Decreasing Obesity Rate in Elementary-School Hispanic Children

Introduction to the Project

Obesity is a serious public health concern in the United States that puts millions of children and adolescents at risks for having poor health. Despite the intentions to control and prevent this condition among the chosen population, its prevalence remains high, and certain improvements are expected from various perspectives. For example, about 18.5% of American youth are reported to be obese, including approximately 21% of adolescents (12-19 years), 18% of school-aged children (6-11 years), and 14% of preschool-aged children (2-5 years) (Hales, Carroll, Fryar, & Ogden, 2017). The investigations of Ogden, Carroll, Kit, and Flegal (2014) showed that there were no considerable changes in childhood obesity prevalence between 2003 and 2012, and additional surveillance is required. Due to the fact that obesity has long-term health and financial consequences, new efforts must be initiated to address this kind of epidemic.

One of the possible solutions to obesity-related problems is the engagement of parents in prevention. Many studies were developed to prove the role of parents in the adoption of healthy behaviors and lifestyles, physical activities, and dietary habits among obese children (Davidson & Vidgen, 2017; Lauricella, Wartella, & Rideout, 2015; Lee et al., 2017). The majority of investigations demonstrated the importance of improved awareness of obesity, parental involvement in children’s education, and multiple steps to be taken to predict and reduce the cases of obesity in families (Liu et al., 2018; Muthuri et al., 2016). This project aims at investigating childhood obesity in a specific population (low-income Latino families) and the implementation of an educational intervention about physical activities among parents. Quantitative methodology and quasi-experimental design will be employed as the main research design and self-reported body weight (SRBW) measurements and a physical activity questionnaire as the major assessment tools to prove the worth of educational sessions for parents.

The educational intervention that will be employed in this project was developed by Slusser et al. (2012) and has proved to be effective. The intervention that went under the title Parent Training Program (PT) targeted Hispanic young children’s parents. The PT was grounded on the health supervision tools outlined in “Bright Futures in Practice: Nutrition” and healthy eating and lifestyle messages of the “Bright Futures in Practice: Physical A” (Slusser et al., 2012). The PT program also involved the use of “Traffic Light” diet “the AAP expert work group’s recommendations, and the philosophy of internal regulation related to eating” (Slusser et al., 2012, p. 54). The program aimed at the increase in parents’ awareness of “yes and no foods based on the 2005 Dietary Guidelines” with the focus on culturally relevant products and common eating-out places (Slusser et al., 2012, p. 54). The other objectives of PT were to teach parents how to promote healthy eating in their families and practice self-monitoring. These objectives are consistent with the goals of the present project, which makes the PT program relevant.

In this chapter, an overall introduction of the project will be given to explain the goals and methods of the project. The background of the project focuses on past studies and achievements made in the field of childhood obesity. Problem and purpose statements will show how this direct practice involvement (DPI) project may contribute to the chosen field and finding out the solution to the problem. A list of clinical questions will help to narrow the focus of the project and identify the most crucial aspects of childhood obesity and parents’ education. There are also several additional sections in this chapter, including advancing scientific knowledge and the project’s significance, that identify and justify the gaps and needs of the current investigation. Finally, the rationale for methodology and design enhance the development of the project and the definition of important terms, limitations, and assumptions.

Background of the Project

During the last several decades, the problem of childhood obesity has been frequently discussed in many healthcare and academic facilities in the United States. The Centers for Disease Control and Prevention (CDC) and the US Department of Health and Human Services are the main organizations that discuss etiology and prevalence of obesity in different populations. Davis, Wojcik, and DeWaele (2016) explained that the rate of obesity in children and adolescents changed from 5% to 21%, giving rise to such major health problems like diabetes, cancer, and cardiovascular diseases. Risk factors caused by obesity include physical inactivity, high levels of cholesterol in the blood, excess weight, and shortness of breath (Sahoo et al., 2015). Therefore, the improvement of a physical condition of a child turns out to be an evident contribution to the progress of childhood obesity statistics, and parental involvement cannot be ignored in this discussion.

The demography and population structure must be taken into consideration in obesity research, as such factors as gender and ethnicity, have specific roles in obesity prevalence and epidemiology. The CDC (2015) traced the statistics of overweight and obese children and adolescents from 1971 until 2012 and indicated the rise of overweight children from 10% to 15% and obese children from 5% to 17%. Among these numbers, there were (Centers for Disease Control and Prevention, 2015):

  • 10% of overweight boys in 1971 and 15.4% in 2012;
  • 5% of obese boys in 1971 and 16.7% in 2012;
  • 10% of overweight girls in 1971 and 14.5% in 2012;
  • 5% of obese girls in 1971 and 17.2% in 2012.

Population race and ethnicity factors also define the frequency and severity of obesity-related problems in children. The investigation of Kimm et al. (as cited in Fradkin, Wallander, Elliott, Cuccaro, & Schuster, 2016) proved that African American and Hispanic children are twice affected by obesity compared to White children because of the inability to keep to healthy lifestyles, low-income levels in families, and poorly developed education and prevention programs. In Hispanic families, low awareness of the threats of fast food and sweetened-beverage consumption is observed, contributing to serious changes in the body mass index (BMI), which results in obesity increase (Guerrero et al., 2016). Today, parental support programs are developed around the world. Even though many of them prove long-term positive effects of vegetable intake on obesity prevention, its efficacy in different ethnic groups remains unknown (Nyherg et al., 2015). Changes in parents’ education about the threats of obesity and fast-food lifestyles in children can be promoted to support parents with different origins in the same racially, unbiased way.

Problem Statement

Being a critical nutritional disorder, obesity leads to several changes in health care, family finances, and communities. Regarding current social norms, living principles, and people’s interests, its morbidity, incidence, and persistence are hard to control. In addition, weight regulation is usually predetermined by various genetic, environment, and development factors, so these mechanisms vary between populations (Pandita et al., 2016). Obesity can be rooted in a child’s behavior, family traditions and customs, and social activities. According to Chesi and Grant (2015), abnormal fat accumulation is a trait that is originated from environmental and genetic factors. For example, when the body consumes an extensive amount of calories through uncontrolled or poorly organized food consumption or sweetened beverages, it is hard to burn them and maintain the required BMI (Xu & Xue, 2016). In some children, genetic factors play a crucial role, and even regular physical activities and exercises are not enough to predict body changes and the work of physiological mechanisms (Chesi & Grant, 2015). Therefore, a child’s weight, height, and other vital signs have to be controlled either by a healthcare provider, a parent, or another caregiver.

Parental responsibilities in regard to their children’s health are thoroughly evaluated in primary care settings, family planning facilities, and other organizations. Parents understand the worth of their influence on children because of the necessity to guide, support, and become good examples from legal and humane points of view (Wolfson, Gollust, Niederdeppe, & Barry, 2015). In modern media, there are many cases when parents are accused of having obese children (Wolfson et al., 2015). In Hispanic, Latino, and African American families, children have high BMI from an early age, and parents must know how to protect their kids regardless of their genetics, environment, and other issues (Guerrero et al., 2016). To avoid unpredictable financial complications and physical or mental impairment, the need to improve people’s awareness about obesity and the necessity to control BMI is apparent.

Still, not many parents are eager to be educated about physical, nutritional, and genetic peculiarities of their children. People expect that school teachers, the medical staff, and administrators are responsible for the development of any child in terms of their knowledge, as well as physiology. It is not known how education sessions may influence parental involvement in controlling their children’s physical activities and BMI. I plan to provide the parents involved in the project with healthy food choices to replace unhealthy snacks, sodas, and high sugar juices.

The project aims at the provision of the effective educational intervention for parents who will receive information concerning the peculiarities of obesity in elementary-school children, its prevalence and causes, as well as preventive measures. The target population for the intervention is parents of elementary-school Latino students diagnosed with obesity. During the proposed intervention, the emphasis will be on both eating habits and exercise. Information about healthy eating should provide parents with both a theoretical basis (nutritional value, micro-, and macroelements) and practical tools. Tips on introducing exercise will be age-appropriate and fit different lifestyles. It is easy to imagine that mothers and fathers might be experiencing a pushback from their children unwilling to commit to making changes, as well as criticism from other parents. Thus, the contents of educational sessions will not only include facts about the benefits of healthy diets and physical activity but also offer guidance and emotional support.

The educational program will last for one month and will contain nine 90-minute sessions that are developed as modules addressing specific objectives. The sessions will take place two or three times a week, and the schedule will be developed and agreed with the participants. No trainers will be invited as the educational sessions will be held by this project’s developer. It is noteworthy that Slusser et al. (2012) developed the Nine Modules to be taught during for months, but the regularity of the sessions was different.

Module One will be devoted to the discussion of cultural peculiarities of healthy eating and physical activity norms and easy steps to establish healthy lifestyles, as well as teaching parents not to use foods and physical activity as rewards and punishment. Module Two will include the discussion of healthy diets (with regards to cultural peculiarities and eating-out spots) and obstacles to healthy lifestyles establishments and ways to eliminate them. Parents will also be trained to communicate effectively with the rest of the family regarding healthy lifestyles. Module Three will focus on training parents to choose healthier foods, to practice self-monitoring, and increase healthy foods accessibility to children.

Modules Four and Five will involve training parents on how to establish healthy routines (appropriate TV time, playing games, and regular sleep) and buying healthy foods (including strategies to use food purchasing vouchers). Modules Six and Seven will be devoted to helping parents to set limits regarding certain activities and foods, setting warnings, and practicing “ignoring” their children’s demands associated with unhealthy behaviors. Module Eight will be devoted to a review of the previous sessions and training parents to praise and warn their children, as well as maintain healthy norms during various celebrations. Module Nine will be a general review of the sessions where parents will share review and reflect on their experiences during the project. The participants will be encouraged to share their perspectives regarding the effectiveness of the intervention and its limitations.

The expected outcomes of this project are children’s improved health status and their families’ adherence to healthy lifestyles and diets. The project can contribute to solving the problem as it will result in the development and assessment of an educational intervention that can become an integral part of the educational services provided at American elementary schools. Parents can potentially become more responsible and committed to maintaining healthy lifestyles, which will translate in the lower rate of overweight elementary-school children.

Purpose of the Project

The purpose of this quantitative project is to explore the effects of an educational intervention aimed at increasing physical activity and reducing caloric intake among low-income Latino elementary-school children diagnosed with obesity. The quality improvement project will occur in three stages. First, demographic information will be gathered about participants, in addition to the number of physical activities and obesity-related problems. Next, the one-month educational intervention will be provided to improve parents’ knowledge about childhood obesity. Parents will be educated about the ways to maintain appropriate energy balance (energy input and output), the role of dietary habits, and the worth of physical activities at an early age (Brown, Halvorson, Cohen, Lazorick, & Skelton, 2015). The intervention, as well as the methodology that will be utilized during this project, has been employed earlier and have proved to be effective when treating young children’s parents. The project will be implemented at a clinic located in Charlotte, NC.

During the educational sessions, it is important to explain why parental involvement in childhood obesity prevention is critical for families. The educational sessions will be held in the clinical setting, and the schedule will be agreed with the participants and the clinic site manager. It is planned to review the records of patients who were diagnosed as overweight or obese at the age of 5 to 11 and choose families with obese children for participation. Measurement of BMI is an important stage of this project. Olfert et al. (2018) recommended self-reported height and weight as simple and economic tools to track changes in a child’s body weight over time.

These measurements may be taken at home and reported to a research team or obtained via calculations without direct measurements and specific measuring tools (Olfert et al., 2018). The exact BMI will be calculated based on the data provided by parents who will note their children’s height and weight. In this project, the Physical Activity Questionnaire for Elementary Children (PAQ-C) will be used. Parents will answer the questions from the questionnaire relying on the results of their children and the observations made. The major purpose of the questionnaire is to examine the level of children’s physical activity during a day. Parents will provide information regarding the time their children spend playing games or being involved in any kind of physical activity. This information is essential for the identification of the deficiencies in children’s lifestyle that are likely to contribute to their health condition. This information may also be used to modify the educational intervention to better meet the participants’ needs.

As has been mentioned above, the Parent Training Program developed by Slusser et al. (2012) will be utilized. This educational tool involves the provision of training to Hispanic parents aimed at improving diets and physical activity of their children. The content of the educational sessions is divided into nine modules of the Parent Training Program that addressed such areas as praise for appropriate behaviors, dietary guidelines, giving proper commands to children, establishing every-day routines related to diets and physical activity, and strategies of “ignoring” to shape children’s behaviors (Slusser et al., 2012). The implementation of this intervention led to the positive health outcomes for children as their BMI scores decreased substantially.

At this point, it is preferable to identify the variables that will be manipulated during the proposed project. The independent variables will be parental involvement and parents’ awareness regarding obesity and prevention methods, as well as the Parent Training Program. The variables will be measured with the help of such instruments as Physical Activity Questionnaire (PAQ-C). The Parent Training Program’s effectiveness will be evaluated via the analysis of the changes in parental involvement and awareness. In addition, independent variables will include such demographic features as parents’ education levels and subjective family economic status. These variables will be measured with the help of the analysis of the questionnaires containing personal information.

As far as the PAQ-C is concerned, it is aimed at measuring the physical activity of children aged between 4 and 12 (Lee et al., 2015). The questionnaire contains nine Likert-Scale questions and one yes-no question that elicit the data concerning children’s physical activity level. The questionnaires will be completed by parents who may (or may not) do it with their children at home. Although children are mature enough to respond to the questions on their own, the focus of the intervention is on parents, so they will complete the questionnaires. This task will also be a motivational factor as parents would be willing to change their children’s behavior and become more involved in this sphere of their lives. This tool is utilized in this project as it provides an efficient measure of the level of physical activity of the target population. This information is needed to identify the gaps in parents’ knowledge on establishing proper physical activity level in their children, which will be instrumental in identifying the effectiveness of the intervention and its relevance for the population in question.

The dependent variables will be children’s health outcomes and their physical activity that will be measured by calculating their BMI and analyzing Physical Activity Questionnaires. As mentioned above the project will contribute to solving the problem of childhood obesity by introducing an effective educational intervention that can be implemented in the clinical setting for parents of elementary-school children diagnosed with obesity. Moreover, it will validate the use of certain protocols that can be employed in subsequent projects and further research.

Clinical Questions

Many studies support the idea of educating parents to prevent and control childhood obesity. For example, the CDC (2018) suggest parents should balance calories consumed by children, be in charge of the quality of food and beverages consumed, and promote physical activities to stay active. There are many technological advances and applications that encourage parents to maintain their children’s healthy lifestyles (Avis et al., 2015). Financial aspects and personal challenges may prevent the use of knowledge, and families need to be ready to combine their experiences to achieve the best results in reducing the weight of children. At the same time, parents’ education and income have to be the two separated issues (Liu et al., 2018). Children from low-income families should not suffer or be reduced in the opportunities just because of their financial statuses, and the task of parents is to overcome the barriers and promote equal health-related conditions.

Clinical questions to be answered in this DPI project depend on the variables chosen for the quantitative quasi-experimental project that include such independent variables as parents’ involvement and their awareness concerning obesity and its prevention, as well as parental education levels and subjective family economic status. The dependent variable will be children’s health outcomes measured by the calculation of their BMI and their physical activity measured by the analysis of Physical Activity Questionnaires. The intervention lasts for three months to make sure that new knowledge is obtained, certain evaluations are made, and some changes occur. It is not enough to offer a new idea and expect that parents accept it with ease. Assessment tools, evaluations, and evident examples have to be used in the project. The following clinical question helps to identify the main variables and predictive statements:

For parents of elementary school-aged Hispanic children from low-income families, will Parent Training Program, compared to no session be effective in controlling and preventing childhood obesity within three months?

Advancing Scientific Knowledge

In modern society, a number of norms and principles on how to control and treat childhood obesity have already been established and approved. In Europe, schools are defined as the key places where people learn how to recognize and treat obesity and develop new intervention studies (Clarke et al., 2015). School-based programs for children and parents result in a considerable reduction in children’s BMI (Pablos, Nebot, Vañó-Vincent, Ceca, & Elvira, 2017; Quattrin et al., 2014). There is a need for investigations about Hispanic families and the challenges or opportunities they have in order to predict and control childhood obesity.

In this project, the social cognitive theory (SCT)is the selected theoretical framework. According to McGee, Richardson, Johnson, and Johnson (2017), the SCT is a perfect solution to explore and evaluate perceptions and beliefs that are related to healthy lifestyles and physical activities in children. This theory predicts social expectations and recommendations to achieve the desired behavioral change. There are seven important components in this theory, including self-efficacy (the belief), behavioral capability (an understanding), expectations (outcomes), expectancies (values), self-control (monitoring), observational learning (modeling), and reinforcements (incentives) (“Social cognitive theory,” n.d.). In terms of this theory, certain motivational factors of parents and children to decrease body weight and avoid obesity-related complications in the future will be elicited.

This project covers the problems of obese children and the participation of parents in BMI control. Weihrauch-Blüher et al. (2018) developed the guidelines to prevent obesity in children and adolescents, and education on physical activities, behaviors, and dietary habits were the parts of the program. Advanced scientific knowledge of this DPI project is to focus on the importance of parents’ education on physical activities for children and the intentions to control calories and the quality of food, regarding their social and financial statuses at the moment of the intervention.

Significance of the Project

Despite numerous attempts to control and prevent obesity in children, this disorder is still a burning issue in health care. This project is addressing childhood obesity through parents’ education about their children’s physical activities, the number of calories consumed, chosen food and beverages, and behaviors. At the end of this project, it is expected that each of the research questions is answered. In the case of the project’s clinical question, it is implied that there will be evidence, or the lack thereof, on the efficacy of school-based interventions. As for the remaining questions, it is necessary to explore a correlation between such variables as family economic status and parents’ education levels and health outcomes in children. In case strong associations are found, educators and policymakers will have a more sophisticated theoretical basis for developing intervention strategies.

Although this project focuses on parents and children, the role of nurses and caregivers cannot be ignored. Laws et al. (2015) admitted that regardless of their preparedness, many nurses lack confidence and experience in raising sensitive lifestyle issues. Therefore, it is important to support education sessions and integrate obesity prevention interventions into real-life practices.

Another benefit of this project is the possibility to improve the knowledge of families about obesity and its further impact on a child’s health. Parental involvement interventions strengthen the relationships between children, parents, and medical workers. However, the findings developed by Kim, Park, Park, Lee, and Ham (2016) showed that five weeks could hardly be enough for involvement programs to observe significant changes in children’s health and weight. In this DPI project, the task is not to achieve considerable reduction in BMI but to improve parents’ awareness of obesity and prove the effectiveness of education sessions in Hispanic low-income families.

The findings of the project will add value to the Hispanic population in terms of health improvement and parent-child cooperation to accomplish the same goal and understand the worth of physical activities and healthy lifestyles. Obesity is a disorder that leads to a variety of diseases and complications, and education sessions must prepare parents for such changes and explain how they can protect their children. Practical application includes the exchange of experience, professional communication between parents and healthcare workers, and new tips for maintaining a healthy weight.

Rationale for Methodology

The choice and justification of methodology is a crucial step in any project because it determines the way of how information should be gathered and analyzed. A quantitative approach that is framed in terms of using numbers, pre-determined methods, and statistical analysis and interpretation are chosen for this DPI project (Creswell, 2014). In medical or nursing research, quantitative data contributes to describing recent literature findings and identify the gaps in research to address them in the future (Gicevic et al., 2016). To answer the clinical question, it is expected to compare different situations and analyze the results and the conditions of dependent variables regarding to the chosen independent variables. In other words, it is necessary to examine the relationship between dependent and independent variables mathematically using statistical analysis. These are the main characteristics of quantitative methods that prove the correctness of the chosen methodology.

In this DPI project, quantitative information is based on the review of the results that are independent of the writer’s opinion, observations, and attitudes towards the problem of childhood obesity in low-income families. Therefore, the chosen approach promotes increased objectivity and biased-free results. In the majority of cases, quantitative data is defined as more credible and reliable for decision-making and evaluations compared to qualitative one (Creswell, 2014). The investigations by Hales et al. (2017) and Muthuri et al. (2016), as well as the results of the CDC (2015), demonstrate how effective statistical data is when the analysis of the disease, its prevalence, and control are required. A quantitative approach is a good opportunity to gather the already available information about childhood obesity in a specific population, identify influential factors for parental involvement and education, and clarify further improvements.

The aforementioned methods of data analysis will be of use when answering the clinical question. I will be comparing pre and post intervention data. In this case, quantitative methodology and statistical analysis will help compare and contrast the percentage of children who gained weight in the group within three months. Thus, quantitative methodology will be helpful in calculating and interpreting the coefficient r. The coefficient r will be the measure of strength of the association of pre and post intervention data.

Nature of the Project Design

A quasi-experimental design resembles an experimental design with the only distinctive feature that is the lack of randomization. It is frequently used to evaluate the effectiveness of treatment or interventions when an independent variable may be manipulated because a dependent variable is measured (Creswell, 2014). Regarding the goals of the project and the necessity to clarify the effectiveness of an education session for parents, a quantitative quasi-experimental pretest-posttest design is chosen.

The strengths of this methodological approach include the identification of specific trends in the project, the possibility not to limit sample size, and the evaluation of the same issue within a different time frame. Peters et al. (2016) used the same design to identify and assess the capacities of low-income communities in their intentions to create appropriate environments and prevent childhood obesity. The same approach with new validated instruments and assessment tools will be developed in this project to understand the worth of parental involvement through education session about physical activities.

It is planned to choose 40 families with obese or overweight children whose parents agree to participate in the intervention and take several lessons about obesity, physical activities, and body weight control. The participants should be residents of Charlotte, NC, and the project will be based at a local clinic, Charlotte, NC. They will receive written consent forms via email or personally in their clinical settings. As soon as they sign the form, they will be provided with survey questions to check their knowledge and abilities to self-report on body weight and height (Olfert et al., 2018). After starting the intervention, several education sessions will be organized for the group of parents during three months. In the end, the same tests and self-reported surveys will be offered to gather final results and begin data analysis based on SPSS software.

Definition of Terms

The analysis and assessment of obesity-related problems begin with the identification of the most important terms. The participants of this project are the parents from Hispanic low-income families, and many of them may lack an understanding of obesity terms and definitions. Therefore, it is necessary to clarify all words that may require an additional explanation to avoid confusion or misinterpretation. The following terms will be operationally used in this DPI project:

  • Overweight. It is a condition that is characterized by excessive fat mass that influences person’s health and contributes to the development of new diseases. The BMI level of overweight people is usually higher than 25 kg/m2 but lower than 30 kg/m2 (World Health Organization, 2018). Overweight is usually a critical sign of obesity in children and adults.
  • Obesity. It is a disorder that involves abnormal body fat that leads to an increase in new health problems and complications. Obesity is a multi-factorial disorder that may have genetic or environmental origins (Chesi & Grant, 2015). This condition is identified if a person has a BMI that is equal to or greater than 30 kg/m2 (World Health Organization, 2018). Regarding the levels of BMI, obesity may be classified as severe and morbid.
  • Body mass index (BMI). It is an important screening tool that is used to measure obesity. BMI is the result of the measurement of a person’s weight in kilograms divided by height in meters squared (Ogden et al., 2014). This comparison is closely related to an understanding of body fatness and measuring weight and height across populations.
  • Fat mass. It is the actual weight of fat in a person’s body. The percentage of body fat can be measured by several methods, including underwater weighing, also known as densitometry, or multi-frequency bioelectrical impedance analysis (BIA) (Sahoo et al., 2015). Fat mass excludes the mass of muscles, human organs, and bones.
  • Self-reported body weight and height (SRBW and SRBH). It is a simple, economical method to measure the changes in body weight and height over time (Olfert et al., 2018). These measurements can be of two categories: those taken in the home environment and then reported to researcher or other involved medical experts and those without direct measurements but obtained from surveys (Olfert et al., 2018). SRBW and SRBH are credible and valid tools to be used within different periods of time.
  • Physical activity. The standard level of physical activity for elementary-school children is 60 minutes or more of daily “moderate- and vigorous-intensity activity” (Office of Disease Prevention and Health Promotion, 2018, p. 48). The activity beneficial for children’s health should include aerobic, bone- and muscle-strengthening activities. Some of the age-appropriate activities include bicycle riding, brisk walking, running, chasing, jumping rope, martial arts, vigorous dancing, swimming, tree climbing, as well as playing softball, soccer, basketball, tennis, and baseball. It is also necessary to pay attention to screen time that should be less than one hour a day. Finally, sedentary behavior should be taken into consideration as well and has to be less than 50% of the working time.

Assumptions, Limitations, Delimitations

There are two main assumptions in this DPI project. Firstly, it is assumed that an education session that will be offered to parents during three months would be organized as per recent credible studies and guidelines developed by the CDC and meet all the care standards and pedagogical techniques. Secondly, it is believed that the participants would give honest and definite answers to all the questions in the PAQ-C and report on weight and height measurements obtained from their children.

The main limitation of the project is the time spent on educational intervention. Kim et al. (2016) already reported about the impossibility to observe evident changes in body weight after a five-week intervention. Another limitation includes a small sample size and the necessity to cooperate with the representatives of one ethnic group (Hispanics) only. The limit of the demographic sample can be improved in further investigations in case at least minimal changes would be recognized. Finally, the data collection methods involve the opinions of parents who may be biased or prejudiced to the idea of obesity in children. Therefore, it is recommended to tape communication between the researcher and participants to identify possible biases.

Delimitations are the things that help to control the project despite the existing limitations and unpredictable assumptions. In this case, the location of the DPI project (local hospitals and communities in Charlotte, NC) is the major delimitation that promotes the possibility to choose people, postpone or plan decisions, and consider the environment. Another benefit includes the chosen quantitative methodology and the possibility to surf the web and find new sources with guidelines and recommendations for educational sessions.

Summary and Organization of the Remainder of the Project

In this DPI project, the main task is to understand the effects of education sessions that may be organized for parents in their intentions to prevent and control obesity in their children. McGee et al. (2017) explained the role of ethnic differences among the participants, and Chesi and Grant (2015) focused on the genetic peculiarities of this nutritional disorder. The necessity to promote parental involvement in monitoring a child’s BMI and the quality of food and beverage intake cannot be ignored in any families, including those with low incomes. The project will have implications for health practitioners, nurses included, as the findings might constitute a theoretical basis for school-based interventions.

Direct communication with parents and their awareness about obesity threats and associated challenges are the core aspects of this project. In addition to the participants having to share self-reported measurements and demonstrate their level of knowledge, they need to understand their roles in their children’s lives. This chapter was instrumental in clarifying the major aspects of future work and identify the questions and available resources.

A theoretical background, a quantitative method, and a quasi-experimental design are the major characteristics of this project. In this chapter, an overall introduction of the work and evidence of the worth of the chosen topic and intervention were given. In the following chapters, a detailed discussion will be developed: the literature review on the chosen topic (Chapter Two), the methodology and design (Chapter Three), data collection/analysis procedures (Chapter Four), and the results of the intervention (Chapter Five).

Literature Review

This quantitative, quasi-experimental DPI project is aimed at examining the effect of education about physical activity received by parents on obesity levels observed in school-aged children residing in the Southeast region of the United States. Therefore, this chapter provides a review of the existing literature on a variety of interventions and approaches that are currently applied by parents and professionals to address the issue of childhood obesity. The chapter includes the background information on the problem of obesity in school-aged children and parental involvement, theoretical foundations guiding this quality improvement project, and the literature review. This literature review section is divided into subsections discussing key themes identified in the literature and related to the project variables: childhood obesity, parental involvement, parents’ awareness, interventions, ethnic and cultural diversity, and community and family involvement.

The recently published literature on the problem of obesity in school-aged children, as well as interventions and programs for parents, has been reviewed and analyzed for this project. The following databases and resources were used to search, survey, and retrieve appropriate articles from peer-reviewed journals: Google Scholar, PubMed, ScienceDirect, EBSCOhost, and CINAHL database. The keywords used during the search included different combinations of the following words: school-aged, children, obesity, parents, parental family, involvement, intervention, physical activity, prevalence, education, community, comorbidity, diversity, ethnic, and cultural. Consequently, 212 articles on the topic of this quality improvement project were retrieved, and their abstracts were analyzed with reference to the inclusion criteria: the publication date, the relevance to the topic, and the type of research. Fifty-four studies that were published between 2013 and 2019 have been selected for further analysis in the context of this quality improvement project. The information found in the articles has allowed for determining the major themes related to the problem and topic of this quality improvement project that are discussed in separate subsections in this chapter.

The problem of improving the physical activity of children living in the United States to prevent obesity has been discussed since the 1950s. In those years, researchers compared the physical fitness of children in the US and European countries for the first time. Researchers’ concerns were later supported by evidence indicating the development of the obesity epidemic among school-aged Americans (Davis et al., 2016). In 2012, it was reported that the rate of childhood obesity almost quadrupled (up to 21%) in comparison to the data for the previous 30 years (Davis et al., 2016). Thus, the current rate of obesity among children in the United States is about 20% (Hales et al., 2017). According to Fradkin et al. (2016), Hispanic and African American children are twice as likely to suffer from obesity in comparison to White youth. This tendency can be associated with socioeconomic and cultural factors.

Numerous interventions to address the problem of obesity among children were found in the articles on the topic. However, despite the active discussion of family-based interventions, there are still gaps in research related to understanding their significance to decreased body mass index (BMI) in children of different ethnic and sociocultural backgrounds. Researchers have concentrated on examining family-based interventions and programs exclusively for parents (Knol et al., 2016; Nyberg et al., 2015). Nevertheless, there is still a lack of evidence on how they predict changes in children’s BMI and physical activity. Thus, the effectiveness of specific interventions to improve the physical activity of children with obesity still requires further examination.

Theoretical Foundations

Social cognitive theory (SCT) is the major theoretical model that guides this quality improvement project. According to the key assumptions and principles of this theory, individuals’ behavior is formed by certain interactions between specific behavioral, social or environmental, cognitive, and personal factors. This theory was introduced by Albert Bandura in 1986 as a result of developing his social learning theory that had been formulated in the 1970s. Bandura (1986) stated that an individual’s behavior is based on the impact of his or her environment and on a personal ability to regulate this behavior. This principle was described in detail in Bandura’s Social Foundations of Thought and Action: A Social Cognitive Theory that is currently used a seminal work to explain SCT. Thus, the author of the theory changed the focus from observational learning to cognitive processes that occur during this learning and directly affect individuals’ behavior.

In this book, the psychologist described the critical aspects of his theory discussing the origin of individuals’ behavior from a unique social-cognitive perspective. Bandura (1986) built his theory on such important components as behavioral capability or the understanding and confidence, self-efficacy, outcomes, expectancies or values, observational learning or modeling, self-control, and incentives. The author also explained how the principles of his theory could be used to analyze personal changes depending on the social change or alterations in the environment.

SCT is actively applied to develop physical activity programs and nutrition recommendations for people suffering from obesity because the theory guides and supports the designing of interventions oriented toward changing environmental factors and behaviors. From this perspective, the clinical question formulated for this project directly aligns with the assumptions and ideas associated with SCT. The reason is that the question asks how obesity in children can be affected as a result of receiving education regarding physical activity by their parents. In the context of this quality improvement project, it is expected to observe how environmental factors, such as changes in parents’ awareness, beliefs, and behaviors, can contribute to changes in children’s behavior regarding their physical activity. Thus, SCT is appropriate to explain how the physical activity of children with obesity as one of the variables can change depending on such a factor as their parents’ education on this aspect.

By referring to the key concepts of the theory, it is possible to understand in much detail how SCT guides this quality improvement project. The behavioral capability of an individual is associated with understanding why and how to change a certain behavior and why to focus on increasing physical activity in the context of the project. Self-efficacy is related to individuals’ confidence in their will and ability to change the situation (Knol et al., 2016). A person needs to be motivated to change depending on their expectations, values, and benefits of altering the behavior. All these changes are the result of observational learning or references to the example of parents in this case, self-control stimulated by educated parents, and provided reinforcements (Bagherniya et al., 2017). According to Lee et al. (2017), changes in parents’ behaviors and environments can directly influence children’s attitude to their usual diet and lifestyle. This principle also works for the case of increasing physical activity as changes in parents’ behaviors, habits, and discussions can shape children’s expectations and behaviors.

While applying SCT to this quality improvement project, it is possible to state that parents will be perceived as role models for children to influence their observational learning. Furthermore, they change the environment in households to stimulate physical activity. According to Bagherniya et al. (2017), changes in home environments are extremely significant for children to alter their behavior and address obesity. It is important to create an atmosphere where children will be not only motivated to increase their physical activity but also supported by parents whose task is to stimulate children’s self-regulation (Knol et al., 2016). When receiving the knowledge and education related to their children’s status and interventions to address obesity, parents become key actors in shaping the environment around youth to achieve changes in children’s physical activity and health.

Review of the Literature

In this section, the review of the literature on the independent variable as parents’ involvement in an educational intervention on physical activity is presented. Additionally, the literature on dependent variables, including children’s obesity and physical activity, has also been reviewed, and its analysis is presented in the chapter. Moreover, studies involving the use of self-reported body weight and height (SRBW and SRBH) measurements, as well as the Physical Activity Questionnaire for Children (PAQ-C), are also discussed to support their selection for the project. Thus, the topics related to the variables and the factors that can influence the project results, including family involvement and ethnicity among others, are also reviewed in this chapter.

Childhood obesity

The review of the articles on the topic has contributed to defining the notion of childhood obesity as the dependent variable used in this quality improvement project. That is the reason for examining researchers’ findings on childhood obesity in the United States in terms of prevalence, risk factors with a focus on ethnicity, and comorbidity. There are many recent studies aimed at determining specific social, genetic, and behavioral factors that trigger the development of childhood obesity, and nine relevant studies have been reviewed in relation to this topic.

Prevalence

The prevalence of obesity among children in the US varies by different factors, including ethnicity and parents’ income among others, and its trends have changed over time. In their study on these trends, Ogden et al. (2016) focused on examining and comparing obesity tendencies in American children and adolescents for 1988-1994 and 2013-2014. The researchers used the data of National Health and Nutrition Examination Surveys (NHANES) for individuals aged 2-19 years and analyzed the measurements for 40,780 children. The researchers found out that obesity prevalence in 2011-2014 was 17%, and it increased for children of all age groups while comparing the results with the data for 1988-1994. After 2004, the prevalence began to decrease for children aged 2-5 years and remained stable for children aged 6-11 years, but it was still higher than the prevalence observed in 1988-1994.

The latest data available regarding the prevalence of obesity in children in the US is related to the period of 1999-2016. Skinner, Ravanbakht, Skelton, Perrin, and Armstrong (2018) examined and analyzed the updated information in their article. The researchers referred to the NHANES data and measured it using statistical analysis and determining p values. It was found out that African American and Hispanic children had significantly higher overweight and obesity rates in comparison to White and Asian American children, and obesity prevalence increased for 2-5-year-old children during 2015-2016. It is possible to state that these data added to the findings provided by Ogden et al. (2016).

Such factors as income and an education level of household heads were also discussed in the literature in the context of obesity prevalence. Ogden et al. (2018) were interested in finding the relationship between income, an education level and obesity. They referred to the NHANES data for 2011–2014 and found out that the highest prevalence (19.9%) was observed among children belonging to the middle-income group. These data allow for further examining this relationship in order to determine trends.

Ethnicity

The ethnicity of children with obesity has been determined in the literature as a risk factor indicating trends in obesity prevalence. In their quantitative study, Guerrero et al. (2016) examined changes in BMI in children belonging to different ethnic groups. By applying statistical analysis, the researchers found out that Latino and African-American children had higher BMI scores in comparison to White children. Davis et al. (2016) also focused on comparing the levels of obesity and physical activity in students depending on their gender and race. Referring to the sample including 413 students, the researchers found out that White students demonstrated better results regarding physical activity and BMI in comparison to students of other races.

The mentioned findings are credible based on the applied methodology and sample sizes, and they are supported by other studies on the topic. Still, according to Fradkin et al.’s (2016) community cohort study involving 4824 children, lower-intensity physical activity contributed to decreasing obesity rates mostly in White and Hispanic male participants. There was no such relationship for females and representatives of African Americans. Furthermore, Kee et al. (2017) used SRBW and SRBH for studying changes in weight in diverse school-aged children and accentuated the effectiveness and accuracy of the measurement. Olfert et al. (2018) also studied the problem of childhood obesity with reference to the use of SRBW and SRBH as measurements to determine children’s status. They noted that self-measurement reports were rather accurate, and they were used for determining weight in representatives of different ethnic groups.

Comorbidity

Obesity is a complex health condition that usually leads to the development of comorbid diseases. According to the qualitative study by Sahoo et al. (2015), overweight and obesity in children are often associated with such comorbidities as cardiovascular disease, hepatic and renal disorders, and diabetes. The environment and lifestyle choices influence the development of these comorbid conditions. According to Pandita et al. (2016), obesity has many comorbidities leading to the discussion of this condition as the fifth risk factor for mortality among other ones identified globally. Therefore, the researchers accentuated the necessity of developing novel interventions to prevent obesity in children as a vulnerable category. Peters et al. (2016) also conducted a quasi-experimental study to determine how communities can influence children’s weight status. The researchers found that, in 14 rural communities, the low rate of obesity among children was associated with active community efforts and interventions oriented toward addressing the issue.

Childhood obesity is discussed and analyzed in the existing literature with reference to its prevalence, the factor of ethnicity, and comorbidities. Although some researchers found decreases in obesity prevalence typical of recent years, others stated that it remained stable or even increased (Ogden et al., 2016; Skinner et al., 2018). Therefore, the further analysis of existing and updated statistics is required. The prevalence of obesity is higher among Hispanics and African Americans, and this aspect influences the choice of the population for this project. Researchers also provided credible evidence to accentuate the risks associated with obesity because of its comorbidities.

Parental involvement

Another theme that is actively discussed in the literature on the efficiency of obesity prevention interventions for parents is parental involvement. Studying the use of different interventions to promote children’s health, researchers found out that parental involvement in programs was a critical factor in improving outcomes for children (Clarke et al., 2015; Parrino et al., 2016). Findings from several studies allowed for determining such subthemes as the involvement of parents in implementing health interventions, the provision of parents’ support, and parents’ knowledge and education on obesity. Epstein et al. (2014) focus on an important but often ignored aspect of the problem, the cost-effectiveness of programs provided to parents and children. The studies mentioned above are characterized by the use of quantitative methodologies. The sample size of the researches concerning parental involvement is substantial ranging from over 100 to almost 82,000 people. Such tools as surveys, physical data, and financial information analysis were utilized.

Involvement of parents

Parent involvement was studied in the context of parents’ activities to contribute to changing children’s lifestyle and behavior. According to Braden, Strong, Crow, and Boutelle’s (2015) quantitative randomized study, family-based interventions to address childhood obesity significantly depend on parental involvement. Referring to the participants from San Diego and Minneapolis, the researchers found out that parents were change agents in their families. Parents’ focus on improving their own weight influenced the weight of children (Braden et al., 2015). Still, this effect was not proved for changes in children’s physical activity depending on the example of their parents.

The effectiveness of parent involvement was accentuated in the reviewed studies, but some limitations were also listed. In their qualitative study based on the use of focus groups, Clarke et al. (2015) explored the obesity prevention intervention applied to children in the UK and found out that parental involvement influenced its success. Thus, parents recognized their important role in forming children’s behavioral changes. Additionally, according to Kim et al.’s (2016) randomized controlled trial involving 42 parents of children with obesity that was aimed at evaluating a parent involvement intervention, children’s behavior can change significantly. However, the researchers found positive relationships only between parental involvement and changes in children’s diets, but there was no relationship between the intervention and changes in the BMI (Kim et al., 2016).

The results of this quality improvement project can be limited by a sample size which is rather small for this type of inquiry. These studies’ findings indicate that parent involvement directly influences changes in children’s behaviors, but not all of them, and the effect can depend on the intervention. Epstein et al. (2014) argue that interventions provided to parents or children separately are less cost-effective compared to the programs involving both parents and their children. As for the limitations of the project, the central one is the use of self-reporting as the data collection tool. Another area to pay attention to is the lack of focus on other factors that may have an impact on children’s physical activity (friends, school-related models, media, and so forth). The recommendations as to further research are mainly related to the inclusion of the analysis of different factors influencing children’s activity when exploring the relations between parental involvement and children’s health-related behavior.

Parents’ support for children

Conclusions about the role of parent involvement found in the reviewed literature were also related to the theme of support and the importance of being supportive for parents. Morris, Skouteris, Edwards, and Rutherford (2015) conducted a systematic review of studies on obesity prevention interventions. The researchers stated that parental engagement, involvement, and support in the context of programs addressing obesity were effective to change children’s BMI. Parrino et al. (2016) performed a quantitative study involving 1521 Sicilian children for the purpose of determining the role of parental factors in the development of obesity in children. They stated that mothers’ obesity and their low education and support levels were correlated with higher risks of children’s obesity, and these findings are statically significant. In their qualitative study, Zhao, Li, and Rukavina (2017) also focused on exploring how parents could support their children with obesity. It was found out that being supportive, teaching self-acceptance, and providing advice were important aspects to help children with obesity in problematic situations at school, including teasing. Thus, studies show that parents’ supportive behaviors are critical in helping children cope with their obesity problem.

Parents’ knowledge and education regarding children’s obesity

It was indicated in the literature that parents’ knowledge regarding risks of obesity, a healthy lifestyle, nutrition, and exercising could be improved with the help of education and was correlated with children’s obesity levels. Yavuz, Van Ijzendoorn, Mesman, and Van der Veek (2015) prepared the meta-analysis of studies on obesity intervention programs. The researchers conducted meta-regression analyses and concluded with reference to 76 studies that interventions involving parents were most effective to address children’s obesity after parents had improved their and children’s knowledge of the condition.

Parent involvement can have positive effects on children with obesity if parents are educated regarding the issue and correctly recognize their children’s status. In their study on parental misclassification of children’s weight status, Cullinan and Cawley (2017) examined the importance of parental education in this area. It was found out that better educated parents, as well as parents without problems with their own weight, discussed their children’s weight status rather accurately. Thus, parents usually tend to perceive their children’s weight as normal rather than to report overweight or obesity. Zacarías, Shamah-Levy, Elton-Puente, Garbus, and García (2019) conducted their study on interventions for children having obesity with reference to the sample of mothers of such children from Mexico. The researchers showed that the intervention oriented toward improving mothers’ knowledge and changing their behavior positively affected children’s weight status. The research indicates that parents need to improve their knowledge regarding weight problems to help their children.

The topic of parental involvement includes the issue of involvement itself, parents’ support for children, and parents’ knowledge and education that are critical to influencing youth’s behaviors referring to parents as role models. However, researchers’ conclusions regarding the effectiveness of parental involvement are different. Involvement and support positively affect behavioral changes in children (Clarke et al., 2015), but there are no significant trends regarding changes in BMI and physical activity (Braden et al., 2015; Kim et al., 2016). Still, Morris et al. (2015) found the positive correlation between parental engagement and BMI. However, researchers agree that parental involvement and their improved knowledge regarding obesity have significant effects on changes in children’s behaviors, lifestyles, and weight status (Cullinan & Cawley, 2017; Yavuz et al., 2015). This factor is important to explain why to use education sessions and interventions for parents to address their children’s obesity.

Parents’ awareness

In addition to the theme of parental involvement, the literature also provided data on the importance of parents’ awareness of the existence of overweight and obesity in their children. Researchers identified such subthemes related to the question as parents’ perceptions of obesity, responsibility, and perceptions of health and physical activity (Davidson & Vidgen, 2017; Liu et al., 2017; Wright et al., 2016). This issue is important to be analyzed with reference to evidence because parents’ awareness is a significant aspect to influence the effectiveness of educational interventions for parents.

Parents’ perceptions of obesity in children

The problem is that many parents of children with weight problems are not aware of this fact. Wright et al. (2016) assessed parents’ perceptions regarding obesity with the help of a survey in the United States. The researchers found out that some parents of children with overweight and obesity problems did not perceive them as having these problems. Still, these parents recognized the risks of developing health problems for these children (Wright et al., 2016). This study refers to the sample of only 502 parents, and more research is required in this area.

Parents’ perceptions of their children’s weight status can be impacted by different factors. Queally et al. (2018) were interested in studying whether mothers appropriately recognized their children’s weight. While referring to the data for the context of Ireland, the researchers stated that mothers frequently could not recognize the weight of their child accurately. Their perceptions were influenced by such factors as a child’s gender and age, mothers’ education and knowledge, income, and the place of living (urban or rural areas) (Queally et al., 2018). These findings can be supported by conclusions made by Love et al. (2018), who studied parental engagement into an obesity prevention program for infants with the help of the qualitative methodology.

The researchers found out that those parents who had less knowledge and experience were more involved in the program than parents with higher self-efficacy (Love et al., 2018). Therefore, parents’ perceptions of children’s weight status and associated knowledge can influence their engagement in interventions and outcomes, but more research is required to study this aspect. The concept of parents’ awareness is associated with such subthemes as parents’ awareness, parents’ and teachers’ perceptions, and impairment. Parents’ (as well as educators’) perceptions concerning health, physical activity, diet, and the similar aspects are linked to the effectiveness of interventions and programs aimed at promoting healthy lifestyles (De Craemer et al., 2013). This concept is explored within the domain of qualitative studies based on the use of semi-structured interviews. De Craemer et al. (2013) explored parents’ and educators’ views on physical activity, barriers and facilitators of physical activity, beverage consumption.

The sample size in the studies mentioned above was rather limited except for the research by De Craemer et al. (2013) that involved over 200 participants. This is one of the primary limitations of the studies. The articles reviewed provide evidence concerning the lack of parents’ understanding of the benefits, opportunities, and hazards associated with physical activity of their school-aged children. It is apparent that parents acknowledge the benefits of physical activity and healthy lifestyles but tend to concentrate on barriers rather than facilitators of the adoption of healthy behaviors. The focus on barriers is especially evident among parents of children with impairments. Perkins et al. (2017) conclude that parents try to remain protective and lack knowledge on the existing opportunities for their children. De Craemer et al. (2013) emphasize that parents often rely on teachers when it comes to maintenance of healthy lifestyles and do not feel their responsibility to develop proper health-related habits. As for further research associated with this concept, it can be effective to implement quantitative studies to identify factors affecting people’s awareness, demographics, environmental and socioeconomic reasons for specific views.

Parents’ responsibility

The responsibility of parents related to their activities in order to address children’s problem of obesity is actively discussed in the existing literature on the topic. As a result of analyzing survey data on parents’ behaviors and the problem of childhood obesity, Wolfson et al. (2015) found that parents focused on the concepts of blame and responsibility. Parents with higher responsibility levels were inclined to more actively support school and community policies on obesity prevention.

It is important to pay attention to two more studies related to the topic of responsibility. Lauricella et al. (2015) performed a quantitative linear regression analysis to measure screen time for children with its reference to obesity and other adverse effects. Referring to the results related to a large sample in 2300 parents, the researchers found out that parents’ own screen time was correlated with their children’s screen time. The strength of this study is in using a large sample, and the findings can explain the importance of parents’ responsibility regarding acting as positive role models for their children. Moreover, Davidson and Vidgen (2017) conducted a qualitative study aimed at investigating parents’ motivation to be enrolled in healthy lifestyle programs. After analyzing interviews, the researchers found out that the key factor in becoming enrolled in the program was parents’ awareness of children’s weight status and their acceptance of their personal responsibility. From this perspective, parents’ awareness is directly related to the issue of parents’ responsibility, the higher levels of which can potentially lead to positive changes in children’s lifestyles.

Parents’ perceptions of children’s health and physical activity

Parents’ activities to prevent obesity in children also depend on perceptions of their children’s health and the role of physical activity in achieving success. Columna, Rocco Dillon, Norris, Dolphin, and McCabe (2017) conducted a qualitative study with 10 parents, whose perceptions regarding children’s physical activity were examined in detail. It was found that parents were not inclined to motivate their children to improve their physical activity because of certain health conditions perceived as barriers. The weakness of this study to support the current research is associated with its qualitative methodology and the primary reference to children with visual impairments.

Other researchers focused on examining parents’ visions of children’s physical activity in other cultural contexts. Thus, Liu et al. (2017) conducted a quantitative study involving 81,857 school-aged Chinese children to determine the relationship between parental support and physical activity levels. They revealed that parents’ positive perceptions of sport, their encouragement, and support were associated with children’s higher participation in physical activities. Still, McGee et al. (2017) chose an opposite perspective in their qualitative study involving seventy African-American children. The researchers found out that these young individuals recognized healthy patterns and unhealthy behaviors leading to obesity referring to their parents’ teaching. If parents have developed knowledge regarding healthy lifestyles and their perceptions of physical activity are positive, they influence children’s healthy behaviors and prevent obesity.

The awareness of parents regarding youth’s obesity is reflected in their perceptions of possible weight problems in their children, their responsibility to create appropriate environments to avoid obesity, and their perceptions of physical activity. The findings of both quantitative and qualitative studies indicated that parents often could not perceive their children’s weight accurately (Queally et al., 2018; Wright et al., 2016). Despite being aware of their responsibility to promote children’s health, parents also made different decisions regarding the promotion of children’s physical activity depending on perceptions and biases (Columna et al., 2017; Davidson & Vidgen, 2017). Therefore, parents’ awareness of their children’s health is important to be examined to understand how they will respond to children’s obesity and what biases or areas need to be addressed to make interventions work.

Interventions to address childhood obesity

The discussion of interventions oriented toward preventing and addressing obesity in children represents another large topic widely covered in the literature on the problem. The authors of the reviewed studies were interested in examining types of interventions, children’s physical activity in relation to BMI, and technology-based interventions (Cochran & Baus, 2015; Gicevic et al., 2016; Nyberg et al., 2015). The theme of interventions for parents is directly related to the problem studied in the current research. Thus, it is important to analyze conclusions regarding the most effective programs that can be used in family-based environments and interventions involving only parents to educate them regarding childhood obesity. Since the evaluation of a parental educational program is the subject matter of this project, intervention is one of the central concepts of the literature review. It is important to consider different aspects of other programs analysis to make sure that the methods used are effective and the focus of the study is relevant. The concept of intervention is associated with the following subthemes: physical activity and screen time, physical activity and diets, low-income parents’ education. Jago et al. (2013) assess the efficacy of an intervention aimed at improving children’s physical activity and reduce screen time.

Types of interventions

The majority of the reviewed studies on interventions to prevent obesity were oriented toward assessing their effectiveness. Gicevic et al. (2016) conducted a quantitative content analysis to discuss the recent research on childhood obesity and interventions. They found referring to 667 studies that most studies were quantitative (80%), and they mostly addressed dietary changes (57%) in contrast to physical activity (23%) (Gicevic et al., 2016). Lee et al. (2015) measured the effectiveness of interventions to increase the physical activity level in children with the help of the Physical Activity Questionnaire for Children (PAQ-C) and supported its validity, consistency, and accuracy. In addition, Weihrauch-Blüher et al. (2018) reviewed the literature on preventing obesity in childhood and found out that the most effective programs and interventions were school-based ones. These programs work as the behavior-oriented prevention, but these interventions cannot demonstrate positive long-term effects on children at risk of obesity. Therefore, there are gaps in research on interventions to overcome childhood obesity that need to be addressed with the help of the current project.

Children’s physical activity

Another subtheme discussed in the literature on interventions is related to assessing their effectiveness to improve the physical activity of children with obesity. Nyberg et al. (2015) conducted a cluster-randomized controlled trial in Sweden to measure the effectiveness of a program based on the principle of parental support to prevent obesity. It is important to note that the findings revealed that the intervention had no positive effects on children’s obesity and physical activity levels. On the contrary, Knol et al. (2016) tested Home Sweet Home, the obesity prevention program based on home environments. It was found that this program contributed to preventing and addressing obesity through decreasing hours spent on sedentary behaviors, reducing calorie intake, and improving physical activity. Bagherniya et al. (2017) conducted a systematic review to assess the effectiveness of different obesity intervention programs with reference to the principles of SCT. The reduced BMI was the outcome of different SCT-based interventions, but their role in improving children’s physical activity and lifestyle was found to be insignificant. These findings point to the necessity of evaluating the role of other interventions in improving children’s health and activity.

Technology-based interventions

A large amount of literature is dedicated to discussing modern technology-based interventions to address obesity in children. Cochran and Baus (2015) studied the interventions for children with obesity that were based on electronic health records. They found out that the information collected with the help of these records could be helpful for healthcare providers working with these patients. Moreover, Avis et al. (2015) conducted a multi-method study to develop an intervention oriented toward increasing parents’ motivation regarding the adoption of a healthy lifestyle to address obesity. The authors stated that parents could successfully use advanced applications to promote healthy lifestyle choices among their children. Lee et al. (2017) also examined the use of mHealth tools as interventions for addressing obesity in children with intellectual disabilities. The researchers invited 115 participants and used regression models to find that the tool had a positive impact on knowledge of students regarding their body weight and BMI (Lee et al., 2017). Thus, the findings can be discussed as valid and reliable. They support the effectiveness of using advanced technologies and modern interventions to improve children’s health status and prevent obesity.

The literature on interventions to address childhood obesity covers such large themes as types of effective interventions to use by parents and other agents and the relationship between using interventions and changes in physical activity. One more theme is the modern trend of using technology-based interventions to promote health. The review of nine articles has indicated that there is no strong evidence of a positive relationship between applying interventions and changing children’s physical activity. Therefore, more research is needed in this area with a focus on this project’s contribution.

Ethnic and cultural diversity

While studying the effectiveness of different types of interventions in preventing obesity in children with a focus on family-based programs and parental involvement, researchers also referred to the aspects of culture and ethnicity. According to Davis et al. (2016), representatives of some races are more predisposed to obesity than other individuals. Moreover, some ethnic and cultural groups less actively adopt interventions and changes than others (Ordway et al., 2018). The impact of ethnicity and cultural peculiarities on parents’ attitudes and involvement is another emerging concept that is closely connected with such subthemes as parents’ attitudes, culturally-appropriate interventions, and the outcomes for particular ethnic groups. Rawlins, Baker, Maynard, and Harding (2012) conducted a qualitative study that concentrated on the views of culturally diverse groups on healthy lifestyles. Fitzgibbon et al. (2013) implemented a quantitative study focusing on the effectiveness of a family-based program involving the Latino population. It is noteworthy that this program was designed for African American children. Bender, Nader, Kennedy, and Gahagan (2013) carried out quantitative research that explored the efficiency of an intervention developed to address obesity among Hispanic groups.

The studies mentioned above are characterized by a significant sample. The target population of the studies is diverse as Rawlins et al. (2012) include participants from different cultural backgrounds while the other two articles provide data on the outcomes for the Latino population. Rawlins et al. (2012) many similarities in different groups’ views as parents of different backgrounds placed significant value on healthy lifestyles. The participants also mentioned similar barriers (for example socio-economic issues) to the adoption of healthy patterns. However, the researchers also point at significant differences concerning the view on healthy diets. Fitzgibbon et al. (2013) concluded that an intervention that was effective with African Americans turned out to be ineffective with the Hispanic population. Bender et al. (2013) describe the positive results of their study that involved Latino mother-child dyads though mothers’ progress was not very significant.

The limitation of the qualitative study is a small sample size and the use of focus groups, which could result in a certain bias and lack of generalizability. Fitzgibbon et al. (2013) concentrated on low-income and poorly acculturated Latino groups, so this homogeneity can have adverse effects on the generalizability of findings. Bender et al. (2013) paid little attention to such factors as school, media, family when evaluating the effectiveness of their program. Further research may involve the evaluation of interventions developed to address the needs and peculiarities of specific ethnic groups. It can be important to include a more diverse sample in terms of socioeconomic status, educational background, and so forth.

Therefore, this topic is important to be identified for the discussion in this literature review because outcomes of parents’ education and interventions for children tend to depend on specific ethnic and cultural backgrounds and contexts.

Ethnic and racial disparities

BMI is discussed to be usually higher in Hispanics and African Americans than in Whites. Zilanawala et al. (2015) studied racial disparities regarding risks of obesity in children with a focus on 5-year-old participants from the UK and the US. The researchers stated that race and cultural factors played an important role to influence BMI in the UK-based population. However, in the US population, there were no reported ethnic disparities regarding obesity levels. Opposite findings were reported by Davis et al. (2016) who identified better results regarding BMI and physical activity in White students in comparison to children of other races. Guerrero et al. (2016) also examined changes in BMI depending on race and found out that Latino and African-American children had higher BMI levels. Thus, more researchers tend to agree that race plays an important role in determining the weight status.

Obesity in Hispanic children

Many studies are primarily focused on examining the obesity issue is Hispanic children. Falbe, Cadiz, Tantoco, Thompson, and Madsen (2015) were interested in examining interventions oriented specifically toward Hispanic children with obesity. As a result of their randomized controlled trial, the researchers noted that the Active and Healthy Families intervention designed for the Latino population had positive effects on decreasing BMI in children. Hatfield, Chomitz, Chui, Sacheck, and Economos (2015) studied changes in physical activity in low-income Hispanic children with obesity. The researchers conducted a quantitative study involving 93 children and found out with the help regression analysis that only age and gender could predict individuals’ physical activity results. Furthermore, Fradkin et al. (2016) noted that physical activity could contribute to decreasing obesity rates in Hispanic males. Therefore, the findings in these studies on obesity in Hispanic children require further examination and support because of their ambiguity.

Cultural diversity

Researchers also focused on the cultural factor as critical to influencing the success of interventions. According to Mech, Hooley, Skouteris, and Williams’s (2016) systematic review on the role of external factors such as socio-economic status on childhood obesity, parents’ BMI, ethnicity, culture, TV time influence children’s weight. Referring to 30 studies, the researchers found that interventions should be culturally and ethnically oriented in order to help children from low-income and diverse families cope with obesity. In their systematic review, Lofton, Julion, McNaughton, Bergren, and Keim (2016) examined obesity rates among Africa American children and supported conclusions by Mech et al. (2016). They found that specific culturally adapted interventions to address obesity had positive outcomes for the youth. Ordway et al. (2018) also developed a study on examining obesity risks for children of the Hispanic and low-income background. Using the data for a randomized controlled trial, the researchers found that a home visiting intervention was effective to prevent obesity in children aged 0-2 years. Thus, cultural environments, in which children are brought up, tend to influence their weight status.

The topic of ethnic and cultural diversity was widely discussed in the literature on childhood obesity. The reason is that some races and ethnicities are viewed as more predisposed to obesity than others (Guerrero et al., 2016). In addition, racially and culturally oriented interventions have better effects on youth, as it was reported by researchers (Mech et al., 2016; Ordway et al., 2018). The focus on Hispanics is important for this project involving parents of children residing in the Southeast region of the US where Hispanics represent the large portion of the population. However, there is a lack of evidence presented in the existing literature regarding the effectiveness of educational interventions for parents to improve the physical activity of their children and decrease BMI.

Family and community involvement

The topic of family and community involvement in activities oriented toward preventing obesity was also described in the literature. Researchers conducted numerous quantitative and qualitative studies to compare and assess family- and community-based interventions for preventing obesity in children (Muthuri et al., 2016; Wang et al., 2015). This area of knowledge is directly related to the problem studied in this project because of explaining the role of external factors in changing children’s behaviors.

Family-related factors

There are numerous factors related to the family environment that influence childhood obesity, including dietary habits, parents’ lifestyle, and parents’ weight among others. Muthuri et al. (2016) studied the relationship between parental education and weight and children’s obesity and physical activity. The provided evidence is strong as the researchers collected data from 4752 children from 12 countries and stated that parents’ overweight was positively correlated with children’s weight. Parents’ education was associated with the absence of overweight, and there was no positive relationship between education and physical activity in families from developing countries.

Parents’ weight and habits as influential factors were also examined in other studies. According to Xu and Xue’s (2016) review, family factors and environments played an important role in influencing children’s obesity. Lifestyle habits associated with spending more time watching television and using computers result in decreasing children’s physical activity in contrast to the increased intake of calories per day. Moreover, Liu et al. (2018) examined the relationship between parents’ education and income and their children’s weight. Referring to a questionnaire survey with 3670 participants from China, the researchers revealed that the interaction was observed for the education of fathers and their children’s obesity. However, there were no findings to support the interaction between mothers’ education and children’s weight.

Family involvement

The topic of family involvement was discussed in the reviewed articles in relation to family-related factors and environments. According to Braden et al.’s (2015) quantitative study, when parents become involved in changing their weight, children tend to imitate their behavior. Still, following Nyberg et al. (2015), interventions based on family involvement do not always result in positive outcomes for children. Moreover, in their open-label randomized study, Yackobovitch‐Gavan et al. (2018) also focused on evaluating the effectiveness of family-based interventions for preventing obesity in children. By referring to the data on 247 children, the researchers claimed that the most effective family-based interventions should be oriented toward both parents and their children to achieve higher effects and decrease BMI.

Community involvement

Finally, the concept of community and family should be taken into account when developing, implementing, and evaluating educational programs for parents. This construct is closely linked to such subthemes as community-based programs for parents and children, community-based interventions for fathers, environment. Timperio et al. (2013) pay close attention to the environment and overall opportunities for children’s participating in sports and different types of physical activity. The availability of sport-related resources at home and in the community is central to this project. Rito, Carvalho, Ramos, and Breda (2013) evaluated the effectiveness of a community-based educational program that involved parents and their children. The focus was on dietary habits and healthy lifestyles. Morgan et al. (2014) assessed an educational intervention for fathers and children delivered in the community setting.

The studies associated with the concept of community and family can be characterized by a similar limitation. All of them utilized self-reporting as a data collection tool, which could lead to certain bias. Apart from that, long-term effects were not explored. Furthermore, Timperio et al. (2013) note that their use of the term sports could be misinterpreted by children who could report on their participation in organized sports rather than their overall physical activity. Rito et al. (2013) state that their participants were not properly randomized and no control group was available. Therefore, the findings can be biased since the participants were committed to following recommendations and being active during the interventions. Further research can address such gaps as the barriers to the effective implementation of community-based interventions. It is also critical to examine long-term effects of educational programs.

Specific community-related factors were also mentioned by researchers as impacting the prevention of childhood obesity. In their review article, Brown et al. (2015) analyzed family and community factors that contribute to obesity prevention in children. Influential community factors include socioeconomic status, ethnicity, school programs, access to food, and access to recreation activities. They also stated that the key family factors to focus on are the home nutritional environment, parenting style, parent modeling, weight status, and monitoring.

Other researchers additionally focused on involving schools in addressing the obesity issue. Wang et al. (2015) quantitatively assessed obesity prevention programs for children to determine the most effective ones. They found out that school-based interventions were rather effective to prevent obesity-related problems in children, but interventions applied in other contexts were not researched in detail. In addition, Berge et al. (2016) were interested in studying community factors in relation to the problem of obesity in children. They applied the community-based participatory research approach in order to test interventions. The researchers found out that both parental involvement and the application of community-based programs had positive effects on the prevention of obesity in children.

Despite disagreements in reviewed articles on family and community involvement in obesity prevention, most researchers concluded that family-based interventions are effective to change children’s weight status. Credible findings of quantitative studies with large samples supported the idea that parents’ example and changes in home environments are key factors to influence children’s obesity. These conclusions explain the focus of the current research on interventions for parents as the form of family-based ones.

Summary

The review of the literature on childhood obesity has allowed for revealing critical topics: obesity and its prevalence in the US, parental involvement, parental awareness, interventions, ethnic and cultural diversity, and family and community involvement. According to the previous research findings, childhood obesity is more typical for Hispanic and African American youth, and this aspect supports the necessity of focusing on the Hispanic population in this project. Cultural backgrounds and parents’ education and income also influence the spread of obesity in children and the effectiveness of applied interventions. Parental involvement in preventing and addressing obesity is an important factor to influence the outcomes of interventions for children with weight problems.

However, there are still gaps in the existing research that need to be addressed with the help of this project. First, there is a lack of literature on the role of cultural and ethnic factors in influencing the effectiveness of interventions involving parents of children with obesity (Cullinan & Cawley, 2017). Second, findings regarding the effectiveness of parent- and family-oriented interventions and the role of parental involvement are rather opposite regarding potential outcomes for children with obesity (Yackobovitch‐Gavan et al., 2018). There is supporting evidence for both the presence and absence of the relationship between interventions and parent involvement and decreased BMI or increased physical activity (Clarke et al., 2015; Morris et al., 2015). Therefore, more research is necessary to cover this gap and examine the effectiveness of interventions involving parents to increase physical activity and decrease obesity in children. The analyzed data allowed for determining the variables to focus on in this project – parental involvement based on interventions and obesity and physical activity – because more research is needed to examine the relationship between them.

The principles of social cognitive theory with a focus on its relevance for this project have been described in the chapter. SCT is selected as a theoretical foundation for this project because it explains how the parental involvement and example can influence changes in children’s health-related behaviors (Knol et al., 2016). The literature has also provided the support for the selection of a method and a research design appropriate for this project. Thus, quantitative and quasi-experimental studies were also used by Braden et al. (2015) and Peters et al. (2016), and they provided valid findings. In addition, the use of SRBW, SRBH, and PAQ-C for data collection and analysis was supported by Kee et al. (2017) and Lee et al. (2015), who accentuated the credibility and reliability of these tools.

Referring to the reviewed literature, further research is essential to determine what educational programs for parents will have positive outcomes for children with obesity belonging to certain ethnic groups or living in specific areas. The analyzed literature accentuates the necessity of conducting a quantitative study on the topic of applying interventions for parents in order to educate them regarding physical activity to predict changes in their children’s BMI. From this perspective, additional research in this field will contribute to addressing the gaps that were identified in the existing literature regarding the relationship between interventions involving parents and children’s BMI and physical activity. Chapter 3 will present the information on the methodology selected for this project depending on specific methods, designs, and approaches that were used by other researchers and mentioned in this chapter.

Methodology

The focus of this quality improvement project is to aid in the reduction of BMI in Hispanic children by teaching their parents healthy food choices and physical activity to decrease obesity in school-aged children. The problem is that Hispanic children are more often diagnosed to have obesity in comparison to the representatives of other races, and parental involvement in interventions to address obesity in children with a focus on increasing physical activity is supported by research. The purpose of the project is to examine the potential effect of the intervention about physical activity on obesity levels in a selected group of school-aged children residing in the Southeast region of the US. The quantitative methodology for this project is selected to address the clinical question regarding the effect of parents’ participation in educational sessions on changes in children’s obesity rates. This chapter restates the problem of research and clinical questions, describes the methodology and design in detail, and presents the population and sample. The used instruments and their validity and reliability are also discussed in the chapter along with data collection and analysis procedures, ethical considerations, and limitations.

Statement of the Problem

Obesity leads to changes in health care, family income, and communities, and its morbidity, incidence, and persistence are hard to control. Weight regulation is usually predetermined by genetic, environment, and development factors, which may vary between populations (Pandita et al., 2016). Obesity can also be rooted in a child’s behavior, family traditions and customs, and social activities. According to Chesi and Grant (2015), abnormal fat accumulation is a trait originated from environmental and genetic factors. Thus, when the body consumes an extensive amount of calories, it is hard to burn them and maintain the required BMI (Xu & Xue, 2016). In some children, genetic factors play a crucial role, and even regular physical activities and exercises are not enough to predict body changes and the work of physiological mechanisms (Chesi & Grant, 2015). Therefore, a child’s weight, height, and other vital signs have to be controlled either by a healthcare provider or a parent or another caregiver.

Parental responsibilities related to their children’s health are thoroughly evaluated in primary care settings, family planning facilities, and other organizations. Parents understand the worth of their influence on children because of the necessity to guide, support, and become good examples from legal and humane points of view (Wolfson, Gollust, Niederdeppe, & Barry, 2015). In modern media, there are many cases when parents are accused of having obese children (Wolfson et al., 2015). Questions and concerns about the quality of care parents are raised in families with low incomes. When people become parents for the first time, they can be lost in information about infant feeding, further physical training, and adaptations to social needs and expectations (Love, Laws, Litterbach, & Campbell, 2018). In Hispanic, Latino, and African American families, children have high BMI from an early age, and parents must know how to protect their kids regardless of their genetics, environment, and other issues (Guerrero et al., 2016). To avoid unpredictable financial complications and physical or mental impairment, the idea to improve people’s awareness about obesity and the necessity to control BMI will be developed.

Still, not many parents are eager to be educated about physical, nutritional, and genetic peculiarities of their children when those are at schools. People expect that school teachers, the medical staff, and administration are responsible for the development of any child in terms of their knowledge, as well as physiology. It is not known how education sessions may influence parental involvement in controlling their children’s physical activities and BMI. Little information is available about childhood obesity prevention in Hispanic families with low incomes, and there is a need to clarify weight changes in children due to education for parents.

In the parents’ educational sessions, the emphasis will be on both eating habits and exercise. Information about healthy eating should provide parents with both a theoretical basis (nutritional value, micro-, and macro-elements) and practical tools. Tips on introducing exercise should be age-appropriate and fit different lifestyles. It is easy to imagine that mothers and fathers might be experiencing a pushback from their children unwilling to commit to making changes as well as criticism from other parents. Thus, the contents of educational sessions should not only include dry facts but also offer guidance and emotional support.

Clinical Question

The clinical question that guides this quality improvement project is: For parents of elementary school-aged Hispanic children from low-income families, will an educational session about physical activities and reduced caloric intake, compared to no session be effective in controlling and preventing childhood obesity within two months? The variables associated with this question and assessed in this project are the parental involvement in the educational intervention and their awareness of the disorder and its prevention as an independent variable and children’s obesity and physical activity levels as dependent variables. To collect the data for the independent variable, it is necessary to provide parents with a questionnaire. Data related to dependent variables will be collected with the help of such measurements as SRBW and SRBH for determining obesity levels and the PAQ-C for determining physical activity levels. SRBW and SRBH are helpful to collect data regarding children’s anthropometric measures required to calculate their BMI in addition to using self-reported data (Olfert et al., 2018). The PAQ-C is effective to evaluate children’s physical activity during a set period of time (Lee et al., 2015).

After completing the project, the author will also answer the questions regarding possible causes of childhood obesity in low-income families and the connection between obesity prevention and the family economic status referring to the project’s results and information provided by parents. To address the clinical question determined for this project, a quasi-experimental design has been selected. This design is most effective to demonstrate whether there are any changes in the weight status and behaviors of children with obesity after the one-month experiment (Peters et al., 2016). Other research designs do not allow for conducting quantitative projects in the form of prolonged experiments based on the use of certain interventions.

Project Methodology

Quantitative methodology is selected for this project in contrast to qualitative and mixed methods. The quantitative method is characterized by generating objective and numerical data about certain processes or phenomena, and the findings of quantitative studies usually have a high level of generalizability. In contrast to the qualitative method, the quantitative method can be applied to finding the relationship between specific variables, testing hypotheses, and identifying the effectiveness of certain interventions (Trochim, Donnelly, & Arora, 2015). In qualitative methodology, the key focus is on subjective data that allows for concluding about the nature of a phenomenon and provides a detailed analysis of a situation (Bryman, 2016). To address the purpose of this project associated with the application of the intervention to influence obesity in children, a quantitative methodology is more appropriate than the qualitative one. The mixed methods research is not selected for this quality improvement project because it is more cost-consuming than quantitative research.

While using a quantitative methodology, it is possible to apply the quasi-experimental design and analyze the data collected regarding the intervention for parents and children’s obesity with the help of statistical analysis techniques. Quantitative methodology to test the effectiveness of interventions to address obesity in children was also used in the studies by Braden et al. (2015) and Lee et al. (2017), as this method is actively used in social, medical, and nursing research. The selected methodology also supports the collection of necessary numerical data to respond to the clinical question because the effectiveness of parental involvement in the intervention for children should be measured using statistical tests. Referring to the existing literature, it is possible to predict the results of applying the quantitative method to understand the relationship between parental involvement in the educational intervention oriented toward improving children’s physical activity and changes in their obesity levels and exercising. It is possible to expect the significant effect of parents’ participation in the intervention on children’s weight status and exercising. The expected results will be objective, generalizable for a wider population, and bias-free.

Project Design

A quasi-experimental design is selected for this project because, in the context of quantitative methodology, it allows for determining the effect of an independent variable on dependent ones, accentuating causal relationships. Those quantitative studies that are based on testing the effectiveness of interventions primarily apply experimental and quasi-experimental designs (Trochim et al., 2015). In contrast to an experimental design, the selected design has all the advantages of an experiment, but it lacks randomization (Bryman, 2016). In this project, a quasi-experimental design allows for organizing the pre- and post-test assessment of children’s weight status based on the intervention. Therefore, a quasi-experimental design is effective to collect data on the relationship between the set variables referring to the conducted intervention.

Population and Sample Selection

Parents of elementary school-aged children with obesity will be recruited to participate in this project from the Southeastern region of the United States (Charlotte, North Carolina, in particular). The total population for this project includes parents of school-aged children with obesity who live in Charlotte, NC. The project population is narrowed to low-income Hispanic families who have elementary school-aged children with obesity and live in Charlotte, North Carolina. The sample for this project is based on the described project population, and it includes 40 parents of both male and female children with obesity where only one parent represents one Hispanic family. Thus, the parents of 20 male and 20 female children will be invited to participate in the project.

The major goal of the overall project is to improve elementary-school children’s health status (the reduction of their BMI) by raising their parents’ awareness about the disorder and major prevention strategies and encouraging parents to maintain healthy behaviors. Schools have certain programs aimed at helping students cope with their health issues including obesity (Clarke et al., 2015). Nevertheless, the effectiveness of these interventions is limited due to various reasons. One of the factors hindering the positive outcomes of school-based projects is their insufficient attention to parental involvement and the provision of specific instruments to establish healthy behaviors in families. The proposed intervention aims at addressing this gap and equipping parents with the necessary tools to ensure their children’s healthy lifestyle. Parents will attend educational sessions where they will be trained to set and maintain healthy behaviors of their children and will be encouraged to pay sufficient attention to this matter.

The selected sample size includes 40 participants out of more than 200 representatives of the project population size who will be chosen depending on inclusion criteria (the weight status of children, age, race, gender, and social status). Power analysis applied to determine the sample size for this project has indicated the necessity of inviting the minimum of 32 individuals (the power value is 0.8 and the type I error rate is 5%). Therefore, 40 participants have been determined as an appropriate sample size. It is necessary to ensure that the number of participants completing data collection instruments is higher than 32.

Referring to the purposive sampling technique appropriate for non-randomized projects, participants will be contacted in a clinic in Charlotte, NC, where people visit the medical staff regarding the childhood obesity issue. Purposive sampling is selected for this project as an effective technique because it is necessary to invite only those parents who are of Hispanic origin (as well as their children), have children with weight problems, can be reached in a local clinic of Charlotte, and they have agreed to participate in an educational intervention. Thus, purposive sampling is applied when there are many inclusion criteria for participants to conduct a quality improvement project in a certain population group (Creswell, 2014). Potential candidates will be provided with invitation letters describing the details of this quality improvement project. All parents participating in the project will sign informed consent forms describing its specifics, the confidentiality issue, and the right to withdraw from the project at any moment. The quasi-experiment will start when all the participants provide the signed consent forms, and then they will be asked to fill in questionnaires and protocols before and after the intervention.

Instrumentation or Sources of Data

To collect quantitative data appropriate to measure the variables in this quality improvement project, it is necessary to use the questionnaire for parents, SRBW and SRBH measurements, the calculated BMI, and the PAQ‐C.

The questionnaire for parents

The data regarding parental involvement in the intervention and demographics will be collected with the help of an electronic questionnaire that consist of 10 questions to obtain demographic data. The questionnaire is based on the questions on parents’ age, gender, weight, education, occupation, and income proposed by Kim et al. (2016). The authors did not refer to the previously designed questionnaire, but they composed questions appropriate for collecting the demographic information on children and parents (Kim et al., 2016). The items on parents’ race and ethnicity will be added to the questionnaire.

SRBW and SRBH protocols

These protocols presenting children’s weight and height before and after the intervention will be completed by parents to determine potential changes in the weight status of children with obesity. These are self-reported questionnaires of MBMI and weight. According to Olfert et al. (2018), self-reported anthropometric measurements are the key ones to determine changes in individuals’ weight status. They are also important for calculating children’s BMI in this project.

BMI

This measure of fat in a person’s body is calculated with reference to a child’s height and weight. This measurement is applied for both male and female children to determine their weight status. Parents will employ the calculator provided by Centers for Disease Control and Prevention (2019) to assess children’s BMI depending on SRBW and SRBH data.

PAQ‐C

The Physical Activity Questionnaire for Children includes 10 questions regarding children’s regular physical activity (see Appendix C). The PAQ-C requires participants to check a list of activities, as far as frequency is concerned using a numerical scale. The other questions cover physical activity, meal choices over past 7 days. The frequency of participation is given for each question. For the purpose of this project, the participants will refer to the period of five weeks. Individuals’ answers are assessed with the help of a 5-point Likert scale for determining the quality and frequency of a certain activity (Lee et al., 2015). Parents will complete the questionnaires based on their observations and their children’s reporting. This tool is discussed by experts as valid and reliable to be applied in children with obesity.

Validity

The validity of BMI varies according to the degree of body fatness. BMI can be misleading it does not take into account muscle mass or bone density. The validity of SRBW and SRBH is measured according to the data provided in a recent study. Olfert et al. (2018) found out that the validity of SRBW and SRBH in comparison to measured anthropometrics is high, and up to 93% of self-reported measurements are accurate. Being one of the most actively used tools for measuring children’s physical activity, the PAQ‐C has a high validity level. In the study by Benítez‐Porres et al. (2016), the internal consistency of this tool was measured referring to the Cronbach’s α coefficient, and it was α = 0.76. According to Voss, Dean, Gardner, Duncombe, & Harris (2017), the internal consistency is α = 0.837. These coefficients indicate the comparably high validity of the PAQ‐C for measuring physical activity in children. Therefore, SRBW, SRBH, and the PAQ‐C have been selected for this project.

Reliability

Depending on the nature of SRBW and SRBH as self-reported measures, their reliability is not high, but these measurements are actively used by researchers because of their validity. To add to the reliability of SRBW and SRBH, BMI is also calculated (Olfert et al., 2018). The reliability of the PAQ‐C is evaluated using intraclass correlation coefficients, and it is 0.96, according to Benítez‐Porres et al. (2016). This figure indicates high-level reliability, and it is supported by Voss et al. (2017). This reliability of the PAQ‐C allows for replicating the project results in the future.

Data Collection Procedures

After being recruited with the help of spreading flyers about the project by nurse practitioners and physician assistants among parents visiting a local clinic in Charlotte, the participants will provide their contact information to the project developer and sign electronic versions of informed consent forms to join the project. All the parents will be informed about the protection of confidentiality and anonymity. Being contacted by e-email, the parents will be asked to complete the electronic versions of the questionnaire including the demographic data, provide SRBW and SRBH data, and complete the PAQ‐C with their children before participating in the intervention. The completed questionnaires and protocols will be sent to the project developer by e-mail, and they will be protected by passwords (Bryman, 2016). During five weeks, the participants will attend educational sessions based on the selected clinic in Charlotte, NC, to learn how to improve children’s physical activity and lifestyle to address obesity. During this period, they will also implement all the recommendations regarding physical activity and a healthy lifestyle in their families with a focus on involving children.

Each week, parents will have two sessions that will last two hours each. I will provide the educational services based on the Parent Training Program developed by Slusser et al. (2012). As mentioned above, the training sessions will be divided into modules with some time devoted to revision and assessment. It is noteworthy that the educational intervention is developed for Latino parents, which is beneficial for the present project that targets Hispanic families as well. However, some modifications may be needed as Slusser et al. (2012) concentrate on parents of young children, so some recommendations may not be applied with elementary-school children. One of the outcomes of the project may also be the development of guidelines for healthcare professionals who will be running the educational sessions. Although the recommendations will be based on the results of a project held at a specific clinic, the data can be further generalized to make them appropriate for other healthcare facilities.

When the participants complete the five-week intervention, they will be contacted by the project developer to conduct the post-test data collection. The participants will send updated SRBW and SRBH data and the newly completed PAQ‐C as electronic documents by e-mail to the project developer. The author of the project will calculate BMI for pre-intervention and post-intervention periods by oneself, referring to the SRBW and SRBH data. The data sent by e-mail will be protected using passwords, and the files not including personal data will be destroyed in three years. The demographic data collected before the intervention will be used for measuring such independent variables as parents’ educational background and family socioeconomic status. The SRBW, SRBH, and BMI data and information collected with the help of the PAQ‐C will be used for measuring dependent variables.

Data Analysis Procedures

To determine the effect of applying the intervention on changes in children’s obesity and their physical activity, it is necessary to apply a linear regression analysis appropriate for quantitative quasi-experimental studies (Braden et al., 2015). This statistical test is selected for the project because it allows for determining the linear relationship between such independent variables as parents’ involvement in the intervention and children’s BMI and physical activity rates. A series of linear regression analysis is effective to identify the relationship between parents’ behaviors based on their participation in the intervention and children’s post-test BMI and address the clinical question. The data analysis will be conducted using Statistical Package for the Social Sciences (SPSS) that is appropriate for completing complex statistical analyses (Braden et al., 2015; Kim et al., 2016). The significance level for the analysis will be set at p < 0.05. Demographics, such as parents’ race, gender, income, and education, are used as covariates in a linear regression model, and raw numerical data provided by the participants will be organized in tables to be entered into SPSS.

Ethical Considerations

The major ethical issue associated with this quality improvement project is the focus on the childhood obesity question and the involvement of children in project. To guarantee the protection of children’s rights and freedoms, parents of youth with obesity are selected as participants for this quality improvement project and responsible persons for providing data. As a result, children will not be ethically affected or compromised during the project realization due to the absence of direct contacts and protecting their confidentiality. The participants’ anonymity, confidentiality, and privacy will be guaranteed as the data provided by parents will be labeled without identifying participants’ names with the help of numerical codes (Trochim et al., 2015). The data will be stored by the project developer and protected using passwords.

Respect, justice, and beneficence in relation to participants will be addressed during data collection, and the project will not start until receiving the approval by the Institutional Review Board, as well as signed consent forms from parents. The principles of the Belmont Report will not be violated because the participants will be treated with respect, there will not be risks associated with their participation in the project, and all project steps will be administered fairly. The collected data will be destroyed in three years after the project completion.

Limitations

One of this project’s limitations is the time period for conducting the intervention and assessing changes in children’s physical activity and weight status. A five-week project can result in observing outcomes that can be less accurate than associated with longer projects. To avoid inaccurate interpretations, this limitation is taken into account while making conclusions regarding the project outcomes. The second limitation is associated with the sample involved in the project in terms of a small sample size and the subjective aspect of parental involvement in the project. The project results based on data from 40 participants can have less generalizability than studies including larger samples. Furthermore, the effectiveness of the intervention can be influenced by parents’ personal factors and their involvement in the project (Clarke et al., 2015). These limitations can be addressed with a focus on future studies involving wider populations.

Another limitation is associated with a quasi-experimental design based on purposive sampling that also limits the generalizability of findings (Bryman, 2016). This limitation is taken into account while making conclusions about the relevance of the findings for a wide Hispanic population with a focus on low-income families with children having obesity. The limitations associated with using self-reported measurements and data reported by parents are addressed with the help of adding the calculation of BMI for children (Braden et al., 2015). All these listed limitations are unavoidable depending on the type of the selected design and its specifics, and they do not influence the findings negatively as they are taken into account during data analysis.

Summary

This chapter has provided detailed information on the methodology applied to this project. The quantitative method based on the use of a quasi-experimental design is selected for this project to address the clinical question. Forty parents will be involved in the quality improvement project to participate in the intervention on physical obesity. The data collection procedure will be organized with reference to gathering information before and after the intervention using the questionnaire for parents, SRBW and SRBH protocols, and the PAQ‐C. The validity and reliability of these instruments are supported by the literature. Data will be analyzed using linear regression models with the help of SPSS software. The chapter has also provided details on the ethical considerations and limitations related to this project. The results of the data analysis will be provided in Chapter 4.

Appendix A

Ten Strategic Points

Ten Strategic Points Comments or Feedback
Broad Topic Area The Prevalence of Obesity in Adolescent Children with Regards to Parental Education
Literature Review Literature review –

Background of the problem/gap;

  1. It has been estimated that approximately 20% of children residing in the USA are diagnosed with obesity (Davis, Wojcik, & DeWaele, 2016).
  2. Fradkin, Wallander, Elliott, Cuccaro, and Schuster (2016) argue that Hispanic children are twice as likely to be predisposed to be obese compared to White children, which is associated with socioeconomic and cultural peculiarities. Researchers and practitioners have developed numerous interventions to address the problem such as the use of electronic health records analyzed by Cochran and Baus (2015).
  3. Nevertheless, Nyberg et al. (2015) note that interventions involving educating children and their families tend to have a positive impact on the target population’s health. However, little is known about their efficacy with different ethnic groups.

Theoretical foundations (models and theories to be foundation for project);

  1. The social cognitive theory will be the guiding theoretical framework for this project. According to this theory, social constructs (including education and socioeconomic status among others) and the way they are perceived by people affect people’s behavior (McGee, Richardson, Johnson, & Johnson, 2017). It is expected that the parents having a higher level of education and economic status may benefit from the participation in the project as they will shape their lifestyles as a result of the intervention.

Review of literature topics with key organizing concepts or topics for each one.

  1. The review of the existing literature on the interventions aimed at addressing childhood obesity shows that various aspects have been explored. Some of the most recurrent themes include parental involvement, parents’ awareness, intervention, ethnic and cultural diversity, as well as the involvement of communities and families.
  2. Parental involvement is regarded as one of the predictors of positive changes in children’s lifestyles and dietary habits (Epstein et al., 2014; Lauricella, Wartella, & Rideout, 2015; Liu et al., 2017).
  3. As far as parents’ awareness it has been found that it positively correlates with the participation in educational interventions (Neely & Holt, 2014; Columna, Rocco Dillon, Norris, Dolphin, & McCabe, 2017).
  4. In terms of the intervention theme, Epstein et al. (2014) found that interventions for parents and children implemented separately were more effective than the ones developed for the participation of both groups.
  5. Researchers tend to assess the effectiveness of interventions among particular ethnic groups (Barr-Anderson, Adams-Wynn, Alhassan, & Whitt-Glover, 2014; Fradkin et al., 2016; McGee et al., 2017).
  6. The involvement of the family and community is another influential factor, and it has been found that this kind of support is associated with interventions’ positive outcomes (Morgan et al., 2014; Quon & McGrath, 2015). The review helps in the identification of the existing gaps. For instance, it is evident that the effectiveness of educational interventions among Hispanic low-income parents of obese children is not fully researched.
  7. The significance of the present project is associated with the development and assessment of an educational intervention that can help parents improve their children’s health status.
  8. This project is an initial step in the development of an effective program that can be used nation-wide.

Summary

  1. Gap/problem: There are certain gaps yet to be addressed. It is necessary to evaluate interventions involving large samples that are diverse. The lack of literature on the role of cultural and ethnic factors in influencing the effectiveness of interventions involving parents of children with obesity (Cullinan & Cawley, 2017). Second, findings regarding the effectiveness of parent- and family-oriented interventions and the role of parental involvement are rather opposite regarding potential outcomes for children with obesity (Yackobovitch‐Gavan et al., 2018).
  2. Prior studies: Prior studies identified the peculiarities of the existing research on educational interventions for parents aimed at increasing their children’s physical activity.
  3. Quantitative study: surveys and questionnaires as primary data collection tools. Such instruments as SRBW and SRBH surveys, SES, and PAQ-C, FAS has been regarded as valid and reliable and widely used in different studies (Morgan et al., 2014; Elgar et al., 2015; Quon & McGrath, 2015). The reliability and validity of these measures are also ensured as self-reports are used in combination with objective measurements such as BMI calculation and family income status. They are used to assess the effects and types of intervention in the study.
  4. Significance: further research is essential to identify the elements of educational programs that have the most positive and well-established outcomes. In order to achieve this goal, it can be necessary to conduct quantitative studies that should cover as large population as possible. The sample should also be diverse while the focus can be on cultural and socioeconomic peculiarities of different groups.
Problem Statement Problem statement – Describes the variables/groups to study, in one sentenceIt is not known whether an educational intervention aimed at teaching the low-income Hispanic parents of elementary-school children affected by obesity on the disease and its prevention will have positive health outcomes? The major contribution of this project will be the identification of the effectiveness of an educational intervention for the target population.
The purpose of this quantitative project is to explore the effects of an educational intervention aiming at the increase in physical activity and the reduction of caloric intake among low-income Latino elementary-school children diagnosed with obesity. The project will include the use of educational survey assessment, BMI calculation, self-reported body weight SRBW and self-reported body height SRBH surveys, and Physical Activity Questionnaire. Pre- and post-test quasi-experimental design will be employed to evaluate the level of participants’ knowledge on the matter.
Clinical/PICO Questions PICOT Questions – In parents of elementary school aged children, residing in the Southeast region, what is the effect of an education session about physical activity benefits and frequency across 2 month when compared to no education intervention, as measured by educational survey assessment tools self-reported body weight SRBW and self-reported body weight SRBH and using Physical Activity Questionnaire (PAQ-C).
These protocols presenting children’s weight and height before and after the intervention will be completed by parents to determine potential changes in the weight status of children with obesity
Sample Population: sample size, both parents (where available) of 20 males and 20 females
Location : Southeast region, Charlotte NC
Define Variables Data collection
Independent Variable: parental involvement, parents’ awareness, parental education levels, family affluence scale, subjective family economic status,Dependent Variable: Obesity and physical activity
Methodology & Design Methodology and design – The quantitative project improvement design involving the use of a quasi-experimental design will be utilized as it is instrumental in evaluating the effectiveness of an intervention. The assessment of the intervention outcomes is instrumental in addressing the PICO question. The benefits of the quantitative design include the ability to cover a larger population (compared to the qualitative approach) and identify certain trends (Lauricella et al., 2015). The focus on self-reports is also justified as, according to Quon and McGrath (2015), people’s behavior is often shaped by the way they perceive their socioeconomic status rather than the actual conditions.
Purpose Statement Purpose statement – The purpose of this quantitative project is to examine the effectiveness of education interventions involving the increase in physical activity or the reduction of caloric intake among elementary school adolescents. This project will involve education surveys for parents measured by educational survey assessment tools self-reported body weight SRBW and self-reported body weight SRBH and using Physical Activity Questionnaire (PAQ-C). Pre and post knowledge will be assessed. I want to see if education impacts the activity.
Data Collection Approach Data collection– Both parents (if possible) of 40 children (20 males and 20 females) diagnosed with obesity will be recruited to participate in the project, so approximately 80 people will take part in the project. Focus is on the parents of the children. This sample is sufficient to obtain preliminary data on the effectiveness of the intervention, and the data will be used to improve the educational program that will be assessed in another study covering a larger population. The parents will be divided into the experimental group that will receive the intervention and the control group where parents will receive some leaflets on the matter. The written consent forms will be sent via email or in the clinical setting. The recruitment process will take place in a local clinic where people visiting the medical staff will be provided with an invitation letter. Once 80 people are recruited, the process will be stopped. The written consent forms will notify the participants about data confidentiality and anonymity, as well as their right to withdraw from the project at any moment. The present project is not associated with any conflicts of interests.
Data Analysis Approach Descriptive statistics will be used to analyze the demographic data of the participants. Linear regression analysis will be employed as the data analysis method since, according to Lauricella et al. (2015), it ensures the identification of the relationship between several independent and dependent variables. Such statistical software as SPSS will be utilized to minimize or eliminate possible errors, increase the analysis reliability, and make it less time-consuming.

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