The Journal of School Nursing2023, Vol. 39(6) 506–516© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI:10.1177/10598405211045888journals.sagepub.com/home/jsn
Given that the obesity rate among school-age children is increasing, school nurses can play a vital role in managing obesity and encouraging healthy living in school settings. Obese children from low-income backgrounds are more vulnerable than other students and require more careful attention and intervention. This qualitative study aimed to explore and understand the barriers recognized by school nurses in managing obesity in low-income household children. A focus group interview was conducted with 17 school nurses working at an elementary school. Children, home, school, political and structural, and social areas were revealed as intricate factors in obesity management. This study can help understand school nurses’ obstacles in managing obese children from low-income families and can help them prepare practical measures to overcome these obstacles.
Keywordschild, school nursing, health disparities, obesity, qualitative research
Childhood obesity is steadily increasing worldwide. In particular, the increase in childhood obesity rate is remarkable in lower socioeconomic groups in developed countries like the United Kingdom (El-Sayed et al., 2012). These health disparities in childhood obesity are a serious problem worldwide, including South Korea. While these disparities are caused by various factors, including race and ethnicity, economic status, health service accessibility, and environmental disadvantages, health status in childhood is primarily affected by the family’s characteristics, including the socioeconomic level of the household (Cheng et al., 2009; Weaver et al., 2019). Childhood obesity can cause chronic diseases, such as high blood pressure and diabetes, and accelerate obesity and metabolic syndrome in adulthood (Jung et al., 2016; Pbert et al., 2016; Reilly & Kelly, 2011). In addition, it also affects psychological and social development processes (Yu & Han, 2017). Children with obesity are more likely to experience a lower quality of life and sociality (Kim & Kim, 2002) and school adaptation problems (An & Park, 2006). In children from low-income families, obesity can contribute to a decline in socioeconomic status and increase vulnerability because of the socioeconomic costs of obesity management and treatment along with socio-psychological and social adjustment problems.
There are various reasons for increasing childhood obesity in low-income households, including the child’s individual characteristics as well as their home, school, and social-structural factors (Lindsay et al., 2018; Park et al., 2020, 2021). First, children from low-income families are more likely to have an unhealthy lifestyle such as binge eating, skipping breakfast, and watching television excessively compared to their counterparts (Kim et al., 2014; Park, 2018). Park et al. (2020) reported that among lowincome families, the child’s lack of self-regulation, risk perception, and coping skills are the major factors that interfere with healthy eating habits. In particular, children from lowincome households tend to relieve their stress and emotional problems (lack of love, loneliness, and anger) by eating. With regard to home-related factors, an association between fast food consumption and obesity in childhood has been reported (Bowman et al., 2004; Braithwaite et al., 2014). Parents play an important role in the child’s eating habits and activities, which are related to obesity. Especially significant is their role of feeding their child and their concern for the child’s health (Danford et al., 2015). A recent Korean study showed similar results. The lack of parental support in healthy eating habits or children’s fast food intake exacerbated childhood obesity (Park & Choo, 2020).
The Institute of Medicine (2012) recommended that schools be a focal point in the fight against obesity. School settings offer continuous, intensive contact with children during childhood providing them an optimal environment for implementation of interventions (Muckian et al., 2017; Schroeder et al., 2016; Tucker & Lanningham-Foster, 2015). In the United States, school nurse practices for childhood obesity management may include counseling a parent regarding a child’s weight concern, recommending weight-loss treatment for obese children, and checking their blood pressure and body mass index (BMI) (Kubik et al., 2007; Moyers et al., 2005). In addition, school-level activities include identifying groups at risk for childhood obesity such as low-income households, consulting with administrators about health-related policies, and educating children and their caregivers—while targeting the lifestyle improvement of the entire school population (Kubik et al., 2007; Moyers et al., 2005). School nursing practices in South Korea are similar to those in the United States, but they are mainly and directly affected by changing government policies circulated by the Ministry of Education and the Ministry of Health and Welfare, among other government bodies (Kim, 2012). Therefore, school nurses are busy carrying out the projects and programs of various government ministries rather than planning, implementing, and continuing programs that are tailored for their school setting. Furthermore, obesity management interventions for school children from lowincome households are insufficient because of the lack of policies (Kim, 2012). School nurses can effectively prevent and reduce overweight and obesity among children in school settings (National Association of School Nurses, 2018; Powell et al., 2018; Schroeder & Smaldone, 2017). Considering the critical role of school nurses in managing obese children at school, it is necessary to identify the barriers that Korean school nurses perceive when managing such children from low-income households.
Several studies have analyzed obstacles in the work or involvement of school nurses related to childhood obesity (Kubik et al., 2007; Morrison-Sandberg et al., 2011; Quelly, 2014; Schroeder & Smaldone, 2017; Steele et al., 2011). However, few studies have been conducted with regard to school nurses’ perception of obesity management in children, specifically from low-income backgrounds. Children from low-income families require more attention and intervention because they are affected by economic deficits along with factors such as deficits in nutrition, physical development, education investment and learning environments, cultural and social capital, and parenting conditions (Yeo, 2018). Therefore, it is necessary to focus on research regarding obesity management in children from low-income households. Considering these factors, this qualitative study aimed to understand and explore the barriers recognized by school nurses in the management of obesity in children from low-income households. The main research question asked about the barriers experienced by school nurses in managing obesity in children from low-income families.
This qualitative research adopted a focus group interview methodology to identify barriers perceived by school nurses in managing obesity in children from low-income families. The participants selected for this study were 17 school nurses working at elementary schools in Busan metropolitan city, who volunteered for the research. The purposive sampling method was used to recruit participants with the help of the Korean School Nurses Association. Since the purpose of this study was to explore the barriers in managing obesity in elementary school students from lowincome families, and the strategies and approaches of preventing and managing obesity between elementary and middle-high school students are different, nurses working in middle and high schools were excluded from this study. Table 1 shows the general characteristics of the participants.
Participants were recruited among school nurses in Busan metropolitan area through the Busan branch office of the Korean School Nurses Association. After informing the participants of the purpose and method of the research, those who voluntarily expressed their intention to participate were selected. The interview schedule was reiterated through text message one day in advance. Before starting the interview, the researcher informed the participants about the purpose and method of this study, explained how there were no disadvantages if they participated in this study, and received written consent for participation. Subsequently, the participants were asked to fill out a questionnaire of their demographic characteristics. Focus group interviews were conducted in October 2018 with three groups: Group A (eight people), Group B (five people), and Group C (four people). The interviews were held in an independent space, with light refreshments and snacks provided to create an atmosphere in which the participants would feel comfortable. The interviews were led by a moderator (one of the authors) who had experience in conducting focus group interviews and had a sufficient understanding of school nurses and childhood obesity. The interviews were recorded after receiving consent from the participants, and the research assistant who attended the interviews observed and documented the participants’ nonverbal behaviors. Each group interview took approximately one and a half to two hours. Questions used in the interviews were semistructured open-ended questions (Table 2). This study was approved by the Institutional Review Board (IRB) of Inje University (IRB number: INJE 2016-08-003-003); the participants were given an honorarium (about 63 US dollars) after participating in the interview.
NVivo R1 is considered an effective tool for systemic data management (Park, 2020). The structure of NVivo R1 is finely tuned for inductive, bottom-up, and theory-building analyses (Saldana, 2009). After the transcriptions were transferred to NVivo R1, one of the researchers precoded the aforementioned research questions with the interview sequence. Then, by reading and rereading the texts, he created codings that were symbolically assigned to the 17 participants’ lived experiences. After the initial coding, ten meetings for coding validity were held by four researchers. The codings and texts were read and reread by them to ensure validity. Obstacles in managing obesity among children from low-income households, as perceived by school nurses, were categorized into aspects of the children and the various environmental factors surrounding them, including family, school, community, policy, and social influence. Member checks from the participants were completed with one interview participant to confirm the trustworthiness of the research results.
The participants of the study voiced 1) children, 2) home, 3) school, 4) political and structural, and 5) social factors as interacting variables in the obesity management program. Table 3 summarizes the finding of this study, and the identified themes are presented ahead along with appropriate verbatim.
Child’s Awareness of Stigma around Low-Income and Obesity. Thirteen participants emphasized the role of children’s awareness of stigma as the most influential negative factor in managing their obesity. It was difficult for participants to carry out the obesity management program because children were ashamed of being from low-income families and being obese, and were reluctant to reveal them to their peers.
When the other kids are not around, they will measure their weight secretly if they stop by. Also, when you have them exercise or educational materials openly, kids tease the obese children about it. It is hard to open an obesity program or related business…The students with obesity become the target of bullying from their peers as if they were patients with an infectious disease. (FG 2, P 1)
Lack of Trust in School Obesity Management Programs. Three participants reported that children with obesity distrust the obesity management programs. Participants perceived that those children with obesity were not sure about the positive aspects of participating in the program and were more interested in programs where improvements were visible.
When I asked children with obesity why they did not come to the nurse’s office, they said they had to go to the academy. They were not sure whether they would lose much weight… (FG 1, P 6)
Children do not believe in the positive aspects that they will be able to change due to this obesity prevention program. (FG 2, P 4)
Vulnerability in Obesity Management at Home. Ten participants considered vulnerable home management a hampering factor in managing the children’s obesity. Obese children from low-income households had either working parents or were classified as being in vulnerable environments. Given that there is no one to take care of them at home, children’s diets are focused on fast food or convenience store food. A participant expressed the need for diet and weight management efforts by caregivers at home.
One day, I asked one of the children with obesity if she had breakfast. Then, she said that she ate cereal again. I asked what she ate yesterday. She said she ate cereal. She ate cereal during the holidays. As a result, she thinks that home was the only place to provide “cereals.†So, she binges at lunchtime when she comes to school. Her parents do not have time to come to school. They are not interested in their children. When I send an official letter to the obese children’s parents, the parents would not reply, even regarding a health class. (FG 2, P 1)
Parents’ Hesitation to Cooperate in the Operation of School-Based Obesity Programs. Eight participants reported parents’ hesitation to cooperate in the school-based obesity program as the second negative factor originating from the home environment. Parents opposed participating in separate programs, fearing that it would lead to other children teasing their children. It was also noted that the management of obese children from low-income households should be conducted with parental participation; however, the program could not be executed correctly because many parents could not take care of their children at home.
A mother said that her child had been getting treated for obesity, and the child was upset about it when she came home. So, her mother hopes that the school does not do it anymore because she would manage her child’s weight at home. (FG 1, P 6)
In my school, I asked obese children from low-income households to record what they ate with pictures. That did not work at all! If their mothers had helped them, things would have been much better. If I ask mothers to monitor their children’s eating habits, they would regard it as a burden in raising their children. I tried every possible measure, but I have run out of ideas. (FG 3, P 2)
Parents’ Low Priority of Child’s Obesity Management. Six participants had much to say with regard to parents’ low priority of obesity management. Parents from low-income families believed that the cause of poverty was their lack of opportunities to education. For this reason, to their children, they emphasized studying hard; therefore, there was a tendency to neglect obesity management programs or weight management of their children.
(…) Particularly unfortunate is that those with difficult living conditions and those from low-income families believe that their children’s diligent studying can be a ladder to social status changes. (FG 1, P3)
Poor Collaboration Between School Nurses and Staffs. Twelve participants viewed poor collaboration between school nurses, physical education teachers, nutrition technicians, and professional school counselors in charge as a debilitating factor for obesity management. They proposed that a multidisciplinary approach and the need to communicate organic relationships among teachers call for further attention.
We cannot do this alone, and we have to share the role. The nutritionist is responsible for some of the work. The gym teacher is in charge of specific work. It is not just once a week for us. It should be long-term… (FG 1, P 4)
Yes. Lack of cooperation among related teachers leads to unwanted results. If a school nurse only does what she can, the wheels will not roll. (FG 2, P 1)
School Nurses’ High Workload. For eleven participants, high workload enormously hindered being an effective manager of the obesity program. Participants complained that cleaning air purifiers, water purifiers, and toilets were allocated to school nurses for health and hygiene management. There were many tasks other than health care and health-related projects for students. They also lamented that the work was carried out at the principal’s judgment because there were no specific guidelines for health teachers.
School nurses’ work involves many strange things every year, so it is tough for us to focus on the obesity program. I am in charge of environmental issues, including those related to the air and emotional matters that sound ridiculous. There is so much work assigned to us, and I wonder what is my role here … (FG 1, P 3)
(…) Suppose this obesity business comes to me again. In that case, because I am involved in managing tasks related to fine dust, air, water purifier, atopy, and other concerns, I think I will have to do the obesity project without passion if I am requested to do the work. I do not have time to do all these things… (FG 1, P 1)
Difficulties in Identifying Obese Children From Low-Income Households. Six participants complained that identifying obese children from low-income households could cause social discrimination, making it difficult to run the program exclusively.
(…) If the obesity program is administered for children from low-income households, they will be stigmatized as poor children and obese children by their peers. I am just mixing all the students and managing the obesity program inclusively… (FG 1, P 5)
Absence of Policies Related to Childhood Obesity Management. Eight participants attributed the lack of policies related to childhood obesity management as a negative factor for obesity management. If the government had a well-implemented policy regarding childhood obesity management, teachers from various fields could quickly develop and carry out obesity management programs. However, this is not the case.
(…) These days, we do a little less obesity-related care than before when we received a pile of official letters related to obesity. We have received fewer official letters relating to the obesity care program in the past two to three years. This trend makes me passive toward obesity-related care now …. (FG 1, P 5)
Poor Environment of After-School Care Center for Vulnerable Children. Four participants cited poor conditions and obesity management at after-school care centers for children from low-income households as problems. The participants thought that their effort for obesity prevention and management should be continued after school, but expressed that the Community Childcare Centers (CCCs), which were in charge of after-school care of children from low-income families, did not provide sufficient health management services.
(…) When I was in B school, there was a ccc, so I went there with the principal once. But the facilities of this center are a bit underdeveloped. The kids get together and live together. The staff takes care of children’s meals, studies, homework, and so on. I wondered if real professional care is available there? For me, it looks like a local children’s center in the cathedral… (FG 1, P 1)
Reinforcement of Policies to Protect Student Privacy. With regard to the reinforcement of policies to protect student identity, four participants raised their concerns. Participants thought it would be effective to conduct an obesity management program at a local children’s center that cared for children from low-income households in the community because it was difficult for schools to identify those children and manage them separately.
(…) The policy mandates that the obesity program should not be run for obese children only. We have an official letter for the policy. (FG 3, P 1)
I would like to move the obesity management program to the CCCs instead of the school. That way, children with obesity will receive special and intensive care. From my perspective, it is hard for us to handle obese children in the formal education setting because human rights can hinder the implementation of the obesity program in school… (FG 3, P 4)
Success-Oriented Social Climate. Three participants considered the success-oriented social climate as a hampering factor for obesity management. In Korean society, which values education, parents pay more attention to activities that improve their children’s grades than managing obesity. In particular, families with low-income want their children to study hard and succeed, making them more eager to escape low income. Therefore, the participants recognized that obesity management is bound to be neglected.
(…) Obese children from low-income households are tragic cases, but their mothers believe that children’s success in their studies can change everything. Their children must study hard. It does not matter if their kids eat or not at home … Their moms came home late, and the working mom’s prioritize changes in their children’s social status by diligent studying. That is what happens. (FG 1, P3)
This qualitative study examined school nurses’ perceptions of obesity prevention and management barriers in children with low income. The barriers were categorized into factors related to the children, home, school, policy, and society; two to four themes were derived for each factor. These themes were obstacles from the perspective of school nurses; these may provide practical and applicable strategies for developing obesity prevention interventions in schools.
Most school nurses perceived that obese children from low-income households experienced a double stigma about low income and obesity. These children experienced feelings of embarrassment or shame from certain words including low-income or obesity among their peers. Therefore, school nurses could not recruit students to participate in obesity management programs in public, a significant obstacle to obesity prevention. As early as preschool, young children attribute negative characteristics and stereotypes to peers with larger body sizes (Su & Di Santo, 2011). Kyle et al. (2018) highlighted that weight stigma impedes progress in eradicating obesity, yet policies addressing obesity prevention neglect youth concerns. Therefore, when developing an obesity prevention program, the implementation must be sensitive and culturally appropriate, avoiding blame and shame, by considering weight stigma. It may be preferable for the school nurse to contact parents by phone or in-person about their child’s eligibility for obesity intervention (Schroeder & Smaldone, 2017). Individualized and customized programs considering individual interests and level of motivation, rather than a general program to be implemented with all obese children, are required in obesity management at school.
School nurses perceived that obese children distrusted the obesity management programs in school. Outcomes of obesity management are not achieved by participating in short-term programs and can only be effective when healthy lifestyle changes continue at school, home, and in daily life (Lagerros & Rössner, 2013). However, children might think that their achievements are invisible by participating in a program without individual or parental effort. Obesity management programs can be effective when the participant and service provider work together toward the same goal, and shared goals intensify individual goal pursuit (Shteynberg & Galinsky, 2011). Therefore, in developing obesity management programs for obese children from low-income households, goal sharing among stakeholders in the management of childhood obesity—children, parents, health teachers, and other related teachers—should be achieved first. Furthermore, collaborative efforts toward healthy lifestyles for these children are required. The school nurse is a unique discipline of professional nursing and is often the sole healthcare provider in an academic setting. Thus, school nurses can coordinate student health care between multidisciplinary teams and play an essential role in managing obesity in children.
School nurses perceived lack of adequate parenting and caring at home as a factor hampering obesity management in children from low-income households. While there is little difference in children’s behavior patterns in school because of similar curricula and having school meals, children of working parents or single-parent families are often left alone at home until late. Therefore, managing their diet or weight is difficult. Parenting is considered an important influence on childhood obesity. Parents can be positive role models in changing the health behaviors for the prevention of obesity and maintenance of healthy weight in children from low-income households (Bean et al., 2020). However, the time and resources to take care of children are insufficient in low-income families. Jurkowski et al. (2014) developed a childhood obesity intervention that addressed parents’ lack of resources and trained parents to leverage existing resources. This program empowered parents, and that in turn, predicted improvement in parenting practices. It is more helpful to develop a program that addresses the building parents’ capacity to promote and sustain healthy lifestyle behaviors within their families, rather than just providing knowledge and skills for healthy lifestyles. Therefore, practical strategies that can be used within these realistic conditions are required.
School nurses in this study believed that parents’ awareness of obesity prevention is vital because lack of physical and emotional support from the primary caregiver is directly related to the child’s unhealthy behavior. However, they mentioned that it is challenging to implement obesity interventions because the parents’ hesitation to cooperation. In vulnerable families, wherein most parents participate in economic activities and children are often left alone, children are exposed to harmful eating habits and lack of physical activities (Park et al., 2020). Full-time maternal employment promotes unhealthy dietary and activity behavior, leading to overweight children (Meyer, 2016). Conversely, parents were concerned about potential negative impacts, including decreased self-esteem and increased weight-related teasing (Moyers et al., 2005). Tatum et al. (2021) reported that while parents largely found obesity prevention programs helpful, they were concerned about stigma, lack of privacy, and unhealthy behaviors and attitudes resulting from school-based screening. The Commission on Ending Childhood Obesity (WHO, 2016) emphasized the critical role of parents and caregivers in encouraging children to engage in healthy behaviors; thus, it is necessary to continue to educate parents to expand the role of parents in preventing childhood obesity and educate the nurses on the best way to engage with the parents to enlist their participation.
School nurses generally believed that schools should offer weight management services and most strongly supported classroom curricula with regard to weight management and referrals to health care providers. They were overwhelmingly regarded as the school professionals who would coordinate weight management intervention. However, obesity prevention for children from low-income households is not a problem that the school nurse can solve alone. Totura et al. (2015) emphasized that barriers to prevention could impede efforts despite school commitment toward prevention, while stakeholder collaboration can enhance the likelihood that practices are in place. Schroeder and Smaldone (2017) also suggested that school staff’s teamwork was a key facilitator of implementation. Therefore, structural multidisciplinary networks must be established in schools to prevent and manage obesity in vulnerable children. School nurses’ organizational and leadership ability is essential for intervention adoption, successful implementation, and sustainability.
In this study, most school nurses were in charge of all health-related administrative tasks, such as managing water purifiers, air purifiers, and toilet hygiene, in addition to students’ health care and education. One school nurse did not have enough time to manage the health of the entire student body; because of various tasks assigned to her, it was difficult to focus on the health management of the student. Consistent with the present study’s findings, Schroeder and Smaldone (2017) reported that being busy and having a heavy workload were perceived as barriers to nurses with obesity prevention and intervention experience. Morrison-Sandberg et al. (2011) found that most school nurses felt that they could provide more services if adequate resources and time were available. These findings are important since they provide insight into how obesity prevention has been integrated into the various services already provided by school nurses. When planning to implement a school nurse-led obesity program, the current nursing workload must be carefully considered. Adequate time to implement obesity interventions, clear job descriptions, and staffing standards, such as maintaining staffing to meet a school nurse-to-student workload of one nurse per 750 students in the US (National Association of School Nurses, 2015), should be established. Furthermore, it is necessary to provide a practical guideline so that school nurses in South Korea can easily implement it.
Eight participants mentioned the lack of policies related to childhood obesity management as a negative factor for obesity management. They argued that it is difficult to raise interest in obesity or conduct related programs because there is no recent policy related to obesity. This means that depending on the level of interest from the government or society, programs on obesity are actively in progress for some period. However, there are still no recent official documents; thus, it is possible that obesity-related programs’ goals and deadlines are not being met. This is consistent with findings that a lack of policy is an obstacle to BMI screening (Stalter et al., 2010), and having mandates positively affects school nurses and their measurement of BMI (Hendershot et al., 2008). According to the School Health Act in South Korea, the school head must conduct health education to prevent students from drinking and smoking, but there is no specific policy on obesity.
Given that school obesity programs are one-time events (Yu & Han, 2017) or short-term and few, long-term and continuous programs reflecting the needs of students and parents are required (Yoo & Lee, 2018). The effectiveness of school-based interventions must also be considered (Park et al., 2017). In particular, obesity among low-income children should be managed comprehensively and systematically in preventive education at national and social levels (Jung et al., 2019).
Participants who had visited a CCC stated that these were poor environments where children simply gathered together to eat and receive help with homework. CCCs did not provide professional care. As a representative child welfare service institution in Korea, the CCC provides various physical and personal services to children from economically disadvantaged classes and complements the role of parents (Lim & Choi, 2016). The number of CCCs steadily increased from 3,260 in 2011 to 41,134 in 2015, with the government-funded budget for CCCs also increasing from 96.3 billion won in 2011 to 136.3 billion won in 2015 (National Youth Policy Institute, 2016). CCCs are unique facilities in Korea, and these are suitable places to provide health care intervention for children from low-income families (Park et al., 2018). However, it is difficult to operate a continuous and systematic childhood obesity management program in CCCs without budget support because most places have poor economic and physical environments (Jung et al., 2019). The long-term management of obese children is difficult to conduct in schools, and parental cooperation and connection with community-related organizations are required (Lee & Oh, 2016). To effectively manage metabolic syndrome in school-age children from low-income families, it is necessary to develop and provide programs based in schools and CCCs (Ra & Gang, 2015). Therefore, methods to use the CCC must be developed.
Participants in the study argued that if obese children are managed separately, they may face human rights issues, making intervention difficult. In addition, given that the Office of Education has sent official letters ordering that programs only for obese children not be implemented because of student human rights, school nurses expressed concern over the conflict between the two situations. This is similar to findings of other studies (Hendershot et al., 2008; Stalter et al., 2010). However, to prevent metabolic syndrome in childhood, it is practical to start early and manage risk groups such as children from the low-income group (Ra & Gang, 2015).
The participants also expressed concern that participation or interest in obesity management or other programs is significantly hindered because of the success-oriented social climate. Academic achievement is highly valued by Korean students, and the degree of its importance was found to be the highest in elementary school students (Park et al., 2005). Academic achievement is regarded to have a great influence on future social status and success, and elementary school fifth and sixth graders are driven to full-scale prior learning and competition for entrance exams. It is necessary to broaden knowledge and aid the development of knowledge through various experiential activities, but because of the stringent educational structure, parents push their children to engage in extracurricular activities related to study. Schools and society, in general, expect students to achieve academically (Koo & Kim, 2014). According to the Korea National Youth Policy Institute (2019), 35.4% of elementary school students have less than 2 hours of personal leisure time in a day, and 36.1% have insufficient sleep.
The ecological model explains that factors at each level influence and affect each other. In addition, human behavior can be effectively changed when environmental factors and individual determinants, including attitude and skills, change simultaneously (McLeroy et al., 1988). This intersectionality also can be observed in this study. In other words, “parents’ low priority of their kids’ obesity management at home factor†and “academic-oriented social climate among policy and social factors†can be influenced by each other. This intersectionality can ultimately affect obesity management. This study aimed to investigate and describe the barriers in managing obesity in children from low-income families at individual and environmental levels. Future studies are needed to investigate the interaction of each barrier described in the study and the effect of intersectionality on obesity management.
While this study provides unique and beneficial information, there are several limitations. This study was performed in a school or primary care setting in South Korea. The work and duty of school nurses might be organized differently in other countries; nonetheless, the barriers to implementing interventions in obesity management in schools discussed above seem to be consistent with international research. Therefore, we believe our findings are applicable to international settings. Additionally, we did not include data from various stakeholders, such as children, parents, care providers in CCCs, and policymakers, which are necessary to have a more comprehensive understanding of obesity management in obese children from low-income households. Despite these limitations, this novel study describes the perspectives of school nurses with regard to obesity management intervention. Future research must illustrate opinions with regard to obesity management in children from lowincome families from varied perspectives and develop comprehensive, effective, and innovative obesity management programs considering these perspectives sufficiently for this population.
School nurses have a significant role in monitoring and managing the health of children and the school community. They must understand problems regarding health disparities in childhood obesity, which is a salient issue in public health. To propose effective obesity management interventions and policies for children from disenfranchised groups, we investigated obstacles to managing obesity among children from low-income households perceived by school nurses. Various factors—including those related to the children themselves, family, school, policy, and social level reflecting the current situation in Korea—were identified. As for the psychological aspect, children from low-income families may experience double stigma related to “low income†and “obesity.†As has been established, the mental health of children from lowincome families is vulnerable. School nurses should carefully pay attention to alleviate the stigma-related emotion that children experience through obesity management.
In addition, according to the results of this study, it was confirmed that cooperation among out-of-school stakeholders (e.g., primary caregiver and community center) and among teachers within the school is important for effective prevention and management of childhood obesity in lowincome families. Therefore, school nurses who fully understand the school circumstances and have secured internal and external personal networks should act as mediators and advocate strengthening this cooperation to prevent childhood obesity in vulnerable groups.
The health status disparities caused by socioeconomic status in childhood obesity are severe worldwide, and South Korea is not an exception. Given that obesity affects physical and mental health from childhood and causes adult obesity and various chronic diseases, early systematic intervention and management are necessary and prioritized. Based on this study, it will not be easy to manage obesity among children from low-income families in South Korea. The success of obesity management among children from low-income households is not achievable with the efforts of school nurses alone. As such, we must first identify the changeable stakeholders (e.g., parents and school teachers) and need to change and continually aim to direct their attention to socioeconomic disparities in health among those with childhood obesity. School nurses play a vital role in establishing collaboration between the home, school, community, and policy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP) [No. 2015R1C1A1A01052892].
Jinah Lee https://orcid.org/0000-0001-7502-9244
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Jeonghyun Cho, RN, PhD, is an associate professor at the College of Nursing, Institute for Health Science Research, Inje University, South Korea.
Jiyoung Park, RN, PhD, is an assistant professor at the College of Nursing, Institute for Health Science Research, Inje University, South Korea.
Chongwon Park, PhD, is a professor at the Division of English Language and Literature, Pukyong National University, South Korea.
Jinah Lee, PhD, is an associate professor at the Department of Social Welfare and Counseling, Catholic University of Pusan, South Korea.
Jina Oh, RN, PhD, is a professor at the College of Nursing, Institute for Health Science Research, Inje University, South Korea.
Gahui Hwang, RN, MSN, is a doctoral candidate at the College of Nursing, Yonsei University, South Korea.
1 College of Nursing, Institute for Health Science Research, Inje University, Busan, South Korea
2 Division of English Language and Literature, Pukyong National University, Busan, South Korea
3 Department of Social Welfare and Counseling, Catholic University of Pusan, Busan, South Korea
4 College of Nursing, Yonsei University, Seoul, South Korea
Corresponding Author:Jinah Lee, Department of Social Welfare and Counseling, Catholic University of Pusan, Address: 57, Oryundae-ro, Geumjeong-gu, Busan 46252, South Korea.Email: jj88@cup.ac.kr
