Healthy Steps a Systematic Review of a Preventive Practice-based Model of Pediatric Care

• Written report protocol
• Open up Access
• Published: 23 January 2014

Steps to Growing Up Healthy: a pediatric primary intendance based obesity prevention program for young children

• James Wiley²,
• Christine McCauley Ohannessian³,
• Commonwealth of dominica Hernandez¹,
• Autherene Grant^two &
• Michelle Chiliad Cloutier³

BMC Public Health book 14, Article number:72 (2014) Cite this article

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Abstract

Background

Leading medical organizations have called on primary care pediatricians to take a central role in the prevention of childhood obesity. Weight counseling typically has not been incorporated into routine pediatric practice due to time and preparation constraints. Cursory interventions with simple beliefs change messages are needed to attain high-take chances children, particularly Latino and Black children who are disproportionately affected past obesity and related comorbidities. Steps to Growing Up Good for you (Added Value) is a randomized controlled trial testing the efficacy of brief motivational counseling (BMC) delivered by primary care clinicians and the added value of supplementing BMC with monthly contact past community health workers (CHW) in the prevention/reversal of obesity in Latino and Black children ages two-4 years former.

Methods/Design

Mother-child dyads (targeted n = 150) are recruited for this 12-month randomized trial at an inner-city pediatric principal intendance clinic and randomized to: 1) BMC delivered past clinicians and nurses at well, sick, and WIC visits with the goal of reducing obesogenic behaviors (BMC); 2) BMC plus monthly phone calls by a CHW (BMC + Phone); or 3) BMC plus monthly habitation visits by a CHW (BMC + Home). During BMC, the medical team facilitates the selection of a specific goal (i.east., reduce sugar sweetened beverage consumption) that is meaningful to the mother and teaches the mother elementary behavioral strategies. Monthly contacts with CHWs are designed to identify and overcome barriers to goal progress. Dyads are assessed at baseline and 12 months and the primary outcome is change in the child'southward BMI percentile. We hypothesize that BMC + Phone and BMC + Home will produce greater reductions in BMI percentiles than BMC alone and that BMC + Dwelling house will produce greater reductions in BMI percentiles than BMC + Telephone.

Discussion

Steps to Growing Upwards Salubrious will provide important information nearly whether a brief main care-based intervention that utilizes a motivational interviewing and goal setting approach can exist incorporated into routine care and is sufficient to prevent/reverse obesity in young children. The study volition also explore whether monthly contact with a community health worker bridges the gap betwixt the clinic and the community and is an constructive strategy for promoting obesity prevention in high-risk families.

Trial registration

ClinicalTrials.gov NCT01973153

Background

Populations of color in the United states have disproportionately high rates of childhood obesity [1–3]. Obese children frequently get obese adults [4, 5] setting the foundation for lifelong health disparities. Unfortunately, medical professionals and parents often fail to recognize obesity in young children and parents tend to minimize the risk that obesity poses to their child's future wellness outcomes [half-dozen–x]. Latina and Blackness mothers commonly equate excessive weight with good health and interpret a body mass index (BMI) at the 97^th percentile or above as a desirable state [11, 12]. When families do express involvement in weight management, access to treatment is frequently limited to university-based clinics staffed by highly trained weight management specialists who are able to attain only a handful of children in demand. Historically, these weight management programs focus on older children and those who are significantly obese, emphasizing obesity handling rather than prevention. This model is an important component of obesity management but it is not sufficient. In light of the difficulty and expense of treating obesity once it has developed, widely available cost-constructive obesity prevention approaches are needed to promote healthy lifestyles in very young children. Consistent with the Chronic Care Model [13, 14], these programs should foster collaborations between health care systems and customs resources and grade partnerships with families to prevent obesity.

The master care setting is an obvious context for addressing weight in very young children. Children encounter their health care provider for regularly scheduled well visits ~10 times before the age of 2 and yearly thereafter [15]. The primary care office thus could provide the continuity of care and frequency of contact needed for weight management in very young children; yet obesity is oft not addressed at these visits [16]. O'Brien and colleagues [17] found that amid obese children, obesity was documented in only 53% of charts, with diet and concrete activity histories reported in simply 69% and xv% of charts, respectively. Similar trends were recently reported in a large national sample of pediatricians, with only 55% reporting that they calculated children'due south BMIs at well child visits [16]. Consequently, many parents are unaware of their kid's weight status [xviii] and receive no specific suggestions from their pediatrician regarding how to improve their child's eating and practice habits [19, 20]. This is particularly true for children under 6 years, those who are overweight but not obese, and African-American, Hispanic, and Asian children [21]. Recognizing this missed opportunity, the American Academy of Pediatrics (AAP) recommends universal assessment of children for obesity take a chance by their primary care provider [22], a recommendation echoed by the Institute of Medicine's 2012 written report on accelerating progress in obesity prevention [23]. The 2007 AAP obesity guidelines outline a xv-infinitesimal obesity prevention protocol to ameliorate early identification of elevated BMI, medical risks and unhealthy habits. These obesity prevention guidelines have not been widely adopted in the chief care setting. In part, this is because the average length of a well child visit is less than twenty minutes [24] and because clinicians often do not feel confident in counseling families about obesity or believe that counseling may not brand a difference [20, 25, 26].

I intervention strategy that shows promise in establishing good for you lifestyles and could fit within the time constraints of primary intendance is motivational interviewing (MI) [27, 28]. Using patient-centered strategies such as open-ended questions, positive affirmations and reflective listing, MI elicits internal motivation for behavior change while addressing the ambivalence and discrepancies between a person's current values and beliefs (e.chiliad., "Heavy is salubrious") and their future goals (e.g., "I don't want my child to get diabetes."). This approach is platonic for primary care provider use because MI can be delivered in brief doses. Enquiry has shown MI to exist constructive beyond a range of wellness behaviors, including diet and nutrition-focused interventions [29–31]. MI has been used successfully to supplement behaviorally-based adult weight loss programs and has been shown to have a positive impact after only 2 sessions [30]. In pediatric settings, MI has been associated with increased parent satisfaction and adherence and has been used in a nonrandomized childhood obesity prevention plan [32]. More research is needed to test whether brief just recurrent doses of MI coupled with primal behavioral strategies known to promote weight control (due east.one thousand., goal setting and self-monitoring) can be integrated into primary care to prevent babyhood obesity and to explore how all-time to support the behavior change process outside of the clinic setting.

Community health workers (CHWs) bridge the gap betwixt the main care office and the customs and may be a viable resource for reinforcing obesity prevention efforts once families go out the doctor's office. CHWs are typically individuals from inside a community who share many demographic similarities and life experiences with their target audience [33]. As a trusted fellow member of a community, CHWs are able to offer culturally appropriate wellness instruction, counseling, and social support that can facilitate access to information and resource [34]. CHWs are being used extensively to accost disease and instance management, wellness information transfer, and health promotion and have been effective in promoting behavior change in multiple settings [35]. CHWs have had a positive influence on diabetes self-management [36] and breastfeeding outcomes [37] likewise as on general nutrition knowledge and dietary intake behaviors among Latinos. A question that remains unanswered is whether CHWs tin enhance obesity prevention outcomes higher up and beyond what can be achieved through chief intendance.

The present study is a randomized controlled trial designed to examine the efficacy of Steps to Growing Up Healthy, a master care based obesity prevention program that utilizes a motivational interviewing framework and selected behavioral strategies to reduce obesogenic behaviors in Latino and Black children 2-4 years of historic period. The behavioral targets are reducing/eliminating sugar sweetened beverage consumption, changing the type and/or corporeality of milk consumed, decreasing screen time to less than ii hours per day, and increasing physical activity to at least 60 minutes per solar day. The primary goal of this study is to examine whether repeated doses of cursory motivational counseling delivered by primary care clinicians and nurses to mothers of young children are sufficient to forbid/reverse childhood obesity in this high risk group or if monthly contacts with a CHW via either telephone or home visits enhances any observed intervention effects. This project is innovative in that the initial obesity prevention activities are embedded in the context of routine clinic visits and are tested in combination with two modalities for providing CHW back up. The written report's focus on preschool age children will also add to the small but growing literature on obesity prevention in this critical developmental window.

Methods/Design

Overview and hypotheses

Latino and Black mother-child dyads (targeted n = 150) are recruited for this 12-month randomized trial at an urban based pediatric primary care clinic (Figure i). Participating dyads are assigned with equal probability to one of three handling conditions: one) brief motivational counseling (BMC) alone delivered past the child's medical team; two) BMC plus monthly phone calls by a CHW (BMC + Phone); or iii) BMC plus monthly abode visits by a CHW (BMC + Home). Dyads are assessed at baseline and 12 months. The primary result is change in the kid'due south BMI percentile. We hypothesize that over the 12-month period both BMC + Telephone and BMC + Home volition produce greater reductions in BMI percentiles than BMC and that BMC + Home will produce greater reductions in BMI percentiles than BMC + Phone. The written report protocol was reviewed by the Scientific Review Commission at Connecticut Children'southward Medical Center (CCMC) in Hartford, CT and received full blessing by CCMC'due south Institutional Review Board.

Figure one

Study flow.

Full size image

Participants

Mother-child dyads are recruited from the Chief Care Clinic (PCC) at Connecticut Children's Medical Center. Mothers of 2-4 year olds have been targeted because of the frequent contact this historic period grouping has with their primary care clinician and because our recent data [38] demonstrates that obesogenic habits are established early, oftentimes by the preschool years. To participate, the kid must be between 2-4 years sometime, of Latino or Black descent by maternal study, and be receiving services through the Special Supplemental Diet Programme for Women, Infants, and Children (WIC) to ensure frequent clinical contact at the PCC over the form of 12 months. There is no BMI cutoff as even children of normal weight with obesogenic behaviors may do good from the intervention. If there is more than one eligible child in a family, data from the first child enrolled in the study will be used for analysis. Dyads are excluded from participating if the mother is younger than 18 years old, if the dyad does non live in the Greater Hartford area or if they have plans to motion out of the expanse in the next 12 months, or if the kid or female parent has special needs (dietary, concrete, and/or emotional) that would make the intervention inappropriate (e.grand., failure to thrive, type ane diabetes, cystic fibrosis).

Recruitment and randomization

Mothers attending the clinic with their child for a well kid or WIC visit are approached in the waiting room by inquiry staff who describe the report and obtain informed consent from mothers who are interested and meet eligibility criteria. Research staff then administers the baseline assessment battery and randomize the dyads into i of the three treatment weather condition using a block randomization process. Dyads receive their first dose of the intervention at this clinic visit.

Interventions

Mutual intervention components across all three weather condition

Overview

The obesity prevention approach we are testing starts with pediatric primary care clinicians and strives to form a partnership between a mother and her child's medical squad using brief motivational interviewing and selected behavioral strategies (BMC). Female parent-child dyads randomized to the added value weather (BMC + Telephone and BMC + Dwelling house) build upon that relationship using CHWs similarly trained in brief motivational interviewing who reinforce the behavior alter messages and provide families with additional support and assistance in reaching their selected goals. The intervention has been designed with extensive feedback from families, the medical team, and the CHWs. A do champion at the primary care clinic with a longstanding interest in babyhood obesity is serving equally a liaison between the enquiry team and clinicians to facilitate the implementation of BMC at the clinic.

Behavioral targets

The intervention centers on four key behavioral targets: reduce/eliminate sugar sweetened drinkable consumption, change the type and/or quantity of milk consumed, subtract screen time to less than 2 hours per day, and increase concrete action to at least 60 minutes per day. While there are many potential behaviors to target to prevent childhood obesity, we highlight these 4 because in that location are articulate historic period-advisable guidelines about these behaviors from the AAP [22] and because focus groups with mothers demonstrated their interest and willingness to implement changes in these areas. There is flexibility in goal setting, however, and mothers are encouraged to select a goal that is personally meaningful fifty-fifty if it is exterior of these key behaviors.

Toolkit

At study enrollment, all dyads receive a study toolkit that contains low-cost items to assist in their behavior change efforts. Toolkit items include a 6 ounce spill-proof cup, a measuring loving cup labeled with appropriate serving sizes for milk and sugar sweetened beverages, a placemat with examples of portion sizes for young children, a foam ball to encourage physical action, and a pedometer for mothers.

BMC

All dyads in the study receive BMC delivered by clinicians and nurses at routine medical visits (well, sick, or WIC check-in) over a 12-month menses. As office of standard care, every kid in the primary care clinic is assigned to one of two teams consisting of attending clinicians, pediatric residents, nurses and medical assistants. Each child on the team is assigned to a "teamlet" (an attention clinician and nurse) who provides all of that kid'southward intendance [39, 40]. Well child visits and the WIC visits are performed by the child's teamlet while ill visits may be conducted by others on the child'due south team. Whatever trained clinician or nurse seeing the family for any type of visit tin offer the intervention. Each BMC dose is approximately 3-five minutes long and incorporates basic MI strategies such as positive affirmations and reflective listening as well as behavioral elements including goal setting and contracting. 7 intervention steps guide this brief come across (Table 1). First, in the waiting room, mothers complete a i-page survey created for this projection (Steps to Growing Up Healthy Survey) regarding their child's eating, physical activity, sedentary activity, and sleep habits (Step ane). At the showtime of BMC, the medical teamlet member apace reviews the survey results with the family focusing first on areas of strength using a colorful round diagram in English and Spanish (Step 2; Figure 2). The clinician then selectively focuses the mother'due south attention on the four central behavioral targets that form the inner circle of the Steps to Growing Up Good for you circular diagram (Footstep 3). Using open up-ended questions and reflective listening skills, the clinician and mother agree upon a behavior that the female parent is ready and able to change (Step 4) and a plan of action specific for that kid is agreed upon and documented in a written behavioral contract that clearly states the female parent's goal (Step v; i.e., the Steps to Growing Up Healthy Action Plan). The clinician or nurse then offers the mother an educational handout containing suggestions for how to implement the desired beliefs modify (Pace half dozen). The BMC dose ends with the clinician or nurse providing the mother with a monthly self-monitoring agenda that the mother can use to rail goal progress via a unproblematic yes/no daily checkbox (Pace 7). At every visit during the next 12 months, the clinician and nurse are encouraged to use the Steps to Growing Up Good for you Survey and BMC with targeted communication to reinforce a previously agreed upon goal or to deliver a new behavior change bulletin and fix a new goal. In add-on, within v-7 days of each clinic visit, a fellow member of the projection staff conducts a brief (≤5 minutes) telephone call with the mother to review the visit, discuss initial implementation of behavior change and any problems encountered with the behavior change, and assess the fidelity of the intervention rendered past the medical teamlet according to the mother's perception of the interaction.

Table one Intervention elements included in a brief motivational counseling (BMC) dose delivered in the primary care setting

Full size table

Figure ii

Steps to growing upward healthy behavior target clinical tool.

Total size paradigm

To encourage medical teamlets to use BMC with their patients, clinicians and nurses receive $10 each time they provide a BMC dose. The clinician/nurse must document the kid's BMI percentile, discuss an obesogenic behavior from the Steps to Growing Upwards Salubrious Survey using BMC, and create a Steps to Growing Up Good for you Action Plan in concert with the family to receive the incentive. Over the form of the 12-month intervention period, we anticipate that families will receive 3-5 doses of BMC in the dispensary (1-2 well child visits, 1-2 sick visits, and 1-2 WIC check-ins) and 3-5 additional telephone follow-upwards calls.

Treatment components specific to the added value weather

BMC + Phone

Mother-child dyads randomized to BMC + Telephone receive BMC doses at clinic visits as described above plus every calendar month a CHW calls the mother to appraise how well the family unit is doing with their selected behavior change, hash out any barriers the family is experiencing in implementing the beliefs change, review the monthly cocky-monitoring calendar, reinforce positive behaviors, appraise the mother'due south confidence in achieving her goal, and assist the female parent to implement her goal through progressive steps and gradual implementation of new behaviors. Behavioral goals are modified if mothers report having met their goals and/or express involvement in selecting a new goal. Each phone call is approximately 10-15 minutes long.

BMC + Habitation

Mother-child dyads randomized to BMC + Home receive BMC doses at clinic visits every bit described higher up plus monthly habitation visits past a CHW. The focus of these hour long home visits is similar in content to BMC + Phone (i.e., CHWs appraise behavior change progress, hash out barriers, review cocky-monitoring, assist the mother in implementing her goal and/or behavior change by breaking information technology into pocket-size, manageable steps, assess the mother's confidence in making the behavior change). In addition, the CHW assists the female parent with label reading and meal planning, how to structure her home environment to support healthy diet and activity choices, how to decide appropriate portion sizes, and how to raise physical activity. Activities are visual, interactive, and based on a goal setting and motivational interviewing approach.

Interventionist training

Main care staff

All clinicians and nurses at the PCC (due north = 32) were invited to participate in the report and receive training in motivational interviewing provided by the study investigators and an external consultant from the Motivational Interviewing Network of Trainers. Clinicians and nurses were asked to attend two 2-hr sessions focusing on key MI strategies such equally asking open-ended questions, using cogitating listening, positive affidavit, decreasing resistance, and assessing the mother's interest and confidence in making change. A treatment manual was provided that included a detailed outline of the BMC intervention steps. Mini-booster sessions were conducted periodically at staff meetings and with individual clinicians throughout the intervention menstruum to encourage on-going employ of BMC and to clinch intervention allegiance. 20-iv clinicians and nurses provided consent assuasive us to collect information about their attitudes towards obesity management and comfort with MI.

Customs wellness workers

Two certified CHWs from AHEC (Central Expanse Health Education Heart, Inc.) were hired and received a total of 84 hours of training. Forty eight hours of training were completed by AHEC and focused on core competencies in the CHW. Thirty-six hours of additional preparation were conducted in motivational interviewing and in project implementation. Approximately 1/3 of this grooming included intervention modification to make the materials more interactive and culturally relevant. A CHW transmission was developed by adapting existing resources developed past WIC, the Cooperative Extension System, and the Parents every bit Teachers model that was recently demonstrated to be effective in irresolute pre-school eating habits [41] to the health literacy and cultural needs of our target customs.

Outcome measures

The post-obit measures are administered at baseline and 12 months unless otherwise noted.

Kid measures

Peak and weight

The master outcome is change in the child'due south BMI percentile. Meridian is measured with the child barefoot and erect against a wall-mounted stadiometer and recorded to the last 0.v cm. Children are weighed in light clothing to the last consummate 100 g. BMI percentile is calculated using age and sex activity-specific information from the 2000 revised CDC/NCH growth charts for the Usa [42].

Diet and physical activity

We are using the parent-report 24-item Children's Dietary Questionnaire to assess dietary quality [43]. This mensurate is advisable for preschool age children and all subscales accept demonstrated satisfactory examination-retest reliability and an ability to detect change in the expected direction following a weight direction intervention. To appraise concrete and sedentary activity, we are using a brief 12-item questionnaire by Spurrier et al. [44] based on the Outdoor Playtime Checklist. The questionnaire assesses outdoor playtime and has been validated against objective accelerometer data. Information technology as well assesses sedentary activity focusing on small screen entertainment (i.east., time spent watching TV and playing video games). This measure has been used in prior studies of preschool aged children and is sensitive to change over time. In add-on, the Steps to Growing Up Healthy Survey, a sixteen-item questionnaire developed specifically for this study is administered at every clinic visit to assess the 4 target areas as well as the kid's general wellness habits (e.g., water consumption, sleep).

Maternal measures

Demographics

Basic demographic data (e.chiliad., gender, age, main language, household living situation, employment status, household income) is obtained via self-written report from mothers.

Acculturation (Baseline only)

Nosotros ask Hispanic mothers to consummate the Brief Acculturation Rating Scale for Mexican Americans II [45]. This 12-detail scale measures acculturation forth three factors (linguistic communication, indigenous identity, and indigenous interaction) and has been used with Mexican Americans and individuals of Puerto Rican decent [45, 46].

Feeding practices

Mothers consummate the 19-item Caregiver'southward Feeding Styles Questionnaire, a well validated and frequently used mensurate of the demandingness and responsiveness of parental feeding practices [47–49].

Boosted maternal variables

We are assessing five potential moderators that might influence handling response including a fifteen-item food insecurity questionnaire [fifty], the 4-item Perceived Stress Calibration [51], a 2-detail maternal depression screening tool [52], the xv-question Wellness Care Climate Questionnaire [53] that assesses the mother'southward perceptions of the degree to which her kid's medical squad provides autonomy support, and an abbreviated version of the Neighborhood Environment Walkability Scale [54, 55].

Procedure evaluation (12 months only)

At the terminate of the intervention menstruum, we ask mothers to evaluate the programme they received, whether they plant it helpful, which components were almost useful, and whether they would refer a friend to receive the same program.

Medical teamlet measures

After obtaining consent and prior to BMC training, clinicians, and nurses completed a fix of questionnaires that address self-efficacy, event value and outcome expectancy related to obesity prevention in children, clinician-parent interactions around obesity, likewise as their feel and thoughts regarding BMC and cognition regarding obesity.

Demographic survey

Task status (full time vs. part fourth dimension), tenure (length of time in the PCC), number of years since receiving highest degree, and Spanish fluency are assessed via self-report.

The role weight management survey

This 52-question musical instrument assessed clinical goals for obesity prevention/reversal, fourth dimension spent in obesity-related activities, cocky-efficacy, outcome value and expectancy and barriers to obesity prevention/reversal. The instrument was made specific for obesity from a general pediatric instrument [56] and from the recommendations of the AAP's Obesity Job Force.

Healthy living questionnaire

This xx-particular questionnaire examines clinician knowledge surrounding healthy behaviors for ii year olds and is based upon the 2007 AAP Guidelines.

Hope and conscientiousness

The personality traits of hope and conscientiousness have been establish in previous research to predict goal directed behavior by principal care clinicians [57]. Nosotros assess these traits among clinicians and nurses at baseline using the 4 agency and 4 pathway statements of the Hope Scale [58] and the Five Factor Inventory [59] in improver to a ten-particular obstacles scale specifically related to piece of work obstacles in a primary care setting [57].

Adherence and treatment fidelity

We are recording the number of BMC visits completed in total and by each member of the medical teamlet (i.e., number of BMC doses delivered; number of signed action plans) and by CHWs, every bit well as the number of telephone contacts completed by CHWs and study staff.

On each post-clinic visit telephone call that is completed within a week of each BMC dose, written report staff are assessing mothers' perceptions of their clinic come across. Specifically, mothers are asked to answer no, somewhat, or yeah to whether the doctor or nurse 1) reviewed their responses to the Steps to Growing Upwardly Healthy Survey, two) told them some things they were doing right in terms of their child's eating and practice habits, 3) talked to them nearly areas in which they could make changes to improve their child'south diet and physical action, and 4) asked in what specific area they would similar to make changes in. Mothers are also asked if the doctor or nurse selected the behavioral goal or if this was decided upon together.

Retention

Proactive efforts are made to retain families for the 12-calendar month written report menses. To aid in locating families for follow-up assessments, contact information (proper name, address, and telephone number) of a family fellow member and friend is obtained at the time of enrollment and at the fourth dimension of each visit. Equally part of the Steps to Growing Upward Wellness study, families are given an honorarium of $25 at baseline and at 12 months for completing these assessments visits (for a possible total of $50). Families in BMC + Phone and BMC + Home receive $5 per telephone telephone call or habitation visit for a possible additional total of $60.

Sample size and power

The primary consequence is modify in child's BMI percentile from baseline to 12 months. We hypothesize that both BMC + Phone and BMC + Home will reduce BMI percentiles compared to BMC. Assuming no modify in BMI percentile for BMC and a 2.5 percentile change in BMI for BMC + Phone (i.e., xc^th% to 87.five^th%) and a v percentile alter in BMI in BMC + Dwelling house (i.e., 90^th% to 85^th%), with an alpha of 0.05 and an ANCOVA with three handling groups, we need 34 children per group to have 0.85 power to be able to perform 3 contrasts: BMC vs. BMC + Phone, BMC vs. BMC + Home, and BMC + Phone vs. BMC + Home. We plan to recruit fifty children per arm to allow for a 15% dropout rate. Even if 25% of participants drop out we will have eighty% ability to test our primary aims.

Statistical analysis

Primary analysis

Nosotros will utilize an-intent-to-treat approach to data analysis. All randomized children will be included in the analyses regardless of whether they receive any actual intervention. We will impute BMI percentile alter among attritors using their historical heights and weights obtained through nautical chart review; however, nosotros too will conduct treatment completer analyses using only complete cases. Baseline variables (east.m., demographics) will be compared between intervention groups using chi-square statistics and t-tests to decide if any group differences exist despite randomization. Baseline variables that differ between groups will exist included as covariates in subsequent analyses.

Repeated measures assay of variance models volition be conducted to address the research questions. In the chief assay, the dependent variable will be BMI percentile. In this model, the within-subject factor will be fourth dimension, which will include 2 levels (baseline and 12 months). Betwixt-subjects factors will include treatment group (BMC, BMC + Phone, and BMC + Dwelling house). Demographic variables that are found to differ across groups will exist included every bit covariates.

Secondary analyses

A similar repeated measures ANOVA approach will be used to examine intervention effects on obesogenic behaviors. The within-subjects and between-subjects factors will be identical to those in the master model in a higher place and the dependent variables will be diet and physical activity. We will also examine dose-response effects of the interventions using regression models predicting 12 month BMI percentile from the number of doses of intervention received decision-making for baseline BMI percentile. Linear mixed modeling volition be used to determine if maternal (low, perceived stress, health intendance climate) and family unit (nutrient insecurity, acculturation) characteristics have principal effects on change in BMI percentiles and, of greater interest, if they moderate handling group effects. In this assay, BMI percentiles at baseline and 12 months will be used as a repeated variable, intervention group will be used as a stock-still discipline variable, and maternal and family characteristics will exist covariates (commencement individually and then jointly) to examine how they relate to changes in weight across the sample. Then, interactions between intervention group and maternal and family characteristics will be entered into the model to make up one's mind if whatever maternal/family characteristics moderate the outcome of intervention grouping on changes in BMI percentiles. Multiple regression analyses will be used to determine if clinician'south attitudes towards obesity, BMC cocky-efficacy, hope and conscientiousness and outcome expectancy predict the number of doses of BMC that they deliver. Finally, as Steps to Growing Up Healthy represents an example of a "applied trial" nosotros plan to evaluate the RE-AIM criteria (Reach; Effectiveness; Adoption; Implementation; Maintenance) [60] past looking at indicators such as the pct of mothers approached about the study who enroll, the percentage of mother-kid dyads who receive more than one dose of BMC, and the number of signed action plans.

Discussion

Obesity is recognized past pediatric primary care clinicians as the near pregnant health problem facing families today [61] yet information technology is often not addressed as part of routine care. Leading medical organizations including the American University of Pediatrics and the Institute of Medicine take called on primary care providers to expand their office in obesity prevention; yet, time constraints, lack of grooming in obesity management, and concerns about the minimal bear on of weight counseling contribute to the limited implementation of electric current prevention guidelines. For progress to be fabricated in this expanse, simple diet and exercise activeness plans are needed that tin be incorporated into pediatricians' busy ongoing practices without extensive training requirements on the part of clinicians [16].

Steps to Growing Up Healthy is a randomized controlled trial testing an evidence-based intervention for mothers of Latino and Black children 2-four years of historic period that offers repeated doses of cursory motivational interviewing coupled with cadre behavioral strategies (i.e., goal setting, self-monitoring) targeting 4 areas of beliefs modify (i.e., sugar sweetened beverage consumption, milk consumption, screen time, physical activity). The doses are administered by the child's existing medical team (the medical teamlet comprised of a primary care clinician and a nurse) during routine visits over the course of i year. We are examining the efficacy of this approach compared to the added value of offering monthly telephone follow-upwardly or home visits by community health workers. We designed the cadre intervention to fit inside regularly scheduled primary care visits to reduce the burden on the medical squad and families with the expectation that a dose will be provided at every clinic visit. Guided by the Chronic Care Model, we are utilizing bilingual/bicultural CHWs who have children of their own and reside in the target customs to facilitate adoption and maintenance of weight-related behavior change by problem-solving with families nigh barriers to successful goal progress and reinforcing beliefs change messages initially received in the primary care office. The study is innovative in its focus on very young children, the use of routine dispensary visits to address obesity management, and the testing of two different types of contact with CHWs in the prevention/reversal of obesity.

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Acknowledgements

The authors would like to acknowledge the assist of Annamarie Beaulieu in the execution of the project and Shelly Morse for administrative back up. We would also like to thank the staff and patients of the Master Care Center at Connecticut Children'southward Medical Eye. This work was supported by grants from the Aetna Foundation and the Community Health Network of Connecticut.

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Affiliations

1. Department of Psychology, Middle for Health, Intervention and Prevention, Academy of Connecticut, 2006 Hillside Road, Unit 1248, Storrs, CT, 06269-1248, The states

   Amy A Gorin & Commonwealth of dominica Hernandez

2. Children's Heart for Community Inquiry, Connecticut Children'south Medical Center, 282 Washington Street, Hartford, CT, 06106, U.s.a.

   James Wiley & Autherene Grant

3. Children'southward Middle for Community Research, Connecticut Children's Medical Center, Academy of Connecticut Wellness Centre, 282 Washington Street, Hartford, CT, 06106, U.s.a.

   Christine McCauley Ohannessian & Michelle M Cloutier

Corresponding author

Correspondence to Amy A Gorin.

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Competing interests

The authors declare that they have no competing interests.

Authors' contributions

AAG and MMC designed, planned, and oversaw all scientific aspects of the report. JW fabricated contributions to the study design and oversaw conquering of data. DH participated in the training of interventionists and in the conquering of data. AG was responsible for database direction. CO was involved in the drafting of the manuscript and devising the analytic plan. All authors read and approved the final manuscript.

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Gorin, A.A., Wiley, J., Ohannessian, C.Chiliad. et al. Steps to Growing Up Salubrious: a pediatric chief care based obesity prevention programme for young children. BMC Public Wellness 14, 72 (2014). https://doi.org/x.1186/1471-2458-fourteen-72

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• Received: 22 October 2013

• Accepted: 05 December 2013

• Published: 23 Jan 2014

• DOI : https://doi.org/10.1186/1471-2458-xiv-72

Keywords

• Weight management
• Latino
• Low-income
• Motivational interviewing

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