- Email: [email protected]
Health Promotion Guidance for a Rural Community
ORIGINAL RESEARCH
Health Promotion Guidance for a Rural Community Dawn Frost, DNP, ARNP-BC, and Susan Porterfield, PhD, NP-C ABSTRACT Purpose: To determine if an educational pamphlet would be useful to parents of overweight/obese/at risk children living in a rural county in the southeastern United States. Data Sources: A sample of 44 rural parents whose children, ages 6-18, attended a private rural health center and have a body mass index (BMI) recorded in the patient chart. Conclusion: An educational pamphlet on diet and exercise is both helpful and acceptable. Implications for practice: An educational pamphlet that outlines healthy eating guidelines and exercise suggestions used as a first line intervention should accompany BMI screening results to aid in parental education. Keywords: childhood obesity, obesity education, parental guidance for obese children, rural obesity © 2012 American College of Nurse Practitioners
T
he prevalence of childhood obesity in the United States has dramatically increased over the past 30 years, reaching epidemic proportions. The prevalence of obesity among children 2-19 years old has tripled, and 31.7% of all children are overweight.1 With the escalating incidence of obesity, children are being diagnosed with adult chronic diseases, such as type 2 diabetes, hypertension, hyperlipidemia, and metabolic syndrome.2 The Department of Health and Human Services3 estimates that 70% of overweight/obese children will become obese adults. Furthermore, the prevalence of obesity is catastrophic in the rural communities. Studies have revealed that rural children have a higher incidence of obesity compared with urban children, 16.5% to 14.4%, respectively.4 The rural South shows the highest levels of overweight (34.5%) and obese (19.5%) children.4 Prevention and early treatment of childhood obesity is of utmost importance to parents and caregivers.5 The involvement of parents or guardians is vital in the promotion of healthy lifestyles for children and education is the key.5 Interventions based on health-promoting 712
The Journal for Nurse Practitioners - JNP
behaviors such as eating a healthy diet, exercising daily, and getting plenty of rest are all primary preventive measures that can combat obesity in children. Promoting nonmedical interventions not only benefits children but entire families, and communities can profit as well. Education of parents is the cornerstone to building the structure to combat childhood obesity. The public school system has taken the initiative to introduce healthier eating and promote exercise, making it an ideal place to implement screenings for obese or overweight children. In fact, several states have instituted annual body mass index (BMI) screenings for children in grades 1, 3, and 6 in an attempt to prevent childhood obesity.2,6 The local county health department routinely screens students in these grades. Although parents or guardians are notified of their child’s BMI results via standardized letter, follow-up procedures are sparse or nonexistent.6 Apparently, the end point of this county-wide initiative is notification alone. Family education and development of early treatment interventions are the key to alleviating childhood obesity.7 There are no formal educational programs in Volume 8, Issue 9, October 2012
place to educate parents/guardians of overweight or atrisk children in rural counties. The Institute of Medicine has taken a proactive approach to decreasing the prevalence of obesity in children by drafting a preventionfocused framework. Unfortunately, budgetary constraints have prevented most school-based health programs from developing, implementing, and following up with parents after screening results have been reported.8 The setting in which this project took place was a rural county in the southeastern United States that has a high incidence of obesity, hypertension, and type 2 diabetes. In 2007, 34.5% of the county had a diagnosis of hypertension and 8.8% had type 2 diabetes. In 2010, approximately 67% of the county was reported to be obese or overweight. In addition, in 2009, 18.4% of middle school children and 15.3% of high school children had a BMI greater than the 95th percentile in relation to other children of the same age children around the state.9 These data show that almost one-third of all students in the county are overweight or obese. School-based BMI screenings have been developed as 1 strategy to combat childhood obesity. Parental notification programs were devised to inform the parents of their children’s BMI status and provide insight into future potential health problems associated with obesity.8 Generally, parents/guardians view BMI notification letters as “warning signs” alerting them to emerging health problems. Unfortunately, others view the notification letters as stressors that needlessly worry students.8 Even if screening alone increases parental and child awareness of weight issues, programs must be developed to prevent obesity. Parents must be provided with the information and tools to become successful in weight loss and weight control.10 Regrettably, little is known about the development and implementation of school-based BMI screenings and parental notification programs.8 Parental involvement and support are critical to the success of any preventive program. Financial constraints within school systems have made a negative impact on many preventive programs, such as height and weight and scoliosis screenings.8 Even if school programs have financial resources, some school nurses lack the knowledge and competence to recommend weight loss programs to parents and children.7 BMI screenings are conducted annually within the 6 schools of the study county. BMI screening results are mailed www.npjournal.org
to parents/guardians of obese and overweight children, but the choice to follow-up with a health care provider falls to those notified. There is no definite follow-up program from the county health department. If parents choose to followup with a health care provider, any testing, education, or guidance is presumed to be offered by the provider. A study conducted by Li and Hooker11 determined that children’s physical and psychological health are significantly affected by weight. Their study examined the relationships among childhood obesity and family, school, and community factors. The results suggest that children who attend public schools are more likely to be overweight or obese. The results further suggest that schools and communities should become actively involved in developing obesity prevention programs.11 Many studies8,10,12 support the fact that obesity is on the rise. Prevention is critical, but programs must be devised to address families and community needs.1 In the study county, educational material tailored to family needs is lacking. A well-designed educational program will enable nurse practitioners (NPs) and school nurses to provide guidance to parents/guardians of at-risk children. Parent education is vital to effectively promote the health of children.5 Parental involvement is necessary in any type of program for children, making parental education a vital part in the effective promotion of the health of children and families. If parents are aware of evidencebased strategies and skills needed to support them, they can become adequate role models for their children.13 Family education regarding physical activity and healthy eating habits should be implemented at home. Parental education can be an ideal bridge in promoting interventions in the fight against childhood obesity.13 METHODS Design This quasi-experimental research design had a pre- and postintervention approach. Study participants were approached by the records custodian of the rural Family Health Center in a southeastern state. The custodian gathered information from the medical records of 50 randomly selected patients who fell into the age group of 6-18 years. Protection of Human Subjects Upon approval from the Florida State University institutional review board, potential subjects were selected and contacted by the records’ custodian by mail. There were The Journal for Nurse Practitioners - JNP
713
no identifiable data on the mailed packets to the participants, with the exception of a number that corresponded to the parent’s identity known only to the primary investigator (PI). Any information received from the participants was locked in a file cabinet inside a locked closet within the PI’s office. Subjects The subjects were the parents of children who attended 1 of the 6 public schools in the study county and have active medical records at the Family Health Center, also in the county. Fifty parents/guardians were asked to participate in the study regardless of their child’s recorded BMI. The only exclusions were parents/guardians who were younger than 18 or older than 65. Procedures The initial contact included a letter that introduced the PI and the study. Aside from the cover letter, the initial mailing (phase 1) included 2 copies of the informed consent, demographic sheet, health practice questionnaire #1, and the health educational pamphlet. The participants were asked to read the informed consent completely, sign 1 copy, and retain the other copy for their records. Then participants were asked to complete the demographic sheet and questionnaire. After completing the first questionnaire, the participants were encouraged to read the educational pamphlet. In addition, the participants were instructed to refrain from placing their names or the names of their children on any of the forms to protect their identity. Upon completion, participants were to mail the completed forms to the records custodian in the pre-addressed/stamped envelope provided. The participants were made aware that a follow-up packet would be mailed within 2-4 weeks. The second packet was mailed within 2 weeks after participants returned the first packet. The second packet (phase II) included a cover letter from the record’s custodian, health questionnaire #2, and health educational pamphlet. The participants were instructed to complete the questionnaire and return the completed form in the pre-addressed/stamped envelope to the record’s custodian. The participants were asked to refrain from placing any type of identifying information on the forms or envelopes. All questionnaires and the health education pamphlet were developed by the PI. The pamphlet consisted of a 714
The Journal for Nurse Practitioners - JNP
trifold, colorful brochure that included facts regarding childhood obesity, BMI calculation chart, exercise tips for the family, and information specific to eating a healthy diet. Various Web sites and phone numbers of local informational sites were also included. After all information was collected, a descriptive and comparative analysis was conducted. Results from demographic information, parental BMI, age category of parents/guardians, and information collected from the questionnaires are included in the following section. Data Analysis Of the 50 packets mailed, 44 parents responded to both mailings. Six parents did not respond, and no guardians were identified. Thirty-eight mothers (86%) and 6 fathers (14%) responded. Forty-one parents reported their race as white and 3 reported black. Thirty (68%) parents reside in the extreme rural areas of the county, while 14 (32%) reside in the less rural areas. Eighteen parents (41%) reported making less than $12,000 per year, and 26 (59%) said their income exceeded $12,000 per year. There were no significant correlations between annual income and marital status. During phase I of the study (pre-intervention), parents were asked to share their own height and weight and their perception of their body weight and BMI. Although 23 (N ⫽ 44) parents said they have a normal weight and BMI, after calculation by the NIH Standard BMI calculator,14 only 13 (n ⫽ 44) parents had a normal weight and BMI. In addition, the parents were asked to describe their children as having either a healthy or abnormal weight. Thirty parents reported that their children had a healthy weight. In reality, the chart review revealed that 100% of the participants’ children had an abnormal BMI, which was greater than the 95th percentile for children of the same age. Descriptive statistics related to parental habits regarding diet, exercise, family meals, child’s health, parent’s health, and willingness to receive educational information on diet and exercise were collected. During phase II (postintervention), parents were again asked to complete a short questionnaire about their perceptions of childhood obesity after reading the educational pamphlet. Questioning in the postintervention phase revealed that parental perception had changed after reading the educational intervention, as evidenced by answers regarding their child’s BMI. A majority of parents Volume 8, Issue 9, October 2012
Figure 1. Parental Perception of Child’s BMI/Weight
(57%) were aware that childhood obesity is a major problem, and as expected, parental perception of their child’s BMI changed. In Phase II, 33 parents answered that their child was actually overweight or had an abnormal BMI. Figure 1 describes parental perception of their child’s BMI or weight at the pre- and postintervention phases of this study. In addition, parents were asked about their willingness to change diet and to begin exercising more regularly. Forty-one parents (93%) agreed to change their diet, and 35 parents (80%) agreed to exercise with their child regularly. Finally, the results from the intervention introduction revealed overwhelmingly that all parents (n ⫽ 44) agreed that the educational pamphlet was very helpful and provided useful information. Also, 100% of parents agreed that the educational pamphlet would be helpful to any parent and could be used with a child of any age. Parental answers collected during the postintervention phase revealed that they unanimously agreed that the educational pamphlet should be distributed along with any BMI notification from the school nurse or at the time of any well-child check-up at a health care provider’s office. DISCUSSION The parents who responded were from the more rural areas of the study county, which shows a fair representation of this county. The respondents were primarily female, which had been anticipated in the planning stages. Unexpectedly, important issues regarding parental www.npjournal.org
awareness of childhood obesity were raised: 57% of respondents were aware that there is a great problem with childhood obesity, but the incorrect parental perception of their child’s BMI and weight may play a major factor in their willingness to change. Parental perception will remain a foremost variable in the success of future educational programs. The Robert Wood Johnson Foundation15 has devoted $500 million to combat childhood obesity. This group believes that the most important factor in their efforts to battle childhood obesity is parental awareness, which is supported by the results of this study. One of the most influential factors in building a foundation for childhood weight problems is the parental unit.16 If parents do not perceive their children as at risk or overweight, weight loss interventions will not be adopted. The distorted perceptions of parents may result from several factors, including fear of being labeled a bad parent or labeling their children at a young age.17 Another factor to consider is that respondents reported that they eat fresh vegetables (73%) and fresh fruits (89%) regularly, which suggest that they are capable of delivering healthy nutrition to their families. However, 90% responded that they buy foods according to price and would buy healthier foods if they could afford them. This finding could again be linked to perception, but this instance includes healthy foods versus unhealthy foods. Finally, the findings from the postintervention inquiry suggest that the respondents were made aware of healthy pediatric weight and BMI. Questions regarding the educational pamphlet revealed that 100% of participating parents thought that the information was helpful and useful. Ninety percent of respondents reported that they would use any information provided on diet and exercise. LIMITATIONS The small sample size made correlation analysis unrealistic. The parents who were recruited for this study were familiar with the PI as their health care provider, so there is a possibility of bias. Participants may not have been truthful in answering questions because weight and healthy weight control are very sensitive issues. Although the sample size is representative of the patient population at the rural Family Health Center, it may not represent larger populations. In addition, the educational pamphlet provided information on BMI calculation, which The Journal for Nurse Practitioners - JNP
715
may have been confusing to some. The focus of this study was to develop an educational visual aid to compensate for the lack of information provided to families regarding BMI screening and to test the feasibility of a pamphlet as a firstline intervention. Finally, BMI screening has been the center of much controversy. The usefulness, the reliability of collection methods, and overall concern that BMI may not accurately measure adiposity have brought much questioning and concern nationally.10 However, until a universal method to determine “fatness” is devised and accepted, standard BMI charts remain the best method of screening for obesity in children. One final limitation of this study is that there is no method of long-term follow-up. After an intervention is introduced, the most appropriate way to determine a successful program is through follow-up. This limitation should be addressed if this study is reproduced. IMPLICATIONS FOR PRACTICE The brevity of office visits makes it very difficult to provide enough information for lifestyle changes. The options for health education of patients are numerous, but the implementation of intervention lies with the willingness to change. NPs in any practice can provide knowledge and power in a simple pamphlet by opening lines of communication. The use of the “food plate” guide is an excellent place to begin nutrition education and should be introduced in both schools (by NPs) and family NP practices. Because childhood obesity is at epidemic levels,10 health care providers must become proactive in the fight. Healthy eating and exercise to prevent obesity should be addressed with each well-child examination, especially in populations at risk. Children will continue to be assessed within the public school system, but parental notification of BMI scores should not be the terminal action. An educational pamphlet that can be easily inserted into the notification letter is recommended. CONCLUSION The extraordinary escalation in the incidence of childhood obesity and the associated comorbid conditions warrant proactive efforts by every health care provider. Obesity-prevention programs and educational and training programs must be developed for parents and providers alike. If parents are provided with concrete, 716
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written information, perhaps accurate perception of BMI, physical exercise, and healthy food would be the outcome. NPs can become proactive by developing protocols for BMI screenings in the office and schools. In addition, the establishment of childhood obesity prevention programs must be developed on state and federal levels. Prevention is always a better alternative than treatment. References 1. Armstrong S, Wacker J, Best D, McPherson M. Fighting childhood obesity: resources to help the community pediatrician curb this epidemic. Contemp Ped. 2011:40-50. http://digital.healthcaregroup.advanstar.com/nxtbooks/ advanstar/cntped_201102/index.php#/48. Accessed August 10, 2012. 2. Fox R, Trautman D. The epidemic of childhood obesity: a case for primary prevention and action. Bariatric Nurs Surg Patient Care. 2009;4(3):169-172. 3. Department of Health and Human Services. Childhood obesity. http://aspe.hhs.gov/health/reports/child_obesity. Accessed September 14, 2011. 4. Liu J. Overweight and physical activity among rural children aged 10-17: a national and state portrait. 2007. South Carolina Rural Health Research Center. 2007. http://www.rhr.sph.sc.edu/report. Accessed September 15, 2011. 5. Huffman F, Kanikireddy S, Patel M. Parenthood—a contributing factor to childhood obesity. Int J Environ Res Public Health. 2010;7(7):2800-2810. 6. Greene S. Personal communication. Washington County School Health Nurse. June 24, 2011. 7. Nauta C, Byrne C, Wesley Y. School nurses and childhood obesity: an investigation of knowledge and practice among school nurses as they relate to childhood obesity. Issues Compr Pediatr Nurs. 2009;32:16-30. 8. Kubik M, Story M, Rieland G. Developing school-based BMI screening and parent notification programs: findings from focus groups with parents of elementary school students. Health Educ Behav. 2007;34:622-633. 9. Florida Charts. Washington County, Florida. http://www.floridacharts.org. Accessed August 28, 2011. 10. Soto C, White J. School health initiatives and childhood obesity: BMI screening and reporting. Policy Polit Nurs Pract. 2010;11(2):108-114. 11. Li J, Hooker N. Childhood obesity and schools: evidence from the national survey of children’s health. J School Health. 2010;8(2):96-103. 12. Seal N, Broom M. Evidence-based interventions for pediatric weight control. J Nurs Praci. 2011;(7)4:293-302. 13. Hesketh K, Campbell K. Interventions to prevent obesity in 0-5 year olds: an updated systematic review of the literature. Obesity. 2010;18(Suppl 1):S27-S35. 14. National institutes of Health, National Heart Lung and Blood Institute. Calculate your body mass index. http://www.nhlbisupoort.com/bmi. Accessed November 24, 2011. 15. Robert Wood Johnson Foundation. Childhood obesity. http://rwjf.org/ childhoodobesity/. Accessed September 13, 2011. 16. Doolen J, Alpert P, Miller S. Parental disconnect between perceived and actual weight status of children: a metasynthesis of the current research. J Am Acad Nurs Pract. 2009;21:160-166. 17. Jain A, Sherman S, Chamberlin L, Carter Y, Powers S, Whitaker R. Why don’t low income mothers worry about their preschoolers being overweight? Pediatrics. 2001;107:1138-1146.
Dawn Frost, DNP, ARNP-BC, owns and operates the Vernon Family Health Center in Vernon, FL, and can be reached at [email protected]. Susan Padham Porterfield, PhD, FNP-C, is an assistant professor in nursing at Florida State University in Tallahassee. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/$ see front matter © 2012 American College of Nurse Practitioners http://dx.doi.org/10.1016/j.nurpra.2012.04.011
Volume 8, Issue 9, October 2012
Health Promotion Guidance for a Rural Community Dawn Frost, DNP, ARNP-BC, and Susan Porterfield, PhD, NP-C ABSTRACT Purpose: To determine if an educational pamphlet would be useful to parents of overweight/obese/at risk children living in a rural county in the southeastern United States. Data Sources: A sample of 44 rural parents whose children, ages 6-18, attended a private rural health center and have a body mass index (BMI) recorded in the patient chart. Conclusion: An educational pamphlet on diet and exercise is both helpful and acceptable. Implications for practice: An educational pamphlet that outlines healthy eating guidelines and exercise suggestions used as a first line intervention should accompany BMI screening results to aid in parental education. Keywords: childhood obesity, obesity education, parental guidance for obese children, rural obesity © 2012 American College of Nurse Practitioners
T
he prevalence of childhood obesity in the United States has dramatically increased over the past 30 years, reaching epidemic proportions. The prevalence of obesity among children 2-19 years old has tripled, and 31.7% of all children are overweight.1 With the escalating incidence of obesity, children are being diagnosed with adult chronic diseases, such as type 2 diabetes, hypertension, hyperlipidemia, and metabolic syndrome.2 The Department of Health and Human Services3 estimates that 70% of overweight/obese children will become obese adults. Furthermore, the prevalence of obesity is catastrophic in the rural communities. Studies have revealed that rural children have a higher incidence of obesity compared with urban children, 16.5% to 14.4%, respectively.4 The rural South shows the highest levels of overweight (34.5%) and obese (19.5%) children.4 Prevention and early treatment of childhood obesity is of utmost importance to parents and caregivers.5 The involvement of parents or guardians is vital in the promotion of healthy lifestyles for children and education is the key.5 Interventions based on health-promoting 712
The Journal for Nurse Practitioners - JNP
behaviors such as eating a healthy diet, exercising daily, and getting plenty of rest are all primary preventive measures that can combat obesity in children. Promoting nonmedical interventions not only benefits children but entire families, and communities can profit as well. Education of parents is the cornerstone to building the structure to combat childhood obesity. The public school system has taken the initiative to introduce healthier eating and promote exercise, making it an ideal place to implement screenings for obese or overweight children. In fact, several states have instituted annual body mass index (BMI) screenings for children in grades 1, 3, and 6 in an attempt to prevent childhood obesity.2,6 The local county health department routinely screens students in these grades. Although parents or guardians are notified of their child’s BMI results via standardized letter, follow-up procedures are sparse or nonexistent.6 Apparently, the end point of this county-wide initiative is notification alone. Family education and development of early treatment interventions are the key to alleviating childhood obesity.7 There are no formal educational programs in Volume 8, Issue 9, October 2012
place to educate parents/guardians of overweight or atrisk children in rural counties. The Institute of Medicine has taken a proactive approach to decreasing the prevalence of obesity in children by drafting a preventionfocused framework. Unfortunately, budgetary constraints have prevented most school-based health programs from developing, implementing, and following up with parents after screening results have been reported.8 The setting in which this project took place was a rural county in the southeastern United States that has a high incidence of obesity, hypertension, and type 2 diabetes. In 2007, 34.5% of the county had a diagnosis of hypertension and 8.8% had type 2 diabetes. In 2010, approximately 67% of the county was reported to be obese or overweight. In addition, in 2009, 18.4% of middle school children and 15.3% of high school children had a BMI greater than the 95th percentile in relation to other children of the same age children around the state.9 These data show that almost one-third of all students in the county are overweight or obese. School-based BMI screenings have been developed as 1 strategy to combat childhood obesity. Parental notification programs were devised to inform the parents of their children’s BMI status and provide insight into future potential health problems associated with obesity.8 Generally, parents/guardians view BMI notification letters as “warning signs” alerting them to emerging health problems. Unfortunately, others view the notification letters as stressors that needlessly worry students.8 Even if screening alone increases parental and child awareness of weight issues, programs must be developed to prevent obesity. Parents must be provided with the information and tools to become successful in weight loss and weight control.10 Regrettably, little is known about the development and implementation of school-based BMI screenings and parental notification programs.8 Parental involvement and support are critical to the success of any preventive program. Financial constraints within school systems have made a negative impact on many preventive programs, such as height and weight and scoliosis screenings.8 Even if school programs have financial resources, some school nurses lack the knowledge and competence to recommend weight loss programs to parents and children.7 BMI screenings are conducted annually within the 6 schools of the study county. BMI screening results are mailed www.npjournal.org
to parents/guardians of obese and overweight children, but the choice to follow-up with a health care provider falls to those notified. There is no definite follow-up program from the county health department. If parents choose to followup with a health care provider, any testing, education, or guidance is presumed to be offered by the provider. A study conducted by Li and Hooker11 determined that children’s physical and psychological health are significantly affected by weight. Their study examined the relationships among childhood obesity and family, school, and community factors. The results suggest that children who attend public schools are more likely to be overweight or obese. The results further suggest that schools and communities should become actively involved in developing obesity prevention programs.11 Many studies8,10,12 support the fact that obesity is on the rise. Prevention is critical, but programs must be devised to address families and community needs.1 In the study county, educational material tailored to family needs is lacking. A well-designed educational program will enable nurse practitioners (NPs) and school nurses to provide guidance to parents/guardians of at-risk children. Parent education is vital to effectively promote the health of children.5 Parental involvement is necessary in any type of program for children, making parental education a vital part in the effective promotion of the health of children and families. If parents are aware of evidencebased strategies and skills needed to support them, they can become adequate role models for their children.13 Family education regarding physical activity and healthy eating habits should be implemented at home. Parental education can be an ideal bridge in promoting interventions in the fight against childhood obesity.13 METHODS Design This quasi-experimental research design had a pre- and postintervention approach. Study participants were approached by the records custodian of the rural Family Health Center in a southeastern state. The custodian gathered information from the medical records of 50 randomly selected patients who fell into the age group of 6-18 years. Protection of Human Subjects Upon approval from the Florida State University institutional review board, potential subjects were selected and contacted by the records’ custodian by mail. There were The Journal for Nurse Practitioners - JNP
713
no identifiable data on the mailed packets to the participants, with the exception of a number that corresponded to the parent’s identity known only to the primary investigator (PI). Any information received from the participants was locked in a file cabinet inside a locked closet within the PI’s office. Subjects The subjects were the parents of children who attended 1 of the 6 public schools in the study county and have active medical records at the Family Health Center, also in the county. Fifty parents/guardians were asked to participate in the study regardless of their child’s recorded BMI. The only exclusions were parents/guardians who were younger than 18 or older than 65. Procedures The initial contact included a letter that introduced the PI and the study. Aside from the cover letter, the initial mailing (phase 1) included 2 copies of the informed consent, demographic sheet, health practice questionnaire #1, and the health educational pamphlet. The participants were asked to read the informed consent completely, sign 1 copy, and retain the other copy for their records. Then participants were asked to complete the demographic sheet and questionnaire. After completing the first questionnaire, the participants were encouraged to read the educational pamphlet. In addition, the participants were instructed to refrain from placing their names or the names of their children on any of the forms to protect their identity. Upon completion, participants were to mail the completed forms to the records custodian in the pre-addressed/stamped envelope provided. The participants were made aware that a follow-up packet would be mailed within 2-4 weeks. The second packet was mailed within 2 weeks after participants returned the first packet. The second packet (phase II) included a cover letter from the record’s custodian, health questionnaire #2, and health educational pamphlet. The participants were instructed to complete the questionnaire and return the completed form in the pre-addressed/stamped envelope to the record’s custodian. The participants were asked to refrain from placing any type of identifying information on the forms or envelopes. All questionnaires and the health education pamphlet were developed by the PI. The pamphlet consisted of a 714
The Journal for Nurse Practitioners - JNP
trifold, colorful brochure that included facts regarding childhood obesity, BMI calculation chart, exercise tips for the family, and information specific to eating a healthy diet. Various Web sites and phone numbers of local informational sites were also included. After all information was collected, a descriptive and comparative analysis was conducted. Results from demographic information, parental BMI, age category of parents/guardians, and information collected from the questionnaires are included in the following section. Data Analysis Of the 50 packets mailed, 44 parents responded to both mailings. Six parents did not respond, and no guardians were identified. Thirty-eight mothers (86%) and 6 fathers (14%) responded. Forty-one parents reported their race as white and 3 reported black. Thirty (68%) parents reside in the extreme rural areas of the county, while 14 (32%) reside in the less rural areas. Eighteen parents (41%) reported making less than $12,000 per year, and 26 (59%) said their income exceeded $12,000 per year. There were no significant correlations between annual income and marital status. During phase I of the study (pre-intervention), parents were asked to share their own height and weight and their perception of their body weight and BMI. Although 23 (N ⫽ 44) parents said they have a normal weight and BMI, after calculation by the NIH Standard BMI calculator,14 only 13 (n ⫽ 44) parents had a normal weight and BMI. In addition, the parents were asked to describe their children as having either a healthy or abnormal weight. Thirty parents reported that their children had a healthy weight. In reality, the chart review revealed that 100% of the participants’ children had an abnormal BMI, which was greater than the 95th percentile for children of the same age. Descriptive statistics related to parental habits regarding diet, exercise, family meals, child’s health, parent’s health, and willingness to receive educational information on diet and exercise were collected. During phase II (postintervention), parents were again asked to complete a short questionnaire about their perceptions of childhood obesity after reading the educational pamphlet. Questioning in the postintervention phase revealed that parental perception had changed after reading the educational intervention, as evidenced by answers regarding their child’s BMI. A majority of parents Volume 8, Issue 9, October 2012
Figure 1. Parental Perception of Child’s BMI/Weight
(57%) were aware that childhood obesity is a major problem, and as expected, parental perception of their child’s BMI changed. In Phase II, 33 parents answered that their child was actually overweight or had an abnormal BMI. Figure 1 describes parental perception of their child’s BMI or weight at the pre- and postintervention phases of this study. In addition, parents were asked about their willingness to change diet and to begin exercising more regularly. Forty-one parents (93%) agreed to change their diet, and 35 parents (80%) agreed to exercise with their child regularly. Finally, the results from the intervention introduction revealed overwhelmingly that all parents (n ⫽ 44) agreed that the educational pamphlet was very helpful and provided useful information. Also, 100% of parents agreed that the educational pamphlet would be helpful to any parent and could be used with a child of any age. Parental answers collected during the postintervention phase revealed that they unanimously agreed that the educational pamphlet should be distributed along with any BMI notification from the school nurse or at the time of any well-child check-up at a health care provider’s office. DISCUSSION The parents who responded were from the more rural areas of the study county, which shows a fair representation of this county. The respondents were primarily female, which had been anticipated in the planning stages. Unexpectedly, important issues regarding parental www.npjournal.org
awareness of childhood obesity were raised: 57% of respondents were aware that there is a great problem with childhood obesity, but the incorrect parental perception of their child’s BMI and weight may play a major factor in their willingness to change. Parental perception will remain a foremost variable in the success of future educational programs. The Robert Wood Johnson Foundation15 has devoted $500 million to combat childhood obesity. This group believes that the most important factor in their efforts to battle childhood obesity is parental awareness, which is supported by the results of this study. One of the most influential factors in building a foundation for childhood weight problems is the parental unit.16 If parents do not perceive their children as at risk or overweight, weight loss interventions will not be adopted. The distorted perceptions of parents may result from several factors, including fear of being labeled a bad parent or labeling their children at a young age.17 Another factor to consider is that respondents reported that they eat fresh vegetables (73%) and fresh fruits (89%) regularly, which suggest that they are capable of delivering healthy nutrition to their families. However, 90% responded that they buy foods according to price and would buy healthier foods if they could afford them. This finding could again be linked to perception, but this instance includes healthy foods versus unhealthy foods. Finally, the findings from the postintervention inquiry suggest that the respondents were made aware of healthy pediatric weight and BMI. Questions regarding the educational pamphlet revealed that 100% of participating parents thought that the information was helpful and useful. Ninety percent of respondents reported that they would use any information provided on diet and exercise. LIMITATIONS The small sample size made correlation analysis unrealistic. The parents who were recruited for this study were familiar with the PI as their health care provider, so there is a possibility of bias. Participants may not have been truthful in answering questions because weight and healthy weight control are very sensitive issues. Although the sample size is representative of the patient population at the rural Family Health Center, it may not represent larger populations. In addition, the educational pamphlet provided information on BMI calculation, which The Journal for Nurse Practitioners - JNP
715
may have been confusing to some. The focus of this study was to develop an educational visual aid to compensate for the lack of information provided to families regarding BMI screening and to test the feasibility of a pamphlet as a firstline intervention. Finally, BMI screening has been the center of much controversy. The usefulness, the reliability of collection methods, and overall concern that BMI may not accurately measure adiposity have brought much questioning and concern nationally.10 However, until a universal method to determine “fatness” is devised and accepted, standard BMI charts remain the best method of screening for obesity in children. One final limitation of this study is that there is no method of long-term follow-up. After an intervention is introduced, the most appropriate way to determine a successful program is through follow-up. This limitation should be addressed if this study is reproduced. IMPLICATIONS FOR PRACTICE The brevity of office visits makes it very difficult to provide enough information for lifestyle changes. The options for health education of patients are numerous, but the implementation of intervention lies with the willingness to change. NPs in any practice can provide knowledge and power in a simple pamphlet by opening lines of communication. The use of the “food plate” guide is an excellent place to begin nutrition education and should be introduced in both schools (by NPs) and family NP practices. Because childhood obesity is at epidemic levels,10 health care providers must become proactive in the fight. Healthy eating and exercise to prevent obesity should be addressed with each well-child examination, especially in populations at risk. Children will continue to be assessed within the public school system, but parental notification of BMI scores should not be the terminal action. An educational pamphlet that can be easily inserted into the notification letter is recommended. CONCLUSION The extraordinary escalation in the incidence of childhood obesity and the associated comorbid conditions warrant proactive efforts by every health care provider. Obesity-prevention programs and educational and training programs must be developed for parents and providers alike. If parents are provided with concrete, 716
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written information, perhaps accurate perception of BMI, physical exercise, and healthy food would be the outcome. NPs can become proactive by developing protocols for BMI screenings in the office and schools. In addition, the establishment of childhood obesity prevention programs must be developed on state and federal levels. Prevention is always a better alternative than treatment. References 1. Armstrong S, Wacker J, Best D, McPherson M. Fighting childhood obesity: resources to help the community pediatrician curb this epidemic. Contemp Ped. 2011:40-50. http://digital.healthcaregroup.advanstar.com/nxtbooks/ advanstar/cntped_201102/index.php#/48. Accessed August 10, 2012. 2. Fox R, Trautman D. The epidemic of childhood obesity: a case for primary prevention and action. Bariatric Nurs Surg Patient Care. 2009;4(3):169-172. 3. Department of Health and Human Services. Childhood obesity. http://aspe.hhs.gov/health/reports/child_obesity. Accessed September 14, 2011. 4. Liu J. Overweight and physical activity among rural children aged 10-17: a national and state portrait. 2007. South Carolina Rural Health Research Center. 2007. http://www.rhr.sph.sc.edu/report. Accessed September 15, 2011. 5. Huffman F, Kanikireddy S, Patel M. Parenthood—a contributing factor to childhood obesity. Int J Environ Res Public Health. 2010;7(7):2800-2810. 6. Greene S. Personal communication. Washington County School Health Nurse. June 24, 2011. 7. Nauta C, Byrne C, Wesley Y. School nurses and childhood obesity: an investigation of knowledge and practice among school nurses as they relate to childhood obesity. Issues Compr Pediatr Nurs. 2009;32:16-30. 8. Kubik M, Story M, Rieland G. Developing school-based BMI screening and parent notification programs: findings from focus groups with parents of elementary school students. Health Educ Behav. 2007;34:622-633. 9. Florida Charts. Washington County, Florida. http://www.floridacharts.org. Accessed August 28, 2011. 10. Soto C, White J. School health initiatives and childhood obesity: BMI screening and reporting. Policy Polit Nurs Pract. 2010;11(2):108-114. 11. Li J, Hooker N. Childhood obesity and schools: evidence from the national survey of children’s health. J School Health. 2010;8(2):96-103. 12. Seal N, Broom M. Evidence-based interventions for pediatric weight control. J Nurs Praci. 2011;(7)4:293-302. 13. Hesketh K, Campbell K. Interventions to prevent obesity in 0-5 year olds: an updated systematic review of the literature. Obesity. 2010;18(Suppl 1):S27-S35. 14. National institutes of Health, National Heart Lung and Blood Institute. Calculate your body mass index. http://www.nhlbisupoort.com/bmi. Accessed November 24, 2011. 15. Robert Wood Johnson Foundation. Childhood obesity. http://rwjf.org/ childhoodobesity/. Accessed September 13, 2011. 16. Doolen J, Alpert P, Miller S. Parental disconnect between perceived and actual weight status of children: a metasynthesis of the current research. J Am Acad Nurs Pract. 2009;21:160-166. 17. Jain A, Sherman S, Chamberlin L, Carter Y, Powers S, Whitaker R. Why don’t low income mothers worry about their preschoolers being overweight? Pediatrics. 2001;107:1138-1146.
Dawn Frost, DNP, ARNP-BC, owns and operates the Vernon Family Health Center in Vernon, FL, and can be reached at [email protected]. Susan Padham Porterfield, PhD, FNP-C, is an assistant professor in nursing at Florida State University in Tallahassee. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/$ see front matter © 2012 American College of Nurse Practitioners http://dx.doi.org/10.1016/j.nurpra.2012.04.011
Volume 8, Issue 9, October 2012