A scoping review of the role of policy in mitigating childhood obesity in underserved populations using the RE-AIM framework.

BACKGROUND: Childhood obesity is an escalating crisis in the United States. Health policy may impact this epidemic which disproportionally affects underserved populations. AIM: The aim was to use the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to assess health policy impact on preventing or treating school-aged children (5 > 18 years) with obesity in underserved populations. METHODS: A scoping review of 842 articles was conducted. Twenty-four articles met the inclusion criteria and underwent data extraction. RESULTS: Twelve studies included subgroup analysis, with four suggesting an impact of policy on at-risk groups. None of the 24 studies fully applied the RE-AIM framework. Policies positively impacted childhood obesity in 12 studies across the sample. LINKING EVIDENCE TO ACTION: Our review revealed inconsistent evidence for the effectiveness of policy on childhood obesity, perhaps due to the lack of focus on the social determinants of health. In addition, many studies did not evaluate the outcomes for underserved populations. Therefore, we propose more attention to social determinants in future legislation and evaluation of policy effectiveness on underserved populations. Findings identify an urgent need for the design, implementation, and evaluation of policies specifically directed to address the inequities of racism, social injustices, and social determinants of health that impact childhood obesity in the United States. Future work needs to identify who was reached by the policy, who benefitted from the policy, and how policies were implemented to address obesity-related health disparities. Nurses should advocate for the evaluation of childhood obesity policies, particularly in underserved populations, to determine effectiveness. Nurses, particularly those trained in population and community health and research, should advocate for policy research that considers inequities rather than controls for these variables. Multi-layered interventions can then be tailored to sub-populations and evaluated more effectively.

Facilitating Health Information Exchange to Improve Health Outcomes for School-Aged Children: School Nurse Electronic Health Record Access.

BACKGROUND AND OBJECTIVES: School-aged children with chronic conditions require care coordination for health needs at school. Access to the student's accurate, real-time medical information is essential for school nurses to maximize their care of students. We aim to analyze school nurse access to medical records in a hospital-based electronic health record (EHR) and the effect on patient outcomes. We hypothesized that EHR access would decrease emergency department (ED) visits and inpatient hospitalizations. METHODS: This retrospective secondary data analysis was conducted using EHR data 6 months pre- and post-school nurse access to students' hospital-based EHR. The main outcome measures were the ED visits and inpatient hospitalizations. RESULTS: For the sample of 336 students in the study, there was a 34% decrease in ED visits from 190 visits before access to 126 ED visits after access (p <0.01). Inpatient hospitalizations decreased by 44% from 176 before access to 99 after access (p <0.001). The incident rate of ED visits decreased (IRR: 0.66; 95% CI: 0.53-0.83; p = 0.00035), and hospitalizations decreased (IRR: 0.56; 95% CI: 0.44-0.72; p <0.0001) from pre to post access. These findings suggest school nurse access to medical records is a positive factor in improving school-aged patient outcomes. CONCLUSION: School nurse access to medical records through the hospital-based EHR may be a factor to improve patient outcomes by utilizing health information technology for more efficient and effective communication and care coordination for school-aged children with chronic medical conditions.

Childhood obesity within the lens of racism.

Despite decades of research and a multitude of prevention and treatment efforts, childhood obesity in the United States continues to affect nearly 1 in 5 (19.3%) children, with significantly higher rates among Black, Indigenous, and People of Colour communities. This narrative review presents social foundations of structural racism that exacerbate inequity and disparity in the context of childhood obesity. The National Institute of Minority Health and Health Disparities' Research Framework guides the explication of structurally racist mechanisms that influence health disparities and contribute to childhood obesity: biologic and genetic, health behaviours, chronic toxic stress, the built environment, race and cultural identity, and the health care system. Strategies and interventions to combat structural racism and its effects on children and their families are reviewed along with strategies for research and implications for policy change. From our critical review and reflection, the subtle and overt effects of societal structures sustained from years of racism and the impact on the development and resistant nature of childhood obesity compel concerted action.

Development and Evaluation of the Pediatric Readiness for Discharge (P-REDI) Tool.

PURPOSE: The purpose of this study was to evaluate the P-REDI discharge tool for safe discharge to home following ambulatory surgery. DESIGN: A quasi-experimental, mixed methods with pre/post nurse surveys and retrospective chart review comparing pre-, interim- and post-implementation of P-REDI on unscheduled clinic visits, Emergency Department visits, hospital readmission, and length of stay. METHODS: The P-REDI tool was developed in collaboration with anesthesia and based upon an extensive review of the literature on safe discharge from the Phase II Postanesthesia Care Unit (PACU). Nurse surveys and patient data extracted from the electronic health record through the computer-assisted reporting system were analyzed using descriptive statistics, bivariate statistics, and correlations to assess outcomes and relationships between variables. FINDINGS: Nurses' perceptions of discharge criteria improved after implementation of P-REDI. There were no differences in adverse events before, during, and after the implementation of the P-REDI instrument. There was a significant decrease in Phase II time after implementation of the tool. There were also significant correlations with the P-REDI score and related variables such as length of surgical procedure time and length of stay. CONCLUSIONS: The P-REDI tool was developed to provide nurses a concrete, objective tool to increase their level of comfort with discharging patients from the Phase II PACU. The tool significantly decreased length of stay in Phase II without any change in adverse events. The cost savings to the institution needs to be examined in future studies.

ReImagine: Amulti-Disciplinary Quality Improvement Plan to Work at Top of Scope.

BACKGROUND: There is a growing need for quality, community care models centered on the care of the child with medical complexity. This quality improvement project was conducted in a community-based medical daycare program within a large, metropolitan, pediatric hospital network of care location. A multi-disciplinary team, led by a clinical nurse specialist, occupational therapist, and early childhood special education teacher, addressed staff frustrations and low morale related to barriers to working at top of scope and feelings of a chaotic care and learning environment for children. AIMS: To improve staff satisfaction through a decrease in perceived barriers to practicing at top of scope and to refocus each discipline's role. A secondary aim was to improve child engagement through restructuring the therapeutic and learning environment and reducing distractions to better meet the unique needs of the children the program serves. METHODS: This quality improvement (QI) project used multiple methods, including staff surveys, child observations and timecard review, to measure the project's impact on ability to work at top scope, child engagement and staff satisfaction. RESULTS: The QI project resulted in positively impacting work culture and structure by increased time professional staff practiced at the top of scope, decreased perceived barriers to do so, improved overall job satisfaction and improved child engagement. CONCLUSION: Increased multidisciplinary collaboration and increased structure promoted an enhanced learning environment, healthier staff environment, and a more fiscally responsible program. There is little knowledge about medical daycares and further investigations in this setting is warranted.

Multidisciplinary Teams are Essential for Developing Clinical Decision Support to Improve Pediatric Health Outcomes: An Exemplar.

Clinical decision support with individualized patient education information can facilitate the translation of evidence-based guidelines into practice to improve pediatric patient outcomes. Interdisciplinary teams are required to develop and implement this technology support into practice. Engineering expertise with attention to three components is required: backend (e.g., data science, predictions), front end (e.g., user interface), and integration (e.g., workflow) must be addressed to achieve useful technology that will be adopted. An engineering framework, Technology Acceptance Model, can be used to guide the development of clinical decision support with patient education materials and includes a partnership with end users, both clinicians and patients.

Linking School Nurses With Health Care Systems Using EHRs: An Integrative Review.

School-aged children spend around 1,080 hr at school each year and many of them have chronic diseases; therefore, it is imperative to include school nurses as part of the health care team. Care coordination between health care providers and school nurses is currently hindered by communication that relies on an inadequate system of fax, phone, and traditional mail. Using electronic health records (EHRs) to link school nurses and health care systems is usually limited in scope despite EHRs advancement in these health care systems. No literature is currently available showing the number of hospitals and health care systems that provide EHR access to school nurses. The purpose of this article was to present a literature review on EHR access for school nurses nationally. This review along with the legal and logistical considerations for this type of implementation will be discussed.

Use of theory to guide development and application of sensor technologies in Nursing.

Sensor technologies for health care, research, and consumers have expanded and evolved rapidly. Many technologies developed in commercial or engineering spaces, lack theoretical grounding and scientific evidence to support their need, safety, and efficacy. Theory is a mechanism for synthesizing and guiding knowledge generation for the discipline of nursing, including the design, implementation, and evaluation of sensors and related technologies such as artificial intelligence and machine learning. In this paper, three nurse scientists summarize their presentations at the Council for the Advancement of Nursing Science 2019 Advanced Methods Conference on Expanding Science of Sensor Technology in Research discussing the theoretical underpinnings of sensor technologies development and use in nursing research and practice. Multiple theories with diverse epistemological roots guide decision-making about whether or not to apply sensors to a given use; development of, components of, and mechanisms by which sensor technologies are expected to work; and possible outcomes.

Predictors of Overweight and Obesity in Childhood Cancer Survivors.

Purpose: The purpose of this study was to explore the potential risk factors for overweight/obesity in survivors of childhood cancer. Design: A retrospective chart review of childhood cancer survivors (N = 321) seen in a cancer survivor clinic was conducted to determine the strongest risks of overweight/obesity. Risk factors were as follows: age, race, gender, cancer diagnosis, body mass index at diagnosis, and treatment. Multivariate logistic regression was used to identify risks of overweight/obesity while simultaneously adjusting for other patient factors. Findings: Data suggested that female cancer survivors, Hispanics, those with higher body mass index at diagnosis, and those with longer duration of treatment had greater odds of being overweight/obese. Conclusions: Many of the risk factors for overweight/obesity in childhood cancer survivors are consistent with the general population, and length of cancer treatment is unique to this population. Implications for Nursing: Findings from this study will inform care for childhood cancer survivors to improve long-term cardiovascular health.

Predictors of Physical Activity in a Predominantly Hispanic Sample of Adolescents.

In the United States, the vast majority of Hispanic high school students do not meet physical activity recommendations. This prospective, observational study tested the Theory of Planned Behavior (TPB) to predict physical activity in a convenience sample of 232 high school students from a predominantly Hispanic, rural-fringe, lower-income community in Southwestern United States. Mindfulness was tested as a moderator of the intention-physical activity relationship. Data were collected via self-report questionnaires. Statistical analysis included structural equation modeling (SEM) and moderation analysis. The model explained 60% and 43% of the variance in intention and physical activity, respectively. Attitude (ß = 0.49, p < 0.001) and subjective norm (ß = 0.44, p < 0.001) predicted intention. Intention (ß = 0.58, p < 0.001) and perceived behavioral control (ß = 0.13, p < 0.027) predicted physical activity. Mindfulness did not moderate the intention-physical activity relationship. The results support using the TPB to predict physical activity in this population and may inspire ideas for targeted interventions.

Using the Technology Acceptance Model to Develop StartSmart: mHealth for Screening, Brief Intervention, and Referral for Risk and Protective Factors in Pregnancy.

INTRODUCTION: Technology decision support with tailored patient education has the potential to improve maternal and child health outcomes. The purpose of this study was to develop StartSmart, a mobile health (mHealth) intervention to support evidence-based prenatal screening, brief intervention, and referral to treatment for risk and protective factors in pregnancy. METHODS: StartSmart was developed using Davis' Technology Acceptance Model with end users engaged in the technology development from initial concept to clinical testing. The prototype was developed based upon the current guidelines, focus group findings, and consultation with patient and provider experts. The prototype was then alpha tested by clinicians and patients. Clinicians were asked to give feedback on the screening questions, treatment, brief motivational interviewing, referral algorithms, and the individualized education materials. Clinicians were asked about the feasibility of using the materials to provide brief intervention or referral to treatment. Patients were interviewed using the think aloud technique, a cognitive engineering method used to inform the design of mHealth interventions. Interview questions were guided by the Screening, Brief Intervention, Referral to Treatment theory and attention to usefulness and usability. RESULTS: Expert clinicians provided guidance on the screening instruments, resources, and practice guidelines. Clinicians suggested identifying specific prenatal visits for the screening (first prenatal visit, 28-week visit, and 36-week visit). Patients reported that the tablet-based screening was useful to promote adherence to guidelines and provided suggestions for improvement including more information on the diabetic diet and more resources for diabetes. During alpha testing, participants commented on navigability and usability. Patients reported favorable responses about question wording and ease of use. DISCUSSION: Clinicians reported the use of mHealth to screen and counsel pregnant patients on risk and protective factors facilitated their ability to provide comprehensive care.

Use of the Delphi Technique to Obtain Community Input on Leading Contributors to Early Childhood Obesity in Latino Communities.

INTRODUCTION: In the United States, Latino children are disproportionately affected by childhood obesity and related comorbidities. Stakeholder engagement has the potential to heighten the efficacy of interventions, thereby reducing the disparate prevalence of obesity among Latino children. The objective of this study was to identify stakeholders' opinions on factors influencing early childhood obesity in Latino children aged 0 to 5 years. METHOD: This study used the Delphi technique to gather and prioritize stakeholders' opinions about the factors and barriers considered most influential in early (age 0-5 years) childhood obesity intervention or prevention within the Latino community. Three sequential phases were used. Participants included Latina women as well as staff from community organizations serving Denver metropolitan's Latino population. RESULTS: Study results revealed that stakeholders value the role of the child's primary care provider in the identification of overweight children and desire more educational support to reduce intake of nonnutritious foods. Participants further determined that obesity-related knowledge gaps and affordability of healthy foods and activities were the largest barriers to helping Latino children maintain healthy weights. CONCLUSION: Use of this stakeholder-informed data could assist in the development of future culturally tailored interventions aimed at reducing the rates of early childhood obesity in the Latino population.

Correlates of Physical Activity and Sedentary Behaviors Among Overweight Hispanic School-aged Children.

PURPOSE: The purpose of this study was to explore potential correlates of physical activity and sedentary screen time behaviors among overweight Hispanic school-aged children, ages 7 to 14years. DESIGN AND METHODS: We conducted an exploratory correlation analysis using baseline data of 40 child-parent dyads from the "Mind Exercise Nutrition Do It!" program conducted in the Western United States. RESULTS: Child self-esteem and parental vegetable intake were moderately associated with physical activity, while parental vegetable intake and child fruit intake were strongly associated with physical activity among males. Physical activity was not significantly associated with body mass index percentile, sedentary screen time behaviors, or body esteem. Only decreased body esteem in males was correlated with sedentary screen time behaviors. CONCLUSIONS AND PRACTICE IMPLICATIONS: Understanding the correlates of physical activity and sedentary screen time behaviors in this underrepresented population allows nurses to better understand the connections between physical activity and other aspects of well-being in children. Further investigation is needed to determine how these relationships can be incorporated into physical activity interventions that improve the health of overweight Hispanic school-aged children.

Reliability and Validity of HeartSmartKids: A Survey of Cardiovascular Risk Factors in Children.

INTRODUCTION: Reliable and valid instruments to measure counseling effectiveness related to eating, activity, and inactivity are lacking. HeartSmartKids (HSK; HeartSmartKids, LLC, Boulder, Colorado) is a bilingual decision-support technology that can be used to assess and counsel families on cardiovascular risk factors in children. The purpose of this study was to establish preliminary test-retest reliability and convergent validity of HSK questions relative to a previously validated questionnaire, HABITS. METHOD: Data were collected from children (ages 9-14 years) during an intervention study. A multitrait/multimethod correlation matrix framework was used to examine the test-retest reliability (n = 35) and convergent validity (n = 103) of HSK relative to HABITS. RESULTS: HSK had moderate/strong test-retest reliability and good convergent validity between HSK and HABITS. DISCUSSION: This study provides preliminary test-retest reliability and convergent validity of a useful clinical tool that can be used to quickly assess children's nutrition (e.g., fruit/vegetable consumption, snacks, sugar-sweetened beverages, breakfast) and activity habits to guide behavior change counseling. Additional work should be done validating HSK with objective measures.

Technology to Support Motivational Interviewing.

PURPOSE: This paper reports the findings of motivational interviewing (MI) training with and without technology support on school-based health center (SBHC) providers' satisfaction with MI training, providers' self-report of behavioral counseling related to childhood overweight/obesity, and parents' perception of care after training. DESIGN AND METHODS: The effects of training and technology on MI is part of a larger comparative effectiveness, cluster randomized trial. Twenty-four SBHCs in six states received virtual training on MI. Half the sites received HeartSmartKids™, a bilingual (English/Spanish), decision-support technology. The technology generated tailored patient education materials. Standard growth charts were plotted and health risks were highlighted to support MI counseling. The results of the MI training included provider satisfaction with MI training and parent assessment of the components of MI in their child's care. Providers and parents were surveyed at baseline, after training, and six months after training. RESULTS: Providers were satisfied with training and reported improvements in counseling proficiency (p<0.0007) and psychological/emotional assessment (p=0.0004) after training. Parents in the technology group reported significant improvement in provider support for healthy eating (p=0.04). CONCLUSION: Virtual training has the potential of preparing providers to use MI to address childhood obesity. Technology improved parent support for healthy eating. Future research should evaluate the impact of technology to support MI on patient outcomes. PRACTICE IMPLICATIONS: Childhood obesity guidelines emphasize that MI should be used to promote healthy weight in children. Training providers on MI may help more providers incorporate obesity guidelines in their practice.

Results From 10 Years of Interprofessional Training on Motivational Interviewing.

Motivational interviewing (MI) is a popular evidence-based method to support health behavior change. We examined evaluations from 10 years of interprofessional workshops on MI to identify trends in trainees' MI-related knowledge, attitude, and behavior. From 2006 to 2015, 394 trainees participated in continuing education MI workshops with our team and completed a validated posttraining questionnaire. Participants were 90% female and 66% White, with M = 12 years in practice. They worked in pediatric and adult care; urban and rural locations; and inpatient, outpatient, and nonhealth settings. The largest groups were nurses (20%), allied health professionals (20%), and health educators or case managers (15%). Trainees' professional diversity increased over time, their average age and years in practice decreased, and the percentage with prior MI training increased. Practitioners in telehealth and nonhealth settings had lower scores overall. Outcomes varied significantly by professional discipline: Mental health professionals, case managers, health educators, and nurses had higher scores on some outcome variables than nonhealth professionals. Years of clinical experience predicted MI-consistent attitude, but prior training, other demographic variables, and training process variations had no consistent effects. Although many trainees had already received MI training, outcome measures showed room for improvement. MI presents continued opportunities for interprofessional education.

Early Initiation of Newborn Individualized Developmental Care and Assessment Program (NIDCAP) Reduces Length of Stay: A Quality Improvement Project.

Infants born at ≤32weeks gestation are at risk of developmental delays. Review of the literature indicates NIDCAP improves parental satisfaction, minimizes developmental delays, and decreases length of stay, thus reducing cost of hospitalization. Half (50.6%) of the infants admitted to this 84-bed Level IV Neonatal Intensive Care Unit (NICU) with a gestational age of ≤32weeks were referred for NIDCAP. The specific aims of this quality improvement project were to 1) compare the age at discharge for infants meeting inclusion criteria enrolled in NIDCAP with the age at discharge for those eligible infants not enrolled in NIDCAP; and 2) investigate the timing of initiation of NIDCAP (e.g., within six days of admission) on age at discharge. During the 12month period of data collection, infants enrolled in NIDCAP (M=27.85weeks, SD=1.86) were 2.02weeks younger than those not enrolled in NIDCAP (M=29.87weeks, SD=2.49), and were 2.32weeks older at discharge (M=38.28weeks, SD=5.10) than those not enrolled in NIDCAP (M=35.96weeks, SD=5.60). Infants who enrolled within 6days of admission were discharged an average of 25days sooner (p=0.055), and at a younger post-menstrual age (by 3.33weeks on average), than those enrolled later (p=0.027).

Comparing Weight-for-Length Status of Young Children in Two Infant Feeding Programs.

Objectives A cross-sectional study comparing weight-for-length status of children 6-24 months old who participated in Nurse-Family Partnership (NFP) or Special Supplemental Program for Women, Infants, and Children (WIC). Methods Secondary analysis of NFP (n = 44,980) and WIC (n = 31,294) national datasets was conducted to evaluate infant and toddler growth trajectories. Weight-for-length status was calculated at 6, 12, 18, and 24 months based on World Health Organization criteria. Demographics and breastfeeding rates were also evaluated. Binary logistic regression was used to calculate odds ratios for high weight-for-length (≥97.7 percentile) at each time point. Results At 6 months, approximately 10 % of WIC and NFP children were classified as high weight-for-length. High weight-for-length rates increased for both groups similarly until 24 months. At 24 months, NFP children had significantly lower rates of excess weight (P = 0.03) than WIC children, 15.5 and 17.5 % respectively. At all time points, non-Hispanic white children had lower rates of high-weight for length than Hispanic and non-Hispanic black children. NFP infants were also found to have higher rates of ever being breastfed than WIC infants (P < 0.0001). Conclusions for Practice Infant and toddler populations served by NFP or WIC were found to be at increased risk for high weight-for-length. This study found NFP participation was associated with a small, but significant, protective impact on weight-for-length status at 24 months. Continued efforts need to be made in addressing weight-related racial/ethnic and socioeconomic disparities during early childhood.