Childhood Obesity: Approaches to Policy Change to Improve Population Health in Baltimore County Public Schools

1. Introduction

• Obesity contributes to poor population health outcomes and chronic diseases that increase the cost of healthcare for a community.
  
• Obesity and chronic disease impact the Social Determinants of Health and lead to financial insecurity and poverty, food and housing insecurity, and poor access to healthcare.
• The prevalence of childhood obesity is on the rise throughout the world.
• This paper illustrates the Advance Practice Nurse’s (APN) approach in leading health policy change to reduce childhood obesity in Baltimore County Public Schools (BCPS) in the state of Maryland.
• The APN participates in two approaches to policy change, the Top-Down Approach, and the Bottom-Up Approach using a Community-Based Participatory Research (CBPR) Method.

2. Public Policy Issue: Childhood Obesity

A. Child Obesity Statistics

• Childhood obesity affects 18.5% or 13.5 million youth, ages 2 to 19 in the United States (Centers for Disease Control and Prevention [CDC], 2018).
• Childhood obesity affects 15.7% of children ages 10-15 and 12.7% of high school-age children in the state of Maryland (The State of Obesity, 2017).

B. The Relevance of Child Obesity

• Childhood obesity impairs the healthy growth and development of young children and adolescents and contributes to chronic diseases like hypertension and heart disease, mental health disorders, and adult obesity (Zuraikat & Dugan, 2015).
• Childhood obesity leads to early-onset puberty, low self-esteem, and social discrimination (Zuraikat & Dugan, 2015).
• Childhood obesity is a product of cultural and genetic influences, socioeconomic status, and parenting styles (Zuraikat & Dugan, 2015).
• New physical activity guidelines recommend 60 minutes of aerobic exercise and muscle- and bone-strengthening activities daily for children ages 6-17 (U.S. Department of Health and Human Services [HHS], 2018).
• BCPS provides 20-30 minutes of recess for students in K-5, Physical Education (PE) for students in K-8, and 1.0 credit hour of PE for students in 9-12 (BCPS, 2017).
• BCPS offers intramural, extracurricular, and athletic programs middle school and high school students and encourages BCPS to incorporate physical activity during academics for all students if possible (BCPS, 2017).

C. Financial Impact: Child Obesity Prevention

• A reduction in childhood obesity improves community health and reduces high costs for healthcare, improves quality of life, and reduces health disparities in the population.
• A healthier community improves the local economy, reduces the cost of state/local healthcare expenditures, and improves financial stability for families.
• Healthy children and families have fewer sick days and improved opportunity for economic stability, food and housing security, and access to healthcare.
• The reduction of childhood obesity improves school attendance, improves student satisfaction, and increases the availability of community funds for teachers, schools, and community programs.

3. Nurse’s Role in Health Promotion

A. Guiding Ethical Principle

• Nurses have an ethical responsibility to engage in advocating for social justice by creating health policies that promote improved outcomes for population health (American Nurses Association, 2015).
• This policy uses the guiding ethical principle of Beneficence to improve population health and reduce the comorbidities associated with childhood obesity.

4. Policy Advocacy: Top-Down Approach

In the Top-Down Approach, a decision-maker uses rules, guidelines, and organizational structures to develop policies and uses a position of power and influence to implement change.

A. Identifying the Decision-Maker

• The decision-maker for this county-level policy proposal is the Executive member of the Board of Education, the Interim Superintendent (IS) of BCPS.

B. Policy Proposal

• Childhood obesity affects 15.7% of children ages 10-15 and 12.7% of high school-age children in the state of Maryland (The State of Obesity, 2017).
• The U.S. government recommends 60 minutes of daily vigorous physical activity for children ages 6-17 that includes aerobic exercise, muscle-strengthening, and bone-strengthen activities (HHS, 2018).
• “Physical activity fosters normal growth and development and can make people feel better, function better, sleep better and reduce the risk of a large number of chronic diseases” (HHS, 2018, p. 4).
• “The (BCPS) physical education program is conducted in accordance with state regulations and aligned with national and state standards” (BCPS, 2017, p.2).
• “School settings are …an optimal environment for interventions because children spend… many waking hours and consume one third to one-half of their daily calories in school” (Quelly, 2014, p. 292).
• A healthier community improves the local economy by reducing the cost of state/local healthcare expenditures, increasing the economic and educational opportunities, and improving the financial stability of families.
• The reduction of childhood obesity improves the health of BCPS students and families, improves student attendance and student satisfaction, and increases the community funds available for teachers, schools, and community programs.
• Based on this evidence, the APN proposes increasing vigorous physical activity in schools to 60-minutes daily for students in grades K-12 to reduce childhood obesity, reduce the incidence of chronic disease, and improve the population health in Baltimore County.
• The APN presents the evidence to the decision-maker, the IS of BCPS.

C. Outcomes of Policy Proposal: 3 Options

Option 1: The IS Rejects the Policy Proposal

• This proposal is too costly and does not represent the current goals and objectives for BCPS.
• The school system is overcrowded, and the school's infrastructure, athletic fields, and athletic facilities are outdated.
• This policy requires stakeholder buy-in from school leaders and teachers, parents, and students.
• This policy requires legislative action for school funding to update facilities, change curriculum and extend school hours, and negotiate teacher’s union contracts and bus transportation contracts.

Option 2: The IS Agrees to Accept the Proposal with Compromise

• The IS mandates the policy must include a joint-proposal between Baltimore County Recreation and Parks and BCPS to honor an existing contract as co-owners of the school’s recreational spaces.
• The IS agrees to present the proposal to the Board of Education but refuses to sponsor any modifications to the academic calendar.
• The IS agrees to present the policy to the Board of Education if a financial sponsor comes forward.

Option 3: The IS Adopts the Policy Proposal

• The IS works with the APN to introduce the policy proposal to the Board of Education.

5. Policy Advocacy: The Bottom-Up Approach

The Bottom-Up Approach uses a community-based approach to identify a community problem and develop a community-based solution.

A. Community-Based Participatory Research (CBPR)

• The Community-Based Participatory Research (CBPR) method uses community organizations, resources, and partnerships cooperatively to influence the decision-maker to implement policy change.
• The CBPR uses three guiding principles that include 1) building a strong community partnership between organizations, 2) using the strengths and resources of the local community, and 3) publishing the findings and outcomes of the CBPR process (Minkler et al., n.d.).

6. Evaluating the Effectiveness of the Two Approaches

A. Strengths of Each Approach

• The decision-maker leads the change with power and influence in the Top-Down Approach and improves the likelihood of policy success.
• The Top-Down Approach has a formal organizational structure with rules, guidelines, and predictable time tables for policy development and implementation that simplify the policy process.
• The Top-Down Approach takes less time and is less costly than the Bottom-Up Approach.
• The Bottom-Up Approach creates a strong base of support and creates alliances with influential organizations to improve the success of the policy process.
• The community learns about the legislative process and becomes empowered to solve community problems with the Bottom-Up Approach.
• The Bottom-Up Approach imposes a heavy community influence over the decision-maker.

B. Challenges of Each Approach

• The success of the Top-Down Approach is dependent on the interest and policy positions of the decision-maker.
• The success of the Top-Down Approach is limited policy if the decision-maker refuses to adopt the proposal.
• The Bottom-Up Approach that uses the CBPR process requires complex planning and involves many community members and organizations.
• The Bottom-Up Approach can lead to collaborative challenges between organizations with various policy positions, timetables, and levels of commitment.
• The Bottom-Up Approach requires a long-term commitment from its members and requires a long-term source of funding.