South Carolina School Nurses' Knowledge, Opinions, Perceptions, and Practice Measures Regarding Childhood Obesity

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1 Garder-Webb Uiversity Digital Garder-Webb Uiversity Nursig Theses, Dissertatios ad Projects Hut School of Nursig 2014 South Carolia School Nurses' Kowledge, Opiios, Perceptios, ad Practice Measures Regardig Childhood Obesity Loga Camp Garder-Webb Uiversity Follow this ad additioal works at: Part of the Occupatioal ad Evirometal Health Nursig Commos, Pediatric Nursig Commos, ad the Public Health ad Commuity Nursig Commos Recommeded Citatio Camp, Loga, "South Carolia School Nurses' Kowledge, Opiios, Perceptios, ad Practice Measures Regardig Childhood Obesity" (2014). Nursig Theses, Dissertatios ad Projects. Paper 4. This Thesis is brought to you for free ad ope access by the Hut School of Nursig at Digital Garder-Webb Uiversity. It has bee accepted for iclusio i Nursig Theses, Dissertatios ad Projects by a authorized admiistrator of Digital Garder-Webb Uiversity. For more iformatio, please cotact digitalcommos@garder-webb.edu.

2 South Carolia School Nurses Kowledge, Opiios, Perceptios, ad Practice Measures Regardig Childhood Obesity by Loga Camp A thesis submitted to the faculty of Garder-Webb Uiversity School of Nursig i partial fulfillmet of the requiremets for the Master of Sciece i Nursig Degree Boilig Sprigs, North Carolia 2014 Submitted by: Loga Camp Date Approved by: Sharo Starr, PhD, RN Date

3 UMI Number: All rights reserved INFORMATION TO ALL USERS The quality of this reproductio is depedet upo the quality of the copy submitted. I the ulikely evet that the author did ot sed a complete mauscript ad there are missig pages, these will be oted. Also, if material had to be removed, a ote will idicate the deletio. UMI Published by ProQuest LLC (2014). Copyright i the Dissertatio held by the Author. Microform Editio ProQuest LLC. All rights reserved. This work is protected agaist uauthorized copyig uder Title 17, Uited States Code ProQuest LLC. 789 East Eisehower Parkway P.O. Box 1346 A Arbor, MI

4 Abstract Childhood obesity has become a sigificat atioal health issue due to risig icideces ad associated chroic medical coditios. School urses across the Uited States of America are i prime positios to address childhood obesity as they have access to large umbers of childre ad adolescets i school settigs. A review of curret literature demostrated that school urses were overall kowledgeable cocerig childhood obesity, but ecoutered umerous barriers i eactig weight-related assessmets ad treatmet programs. The purpose of this research study was to determie the kowledge, opiios, perceptios, ad practice measures of South Carolia school urses regardig childhood obesity. The School Nurses Perceptios of Childhood Obesity Tool questioaire was set electroically to school urses i South Carolia. Results from the questioaire idicated that school urses i South Carolia uderstood the causes ad egative health effects of childhood obesity. Despite this awareess, the school urses were ot actively coductig weight status screeigs or developig weight maagemet programs for studets. Keywords: childhood obesity, school urses ii

5 Ackowledgmets I would like to express my appreciatio for the guidace ad assistace I received from others durig the MSN Thesis process. I would first like to thak my parets, Dr. L. Jerry ad Sadra Camp, for their ecouragemet ad support durig my graduate studies. I would also like to thak my thesis advisor, Dr. Sharo Starr, whose directio was vital to the completio of this research project. iii

6 Loga Camp 2014 All Rights Reserved iv

7 TABLE OF CONTENTS CHAPTER I: INTRODUCTION Brief Backgroud...1 Research Problem...2 Research Purpose...2 Research Questios...3 Coceptual/Theoretical Framework...3 Sigificace to Nursig...6 CHAPTER II: RESEARCH BASED EVIDENCE Review of Literature...7 Summary...13 CHAPTER III: METHODOLOGY Implemetatio...14 Settig...14 Sample...15 Desig...15 Protectio of Huma Subjects...15 Istrumet...16 Data Collectio...16 Data Aalysis...17 Summary...17 v

8 CHAPTER IV: RESULTS Sample Characteristics...18 Major Fidigs...20 Summary...35 CHAPTER V: DISCUSSION Implicatio of Fidigs...36 Applicatio to Coceptual/Theoretical Framework...40 Limitatios...43 Implicatios for Nursig...43 Recommedatios...44 Coclusio...46 REFERENCES...47 vi

9 List of Figures Figure 1: Peder s Health Promotio Model...5 vii

10 List of Tables Table 1: Demographic Iformatio...19 Table 2: Sectio Oe: School Nurses Perceptios Regardig School Age Obesity ad Weight Cotrol Programs...22 Table 3: Sectio Two: School Nurses Opiios Cocerig Childhood Obesity...24 Table 4: Sectio Three: Referral for Obesity...26 Table 5: Sectio Four: School Role i Weight Cotrol...28 Table 6: Sectio Five: Defiitio of Obesity...30 Table 7: Sectio Six: Health Risks Associated with Obesity...31 Table 8: Sectio Seve: Etiology of Childhood Obesity...33 Table 9: Sectio Eight: Sources of Weight Cotrol Iformatio...34 viii

11 1 CHAPTER I Itroductio Brief Backgroud Childhood obesity has developed ito a serious medical issue with egative effects o overall health ad welless. Accordig to the Ceters for Disease Cotrol ad Prevetio (CDC), approximately 17% of America childre ad adolescets betwee the ages of two through ietee are obese (CDC, 2011). I regards to the state of South Carolia, 12.8% of childre ad 16.7% of adolescets are cosidered obese (CDC, 2012). Weight status is determied by aalyzig idividuals height ad weight i order to calculate their body mass idex (BMI). Obesity is defied whe the BMI-for-age percetile is equal to or greater tha the 95 th percetile for people of the same age ad geder (CDC, 2011). Multiple elemets cotribute to childhood obesity. Obesity is the result of a eergy imbalace that occurs from cosumig a icreased umber of calories ad participatig i decreased physical activity (CDC, 2011). May childre ad adolescets are cosumig large portio sizes of meals ad beverages that are high i sugar cotet while leadig more sedetary lifestyles of watchig televisio ad playig video games. Geetics, metabolism, ad social factors, such as socioecoomic status ad culture, also ifluece the developmet of childhood obesity (Bejami, 2011). There are umerous health risks associated with childhood obesity, icludig asthma, diabetes, hypertesio, ad adult obesity. As a result, the lifetime medical costs of obese childre are estimated to icrease by $19,000 per child whe compared to the medical costs of childre who maitai healthy weights (Fikelstei, Graham, & Malhotra, 2014).

12 2 Accordig to Mehrley ad Leibold (2011), from the Natioal Associatio of School Nurses, school urses have the kowledge ad expertise to promote the prevetio of overweight ad obesity ad address the eeds of overweight ad obese youth i schools (p. 1). School urses are vital to the issue of childhood obesity as they have access to large umbers of childre ad adolescets i school settigs. School urses may coduct weight status screeigs to idetify obese studets, refer obese studets to health care providers for further evaluatio ad treatmet, ad participate i the developmet of weight loss ad maiteace programs. I additio, school urses may educate the school commuity regardig healthy lifestyle choices (Mehrley & Leibold, 2011). Research Problem School urses are i prime positios to recogize ad provide treatmet i respose to the growig prevalece of childhood obesity. School urses must have adequate kowledge regardig the causes ad health risks of childhood obesity. They also eed to utilize effective actios i their practice to assess ad treat childhood obesity, such as weight status screeigs ad referrals to weight maagemet programs. Research to explore school urses kowledge ad practice behaviors related to childhood obesity is importat to determie whether or ot school urses have a active role i addressig this issue. Research Purpose The purpose of this research study is to assess South Carolia school urses kowledge, opiios, perceptios, ad practice measures regardig childhood obesity.

13 3 Research Questios What kowledge, opiios, ad perceptios do South Carolia school urses have regardig childhood obesity? What practice measures do South Carolia school urses employ i addressig childhood obesity? Coceptual/Theoretical Framework Peder s Health Promotio Model, displayed i Figure 1, is the theoretical framework for this research study. Nola Peder first developed the Health Promotio Model durig the 1970s ad 1980s ad later revised the model durig the 1990s (McEwe & Wills, 2011). The Health Promotio Model focuses o health-promotig behaviors ad the factors that ifluece these behaviors. Peder believes that the ultimate goal of ursig is to aid others i providig care for themselves (Sakraida, 2010). Peder s Health Promotio Model is useful as the theoretical framework for research that examies health-promotig actios to improve the health of populatios. The major cocepts of the Health Promotio Model are idividual characteristics ad experieces, behavior-specific cogitios ad affect, ad behavioral outcomes (McEwe & Wills, 2011). Idividual characteristics ad experieces ecompass prior related behavior ad biological, psychological, ad sociocultural persoal factors (McEwe & Wills, 2011). These variables are determiats as to whether or ot a idividual will partake i healthpromotig behaviors. Behavior-specific cogitios ad affect ivolve perceived beefits of actio, perceived barriers to actio, perceived self-efficacy, activity-related affect, ad iterpersoal ad situatioal iflueces. These factors serve as motivators for health-

14 4 promotig behaviors ad may be iflueced by ursig care (Stark, Chase, & DeYoug, 2010). Behavioral outcomes iclude commitmet to a pla of actio, immediate competig demads ad prefereces, ad health-promotig behavior. These iflueces affect activities that cotribute to health-promotig behaviors (McEwe & Wills, 2011). For this study, the Health Promotio Model will be utilized to research South Carolia school urses kowledge, opiios, perceptios, ad practice measures regardig childhood obesity. Idividual characteristics ad experieces will explore South Carolia school urses demographic ad persoal iformatio. Behavior-specific cogitios ad affect will examie what the school urses view as beefits ad barriers to actio, ad also how competet the school urses feel about addressig childhood obesity. Behavioral outcomes will demostrate if the school urses make commitmets to plas of actio to idetify obese studets, refer obese studets to weight maagemet programs, ad promote healthy behaviors. Based o Peder s Health Promotio Model, two theoretical assumptios are applicable to this research study. The first theoretical assumptio is that South Carolia school urses will be kowledgeable about the causes ad health risks of childhood obesity. The secod theoretical assumptio is the school urses will use BMI screeigs o a regular basis to idetify obese studets ad refer these studets to weight maagemet programs. Data from the study will demostrate whether or ot these assumptios are supported.

15 Figure 1: Peder s Health Promotio Model (McEwe & Wills, 2011) 5

16 6 Sigificace to Nursig Childhood obesity is a importat health matter facig school urses. It is imperative that school urses are proactive cocerig this issue due to the chroic medical coditios associated with childhood obesity. Through appropriate idetificatio of obese studets ad referrals to weight maagemet programs, school urses are able to aid childre ad adolescets i adoptig healthy lifestyles. Research ito the kowledge, opiios, perceptios, ad practice measures of school urses regardig childhood obesity is sigificat to determie whether or ot school urses feel competet i their abilities.

17 7 CHAPTER II Research Based Evidece School urses ivolvemet i idetifyig ad treatig studets affected by childhood obesity has become a icreasigly importat topic. School urses ofte iteract with studets o a daily basis ad are valuable assets i addressig weight-related issues. Several published studies ad research joural articles have ivestigated the relatioship betwee school urses ad childhood obesity. Fidigs from these resources provide backgroud iformatio, research data, ad areas that eed further exploratio cocerig this subject. Review of Literature Oe study coducted by Murphy ad Polivka (2007) examied paretal perceptios of schools roles i addressig childhood obesity. Oe hudred sevetee parets of childre i a after-school program affiliated with a Ohio suburba school system completed the Paretal Perceptios of Body Mass Idex ad Obesity i School- Age Childre survey. The research tool asked yes/o ad Likert-type questios regardig parets familiarity with BMI screeigs, opiios cocerig obesity, causes of obesity, ad schools roles i the prevetio ad treatmet of childhood obesity. Eighty percet of respodets agreed that BMI is appropriate for schools to utilize i weight screeigs. Approximately 67% of participats selected that they would prefer to receive a letter from the school urse regardig their child s BMI. Sixty percet of parets i the study believed that schools should recommed treatmet for weight loss for childre ad parets who ask for help. I additio, over 80% of the parets felt schools should provide educatioal uits o utritio ad weight cotrol, as well as offer physical educatio classes. Peder s Health Promotio Model served as the theoretical framework

18 8 for the study. The model evaluated how the cocepts of perceived barriers ad perceived beefits iflueced paretal perceptios of schools roles i addressig childhood obesity. There were two mai assumptios based o the Health Promotio Model. First, perceived barriers would ihibit the iitiatio of actio i reducig childre s weight. Barriers icluded limited physical educatio classes, studets ot participatig i physical activity due to embarrassmet, ad poor quality of food choices at school. Secod, perceived beefits would lead to better school policies o the collectio ad distributio of BMI iformatio to parets. Beefits icluded implemetatio of health screeig programs, itroductio of special low-calorie meals, ad elimiatio of juk food machies to ecourage healthier lifestyles ad a reductio i childhood obesity. Nauta, Byre, ad Wesley (2009) coducted research to evaluate school urses kowledge ad practice measures regardig childhood obesity. Oe hudred three school urses from New Jersey, who atteded couty School Nurses Associatio meetigs, completed the School Nurses Perceptios of Childhood Obesity Tool. The istrumet was a 55-item, five-poit Likert-type questioaire that collected iformatio cocerig kowledge about childhood obesity ad weight cotrol programs, practices about referral for obesity, schools roles i weight cotrol, criteria utilized for determiig obesity, health risks related to childhood obesity, ad sources of weight cotrol iformatio. Fidigs from the study demostrated that school urses were overall kowledgeable about childhood obesity. Niety-ie percet of study participats believed that poor eatig behavior ad excessive caloric cosumptio were major cotributors to the occurrece of childhood obesity. Thirty-four percet of respodets stated that they recommeded treatmet for weight loss for obese childre. Sixty-five percet of the

19 9 school urses sampled i the study replied that they sometimes, rarely, or ever use agespecific BMI to calculate childhood obesity. Also, 77% of the urses believed that schools were ot doig eough to alleviate childhood obesity. Nauta et al. (2009) selected Peder s Health Promotio Model as the coceptual framework for this study. The Health Promotio Model focused o three factors to describe school urses kowledge ad practice regardig childhood obesity: idividual characteristics ad experieces, behavior-specific cogitios ad affect, ad behavioral outcomes. The key cocepts of the study were childhood obesity, kowledge, practice measures, ad school urses. Based o the Health Promotio Model, it was assumed that school urses would coduct BMI screeigs ofte ad iform families about weight cotrol programs. Overall, this assumptio was ot supported i the study s fidigs as less tha half of the respodets coducted regular BMI screeigs or recommeded weight loss treatmet. A qualitative study by Della Torre, Akré, ad Suris (2010) ivestigated the opiios of school stakeholders regardig childhood obesity prevetio. Forty school represetatives from six stakeholder sets i Switzerlad schools atteded focus groups. School directors, physical educatio teachers, caterig staff, school urses ad health educators, parets of youg adolescets, ad youg adolescet studets represeted the six stakeholder groups. The pricipal ivestigator utilized a semistructured questioaire to guide discussios o childhood obesity prevetio recommedatios. Subject matter for prompt questios icluded strategies to promote healthy eatig ad physical activity for studets, parters that should be ivolved i the developmet of childhood obesity prevetio measures, possible egative effects of obesity prevetio itervetios, ad recommedatios for plaig obesity prevetio programs. Healthy eatig, physical

20 10 activity, health messages, ad prevetio programs were the four major topics that emerged from the focus groups. I regards to healthy eatig, members of the focus groups ackowledged the improved quality of meals served i school cafeterias, but cited alterative uhealthy food optios ad lack of time to eat as barriers to childhood obesity prevetio. The school represetatives discussed the decreased amout of time studets spet i physical educatio classes as a challege to meetig adequate physical activity requiremets. Subjects agreed that health promotio messages were eeded i the school settig, but expressed cocers of effectiveess due to limited paretal support ad resistace from studets. I additio, participats reported that iitiatives for childhood obesity prevetio programs were curretly i place i schools; however, the programs required icreased coordiatio ad clearer guidelies for successful developmet ad implemetatio. Data aalysis was based o the grouded theory process to idetify predomiat ad reliable themes. Coceptual similarities ad differeces were derived from focus group members resposes to create explaatory schemes. Steele et al. (2011) aalyzed the perceived barriers school urses ecoutered i discussig weight issues with studets ad their families. Twety-two school urses from three school districts located i the Midwester Uited States participated i focus groups. The mai cotet areas for the focus groups were the school urses attitudes ad kowledge cocerig childhood obesity. Barriers idetified by the school urses were orgaized ito five categories: idividual (urse) factors, family factors, iteractios betwee urses ad families, istitutioal factors, ad societal factors. Regardig idividual (urse) factors, study participats stated that lack of kowledge or resources ad self-perceived competecy ihibited them from addressig weight issues with

21 11 studets. For family factors, subjects ackowledged that characteristics of studets families, familial cultural factors, ad lack of motivatio amog studets affected weightrelated discussios. Iteractios betwee school urses ad families were ihibited by barriers such as fear of others reactios, difficulty establishig relatioships with studets, ad egative past experieces whe addressig weight with studets ad their families. Cocerig istitutioal factors, respodets cited a lack of support from school admiistrators i relatio to childhood obesity, professioal time costraits, ad the food choices offered at schools as barriers. I the fial category of societal factors, school urses reported social orms, such as icreased sedetary behaviors, chagig perceptios of ormal weight, ad larger portio sizes of meals, as barriers to addressig weight-related issues. Brofebreer s Socioecological Model provided the coceptual framework for the study, which examied how macrosystemic ad exosystemic factors iteracted ad iflueced mesosystems ad microsystems. The topics of barriers, commuicatio, childhood obesity, school urses, ad weight-related health served as the major cocepts of the study. Jai ad Lagwith (2013) studied real-world implemetatios of itervetios addressig childhood obesity i school settigs. Six school districts from Florida, Georgia, ad Texas were selected to partake i the Activate for Kids iitiative. Activate for Kids was desiged to reduce obstacles i dealig with weight-related issues by providig traiig ad support to school urses ad by placig welless coordiators i the school districts. Nietee key iformats, icludig admiistrators, school urses, ad welless coordiators, participated i semistructured iterviews. Iterview questios were ope-eded ad focused o the establishmet of Activate for Kids, iformats

22 12 roles ad resposibilities related to childhood obesity itervetios, schools policies regardig welless programs, ad the implemetatio ad effectiveess of iitiatives. Overall, the iformats felt that Activate for Kids was successful with a icreased awareess amog studets of the coectio betwee weight status ad overall health. Subjects also idetified the participatio ad ecouragemet of school urses as valuable to the iitiative. Results from the study demostrated that i order to be successful, the program had to be customized based o specific eeds ad provide o-the-job support ad assistace. Furthermore, the study foud that havig a sigle perso committed to decreasig childhood obesity was essetial to chages i behavior ad practice. Brya, Broussard, ad Bellar (2013) discussed the collaborative relatioship betwee school urses ad physical educatio teachers i combatig childhood obesity. School urses had several primary roles related to weight maagemet i the educatioal settig. These roles icluded promotig ormal developmetal patters, facilitatig positive itervetio resposes, servig as leaders for health ad safety iitiatives, providig quality health care with idetificatio of health problems, ad workig with school ad commuity members to create a healthy learig eviromet for studets ad families. Through these roles, school urses were able to joi physical educatio teachers i developig istructive programs regardig childhood obesity. Compoets of these programs ivolved screeigs for BMI ad blood pressure, early detectio of overweight childre with appropriate itervetios, ad iformatio o healthy diet ad activity practices. This collaborative approach positively impacted the overall well-beig of studets ad their ability to make healthy lifestyle choices. The partership betwee

23 13 school urses ad physical educatio teachers also icreased the exposure of healthrelated iformatio ad reiforced the importace of addressig childhood obesity. Summary School urses are at the forefrot of the childhood obesity epidemic. Research has show that parets would choose to receive iformatio regardig their child s weight status from school urses ad that parets believe that schools should take more active roles i weight maagemet (Murphy & Polivka, 2007). Fidigs from aother study demostrated that school urses are overall kowledgeable regardig the etiology of childhood obesity, but age-specific BMI screeigs are ot routiely utilized for weight assessmets (Nauta et al., 2009). School stakeholders, icludig school urses, uderstad the importace of childhood obesity prevetio measures, but ecouter a multitude of barriers i addressig weight-related issues (Della Torre et al., 2010; Steele et al., 2011). Research fidigs also recogize school urses as key to establishig behaviors ad practices to decrease childhood obesity (Jai & Lagwith, 2013). Parterships ad collaboratios betwee school urses ad physical educatio teachers have a positive impact o iitiatives to promote healthy eatig patters ad appropriate activity levels (Brya et al., 2013). Further research is eeded to idetify school urses kowledge ad practice measures related to childhood obesity. I additio, it would be beeficial to ivestigate the impact that studets ages ad grade levels have o receptiveess to iformatio cocerig childhood obesity.

24 14 CHAPTER III Methodology Due to risig occurreces ad associated egative health effects, childhood obesity has become a prevalet medical topic requirig attetio (Bejami, 2011). Nurses workig i school settigs are i uique ad valuable roles to idetify obese studets ad develop obesity treatmet ad prevetio programs. School urses must have adequate kowledge ad appropriate practice measures to address childhood obesity. The purpose of this research study is to assess South Carolia school urses kowledge, opiios, perceptios, ad practice measures regardig childhood obesity. Implemetatio A quatitative study was coducted to research the kowledge, opiios, perceptios, ad practice measures of South Carolia school urses i regards to childhood obesity. A formal ad objective process was employed to collect data for statistical aalysis i order to describe variables (Burs & Grove, 2009). Participats respoded to a questioaire etitled, School Nurses Perceptios of Childhood Obesity Tool (Nauta et al., 2009). Permissio to use the questioaire was obtaied from the istrumet s developers. Settig Subjects respoded to the School Nurses Perceptios of Childhood Obesity Tool i a olie settig through the SurveyMokey website. The questioaire was uploaded to the secure website. Participats were able to aswer questios from remote locatios by usig computers with iteret access capabilities.

25 15 Sample Participats were recruited from a South Carolia lead school urse meetig ad idividual school websites. Subjects were cotacted via electroic mail. Six hudred ietee questioaires were set to school urses i South Carolia, ad 162 questioaires were completed. Desig A descriptive, correlatioal, cross-sectioal desig was utilized for this study. The research provided a accurate portrayal of South Carolia school urses while ivestigatig the relatioships amog several variables related to childhood obesity (Burs & Grove, 2009). Subjects completed the School Nurses Perceptios of Childhood Obesity Tool i a olie settig. Data was collected ad statistically aalyzed utilizig the IBM Statistical Package for the Social Scieces (SPSS) software program. Protectio of Huma Subjects Permissio from the Iterim South Carolia School Nurse Cosultat was obtaied for research purposes. The South Carolia Departmet of Health ad Evirometal Cotrol, the South Carolia Departmet of Educatio, ad the South Carolia Associatio of School Nurses were ot resposible or associated with this research study or results. Participats were ot exposed to ay risks or beefits durig the coductio of the research. Letters of iformed coset detailig the purpose, risks, beefits, ad volutary completio of the questioaire were set to all school urses cotacted for the research study. Subjects were protected throughout the implemetatio

26 16 ad dissemiatio of results by the cocealmet of idetifyig demographic ad persoal iformatio. Istrumet The research istrumet was the School Nurses Perceptios of Childhood Obesity Tool. The 55-item, five-poit Likert-type questioaire was origially developed by Price, Desmod, Ruppert, ad Stelzer i 1987 (Nauta et al., 2009). The questioaire was divided ito ie sectios based o the followig topics: school age obesity ad weight cotrol programs, school urses opiios cocerig childhood obesity, referral for obesity, school role i weight cotrol, defiitio of obesity, health risks associated with obesity, etiology of childhood obesity, sources of weight cotrol iformatio, ad demographic questios. Based o the sectios, aswer choices raged from agree or disagree, ratigs of how ofte actios were performed, ad rakigs of importace. Reliability of the origial istrumet was =.80. Three vetera school urses established cotet validity of the istrumet. Moyers, Bugle, ad Jackso revised the tool i 2005 ad admiistered it to 106 school urses (Nauta et al., 2009). Reliability of this revised istrumet was =.74. Nauta et al. (2009) utilized the revised istrumet i their study of New Jersey s school urses kowledge ad practice measures related to childhood obesity. Reliability of the revised istrumet for their study was =.77. Data Collectio The data required for the research study were aswers from the School Nurses Perceptios of Childhood Obesity Tool questioaire. South Carolia school urses were the sources of the data. addresses for South Carolia school urses were

27 17 collected from a South Carolia lead school urse meetig ad idividual school websites. Letters of iformed coset ad the hyperlik to the olie questioaire were set to the school urses via . Participats completed the questioaire, ad the data was stored o the SurveyMokey website. The researcher collected resposes to questios from the SurveyMokey website. Data Aalysis The researcher etered the data ito the IBM SPSS software program for statistical aalysis. There were two theoretical assumptios for data aalysis. First, South Carolia school urses would be kowledgeable cocerig the etiology ad health risks of childhood obesity. Secod, South Carolia school urses would use BMI screeigs o a regular basis to idetify obese studets ad refer these studets to weight maagemet programs. Summary A descriptive, correlatioal, cross-sectioal research desig was utilized to study South Carolia school urses kowledge, opiios, perceptios, ad practice measures regardig childhood obesity. Participats were cotacted via ad aswered questios from the School Nurses Perceptios of Childhood Obesity Tool. Resposes provided data for statistical aalysis usig the IBM SPSS software program. The researcher protected the rights ad privacy of subjects by maitaiig the cofidetiality of idetifyig iformatio..

28 18 CHAPTER IV Results As the prevalece of childhood obesity grows, it is importat to uderstad school urses kowledge, opiios, perceptios, ad practice measures regardig this health issue (CDC, 2012). I order to assess this iformatio, school urses from South Carolia completed the School Nurses Perceptios of Childhood Obesity Tool questioaire. Resposes to the questioaire provide isight ito school urses awareess of causes of childhood obesity ad related health effects. Major fidigs from the research study demostrate how childhood obesity is curretly beig addressed i South Carolia schools. Sample Characteristics The School Nurses Perceptios of Childhood Obesity Tool questioaire was set through electroic mail to 619 school urses i South Carolia. The fial sample size was 162 South Carolia school urses. All of the respodets did ot aswer all of the items for each collected questioaire. There were 457 total oresposes, ad o withdrawals or losses. Questios regardig demographic iformatio of the sample were located i sectio ie of the questioaire ad icluded level of educatio, credetials, umber of years practicig as a school urse, ad umber of studets ad grade levels school urses were resposible for at their schools. The majority of the subjects had a bachelor degree i ursig ( = 73), followed by a associate degree i ursig ( = 58). Most respodets were registered urses ( = 129) as opposed to licesed practical urses ( = 19). The years of practice spaed from 0.5 to 38 years with a mea umber of 11 years. The umber of studets that school urses were resposible for at their schools

29 19 raged from 0 to 4000 studets with a mea umber of studets. I regards to the grade levels of studets participats cared for, a majority reported preschool ad elemetary studets followed by middle school/juior high ad high school studets (Table 1). Table 1 Demographic Iformatio Items What is your level of educatio? Associate Degree i Nursig Bachelor Degree i Nursig Master Degree i Nursig Doctorate i Nursig Resposes = 58, (42%) = 73, (52.9%) = 7, (5.1%) = 0, (0%) What are your credetials? Licesed Practical Nurse (LPN) Registered Nurse (RN) = 19, (12.8%) = 129, (87.2%) How may years have you practiced as a school urse? Miimum Maximum Mea 0.5 years 38 years 11 years How may studets are you resposible for at your school(s)? Miimum Maximum Mea 0 studets 4000 studets studets What are the grade levels of studets you care for? (Select all that apply) Preschool Elemetary Middle School/Juior High High School = 44, (29.3%) = 93, (61.3%) = 47, (31.3%) = 30, (20%)

30 20 Major Fidigs The questioaire was divided ito ie sectios. Sectios oe through eight focused o school urses kowledge, opiios, perceptios, ad practice measures regardig childhood obesity alog with sources of weight cotrol iformatio. Sectio ie gathered demographic iformatio from participats to provide sample characteristics. Based o the sectios, aswer choices raged from agree or disagree, ratigs of how ofte actios were performed, ad rakigs of importace. Reliability of the istrumet was measured by Crobach alpha statistical testig. For this research study, the Crobach alpha coefficiet for the total istrumet was =.985. Sectio oe Sectio oe cotaied eight statemets measurig school urses perceptios regardig school age obesity ad weight cotrol programs. Participats were able to select Strogly Agree, Agree, Ucertai, Disagree, or Strogly Disagree based o the cotet of statemets. The Crobach alpha coefficiet for sectio oe was =.964. Most subjects strogly agreed that ormal weight was importat to the health of childre while the majority either strogly agreed or agreed that school urses should be role models by settig a example as oe who maitaied their ormal weight. Respodets were divided i their thoughts about the obligatio of school urses to cousel the parets of obese childre cocerig the health risks of obesity ad feelig competet i recommedig weight loss programs. The majority of study participats strogly agreed or agreed that desigig programs ad couselig childre ad parets about weight loss was difficult. The subjects resposes for couselig childre ad their parets o weight beig icoveiet were cocetrated aroud strogly disagree ad

31 21 disagree. Selectios for statemets cocerig professioal gratificatio for weight loss advisemet ad schools actios i alleviatig childhood obesity were spread out amog the optios (Table 2).

32 22 Table 2 Sectio Oe: School Nurses Perceptios Regardig School Age Obesity ad Weight Cotrol Programs Items 1. Normal weight is importat to the health of childre. Strogly Agree 119 (73.5%) Agree 42 (25.9%) Ucertai 1 (0.6%) Disagree 0 (0%) Strogly Disagree 0 (0%) 2. I believe school urses should be role models by settig a example as oe who maitais their ormal weight. 58 (35.8%) 89 (54.9%) 8 (4.9%) 4 (2.5%) 3 (1.9%) 3. School urses are obligated to cousel the parets of obese childre cocerig the health risks of obesity. 6 (3.7%) 45 (28%) 58 (36%) 45 (28%) 7 (4.3%) 4. I feel competet i recommedig weight loss programs for childre. 9 (5.6%) 37 (22.8%) 48 (29.6%) 56 (34.6%) 12 (7.4%) 5. Desigig programs ad couselig childre ad their parets about weight loss is difficult. 61 (37.9%) 82 (50.9%) 8 (5%) 7 (4.3%) 3 (1.9%) 6. Couselig childre ad their parets o weight is icoveiet. 6 (3.8%) 33 (20.6%) 24 (15%) 81 (50.6%) 16 (10%) 7. Couselig childre ad their parets o weight loss is professioally gratifyig. 9 (5.7%) 67 (42.4%) 61 (38.6%) 18 (11.4%) 3 (1.9%) 8. Schools are ot doig eough to help alleviate childhood obesity. 27 (16.7%) 51 (31.5%) 31 (19.1%) 46 (28.4%) 7 (4.3%)

33 23 Sectio two Sectio two had seve statemets regardig school urses opiios cocerig childhood obesity. Participats were able to select Strogly Agree, Agree, Ucertai, Disagree, or Strogly Disagree based o the cotet of statemets. The Crobach alpha coefficiet for sectio two was =.965. Most participats strogly agreed or agreed that childhood obesity was becomig more prevalet, that alleviatig childhood obesity was more importat to health tha alleviatig obesity i adulthood, ad that childhood obesity was a sigificat cause of peer rejectio. The majority of subjects strogly disagreed or disagreed that most obese childre would outgrow their obesity. Respodets were divided i their opiios about childhood obesity beig more ameable to treatmet tha adult obesity. Furthermore, the majority of participats strogly agreed or agreed that with proper guidace, most obese childre were able to lose sigificat amouts of weight ad maitai their weight loss (Table 3).

34 24 Table 3 Sectio Two: School Nurses Opiios Cocerig Childhood Obesity Items 9. Childhood obesity is becomig more prevalet. Strogly Agree 85 (52.8%) Agree 70 (43.5%) Ucertai 6 (3.7%) Disagree 0 (0%) Strogly Disagree 0 (0%) 10. Most obese childre will outgrow their obesity. 0 (0%) 3 (1.9%) 18 (11.2%) 97 (60.2%) 43 (26.7%) 11. Alleviatig childhood obesity is more importat to health tha alleviatig obesity i adulthood. 31 (19.4%) 79 (49.4%) 26 (16.3%) 24 (15%) 0 (0%) 12. Childhood obesity is a sigificat cause of peer rejectio. 47 (29.2%) 85 (52.8%) 17 (10.6%) 12 (7.5%) 0 (0%) 13. Childhood obesity is more ameable to treatmet tha adult obesity. 19 (11.9%) 69 (43.1%) 44 (27.5%) 25 (15.6%) 3 (1.9%) 14. With proper guidace, most obese childre are able to lose sigificat amouts of weight. 9 (5.7%) 74 (46.5%) 61 (38.4%) 14 (8.8%) 1 (0.6%) 15. With proper guidace, former obese childre are able to maitai their weight loss. 9 (5.6%) 84 (52.5%) 57 (35.6%) 8 (5%) 2 (1.3%)

35 25 Sectio three Sectio three was comprised of four statemets that focused o school urses referrals for obesity. Participats were able to select Strogly Agree, Agree, Ucertai, Disagree, or Strogly Disagree based o the cotet of statemets. The Crobach alpha coefficiet for sectio three was =.931. Most of the respodets strogly disagreed or disagreed that they usually recommeded treatmet for weight loss for all obese childre. I compariso, the majority strogly agreed or agreed that they usually recommeded treatmet for weight loss for childre or parets who asked for help. Participats recommedatios for weight loss treatmet varied for childre with a health problem affected by their obesity. Selectios also demostrated a predomiace of subjects strogly agreeig or agreeig that they usually did ot recommed treatmet for weight loss (Table 4).

36 26 Table 4 Sectio Three: Referral for Obesity Items 16. I usually recommed treatmet for weight loss for all childre who are obese. Strogly Agree 1 (0.6%) Agree 12 (7.6%) Ucertai 24 (15.3%) Disagree 103 (65.6%) Strogly Disagree 17 (10.8%) 17. I usually recommed treatmet for weight loss oly for childre (or parets of) who ask for help. 23 (14.6%) 84 (53.5%) 18 (11.5%) 27 (17.2%) 5 (3.2%) 18. I usually recommed treatmet for weight loss oly for childre with a health problem affected by their obesity. 9 (5.8%) 47 (30.1%) 26 (16.7%) 67 (42.9%) 7 (4.5%) 19. I usually do ot recommed treatmet for weight loss. 15 (9.6%) 74 (47.1%) 16 (10.2%) 50 (31.8%) 2 (1.3%)

37 27 Sectio four Sectio four ivolved four statemets cocerig school urses thoughts o schools roles i weight cotrol. Participats were able to select Strogly Agree, Agree, Ucertai, Disagree, or Strogly Disagree based o the cotet of statemets. The Crobach alpha coefficiet for sectio four was =.958. The majority of subjects strogly agreed or agreed that a comprehesive health curriculum with uits o utritio ad weight cotrol should be available i every school ad that schools should elimiate juk food machies. Most also strogly agreed or agreed that schools should offer special low-calorie luches ad that physical educatio classes, especially for overweight childre, should be available i every school. Respodets were divided i their thoughts cocerig whether or ot schools should offer o-site weight cotrol treatmet programs for studets (Table 5).

38 28 Table 5 Sectio Four: School Role i Weight Cotrol Items 20. A comprehesive health curriculum with uits o utritio ad weight cotrol should be available i every school. Strogly Agree 74 (48.4%) Agree 71 (46.4%) Ucertai 8 (5.2%) Disagree 0 (0%) Strogly Disagree 0 (0%) 21. Schools should elimiate "juk food" machies. 75 (48.7%) 47 (30.5%) 16 (10.4%) 14 (9.1%) 2 (1.3%) 22. Schools should offer special low-calorie luches. 49 (31.8%) 71 (46.1%) 17 (11%) 17 (11%) 0 (0%) 23. Schools should offer osite weight cotrol treatmet programs for studets. 26 (16.9%) 46 (29.9%) 42 (27.3%) 32 (20.8%) 8 (5.2%) 24. Physical educatio classes, especially for overweight childre, should be available i every school. 80 (51.9%) 61 (39.6%) 7 (4.5%) 6 (3.9%) 0 (0%)

39 29 Sectio five Sectio five focused o school urses defiitios of obesity by askig which methods respodets used to assess excess weight i childre ad adolescets. Participats were able to select Most of the Time, Ofte, Sometimes, Rarely, or Never based o the varyig optios. The Crobach alpha coefficiet for sectio five was =.934. Cliical impressio, body mass idex (BMI = weight/height 2 ), ad BMIfor-age percetile were the optios with the highest percetages of beig selected as used for most of the time. Ski-fold thickess percetile ad waist-hip ratio or waist circumferece were the optios most ofte selected as ever utilized. Overall, the majority of subjects respoded that they sometimes, rarely, or ever used most of the weight screeig methods to assess excess weight i childre ad adolescets (Table 6).

40 30 Table 6 Sectio Five: Defiitio of Obesity How ofte do you use each of the followig methods to assess excess weight i childre ad adolescets? Most of the Time Items 25A. Cliical impressio 47 (32.2%) Ofte 42 (28.8%) Sometimes 30 (20.5%) Rarely 6 (4.1%) Never 21 (14.4%) 25B. Weight for height percetile 22 (15.1%) 21 (14.4%) 26 (17.8%) 22 (15.1%) 55 (37.7%) 25C. Body mass idex (BMI = weight/height 2 ) 29 (19.9%) 18 (12.3%) 29 (19.9%) 18 (12.3%) 52 (35.6%) 25D. BMI-for-age percetile 25 (17.2%) 21 (14.5%) 25 (17.2%) 17 (11.7%) 57 (39.3%) 25E. Ski-fold thickess percetile 2 (1.4%) 2 (1.4%) 2 (1.4%) 21 (14.5%) 118 (81.4%) 25F. Waist-hip ratio or waist circumferece 1 (0.7%) 3 (2.1%) 3 (2.1%) 19 (13.3%) 117 (81.8%)

41 31 Sectio six The topic of sectio six was health risks associated with obesity as school urses i the study aswered the questio, What role does obesity play i the etiology of the followig diseases? Participats were able to select Major Role, Mior Role, or No Role based o the preseted health coditios. The Crobach alpha coefficiet for sectio six was =.819. The majority of all respodets idicated their beliefs that obesity played a major role i the developmet of hypertesio, coroary heart disease, strokes, diabetes mellitus type 2, stress, osteoarthritis, ad colo cacer (Table 7). Table 7 Sectio Six: Health Risks Associated with Obesity What role does obesity play i the etiology of the followig diseases? Major Role Items 26A. Hypertesio 146 (97.3%) 26B. Coroary heart disease 146 (97.3%) 26C. Strokes 139 (92.7%) 26D. Diabetes mellitus type (98.7%) 26E. Stress 120 (80%) 26F. Osteoarthritis 118 (79.2%) 26G. Colo cacer 84 (58.3%) Mior Role 4 (2.7%) 4 (2.7%) 11 (7.3%) 2 (1.3%) 28 (18.7%) 29 (19.5%) 53 (36.8%) No Role 0 (0%) 0 (0%) 0 (0%) 0 (0%) 2 (1.3%) 2 (1.3%) 7 (4.9%)

42 32 Sectio seve Sectio seve examied the causes of childhood obesity with the questio, What role do the followig items play i the etiology of childhood obesity? Participats were able to select Major Role, Mior Role, or No Role based o the preseted optios. The Crobach alpha coefficiet for sectio seve was =.911. The majority of all subjects expressed their opiios that poor eatig behavior, excessive caloric cosumptio, sedetary lifestyle, heredity, cultural factors, prevalece of machiedispesed juk food, lack of paretal cocer, ad low socioecoomic class played a major role i childhood obesity. Most felt that peer pressure, i utero developmet of adipose hypercellularity, ad hormoe problems had a mior role i the developmet i childhood obesity (Table 8).

43 33 Table 8 Sectio Seve: Etiology of Childhood Obesity What role do the followig items play i the etiology of childhood obesity? Major Role Items 27A. Poor eatig behavior 144 (96.6%) Mior Role 4 (2.7%) No Role 1 (0.7%) 27B. Excessive caloric cosumptio 146 (98%) 3 (2%) 0 (0%) 27C. Sedetary lifestyle 145 (97.3%) 27D. Heredity 95 (63.8%) 27E. Cultural factors 115 (77.7%) 4 (2.7%) 53 (35.6%) 32 (21.6%) 0 (0%) 1 (0.7%) 1 (0.7%) 27F. Prevalece of machiedispesed juk food 81 (54.7%) 64 (43.2%) 3 (2%) 27G. Lack of paretal cocer 128 (85.9%) 27H. Low socioecoomic class 104 (69.8%) 27I. Peer pressure 64 (43.8%) 20 (13.4%) 41 (27.5%) 71 (48.6%) 1 (0.7%) 4 (2.7%) 11 (7.5%) 27J. I utero developmet of adipose hypercellularity 32 (21.9%) 95 (65.1%) 19 (13%) 27K. Hormoe problems 56 (38.1%) 89 (60.5%) 2 (1.4%)

44 34 Sectio eight Sectio eight collected data o school urses sources of weight cotrol iformatio. Participats were able to select all sources they used cocerig the subject of childhood obesity based o a list of optios. The resources with the highest resposes were ursig jourals, workshops/semiars, ad past experiece. Colleagues ad mass media were also refereces for a majority of the respodets. Nursig school classes ad textbooks were the least utilized sources of weight-related iformatio (Table 9). Table 9 Sectio Eight: Sources of Weight Cotrol Iformatio Select all sources you use for iformatio o childhood obesity. Resposes Items 28A. Colleagues 85 (59%) 28B. Mass media 81 (56.3%) 28C. Nursig jourals 117 (81.3%) 28D. Nursig school classes 41 (28.5%) 28E. Past experiece 89 (61.8%) 28F. Textbooks 41 (28.5%) 28G. Workshops/Semiars 102 (70.8%)

45 35 Summary South Carolia school urses are valuable assets i addressig, treatig, ad prevetig childhood obesity. Data collected from the School Nurses Perceptios of Childhood Obesity Tool questioaire icreased the uderstadig of the kowledge, opiios, perceptios, ad practice measures of South Carolia school urses i regards to childhood obesity. Each sectio of the questioaire focused o importat aspects of childhood obesity, icludig defiitios of obesity, referrals for obesity, school role i weight cotrol, ad health risks ad etiology of childhood obesity. The Crobach alpha coefficiets demostrated the reliability of the istrumet ad questioaire sectios.

46 36 CHAPTER V Discussio Childhood obesity has become a sigificat health problem affectig America youth ad resultig i associated medical coditios (CDC, 2011). Through educatioal uits o balaced utritio ad physical activity i school settigs, childre ad adolescets are able to lear ad develop healthy habits. School urses are i prime positios to help combat childhood obesity as they care for select demographic groups affected by this disease. Idetificatio of overweight studets ad programs for weight loss ad maiteace are importat compoets to successful results. Implicatio of Fidigs Resposes to the School Nurses Perceptios of Childhood Obesity Tool questioaire provide isight ito South Carolia school urses kowledge, opiios, perceptios, ad practice measures regardig childhood obesity. Subjects agreed that ormal weight is importat to the health of childre ad that school urses should be role models i maitaiig their ormal weight. School urses uderstad that may studets observe the actios of others as examples for their ow behaviors. By displayig balaced eatig ad exercise habits i their persoal lives, school urses are able to have a greater impact o helpig studets make healthy lifestyle choices. Participats mostly agreed that desigig programs for weight loss is difficult. This perceptio of difficulty is reflected i the divided resposes of the school urses thoughts o their obligatios to cousel the parets of obese childre, their levels of competecy i recommedig weight loss programs for childre, ad schools actios i alleviatig childhood obesity. As weight iformatio is a sesitive subject to may studets ad parets, creatig

47 37 programs for weight loss ivolves rigorous adherece to evidece-based practice stadards to esure the safety of studets. The time commitmet required for weight status screeigs ad the developmet of successful weight loss programs may be overwhelmig for school urses as they already have umerous resposibilities. McBride, Hall, ad McKiey (2014) describe the duties of a school urse i their article, A Day Iside a School Nurse Office. The authors discuss the various medical coditios school urses potetially ecouter o ay give school day, icludig aaphylaxis, asthma attacks, ad studets experiecig abdomial discomfort. I additio to assessmets ad treatmets, school urses admiister medicatios, coduct health screeigs, develop health care plas for chroically ill studets, ad moitor immuizatio records to esure compliace with state stadards. School urses are challeged with fidig the time to complete these tasks while cotiuig to meet the health eeds of studets (McBride et al., 2014). The school urses i the study felt strogly i their opiios that childhood obesity is becomig more prevalet, that alleviatig childhood obesity is more importat to health tha alleviatig obesity i adulthood, ad that most obese childre are able to lose sigificat amouts of weight ad maitai their weight loss with proper guidace. School urses uderstad the growig prevalece of childhood obesity ad the health effects excessive weight may have o the preset ad future health of studets. The majority of all respodets idicated their beliefs that obesity plays a major role i the developmet of hypertesio, coroary heart disease, strokes, diabetes mellitus type 2, stress, osteoarthritis, ad colo cacer. Ecouragig studets to make chages i their dietary ad exercise behaviors aids them i creatig healthy habits that are favorable to

48 38 weight loss ad maiteace. This also helps studets to have healthy weight statuses ito adulthood. Despite the school urses beliefs that desigig programs for weight loss is difficult, they ackowledge that most obese studets are able to lose weight with supervisio ad support. May childre ad adolescets eed structure i order to complete tasks, ad havig a maaged weight loss pla may be beeficial to successful results. I relatio to this, a research study coducted by Pbert et al. (2013) examied the effects of a school urse desiged itervetio program for overweight ad obese adolescets. Subjects i the cotrol group atteded 6 oe-o-oe visits with the school urse over a two moth period. The visits allowed the school urse to assess the participats weight ad discuss weight-related iformatio. At the coclusio of the study, subjects reported eatig breakfast o more days each week, havig a lower itake of total sugar, ad limitig their soft drik ad fast food cosumptio (Pbert et al., 2013). Cocerig referrals for obesity, most of the school urses partakig i the study idicated that they usually do ot recommed treatmet for weight loss for all obese studets or treatmet for weight loss i geeral. However, the majority strogly agreed or agreed that they usually recommed treatmet for weight loss for studets or parets who ask for help. The professioal time costraits school urses face i completig madated ad required activities may be directly related to the lack of referrals for weight loss treatmet as they are ot able to scree the weight statuses of all studets. O the other had, whe studets or parets actively seek assistace, school urses are able to build persoal relatioships ad offer guidace. As school urses are employed i educatioal settigs, their thoughts o schools roles i weight cotrol affect their practice. Study subjects expressed their opiios that