Evaluation overview for the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project

The range of outcomes and outcome measurement instruments collected in multisectoral community-based obesity prevention interventions in children: A systematic review

Multicomponent and multisectoral community-based interventions (CBIs) have proven potential in preventing overweight and obesity in children. Synthesizing evidence on the outcomes collected and reported in such CBIs is critical for the evidence of effectiveness and cost-effectiveness. This systematic review aimed to identify the range of outcomes and outcome measurement instruments collected and reported in multisectoral and multicomponent CBIs for obesity prevention in children. A systematic search updated an existing review and extended the search to 11 academic databases (2017-2023) and gray literature. Outcomes were classified into outcome domains, and common measurement instruments were summarized. Seventeen outcome domains from 140 unique outcomes were identified from 45 included interventions reported in 120 studies. The most frequently collected outcome domains included anthropometry and body composition (91% of included interventions), physical activity (84%), dietary intake (71%), environmental (71%), and sedentary behavior (62%). The most frequently collected outcomes from each of these domains included body mass index (89%), physical activity (73%), fruit and vegetable intake (58%), school environment (42%), and screen time (58%). Outcome measurement instruments varied, particularly for behavioral outcomes. Standardization of reported outcomes and measurement instruments is recommended to facilitate data harmonization and support quantifying broader benefits of CBIs for obesity prevention.

The Healthy Kids & Families study: Outcomes of a 24-month childhood obesity prevention intervention

Socioeconomically disadvantaged children experience a high burden of obesity but few interventions address obesity prevention in this population subgroup. The Healthy Kids & Families study tested the effect of a parent-focused community health worker (CHW)-delivered lifestyle intervention to prevent childhood obesity. Participants were child-parent/guardian (Kindergarten to 6th grade at baseline) dyads (n = 247) recruited through schools located in socioeconomically disadvantaged neighborhoods in Worcester, MA, USA. Using a quasi-experimental design, the study tested the impact of Healthy Kids & Families, a theory-based, low-intensity, parent-focused, CHW-delivered intervention to improve children's weight, healthy eating and physical activity. The attention-control comparison condition was a positive parenting intervention. The primary outcome was change in child body mass index (BMI) z-score at 24 months. Secondary outcomes included number of positive child and parent changes in selected diet and physical activity behaviors targeted by the intervention and change in parent BMI. Outcomes were assessed following the intent-to-treat principle and using multivariable generalized linear mixed models. Compared to the attention-control comparison condition, the Healthy Kids & Families intervention led to a greater reduction in children's BMI z-score (β = -0.17, 95 %CI: -1.92 to -0.36; p = 0.057) and a greater number of positive behavior changes among children (β = 0.57, 95 %CI: 0.08-1.06; p = 0.02) at 24 months. There was no significant change in parent outcomes. The Healthy Kids & Families intervention shows promise for obesity prevention among children in socioeconomically disadvantaged communities.

A scoping review of whole-of-community interventions on six modifiable cancer prevention risk factors in youth: A systems typology

Whole-of-community interventions delivered across entire geospatial areas show promise for improving population health for youth cancer prevention. The aims of this scoping review were to synthesize the whole-of-community intervention literature on six modifiable risk factors in youth for cancer prevention (alcohol use, diet, obesity, physical activity, sun exposure, tobacco use) and to develop and apply a typology describing the inclusion of fundamental control system functional characteristics. A systematic search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, and Scopus for studies published to the end of 2019. Eligible studies included a geospatially defined whole-of-community intervention; youth 0-18 years; and at least one of the six cancer risk factor outcomes. An iterative process was undertaken to create a typology describing the functions for whole-of-community interventions guided by systems theory, and the typology was used to code the included interventions. A total of 41 interventions were included. Most interventions (43.9%) assessed multiple cancer risk factors. Few interventions provided fundamental functions necessary for community system coordination: sensor, controller, effector. Although communities are a patchwork quilt of microsystems where individuals interact in geographically bounded places nested within larger whole systems of influence, a control systems approach has not been used to frame the literature. Whole-of-community interventions can be characterized by the fundamental system functions necessary for coordinating population health improvement. Future whole-of-community intervention efforts should draw on fundamental knowledge of how systems operate and test whether adoption of the key functions is necessary for whole-of-community population health improvement.

Stakeholder perspectives and sustainability of an integrated care model for the prevention and management of obesity: the Childhood Obesity Research Demonstration (CORD) project

Although reliable strategies exist to promote healthy habits that reduce childhood obesity, the sustainability of these strategies remains an ongoing public health challenge. This study aimed to identify factors experienced in a large, multisite project aimed at reducing childhood obesity that might contribute to project sustainability. Hypothesized constructs underpinning sustainability included replicability, continuation of benefits, institutionalization, and community capacity. Key informants (n = 27) completed 60 min, in-depth interviews, which were audio recorded and transcribed. Transcripts were first coded using a combined deductive and inductive approach. Four major themes emerged (with numerous subthemes): developing partnerships, challenges to the sustainability of implemented programming, the importance of intervening in multiple settings, and ongoing implementation and evaluation strategies. Replicability of complex childhood obesity interventions is possible when there are strong partnerships. Benefits can continue to be conferred from programming, particularly when evidence-based strategies are used that employ best practices. Implementation is facilitated by institutionalization and policies that buffer challenges, such as staffing or leadership changes. Community capacity both enhances the sustainability of interventions and develops as a result of strengthening partnerships and policies that support childhood obesity programming.

Effectiveness in adapting the implementation of the Early Care and Education Learning Collaboratives Project (ECELC) using real-world conditions

The National Early Care and Education Learning Collaboratives Project (ECELC) was a multistate intervention that was highly effective in implementing best practices for healthy eating physical activity (HEPA) in early care and education (ECE) programs across the USA. The ECELC included didactic in-person learning sessions, technical assistance, and self-assessment-guided action planning. This study aimed to describe the effectiveness of adaptions to the self-assessments, learning sessions, and overall support, and also aimed to compare the effectiveness of each to the Original ECELC Model, when applicable. This study utilized a pre-poststudy design using data collected via the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) instrument for ECE programs that adapted the Original ECELC Model. Adaptations to the Original ECELC Model were found to promote best practices and policies with regard to Breastfeeding & Infant Feeding, Child Nutrition, Infant & Child Physical Activity, Outdoor Play & Learning, and/or Screen Time as demonstrated by the NAP SACC (p < .05), with some exceptions of nonstatistically significant increases. Improvements were found to be statistically similar to improvements made among participants of the Original ECELC Model. Partner-driven, scalable, and customizable policy- and practice-based interventions to promote HEPA among children in ECE settings may serve as a key strategy to work toward reducing risk for childhood obesity.

Measurement of screen time among young children aged 0-6 years: A systematic review

The impact of screen-based devices on children's health and development cannot be properly understood without valid and reliable tools that measure screen time within the evolving digital landscape. This review aimed to summarize characteristics of measurement tools used to assess screen time in young children; evaluate reporting of psychometric properties; and examine time trends related to measurement and reporting of screen time. A systematic review of articles published in English across three databases from January 2009 to April 2020 was undertaken using PROSPERO protocol (registration: CRD42019132599) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included articles measured screen time as outcome, exposure, or confounder in children 0-6 years. The search identified 35,868 records, 1035 full-text articles were screened for eligibility, and 622 met inclusion criteria. Most measures (60%) consisted of one to three items and assessed duration of screen time on a usual day. Few measures assessed content (11%) or coviewing (7%). Only 40% of articles provided a citation for the measure, and only 69 (11%) reported psychometric properties-reliability n = 58, validity n = 19, reliability and validity n = 8. Between 2009 and 2019, the number of published articles increased from 28 to 71. From 2015, there was a notable increase in the proportion of articles published each year that assessed exposure to mobile devices in addition to television. The increasing number of published articles reflects increasing interest in screen time exposure among young children. Measures of screen time have generally evolved to reflect children's contemporary digital landscape; however, the psychometric properties of measurement tools are rarely reported. There is a need for improved measures and reporting to capture the complexity of children's screen time exposures.

Impact of Hurricane Harvey on the Growth of Low Income, Ethnic Minority Adolescents

OBJECTIVE

This study examined the differential impact of Hurricane Harvey on adolescent standardized Body Mass Index (zBMI), physical activity, diet, and perceived stress.

METHODS

Prior to Hurricane Harvey, 175 ethnic minority adolescents were recruited from an independent school district in Houston. Height and weight were directly measured. The School Physical Activity and Nutrition Questionnaire assessed diet and physical activity. Stress was assessed with the Perceived Stress Scale. High hurricane impact was classified as at least 1 affirmative response to house damage, rescue, displacement, or going without food, water, or medicine. Repeated measures such as ANCOVA models were developed to assess differences in zBMI, physical activity, diet, and stress between the hurricane impact groups. Regression models were used to assess stress as a mediator of the hurricane impact and zBMI change relationship.

RESULTS

Students who were highly impacted by the hurricane had a greater decrease in zBMI than those less impacted from pre-hurricane to 15 weeks post-hurricane (95% CI 0.02 to 0.25, p<0.05). Physical activity and diet did not differ by impact. Perceived stress at 3 weeks post-hurricane mediated the impact and zBMI change relationship (β=-0.04 95% CI -0.12 to -0.002).

CONCLUSION

The decrease in zBMI among highly impacted students warrants further monitoring. Perceived stress, immediately following the hurricane, impacted student growth months later.

Childhood Obesity Evidence Base Project: A Systematic Review and Meta-Analysis of a New Taxonomy of Intervention Components to Improve Weight Status in Children 2-5 Years of Age, 2005-2019

Objective: To evaluate the efficacy of childhood obesity interventions and conduct a taxonomy of intervention components that are most effective in changing obesity-related health outcomes in children 2-5 years of age. Methods: Comprehensive searches located 51 studies from 18,335 unique records. Eligible studies: (1) assessed children aged 2-5, living in the United States; (2) evaluated an intervention to improve weight status; (3) identified a same-aged comparison group; (4) measured BMI; and (5) were available between January 2005 and August 2019. Coders extracted study, sample, and intervention characteristics. Effect sizes [ESs; and 95% confidence intervals (CIs)] were calculated by using random-effects models. Meta-regression was used to determine which intervention components explain variability in ESs. Results: Included were 51 studies evaluating 58 interventions (N = 29,085; mean age = 4 years; 50% girls). Relative to controls, children receiving an intervention had a lower BMI at the end of the intervention (g = 0.10, 95% CI = 0.02-0.18; k = 55) and at the last follow-up (g = 0.17, 95% CI = 0.04-0.30; k = 14; range = 18-143 weeks). Three intervention components moderated efficacy: engage caregivers in praise/encouragement for positive health-related behavior; provide education about the importance of screen time reduction to caregivers; and engage pediatricians/health care providers. Conclusions: Early childhood obesity interventions are effective in reducing BMI in preschool children. Our findings suggest that facilitating caregiver education about the importance of screen time reduction may be an important strategy in reducing early childhood obesity.

Cross-Site Process Evaluation Results for the Early Childhood Education Center Setting: CORD Study

Background: The Childhood Obesity Research Demonstration project aimed to deliver evidence-based obesity prevention interventions to at-risk families at three demonstration sites. The interventions were delivered in multiple settings, including early childhood education centers (ECECs), public schools, and primary care clinics. An evaluation center conducted cross-site process, impact, and sustainability evaluations. Results of the cross-site process evaluation for the ECECs will be described. Methods: Reach (proportion of the target population who participated), dose delivered (materials and interventions that were distributed), and fidelity (proportion of planned intervention components delivered) were assessed at two levels (researcher-to-provider and provider-to-family levels). Standardized data forms were completed by research team members at each demonstration site with assistance from the evaluation center. Results: The Childhood Obesity Research Demonstration project reached 5174 children and 390 teachers in 58 ECECs. The centers delivered an average of 3.9 hours of training to teachers. A total of 1382 different types of materials were distributed to providers, and from 1.3 to 4.3 hours of technical support were delivered to centers monthly. For fidelity at the researcher-to-provider level, 49.5% (n = 370) of eligible teachers completed all training sessions. Considerable variations across demonstration sites in reach, dose delivered, and fidelity across were observed. Conclusion: The Childhood Obesity Research Demonstration project reached large numbers of children, families, teachers, and ECECs. Maintaining intervention fidelity while reaching large numbers of at-risk individuals proved to be a challenge.

Evaluating sustainability in the Childhood Obesity Research Demonstration project: the model and process

Background

In the context of health-related interventions, sustainability is the capacity to maintain the changes resulting from the intervention. These can be improved policies, practices or trends intended to improve population health. The Childhood Obesity Research Demonstration (CORD) project was a multi-site, multi-intervention collaboration testing the Obesity Chronic Care Model with interventions for childhood obesity prevention and management. We present the model, definitions and methodology used for the cross-site sustainability evaluation of CORD.

Methods

We applied the Ecologic Model of Obesity to childhood obesity interventions to operationalize four sustainability constructs: replicability, continuation of benefits, institutionalization, and community capacity. We used a triangulation approach and employed mixed methods to assess sustainability constructs at each level of the Ecologic Model of Obesity: Micro, Meso, Exo and Macro. We constructed checklists to count and code intervention activities, use of evidence-based practices among providers, and environmental factors and policies hypothesized to influence intervention sustainability. We developed in-depth interviews for principal investigators and project leads. We applied the Wilder Collaboration Factors Inventory with key stakeholders.

Results

Lessons learned suggested that sustainability constructs should be clearly identified and operationalized a priori. Constructs must be flexible to account for differences between intervention plans and implementation to obtain robust and informative data.

Conclusion

Strong links are needed among researchers, program implementers and communities to accomplish consistent, robust and valuable data collection efforts to assure sustainable and healthy communities.

Design and methods of the Healthy Kids & Families study: a parent-focused community health worker-delivered childhood obesity prevention intervention

Background

One third of U.S. children and two thirds of adults are overweight or obese. Interventions to prevent obesity and thus avert threats to public health are needed. This paper describes the design and methods of the Healthy Kids & Families study, which tested the effect of a parent-focused community health worker (CHW)-delivered lifestyle intervention to prevent childhood obesity.

Methods

Participants were English or Spanish-speaking parent-child dyads (n = 247) from nine elementary schools (grades K-6) located in racial/ethnically diverse low-income communities in Worcester, Massachusetts. Using a quasi-experimental design with the school as the level of allocation, the study compared the lifestyle intervention vs. an attention-control comparison condition. The lifestyle intervention was guided by social cognitive theory and social ecological principles. It targeted the child’s social and physical home environment by intervening with parental weight-related knowledge, beliefs, and skills for managing child obesogenic behaviors; and addressed families’ needs for community resources supportive of a healthy lifestyle. The two-year CHW-delivered intervention was structured based on the 5As model (Agenda, Assess, Advise, Assist, Arrange follow up) and included two in person sessions and two telephone follow-ups per year with the parent, with a personalized letter and print materials sent after each contact. Parents also received quarterly newsletters, Facebook messages, and invitations to community events. The attention-control comparison condition used the same format and contact time as the intervention condition, but targeted positive parenting skills. Measurements occurred at baseline, and at 6-, 12-, 18- and 24-month follow-up. Assessments included anthropometrics, accelerometry, global positioning system (GPS), and self-report surveys. The primary outcome was child body mass index (BMI) z score. Secondary outcomes were parent BMI; and parent and child diet, physical activity, sedentariness, and utilization of community resources supportive of a healthy lifestyle.

Discussion

A CHW-delivered parent-focused lifestyle intervention may provide a translatable model for targeting the high priority public health problem of childhood obesity among low-income diverse communities. If demonstrated effective, this intervention has potential for high impact.

Trial registration

ClinicalTrials NCT03028233. Registered January 23,2017. The trial was retrospectively registered.

Association of parental body mass index (BMI) with child's health behaviors and child's BMI depend on child's age

Background

Parent’s and child’s body mass index (BMI) are strongly associated, but their relationship varies by child’s sex and age. Parental BMI reflects, among other factors, parents’ behaviors and home environment, which influence their child’s behaviors and weight. This study examined the indirect effect of parent’s BMI on child’s BMI via child health behaviors, conditional on child’s sex and age.

Methods

Data from 2039 children and 1737 parents from eight cities of the U.S. involved in the Childhood Obesity Research Demonstration project tested the association between parental BMI and child’s percentage of 95th BMI percentile (%BMIp95). A generalized structural equation modeling approach to path analysis was used to estimate and test simultaneously the associations among parental BMI and child’s health behaviors and BMI across three age groups (preschool 2-4 yr., elementary 5-10 yr., and middle school 11-12 yr). Child’s health behaviors were examined as mediators.

Results

Parental BMI was related to %BMIp95 across all age groups, and was strongest in 11-12 yr. children. Parental BMI was positively associated with boys’ fruit and vegetable (FV) intake and girls’ sugar-sweetened beverage (SSB) intake. Compared to 2-4 yr., older children had less FVs and physical activity, more screen time and SSB, and higher %BMIp95. Mediation effects were not significant.

Conclusions

Parental BMI was associated with child’s %BMIp95 and some child behaviors, and this association was stronger in older children; older children also exhibited less healthy behaviors. Age- and sex-specific interventions that focus on age-related decreases in healthy behaviors and parental strategies for promoting healthy behaviors among at-risk children are needed to address this epidemic of childhood obesity.

Process Evaluation and Lessons Learned From Engaging Local Policymakers in the B'More Healthy Communities for Kids Trial

Partnerships linking researchers to the policymaking process can be effective in increasing communication and supporting health policy. However, these policy partnerships rarely conduct process evaluation. The Policy Working Group (Policy WG) was the policy-level intervention of the multilevel B'More Healthy Communities for Kids (BHCK) trial. The group sought to align interests of local policymakers, inform local food and nutrition policy, introduce policymakers to a new simulation modeling, and sustain intervention levels of BHCK. We conducted an evaluation on the Policy WG between July 2013 and May 2016. We evaluated process indicators for reach, dose-delivered, and fidelity and developed a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The policy intervention was implemented with high reach and dose-delivered. Fidelity measures improved from moderate to nearly high over time. The number of health-related issues on policymakers' agenda increased from 50% in the first 2 years to 150% of the high standard in Year 3. SWOT analysis integrated a stakeholder feedback survey to consider areas of strength, weakness, opportunity, and threats. Although the fidelity of the modeling was low at 37% of the high standard, stakeholders indicated that the simulation modeling should be a primary purpose for policy intervention. Results demonstrate that process evaluation and SWOT analysis is useful for tracking the progress of policy interventions in multilevel trials and can be used to monitor the progress of building partnerships with policymakers.

Evaluation of complex community-based childhood obesity prevention interventions

BACKGROUND

Multi-setting, multi-component community-based interventions have shown promise in preventing childhood obesity; however, evaluation of these complex interventions remains a challenge.

OBJECTIVE

The objective of the study is to systematically review published methodological approaches to outcome evaluation for multi-setting community-based childhood obesity prevention interventions and synthesize a set of pragmatic recommendations.

METHODS

MEDLINE, CINAHL and PsycINFO were searched from inception to 6 July 2017. Papers were included if the intervention targeted children ≤18 years, engaged at least two community sectors and described their outcome evaluation methodology. A single reviewer conducted title and abstract scans, full article review and data abstraction. Directed content analysis was performed by three reviewers to identify prevailing themes.

RESULTS

Thirty-three studies were included, and of these, 26 employed a quasi-experimental design; the remaining were randomized control trials. Body mass index was the most commonly measured outcome, followed by health behaviour change and psychosocial outcomes. Six themes emerged, highlighting advantages and disadvantages of active vs. passive consent, quasi-experimental vs. randomized control trials, longitudinal vs. repeat cross-sectional designs and the roles of process evaluation and methodological flexibility in evaluating complex interventions.

CONCLUSIONS

Selection of study designs and outcome measures compatible with community infrastructure, accompanied by process evaluation, may facilitate successful outcome evaluation.

Rationale and design of the Clinic and Community Approaches to Healthy Weight Randomized Trial

BACKGROUND

Recent studies have demonstrated the effectiveness of family-centered, pediatric weight management programs in reducing childhood obesity. Yet, programs to optimize the care of low-income children with obesity are needed. We sought to examine the comparative effectiveness of two, potentially scalable pediatric weight management programs delivered to low-income children in a clinical or community setting.

MATERIALS AND METHODS

The Clinic and Community Approaches to Healthy Weight Trial is a randomized trial in two communities in Massachusetts that serve a large population of low-income children and families. The two-arm trial compares the effects of a pediatric weight management program delivered in the Healthy Weight Clinics of two federally qualified health centers (FQHC) to the Healthy Weight and Your Child programs delivered in two YMCAs. Eligible children are 6 to 12 years old with a body mass index (BMI) ≥ 85th percentile seen in primary care at the two FQHCs. Both programs are one-year in duration and have at least 30 contact hours throughout the year. Measures are collected at baseline, 6 months, and 1 year. The main outcome is 1-year change in BMI (kg/m2) and percent change of the 95th percentile (%BMIp95).

CONCLUSION

The Clinic and Community Approaches to Healthy Weight Trial seeks to 1) examine the comparative effects of a clinical and community based intervention in improving childhood obesity, and 2) inform the care of >7 million children with obesity covered by the Children's Health Insurance Program or Medicaid.

Health Marketing for the Massachusetts Childhood Obesity Research Demonstration Study: A Case Study

Introduction. This case study describes the Massachusetts Childhood Obesity Research Demonstration Study (MA-CORD) health marketing campaign, examines the strategies used in such campaigns, and offers lessons learned to improve health marketing for future interventions. MA-CORD Health Marketing Components and Implementation. The three main components were an outdoor printed advertisement and texting campaign, social media with a focus on Facebook, and the Summer Passport Program, an event-based initiative in parks for children. The advertisements consisted of billboards, bus advertisements, and handouts. The text messaging component, which required families to actively text a keyword to join, had a low opt-in rate. Facebook page "likes" increased from 1,024 to 1,453 in New Bedford and from 175 to 1,091 in Fitchburg. Fitchburg received technical assistance and paid for ads on Facebook. The Summer Passport participation in parks ranged from 120 to 875 children with participation in the free park lunch program doubling in Fitchburg. Discussion. Key lessons learned are engage communication experts from each community at the beginning of the project, use text messaging components with in-person staff onsite to assist participants in the opt-in process, build momentum for a Facebook presence through purchasing Facebook advertisements, and partner with local park departments for programming.

Clinical effectiveness of the massachusetts childhood obesity research demonstration initiative among low-income children

OBJECTIVE

To examine the extent to which a clinical intervention resulted in reduced BMI z scores among 2- to 12-year-old children compared to routine practice (treatment as usual [TAU]).

METHODS

The Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project is a multifaceted initiative to prevent childhood obesity among low-income children. At the federally qualified community health centers (FQHCs) of two communities (Intervention Site #1 and #2), the following were implemented: (1) pediatric weight management training, (2) electronic decision supports for clinicians, (3) on-site Healthy Weight Clinics, (4) community health worker integration, and (5) healthful clinical environment changes. One FQHC in a demographically matched community served as the TAU site. Using electronic health records, we assessed BMI z scores and used linear mixed models to examine BMI z score change over 2 years in each intervention site compared to a TAU site.

RESULTS

Compared to children in the TAU site (n = 2,286), children in Intervention Site #2 (n = 1,368) had a significant decline in BMI z scores following the start of the intervention (-0.16 units/y; 95% confidence interval: -0.21 to -0.12). No evidence of an effect was found in Intervention Site #1 (n = 111).

CONCLUSIONS

The MA-CORD clinical interventions were associated with modest improvement in BMI z scores in one of two intervention communities compared to a TAU community.

Childhood obesity prevention in the women, infants, and children program: Outcomes of the MA-CORD study

OBJECTIVE

To examine the extent to which a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) intervention improved BMI z scores and obesity-related behaviors among children age 2 to 4 years.

METHODS

In two Massachusetts communities, practice changes in WIC were implemented as part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) initiative to prevent obesity among low-income children. One WIC program was the comparison. Changes in BMI z scores pre and post intervention and prevalence of obesity-related behaviors of WIC participants were assessed. Linear mixed models were used to examine BMI z score change, and logistic regression models were used to examine changes in obesity-related behaviors in each intervention site versus comparison over 2 years.

RESULTS

WIC-enrolled children in both intervention sites (vs. comparison) had improved sugar-sweetened beverage consumption and sleep duration. Compared to the comparison WIC program (n = 626), no differences were observed in BMI z score among children in Intervention Site #1 (n = 198) or #2 (n = 637). In sensitivity analyses excluding Asian children, a small decline was observed in BMI z score (-0.08 units/y [95% confidence interval: -0.14 to -0.02], P = 0.01) in Intervention Site #2 versus comparison.

CONCLUSIONS

Among children enrolled in WIC, the MA-CORD intervention was associated with reduced prevalence of obesity risk factors in both intervention communities and a small improvement in BMI z scores in one of two intervention communities in non-Asian children.

Student obesity prevalence and behavioral outcomes for the massachusetts childhood obesity research demonstration project

OBJECTIVE

To examine changes in prevalence of obesity and target health behaviors (fruit, vegetable, and beverage consumption; physical activity; screen time; sleep duration) among students from communities that participated in the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project compared to controls.

METHODS

MA-CORD was implemented in two low-income communities. School-level prevalence of obesity among students in first, fourth, and seventh grades was calculated for the intervention communities and nine matched control communities pre and post intervention. Fourth- and seventh-grade students' self-reported health behaviors were measured in intervention communities at baseline and post intervention.

RESULTS

Among seventh-graders (the student group with greatest intervention exposure), a statistically significant decrease in prevalence of obesity from baseline to post intervention in Community 2 (-2.68%, P = 0.049) and a similar but nonsignificant decrease in Community 1 (-2.24%, P = 0.099) was observed. Fourth- and seventh-grade students in both communities were more likely to meet behavioral targets post intervention for sugar-sweetened beverages (both communities: P < 0.0001) and water (Community 1: P < 0.01; Community 2: P = 0.04) and in Community 2 for screen time (P < 0.01).

CONCLUSIONS

This multisector intervention was associated with a modest reduction in obesity prevalence among seventh-graders in one community compared to controls, along with improvements in behavioral targets.

Assessment of nutrition and physical activity practices using self-report and observation in early care and education across multiple US states

OBJECTIVE

The National Early Care and Education Learning Collaboratives (ECELC) Project aims to promote healthy physical activity and nutrition environments, policies and practices in early care and education (ECE) programmes across multiple states. The present pilot study sought to assess changes to the physical activity and nutrition practices in a sub-sample of ECE programmes participating in the ECELC using the Environment and Policy Assessment and Observation (EPAO). Additionally, it sought to compare results with the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC).

DESIGN

Quasi-experimental pre-post pilot study where paired-sample t tests examined changes to physical activity and nutrition practices from pre-assessment to post-assessment (P<0·05). Pearson correlation coefficients examined change scores from EPAO compared with NAP SACC with statistical significance set at a two-sided α level of P<0·10 to account for sample size.

SETTING

The study occurred among ECE programmes.

SUBJECTS

Pre-school classrooms in nineteen ECE programmes across four US states were observed.

RESULTS

EPAO data demonstrated an increase in total score from pre-assessment to post-assessment (150 (sd 30) to 176 (sd 35)). NAP SACC change scores demonstrated little relationship with EPAO domain change scores, with exceptions in Nutrition Policy and Physical Activity Policy (r=-0·4 and -0·6, respectively).

CONCLUSIONS

The overall improvements reported through the EPAO suggest participation in the ECELC resulted in changes in critical nutrition- and physical activity-related practices. However, considerable differences in data reported using the NAP SACC compared with the EPAO suggest subjective data should be interpreted with caution and objective measurement should be used when feasible.

Lessons Learned by Community Stakeholders in the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) Project, 2013-2014

INTRODUCTION

Childhood obesity is a multifaceted disease that requires sustainable, multidimensional approaches that support change at the individual, community, and systems levels. The Massachusetts Childhood Obesity Research Demonstration project addressed this need by using clinical and public health evidence-based methods to prevent childhood obesity. To date, little information is known about successes and lessons learned from implementing such large-scale interventions. To address this gap, we examined perspectives of community stakeholders from various sectors on successes achieved and lessons learned during the implementation process.

METHODS

We conducted 39 semistructured interviews with key stakeholders from 6 community sectors in 2 low-income communities from November 2013 through April 2014, during project implementation. Interviews were audio-recorded, transcribed, and analyzed by using the constant comparative method. Data were analyzed by using QSR NVivo 10.

RESULTS

Successes included increased parental involvement in children's health and education, increased connections within participating organizations and within the broader community, changes in organizational policies and environments to better support healthy living, and improvements in health behaviors in children, parents, and stakeholders. Lessons learned included the importance of obtaining administrative and leadership support, involving key stakeholders early in the program planning process, creating buffers that allow for unexpected changes, and establishing opportunities for regular communication within and across sectors.

CONCLUSION

Study findings indicate that multidisciplinary approaches support health behavior change and provide insight into key issues to consider in developing and implementing such approaches in low-income communities.

Using School Staff Members to Implement a Childhood Obesity Prevention Intervention in Low-Income School Districts: the Massachusetts Childhood Obesity Research Demonstration (MA-CORD Project), 2012-2014

Introduction

Although evidence-based interventions to prevent childhood obesity in school settings exist, few studies have identified factors that enhance school districts’ capacity to undertake such efforts. We describe the implementation of a school-based intervention using classroom lessons based on existing “Eat Well and Keep Moving” and “Planet Health” behavior change interventions and schoolwide activities to target 5,144 children in 4th through 7th grade in 2 low-income school districts.

Methods

The intervention was part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project, a multisector community-based intervention implemented from 2012 through 2014. Using mixed methods, we operationalized key implementation outcomes, including acceptability, adoption, appropriateness, feasibility, implementation fidelity, perceived implementation cost, reach, and sustainability.

Results

MA-CORD was adopted in 2 school districts that were facing resource limitations and competing priorities. Although strong leadership support existed in both communities at baseline, one district’s staff reported less schoolwide readiness and commitment. Consequently, fewer teachers reported engaging in training, teaching lessons, or planning to sustain the lessons after MA-CORD. Interviews showed that principal and superintendent turnover, statewide testing, and teacher burnout limited implementation; passionate wellness champions in schools appeared to offset implementation barriers.

Conclusion

Future interventions should assess adoption readiness at both leadership and staff levels, offer curriculum training sessions during school hours, use school nurses or health teachers as wellness champions to support teachers, and offer incentives such as staff stipends or play equipment to encourage school participation and sustained intervention activities.

"Whole-of-Community" Obesity Prevention: A Review of Challenges and Opportunities in Multilevel, Multicomponent Interventions

The causes of obesity worldwide are complex and multilevel, including changing food environments, physical activity levels, policies, and food production systems. This intricate context requires multilevel and multicomponent (MLMC) interventions to improve health outcomes. We conducted a literature review of MLMC interventions for obesity prevention and mitigation; 14 studies meeting search criteria were identified. We found examples of successes in preventing obesity, reducing overweight, improving healthful behaviors, and enhancing some psychosocial indicators. Of eight studies that reported health and behavioral results, five showed no significant impact and three showed reductions in obesity. Four studies showed significant improvement in dietary behavior, and five reported significant desirable effects in physical activity or screen time. Five studies reported psychosocial impacts, and three of these showed significant improvements. MLMC approaches show promising results, particularly when they are able to integrate components at the policy, community, and interpersonal levels.

Measurement of obesity prevention in childcare settings: A systematic review of current instruments

OBJECTIVE

The incidence of childhood obesity is highest among children entering kindergarten. Overweight and obesity in early childhood track through adulthood. Programs increasingly target children in early life for obesity prevention. However, the published literature lacks a review on tools available for measuring behaviour and environmental level change in child care. The objective is to describe measurement tools currently in use in evaluating obesity-prevention in preschool-aged children.

METHODS

Literature searches were conducted in PubMed using the keywords "early childhood obesity," "early childhood measurement," "early childhood nutrition" and "early childhood physical activity." Inclusion criteria included a discussion of: (1) obesity prevention, risk assessment or treatment in children ages 1-5 years; and (2) measurement of nutrition or physical activity.

RESULTS

One hundred thirty-four publications were selected for analysis. Data on measurement tools, population and outcomes were abstracted into tables. Tables are divided by individual and environmental level measures and further divided into physical activity, diet and physical health outcomes. Recommendations are made for weighing advantages and disadvantages of tools.

CONCLUSION

Despite rising numbers of interventions targeting obesity-prevention and treatment in preschool-aged children, there is no consensus for which tools represent a gold standard or threshold of accuracy.

Media Competition Implementation for the Massachusetts Childhood Obesity Research Demonstration Study (MA-CORD): Adoption and Reach

The Massachusetts Childhood Obesity Research Demonstration Study (MA-CORD) was a multi-level, multi-sector community intervention with a media competition component to provide an overarching synergy and promote awareness of target behaviors to reduce childhood obesity. Students participating in the media competition were tasked with developing videos, song/rap lyrics, and artwork that reflected the goals. The aim of this study is to document the process used to develop and implement the media competition along with its reach and adoption. An adapted version of Neta and colleagues’ 2015 framework on dissemination and implementation was used to summarize the process by which the media competition was developed and implemented. Adoption was defined by whether eligible schools or afterschool programs decided to implement the media competition. Reach was defined by student participation rates within schools/programs and the number of votes cast for the finalists on the coalition website and students’ paper ballots. A total of 595 students participated in the media competition from 18 school and afterschool programs in two communities. Adoption of the media competitions ranged from 22% to 100% in programs and reach ranged from 3% to 33% of the student population. The documentation of the implementation should contribute to the replication of the media competition.

A Cascade of Champions: A Qualitative Study about the MA-CORD Media Competition Implementation

A media competition was part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) Study. Criss et al., previously outlined the development and implementation of the competition, including variation in reach and adoption of the intervention across schools and afterschool programs. In this qualitative study, we examine community, provider, and organizational factors that explain the variation of media competition reach in school and afterschool programs, and describe the awareness of the media competition across other community sectors. Durlak and DuPre's ecological framework for understanding effective implementation provided the theoretical underpinnings for this study. Fifty-four key informant interviews were conducted, transcribed, and analyzed. Organizational capacity of committed teachers/staff and adaptability of the media competition seemed to be drivers for higher reach within school and afterschool programs. Salient themes that emerged as facilitators of effective implementation were having a cascade of champions and providing opportunity to participate in the media competition outside traditional class time. Clinics and coalitions were identified as additional sectors aware of the media competition. Specifically, our findings offer a new perspective on intervention design and a recommended direction for further study.

Community Stakeholders' Perceptions of Major Factors Influencing Childhood Obesity, the Feasibility of Programs Addressing Childhood Obesity, and Persisting Gaps

Prior research has identified numerous factors contributing to increased rates of childhood obesity. However, few studies have focused explicitly on the experience of community stakeholders in low-income communities. This study sought to capture the perspectives of these on-the-ground experts regarding major factors contributing to childhood obesity as well as gaps in current prevention and control efforts. We conducted semi-structured interviews with 39 stakeholders from different community sectors (e.g., healthcare providers, childcare providers, teachers). Data were drawn from the Massachusetts Childhood Obesity Research Demonstration project, a multi-level, multi-sector intervention designed to reduce childhood obesity being implemented in two low-income communities in Massachusetts. Interviews were conducted at baseline, transcribed, coded using grounded theory approach, and analyzed in NVivo 10.0. The vast majority of stakeholders had recently participated in obesity prevention strategies, and nearly all of them identified gaps in prevention efforts either within their organizations or in the broader community. In addition to factors previously identified in the literature, several themes emerged including the need to change policies to increase physical activity during school, offer healthier snacks in schools and afterschool programs, and increase communication and collaboration within the community in prevention efforts. Community stakeholders can impact the success of interventions by bridging the gap between science and lived experience. The results of this study can guide future research by highlighting the importance of including stakeholders' frontline experiences with target populations, and using information on identified gaps to augment intervention planning efforts.

Reasons Low-Income Parents Offer Snacks to Children: How Feeding Rationale Influences Snack Frequency and Adherence to Dietary Recommendations

Although American children snack more than ever before, the parental role in promoting snacking is not well understood. In 2012–2013 at baseline in an intervention study to prevent childhood obesity in low-income Massachusetts communities, n = 271 parents of children aged 2–12 years completed surveys regarding nutritive and non-nutritive reasons they offered children snacks, demographics, and dietary factors. An analysis of variance demonstrated that parents reported offering snacks (mean/week; standard deviation (SD)) for nutritive reasons like promoting growth (x̄ = 2.5; SD 2.2) or satisfying hunger (x̄ = 2.4; SD 2.1) almost twice as often as non-nutritive reasons like keeping a child quiet (x̄ = 0.7; SD 1.5) or celebrating events/holidays (x̄ = 0.8; SD 1.1). Parents reported giving young children (2–5 years) more snacks to reward behavior (1.9 vs. 1.1, p < 0.001), keep quiet (1.0 vs. 0.5, p < 0.001), and celebrate achievements (1.7 vs. 1.0, p < 0.001) than parents of older children (6–12 years). Multivariable logistic regression models were used to obtain adjusted odds ratios, which indicated reduced child adherence to dietary recommendations when parents offered snacks to reward behavior (Odds Ratio (OR) = 0.83; 95% Confidence Interval (CI) 0.70–0.99), celebrate events/holidays (OR = 0.72; 95% CI 0.52–0.99), or achievements (OR = 0.82; 95% CI 0.68–0.98). Parental intentions around child snacking are likely important targets for obesity prevention efforts.

Community stakeholders' perceptions of barriers to childhood obesity prevention in low-income families, Massachusetts 2012-2013

INTRODUCTION

The etiology of childhood obesity is multidimensional and includes individual, familial, organizational, and societal factors. Policymakers and researchers are promoting social-ecological approaches to obesity prevention that encompass multiple community sectors. Programs that successfully engage low-income families in making healthy choices are greatly needed, yet little is known about the extent to which stakeholders understand the complexity of barriers encountered by families. The objective of this study was to contextually frame barriers faced by low-income families reported by community stakeholders by using the Family Ecological Model (FEM).

METHODS

From 2012 through 2013, we conducted semistructured interviews with 39 stakeholders from 2 communities in Massachusetts that were participating in a multisector intervention for childhood obesity prevention. Stakeholders represented schools; afterschool programs; health care; the Special Supplemental Nutrition Program for Women, Infants, and Children; and early care and education. Interviews were audio-recorded, transcribed, coded, and summarized.

RESULTS

Stakeholder reports of the barriers experienced by low-income families had a strong degree of overlap with FEM and reflected awareness of the broader contextual factors (eg, availability of community resources, family culture, education) and social and emotional dynamics within families (eg, parent knowledge, social norms, distrust of health care providers, chronic life stressors) that could affect family adoption of healthy lifestyle behaviors. Furthermore, results illustrated a level of consistency in stakeholder awareness across multiple community sectors.

CONCLUSION

The congruity of stakeholder perspectives with those of low-income parents as summarized in FEM and across community sectors illustrates potential for synergizing the efforts necessary for multisector, multilevel community interventions for the prevention of childhood obesity.

Design of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) study

BACKGROUND

Childhood obesity is highly prevalent, is associated with both short- and long-term adverse outcomes, disproportionately affects racial/ethnic minority and economically deprived children, and represents a major threat to public health. Among the most promising approaches for its prevention and management are multilevel, multisector strategies.

METHODS/DESIGN

The Massachusetts Childhood Obesity Research Demonstration (MA-CORD) Study was a comprehensive, systematic intervention to prevent and reduce childhood obesity among low-income children ages 2-12 years in two selected cities in Massachusetts. Building on the Obesity Chronic Care Model, MA-CORD expanded a state public health department community-level obesity prevention initiative that incorporated evidence-based interventions in primary healthcare, the Women, Infants, and Children program, early care and education, schools/afterschool programs, as well as community-wide programs to improve food, beverage, physical activity (PA), and messaging environments. The study used a combination of pre- and post-time series and quasi-experimental designs to examine the extent to which the intervention resulted in changes in BMI, individual-level lifestyle behaviors, satisfaction with healthcare services, and quality of life among children, as well as changes in health policies, programs, and environments in the two intervention cities, compared to a comparison city. The intervention period was 2 years.

CONCLUSIONS

MA-CORD will determine the extent to which a multisetting, multilevel intervention that integrates activities in primary care with broader public health interventions in schools, early care and education, and the community at large can improve children's dietary and PA behaviors and ultimately reduce obesity in low-income children.

Childhood Obesity Research Demonstration project: cross-site evaluation methods

INTRODUCTION

The Childhood Obesity Research Demonstration (CORD) project links public health and primary care interventions in three projects described in detail in accompanying articles in this issue of Childhood Obesity. This article describes a comprehensive evaluation plan to determine the extent to which the CORD model is associated with changes in behavior, body weight, BMI, quality of life, and healthcare satisfaction in children 2-12 years of age.

DESIGN/METHODS

The CORD Evaluation Center (EC-CORD) will analyze the pooled data from three independent demonstration projects that each integrate public health and primary care childhood obesity interventions. An extensive set of common measures at the family, facility, and community levels were defined by consensus among the CORD projects and EC-CORD. Process evaluation will assess reach, dose delivered, and fidelity of intervention components. Impact evaluation will use a mixed linear models approach to account for heterogeneity among project-site populations and interventions. Sustainability evaluation will assess the potential for replicability, continuation of benefits beyond the funding period, institutionalization of the intervention activities, and community capacity to support ongoing program delivery. Finally, cost analyses will assess how much benefit can potentially be gained per dollar invested in programs based on the CORD model.

CONCLUSIONS

The keys to combining and analyzing data across multiple projects include the CORD model framework and common measures for the behavioral and health outcomes along with important covariates at the individual, setting, and community levels. The overall objective of the comprehensive evaluation will develop evidence-based recommendations for replicating and disseminating community-wide, integrated public health and primary care programs based on the CORD model.

Childhood Obesity Research Demonstration (CORD): the cross-site overview and opportunities for interventions addressing obesity community-wide

BACKGROUND

This is the first of a set of articles in this issue on the Childhood Obesity Research Demonstration (CORD) project and provides an overview of the multisite approach and community-wide interventions. Innovative multisetting, multilevel approaches that integrate primary healthcare and public health interventions to improve outcomes for children with obesity need to be evaluated. The CORD project aims to improve BMI and obesity-related behaviors among underserved 2- to 12-year-old children by utilizing these approaches.

METHODS

The CORD consortium, structure, model terminology and key components, and common measures were solidified in year 1 of the CORD project. Demonstration sites applied the CORD model across communities in years 2 and 3. Evaluation plans for year 4 include site-specific analyses as well as cross-site impact, process, and sustainability evaluations.

RESULTS

The CORD approach resulted in commonalities and differences in participant, intervention, comparison, and outcome elements across sites. Products are to include analytic results as well as cost assessment, lessons learned, tools, and materials.

DISCUSSION

Foreseen opportunities and challenges arise from the similarities and unique aspects across sites. Communities adapted interventions to fit their local context and build on strengths, but, in turn, this flexibility makes cross-site evaluation challenging.

CONCLUSION

The CORD project represents an evidence-based approach that integrates primary care and public health strategies and evaluates multisetting multilevel interventions, thus adding to the limited research in this field. CORD products will be disseminated to a variety of stakeholders to aid the understanding, prevention, and management of childhood obesity.

Sleep duration, restfulness, and screens in the sleep environment

BACKGROUND AND OBJECTIVE

Associations of inadequate sleep with numerous health outcomes among youth necessitate identifying its modifiable determinants. Television (TV) has been associated with sleep curtailment, but little is known about small screens (eg, smartphones), which can be used in bed and emit notifications. Therefore, we examined associations of different screens in sleep environments with sleep duration and perceived insufficient rest or sleep.

METHODS

Participants included 2048 fourth- and seventh-graders participating in the Massachusetts Childhood Obesity Research Demonstration Study in 2012 to 2013. Using linear and log binomial regression, we examined cross-sectional associations of small screens and TVs in sleep environments and screen time with weekday sleep duration and perceived insufficient rest or sleep in the past week.

RESULTS

Children who slept near a small screen (compared with never) reported 20.6 fewer minutes of sleep (95% confidence interval [CI], -29.7 to -11.4) and had a higher prevalence of perceived insufficient rest or sleep (prevalence ratio, 1.39; 95% CI, 1.21 to 1.60). Children who slept in a room with a TV (compared with no TV) reported 18.0 fewer minutes of sleep (95% CI, -27.9 to -8.1). TV or DVD viewing and video or computer game playing were associated with both sleep outcomes (P < .01). Some associations were stronger among Hispanic, non-Hispanic black, and older children (P < .05 for heterogeneity).

CONCLUSIONS

Sleeping near a small screen, sleeping with a TV in the room, and more screen time were associated with shorter sleep durations. Presence of a small screen, but not a TV, in the sleep environment and screen time were associated with perceived insufficient rest or sleep. These findings caution against unrestricted screen access in children's bedrooms.

Evaluation protocol to assess an integrated framework for the implementation of the Childhood Obesity Research Demonstration project at the California (CA-CORD) and Massachusetts (MA-CORD) sites

BACKGROUND

The long-term success of child obesity prevention and control efforts depends not only on the efficacy of the approaches selected, but also on the strategies through which they are implemented and sustained. This study introduces the Multilevel Implementation Framework (MIF), a conceptual model of factors affecting the implementation of multilevel, multisector interventions, and describes its application to the evaluation of two of three state sites (CA and MA) participating in the Childhood Obesity Research Demonstration (CORD) project.

METHODS/DESIGN

A convergent mixed-methods design is used to document intervention activities and identify determinants of implementation effectiveness at the CA-CORD and MA-CORD sites. Data will be collected from multiple sectors and at multiple levels of influence (e.g., delivery system, academic-community partnership, and coalition). Quantitative surveys will be administered to coalition members and staff in participating delivery systems. Qualitative, semistructured interviews will be conducted with project leaders and key informants at multiple levels (e.g., leaders and frontline staff) within each delivery system. Document analysis of project-related materials and in vivo observations of training sessions will occur on an ongoing basis. Specific constructs assessed will be informed by the MIF. Results will be shared with project leaders and key stakeholders for the purposes of improving processes and informing sustainability discussions and will be used to test and refine the MIF.

CONCLUSIONS

Study findings will contribute to knowledge about how to coordinate and implement change strategies within and across sectors in ways that effectively engage diverse stakeholders, minimize policy resistance, and maximize desired intervention outcomes.