Childhood obesity: Qualitative research with key ethnic minority groups
Summary of findings
The Cultural Context
It was clear from the first phase of this research that Black African, Bangladeshi and Pakistani families had a different set of priorities for their children compared with the mainstream population covered by the previous 2CV qualitative research. This had an impact on their behaviour with respect to diet, healthy eating and physical activity levels. The main priorities for most parents were their children’s education, both mainstream and faith based, and their religious and cultural values.
By contrast, most parents from the Gujerati Hindu, Punjabi Sikh and Black Caribbean communities had priorities that encompassed all aspects of their children’s lives. Whilst education was a key priority for these parents, they also had other aspirations; many parents talked of their desire to see their children also achieve in other spheres such as sports and music, for them to enjoy their childhood and to have access to a wide range of opportunities (educational, social and leisure). This evidently had an impact on attitudes to diet and exercise for children and the whole family; food was less central to the lives of these families and there were fewer restrictions to the time available for children to be active.
We observed more authoritarian parental styles amongst many Bangladeshi, Pakistani and Black African parents which resulted in greater control being exercised over the lives of their children and the freedom and time they had for activity. Freedom and independence for their children were not seen as important for parents from these three communities. To counteract this, many parents loosened control over their children’s diet. Because of this, children were able to exercise their choice for Western convenience, processed and fast foods. Amongst most Gujerati Hindu, Punjabi Sikh and Black Caribbean parents, parenting styles were typically less rigid and more relaxed. Parents tended to be quite receptive to the specific needs and wants of their children although respect for elders and family as well as discipline were also deemed important.
The Impact of Faith
Religious faith played a central role in the lives of many parents researched in phase 1 of the research. Muslim children and parents adhered strictly to food requirements and children were expected to attend regular religious instruction classes. This impacted on the time available for children to participate in other activities.
Whilst religion played a part in the lives of many Gujerati Hindus and Punjabi Sikhs, this was more likely to be practiced as a personal experience and appeared to make less demands on everyday lives compared with Muslims from phase 1. However, there were some dietary requirements with respect to not eating meat for many Gujerati Hindus and the avoidance of beef for Gujerati Hindus and Punjabi Sikhs.
Religion played a largely peripheral role in the day to day lives of the Black Caribbean families in the sample.
The Role of Fathers
Typically, Bangladeshi, Pakistani and Black African fathers’ roles in bringing up their children was fairly limited. Bangladeshi, Pakistani and many Black African men were culturally not expected to be involved in the day to day lives of their children. Their roles were quite traditional: being the main breadwinner for the family and ensuring that education and religious priorities for their children were taken care of.
By some comparison, there was evidence of less traditionally defined gender roles amongst Gujerati Hindu, Punjabi Sikh and Black Caribbean (where fathers were present) households. There was greater interest in all aspects of their children’s lives including health and fitness and greater involvement in their day to day lives.
Impact of Extended Family Members
In traditional Bangladeshi and Pakistani families, the elders in the family, especially if living within the same households, had a significant impact on how children were brought up in terms of their diet and physical activities. In these families, grandparents saw it as their right to indulge their grandchildren and to restrict outside activity, particularly for female children and women.
Extended families were less prevalent in the Gujerati Hindu and Punjabi Sikh samples. However, in the few extended family households in the sample, family elders were typically positive role models; they were often well educated and open minded themselves and those with weight related health problems tended to encourage more positive lifestyles for all the family.
Attitudes to Health and Weight
Many Bangladeshi, Pakistani and Black African parents tended to define their children’s health in rational and physical terms. Their children were considered healthy if there were no obvious signs of illness and if they appeared generally alert. By contrast, a number of Gujerati Hindu, Punjabi Sikh and Black Caribbean parents took a more holistic approach to their children’s health. Health was defined on a number of levels by these parents, in terms of emotional, psychological and physical well being.
Amongst many older Bangladeshi, Pakistani and Black African adults and a small minority of Black Caribbeans, a child that was relatively big in size was perceived to be healthy because this was seen, culturally, as a sign of wealth and status. Health professionals suggested that this was a major barrier to encouraging changes in behaviour amongst families where older family members exerted strong influence.
In the absence of any outward signs of weight issues and health risks, many parents from the phase 1 sample generally did not recognise the importance of a healthy lifestyle for their children’s current and future health. Health experts suggested that children’s weight became a concern for parents as they started secondary school. This was when worries tended to arise about children being bullied at school and not being able to take part in school activities. However, a number of parents from phase 2 of the research were much more aware of the link between current lifestyles and their children’s future health.
There was relatively high awareness of adult obesity across the six communities. This was because some adults in the sample had weight related health problems and most had relatives with serious illnesses such as heart disease and high blood pressure. Amongst a number of Bangladeshi, Pakistani and Black African adults there was some attempt to modify their diet and but there was little evidence of any increase in activity levels. Also, typically, this did not translate into changes in the diet and activity levels for children. However, many Gujerati Hindu, Punjabi Sikh and Black Caribbean parents were aware of the long term risks of poor lifestyles for themselves and the need for healthy foundations for their children. Many of these parents had made positive changes to their and their children’s lifestyles although this was less evident amongst Black Caribbeans from lower SEGs.
Amongst Bangladeshi, Pakistani and Black African parents, there was generally little acknowledgement of childhood obesity. Whilst a few parents recognised that childhood obesity was rising within their ethnic groups, others failed to recognise this as a problem for their own children. This was because there was no real understanding of when a child is of a healthy weight, when a child is overweight and what exactly constitutes obesity. Also, there was little motivation for parents to change their behaviour with respect to their children’s diet and activity levels in the absence of any outward signs of health risks. Gujerati Hindu, Punjabi Sikh and Black Caribbean parents were more likely to acknowledge the rising incidence of childhood obesity. However, many parents did not necessarily perceive their own children to be at risk, either because they believed that they were already actively focussed on the family’s health or that there were no outward signs of weight problems amongst their children.
A few parents across all six communities did have children whose weight was a concern for them and these parents recognised that it was more difficult to tackle weight issues once children were becoming teenagers as their food habits were harder to change and emotional problems were setting in. Health experts from phase 1 confirmed that parents generally did not seek advice until their children’s weight was more problematic. They also suggested that any attempts by Bangladeshi, Pakistani and Black African parents to instil better eating habits were often undone by elders in the family. Those Gujerati Hindu and Punjabi Sikh families who had children with weight problems were taking active measures to address these by introducing healthier diets and increasing physical activity levels for these children. However, one Black Caribbean parent with a daughter defined as obese did not acknowledge her daughter’s weight as a serious issue.
Although many parents across the six communities did not always recognise childhood obesity as an issue of direct relevance to them, the research showed that it was possible to talk to ethnic minority parents directly about childhood obesity and the associated risks. Unlike the mainstream sample researched by 2CV, clear and direct messages were much more motivating and more likely to grab parents’ attention. Parents were interested in the long term health risks of a poor lifestyle and the long term benefits of healthier choices especially if communication messages were framed around their children’s future success.
Food and Physical Activity
Most families from phase 1 and 2 except Black Caribbeans tended to eat regular cultural family meals cooked from scratch using fresh ingredients. However, amongst many Bangladeshi, Pakistani and Black African households these were usually cooked in traditional ways and were generally not adapted to make them healthier. Many Gujerati Hindu and Punjabi Sikh mothers had adapted their cooking methods and were using a variety of kitchen equipment such as fat reducing grills and pressure cookers in an attempt to prepare healthier cultural meals.
Limited levels of physical activity were observed amongst many Bangladeshi, Pakistani and Black African adults and children and some from the Black Caribbean community. This may have been because physical activity was largely defined as organised exercise and many parents felt that this was not a key part of their cultural lives. Whilst some people claimed they walked whenever possible with their children and they recognised the importance of being active, lack of time, general tiredness and the weather were consistently given as reasons for low activity levels.
Amongst many of these families there appeared to be little free time given to children to take part in physical activity. Religious education and extra tuition were given precedence by Muslim parents. However, some younger Bangladeshi, Pakistani and Black African fathers did encourage their children, especially boys, to take part in sports out of school hours.
We observed higher levels of physical activity amongst many Gujerati Hindu, Punjabi Sikh and some Black Caribbean children and adults. Children in these households were engaged in a wide range of structured activities outside of school and were given more freedom for unstructured play in the garden, on the roads outside the house and in local parks.
A combination of low levels of physical activity, high consumption of Western snacks/fast foods and unhealthy traditional family meals highlighted particularly poor lifestyles amongst some elements of the samples in phases 1 and 2:
- Bangladeshi and Pakistani mothers born and brought up in the UK for whom English language difficulties and lack of authority over their children’s health were key barriers to a healthier family diet;
- and older, more traditional Black African mothers whose sense of cultural isolation from mainstream society, a more traditional approach to family foods and their apathetic attitude to their children ‘s diet and physical activity levels were reasons for poor lifestyles;
- more complacent parents across all six communities who took a more ‘hands off’ approach to parenting resulting in parents under-estimating of the amounts of snacking and Western fast foods their children were consuming and over-estimating their levels of physical activity.
By contrast, some younger Bangladeshi and Pakistani women brought up in the UK, younger Black African women and the more integrated Gujerati Hindu, Punjabi Sikh and Black Caribbean women were more interested in issues around healthy lifestyle, diet and exercise. These groups were encouraging their children to be healthier and more active but, for some, busy lifestyles were given as reasons why their children’s diet was not as healthy as it could have been and children were not as active as mothers would have liked.
Attitudes & Behaviour: Key Typologies
It was clear that ethnic minority parents in the samples in phase 1 and 2 of the research did not fit with the six clusters identified by TNS in the previous quantitative research. Whilst there were some correlation between attitudes and behaviours with demographics these were not clear cut especially amongst Pakistanis and Bangladeshis. Economic status had some impact on attitudes and behaviours amongst the Black African, Gujerati Hindu, Punjabi Sikh and Black Caribbean samples.
However, on considering the samples from phases 1 and 2, four broad types of parents emerged in terms of diet and physical activity behaviour. A number of these typologies were also observed amongst the mothers researched as part of the Ethnic Minority Baby and Toddler Nutrition research conducted by Ethnic Dimension during January and March 2008. The four typologies are: Modern Adapters, Complacent Parents, Traditional Parents and Anxious Parents. Detail around these is outlined in the full report.
Awareness of Current Health Messages
Across the entire sample, there was awareness of the Government’s health messages on diet, and to some extent, physical exercise. For Bangladeshi and Pakistani mothers brought up abroad and older, more traditional Black African mothers this was mainly from information provided by schools and advice from health professionals such as doctors and health visitors.
Other Bangladeshi, Pakistani and Black African mothers and most Gujerati Hindu, Punjabi Sikh and Black Caribbean mothers were able to access mainstream messages because language and comprehension were not problematic for them. However, for many mothers in phase 1 and some in phase 2 (mainly Complacent and Traditional mothers) there was some difficulty in knowing how to translate these messages into the specific changes they needed to make to their family’s diet and exercise levels.
Health Professionals’ Perspective
There was a great deal of consistency between health professionals regarding what they saw as the key causes of childhood obesity and the barriers they encountered in trying to communicate healthy diet and exercise messages. Health professionals suggested that Bangladeshi, Pakistani, Black African and Black Caribbean families and more traditional Gujerati Hindu and Punjabi Sikh families were at greatest risk.
Generally, a majority of health professionals confirmed that the key causes of childhood obesity were poor family diets, the high consumption of Western snacks, convenience and fast foods and the low levels of physical exercise. Most health professionals felt that a number of cultural barriers would need to be overcome in order to change attitudes and behaviour amongst the target ethnic minority communities.
Responses to Additional Stimuli
Branding (Phases 1 & 2)
A number of organisations were presented which could communicate with the target ethnic minority audiences on messages regarding childhood obesity. Across the board there was rejection of a dedicated body because a majority of the sample were generally unclear about who these organisations were and how they might operate. The NHS was preferred by most across all six communities as the most credible organisation. This reflected the general trust placed by people from these ethnic minority communities in the health profession. A number of Bangladeshis and Pakistanis mentioned that communications via Sure Start could also be effective because they were familiar with the organisation and many had used its’ services.
The Movement (Phase 2 only)
Interest in the Movement as a communication device, as presented to participants in this research, was generally limited amongst Gujerati Hindu, Punjabi Sikh and Black Caribbean parents. Some parents felt there was little need because they were already following good practice. Others were less familiar with accessing information in this way. However, there was some interest in finding out about local activities and the money off vouchers.
5- 2-1-0 (Phases 1 & 2)
Parents were also shown the new 5-2-1-0 idea designed to raise awareness of the daily guidelines for diet and physical activity. Most parents across the six ethnic minority groups liked the overall idea because guidelines were presented in a simple, clear and easy to understand way. The information about what parents need to do in terms of their children’s diet and activity levels was seen as useful. However, more detailed information was seen as desirable.
- The primary research objective was to provide a detailed understanding of cultural issues and the impact of these on awareness, knowledge and attitudes towards healthy eating and physical exercise amongst the key ethnic minority audiences identified.
More specifically, there was a need to understand real behaviour with regard to eating a healthy diet and taking physical exercise and, in particular, understanding of:
1. Current awareness and understanding of:
- the concept of healthy eating and nutrition and how this relates to Western foods (including snacks and drinks) and traditional ethnic foods;
- the benefits of healthy eating and taking physical exercise;
- childhood obesity and the associated long term risks;
- medical views of definitions and dangers of obesity;
- sources of information.
2. Current attitudes towards concepts such as:
- obesity and being overweight in children and babies: is this understood and accepted as a potential risk;
- how are ‘healthy, ‘overweight’ and ‘obesity’ defined in relation to children and what influences these views;
- healthy eating and physical exercise and what impacts on this (e.g. culture, religion and family dynamics);
3. Current behaviour regarding:
- what is eaten: Western vs. traditional ethnic foods and the reasons for food choices;
- what constitutes snacks, after school meals, family meals and celebratory meals and why these;
- taking physical exercise: leisure activities undertaken and the role of exercise within this, any differences between family members and reasons for this;
- whether parents’/carers’ or children’s behaviours are different depending on where the child sits within the family or the age of the child;
4. What can affect changes in lifestyle, attitudes and behaviour:
appropriateness of mainstream intervention propositions;
- what specific barriers may need to be overcome for ethnic minority audiences;
- what messages, incentives and triggers could motivate ethnic minority parents and shift attitudes and behaviour;
- Who do these messages need to target: parents, children, key ‘influencers’ (e.g. extended family) and how.
Above all, the research needed to provide real insight into attitudes and behaviours and depth of understanding of the cultural, religious and family contexts that might impact on these.
Additionally, the research was required to highlight:
- differences and similarities between the different ethnic minority group targets;
- any differences and similarities between the ethnic and mainstream samples;
- whether the six ‘clusters’ identified amongst the mainstream sample had any relevance for the ethnic sample.
There has been concern regarding the rising number of overweight and obese people within the population which is having a profound affect on the nation’s health, with obesity affecting a growing number of children.
The Government’s Health White Paper, Choosing Health: making healthier choices easier sets out the commitment for action on obesity including stemming the rise in obesity amongst children under the age of eleven.
This reflects the Public Service Agreement shared by the Department of Health, DCSF and DCMS to halt the year on year rise in obesity amongst children aged two to eleven years old by 2010 in the context of a wider strategy to deal with obesity in the population as a whole.
In March 2007 the Department of Health launched the Obesity Social Marketing Programme with an aim to reach families with children aged between two and eleven.
This programme relies on sound understanding of parental behaviours, attitudes and barriers to change. Research findings on these issues for the mainstream population include major quantitative and qualitative studies which aim to inform the delivery of the Marketing Plan.
People from ethnic minority communities have been recognised as a key audience for the various elements of the Social Marketing Programme as obesity related diseases e.g. coronary heart disease and diabetes are more prevalent amongst key ethnic minority groups. Childhood obesity amongst key ethnic minority communities is also a major concern. For example, the findings from the National Diet and Nutrition Survey of young people aged between four and eighteen found that Asian children are four times more likely to be obese than white children.
In 2007, the COI Diversity Unit conducted a scoping exercise to review parental attitudes towards diet and physical activity amongst a range of ethnic minority communities.
This review identified the need for specific and detailed research amongst a number of priority ethnic minority communities to understand parental attitudes and behaviours towards their children’s diet and physical activity. The COI’s Diversity Team also highlighted the fact that mainstream messages and interventions may not be relevant or appropriate for ethnic minority audiences. It was felt to be important that future messages and interventions are culturally relevant and motivating to affect changes in attitudes and behaviour regarding healthy eating and exercise amongst the key ethnic minority groups. There was further need to research communications needs amongst these communities.
The main priorities for Black African, Bangladeshi and Pakistani parents were their children’s education, both mainstream and faith based, and their religious and cultural values. By contrast, most parents from the Gujerati Hindu, Punjabi Sikh and Black Caribbean communities had priorities that encompassed all aspects of their children’s lives. There was relatively high awareness of adult obesity across the six communities. However, Amongst Bangladeshi, Pakistani and Black African parents, there was generally little acknowledgement of childhood obesity. Gujerati Hindu, Punjabi Sikh and Black Caribbean parents were more likely to acknowledge the rising incidence of childhood obesity. Although many parents across the six communities did not always recognise childhood obesity as an issue of direct relevance to them, the research showed that it was possible to talk to ethnic minority parents directly about childhood obesity and the associated risks. Clear and direct messages were much more motivating and more likely to grab parents’ attention. Parents were interested in the long term health risks of a poor lifestyle and the long term benefits of healthier choices especially if communication messages were framed around their children’s future success.
Black African, Bangladeshi, Pakistani, Black Caribbean, Gujerati Hindu and Punjabi Sikh.
Families so range of ages. Main focus mothers with children aged 2-11.
Given the complex nature of this research, it was felt that a number of methodologies and approaches would be required in order to meet the research objectives. During the first phase, researching the Black African, Bangladeshi and Pakistani communities, four stages of research were conducted. Two of these stages were replicated for the second phase of research amongst the Gujerati Hindu, Punjabi Sikh and Black Caribbean communities.
Ethnographic family home visits
Phase 1: Six home visits were conducted amongst the three ethnic minority communities. A total of eighteen home visits were completed. Before each visit, mothers and any children over the age of six were asked to complete a pre-task diary (see appendix). The mothers’ task was designed as a record of the family’s meals over a one week period. Children were asked to write and draw the foods they liked, foods they disliked, the things they liked to do and the things they did not enjoy. This would provide insights into the types of foods children would choose to eat; their preference for healthy versus less healthy foods and the things they did in their free time.
This was followed by a home visit to each family and included an accompanied shopping trip with the family/family member responsible for the household’s groceries to any shops (including ethnic grocery stores) they routinely used.
Each home visit took approximately five to six hours. The ethnographic element was designed to allow us to observe the family ‘going about their normal business’, to sit in on a family meal and to see how family members interacted with each other. The purpose of this was to allow actual behaviour to be observed rather than claimed behaviour. This was then followed by short discussions with parents as well as children over the age of six. Other family members living with the household were also interviewed where possible. These discussions elicited the attitudes of different family members to diet, food and physical exercise.
Phase 2: Six home visits were conducted amongst each of the three communities: Gujerati Hindu, Punjabi Sikh and Black Caribbean. Each home visit was four hours long as the accompanied shopping trips were not undertaken for this phase of research (as it was agreed that shopping behaviour was unlikely to differ from that amongst the first three communities).
‘Gallery Visits’ (Phase 1 only)
These visits explored the responses of women and children between the ages of eight and eleven to a number of stimuli. They were taken (separately) around a number of ‘installations’ or visuals which comprised of:
- a display of current health messages;
- a collage of celebration foods and more ‘everyday’ foods (both ethnic and Western);
- a collage of physical activities that were appropriate for women and children;
- a visual display of a range of physical and sedentary activities for children to identify the types of activity they were involved with and those that they would like to participate in.
Small group discussions (Phase 1 only)
A number of mini group discussions were conducted amongst mothers of children between the ages of two and eleven as well as a number of paired depths with fathers. Propositions developed for the mainstream sample and adapted for the ethnic sample were tested as well as a number of other communications messages.
Health Expert Interviews (Phase 1 and 2)
A number of individual depth interviews were undertaken amongst health visitors and other professionals involved in health promotion work. These experts were identified as those who provided advice on diet, nutrition and health for families for all six target ethnic minority communities.
Data collection methodology
Other data collection methodology
- 36 home visits
- 12 children paired depths (n=24)
- 6 mum mini groups (n=24)
- 6 dad paired depth (n=12)
- 9 health experts
- 5 x community health promotion workers
The audiences were based in London, Birmingham and Leicester.
June - July 2008