Perspectives on Community-Based Pediatric Obesity Prevention and Management Programs in South Korea: A Qualitative Interview Study of School and Local Public Health Center Providers

Abstract

Background

Pediatric obesity has increased globally, and South Korea has reported the highest prevalence in East Asia. Despite national policies addressing children’s nutrition and health, fragmented governance and overlapping programs may limit their effectiveness. We compared education and public health providers’ perspectives to identify barriers to pediatric obesity prevention and management (POPM) in South Korea and inform an integrated operational model.

Methods

This qualitative study included in-depth and focus group interviews with 25 POPM providers from 18 education and public health institutions. The interview guide addressed program operations, strategies, collaboration, treatment referrals, vulnerable populations, implementation facilitators, and optimal program design.

Results

Both sectors prioritized physical activity and nutrition and used physical assessments. Schools targeted individual students, whereas public health centers targeted institutions. Barriers included low participation, limited resources, weak coordination, and inconsistent referral pathways, with few services for out-of-school youth. Suggested facilitators included greater parental awareness, provider training, clear guidance, stronger community linkages, and adequate funding.

Conclusion

Providers’ accounts of fragmented roles, weak coordination, and referral gaps support consideration of a school-centered model with local public health center support and clearly defined institutional roles. Such a model would require sustained support for participation, implementation guidance, and workforce development. It would also require clinical referral pathways, including for medically vulnerable children, and improved data infrastructure.

INTRODUCTION

The global prevalence of overweight and obesity continues to rise; if current trends persist, more than 4 billion people will be affected by 2035.¹ Pediatric obesity imposes substantial health, economic, and social burdens, underscoring the need for prevention.^2,3 Among East Asian countries, South Korea has been reported to have the highest combined prevalence of overweight and obesity among children and adolescents from 2010 to 2022: approximately 43.0% in boys and 24.6% in girls.⁴ Pediatric obesity is therefore a major public health concern in South Korea.

Pediatric obesity reflects an interplay of genetic, endocrine, environmental, behavioral, dietary, and socioeconomic factors. It therefore requires responses beyond the individual and family levels. Obesity in childhood and adolescence increases chronic disease risk and can affect physical and mental health, social participation, and self-esteem. Approximately 80% of children and adolescents with obesity remain obese in adulthood, increasing their risk of adult-onset disease.⁵ These consequences support coordinated national prevention and management strategies.^3,6

In response, South Korea has implemented several public policies aimed at improving children’s nutrition, dietary practices, and health awareness. Examples include the ‘Special Act on the Safety Management of Children’s Dietary Life’ (Ministry of Health and Welfare), the ‘National Health Promotion Act’ (Ministry of Health and Welfare), the ‘School Meals Act’ (Ministry of Education, Science and Technology), the ‘Support for Diet Education Act’ (Ministry of Agriculture, Food and Rural Affairs), as well as the ‘Comprehensive National Health Plan and the Basic Plan for National Nutrition Management.’⁷ However, without integrated governance across ministries, programs may overlap and serve the same groups, raising concerns about efficiency.^8,9 At the community level, local public health centers collaborate with community child care centers, schools, child welfare facilities, and health management associations to operate short-term obesity programs.¹⁰ Current pediatric obesity prevention and management (POPM) programs remain largely school-based and generalized, with limited tailoring to children’s characteristics or obesity severity.¹¹

We therefore sought to identify challenges in South Korean POPM programs and potential strategies for improvement. We interviewed providers and other stakeholders involved in these programs.

METHODS

Study design and data collection

We conducted in-depth and focus group interviews (FGIs) with POPM providers. The study was conducted as part of a larger project, ‘Research on Empowerment of Prevention and Management of Pediatric Obesity,’ commissioned by the Korea Disease Control and Prevention Agency (KDCA). A preceding structured quantitative survey informed the interview guide.¹¹ The guide covered program operations, improvement needs, future directions, collaboration, treatment referrals, vulnerable populations, and implementation facilitators (Table 1). Core questions were adapted to each interviewee’s affiliation, position, and responsibilities. Study design, data collection, and reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Table 1.

Main topics covered in the in-depth interviews

	Content
Program operation	Roles and responsibilities of institutions in pediatric obesity prevention projects Project focus and target population Operational challenges, including difficulties in adjusting operating hours
Awareness and direction	The concept of active intervention for students who are not aware of their own obesity Severity of pediatric obesity Necessity of obesity programs for students Essential role of institutions, especially for students, in obesity prevention
Collaboration	Status and methods of collaboration with external organizations, including public health institutions Degree of connection with relevant organizations and outcomes of such efforts
Treatment linkage	Current status of treatment linkage for participants who need medical intervention
Perception of vulnerable groups	Status of projects targeting out-of-school children/adolescents
Key factors for program activation	Key elements required to vitalize programs Important or critical considerations during implementation
Suggestions for appropriate program operation	Suggestions on appropriate duration, frequency, session time, staffing and teamwork, evaluation methods, and key components of effective programs
Others	Additional suggestions

Participants and recruitment

We interviewed 25 providers from 18 institutions: twelve urban and six rural sites with varying levels of program implementation. The education sector included six urban and four rural institutions, and the public health sector consisted of six urban and two rural institutions. Participants included educators, administrators, and healthcare specialists. Detailed demographic profiles were anonymized in the report to protect participants from potential identification through their combined regional and professional information (Table 2). Study sites were primarily selected based on recommendations from the KDCA. To broaden the range of perspectives, we also recruited institutions in underserved areas and those with limited program implementation. We included institutions with established programs as well as those facing operational challenges or expressing a strong willingness to participate. Interviews were conducted in person or remotely according to institutional preference.

Table 2.

Distribution of participating institutions by region

Region	Public health sector*	Education sector†	Total institutions
Seoul metropolitan city	2	5	7
Gyeonggi (Gyeonggi-do and Incheon)	2	3	5
Gangwon	1	0	1
Chungcheong (Daejeon, Sejong, Chungbuk, and Chungnam)	1	0	1
Jeolla (Gwangju, Jeonbuk, Jeonnam, and Jeju)	1	1	2
Gyeongsang (Busan, Daegu, Ulsan, Gyeongbuk, and Gyeongnam)	1	1	2
Total	8	10	18

^*Public health sector: providers from local public health centers; ^†Education sector: providers from Offices of Education, schools, the Center for Childcare Foodservice Management, and academic experts.

Five interviewers used a common guide and protocol to promote consistency. After each interview, findings were documented on standardized reporting sheets. Institutional selection considered geography and urban–rural setting; individual selection considered affiliation and position.

Ethical considerations

Before data collection, participants were informed of the study’s purpose, procedures, potential benefits, and risks. Written informed consent was obtained from all participants. The study protocol was reviewed and approved by the Institutional Review Board (IRB) of Soonchunhyang University Bucheon Hospital (IRB approval No. SCHBC 2023-08-011-001).

RESULTS

We compared education and public health providers’ accounts across seven themes: program operation status, awareness and strategic directions, linkage status, clinical referral linkage, interventions for vulnerable groups, facilitators of program implementation, and recommendations for optimal operation (Table 3).

Table 3.

Comparison of public health and education provider perspectives on pediatric obesity prevention and management

Category	Public health sector	Education sector
Primary programs	Practice-oriented physical activity and nutrition interventions	School-based physical activity and nutrition education
Evaluation tools	Anthropometric measurements and surveys	Physical Activity Promotion System (PAPS)
Target and approach	Setting-based approach (daycare centers, schools, etc.)	Individual-student-focused (based on PAPS grades)
Operational barriers	Concerns over social stigma and lack of data/standardized manuals	Low parental awareness and infrastructure (time/staff) constraints
Strategic goals	Ongoing monitoring, hands-on training, and incentives	Environment creation and securing protected time for practice
Intra-linkage	Consistent interdisciplinary collaboration (within the same team)	Ad hoc/project-based linkage (limited to specific initiatives)
Inter-linkage	Proactive partnerships for space and program delivery	Passive engagement (responding to external requests)
Clinical referral constraints	Lack of specialized expertise and absence of accessible medical institutions	Perception of school roles limited to health management (parental responsibility)
Vulnerable populations	Awareness of the need, but limited by data gaps and low participation	Absence of dedicated programs for out-of-school youth
Facilitators	Clear policy/institutional mandates and multidisciplinary staffing	Improved parental awareness and community-linked infrastructure

Program operation status

Both sectors mainly delivered physical activity and nutrition programs. For evaluation, education providers used the Physical Activity Promotion System (PAPS), a mandatory annual student health and fitness assessment, whereas public health providers used physical measurements and surveys. Targeting also differed: the education sector focused on individual students, particularly those classified in PAPS grades 4 or 5, which indicate low physical fitness and high obesity risk according to a 5-tier national scale (where grade 1 is the highest). Public health providers instead worked with daycare centers, kindergartens, schools, and community child care centers.

“We operate physical education programs according to PAPS physical fitness grades.” (Education sector) “We provide nutrition education and cooking practice for students at community child care centers.” (Public health sector)

Both sectors described difficulties with interinstitutional cooperation. The education sector reported limited awareness among parents/guardians and students, insufficient infrastructure (facilities, resources, personnel, and time), and a shortage of specialized instructional materials. In contrast, the public health sector emphasized stigma-related difficulties in selecting participants, a lack of data, guidelines, and manuals to support program planning and implementation, and limited budgets and qualified personnel.

“It is difficult to obtain consent from parents/guardians, and participation rates are low.” (Education sector) “The public health center budget is insufficient, and without school cooperation we cannot proceed.” (Public health sector) “Even when cooperation is requested, nothing can move forward if the principal is not interested.” (Public health sector)

Awareness and strategic directions for POPM

Providers in both sectors recognized the seriousness of pediatric obesity and the need for POPM programs. Their proposed approaches differed. The education sector emphasized education, management, and provision of protected time and supportive environments for practice. Public health providers prioritized ongoing monitoring, hands-on physical activity and nutrition training, creating supportive environments, and offering incentives to motivate children and adolescents.

“Education is important, but rather than just delivering knowledge, we need to provide time and an environment for practice.” (Education sector) “Incentives. If they achieve their goals and are rewarded, word spreads, and it motivates them.” (Public health sector)

Providers in both sectors favored school-led POPM programs supported by public health centers.

“It’s most efficient if schools lead the programs and public health centers support them.” (Public health sector)

Linkage status

Within institutions, providers in both sectors reported difficulty coordinating across separate departments. Education providers described coordination mainly within designated initiatives, such as Research Schools or Healthy Dream School projects; public health providers reported more routine coordination when physical activity and nutrition staff worked in the same team.

“We have experience linking physical education, homeroom, and art when designated as a research school.” (Education sector) “Physical activity and nutrition are organized as one team, so linkage is constant.” (Public health sector)

Public health providers described more active and structured external collaboration. Education providers generally promoted programs when outside organizations requested it. Public health providers partnered with daycare centers, schools, and community child care centers, typically providing physical activity and nutrition programs and conducting before-and-after evaluations while partner institutions provided space.

“The public health center provides physical activity programs, and the school only lends the space.” (Public health sector) “When requests come from the public health center or the Office of Education, we just provide information about our operating programs.” (Education sector)

Linkage for treatment

Neither sector reported routine treatment referrals. Education providers viewed schools as responsible for student health management but considered treatment referral a parental or guardian responsibility. Public health providers cited limited specialized knowledge, low parental awareness, and a lack of accessible medical institutions able to receive referrals.

“Even if we highlight the results on the notification and send it, there’s nothing we can do if parents/guardians don’t follow up.” (Education sector) “There are no institutions to link with, and even if we have linkage, we don’t know where to send them.” (Public health sector)

Intervention for vulnerable populations

Both the education and public health sectors reported that they did not operate programs specifically targeting out-of-school children and adolescents. Although the public health sector acknowledged the importance of dedicated programs for this group, providers cited difficulty identifying eligible individuals because of limited data and reported low participation.

“We feel the need, but there’s no data for identifying out-of-school children.” (Public health sector) “When it comes to out-of-school children, we tend to think of risky behaviors before health.” (Public health sector)

Program facilitation factors

Education providers called for greater awareness among parents, guardians, and children; more provider training; stronger community links; public outreach; and adequate budgets and facilities. Public health providers similarly emphasized communication, facilities, funding, and clearer policy and institutional arrangements.

“It’s most important to educate parents/guardians and students that ‘obesity is a disease.’” (Education sector) “Facilities are important. Where you receive the program is linked to trust.” (Public health sector)

Education providers also stressed addressing family living environments (e.g., socioeconomic factors), motivating parents/guardians and students, acknowledging limitations of public health center-led models, ensuring sustainability, and providing guidelines or materials. Public health providers highlighted designing programs that sustain students’ interest, securing cooperation from the Ministry or local Offices of Education, conducting programs within schools, establishing local linkage systems, and creating a specialized coordinating organization.

“Ultimately, without the improvement of parents/guardians’ awareness and students’ participation, it’s impossible.” (Education sector) “If the Ministry of Education includes it as an evaluation factor, or designates excellent schools, participation will increase.” (Public health sector)

Providers’ perspectives on optimal program operation

Providers differed in their views of optimal program design. For appropriate operating periods, the education sector proposed semester-long or year-long programs, whereas the public health sector suggested durations of 6 months or more (with 3 months considered the minimum feasible period) or programs conducted during school breaks. Recommendations for frequency and session duration also differed: the education sector recommended twice a month to once a week or more (30 to 60 minutes), while the public health sector proposed three or more sessions per week, lasting 40 to 120 minutes.

“It would be possible if it’s included within class hours as an integrated program.” (Education sector) “Realistically, it needs to be at least 2–3 times a week, for over 40 minutes, to be effective.” (Public health sector)

Education providers recommended at least three staff members, including nutritionists, exercise specialists, and obesity treatment specialists; public health providers suggested two or three staff members from exercise, nutrition, and nursing. Both sectors found it difficult to estimate an appropriate budget. Across sectors, providers emphasized interinstitutional collaboration and systematic support for evaluation, recruitment, and delivery (Table 4, Fig. 1).

Table 4.

Providers’ perspectives on optimal program operation

Question	Suggestion
Appropriate program duration	At least 6 months (with at least 3 months suggested as a practical alternative) Only during school break periods
Appropriate program frequency	At least three times per week (with at least twice per week suggested as a practical alternative)
Recommended time per session for participants	40 to 120 minutes
Number and type of supporting personnel	2–3 professionals per program, typically including exercise, nutrition, and nursing or obesity-management specialists
Appropriate budget level	Difficult to estimate
Recommendations for optimal program composition	Combine physical activity and nutrition education; theoretical education on obesity prevention should precede Education to correct eating habits and physical activity behaviors
Appropriate evaluation methods	Pre-, mid-, and post-evaluation (if operated for more than 6 months) Evaluation methods: anthropometric measurements (BMI, etc.), blood tests conducted in healthcare institutions, surveys (awareness and satisfaction)
Recommended participant recruitment methods	Promotion and application recruitment through cooperation with the Ministry of Education and schools
Essential elements for program enhancement	Active promotion Infrastructure Budget support Institutional and environmental improvements

BMI, body mass index.

Figure 1.

Integrated perspectives on optimal program operation. This conceptual model was developed based on the perspectives of program providers and integrates seven key components identified as important for effective program implementation: program duration (at least 6 months), frequency (at least three sessions per week), post-program evaluation (anthropometric measurements, blood tests, and satisfaction surveys), facilitating factors (infrastructure expansion, financial support, and systemic and environmental improvements), staffing (2–3 professionals per program), session duration (40–120 minutes), and program content (physical activity and nutrition). Blood tests are conducted at healthcare institutions. The central element illustrates the integration of these components into a comprehensive approach to program implementation.

DISCUSSION

Our interviews indicate that although both the education and public health sectors acknowledge the seriousness of pediatric obesity and the necessity of POPM, they differ in implementation approaches. The education sector emphasizes broad, school-based physical activity and nutrition education and uses PAPS for evaluation; however, barriers include obtaining parental or guardian consent, sustaining participation, limited awareness, and a shortage of specialized instructional materials. Public health providers, by contrast, deliver programs through institutions such as kindergartens and schools but face structural constraints, including stigma in participant selection, insufficient data and practical guidance, and chronic shortages of budget and specialized personnel. Both sectors therefore face resource and coordination constraints that may undermine program coherence and sustainability.¹⁰

The sectors also differed in their approaches to intervention. Education providers emphasized teaching, management, and supportive environments. Public health providers emphasized monitoring and practical physical activity and nutrition services. This pattern aligns with international qualitative evidence showing that the adoption and sustained delivery of school-based programs depend on institutional leadership, staffing capacity, clear guidance, and the broader external environment and partnerships.^12,13 It is also consistent with primary-care reports identifying stigma concerns, limited consultation time, and the need for more structured support.¹⁴

Public health providers described more external collaboration, although some activities appeared to be driven by performance evaluation requirements rather than integrated planning. Neither sector reported consistent clinical referral pathways for students who require medical intervention, underscoring a need for coordination among schools, families, and community primary care.^10,15

Out-of-school children and adolescents were a notable gap in provision. Neither sector reported tailored programs for this group, and limited information about their needs complicates intervention planning.¹⁶ International evidence suggests that weight stigma, particularly among adolescents from low-income backgrounds, can reduce engagement and worsen disparities.^17,18 Consistent with these findings, both adolescents and caregivers report deficits in motivation, stigma-related barriers, and unmet needs for practical support. These concerns parallel Korean caregiver FGIs that highlighted the need for clearer guidance, accessible resources, and stigma-sensitive interventions.¹⁹

Together, these findings support consideration of a school-centered model in which public health centers assist with monitoring, workforce training, and clinical referrals. Implementing such a model would require greater parental participation, provider training, community links, clear guidance, and adequate funding and facilities, consistent with earlier work.²⁰ Stigma-sensitive data systems could draw on school records and surveys that include out-of-school children, with feedback to inform programs without reinforcing stigma.¹⁶ The clinical practice guidelines for pediatric obesity from the Korean Society for the Study of Obesity reaffirm the importance of early diagnosis and systematic management based on severity, specifically emphasizing multidisciplinary approaches and structured referral systems.²¹ Evidence on preventive strategies can further guide communication and implementation components.²² Delivery would also depend on manuals, staff training, resources, and structured community partnerships.^11,20

Participatory approaches may improve the acceptability of school-centered POPM for adolescents; government-level coordination could help address referral gaps.²³ In addition, the respective roles of schools, local public health centers, families, and primary-care institutions should be clearly defined. Child-centered, tailored, and sustainable POPM may help reduce pediatric obesity and its associated health and social burdens.^1,3,5

This study has several limitations. It reflects only the perspectives of providers in the education and public health sectors and does not fully incorporate the viewpoints of parents/guardians or students. Although regional distribution and institutional size were considered, the sample may not represent all providers, and reliance on self-reported interview data may have introduced recall or social desirability bias. Participants in a government-funded project may also have felt constrained in criticizing current policies. However, the findings consistently reflect operational barriers identified in prior large-scale quantitative research.¹¹ To broaden the sample, we included institutions facing operational difficulties as well as agency-recommended sites; 66.7% were urban and 33.3% rural. Notwithstanding these measures, the small sample size of institutions and participants limits the broader generalizability of the results. Furthermore, although participants were categorized into the education and public health sectors, meaningful differences likely exist within the education sector itself, for example, between providers responsible for nutrition and those responsible for physical education. The interviews identify practical concerns but do not establish clinical effectiveness or define an operational protocol. Findings from these 18 institutions may not transfer to every POPM program in South Korea.

These findings may inform a school-centered model supported by local public health centers, with clear roles for schools, families, and primary-care providers. Such a model would need sustained referral pathways and opportunities for meaningful participation. Clear implementation guidance, workforce development, operational resources, and robust data systems would support its delivery.