Kirsten Davison, Ph.D. - "Developing Sustainable Family-Centered Obesity Interventions"

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The Youth-Nex Conference on Physical Health and Well-Being for Youth, Oct 10 & 11, 2013, University of Virginia …

The Youth-Nex Conference on Physical Health and Well-Being for Youth, Oct 10 & 11, 2013, University of Virginia

"Developing Sustainable Family-Centered Obesity Interventions: What Can
We Learn from Developmental Psychology and Implementation Science?"
- Kirsten Davison, Ph.D.

Davison is an Associate Professor of Nutrition at the Harvard School of Public Health. She completed her PhD at the Pennsylvania State University in Child and Family Development.

Panel 3 — Nutrition and Healthy Eating. As we understand more about what defines good nutrition for youth, we are also increasingly understanding the importance of instilling healthy eating habits for youth in the context of family, school, and sport. This varied panel covers major topics within this under-considered but important area of youth development.

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  • 1. Developing Sustainable Family-Centered Obesity Interventions: What Can We Learn from Developmental Psychology and Implementation Science PRINCIPAL INVESTIGATORS: CO-INVESTIGATORS Kirsten K. Davison, PhD (PI) Janine M. Jurkowski, PhD, MPH (PI) Hal Lawson (co-I), Sibylle Kranz (co-I) Lawrence Schell (co-I) Glenn Deane (co-I) Funded by NIH R24 MD004865 Davison et al. (2013). A childhood obesity intervention developed by families for families: results from a pilot study. International Journal of Behavioral Nutrition and Physical Activity, Jan 5;10:3.
  • 2. Key challenges of family-based childhood obesity interventions • Reaching families • Passive refusals (consent but don’t show up) • Parents not interested if don’t see immediate need • Priorities for intervention do not match family priorities
  • 3. Possible strategies • Maintain contact with families over time • Partner with organizations that reach families • Use electronic means to collect data • Build intervention into other appointments • Design programs around the needs and interests of families • Ask families members what they hope to gain from participating
  • 4. Goals 1. Utilize community-based participatory research (CBPR) to develop and pilot test a family-centered obesity prevention program for children enrolled in Head Start. 2. Incorporate the resulting intervention into systems of care (e.g., Head Start, WIC, pediatric care).
  • 5. Family Action-based Model of Intervention Layout and Implementation (FAMILI) Phase 1: Theory Phase 2: Research Phase 3: Intervention Design & Implementation Utilize theories of family development to frame family-centered research Use a mixed methods approach to examine factors impacting on parents and families that are relevant for intervention design. Utilize a CBPR paradigm to develop interventions that empower parents and caregivers to foster healthy family lifestyles and establish systems-level change that reinforces family change. CBPR = community-based participatory research Davison, Lawson, & Coatsworth (2011). Health Promotion Practice
  • 6. Family Ecological Model Family Demographics Policies and the Media • School PE and food policies • Advertising to children • Nutrition labeling Knowledge and Beliefs about behaviors that educe/promote obesity risk behaviors Accessibility of healthy and unhealthy eating and physical activity options Community Characteristics • Neighborhood walkability •Crime levels •Access to healthy foods and recreational spaces PARENTING • Family income • Single versus two parent household • Ethnicity • Education Modeling of healthy and unhealthy eating and activity behaviors Shaping children’s eating and physical activity behaviors by the use of reward and punishment systems Child Characteristics • Age • Gender • Weight status • Athletic competence Organizational Characteristics • • • School environment Job characteristics Work demands Davison & Campbell (2005). Public health approaches to the prevention of obesity. Oxford University Press
  • 7. Setting • Small city in upstate New York • Five Head Start centers (423 2-5-year olds) 38.5% non-Hispanic White 17.8% non-Hispanic Black 6.1% Hispanic or Latino 13.5% biracial 24% unknown • Primary household language 90% English 6% Spanish
  • 8. Phase 1 Community Advisory Board – Majority were parents/grandparents of children in Head Start Participated in all aspects of project – Development of the mission, logo, topics to explore – Recruitment, data collection (IRB trained), workshops and conferences, research team meetings
  • 9. Phase 2 Community Assessment – – – – – – – Focus groups Key informant interviews Photovoice 24 hour dietary recall (children); Sibylle Kranz 7-day accelerometery (children); Karin Pfeiffer Surveys, follow-up interview Behavioral observation in centers Findings were presented to the community in two town hall meetings. Solicited ideas on what the program should entail.
  • 10. What did we learn? Children • Watched TV extensively; a coping strategy • Excessive consumption of sugar-sweetened beverages • 35% overweight or obese; 14% met PA recommendations Parents • failed to recognize when their children were overweight • didn’t like how physicians interacted with them • wanted • to gain advocacy skills • to connect with other parents • the program to be center-based • their children to gain something from the program
  • 11. What did we learn? Children • watched TV extensively; a coping strategy • excessive consumption of sugar-sweetened beverages • 35% overweight or obese; 14% met PA recommendations Parents • Failed to recognize when their children were overweight • Didn’t like how physicians interacted with them • Wanted • to gain advocacy skills • to connect with other parents • the program to be center-based • their children to gain something from the program
  • 12. What did we learn? Community • No where to send parents concerned about their child’s weight • Some programs available in community to promote healthy living, but underutilized
  • 13. Phase 3 The CHL program Multiple components 1. Health communication campaign 2. BMI letters sent home 3. Family coffee hour with nutrition counseling 4. Parent’s Connect for Family Wellness program
  • 14. Phase 3 The CHL program Multiple components 1. Health communication campaign 2. BMI letters sent home 3. Family coffee hour with nutrition counseling 4. Parent’s Connect for Family Wellness program
  • 15. Parents Connect for Healthy Living • • • • 6 week parent-led program 2 hour session each week; meal provided Center-based Sessions focused on: – – – – Resource empowerment Nutrition, media literacy, and communication (workshops) Conflict resolution, social networking and stress (hands-on) Effective communication with health professionals (panel discussions with pediatricians)
  • 16. Intervention and Evaluation Timelines Sept Oct Baseline Survey (N=154) Nov Dec Jan Feb Mar Intervention Implemented Survey (N=88) Apr May Jun Follow-up Survey (N=109) Activity Monitors (N=90) Activity Monitors (N=57) Diet recall (N=55) Diet recall (N=33)
  • 17. Evaluation sample and methods Recruited from all five Head Start centers White (45%); African American (15%) Some high school (21%); high school graduate (37%); some college (42%) Construct Method Child BMI; obesity Record extraction: measured height and weight 152 136 Parenting, empowerment, demographics, intervention exposure Parent survey 145 102 Child dietary recall 24 Hour Dietary Recall 55 33 Child physical activity 7-day accelerometry 83 57 Sample size Sample size (Pre-test) (Pre-test)
  • 18. Community Advisory Board Participation Rates Parents (N= 13) Range 3-19 out of 23 meetings Average = 41% of meetings attended Median = 35% of meetings attended Community members & Agency staff (N= 8) Range = 4-17 of 23 meetings Average = 42% of meetings attended Median = 43% of meetings attended
  • 19. Results Program exposure •Health communication campaign: 90%+ parents reported seeing posters, 85% reported reading posters •Family coffee hour: 40% parents heard about, 29% spoke with a nutrition counselor •Parents Connect program: 69% heard about program, 20% attended at least one session. •Total number of components parents exposed to: 1 (16%), 2 (50%), 3+ (30%) 0 (4%),
  • 20. Results Pre-post intervention differences in child and parent outcomes • Paired t-tests examined pre-post intervention change in measures of: – child BMI, dietary intake, and physical activity – food, physical activity, and screen-related parenting, parent resource empowerment • Performed as intent to treat analyses
  • 21. Child Outcomes Pre intervention Mean (std) Child weight status BMI z-score Obesity (%) Child TV viewing (min/day) Child diet – dietary recall     Total energy (kcals)     Total fat (gm)     Total carbohydrate (gm)     Total protein (gm) * p< .05  ** p< .01  *** p< .001 t-value 0.72 (1.12) 15.8%   1.69 10.7** 33.3 (4.0) 21.2 (2.9) 4.7 (1.5) 32.6 (1.82) 21.7 (3.2) 4.9 (1.5)   1.82 -2.04* -1.76 141.9 (77.0) 94.10 (61.2) 8.62** 0.86 (1.24) 19.7% Child physical activity (min/day) Sedentary Light physical activity Moderate physical activity Post intervention Mean (std) 1531.2 (405.3) 50.1 (18.6) 214.6 (57.4) 58.1 (18.7) 1395.7 (423.8) 47.3 (20.1) 199.1 (59.4) 52.9 (17.5)   3.20** 2.27* 2.60* 3.15**
  • 22. Parent outcomes Pre intervention Post intervention Mean (std) Mean (std) t-value Parent resource empowerment Weight  Physical activity Diet 3.37 (.63) 3.21 (.63) 3.33 (.61) 3.53 (0.82) 3.40 (.66) 3.48 (.59) 3.19** 4.24*** 3.96** Parenting: Diet Freq. eat fast food Freq. offer fruits and vegetables Self efficacy to offer healthy foods 1.19 (.61) 4.43 (1.15) 4.64(.50) 1.15 (.59) 4.56 (1.14) 4.78 (.39) .69 -1.87 -4.08*** Parenting: Physical activity Support for physical activity 3.37 (.51) 3.50(.50) -3.36*** 3.34 (.53) 66% 3.33 (.60) 65% .57 0.69 Parenting: Television viewing Monitor child screen time TV in child’s bedroom * p< .05  ** p< .01  *** p< .001
  • 23. Dose effects Dose = # components of CHL to which parents were exposed Multiple regression analysis Outcome (post test) = outcome (pre test) + dose Estimate Outcome: Child BMI z-score (post) BMI z-score (pre) Dose Outcome: Child moderate PA (post) Child moderate PA (pre) Dose Outcome: Child TV viewing (post) Child TV viewing (pre) Dose Outcome: Child energy intake1 (post) Child energy intake (pre) Dose SE t-value P-value 0.71 .0.1 .058 .05 12.09 0.137 <.0001 .89 0.72 0.08 .08 .09 8.68 0.86 <.0001 0.39 0.66 -16.59 0.05 2.73 12.56 -6.08 <.0001 <.0001 0.83 -48.92 .10 28.35 8.67 -1.73 <.0001 0.09 To reduce the risk of type II error, dose effects were only assessed for one key indicator for each construct. 1
  • 24. Dose effects Estimate Outcome: Parent empowerment1 (post) Parent weight-related empowerment (pre) Dose Outcome: Parent support for child PA (post) Parent support for child PA Dose  Outcome: Parent self efficacy-healthy foods Parent self efficacy (pre) Dose SE t-value P-value .634 .09 .083 .046 7.63 1.97 <.0001 .05 0.66 0.06 0.06 0.02 11.35 2.74 <.0001 .006 0.51 0.05 10.51 <.0001 0.05 0.02 2.84 0.005 To reduce the risk of type II error, dose effects were only assessed for one key indicator for each construct. 1
  • 25. Summary of Results • Successful parent and community engagement • Broad exposure to CHL • Improvements in child and parent outcomes • Dose effects were observed Limitations •Absence of a control group •Small sample size
  • 26. What now? Scaling up a CBPR-based program •Focus on best processes rather than best practices Component Practice Process Health communication campaign Posters illustrating myths endorsed by parents and research dispelling such myths Parent awareness and understanding of their child’s weight status Family nutrition counseling Nutrition graduate student is available during “pick up” to answer parents’ questions Nutrition knowledge; parent social networking; knowledge of relevant community resources
  • 27. Implementation science as a framework for future research Challenges us to: •Utilize methods to efficiently move research to practice •Focus on ecological validity (applicability, utility, feasibility, implementation effectiveness) •Collect measures relevant to stakeholders and key decision makers •Ensure representative samples