guide.

1. Tell me, what comes to mind when you hear the term “healthy eating”?

2. Let us talk about challenges or difficulties, in general, within your family regarding healthy eating.

3. Tell me about what you do to choose and eat healthy foods.

4. Let us talk now specifically about challenges or difficulties with getting your children to eat healthy foods.

5. Eating at school may or may not be different from eating at home. What concerns do you have about any of the foods your children eat at school?

6. Where do you usually get your information about food and healthy eating?

7. We would like to suggest having some classes to teach about nutrition. What topics would you like to learn about?

8. What do you think about families having routines or rules at home that could help children to develop good eating habits?

8a. Does your family have such routines or rules? If yes, what?

9. Let us talk about eating and food habits; that is, what and why you usually eat the way you do.

10. What do you think is the best way to encourage people to eat healthy foods?

11. How can you help your children to choose healthy foods?

All focus group sessions were hosted at the local primary school and moderated by a trained qualitative expert. Field note-takers were present to document observed reactions, manage the audio recorder, and take notes. Sessions began with an open-ended question that sought to define parents’ perception of healthy eating, for example, “What comes to your mind when you think of healthy eating?” Each session had an average of five participants and lasted for approximately 60 min.

Analysis of data

The data were transcribed verbatim and analyzed using a phenomenological approach.¹⁰ Two research team members read and reviewed the transcripts a number of times separately. Line-by-line coding was conducted, and reoccurring words and phrases emerged into themes and key concepts. During the process, a codebook was established with descriptions to ensure consistency and validity. Peer debriefings were completed at each stage of the analysis to ensure that all researchers agreed with the decisions and interpretations. Whenever there were discrepancies, differences were discussed until consensus was reached. The inter-coder reliability was 90%.

Results and discussion

Definition of healthy eating

Our analysis revealed various definitions of healthy eating. Many parents perceived healthy eating in terms of food choices such as “foods low in fat, vegetables, and starchy foods.” Others associated healthy eating with individual nutrients, for example, “eating from the five food groups, which include carbohydrates, vitamins, protein, fats, and staple foods.” Another parent expressed that healthy eating can be anything you consume that is good for you, like “porridge, tea, or eating three square meals per day.” While these definitions appear vaguely correct, none of the parents mentioned eating a variety of foods and portion control or sizes as main components of eating healthy. This highlights a concern, as parents can consume a variety of foods from the six Caribbean food groups, but eating a large amount of fat and starchy foods with a small amount of fruits and vegetables can lead to chronic disease. However, the typical Caribbean diet does not emphasize moderation.

In addition, parents’ inability to recognize the relationship between food consumption and the six Caribbean food groups suggest the need for a greater understanding of their cultural beliefs as it relates to food and health. This broad conceptualization of healthy eating may be contributing to the growing obesity epidemic in Trinidad and Tobago among school-age children, as there are gaps in parents’ nutrition knowledge about healthy eating and unhealthy nutritional habits.

Barriers that inhibit healthy food consumption

Many parents admitted that they were aware of healthy eating, yet several barriers to access healthy foods emerged. The parents suggested limited availability of fresh produce, food cost, and long distances to grocery stores as some challenges to obtaining healthy foods. A few parents suggested that “Pak choi with bugs and holes are good [examples of] concerns about shelf-life, and changes in food quality are an issue.” For example, they observed changes in potatoes, which are sometimes too soft, and cabbage, which is often water-filled. Other parents mentioned that going early to the market might be more meaningful in obtaining better quality produce. In addition, food cost and availability are often factors to purchasing a variety of fresh fruits and vegetables. The parents indicated that they might have the desire to purchase what is available, but were sometimes unsure about how foods are processed and the type of chemicals used in foods or its freshness. These findings are well documented in previous literature that examined barriers to healthy food consumption.¹¹

The parents were explicit about the different sources of health messages contributing to their understanding of healthy eating. Parents indicated that their information regarding food and nutrition was often obtained from the television or internet. They mentioned that occasionally they would read the food labels or manufacturers’ information. Some mothers stated, “so many different things are said; we feel the need to be informed; we feel their habits cannot change.”

Since parents are hearing mixed messages about healthy eating, it is essential for them to have a clear understanding of what is healthy eating. Evidence-based literature reported that parents are key to health promotion, particularly in the home environment. Healthy eating is also critical to combating obesity.^12,13 Parents need to apply healthy eating knowledge in their personal everyday lives as well as their children’s. Parents can reinforce and support healthy eating and provide the necessary support to maintain positive behavior change.^12,13

In addition, several participants suggested that children are exposed to television at an early age and that their appreciation for healthy foods is declining. One participant explained, “They are exposed to television and do not learn to enjoy healthy foods.” Some participants indicated that they implemented punitive measures as a way to increase healthy eating in children. For example, one parent explained, “I told the child I would deny snacks and television.”

Another parent indicated withholding activities if the child refused or did not consume all the meals served to them: “No juice, no play.” This may not be the best way to change behavior. Longitudinal studies have reported that excessive parental control and pressure to eat were associated with lower fruit and vegetable intake.¹⁴ The National Institute of Child Health and Human Development revealed that an authoritative feeding style increases the risk of being overweight in children.¹⁵ While this may seem acceptable to parents in the present situation, short-term behavioral control of food intake may result in children eating more food than is nutritionally appropriate.

Strategies for promoting fruit and vegetable consumption in children

Different strategies to increase healthy eating in children were discussed. Many parents expressed incorporating vegetables in foods children enjoyed. The responses were varied among parents, “I mix pumpkin with meat to get the child to eat healthy…,” or “You can put something they like with healthy foods,” or “Make faces with food.” The parents suggested that these strategies had a positive impact on their children’s eating behaviors.

Overall, the study findings are consistent with prior literature globally.^16,17 Notably, parents discussed definitions of healthy eating, barriers that inhibit healthy food consumption, and strategies for promoting consumption of fruit and vegetables in children. The current findings provide a contextual understanding of eating practices within the Caribbean, particularly in Trinidad and Tobago. Also, this study adds to a growing body of literature on factors influencing obesity from parents’ perspectives in a developing country. Worldwide, obesity continues to be a major public health issue affecting many children and adults.^18–20 In addition, this study is the first to report these findings from Trinidad and Tobago. Possible explanations for this may be the lack of research in the area of food and nutrition literacy from the parents’ perspective, inadequate literature reports, and limited available resources for funding public health research in developing countries.

There were a few limitations in this study that warrant reporting. During the recruitment process, a low response rate was received. This may be due to a lack of trust and limited awareness of research, which parents may not deem important to their everyday lives. For future research, it will be important to increase participation with incentives to better understand trust issues and individual behavior. A more comprehensive mixed-method study could incorporate the socioecological model as a tool to measure quantifiable data. In addition, we utilized a qualitative approach with a small sample; therefore, the findings should not be generalized.

The major strength of this study is its exploratory design. Since this is the first study conducted in Trinidad and Tobago, its preliminary data can be useful in guiding future intervention ideas to address childhood obesity.

Conclusion

This study explored perceptions of parents of primary school children in north-east Trinidad about healthy eating. The overall findings suggest that more collaboration and training is needed to increase healthy eating literacy. Evidently, parents are in a position to promote and encourage healthy eating in children. However, effective interventions are needed to address the major barriers that emerged in this study. For example, practical guidline for parents that include a healthy eating pattern for children, food intake regulation in the home and promotion of food literacy might be helpful. Giving parents easy-to-use information about the food groups and portion sizes for children may be helpful to clarify their perception of healthy eating. One of the primary recommendations to reduce childhood obesity is healthy eating and physical activity.²¹ Therefore, incorporating some of these healthy tools mentioned is essential to meeting the dietary recommendations.

Footnotes

Acknowledgements

The authors wish to thank Associate Professor Katherine Gray-Donald for her skillful review and edit of the manuscript.

Authors’ note

Any underlying research materials related to this paper can be accessed on request from the corresponding author.

Declaration of conflicting interest

The authors declare that there is no conflict of interest.

Funding

Funding for this research was provided by The Canadian International Food Security Research Fund (CIFSRF) a program of Canada’s International Development Research Centre (IDRC), Ottawa, Canada, , and financial support from the Government of Canada, provided through Global Affairs Canada (GAC). Project number 106525.

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Parents’ perceptions of healthy eating practices in north-east Trinidad