Insights into the challenges and facilitators to physical activity among brooklyn teens enroled in a weight management programme

Abstract Purpose A qualitative study was carried out to explore obese adolescents' understanding of physical activity, perceptions of the ideal body type and to identify facilitators of and barriers to physical activity. Methods Twenty‐two adolescents 12–18 years of age and 14 of their parents were recruited from an obesity intervention programme in Brooklyn, New York, from June to November 2017. Data were collected using focus groups and individual semi‐structured interviews, followed by interpretative phenomenological analysis of the transcripts. Results The adolescents wanted to ‘lose some weight’, but not to be ‘thin’ or ‘look hungry’. Most females desired a ‘slim‐thick’ figure, which was ‘a flat stomach with big thighs, and curvy’. Fun and support from parents, peers and programme staff facilitated achieving their physical activity goals. Barriers included low self‐efficacy, inactive families, fear of neighbourhood gangs and crime and perceptions that the parks were small and overcrowded, with limited physical activity options for adolescents. Conclusion These findings highlight the need to consider local norms concerning body image when designing obesity interventions. To effectively reduce childhood obesity in New York City, policy should prioritize the promotion of public safety, improvement of neighbourhood parks and increase options for physical activity. Patient or Public Contribution The voices and narratives of patients and their families informed this study.


| BACKGROUND
In 2017-2018, the prevalence of obesity among US youth 2-19 years of age was 19.3%, and 21.2% of adolescents 12-19 years of age were obese. 1 There are also racial and ethnic disparities in obesity, with increased prevalence among non-Hispanic Blacks (29.1%), and Hispanic (23%) adolescents when compared with their White (14.8%) and Asian (5.1%) peers. 1 Obesity is also more prevalent among socioeconomically disadvantaged groups. 2,3 Central Brooklyn is one of the poorest areas in New York City (NYC). Most residents are Black and experience a disproportionate burden of obesity-related diseases. 4,5 Obesity rates in children 5-14 years of age are among the highest in NYC at 23%-25%. 6 Childhood obesity has been accompanied by an increased prevalence of hypertension and Type 2 diabetes, other obesityrelated comorbidities 7,8 and a lower health-related quality of life. 9 Childhood obesity persists into adulthood, 10 and is associated with higher early adult mortality. 11 Effective obesity interventions are needed to improve health outcomes and reduce the high medical costs of treatment of children with excess weight and obesity-related conditions.
A combination of physical activity, reduced sedentary behaviour and dietary modification is recommended for the reduction of obesity and related comorbidities. 12,13 However, the Youth Risk Behaviour Survey found that most adolescents do not meet the physical activity guidelines. There are also disparities in physical activity levels, with black and Hispanic adolescents less active than their white peers. 14 Decreasing adolescent obesity is a public health challenge.
Adolescence is a critical period of development, 15 where lifestyle and health-related behaviours are established and the risk for obesity is increased. 16,17 Overweight and obese adolescents are less active than normal-weight adolescents. 18,19 They face additional challenges to engage in physical activity, are victimized by peers and experience higher rates of low self-esteem and loneliness than their peers who are normal weight. 20 Previous studies indicate that intrapersonal, interpersonal and community factors affect obese adolescents' physical activity behaviours. [21][22][23] Facilitators include motivation to improve their health 24,25 and appearance, 26 and family and peer support. 25,27 The availability of physical resources such as parks and recreation facilities in their neighbourhoods, and opportunities to be physically active in school have also been reported as facilitators. 23,28 Barriers to physical activity have included lack of motivation, 26,28,29 lack of knowledge and misperceptions of physical activity, 30 cultural attitudes about weight 29,31 and misperceptions about their weight. 31,32 Heightened body consciousness, including insecurity about their appearance, avoidance of humiliation, bullying and lack of social support, 20,33 concerns about neighbourhood safety, 28 lack of resources and limited access to community resources 31,34 have also been reported as barriers to physical activity.
A systematic review of qualitative studies by Stankov et al. 35 identified common barriers to physical activity faced by adolescents who were overweight or obese including negative body and unsafe neighbourhoods. However, although socioeconomic status was not adequately considered, the review points to potential variation by sex, race/ethnic group and socioeconomic status. For example, there seemed to be greater acceptance of obesity reported in studies among African-American girls, relative to studies in White and more affluent populations. 35 Additionally, there are few recent qualitative studies of the perceptions related to physical activity among adolescents with obesity who reside in low-income inner-city neighbourhoods.
The Social-Ecological Model postulates that multiple levels of influence (intrapersonal factors, interpersonal processes and primary groups, institutional and community factors and public policy) affect behaviour, and that the different levels interact with each other. 36 It is a framework to examine physical activity. 37 The exploration of the lived experiences of adolescents with obesity from communities of colour, their perceptions of the intrapersonal, social and environmental facilitators and barriers to being physically active may improve understanding. This is important for development of sustainable intervention programmes. The purpose of this qualitative study was to explore the facilitators and barriers for physical activity among adolescents with obesity who reside in Central Brooklyn, New York, and enroled in a tertiary care obesity intervention programme. The objectives were to explore the concepts involved in the perception of physical activity among adolescents with obesity, their perceptions of the ideal body type and the personal, social and environmental factors that facilitate and present barriers to physical activity.

| Setting
Participants were recruited from the Live Light Live Right (LLLR) tertiary care childhood obesity programme. 38 LLLR utilizes a multidisciplinary approach (medical evaluation, nutrition education, physical activity and behavioural counselling) 38 and is the only communityengaged obesity treatment programme serving children in Brooklyn.
Institutional Review Board approval for the study and all study material was received from SUNY Downstate Health Sciences University. Participants in the study were recruited from June to November 2017.

| Recruitment and sample
Using purposeful sampling, we recruited adolescents 12-18 years of age with overweight/obesity, who were English speaking, enroled in the LLLR programme. We also recruited one parent of each child for interview. We distributed separate recruitment flyers to the adolescents and their parents during their medical appointments or during their attendance at exercise sessions, and they were invited to participate. We explained the general purpose of the study to potential parents/adolescents who expressed interest, and those BROWNE ET AL. | 1833 who agreed to participate were guided through the assent and consent procedure. Recruitment procedures yielded 33 adolescents aged 12-18 years and 27 interested parents.

| Data collection
A female Caribbean American doctoral-level researcher (V. B.), who is a registered nurse with maternal child health experience, led this study. 39 Her interest in the health and development of children of colour living in disadvantaged neighbourhoods was the motivation for this study. She volunteered at LLLR and exercised alongside the children, conscious of her position as an 'insider' because of similar racial and socioeconomic backgrounds with many of the participants but also as an 'outsider' to these adolescents and their families because of her position as a female researcher affiliated with an academic institution, and her professional experience. She was aware of her preconceptions and acknowledged that the researcher's biases may have influenced the data collection and analysis.
Separate focus group and semi-structured interview guides were indicates that there are gender differences in adolescents' physical activity levels, 40 and in their attitudes towards physical activity. 41 Stratification by gender may have elicited more in-depth information.
We also conducted two focus group interviews with five mothers of 12-15-year-old female adolescents, and four mothers of 12-15-year-old male adolescents. When the focus group participants chose their seats, their initials were written on a seating chart for note-taking of significant comments or reactions. The interviews were audiotaped and were 45-60 min in duration. Due to low turnout for the focus groups with older adolescents (ages 16-18 years) and their parents, we offered them the option of individual semi-structured interviews. We interviewed 14 participants, 9 older adolescents (16-18 years) and 5 parents who expressed agreement at exercise and clinic sites, with each interview lasting 25-30 min. Each adolescent and parent were given a $20 and $40 gift card as an honorarium.

| Analysis
Data collection and analysis occurred simultaneously. Interpretative phenomenological analysis (IPA) was the approach used as the guiding perspective to explore the lived experiences of the adolescents and their parents in their social and community environments. 42 IPA aims to explore in detail how participants make sense of their personal and social world, to examine the meanings that particular experiences and events hold for participants and to deepen or extend understanding of the participants' experiences. 43,44 The audio tapes were transcribed verbatim and analysed as soon as possible following the focus group and individual interviews. Notes were taken to document ideas, and the researcher's conceptual thoughts and reflections as they occurred during the analyses. Each transcript was read several times and distinctive phrases and emotional responses were highlighted. We identified participants' statements by gender and their age groups (younger adolescents: 12-15 years, older adolescents: 16-18 years) to respect their request that we do not use pseudonyms in the report.
Each highlighted item was assigned a code and organized into emergent themes that were relevant to the aim of the study. The themes were grouped according to conceptual similarities, reexamined for significance and assigned descriptive labels. Themes from all of the adolescent interviews were combined into a list to reflect the findings. This process was repeated with the themes from the adult interviews. In the final phase, these lists were combined in a list of superordinate themes and organized to reflect participants' perceptions. A journal with memos and notes was utilized in conjunction with the interview. During this process, the researcher used 'reflexivity' for awareness of personal biases, assumptions and beliefs that she brought to the study 38 and deliberately 'bracketed' them. 45 Data collection and analysis continued until after four focus groups and 14 individual interviews, when we reached thematic saturation and no new themes emerged.

| Validity considerations
We evaluated this study utilizing rigour as recommended by Lincoln and Guba. 46 Prolonged engagement to understand the lived experiences of the adolescents and families enhanced credibility.
The researcher volunteered at the programme sites and exercised with the adolescents and families to become familiar with them to build trust and rapport. Rigorous techniques and methods (audio recording and note taking) garnered high-quality data from multiple sources about the adolescents (focus groups, individual interviews and notes). Prolonged engagement with the data provided in-depth information of the adolescents' physical activity perceptions and behaviours. 43,46 Member-checking with participants confirmed that the summary of findings that we shared with them reflected their experiences and perceptions, 46 and helped to validate the conclusions. 47 Detailed information is provided about the participants, the composition of focus groups and the contexts and assumptions underlying the study. The researcher's actions, changes and the rationale for them, notes and reflections were recorded in a journal throughout the study. Another member of the research team evaluated whether the findings, interpretations and conclusions were supported by the data.

| RESULTS
The adolescents had a mean age of 14.9 years, were 50% male and the majority were African-America/Black (86%). Twenty-one participants were obese/severely obese (body mass index [BMI] percentile >95th), and one participant was overweight (BMI percentile 90th), and the average BMI was 36.6 (range: 25.3-57.5). Sixteen adolescents had been attending the obesity clinic or enroled in the exercise programme for more than 6 months and six for less than 6 months.
The main themes that emerged from the participant interviews are presented here, organized according to Socioecological Model (SEM) levels.

| Individual and interpersonal factors
3.1.1 | Adolescents' body image: 'slim-thick' and 'toned and neat' All the adolescents wanted to lose weight; 19 adolescents expressed the desire to change their appearance. However, adolescents revealed that they did not embrace a thin body as their ideal and this was not their motivation for physical activity.
'To be at the right body size', 'To be fit', and 'I want to you know, not skinny, skinny, but lose some weight'.
Gender differences emerged about how the ideal body type was constructed. Most male adolescents wanted to look slim 'toned' and muscular, but did not want to 'look hungry'.
According to an older male, 'I do it because also I want to look more toned instead of looking like wide and I would say sloppy. I'd like to look more toned and neat'.
Conversely, females desired the ideal body type that was 'slimthick'. When probed, a younger female described this as 'when you are skinny, and you got a big butt, your stomach is flat, but you still got curves'. Two younger female participants volunteered to draw the image to demonstrate exactly what they meant. Figure 1 shows younger female adolescents' drawings of the 'slim-thick  Few female participants reported that they enjoyed team sports, and most preferred dancing and playing fun games. They did not want to exercise or play sports or compete with peers. They felt that they could exercise when their performance was not being judged: When it was easy for me to exercise, I was alone.  Table 1 presents exemplary quotes about the gender differences in motivation for physical activity.

| Low self-esteem and fear of ridicule
Low self-efficacy emerged as a barrier for physical activity when the adolescents described their feelings about the difficulties that they experienced with activities. Parents also revealed that the adolescents' perception of their weight affected their self-confidence.
I just have no confidence to do it. I feel that exercising is important, but I feel like I just have no T A B L E 1 Statements about gender differences in motivation for physical activity.  'He is over,obese. I try to make him do some exercise, not to sit around, move around a little. Keep his blood flowing, his heart pumping the right way. So, I think it's very important to me and to him. I am okay with him doing physical activity. I push him because sometimes he lies back. So, I always push him and say "you need to do a little exercise even in the house. You get up for fifteen, twenty minutes, do something instead of sitting around". I try to make him active. I even made him do swimming, just to keep him active'. (Mother of older male) Live Light Live Right 'I like how she pushes me. Even when she is being mean, like you know that deep down is not because it's like she is "I hate you". It is because "I want to see you succeed"'. (Younger female) '…different stuff you all try to incorporate into it. The basketball program, the step thing, the dancing, the cardio stuff, it gives kids the option if you don't want to work out. Not everybody works out the same. People want to do different things. So, you created more options for everyone, that's good'.  Table 3 presents additional exemplary statements about barriers to physical activity. Additionally, Figure 2 shows the participants' perceptions of facilitators and barriers in the context of the SEM. 37,38 4 | DISCUSSION This qualitative study aimed to explore the perception of physical activity among adolescents with obesity, their perceptions of the ideal body type and the personal, social and environmental factors that facilitate and present barriers to physical activity.
The finding that the adolescents did not perceive a thin image as their ideal body type is contrary to a study of African American girls aged 11-14 years, who viewed a slender frame as an attractive body size. 48 This is consistent with a previous study of African American adolescent girls who did not embrace a slim image and were satisfied with their bodies, but expressed specific areas for change.
However, in that study, the BMI status of those participants was unknown. 49 The male adolescents' desire to be toned is consistent with the study of obese adolescents in the Bronx, New York, in which many male participants desired developed muscle mass and less body mass. 24 Although the previous studies revealed that the adolescents were comfortable with their larger body image, the current finding of the specific 'slim-thick' figure is novel and is a characterization of the ideal body type that resonated with Brooklyn female adolescents we interviewed. Local and cultural norms concerning body image should be a consideration in planning intervention programmes.
The influence of media personalities differs from previous studies with African American girls. In several studies, participants compared their bodies and appearances to images in the media and embraced the slim images of models. 48,49 It has been suggested that as the number of African American women in the media increases, African American girls may begin to use these images for social comparison. 50 The participants' internalization of the celebrity body types as ideal can potentially place them at risk for engaging in unhealthy weight loss behaviours to attain the desired shapes.
The scepticism of the reality of the body types portrayed in the media is consistent with prior research on African American adolescent girls who recognized that some celebrity attributes were fake 48 and unrealistic, and the strategies used by media and celebrities to hide flaws and change. 49 Despite the idealized 'thick-thin' image, these adolescents' media literacy may be a protective factor for engaging in healthy weight-related behaviours.
Gender differences in the norms and motivations for physical activity among the adolescents are consistent with previous studies of adolescents with obesity. 23,24 Consideration of these differences in motivation and exercise preferences and providing female adolescents with options for noncompetitive activities can potentially improve their physical activity behaviours.
Low self-esteem and perceived inabilities prevented adolescents from participating in physical activity in various settings. Prior research supports the importance of self-efficacy for exercise among adolescents. 51,52 According to Bandura, people tend to avoid situations they believe exceed their coping skills and participate in those they judge that they are capable of doing. 53 Heightened body consciousness (insecurities about their appearance, the fear of ridicule and bullying), perceived as a barrier by these adolescents, is similar to previous qualitative studies. 20,33 Salvy et al. 54 indicated that experiencing negative peer influences appeared to deter youth from being physically active, and that children and adolescents may avoid physical activities in an attempt to avoid further weight criticism, teasing and victimization from peers in general.
The perception of family dynamics as barriers is consistent with prior research that found that the lack of parental motivation prevented obese African American adolescents from being physically active. 26 These findings highlight the importance of social support and family behaviours for the inner-city adolescents with obesity.
The negative perceptions of the parks, safety concerns and the fear of gangs as barriers to physical activity is consistent with previous studies that generally report about the fear of unsafe neighbourhoods. 28,30,34 They highlight the need for neighbourhood improvements in low-income inner-city communities.

| Policy and practice implications
This study provided insights about adolescents with obesity in a lowincome neighbourhood that has not been explored previously. 'I have a brother with a disability so a lot of times I just stay home to help. So, I never really get a chance to go out. Sometimes I'd be exhausted. I also have a little brother, 2-years-old that I usually watch and take care of a lot. Being with them just makes you want to stay inside a lot. 'It's just not as good as the others. It's just that they are small. Prospect Park and Marine Park they have the trees and stuff. The parks that I like are big parks and these are smaller. I guess in places like Marine Park you could go to the park and other places like restaurants or something that you could just hang out at. But these they don't really have those. In other neighborhoods its

| Strengths and limitations
The use of focus groups and individual interviews in this study elicited rich data and insights about how the adolescents with obesity from low socioeconomic and disadvantaged neighbourhoods perceive the cultural and contextual facilitators and barriers to physical activity. It also filled the gap in knowledge about these inner-city adolescents' perceptions of their ideal body type, and the influences on their perceptions. However, this is a small purposeful sample of adolescents with obesity and their parents who live in traditionally socially disadvantaged and medically underserved neighbourhoods.
Participants were recruited from an obesity intervention programme, and they also volunteered to participate in the study. Their perceptions may be different from those of other adolescents.
Therefore, the findings may not be generalizable to the broader community.

| CONCLUSION
This study found that the factors that affect these obese adolescents'