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H.O.M.E. (Homeless Outreach and Medical Education) Project is a health clinic operated by medical students from the John A. Burns School of Medicine. It was established in 2005 to provide free health-care to homeless shelters on O‘ahu. H.O.M.E. Project is also geared toward increasing medical students' awareness and understanding of the homeless population and their healthcare needs. In 2009–10, a few first year medical students developed a sustainable exercise program for homeless children to enable them to increase their exercise levels while finding an interest and motivation to improve their physical and mental health. The Keiki Ola Pono “children's health and wellness” Sports Program was adapted from an existing one that was started a few years ago.

In the past decade, rates of body mass index (BMI) and risk for being overweight have increased alarmingly among children and are continuing to elevate.⁴ Childhood obesity is a major public health focus because adult-associated co-morbidities such as diabetes mellitus type II, metabolic syndrome, cardiovascular disease, and non alcoholic fatty liver disease are emerging at a younger age.³ Miech, Kumanyika, and Steller⁵ found increasing trends of overweight children in families below the poverty line, especially among older adolescents. A contributing factor to childhood obesity is the scarce opportunity for structured exercise outside of physical education offered in schools.⁴ Furthermore, in 2000, less than 10% of United States schools had daily physical education classes available, and recess periods were insufficient as stated in the physical activity guidelines recommended by the American Academy of Pediatrics. Studies show that implementation of intervention programs that provided game equipment and organized sports activities resulted in enhanced physical activity during leisure time and less of a decline in moderate to vigorous physical activity after two years.⁴

Goals of the Project

Although the primary goal of the sports program was to reduce early onset of obesity through exercise, it was equally important to examine the benefits of exercise beyond physical changes. These benefits include improved quality of life and commitment to healthy lifestyle choices among all participants, even those that were not overweight. Studies have shown that physical activity is negatively correlated with depression, anxiety, and low self esteem.⁴ Social learning variables are also important correlates to the frequency at which children exercise; 5th and 6th grade males and females demonstrated increased participation in physical activity due to enjoyment of physical activity and family support; and, girls were additionally influenced by the availability of exercise-related equipment at home.⁷ Previous research also shows that children who do not participate in traditional structured physical activities demonstrate lack of confidence and enjoyment in these activities.⁴

The Keiki Ola Pono Sports Program is designed to incorporate team sports activities to encourage fun competition and increase the excitement to improve fitness.

Methodology

Participants in the program included male and female residents, 18-years-old or younger, at the Kaka'ako Next Step Shelter¹ (temporary homeless shelter located in Honolulu, O‘ahu) and the Onelauena Shelter (provides housing units for the homeless and is located in Kapolei, O‘ahu). The schedule of the program consisted of two 60-minute exercise activities at the Kaka‘ako Next Step Shelter and one 120-minute exercise activity at the Kalaeloa Onelauena Shelter every week (a total of four hours per week at each shelter). Unfortunately, the program at Onelauena Shelter was discontinued after a few months due to low attendance, which may be attributed to scheduling and conflicting activities for children during this time.

The methodologies employed are based on the effective exercise programs found in literature.^1,2 One program equated to 225 minutes every two weeks (112.5 minutes a week) and resulted in improved body composition and cardiovascular fitness in non-obese children. The study maximized the effectiveness of a program of shorter duration by reducing the number of children on a team to maximize the duration of continuous movement. Another program incorporated behavioral modifications such as self-monitoring, awareness of health benefits, decision-making, and fundamental motor skills into a program that increased exercise enjoyment and participation.⁶

The activities of Keiki Ola Pono Sports Program included basketball, soccer, football, jump-rope, volleyball, tennis, and relay races. Multiple activity stations were run simultaneously by University of Hawai‘i student volunteers to maximize the time of child play. Sports equipment was generously funded through a health grant written by a former JABSOM graduate and appropriated by Aloha Care (a non-profit organization that offers a health plan to Hawai‘i residents; a grant was awarded on the basis of promoting preventative health care and reducing the onset of childhood obesity).

Assessments

Children were evaluated for mental health and physical health status at the start of the program. Repeat assessments were attempted at the end of the program, but due to the transitional nature of the shelters, there were only a few participants who were reevaluated. Mental and physical health status was measured with the Pediatric Quality of Life (PQL) Survey. Survey statements, which were orally administered to each individual, included physical assessments (e.g., “It is hard for me to run”), emotional assessments (e.g., “I feel sad or blue”) and social assessments (e.g., “I have trouble getting along with other kids”). Participants responded with “not at all,” “sometimes,” or “a lot.” Additionally, questions were asked about the KOPS program and exercise motivation.

Thirteen children were evaluated with the PQL survey. Although it was not possible to obtain significant numbers for post-evaluation, the initial surveys still highlighted some key areas of interest. At least one child from the group responded “A lot” to each of these statements: feeling sad, angry, worried, having trouble sleeping, and a range of social and school-related problems (e.g., paying attention, peer relationships, and trouble with schoolwork).

Some concerning emotional and social responses included the following:

“I worry about what will happen to me”

(7- “not at all”, 5- “sometimes”, and 1- “a lot”)

“It is hard to keep up when I play with other kids”

(5- “not at all”, 5- “sometimes”, and 3- “a lot”)

“I have trouble getting along with other kids”

(6- “not at all”, 3- “sometimes”, and 4- “a lot”)

These negative responses suggest that children in homeless shelters may benefit from exercise programs that allow children to practice positive social interactions with their peers through team sports. Some activities that allowed the children to improve their social skills included tag-relay races, alternating turns for jump-rope, and a range of games involving teamwork.

The statements concerning physical abilities generally resulted in a wide spread of responses, suggesting that the participants in the program are at a range of needs and skills. It was difficult to quantify the physical improvements of the participants, but the consistent attendance of some participants yielded marked improvement over the course of the program. For example, one child learned how to jump-rope through an entire medley involving a complicated routine of simultaneous toe-touches, turning, and hops; this was a proud feat for the young girl who started the program quietly observing the others jump-roping.

The survey suggests strongly that the children reflected upon Keiki Ola Pono as positive to their health. Three responded “sometimes” and ten responded “a lot” to “I enjoy being in the KOPS Program.” There were zero “not at all” responses to statements pertaining to the program's goal of promotion of health and happiness.

Role in Medical Education

The Keiki Ola Pono Sports Program has been a valuable learning experience for the medical students' education. Initially, the intent was to focus on affecting physical change and combating obesity, but the program ended up recognizing other important areas of well-being. For example, it was discovered that homelessness predisposes children to greater risk of abuse. The supervising medical students were able to earn some of the children's trust through regular interaction in the clinic. As a result, some children voiced problematic details about past domestic violence or abuse. The alarming survey responses suggested that programs focusing on homeless children's wellbeing are urgently needed in order to manage the care and custody of children who do not feel safe in their current living situations. Furthermore, working with the homeless children has helped medical students to identify important social determinants in their physical and mental health. Living in a homeless shelter subjects children to poorer health conditions, including limited sanitation, educational resources, food choices, and living space. The medical students were able to witness the tremendous impact of these conditions on the children's wellbeing, ability to stay active, and ability to concentrate on schoolwork. Serving as mentors in this program has helped the medical students prepare for their future as practicing physicians because they will have the background and understanding to properly care for homeless patients.

In addition, the program has helped the medical students to develop skills that are important for interacting with children and their parents. During the program, there were many opportunities to encourage, support, and converse with children of different ages. There were times when parents would ask the medical students for advice regarding proper diet and exercise habits for their children. These moments of interaction paved ways of learning effective communication that will be beneficial in becoming physicians.

Although the physical changes or risk of obesity for the child participants were not quantifiable, the Keiki Ola Pono Sports Program challenged students to strengthen their preventative medicine efforts. Initial unpredictable and poor attendance prompted the development of feasible and effective ways to maximize attendance. Reusable water bottles were dispensed for the child participants that resulted in increased participants' return every week to the program. The water bottles were one way to indicate to children that exercise can be rewarding and fun. The relatively inexpensive water bottles served other purposes as well: promoting hydration, environmental awareness, and taking responsibility for one's possessions. This mindset for approaching problems through realistic, effective interventions served as valuable training for effecting public health and preventative medicine for future physicians.

H.O.M.E. Project has since supported the continuation of weekly exercise sessions at Kaka'ako and now all H.O.M.E. Project first-year students will have this educational opportunity to participate in the sports clinic. It is anticipated that the Keiki Ola Pono Sports Program will continue to grow and provide valuable teaching experience for participating medical students.