Exploring the obesity health beliefs of women in Curaçao: a mixed methods study of women who have given birth at Curaçao Medical Centre

Sarah Ward¹, Nurah Hammoud^2,3
1 Vrije Universiteit, Amsterdam Affiliation
² Curacao Medical Center
³ Julius Centre Department, Global Public Health UMC Utrecht

Corresponding Author:
Sarah Ward
Email: [email protected]

DOAJ: a265d501af034b04be24fab8285d1940
DOI: https://doi.org/10.48107/CMJ.2025.09.002
Published Online: September 30, 2025

Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

©2025 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association

ABSTRACT
Background: Most of the Small Island Developing States (SIDS) face a ‘triple burden’ of malnutrition, in which persistent levels of micronutrition and undernutrition deficiencies coincide with the increasing prevalence of overweight and obesity. Curaçao is classified as a SIDS and is recorded to have a persistently high rate of obesity over the last 30 years.

Objective: This research aims to contribute to the United Nations’ established Sustainable Development Goal of one-third reduction in premature mortality from non-communicable diseases (NCDs) and suicide before 2030 in Small Island Developing States. This research provides insights into sociopsychological and environmental factors of obesity for women in Curaçao, to provide contextualised recommendations for future weight management programmes.

Methods: A mixed methods explanatory sequential design was employed with 17 previous obstetric patients who have a cardiovascular risk profile from Curaçao Medical Center. Data were collected via electronic patient records, a structured questionnaire and semi-structured follow-up questions.

Results: The barriers to weight management behaviours are largely rooted within the obesogenic environment of Curaçao. Sociopsychological factors, such as the challenges associated with new motherhood, have a significant impact on participants’ lifestyle choices.

Conclusion: To ensure a lasting impact, future weight management programmes in Curaçao should prioritise enhancing participants’ self-efficacy and establishing multi-level support systems. These programmes must include education on obesity and its associated comorbidities to build a foundational understanding of health risks. Additionally, interventions should deliver culturally contextualised guidance on healthy lifestyle behaviours, considering the local obstetric environment and ensuring recommendations are realistic and sustainable for individuals to integrate into their daily lives.

Keywords: obesity, maternal health, weight management behaviours, obesity risks during birth, obesity risks during pregnancy, cardiovascular risk profile

INTRODUCTION
Obesity, defined as excessive fat accumulation that poses a risk to health, is a chronic NCD associated with many comorbidities such as hypertension and cardiovascular disease.^(1,2) The causes of obesity are complex because they result from long-term lifestyle choices, such as unhealthy eating, drinking and physical immobility. These lifestyle behaviours can be compounded by an individual’s genetic predisposition to being overweight.⁽²⁾ Moreover, obesity is also a complex social disease. People living in poverty, minorities and women comprise a large percentage of the affected population.⁽³⁾

Small Island Developing States (SIDS) is a classification that encompasses significantly diverse islands; however, they share core characteristics such as their small size, remoteness and maritime environment.⁽⁴⁾ These characteristics increase the likelihood of food insecurity.^(5,6) The majority of SIDS face a ‘triple burden’ of malnutrition, in which persistent levels of micro-nutrition and undernutrition deficiencies coincide with the increasing prevalence of overweight and obesity.⁽⁵⁾ The UN (United Nations) has recognized the burden of NCDs in most SIDS and has responded by establishing a Sustainable Development Goal: a one-third reduction in premature mortality from NCDs and suicide before 2030.⁽⁸⁾ To achieve this goal, the UN recommends that SIDS implement ‘low-cost, high-impact’ solutions to tackle obesity and other NCDs rates.⁽⁸⁾

Curaçao is classified as a SIDS and is recorded to have a persistently high rate of obesity over the last 30 years. ^(7,8) By 2017, two-thirds of the adult population within Curaçao (aged 18 and older) were overweight and 29% were obese.^(7,9)Research suggests that the prevalence of obesity in Curaçao  varies by gender.⁽¹⁰⁾ Women in Curaçao have disproportionately higher rates of being overweight and obese in comparison to the male population.⁽¹¹⁾ Obese women have specific health risks during pregnancy and childbirth, which can cause ramifications for the mother and foetus(es). Among others, maternal risks include hypertensive disorders and gestational diabetes; the foetus is at higher risk for congenital anomalies and stillbirth.⁽¹²⁾ Obesity during pregnancy can also negatively impact health later in life for both the mother and child. The chance of cyclical development of generational obesity is higher in children born from obesity during pregnancy and development.⁽¹³⁾

Due to the higher prevalence and specific health implications of obesity for women in Curaçao, weight management interventions are necessary. Little research exists on the link between how wider social determinants influence the lifestyle choices of women in Curaçao.⁽¹⁴⁾ Meeting health intervention needs of women living in Curaçao requires gaining insights into sociopsychological and environmental factors of obesity. This research aims to contribute to the UN’s Sustainability Development Goal by helping to transform weight management behavioural interventions towards contextualised methods for women in Curaçao. This study aimed to explore the feasibility and inform preparations for a future island-wide investigation on this topic by employing a mixed methods explanatory sequential design. The study engaged non-scientific actors, specifically former obstetric patients from the gynaecology clinic at Curaçao Medical Center (CMC). Therefore, the primary objective was to examine how the health beliefs and perspectives of postpartum patients inform and influence the design of future weight management interventions.

METHODS
Curaçao Medical Center
Curaçao Medical Center (CMC) is a new state-of-the-art hospital, a provider of both specialised medical care and high-level clinical care. The hospital has 300 beds in total. The maternity ward has five delivery rooms and 24 beds. The average number of deliveries on a yearly basis is 1200. The average yearly number of gynaecological patients in the outpatient clinic is around 35,000. CMC provides tertiary care for obstetric patients from the region, with a highly functional NICU unit, with active care from 25 weeks gestation onwards. It also provides a tertiary care function for the region concerning gynaecologic oncology and difficult gynaecological cases.

The Conceptual Model
The Health Belief Model (HBM), developed by Rosenstock and Becker, is a theoretical framework used to study behaviours and mindsets. It posits that an individual’s belief system significantly influences their decision-making and ability to adhere to specific behaviours.⁽¹⁵⁾ The HBM is based on six constructs that help predict behaviour: Perceived severity (the stronger an individual’s perception of the consequences of a disease, the more motivated they are to act to avoid the outcome); Perceived susceptibility (motivation to adopt healthy behaviours increases if an individual perceives higher risk of acquiring the disease); Perceived benefits (belief in the effectiveness of the behaviour in reducing disease severity is necessary for action); Perceived barriers (an individual’s assessment of obstacles and costs to action); Cues to Action (internal and external events that may prompt behaviour adoption); and Self-efficacy (belief in one’s ability to perform the behaviour).^(15–17) The model also recognises that modifying factors indirectly aid in translating health attitudes into health practices.^(18,19) These constructs provide a conceptual foundation for designing individualised behavioural interventions, refer to Figure 1.

Figure 1: The Health Belief Model developed by Rosenstock and Becker. The Conceptual Model for this research is derived from the Health Belief Model and its core concepts which aim to predict health-related behaviours.¹⁶

Study Design
This study utilised a mixed methods explanatory sequential design, where quantitative data collection and analysis preceded qualitative exploration. This approach facilitated an initial assessment of participants’ beliefs and perceptions related to obesity and weight management using a structured HBM questionnaire. Subsequently, semi-structured interviews were conducted to contextualise and deepen understanding of the survey findings. Data were integrated during the interpretation phase to identify patterns and inform recommendations for patient-centered interventions.

Target Population and Sampling
The target population comprised mothers who delivered at CMC between 1 January 2021 and 1 March 2023, a period selected to ensure the availability of electronic patient records. Eligible participants had a cardiovascular risk profile, defined as being overweight, obese and/or hypertensive, aligning with the study’s focus on obesity and ensuring the availability of relevant data. Based on these criteria, 390 eligible records were identified and compiled into a master dataset.

A 10% sampling strategy was used to determine a feasible and representative sample for the in-person interviews, resulting in a target of approximately 40 participants. To account for potential non-responses, this target was increased to 45. Using random sampling, 108 patients were contacted, of whom 39 consented to participate and 17 (44%) completed in-person appointments. During their appointments, participants had their height and weight measured, completed the HBM questionnaire and participated in a semi-structured interview. Due to time constraints in the data collection period (April–May 2023), recruitment was not extended further.

The same 17 participants completed both the quantitative and qualitative components. This approach aligns with mixed methods principles by facilitating robust data integration and ensuring consistency across datasets. The qualitative interviews served to elaborate on participants’ survey responses, enabling further interpretation of the HBM constructs within their lived experiences. Prior to participation, the study was verbally explained and written informed consent was obtained. Data analysis was conducted from April to July 2023.

Quantitative Data Collection and Analysis
Participants’ height and weight were measured to calculate body mass index (BMI). They then completed an online HBM questionnaire created by Saghafi Asl et al.¹⁷The 89-item instrument comprises seven subscales reflecting HBM constructs: perceived severity, susceptibility, benefits, barriers, self-efficacy (in dieting and exercise), cues to action and adding the subscale of behavioural intention. Items were rated on a five-point Likert scale (one = strongly disagree to five = strongly agree), with subscale scores calculated as mean values; higher scores indicate stronger agreement with the corresponding belief. Internal consistency was assessed using Cronbach’s alpha (acceptable if ≥ 0.70). The data were analysed in SPSS v29 using descriptive statistics. Missing values were addressed using a multiple imputation expectation-maximisation algorithm.

Qualitative Data Collection and Analysis
Following completion of the questionnaire, participants took part in semi-structured interviews aimed at contextualising and further exploring their survey responses. The interview guide was developed based on key constructs of the HBM and included three open-ended questions designed to elicit participants’ perspectives on the prevalence of obesity in Curaçao and to gain insight into their lived experiences on the island. Interviews were conducted in a private room at CMC, lasted 30–60 minutes and were audio-recorded with participant consent. Transcripts were then created verbatim via the recordings and analysed thematically using Braun and Clarke’s six-step framework. An inductive coding approach was applied, with codes organised into themes reflecting both HBM constructs and emergent patterns from participant narratives. Analysis was conducted using ATLAS.ti v22.

Data Integration
Integration of quantitative and qualitative data occurred during the interpretation phase through side-by-side comparison of HBM subscale scores and corresponding qualitative themes. This process allowed for the identification of convergence, divergence and complementarity across data sources, thereby enhancing the depth, coherence and trustworthiness of the findings.

RESULTS
Participant Characteristics
The mean age of the 17 participants when they gave birth was 30±7.47 (range 18-52) years. Based on the height and weight taken at the appointment, the participants’ mean BMI was 34.21±5.99 (range of 17.9-43.7) kg/m². Most of the participants (82.3%) were obese and over half (57%) currently had hypertension.

The BMI when the same 17 participants gave birth, was also noted from the previous obstetric patient records. The mean BMI at the time of birth was 37.3±5.55 (range of 21.1-48), with 16 participants (94.1%) being obese at the time they gave birth. The one participant who was not obese at the time of the birth had pregnancy-induced hypertension. Patient records taken from the target initial electronic patient record analysis revealed that over half (53%) of the participants had pre-existing hypertension and 29.4% of participants had pregnancy-induced hypertension. 17.6% (n=3) of participants had type 2 diabetes. 11.8% (n=2) were diagnosed with gestational diabetes during their pregnancy. These characteristics are displayed in Table 1.

Table 1: Baseline characteristic of the research participants. *Standard deviation

Participant Modifying Factors
Open-ended responses and interviews revealed modifying factors impacting health behaviours, grouped under a sociopsychological category, refer to figure 2. When asked about the population, all participants stated that there are high rates of obesity in Curaçao. Participants indicated that ‘food truck culture’ (truk’i pan) encompassed the eating preferences of the general population. Food truck culture involves eating generally unhealthy food, in large quantities, late at night. Furthermore, many participants indicated that supermarket food products must be imported to the island, increasing their prices. One participant stated, ‘When you go to a food truck, with ten guilders ($5.55) you can get a meal…But when I go to the grocery store to get healthy food, with ten guilders I get nothing.’

When asked about themselves, some participants recognised their personality traits and/or social circles influence their unhealthier eating habits. If a person’s social circle (friends, family, co-workers) generally opted for unhealthier food options, they chose those options as well. Moreover, some participants mentioned that they had coping mechanisms, such as stress/emotional eating tendencies, which increased their struggles with weight management.

Figure 2: Codes derived from semi-structured questions transcript analysis and then organized within the Health Belief Model

Participants Weight Related Beliefs
The total subscale scores for obesity severity, susceptibility, cues to action, self-efficacy in dieting and exercise and behavioural intention of weight management had a mean of over 3.0 on the five-point Likert scale, indicating more agreement with the questionnaire questions. The aforementioned subscales have an acceptable Cronbach’s alpha score (≥ 0.7), except for self-efficacy in exercise (0.66), refer to Table 2.

Table 2: The participants mean subscale score of weight-related beliefs.

Perceptions of Obesity
In the susceptibility subscale to obesity, participants agreed that their environmental (3.34±1.12) and lifestyle factors (3.60±1.33) influenced their health. Susceptibility was also recognised during the open-ended questions by participants who stated that they needed to lose weight to avoid obesity health implications. These participants mentioned that they could put more effort into their day-to-day lives to eat and/or exercise to become healthier.

Within the severity subscale, emotional/mental health (3.23±1.33) and physical health/fitness (3.51±1.28) had the highest mean scores. However, the former had an acceptable alpha score (0.86) while the latter did not (0.52), refer to Table 2. Participants indicated the severity of obesity by stating significant implications. First, their children’s health could suffer if unhealthy lifestyle choices were made in the household. Additionally, one participant mentioned that it is common for children to eat/drink many sugary products, influencing childhood obesity rates. Other participants acknowledged that their health could suffer from obesity, increased blood pressure, kidney disease and the longevity of their lifespan.

Perceptions of Weight Management Actions
The perceived self-efficacy in dieting and exercise subscales both had a score above three. The emotional/mental health subscale for dieting and total subscale score for exercise did not have an alpha score above 0.7, refer to Table 2. During the open-ended questions, the majority mentioned that their income levels either helped or hindered their ability to adopt healthy behaviours. Two participants stated that because they had an adequate income, they were able to prioritise buying fruits and vegetables. Others mentioned that their income level made fast food options more realistic than shopping at a grocery store. These participants also stated that recently having a child decreased their amount of disposable income.

However, participants recognised that there were high present and future benefits of weight management actions. The perceived benefits had a total subscale score above 4.0 (4.18±0.91). The emotional, physical, and social, subscale scores were also high with excellent alpha scores, refer to Table 2. Participants articulated potential benefits to behaviours such as eating well and exercising regularly. They acknowledged a likelihood that they would live longer lives with their children, but also better lives for their children, refer to Figure 2. One participant explained why eating healthy was important: ‘If you do not eat healthy, you get problems with your kidneys and your blood pressure. Then you have to come to the hospital all the time, you can’t be a fun mum and the kids will have the negative effects of that.’ Another identified benefit included fertility rates. One participant described that when she adopted healthier habits and lost weight, she was able to become pregnant after years of fertility issues. ‘…Before my pregnancy, I did not know that obesity can affect my fertility. So, I think if young girls know that they will be more self-conscious about food choices… Because I think most of them want to have a child.’

While there were significant benefits to these actions, there were several identified barriers as well. The total perceived barriers were the only subscale with a mean score of less than 3.0 (2.94±1.46); however, many of the participants agreed that having a young child created roadblocks to prioritising their health. These barriers included a lack of time or energy to go to the store, cook, exercise, or go to the doctor. ‘But if I go to a supermarket, I have to plan it after work, after I pick up my kid. And then after grocery shopping, I don’t have time to prepare the meal myself. So, I will buy KFC (a fast-food chain) … that is around the corner from my house.’ Lack of time and energy was often compounded by an increase of stress of being a new mother, their home life, income level and/or employment. Additionally, nearly all participants mentioned that the high cost of healthy food at a supermarket is one of the largest barriers to eating well. One participant summarised this finding as: ‘Food is expensive, you are going to buy it one week, the other week you have no money.’

Perceptions of Cues to Weight Management Action
Participants scored the total cues to action subscale as 3.60±1.24. Internal cues had a score of 3.70±1.22 but did not have an acceptable alpha score. As stated above, the internal drivers indicated by participants included the benefits to their overall health, but also happiness with their body image. ‘We have a lot of people that are obese…maybe they say that it does not bother them but I know for a fact that it does because with me, it was the same thing…I couldn’t get the clothes I want, I was shy, I did not like to go where many people were.’ This finding was supported by another participant who stated that seeing slimmer models on social media encourages them to take weight management action. Additionally, external cues had an overall subscale score of 3.50±1.27 with an excellent alpha score. Weight management information or free programmes advertised on social media, television and/or the radio were identified as effective cues to action for participants and the population.

The mean rating on behavioural intention of weight management was 3.30±1.17. The results suggest that participants were planning to adopt healthier behaviours, with preference toward dieting rather than exercising, refer to Table 2. During the open-ended questions, participants stated various actions that they could adopt to manage their weight: cooking at home, growing their vegetables and exercising. Furthermore, actions were expanded to include the outside sources that could help participants and the overall population manage their weight, refer to Figure 2.

These outside sources included a supportive person, (friend or coworker) who could join them in their healthy behaviour. The benefits of having a person were stated as encouragement and accountability to adopt the behaviour. Next, they stated that CMC itself could do more to help their patient population lose weight. Participants stated that when they became pregnant, CMC aided them in weight and blood pressure management, which helped and motivated them to adhere to behavioural changes. From these experiences, participants suggested that the population would benefit from weight counselling during primary care visits. Finally, it was identified that if CMC could expand access to dietitians, patients would likely attend consultations to create realistic goals and long-lasting health changes.

DISCUSSION
Women are overrepresented in the persistently high rates of obesity in Curaçao, which is alarming due to the possible implications obesity can cause or aggravate during pregnancy and childbirth.⁽¹²⁾. The goal of the study was to explore the obesity health beliefs of former obstetric patients with a cardiovascular risk profile. It did this by administering the HBM questionnaire and contextualising the results with semi-structured follow-up questions. The findings from this mixed methods study could be included in future weight management interventions.

The results demonstrate that the sociopsychological and environmental factors heavily influence the food culture of Curaçao. Participants identified that the abundance of unhealthy food options is favourable to the general population due to its affordability and time for meal preparation. Participants identified that grocery stores, while acknowledged as the healthier option, are often more expensive due to food importation. For new mothers reporting more stress, less time and financial strain, buying fast food is a simple alternative. Another study noted that Curaçaoan food truck culture coupled with the lack of incentives to stimulate individuals to make healthy food choices created an obesogenic environment conducive to overeating unhealthy foods.⁽¹¹⁾ The influence of obesogenic environments on individuals was also noted in research done in Mexico. The findings of the study suggest that an individual’s decision-making process for unhealthy food options is associated with food accessibility and acceptability factors.⁽²⁰⁾

Mothers who reported increased stress levels also stated that they struggle with coping mechanisms such as emotional eating. These coping mechanisms can be reinforced by the normalcy of eating unhealthy food options in social situations. This finding is congruent with others that show that eating is a social behavior; therefore, people tend to eat as their peers.^(21,22) Another study recognised the importance of social influence on adherence to healthy behaviours. It found that social circles undermining diet plans were associated with participant weight gain within 24 months.⁽²³⁾

The perceived susceptibility and severity of obesity were recognised in questionnaire and semi-structured questions. Environmental and lifestyle variables were found to be significant factors that could increase participants’ risk of becoming obese. Furthermore, the severity of obesity was indicated by participants as having implications for their children’s health and their own. These results suggested that participants perceived the long-term effects of obesity as substantially negative for their families. The questionnaire data showed significant agreement that there were emotional, physical and social benefits to adopting healthier lifestyle behaviours. These benefits were reflected by participants stating present and future benefits to weight management behaviors. This finding coincides with most participants stating their intention to adopt healthy behaviours within the next six months. The participants favoured diet therapy over exercising as their mode of managing weight. This finding is congruent with participants stating they have more self-efficacy for dieting rather than exercise. Dieting methods were also considered the most effective form of weight management.

The perceived barriers to weight management behaviour were multifactorial, ranging from lack of time, energy and income. The participants stated that becoming a mother either created these barriers or exacerbated their prior existence. These findings are in line with another study that described barriers to maternal self-care as time, limited money, lack of support system and difficulty in setting boundaries.⁽²⁴⁾ This study also suggested that new motherhood resulted in two dichotomies: self-care is of primary importance, or the lack of self-care is an extreme form of self-sacrifice.⁽²⁴⁾Motherhood influences how participants perceive their self-efficacy and personal barriers to adopting healthier behaviors. This emphasises that motherhood has significant lifestyle impact. Despite these barriers, many of the participants acknowledged that they have internal and external cues to manage their weight. Internal cues identified by participants were their own body weight satisfaction and drive for better health. Effective external cues were found to be media platforms, specifically social media.

Possible individual actions include growing a personal or community garden because it is a cheaper alternative to supermarkets. Additionally, participants stated that they would benefit from a person (family member, friend, or co-worker) adopting the behaviour. These results are reinforced by another study, which found that friend and coworker support promoted healthy eating habits and predicted adherence to exercise programs.⁽²³⁾ Participants also indicated that CMC, specifically general practitioners or dietitians, could be an effective avenue to relaying obesity health information and behavioural interventions to the population. Another study found that patients with weight-related problems identified their general practitioner as a crucial conduit for weight counselling and obesity risks.⁽²⁵⁾ The importance of health information was also found by researchers¹⁷, who suggested that if patients are aware of the benefits of dieting and exercising behaviours, they may become more involved in the programmes.⁽¹⁷⁾ Therefore, a multi-level support system coupled with obesity counselling could help the population make improved, long-lasting lifestyle choices.

There are several limitations to this study. First, the number of participants did not meet the calculated sample size to represent this population. The sample size goal was not met possibly because no monetary or medical advice incentives were provided and the appointments were held during daytime hours. Another limitation is that the results primarily emphasised individual behavioural changes. This is largely in part due to the individualistic model which guided this research. These results indicate that obesity is a structural problem and not an individualistic one. Therefore, it is recommended that future studies engage a wider range of stakeholder, such as government officials, nonprofit organizations, midwives, and healthcare practitioners, to identify possible programs for creating a multi-level support system for women living in Curaçao. Finally, given that obesity is a multifactorial condition, future research should also include analyses over the influences of socioeconomic status and other social determinants, such as race and ethnicity, which were not addressed in this study.

CONCLUSION
The high obesity rates for women in Curaçao and the risks associated with obesity during pregnancy and birth, indicate an urgency to address this problem. The variables of perceived severity, susceptibility, barriers, benefits and cues to action were significant subscale findings. The barriers to weight management behaviours are largely rooted within the obesogenic environment of Curaçao. It was also found that sociopsychological factors, such as the challenges associated with new motherhood, have significant influence over participants’ behaviours. Therefore, to ensure a long-lasting impact, future weight management programmes should aim to facilitate participant self-efficacy and the creation of multi-level support systems. Such programmes should provide transparent health information about obesity and emphasise culturally contextualised solutions that are realistic for the population to adopt into their lifestyle.

Acknowledgements: The authors would like to thank Durwin Lynch, Master MPA Program Coordinator, Vrije Universiteit Amsterdam, for supervising and providing relevant feedback on the creation of the research phases and the editing of this article. The authors would also like to thank the participants involved in this research. We acknowledge the support of Curaçao Medical Center and Vrije Universiteit Amsterdam.
Ethical Approval Statement: Approval was obainted from Curaçao Medical Center’s ethical approval board (METC) under number: CMC-METC 2802202301
Conflict of interest: The authors declare no conflict of interest.
Informed consent: Obtained
Funding statement: None
Authors Contributions: Sarah Ward, MSc, was the primary researcher and writer for this study and subsequent article. Dr. Nurah Hammoud was the supervising onsite advisor throughout the research design, data collection, and editing of this article.

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