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Community Stakeholders’ Perceptions of Barriers to Childhood Obesity Prevention in Low-Income Families, Massachusetts 2012-2013

The Family Ecological Model (FEM) is divided into 4 vertical sections labeled: Family Ecology, Family Social and Emotional Context, Parenting Practices and Child Outcomes, and Family Health Outcomes. The sections flow stepwise from left to the right, starting with the first 2 sections, which list the most important, broader life factors that may inhibit healthy lifestyle behaviors in low-income families. The first section is divided into 5 boxes:

  1. Family History and Structure:
    • Ethnicity-cultural background;
    • Parent educational attainment; Individuals residing in household;
    • Family size, children’s age distribution;
    • Family health risk and protective factors; and
    • Family generational poverty/income.
  2. Child-specific Characteristics:
    • Age- and gender-specific needs;
    • Preferences/perceived competencies;
    • Peer characteristic behaviors; and
    • Disability status,
  3. Organizational Factors:
    • Job characteristics and work demands;
    • Child- versus family-centered services;
    • Quality of relationships with staff in key institutions, staff stability; and
    • Provision and integration of services.
  4. Community Factors:
    • Availability/accessibility of healthy foods;
    • Accessibility of safe housing, play areas;
    • Neighborhood social capital;
    • Availability/ accessibility of community programs and services;
    • Access to reliable public transport, and
    • Quality/accessibility of health care.
  5. Media and Policy Factors:
    • Marketing to young children;
    • Mandates linked with public assistance;
    • Child protective services; and
    • Health information sources.

From each of the 5 boxes a 1-way horizontal arrow runs to the second section, Family Social and Emotional Context, which results from the Family Ecology section. This section has 2 boxes that are connected with a 2-way vertical arrow:

  1. Family Knowledge and Social Norms, with the following subdomains:
    • Beliefs about food, physical activity, screen-based behaviors and childhood obesity;
    • Self-efficacy for healthy lifestyles;
    • Knowledge of healthy lifestyles;
    • Parenting efficacy;
    • Distrust of health care providers; and
    • Selection of child role models.
  2. Social Disparities and Chronic Stress, with the following subdomains:
    • Economic/employment stress;
    • Housing instability;
    • Food insecurity;
    • Social support and networking;
    • Chronic disruption of family routines and relationships;
    • Lack of parental sense of control;
    • Disappointment about own life;
    • Transportation and child care challenges force difficult choices;
    • Competing priorities overrule child obesity and risk behaviors;
    • Adoption of survival/coping strategies;
    • Resource shortfalls; and
    • Parent mental health needs.

Each box is connected with a 1-way horizontal arrow to the first box in the third section,

  1. Parenting Practices and Child Outcomes. The third section consists of 2 boxes:
    • Parenting Specific to Healthy Lifestyles and includes the following subdomains:
    • Parents’ dietary, physical activity and screen-based behaviors and
    • Parenting practices specific to healthy lifestyles, with:
    • Purchase, preparation of affordable, convenient foods;
    • Frequency of eating at fast food restaurants;
    • Frequency of family meals;
    • Creating opportunities for active play/recreation; and
    • Developing/enforcing rules for screen-based activities. This box connects by a one-way vertical arrow to the box underneath called Children’s Cognitions and Behaviors, which has the following subdomains:
    • Diet, physical activity and screen-based behaviors;
    • Self-efficacy for healthy lifestyles;
    • Knowledge about, and belief in importance of healthy lifestyles;
    • Preference for healthy foods; and
    • Pursuit of physical activity and health-enhancing recreational activities.
  2. Family Health Outcomes, the last section, results from all the other 3 sections. Two boxes from the third section are each connected to the last section by a 1-way horizontal arrow and have the following subdomains:
    • Parents’ Outcomes:
    • Health status;
    • Obesity status;
    • Self-efficacy; Critical awareness;
    • Resource access; Employability;
    • Social integration; Civic engagement;
    • Substance use/abuse; and
    • Health system involvement.
    • Children’s Outcomes are:
    • General health status;
    • Weight status, obesity;
    • Glucose tolerance, type II diabetes;
    • Physical fitness;
    • Asthma, sleep apnea;
    • Mental health status;
    • Social-cognitive functioning related to health and well-being;
    • School readiness, attendance, engagement and performance;
    • Peer group memberships and effects; and
    • Intergenerational effects on parenting and health-related outcomes.

Figure. The Family Ecological Model. Reprinted with permission from Davison KK, Jurkowski JM, Lawson HA. Reframing family-centred obesity prevention using the Family Ecological Model. Public Health Nutr 2013;16(10):1861-9.

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