Implementing NutriSTEP® in Ontario - Success Stories, Lessons Learned and Next Steps

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This presentation will briefly cover what is nutrition screening and the ethical issues around screening for nutritional risk in young children. …

This presentation will briefly cover what is nutrition screening and the ethical issues around screening for nutritional risk in young children.

In addition to this brief introduction, we will have a number of dietitians present the implementation and evaluation of NutriSTEP in their communities as well as in other communities using similar models. A brief summary of the provincial process evaluation results will be reviewed and then we will wrap up with some of the other activities and next steps in the NutriSTEP Program. We will conclude with a 20-30 minute discussion period for a Q&A Period.

The NutriSTEP questionnaire targets The child’s parent or primary caregiver—the person who is most knowledgeable about the child’s eating and other health habits.
It is a paper and pencil questionnaire with 17 questions covering the four constructs of nutrition risk for this age group. These are:
Physical growth and weight concerns
Food and fluid intake
Physical activity and screen time
Factors affecting food intake (food security; and the psychosocial feeding environment)

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  • Good afternoon. My name is Lee Rysdale and I am the Program Coordinator for NutriSTEP with the Nutrition Resource Centre of the Ontario Public Health Association. As of spring 2007, NutriSTEP ® has been an NRC program with funding from the MHPS. This presentation will be of interest to a number of programs and agencies that service young children and their families. I will be your moderator today and will introduce each of our speakers throughout this web cast.
  • This presentation will briefly cover what is nutrition screening and the ethical issues around screening for nutritional risk in young children. For additional background information, please visit the NRC website for the archived web cast from June 2009 or the NutriSTEP website. In addition to this brief introduction, we will have a number of dietitians present the implementation and evaluation of NutriSTEP in their communities as well as in other communities using similar models. A brief summary of the provincial process evaluation results will be reviewed and then we will wrap up with some of the other activities and next steps in the NutriSTEP Program. We will conclude with a 20-30 minute discussion period to answer your questions. I would ask you to send your questions and comments using the question manager function on this webcast. Please feel free to send your responses at any point during the web cast.
  • Early surveillance and prevention of nutrition problems begins with valid and reliable screening tools and data. NutriSTEP ® is a valid and reliable nutrition risk screening questionnaire, now available in 8 languages, for children 3 to 5 years of age. NutriSTEP ® stands for Nutrition Screening Tool for Every Preschooler. It takes approximately five minutes to complete, and has been designed for administration by parents, caregivers or community professionals in a variety of settings. In addition to the screening tool, there is an Implementation Toolkit and a number of supporting resources including an Online community. There is also practice based research with U of G and others, which will be presented today.
  • The child’s parent or primary caregiver—the person who is most knowledgeable about the child’s eating and other health habits—should complete the NutriSTEP questionnaire. It is a paper and pencil questionnaire with 17 questions covering the four constructs of nutrition risk for this age group. These are: Physical growth and weight concerns Food and fluid intake Physical activity and screen time Factors affecting food intake (food security; and the psychosocial feeding environment)
  • Each question has up to five possible responses and each response has a score from 0 to 4. Parents check off which answer best suits their child’s typical nutrition habits. Once the questionnaire is completed, the nutrition risk score must be determined by adding the scores for the 17 questions to receive a total score. The higher the score, the greater the nutrition risk. There are three levels of nutrition risk: low, moderate and high. For each risk level, there are guidelines for parents on their next steps: If the total score is 20 or less (low risk) the child’s nutrition habits are quite good. And parents are advised to consult the accompaning educational booklets for tips. If the total score is 21 to 25 (which is moderate risk): A parent can improve their child’s nutrition habits by making some small changes. Parents are directed to contact their public health unit, community health centre or EatRight Ontario for additional information, educational materials or community programs. If the total score is 26 and greater (which is high risk): Parents can can improve their child’s nutrition habits by making changes. They are advised to talk with a health care professional, such as a registered dietitian, their family doctor or pediatrician. Based on the validation work, it is anticipated that the high risk nutrition referrals will be 10-15% of the children screened. This is similar to the number of children identified at risk in the HBHC and the provincial dental screening programs. The moderate risk referrals will be approximately 20-30% of the children screened with the remaining children, about 50% being identified as low risk.
  • A nutrition screening program can identify a large number of risk factors with interventions that can be delivered through targeted educational materials as well as group educational workshops. These screening interventions are quite feasible in reaching large groups of people vs individualized counselling services which can be limited or less accessible in some communities. Today we will present a number of feasible and sustainable screening programs that provide interventions that can be general in nature or individualized to benefit the target group of children in their community or to meet their agency’s mandates.
  • Nutrition screening can benefit children and their families, child and health care providers and communities by: Raising awareness and knowledge about healthy eating, healthy weights and physical activity Promoting early intervention and decreasing the risk of malnutrition for conditions such as anemia and overweight/obesity Targeting children at risk for further assessment and treatment Streamlining the referral process and prioritizing services to those most in need Identifying the needs in a population group to integrate services and target nutrition programs
  • Ethical nutrition screening means that a child is not only screened for nutritional risk but the family is provided with opportunities to improve their child’s eating and activity habits. Ethical screening involves voluntary participation in a screening process. It also includes a responsibility to: 1) Target people in need of resources or education through the consistent use of a valid and reliable screening tool. 2) Provide those identified to be at risk with reasonable options for assessment and treatment through resources, services or education. 3) Follow-up with these individuals to ensure that their nutritional needs are met with the intervention.
  • Those who screen positive or higher risk can be referred for a nutritional assessment and treatment if necessary. There may be other professionals and services which are more appropriate such as a social worker, family counsellor or family physician/nurse practitioner.
  • Screening models identify: 1) How screening happens 2) The appropriate and feasible referrals and how they would occur 3) How follow-up would be completed to ensure that the client’s needs will be met There were few best practice models for preschool nutrition risk screening and so i n 2006, a National Think Tank was held with 12 stakeholders and the NutriSTEP ® research team to discuss implementation models that were likely to be useful approaches to preschool nutrition screening across the country. This group suggested the following models: -screening fairs -day cares -JK and SK registration -doctors’/primary care offices All of these models are suitable for implementation but are they feasible and ethical-we will show you today what has been seen with implementing NutriSTEP in most of these models in Ontario. We will also describe today universal vs targeted screening programs which are dependent on the resources available and knowledge of the populations served. For example, you will see the targeted approach in “vulnerable” schools identified 22% high risk vs. 4-14% with a universal approach. Also keep in mind that “Moderate risk” preschoolers and their parents need primary prevention too – this means knowing their community services.
  • A successful screening program ensures an ethical approach by using an appropriate screening tool and setting; has developed a comprehensive action plan that includes referral processes for all risk levels; has sustainable funding with key stakeholders on board, and, throughout the planning and implementation, the needs and wishes of the target population are considered in the process.
  • Over the past three years NutriSTEP has been implemented and evaluated in a number of Ontario communities using a variety of models. Today we will take a closer look and discuss some of these models, their results and lessons learned. In addition to this web cast discussion, some of these models have been included in the six case summaries that are posted on the NutriSTEP website under Success Stories.
  • To discuss JK registration models, I have asked Kim McGibbon, a public health dietitian with the Thunder Bay District Health Unit to review the implementation and evaluation of NutriSTEP in her community. She will also cover the activities for York Region which are lead by Mary Turfryer, Public Health Nutritionist, at the York Region Health Department. Both Kim and Mary are members of our Provincial Advisory Committee.
  • The introduction of NutriSTEP® started as part of targeted implementation research being conducted by the University of Guelph through three health units: TBDHU, SDHU and York Region Health Dept. In Thunder Bay… Thunder Bay Start date – January 2008 Integrated with the Fair Start JK screening process
  • Thunder Bay via secretary at schools York Region Delivery Method Approximately 6,000 children were expected to register to start JK in September 2008 through this school board. Parents received a NutriSTEP research package at their child’s school in one of two ways: either as they registered their child for kindergarten or at a “Welcome to Kindergarten” parent orientation session.
  • Review referral map. Team members Public Health Dietitian, Fair Start Coordinators Community partner Fair Start program within health unit that works with various community partners to do early childhood screening Costs Danone Institute of Canada Grant-in-Aid Program Estimated in-kind cost is largely due to PHRD and support of two staff in Fair Start, and numerous volunteer hours of screeners
  • York Region Health Connection phone line A free and confidential telephone counselling and information service provided by York Region Health Dept. RDs available to: do brief counselling with parents regarding their child’s NutriSTEP scores; refer parents to appropriate community services as required; and provide educational resources. (Note, since this pilot, there is no longer an RD on the Health Connection phone line; however, York now has a dedicated NutriSTEP RD line for parents to call) Referral options included in the York Region NutriSTEP referral map included: Outpatient RDs (e.g., hospital RDs, private practice RDs) Physicians Outpatient specialty services (e.g., feeding clinics, allergists) Community parenting programs for children at high risk (e.g., HBHC, Nobody’s Perfect, CAPC) Community parenting programs for children at moderate and low risk (e.g., Ontario Early Years, Best Start Hubs) Nutrition education resources (e.g., York Region NutriSTEP website, fact sheets) Community Partner York Region District School Board, which is the largest school board in York Region
  • York Region If asked….here are some thoughts on why Health Connection did not receive any parent calls: - Some parents may have spoken to their child’s physician, which was another option available to the parents. - Some parents whose children scored low and moderate risk on NutriSTEP could have had their education needs met through the education booklet and the website, which would have been appropriate . - Some parents whose children scored high risk may just have attempted to have their needs met through the accompanying education resource or the NutriSTEP website instead of the calling the Health Connection RD. This would have been inappropriate . - York Region’s population is very multicultural and many parents do not speak English well or at all. Perhaps many parents were unable to complete the NutriSTEP questionnaire due to language issues, and/or would have been uncomfortable speaking on the phone in English. - Perhaps parents don’t consider nutritional risk as a concern. - Some parents may have been overwhelmed and confused by the forms and phone numbers in the research package. Without the research components, more parents may have completed the questionnaire and/or called Health Connection. - Some parents may have been intimidated with the consent information that was a part of the research forms and did not phone Health Connection for fear of unknown consequences. - Some parents may not want to involve others in “their business.”
  • York Region Benefits of the self referral method are as follows: Can reach a large number of the target population. This is key for health units with large populations A method that can be used for health units that don’t have screening opportunities such as preschool screening fairs No need to recruit or train screening facilitators Most parents are able to self complete and score NutriSTEP independently. School boards can be very interested/appropriate partners Self-referral model is a reality for communities that have large numbers of preschoolers and that don’t have the capacity to reach these preschoolers through the assisted or guided referral methods
  • Biggest jumps seen in the high risk groups around milk, fruit and meat as well as fast food Vegetables seems a concern for the mod and high risk
  • York Region High risk pilot-will be reviewed later in web cast.
  • Thanks Kim. Now to review the preschool screening fair models, I would like to introduce Judith Kitching, Public Health Nutritionist for Waterloo Region Public Health, who will provide an overview for her community as well as similar implementation work done in Oxford County, which has been lead by Karen Reading, Public Health Nutritionist for Oxford County Public Health Unit.
  • Waterloo PH Nutritionist: lead role for planning and implementation of NutriSTEP ® PH Nurse/Community Partner: directs parents to nutrition screening Information Assistant: enters risk score and referral information into data-base PH Planner captures data in a CHF summary report Community Partners include: ROW Social Services, Infant & Child Development Program KidsLINK, Early intervention services Community living Cambridge; Elmira & District Association for Community Living KW Habilitation Services Printing cost for other resources not available through Service Ontario (How to Build a Healthy Preschooler; Eat Right Be Active are available from SOP) For example resources for issues identified in screening tool – Healthy Choices - Start Now series: deals with issues such as picky eater, refusing to eat vegetables, milk and meat, choking prevention tips (adapted from York resources)
  • Waterloo: Parents have no set time to go to nutrition screening area; sometimes get a number of parents at a time Screening done at nutrition display table; only staff at display is nutritionist must fit NutriSTEP around talking with parents of infants and toddlers Screening done in room with other displays and may have limited space to implement; no room for table for parents to write on Extra staff could include PH Nurse, or Nutrition student/intern
  • Thanks Judith. Our next presenter is Melissa Westoby. Melissa is a public health dietitian for Niagara Region Public Health Unit. Melissa will provide us with an overview of their pilot in the HBHC program. Melissa will also review the York Region School Board pilot conducted in high risk schools and the NutriSTEP component was lead by Mary Turfryer, Public Health Nutritionist for York Region Health Department.
  • Niagara Region Public Health implemented NutriSTEP in October 2009 as a pilot project in the Healthy Babies Healthy Children program. The goal was to screen approximately 120 preschoolers in HBHC using the assisted referral method of public health nurses providing the NutriSTEP tool to clients during a home visit along with educational resources. The PHNs assisted the client with completing the screening tool if necessary.
  • Public Health Dietitian Planning including referral map and forms Community partnerships for referrals Provide PHN training Data collection Public Health Nutritionist Assisted with research proposal and planning PHNs Deliver screening tool, resources, referrals Public Health Epidemiologist Develop database Analysis of data collected from screening tool and follow-up survey HBHC Manager Reviews and approvals
  • In Sept 2008, York Region District School Board invited York to participate in a screening program at 11 schools that have high numbers of newcomer families The program included dental, nutrition and vision screening. 667 parents or caregivers of JK and SK students attended the nutrition screening with their children. 635 of these parents consented for us to collect their information Parents completed and scored the questionnaire. HU RDs and Nutrition Educators (Nutrition degree but no internship or Masters) discussed the child’s nutrition risk level with the parent and provided guidance on the recommended next steps for the family The school board arranged for volunteer translators to assist with the screening. (Guided referral model) (The results of this pilot also show a greater number of children at high nutrition risk (8%) compared to the targeted implementation study that was done in York earlier in 2008 with 137 YRDSB schools) (participation rate based on 1,183 students registered in JK/SK)
  • Q.9 In the discussions that the Nutrition Screeners had with the parents, many children were still drinking from a baby bottle. - Delayed weaning from bottle feeding is associated with anemia, poor weight gain, and obesity (Frazier JP, Countie D, Elerian L, Parental barriers to weaning infants from the bottle, Arch Pediatr Adolesc Med 1998;152:889-92) __________________________ Eg, Daytime bottle use beyond 16 months is a predictor or iron deficiency and iron deficiency anemia (Sutcliffe TL, et al Arch Pediatr Adolesc Med. 2006;160(11):1114-1120)
  • There are many possible explanations for parents not calling, especially that the parents are not comfortable with or able to speak English. Education resources are not available in all languages which does not meet the needs of many parents in York Region. -The newly translated NutriSTEPs and educational resources will be very helpful in meeting the needs of many more York Region parents. Would like to do additional screening programs at high risk schools at JK/SK entry using a guided referral method. However, York Region has insufficient staff and funds for screening programs due to the intensive nature of the guided referral method. Complete funding is needed to see this through. ______________________________________________ -large population and thus can’t screen all (total 34,000 3,4,and 5 year olds in York Region. (over 11,000 each year - 3 year olds, 4 year olds and 5 year olds). And this screening program was very time/staff-intensive, yet only reached 636 parents. -language barrier
  • Thanks Melissa for reviewing the use of NutriSTEP with high risk populations such as HBHC and schools designated as high risk. To determine which schools might be the most appropriate for nutrition screening, it may be useful to consider those schools or neighbourhoods designated as vulnerable using the Early Developmental Index mapping. We are investigating the use of EDI mapping processes to also map preschool nutrition risk by neighbourhoods in Thunder Bay. We do know that nutrition is related to cognitive function, school readiness and school performance, and we are hoping that this strategy will allow us to view and present preschool nutrition risk visually as well as look at the EDI neighbourhood maps and see if there are similarities in EDI vulnerability and preschool nutrition risk. Like HBHC surveillance databases, we would like to see the integration of NutriSTEP in the EDI data collection done at the parent level as well as in provincial databases. Other high risk groups to consider using NutriSTEP are CAS and the new provincial low income dental program. Again we know nutritional health is a predictor of dental health and we have been advised by the MHPS to urge health units to investigate interdepartmental opportunities to integrate NutriSTEP into their dental programs for their communities. We are interested to hear from health units that are planning to include NutriSTEP in this new program, either during the question and discussion period or in the future.
  • To help support a provincial preschool nutrition screening program, it was key to collaborate with other related provincial nutrition programs such as ERO. Christine Mehling, is the Content Manager at ERO and also a member of our Provincial Advisory Committee. Christine will review ERO’s mandate and role in supporting NutriSTEP.
  • Thanks Christine. Our next speaker is Dr. Janis Randall Simpson from the Department of Family Relations and Applied Nutrition at the University of Guelph . Janis is also a co-owner of the NutriSTEP questionnaire, a Provincial Advisory Committee member and the Principal Investigator of the majority of the evaluation research that has been conducted on the implementation of NutriSTEP in Ontario. Janis will review implementation results from two FHTs as well as the use of NutriSTEP in a larger study from the HSC in Toronto, in which Janis is a study collaborator. Janis will begin with the Toronto pilot which is lead by Dr. Catherine Birken and others who have graciously provided us with this information for today’s presentation.
  • TARGet Kids! is a A child health promotion research platform embedded in primary healthcare.
  • TARGet Kids! is a collaboration between family medicine, community paediatrics and research leaders from SickKids and St, Michaels hospital.
  • TARGet Kids is a collaboration of 4 large paediatric practices, and 1 large family medicine practice. Our goals is to improve child health. We are focusing on common paediatric problems seen in practice – obesity, vitamin D deficiency, and iron deficiency. We have a steering committee consisting of research leads, community clinician leadership. We are collaborating with Applied Health Rsearch Centre at Li Ka Shing Knowledge Institute of Saint Michaels hospital and have implemented a NIH grade data management system that allows for direct data entry by web portal at all sites. We are collaborating with Mount Sinai Services Laboratories who provide laboratory results to our practices within 48 hours. We have research assitants at each practice site.
  • We are currenlty located in Toronto, and are working with partners in other urban centres in Canada to move this program nationally.
  • Our process includes identification of eligible families, sending letters our prior to scheduled annual appointments.
  • Resaerch assistants greets family, discusses the study, gains consent.
  • Families are then complete qustioniares including the NutriSTEP in the waiting room or in the office prior to seeing the MD or nurse. The RA checks the form for completeness, and then takes measurements, and laboratory tests.
  • We have three models for blood sample collection,
  • We have had some challenges to recuitment.
  • Enrollement was phased in by site, and by blood collection,
  • This is the age distribution of patients.
  • Gender distribution.
  • We are currently entering all the data from prior to our data management system was in affect. We anticipate data analysis looking at cross sectional analysis of associations between NutriSTEP and adiposity, and health outcomes to be completed in December 2010. We look forward to working with the research team to develop a toddler version, which will service our population well.
  • The FHT pilots were coordinated by…….
  • Note from JRS: Need to delete far right column and last row of table
  • No difference between sites
  • Overall most parents found that the screening process increased awareness in nutrition/preschooler diets Some reported that they had changed their behaviours re NutriSTEP items NutriSTEP was good affirmation of their perceptions NutriSTEP good benchmark
  • Mention HSC study here and how pediatricians really like NutriSTEP – same experience as the NP in Stratford.
  • During the targeted implementation with the health unit sites as well as the two FHTs (Hamilton and Stratford), it was identified that health practitioners especially RDs felt unprepared to assess and counsel high risk preschool nutrition concerns. Based on a provincial FHT RD needs assessment, five areas were identified as top learning needs for RDs. The topics are: Growth assessment principles Growth concerns such as FTT and overweight and obesity Pediatric nutritional assessment Key nutrient deficiencies Food allergies and intolerances
  • An environmental scan was conducted and five modules or RD Primers were developed and evaluated in 2008. In early 2009 the primers were updated, refined and translated into French. These primers were posted on the Nutristep website but RDs asked for a series of webcasts covering these five topics. Year end funds from MHPS were received in early 2010 to update and reformat the 5 modules into audio modules in both languages. The series were relaunched in late July and traffic has been terrific with over 3500 visits since July.
  • We must not get discouraged since many other health screening programs and public health interventions are created and well resourced before true health status outcome data are available. Adequate resources and integrated systems/data sets are required to track outcomes to illustrate effectiveness.
  • To summarize the provincial process evaluation work to date, it has been conducted in both public health and primary health care settings. The targeted implementation of NutriSTEP in Thunder Bay, Sudbury and York Region through public health has been previously reported in our June 2009 web cast as well as briefly again today for Thunder Bay and York Region. The evaluation in primary health care settings in two FHTs has been reviewed today.
  • Almost 500 questionnaires and demographic forms were completed along with over 200 telephone interviews with parents. Data and feedback was also collected from screen administrators, Site Coordinators and RDs and NPs involved in the implementation of NutriSTEP. Overall, 52% of the sample were boys with the majority English speaking and Canadian. Almost 20% or one in five preschoolers were high/moderate nutrition risk. NutriSTEP was found to be acceptable to parents, leads to increased nutrition knowledge and awareness and parents report making changes after completing NutriSTEP. The implementation is feasible and acceptable to healthcare providers in a variety of settings and most demonstration sites continue to use NutriSTEP showing sustainability of the program.
  • Lee At this point, I will take a few minutes to provide an update on a number of the other program activities and potential opportunities.
  • The NutriSTEP website was launched in July 2009 and has been considered a very busy site with traffic of over 20000 visits including more than 50% from the US. In April of this year, we posted six implementation case studies, some of them were summarized today and the visits to this section has also been very encouraging. Keep in mind the implementation toolkit, available in English and French, can be downloaded from the website. NRC also has binder/CD versions-the order form can be found on the NRC website. As previously mentioned we have updated and reformatted the RD Primers in both English and French. Our Online community has over 30 members and so please sign up if you want to share ideas, ask questions and support others implementing the program. Our site also includes abstracts for the research activities completed as well as the executive summary for the targeted implementation of NutriSTEP in Ontario three health unit jurisdictions. A lessons learned article has also been posted on the Online Community. We also have developed a bibliography maintained by U of G to inform our research activities as well as resource development and updates.
  • In addition to the NutriSTEP website, we maintain support of the program materials through Flintbox and Service Ontario Publications with the University of Guelph Business Development Office. Flintbox provides electronic versions of the questionnaires and the toolkit and is the site to obtain a license to use the questionnaires, which are copyright protected. To help us track the uptake of the screening tool and program and to evaluate where the program is being used, we ask that all users register for a license. In Ontario, licenses are free. We also have an agreement with SOP to disseminate print copies of the questionnaires and booklets free of charge in Ontario. To date, this route seems to be quite successful with over 70000 questionnaires ordered by 16 health units and 120,000 booklets ordered by 23 health units and the general public. Ontario practitioners not working in public health and wanting print versions of the questionnaires should contact their local public health unit for copies or to have their health unit order through the pass protected side of SOP.
  • The provincial program evaluation activities are determined through an overall strategic and evaluation plan in consultation with the University of Guelph and the program’s PAC. The plan is used to guide short and long term planning for this NRC program and is based on the guiding principles of the Ontario Public Health Standards, which are: need, impact, capacity and community partnerships and collaboration.
  • Most evaluation activities are quite time consuming and costly. To provide this level of data, there needs to be sufficient capacity as well as funds. And so many of our evaluation activities are determined by the funding available to do this work. One of our evaluation goals is to share our knowledge and findings through publications. Two papers are drafted on the Targeted Implementation of NutriSTEP, which was funded by a Grant from the Danone Institute. Stay tuned for these papers to be published on parent perception of nutrition risk screening in public health settings as well as on the targeted implementation in FHT settings. We have also had inquiries for an evaluation plan template and database template. Again we are trying to develop these resources and will post on the NutriSTEP web site in the near future. Some of the proposed evaluation activities for the next fiscal will be the program uptake as well as a review of the program resources such as the Implementation Toolkit and RD Primers. A CIHR proposal was submitted to evaluate the process and effectiveness of this program in Ontario public health settings. The process evaluation would include feasibility and acceptability while program effectiveness would include the child’s nutrition risk score and BMI, parent’s knowledge, attitudes, beliefs and practices as well as changes in the child’s behaviour. Unfortunately this submission was unsuccessful. Another implementation and evaluation proposal has been submitted to PHAC by the Perth District Health Unit and U of G to include NutriSTEP in an innovative healthy weights program for young children. The outcome of this submission is still pending.
  • We maintain a number of partnerships to promote the program. These include ERO as Christine has described. Other promotion occurs through DC via their HSFL website, the PEN preschool pathway and participating in the updated collaborative growth statement released early 2010. We also have NutriSTEP included in two nutrition workshops hosted by the OCFP that are conducted across the country to GPs. The NutriSTEP resources are also promoted on the BSRC website as well as at their annual conferences. The screening tool as well as educational resources are noted in a number of BSRC resources including an aboriginal childhood obesity prevention toolkit, upcoming school readiness brochure as well as the soon to be released On Tracks online resource. There are also plans to include NutriSTEP in the new online Good Beginnings course for ECEs from DFC.
  • The NutriSTEP® questionnaire is listed as a valid and reliable tool in the Child Health Program, Requirement # 11 of the Ontario Public Health Standards (OPHS), released November 2008. NutriSTEP® is included in several of OPHS Guidance Documents, June 2010. Discussions and feedback has been provided to the Ontario Agency for Health Protection and Promotion on the inclusion of NutriSTEP in provincial child health and nutrition surveillance plans. Discussions and pilots has been done on the integration of NutriSTEP into the HBHC program and ISCIS database and as well using the mapping strategy for EDI. NutriSTEP has been included in the draft FPT framework for action to promote healthy childhood weights. The recent release of Curbing Childhood Obesity provides a number of opportunities to include NutriSTEP in areas such as screening and early identification as well as increasing parent knowledge and awareness, which has been demonstrated as effective in our evaluations to date. Another opportunity being considered is the development of a platform suite for nutrition screening across the lifespan. This platform would include the current NutriSTEP for preschoolers, the toddler version of NutriSTEP under development and SCREEN, a nutrition screening tool for seniors. SCREEN was developed by Dr. Heather Keller from the University of Guelph who is also a co-owner of NutriSTEP and a PAC member. Preliminary discussions have begun with potential collaborators. The online version of NutriSTEP, in which intermodal testing has been recently completed and found to be as reliable as a paper and pencil version, would be the basis for the screening questionnaire with a platform designed to provide parents with nutrition advice and guidance on resources and referrals. This electronic format would help assist those parents with limited access to nutrition services such as in remote communities in Ontario and Canada and to support practitioners with limited capacity to provide assisted or guided referral models.
  • Throughout this presentation, you have seen the data that has been collected and the evaluations that have taken place. We have provided you with some of the challenges in collecting and reporting this level of data at the local and provincial level including local and provincial capacity issues and the associated costs. We have been actively advocating for integration of NutriSTEP in other provincial databases and programs and are seeking funds to provide further process evaluation and effectiveness results. We would be interested to hear your comments and thoughts on the need for a centralized database on preschool nutrition risk to be able to monitor nutrition issues and see if our programs are making difference. Please let us know what you think during our discussion period.
  • Other program activities include promotion and knowledge transfer. A program brochure in English and French has been available since Jan 2010 and order forms are available on the NRC website for those sites wanting copies to plan and/or promote the program in their communities. The NutriSTEP website has also been featured this year in a CIHR Knowledge to Action Casebook which is available online at CIHR. We have presented at a number of conferences in the past year including to RDs in FHTs and FNIHB of HC, in the UK, in US at the Society for Nutrition Education conference and at CPHA conference. Stay posted for a year end report on our program highlights released in Spring 2011.
  • Lastly, I would like to briefly give you an update on the toddler version of NutriSTEP which is a CIHR funded project led by U of Guelph with a number of collaborators. This multiphase project will be completed in 2012 and includes parent focus groups, RD content validation and parent key intercept interviews taking place this fall and winter.
  • The questionnaire reliability and validity testing will take place in 2011 with an English and French questionnaire ready in spring 2012. To accompany the questionnaire, we have developed and evaluated a parent education booklet called How to Build a Healthy Toddler. The booklet has been translated, professionally designed and electronic versions will be posted shortly on the NRC website.
  • At this point, we have XX minutes for your questions and comments. Please send them through the question manager function of the webcast.
  • In conclusion, the overall goal of the NutriSTEP ® program is to improve the health status of young Canadian children. NutriSTEP ® provides an excellent basis for a nutrition screening and/or surveillance system for nutrition risk in preschool children across Canada. A community or service provider interested in implementing such a program needs: -A site coordinator to oversee the program and its evaluation. -Have an implementation toolkit and support materials. The toolkit in both languages will continue to undergo revisions and additions based on evaluation. - Train screen administrators, and the individuals in the referral process - Individualize resources for those who will benefit from the program -Know the issues with data collection and management -Develop referral maps or a process for ethically meet the needs of groups identified to be at low, moderate or high nutrition risk. -A site coordinator to monitor the process to inform current practices and support changes to programs and services if appropriate. A long-term comprehensive action plan will ensure that all key stakeholders are on board, that financial resources are available to sustain a program over time, and that there is action on the results of preschool nutrition screening.
  • For more information on NutriSTEP ® , check out the program website as well as program link at the Nutrition Resource Centre website.
  • I would like to thank all of our speakers today as well as our web cast participants for your questions and comments. Please tell us what you think of this presentation by completing the short online survey link on this slide. Everyone who completes the evaluation will be entered into a draw for one of four $25 Chapter’s giftcards. Thanks again and have a good afternoon.

Transcript

  • 1. Implementing NutriSTEP ® in Ontario Success Stories, Lessons Learned and Next Steps November 1, 2010
  • 2. Outline
    • What is NutriSTEP ® and ethical nutrition screening?
    • Using NutriSTEP ® in your communities: Ontario models in public and primary health care settings
    • Provincial process evaluation results
    • Other activities and future plans
    • Discussion period
    • Wrap-up
  • 3. NutriSTEP ® Program is …
    • Parent-focused nutrition education and skill building program that starts with:
      • Nutrition risk screening index for preschoolers (3-5 years)
        • Multi-ethnic
        • 8 languages
        • Parent-administered - 5 minutes to complete
    • On-going collaborative practice-based research with University of Guelph and others
    • Implementation Toolkit and resources
    • NutriSTEP ® Online Community
  • 4. What NutriSTEP ® Measures: Constructs of Nutritional Risk
    • Physical growth/weight concern
    • Food and fluid intake
    • Physical activity and screen time
    • Factors affecting food intake (food security, psychosocial feeding environment)
  • 5.  
  • 6. What a Screening Program Can Do
    • Phase 1
    • Risk Factors Present
    • Food Intake
    • Food security
    • Feeding environment
    • Physical ability
    • Weight
    • Growth
    • Phase 2
    • Impaired Food Intake
    • Food groups
    • Nutrients
    • Energy
    • Phase 3
    • Sub-clinical
    • Malnutrition
    • Weight
    • Perceptions
    • Gain
    • Loss
    • Biochemistry
    • Phase 4
    • Overt Malnutrition
    • Significant changes in:
    • Weight
    • Biochemistry
    DE T E RMINANT S Targeted educational Interactive education materials Individualized counseling Screening Assessment INTERVENTIONS
  • 7. Why Are We Screening For Nutritional Risk?
    • Leads to early identification and prevention of nutrition problems
    • Increases nutrition awareness with families and providers
    • Means treatment can occur, reducing serious consequences
    • Helps manage scarce community resources
    • Screening data can be used to monitor trends over time (surveillance)
  • 8. What is “Ethical” Nutrition Screening?
    • Target screening to the right people
    • Identify nutrition problems and appropriate course of action (e.g. assessment, resources)
    • Has a referral/resource framework that meets needs
    • Includes follow-up after screening
  • 9. Ethical Nutrition Screening
      • Refer
      • Provide
      • Info
      • Monitor
    Ongoing nutrition screening Child not at nutritional risk Provide nutrition info Child at nutritional risk Physician Assess Treat Dietitian Assess Counsel Other Community Services
  • 10. Can everyone be screened? Universal is ideal; targeted approach realistic
    • Primary Sites for Screening: Think Tank 2006
      • Screening fairs; day cares; JK/SK registration packages; doctors’ offices; and, outpatient clinics
    • Dependent on resources available and knowledge of populations served
      • Targeted NutriSTEP ® screening at “vulnerable” schools 22% high risk vs. 6-14% universal approach
      • “ Moderate risk” preschoolers and their parents need primary prevention too – knowledge of community services key
  • 11. The Keys to Successful Screening
    • Ensure ethical screening
    • Select an appropriate screening tool
    • Choose the setting for screening
    • Develop a comprehensive action plan
    • Ensure funding can sustain
    • Make sure all key stakeholders for successful screening are on board
    • Keep target population in mind and respect their wishes
  • 12. Ontario Models
    • JK Registration
    • Preschool Screening Fairs
    • HBHC and High Risk Models
    • Provincial Support
    • Primary Health Care Settings
  • 13. JK Registration Thunder Bay District Health Unit York Region Health Department
  • 14. Launch & Location Thunder Bay/York Region
    • Thunder Bay
      • Start date – January 2008
      • Integrated with the Fair Start JK screening process
    • York Region
      • Start date – Jan 2008 (part of U of G targeted implementation study)
      • Community is comprised of 43% immigrants
  • 15. Target & Delivery Mode Thunder Bay/York Region
    • Thunder Bay
      • Parents whose 3-5 year olds are entering JK
      • NutriSTEP ® questionnaires and education booklets distributed to parents through city schools during JK registration with Fair Start booklet
      • Parents completed NutriSTEP® independently and facilitator reviewed and provided resources and/or referral
    • York Region
      • Parents whose 3-5 year olds are entering JK/SK
      • 1400 NutriSTEP ® questionnaires and education booklets distributed to parents through 137 York Region schools during JK/SK registration
        • Parents completed NutriSTEP ® independently
  • 16. Implementation Notes Thunder Bay
    • Assisted referral model
        • Parents complete and score the tool independently, return to school with registration package
        • Facilitator reviews score (corrects if needed) and provides resources
        • High risk score receive referral to their MD/NP from Fair Start using triplicate form
        • All risk levels receive the same nutrition education material “How to Build a Healthy Preschooler”
      • Community Partner: Fair Start
      • Team Members: Public Health Dietitian, Fair Start staff (and numerous volunteers)
      • Costs: many in-kind costs through Fair Start and HU support
  • 17. Implementation Notes York Region
    • Self-referral model
        • Parents complete and score the tool, ID risk level, contact a Health Connection RD by phone or go to www.york.ca/NutriSTEP
      • Team: Public Health Nutritionist and Public Health Dietitian
      • Community partner: York Region District School Board
      • Costs
        • Danone Institute of Canada Grant-in-Aid Program
        • In-kind cost 2.0 FTE (mainly Public Health Nutritionist)
  • 18. Challenges & Solutions Thunder Bay/York Region
    • Thunder Bay
      • Few parents followed up with their health care provider
      • Numbers not calculated correctly by parent and not corrected by screener may change risk level (9%)-were encouraged at training to recalculate
    • York Region
      • No calls to Health Connection RD but 1011 hits on York NutriSTEP ® website
      • Eat Right Be Active (3-5 years) is heavy and challenge to store. Now using How to Build a Healthy Preschooler
  • 19. Program Benefits & Evaluation Thunder Bay/York Region
    • Thunder Bay
      • Prevalence of nutritional risk (2009):
        • 84% low risk; 12% moderate; and 4% high risk
    • York Region
      • Prevalence of nutritional risk:
        • 77% low risk; 15% moderate risk; and 8% high risk
      • Benefits
        • Self-referral can reach a large number of 3-5 year olds
        • Good partnership opportunity for public health and schools
        • Feasible and sustainable model
  • 20. Evaluation Results Thunder Bay
  • 21. Evaluation Results Thunder Bay
  • 22. Next Steps & Future Plans Thunder Bay/York Region
    • Thunder Bay
      • Continue in JK packages, expand in all district offices
      • Trained HBHC program to use with 3-5 year olds
      • Implement Toddler version in screening fairs through Fair Start
    • York Region
      • Presentations and promotion with wide distribution-OEYCs, EIS, child care centres, HU child health program, MDs, and JK/SK
      • Approximately 26,000 questionnaires have been distributed
      • NutriSTEP ® phone line for parents to discuss NutriSTEP ® scores with RD and receive referral if required
      • Now promoting translated NutriSTEP ® questionnaires
      • Fall 2008 Pilot-screening at high risk schools
  • 23. Preschool Screening Fairs Waterloo Region Public Health Oxford County Public Health
  • 24. Launch & Location Waterloo Region/Oxford County
    • Waterloo Region
      • Pilot-tested fall 2008-winter 2009; started fall 2009
      • Regional Child Health Fairs (CHF) (about 6/year)
      • Held across region-in areas identified as higher risk of poor outcomes
      • Locations: OEYCs, churches, schools and community centres
    • Oxford County
      • Annual Preschool Health Fairs (JK screening fairs)
      • 4 locations in County (one at PHU)
      • 3 – 5 year olds in the County
      • April – June (2009 and 2010)
      • Community Partners: 3 school boards (JK registration), daycares, OEYCs, Libraries (advertisement)
  • 25. Target & Delivery Mode Waterloo Region/Oxford County
    • Waterloo Region
      • Parents varied ethnic backgrounds and SES
      • Parents of all 3-5 year-olds at CHF invited to participate
      • PH Nutritionist assists with scoring, reviews results with parents
      • Resources and referrals provided as appropriate
    • Oxford County
      • Parents of preschool children attending JK in the fall
      • Guided Referral Method
        • Parent completes and scores
        • PHN reviews score, provides feedback, appropriate resources and referrals
  • 26. Implementation Notes Waterloo Region/Oxford County
    • Waterloo Region
      • No follow up planned at this time
      • Team: PH Nutritionist (lead), PHNurse/Community partners, Information Assistant, PH Planner
      • Minimal cost – only printing of resources not provided by Service Ontario Publications
    • Oxford
      • Resources and referrals- according to risk score
      • Moderate Risk – referral to Public Health Nutritionist and ERO
      • High Risk – same plus referral form to take to family physician; RD follows up re: discussed with MD or need more info
      • Team: Public Health Nutritionist, PHNs, Dietetic Interns (when available), admin support
      • Costs-resource materials, rental of facilities
  • 27. Challenges & Solutions Waterloo Region/Oxford County
    • Waterloo Region
      • No appointments for nutrition screening; "drop-by" basis
      • Nutritionist also available to parents of infants and toddlers
      • Physical set-up may not be ideal depending on location
      • Ideal solution: another staff person to "man" display with nutrition screening in own room with appointments
    • Oxford County
      • Staff dedicated exclusively to implementation of NutriSTEP ® at Fair
      • Challenges
        • Follow up with High Risk families
        • Extra time to implement for low literacy families
  • 28. Program Benefits & Evaluation Waterloo Region/Oxford County
    • Waterloo Region
      • Increase awareness of preschool nutrition with parents
      • Opportunity to provide information and resources as needed
      • Provide referral for moderate - high risk scores
      • No evaluation at this time
    • Oxford County
      • Results
        • 806 completed questionnaires (2009)
          • 682 (84.6%) Low Risk
          • 96 (11.9%) Moderate Risk
          • 28 (3.5%) High Risk
  • 29. Next Steps & Future Plans Waterloo Region/Oxford County
    • Waterloo Region
      • Plan to use NutriSTEP ® in HBHC program
        • Finalizing implementation protocol and data collection
      • Conduct evaluation in the future – no plans at this time
      • Would like: NutriSTEP ® added to provincial HBHC protocol and included in ISCIS data base for surveillance purposes (generate reports)
    • Oxford County
      • Plan for 2010
        • New referral mapping-add new FHT RD to referral for Moderate and High Risk children
  • 30. HBHC and Other High Risk Settings Niagara Region Public Health Pilot York Region School Board Pilot
  • 31. HBHC Pilot Niagara Region
    • Goal: to screen approximately 120 preschoolers in HBHC
    • Assisted referral method: public health nurses provide the NutriSTEP ® tool to clients during a home visit
      • PHNs receive a monthly list identifying 3-5 year old children on their caseload
      • Packages consist of the screening tool and educational resources for PHN to take on home visit
      • Assist client with completing the screen if necessary
  • 32. HBHC Pilot Niagara Region
    • Follow-up:
      • PHN reviews the score with client and provides educational resources and parent feedback form
      • Moderate risk : Referred to ERO and encouraged to attend healthy eating/active play workshops
      • High risk : Referral form completed and client encouraged to follow up with family doctor. Form and tool faxed to doctor
      • Chewing/Swallowing concerns: Referred to Niagara Peninsula Children’s Centre (NPCC) for follow-up with SLP/OT
      • Growth Concerns: Client encouraged to follow up with family doctor. Referral form and tool faxed to doctor
  • 33. HBHC Pilot Niagara Region
    • Follow-up:
      • PHN enters screening tool into ISCIS
      • Returns screening tool to RD for data collection
      • Clients receive follow-up phone call 3 months after screening
        • Satisfaction with screening process & resources
        • Access to referrals
        • Changes to child’s nutrition or activity habits
  • 34. HBHC Pilot Niagara Region
    • Implementation Team:
      • Public Health Dietitian
      • Public Health Nutritionist
      • PHNs
      • Public Health Epidemiologist
      • HBHC Manager
    • Costs:
      • Printing costs for forms
      • Physician mail-out
      • Food and supplies for Healthy Eating and Active Play workshops
  • 35. HBHC Pilot Niagara Region
    • Challenges:
      • Number of screens completed to date
        • Challenges with finding opportunities to screen high risk families
        • Pilot study end date extended to Sept 2011
      • Accuracy of client responses
        • Contradicts what PHN observes in the home
      • Contacting clients to complete follow-up phone survey
  • 36. HBHC Pilot Niagara Region
      • Of 150 children, 50 screens completed to date
    Risk Category N value (%) Low Risk 32 (64%) Moderate Risk 12 (24%) High Risk 6 (12%)
  • 37. Preliminary Results NutriSTEP ® Question Response My child eats vegetables (less than 2 times a day) 42.2% I have difficulty buying food because food is expensive (sometimes or most of the time) 32.7% I let my child decide how much to eat (sometimes, rarely or never) 51.1% My child eats while watching TV (sometimes, most of the time or always) 64.4% Screen time: 1 hour or less a day 4.4% 2 hours a day 48.9% 3 hours or more a day 46.7%
  • 38. Follow-up Telephone Survey
    • 31 surveys completed
    Survey Question Response The screening has made me more aware of preschool nutrition and eating habits. 87.1% The screening has made me aware of nutrition concerns for my child that I was not aware of before. 48.4% How helpful did you find the educational resources? Very helpful Somewhat helpful 64.5% 32.3% The screening and resources helped me make changes to my child’s nutrition or activity habits. 93.5% I feel more aware of nutrition programs, services and resources available? 90.3%
  • 39. Next Steps and Future Plans
    • Evaluation of pilot study - Sept 2011
    • Policy drafted to include as routine screening in HBHC
    • Interest from community groups
      • Quality Child Care Niagara
      • Ontario Early Years Centres
      • Family Health Teams
  • 40. York Region Pilot-Fall 2008
    • 11 schools; 90% ESL
    • Dental, vision, and NutriSTEP ® screening with JK/SK students
    • 8 screeners: RDs and Nutrition Educators
    • Volunteer translators on-site
    • 667 parents/caregivers participated (56%)
    • 635 parents/caregivers consented to data collection (54%)
    • Prevalence of nutrition risk:
      • 50% low risk
      • 28% moderate risk
      • 22% high risk (more than double the 10% expected prevalence for high risk)
  • 41. 30% or more were at nutrition risk for the following questions Q.1 Grain products Q.2 Milk and alternatives Q.3 Fruit Q.4 Vegetables Q.5 Meat and alternatives Q.9 Child not hungry due to fluid intake (many children drinking from baby bottle) Q.11 Parent not letting child control how much to eat Q.15 Sedentary activity level ( excessive TV, computer, video games)
  • 42. Challenges & Solutions York Region Pilot
    • High risk families not calling NutriSTEP ® RD line
    • NutriSTEP ® questionnaires available only in English and French (now in 8 languages)
    • Education resources are not available in all languages (now in 6 languages)
    • Desire: to do additional screening programs at high risk schools at JK/SK entry
    • Challenge: insufficient staff and funds for guided referral screening programs
  • 43. High Risk Children Potential Models
    • High Risk Schools via EDI mapping
    • CAS/ CCAS
    • Low income dental program
      • MHPS and MOHLTC funded
      • Investigate health unit interdepartmental opportunities to integrate NutriSTEP ®
  • 44. Provincial Program Support EatRight Ontario
  • 45. Implementing NutriSTEP ®
  • 46. EatRight Ontario Service Overview
    • Access to healthy eating advice for Ontario
      • Emphasis on health promotion and disease prevention
      • Public & health intermediaries
    • Access thru phone
      • Toll free 1-877-510-510-2
      • Mon-Fri 9-5; 2 evening hours
    • Access thru web
      • www.ontario.ca/eatright
      • Email service
    • Consistent; evidence-based
    • Free
    • Over 100 languages
    • Funded by Ministry of Health Promotion and Sport
    • Managed by Dietitians of Canada
  • 47. ERO NutriSTEP ® Launch
    • ERO Launch Date:
        • March 2009
        • Implemented all across Ontario
    • Delivery Method:
        • Phone
        • Email
        • Website
  • 48. Getting Ready for Launch
    • In preparation:
        • Developed evidence based counseling tool to respond to incoming calls and emails
        • Collected and reviewed client handouts to respond to incoming calls
        • Updated our contact referral database
        • Trained staff on NutriSTEP ®
  • 49. ERO’s Role in Implementing NutriSTEP ®
    • ERO supports
      • Parents looking for follow up information once preschooler has been screened
      • Administrators interested in setting up a screening program.
    • ERO does not:
      • Administer
      • Score
      • Send out NutriSTEP ® questionnaires
  • 50. ERO supports the Parent:
      • Provides tailored evidence based nutrition advice on healthy eating once preschooler screened
        • Via Phone, email, or website
        • Convenient hours available
        • Tailors response to parent’s questions and needs
        • Mail or email client handouts
      • Link parents to community agencies and health professionals for customized follow-up
  • 51. ERO supports the professional implementing screening
    • Act as a nutrition resource for the screening administrator
        • Answer nutrition questions
        • Provide client handouts
        • Act as a resource for parents
    • ERO is able to direct administrators to resources that may help in implementing screening program
        • ERO is unable to provide detailed support
  • 52. Challenges and Solutions
    • Getting the word out!
      • EatRight Ontario is here to support the:
        • Parents of preschoolers
        • Screen administrators implementing NutriSTEP ®
    • Promote EatRight Ontario
      • Add contact information to your NutriSTEP ® tools and community referral maps
      • Include ERO promotional material with the screening packages:
        • Magnets
        • Book marks
        • Tear pads etc.,
  • 53. Next Steps
    • Continue to support incoming NutriSTEP ® calls
    • Keep client handouts and professional tools up to date
    • Expand website content on preschool nutrition
    • Promote ERO’s role with NutriSTEP ®
    • Build bridges with community agencies
  • 54. Primary Health Care Settings TARGetKids!, Toronto Hamilton and Stratford Family Health Teams
  • 55. Healthy Children Through Preventive Healthcare
  • 56. A child health promotion research platform embedded in primary healthcare “ Health Research For Every Child ” Family Medicine Community Pediatrics AHRC - St. Michael’s PORT - SickKids
  • 57. TARGet Kids! Structure Village Park Paediatrics Dr Eddy Lau Dr Brian Chisamore Dr Sharon Naymark Taran Malhi (RA) Clairhurst Paediatrics Dr Michael Peer Dr Sheila Jacobson Dr Carolyn Taylor Subitha Rajakumaran (RA) Danforth Paediatrics Dr Patricia Neelands Dr Janet Saunderson Dr Anh Do Kanthi Kavikondala (RA) Danforth Paediatrics Dr Marty Perlmutar Dr Joanne Vaughan Dr Alana Rosenthal Kanthi Kavikondala (RA) St Michael’s 410 Sherbourne Family Medicine Clinic Tamara Wagner (Research Student) Research Leads: Dr Patricia Parkin Dr Catherine Birken Dr Jonathon Maguire Research Coordinators: Julie DeGroot Marina Khovratovich Steering Committee: Dr Mark Feldman Dr Moshe Ipp Dr Brian Chisamore LABORATORY SERVICES Mount Sinai Services Dr Azar Azad Michelle Rodrigues Lab Team DATA MANAGEMENT Applied Health Research Centre Muhammad Mamdani Magda Melo Patricia Nguyen Bryan Boodhoo Damian Jankowicz
  • 58. Where?
  • 59. Research Process
    • Prior to child’s visit:
    • Research assistant (RA) identifies families to be approached (based on the schedule of upcoming visits)
    • RA sends out letter with a brief description of the study 2 weeks prior to child’s visit to the clinic
  • 60. Research Process
    • Recruitment:
    • RA meets and greets family at the doctor’s office and explains them goals of the study and family’s involvement
    • RA answers to all the question
    • If family agrees to participate, RA explains one or both of the parents consent form and all questionnaires
  • 61. Research Process
    • Recruitment (continue):
    • NutriSTEP ® , child temperament, health questionaires administered completed by parents in the waiting room
    • RA checks the forms for completeness
    • RA takes measurements:
      • Child – height (cm), weight (kg), waist circumference (cm) and BP
      • Parent - height (cm), weight (kg) and waist circumference (cm)
    • Blood sample is collected
  • 62. Models of Blood Sample Collection
    • RA / Phlebotomist – research assistant is a certified phlebotomist and collects blood samples from each participant (Village Park, Danforth Paediatrics)
    • RA + Nurse – blood collection is done by nurse who works at the doctor’s office (Clairhurst Paediatrics)
    • RA + Phlebotomy Clinic – blood collection is done at the phlebotomy clinic located in the same building with the doctor’s office (Gamma-Dynacare, Danforth Paediatrics)
  • 63. Challenges of Recruitment
    • Participation in the study extends the visit for 30 min or more
    • Limited space in clinics
    • Paediatric practices: limited new recruitment – practices full
    • Family medicine practices:
      • Small sample size
      • Less follow up
  • 64. Enrollment in TARGet Kids!
    • Over the last 2 years…
    Site Total Enrolled Blood Samples Collected Village Park Paediatrics 1134 657 Clairhurst Paediatrics 1098 465 Danforth Paediatrics (4 th floor) 629 216 Danforth Paediatrics (1 st floor) 234 167 St Michael’s Family Medicine 7 7 Total 3102 1512
  • 65. Age Distribution
  • 66. Gender Distribution, by site
  • 67. Future Plans
    • Data entry >1000 subjects
    • Data analysis ongoing
    • Establish stable infrastructure funding
    • Continue to secure project based grants
    • Nurture and build partnerships
    • Expand TARGet Kids! other local and national sites
    • Enhance communication and feedback
  • 68. Launch & Location Stratford and Hamilton FHTs
    • Stratford
        • Wellness Clinic for Tots
        • All 3-year-olds in FHT invited to participate
        • 2 locations (Stratford & Milverton)
        • NutriSTEP ® discussed by NP with parents
        • Referrals to FHT RDs
    • Hamilton
        • In conjunction with ‘acute’ physician visits at 12 offices
        • Recruitment to study by receptionists
        • NutriSTEP ® not reviewed at physician visit
        • Referrals to FHT RDs
  • 69. Procedures
    • Objectives
      • Feasibility and acceptability in FHT models
    • Parents
        • NutriSTEP ® questionnaires, demographic questionnaires returned to Guelph
        • Parents who agreed were called by a research assistant
        • Questionnaire with closed and open-ended questions
    • Receptionists/Health Care Professionals
        • Questionnaires
        • Focus group with RDs in Hamilton
  • 70. Parent Phone Interviews
    • Participants: Stratford, 79; Hamilton, 56
    • Agreed to phone interview: 103 (76%)
    • Phone interviews: 65 (63%)
    • RD referrals: Stratford, 2; Hamilton, > 5
    Low Risk Moderate Risk High Risk Hamilton 70% 16% 14% Stratford 88% 8% 4% Combined 80% 11% 8%
  • 71. Feasibility
      • Parents
        • 98% thought setting was good
      • Providers
        • Stratford
          • NP thought screening clinic great venue for NutriSTEP ® and should be used on an ongoing basis
          • NutriSTEP ® provided NP with opportunity to address with parents the constructs related to nutrition risk
  • 72. Feasibility
        • Hamilton
          • Good venue: 3/4 receptionists, 3/5 RDs & 1 NP
          • “ Maybe” ongoing use: 4/4 receptionists, 3/5 RDs &1 NP
          • Better for a check-up/immunization visit vs. acute visit and with physician “buy-in”
          • Study materials took a lot of time to complete
          • Difficult for parents while watching children
          • Literacy level of study materials was high
          • Parents would prefer to take NutriSTEP ® home
          • Lack of ‘buy-in’ from practices for the study
  • 73. Acceptability - Parents
    • Affirmation
    Facilitation Changing behaviour Increasing knowledge & awareness Feel good factor Benchmark © D. Van Dyke
  • 74. Acceptability - Parents
    • “ I re-evaluated nutrition and bought different groceries.”
    • “ It allowed me to focus on all aspects on my kids’ meals. It’s useful to see where to improve.”
    • “ It was useful and reinforced what I knew…”
    • “ I was embarrassed she scored so [high]. It was good motivation to get me to feed her better.”
    • “ It made me aware to keep trying new foods…”
    • “ I’ve stopped dictating how much my child should eat and learned not to be so stressed out.”
    • “ It reassured me that she was reaching her nutritional benchmarks.”
    • “ It’s important to fill questions like that out because a parent may not know there is an issue.”
  • 75. Acceptability – RDs and NPs
    • RDs
    • Training for process: fine
    • Comfortable answering parent questions:
      • Yes 2/5, No 1/5
      • Parent questions: score interpretation, question clarification, sources for resources
    • Comfort with this age group: 3/5
    • “ I would definitely promote NutriSTEP ® to other dietitians and health care professionals.”
    • NPs
    • “ Great tool for opening the discussion on feeding issues, etc.”
    • “ I would like to see NutriSTEP ® used on an ongoing basis without the study and consent.”
  • 76. What We Found Out After Evaluating FHT Sites
    • Screening Clinic Model
      • Feasible and sustainable – another FHT in Stratford is continuing with NutriSTEP ® in Wellness Clinic for Tots
    • Physician Visit Model
      • Need buy-in from physicians
      • Would work better if not a research study
      • Did not overwhelm follow-up services
    • Training about preschool nutrition for follow up by health professionals may be needed
  • 77. Preschool Nutrition Modules “RD Primers”
    • Front-line health professionals require extra training on preschool nutrition
    • Top 5 preschool nutrition issues identified as learning opportunities for Registered Dietitians (RDs):
        • Growth assessment (part 1) - theoretical and background information
        • Growth assessment (part 2) - abnormal growth (failure to thrive, overweight and obesity) and body image/self-esteem
        • Nutritional assessment - developmental stages, parenting and the feeding environment
        • Nutrient deficiencies - iron and vitamin D
        • Food allergies and intolerances
  • 78. “ RD Primers”
    • Development-March and April 2009
    • Translated into French
    • E/F Primers launched June 2009
    • E/F Audio modules
      • Updated, reformatted and launched late July 2010
    • NutriSTEP ® website ( www.nutristep.ca )
    • 3500+ visits since July
  • 79. Key Learnings
    • Study settings and procedures need to be individualized
    • Nutrition concerns are complex to address
    • We can screen, ID, refer and gather data well
    • Ethical practice hard to do - follow-up is critical
    • Measuring efficacy and effectiveness requires long-term evaluation efforts
  • 80. Process Evaluation of NutriSTEP ®
    • Sites
      • Public health
        • Screening fair, drop-in program, JK/SK registration
      • Primary health care
        • Screening clinic, ‘acute’ physician visits
    • Participants
      • Parents and caregivers
      • Program providers
      • Health professionals (RD, NP)
  • 81. Process Evaluation of NutriSTEP ®
    • Results
      • 499 parents completed questionnaire and demographic form
      • 229 completed telephone interview
      • 52% boys; 94% English-speaking; 95% Canadian
      • 7% high risk; 12% moderate risk; 81% low risk
    • Conclusions
      • Parents: increases knowledge and awareness; change behaviours
      • Health care providers: acceptable, feasible and continue to use in practice
  • 82. Other Activities and Opportunities
  • 83. Website & Online Community
    • Background information and FAQs
      • 20,000+ visits since July 2009 ( >50% US)
    • Success stories: 6 case studies posted April 2010
      • 900+ visits to date
    • Implementation Toolkit (E/F)
      • Electronic and binder/CD versions (available from NRC)
    • Nutrition Primers for RDs (E/F)-updated and reformatted
    • Online Community
      • 30+ members
    • Research Activities
      • Publications-Executive Summary; Lessons learned
      • Annotated Bibliography-550+ references
  • 84. Flintbox and SOP
    • Flintbox
      • Electronic versions of questionnaires
      • License for questionnaire use
      • Tracking uptake and use
    • Service Ontario Publications
      • Print versions of questionnaires and education booklets
      • Questionnaires-password protected side
        • 8 languages
        • 70,000+ since July 2009 (16 PHUs)
      • Education booklets-general side
        • 6 languages
        • 120,000+ since July 2009 (23 PHUs)
  • 85. Evaluation Activities
    • Program Evaluation Plan
      • Short and longer term planning
      • Evaluation objectives
        • Need – Who is the target group?
        • Impact – NutriSTEP ® are evidence-informed
        • Capacity/Appropriateness
        • Community partnerships and collaboration
      • Tools for evaluation and timelines
        • How will each activity of the program be evaluated?
      • Lead(s) and partners’ roles
      • Who and how data is shared
  • 86. Evaluation Activities
    • Publications
      • Parent perception (targeted implementation in public health settings)
      • FHT implementation evaluation
    • Evaluation plan and database templates
      • To be posted on NutriSTEP ® website in near future
    • Provincial Plans 2011-12
      • Program uptake and resources e.g. Implementation Toolkit, RD Primers
      • Ongoing process and impact evaluation
        • Process evaluation and program efficacy (CIHR unsuccessful)
        • PHAC proposal with Perth District Health Unit and U of G
  • 87. Partnerships and Promotion
    • ERO web site and call centre
    • DC
      • Healthy Start for Life
      • PEN preschool pathway
      • Updated Collaborative Growth Statement, 2010
    • OCFP nutrition workshops
    • BSRC
      • Website, conference exhibits, resources
    • DFC Good Beginnings Online Preschool Nutrition Course for ECEs
  • 88. Partnerships and Promotion
    • OPHS, 2008
      • Child Health, Requirement #11
      • Guidance Documents, June 2010 (Child Health, School Health, and Healthy Eating, Active Living, Healthy Weights)
    • OAHPP
      • Preschool nutrition surveillance
    • MCYS
      • HBHC ISCIS database
      • EDI mapping
    • Curbing Childhood Obesity: FPT Framework for Action to Promote Healthy Weights
    • Platform suite for nutrition screening
      • Online version of NutriSTEP with referrals
  • 89. Need Centralized Screening Data Base(s)
    • Program Evaluation is a MUST
      • Data = Power = Resources
    • When asked: “How do you know your program works? “Are you making a difference?”
    • “ What are our rates for X?”
      • Need to put in place a way to collect
      • data at site/community level as well as
      • aggregate across Ontario and Canada
  • 90. Promotion and Knowledge Transfer
    • Promotional brochure-E/F
      • 3000 since January 2010
    • CIHR
      • Knowledge to Action: Casebook
    • Conferences
      • FHT RDs (Oct 2009)
      • FNIHB RDs (Dec 2009)
      • UK (March 2010)
      • CPHA (June 2010)
      • SNE (July 2010)
    • Year end report
      • Spring 2011
  • 91. Toddler NutriSTEP ®
    • CIHR funded study 2010-12
      • PI: U of Guelph
      • Collaborators: SDHU, TBDHU, York Region Health Dept
    • Parent focus groups-May-June 2010
      • 6 groups-Sudbury, York Region, Hamilton
    • Pediatric RD Content Validation-July-Sept 2010
      • 13 RDs from 5 provinces
    • Parent key intercept interviews-Nov 2010- Feb 2011
      • 90 parents from Thunder Bay, Sudbury, York Region, Hamilton, Guelph
  • 92. Toddler NutriSTEP ®
    • Reliability testing-Spring 2011
      • 140 parents
    • Criterion Validation-Summer and Fall 2011
      • 200 parents
    • Toddler questionnaire (E/F)-Spring 2012
    • Education booklets (E/F)
      • Development/peer review-winter 2010
      • Parent evaluation-spring/summer 2010
      • Translation/professional design-fall 2010
      • Electronic versions available soon
  • 93. QUESTIONS AND DISCUSSION
  • 94. Steps Towards Implementation
    • Select a Site Coordinator/Lead
    • Use NutriSTEP ® Implementation Toolkit
    • Train those involved in the process
    • Identify resources to meet needs
    • Develop referral maps for services
    • Monitor and evaluate process and outcomes
    • Use results to inform practice and service delivery
  • 95. For More Information
    • NutriSTEP ® Web site:
      • www.nutristep.ca
    • Nutrition Resource Centre:
    • www.nutritionrc.ca
    • Provincial Program Coordinator:
    • Lee Rysdale:
    • [email_address]
  • 96. Nutrition Screening Tool for Every Preschooler Évaluation de l’alimentation des enfants d’âge préscolaire The NutriSTEP ® name and logo are owned by the Sudbury & District Health Unit http://www.surveymonkey.com/s/nutristep_webcast_Nov2010