'eatNplay' - a rurally-tailored, family-based, telehealth intervention for childhood obesity: Protocol for a mixed-methods randomized newsletter controlled pilot study.

BACKGROUND: Childhood obesity disproportionately affects rural communities where access to pediatric weight control services is limited. Telehealth may facilitate access to these services. OBJECTIVE: This paper describes the rationale, curriculum, and methodology for conducting a randomized controlled pilot trial of a rural, family-based, telehealth intervention that aims to improve weight-related behaviors among children, compared to monthly newsletters. METHODS: A mixed-methods randomized design will randomly assign 44 rural families with one or more children aged 5 to 11 years identified as overweight or obese to an intervention or newsletter control group. The intervention group will attend 'eatNplay' group videoconferencing telehealth sessions, conducted weekly by a registered nurse and a motivational interviewing expert, to discuss diet, exercise, sleep, and peer group influences. The control group will receive newsletters covering these topics. Outcome measures at baseline, 12, and 26 weeks will assess 1) participant engagement and satisfaction with 'eatNplay'; 2) child's BMI, dietary behavior, physical activity, and sleep behavior; and 3) parent/guardians' self-reported beliefs, behaviors, attitudes, perceived stress, and perceived quality of life. Analyses will employ 1) thematic analysis of semi-structured parent/guardian interviews after follow-up to help refine the intervention (e.g., curriculum), and 2) linear mixed models to compare outcomes between groups pre- and post-intervention and reduce bias from unobserved variables. Results of this pilot study could refine methodology for conducting telehealth studies, acceptability of healthcare provider-involved recruitment, interdisciplinary team approach, and addressing childhood obesity in rural communities through telehealth.

Tailored motivational interviewing (TMI): Translating basic science in skills acquisition into a behavioral intervention to improve community health worker motivational interviewing competence for youth living with HIV.

Objective: Interventions to promote evidence-based practices are particularly needed for paraprofessional staff working with minority youth with HIV who have higher rates of HIV infection but lower rates of linkage and retention in care compared to older adults. Utilizing the ORBIT model for behavioral intervention development, we defined and refined a behavioral intervention for providers, Tailored Motivational Interviewing (TMI), to improve provider competence in previous studies (Phase 1a and 1b). The current study focuses on ORBIT Phase 2a-proof of concept. We hypothesized that TMI would be acceptable and feasible and would show a signal of efficacy of improving and maintaining community health worker (CHW) MI competence scores using an innovative statistical method for small N proof-of-concept studies. Method: Longitudinal data were collected from 19 CHWs at 16 youth HIV agencies. CHWs from 8 sites were assigned to the TMI group per the cofunders request. The remaining 8 sites were randomly assigned to TMI or services as usual. MI competence was assessed at baseline and up to 15 times over 2 years. Random coefficient models were utilized to examine time trajectories of competence scores and the impact of the intervention on competence trajectories. Semistructured interviews were conducted to determine barriers and facilitators of TMI. Results: Competence scores in the TMI group significantly increased while the scores of the control group significantly decreased. Further analysis of the intervention group demonstrated that scores significantly increased during the first 3 months after initial workshop and was sustained through the end of the study. Qualitative findings revealed insufficient time and competing priorities as perceived barriers whereas integrating MI into routine agency practices and ongoing training might facilitate implementation. Conclusions: Following a successful proof-of-concept, the next step is a fully randomized pilot study of TMI relative to a control condition in preparation for a stepped-wedge cluster randomized full scale trial. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Identifying Effective Motivational Interviewing Communication Sequences Using Automated Pattern Analysis.

Motivational Interviewing (MI) is an evidence-based strategy for communicating with patients about behavior change. Although there is strong empirical evidence linking "MI-consistent" counselor behaviors and patient motivational statements (i.e., "change talk"), the specific counselor communication behaviors effective for eliciting patient change talk vary by treatment context and, thus, are a subject of ongoing research. An integral part of this research is the sequential analysis of pre-coded MI transcripts. In this paper, we evaluate the empirical effectiveness of the Hidden Markov Model, a probabilistic generative model for sequence data, for modeling sequences of behavior codes and closed frequent pattern mining, a method to identify frequently occurring sequential patterns of behavior codes in MI communication sequences to inform MI practice. We conducted experiments with 1,360 communication sequences from 37 transcribed audio recordings of weight loss counseling sessions with African-American adolescents with obesity and their caregivers. Transcripts had been previously annotated with patient-counselor behavior codes using a specialized codebook. Empirical results indicate that Hidden Markov Model and closed frequent pattern mining techniques can identify counselor communication strategies that are effective at eliciting patients' motivational statements to guide clinical practice.

Outcomes From a Sequential Multiple Assignment Randomized Trial of Weight Loss Strategies for African American Adolescents With Obesity.

BACKGROUND: Minority adolescents are at highest risk for obesity and extreme obesity; yet, there are few clinical trials targeting African American adolescents with obesity. PURPOSE: The purpose of the study was to develop an adaptive family-based behavioral obesity treatment for African American adolescents using a sequential multiple assignment randomized trial (SMART) design. METHODS: Fit Families was a SMART where 181 African American adolescents (67% female) aged 12-17 were first randomized to office-based versus home-based behavioral skills treatment delivered from a Motivational Interviewing foundation. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based behavioral skills treatment or contingency management with voucher-based reinforcement for adolescent weight loss and for caregiver adherence to the program. All interventions were delivered by community health workers. The primary outcome was treatment retention and percent overweight. RESULTS: All adolescents reduced percent overweight by -3.20%; there were no significant differences in percent overweight based on treatment sequence. Adolescents receiving home-based delivery in Phase 1 and contingency management in Phase 2 completed significantly more sessions than those receiving office-based treatment and continued skills without CM (M = 8.03, SD = 3.24 and M = 6.62, SD = 2.95, respectively). The effect of contingency management was strongest among older and those with lower baseline confidence. Younger adolescents experienced greater weight reductions when receiving continued skills (-4.90% compared with -.02%). CONCLUSIONS: Behavioral skills training can be successfully delivered to African American adolescents with obesity and their caregivers by community health workers when using a home-based service model with incentives. More potent interventions are needed to increase reductions in percent overweight and may need to be developmentally tailored for younger and older adolescents.

Developing Machine Learning Models for Behavioral Coding.

OBJECTIVE: The goal of this research is to develop a machine learning supervised classification model to automatically code clinical encounter transcripts using a behavioral code scheme. METHODS: We first evaluated the efficacy of eight state-of-the-art machine learning classification models to recognize patient-provider communication behaviors operationalized by the motivational interviewing framework. Data were collected during the course of a single weight loss intervention session with 37 African American adolescents and their caregivers. We then tested the transferability of the model to a novel treatment context, 80 patient-provider interactions during routine human immunodeficiency virus (HIV) clinic visits. RESULTS: Of the eight models tested, the support vector machine model demonstrated the best performance, achieving a .680 F1-score (a function of model precision and recall) in adolescent and .639 in caregiver sessions. Adding semantic and contextual features improved accuracy with 75.1% of utterances in adolescent and 73.8% in caregiver sessions correctly coded. With no modification, the model correctly classified 72.0% of patient-provider utterances in HIV clinical encounters with reliability comparable to human coders (k = .639). CONCLUSIONS: The development of a validated approach for automatic behavioral coding offers an efficient alternative to traditional, resource-intensive methods with the potential to dramatically accelerate the pace of outcomes-oriented behavioral research. The knowledge gained from computer-driven behavioral research can inform clinical practice by providing clinicians with empirically supported communication strategies to tailor their conversations with patients. Lastly, automatic behavioral coding is a critical first step toward fully automated eHealth/mHealth (electronic/mobile Health) behavioral interventions.

African-American Adolescents' Weight Loss Skills Utilization: Effects on Weight Change in a Sequential Multiple Assignment Randomized Trial.

OBJECTIVE: Successful weight loss interventions for African-Americans adolescents are lacking. Cognitive-behavioral interventions seek to develop weight loss skills (e.g., counting calories, goal setting, managing one's environment). Little is known about how well adolescents implement such skills in their daily lives. Study aims were to (1) examine weight loss skills utilization at midpoint and end of a 6-month cognitive-behavioral/motivational interviewing weight loss sequential multiple assignment randomized trial (SMART), and (2) determine if greater skill utilization predicted weight loss at treatment end and 3 months post-treatment. METHOD: One hundred and eighty six African-Americans adolescents with obesity and their caregiver were first randomly assigned to complete 3 months of cognitive-behavioral and motivational interviewing family-based weight loss treatment in their home or in the research office (Phase 1). Nonresponders (i.e., those who lost < 3% of initial weight, n = 161) were rerandomized to 3 months of continued skills training (n = 83) or contingency management (n = 78) for Phase 2; responders were allocated to 3 months of relapse prevention (n = 20). Adolescents' frequency of weight loss skills utilization was assessed via questionnaire at treatment midpoint and end. RESULTS: Higher treatment attendance was associated with better skill utilization. Higher skill utilization was associated with more weight loss at treatment end, whereas higher baseline confidence was associated with more weight loss at follow-up. CONCLUSIONS: This study indicates the importance of attending weight loss intervention sessions to develop and strengthen weight loss skills in African-American adolescents with obesity, and strengthening confidence to use such skills for continued weight loss.

From the Classroom to Entrustment - The Development of Motivational Interviewing Skills as an Entrustable Professional Activity.

This article was migrated. The article was marked as recommended. Introduction The move towards value-based care and population health has highlighted the prominent role of social and behavioral factors in determining health outcomes. Patient-centered behavioral guidance to improve patient self-management is recognized as an evidence-based intervention for a variety of chronic conditions but has yet to be adopted as a core competency or core entrustable professional activity (EPA). Motivational Interviewing (MI) is an evidence-based behavioral intervention involving an integrated set of competencies, featuring reflective listening, affirmation, evocation, and collaborative planning. An MI encounter is an observable, discrete task that can be framed as an EPA. Successful implementation of EPAs in the workplace requires institutional engagement, a thoughtful curricular approach, faculty development, and feasible, valid workplace-based assessment (WBA). Methods We implemented competency-based MI training and assessed competency outcomes for students and faculty. After joining the Association of American Medical Colleges Core EPA Pilot, we applied an iterative group process to develop an EPA and workplace-based assessment based on established MI competencies. Results Drawing upon nine years of developing MI curriculum, we present competency data for a student training study and a faculty coaching study, describe how we transitioned training from the classroom to the clinical setting employing an EPA framework, and present a one-page schematic and related WBA for an EPA based on MI. Conclusion We propose that MI is a core EPA for future physicians practicing value-based care, and offer a roadmap for curriculum implementation.

Effectiveness of Nutrition Intervention in a Selected Group of Overweight and Obese African-American Preschoolers.

High prevalence of childhood obesity persists as a public health concern in the USA. However, limited study has been conducted on the effectiveness of nutrition education focused on African-American (AA) preschoolers (PSLRs) in the preschool settings. The aim of this pilot study was to explore the effectiveness of nutrition education on AA PSLR's health. A convenience sample of 164 PSLRs (95% AA, 44% female) from six Head Start (HS) centers in a Midwestern metropolitan area was randomly assigned to 3 groups: intervention group A, standard curriculum plus nutrition education for PSLRs; intervention group B, standard curriculum plus nutrition education for PSLRs and their caregivers (CGs); and control group, standard curriculum. Baseline and post-intervention differences within each group and differences among the three groups in body mass index (BMI) percentiles, blood lipid profile, and food preference/knowledge were analyzed. No significant changes in BMI percentiles among the three groups were observed. When only overweight and obese PSLRs were considered, there was a significant reduction in BMI percentile in group B (PSLR + CG) and control group. More PSLRs in all three groups had blood lipid levels in the acceptable with few in the high-risk levels. There were no changes in nutrition knowledge and healthy eating behavior post-intervention. This pilot study supports including both PSLRs and CGs in future preschool-based interventions and the need for more intense intervention to optimize healthy outcomes, especially for those AA PSLRs who are overweight or obese.

Correction to: Effectiveness of Nutrition Intervention in a Selected Group of Overweight and Obese African-American Preschoolers.

Part of our original analyses was performed with overweight and obese preschoolers only. This procedure may have created a subgroup of individuals with extreme values at baseline and this may likely be inappropriate.

Building Motivation in African American Caregivers of Adolescents With Obesity: Application of Sequential Analysis.

Objective: We sought to examine communication between counselors and caregivers of adolescents with obesity to determine what types of counselor behaviors increased caregivers' motivational statements regarding supporting their child's weight loss. Methods: We coded 20-min Motivational Interviewing sessions with 37 caregivers of African American 12-16-year-olds using the Minority Youth Sequential Coding for Observing Process Exchanges. We used sequential analysis to determine which counselor communication codes predicted caregiver motivational statements. Results: Counselors' questions to elicit motivational statements and emphasis on autonomy increased the likelihood of both caregiver change talk and commitment language statements. Counselors' reflections of change talk predicted further change talk, and reflections of commitment language predicted more commitment language. Conclusions: When working to increase motivation among caregivers of adolescents with overweight or obesity, providers should strive to reflect motivational statements, ask questions to elicit motivational statements, and emphasize caregivers' autonomy.

A comparison of snack serving sizes to USDA guidelines in healthy weight and overweight minority preschool children enrolled in Head Start.

BACKGROUND: Obesity disproportionately affects children from low-income families and those from racial and ethnic minorities. The relationship between snacking and weight status remains unclear, although snacking is known to be an important eating episode for energy and nutrient intake particularly in young children. The purpose of this pilot study was to examine the snack intake of minority preschool children enrolled in the Head Start Program in four centers in Detroit, Michigan, and investigate differences by child weight status. METHODS: This secondary data analysis used snack time food observation and anthropometric data from a convenience sample of 55 African American children (44 % girls, mean age = 3.8 years). Snack intake data was obtained over a mean of 5 days through direct observation of children by dietetic interns, and later converted into food group servings according to the United States Department of Agriculture (USDA) meal patterns and averaged for each child. Height and weight measurements were systematically collected and BMI-for-age percentiles were used to classify children into weight categories. One sample, paired samples and independent samples t-tests were performed to test for differences within and between means. RESULTS: Based on BMI-for-age percentiles, 72.7 % of the sample was under/healthy weight and 27.3 % was overweight/obese. Average (mean ± SD) intake of milk (0.76 ± 0.34) and overall fruits/vegetables (0.77 ± 0.34) was significantly lower than one USDA serving, while average intake of grains and breads (2.04 ± 0.89), meat/meat alternates (2.20 ± 1.89) and other foods (1.43 ± 1.08) was significantly higher than one USDA serving (p ≤ 0.05). Children ate more when offered canned versus fresh fruits (0.93 ± 0.57 vs. 0.65 ± 0.37, p = 0.007). Except for a significantly higher milk intake in the overweight/obese group compared to the under/healthy weight group (0.86 ± 0.48 vs. 0.72 ± 0.27, p = 0.021], no relationship was found between snack food intake and weight category. Only in the overweight/obese group was the intake of milk and fresh fruits not significantly different than one USDA serving. CONCLUSIONS: Findings suggest that regardless of weight status low-income minority preschool children are consuming larger serving sizes when offered less healthy versus healthier snack foods. Continued efforts should be made to provide healthful snack foods at preschool settings to prevent obesity and promote healthier food habits.

Effective Patient-Provider Communication in Pediatric Obesity.

Effective patient-provider communication is not a primary focus of medical school curricula. Motivational interviewing (MI) is a patient-centered, directive communication framework appropriate for in health care. Research on MI's causal mechanisms has established patient change talk as a mediator of behavior change. Current MI research focuses on identifying which provider communication skills are responsible for evoking change talk. MI recommends informing, asking, and listening. Research provides evidence that asking for and reflecting patient change talk are effective communication strategies, but cautions providers to inform judiciously. Supporting a patient's decision making autonomy is an important strategy to promote health behaviors.

A study of the effectiveness of machine learning methods for classification of clinical interview fragments into a large number of categories.

This study examines the effectiveness of state-of-the-art supervised machine learning methods in conjunction with different feature types for the task of automatic annotation of fragments of clinical text based on codebooks with a large number of categories. We used a collection of motivational interview transcripts consisting of 11,353 utterances, which were manually annotated by two human coders as the gold standard, and experimented with state-of-art classifiers, including Naïve Bayes, J48 Decision Tree, Support Vector Machine (SVM), Random Forest (RF), AdaBoost, DiscLDA, Conditional Random Fields (CRF) and Convolutional Neural Network (CNN) in conjunction with lexical, contextual (label of the previous utterance) and semantic (distribution of words in the utterance across the Linguistic Inquiry and Word Count dictionaries) features. We found out that, when the number of classes is large, the performance of CNN and CRF is inferior to SVM. When only lexical features were used, interview transcripts were automatically annotated by SVM with the highest classification accuracy among all classifiers of 70.8%, 61% and 53.7% based on the codebooks consisting of 17, 20 and 41 codes, respectively. Using contextual and semantic features, as well as their combination, in addition to lexical ones, improved the accuracy of SVM for annotation of utterances in motivational interview transcripts with a codebook consisting of 17 classes to 71.5%, 74.2%, and 75.1%, respectively. Our results demonstrate the potential of using machine learning methods in conjunction with lexical, semantic and contextual features for automatic annotation of clinical interview transcripts with near-human accuracy.

Exploring ambivalence in motivational interviewing with obese African American adolescents and their caregivers: A mixed methods analysis.

OBJECTIVE: We conducted an exploratory mixed methods study to describe the ambivalence African-American adolescents and their caregivers expressed during motivational interviewing sessions targeting weight loss. METHODS: We extracted ambivalence statements from 37 previously coded counseling sessions. We used directed content analysis to categorize ambivalence related to the target behaviors of nutrition, activity, or weight. We compared adolescent-caregiver dyads' ambivalence using the paired sample t-test and Wilcoxon signed-rank test. We then used conventional content analysis to compare the specific content of adolescents' and caregivers' ambivalence statements. RESULTS: Adolescents and caregivers expressed the same number of ambivalence statements overall, related to activity and weight, but caregivers expressed more statements about nutrition. Content analysis revealed convergences and divergences in caregivers' and adolescents' ambivalence about weight loss. CONCLUSION: Understanding divergences in adolescent-caregiver ambivalence about the specific behaviors to target may partially explain the limited success of family-based weight loss interventions targeting African American families and provides a unique opportunity for providers to enhance family communication, foster teamwork, and build self-efficacy to promote behavior change. PRACTICE IMPLICATIONS: Clinicians working in family contexts should explore how adolescents and caregivers converge and diverge in their ambivalence in order to recommend weight loss strategies that best meet families' needs.

Sequential Multiple Assignment Randomized Trial (SMART) to Construct Weight Loss Interventions for African American Adolescents.

The purpose of this study was to develop an adaptive behavioral treatment for African American adolescents with obesity. In a sequential multiple assignment randomized trial, 181 youth ages 12-16 years with primary obesity and their caregiver were first randomized to 3 months of home-based versus office-based delivery of motivational interviewing plus skills building. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based skills or contingency management. Primary outcome was percent overweight and hypothesized moderators were adolescent executive functioning and depression. There were no significant differences in primary outcome between home-based or office-based delivery or between continued home-based skills or contingency management for nonresponders to first-phase treatment. However, families receiving home-based treatment initially attended significantly more sessions in both phases of the trial, and families receiving contingency management attended more sessions in the second phase. Overall, participants demonstrated decreases in percent overweight over the course of the trial (3%), and adolescent executive functioning moderated this effect such that those with higher functioning lost more weight. More potent behavioral treatments to address the obesity epidemic are necessary, targeting new areas such as executive functioning. Delivering treatment in the home with contingency management may increase session attendance for this population.

Advanced Patient-Centered Communication for Health Behavior Change: Motivational Interviewing Workshops for Medical Learners.

INTRODUCTION: Medical settings are critical access points for behavior change counseling, and lifestyle behavior change is considered a key component of chronic disease management. The Association of American Medical Colleges recommends that future physicians be competent in shared decision making and patient-centered behavioral guidance to prevent illness and improve patient self-management of chronic disease. Motivational interviewing (MI) is a patient-centered, directive method of communication to enhance behavior change. Specific teachable strategies underlie the collaborative MI communication style that aims to reduce discord and build motivation for change. METHODS: We present our three-session 12-hour MI curriculum as an advanced form of patient-centered communication. Each session includes presession assignment, large-group interactive lecture, and small-group activities for practice. An interdisciplinary team consisting of medical educators and health behavior change research-educators who are also members of the Motivational Interviewing Network of Trainers created the submission. The purpose of this resource is to provide medical educators with a short curriculum that incorporates materials and learning activities to promote skill in MI. RESULTS: In addition to positive feedback from student evaluations including the areas of relevance to training and self-rated skills improvement, preliminary pre- and posttraining scores from the medical students show significant improvement in expression of empathy and the ratio of reflections to questions. DISCUSSION: Implementation of the curriculum allows learners the opportunity to practice evidence-based communication that promotes intrinsic motivation for health behavior change in patients, a key treatment focus in chronic disease management.

Contingency management adapted for African-American adolescents with obesity enhances youth weight loss with caregiver participation: a multiple baseline pilot study.

BACKGROUND: Contingency management (CM) interventions, which use operant conditioning principles to encourage completion of target behavioral goals, may be useful for improving adherence to behavioral skills training (BST). Research-to-date has yet to explore CM for weight loss in minority adolescents. OBJECTIVE: To examine the effects of CM in improving adolescent weight loss when added to BST. DESIGN: The study utilized an innovative experimental design that builds upon multiple baseline approaches as recommended by the National Institutes of Health. PARTICIPANTS/SETTING: Six obese African-American youth and their primary caregivers living in Detroit, Michigan, USA. INTERVENTION: Adolescents received between 4 and 12 weeks of BST during a baseline period and subsequently received CM targeting weight loss. MAIN OUTCOME MEASURES: Youth weight. STATISTICAL ANALYSIS PERFORMED: Linear mixed effects modeling was used in the analysis. RESULTS: CM did not directly affect adolescent weight loss above that of BST (p=0.053). However, when caregivers were involved in CM session treatment, contingency management had a positive effect on adolescent weight loss. The estimated weight loss due to CM when caregivers also attended was 0.66 kg/week (p<0.001, [95% CI; -1.96, -0.97]) relative to the baseline trajectory. CONCLUSION: This study demonstrates application of a novel experimental approach to intervention development and demonstrated the importance of parent involvement when delivering contingency management for minority youth weight loss. Lessons learned from contingency management program implementation are also discussed in order to inform practice.

Recruitment strategies and the retention of obese urban racial/ethnic minority adolescents in clinical trials: the FIT families project, Michigan, 2010-2014.

INTRODUCTION: The successful recruitment and retention of participants is integral to the translation of research findings. We examined the recruitment and retention rates of racial/ethnic minority adolescents at a center involved in the National Institutes of Health Obesity Research for Behavioral Intervention Trials (ORBIT) initiative by the 3 recruitment strategies used: clinic, informatics, and community. METHODS: During the 9-month study, 186 family dyads, each composed of an obese African American adolescent and a caregiver, enrolled in a 6-month weight-loss intervention, a sequential multiple assignment randomized trial. We compared recruitment and retention rates by recruitment strategy and examined whether recruitment strategy was related to dyad baseline characteristics. RESULTS: Of the 186 enrolled families, 110 (59.1%) were recruited through clinics, 53 (28.5%) through informatics, and 23 (12.4%) through community. Of those recruited through community, 40.4% enrolled in the study, compared with 32.7% through clinics and 8.2% through informatics. Active refusal rate was 3%. Of the 1,036 families identified for the study, 402 passively refused to participate: 290 (45.1%) identified through informatics, 17 (29.8%) through community, and 95 (28.3%) through clinics. Recruitment strategy was not related to the age of the adolescent, adolescent comorbidities, body mass index of the adolescent or caregiver, income or education of the caregiver, or retention rates at 3 months, 7 months, or 9 months. Study retention rate was 87.8%. CONCLUSION: Using multiple recruitment strategies is beneficial when working with racial/ethnic minority adolescents, and each strategy can yield good retention. Research affiliated with health care systems would benefit from the continued specification, refinement, and dissemination of these strategies.