Proactive Assessment of Obesity Risk during Infancy (ProAsk): a qualitative study of parents' and professionals' perspectives on an mHealth intervention.

BACKGROUND: Prevention of childhood obesity is a public health priority. Interventions that establish healthy growth trajectories early in life promise lifelong benefits to health and wellbeing. Proactive Assessment of Obesity Risk during Infancy (ProAsk) is a novel mHealth intervention designed to enable health professionals to assess an infant's risk of future overweight and motivate parental behaviour change to prevent childhood overweight and obesity. The aim of this study was to explore parents' and health professionals' experiences of the overweight risk communication and behaviour change aspects of this mHealth intervention. METHODS: The study was conducted in four economically deprived localities in the UK. Parents (N = 66) were recruited to the ProAsk feasibility study when their infant was 6-8 weeks old. Twenty two health visitors (HVs) used a hand-held tablet device to deliver ProAsk to parents when their infants were 3 months old. Parents (N = 12) and HVs (N = 15) were interviewed when infants in the study were 6 months old. Interview data were transcribed and analysed thematically using an inductive, interpretative approach. RESULTS: Four key themes were identified across both parent and health visitor data: Engaging and empowering with digital technology; Unfamiliar technology presents challenges and opportunity; Trust in the risk score; Resistance to targeting. Most participants found the interactivity and visual presentation of information on ProAsk engaging. Health visitors who were unfamiliar with mobile technology drew support from parents who were more confident using tablet devices. There was evidence of resistance to targeting infants at greatest risk of future overweight and obesity, and both parents and health visitors drew on a number of reasons why a higher than average overweight risk score might not apply to a particular infant. CONCLUSIONS: An mHealth intervention actively engaged parents, enabling them to take ownership of the process of seeking strategies to reduce infant risk of overweight. However, cognitive and motivational biases that prevent effective overweight risk communication are barriers to targeting an intervention at those infants most at risk. TRIAL REGISTRATION: NCT02314494 . Date registered 11th December 2014.

Systematic review of randomised controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood.

The risk factors for childhood overweight and obesity are known and can be identified antenatally or during infancy, however, the majority of effective interventions are designed for older children. This review identified interventions designed to reduce the risk of overweight/obesity that were delivered antenatally or during the first 2 years of life, with outcomes reported from birth to 7 years of age. Six electronic databases were searched for papers reporting randomised controlled trials of interventions published from January 1990 to September 2013. A total of 35 eligible studies were identified, describing 27 unique trials of which 24 were behavioural and three were non-behavioural. The 24 behavioural trials were categorised by type of intervention: (1) nutritional and/or responsive feeding interventions targeted at parents of infants, which improved feeding practices and had some impact on child weight (n = 12); (2) breastfeeding promotion and lactation support for mothers, which had a positive effect on breastfeeding but not child weight (n = 5); (3) parenting and family lifestyle (n = 4); and (4) maternal health (n = 3) interventions that had some impact on feeding practices but not child weight. The non-behavioural trials comprised interventions manipulating formula milk composition (n = 3). Of these, lower/hydrolysed protein formula milk had a positive effect on weight outcomes. Interventions that aim to improve diet and parental responsiveness to infant cues showed most promise in terms of self-reported behavioural change. Despite the known risk factors, there were very few intervention studies for pregnant women that continue during infancy which should be a priority for future research.

UK health visitors' role in identifying and intervening with infants at risk of developing obesity.

Childhood obesity is associated with a number of modifiable risk factors that can be identified during infancy or earlier. In the UK, health visitors advise parents about infant feeding, but little is known about their role in obesity prevention. The aim of this study was to investigate the beliefs and current practices of UK health visitors in relation to recognising and intervening with infants at risk of developing obesity. Thirty members of the health visiting team were interviewed. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was applied using an interpretative, inductive approach. Health visitors were aware of some of the modifiable risk factors for childhood obesity such as infant feeding practices. They felt they had a role in advising parents about diet but did not formally identify and/or intervene with larger infants. Infant overweight was considered a sensitive issue that was difficult to raise with parents. They believed some parents preferred larger infants and were unaware that their feeding practices might be contributing to obesity risk. A need for training and guidance was identified together with strategies to overcome system barriers. Health visitors do not currently target parents of infants at risk of obesity largely because they do not perceive they have appropriate guidance and skills to enable them to do so. There is an urgent need for tools and training to enable all health care professionals to recognise and manage infants at risk of developing obesity without creating a sense of blame.

Student-led approaches to mental health support.

Mental health issues amongst university students are rife. Increasing mental health literacy and an emphasis on wellbeing have revealed the importance of having a plethora of resources available to students surrounding mental health support. The Welfare Hub is a student-led project created at the University of Nottingham Medical School to destigmatise mental health discussion, enhance mental health education, and share experiences of healthcare professionals regarding their mental health and university support. In this paper, we incorporate discussion around improvements the Welfare Hub can make regarding its content and how to best support future students. This project identified that the Welfare Hub's Instagram account was closely associated with mental health awareness and education, and that the best performing posts were those that offered positive connotations of support relevant to medical students and those that detailed lived medical student's experiences and advice. The Welfare Hub has had a positive impact on committee members and allowed them to fulfil their desires regarding destigmatising and discussing mental health. Future development following these findings aim to produce more educational and supportive content, develop connections of the Welfare Hub within the University and other institutions, and host events for the well-being of medical students.

Evaluating the effectiveness of a schools-based programme to promote exercise self-efficacy in children and young people with risk factors for obesity: steps to active kids (STAK).

BACKGROUND: Low levels of physical activity in children have been linked to an increased risk of obesity, but many children lack confidence in relation to exercise (exercise self-efficacy). Factors which can impact on confidence include a chronic health condition such as asthma, poor motor skills and being overweight. Increasing levels of physical activity have obvious benefits for children with asthma and children who are overweight, but few activity interventions with children specifically target children with low exercise self-efficacy (ESE). This study aims to evaluate the efficacy and feasibility of a schools-based activity programme suitable for children with risk factors for adult obesity, including asthma, overweight and low exercise self-efficacy. METHODS/DESIGN: A clustered (at the level of school) RCT will be used to compare a targeted, 10 week, stepped activity programme (activity diary, dance DVD, circuit-training and motivational interviewing) designed to promote ESE. We will recruit 20 primary schools to participate in the intervention and 9-11 year old children will be screened for low levels of ESE, asthma and overweight. In order to provide sufficient power to detect a difference in primary outcomes (Body Mass Index-BMI & ESE at 12 month follow-up) between children in the intervention schools and control schools, the target sample size is 396. Assessments of BMI, ESE, waist circumference, peak flow, activity levels and emotional and behavioural difficulties will be made at baseline, 4 months and 12 month follow-up. DISCUSSION: We aim to increase ESE and levels of physical activity in children with risk factors for adult obesity. The outcomes of this study will inform policy makers about the feasibility, acceptability and effectiveness of delivering targeted health interventions within a school setting. TRIAL REGISTRATION: ISRCTN Register no. ISRCTN12650001.

Preventing childhood obesity during infancy in UK primary care: a mixed-methods study of HCPs' knowledge, beliefs and practice.

BACKGROUND: There is a strong rationale for intervening in early childhood to prevent obesity. Over a quarter of infants gain weight more rapidly than desirable during the first six months of life putting them at greater risk of obesity in childhood. However, little is known about UK healthcare professionals' (HCPs) approach to primary prevention. This study explored obesity-related knowledge of UK HCPs and the beliefs and current practice of general practitioners (GPs) and practice nurses in relation to identifying infants at risk of developing childhood obesity. METHOD: Survey of UK HCPs (GPs, practice nurses, health visitors, nursery, community and children's nurses). HCPs (n = 116) rated their confidence in providing infant feeding advice and completed the Obesity Risk Knowledge Scale (ORK-10).Semi-structured interviews with a sub-set of 12 GPs and 6 practice nurses were audio recorded, taped and transcribed verbatim. Thematic analysis was applied using an interpretative, inductive approach. RESULTS: GPs were less confident about giving advice about infant feeding than health visitors (p = 0.001) and nursery nurses (p = 0.009) but more knowledgeable about the health risks of obesity (p < 0.001) than nurses (p = 0.009). HCPs who were consulted more often about feeding were less knowledgeable about the risks associated with obesity (r = -0.34, n = 114, p < 0.001). There was no relationship between HCPs' ratings of confidence in their advice and their knowledge of the obesity risk.Six main themes emerged from the interviews: 1) Attribution of childhood obesity to family environment, 2) Infant feeding advice as the health visitor's role, 3) Professional reliance on anecdotal or experiential knowledge about infant feeding, 4) Difficulties with recognition of, or lack of concern for, infants "at risk" of becoming obese, 5) Prioritising relationship with parent over best practice in infant feeding and 6) Lack of shared understanding for dealing with early years' obesity. CONCLUSIONS: Intervention is needed to improve health visitors and nursery nurses' knowledge of obesity risk and GPs and practice nurses' capacity to identify and manage infants' at risk of developing childhood obesity. GPs value strategies that maintain relationships with vulnerable families and interventions to improve their advice-giving around infant feeding need to take account of this. Further research is needed to determine optimal ways of intervening with infants at risk of obesity in primary care.

Parents' beliefs about appropriate infant size, growth and feeding behaviour: implications for the prevention of childhood obesity.

BACKGROUND: A number of risk factors are associated with the development of childhood obesity which can be identified during infancy. These include infant feeding practices, parental response to infant temperament and parental perception of infant growth and appetite. Parental beliefs and understanding are crucial determinants of infant feeding behaviour; therefore any intervention would need to take account of their views. This study aimed to explore UK parents' beliefs concerning their infant's size, growth and feeding behaviour and parental receptiveness to early intervention aimed at reducing the risk of childhood obesity. METHOD: Six focus groups were undertaken in a range of different demographic localities, with parents of infants less than one year of age. The focus groups were audio-recorded, transcribed verbatim and thematic analysis applied using an interpretative, inductive approach. RESULTS: 38 parents (n=36 female, n=2 male), age range 19-45 years (mean 30.1 years, SD 6.28) participated in the focus groups. 12/38 were overweight (BMI 25-29.99) and 8/38 obese (BMI>30). Five main themes were identified. These were a) parental concern about breast milk, infant contentment and growth; b) the belief that the main cause of infant distress is hunger is widespread and drives inappropriate feeding; c) rationalisation for infants' larger size; d) parental uncertainty about identifying and managing infants at risk of obesity and e) intentions and behaviour in relation to a healthy lifestyle. CONCLUSIONS: There are a number of barriers to early intervention with parents of infants at risk of developing obesity. Parents are receptive to prevention prior to weaning and need better support with best practice in infant feeding. In particular, this should focus on helping them understand the physiology of breast feeding, how to differentiate between infant distress caused by hunger and other causes and the timing of weaning. Some parents also need guidance about how to recognize and prepare healthy foods and facilitate physical activity for their infants.

Learning sets ... the way forward?

Community nursery nurses (CNNs) have increasingly important roles within clinical service delivery. Maintaining and enhancing their learning has not been extensively developed within the NHS. We report on a cost-effective, structured programme that focused on one aspect of their learning: managing childhood behaviour. Childhood behaviour problems place substantial demands on the health service. CNNs are increasingly recognised as being potentially in the front line for managing these issues. CNNs have excellent training within play skills but often have more limited training in managing childhood behaviour problems. Learning sets were developed and evaluated as effective in delivering training to CNNs on childhood behaviour. Our programme allowed CNNs to shape learning over a six-month period. It aimed to value existing skills and promote a learner-centred approach. This teaching method encouraged generic skills in exploring evidence-based approaches to clinical care. Learners valued collaboration and identified new clinical strategies that included standardisation of advice given.

Digital technology to facilitate Proactive Assessment of Obesity Risk during Infancy (ProAsk): a feasibility study.

OBJECTIVE: To assess the feasibility and acceptability of using digital technology for Proactive Assessment of Obesity Risk during Infancy (ProAsk) with the UK health visitors (HVs) and parents. DESIGN: Multicentre, pre- and post-intervention feasibility study with process evaluation. SETTING: Rural and urban deprived settings, UK community care. PARTICIPANTS: 66 parents of infants and 22 HVs. INTERVENTION: ProAsk was delivered on a tablet device. It comprises a validated risk prediction tool to quantify overweight risk status and a therapeutic wheel detailing motivational strategies for preventive parental behaviour. Parents were encouraged to agree goals for behaviour change with HVs who received motivational interviewing training. OUTCOME MEASURES: We assessed recruitment, response and attrition rates. Demographic details were collected, and overweight risk status. The proposed primary outcome measure was weight-for-age z-score. The proposed secondary outcomes were parenting self-efficacy, maternal feeding style, infant diet and exposure to physical activity/sedentary behaviour. Qualitative interviews ascertained the acceptability of study processes and intervention fidelity. RESULTS: HVs screened 324/589 infants for inclusion in the study and 66/226 (29%) eligible infants were recruited. Assessment of overweight risk was completed on 53 infants and 40% of these were identified as above population risk. Weight-for-age z-score (SD) between the infants at population risk and those above population risk differed significantly at baseline (-0.67 SD vs 0.32 SD). HVs were able to collect data and calculate overweight risk for the infants. Protocol adherence and intervention fidelity was a challenge. HVs and parents found the information provided in the therapeutic wheel appropriate and acceptable. CONCLUSION: Study recruitment and protocol adherence were problematic. ProAsk was acceptable to most parents and HVs, but intervention fidelity was low. There was limited evidence to support the feasibility of implementing ProAsk without significant additional resources. A future study could evaluate ProAsk as a HV-supported, parent-led intervention. TRIAL REGISTRATION NUMBER: NCT02314494 (Feasibility Study Results).

Validation, Optimal Threshold Determination, and Clinical Utility of the Infant Risk of Overweight Checklist for Early Prevention of Child Overweight.

BACKGROUND: Previous research has demonstrated the predictive validity of the Infant Risk of Overweight Checklist (IROC). This study further establishes the predictive accuracy of the IROC using data from the Avon Longitudinal Study of Parents and Children (ALSPAC) and examines the optimal threshold for determining high risk of childhood overweight. METHODS: Using the IROC algorithm, we calculated the risk of being overweight, based on International Obesity Task Force criteria, in the first year of life for 980 children in the ALSPAC cohort at 5 years. Discrimination was assessed by the area under the receiver operating curve (AUC c-statistic). Net reclassification index (NRI) was calculated for risk thresholds ranging from 2.5% to 30%, which determine cutoffs for identifying infants at risk of becoming overweight. RESULTS: At 5 years of age, 12.3% of boys and 19.6% of girls were categorized overweight. Discrimination (AUC c-statistic) ranged from 0.67 (95% confidence interval [CI], 0.62-0.72) when risk scores were calculated directly to 0.93 (95% CI, 0.88-0.98) when the algorithm was recalibrated and missing values of the risk factor algorithm were imputed. The NRI showed that there were positive gains in reclassification using risk thresholds from 5% to 20%, with the maximum NRI being at 10%. CONCLUSIONS: This study confirms that the IROC has moderately good validity for assessing overweight risk in infants and offers an optimal threshold for determining high risk. The IROC algorithm has been imbedded into a computer program for Proactive Assessment of Obesity Risk during Infancy, which facilitates early overweight prevention through communication of risk to parents.

Role of a paediatric nurse in primary care 2: research findings.

This article is the second of a two-part article that presents the findings of a study focusing on the role and function of two qualified children's nurses, each working within a different primary healthcare team (PHCT). The first part described the variation in settings for community paediatric nurses, the paucity of literature discussing the role of a paediatric nurse working as a member of a PHCT, the application of a research methodology that incorporated practitioner values and experience, the application of naturalist inquiry and the use of a formative evaluation strategy which enabled the researcher to be involved in directing and supporting the research nurses with the data collection (Vol 11(22): 1452-60). This second part focuses on the findings and discussions where it was demonstrated that qualified children's nurses working in community setting contributes to raising the overall support and quality of care for a whole range of conditions currently perceived as low profile. There was evidence that these nurses catered for unmet needs and were, at times, functioning as nurse practitioners and on occasions as advanced practitioners. These findings may contribute as a catalyst for change in informing the development of children's nursing services as part of the Children's National Service Framework.

Role of a paediatric nurse in primary care 1: research issues.

This study, which looked at the potential for the role of a paediatric nurse in primary care, was a tripartite partnership arrangement with Community Health Sheffield NHS Trust, the University of Sheffield and the Children's Hospital Sheffield. The study focused on the role and function of two qualified children's nurses each working within a different primary healthcare team (PHCT). It was important to allow the role to evolve without undue pressure, so that members of the PHCT could work with the nurses to establish what would be the most useful and relevant tasks to be carried out by the team. The methodological problems posed in this type of study where little was known about how a children's nurse would work in a PHCT resulted in exploring the concept of a formative evaluation process. The major data source and contribution to the evaluation were the nurses' reflective accounts of their role and function as members of the PHCT. Case studies written in the form of reflective diaries provided a self-critical approach to the record of tasks undertaken and explained why the service was taken up. Five constructions emerged: duplication and perceived threats to established nursing roles within the PHCT; improved care of children in PHCT settings; the nature of support for children and families; working as a nurse practitioner; and meeting unmet need. A clear need was demonstrated for a qualified children's nurse working in a community setting to raise the overall support and quality of care for a whole range of conditions which are currently low profile. There was evidence that these nurses met unmet need and were, at times, functioning as nurse practitioners and at times as advanced practitioners. This article, the first of two parts, focuses on the methods used and the associated problems. The second part will present the findings and discussions of the research.

How best to teach developmental assessment? A single-blinded randomised study.

OBJECTIVE: Developmental assessment is a core paediatric competency, but research demonstrates teaching gaps. This single-blinded, randomised controlled study compares three teaching approaches to developmental assessment in a large group setting based on a student's self-perception and objective competency assessment. DESIGN: Students were randomised into one of the following: ▸ a didactic lecture followed by self-study with online resources (control group), ▸ a didactic lecture and small group tutorial (small group) ▸ a combined didactic lecture and interactive component using audio-visual equipment (Interactive Developmental Teaching-IDT group). Competency scores (based on the Royal College of Paediatrics and Child Health (RCPCH) scoring system, adapted for undergraduates), mean scores of self-reported confidence and degree of motivation were compared between groups. RESULTS: 114 students participated. Statistically significant difference between mean assessment scores was demonstrated for the small group (38.0; 95% CI 36.5 to 39.6) and the IDT group (37.9; 95% CI 36.5 to 39.4) compared to the control group (34.8; 95% CI 33.2 to 36.4). Students' self-reported confidence, acquisition of knowledge and degree of motivation to practice was higher in IDT and small groups compared to the didactically taught control group. Teaching costs, if measured by trainer's time, were one-fifth in the IDT group compared to the small group teaching. CONCLUSIONS: The IDT is an effective teaching method in large groups, improves competencies compared to didactic lecturing, and is as effective as small group teaching. Adoption of the IDT appears to facilitate learning and can be easily delivered with falling ratios of teachers to students.

Estimating overweight risk in childhood from predictors during infancy.

OBJECTIVE: The aim of this study was to develop and validate a risk score algorithm for childhood overweight based on a prediction model in infants. METHODS: Analysis was conducted by using the UK Millennium Cohort Study. The cohort was divided randomly by using 80% of the sample for derivation of the risk algorithm and 20% of the sample for validation. Stepwise logistic regression determined a prediction model for childhood overweight at 3 years defined by the International Obesity Task Force criteria. Predictive metrics R(2), area under the receiver operating curve (AUROC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: Seven predictors were found to be significantly associated with overweight at 3 years in a mutually adjusted predictor model: gender, birth weight, weight gain, maternal prepregnancy BMI, paternal BMI, maternal smoking in pregnancy, and breastfeeding status. Risk scores ranged from 0 to 59 corresponding to a predicted risk from 4.1% to 73.8%. The model revealed moderately good predictive ability in both the derivation cohort (R(2) = 0.92, AUROC = 0.721, sensitivity = 0.699, specificity = 0.679, PPV = 38%, NPV = 87%) and validation cohort (R(2) = 0.84, AUROC = 0.755, sensitivity = 0.769, specificity = 0.665, PPV = 37%, NPV = 89%). CONCLUSIONS: Using a prediction algorithm to identify at-risk infants could reduce levels of child overweight and obesity by enabling health professionals to target prevention more effectively. Further research needs to evaluate the clinical validity, feasibility, and acceptability of communicating this risk.