Pediatric Obesity Community Programs: Barriers ... - Springer Link

J Community Health (2010) 35:348–354 DOI 10.1007/s10900-010-9262-5

ORIGINAL PAPER

Pediatric Obesity Community Programs: Barriers & Facilitators Toward Sustainability Eli K. Po’e • Sabina B. Gesell • T. Lynne Caples Juan Escarfuller • Shari L. Barkin

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Published online: 30 March 2010 Springer Science+Business Media, LLC 2010

Abstract Our current generation of young people could become the first generation to live shorter lives than their parents. Families need resources in their community to address this issue. Identifying barriers and facilitators of community organizations to offer obesity-related services is a first step in understanding sustainable community programs. The objective of this study is to identify common barriers and facilitators in community organizational programs designed to prevent or reduce pediatric obesity. We conducted an exploratory qualitative research study based on grounded theory. Thirty-six community organizations were identified based on self-descriptions of goals involving pediatric obesity. Semi-structured, systematic, face-to-face interviews among program directors (n = 24) were recorded, transcribed, and coded for recurrent themes. Relevant themes were abstracted from interviews by a standardized iterative process by two independent reviewers between December 2007 and November 2008. Theme discordance was reconciled by a third reviewer. Seventy percent of organizations indicated that obesity prevention/ treatment was their explicit goal with remaining groups indicating healthy lifestyles as a more general goal. Facilitators to provision of these programs included: programmatic enhancements such as improved curriculums (73%), community involvement such as volunteers (62.5%), and partnerships with other programs (54.2%). Barriers that threatened sustainability included lack of

E. K. Po’e (&) S. B. Gesell T. Lynne Caples J. Escarfuller S. L. Barkin Division of General Pediatrics, Pediatric Clinical and Translational Research, Vanderbilt University Medical Center, S0119 MCN, Nashville, TN 37232, USA e-mail: [email protected]

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consistent funding (43.8%), lack of consistent participation from the target population (41.7%) and lack of support staff (20.8%). New approaches in fostering partnerships between organizations need to be developed. Building coalitions and engaging community members in developing community based programs may be a helpful strategy to strengthen community-based programs to address the pediatric obesity epidemic. Keywords Community health Community-based organizations Pediatric obesity Childhood overweight

Introduction Our current generation of young people could become the first generation to live shorter lives than their parents [1, 2]. Recent reports indicate that, nationally, one in four children are overweight or obese [3]. Overall trend data have clearly indicated childhood obesity rates increasing dramatically since the 1970’s [4]. In a recent Robert Wood Johnson Report, no state has reached the Healthy People 2010 goal of reducing obesity to 15% [5]. In fact, almost two-thirds of states have obesity rates above 25% [5]. Although many attempts have been made to address pediatric obesity on the individual level, effective and sustainable interventions on the population level remains to be elusive [6, 7]. A number of recent studies suggest that the next-generation of interventions must involve the community or systemic societal changes [8–10]. In a recent article, Huang et al. argue that a systems-oriented multilevel framework must be established given the complexity of the obesity epidemic, suggesting that structural modifications to multilevel interventions must be in place in order to effectively address pediatric obesity [9]. A couple studies demonstrated

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promise in reducing BMI z-scores in children with this approach [11, 12]. Consequently, community-based programs are fundamental to address pediatric obesity prevention and intervention. For pediatric obesity-related community programs to exist there needs to be a clear understanding of facilitators and barriers related to sustainability. Community-based efforts aimed in preventing childhood obesity can range from youth-related organizations (e.g., Girl Scouts and the YMCA), community centers and after school programs (e.g., Boys and Girls Clubs), clinics and hospitals, or local governments [13]. Therefore, we conducted a listening tour of community-based pediatric obesity prevention/intervention programs, in a community where one in three children are overweight, to assess elements that support or deter program sustainability [5].

Methods

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all interviews were audio-recorded and conducted in English. Each interview was conducted by the same interviewer. No compensation was provided. Interview Procedure We used a semi-structured survey of nine questions developed by obesity researchers at Wake Forest and Vanderbilt University as part of a collaborative effort in community engaged research. Questions ascertained scope of services provided, facilitators and barriers to successful program implementation and sustainability efforts. Prior to the interview, written informed consent was administered. All questions were open-ended and the interviewer probed the respondent to elaborate on responses until he/she had nothing further to add. We allowed all participants the opportunity to voice their opinion on a question before proceeding to the next question. Interviews averaged twenty-one minutes. All interviews were transcribed verbatim from audiotapes.

Study Design Data Analysis An exploratory, cross-sectional, qualitative research study based on grounded theory was conducted. Unlike a deductive approach, based on theory and validated with empirical data, grounded theory is a qualitative methodology used to create a substantive theory grounded in empirical data [14]. Systematic, in-depth, face-to-face semi-structured interviews with key personnel representatives (e.g., directors, executive directors, or leading managers) of community organizations were conducted. We conducted a single interview per organization. Eligibility criteria included currently active community organizations in Davidson County of Nashville, TN with (1) self-identified programs related to pediatric obesity; and (2) service provision to children and youth (0–18 years of age) with an emphasis on healthy lifestyle behaviors (e.g., nutrition, physical activity). Data were collected from December 2007 to February 2008. The Vanderbilt University Institutional Review Board approved this study. Participant Recruitment Supervised student interns reviewed the Community Services Directory of Middle Tennessee, a manual of available non-profit community agencies in Davidson County, to identify and recruit eligible community organizations by phone [15]. Eighty community organizations met criteria. Once prospective organizations had been identified, directors of organizations with active programs were contacted via e-mail or telephone and invited to participate in a semi-structured face-to-face interview. All interviews were scheduled and conducted at the organization’s location, and

Two trained and independent reviewers analyzed written transcripts. As a team, a cyclic process of abstracting, comparing, and agreeing on codes for themes was generated until theme saturation (no new themes) had been achieved [16]. We used a constant inductive and deductive analysis approach to extract words and concepts and generate themes and subthemes [17]. Essentially, the form of the question was considered a theme and the separate constituent properties were collected as categorical subthemes (e.g., Question: How long does your program last? theme: duration of program; subtheme: annually). Thus, relevant and recurrent categorical subthemes were elicited from the transcripts by a standardized iterative process. Each subtheme was then compared with every other subtheme to ensure that they were mutually exclusive categories. Once the researchers reached a consensus on a framework that reflected a collective representation of themes and subthemes, a codebook was developed. This approach is consistent with standard qualitative methodology [14]. Both reviewers then independently reread the transcripts and tallied the subtheme frequency. If a respondent mentioned an established subtheme once or more, that subtheme was counted only once for that particular organization. Both reviewers generated a separate frequency total for each subtheme. Totals for each subtheme were analyzed independently by each reviewer. If the totals differed from each reviewer by a number of two, then that particular subtheme was set aside for further discussion of its validity. To ensure inter-

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rater reliability, data triangulation was used where theme discordance among reviewers was reconciled by a third independent reviewer. Inter-coder agreement produced a crude measure of association with a subtheme and its independent construct. If a subtheme was marked as highly associated to its construct by two out of three coders, then that subtheme was maintained. If not, then the subtheme was discarded [17]. Qualitative data presented includes selected quotes from interviewee’s responses from categories with complete coder concurrence.


Major Theme: Facilitators and Success Facilitators of perceived success referred to an organization’s capacity to reach or maintain their goals. Three subthemes were identified: (1) programmatic enhancements; (2) community involvement; and (3) the establishment of partnerships. Refer to Table 1 for Facilitator subtheme frequencies. 1.

Results Sample Description Of the eighty local community-based organizations identified, 30 were randomly selected and interviews were arranged. Of these 30 community organizations, 24 interviews were conducted and completed. Five interviews could not be conducted due to conflicting times of schedule and one organization withdrew from the study because of non-involvement in services related in ‘‘pediatric obesity.’’ Of the 24 organizations that participated in this study, three main types emerged: community outreach programs (e.g., Nashville Metro Parks & Recreation), after-school programs (e.g., Boys and Girls Club) and clinic-based programs (e.g., Meharry Medical College). Further interviews were not pursued due to the achievement of theme saturation [17].

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Programmatic Enhancements: Programmatic Enhancements referred to newly renovated programs, recent increase in number of activities, or an extension of services for a broader target population. Seventy-three percent of organizations identified some programmatic enhancement that led to success. One participant stated, ‘‘In terms of the Veggie Project, there were thousands of pounds of fresh fruits and vegetables sold in neighborhoods where we know there’s not as much access to healthy fresh fruits and vegetables, and so I think that’s a huge success.’’ Community Involvement: Over 62% of organizations claimed that community involvement was an important contributor towards success. Community involvement referred to interaction with community organizations or its members. One participant stated, ‘‘We like to say that we foster uncommon connections between our partner

Table 1 Major themes: barriers, facilitators and sustainability factors of obesity-related programs (N = 24 community organization directors) Major themes & subthemes

General Themes Of the organizations interviewed, 70% explicitly focused on either the treatment of pediatric obesity or the prevention of pediatric obesity, while the rest considered their main objective to be overall healthy living. Fifty percent indicated existing resources in place to address prevention/ treatment of pediatric obesity, such as established partnerships, volunteers, paid staff or source of external funding. A little more than half (54%), provided actual education classes or services to raise awareness of obesityrelated behaviors such as providing cooking classes, exercise programs, and open discussions with health experts. Almost half of the organizations (46%) focused efforts explicitly for vulnerable populations. These vulnerable populations included under-served, low income/low social economic families, immigrants, and refugees. The other half focused on generic groups or populations such as school-aged children, parents, child care centers, and public schools. About a third (29%) of organizations tailored programs for a selected age group. About a third (35%) targeted a specific geographic region.

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No.* (%) of organizations that indicated this subtheme at least once

Major theme: barriers (a) Funding/money

10.5 (43.8)

(b) Lack of participation

10 (41.7)

(c) Lack of support staff

5 (20.8)

Major theme: facilitators (a) Programmatic enhancements**

17.5 (73.0)

(b) Community involvement

15 (62.5)

(c) Partnerships

13 (54.2)

Major theme: sustainability (a) Partnerships***

12 (50.0)

(b) Funding

10 (41.7)

(c) Support staff

6.5 (27.1)

* Mean of sum frequencies from both coders ** Programmatic enhancement: the development of new programs, new projects or initiatives that provides services or the availability of established services that greatly improves the maintenance of a specific goal (e.g., improved curriculums or recreational activities) *** Partnerships: an alliance or coalition to integrate resources


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organizations. We will bring together a nutrition educator with a farmer to do outreach to kids and adults. We’ll bring people together to talk about an issue like women in agriculture. But that also includes a discussion of families and feeding practices and so I think as we’re tracking these uncommon connections that are created, there are also some huge successes in how people are thinking about the work that they do. I think that’s something that people see as a win–win’’. Establishment of Partnerships: More than half of all the organizations, 54.2%, indicated the importance of developing alliances whether they were partnerships or coalitions that integrate resources. One participant expressed a particular relationship, ‘‘We measure success by the number of kids that come to the program. Not by whether they leave healthier than when they began. So that’s where the partnership [with the Monroe Carroll Jr. Children’s Hospital at Vanderbilt] has been great to get us to see the importance of that…I’d love to say that we had 800 kids in the softball program or dance program and 90% of them are living a healthier lifestyle, to be able to cite some of those examples, but we don’t do that [yet]’’.

One respondent attributed much of their success with a particular individual that had existing relationships in the community, stating, ‘‘We’re very lucky because [one community liaison] brought together a ton of different folks, some dietitians, folks who were really involved in exercise at Vanderbilt, and then a lot of different community partners. So I think what really worked was [the community liaison] already having a relationship with a lot of different community partners. We hope to continue to bring a lot of different groups together.’’ Major Theme: Barriers and Challenges Barriers referred to those obstacles that inhibit an organization in promoting pediatric obesity-related programs or negatively affect its effectiveness. Independent coders identified three subthemes: (1) limited or lack of funding; (2) lack of participation amongst target participants; and (3) lack of organizational support staff. Refer to Table 1 for Barrier subtheme frequencies. 1.

Limited Funding: Funding was the highest perceived barrier. Approximately 44% of organizations reported this barrier. One participant stated, ‘‘Funding is a key to us. That’s a big issue is having enough funding to do the things we’d like to do. So that’s a hindrance and probably an obstacle to a lot of things we wish we could do here’’.

Even to provide general health services, the inability to establish steady funding may be deleterious to the

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community. One participant stated an example, ‘‘Because a majority of our patients speak other languages, it’s very difficult to put together a good interview and examination session because you have to have translators and interpreters…So [people in the community] donate costs to run a phone interpreting line…And then when they have no money at all, then you have to find whatever you can to help them that’s free’’. 2.

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Lack of participation: Another barrier was the lack of participation in community services by the intended participant; 42% of respondents noted this barrier. One participant expressed her concern by saying, ‘‘For me the biggest frustration or challenge would be getting consistency among children. I might see [the children] five out of the 10 weeks, but not consistently every single week. It’s after school and we’re a community center, so it’s totally their decision whether to come to the community center or not’’. Lack of organizational support: Lastly, a lack of support staff emerged as a fundamental barrier. Approximately 21% of organizations identified with this subtheme. One participant expressed, ‘‘Some people want to have a person, a different face, to promote [physical activity] with their individual schools. And it’s just tough for us to make that happen. So we do try to work with our volunteers. And we try to make it work to have a staff member there… But there are only so many of us that can help that way’’.

Major Theme: Sustainability Sustainability of community programs was the third major theme explored. Coders identified three subthemes: (1) the establishment of partnerships; (2) funding; and (3) support staff. See Table 1 for Sustainability subtheme frequencies. 1.

2.

Establishment of partnerships: Fifty percent of organizations noted that the establishment of partnerships was a valuable resource. One participant described a process that promoted sustainability, ‘‘Our goal is to make our programs sustainable—that was built into the program from the beginning—the farmers would be paid a fair price for their food. The food would also be fairly priced for the communities where the food was sold, and several of the Boys and Girls Clubs have already indicated that it’s a program that they’d like to incorporate into how they think about their work.’’ Funding: Funding was found to have an impact on sustainability as well. Out of all organizations, 42% identified with this issue. One participant elaborated, ‘‘Now, as far as sustainability goes, a lot of the

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programs we do, don’t cost a lot of extra dollars…What we’re always trying to do, just like everybody else, is find out what is going to work. We’ve done some of these little programs, but we haven’t solved the problem yet, unfortunately. We want to kind of be sure that we’re keeping up with what’s happening. I monitor a lot of the pediatric obesity literature to see what kind of programs work. And see if those things can be implemented as well. But again, money is always a limiting factor in a lot of those things.’’ Support staff: About a third of the organizations, 27%, found support staff such as existing staff or volunteers, to have an impact on sustainability. One participant expressed the need for human resources and the money necessary to fund them, ‘‘I have a group of somewhere between 10 and 13 students. And they basically design the programs, design the curriculum, and run the programs. So the sustainability of our programs depends on having the money to pay those students to run them.’’

Some participants recognized the significance of rolemodeling within existing staff as a facilitator that fosters the capacity to maintain sustainability. One participant expressed this as a work in progress, ‘‘You know what’s been tough, and we’re just gonna be candid about this—it’s our staff. Our staff has struggled with [eating healthy and exercising]. We have staff at our school age service sites that are promoting this, but they’re struggling with doing it themselves…So we see that some work with even our staff promoting this is one that we need to continue to be working on. We did not have a total buy in from our staff team to change their eating habits and increase their physical activity. We had about 50%. So, we feel very strongly that we need to set an example for what we’re promoting’’.

Discussion Given the severity of the childhood obesity epidemic, understanding facilitators and barriers that lead to sustainability for community agencies addressing pediatric obesity is crucial. Tennessee is considered the fourth fattest state, with an obesity prevalence of 36.5% [5]. The Institute of Medicine (IOM)’s blueprint for addressing this obesity epidemic includes many key stakeholder groups, with community agencies identified as one of them [13]. This exploratory study identified common facilitators and barriers that contribute to sustainability of community programs that address pediatric obesity. A key facilitator for the majority of community agencies interviewed included the notion of developing coalitions

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and partnerships. This was clearly linked to sustainability in the interviewees mind. Other studies have documented the importance of forging partnerships across multiple levels, including home, school, and community [9, 18]. Huang et al. argues that a systems-oriented multilevel framework is indispensable given the complexity of the obesity epidemic, suggesting that structural modifications to multilevel interventions must be in place to effectively address obesity [9]. In this study, community-based organizations that focused on one aspect of obesity, such as physical activity, established coalitions with other organizations allowing a broadened scope of services to better address pediatric obesity prevention. Even those organizations with a broader focus including both nutrition and physical activity relied on the resources of other organizations to contribute toward their success. Coalition building is a potentially low cost, high yield proposition. The IOM supports the notion of community coalitions and suggests they consist of public- and private-sector organizations, together with individual citizens, working in a coordinated effort toward a common goal [13]. This exploratory study did not explore the depth or level of longevity of these existing coalitions and partnerships [19]. It seems likely that not only the depth but the duration of exposure of these partnerships could affect its ability to be effective. In developing future studies, further exploration of successful partnerships characteristics would be warranted. In addition to building coalitions with other community agencies, the respondents highlighted the importance of engaging community members themselves to become part of the workforce. Other studies have also validated this approach [20, 21]. As one community leader in this study reported, ‘‘We have a lot of people in our neighborhood who can not work, but want to do something. They want to contribute to their community somehow. They want to have something meaningful to do every day when they get up.’’ Respondents expressed that just having ties with community resources, engaging with its members or having established existing relationships was invaluable and a critical part towards its viability as a community-based program. Research academics and public health professionals have recognized this value with the growing movement of community-based participatory research (CBPR), a research approach that bridges scientists and communities through shared knowledge and experiences to solve major health issues [22]. Building a workforce that involves community members who participate in community agencies to address pediatric obesity, could be yet another low-cost high yield approach. Conversely, a common barrier highlighted was lack of consistent participation from the target children and families that agencies hoped to reach. Consistent community


participation is not only a requirement for these programs, but critical to its success. A qualitative study that investigated reasons why youth do not participate in school-based and community-based programs suggested four main reasons: (1) lack of time; (2) had other interests; (3) held negative opinions of the center or (4) constrained by parents or guardians [23]. The authors concluded that consistent participation requires accessible programming with high quality staff targeting the specific needs of the community. Researchers at RAND proposed a slightly different theoretical model that suggested individual participation falls into three groups: (1) those currently participating; (2) those inclined to participate; and (3) those disinclined to participate. They concluded that the key to increased participation is the individual’s program perception and an environment that fosters effective engagement [24]. These findings, along with our exploratory data, suggest that next steps should include the application of a communityengaged approach to develop sustainable community-based pediatric obesity programming. A recent study documented an example of CBPR being utilized just in this manner to generate community-based approaches to advance healthy eating and exercise, indicating the feasibility of this kind of approach to address this common barrier [18]. It was not surprising that funding was the major barrier noted. Funding is necessary to initiate and maintain community programming. In one review of 23 ethnically inclusive childhood obesity studies, fewer than half of the studies reported outcome evaluation data [25]. Funding favors community-based programs that have been proven effective, thus rigorous evaluations of efforts, and dissemination of lessons learned, must be a priority [13]. Although these barriers cannot be overcome easily, community leaders can work together with community members with existing resources to maximize the delivery and sustainability of these community-based programs. Due to the large scale prevalence of the obesity epidemic, approaches in addressing pediatric obesity should shift from an individual-oriented perspective to a communityoriented perspective. Childhood obesity is an illness that affects the individual, but lives in families and communities. Therefore, preventive services and programs in the community are vital and must be readily available and accessible to families. This exploratory study offers insight on which strategies could influence community-based program sustainability to contribute to the solution of pediatric obesity. The limitations of this study include interviewing a small sample of community leaders; this makes generalizing our findings limited. However, qualitative techniques to attain theme saturation were employed; leading the team to discontinue further interviews after this was achieved. Also, we defined a community leader as one who actively

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runs an existing community program designed for children/ youth. Other interviews with children, patients, or adolescent program participants might have contributed a different perspective of what may seem to be working and not working for community-based programs. Despite these limitations, this exploratory study offers important insights. Building coalitions and engaging community members in developing and sustaining community based programs might be a helpful strategy to strengthen community-based programs, enabling them to be an effective part of the solution for the epidemic of pediatric obesity. Given that fewer than 19 states now have an obesity rate of less than 25%, with the majority of states approaching 30%, strengthening community stakeholders’ ability to be effective is a crucial next step towards addressing this childhood epidemic [5].

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