Exploring Parental and Children Perspectives towards Healthy Eating and Active Living in Lebanon: A Qualitative Study

Abstract

Background. Childhood obesity remains one of the major public health problems worldwide. During the past four decades, the global prevalence of obesity among children and adolescents has been increasing rapidly, reaching alarming rates. Childhood obesity has been an increasingly challenging health problem for low- and middle- income countries undergoing remarkable nutrition transition. Lebanon, a small Mediterranean country has been undergoing a nutrition transition, with rising rates of Lebanese school-aged children who are obese. The shift in dietary intake and food consumption behaviors of children towards more highly processed, ‘westernized’ dietary patterns, together with increased sedentary behaviors have been increasing the risk of pediatric obesity and its adverse health consequences among Lebanese children and youth. However, the experiences and perceptions of healthy eating and active life have never been qualitatively explored among Lebanese children and/or their parents to understand the influences behind the eating and activity behaviors of children.

Objectives. The main objective of this study was to explore the perspectives and experiences of school-aged children (10 to 11 years) and their caregivers (mothers) towards healthy eating habits and regular physical activity in the urban area of Beirut, Lebanon. A secondary objective of the study was to compare the parental and children perspectives towards these eating and lifestyle behaviors. A third objective of the study is to identify potential strategies and approaches that can be recommended to improve the eating and lifestyle behaviors of children.

Methods. A qualitative approach was adopted to investigate the perspectives and experiences towards healthy eating and active living of both children and mothers and to identify factors that affect these lifestyle behaviors among school-aged children. Three schools were selected using a purposive sampling approach. Focus group discussions and in-depth interviews were conducted with children and their mothers from one public and two private schools purposively selected from the Beirut area, Lebanon. Due to COVID-19 and the interruption of the regular school year, data collection was conducted through in-person focus group discussions and in-depth interviews, as well as through virtual platforms (i.e., Zoom, Microsoft Teams, phone calls). Thematic saturation was achieved at five FGDs (3 FGDs with 15 girls and 2 FGDs with 9 boys), and eight interviews with mothers. Topic guides covered the main constructs of the social cognitive theory. The analysis was conducted using the thematic inductive analytical approach to gather and analyze the data. This approach includes becoming familiar with the data, generating initial codes, creating, reviewing and defining themes and sub-themes, and writing the findings. Ethical approval for the study was secured from the Institutional Review Board at AUB. In addition, informed consent and assent were secured from mothers and children, respectively, prior to participation in the study.

Results. Six FGDs were conducted as part of the study: 3 FGDs with girls (n = 16) and 3 FGD with boys (n = 11). In addition, in-depth interviews were conducted with 11 mother of participating children. Thematic analyses showed four main overarching themes that were common between the nutrition and physical activity behaviors, namely: i) perceptions of healthy eating behavior and physical activity, and their impact on children’s wellbeing, ii) determinants of eating and physical activity, iii) school and sports environment, and iv) suggestions to encourage healthy eating and physical activity among children. In addition, for nutrition behaviors, eleven sub-themes emerged, whereas nine sub-themes emerged from our study when exploring the perceptions and experiences of children towards their physical activity behaviors. In the first theme, children perceived healthy eating based on food types, color, and balance and moderation, whereas mothers related healthy eating mostly based on nutrients. In addition, both children and mother participants determined activity patterns based on children’s activity preferences (i.e., organized sports, leisure activities) and their own enjoyment. Children and mothers presented their views regarding the impact of healthy eating and physical activity on children’s wellbeing. Children discussed the general health benefits related to their overall physical health and wellbeing, as opposed to the perceived benefits reported by their mothers, such as disease risk reduction. In parallel, children and mothers perceived distinct benefits of physical activity, and expressed negative attitudes related to physical discomfort and safety concerns. In the second emergent theme, participants described a set of intrapersonal, social, and environmental determinants that influence children’s eating and activity habits. Individual factors included food preferences and choices and eating out of boredom or as a result of strict restrictions to reduce the spread of COVID-19. Also, the use of rewards or compensations to engage in healthy eating and active behaviors and the perceived ability of children to eat healthily and to participate and succeed in physical activities were other individual determinants that were perceived differently among children and their mothers. Social factors encompassed the influence of families and friends. Children and mothers generally agreed that families (parents, siblings, and extended family members) affect food and activity choices. However, peer influence was only raised by children, as mothers discussed only the influence of parents and family members on their children’s eating and activity habits. The availability and affordability of healthy foods and spaces to practice physical activity, as well as food advertisements, were key environmental factors expressed in our findings. Another theme that emerged from the FGDs and interviews was the role of schools and sports facilities in setting a good example for children’s healthy eating and active behaviors. Several subthemes emerged under this theme including the influence of food environment, timing of physical activity, and the role of teachers. In the fourth theme, participants have suggested relevant solutions to provide support at multiple levels. These strategies include intrapersonal strategies (e.g., improve self-efficacy, promote the immediate benefits and the way to cope with environmental barriers for desired behaviors) that were suggested by children. In addition, children and mothers suggested social strategies that can be promoted such as parental education, increasing peer and parental support and role modelling. Furthermore, school strategies were suggested by children and mothers (e.g., provide the necessary knowledge, skills, positive support towards dietary and physical activity practices, increasing the availability of healthy food choices while decreasing that of unhealthy foods). Lastly, societal strategies and political decisions were raised by participants, such as the provision of easily accessible and affordable facilities that encourages healthy foods and physical activity and reducing the prices of healthy food options.

Conclusion. The study findings highlight the overall positive perceptions and experiences of school-aged children and their mothers towards healthy eating behavior and physical activity. Several individuals, social, and environmental influences were reported by children and their mothers as it pertains to children’s eating and activity habits. These factors were also supported by recommendations as to why and how to best promote behavioral change among children using the social cognitive theory. This study also demonstrates the similarities and differences found between children’s and their mothers’ insights, demonstrating the importance of including both children and parents in the data collection process and support effective communication between parents and children in future health-related interventions. Furthermore, our study findings highlight student and parental-driven recommendations for practical initiatives to help promote healthy eating and lifestyle behaviors among youth. The generated knowledge and suggested initiatives can be theory-based and can be used as a platform to inform the stakeholders and policymakers on the key aspects to be addressed in the development of effective school and family-based programs and interventions to address pediatric overweight and obesity.