In accordance with the aim of this study, we found a wide variation in CHC-nurses conceptions of overweight in children. Several descriptions emerged regarding overweight children, all of which were regarded as difficult to deal with at the CHC due to some of their core elements. The findings of the present study have, to some extent, features that are parallel to previous findings regarding the attitudes and beliefs among health care personnel and parents regarding overweight children [15
]. These findings will be summed up and dealt with further in this text following the order of the presented results.
This study adds to the knowledge related to overweight and obese children and the acceptance by society of the problems of children’s excess weight. This acceptance affects CHC-nurses conceptions of what is a healthy weight for a child, which is an important finding that adds to the existing knowledge. Nurses consider that the view of both the Swedish society and the health care professionals about the healthy weight of preschool children has changed. Earlier views have been revised due to the increased proportion of overweight children in society. Nevertheless, the CHC-nurses in this study emphasised the seriousness of childhood overweight and their experience was that it increases with a child’s age.
There is a vast difference between being aware of one’s child excess weight and to actually realise that it is overweight. The participating CHC-nurses expressed that most of the parents are aware of their children’s overweight, but the few parents who seek help for their overweight child do not express their concern about the health issues. Hence, the participating CHC-nurses emphasised that it is the child’s appearance and the parent’s fear of their child being bullied that leads them to seek help from the CHC. This finding is supported by research indicating that mothers´ focus more on concerns over stigmatisation and bullying and less on the physical ramifications of the problem [46
When asked, more than 90 percent of the public believed that it is the parents who have the main responsibility for reducing childhood overweight [35
]. This result is in line with our finding regarding CHC-nurse’s perception that it is up to the parents whether or not they choose to make a change in their children’s weight. Paradoxically, all of the CHC-nurses in our study perceive childhood overweight as a problem of great concern and emphasise that it is important to motivate the family to change and not just to criticise the parents. At the same time, a great majority of them did not take overweight among children in their early preschool years seriously. The CHC´s responsibility for a child extends until the child’s care is transferred to the school health care system at 6
years of age. It may be possible that this fact makes it easier for the CHC-nurses to put the problem aside as at six years they are able to hand the responsibility for the child and its overweight problem over to the school nurses. However, to the best of our knowledge, there are no other studies implying such findings.
The participating CHC-nurses experience having negative thoughts towards parents and blame them for their children’s excess weight. These negative thoughts are expressed in terms of being a burden for the CHC as these families are time consuming. One reason for these experiences may be that CHC-nurses are uncomfortable with their encounters with parents who are often overweight themselves [25
]. Moreover, the CHC-nurses expressed that lack of time, financial resources and staff, constitute barriers against working with childhood overweight, which is supported by Moyers et al. [15
]. Furthermore, some of the CHC-nurses in our study expressed that fathers and children were more likely to tell the truth about the children’s dietary habits than the mothers. As far as we know, there are no studies dealing with the gender differences between parents concerning honesty in reporting family dietary habits. Traits like negative thoughts, suspicion and blame among health care personnel are reflected in their encounter with the parents of overweight children. Perceptions of help- seeking experiences among parents of overweight children indicate that they occasionally experience the health care professional’s response as negative and dismissive [31
]. Our present knowledge about parents of overweight children facing stigmatisation is based upon literature from the fields of both nursing and medicine dealing with difficult patients and parents. These parents are often referred to in terms of blame and stigmatisation [32
]. There is therefore an imminent risk that negative thoughts and lack of resources of CHC-nurses are reflected as negative attitudes in an encounter with an overweight child and its parents, which in turn may affect the parent-nurse relationship.
The nurses who participated in this study indicated that some parents have difficulties in setting limits for their children’s demands regarding food preferences, which is supported by previous research [24
]. Our findings show that the CHC- nurses conceived that parental stress and lack of time was compensated by fast food and that it was difficult for parents to say no to their children since food has an emotional meaning and could be used as a substitution for parental love. Food can be used as a tool for coping with stress and as a tool in parenting [24
], which is in line with our results.
One of the strongest social determinants of childhood overweight and obesity is known to be the education of mothers [40
]. The CHC-nurses in this study stressed that it was important to give priority to families with a poor economy and a low level of education, as children in these families are especially vulnerable regarding childhood overweight. Our findings are supported by a previous qualitative study [41
], which showed that parents from high and low socio-economic groups differ in their ways of handling overweight related health problems and therefore intervention strategies should be individually tailored to each group and family. Further, there is a body of literature showing that mothers with a lower educational level are less likely to recognise their children as being overweight, despite their children’s obvious excess weight [38
]. Additionally, children’s probability of becoming overweight is linked to their mother’s time and hours spent working per week [38
]. Our study show that parental lifestyles and time spent with children is perceived to have a great impact on dietary intake and thereby children’s weight, which is also supported by Jackson et al. [39
A study by Heubeck [44
] indicates that it is least likely that poorer and immigrant subgroups identify childhood overweight as a serious problem. The CHC-nurses in our study stressed that existing cultural differences regarding eating habits and body perception, affect the probability for childhood overweight in families from different cultures. In their study, Fisher and Birch [45
] reported that it was more important to parents belonging to lower socio- economic groups that there was food available and that their children consumed a sufficient quantity of food. There is an equivalent finding in this present study regarding mothers constantly offering their children food and never letting them feel hungry.
The overall conception of the participating CHC-nurses was that overweight in children becomes a concern first when the children reach school-age. The participants considered it important to motivate the family to change their habits, but it is up to the parents whether or not they make dietary changes that will bring their child’s weight into line. The CHC is voluntary and this situation may result in the CHC-nurses making less effort and reducing their persistence to raise the subject with the parents. All of what is mentioned above, as well as the fact that overweight in children is perceived to be a sensitive subject may lead to the risk of tactical underestimation of a child’s overweight by the CHC and thereby lead to insufficient treatment [48
There are certain strengths, as well as limitations, to consider that may affect the interpretation of the present study. Strengths are that all of the interviews and the analysis were conducted by the first author (GEI) and all of the participants were asked the same initial question. Almost all of the CHC-nurses (n
19) who were requested to participate in this study wished to be included apart from one. This meant that 18 CHC-nurses represented the 17 different CHCs included in the study. Further strengths are that the interviews were experienced as positive by the participants who were generally open and easy to talk to. There existed an understanding of the profession-specific terms and routines used in CHC due to the professional background of the first author (GEI), which could possibly have facilitated the interview process.
The CHCs included were situated in both well to do and poor areas of the four municipalities chosen and the CHCs differed in both the composition of RSCNs´ and DNs´ and the number of employees per unit. They all had the same local director but different responsible clinic managers. This should not have influenced the findings as they all have the same general guidelines for CHC. The limitation of this study is that the findings can only be valid for those nurses who participated in the present study, which means that a gender perspective is missing. The number of eligible male RSCNs and DNs in CHC is low in the southern part of Sweden, however, all those eligible took part in this study. Further, the authors believe that the result of this study might be transferable to similar contexts of CHC as the sample of CHCs represented both urban and rural areas.
Another strength is that the findings from the study were continuously discussed back and forth between the authors during the analysis. Further, this interdisciplinary cooperation facilitated the guarding against the effects of personal biases and thereby improves the trustworthiness. The derived conceptions and later the categories of description were regularly scrutinised by the third author (GA), who is experienced in phenomenographic analysis, to attain greater rigour.
This area of research is still unexplored and there are few studies conducted involving CHC-nurses. This study adds to the accumulated knowledge the perceptions of the CHC-nurses, who apart from other health care personnel are those who most frequently encounter preschool children with overweight and obesity at the CHCs.