Socioeconomic Status and Childhood Obesity

Introduction

Over the last few years, the rates of obesity among both children and adults have been on the rise (Rogers et al., 2015). One impact that can increase the risk of someone becoming obese is their socioeconomic status. Socioeconomic status encompasses more than just the financial resources that someone has access to, it is more of an accumulation of income, occupation, and education (Socioeconomic Status, n.d.). One's socioeconomic status can impact not only access to resources, but also privilege and control (Socioeconomic Status, n.d.). This paper is going to prove the relationship between poor socioeconomic status and childhood obesity in rural communities.

Background

The American Heart Association describes obesity as a person who has a body mass index (BMI) of over 30, in other words you weigh 20% more than your ideal weight (Obesity Information, 2014). Nearly 70 percent of adults in America fall into this overweight or obese category, so it is a fairly common affliction in this country (Obesity Information, 2014). When it comes to American youth, about one in three children aged 2-19 are obese (Obesity Information, 2014). And unfortunately research shows that children that are obese are more likely to be obese once they reach adulthood (Cole et al., 2000). Obesity can also be dangerous for your health. It is a known risk factor of high blood pressure, diabetes, sleep apnea, heart disease, and even certain cancers (Obesity Information, 2014).

Childhood obesity also has its slew of more specific risk factors. Child development can be curbed by the mechanical stress caused by the access weight, as well as consequences of adipose tissue disrupting normal organ function (Lutfiyya et al., 2012). Even more rarely discussed is the psychological impact that being overweight has on the development of young children and teens (Lutfiyya et al., 2012). Children living in rural areas are also at a higher risk of poverty, no health insurance, no preventive care in the past year, and little physical activity (Lutfiyya et al., 2012).

Obesity is not a disease that develops overnight. This is a chronic condition that can take years to slowly manifest. It is a learned and repeated habit of eating too much and exercising too little (Harvard Health Publishing, 2017). There are a few other indicators like that some individuals are genetically more likely to become obese, but the largest risk factor is the link to behavior (Harvard Health Publishing, 2017). The modern world's heavily sedentary lifestyle is another factor, for example an average American spends 4 hours watching television a day (Harvard Health Publishing, 2017).

An activity that expends little to no calories compared to walking or other types of exercises.
One piece of research that is proving to be very interesting is the role of food advertisements in this cycle. Harvard Health Publishing explains that the average television episode hosts around 11 food and beverage commercials, which are literally created and aired to encourage people to consume (2017). Health research also uncovered that eating while watching television could stimulate viewers to consume more calories in total, especially calories that come from fatty foods (Harvard Health Publishing, 2017).

Moreover, when researchers would limit the amount of television that kids would watch, it actually had a positive impact on their health and they lost weight (Harvard Health Publishing, 2017). But this act wasn't because of the actual lack of screen time that they children were experiencing, it was discovered that there is a positive correlation between the hours of TV and the hours of snacking (Harvard Health Publishing, 2017). So its more than just watching television that can be dangerous to one's health, it's also the mindless snacking that often occurs simultaneously.

There are a lot of programs and groups in the United States today that work to target the increasingly high rates of obesity, especially in children. Each of them have a pretty similar premise; education about exercise and healthy eating that will lead to positive life long habits, as well as a link to their schools and parental involvement. The Centers for Disease Control (CDC) has a program called The Whole School, Whole Community, Whole Child (WSCC) model. This program supports school aged children with nutritional education, physical activity, community and family engagement, and the application of school health services (Healthy Schools, 2018).

One familiar program is the Let's Move! program started by Michelle Obama. This model is also target at school aged children, getting them to move more and eat healthier. One big caveat here is that it worked on a larger scale within the education system itself. Obama used her platform to successfully work with legislation to have the public school systems' lunch menus changed, in order to provide healthier and less caloric options to children (Learn the Facts, n.d.).

This program has proved to be effective however, especially in how they are utilizing public service announcements (PSAs) to share their information (Georgiadis, 2013). Their PSAs encourage viewers to eat better and exercise more, and their health messages are also in line with the health belief model and social cognitive theory (Georgiadis, 2013).
Legislation does play a large role in the fight against childhood obesity. As public knowledge increases, health policies have been put in place to try and curb this problem. In a three year study performed by Brownson et al.; there were 717 bills introduced, and 123 of them were adopted (2007). The majority of which were at the state level, which is where many of the health policy decisions are made (Brownson et al., 2007).

Target Population

Children are a very unique group to work with in the public health setting. They are one of the few populations that do not have complete control over their environments. Children are dependent on the environment that their parents create for them, for worse or for better. In rural settings this can mean the specific geography. If their parents own a house that is over an hour from the nearest emergency medical facility or fresh food outlet, the child has little ability to make a difference in his/her outcome.

Consequently, studies show that youth growing up in rural locations are at a higher risk of becoming obese (Liu et al., 2012). Liu et al. performed a cross sectional analysis of both urban and rural children and found that on average rural children ate more calories, at less fruit, and exercised less than their urban counterparts (2012). Lutfiyya et al. found that rural children are actually 25 percent more likely to become obese or overweight compared to urban children (2012). Oftentimes with children it is the habits that they develop when young that carry over into adulthood. So poor eating and physical activity habits, as well as childhood obesity, will follow them and could lead to obesity in adulthood.

Demographics of rural households tend to be very different from urban households however. The most recent US Census noted that there are lower rates of poverty in rural communities compared to urban ones, but parents are less likely to have achieved any higher education above high school level (US Census Bureau, 2016). It is also notable that rural American has lower household income medians, but also lower household expenses - like mortgage (US Census Bureau, 2016). These factors can definitely impact that amount of financial resources and education that families have to focus on providing healthy choices and access to physical activity. As previously mentioned, children are a difficult target population to work with especially when trying to measure socioeconomic status. But both parental education level and average household income have been used to explain variability in childhood obesity (Whitaker & Orzol, 2006).

Some recent research on the correlation of geography and obesity does add another layer. Fang et al. has noted that although obesity is not contagious, it is considered to be a social contagion (2018). Social contagion is the idea that individuals who spend a significant amount of time together will often adopt the same habits, in this case it is obesity. In rural America children are often interacting with the same people at home, at school, and in public spaces.

It is here that the social contagion effect can take place. Overweight children will begin to associate with one another and with the help of social norming, the likelihood of them continuing to be overweight or obese will increase (Fang et al., 2018). When you take into account that growing up in a rural community increases your chances of living in the same state of birth, then it can be seen that this social contagion is cyclical (US Census Bureau, 2016).

Integration of the Health Issue and Target Population

There are also some fickle cultural anomalies that researchers may find when working with rural populations. Holmes and Levy describe the importance of community connection in their research among rural communities (2015). Rural community members tend to take care of each other and work together towards a greater good (Holmes & Levy, 2015). Their interactions with doctors are also very different, rural patients don't tend to be very engaging with physicians. They would prefer to be told what is wrong and how they can remedy it, and that is the end of the interaction (Holmes & Levy, 2015).

These communities also see structural challenges like care affordability, distance, and actual availability of services needed (Holmes & Levy, 2015). Most notable is the view of health services. Rural communities tend to see health services as more of a crisis intervention than a preventative measure (Holmes & Levy, 2015). People in these areas just don't seek out medical care unless there is already a problem. These behaviors can serve as a risk factor because many complications associated with obesity may go undetected until it becomes dangerous, like diabetes or heart disease.

On top of these intangible, cultural preferences there is more and more research that is discovering the importance of built environments as well. When it comes to rural areas, the built environments often don't have the same resources that one might find in urban communities. The lack of a dynamic built environment can lead to a sedentary lifestyle (Lutfiyya et al., 2012). Some factors that could be beneficial to communities and lower obesity include access to parks, exercise facilities, sidewalks, public transportation, and physical education classes (Lutfiyyya et al., 2012).

Some positives to this tight knit community feel is that people are also looking out for one another. So this could help as members might encourage one another to seek medical attention. The largest positive to working with children is that if the parents are supportive, it is easier to get child buy in. Because they are still wards of their parents, they are at the mercy of their parent's decisions. So if mom and dad are willing to encourage physical activity and buy healthier food options - there should be great impacts on the habits of the children. But parents can also hinder a child's progression, as they are the sole-providers. Without parental support children will not have the necessary control over their environment to makes lasting changes, especially if they are very young.

Theory to Address the Health Issue

Many theories require a person to have complete control over their environment, like the Social Action Theory and the Social Cognitive Theory (DiClemente et al., 2013). These theories can be used to create a health program to target childhood obesity, but children don't have a lot of control so they would have to be aimed at changing parental beliefs.

The Transtheoretical Model of Change (TMC) is applicable in health promotion for this health issue. This model utilizes many theories to create lasting behavior change among the target population (DiClemente et al., 2013). Because when working with children there are so many stakeholders, this allowance of ambiguity will help increase the strength of the program. The TMC recognizes that lasting change takes work, and people will move in all directions in between its stages (DiClemente et al., 2013). Understanding that health behavior change includes some failed efforts and missteps will be critical in creating a framework for a program that will target families.

Processes of change (POC) within the TMC could also be helpful in working with rural residents. Environmental reevaluation is going to be a critical piece when education parents about how their decisions all have consequences for their children (DiClemente et al., 2013). This POC can be used to demonstrate to parents that they are role models for their children, and if they are obese their children are more likely to pick up those same bad habits. Another POC that could be utilized in rural towns is helping relationships (DiClemente et al., 2016). Creating programs that values relationship building and accountability buddies would work well with their desire to have strong communal ties. These ties could link participants to another POC called self-liberation.

If the focus of this health program is fellowship, having participants share their goals with one another could also help people feel empowered to stick with their goals (DiClemente et al., 2016).
The theory that could be the most useful in addressing this health issue is the Diffusion Theory. This theory explains how innovations and changes spread among a specifically targeted population (DiClemente et al., 2013).

Diffusion Theory suggests that if someone sees another person adopt an innovation and acquire a positive outcome, they are more likely to attempt this innovation themselves. There is a framework for how to make your innovation, or health practice, adoptable for your audience. Interpersonal communication is very important to this theory, including the concept of homophily, when 2 or more people share values or norms (DiClemente et al., 2013). As discussed by Holmes and Levy, this often proves to be a major theme of rural communities in America (2015).

In the case of socioeconomic status and childhood obesity, this Diffusion Theory is going to help get parents on board and excited about making changes for the family. It is also going to utilize the close knit culture of rural towns. Because people are more likely to try something that they see their neighbors doing successfully, it should help integrate a program into this community. Parents might not have access to large financial resources that will allow them to move away from their current environment or start buying completely organic, but utilizing the strong community ties already in place is going to fight obesity and socioeconomic challenges. Move more and eat less, this is a simple message that can be adapted by anyone “ no matter your education level or occupation.

Diffusion theory uses four elements to outline the dissemination of innovation. Innovation, communication, time, and the social system (DiClemente et al., 2013). Innovation is important because it includes the new health habits, like exercising more and eating healthier. Communication is about how the message is spread, what channels are used and relationships are built. Time will be used to ensure that the outcomes are positive and relevant. And then finally the social system's role is probably the largest in this community. It includes the cultures, norms, and other boundaries of the diffusion within the rural community (DiClemente et al., 2013).

Diffusion Theory relies on human interaction, word of mouth, and basic observation of others in order to be successful. Each of these are characteristics of rural residency. If a health program can integrate into a community, and its creators/implementers can develop relationships within that community it will have an even better chance. One positive aspect about obesity in this sense is that it is a very visible affliction, and it is one that is widely accepted and understood.

Community members are able to easily spot who the overweight people are, and it is no secret that Americans are growing larger and larger. That being said if this program is introduce and people begin to lose weight or look more healthy - their community will be able to tell. If a program is successful, this is free advertising at its best. If a program can get to the point where valued members of that rural town are buying in and losing weight, the dissemination through the town should happen rapidly.

This dissemination is important because children will need their parents to make life changes in order for them to follow suit. Diffusion Theory can also help out with this, because the schools are nothing but smaller institutions within the community. When parents start to adopt changes for themselves and their children, other children might observe this and encourage their parents to get involved.

Conclusions and Recommendations

Synthesis of the texts included in this work show that there is a strong relationship between the socioeconomic status and childhood obesity in rural communities. Rural children are actually 25 percent more likely to become obese or overweight compared to children of the same age in an urban setting (Lutfiyya et al., 2012). And their parents have an increased chance of being less educated and having a lower median household income than parents in the city (US Census Bureau, 2016). Although socioeconomic status is more difficult to measure for children, it has be noted that those are two strong and frequently used indicators (Whitaker & Orzol, 2006). And the small town feel of these rural locations along with frequent interactions with the same peers put these children at a higher risk of developing obesity through social contagion (Fang et al., 2018).

But it is this community that could prove to be the strongest resource we have to fight obesity among rural families. Leaning on their fellow citizens and tapping into the heart of the strong ties among these groups can use education and determination to create change without having to change the financial makeup of the town. Education in schools and among parents is going to be a determining factor of whether or not a health program is going to make a positive and lasting change on the reports of obesity. The culture of rural residents does not encourage them to be self-advocates in the doctor's office - so programs are going to have to be engaging and work to increase the self efficacy of the entire community.

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