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Optum is part of United Health Group – a United States healthcare and insurance firm located in Minnetonka, Minnesota. Optum serves clients via three businesses namely, Optum Insight, Optum Rx, and Optum Health. Optum Health is the most important business line of United Health Group. Optum Care was established in 2011, and today it is a leading health service business. The company believes that a healthy life is one that is well lived.
Optum has a bold mission; “help individuals live healthier lives and make the health system work efficiently for everybody” (Optum, 2020). At the core of this mission is around 60,000 doctors who work together to assist people to live healthier lives (UnitedHealth Group, 2022). The target population comprises of at-least two million patients (children and adults) of mixed backgrounds including African Americans, Asians, Hispanics who have different health insurance plans including commercial, Medi-Cal, or senior plans. Health Enhancement department at Optum Health California is one of the most important departments of Optum Health. Health Enhancement department provides health education classes to Optum patients. Their mission is to help patients to better understand what is needed to maintain their health and helping the patients to achieve competencies with self- management of their diseases. Health Enhancement department has different health education programs including Living with Diabetes, Weight Management Program, and chronic kidney diseases. However, Optum Care has a service gap as it does not provide weight management sessions for children as compared to other health care organizations. Instead, Optum refers obese children to treatments programs in the community.
A program planning model acts as the organizing framework for a health promotion effort that seeks to reduce the incidence of a certain disease or condition. The PRECEDE-PROCEED model (Appendix A) is a detailed structure for evaluating health needs for planning, implementing and assessing health promotion and other public health programs to satisfy those needs. PRECEDE is a synonym for predisposing, reinforcing and enabling constructs in educational analysis and evaluation.
Precisely, PRECEDE entails evaluating these community factors, such as social assessment, epidemiological assessment, ecological assessment, identify policy, and interventions implementation (Porter, 2016). Social assessment identifies the social problem, needs and desired results of the population of interest. In the current program, the social problem is childhood obesity in children from 8-15 years old in Los Angeles County, CA. The desired result is to have children who are healthy and free from obesity. Epidemiological assessment involves identifying the health determinants of the problem of interest then set goals and priorities. Ecological assessment entails identifying the environmental and behavioral factors that predispose, strengthen and enable the lifestyle of behavior of interest. Identify policy and administrative factors that affect implementation and match the suitable interventions that encourage expected and desired changes.
PROCEED is a synonym for Policy, Regulatory and Organizational factors in program implementation. It entails identifying the desired outcomes and implementing the program. PROCEED involves implementation (identifying whether the needed resources are available), process evaluation, impact evaluation and outcome evaluation (Porter, 2016).
The rationale for choosing PRECEDE-PROCEED model is that Optum Care is a big organization, and the program targets a wide population comprising of parents. Hence, the PRECEDE-PROCEED model is the most appropriate as it provides a detailed and systematic framework for designing, implementing and assessing a public health program. The use of the PRECEDE-PROCEED model by Optum is appropriate because it starts by engaging the study population in a process of identifying their health issues. The model then guides practitioners and researchers in determining the cause of the problem at hand.
According to the Centers for Disease Control and Prevention (CDC), childhood obesity is a severe problem in the United States of America as it puts adolescents and children at risk of poor health (CDC, 2022). The prevalence of obesity in adolescents and children is high. Precisely, between 2017 and 2020 about 14.7 million adolescents and children were affected by obesity. The US Department of Health and Human Services and Office of Disease Prevention and Health Promotion (2021) further stated that one in every five adolescents and children in USA are obese while many others have weight issues. The CDC (2021) notes that obesity rates in California and Los Angeles are rising.
According to Child Health Data.org, (2022). The prevalence of obesity in California has been increasing since 2003. Specifically, 30.5% of children in California are either obese or overweight. Over 40% of school going children from California are overweight. Nobari et al., (2019) specified that 17% of children in Los Angeles County (LAC) are obese. As the county with the highest population in the United States, LAC has a diverse population of over 9.8 million individuals (CDC, 2021). The prevalence of childhood obesity in Hispanic children is 26.2%, 24.8% among non-Hispanic Black children, 9.0% among non-Hispanic Asian children and 16.6% among non-Hispanic white children (CDC, 2022). Recent statistics released by CDC show that the number of obese children increased during the COVID-19 pandemic. Precisely, obesity rate rose to 22% in 2022 from 19% in pre-pandemic. The greatest increase was observed in children 6-11 year of age as well as those who were overweight prior to the start of the pandemic (Dyer, 2021). The reason behind the rise in the rate of obesity is increase in screen time during the COV-19 pandemic.
A literature review shows that obesity in children is a complex issue with multiple causes (Pinto et al., 2016: Sahoo et al., 2015: Sanyaolu et al., 2019: Williams & Greene, 2018). Precisely, Sanyaolu et al. (2019) argued that obesity could be triggered by hormonal, nutritional, lifestyle, genetic, psychological, and environmental factors. However, childhood obesity is mainly caused by poor eating habits and low levels of physical activity, but these aspects can be controlled by parents and schools. Research by Healthy People.gov (2020) shows that around 81.8% of children and adults do not attain the recommended amount of physical activity. This was reiterated by Sahoo et al. (2015) and Sanyaolu et al., (2019).
Sanyaolu et al., (2019) indicated that modern-day children are not sufficiently active because only 16% of them bike or walk to school today, likened to 42% in the 1960s. Additionally, only 13.8% of school offer sufficient daily physical education classes for four or more hours in a week. Children also spend a lot of time on television and playing video games. Every additional hour of watching television per day has been linked to an increase in the possibility of developing obesity by 2% (Sahoo et al., 2015). If children spend more time on sedentary behavior, they consequently spend less time in physical activity.
Both educators and parents have a major role to play in efforts to prevent childhood obesity. This is because as stated by Sigmund, Sigmundová & Badura (2020), adolescents and children spend a lot of their childhood time in school and at home where their social, lifestyle and health related habits are formed through learning and the application of school and family rules. Bjelanovic et al. (2017) further argued that children receive meals in schools that are neither monitored by a nutritionist or standardized. Thus, to prevent childhood obesity, their eating habits in school should be observed to ensure they obtain the right diet. Additionally, schools can prevent obesity by educating students about physical activity and nutrition.
Moreover, physical activity and nutrition lessons should be included in the school curriculum to impart skills that children require to develop and maintain healthy lifestyles (Harvard School of Public Health, 2012). On the other hand, parents should ensure that children get the right diet while at home. Sigmund et al. (2018) reported on parents’ ability to form children’s health habits. Arredondo et al. (2018) likewise considers parents as “agents of change for their children”. Both researchers emphasize the crucial role played by parents in the failure or success of lifestyle interventions for overweight or obese children. They also agree that parents have significant influence on whether children participate in weight management programs (Sigmund et al., 2018; Arredondo et al., 2018).
According to Ickes et al. (2014) and Lambrinou et al. (2020) childhood obesity preventive efforts have frequently focused on schools because they prevent obesity by offering nutrition education, providing nutritious food and promotion of physical activity through policy, practice and supportive environment. Appendix B shows successful measures introduced by schools to prevent obesity. As shown in the table, schools can increase children’s PA level by for instance, requiring obese children to take part in a supervised lifestyle program and introducing active breaks. An example of an intervention conducted in schools is the European strength2Food project that sought to improve both the sustainability and nutritional quality of school meals (EUFIC.org, 2022). Schools also prevent childhood obesity by limiting advertising and marketing of food that contain excess fats, salt and/or sugar. Another intervention targeting schools is Coordinated Approach to Child Health. The program targets children from preschool to 8th grade and has been executed in numerous schools and after-school organization. The program has adopted a holistic approach which includes physical education and food service elements. Moreover, the program promotes healthy food choices and physical activity in children (Rural Health Information Hub, 2022). The program has been successful in preventing childhood obesity by improving children’s diet and increasing their levels of physical activity.
It is widely accepted that obesity results from an imbalance between the amount of energy taken in (in the form of food) and the amount of energy used (through physical activity and or exercise) (Sanyaolu et al., 2019; Sahoo et al., 2015; Anderson & Butcher, 2006). To put it simply, obesity occurs when a person eats more than their body needs to fuel its activities. From the ecological model, therefore, it can be concluded that obesity is caused by poor diet, physical activity, and sedentary behavior. Other factors such as genetic and hormonal also trigger obesity but that their contribution is minimal especially when the subjects are minors (Sanyaolu et al., 2019).
Nevertheless, according to Bandura’s social cognitive theory, an individual’s lifestyle and behavior, which, in this case, involve eating and exercising, are learned through social observation and subsequent imitation of modeled behavior. Humans, the children in particular, learn from observing the actions and resulting consequences of others, usually those in their regular environment, such as their parents or primary caretakers, teachers, brothers and sisters, and peers. They tend to imitate those behaviors which they observe to generate positive results and to unlearn those behaviors which they observe to generate negative results. Social cognitive theory highlights the importance of direct experiences and the capacity of an individual to perform a behavior. Human behavior, in this regard, is influenced by the dynamics between modelling, direct experiences, and self-efficacy. Basically, direct experiences are those that children learn by engaging in an activity or through the use of their senses. Meanwhile, self-efficacy denotes the belief that an individual is in control of and able to change a behavior. However, the proposed change in behavior has to be motivated with a positive outcome for it to happen. When a person believes that the behavior will not lead to a desired outcome, or in the face of an obstacle or aversive experiences, self-efficacy will not drive behavior change (Bandura, 1977).
Social cognitive theory, therefore, suggests that children are obese most likely because of the unhealthy lifestyle they have learned both from their environment and their own relevant experiences. For children between 8 and 15 years old, eating is mostly done at home and in school, during breaktime. Hence, it is safe to assume that the food regularly served to them in these environments as well as the eating habits they observe from the older members of their family, their teachers, and classmates all contribute to their eating behavior. Children will not only have to be served the right type and amount of food, but also be able to model healthy eating habits both at home and in school. Parents and teachers should act as role models to them. In addition to that, they should be motivated and given opportunities to engage in physical activities and or sports. This finding also suggests the importance of a family approach to intervening and or preventing obesity in children.
Then again, as discussed above, behavior change will not happen if the children do not believe that it will benefit them later on. It means that even when everybody else around them demonstrates a healthy lifestyle, children may still refuse to change if they are not convinced that they will get something good from it. Alternatively, despite the presence of negative influences in their environment, children may still adopt a healthy lifestyle if they believe that they will reap a reward from it. This, therefore, explains the need to not only educate children about the benefits of healthy diet and exercise but also to focus on those benefits that the children will be most interested in. It is important to identify the motivations of the children and on the specific benefits that will drive them to change a behavior.
Goal: To reduce the rate of obesity among children from low-income families in Los Angeles, CA. Studies show that obesity is more prevalent in children from low-income families than in children from more affluent families (citation here). On top of that, obesity leads to several health problems, including hypertension, breathing problems, cardiovascular dysfunctions, gallstones and gallbladder disease, psychological problems, and low self-esteem (CDC, 2022; Cui et al., 2019), which can financially burden families with minimal to zero health insurance.
Process objective: By the end of the first three months, the program planner will have recruited 50 parents and 50 children to initially participate in the education program. The basis for this number is the maximum seating capacity of the meeting hall where the program will be conducted. The next batch will be recruited while the program for the initial batch is ongoing. There will be a separate program for the parents and children based on the finding that they need different intervention strategy. The child participants will be identified using information as age and body mass index (BMI) through electronic health records. The parents will be invited to participate in the program through in-person invitations and using the snowball technique. The participants will be encouraged to invite others to join the program for the next batch.
Impact objective (immediate): After their first class, the participants should have understood the ill effects of obesity in children and appreciated the benefits maintaining a healthy weight. Such understanding will be demonstrated by their attendance to the next class. The first class, which, based on self-efficacy theory, will focus on motivation or convincing the participants to want to and believe that they can change their behavior, is effective if more than 80 percent of the participants come back for the next class.
Impact objective (medium term): Towards the end of the program, the participants will have started a healthy diet and physical activity/exercise routine. This will be determined through a written evaluation after the final week. The evaluation will consist of a series of questions to determine if they are applying what they learned from class.
Impact objective (long term): A follow-up evaluation/interview will be conducted every six months from the completion of the program to determine their progress. After the first six months, progress will be determined by at least a zero-percent increase in the body mass index (BMI) of the child participants. As a child can reduce a pound per month limiting daily intake to a maximum of 1500 calories and exercising for at least 60 minutes five days a week (Altman & Wilfley, 2014), the first year after the program will have reduced their weight by more or less six pounds.
The program will be a four-week health education class that follows a curriculum prepared by different healthcare specialists, including a registered dietician, a psychologist, a health educator, and an exercise physiologist. The classes will be held once a week, preferably Saturday, and will last for 2.5 hours. The participants will have to attend all four classes to complete the program and maximize the benefits of each class. A different topic or strategy will be discussed every week. The classes for parents and their children will be separate but held simultaneously on the same day. To comply with the legal and ethical requirements of the program, the parents will sign a consent form on the first day and be advised that their participation in the program is fully voluntary. They can opt out together with their children anytime they decide to.
Every class will comprise of; a) group discussions on promoting positive values, outcome expectations as well as skills and knowledge on healthy eating; b) demonstration of an ideal recipe following the PlateMethod; c) cooking demonstrations to promote self-efficacy for nutritious cooking; e) mindful eating techniques, topics will include lessening emotional eating, creating a home environment that lowers possibility of eating due to external cues and identifying internal cues to eating like satiety cues and physical hunger; f) teaching parents how to practice behavior modification tactics like self-monitoring; g) parents will receive informative/educational materials (like newsletters) that will comprise of useful information such as healthy recipes. The targeted newsletters will reinforce the skills that have been taught during the program; h) identification of barriers to adoption of a healthy lifestyle and how to overcome them; i) Homework comprising of cooking activities, parents will be required to cook healthy meals at home together with their children. Cooking demonstrations will not only boost parents’ knowledge of healthy cooking (behavioral capability) but also promote observational learning and split nutritious cooking in small steps (self-efficacy). Parents will also model to their children how to prepare and shop for healthy food options leading to transfer of crucial food preparation skills to children (Muzaffar, Metcalfe & Fiese, 2018). This means that children will be involved in observational learning. The takeaway assignment comprising of a parent-child hands-on cooking session will lead to improvement in children’s eating habits and cooking skills. This is because cooking at home is linked to better diet quality (Olfert et al. 2019). Besides, children who take part food-related activities have demonstrated higher self-efficacy for eating and choosing healthy foods.
Some parents do not cook healthy meals because of lack of time due to their busy work schedules while others lack knowledge on how to cook healthy meals (Kramer, 2014). The same argument was made by Olfert et al. (2019) who contended that some parents have limited food preparation skills and knowledge. Thus, as indicated by Lambrinou et al. (2020), the goal of educating parents will be to improve their behavioral capability and stimulate change in the home environment in a bid to promote the desired behavior (like consumption of vegetables and fruits, reducing ssedentary activity and discouraging consumption of high sugar/high fat foods). At the end of the session, parents will set healthy eating and PA goals which they will be expected to work towards achieving after the program is completed. The motivation of setting these goals is that parental practices like making unhealthy food products at home and their nutritional knowledge contribute significantly to children’s PA and eating habits (Döring et al, 2014). Besides, at the end of every session, there will be 15 minutes of answering questions that the participants will raise and wrap up.
The following are the important stakeholders/partners who are important in ensuring the success of the program.
Registered Dietician teaches Plate Method, healthy snack choice, and reading food label. MyPlate method will be taught and illustrated during classes. The method represents a healthy way to fill a plate in every meal. Based on MyPlate recommendations, half the plate should contain fruits and vegetables and the remaining half, should contain grains and proteins-proteins taking the smallest section (Kidshealth.org, 2022). Protein replaces meat since most proteins are not from animals. There is also a separate dairy section. MyPlate method also encompasses recommendations for PA (Kliegman et al., 2017). MyPlate method will be emphasized because most children in the USA do not take a diet that aligns with the suggestions of MyPlate. MyPlate will be used as a tool to help the dietician in educating parents on optimal eating plans for long-term and short-term health. Healthy snack choice is another topic that will be covered. The most appropriate snacks are those that are low in salt, fat, and sugar. They include fresh vegetables and fruits, low-fat dairy, protein foods and whole grains (Gavin, 2022). Healthy snacks add more nutrients to children’s bodies. However, research by Hart et al., (2015) shows that parents need nutrition education because their feeding practices like pressuring children to eat and limiting intake of snacks are linked to weight gain or unhealthy eating behaviors.
Psychologist: together with the dietician will focus on the mindful eating element of the program. Mindfulness will be covered as it aids in treating obesity by modifying challenging eating behaviors like intake of excess calories in response to external cues. According to Kumar et al. (2018), mindfulness-based interventions have proved effective in improving external eating, emotional eating and binge eating behaviors as well as boosting self-control. Mindfulness techniques have been reported as effective when taught to parents, children or both.
Health Educator will be teaching diseases associated with overweight and obesity, intuitive eating, and the psychological aspect of childhood obesity. The diseases thatchildhood obesity can contribute to include hypertension, dyslipidemia, cardiovascular disease and type 2 diabetes (Knol et al., 2016).
Exercise physiologist: will be teaching physical activities. Some of the topics that will be covered include; physical activity and play in management of children’s weight, children’s barriers to taking part in PAs and how to overcome them. The exercise physiologist will also cover the various exercises including active play, active gaming, endurance activities, resistance training, sport-based games, plyometric exercises and aerobic activities. Appendix D shows the physical activity guidelines that the exercise physiologist will discuss with parents. The exercise physiologist will still touch on frequency, intensity, Type and Time of activity (FITT) guidelines. A goal setting approach will be stressed as it will encourage steady increase in the physical activity level of children. Activities that the child considers as fun should be encouraged and parents should ensure there is someone for the child to play actively with. Games with siblings, friends and parents will enable the child to boost his/her confidence in active play (O’Malley & Thivel, 2015).
In line with the behavioral capability element of SCT, the program will seek to increase parents’ knowledge about the risks associated with having obese/overweight children and to further encourage parents to promote healthy behaviors. However, it is only parents who view excess weight as a health risk to their children who will be more motivated to promote healthy behavior as compared to those who do not. Hence, parental education and support is crucial in promoting healthy behaviors in children. Karmali et al., (2019) states that parental education is important in preventing childhood obesity since obesity related behaviors of children are influenced by their parent’s knowledge (how to cook meals that are healthy) modeling (being physically active themselves), encouragement, attitude (valuing PA) and support (logistical, financial and playing with the child).
Program evaluation will involve process, summative and formative evaluation. All participants (parents) and experts will review every aspect of the program. Process evaluation will involve an exit survey from every session. The exit survey completed after every class will request the participants to rate their experience using five questions pertaining to; a) quality of the information shared during the program; b) usefulness of the information; c) perception of MyPlate approach; d) overall experience and; e) location. Summative evaluation is whereby an interview guide comprising of a questionnaire will be used to gauge changes in the targeted behavior and other elements of the SCT. For instance, self-efficacy will be measured through the use of a 5-item survey to gauge how sure participants are that they can; a) take over five servings of vegetables and fruits daily: b) consume a vegetable like celery sticks or carrots for a snack; c) take a fruit as a snack; d) take a side salad as opposed to French fries when eating out; d) drink pure vegetable or fruit juice at meals. The answer options will be numeric on a scale of 0-10. This measurement was utilized by Ko et al. (2016) and demonstrated positive results. Perceived barriers will be measured with 4 statements and participants will choose whether they disagree or agree. Examples includes; ‘you lack skills required to prepare healthy meals’ and ‘you lack time to prepare healthy meals at home.’ Food outcome will be measured using 10 statements and participants will indicate whether they disagree or agree. Example is ‘if you take healthy foods daily, do you expect to miss the food that you like’
There will also be pre-and-post intervention interviews which will be done 1-2 weeks before the first session begins and after the first week is over. The aim of this interview will be to gauge whether the participants will be able to prepare their meal following MyPlate method. Ten open-ended questions will be asked and participants will respond. For instance, ‘participants will be asked; ‘are you able to follow MyPlate in every meal?’ and ‘are you able to eat the recommended servings of vegetables and fruits?’ Behavior change especially sedentary activity in children will be measured using two questions that asked parents to report the number of hours their kids played video games or watched television. The aim will be to determine if the participants are exercising for at least 30 minutes, 5 times per week.
Mindful eating will be measured using Mindful Eating Questionnaire (MEQ). Four of the five subscales of the MEQ will be used. They include; disinhibition, awareness of color, texture and flavor of food, distracted and emotional eating. A Likert Scale (1=never and 5=always) will be used to capture responses for the MEQ. Higher scores of MEQ were linked to more mindful eating techniques (Knol et al. 2016). To measure the change in obesity rate, participating parents will measure the weight and BMI of at-least one of their children prior to the start of the program. Two years after the program, the weights and BMI of the same children will be measured to identify if there is any change. The parents will also report the degree to which they are adhering to what was taught during the program. This will be measured using a Likert scale with these response options 1=never, 2=rarely, 3 sometimes, 4=0ften and 5=always. Qualitative interview data will be analyzed through thematic analysis. Whereas statistical analysis will be conducted for quantitative data.
