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,

3. 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.
4. 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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