Abstract:

Objective:

To identify strengths, weaknesses, opportunities, and threats (SWOT) perceived by childcare staff for preventing childhood overweight.

Materials and methods:

Qualitative study using an interpretative phenomenological approach; 18 in-depth, semi-structured interviews and 12 focus groups with 89 key informants working in six Mexican public childcare centers (CCC) were conducted. Through content and SWOT analyses, experts further ranked fifty-nine recurrent perceptions regarding healthy feeding and physical activity (PA), using the Delphi method.

Results:

Strengths: Acknowledgement of the CCC’s responsibility in fostering healthy feeding, availability of organizational regulations, and access to PA infrastructure/indoor activities. Weaknesses: Disregard of preschool overweight as a health problem, nutritional misperceptions, and perceived risk of child injuries while conducting PA. Opportunities: Willingness to reduce children’s access to junk foods, and parental active play with children during weekends. Threats: Limited family nutritional education, and restricted parental time/economic constraints/access to safe public spaces for PA.

Conclusion:

The identified SWOT must be considered when developing obesity-prevention interventions targeted at CCC.

Keywords:
preschool; overweight; child care; day care; healthy diet; exercise

Resumen:

Objetivo:

Identificar fortalezas, debilidades, oportunidades y amenazas (FODA) percibidas por personal de guarderías, para prevenir sobrepeso en preescolares.

Material y métodos:

Estudio cualitativo con enfoque fenomenológico interpretativo en seis guarderías públicas de la Ciudad de México. Se realizaron 18 entrevistas semiestructuradas a profundidad y 12 grupos focales con 89 directivos y trabajadores. Mediante análisis de contenido y FODA se identificaron 59 percepciones sobre alimentación y actividad física (AF), jerarquizadas por expertos mediante el método Delphi.

Resultados:

Fortalezas: Reconocimiento del potencial de guarderías en promover alimentación saludable, disponibilidad de reglamentos y acceso a infraestructura/práctica de AF en interiores. Debilidades: No se considera el sobrepeso infantil como un problema de salud, baja alfabetización nutricional y percepción de riesgo de lesiones al practicar AF. Oportunidades: Voluntad de limitar acceso a alimentos chatarra y estimular a padres e hijos a realizar juegos activos en fines de semana. Amenazas: Limitada orientación alimentaria y restricciones temporales/económicas/de acceso a espacios seguros para AF.

Conclusión:

Las FODA identificadas deben considerarse en las intervenciones para prevenir el sobrepeso en guarderías.

Palabras clave:
preescolar; sobrepeso; cuidado del niño; centro de atención diurna; dieta saludable; ejercicio

Introduction

In recent decades, changes in the patterns of childcare have been remarkable due to the progressive incorporation of women into the paid labor market outside of the home, including mothers with young children.¹1. del Boca D. Child care arrangements and labor supply. IDB Working Paper Series 569. Washington, D.C: Inter-American Development Bank. 2015;35. [cited 2017 May 19]. Available from: https://publications.iadb.org/handle/11319/6812
https://publications.iadb.org/handle/113... These social changes have resulted in an increased demand for childcare centers (CCC) worldwide. In 2014, the Organization for Economic Cooperation and Development reported that in incorporated countries, 35% of children <3 years of age, on average, attended a CCC.²2. Organization for Economic Cooperation and Development. LMF2.2: Patterns of employment and the distribution of working hours for couples with children. Paris, France: Social Policy Division, 2016. This value varies by country from <10 to >60%, reflecting differences in family, institutional, and cultural structures among the countries that are relevant for child development and health.³3. O’Dea JA, Ericksen M. Approaches to prevention. In: O’Dea JA, Ericksen M, eds. Childhood obesity prevention: international research, controversies, and interventions. New York: Oxford University Press, 2010:195-238. https://doi.org/10.1093/acprof:oso/9780199572915.001.000
https://doi.org/10.1093/acprof:oso/97801... In Mexico, the number of children attending public CCC is increasing each year. In 2015, >190 000 preschool children of working mothers were enrolled in public CCC that are run by the largest public health care system in Mexico, which provides health and social care to approximately 45% of the national population.⁴4. Instituto Mexicano del Seguro Social. Informe al Ejecutivo Federal y al Congreso de la Unión sobre la situación financiera y los riesgos del Instituto Mexicano del Seguro Social 2015-2016. México: Instituto Mexicano del Seguro Social, 2016. [cited 2017 Jan 18]. Available from: http://www.imss.gob.mx
http://www.imss.gob.mx...

Child overweight represents a burden to the individual, society, and health services, evidencing the need for conducting opportune preventive interventions, including those targeted to CCC. In developed countries, approximately 12% of children <5 years old are overweight, whereas in developing countries, 6.1% of preschool children, on average, have this condition.⁵5. de Onis M, Blössner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clinical Nutr. 2010;92:1257-64. https://doi.org/10.3945/ajcn.2010.29786
https://doi.org/10.3945/ajcn.2010.29786... Environmental and personal factors are relevant to prevent child overweight by promoting healthy feeding and physical activity (PA), in preschool children. Some studies have documented that CCC caregivers can be aware and concerned about child overweight, showing positive attitudes and practices for promoting healthy feeding and active play.⁶6. Pagnini D, King L, Booth S, Wilkenfeld R, Booth M. The weight of opinion on childhood obesity: recognizing complexity and supporting collaborative action. Int J Pediatr Obes. 2009;4(4):233-41. https://doi.org/10.3109/17477160902763333
https://doi.org/10.3109/1747716090276333... ^,77. Bleich SN, Bandara S, Benett W, Cooper LA, Gudzune KA. U.S. health professionals’ views on obesity care, training, and self-efficacy. Am J Prev Med. 2015;48(4):411-8. https://doi.org/10.1016/j.amepre.2014.11.002
https://doi.org/10.1016/j.amepre.2014.11... In contrast, other studies have shown that CCC caregivers may discourage healthy behaviors and overlook opportunities for promoting PA.⁸8. Larson N, Ward DS, Neelon SB, Story M. What role can child-care settings play in obesity prevention? A review of the evidence and call for research efforts. J Am Diet Assoc. 2011;111(9):1343-62. https://doi.org/10.1016/j.jada.2011.06.007
https://doi.org/10.1016/j.jada.2011.06.0... ^,99. Moore DA, Goodwin TL, Brocklehurst PR. When are caregivers more likely to offer sugary drinks and snacks to infants? A qualitative thematic synthesis. Qual Health Res. 2017;27(1):74-88. https://doi.org/10.1177/1049732316673341
https://doi.org/10.1177/1049732316673341...

Aside from previous studies, there is limited empirical evidence about the perceptions of CCC staff regarding their personal and organizational capacity for preventing child overweight. Therefore, this study aims to identify significant strengths, weaknesses, opportunities, and threats (SWOT) that are relevant to foster healthy feeding and PA, derived from the perceptions of five types of staff working at Mexican public CCC. This study will provide evidence for designing CCC interventions for preventing overweight in preschool children of working mothers.

Materials and methods

Study design and sampling

A cross-sectional qualitative study was conducted based on an interpretative phenomenological approach ¹⁰10. Masrour F. Phenomenal objectivity and phenomenal intentionality: In defense of a Kantian account. In: Kriegel U, editor. Phenomenal Intentionality. New York: Oxford University Press , 2013:116-36. [cited 2016 Nov 18]. Available from: https://philarchive.org/archive/MASPOA-4v2
https://philarchive.org/archive/MASPOA-4... to explore the CCC staff’s perceptions, as derived from their daily experiences with and perspectives on two main components: child feeding and PA in the social context of a CCC. This study was conducted in Mexico City from October 2010 to February 2012. A total of six public CCC located in four different regions of the city were purposefully selected from the 51 CCC that are run by the largest public health care system in Mexico,⁴4. Instituto Mexicano del Seguro Social. Informe al Ejecutivo Federal y al Congreso de la Unión sobre la situación financiera y los riesgos del Instituto Mexicano del Seguro Social 2015-2016. México: Instituto Mexicano del Seguro Social, 2016. [cited 2017 Jan 18]. Available from: http://www.imss.gob.mx
http://www.imss.gob.mx... based on strategic inclusion criteria:¹¹11. Kuzel AJ. Sampling in qualitative inquiry. In: Crabtree BF, Miller WL, Eds. Doing qualitative research, 2nd ed. Thousand Oaks, CA: Sage Publications, 1999: 33-45. having at least 40 registered preschool children, and being the first CCC in accepting voluntary participation in each of the study regions. These facilities provide childcare services to working mothers of children aged from 43 days old to 5 years of age. Children receive two to three hot meals during the 8- to 10-h period that they spend at the facility. All CCC have similar physical infrastructure and organizational regulations.⁴4. Instituto Mexicano del Seguro Social. Informe al Ejecutivo Federal y al Congreso de la Unión sobre la situación financiera y los riesgos del Instituto Mexicano del Seguro Social 2015-2016. México: Instituto Mexicano del Seguro Social, 2016. [cited 2017 Jan 18]. Available from: http://www.imss.gob.mx
http://www.imss.gob.mx...

The director, teacher, and dietitian from each CCC were invited to participate as key informants, and a purposive sample, composed of caregivers and kitchen staff was selected. The inclusion criteria were CCC workers in the contractual categories of interest, voluntary participation, and theoretical saturation; there were no exclusion criteria. To recruit the study participants, an introductory meeting was conducted in each CCC. The researchers informed the staff of the aims of the study, the data collection procedures, and the ethical considerations.

Data collection

Focus groups and semi-structured in-depth interviews were conducted at each facility. These techniques were selected based on the wealth and depth of information that can be obtained.¹²12. Ritchie J, Lewis J, McNaughton C. Qualitative research practice a guide for social science students and researchers. 2nd ed. London: Sage Publications, 2014: 131-8. No repeated interviews were performed with the directors, dietitians, and teachers. The focus groups were independently conducted with the CCC caregivers and kitchen staff.

A semi-structured interview guide was developed for the interviews and the focus groups, based on the literature and the previous experiences of the researchers in the study setting. The main inquiry topics were child feeding and PA, specific topics were: 1) Caregiving routines inside and outside of the facility and their potential impact on preventing child overweight, 2) Self-perception of capacity, skills, and accountability to foster healthy environments, 3) Parental involvement with the CCC staff and communication strategies with parents and relatives, 4) Views and expectations about the CCC’s organizational regulations, 5) The CCC’s physical environment, and 6) Proposals to promote healthy behaviors. The questions were intended to be suggestive and not prescriptive; the participants were encouraged to address the emerging topics anytime during the sessions. The interview guide was pilot tested on a local CCC and some questions were adjusted for content and reworded to include local terminology.

Two researchers experienced in qualitative data collection conducted the sessions face-to-face, in Spanish, during working hours at the workplace, in a private room at the director’s office or in a classroom, and neither the CCC director nor other institutional representatives were present. The researchers took field notes during the sessions which were audio recorded and were later transcribed verbatim. The interviews lasted 50 min, the focus groups lasted 93 min, on average, and six participants attended each focus group, on average. Before initiating these sessions, the participants were asked to answer a socioeconomic questionnaire that was comprised of eight questions.

Data analysis

A content analysis was conducted in which the researchers approached the discourse of the participants with an initial understanding that came from their prior knowledge and personal experience.¹³13. Bos W, Tarnai Ch. Content analysis in empirical social research. International Journal of Educational Research. 1999;31(8):659-71. https://doi.org/10.1016/S0883-0355(99)00032-4
https://doi.org/10.1016/S0883-0355(99)00... Initially, two researchers verified the quality of the transcripts by comparing the audio recording with the texts and their field notes. A codebook was independently developed by these researchers following an analytical process of a circular structure of understanding,¹³13. Bos W, Tarnai Ch. Content analysis in empirical social research. International Journal of Educational Research. 1999;31(8):659-71. https://doi.org/10.1016/S0883-0355(99)00032-4
https://doi.org/10.1016/S0883-0355(99)00... looking for theoretical connections, new insights, and unit meanings within and across the transcripts. The main themes were grouped into 11 categories and the identified sub-themes were coded to integrate a coding tree. To enhance data quality, an inter-coder exercise was performed obtaining 92% of agreement. Subsequently, the transcripts were coded by two researchers using the Ethnograph v.5 software, and emerging themes were added into the coding tree.

The perceptions on child feeding and PA were registered in five conceptual matrices, one for each type of participant. Two researchers identified the recurrent perceptions (those mentioned by at least two of the five types of participants) and researchers conducted SWOT analysis by categorizing these perceptions accordingly.¹⁴14. Kipley D, Lewis AO, Jeng JL. Extending Ansoff´s strategic diagnosis model: defining the optimal strategic performance-positioning matrix. Sage Open. 2012;2(1):1-14. https://doi.org/10.1177/2158244011435135
https://doi.org/10.1177/2158244011435135... The strengths and opportunities included the perceptions that may have a positive influence on child feeding and PA behaviors, while the weaknesses and threats included those that may have a negative influence on these behaviors. The interpretation of the results was performed in Spanish and was later translated into English. A report with the meanings inherent to the participants’ experience was developed, and its compliance with the “Consolidated criteria for reporting qualitative research” was verified to enhance the quality and transparency of the study.¹⁵15. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57. https://doi.org/10.1093/intqhc/mzm042
https://doi.org/10.1093/intqhc/mzm042...

To identify the key SWOTs that are relevant for the design of interventions to prevent child overweight in CCC, an expert consultation was carried out using the modified Delphi method.¹⁶16. Okoli Ch, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Information & Management. 2004;42(1):15-29. https://doi.org/10.1016/j.im.2003.11.002
https://doi.org/10.1016/j.im.2003.11.002... A group of nine experts on the prevention of child overweight from different disciplines (medicine, nutrition, psychology, and PA) independently ranked the identified perceptions about child feeding and PA, using a decimal scale from 0-1 point.

Ethical considerations

Written informed consent was obtained from the participants to conduct and audio record the interviews and focus groups. The research protocol was approved by both the Research Review Board at the public health institution where the study was carried out (2007-785-049) and the Research and Ethics Review Board of the National Institute of Public Health of Mexico (CE 832, Reg. 719).

Results

A total of 89 participants took part in the study; we conducted 12 focus groups with 39 caregivers and 32 kitchen staff, as well as 18 semi-structured in-depth interviews with six directors, six teachers, and six dietitians.

Characteristics of participants

The majority (81%) of the participants in the study were women; 19% were men and they corresponded to the kitchen staff. The age range of participants was 20 to 62 years old. The educational level of the caregivers and kitchen staff was 6 to 9 years whereas the directors, teachers, and dietitians had 12 or more years of education. Half of the participants had more than 10 years of labor seniority.

Perceptions of the CCC Staff

A total of 90 perceptions expressed by the five types of participants were identified. Of these, 59 recurrent perceptions (33 referred to child feeding and 26 to child PA) were classified into 18 strengths, 15 weaknesses, 11 opportunities, and 15 threats. Tables I to IV show the results of the Delphi analysis performed by the experts by weighing the CCC staff perceptions.

Child feeding perceptions

Table I shows the child feeding perceptions of the internal environment. The most important strength was the recognition by all types of participants about the responsibility and potential impact of CCC in fostering children’s healthy eating behaviors. Directors and teachers noted that the institutional child feeding regulations provide information on the managerial line and on their responsibilities and caregiving routines.

The main weakness was the lack of recognition that fostering healthy feeding behaviors from preschool age is relevant for preventing overweight. Some participants mentioned that sweetened beverages (i.e., juices and fruit-flavored sweetened water), are “suitable for children due to their acceptability and potential rejection to plain water”. The caregivers indicated that sugary foods (i.e., peaches in syrup, sugary cookies, and cereal with marshmallows), are offered at the facility and did not mention the potential consequences on child health from the overconsumption of sugary foods. To increase the variety of the CCC menus, the caregivers and kitchen staff proposed adding pancakes, vegetable cream soup, eggs with bacon, enchiladas and fried tacos with beans and cheese (Mexican dishes prepared with corn dole).

Table II shows the child feeding perceptions of the external environment. The opportunities relate to the staff’s perceptions that parents are receptive to accepting guidance on the type of foods they provide to children. However, some participants reported that some parents cannot offer to their children a variety of foods, due to the poor conditions under they live.

Finally, as a threat, most of the participants reported that the family environment can have a negative influence on the formation of healthy feeding behaviors in children:

Perceptions of physical activity

The willingness of the staff to receive training, accept changes in the current recreational routines involving PA, and the availability of adequate infrastructure and equipment for PA, were important strengths (table III).

One of the main weaknesses was the lack of awareness that a sedentary lifestyle is related to young child overweight. Among other weaknesses, the caregivers reported not feeling confident enough or having insufficient knowledge to establish PA routines. Most participants indicated that “when children engage in PAs, they are at risk of getting injuries, generating complaints from parents.” Some caregivers reported that in such cases, they could be disciplined.

Regarding the external environment (table IV), among the main opportunities about PA, it is believed that “parents value practicing PA with their children during weekends.” Directors, caregivers, and teachers, noted that children with supportive parents and relatives are the most active/agile children.

The most important threat is that parents lack the time to engage in PAs with their children during the evenings and weekends.

Directors and teachers noted as limiting factor for performing PA outside the CCC that several children must travel up to two hours using public transportation to arrive home.

Discussion

This study identified the significant perceptions of CCC staff regarding healthy feeding and PA, relevant for preventing preschool child overweight and for expanding current knowledge about caregiving routines, the physical environment, and organizational regulations, in Mexican public CCC.

In regards of the healthy feeding component, the recognition of the responsibility and potential impact of CCC in fostering child healthy feeding for preventing child overweight, is a key strength for capacity building in the CCC staff. Studies conducted with health providers and teachers showed that health personnel needs appropriate training for having skills to participate effectively in weight management programs.⁶6. Pagnini D, King L, Booth S, Wilkenfeld R, Booth M. The weight of opinion on childhood obesity: recognizing complexity and supporting collaborative action. Int J Pediatr Obes. 2009;4(4):233-41. https://doi.org/10.3109/17477160902763333
https://doi.org/10.3109/1747716090276333... ^,77. Bleich SN, Bandara S, Benett W, Cooper LA, Gudzune KA. U.S. health professionals’ views on obesity care, training, and self-efficacy. Am J Prev Med. 2015;48(4):411-8. https://doi.org/10.1016/j.amepre.2014.11.002
https://doi.org/10.1016/j.amepre.2014.11...

The availability of child feeding organizational manuals was identified as a key strength. According to Tolbert and Hall,¹⁷17. Tolbert PS, Hall RH. Organizations, structures, processes, and outcomes. New York, US: Routledge, 2016:261. https://doi.org/10.1093/intqhc/mzm042
https://doi.org/10.1093/intqhc/mzm042... the explicit division of responsibilities, the understanding of how work should be done, and the description of interpersonal coordination, may foster accountability of the staff, strengthening organizational performance. In contrast, some authors have pointed out that highly structured organizations may limit the flexibility for decision-making.¹⁷17. Tolbert PS, Hall RH. Organizations, structures, processes, and outcomes. New York, US: Routledge, 2016:261. https://doi.org/10.1093/intqhc/mzm042
https://doi.org/10.1093/intqhc/mzm042... ^,1818. Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011;378(9793):804-14. https://doi.org/10.1016/S0140-6736(11)60813-1
https://doi.org/10.1016/S0140-6736(11)60... Limited flexibility may determine staff capacity to consider individual feeding needs of children within the local context and eventually, turning out a strength into a weakness.

A key weakness identified in this study is the lack of awareness of the potential consequences of childhood unhealthy feeding. This perception that was shared by several participants and particularly by the CCC caregivers, might be detrimental for conducting preventive care actions at the facility as shown by Moore and colleagues.⁹9. Moore DA, Goodwin TL, Brocklehurst PR. When are caregivers more likely to offer sugary drinks and snacks to infants? A qualitative thematic synthesis. Qual Health Res. 2017;27(1):74-88. https://doi.org/10.1177/1049732316673341
https://doi.org/10.1177/1049732316673341... In addition, the beliefs of the staff that sweetened beverages and several energy-dense dishes are suitable for preschool children also emerged as a relevant weakness in this study. Misperceptions of caregivers regarding unhealthy feeding practices are consistent with previous reports.¹⁹19. Entin A, Kaufman-Shriqui V, Naggan L, Vardi H, Shahar DR. Parental feeding practices in relation to low diet quality and obesity among LSES children. J Am Coll Nutr. 2014;33(4):306-14. https://doi.org/10.1080/07315724.2013.874936
https://doi.org/10.1080/07315724.2013.87... ^,2020. Power TG, O’Connor TM, Fisher JO, Hughes SO. Obesity risk in children: The role of acculturation in feeding practices and styles of low -income Hispanic families. Child Obes. 2015;11(6):715-21. https://doi.org/10.1089/chi.2015.0036
https://doi.org/10.1089/chi.2015.0036... Overcoming this situation is particularly relevant in countries with a high prevalence of overweight and obesity such as Mexico,²¹21. Gutiérrez JP, Rivera-Dommarco J, Shamah-Levy T. Encuesta Nacional de Salud y Nutrición 2012. Resultados Nacionales. México: Instituto Nacional de Salud Pública; 2012:55-73. were the overconsumption of unhealthy foods by children have been consistently documented.²²22. Rivera-Dommarco JA, Perichart-Perera O, Moreno-Saracho J. Determinantes de la obesidad: marco conceptual y evidencia científica. (Sección 1) In: Rivera-Dommarco JA, Hernández-Ávila M, Aguilar-Salinas CA, Vadillo Ortega F, Murayama-Rendón C, eds. Obesidad en México: Recomendaciones para una política de Estado. México: Universidad Nacional Autónoma de México, 2012. Continuing training to caregivers should be implemented as a priority within the institutional obesity prevention programs.

The opportunities identified in our study clarify the importance of parental engagement to the staff in fostering healthy feeding behaviors in children. Cooperation and communication between parents and caregivers have been related to young children’s acquisition of social, motor, and adaptive skills that are relevant for healthy feeding.²³23. Weiss HB, Caspe M, Lopez ME. Family involvement makes a difference: evidence that family involvement promotes school success for every child of every age. Harvard Family Research Project Series. Harvard Graduate School of Education. 2006;1:1-8. [cited 2017 Jun 5]. Available from: http://5c2cabd466efc6790a0a-6728e7c952118b70f16620a9fc754159.r37.cf1.rackcdn.com/cms/Section3_1513.pdf
http://5c2cabd466efc6790a0a-6728e7c95211... Furthermore, encouraging partnerships between caregivers and parents might help reduce the exposure to energy-dense foods and to low-nutrient foods, common in the Mexican and the Latin-American family diet,²²22. Rivera-Dommarco JA, Perichart-Perera O, Moreno-Saracho J. Determinantes de la obesidad: marco conceptual y evidencia científica. (Sección 1) In: Rivera-Dommarco JA, Hernández-Ávila M, Aguilar-Salinas CA, Vadillo Ortega F, Murayama-Rendón C, eds. Obesidad en México: Recomendaciones para una política de Estado. México: Universidad Nacional Autónoma de México, 2012.^,2424. Montagnese C, Santarpia L, Lavarone F, Strangio F, Caldara AR, Silvestri E, et al. North and South American countries food-based dietary Guidelines: A comparison. Nutrition. 2017;(42):51-63. https://doi.org/10.1016/j.nut.2017.05.014
https://doi.org/10.1016/j.nut.2017.05.01... which also is influenced by mass media exposure to non-healthy food.²⁵25. González-Hidalgo C. Análisis de los alimentos publicitados entre la audiencia infantil en la televisión chilena. Salud Publica Mex 2017;59:691-700. https://doi.org/10.21149/7706
https://doi.org/10.21149/7706... This approach enables caregivers at the CCC to be aware of the cultural influences shaping family food-related beliefs, practices, and behaviors.²⁰20. Power TG, O’Connor TM, Fisher JO, Hughes SO. Obesity risk in children: The role of acculturation in feeding practices and styles of low -income Hispanic families. Child Obes. 2015;11(6):715-21. https://doi.org/10.1089/chi.2015.0036
https://doi.org/10.1089/chi.2015.0036...

The child feeding issues discussed above reveal the need for ongoing nutritional training of both the staff and families that is aimed at improving their “nutritional literacy,” awareness about the consequences of childhood overweight, skills for developing effective health communication strategies, and caring capacity.²⁶26. Redsell S, Edmonds B, Swift JA, Siriwardena AN, Weng S, Nathan D, et al. Systematic review of randomized controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood. Matern Child Nutr. 2016;12(1):24-38. https://doi.org/10.1111/mcn.12184
https://doi.org/10.1111/mcn.12184... Improving nutritional literacy might also encourage healthy individual feeding behaviors by the staff and parents.²⁷27. Gooze RA, Hughes CC, Finkelstein DM, Whitaker RC. Reaching staff, parents, and community partners to prevent childhood obesity in Head Start, 2008. Prev Chronic Dis. 2010;7(3):1-9. [cited 2017 Jul 24]. Available from: http://www.cdc.gov/pcd/issues/2010/may/09_0115.htm
http://www.cdc.gov/pcd/issues/2010/may/0... The latter is relevant to children’s role modeling, as the observational learning of significant others may build up or discourage desirable feeding beliefs and behaviors in young children.²⁸28. Erinosho TO, Hales DP, McWilliams CH, Emunah J, Ward DS. Nutrition policies at child-care centers and impact on role modeling of healthy eating behaviors of caregivers. J Acad Nut Diet. 2012;112:119-24. https://doi.org/10.1016/j.jada.2011.08.048
https://doi.org/10.1016/j.jada.2011.08.0... ^,2929. Bandura A. Social Cognitive Theory in cultural context. Appl Psych. 2001; 51(2):269-90. https://doi.org/10.1111/1464-0597.00092
https://doi.org/10.1111/1464-0597.00092...

In regards of the PA component, several environmental factors of the CCC, such as access to adequate PA infrastructure, activity-friendly didactic material, and the encouragement of both indoor and outdoor recreational activities by teachers and caregivers, were identified as key strengths. Consistently, some authors have found that the suitability of the PA space, the teacher’s encouragement, and the time spent in indoor play, are predictors of moderate to vigorous PA in the 3- to 5-year-old children who are attending CCC.³⁰30. Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12(43):1-9. https://doi.org/10.1186/s12966-015-0198-0
https://doi.org/10.1186/s12966-015-0198-... ^,3131. Kwon S, Mason M, Becker AB. Environmental factors associated with child physical activity at childcare. Health Behav Policy Rev. 2015;2(4):260-7.

Another key strength relates to the willingness of caregivers to receive training for planning and performing PA with children. This could help overcome one of the identified key weaknesses, which is concerned with their lack of confidence in promoting PA,⁷7. Bleich SN, Bandara S, Benett W, Cooper LA, Gudzune KA. U.S. health professionals’ views on obesity care, training, and self-efficacy. Am J Prev Med. 2015;48(4):411-8. https://doi.org/10.1016/j.amepre.2014.11.002
https://doi.org/10.1016/j.amepre.2014.11... probably worsened by caregivers’ fear regarding parents’ perception of unsafety PA activities at CCC. Other authors have explored the relationship between parental perception of school safety and children’s physical activity without conclusive evidence.³²32. Hutchens A, Soltero EG, Barquera S, Lévesque L, Jauregui E, Lopez y Taylor J, Lee RE. Influence of parental perception of school safety and gender on children’s physical activity in Mexico: A cross sectional study. Salud Publica Mex 2016;58:7-15. https://doi.org/10.21149/spm.v58i1.7662
https://doi.org/10.21149/spm.v58i1.7662... Further research will be necessary in this topic.

To foster caregivers’ capacity for leading PA at the CCC, staff PA training programs must be supported by organizational initiatives that encourage active behaviors in children.⁶6. Pagnini D, King L, Booth S, Wilkenfeld R, Booth M. The weight of opinion on childhood obesity: recognizing complexity and supporting collaborative action. Int J Pediatr Obes. 2009;4(4):233-41. https://doi.org/10.3109/17477160902763333
https://doi.org/10.3109/1747716090276333... ^,77. Bleich SN, Bandara S, Benett W, Cooper LA, Gudzune KA. U.S. health professionals’ views on obesity care, training, and self-efficacy. Am J Prev Med. 2015;48(4):411-8. https://doi.org/10.1016/j.amepre.2014.11.002
https://doi.org/10.1016/j.amepre.2014.11... ^,1717. Tolbert PS, Hall RH. Organizations, structures, processes, and outcomes. New York, US: Routledge, 2016:261. https://doi.org/10.1093/intqhc/mzm042
https://doi.org/10.1093/intqhc/mzm042...

Staff perceptions about the role of families to foster active lifestyles in children consistently emerged as an opportunity in this study. However, the lack of time by the parents for engaging in PA and the reduced likelihood of children of single parents in performing PA outdoors, were identified as key weakness. Effective interventions have documented the importance of involving families in supporting the CCC’s PA initiatives.²⁶26. Redsell S, Edmonds B, Swift JA, Siriwardena AN, Weng S, Nathan D, et al. Systematic review of randomized controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood. Matern Child Nutr. 2016;12(1):24-38. https://doi.org/10.1111/mcn.12184
https://doi.org/10.1111/mcn.12184... ^,3333. Pate RR, O’Neill JR. Physical activity guidelines for young children: an emerging consensus. Arch Pediatr Adolesc Med. 2012;166(12):1095-6. https://doi.org/10.1001/archpediatrics.2012.1458
https://doi.org/10.1001/archpediatrics.2... As noted by Pocock and colleagues,³⁴34. Pocock M, Trivedi D, Wills W, Bunn F, Magnusson J. Parental perceptions regarding health behaviours for preventing overweight and obesity in young children: a systematic review of qualitative studies. Obes Rev. 2010;11(15):338-53. https://doi.org/10.1111/j.1467-789X.2009.00648.x
https://doi.org/10.1111/j.1467-789X.2009... health promotion strategies are more effective if they are directed at the wider family, in view of the intergenerational influences on parental health beliefs and knowledge. Involving parents in interactive education and in-hand experiences strategies for promoting PA has been recommended.³3. O’Dea JA, Ericksen M. Approaches to prevention. In: O’Dea JA, Ericksen M, eds. Childhood obesity prevention: international research, controversies, and interventions. New York: Oxford University Press, 2010:195-238. https://doi.org/10.1093/acprof:oso/9780199572915.001.000
https://doi.org/10.1093/acprof:oso/97801... ^,3535. Ling K, Robbins LB, Wen F. Interventions to prevent and manage overweight or obesity in preschool children: A systematic review. Int J Nurs Stud. 2016;(53):270-89. https://doi.org/10.1016/j.ijnurstu.2015.10.017
https://doi.org/10.1016/j.ijnurstu.2015....

The potential limitations of our study relate with the generalizability of the results, as the study was held in a particular setting. Nonetheless, our approach allowed an in-depth exploration of both environmental and personal factors that prevent child overweight, which is relevant to other similar settings. Another limitation relates to the participant’s sensitivity about discussing issues regarding their work environment; however, a number of them did discuss compelling issues, as confidentiality was assured and separate focus groups were conducted based on participant type. A strength of this study is the inclusion of diverse types of stakeholders allowing us to provide in-depth insights on the providers’ perspectives, misperceptions, and personal experiences.

Additional studies using mixed-methods and having a multidisciplinary perspective are necessary to further delve into the CCC staff’s perceptions and practices for preventing child overweight. Considering the increased use of non-parental childcare and the growing prevalence of childhood obesity worldwide, public policy and culturally appropriate interventions that ensure the quality of institutional childcare are needed, while building on the strengths/ opportunities and overcoming the weaknesses/ threats that were identified in this study. Finally, it must be acknowledged that additional determinants of health should be addressed through an ecological and behavior-changing approach to tackling the global burden of childhood obesity.

Acknowledgments

This work was carried out with the support from the CONACyT Grant#S0008-114027, and CAMBIO - Canada and Mexico Battling Childhood Obesity - which is funded by the Global Health Research Initiative (GHRI) . We thank the participants and CCC authorities for their valuable collaboration.

References

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