Abstract
Childhood obesity has become a serious public health issue in the USA affecting a considerable part of the country’s population. The present quantitative project aimed to examine the influence of an intervention involving the parents of low-income Hispanic children aged between five and eleven years old diagnosed with obesity on these children’s BMI (body mass index) and physical activity.
The cognitive behavioral theory guided the implementation of this project. Quasi-experimental pre-test/post-test design was employed, and the project involved 40 parents who participated in Parent Training Program aimed at raising their awareness regarding obesity and its effects on child development. Physical Activity Questionnaires for Children (PAQ-C) and BMIs were measured to identify the changes in physical activity. The majority of children displayed minimal changes in their BMI and physical activity. The mean reduction of children’s BMI was 0.6 for girls and 0.4 for boys. Children’s physical activity increased and reached 2.8 for girls and 2.9 for boys with the mean change of 0.4, which was equal for boys and girls.
The t-test indicated a statistical finding at p<0.05. The findings of this project suggest that effective interventions aimed at improving children’s weight status can be implemented in the clinical setting, but longer intervention and longitudinal data are needed to determine efficacy. Recommendations for future projects include longitudinal data collection and qualitative data to tailor interventions for diverse populations and parental educational needs.
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 low-income Hispanic elementary-school-aged children, its prevalence remains high. 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 prevalence of childhood obesity in Hispanic children and adolescents is 25.8% (CDC, 2019b).
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 recommended. Given that obesity has long-term health and financial consequences, new efforts must be initiated to reduce the incidence. Childhood obesity is associated with such health concerns as cardiovascular disorders and numerous mental health issues (Tremmel, Gerdtham, Nilsson, & Saha, 2017). It has been estimated that 5% of deaths across the globe was attributed to childhood obesity (Tremmel et al., 2017). The financial burden of obesity in the USA reached almost US $7,000 per capita annually in the early 2010s (Tremmel et al., 2017).
One of the possible solutions to obesity-related problems is the engagement of parents in prevention. Studies have demonstrated 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). These 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 obesity in families (Liu et al., 2018; Muthuri et al., 2016).
This project aimed to investigate implementation of an intervention aimed at raising Hispanic parents’ awareness about obesity, its prevention, and strategies to help them address their obese children’s weight problem. Quantitative methodology and quasi-experimental pre-test/post-test design were employed as the project design. Self-reported body weight (SRBW) measurements and a physical activity questionnaire were utilized assess outcomes of educational sessions for parents.
The intervention that was employed in this project, the modified Parent Training Program (PTP), targeted low-income elementary-school-aged Hispanic children and was developed by Slusser et al. (2012). The PTP was grounded on the health supervision tools outlined in “Bright Futures in Practice: Nutrition,” “Traffic Light” diet, and healthy eating and lifestyle messages of the “Bright Futures in Practice: Physical A” (Slusser et al., 2012).
The program aimed at decreasing the weight of low-income Hispanic children aged between 5 and 11 years old by increasing 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 PTP were to teach parents how to promote healthy eating in their families and practice self-monitoring. The PTP objectives are consistent with the goals of the present project.
This chapter provides background for the project and introduces 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. The clinical question posed will help to narrow the focus of the project and identify the most crucial aspects of childhood obesity and parents’ education. This chapter also includes discussion in how the project advances scientific knowledge, the project’s significance, and identifies gaps in the literature addressed by the current investigation. Finally, the rationale for methodology and design, definition of important terms, limitations, are discussed.
Background of the Project
During the twentieth century the increasing prevalence of obesity led to the growing interest of researchers and healthcare practitioners to the problem. However, it was not until the early 1990s, when the World Health Organization (WHO) developed a classification of BMIs that became commonly accepted in academia (Nuttall, 2015). Davis, Wojcik, and DeWaele (2016) determined 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 associated with obesity include physical inactivity, high levels of cholesterol in the blood, and shortness of breath (Sahoo et al., 2015).
The Centers for Disease Control and Prevention (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%. Population race and ethnicity factors also define the frequency and severity of obesity-related problems in children. The investigation of Kim et al. (as cited in Fradkin, Wallander, Elliott, Cuccaro, & Schuster, 2016) suggests that African American and Hispanic children are significantly more affected by obesity compared to White children due to unhealthy lifestyles, low-income levels in families, and limited access to 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) (Guerrero et al., 2016). Despite the availability of parental education and support for obesity prevention programs, 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 using racially, unbiased education.
Problem Statement
The PTP was implemented with younger children, so it is unknown what effects it could have on elementary-school-aged children within a period of six weeks. Weight regulation is usually influenced 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. 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). It was not known if the PTP implemented during six weeks would contribute to the reduction of children’s BMI and increase in their physical activity. The intervention based on the PTP and utilized in this project will be further referred to as Parent Training Program for Elementary-School-Aged Children (PTP). The PTP has a shorter duration (six weeks) compared to the PTP.
The project aimed at examining whether the PTP would result in children’s decrease of BMI and increase in their physical activity. The target population for the intervention are parents of low-income Hispanic students aged between 5 and 11 years old and diagnosed with obesity. During the present intervention, the emphasis was on both eating habits and exercise. Information about healthy eating provided parents with both a theoretical basis (nutritional value, micro-, and macroelements) and practical tools. Tips on introducing exercise was age-appropriate and tailored to different lifestyles. Thus, the contents of educational sessions included facts about the benefits of healthy diets and physical activity and offered guidance and emotional support.
The parent training sessions lasted for six weeks and contained nine 90-minute sessions that were developed as modules addressing specific objectives. The sessions took place one or two times a week, and the schedule was developed and agreed with the participants. Parents who missed a session had access to the materials of the educational session missed by email. The Parent Training Program developed by Slusser et al. (2012) was utilized. The educational sessions conducted by the investigator. It is noteworthy that Slusser et al. (2012) created the nine modules to be taught during four months, but the timeline of the DPI prevented full duration of the sessions as recommended by Slusser.
All educational modules were a part of the Parent Training Program. Module One was devoted to the discussion of cultural norms 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 included the discussion of healthy diets (with regards to cultural norms and eating-out spots) and obstacles to the establishment of healthy lifestyles and methods to overcome them. Parents were also trained to communicate effectively with the rest of the family regarding healthy lifestyles.
Module Three focused on training parents to choose healthier foods, to practice self-monitoring, and increase healthy foods accessibility to children. Modules Four and Five involved 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 were 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 included 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 was a general review of the sessions where parents shared their views and reflected on their experiences during the project. The participants were encouraged to prepare healthy snacks and foods in order to reduce the BMI in children. Parents shared their perspectives regarding the effectiveness of the intervention and its limitations.
The expected outcome of this project was the evaluated effectiveness of the PTP with the target population. It was expected that the PTP would lead to children’s lower BMIs and increased physical activity, as well as their families’ adherence to healthy lifestyles and diets. The project can contribute to solving the problem as it resulted in the development and assessment of an intervention that can become an integral part of the services provided within the U.S. healthcare system. Parents can potentially become more knowledgeable and committed to maintaining healthy lifestyles, which will translate to a lower rate of overweight and obese elementary-school children.
Purpose of the Project
The purpose of this quantitative project is to explore the effectiveness of PTP aimed at increasing physical activity and reducing BMI among low-income Hispanic elementary-school-aged children diagnosed with obesity. The quality improvement project occurred in three stages. First, demographic information was gathered about participants, in addition to a history including the level of physical activity and obesity-related problems.
Next, the six-week educational program was provided to improve parents’ knowledge about childhood obesity. Parents were educated about the ways to maintain appropriate energy balance (energy input and output), the role of dietary habits, and the value of engaging in physical activity at an early age (Brown, Halvorson, Cohen, Lazorick, & Skelton, 2015). The intervention, as well as the methodology that was utilized during this project, was employed in previous research and found to be effective with younger children. The project was implemented at a clinic located in Charlotte, NC.
The exact BMI was calculated based on the data provided by parents who noted their children’s height and weight (see Appendix E and Appendix F). In this project, the Physical Activity Questionnaire for Elementary Children (PAQ-C) was used (see Appendix F).
Parents answered the questions from the questionnaire relying on the results reported by their children and the observations they made. Parents provided information regarding the time their children spent playing games or being involved in any kind of physical activity. This information was essential for the identification of the deficiencies in children’s lifestyle that were likely to contribute to their being overweight or obese. The Parent Training Program (PTP) developed by Slusser et al. (2012) was utilized. The PTP involved the provision of training to low-income Hispanic parents aimed at improving diets and physical activity of their children.
The independent variable was the PTP. The utilization of recommendations discussed during the Parent Training Program for Elementary-School-Aged Children was evaluated during reflection and discussions that took place during the concluding training sessions. The dependent variables were children’s BMI and their physical activity. The dependent variables were measured with the help of the calculation of children’s heights and weights (BMI) along with the analysis of the Physical Activity Questionnaires.
The developer of this project utilized the weight-for-age percentiles growth chart provided by the CDC (2019a) to calculate their child’s BMI. The project aimed at solving the problem of childhood obesity by introducing an effective educational intervention that could be implemented in the clinical setting for parents of elementary-school-aged children diagnosed with obesity. Moreover, the project attempted to validate the use of certain protocols that can be employed in subsequent projects and further research.
Clinical Question
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. This DPI project can potentially increase families’ access to healthier lifestyle by raising parents’ awareness of available resources and affordable strategies to establish and maintain healthy lifestyles.
The dependent variable was children’s BMI and their physical activity measured by the analysis of Physical Activity Questionnaires. The clinical question was: For parents of elementary school-aged Hispanic children from low-income families, will Parent Training Program for Elementary-School-Aged Children, compared to no session be effective in controlling and decreasing the BMI in six weeks?
Advancing Scientific Knowledge
School-based programs for children and parents have the potential to promote reduction in children’s BMI (Pablos, Nebot, Vañó-Vincent, Ceca, & Elvira, 2017; Quattrin et al., 2014). Due to high prevalence in overweight and obesity in this population and limited access to education, there is a need for investigations about Hispanic families and the challenges or opportunities they have in order to predict and control childhood obesity. The incorporation of evidence-based intervention that is effective in decreasing obese children’s BMIs and increasing their physical activity into US healthcare setting can be instrumental in developing sound policies and projects to address 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 an appropriate theory guide and evaluates perceptions and beliefs 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) (Bandura, 1986). 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 seeks to address the educational needs for parents of obese children and promote 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 that guided aspects of this program. Advanced scientific knowledge of this DPI project is instrumental in determining if the implementation of the PTP is an effective intervention for older children in an abbreviated time frame.
Significance of the Project
Despite numerous attempts to control and prevent obesity in children, this disorder is still a significant population problem. This project addressed 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 was found that PTP could have a positive effect and contribute to the reduction of children’s BMI and increase in their physical activity.
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 six-week DPI project, the task was to determine if reduction in BMI could be achieved through a shortened course of educational content based on the PTP. 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. The PTP implies the training of parents who receive information concerning appropriate diets and physical activity patterns, methods to encourage their children to change their behavior, and communication strategies to develop effective relationships with 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 (Creswell, 2014). 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. To answer the clinical question, it is necessary to examine the relationship between dependent and independent variables mathematically using statistical analysis, which are the main characteristics of quantitative.
In this DPI project, quantitative findings are independent of the writer’s opinion, observations, and attitudes towards the problem of childhood obesity in low-income families. Therefore, the quantitative 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. The review of the literature provides evidence to determine study variables that can be examined statistically.
Nature of the Project Design
A quasi-experimental design resembles an experimental design without experimental control and randomization of subjects. It is frequently used to evaluate the effectiveness of treatment or interventions when an independent variable may be manipulated to determine effects through measurement of the dependent variable (Creswell, 2014). Regarding the goals of the project and the necessity to clarify the effectiveness of the PTP for parents, a quantitative quasi-experimental pretest-posttest design is chosen.
The strengths of this approach include the identification of specific trends in the project, the option of convenience sampling, and evaluation of the dependent variable before and after intervention. Peters et al. (2016) used the quasi-experimental design to identify and assess the capacities of low-income communities in their intentions to create appropriate environments and prevent childhood obesity. A quasi-experimental pre-test/post-test design with validated instruments and assessment tools was utilized in this project to examine the efficacy of an educational program for parents to promote parental involvement to reduce BMI and increase physical activity.
The participants were 40 families with obese or overweight children whose parents agreed to participate in the intervention and by attending educational sessions on preventing obesity through healthy food choices and physical activities. The participants were residents of Charlotte, NC, and the project was based at a local clinic, Charlotte, NC. Parents received written consent forms via email or personally during office visits.
As soon as they signed the form, they were provided with survey questions to check their knowledge and abilities to self-report on body weight and height (Olfert et al., 2018). Several training sessions were organized for the group of parents during six weeks. Finally, the same tests and self-reported surveys were offered to gather final results and begin data analysis using Statistical Package for the Social Science (SPSS) software application.
Definition of Terms
The analysis and assessment of obesity-related problems begin with the identification of the most important terms. The target health conditions and instruments are explained in detail. The following terms were 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 (Chesi & Grant, 2015).
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 (Ogden et al., 2014).
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 (Sahoo et al., 2015).
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 (Olfert et al., 2018).
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 (Office of Disease Prevention and Health Promotion, 2018).
Parent training program
The parent-training program involves 1.5-hour classes held once a week for six weeks and is designed to integrate nutrition and physical fitness education Slusser et al. (2012).
Assumptions, Limitations, Delimitations
There are two main assumptions in this DPI project:
- It was assumed that the training session offered to parents during six weeks was grounded on credible studies and guidelines developed by the CDC and met all the care standards and pedagogical techniques.
- It was 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.
Three limitations of this project are apparent.
- The main limitation of the project was the time spent on the intervention. Kim et al. (2016) already reported the unlikelihood of observing changes in body weight after a five-week intervention.
- Another limitation included a small sample size and the necessity to cooperate with the representatives of one ethnic group (Hispanics) only. Improving access for Hispanic children is a worthy cause, so broader recruitment at multiple sites might be another strategy to overcome this limitation.
- Finally, the data collection methods involved the opinions of parents who could be biased or prejudiced to the idea of obesity in children.
Delimitations are the boundaries that help to control the project despite the existing limitations (Creswell, 2014). Two major delimitations can be identified:
- In this case, the location of the DPI project (a local clinic in Charlotte, NC) is the major delimitation that ensures the inclusion of people facing a similar issue (their children’s health status).
- Another delimitation includes the chosen quantitative methodology.
Summary and Organization of the Remainder of the Project
In this DPI project, the goal was to improve Hispanic children’s health status by reducing their BMI through their parents’ participation in the PTP. The parents were trained to modify their children’s diets and physical activity patterns, improve their communication with children, and use effective strategies to establish and maintain healthy lifestyles. The focus on a specific ethnic group is one of the benefits of this project as 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.
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 set the foundation of this project and highlighted the major details regarding the employed methodology.
The chapter provided an introduction to the project, rationale, description, theoretical background, method, and design. In the following chapters, a detailed discussion will be developed: the literature review on the chosen topic (Chapter 2), the methodology and design (Chapter 3), data collection/analysis procedures (Chapter 4), and the results of the intervention (Chapter 4), as well as conclusions, implications, and recommendations (Chapter 5).
Literature Review
This quantitative, quasi-experimental pre-test/post-test design DPI project is aimed at examining the effect of education intervention about physical activity and healthy diet for parents on obesity levels observed in school-aged children residing in the Southeast region of the United States. 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). 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 association with 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 parents’ effort to maintain children’s health or reduce their BMI and increase their physical activity is given. 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 dependent variable for this project is obesity. The rise in the incidence of childhood obesity is well documented in the literature. Therefore, it is essential to examine 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.
Prevalence
Obesity is a considerable public concern as it is associated with considerable health, social, and financial issues people have to face (Tremmel et al., 2017). 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. It has been acknowledged that the incidence of childhood obesity has remained almost unchanged among the overall population of American children during the past thirty years (Davis et al., 2016). Nevertheless, the proportion of overweight children of different ethnicities has seen certain changes as the prevalence of obesity among white population decreased while the rate of obese children among underprivileged groups grew (Hales et al., 2017).
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. 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. Fradkin et al. (2016) found that Hispanic children were twice as likely to be diagnosed with obesity compared to their White peers.
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 (Ogden et al., 2018). Skinner et al. (2018) also note that socioeconomic factors have a substantial impact on children’s weight and physical activity.
To sum up, recent research on childhood obesity in the USA suggests that the incidence of this disorder has not increased in terms of the entire population. However, the proportion of obese Hispanic children has reached up to almost 26% and is likely to continue increasing. The incidence of obesity is linked to the socioeconomic status of families.
Ethnicity
The ethnicity of children with obesity has been determined in the literature as a risk factor indicating trends in obesity prevalence. Hispanic and African American children and adolescents are more likely to develop obesity as compared to their White or Asian peers (Guerrero et al., 2016). Although the incidence of obesity is well-researched, it is still important to trace the changes that may occur regarding the obesity rate among different ethnic groups. However, more attention should be paid to the effectiveness of interventions targeting diverse populations affected by obesity.
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 Hispanic 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 higher levels of physical activity and lower BMI in comparison to students of other races.
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. At the same time, it has been reported that although the prevalence of obesity among ethnic groups has been properly investigated, the effectiveness of interventions and policies aimed at reducing obesity rate among vulnerable groups is still under-researched (Nyherg et al., 2015).
In summation, ethnicity has proved to be one of the major factors affecting the development of obesity in children. Hispanic children are regarded as one of the most vulnerable groups. Researchers also claim that the prevalence of obesity is in scholars’ focus, but the effectiveness of interventions aimed at Hispanic children is still insufficient.
Comorbidity
Obesity is a complex health condition that usually leads to the development of comorbid diseases. Associated disorders include cardiovascular issues, diabetes, eating disorders, and mental health problems (Sahoo et al., 2015). Physical inactivity and comorbid states also result in emotional and social problems.
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. Sahoo et al. (2015) note that obesity is often associated with emotional issues especially among adolescents. Obese children also may face social issues and feel the stigma or even become victimized (Sahoo et al., 2015).
In conclusion, it is necessary to note that comorbidity of obesity makes this disorder one of the priorities for researchers. Obesity is associated with such health conditions, as cardiovascular diseases, diabetes, mental health disorders, as well as social and emotional issues. The researchers developing interventions addressing obesity in Hispanic children should consider comorbidity to achieve the established goals.
Summary
On balance, the increasing disproportion in the prevalence of obesity among diverse ethnic groups is apparent and requires immediate measures to be undertaken. 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 in 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 efficacy 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) focused 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. Research suggests that parents’ involvement is manifested in being a role model, establishing familial norms and traditions, expressing positive attitudes towards certain behavioral patterns, and parents’ participation in interventions. All these techniques have proved to have a positive influence on children’s dietary habits and physical activity.
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.
It has been acknowledged that established family norms and traditions have a substantial impact on the development of children’s behavioral patterns. Garriguet, Colley, and Bushnik (2017) explored sedentary behaviors of parents and found that these patterns had a direct effect on their children’s physical activity and sedentary behaviors. It is noteworthy that children’s gender tended to play a considerable role in the way parental conduct influenced them. Tate et al. (2015) also note that parents’ modeling has a positive impact on children’s development and their physical activity.
It is also emphasized that parental encouragement is the most influential factor affecting children’s behavior. McMurray et al. (2015) also found a direct link between parents’ sedentary behaviors and their children’s physical activity, which was specifically apparent during weekends. In their study, Liu et al. (2017) identified a clear correlation between parents’ positive attitudes towards sports and healthy lifestyle and their children’s physical activity. Kim et al. (2016) explored the relationship between parents’ dietary habits and their children’s dietary intake. However, these positive trends did not translate into improved BMI and physical activity in children.
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.
In conclusion, it has been acknowledged that parents play an important part in the development of their children’s dietary and behavioral patterns. Parents who establish healthy norms and traditions, become role models, express positive views regarding healthy lifestyles, and participate in interventions along with their children can help them decrease their weight and become more physically active. However, it is still necessary to pay attention to other factors affecting children’s behaviors when developing interventions aimed at decreasing childhood obesity rate.
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. Supportive parents encouraged their children to change and recommended various methods to reach this goal, but they also taught their children self-acceptance. However, researchers provide evidence that such techniques as teaching self-acceptance could lead to undesirable social issues, including teasing at school.
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. Motivation, encouragement, and the provision of recommendations were effective techniques. At the same time, such ways to support a child as teaching self-acceptance could also result in undesirable outcomes such as social issues.
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. Parent involvement can have positive effects on children with obesity if parents are educated regarding the issue and correctly recognize their children’s status. It has been found that parent training aimed at increasing parents’ awareness of obesity and prevention has a positive effect on children’s health by shaping their behaviors.
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. 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. One of the central areas to focus on among the Hispanic population is raising parents’ awareness of their children weight, as well as obesity, associated risk factors, and prevention. The interventions, including the elements mentioned above, lead to the change of parents’ attitude towards their children’s health status and the focus on healthy lifestyles.
Concluding remarks on parental involvement
In conclusion, 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). Parents’ awareness is important to be analyzed with reference to evidence because it is a significant aspect to influence the effectiveness of educational interventions for parents.
Davidson and Vidgen (2017) argue that parents’ awareness of their children’s weight and health status, as well as possible outcomes of obesity and their personal responsibility for their children’s development, was the primary motivating factor to participate in interventions aimed at improving their children’s health and lifestyle. Importantly parental educational background does not necessarily translate onto their awareness of obesity and its adverse effect on people’s health. Parents’ education had a well-pronounced effect on the family’s dietary behaviors, but it has insignificant effects on children’s physical activity (Muthuri et al., 2016).
Parents’ perceptions of obesity in children
The problem is that many parents of children with weight problems are not aware of this fact. It is found that parents’ perspectives regarding their children’s weight and physical activity are influenced by children’s gender, parents’ education level, and family income. Parents are often focused on barriers to the establishment of healthy lifestyles rather than existing opportunities, which has to be considered by the developers of interventions aimed at decreasing childhood obesity rate and involving parents.
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, Laws, Litterbach, and Campbell (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 the 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.
To sum up, parents’ perspectives regarding their children’s weight and physical activity depend on parents’ education, family income, and children’s gender. Parents tend to report numerous obstacles to setting healthy patterns and shaping their children’s behaviors, as well as rely on educators when it comes to children’s physical activity and healthy habits. The peculiarities of parents’ perceptions of the problem should be considered when working on intervention aimed at addressing childhood obesity.
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. It is proved that the level of parents’ responsibility positively correlates with their involvement in changing their children’s health behaviors and, as a result, their children’s weight and physical activity. The effectiveness of interventions involving parents and aiming at decreasing children’s weight is also linked to parents’ responsibility.
As a result of analyzing survey data on parents’ behaviors and the problem of childhood obesity, Wolfson, Gollust, Niederdeppe, and Barry (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 2,300 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 with high levels of responsibility are more involved in their children’s life and establishment of healthy behavioral patterns. Responsible parents are also more likely to participate in interventions targeting obese children, and this participation tends to be beneficial for children.
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. Recent research suggests that parents tend to have false perceptions regarding their children’s physical activity. At the same time, parents who have positive attitudes towards sports and encourage their children to be physically active have a positive effect on their children’s physical activity.
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.
In summation, 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. Parents are also able to shape their children’s behavior by encouraging them to take part in various kinds of sports. Parents positive perspectives regarding physical activity motivates children to be more physically active.
Conclusion
To sum up, 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.
Research focus
The majority of the reviewed studies on interventions to prevent obesity were oriented toward assessing their effectiveness. It is found that school-based interventions reveal the most beneficial outcomes. However, the long-term effects of interventions aimed at decreasing childhood obesity are still insufficient.
Gicevic et al. (2016) conducted a quantitative content analysis to discuss 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). 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.
In summary, the primary focus of the current research is on the effectiveness of interventions aimed at decreasing childhood obesity. However, the long-term effects of such programs still remain under-researched. It is also proved that school-based interventions are more effective as compared to projects set in other environments (for example, home-based).
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. Such interventions are often based on SCT concepts and have a focus on the establishment of healthier behaviors in children with clear positive outcomes. Other aspects (such as dietary habits) are often excluded from the scope of these interventions.
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.
To sum up, the inquiry into the effectiveness of interventions aimed at decreasing childhood obesity is associated with the focus on children’s physical activity. The principles of SCT often guide the development and implementation of such interventions. The major focus of these projects is mainly on children’s physical activity, and other aspects (dietary habits) receive less attention.
Technology-based interventions
A large amount of literature is dedicated to discussing modern technology-based interventions to address obesity in children. It is suggested that the use of technology increases the effectiveness of interventions aimed at decreasing childhood obesity. Mobile-based technologies have become an effective tool employed by researchers and educators working on the development of interventions targeting obese 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. Mobile-based technologies are gaining popularity among intervention developers and parents.
Review of major points regarding interventions addressing childhood obesity
To sum up, 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. At the same time, interventions aimed at decreasing the childhood obesity rate have proved to be effective when shaping children’s dietary habits, which can be regarded as a positive outcome.
Therefore, more research is needed in this area with a focus on this project’s contribution. It can be important to pay more attention to qualitative data and elicit people’s attitudes and the reasons behind their actions and behaviors. The analysis of people’s perspectives can shed light on people’s limited readiness to shape their behavior regarding physical activity, but their willingness to shape their dietary patterns.
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 Hispanic 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 Hispanic 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 Hispanic 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 Hispanic 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. Disproportionate access to resources is one of the primary factors affecting parents’ perceptions regarding obesity, as well as children’s health status. The influence of neighborhoods and environments needs further investigation and should be considered when developing interventions aimed at decreasing obesity among ethnic minority children.
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 Hispanic 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.
Many studies are primarily focused on examining the obesity issue in 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 Hispanic 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.
In conclusion, it is necessary to research such aspects as cultural and socioeconomic factors affecting people’s lifestyles and their weight. Ethnicity in the USA is closely linked to economic disparity, so vulnerable groups have lower access to quality healthcare, healthy food, appropriate physical environment (Fradkin et al., 2016). The influence of neighborhoods and communities should also be properly studied in relation to ethnicity-based disparities. Finally, social ties have to be researched especially when it comes to cross-cultural relationships.
Cultural diversity
Researchers also focused on the cultural factor as critical to influencing the success of interventions. At present, interventions aimed at decreasing childhood obesity tend to target a broad audience. The effectiveness of these interventions is insufficient among diverse cultural groups.
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. Therefore, interventions aimed at addressing childhood obesity should target diverse cultural groups. At present, the number of such culture-sensitive interventions is insufficient to address the needs of vulnerable groups’ needs.
Concluding remarks
In conclusion, 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. In different cultures, parents tend to develop specific behavioral patterns that affect their children’s weight and physical activity. It is also found that fathers and mothers have a different influence on their sons and daughters.
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.
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.
In summary, the involvement of families is often shaped by parents’ education, income, health status, and health-related habits. It is noted that parents have a different impact on their children. The involvement of families is beneficial for children’s physical activity and health.
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. It is noted that it is necessary to examine the long-term effects of educational programs.
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.
All in all, 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. In their review article, Brown et al. (2015) analyzed family and community factors that contribute to obesity prevention in children. 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.
On balance, various community-related factors were mentioned by researchers as impacting the prevention of childhood obesity. Influential community factors include socioeconomic status, ethnicity, school programs, access to food, and access to recreation activities. Further research can address such gaps as the barriers to the effective implementation of community-based interventions.
Major aspects related to family and community involvement
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.
PAQ-C and SRBW / SRBH
Research on childhood obesity is characterized by the use of diverse tools and measurements. However, such instruments as Physical Activity Questionnaire for Children (PAQ-C) and SRBW and SRBH are used rather frequently. These data collection tools’ validity is proved, and they can be applied in different settings.
The Physical Activity Questionnaire for Children is a tool that is commonly used in research associated with children’s physical activity measurements (Benítez‐Porres et al., 2016). The major purpose of the questionnaire is to examine the level of children’s physical activity during a day. The participants’ 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). Lee et al. (2015) measured the effectiveness of interventions to increase the physical activity level in children with the help of the PAQ-C and supported its validity, consistency, and accuracy.
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 accurate, and they were used for determining weight in representatives of different ethnic groups.
The ease of use and validity of PAQ-C and SRBW and SRBH have made these instruments commonly used in research on childhood obesity. Although the tools are based on self-reporting, this limitation has no statistically significant influence on studies’ results. Therefore, PAQ-C and SRBW and SRBH have been chosen as data collection instruments for the present project.
Summary
The review of the literature on childhood obesity revealed 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 document the validity 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. Additional research in this field will contribute to addressing the gaps that were identified in the existing literature regarding the relationship between interventions involving children’s BMI and physical activity.
The apparent gap that has to be addressed is the achievement of long-term effects of interventions aimed at decreasing obese children’s weight and improving their lifestyles. It may be beneficial to identify the factors that have a positive impact on the development of social ties between children with obesity and their peers, neighborhood members, or other people. The channels for the establishment of effective relationships that could shape obese children’s physical activity and health status should be explored and described in detail.
The analysis of qualitative data may also be instrumental in developing effective interventions that will shape people’s behaviors and attitudes to their and their close one’s health. Chapter 3 will discuss the methodology selected for this project based 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 low-income Hispanic children by teaching their parents healthy food choices and physical activity to decrease obesity in elementary-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 (CDC, 2019b).
Childhood obesity is diagnosed in 25.8% of Hispanic children and adolescents (CDC, 2019b). 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 and self-reported level of physical activity. This chapter restates the problem of research and clinical questions, describes the methodology and design in detail, and presents the population and sample. SRBW and SRBH protocols, BMI measurement, and PAQ-C 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 is associated with the development of cardiovascular, mental health, and reproductive health issues, and its morbidity, incidence, and persistence are hard to control (Pandita et al., 2016). 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 associated with environmental and genetic factors. 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).
Parental responsibilities related to their children’s health are thoroughly evaluated in primary care settings, family planning facilities, and other organizations (Wolfson et al., 2015). Parents value their influence on children because of the necessity to guide, support, and become good examples from legal and humane points of view (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 et al., 2018).
The PTP was implemented with younger children, so it is unknown whether this program implemented during six weeks would contribute to the reduction of children’s BMIs and their physical activity. Weight regulation is usually influenced by various genetic, environment, and development factors, so these mechanisms vary between populations (Pandita et al., 2016). In Hispanic 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). Obesity can be rooted in a child’s behavior, family traditions and customs, and social activities.
The project aimed at examining whether the PTP would result in children’s decrease of BMI and increase in their physical activity. The project’s developer provided the parents involved in the project with the data concerning healthy food choices to replace unhealthy snacks, sodas, and high sugar juices.
In the parents’ training sessions, the emphasis was on both eating habits and exercise. Information about healthy eating provided parents with both a theoretical basis (nutritional value, micro-, and macro-elements) and practical tools. Tips on introducing exercise were age-appropriate and fit different lifestyles. In order to make the training sessions motivating, their contents did not include dry facts only but also offered guidance and emotional support.
Clinical Question
The clinical question that guided this quality improvement project was: For parents of elementary school-aged Hispanic children from low-income families, will Parent Training Program for Elementary-School-Aged Children, compared to no session be effective in decreasing the BMI in six weeks? The independent variables associated with this question and assessed in this project was the PTP, while dependent variables were children’s BMI and their physical activity levels.
Data related to dependent variables was 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 developer of this project calculated BMI based on the data provided by the parents. The PAQ-C is effective to evaluate children’s physical activity during a set period of time (Lee et al., 2015).
These tools were instrumental in addressing 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 pre-test/post-test design was 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 experiment (Peters et al., 2016).
Project Methodology
Quantitative methodology was 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 (Trochim, Donnelly, & Arora, 2015). 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 et al., 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 was more appropriate than the qualitative one.
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. 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 (Bryman, 2016). A positive effect of parents’ participation in the intervention related to their children’s weight status and exercising was identified.
The PTP involved several training sessions, during which parents were instructed regarding several topics. Parents were informed about healthy dietary and physical activity patterns for elementary-school-aged children, and various risk factors associated with the development of obesity. The participants were also trained to communicate with their children effectively and encourage them to change their behaviors. The parents reported their achievements and the challenges they met during the training sessions. They also discussed methods to overcome the obstacles they faced. These discussions were an important part of the PTP and could influence the effectiveness of the program as parents received more information that could help them change their children’s behavior and diets.
Project Design
A quasi-experimental pre-test/post-test design was selected for this project because it allowed for determining the effect of an independent variable on dependent ones. 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 and control (Bryman, 2016). In this project, a quasi-experimental pre-test/post-test design allowed for organizing the pre- and post-test assessment of children’s weight status based on the intervention. Therefore, a quasi-experimental design is effective for the collection of data on the relationship between the set variables referring to the conducted intervention.
The independent variable in this project was the PTP. The dependent variables established for the purpose of this research were the children’s physical activity level and their BMIs. The variables are consistent with the clinical question that implies the identification of the relationship between the PTP and parents’ activities aimed at shaping their children’s behavior and the children’s BMI and physical activity levels.
In order to measure dependent variables, quantitative data were collected with the help of SRBW and SRBH (to identify BMIs) and PAQ-C (to determine children’s physical activity level). The PAQ-C is an effective tool that have been utilized in several studies to identify children’s physical activity levels (Lee et al., 2015). The PAQ-C is appropriate for the present DPI project as the PTP incorporates parents’ training regarding children’s engagement in sports activities, sport games, and similar behaviors that are mentioned in PAQ-C.
Population and Sample Selection
Parents of elementary-school-aged children with obesity were 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 included parents of children aged between 5 and 11 years old with obesity who lived in Charlotte, NC. The inclusion criteria were families’ income, ethnicity, children’s age, place of residence, and health status.
A low-income family in this project had an income of US $20,000 or less for four people (Slusser et al., 2012). Low-income elementary school-aged Hispanic children with obesity and their parents who lived in Charlotte, North Carolina, took part in the project. The parents noted their household income in a brief questionnaire. The exclusion criterion was the parents’ low English proficiency. People fluent in English participated in the project. The sample for this project was based on the described project population, and it included 40 parents of both male and female children with obesity where only one parent represented one Hispanic family. Thus, the parents of 18 boys and 22 girls were invited to participate in the project.
The major goal of the overall project was to reduction the BMI of elementary-school-aged children by raising their parents’ awareness about the disorder and major prevention strategies and encouraging parents to maintain healthy behaviors. Parents used effective communication strategies to encourage their children to be more physically active and have healthier diets. Parents also engaged their children into sports games and activities by playing with them, inviting their children’s peers, and visiting sports events. Schools have certain programs aimed at helping students cope with their health issues including obesity (Clarke et al., 2015).
Nevertheless, the effectiveness of these efforts 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 present intervention aimed at addressing this gap and equipping parents with the necessary tools to ensure their children’s healthy lifestyle.
Parents attend training sessions where they learned to set and maintain healthy behaviors of their children and were encouraged to pay sufficient attention to this matter. The selected sample size included 40 participants. 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 were determined as an appropriate sample size.
Referring to the purposive sampling technique appropriate for non-randomized projects, participants were contacted in a primary care clinic in Charlotte, NC. Purposive sampling was selected for this project as an effective technique because it was necessary to invite only those parents who were of Hispanic origin (as well as their children), had children with obesity, could be reached in a local clinic of Charlotte, and they agreed to participate in the intervention. 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 were provided with invitation letters describing the details of this quality improvement project. All parents participating in the project signed informed consent forms describing its specifics, the confidentiality issue, and the right to withdraw from the project at any moment. The participants signed consent forms, and then they were asked to fill in questionnaires and protocols before and after the intervention.
Instrumentation or Sources of Data
Data was collected with the help of SRBW and SRBH measurements (see Appendices G and H), the calculated BMI, and the PAQ‐C (see Appendix F). Self-reporting was chosen as the primary data collection approach since it ensured the availability of a substantial bulk of data (Creswell, 2014). Age-appropriate SRBW and SRBH measurements and the PAQ‐C were employed to ensure the validity of the findings.
SRBW and SRBH protocols
The participants provided their children’s weight and height using SRBW and SRBH protocols before and after the intervention. 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
The measurement 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. The developer of this project employed 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 F). 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 referred to the period of six weeks. Parents completed the questionnaires based on their observations.
Validity
Validity can be defined as the extent to which the research design and instrumentation can be applied to explore the selected phenomenon or issue (Bryman, 2016). 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 (Olfert et al., 2018). Nevertheless, this measurement is regarded as one of the most common tools to identify people’s weight status, so BMI was utilized in the present DPI project. The validity of SRBW and SRBH protocols is supported by the evidence provided by Olfert et al. (2018) who found out that the validity of SRBW and SRBH in comparison to measured anthropometrics is high, and up to 93% of children’s self-reported measurements were 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, and 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.
In addition, the activities mentioned in the questionnaire are incorporated into the PTP, which ensures that parents will be able to measure children’s physical activity with a considerable degree of precision. Therefore, SRBW, SRBH, and the PAQ‐C are consistent with the clinical question and the goals of the present project, so these instruments were selected for this project.
Reliability
Reliability is the degree of findings’ consistency meaning that reliable results can be repeatable if certain methodology is utilized (Bryman, 2016). To add to the reliability of SRBW and SRBH, BMI is calculated (Olfert et al., 2018). BMI is a commonly used instrument to identify people’s weight and the corresponding changes. It can be calculated easily if objective data (height and weight) are provided. The reliability of this tool is high and was also proved during this DPI project. One of the primary concerns regarding the reliability of BMI calculation was associated with data collection method as self-reporting is often employed. Nevertheless, the level of bias is comparatively insignificant as the data are collected several times, and the focus is on changes rather than exact BMIs.
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. PAQ-C has been widely used in current research, so the reliability of this measurement has been properly established by many researchers. The fact that the tool was effectively used in the present project also adds to the reliability of PAQ-C. Moreover, the tool can be replicated in diverse settings, which enhances its reliability and makes it an effective measurement that is frequently utilized by researchers.
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 provided their contact information to the project developer and signed electronic versions of informed consent forms to join the project. All the parents were informed about the protection of confidentiality and anonymity.
They were also asked about the preferable communication channel. Being contacted by e-email (which was the preferred communication channel as noted by the participants), the parents were 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 were sent to the project developer by e-mail, and they were protected by passwords (Bryman, 2016). The participants attended training sessions for six weeks at the selected clinic in Charlotte, NC, to learn how to improve children’s physical activity and lifestyle to address obesity. During this period, they also reported having implemented the recommendations regarding physical activity and a healthy lifestyle in their families with a focus on involving children.
Each week, parents had two sessions that lasted 90 minutes each. The investigator provided the educational services based on the Parent Training Program developed by Slusser et al. (2012). As mentioned above, the training sessions were divided into modules with some time devoted to revision and assessment. It is noteworthy that the PTP was developed for Hispanic parents, although it was provided in English. Some modifications were needed as Slusser et al. (2012) concentrated on parents of young children, so some recommendations were not used.
One of the outcomes of this PTP was the use of guidelines (developed by Slusser et al. (2012)) for healthcare professionals who would be running the educational sessions. Although the recommendations were 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 completed the six-week intervention, they were contacted by the project developer to conduct the post-test data collection. The participants sent updated SRBW and SRBH data and the newly completed PAQ‐C as electronic documents by e-mail to the project developer. The data sent by e-mail was protected using passwords, and the files not including personal data will be destroyed in three years. The SRBW, SRBH, and BMI data and information collected with the help of the PAQ‐C were used for measuring dependent variables.
Data Analysis Procedures
The clinical question guiding this DPI project was: For parents of elementary school-aged Hispanic children from low-income families, will Parent Training Program for Elementary-School-Aged Children, compared to no session be effective in controlling and decreasing the BMI in six weeks? The dependent variable was children’s BMIs and physical activity levels. The independent variable was the PTP.
To determine the effect of applying the intervention on changes in children’s BMI and their physical activity, a linear regression analysis was conducted (Braden et al., 2015). Linear regression analysis was selected for the project because it allowed for determining the linear relationship between the PTP and children’s BMI and physical activity rates. A series of linear regression analysis was 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 (Braden et al., 2015). The data analysis was conducted using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows Version 23.0 (Braden et al., 2015; Kim et al., 2016). The t-test indicated a statistical finding at p<0.05. Raw numerical data provided by the participants was organized in tables entered into SPSS.
Ethical Considerations
The major ethical issue associated with this quality improvement project was 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 were selected as participants for this quality improvement project and responsible persons for providing data. In order to minimize the possible emotional distress from children being identified as obese, the participants were instructed to discuss their participation in the program with the children stating that they volunteered to take part in the study regarding the establishment of healthy lifestyles.
The participants’ anonymity, confidentiality, and privacy were guaranteed as the data provided by parents was labeled without identifying participants’ names with the help of numerical codes (Trochim et al., 2015). The data was stored on the computer of the project developer and protected with the help of passwords.
Respect, justice, and beneficence in relation to participants were addressed during data collection, and the project did not start until the approval by the Institutional Review Board, as well as signed consent forms from parents, were received (see Appendix I). The principles of the Belmont Report were not violated because the participants were treated with respect, there will not be risks associated with their participation in the project, and all project steps were administered fairly. Beneficence and justice were also ensured as all participants were treated equally and were not discriminated against in any way. The focus of the intervention was on the positive health outcomes for children, and these positive shifts took place. The collected data will be destroyed in three years after the project completion.
Limitations
One of the limitations of the project is 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 pre-test/post-test design was selected for this project to address the clinical question. Forty parents were involved in the quality improvement project to participate in the intervention on physical obesity. Data collection occurred 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 were supported by the literature. Data was 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.
Data Analysis and Results
Childhood obesity affects 25.8% of Hispanic children and adolescents, despite availability of various projects and policies to reduce the rate of affected people (CDC, 2019b). It has been found that children gain dietary habits observing their parents’ behaviors, so parents play a major role in shaping their children’s eating behaviors (Davidson & Vidgen, 2017). Liu et al. (2018) noted that factors including parental involvement in their children’s lives and their awareness of obesity and prevention strategies are instrumental in decreasing this disorder’s prevalence.
However, it has also been acknowledged that cultural traditions of diverse groups have a considerable impact on health and wellness practices (Mech et al., 2016). This direct practice involvement (DPI) project was concerned with the evaluation of the effectiveness of the educational intervention, a modified Parent Training Program developed by Slusser et al. (2012), aimed at decreasing childhood obesity in low-income Hispanic children aged between 5 and 11 years old.
The project involved the implementation of the PTP for parents of Hispanic elementary-school children diagnosed with obesity. The parents were provided with the information regarding the hazards related to obesity, healthy diets and lifestyles, methods to change their children’s behavior to the desired model, strategies of effective communication, as well as the ways to adjust healthy lifestyles with some cultural peculiarities of the target population. The quantitative methodology was employed to address the goals of the project, which was to identify the exact effects of the educational intervention on children’s BMI and physical activity.
The educational sessions were modified from the protocol from the PTP developed by Slusser et al. (2012). The duration was six weeks, which was a modification from the period of four months recommended by Slusser et al. (2012). The protocol was also adapted for an older age child. The educational sessions included brief lectures, discussions, workshops, role-play activities, and reflections.
Apart from informing parents about the negative effects of obesity and comorbid health issues, the parents were trained to communicate with their children, motivate them, and shape their behaviors. Parents learned about healthy diets and lifestyle, as well as strategies to adjust some Hispanic traditions with healthy diets. The participating parents were encouraged to discuss their concerns regarding their children’s health and lifestyle, the challenges they face when establishing healthy ways of life, as well as success stories and helpful tips they were able to develop.
The participants applied the information they received during training sessions in their home settings. They used the communication strategies discussed during training, used dietary frameworks provided by the developer of this project, and employed numerous recommendations regarding shaping children’s diet and lifestyles. The participants reflected on these experiences and shared their views on various aspects of the intervention. During discussions, the parents claimed that they utilized many strategies while some remained unused. However, the participants also noted that they would continue using the recommendations, as well as strategies they employed and those they were yet to use.
In order to identify the impact of the intervention on children’s health status, children’s BMI was measured, and their parents completed physical activity questionnaires and self-reported body weight (SRBW) questionnaires. Quantitative data was collected before the start of the educational sessions and after the termination of the intervention. A quasi-experimental pre-test/post-test design was chosen as the research methods as it is instrumental in quantifying the impact of a specific intervention. The data were analyzed with the help of SPSS software. The clinical question guiding this DPI project was:
For parents of elementary school-aged Hispanic children from low-income families, will Parent Training Program for Elementary-School-Aged Children, compared to no intervention be effective in controlling and decreasing the BMI in six weeks?
Chapter 4 presents the results of the project and includes the following sections: descriptive data, data analysis procedures, results, and summary. The chapter starts with a brief introduction, followed by the provision of descriptive data and the description of data analysis procedures. The following section is devoted to the results that are presented in the textual and visual forms. The chapter ends with a summary of the major points discussed in this part of the paper. Finally, a brief introduction to Chapter 5 is provided as well.
Descriptive Data
The purpose of this project was to explore the effect of the modified Parent Training Program that was provided to parents of Hispanic children aged between 5 and 11 years old residing in Charlotte, North Carolina. The setting for this project was a healthcare facility in Charlotte, North Carolina. The participants attended nine sessions that were held in a clinic in Charlotte, North Carolina, over six weeks.
The participants were provided with the information concerning the adverse health outcomes related to obesity, healthy diets, healthy lifestyles, strategies to maintain healthy lifestyles and adjust them with cultural traditions of the target group. Parents were also trained to communicate and interact with their children effectively, to shape their children’s behaviors, encourage and motivate them. The activities practiced during the training sessions are described in Appendix G.
Overall, 40 people participated in the project; these were parents of 18 male and 22 female elementary-school Hispanic children. Power analysis was implemented to identify the appropriate sample size for this DPI project.
The type I error was 5% and power value was 0.8. The minimal sample size to be included was 32 participants, so 40 people were recruited to take part in the project. Hispanic children aged between five and eleven years old who were diagnosed with obesity were included in the project. One parent from each family took part in the project. Hispanic families who resided in Charlotte, NC, took part in the study. The children who took part in the project were Hispanic Americans aged between 5 and 10 years old (median age was 7.5 years old) (Figure 1a).
As far as the gender of children is concerned, boys constituted 55% of the participants (see Figure 1b). The median BMI indicator was 21.9, and children’s BMIs ranged from 18.6 to 24. The median BMI indicator among male participants was 22.1, and the same indicator for girls was 21.7.
Data Analysis Procedures
The purpose of this DPI project was to decrease the level of childhood obesity among Hispanic elementary-school children by training their parents to establish proper dietary behaviors and lifestyles in their families. The clinical question that was instrumental in achieving the goal of the project is:
For parents of elementary school-aged Hispanic children from low-income families, will the Parent Training Program, compared to no intervention be effective in controlling and decreasing the BMI in six weeks?
Inferential analysis was employed in order to identify the relationship between the dependent and independent variables. Linear regression was used to achieve this objective (Braden et al., 2015). The dependent variables were children’s BMI and their physical activity; the independent variable was the PTP. The correlation between the established variables was expected to demonstrate the degree of effectiveness of the training progress and its relevance in addressing childhood obesity. The t-test indicated a statistical finding at p<0.05.
The data was collected using the SRBW and SRBH, and PAQ-C. The SRBW and SRBH questionnaires were utilized to calculate the children’s BMI percentiles. The parents sent the completed questionnaires before and after the implementation of the intervention, the BMI percentiles were calculated with the help of the software (Microsoft Excel). The developer of this project calculated BMIs by inserting the data received from parents’ SRBW and SRBH protocols in Microsoft Excel file, and the corresponding formulas were employed to calculate BMIs.
In order to ensure the reliability of the results, six sets of data were chosen randomly, and BMIs were calculated manually. Parents completed PAQ-C questionnaires before the beginning and after the termination of the intervention. The PAQ scores were calculated manually, and the results were transferred to Microsoft Excel that was used to calculate mean and mode scores. The BMI percentiles and PAQ-C scores were also measured with the help of SPSS software, which contributed to the reliability of the data.
The exact correlation between the changes in children’s PAQ-C scores, their BMI percentiles, and their parents’ participation in the educational intervention was measured with the help of a linear regression analysis. This statistical test has been commonly employed to identify the relationship between variables (Braden et al., 2015). This statistical analysis was effective in measuring the correlation between parents’ participation in the intervention and their children’s BMI percentiles. The exact correlation between children’s physical activity and their BMI was identified with the help of the simple linear regression test.
BMI tends to be misleading in some cases due to the lack of focus on bone density or muscle mass. SRBW and SRBH are protocols characterized by a high degree of validity (93% of accurateness) and are commonly utilized for the identification of people’s BMI (Olfert et al., 2018). The PAQ-C is also a valid tool, which is evident from its Cronbach’s α coefficient (α = 0.76) (Benítez‐Porres et al., 2016). The reliability of the PAQ-C was identified with the help of intraclass correlation coefficients (0.96) (Benítez‐Porres et al., 2016). Therefore, the employed data analysis instruments have sufficient reliability and validity.
Results
The project aimed at exploring the impact the educational intervention provided to parents of Hispanic elementary-school children on these children’s BMI. The clinical question was as follows: For parents of elementary school-aged Hispanic children from low-income families, will Parent Training Program for Elementary-School-Aged Children, compared to no intervention be effective in controlling and decreasing the BMI in six weeks?
The analysis identified a positive correlation between parental involvement and their children’s BMI. The t-test indicated a statistical finding at p<0.05. Parental training led to an increase in their awareness regarding the disorder and its prevention and certain decrease in children’s BMI as the majority of the SRBW and SRBH (over 72%) revealed the decrease in children’s BMI. The mean decline was 0.4 percentile for boys and 0.6 for girls (see Figure 2). The change in children’s BMI percentile ranged between 0.3 and 1.7 percentile for boys and 0.3 and 1.2 percentile for girls (see Figure 3). The mode BMI percentile for boys was 0.4, and the mode percentile for girls was 0.9.
The physical activity scores of the vast majority of the participants improved (see Figure 2). The percentage of the time spent on some kind of physical activity increased six weeks after the start of the intervention. Only 12.5% of the parents reported no change in their children’s physical activity. The mean PAQ-C scores were 2.9 for boys and 2.8 for girls. The mean change of the scores was equal for boys and girls (0.4). The mode score for boys was 2.9 and the mode score for girls 2.8. The t-test indicated a statistical finding at p<0.05.
The relationship between children’s physical activity and their BMI percentiles was minimal (see Figure 4). The parents’ participation in the project led to children’s increased physical activity and decreased BMI. The r2 value of the relationship between boys’ physical activity and their BMI percentile was 0.0686 while the r2 value for the correlation between girls’ physical activity and BMI was 0.0379 (see Figure 4).
Summary
The purpose of the project was to evaluate the impact of the training program provided to parents on their children’s BMI and physical activity. The inferential analysis was the most appropriate statistical tool in this case, as it is instrumental in identifying the correlation between variables. The data analysis procedures included the use of the Statistical Package for the Social Sciences (SPSS).
The dependent variables were children’s BMI and physical activity, while the independent variable was the PTP. The data collected with the help of SRBW and SRBH, as well as PAQ-C, were analyzed using statistical software, SPSS and Microsoft Excel, which contributed to the reliability of the findings. The analysis of the data demonstrated a positive relationship between parents’ participation in the project and their children’s BMI and physical activity.
The changes were apparent as 72% of SRBW and SRBH indicated that children’s BMI decreased. The mean reduction of the BMI was 0.4 percentile for boys and 0.6 for girls. The mean PAQ scores after the implementation of the intervention were 2.9 for boys and 2.8 for girls. The mean increase in the PAQ scores was equal for all children (0.4). The correlation between boys’ BMI and physical activity was 6.86%, and the relationship between girls’ physical activity and BMI was 3.79%.
These findings, as well as their implications for the clinical practice, will be discussed in Chapter 5. This segment of the paper will include a discussion of the relationships identified between the variables, and the links between the demographic data and dependent variables. The implications for the use of the training program will be considered as well. The chapter will conclude with a narrative regarding the project’s implications for the clinical setting and the way it can facilitate the development of the healthcare system and public health.
Summary, Conclusions, and Recommendations
This DPI project is concerned with the exploration of the impact of an educational intervention aimed at decreasing BMI by reducing caloric intake and enhancing physical activity among Hispanic elementary-school children with obesity. The prevalence of this disorder and its comorbidity among US children is still alarming as approximately 20% of American children and adolescents are obese (Hales et al., 2017). Hispanic children are vulnerable due to certain socioeconomic and cultural factors (Ogden et al., 2014).
It has been estimated that 25.8% of this population are diagnosed with obesity (CDC, 2019b). Parents have a considerable effect on their children’s dietary intake and physical activity as families are influential in the development of eating habits and lifestyles (Liu et al., 2018). Therefore, it is critical to make sure that parents have the necessary skills and knowledge to contribute to the creation of proper dietary and physical activity patterns. Although some studies have addressed the issue and examined the effectiveness of educational interventions, the outcomes of an educational program for Hispanic elementary-school children are still unknown.
The Parent Training (PT) Program developed by Slusser et al. (2012) was modified for this project to meet the needs of the Hispanic elementary-school children residing in Charlotte, NC. Although the PT Program has proved to reduce children’s BMI, it involved younger children with obesity and was characterized by a one-year duration. This DPI project aimed at exploring the effects of a six-week educational project on children’s BMI through shaping their physical activity and dietary intake. Quantitative data were necessary for the project to be replicated to create an intervention that could be employed state- or even nationwide. The abbreviated protocol has the potential for greater efficiency compared to the extended time frame.
Summary of the Project
The purpose of this DPI project was to examine the effects of an educational intervention provided to parents of elementary-school Hispanic children to reduce BMI through shaping their dietary behaviors and physical activity. The clinical question for this project was: For parents of elementary school-aged Hispanic children from low-income families, will Parent Training Program for Elementary-School-Aged Children, compared to no session be effective in controlling and decreasing the BMI in six weeks? In order to address this clinical question, a quantitative quasi-experimental pre-test/post-test design project was implemented.
This project involved the analysis of dependent variables including children’s BMI and their physical activity. The target populations’ BMI was calculated by the developer of this project. The measurement of children’s physical activity was conducted with the help of Physical Activity Questionnaires (PAQ) designed for children. The independent variable was the PTP.
The educational intervention included nine sessions held once or twice a week for six weeks. The sessions involved such activities as lectures, workshops, role-play tasks, discussions, and reflection. Parents were provided with the data concerning the negative health outcomes associated with obesity, strategies to establish healthy lifestyles, and follow a healthy diet. In addition, parents were trained to communicate with their children effectively and shape their behaviors.
The overall number of participants was 40 parents of Hispanic elementary-school children. The participants had two or three sessions of the PT Program each week during six weeks. Each educational session was devoted to a specific topic associated with obesity, its treatment, healthy eating and lifestyle, as well as shaping behaviors. Before the start of the intervention, the parents completed PAQs and BMI reports. Self-reporting was chosen as a data collection method because it has been shown to be a practical and valid method in previous studies (Olfert et al., 2018). The analysis of the collected data was conducted with the help of SPSS, which enhanced the validity of the findings. Linear regression analysis was utilized to address the clinical question to measuring the correlation between variables.
This chapter includes the discussion of the results of the project and the implications for practice and project. The findings are analyzed and put into the context of the existing interventions aimed at reducing children’s BMI. Conclusions concerning the impact of the intervention on children’s dietary intake and physical activity are drawn. Theoretical and practical implications of this DPI project are discussed. Several recommendations regarding the implementation of the project are also provided in this chapter.
Summary of Findings and Conclusion
This DPI project was instrumental in identifying the outcomes of an adaptation of the PT Program provided to parents of Hispanic elementary-school children (Slusser et al., 2012). The clinical question guiding this project was: For parents of elementary school-aged Hispanic children from low-income families, will Parent Training Program for Elementary-School-Aged Children, compared to no session be effective in controlling and decreasing the BMI in six weeks? Although Kim et al. (2016) found that educational interventions shorter than five weeks can hardly be effective, moderate improvements regarding children’s BMI and physical activity were demonstrated.
The reduction of children’s BMI and an increase in their physical activity were observed. The vast majority of parents (72%) reported a decrease of their children’s BMI, which shows that parents have acknowledged the results of the intervention. The fact that parents traced the changes in their children’s body mass is likely to have a positive effect on their compliance with the norms trained during the educational sessions.
The decline of BMI percentile in children did not reach 0.4 BMI percentile for boys and 0.6 percentile for girls. The children’s physical activity scores improved and reached the recommended baseline of 2.9 PAQ scores for boys and 2.8 for girls. The recommended physical activity scores are a minimum of 2.9 for boys and 2.7 for girls (Voss, Ogunleye, & Sandercock, 2013). These changes suggest that the educational intervention may have a positive effect on elementary-school Hispanic children’s BMI and physical activity.
These findings are consistent with the results of several studies aimed at evaluating the effectiveness of similar interventions (Knol et al., 2016; Clarke et al., 2015). This project also provided evidence to support the assumption that parental involvement is one of the most influential factors affecting the outcomes of the interventions targeting obese children. The engagement of parents in their children’s development of dietary and physical activity patterns translates into the formation of healthy lifestyles in children.
Implications
The intervention demonstrated nonsignificant positive changes in the target population. Further studies are needed to conclude the efficacy of this modification to the PFP protocol in other settings. The project has several theoretical and practical implications. This educational intervention is designed for the clinical setting, so its implications are mainly related to this area. The major stakeholders include children, parents, medical staff, and healthcare facilities’ administrations.
Theoretical implications. This DPI project has theoretical implications for application of the social cognitive theory. The program aimed to shape behaviors as parents gained knowledge and skills, which led to the shift in their children’s physical activity and dietary patterns. The social cognitive theory (SCT) has been widely used in studies aimed at changing people’s behavior, as well as attitudes towards certain phenomena, lifestyles, and activities (Knol et al., 2016; Bagherniya et al., 2017; Lee et al., 2017). It has been acknowledged that the focus on behaviors and attitudes is beneficial when addressing obesity (Lee et al., 2017).
It is important to pay specific attention to motivating participants to remain active throughout the entire project, which was also mentioned by Bagherniya et al. (2017). During the implementation of this project, the trainer managed to maintain the participants’ motivation at an appropriate level. Parents were willing to be active as they understood the benefits of the training sessions and their impact on their children’s health. The activities chosen to train the participants were motivational, and the parents’ interest appeared to be intact throughout the six weeks. The weakness in the design chosen for this DPI project was its reliance on purposive sampling that can undermine the generalizability of the findings.
Practical implications. The practical implications of this DPI project are manifold and can have a positive effect on nursing practice. One of the primary benefits of this intervention is its efficiency and applicability for various healthcare facilities. Nursing staff can also be trained to implement the project due to the availability of resources (Slusser et al., 2012; Lee et al., 2015). In addition, healthcare facilities will be able to improve the quality of the services they provide through the delivery of educational intervention that results in positive outcomes of public health.
This project can also be utilized in the educational setting as schools may offer the program evaluated in this project for their overweight students or those diagnosed with obesity. As mentioned above, school-based interventions targeting students’ lifestyle and dietary intake have shown to be more effective than those based in clinical, home, or other settings (Weihrauch-Blüher et al., 2018). Students and their parents are accustomed to their school environment and often find school-based programs more convenient, which has a positive effect on their motivation, engagement, and compliance (Weihrauch-Blüher et al., 2018).
Therefore, educational facilities could benefit from the implementation of the PT program that can be modified to address the specific needs of the population. School nurses will play the central role in the application process, so they will need the corresponding training.
Future implications. Further steps in the area may involve the focus on generalizability and people’s attitudes. First, it is necessary to implement a project that will involve a considerable sample. The intervention can also be conducted in different settings and adapted to diverse populations to accommodate cultural traditions. Longitudinal studies conducted over time are also needed to determine long term effects of the intervention. Children’s BMI was measured six weeks after the start of the educational sessions, which can be insufficient since the changes related to weight do not appear immediately. Optimally, BMIs and PAQ scores should be measured three and six months after the termination of the project (Weihrauch-Blüher et al., 2018).
Recommendations
It is possible to provide several recommendations regarding the implementation of this project. Some of the major areas to focus on include the sample size, long-term effects, and stakeholders’ perspectives. Nurses and the administration of healthcare facilities should implement the offered PT program described that is efficient and easy-to-conduct. These steps can improve the analyzed intervention and address children’s obesity, which can have a lasting effect and persist in these children’s adulthood.
Recommendations for future projects. Future projects aimed at reducing obesity in children can employ quasi-experimental designs but concentrate on enhancing the generalizability of the findings. Researchers should make sure that the interventions they develop can be utilized in various settings and address the needs of diverse populations. It is necessary to explore the effects of the intervention by including a larger sample. It can be sufficient to include a considerable number of parents to obtain valid data unveiling the short-term effects of a program for a specific geographic location (Braden et al., 2015).
Furthermore, it is essential to conduct a longitudinal study to examine the long-term effects of the educational intervention. Weihrauch-Blüher et al. (2018) note that projects targeting children’s dietary habits and physical activity tend to have short-term effects. Therefore, it is important to make sure that this intervention shapes parents’ and children’s behaviors affecting children’s health patterns. If children whose parents have participated in the project fail to maintain healthy lifestyles in their adolescence and adulthood, the project can be regarded as only partially effective.
The identification of stakeholders’ attitudes towards some aspects of the intervention will help in designing an effective educational intervention. Clarke et al. (2015) stress that parental involvement and their motivation play a substantial role in the success of the project. Therefore, it is critical to explore the reasons behind parents’ willingness to participate, commitment to the goals of the project, and their expectations regarding the outcomes of the intervention.
It is also important to pay attention to the medical staff’s perspectives, so a qualitative study involving the involved nursing professionals will be instrumental in identifying the program’s weaknesses. De Craemer et al. (2013) emphasize that the staff’s views can help in identifying ways to improve the training process to make parents more engaged. Nursing practitioners can also report any barriers to the successful implementation of the project.
Further analysis of children’s health conditions and their physical activity could provide more insights into the efficacy of the suggested intervention. One of the suggestions for future research is to estimate the participants’ BMIs and physical activity scores three months after the termination of the educational sessions and six months after the end of the project. The participants will receive emails with a request to complete SRBW, SRBH, and PAQ-C three and six months after the termination of this project. The reassessment of children’s BMIs and physical activity will unveil the long-term effects of the project if any. It will be evident whether parents managed to establish a healthy agenda for their children.
Furthermore, it can be beneficial to identify stakeholder’s views on the program, its weaknesses and outcomes. Parent’s opinions regarding their expectations, the project’s results, challenges they faced during the project, its strengths and weaknesses will provide insights into the factors behind parents’ willingness or reluctance to be active. The analysis of the participants’ perspectives can be instrumental in adjusting the educational intervention to the needs and peculiarities of the target population, making the project more effective and viable.
Recommendations for practice. Healthcare interdisciplinary teams can be the primary change agents who will implement this project. The program is efficient and involves a limited number of sessions, so parents are likely to remain motivated, which will positively affect their children’s health outcomes. Moreover, the sessions include activities that make trainees’ engaged and active. Nurses are often reluctant to implement and initiate any changes due to the lack of knowledge, experience, as well as the need to be involved in complex projects (Laws et al., 2015).
However, this project is comparatively easy to conduct, and it can be an illustration of the way nurses can implement change and improve children’s health. One of the recommendations to the nursing staff and medical centers administration is the need to provide proper training to the staff engaged in the project. In order to provide effective training, during the process of the nursing professionals training, these practitioners should try the activities that are a part of the intervention.
Educators can also benefit from reading and implementing this DPI project’s findings. Teachers can reach parents of Hispanic children diagnosed with obesity and encourage them to take part in the project in the school setting. Parents are often involved in children’s academic life and participate in various educational incentives, so they may be more likely to invest time in such school-based activity. Overall, the implementation of this intervention, its further improvement, and its transformation into a nation-wide policy will be beneficial for Hispanic children, and potentially other vulnerable groups. The project can become the foundation of a new intervention that can be implemented in different settings and reach wide audiences, which will be instrumental in addressing such serious public health issue as childhood obesity.
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Appendix A
Appendix B
Appendix C
Appendix D
PAQ-c Tool
Appendix E
Appendix F
Appendix G
Parent Training Program
Practice-Based Learning Activities
The following activities are meant to complement the Parent Training Program and offer new facilitators the opportunity to participate in activities to become familiar with the content and format of the Parent Training Program. You may choose to incorporate one or more of the following suggestions into your intervention.
Activity #1: Observe a Workshop
Share a calendar of your upcoming workshops with new facilitators so they can potentially observe a workshop in action! There is no better way to learn than to see it happening in real time. Encourage new facilitators to bring a copy of the Facilitator Manual to a workshop so they can follow along. Do not forget to include your contact information!
Activity #2: Demonstrate a Role Play
Description: Choose a participant to help demonstrate one of the parenting concepts. If there are no volunteers, consider having the trainers demonstrate a role play first. Remember, enthusiasm is infectious. So, enjoy yourself when you role play! Keep it light and fun for the whole audience.
Activity #3: Facilitate a Nutrition or Parenting Reflection Session
Description: The Reflection Sessions are the most important component of the workshop series! Choose a workshop in advance (not Workshop #1) to demonstrate how to conduct a Reflection Session. Print out the appropriate. Ask for volunteers to act as the parents. Facilitate a Reflection Session with these “parents” using prompts from the Facilitator Guide. Remember to prompt each “parent” for as much detail as possible.
Activity #4: Facilitate a Discussion
Description: Choose one of the six workshops. Using a copy of the ‘Discussion’ section from that workshop in the Toolkit, have someone act as the facilitator and other volunteers act as parents. The “facilitator” can ask questions based on the Toolkit and “parents” can answer and discuss. Be aware of the allotted time for the activity, and practice facilitating a discussion within the timeframe available.