Health behaviours and childhood obesity among refugee families with young children

Abstract

Childhood obesity represents a leading public health issue over the last decade, with a progressive rise reported in the prevalence of obesity among children living in low socioeconomic status in developing countries as well as groups of ethnic minorities. A high prevalence of obesity is also reported amongst refugee children who move to developed countries, where they often live in low income families. Poor health consequences associated with childhood obesity, include hypertension, insulin resistance, orthopaedic problems, and low quality of life. Refugees and their families commonly face complex physical and psychological challenges, exacerbated by their low income status, after resettlement in a new environment, which can undermine their health and put them at higher risk of being overweight or obese. Every year there are increased numbers of refugee families resettled in developed countries. This posing a very serious challenge to the governments of host countries, especially as these vulnerable populations face challenges that can affect their health, there is still a noticeable lack of research on refugee children's health behaviours and obesity. To address this health issue, it is essential to understand the challenges they face and how they affect their obesity-related behaviours. In particular, it is essential to identify the key factors related to health behaviours and childhood obesity among refugee children. This would inform the development of a culturally informed weight management intervention that supports appropriate nutrition and the prevention of obesity and associated disease in this population. Objectives: The overall aim of this thesis was to understand the factors influencing obesity behaviours in refugee children settled in developed countries, and to develop a theoretically informed intervention to address key health behaviours that impact on refugee children obesity. Methods: These research objectives were addressed through a series of four studies. Firstly, a systematic review that synthesised the literature to identify the factors that influence health behaviours related to obesity in refugee families with young children after their resettlement in the developed countries. The second was a qualitative study (N=27), that built on the review, to investigate refugee parents’ experiences and perspectives regarding the health behaviour changes (i.e. changes in diet, levels of physical activity) of their young children. The third study developed an intervention (Be healthy) informed by the Behaviour Change Wheel and based on findings from the first two studies, as well as Public patients involvements (PPI) and stakeholder involvement. The final study (N=23), that aimed to refine the intervention through assessing its acceptability to the targeted population. Findings: The data synthesis process revealed, several factors that influence the health behaviours of children. Several factors contributed to unhealthy food choices, including poor food literacy, increasing availability of unhealthy foods, and decreasing availability of healthy foods. There were multiple factors linked to overconsumption of food, including temptation from increased variety and abundance of food that is greater than in their home countries, as well as reacting to previous food insecurity by overeating while food was available. There were several factors related directly to physical activity, including poor weather, labour saving devices, and lack of value given to sporting activities. The review also revealed the parental practices that influence the health behaviours of children, especially those aged 2 to 10 years. The results suggested a need to understand further the role that parents have in influencing the health behaviours and weight trajectories of children following resettlement. Finding from qualitative interviews revealed that parents face substantial changes to their lifestyle and personal context, including restricted living space, restricted neighbourhood/community and inclement weather. These environmental differences required parents to adjust their roles and practices around their own and their children’s eating habits. These changes influenced refugee children’s health behaviours. Of particular concern to parents were increased sedentary behaviour and consumption of unhealthy snacks. Parent's beliefs about relevant health behaviours included cultural beliefs regarding body shape, perception that the new environment is restricted and unsafe and issues with knowledge about and trust in, the food in the host country. These beliefs have influenced the parents and their children’s diet and level of physical activity, shaping the ways that they interact with their new living environment. These findings suggest targeting these behaviours in tailored interventions may improve the health of refugee children. Using the COM-B model and Theoretical Domains Framework to guide the behavioural diagnosis, findings suggested that behaviour changes should be targeted at Psychological Capability, Physical Opportunity, Reflective Motivation and Social Opportunity. This resulted in the design of a four-week family-based intervention, “Be healthy”, that targeted snacking and sedentary behaviours. The final study found that the intervention was acceptable. Parents had a positive attitude towards attendance and perceived that the programme was effective in motivating and initiating behaviour change. Suggested changes to further refine the “Be healthy” intervention that more positive experiences and solutions be shared, more photos be included in the booklet to enhance accessibility, and improvements be made to the referral process in order to make potential participants more aware of the level of difficulty. Conclusion: Children in refugee families are at risk of increased sedentariness and unhealthy snacking post-settlement. An intervention targeted at parents that takes into account their complex and unique challenges, as well as their cultural background, is acceptable. Future research should determine the effectiveness of “Be healthy” within this setting using a randomised controlled trial, with feasibility studies being required to determine its transferability to other contexts.