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Implementing NutriSTEP Ontario - June 09 Webinar


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We would like to tell you about NutriSTEP®. This work has been led by dietitian researchers from the Sudbury & District Health Unit Public Health, Research, Education & Development (PHRED) program, NRC and the University of Guelph, Dr Heather Keller and Dr Janis Randall Simpson.

As of spring 2007, NutriSTEP® has been a program of the Nutrition Resource Centre of the Ontario Public Health Association.
NutriSTEP® is of interest to a number of programs and agencies that service young children and their families.

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Implementing NutriSTEP Ontario - June 09 Webinar

  1. 1. Implementing NutriSTEP ® in Ontario <ul><ul><li>June 24, 2009 </li></ul></ul><ul><ul><li>Provincial Webinar </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>Lee Rysdale, Joanne Beyers, </li></ul></ul><ul><ul><li> Dr. Janis Randall Simpson and Dr. Heather Keller </li></ul></ul>
  2. 2. What We Will Cover <ul><li>What is the NutriSTEP ® Program </li></ul><ul><li>Research background - validation of NutriSTEP ® </li></ul><ul><li>Where NutriSTEP ® is being implemented right now and ongoing evaluation </li></ul><ul><li>Natural fit as screening and/or surveillance tool with public health, education, primary health care </li></ul><ul><li>Opportunities, challenges and next steps </li></ul>
  3. 3. NutriSTEP ® Program is … <ul><li>Parent-focused nutrition education and skill building program that starts with: </li></ul><ul><ul><li>Nutrition risk screening index for preschoolers (3-5 years) </li></ul></ul><ul><ul><ul><li>Multi-ethnic </li></ul></ul></ul><ul><ul><ul><li>English and French </li></ul></ul></ul><ul><ul><ul><li>Parent-administered - 5 minutes to complete </li></ul></ul></ul><ul><li>On-going collaborative practice-based research with University of Guelph, PHRED and others </li></ul><ul><li>Implementation Toolkit and resources </li></ul><ul><li>NutriSTEP ® Online Community </li></ul>
  4. 4. What NutriSTEP ® Measures: Construct of Nutritional Risk <ul><li>Physical growth/weight concern </li></ul><ul><li>Food and fluid intake </li></ul><ul><li>Physical activity and screen time </li></ul><ul><li>Factors affecting food intake (food security; psychosocial feeding environment) </li></ul>
  5. 5. Caregiver Resources - Education Booklets
  6. 6. Why NutriSTEP ® Program? <ul><li>Canary in the Coal Mine </li></ul><ul><li>Screening, Parent Education and Skill Building… </li></ul><ul><li>Leads to early identification and prevention of nutrition problems in priority populations </li></ul><ul><li>Increases nutrition awareness with families and providers </li></ul><ul><li>Means treatment can occur, reducing serious consequences </li></ul><ul><li>Helps manage scarce community resources </li></ul><ul><li>Screening data can be used to monitor trends over time (surveillance) </li></ul>
  7. 7. Ethical Screening… <ul><ul><li>Refer </li></ul></ul><ul><ul><li>Provide </li></ul></ul><ul><ul><li>Info </li></ul></ul><ul><ul><li>Monitor </li></ul></ul>Parent fills in tool Child not at nutritional risk Provide nutrition info Child at nutrition risk (mod or high) Physician Assess Treat Dietitian Assess Counsel Other Community Parent Programs/Workshops/Services
  8. 8. Referral Mapping ®
  9. 9. Primary Sites for Screening… CIHR Think Tank 2006 <ul><ul><ul><li>Screening fairs </li></ul></ul></ul><ul><ul><ul><li>Day cares </li></ul></ul></ul><ul><ul><ul><li>Kindergarten registration packages </li></ul></ul></ul><ul><ul><ul><li>Doctors’ and primary health care offices </li></ul></ul></ul><ul><ul><ul><li>Outpatient clinics </li></ul></ul></ul><ul><ul><ul><li>Parent education programs </li></ul></ul></ul>
  10. 10. Evaluating Targeted Sites June 2007-2009 <ul><li>Funded by NRC and Danone Institute grant </li></ul><ul><li>Two feasible models for public health </li></ul><ul><ul><li>Self-scoring and self-referral </li></ul></ul><ul><ul><li>Administrator assisted scoring and referral </li></ul></ul><ul><li>Ontario sites </li></ul><ul><ul><li>York Region-JK/SK registration packages </li></ul></ul><ul><ul><li>Thunder Bay-Fair Start screening program, JK/SK registration events </li></ul></ul><ul><ul><li>Sudbury- new “Best Start” hubs in schools </li></ul></ul>
  11. 11. Implementation Study Goal and Objectives <ul><li>Goal </li></ul><ul><ul><li>To determine the resources required as well as the feasible and appropriate processes for implementing NutriSTEP ® in the Public Health system in Ontario </li></ul></ul><ul><li>Objectives </li></ul><ul><ul><li>Implement NutriSTEP ® screening based on the proposed models </li></ul></ul><ul><ul><li>Evaluate the targeted implementation of NutriSTEP ® </li></ul></ul>
  12. 12. Overall Results <ul><li>York Region-131(9.5%) were returned </li></ul><ul><li>Thunder Bay-153 children were screened </li></ul><ul><li>Sudbury-80 children were screened </li></ul><ul><li>Only 2 parents in Thunder Bay and Sudbury declined screening process </li></ul><ul><li>Total: 364 NutriSTEP ® and demographic questionnaires returned </li></ul><ul><li>Nutritional risk levels: </li></ul><ul><ul><li>6% high risk </li></ul></ul><ul><ul><li>13% moderate risk </li></ul></ul><ul><ul><li>81% low risk </li></ul></ul>
  13. 13. Parent Phone Interviews <ul><li>Total Packages Received: 364 (consent: 264) </li></ul><ul><li>Interviews conducted: 164 </li></ul><ul><li>Participation Rate: 62% </li></ul>43.3% 71 13 58 Thunder Bay 100% 164 35 58 Total 20% 32 9 10 Mod/ High Risk 80% 132 26 48 Low Risk ----- % 100.0% Total 21.3% Sudbury 35.4% York Region %
  14. 14. Parent Thoughts on Score <ul><ul><li>Low Risk </li></ul></ul><ul><ul><ul><li>Reassured, happy, relieved, useful confirmation </li></ul></ul></ul><ul><ul><li>Moderate or High Risk </li></ul></ul><ul><ul><ul><li>Often a chronic health or health history issue (e.g. anemia) </li></ul></ul></ul><ul><ul><ul><li>Confirmation of issues that were suspected </li></ul></ul></ul><ul><ul><ul><li>Screening helped to see changes can be made and reinforced importance of good eating habits </li></ul></ul></ul><ul><ul><ul><li>Increased awareness of less healthful behaviours (e.g. TV watching) </li></ul></ul></ul><ul><ul><ul><li>Got caregiver resources </li></ul></ul></ul>
  15. 15. Parent Thoughts on Site <ul><li>Assisted Referral Model-Screening Fairs and Hubs </li></ul><ul><ul><li>Good place, convenient, self-selection, missing those who need most </li></ul></ul><ul><ul><li>Multiple screens, some steps can get missed </li></ul></ul><ul><ul><li>Concern about follow-up </li></ul></ul><ul><ul><li>Lack of space, time, environmental issues for completion </li></ul></ul><ul><ul><li>Site needs to be flexible-drop-in is not ideal for screening </li></ul></ul><ul><li>Self Referral Model </li></ul><ul><ul><li>School is for everyone </li></ul></ul><ul><ul><li>Being part of school entry package reinforced importance and relevance </li></ul></ul><ul><ul><li>Parents liked being able to take questionnaire home </li></ul></ul><ul><ul><li>Increased awareness of nutrition issues </li></ul></ul>
  16. 16. Parent Conclusions <ul><li>Main Benefit </li></ul><ul><ul><li>Screening increased parent awareness </li></ul></ul><ul><li>Barriers to Referrals/Screening </li></ul><ul><ul><li>Already aware </li></ul></ul><ul><ul><li>Other situations take precedence </li></ul></ul><ul><ul><li>No time to make changes </li></ul></ul><ul><li>Need to ensure adequate follow-up of ‘at risk’ families </li></ul>
  17. 17. What We Found Out After Evaluating Three Sites <ul><li>Assisted Referral Model </li></ul><ul><ul><li>Feasible, need for training of facilitators, communication with numerous community partners </li></ul></ul><ul><li>Self Referral Model </li></ul><ul><ul><li>Would likely work better if not part of a research project </li></ul></ul><ul><ul><li>Can reach a large number </li></ul></ul><ul><ul><li>Good partnership opportunity for public health, schools </li></ul></ul><ul><li>Did not overwhelm follow-up services </li></ul><ul><li>Training about preschool nutrition for follow up by health professionals may be needed </li></ul>
  18. 18. Key Learnings <ul><li>Study settings and procedures may not be typical/usual </li></ul><ul><li>Nutrition concerns are complex to address </li></ul><ul><li>We can screen, ID, refer and gather data well </li></ul><ul><li>Ethical practice hard to do - follow-up with parents is critical </li></ul><ul><li>Measuring efficacy and effectiveness requires long term evaluation efforts </li></ul>
  19. 19. Preschool Nutrition Modules “Primers” <ul><li>Front line health professionals require extra training on preschool nutrition </li></ul><ul><li>Top five preschool nutrition issues identified as learning opportunities for Registered Dietitians (RDs): </li></ul><ul><ul><li>1) growth assessment (part 1) – theoretical and background information </li></ul></ul><ul><ul><li>2) growth assessment (part 2) - abnormal growth (failure to thrive, overweight and obesity) and body image/self-esteem </li></ul></ul><ul><ul><li>3) nutritional assessment - developmental stages, parenting and the feeding environment </li></ul></ul><ul><ul><li>4) nutrient deficiencies - iron and vitamin D </li></ul></ul><ul><ul><li>5) food allergies and intolerances </li></ul></ul>
  20. 20. RD Primers <ul><li>March and April 2009- updated and refined; translated into French </li></ul><ul><li>English and French Primers posted on the NutriSTEP ® website ( ) </li></ul><ul><li>Ideally need to host a series of 5 web casts for Ontario RDs and their health care team members (public health, community, and clinical) - additional funds are required </li></ul>
  21. 21. Implementing NutriSTEP ® in Ontario <ul><li>Nutrition Resource Centre (NRC) </li></ul><ul><li>University of Guelph / </li></ul><ul><li>PHRED </li></ul><ul><li>Eat Right Ontario (ERO) Call Centre </li></ul><ul><li>Ontario Public Health Standards (OPHS) </li></ul><ul><li>Service Ontario </li></ul>
  22. 22. Eat Right Ontario Call Centre <ul><li>Parents </li></ul><ul><ul><li>Standardized counseling tool </li></ul></ul><ul><ul><ul><li>covers low, moderate and high risk </li></ul></ul></ul><ul><ul><li>Contact referral database-general, provincial, site specific </li></ul></ul><ul><ul><li>Will redirect parents to local health units and other referral sources </li></ul></ul><ul><li>Practitioners </li></ul><ul><ul><li>Direct callers to Flint Box and NutriSTEP ® website </li></ul></ul><ul><ul><li>Future Role- a resource to assist agencies in setting up a screening program </li></ul></ul><ul><li>1- 877- 510- 510- 2 </li></ul>
  23. 23. Fit with OPHS: Screening, Surveillance & Requirements Related to Children <ul><li>Foundational Standard: </li></ul><ul><ul><li>1, 2, 3, 4, 5, 6 </li></ul></ul><ul><li>Chronic Disease Prevention: </li></ul><ul><ul><li>1, 3, 7, 11 </li></ul></ul><ul><li>Child Health: </li></ul><ul><ul><li>1, 4, 5, 6, 7, 8, 9, </li></ul></ul>11
  24. 24. NutriSTEP ® and New Ontario Public Health Standards <ul><li>Child Health Requirement # 11: </li></ul><ul><ul><li> The BOH shall facilitate access and support for families to complete screening tools(*19) to monitor their child’s health and development, and provide a contact for families to discuss results and arrange follow-up. </li></ul></ul><ul><ul><li>* …such as NutriSTEP ® </li></ul></ul>
  25. 25. School Readiness… if nutritionally well, ready to learn <ul><li>Where NutriSTEP ® fits </li></ul><ul><ul><li>JK/SK registration (York Region and TBay) </li></ul></ul><ul><ul><li>Immunization/well child clinics (Calgary); developmental screening fairs </li></ul></ul><ul><ul><li>HBHC Program </li></ul></ul><ul><ul><li>FHTs </li></ul></ul><ul><ul><li>EDI for JK/SK (dovetail with parent survey component – logical fit for NutriSTEP ® ) </li></ul></ul><ul><ul><ul><li>Local communities data available for surveillance and planning </li></ul></ul></ul><ul><ul><li>Dental screening </li></ul></ul>
  26. 26. Steps to Implementation <ul><li>NutriSTEP ® Online </li></ul><ul><ul><li>Background, FAQs, Collaborative 3 rd party site </li></ul></ul><ul><ul><li>Implementation Toolkit, supportive resources </li></ul></ul><ul><li>Flintbox </li></ul><ul><ul><li>Electronic questionnaire and license; online toolkit </li></ul></ul><ul><li>Service Ontario /publications </li></ul><ul><ul><li>Print questionnaires (password protected side only) </li></ul></ul><ul><ul><li>Electronic and print educational booklets </li></ul></ul><ul><li>Nutrition Resource Centre </li></ul><ul><ul><li>Provincial Program Coordinator: </li></ul></ul><ul><li> Lee Rysdale: [email_address] </li></ul>
  27. 28. Implementation Toolkit <ul><li>English and French </li></ul><ul><li>Online version </li></ul><ul><ul><li> </li></ul></ul><ul><ul><li> </li></ul></ul><ul><li>Binder/CD version </li></ul><ul><ul><li>NRC order form </li></ul></ul><ul><ul><li>Provided on this webcast </li></ul></ul><ul><ul><li>Ontario only </li></ul></ul>
  28. 29. NutriSTEP ® Questionnaire <ul><li>Electronic versions </li></ul><ul><ul><li> </li></ul></ul><ul><li>Print versions </li></ul><ul><ul><li> /publications (Ontario Health Units; password </li></ul></ul><ul><ul><li>protected side only) </li></ul></ul>
  29. 30. <ul><li>Electronic and print </li></ul><ul><li>Print versions from </li></ul><ul><ul><li>ServiceOntario only </li></ul></ul><ul><li>English and French </li></ul><ul><li>Cultural Adaptations </li></ul><ul><ul><li>Summer/fall 2009 </li></ul></ul><ul><ul><li>Chinese </li></ul></ul><ul><ul><ul><li>Simplified </li></ul></ul></ul><ul><ul><ul><li>Traditional </li></ul></ul></ul><ul><ul><li>Vietnamese </li></ul></ul><ul><ul><li>Punjabi </li></ul></ul>
  30. 31. Steps Towards Implementation <ul><li>Obtain the NutriSTEP ® Implementation Toolkit </li></ul><ul><li>Select a Site Coordinator </li></ul><ul><li>Train those involved in the process </li></ul><ul><li>Identify resources to meet needs including Eat Right Ontario and the Call Centre </li></ul><ul><li>Develop referral maps for services </li></ul><ul><li>Monitor and evaluate process and outcomes </li></ul><ul><li>Use results to inform practice and service delivery </li></ul>
  31. 32. Some Next Steps <ul><li>Work towards a “one stop data shop” for NutriSTEP ® (for screening and surveillance purposes at all levels - national, provincial, regional and local) </li></ul><ul><li>NutriSTEP ® validation with other age groups of children e.g. 18 months </li></ul><ul><li>NutriSTEP ® validation in other languages </li></ul><ul><li>Long-term: Testing of effectiveness of preschool nutrition screening and outcomes </li></ul>
  32. 33. Take away <ul><li>Valid and reliable questionnaire-English and French </li></ul><ul><li>Fills need for simple index for preschool screening </li></ul><ul><li>Just completing the tool increases parent food and nutrition awareness </li></ul><ul><li>Caregiver resources well developed </li></ul><ul><li>Integrates into existing programs with many different partners e.g. ERO, HBHC, school readiness </li></ul><ul><li>Reaches at risk, priority populations </li></ul><ul><li>Can be used for screening and surveillance </li></ul><ul><li>Requires enhanced capacity for provincial coordination and evaluation </li></ul>
  33. 34. Acknowledgements <ul><li>University of Guelph </li></ul><ul><ul><li>Researchers: </li></ul></ul><ul><ul><ul><li>Janis Randall Simpson: [email_address] </li></ul></ul></ul><ul><ul><ul><li>Heather Keller: [email_address] </li></ul></ul></ul><ul><li>SDHU PHRED Program </li></ul><ul><ul><li>Past project updates and documents: </li></ul></ul><ul><ul><li>Researcher: </li></ul></ul><ul><ul><ul><li>Joanne Beyers: [email_address] </li></ul></ul></ul><ul><li>Nutrition Resource Centre </li></ul><ul><ul><li>Provincial Program Coordinator: </li></ul></ul><ul><li> Lee Rysdale: [email_address] </li></ul>
  34. 35. © 1998-2008. Sudbury & District Health Unit, Janis Randall Simpson, and Heather Keller. All Rights Reserved. The NutriSTEP® mark and Bear Logo are owned by the Sudbury & District Health Unit. Refer to for more information.