This study identified the main barriers and facilitators involved in childhood and adolescent obesity prevention policies in Iran. As far as the researchers investigated, this is the first study to evaluate the barriers and facilitators of the mentioned policies from the perspective of the main policy makers of Iran. In addition, our study attempted to fill the existing gap through introducing the factors affecting the implementation of interventions related to these policies.
The most important type of barriers to the implementation of childhood and adolescent obesity prevention policies was structural level barriers. In this regard, the insecurity of physical activity environments for children and adolescents was one of the structural barriers. Physical activity in children and adolescents, as both professional and recreational sports, requires a safe environment where parents and children feel less at risk. One of the most important factors in this regard is the security of roads to/from schools. Heath et al. showed that environmental policies and interventions to improve the safety of physical activity environments, such as building safe cycling routes, significantly increase the level of physical activity in children and adolescents [17].
Similar to our study, the results of the determinants of diet and physical activity (DEDIPAC) study, which examined the barriers to physical activity and food intake in the school environment through interviewing key stakeholders, showed that insecurity in physical activity environments can be a barrier to the level of physical activity in children and adolescents [18]. Among the important structural barriers was the high access of children and adolescents to unhealthy foods. Selling unhealthy foods in the community, especially in stores near the schools and even inside them, often at low prices, can increase the access of children and adolescents to such foods and pose health risks [19]. Studies show that the proximity of such stores to schools, for example less than 200 meters in the study by Caraher [20] or less than 800 meters in the study by Davis [21], can change the eating patterns of students and result in obesity among them. Furthermore, taxing unhealthy foods [22, 23], subsidizing some healthy foods [22, 24], and using food guide labels on the packages [25] are among the main recommended strategies. Other suggested strategies to prevent obesity among children and adolescents include: teaching nutritional facts to children and adolescents, holding workshops for parents, supporting intervention policies [26,27,28], and running social health-related campaigns. For example, a campaign entitled "Say No To Fast Food" was run in Iran in 2017.
Extensive advertisement of fast foods, as one of the most effective factors in increasing obesogenic environments, was selected as another barrier in the implementation of childhood and adolescent obesity prevention policies, Similar to the results of Cyril et al. (2017) study [29]. More than 60% of television commercials in Iran are related to food products [30] , and most of these commercials advertise unhealthy foods that strongly affect children's food choices [31]. In this regard, in 2009, advertising unhealthy foods was restricted in the United Kingdom; as a result, children aged 3-9 years and 10-15 years were 52% and 22% less exposed to these commercials, respectively [32].
Some studies reported the following individual barriers: insufficient awareness and lack of understanding the risk of obesity, lack of self-control when eating, and high stress in students [33]. However, as the results of the present study and several other studies [34] indicated, desirable and popular interventions could solve the above problems to some extent and serve as a facilitators for childhood and adolescent obesity prevention policies. Although the overlap of intervention programs with students' school hours was cited as a barrier to implement the policies, one of the most important structural facilitators in this study, similar to the study by Hayes et al., was the integration of intervention programs with the school curriculum. In a different study, Villegas et al. claimed that if we can incorporate the policy interventions into the school curriculum by offering more variety in the relevant subjects as well as by the behavioral management of school staff and the timely provision of teaching resources, we can increase awareness among the staff and students and implement the health policies, such as preventing childhood obesity, in a much better way [35].
Lack of comprehensive data on the effectiveness of childhood obesity prevention policies and lack of mandatory weight control for all school students were identified as other barriers. In some countries the effectiveness of childhood and adolescent obesity prevention policies has been measured by different methods [36,37,38], but there is no such data on the effectiveness of these policies in Iran, leading to problems in policymaking. Having data on effectiveness and knowing which methods have had the greatest health benefits for society make it easier for policymakers to decide on the type and method of policies. These analyses are important because the financial resources and staffing of the health system are limited. Hence, in a world with limited resources, it is expected that effective interventions with the greatest benefits be selected [39].
The impact of parents on childhood and adolescent obesity prevention policies has been studied in various studies, and it has been shown that parental involvement has a key role [28, 36]. In this regard, the results of the present study were in line with the studies that showed insufficient knowledge and awareness [29], difficulty in the effective use of children's health services [40], improper use of vehicles [18], and lack of participation in intervention programs [26] are some important barriers in advancing the childhood obesity prevention policies. Therefore, through appropriate planning and policies, and especially designing programs to increase parental awareness and attitude towards the complications of childhood obesity and methods to prevent it, these barriers can partially be solved. Similar to our study, other studies identified lack of staffing [28], financial constraints at the implementation level [26, 41], and at the family level [33, 42] as the barriers to this policy.
There are many barriers to access and consume a healthy diet, even when people prefer to eat healthy foods. This problem is especially important for the lower socio-economic groups. Many of these barriers are due to the structure of a society's food system [43]. Studies show that healthy foods are usually more expensive than less healthy foods [44], and that low-income families cannot afford healthy and culturally appropriate diets [45]. In the United States, a study examining school nutrition programs showed that funding from the government and private institutions can help in shaping the effective policies, and it can lead to positive changes in food and beverages sold in the school environments [46].
The selected approach in policymaking was identified as another effective factor in childhood and adolescent obesity prevention policies. The findings of the present study showed that due to the existence of a top-down policy approach, the implementation of most policies encounters serious problems. Other studies have shown that the centralized healthcare system in Iran has resulted in top-down policies, as well as implementation problems [47]. In top-down policies, there is not much consultation with executive stakeholders in the systems, and policymakers announce the policies to lower levels based on their own experiences. In such an approach, the desired goals are often not met; it may also destroy the innovations and policies developed [48].
Insufficient knowledge and communication skills along with frequent transfers of the employees are among the main barriers related to the executive staff [49]. Since the Iranian healthcare system has undergone fundamental changes in recent years, it is believed that with the addition of executive processes and assigning new tasks to the employees, many functional changes are made in the system [50]. In addition, the knowledge, skills, and practices needed in one area may be different from another one. Similar to some other studies, another barrier in the present study was the lack of sufficient cooperation between stakeholders [47]. According to Adhikari, unless there is sufficient cooperation between stakeholders, we should not expect effective implementation of health policies in that system [51].
Nowadays, stakeholders at the policy formulation and implementation level, have a high level of ability to influence childhood and adolescent obesity prevention policies. Therefore, their participation in the process of policy making can play an important role in reducing the prevalence of childhood and adolescence obesity. In addition, these stakeholders should be aware of the barriers and facilitators of this policy and manage them to effective participation in this policy. Based on the findings, nurse leaders should make the best use of the window of opportunity for involvement in the policy-making process. In addition, The Ministry of Health, Treatment and Medical Education, as the main trustee of childhood and adolescent obesity prevention policies in Iran, should have the training, support and opportunity for involvement other stakeholders with effective advocacy.
