An Exploration of Childhood Obesity in India: A Qualitative Study

This document presents a comprehensive qualitative research proposal focused on childhood obesity in India. The study aims to explore the knowledge, attitudes, and perceptions of mothers, school staff, and healthcare staff regarding this critical health issue. Employing a phenomenological framework, the research will utilize interviews and focus groups to gather data from participants in rural India, specifically at Primary Health Centers. The research questions address how these stakeholders perceive childhood obesity, their awareness levels, and their roles in addressing the problem. The proposal outlines the research design, including sampling criteria, data collection procedures, and the planned thematic analysis. Ethical considerations, proposed limitations, and a detailed timeline are also included. The study seeks to provide valuable insights into effective interventions to address the growing concern of childhood obesity in India.

Title: An exploration of knowledge and perception of mothers, school staff and
healthcare staff to address childhood obesity in India: A qualitative study
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Table of contents:
1 Summary 3
2 Introduction 3
3 Background and rationale 4
4 Research questions 5
5 Aims and objectives 6
5.1 Aims 6
5.2 Objectives 6
6 Research design 6
6.1 Qualitative research 6
6.2 Methodological framework: Phenomenology framework: 6
7 Research process 7
7.1 Setting of the study 7
7.2 Study population 7
7.2.1 Sampling criteria 8
7.3 Data collection procedure 8
7.3.1 Interview 8
7.3.2 Focus group 10
7.4 Data analysis 10
8 Ethical consideration 11
9 Rigour 12
10 Proposed limitations of the study 12
11 Timeline 12
12 References 13
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1 Summary:
This research aims to explore the knowledge, attitude and perception of mothers, school staff
and healthcare staff about childhood obesity. This is a qualitative study which adopts
constructivist theory as the main methodological framework. Participants of this study will be
mothers of children (4-14 years), school staff and healthcare staff. These participants will be
from the rural part of India and this study will be carried out at Primary Health Centre (PHC).
This study will implement interview and focus method for data collection and thematic
analysis for data analysis.
2 Introduction:
Childhood obesity is a global health issue and its consequences on health of an individual are
well documented (Weihrauch-Blüher and Wiegand, 2018). Childhood obesity is attributable
to different factors such as lack of physical activity, excessive consumption of calorie and
lifestyle related factors. All these factors can be effectively monitored by family members
and school staff of the children (Kar, and Khandelwal, 2015). In India, childhood obesity is
being ignored topic because India has been considered as the country associated with the
problem of malnutrition (Misra et al., 2011). It is evident that overnutrition is the significant
reason for the occurrence of obesity in the school going children. Calorie intake from fat is
estimated to be 25 % more in children as compared to the normal diet (Sahu et al., 2015).
Hence, it is essential to give equal attention to the problem of childhood obesity to prevent
further epidemic. Multisectoral efforts need to be implemented for the prevention of obesity
in the children. Along with family members, schools and primary care settings should come
forward to address the issue of childhood obesity in India (Ranjani et al., 2016). Schools and
primary healthcare centres should arrange obesity-focused education for children and their
family members. Since, schools are the best places for providing education to augment
awareness about specific issue among the stakeholders. Schools can contribute significantly
in the prevention of childhood obesity through promoting physical activity, banning
unhealthy foods in cafeteria, incorporation of physical activity and nutrition-based education
in school curriculum and training teachers about nutrition education. Family members can
improve healthy lifestyle in children through limiting television and other media, improving
physical activity and restricting junk food consumption at home (Misra et al., 2011). Audio-
visual media should be used for providing nutrition and physical education to the children
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and family members. Primary health centres should arrange clinical counselling programmes
for children and family members (Aggarwal and Jain, 2018).
It is mandatory to address childhood obesity because it is attributable to health consequences
such as hyperlipidaemia, hypertension and abnormal glucose tolerance, sleep apnoea,
pseudotumor cerebri (increased intracranial pressure) and orthopaedic complications
(Rawlins, Baker, Maynard, and Harding, 2013). Moreover, childhood obesity is also
associated with social and emotional issues such as negative self-esteem, negative self-image,
anxiety, loneliness, social isolation and risky behaviour (Rawlins, Baker, Maynard, and
Harding, 2013). Approximately 80 % childhood obesity get carried to the adulthood due to
lack of proper intervention.
3 Background and rationale:
Epidemiological studies estimate that worldwide over 22 million children are obese and
approximately 1 in 10 children are overweight. Proportion of obesity in school going children
have doubled in 2010 in comparison to the 2000 (Ranjani et al., 2016). Though, there is
limited data available for the burden of obesity and overweight children in India; few of the
studies reported prevalence of obesity and overweight children among school aged children.
Prevalence of overweight and obesity among school aged children in India was 14.4% and
2.8% by International Obesity Task Force (IOTF) cut offs, 14.5% and 4.8% by Centre for
Disease Control (CDC) cut offs, and 18.5% and 5.3% by World Health Organization (WHO)
(Ranjani et al., 2016).
Both physical activity and healthy eating play significant role in the prevention of childhood
obesity (Aggarwal and Jain, 2018). Interventions for childhood obesity prevention are
complex in nature; hence, it is difficult to conclude contribution of individual stakeholder in
the prevention of childhood obesity (Aggarwal and Jain, 2018). Quality research proved
beneficial in getting insight into attitude, perception, opinions, motivations and concerns of
the key stakeholders such as children and young people, parents and guardians, national
health service (NHS) staff and school authority staff. In turn, it is useful in understanding key
stakeholders and their role in obesity prevention. Few studies have explored parents and child
perceptions on the development phase of obesity prevention intervention (Pallan, Parry,
Cheng, and Adab, 2013; Pocock, Trivedi, Wills, Bunn, and Magnusson, 2009). However,
there is scarcity of literature available on the evaluation phase of the obesity prevention
intervention.
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School is the place where promotion of healthy eating and activity can assist in the
development of healthy behaviours among school going children. Moreover, it promotes the
parent’s engagement in healthy behaviour at home setting (Kar and Kar, 2015). Hence,
school staff being considered as the important stakeholders for the prevention of childhood
obesity (Waters et al., 2011). Unsuccessful interventions for weight management might be
attributable to the inadequate behavioural and educational techniques. Hence, it is essential to
produce suitable environment for the weight management in the obese children. It can be
achieved through establishing holistic care pathway comprising of lifestyle interventions for
the weight management in the children. Possible interventions include dietary advice from
the school staff and healthcare professionals, positive perception of parents and family
members, free facility allocation by school and local authority for physical activities,
incentives in the form of rewards and specialised support from the paediatrician, dietician and
consultant psychologist (Eyre, Duncan, Birch, and Cox, 2013; Griffin et al., 2014).
Different types of interventions such as home based, pre-school based, community based and
school-based interventions were being implemented for the management of childhood
obesity. However, school-based interventions combined with diet and physical activity
components were proved successful in the management of childhood obesity (Bleich et al.,
2018; Oude Luttikhuis et al., 2009). However, Sharma (2011) reported that most of the
school-based interventions were implemented in the United states and United Kingdom.
None of the school-based interventions were implemented for the management of childhood
obesity in India.
It is essential to incorporate different stakeholders in the obesity prevention programme
because family, social, economic and cultural aspects are responsible for the development of
childhood obesity. Interventions demonstrated that children who attended interventions
achieved reduction in Body Mass Index (BMI). However, dropout rate was approximately
50% before completion of the intervention (Oude Luttikhuis et al., 2009). This dropout rate
was more in children from the deprived areas. Possible explanations given for the dropout
were perceived negative perceptions of family members and stakeholders such healthcare
professionals and school staff. Lack of perceived acceptability of intervention, family
problems and lack of motivation are mainly responsible for the negative perceptions of
family members and school staff for negative perceptions of weight management
interventions in children (Sánchez-Carracedo, Neumark-Sztainer, and López-Guimera, 2012).
Non-accessibility to obese children and lack transport facilities for implementing intervention
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are mainly responsible for the negative perceptions among healthcare staff (Adab et al.,
2015). Since, very few studies have been conducted for childhood obesity in school setting;
there is scarcity of information about the above-mentioned barriers.
It is difficult to implement specific intervention for childhood obesity in India because there
is scarcity of representative national data on childhood obesity due to geographical, social
and cultural norms. Hence, it is difficult to implement uniform intervention in different parts
of India. Considering all these factors, implementation of school-based childhood obesity is
difficult in India. Hence, the current study is planned to explore knowledge and perception of
mothers, school staff and healthcare staff to address childhood obesity in India.
4 Aims and objectives:
4.1 Aim:
Aim of this study is assess perception, attitude and knowledge of family members, school
staff and healthcare staff about the childhood obesity.
4.2 Objectives:
 To assess level of knowledge among family members and school staff about
childhood obesity.
 To assess level of experience of healthcare staff for the implementation of obesity
management intervention.
4.3 Research questions:
 How do family members and school staff in India perceive childhood obesity?
 What is the level of knowledge and awareness of family members and school staff
about childhood obesity?
 What are family members’ perceptions of their role in combatting children obesity?
What are school staff’s perceptions of their role in combatting childhood obesity?
5 Research design:
5.1 Qualitative research:
Qualitative research is a type of scientific research which seeks answers to specific questions,
use specific procedures to answer the questions and collect evidence (Liamputtong, 2017).
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Moreover, qualitative research is also effective in obtaining information about the values,
opinions, behaviours and social contexts of the specific group of people. Qualitative research
also describes the complex textual experience of specific population about issue. In this
study, childhood obesity issues will be discussed with different stakeholders such as mothers,
school staff and healthcare professionals. The methodological framework which will adopted
in this study is Phenomenology framework.
5.2 Methodological framework: Phenomenology framework:
Phenomenological framework will be useful in understanding, describing, interpreting human
behaviour in relation to experience. Phenomenological studies usually effective in
demonstrating the experience and perception of participants in relation to the specific
phenomenon (Liamputtong, 2010). Outcome of phenomenological studies mainly based on
the perspectives of participants. Phenomenological studies do not depend upon the
assumptions of the participants; however, these are based on the experience of individuals
which can be effective in explain their behaviour (Liamputtong, 2010).
Phenomenological framework includes data collection through interview process and focus
group. Both these designs are effective in collecting information about experience and
perceptions of the participants. In this study also, interviews will be carried out to explore
understanding and perceptions of stakeholders such as mothers, school staff and healthcare
professionals about childhood obesity. Hence, each interview will be unique and slightly
different (Serry & Liamputtong, 2017). Focus group will also be beneficial for the
participants to express their experiences and feelings at their will (Liamputtong, 2017).
Hence, phenomenological framework will be effective in this study to explore knowledge,
attitude and perceptions of mothers, school staff and healthcare professionals about childhood
obesity.
6 Research process:
6.1 Setting of the study:
Setting for this study will be Primary Heath Centre at in rural India.
6.2 Study population:
Mothers of obese children (25), school staff (25) and healthcare staff (20) will be recruited in
this study. Participants will be recruited by employing non-probability and purposive
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sampling method. Non-probability sampling method can be considered as suitable method for
this cross-sectional study because this method can be employed when large number of
participants should be contacted and recruited. Purposive sampling method can be considered
as suitable method for this cross-sectional study because all the recruited participants should
be recruited with similar characteristics or specific purpose (Liamputtong, 2013; Chandler
and Shapiro, 2016). Specific characteristic of all the recruited participants in this study will
be involvement in the childhood obesity intervention.
6.2.1 Sampling criteria:
 Healthcare professionals with prior experience in the childhood obesity management.
 Healthcare professionals with minimum post-graduate experience in what – do you
mean that they must have a postgraduate degree ?.
 School staff with prior training in childhood obesity management.
 Mothers of obese children who are (1) Married (2) non-working
 Mothers of children those who are not consuming anti-obesity medications.
Participants will be allowed to withdraw from the study at any time point.
6.3 Data collection procedure:
Both structured and semi-structured in-depth interview and focus group will be conducted for
the data collection. Interview and focus group will be conducted for mothers, school staff and
healthcare professionals. Questions and discussion during interview and focus group will be
based on relevant literature.
6.3.1 Interview
Interview will be conducted for 25 mothers, 25 school staff and 20 healthcare staff. One each
interviewer will be employed for conducting interview for mother, school staff and halthcare
staff. Three interviews will be conducted.
Interview based study will be useful in obtaining evidence about the behaviour, opinion,
feelings and knowledge of the participants. Behaviour provide information related to the
participant’s ability to perform certain tasks with ease. Opinion provide evidence about the
participant’s thinking capability about specific issue. Feelings disseminate participant’s
experience in performing certain tasks. Knowledge demonstrate awareness of participant
about facts of specific topic. All these aspects will be useful in understanding knowledge and
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perception of mothers, school staff and healthcare staff about the childhood obesity.
Interview based data collection is being considered as the important component of the
qualitative research because it demonstrates accurate insight of participants about specific
issue and research question (Biener and Hargraves, 2015). Interview will be conducted by the
interviewer who is un-known to the participants. Interview conducted by the known
interviewer to the participants might lead to the biasness in the data collection.
Structured and semi-structured interviews will be conducted by the experienced researcher
and interviews will be conducted by the single interviewer. Single interviewer will be
employed for conducting interview because different interviewers might give different
interpretations. Questions for the structured and semi-structured interview will be prepared
based on the literature review and these questions will be in alignment with the aims and
objectives of the research. Questions asked in this study can be considered as valid questions
because these questions will be developed based on the relevant literature. Hence, these
questions will able to provide reliable, comparable and qualitative data. Structured and semi-
structured interviews will usually comprise of the open-ended questions which will facilitate
participants to express their views and experience in more independent manner. Both verbal
and non-verbal ques are essential to understand the perception of participants. Hence,
interview will be conducted by experienced researcher to understand verbl and non-verbal
ques (Liamputtong, 2017).
Before the start of the interview, participants will be explained about the research. Interview
will be conducted in the PHC for the duration of approximately 2 hours. Whole interview
process will be audio recorded for the future use. Copy of audio recording will be provided to
each participant. Interview will start with the introduction of the participants and
subsequently questions will be asked about the knowledge and perception of the participants
about the childhood obesity. Main purpose of interview will be to get insight about the
participants views and understanding of the participants about the childhood obesity.
In the second phase of the interview specific questions will be asked to each stakeholder in
relation to the childhood obesity. Mothers will be asked questions about eating habits of their
children, food preferences of their children, food preferences of their family, healthy cooking
and physical exercise habits of their children.
School staff will be asked questions about their experience in the childhood obesity
management, interventions implemented by the school for childhood heath management,
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dietary education provided by the school for children and their parents for healthy diet and
sports activities planned for children for improvement in health.
Healthcare professionals will be asked questions about their educational qualification in
relation to the childhood obesity, their experience in the childhood obesity management and
health promotion programmes conducted by PHC for management of childhood obesity.
In the third phase questions will be asked to assess their decision-making ability in relation to
the childhood obesity. Main purpose of asking questions in relation to the decision-making is
to assess their ability to implement obesity prevention intervention based on the dietary and
physical needs of the participants.
Much better description of the method above
7.3.2 Focus group:
Representatives of mothers (8), school staff (8) and healthcare staff (6) will be involved in the
focus group. Focus group will be conducted in the PHC in the closed room. One researcher
will be employed in the focus group and another researcher will take notes on the opinion and
perceptions of the participants during the focus group discussion. One focus group will be
conducted. Focus group will be recorded for the future reference.
Focus group is a discussion among small group of people with diverse characteristics. People
involved in the focus group will be involved in the open discussion among specific issue
which would be helpful in determining opinions and perceptions of the people (Rezk-Hanna
et al., 2018). In this study, mothers, school staff and healthcare professionals will be involved
in the focus group. It will be helpful in determining the perceptions and opinion of
participants about childhood obesity intervention. Representative participants from group of
mothers, school staff and healthcare professionals will be invited for the focus group.
Invitation for the focus group will be sent to the participants through phone call. Researcher
will pose questions to the participants in such manner that participants will respond in honest
and truthful manner to explore their opinion and feelings. Focus group is more beneficial in
research studied where response is more unpredictable. In this research study also response of
different stakeholders such as mothers, school staff and healthcare professionals in relation to
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the childhood obesity is unpredictable. Focus group is also effective in exploring distinctive
opinions and feelings which would not be possible in more structured surveys and paper-
pencil tests. Dynamism is another important feature of focus group because it is effective in
sharing and exchanging ideas among participants with different characteristics. In this study,
different stakeholders such as mothers, school staff and healthcare professionals will be
having different opinions and feelings which will be effectively shared among different
participants (Liamputtong, 2017).
8.7 Data analysis:
Data collected interview and focus group will be transcribed verbatim and coded, with
themes entered in Microsoft excel sheet. Coding of the data will be done by the researcher
who will not be involved in the study. In qualitative research, coding can be performed at
three levels such as open coding, axial coding and selective coding. Open coding will be
performed where data need to be deconstructed, sorted and organised with respect to
individual idea brought about by the participants. These data will be coded individually.
Axial coding will be useful in further examination and organisation of codes to identify
correlation among the data obtained through open coding. In the qualitative research, final
step will be selective coding. Selective coding will be useful in the identifying the themes,
making causal connections and integrating it to the theoretical aspects of the study (Mellinger
and Hanson, 2016).
8 Ethical consideration:
Ethical consideration is an important aspect during conducting research study. Ethical aspects
of the study facilitate maintenance of integrity, validity and reliability of the research.
Protocol for conducting study will be prepared by experienced researcher and it will be
approved by the institutional human ethics committee. Ethical approval will ensure all the
ethical practices and process being followed for conducting the study. Moreover, it will
ensure codes and policies of Institutional Review Board (IRB) during conduct of the study
(Nicholson, 2015). All the information related to the study will be provided to the participants
either through verbal communication or through brochure. Moreover, written informed
consent will be taken from the participants. Participants will be allowed to withdraw from the
study at any time point. Anonymity and confidentiality of the participants will be maintained
which would be helpful in maintaining ethical standards of the study. Ethical standards will
be helpful in improving moral standards in conducting the study. Dignity of the researcher
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will be improved through maintaining ethical standards during conduct of the study. Ethical
standards will be helpful in maintaining human rights and values to maintain social
responsibility (Nicholson, 2015). There will not be any type of physical or biological effect
on the participants. However, there will be possibility of emotional or psychological impact
on the mothers, school staff and healthcare staff. It might be due to feeling of inadequate
knowledge and awareness about the childhood obesity intervention. However, this issue will
be effectively addressed through informing participants about the potential risks and benefits
of the research. Assurance will be given to the participants about the privacy and
confidentiality of the collected data. Moreover, participants will be informed that collected
data will be used for the research purpose and this data will not be used for any other
purpose. Permission will be taken from the management of primary care centre for utilization
of manpower and facilities for conducting interviews and focus group.
9 Rigour:
Rigour is an important aspect in qualitative research. Rigour in the qualitative study is helpful
in improving validity of the research which can improve trustworthiness of the study.
Purposive sampling method will be helpful in improving rigour of the study because specific
participants will be recruited which can produce targeted outcome. All the steps of the study
such study protocol preparation, data collection and data analysis will be carried out by the
experienced researchers. Hence, findings of the study can be considered as the robust
findings which would be helpful in improving rigour of the study. Rigour in any qualitative
study can be influenced due to chances of biasness in the data collection and data analysis.
Efforts will be taken at each step to reduce the chances of biasness. Data will be coded during
data analysis and researcher will be blinded during data analysis. It will be helpful in
reducing the biasness.
10 Proposed limitations of the study:
Selected mothers for this study will be mothers of school going children. Hence, it might be
highly possible that these mothers might be highly motivated about childhood obesity. These
mothers might be already interested in healthy eating and healthy lifestyle. Moreover, level of
knowledge, attitude and perception of these mothers might be similar for all the mothers
participated in the study. Response rate of the participant mothers might be less because
mothers in the rural India might not be interested in the participation in the childhood obesity
intervention. Chances of this biasness might be due to the matter of fact that researchers
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