A Community-Based Participatory Assessment of the Health Status and Obesity Risks in Children From Rural Farmworker Families in the Midwest

Abstract

Obesity prevalence is higher among Hispanic children (22.4%) compared with general U.S. children (17%). Children of migrant and seasonal farmworking families are at heightened risk for obesity and related conditions. Limited research, including needs assessments and health promotion programs, has been conducted in Latino migrant farm working communities. Our objective was to identify needs, opportunities, and barriers for designing health promotion programs for children attending a community agency in a small Midwestern town. As part of a community-based participatory research project, a needs assessment was undertaken with 38 children aged 5 to 12 years (74% Latino). Measures included demographics, dietary patterns, physical activity (PA), and anthropometrics. The study was approved by the university’s institutional review board and written parental consent, and child assent, was obtained. More than half of the sample had overweight (29%) or obesity (26%); 31% had elevated blood pressure levels. Participants did not meet the U.S. Department of Agriculture recommendations for most food groups and nutrients; 13% fell into the “poor” and 87% into the “needs improvement” category based on Healthy Eating Index scores. PA levels were low; only 34% of respondents engaged in sufficient exercise. Findings indicate the need for programs promoting improvements in dietary intake and increased PA.

Keywords

physical activity Latino populations children rural nutrition

Introduction

Rural youth have a higher prevalence of overweight and obesity compared with their urban counterparts, regardless of age, ethnicity, or socioeconomic status (Champion & Collins, 2011; Edwards, Miller, & Blackburn, 2011). Rural residents often have limited access to nutrient-dense foods and limited recreational opportunities (Edwards et al., 2011; Kumanyika et al., 2008). Such environmental constraints are associated with increased consumption of snacks and fast food, and low levels of physical activity (PA) (Torres-Aguilar, Teran-Garcia, Wiley, Raffaelli, & Morales, 2015). At particularly high risk are the estimated five million migrant and seasonal farmworkers, the majority of whom are of Latino/Hispanic origin or descent, residing in rural communities across the United States. These families confront the same risk factors as other rural dwellers, plus additional risks associated with low income, long working hours, seasonal income, immigration status, and low levels of acculturation (Lichter, 2012). These factors combine to place children of farmworker families at heightened risk for overweight, obesity, hypertension (HTN), asthma, cardiovascular diseases, and diabetes mellitus (Kilanowski & Moore, 2010; Lim, Song, & Song, 2017).

According to the 2011 to 2012 National Health and Nutrition Examination Survey (NHANES), 38.9% of Hispanic children have overweight or obesity (Ogden, Carroll, Kit, & Flegal, 2014). Prevalence rates tend to be higher among rural than urban Hispanics (Hammons, Wiley, Fiese, & Teran-Garcia, 2013). Hispanic children are also at an increased risk for high blood pressure (BP) that is associated with excess weight, unhealthy eating patterns, lack of PA (Chobanian et al., 2003), and long-term health risks (Carrico, Sun, Sima, & Rosner, 2013). Comparably high levels of overweight/obesity and related conditions are also reported in low-income migrant farmworker children of other ethnicities (Kilanowski & Moore, 2010). Thus, efforts to prevent and treat obesity and HTN in low-income farmworker populations in rural areas represents a sound investment in the nation’s future. To accomplish this work, accurate information regarding the health status and behaviors of migrant farmworkers and their families is needed. A small but growing body of research has examined physical health status, dietary intake, and patterns of PA in rural Hispanic children and adolescents, although these factors have not been typically examined within the same study.

To expand the sparse research base, we addressed the following research goals in a predominantly Hispanic sample of children from migrant and seasonal farmworker families:

Determine the prevalence of overweight, obesity, and HTN and examine their interrelations

Assess dietary and PA patterns and compare them with federal guidelines

Determine the association between behavioral factors (i.e., diet and PA) and physical health indicators (i.e., overweight, obesity, and HTN)

Background

The study employed community-based participatory research (CBPR), which is increasingly utilized for health disparities research (Wallerstein & Duran, 2006), including studies with Latinos/Hispanics (Amendola, 2013). In CBPR, community agents and universities collaborate to address issues of concern to the community (Gonzalez-Kruger, Zamboanga, & Carlo, 2000). One of the initial steps of CBPR is needs assessment to provide a deeper understanding of community needs (Kelly, 2005), thus creating interventions that are responsive to local needs. The university researchers for this study partnered with a community center serving primarily Latino families in a nonmetropolitan community, using CBPR to establish a collaborative relationship and identify critical health needs. The community center came into existence to provide free services to migrant and seasonal farmworkers’ families. The center provides free-of-cost childcare for children 0 to 5 years of age and after school care for school going children. The center runs on funds collected from donations and grant awards from the Illinois State Board of Education. The study team comprised of four university researchers, community center director, community center staff, and a student intern. The larger project was divided into three phases: (1) Relationship Building, (2) Needs Assessment, and (3) Program Implementation.

During the first phase, the researchers met regularly with the center staff to explore areas of mutual interest and participated in center activities (e.g., health fairs, family events), which gave the researchers an opportunity to connect with the center staff and the families. The center representatives also gave a presentation about the center inception and activities to the faculty and students at the university. The researchers obtained funding to place a Spanish-speaking intern at the center for an academic semester. The intern assisted staff with their work and observed the rhythm of daily activities. The study lead investigator provided free nutrition consultations to parents of children between 3 months and 5 years to strengthen the relationship with the center staff and families. The study lead investigator also connected the center with the University of Illinois Extension’s “Cooking with Kids” Program, which then offered cooking classes to the children in the afterschool care at the center. Phase 1 ultimately identified the nutrition and PA habits of children attending the center’s after-school program as an area of concern. This led to the needs assessment in Phase 2. The objectives of the needs assessment were to assess health indicators and associated behavioral factors of children in the after-school program. In the third phase, findings are being used to develop health promotion programs for the families served by the center. This article describes the needs assessment phase, including descriptive data.

Methods

Participants

Recruitment packets (study description, consent and assent forms) were sent home with children served by the after-school program, and parents were given a second recruitment packet when they came to the center. The inclusion criteria were: children 5 years and older who attended the after-school program, returned signed parent consent forms, and provided signed child assent. An institutional review board approval was obtained prior to data collection (IRB Protocol No. 15126). Approximately 50 children, ages 5 to 12 years, attended the after-school program; 42 enrolled in the study, but 4 withdrew due to limited reading and comprehension skills.

Data Collection

Data collection was conducted by trained research staff and occurred during the time children were normally at the center. Children completed age appropriate self-report measures of food intake and PA in small groups (3-5 children), in sessions lasting 45 to 60 minutes. Anthropometric measures of height, weight, and BP were collected at a separate time. At least one university researcher and a Spanish speaking graduate student were present at each session to help children with limited English proficiency to complete study questionnaires. All questionnaires, except the food frequency questionnaire, were completed in English. Children received healthy snacks and jump ropes as a participation incentive.

Measures

Participants self-reported basic demographic variables (e.g., age, ethnicity, living situation, language spoken at home) and completed the following measures:

Anthropometrics and blood pressure

Standing height was measured to the nearest 0.1 cm with a portable stadiometer (Seca, Model 242, Hanover, MD). Body weight was measured using a digital scale (HealthOmeter, Model 349KLX, Jarden Consumer Solutions, Boca Raton, FL) to the nearest 0.1 kg. BP was measured with an electronic, digital, portable upper arm BP monitor (Omron HEM-712C Automatic Blood Pressure Monitor, Hoffman Estates, IL). Two BP readings were taken on each participant’s left arm, in the sitting position, with an interval of 3 minutes. An average of the two readings was used for data analysis.

Food Frequency Questionnaire

Participants completed either the English or Spanish version of the Hispanic Block Kids 2004 Food Frequency Questionnaire (FFQ; NutritionQuest, Berkeley, CA) (Cullen, Watson, & Zakeri, 2008), which demonstrates adequate validity and reliability with Hispanic children (Zoorob et al., 2013). Participants reported foods eaten in the past week at home, at school, from snack machines, or from fast food or restaurants, indicating how many times per week they consumed each food and how much they ate in one sitting using a portion size graphic to aid in quantification.

Physical Activity Questionnaire

Participants completed the 6-item short version of the Physical Activity Questionnaire for Children (PAQ-C), which was previously validated and shown to be reliable and used with Latino children (Mandich, Burke, Gaston, & Tucker, 2015). The first question asked for a list of 23 activities: “Have you done any of the following activities [in your spare time] in the past 7 days (past week)? If yes, how many times?” Participants rated each item from 1 to 5 (1 = no, 2 = 1-2, 3 = 3-4, 4 = 5-6, 5 = 7 times or more). Questions 2 to 6 asked participants to rate their PA during the past 7 days in various contexts (e.g., physical education class, recess, right after school) on a scale from 1 (not active at all) to 5 (very active).

Data Analysis

Descriptive statistics including percentages or means and standard deviations were calculated for the demographic variables. For the anthropometric data, body mass index (BMI) percentiles were calculated using height, weight, and age data; participants were then classified as normal weight, overweight, and obese according to age- and sex-specific growth charts (Centers for Disease Control and Prevention, 2000). Participants were classified based on their BP readings as Normal BP, Prehypertension, Stage 1 Hypertension, and Stage 2 Hypertension (National Heart, Lung and Blood Institute, 2007). A Spearman correlation coefficient was calculated between BMI percentile and BP.

Completed FFQs were mailed to the NutritionQuest Company, which generated individual reports that quantified food intake in terms of the numbers of servings consumed for each food group and also expressed micronutrients and macronutrients as daily intakes to assess the adequacy of diet. We calculated the means and standard deviations of the variables of interest, and categorized participants as meeting or failing to meet the recommended intakes based on the Dietary Guidelines for Americans and Dietary Reference Intakes (Nelson et al., 2013; U.S. Department of Health and Human Services & U.S. Department of Agriculture, 2005).

Diet quality was assessed using the 2015 Healthy Eating Index (HEI-2015) score, which allows for comparison of an individual’s diet to the Dietary Recommendations for Americans (Bowman, Lino, Gerrior, & Basiotis, 1998). A HEI-2015 score of 80 or higher is rated as “good,” a score of 51 to 80 as “needs improvement,” and a score 50 or lower as “poor.” Spearman Correlation Coefficient was used to examine the association between HEI-2015 score and physical health indicators (BMI percentile, BP).

Question 1 on the PAQ-C indicated the most common physical activities. An average PA score was calculated from Questions 2 to 6 for each participant. A score of 3 and higher indicates adequate activity (Zoorob et al., 2013). Spearman correlation coefficient was used to examine relations between PA score and physical health indicators.

Preliminary analyses were conducted to test for differences between Latino and non-Latino participants on study outcomes. There were no significant differences in BMI percentile (p = 1.000), HEI score (p = .505), and physical activity level (p = .422). The only difference was that 70% of non-Hispanic had normal BP, compared with 64% of Hispanics (p = .044). Thus, the entire sample was treated as one group. A systematic review of studies with migrant and seasonal farmworker families found that for 8 out of 10 studies, the sample included a small percentage of non-Latino participants and data were pooled for analysis (Lim et al., 2017).

Results

Demographics

As displayed in Table 1, 38 children (66% female) had complete questionnaire data. The mean age was 7.9 ± 2.1 years (range 5-12 years). All but one (97%) lived with their biological mothers; 45% lived with their biological fathers, and 26% with a stepfather. Most (87%) lived with at least one sibling and 29% had other relatives/friends living in their house. The majority of the participants (87%) were born in the United States. Half (50%) of the participants spoke both English and Spanish. Most children (74%) were Latinos, primarily of Mexican/Mexican American descent.

Table 1.

Demographic and Anthropometric Characteristics.

Characteristic	N or Mean	Percentage or ± standard deviation
Sex; N = 38
Boy	13	34
Girl	25	66
Age (years); N = 38	7.92	±2.1
Race/Ethnicity; N = 38
Mexican/Mexican American	24	63
Puerto Rican	2	5
Other Latino	2	5
Black/African American	3	8
White	7	18
Other (European)	1	3
Language spoken at home; N = 38
English only	29	76
Spanish only	28	74
English and Spanish	19	50
Living arrangement; N = 38
Mother (biological or adopted)	37	97
Stepmother	1	3
Father (biological or adopted)	17	45
Stepfather	10	26
Brothers/half-brothers/stepbrothers	22	58
Sisters/half-sisters/stepsisters	24	63
Other people (e.g., relatives or friends)	11	29
Birth place; N = 38
United States	32	84
Mexico	5	13
Other (Honduras)	1	3
Height (cm); N = 36	130.72	±12.98
Weight (kg); N = 36	33.84	±11.39
Body mass index percentile classification; N = 36
Normal weight	18	50
Overweight	8	22
Obese	10	28
Blood pressure classification (BP); N = 32
Normal	22	69
Prehypertension	4	13
Stage 1 hypertension	5	16
Stage 2 hypertension	1	3

Note. N = 38. Sex, age, race/ethnicity (1 participant selected both Mexican/Mexican American and Puerto Rican), language spoken, living arrangement, birth place; N = 36: BMI percentile (missing height and weight for 2 participants); N = 32: BP classification (missing BP readings for 6 participants).

Anthropometrics and Blood Pressure (Physical Health Indicators)

Thirty-six participants had valid BMI data and 32 had valid BP readings (Table 1). Less than half (45%) were of normal weight; 26% were obese, 29% overweight. More than two thirds (69%) of participants had normal BP readings; the remainder were classified in the prehypertension, Stage 1 HTN, or Stage 2 HTN categories. BMI percentile and systolic/diastolic BP were not significantly correlated (Table 2).

Table 2.

Correlation Matrix for HEI, PA Score, BMI Percentile, Systolic and Diastolic BP.

	HEI	BMI percentile	Systolic BP	Diastolic BP	PA score
HEI	1
BMI percentile	−0.076	1
Systolic BP	0.225	0.142
Diastolic BP	0.292	0.252	0.698*	1
PA score	0.556	0.251	−0.146	0.007	1

Note. HEI = Healthy Eating Index BMI = body mass index; BP = blood pressure; PA = physical activity. Correlation values (r) reported in the table.

*p ≤ .05.

Food Frequency Questionnaire (Dietary Intake)

Daily mean intakes for all food groups, except protein and dairy, did not meet U.S. Department of Agriculture (USDA) dietary recommendations (Table 3). A small number of participants met the USDA Dietary Recommendations for saturated fat (3%), sodium (47%), calcium (34%), and fruits and vegetables (24%). The mean HEI-2015 score was 58.5 ± 7.8. Most of the participants (87%) had HEI-2015 scores in the range of 51 to 80 (needs improvement); and 13% participants had a score of 50 or lower (poor). Of the individual HEI-2015 components, the participants had the lowest scores for vegetables and whole grains. The Spearman correlation coefficient was not significant for the relation between HEI-2015 and either BMI percentile or systolic/diastolic BP (Table 2).

Table 3.

Dietary Characteristics of Study Participants—Ages 5 to 12 Years.

Characteristic nutrients	Mean	±Standard deviation	2015 Dietary recommendations
Food groups
Dairy (servings/day)	2.08^a	±1.25	2-3 servings/day
Fruit (servings/day)	1.92	±1.49	2-4 servings/day
Vegetable (servings/day)	1.32	±1.54	3-5 servings/day
Grains (servings/day)	5.73	±5.03	6-11 servings/day
Protein (servings/day)	2.40^a	±2.52^a	2-3 servings/day
Dietary fiber (grams/day)	17.83	±14.42	20-35 grams or more
Vitamin A (RAE/day)	571.44	±450.51	700 RAE/day
Vitamin C (mg/day)	157.22	±152.58	200-400 mg/day
Vitamin E (mg/day)	6.35	±6.87	12.00 mg/day
Total fat (% kcal)	32.27^a	±6.29	25%-35% of total calories
Saturated fat (% kcal)	11.92	±2.69	<7% of calories
Sodium	3107.81	±2807.40	≤2400 mg
Cholesterol (mg/day)	246.20	±233.49	<200 mg
Healthy Eating Index score	58.5	±7.81	≥80

Note. RAE = retinol activity equivalent.

^aMeets US Department of Agriculture recommendations; N = 38 participants.

Physical Activity

PA levels were low across the sample (Table 4). The most common activities were jogging, tag, skipping, dance, walking for exercise, and basketball. The average PA score for Questions 2 to 6 was 2.71 (range = 1.2-4.0). Only 34% of the participants attained a summary score of 3 or more (indicating adequate activity). PA score was not significantly correlated with BMI percentile, HEI-2015, or systolic/diastolic BP (Table 2).

Table 4.

Physical Activity Questionnaire.

Question	Mean score	±Standard deviation
Q1. Activities engaged in the last week	2.33	±0.93
Q2. Activity during physical education classes	4.03	±1.30
Q3. Activity at recess	3.59	±1.57
Q4. Activity at lunch	1.11	±0.46
Q5. Activity right after school	1.54	±1.17
Q6. Activity in the evenings	3.30	±1.75
PA score (mean of Q2-Q6)	2.71	±0.66

Note. N = 38 participants.

Discussion

This study contributes to the emerging literature on the health status of migrant and seasonal farmworker populations in rural areas across the United States. As part of a larger CBPR project, we conducted a needs assessment of children from primarily Latino farmworker families. Results indicated that many children were at risk of obesity and related comorbidities, did not meet USDA dietary guidelines, and had low levels of PA.

Health Status and Risks

Health assessments indicated that more than half of study participants had overweight or obesity and almost one third had high BP. Rates of overweight and obesity (55%) were similar to those reported in rural Latino adolescents (56.6%) (Nelson et al., 2013), and higher than among 3- to 16-year-old children in a migrant farmworking community (47%) (Ogden et al., 2014), or 6- to 13-year-old Latino children from the same geographic area where our study was conducted (51%) (Hammons et al., 2013). Moreover, nearly one third (31%) of the sample had elevated BP readings, more than the 22% found in rural Latino adolescents (Nelson et al., 2013). Overweight, obesity and high BP increase the risk for developing diabetes and cardiovascular problems during adolescence and these risk factors persist into adulthood (Nelson et al., 2013).

Nutritional assessments indicated that none of the participants met all the dietary guidelines for consuming a healthy diet, which was also reflected in their HEI-2015 scores. The mean HEI-2015 score (58.5) for the sample is comparable to the national HEI average score (55) for all U.S. children (Ogden et al., 2014). About 12% of the U.S. population score higher than 80 (Bowman et al., 1998); however, in our study none scored in the “good” range (≥80; indicative of meeting all the nutritional requirements). Twelve percent of the study participants did not meet the daily requirements for most food groups, including fruits, vegetables, and whole grains, resulting in inadequate intakes of vitamins A, C, and E. The intake of fat and saturated fat was above the recommended limit. Low intake of dietary fiber, due to low consumption of fruits, vegetables, and whole grains, has been recognized as a culprit for obesity and related disorders in Latino population (Davis et al., 2005). Increasing dietary fiber intake by increasing consumption of fruits, vegetables and whole grains, is an effective weight maintenance strategy (Rolls, Ello-Martin, & Tohill, 2004). A successful program for predominantly Latino children, which emphasized fiber intake by promoting consumption of whole grains, fruits and vegetables, resulted in decreased BP, weight loss, and improved vitamin intake (Davis, Ventura, Cook, Gyllenhammer, & Gatto, 2011). Such a program will likely be beneficial for children who attend the Community Center where our study was conducted.

Children at the center also had low levels of PA, with only a third engaging in “sufficient” activity (PA SCORE of “3” or more). Participants reported being most inactive during the after-school hours, which was consistent with our observations (during the relationship building phase of the project) that children in the after-school program would typically eat a snack, sometimes work on their homework, and engage in passive leisure activities. Previous research suggests that PA levels are lower for Hispanic adolescents as compared to non-Hispanic Whites and particularly low in rural Hispanic girls outside of school (Rodriguez, Weffer, Romo, Aleman, & Ortiz, 2011). Literature also suggests that U.S. Latinos are the most physically inactive racial group (Ham, Yore, Kruger, Heath, & Moeti, 2007). Among children, reduction in physical education and recess time in schools has also resulted in decrease in physical activity levels (Lindsay, Kim, Mucha, & Gortmaker, 2006; Patrick et al., 2004).

A novel aspect of this study was the assessment of physical health markers (BMI percentile and BP), dietary intake (HEI score), and physical activity in a single sample of children. This allowed us to examine associations between these different health indicators. Among adults, HTN is associated with overweight, and overweight and high BP are associated with unhealthy eating patterns and lack of PA (Chobanian et al., 2003). The association between overweight and unhealthy eating/lack of PA has been seen for Latino children or adolescents in some studies (Fuentes-Afflick & Hessol, 2008; Patrick et al., 2004; Rodriguez et al., 2011). However, we did not find significant correlations between BP and BMI percentile, or between these physical health markers and HEI-2015 or PA scores. Similarly, a study by Kilanowski and Moore (2010) also identified no association between dietary intake and the risk of overweight/obesity of migrant farmworker children (N = 50). Our study and the study by Kilanowski and Moore (2010) had small sample sizes; suggesting that studies with larger samples may be needed to further explore these findings.

Implications for Intervention

The findings indicate the need for a structured healthy lifestyle program for these children. The third phase of the project involves using the results of previous phases to inform intervention development or adaptation of existing programs, encompassing structured activities that can be integrated into the after-school program at the center. Children and adolescents learn well when various modes of instruction are used (Muzaffar, Metcalfe, & Fiese, 2018). A program including PA games, interactive demonstrations, cooking activities, and gardening activities would increase the appeal of the program for participants (Muzaffar et al., 2018). The Community Center has a garden that can be utilized for a gardening component. Similarly, it has a kitchen facility that is available after 3 p.m. for cooking activities. The center also has a computer lab to allow incorporation of online components. Family-based interventions have been successful in Latino populations (Hammons et al., 2013), and it would be optimal to incorporate parents in the program at some level. Literature consistently suggests the importance of adding a parental component to health promotion programs for prevention and management of childhood obesity (McLean, Griffin, Toney, & Hardeman, 2003; Rolls et al., 2004).

Limitations and Contributions

The needs assessment study had some limitations. First, the study involved a convenience sample of children who attended the center for after-school care. The sample size was small and gender, age, or ethnic group differences could not be examined. Second, self-report assessments of dietary patterns and PA were obtained. Although the FFQ provides a fair estimate of macronutrient intake, it is a retrospective method that relies on memory, and is subject to participant error. An objective measure, such as plate waste or digital photography, would provide more accurate information about food intake. Similarly, although the PAQ-C provides a general sense of activity level, it does not measure caloric expenditure or the frequency, duration and intensity of physical activities. An objective measure, such as an accelerometer, would allow more accurate measurement of the time and intensity of daily physical activity. Last, it would have been useful to collect additional objective measures of cardiometabolic health, such as blood sugar and blood lipids, to characterize the health profile of study participants.

Conclusions

The CBPR principles of participatory research and community involvement are useful strategies for addressing health disparities in obesity (National Institutes of Health, 2004). A review suggests that incorporation of community engagement principles is positively associated with the attainment of intervention target outcomes (Krishnaswami, Martinson, Wakimoto, & Anglemeyer, 2012). This study illustrates the utility of CBPR in health research. Findings contribute to a growing body of literature on the health status and risks of predominantly Latino children in farmworker families and are being used as the basis for intervention development and implementation in the third (current) phase of this research.

Footnotes

Acknowledgments

The project was conducted in collaboration with the Multicultural Community Center in Rantoul, Illinois that offers a unique opportunity for building a University–Community partnership related to issues of Latino health and well-being.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was funded by the Collaborative Seed Grant awarded by the Family Resiliency Center at the University of Illinois at Urbana-Champaign.

ORCID iD

Henna Muzaffar

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