The Role of Physical Therapists in Pediatric Health Promotion and Obesity Prevention

Comparison of Attitudes

Abstract

Purpose: 

To identify attitudes of teachers, parents, and physical therapists (PTs) toward PTs' roles in health promotion (HP), obesity prevention (OP), and physical activity (PA) for preschoolers.

Methods: 

Surveys (n = 618) were distributed to preschools and pediatric PTs.

Results: 

Overall response rate was 42%. Dietitians or physicians were selected as most knowledgeable about HP/OP/PA. Teachers were selected as most appropriate to educate preschoolers, whereas PTs were identified as appropriate to educate parents and teachers about HP/OP/PA. Most respondents were unaware of PTs' involvement in HP/OP/PA.

Conclusions: 

Physical therapist expertise is underrecognized and underused for pediatric HP/OP/PA. Parents and teachers are open to PT's involvement. Physical therapists need to improve awareness and become involved.

In Brief

After surveying parents, teachers, and PTs, the authors conclude that PT expertise is underrecognized and underutilized for pediatric health promotion and obesity prevention.

INTRODUCTION

Obesity is affecting children and adolescents at a startling rate.¹ Since 1980, the occurrence of obesity among school-age children and adolescents has tripled.^2–4 For children and adolescents, overweight is defined as being at or above the 85th percentile of body mass index (BMI) for age and gender, and obese is defined as being at or above the 95th percentile of BMI for age and gender.¹ Currently, 31.7% of children and adolescents 2 to 19 years old are overweight or obese.⁵ Although recent research indicates that high BMI levels among most children and adolescents have not significantly changed from 1999 to 2008,⁵ high BMI levels among children and adolescents continue to be a public health concern.

To prevent pediatric obesity, researchers have recommended that programs include the school, family, and community and focus on increasing physical activity (PA) levels^6,7; however, recommendations are not given regarding which specific health care professionals are the providers of choice to implement such programs. Thus, investigating perceptions of teachers, parents, and community members about who should assist in the implementation of preschool-based health promotion (HP) programs will benefit such programs and the students participating in such programs.

Studies of the perceptions of parents of preschoolers have indicated that many parents did not recognize that their child was overweight and many parents who were aware were either not concerned or did not know what action to take regarding their child being overweight.^8–11 Eckstein et al⁹ suggested that the first step to prompt families to participate in HP programs was to identify strategies to increase parent awareness. A focus group of mothers of preschool-aged children provided preliminary insight into 1 aspect of the problem by indicating that the lack of opportunity restricted their participation in parent education programs and their children's participation in PA (ie, broken or inappropriate playground equipment and allowing children to play outside only with adult supervision).¹² These mothers also indicated that they were interested in accepting support for obesity-prevention strategies for their children.

Whereas the reasons for the parents' failure to realize that their child was overweight remain unclear,^{8–11,13–15} the need for teacher and parent involvement in HP programs as well as teacher and parent education programs is clear.^{8–10,12–17} Although preliminary insight has been provided regarding parent¹² and teacher¹⁶ interest in learning more about HP, the knowledge and willingness of parents and preschool teachers to incorporate HP into the home and preschool as well as the willingness to attend education programs have not been adequately addressed. Also, none of the studies addressed which health care professionals had the knowledge and willingness to play a primary role in school-based HP programs or parent and teacher education programs.^{8–12,13–15}

A study of child care providers' perceptions indicated that child care environments should encourage preschoolers to be less sedentary by including indoor and outdoor PA opportunities.¹⁶ The child care providers also wanted additional education to enhance their skills in promoting health for preschoolers.¹⁶ Thus, there is a need for research to identify teachers' current knowledge, perceptions, and expectations of their roles in HP programs.¹⁷

Minimal research has been conducted regarding physical therapists' (PT) perceptions of their role in HP for the general student population. A study of 257 pediatric PTs gathered wellness promotion beliefs and practices and showed that 1 of 3 respondents was thinking of or preparing to incorporate wellness promotion into practice and only 54% were incorporating wellness into practice.¹⁸ The most frequently reported barriers to incorporating wellness into practice were resources, time, and lack of interest by the family and/or child. These findings provided preliminary insight into perceptions of pediatric PTs regarding their involvement in HP; however, this topic has not been adequately examined.¹⁸

PURPOSE

The purpose of this study was to identify the attitudes of public preschool teachers, child care teachers, parents, and pediatric PTs regarding the role of PTs in pediatric HP. We hypothesized that parents and teachers would not be aware that PTs could play a primary role in pediatric HP. We also hypothesized that PTs would be willing to educate parents and teachers, and parents and teachers would be willing to attend education classes. Finally, we hypothesized that except for PTs, no respondents would select PT as the first choice as most knowledgeable about HP or most appropriate to educate preschool students about HP because of lack of awareness of the PTs' role in this area.

METHODS

Participants

This study was approved by the institutional review board at the University of Indianapolis. Surveys were distributed to 3 randomly selected public school early-childhood programs, 3 randomly selected private preschool programs, and 2 randomly selected daycare centers within 2 zip codes in southwest Ohio, as well as to all pediatric PTs who were employed within these 2 zip codes. An administrative change during survey distribution resulted in a third daycare center declining to participate. Pediatric PTs were identified through a local phone directory. Parents and professionals from these zip codes were chosen on the basis of a sample of convenience; however, researchers assumed that the zip codes represented all socioeconomic classes in southwest Ohio. Survey participation was requested from every pediatric PT in these 2 zip codes and from every parent and teacher from each facility randomly selected within these 2 zip codes. A total of 618 surveys were distributed.

Survey Instrument

A paper-and-pencil survey was developed and consisted of 7 demographic items and 21 attitudinal items rated on a 5-point Likert scale. The reliability of the attitudinal items was checked by using Cronbach coefficient α (α = 0.84). Strong internal consistency of the survey tool was noted. For tool validation, question wording and the order of the questions underwent expert review by faculty members in Indiana, Ohio, and Tennessee. The survey items addressed which professional was perceived to be the most knowledgeable about and most appropriate to educate preschoolers about HP/obesity prevention (OP)/PA, the perceived role of pediatric PTs in HP/OP/PA, and parent and teacher involvement in HP/OP/PA.

Procedure and Data Analysis

Surveys were hand delivered to the facility administrators with a self-addressed envelope for survey return. A cover letter describing the research and survey instructions accompanied the survey and served as informed consent to participate. Facility administrators were instructed to distribute the survey to their staff and send the survey home with every student for the parents to complete. A sealed drop box was provided at each facility for survey collection. Participants completed the survey in 10 to 20 minutes. Respondents had 2 weeks to complete the survey. One week after survey receipt, a reminder letter was distributed. Survey responses were analyzed by using PASW Statistics (SPSS Inc, Chicago, Illinois). Descriptive statistics were used to analyze demographic information and nonparametric statistics (ie, Kruskal-Wallis test) were used to analyze difference in responses on the basis of participant and select demographic characteristics of the participants.

RESULTS

Demographics

Respondents were grouped by role: parents, pediatric PTs, public preschool teachers, and child care teachers (ie, private preschool and daycare center teachers). Teachers were grouped according to the state agency responsible for the regulation of the program (ie, Ohio Department of Education for public preschools and Ohio Department of Job and Family Services for private preschools and daycare centers). The overall response rate was 42% (Table 1).

TABLE 1: Demographic Information

Most Knowledgeable and Most Appropriate to Educate

With the choices of dietitian, nurse, parent, PT, physician, or teacher, overall, a majority of respondents selected dietitian or physician as the most knowledgeable person about HP/OP/PA and a majority of respondents selected teacher or parent as the most appropriate person to educate preschool students about HP/OP/PA (Table 2). When further delineated by role, a majority of parents and teachers indicated that dietitians or physicians were the most knowledgeable, whereas a majority of PTs chose PTs. A majority of parents indicated teacher or parent as the most appropriate to educate, whereas a majority of child care teachers chose parent, dietitian, or teacher; a majority of public preschool teachers chose PT or teacher; and PTs chose themselves.

TABLE 2: Most Knowledgeable and Most Appropriate Person to Educate About HP/OP/PA

Perceived Role of Pediatric PTs

When forced to consider only PTs by using a 5-point Likert scale, a majority of respondents agreed that PTs were appropriate professionals to educate teachers and parents on HP/OP/PA programs (Table 3). Broken down by target audience, all pediatric PTs, most public preschool teachers, and most child care teachers agreed that PTs were willing to educate teachers on how to include HP/OP/PA into preschool, whereas most parents were “neutral,” neither agreeing nor disagreeing. In regard to teaching parents how to include HP/OP/PA into the home, most pediatric PTs and public preschool teachers agreed that PTs were willing, whereas a majority of parents and child care teachers were “neutral.” A majority of pediatric PTs disagreed that PTs in their area were currently involved in HP/OP/PA programs, whereas a majority of all other participants were neutral in their response (Table 3).

TABLE 3: Perceived Role of Pediatric Physical Therapists

Differences in responses about the perceived role of PTs by respondent role, education level, and years of experience are shown in Table 3. A statistically significant difference (P < .05) was noted between parents and PTs and between child care teachers and PTs for item 9 (appropriate to educate teachers) and between parents and PTs for items 10 (willing to educate teachers), 13 (appropriate to educate parents), and 15 (PTs currently involved). Although all groups either strongly agreed or agreed that PTs are appropriate to educate parents, a statically significant difference (P < .05) was noted between the responses of participants holding a master's and bachelor's degree and between those holding a master's degree and a high school diploma. When examining years in professional role, no significant findings were noted.

Teacher and Parent Involvement

Most public preschool and child care teachers indicated that teachers were not currently educated to design and implement HP/OP/PA programs into the curriculum (Table 4). A majority of teachers indicated that teachers are willing to attend education programs on HP/OP/PA, are interested in learning specific programs for indoor and outdoor physical activities, and are willing to include HP/OP/PA in preschool. Most parents indicated that they would attend education programs on including HP/OP/PA in the home and were interested in learning specific programs for indoor and outdoor physical activities.

TABLE 4: Teacher and Parent Involvement

DISCUSSION

Health promotion is within the scope of practice of PTs,^19–21 but little research has been done to identify how aware those involved in the lives of preschool age children (i.e. teachers and parents) are about the abilities of PTs to play a primary role in HP. With all research hypotheses supported, the results of this survey call attention to the lack of general public knowledge of the role of PTs in pediatric HP and to the opportunity for PTs to get more involved in this area.

Most Knowledgeable and Most Appropriate to Educate

When given a list of health care professionals to choose from, our participants overall chose dietitians and physicians as most knowledgeable about HP/OP/PA (Table 2). Our data support previous research, indicating that parents view physicians as knowledgeable about HP.⁹ Previous research also suggested a lack of awareness among low-income mothers of the relationship between increased PA and health.¹⁰ Although demographic information on socioeconomic level was not gathered in this study, our findings might also suggest a lack of awareness of the relationship between PA and health, as a majority of respondents selected dietitians as one of the most knowledgeable professionals to address these issues. Participants may have had a greater association between nutrition and eating habits with HP and OP than between fitness and activity level. Except for PTs, our participants were generally unaware of the PTs' role in HP. Results of this study may also suggest an overall lack of awareness of the scope of practice of PTs and dietitians. The scope of practice of PTs includes health, wellness, and fitness,²¹ whereas in the state of Ohio, the scope of practice of a dietitian does not include exercise prescription or fitness.^22,23

When given a list of professionals to choose from, our participants overall chose teachers and parents as most appropriate to educate preschoolers about HP/OP/PA (Table 2). Our data support previous research, indicating the importance of teacher and parent involvement in HP.^13–17,24 Because a majority of public preschool teachers chose the PT or teacher as most appropriate to educate, our findings suggest that public preschool teachers were more aware than child care teachers and parents of the PTs' role in HP. Since students with special needs are integrated into public preschools with physical therapy as a related service, public preschool teachers may have more exposure to PTs and thus greater insight into the PTs' scope of practice.

Most PTs selected themselves as most knowledgeable and most appropriate to educate preschoolers about HP/OP/PA (Table 2). One exception, a PT, who had more than 20 years of experience, chose physicians as the most knowledgeable. With current PT programs having increased content in HP, this apparent lack of awareness from a veteran PT may be the result of the lack of emphasis on HP in entry-level education in the past. This is further supported by the PTs' responses by educational level in that all PTs with a postbaccalaureate degree selected themselves as most knowledgeable, whereas the responses of PTs with a bachelor's degree were divided between PT, dietitian, and physician. The apparent message here is that the recent emphasis on HP in our educational programs has indeed changed the attitudes of PT students, whether they are in a professional or postprofessional program of study.

Perceived Role of Pediatric PTs

In contrast to the previous findings based on a list of professionals, opinions about the role of PTs were more favorable when participants were asked to respond by using a 5-point Likert scale. Most participants agreed that PTs were appropriate professionals to be involved with HP/OP/PA (Table 3). Thus, although PTs were not the first choice of parents and teachers, respondents were willing to consider that PTs could be an important part of a team approach to address pediatric obesity. When asked specifically about the role of PTs, a majority of parents and teachers indicated that PTs were appropriate to educate parents and teachers about HP/OP/PA. These conflicting responses may indicate a lack of exposure or awareness of the PTs' role in HP when compared with other health care professionals.

In this study, a majority of respondents were aware that the role of PTs includes educating parents and teachers, although pair-wise comparisons indicated that not all were aware and that parents were the least aware (Table 3). These differences may indicate that parent and child care teacher exposure to PTs has been in the traditional role in which PTs are seen delivering patient care and caregiver education about a specific PT need of the patient. However, the reason behind this apparent lack of awareness was not investigated.

Similar to previous research demonstrating PT willingness to participate in HP,¹⁸ PT respondents in this study indicated their willingness to educate teachers and parents (Table 3). A majority of public preschool teachers also indicated that PTs were willing to educate teachers and parents. The neutral responses by parents and child care teachers in regard to the willingness of PTs to educate teachers or parents further supported the theory that parents and child care teachers may have had less exposure to PTs than public preschool teachers. Thus, parents and child care teachers were least aware of the PTs' role. Trends by education level and years in professional role also suggested that participants with a higher level of education or those with the least experience were more aware of PTs' role in HP.

All PTs stated that PTs were willing to educate teachers and parents (Table 3). Within southwest Ohio, few of the respondents were aware of PTs in the area who were involved in HP in preschools. These results could indicate that either PTs were not participating in pediatric HP programs in the area surveyed or, if PTs were involved in such programs, there was a lack of awareness of their efforts by the general public (parents and teachers) as well as other local PTs. This lack of awareness of PTs' involvement in HP programs in Ohio appears to contradict the findings of Goodgold,¹⁸ who reported that 54% of a national sample of PTs were incorporating wellness into practice. Although Goodgold¹⁸ asked PTs whether they were actually doing HP while we asked about awareness of it being done by PTs in the community, the argument could be made that incorporating HP into practice would also increase awareness of PT involvement in the community. The difference in results between the 2 studies can likely be attributable to the small sample from 1 city tapped in our study. Also, Goodgold¹⁸ focused on incorporating wellness into pediatric practice in general, whereas this study focused on HP in preschools.

Teacher Involvement

Although the knowledge and willingness of preschool teachers to incorporate HP into preschool had been minimally investigated,^13–17 our study indicated that a majority of teachers were willing to include HP/OP/PA into preschool, but they were not currently educated to design and implement programs (Table 4). Our results and previous research¹⁶ also indicated that teachers were willing to attend education programs on including HP/OP/PA into preschool and were interested in learning specific programs for indoor and outdoor physical activities.

Parent Involvement

Previous studies have suggested the need for OP programs for preschool parents.^8–10 Previous studies also reiterate the importance for future research to gather parent perceptions regarding pediatric obesity, PA, and parent willingness to participate in education programs.^8,9,11,13 Our results provided this insight with preschool parents, indicating that they would attend education programs on heath promotion in the home and were interested in learning specific programs for indoor and outdoor physical activities (Table 4).

While our results and previous research^12,15 indicated parent interest and willingness to participate in HP, opinions gathered by Goodgold¹⁸ indicated PTs' perceived lack of interest by the family as one of the most frequently reported barriers to incorporating wellness into practice by PTs. Apparently, there is a lack of knowledge or even misunderstanding with all groups (parents, teachers, and PTs) about each others' willingness and ability to contribute meaningfully to the solution for pediatric obesity. The results of our study seem to indicate a tremendous opportunity for PTs to expand their role in addressing pediatric obesity.

LIMITATIONS

Although the survey had a very good return rate of 42% (260 participants), this convenience sample used participants from 1 city; thus, not enough evidence is available to draw broad conclusions. Future studies should investigate perceptions of preschool teachers, parents, and PTs from a larger, more geographically diverse sample. Furthermore, the sample of respondents may have been biased with individuals more interested in HP being more likely to respond. The use of close-ended questions did not allow for participants to elaborate on the reasons for their choice of professional in regard to who was most knowledgeable or most appropriate to educate. Future research is needed to understand why participants chose particular professionals for those roles (ie, dietitian vs PT). Also, HP/OP/PA were examined together as a single variable. Thus, it cannot be determined whether participants' responses were in reference to only 1, 2, or all 3 components of this variable. Perhaps, responses would have been different if each component was queried separately.

CONCLUSIONS

Only PTs selected PT as the professional of choice for most knowledgeable about HP/OP/PA and most appropriate to educate teachers, parents, and preschoolers about HP/OP/PA. Clearly, the services of PTs in HP are currently underrecognized and underused by teachers and preschool parents. For teachers and parents to take interest in PTs as the professionals of choice in addressing pediatric HP, awareness of the PTs' knowledge and skill set needs to be heightened. Increasing parent and teacher awareness of the PTs' role in HP may lead to more opportunities for PTs in pediatric HP and may help to address the growing pediatric obesity problem.