This evaluation research examines the use of child wellness visits to reduce obesity in children in low income homes Childhood obesity is a serious medical problem that affects the children and the adolescents where the body mass index of a child exceeds the normal standard level, as per the age of the child. In United States, the percentage of children affected due to obesity has tripled in number since 1970 (CDC, 2018).Globally, obese and overweight children under the age of five has been estimated to be more than 41 million.
Childhood obesity has several short and long terms effects on the social, physical and the emotional health of an individual. Children with obesity are more vulnerable to chronic health conditions and diseases like type -2 diabetes and risk factors for heart disease (CDC, 2018). Children with obesity are often bullied and are teased more than their peers who are normal weight and hence are teased more than their normal weight peers. Vos and Welsh, (2010), have highlighted evidences regarding the role of the maternal body mass index, genetics, environmental factors, dietary habits and other demographic factors as the predisposing factors of obesity. The dietary habits can again be linked to social, cultural and the economic aspects of a population.
One of the more concerning fact is that obesity have been found to be increased by 23-33% for children in low income, low education and higher unemployment households. Moreover, the low income families are less likely to realize that their child is obese. Furthermore, the low income families face lots of barriers for improving the health status. They are more likely to consume unhealthy and cheap food due to the high price of the fresh food. Lower household income can be strongly correlated to higher prevalence of childhood obesity. Community based wellness visits and surveys in low income household and health promotion programs have been found to be effective in mitigating child hood obesity.
This evaluation would examine the effectiveness of the child wellness visits in low income households to reduce child obesity.
Significance statement
Obesity in UK is a common problem and it is estimated that every four adult and a fifth of 10 -11 years olds are overweight or obese (BBC news. 2018). According to the Public health England, nearly half of the kids are overweight in parts of the United Kingdom, with seven out of the fattest areas in Britain. In September 2018, United Nations has reported that UK is the third fattest nation in Europe after turkey and Malta (Wang & Lim, 2012). Hence, checking for obesity in children and health promotion related to obesity control during the well-child visits can mitigate the problem from the grassroot level.
In contrast to other threats to the health status of the children of the United Kingdom, the prevention and the treatment of childhood obesity are considered to be useful. Sometimes the societal stigmatization of the obese children and some environmental factors induce the children to consume nutritionally poor food (Puhl & Heuer, 2010). Hence the parents of the overweight children are left in a position to fear the social and the health consequences of the childhood obesity. Childhood obesity is a social justice issue as it affects the poor and the minorities disproportionately. Hence, poverty and stigmatization are the social justice issue related to childhood obesity. The intersection of the obesity and poverty should be understood as an injustice that demands structural changes (Brewis, 2014). Hence, it is important for the social workers to have clear idea about this social problems
Child wellness visits are a part of community social services work that involves screening of clinical conditions in children, immunizing them, checking on their diets (Wang & Lim, 2012). These welfare visits are like a much needed safety net for the people suffering from socio-economic challenges or for families or the children in need for advocacy. Hence such evaluation research will provide an in depth understanding of the societal factors and the risk factors associated to obesity including the statistical data about the prevalence all around the United Kingdom, such that appropriate interventions can be taken.
Hypotheses
It is hypothesized that child wellness visits can help to reduce obesity in children in the low income homes.
The intervention that has been chosen for bringing about a reduction in the childhood obesity is to conduct well- child visits in the low income household to keep a check on the prevalence, the extent of the problem, the social determinants and risk factors associated to obesity in children.
Childhood obesity prevention approaches should be considered in the well child visit by the social workers due to its association to the social injustice issues. Childhood obesity has nearly tripled over the past three decades and has impacted the children belonging to different racial groups (Vos & Welsh, 2010). Obesity among the African children have been found to be more when compared to the other races. As per the basic rights of the children, every child is entitled to grow in non –poor and healthy condition irrespective of the socio-economic status. It is the duty of the social workers to look after health and the wellbeing of each of the child.
Negative attitudes towards the obese children have increased 66 % over the past three decades. According to Brewis (2014), society perceives obese persons as innocent persons but as the architect of their health and often considers laziness and over eating to be the main cause. Some of these common assumptions lay the foundation of the weight stigma. Hence, the social workers on a well-child visit, are accountable to eradicate the stigma related to child hood obesity or change the perception of the parents of the obese children.
Parents play a significant role in preventing childhood obesity. Paradoxically, it has been found that there are several parents that do not perceive the excess weight of their child as a health concern. Hence, it is important to educate the parents about childhood obesity (Avis et al., 2015). It has been found that parents who have a clear perception about the body mass index of their child are likely to sustain a healthy life style. One of the important way of developing supportive family- clinician interaction is through a child wellness visit at homes. By child wellness visit, the pediatricians can begin providing education to the patients regarding shortly after the birth about the ways to maintain a healthy life style, or developing proper diet chart for the babies (Avis et al., 2015).
Cha and Besse, (2015), conducted a study among the English speaking parents in the UK, where the odds for the childhood obesity were found to have been increased with the low health literacy scores of the parents. Health literacy of the parents has also been associated with obesogenic care behavior on the infants, such as feeding them with more formula than breast milk (Marks, 2015). A study conducted by the same author had demonstrated that nutritional knowledge of the parents are variable (Marks, 2015).
A health belief model can be used to understand the barriers to maintain a proper body mass index. According this belief, health literacy via welfare visits helps to understand or predict the health related behaviors. Hence, such welfare visits will help to identify predisposing factors of the childhood obesity. A well- child check allows the health care professionals to keep a track of the development of the child and make sure they are getting whatever to stay healthy (Tzioumis & Adair, 2014). They help to identify the evidence based behavioral changes in the diet and the physical activity for preventing obesity in children. They also counsel families using empathize provide communication techniques, discuss about the stages of the obesity treatment. Additionally, a well- child visit an act as a forum for addressing the maternal health needs affecting the child. Groner et al., (2009) have stated that, anticipatory guidelines, about the nutrition, health and safety of the child is the main component of a child well care.
It has been found that in most of the household having low education and unemployment, people are more likely to be ignorant about the standard dietary guidelines. Hence, implementation of the recommended guidelines can produce significant health outcomes when administered at a population level. A pediatrician taking part in the child wellness visit can suggest the parents with interventions and can also correct the inaccurate perception of the weight status of their children. In many cases families having lower levels of health literacy might be unaware of rights or the grants that might be available for them (Marks, 2015). Such well- child visits can also provide useful referrals to the families seeking for financial help.
Methods
Study sample and research design
The eligible participants will be 20 children aged 2-5 years and who have attended a well-child care visit at the “X” health community health service clinic within 12 months before the recruitment and on the visit had a body mass index >85th percentile as per the age. The wellness visit will be delivered by a pediatrician followed by a researcher.
This study will follow a quantitative evaluation research.
Instruments
A questionnaire related to childhood obesity will be made to fill by the parents prior to the interventions and the same will also be made to fill after the commencement of the interventions. The interventions provided focused on parenting style, nutrition and physical activity. 2 visits each month over a six months period will be considered for providing educating the parents about childhood obesity. Other interventions included recommendation of dietary guidelines for each of the children.
Outcome measures
The primary study outcome will be measured by any improvement in the health literacy as perceived from the filled questionnaire and a significant change in the BMI z score from the baseline till the post intervention period.
Ethical considerations
Each of the families will be invited by an email and telephonic calls. Before the conduction of the study each of families will be made to sign a consent form containing all the aims, pros and cons of the study. Before the trial, ethical approval should be taken from the local ethics committee.
Data analysis
Primary analysis
The change in the BMI score will be noticed to compare the changes over an equivalent time frame with the help of growth curve models having random intercepts and random slopes.
Secondary analysis
For determining the effect of the interventions on the physical activities, the mean “5-2-1-0” index from baseline to post-intervention will be measured using a paired t-test.
The anticipated outcome is that such interventions will bring about an improvement in the health literacy among the parents and children. A statistically significant reduction in the BMI will be noticed.
Limitation
One of the limitation that can be associated with this study is the smaller sample sized and the age group. Outcome of twenty children cannot be generalized to the entire population. Furthermore, children above the age of five are more independent and hence their dietary habits or physical activities might not be dependent upon the parenting skills or the socio-economic status and can be due to peer influence. Lack of control groups might lead to bias.
Implications to practice
Childhood obesity is an overlooked child protection the protection concern that should be addressed by the social workers as well as the health care professionals. There had been several literary evidences about the importance of the well child visits on enhancing the heath literacy about childhood obesity among the parents (Marks, 2015). It will not only make them aware about the prevalence of childhood obesity but will also help them in choosing healthy dietary choices and planning physical activities for their children.
The strength of the study is that it will target the low income population, who had often experienced the social and the environmental obstacles. Such study will help to understand the reasons for the particular behavioral activity towards obesity and the will also help in locating any gaps left in the interventions (Avis et al., 2014). Moreover, a comprehensive and a holistic approach should be taken to address this societal problem of obesity.
References
Avis, J. L., Cave, A. L., Donaldson, S., Ellendt, C., Holt, N. L., Jelinski, S., Martz, P., Maximova, K., Padwal, R., Wild, T. C., … Ball, G. D. (2015). Working With Parents to Prevent Childhood Obesity: Protocol for a Primary Care-Based eHealth Study. JMIR research protocols, 4(1), e35. doi:10.2196/resprot.4147
Cha, E., & Besse, J. L. (2015). Low parent health literacy is associated with ‘obesogenic’infant care behaviours. Evidence-based nursing, 18(2), 46-46. https://dx.doi.org/10.1136/eb-2014-101881
Groner, J. A., Skybo, T., Murray-Johnson, L., Schwirian, P., Eneli, I., Sternstein, A., Klein, E., … French, G. (2009). Anticipatory guidance for prevention of childhood obesity: design of the MOMS project. Clinical pediatrics, 48(5), 483-92.
Jacobson Vann, J. C., Finkle, J., Ammerman, A., Wegner, S., Skinner, A. C., Benjamin, J. T., & Perrin, E. M. (2011). Use of a tool to determine perceived barriers to children’s healthy eating and physical activity and relationships to health behaviors. Journal of pediatric nursing, 26(5), 404-15. doi: [10.1016/j.pedn.2010.10.011]
Karnik, S., & Kanekar, A. (2012). Childhood obesity: a global public health crisis. Int J Prev Med, 3(1), 1-7. https://www.taylorfrancis.com/books/e/9781498721738/chapters/10.1201%2Fb18227-7
Marks, R. (2015). Childhood Obesity and Parental Health Literacy. Adv Obes Weight Manag Control, 3(3), 00055. DOI: 10.15406/aowmc.2015.03.00055
Rogers, R., Eagle, T. F., Sheetz, A., Woodward, A., Leibowitz, R., Song, M., Sylvester, R., Corriveau, N., Kline-Rogers, E., Jiang, Q., Jackson, E. A., … Eagle, K. A. (2015). The Relationship between Childhood Obesity, Low Socioeconomic Status, and Race/Ethnicity: Lessons from Massachusetts. Childhood obesity (Print), 11(6), 691-5.
Tzioumis, E., & Adair, L. S. (2014). Childhood dual burden of under-and overnutrition in low-and middle-income countries: a critical review. Food and nutrition bulletin, 35(2), 230-243.
Vos, M. B., & Welsh, J. (2010). Childhood obesity: update on predisposing factors and prevention strategies. Current gastroenterology reports, 12(4), 280-287.
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