Using a customer discovery process to enhance the potential dissemination and scalability of a family healthy weight program for rural communities and small towns.

AIM: Customer discovery, an entrepreneurial and iterative process to understand the context and needs of potential adoption agencies, may be an innovative strategy to improve broader dissemination of evidence-based interventions. This paper describes the customer discovery process for the Building Healthy Families (BHF) Online Training Resources and Program Package (BHF Resource Package) to support rural community adoption of an evidence-based, family healthy weight program. METHODS: The customer discovery process was completed as part of a SPeeding Research-tested INTerventions (SPRINT) training supported by the U.S. Centers for Disease Control and Prevention. Customer discovery interviews (n=47) were conducted with people that could be potential resource users, economic buyers, and BHF adoption influencers to capture multiple contextual and needs-based factors related to adopting new evidence-based interventions. Qualitative analyses were completed in an iterative fashion as each interview was completed. RESULTS: The BHF Resource Package was designed to be accessible to a variety of implementation organizations. However, due to different resources being available in different rural communities, customer discovery interviews suggested that focusing on rural health departments may be a consistent setting for intervention adoption. We found that local health departments prioritize childhood obesity but lacked the training and resources necessary to implement effective programming. Several intervention funding approaches were also identified including (1) program grants from local and national foundations, (2) healthcare community benefit initiatives, and (3) regional employer groups. Payment plans recommended in the customer discovery interviews included a mix of licensing and technical support fees for BHF delivery organizations, potential insurance reimbursement, and family fees based on ability to pay. Marketing a range of BHF non-weight related outcomes was also recommended during the customer discovery process to increase the likelihood of BHF scale-up and sustainability. CONCLUSIONS: Engaging in customer discovery provided practical directions for the potential adoption, implementation, and sustainability of the BHF Resource Package. However, the inconsistent finding that health departments are both the ideal implementation organization, but also see childhood obesity treatment as a clinical service, is concerning.

Building Healthy Families: Outcomes of an Adapted Family Healthy Weight Program Among Children in a Rural Mid-Western Community.

Background: This study aimed to evaluate the effectiveness of implementing an adapted, evidence-based 12-week Family Healthy Weight Program (FHWP), Building Healthy Families, on reducing BMI metrics and clinical health indicators in a real-world community setting. Methods: Ninety child participants with a BMI percentile greater or equal to the 95th percentile for gender and age and their parents/guardians (n = 137) enrolled in the program. Families attended 12 weekly group-based sessions of nutrition education, family lifestyle physical activity, and behavior modification. A pre-post study design with a 6-month follow-up was used. Results: Nine cohorts of families between 2009 and 2016 completed the program with 82.1% retention at 12 weeks and 53.6% at 6 months. Participants had statistically significant improvements at 12 weeks in BMI z-score, %BMIp95, body mass, body fat, fat mass, fat-free mass, and systolic blood pressure with greater improvement at 6 months in body mass, BMI metrics, body fat, fat mass, fat-free mass, and systolic blood pressure. Parents/guardians of the participants had similar statistically significant body composition and blood pressure improvements (p < 0.05). In addition, children had significant improvements in high-density lipoprotein (HDL) cholesterol and aspartate aminotransferase (AST) liver enzymes at 6 months. Conclusions: Overall, this study demonstrated that an evidence-based FHWP can result in statistically meaningful declines in BMI z-score and accompanied clinically meaningful changes in health risk. Participants lost ∼4% of their body mass in 12 weeks, while their parents/guardians lost closer to 7% of their body mass, which supports previous literature suggesting body mass changes influence health.

Qualitative Comparative Analysis of Program and Participant Factors That Explain Success in a Micropolitan Pediatric Weight Management Intervention.

Background: Building Healthy Families (BHF) was developed through a community-academic partnership to provide a 12-week family-based obesity treatment program. Nine cohorts of BHF have been delivered in multiple micropolitan settings between 2009 and 2016, but participant outcomes have varied. This study sought to explore the variation in BHF outcomes to identify the necessary and sufficient conditions that are associated with larger 12-week reductions in BMI z-scores. Methods: A qualitative comparative analysis was used to determine potential causal conditions or combination of conditions associated with larger reductions in BMI z-score. Seventy-five participants with 12-week outcome data were rank ordered as the 10 most successful participants (largest reductions in BMI z-score; m ± std = -0.64 ± 0.18) and the 10 least successful participants (smallest reductions or an increase in BMI z-score; m ± std = 0.02 ± 0.04). The conditions selected for analysis were identified based on theory and the delivery team's experience with implementing BHF. Results: Necessary conditions (i.e., present in all highly successful participants, but also some less successful participants) included children with high attendance and self-regulation, at least one adult with high attendance and self-regulation, a mother who lost weight during the program and achieved clinically meaningful weight loss. Sufficient conditions (i.e., present in only the highly successful participants) included mothers with self-regulation scores >45% (range 46.7%-98.2%), and children with a combination of high attendance (72%-100%) and self-regulation scores ≥45% (45%-92.7%). Conclusion: Program implementers should continue to focus on encouraging high attendance and emphasize the necessity of enacting self-regulation strategies at both the child and parent level.

A Dissemination Strategy to Identify Communities Ready to Implement a Pediatric Weight Management Intervention in Medically Underserved Areas.

PURPOSE AND OBJECTIVES: We developed a competitive application process to test the feasibility of a fund and contract dissemination strategy to identify and engage communities that demonstrated the necessary resources and motivation to adopt, implement, and sustain a pediatric weight management intervention, Building Healthy Families, in rural and micropolitan (<50,000 residents) communities in Nebraska. INTERVENTION APPROACH: From April through December 2019, a community advisory board with representation from rural and micropolitan clinical, public health, education, and recreational organizations collaboratively developed a request for applications, as a fund and contract dissemination strategy, to encourage community adoption of Building Healthy Families. EVALUATION METHODS: Quantitative assessments included determining the distribution of requests for applications, evaluating organizational readiness to change assessment (ORCA) ratings (on a scale of 1 to 5, from strongly disagree to strongly agree that the organization is ready to change), and reviewing community advisory board member ratings of applications. We gathered qualitative data from community narratives provided in response to the request for applications and community advisory board reviews of the applications. RESULTS: The request for applications was distributed to all 93 counties in Nebraska. Of the 8 communities that submitted a letter of intent, 7 submitted a community narrative. Across the 8 communities, 31 ORCAs were completed by the organizational decision makers (n = 15) and staff members (n = 16) who would be responsible for screening, recruiting, or implementing the intervention. Overall mean ORCA scores varied by ratings of evidence (4.1-4.6), context (4.2-4.9), and facilitation (4.3-4.8), indicating a high degree of readiness. Community advisory board ratings of applications ranged from 2.3 to 3.4 of 4 points. Qualitative data indicated that lower community narrative scores were primarily caused by weak implementation and sustainability plans. IMPLICATIONS FOR PUBLIC HEALTH: Findings provide guidance for translating pediatric weight management programs in medically underserved geographic areas by maximizing the probability of successful adoption and implementation through a fund and contract dissemination strategy.

Calibration of context-specific survey items to assess youth physical activity behaviour.

This study tests calibration models to re-scale context-specific physical activity (PA) items to accelerometer-derived PA. A total of 195 4th-12th grades children wore an Actigraph monitor and completed the Physical Activity Questionnaire (PAQ) one week later. The relative time spent in moderate-to-vigorous PA (MVPA%) obtained from the Actigraph at recess, PE, lunch, after-school, evening and weekend was matched with a respective item score obtained from the PAQ's. Item scores from 145 participants were calibrated against objective MVPA% using multiple linear regression with age, and sex as additional predictors. Predicted minutes of MVPA for school, out-of-school and total week were tested in the remaining sample (n = 50) using equivalence testing. The results showed that PAQ ß-weights ranged from 0.06 (lunch) to 4.94 (PE) MVPA% (P < 0.05) and models root mean square error ranged from 4.2% (evening) to 20.2% (recess). When applied to an independent sample, differences between PAQ and accelerometer MVPA at school and out-of-school ranged from -15.6 to +3.8 min and the PAQ was within 10-15% of accelerometer measured activity. This study demonstrated that context-specific items can be calibrated to predict minutes of MVPA in groups of youth during in- and out-of-school periods.

Healthier School Environment Leads to Decreases in Childhood Obesity: The Kearney Nebraska Story.

BACKGROUND: Schools play a role in addressing childhood obesity by implementing healthy eating and physical activity strategies. The primary aim of this case study was to describe prevalence of overweight and obesity among elementary school students in a rural Mid-western community between 2006 and 2012. The secondary aim was to use a novel approach called "population dose" to retrospectively evaluate the impact dose of each strategy implemented and its estimated potential population level impact on changes in overweight and obesity. METHODS: Weight and height were directly measured annually beginning in January 2006 to assess weight status, using BMI (kg/m(2)), for all kindergarten to fifth-grade students (N ≈ 2400 per year). Multiple evidence-based strategies were implemented in nine schools to increase physical activity and healthy eating behaviors. BMI reporting and revised school meal programs were implemented districtwide. Comprehensive school physical activity programs, school food environment, and supportive/promotional strategies were implemented at individual schools. RESULTS: The absolute change in prevalence of obesity (BMI ≥95th percentile) decreased from 16.4% to 13.9%, indicating a 15.2% relative change in prevalence of obesity in 6 years. There was an inverse relationship between the number of strategies implemented and prevalence of overweight and obesity over time. CONCLUSIONS: District and school-level approaches have the potential to impact childhood obesity. Schools can successfully implement strategies to address overweight and obesity, but the extent of implementation between schools may vary. Population dose analysis can be used to estimate impact of clusters of strategies to address overweight/obesity.

Eight-month follow-up of physical activity and central adiposity: results from an Internet-delivered randomized control trial intervention.

BACKGROUND: Less than half of U.S. adults engage in the recommended amount of physical activity (PA). Internet-delivered PA programs increase short-term PA but long-term adherence is largely equivocal. PURPOSE: To determine whether increased PA following the 16-week Internet-delivered Active Living Every Day (ALED-I) program is maintained 8 months later in sedentary and overweight rural adults. METHODS: In our previous randomized controlled trial (N = 32; 18 intent-to-treat controls, 14 ALED-I interventions), the ALED-I group increased PA (+1384 steps/day; E.S. = 0.95) and reduced central adiposity. Nine original intervention participants and ten delayed intent-to-treat control participants completed ALED-I and an 8-month followup. Pedometer-measured PA, anthropometric variables, and cardiometabolic disease risk factors were assessed at baseline, postintervention, and at 8 months. RESULTS: Control crossover participants increased PA (+1337 steps/ day; P = .04). Eight months following completion of ALED-I (N = 19), PA levels relapsed (-1340 steps/day) and were similar to levels before the intervention (6850 +/- 471 steps/day vs. 6755 +/- 543 steps/day; P = .89). Total cholesterol and triglycerides improved, -9.9% and -18.2%, respectively, and reductions in central adiposity were maintained (97.1 +/- 2.2 cm vs. 97.2 +/- 2.2 cm; P = .66). CONCLUSIONS: The ALED-I intervention was efficacious in the short-term but did not produce longer-term adherence to PA. Future theory-based internet-delivered interventions that produce habituation of increased PA are warranted.

Prevalence of overweight and influence of out-of-school seasonal periods on body mass index among American Indian schoolchildren.

INTRODUCTION: The prevalence of overweight and obesity among American Indian youth may be 2 to 3 times higher than the national average. Whether weight gain during discrete out-of-school periods is occurring and contributing to the prevalence of overweight and obesity in this population is unknown. METHODS: We obtained repeated cross-sectional body mass index (BMI) samples from third-, fourth-, fifth-, seventh-, and eighth-grade boys and girls who reside on the Wind River Indian Reservation in central Wyoming. We collected measures at the beginning of 2 school years (N = 251), during 2 holiday breaks (N = 226), and during 1 summer recess (N = 141). We determined prevalence of normal weight and overweight among participants by grade level, and we calculated paired comparisons of BMI, BMI z score, and weight status during the holiday breaks and summer recess. RESULTS: Combined prevalence of at risk for overweight and overweight was 62.0% for boys and 56.6% for girls. For fifth-grade girls, significant increases in BMI (P = .01) and z score (P < .001) occurred over the holiday break. BMI increased significantly over the summer among third- and fifth-grade girls and among fourth-grade boys, but changes in z scores were nonsignificant. We observed an increase in weight status by out-of-school time in BMI (P < .001) for schoolchildren at or above the 85th BMI percentile over the summer recess, but corresponding z scores did not change. CONCLUSION: Prevalence of overweight among American Indian schoolchildren was higher than national estimates and higher than the prevalence in other similarly aged American Indian youth. Increases in BMI during out-of-school periods are likely due to normal growth, except among fifth-grade girls.

Body mass index in rural first grade schoolchildren: progressive increase in boys.

CONTEXT: Childhood overweight is a global health problem. Monitoring of childhood body mass index (BMI) may help identify critical time periods during which excess body weight is accumulated. PURPOSE: To examine changes in mean BMI and the prevalence of at-risk-for overweight in repeated cross-sectional samples of rural first grade schoolchildren between 1999 and 2004. METHODS: BMI was determined in 479 first graders from a rural Wyoming school district. BMI and gender-specific BMI-for-age percentiles were determined and evaluated over the 6 years. Children were also classified as normal or at-risk-for overweight according to CDC classification procedures. FINDINGS: From 1999 to 2004, there was a significant increase in the average BMI of first graders, 15.8+/-2.2 kg/m2 versus 16.8+/-2.2 kg/m2, respectively (P<.05). First grade boys had a progressive increase in BMI from 1999 to 2004 (15.6+/-2.2 kg/m2 compared to 17.3+/-2.2 kg/m2, respectively), but no change was evident for first grade girls. There was an approximate 4-fold increase in the percentage of rural first grade boys classified as at-risk-for overweight between 1999 and 2004. CONCLUSIONS: A progressive increase in the BMI and the significant increase in prevalence of at-risk-for overweight in rural first grade boys highlight the need for future gender and age group-specific investigations. Focus should be given to primary prevention programs targeting potentially vulnerable time periods when excess weight gain may be occurring.

Internet-delivered behavior change program increases physical activity and improves cardiometabolic disease risk factors in sedentary adults: results of a randomized controlled trial.

OBJECTIVES: To determine whether the Active Living Every Day (ALED-I) internet-delivered theory-based physical activity (PA) behavior change program increases PA and improves cardiometabolic disease risk factors (CDRF) in sedentary overweight adults. METHODS: The study was a randomized control trial that took place in southern Wyoming and northern Colorado from 2005-2007. Thirty-two men and women (21-65 years) were randomized to a 16-week ALED-I intervention (n=14; age=41.4+/-3.7 years; BMI=32.3+/-1.3 kg/m(2)) or a delayed intent-to-treat control condition (n=18; age=49.4+/-1.7 years; BMI=30.6+/-0.8 kg/m(2)). At baseline and post-intervention, PA by pedometer and CDRFs were measured. RESULTS: Both groups had similar baseline PA levels. ALED-I increased PA by an average of 1384 steps/day (p=0.03) compared to 816 steps/day (p=0.14) for the control group. Waist circumference (100.6+/-2.4 vs. 96.6+/-2.7 cm) and Coronary Risk Ratio (5.1+/-0.3 vs. 4.7+/-0.3) decreased in the ALED-I group and did not change in the control group (99.2+/-2.2 vs.99.8+/-2.1 cm) and (3.7+/-0.1 vs. 3.7+/-0.1), respectively. CONCLUSIONS: The internet-delivered ALED program increased PA and improved some CDRFs in sedentary overweight/obese adults. To our knowledge, this is the first efficacy trial of the internet-delivered ALED program. Further studies are warranted due to the reach and cost-effectiveness of internet-delivered PA programs.

Existence of the school health coordinator in a frontier state.

The purpose of this study was to determine whether school districts in a rural western state employed school health coordinators or at least employed individuals who possessed the skills suggested for school health coordinators. Baseline data were collected soliciting the involvement of all 48 state school districts and the state girl's school (N = 49). Thirty-seven districts responded (75.5%). Identified school health coordinators were predominantly health and physical education teachers. Most coordinators spent minimal time (less than 10% of time) each week on school health coordination activities; nearly one half identified little or no coordination of school health efforts in their school districts; few identified personal involvement in budgetary matters concerning school health; and most identified their primary teaching responsibilities as the areas where the majority of their time was spent. Data collected help create a profile of the "typical" district level-school health coordinator in this frontier state and can assist in the development of future efforts aimed at school health coordination through the work of district-level school health coordinators.

Does a family history of coronary heart disease modify the relationship between physical activity and blood pressure in young adults?

BACKGROUND: The purpose of this study was to examine the relationships between physical activity, a family history (FH) of coronary heart disease (CHD), and blood pressure (BP) in young adults. We were specifically interested in determining whether the relationship between moderate-to-vigorous physical activity and BP was modified by a FH of CHD. METHODS: Subjects were 230 (103 males, 127 females) university students. Family history was self-reported and habitual physical activity was assessed with a 3-day activity diary. Indicators of habitual physical activity included estimated daily energy expenditure (EE) and EE in moderate-to-vigorous physical activity (MVPA) [median metabolic equivalent (MET) > or =4.8] and inactivity (IA) (MET<2.8). Blood pressure was measured by an automated device according to standard procedures. RESULTS: A large proportion of the sample (63% of males and 68% of females) reported a FH of CHD. In general, correlations between physical activity and BP were low (r<0.30), but in the expected direction (i.e., positive for IA and negative for MVPA and EE). In males IA was significantly related to BP (r =0.25-0.29), but MVPA was not significantly related to BP (r= -0.01 to -0.16). In females diastolic BP was significantly related to IA (r= -0.21) and total EE (r= -0.18). Total EE was significantly correlated to DBP (r= -0.22) in males and to mean arterial pressure (r= -0.18) in females. No significant differences in BP were found between subjects with or without a FH of CHD. Slightly stronger correlations emerged between MVPA and BP for subjects with a negative FH of CHD compared to those with a positive FH of CHD. CONCLUSION: These data show a significant association between sedentary behavior and blood pressure in young adults. It is suggestive that the magnitude of the relationship between MVPA and BP may be modified by a FH of CHD. Thus, individuals with a FH of CHD may not be as responsive to increased levels of MVPA compared to those without a FH of CHD.

Assessing competencies of the public health workforce in a frontier state.

The purpose of this study was to determine the level of perceived proficiency of a public health workforce based on the Public Health Practice Core Competencies. The Public Health Profile and Training Needs Assessment questionnaire was mailed out to public health employees representing mostly public health nursing, environmental health, mental health, and public health management/administration (n = 696). Nearly three-quarters (74%) of participants were female and 96% reported being white. Eighty one percent of participants were currently employed full-time. The majority of participants were trained at the bachelors level (54%). The response rate was 63.9%. Findings from this study show that all disciplines reported higher perceived proficiency in the Communication skills domain compared to the other seven skills domains. Perceived low skills domains included "financial planning and management skills" and "policy development/program planning skills" among public health nurses, mental health professionals, and environmental health specialists. Management/administration level staff reported their lowest perceived proficiency in Basic Public Health Science skills. Each group had different strengths and weaknesses and the necessary level of skill needed differs among discipline groups, thus future trainings on the Public Health Core Competencies should be discipline specific.

Self-reported alcohol use and sexual behaviors of adolescents.

Research has demonstrated a relation between alcohol use and engaging in high-risk sexual behaviors. Alcohol use, especially binge drinking, has been linked to a host of problems including high-risk sexual behavior, date rape, and academic problems. As such, the purpose of this study was to provide a descriptive profile of alcohol consumption among adolescents and to examine the relations of alcohol use (lifetime, current, binge) with sexual activity variables (sexual initiation, multiple sex partners, condom use, and pregnancy) among adolescents completing the 1993-1999 Youth Risk Behavior Survey. Analysis showed alcohol use was associated with high-risk sexual activity. Binge drinking had stronger relations with sexual activity variables than lifetime use and current use of alcohol. This result is of particular concern, in that binge drinking has been implicated in many problem behaviors. As such, it is of great importance to intervene in the high-risk practices of adolescents before problems occur.

Physical activity, TV viewing, and weight in U.S. youth: 1999 Youth Risk Behavior Survey.

OBJECTIVE: To examine the relationship between physical activity, TV watching, and weight in U.S. youth ages 14 to 18 years. RESEARCH METHODS AND PROCEDURES: Data from a nationally representative sample of 15,143 U.S. high-school students participating in the 1999 Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Survey were examined. Prevalence rates of participation in moderate physical activity (MPA), vigorous physical activity (VPA), and television watching (TV) were determined. The association between MPA, VPA, TV and the body mass index (BMI) and overweight status (BMI > or =85th percentile of age- and sex-specific CDC/National Center for Health Statistics reference values) were examined by analysis of covariance and logistic regression. RESULTS: Overall, 45% reported participating in MPA > or =3 d/wk, 65% reported participating in VPA > or =3 d/wk, and 25% reported watching TV > or =4 h/school day. Boys reporting six to seven bouts of MPA had a significantly lower BMI compared with boys reporting three to five or less than two. The mean BMI differed significantly between the lowest and highest levels of MPA groups in girls. The mean BMI was significantly lower in the highest VPA group compared with the other two groups in both sexes. There was a significant graded response for BMI across all levels of TV. Decreased levels of MPA and 3 to 4 days of VPA were significantly associated with an increased risk of overweight in boys when compared with those engaging in 6 to 7 d/wk (odds ratio = 1.26 to 1.37). A graded response existed between TV and overweight in both sexes. Boys and girls were approximately 20% to 25% less likely to be classified as overweight if they reported 2 to 3 hours of TV per day and approximately 40% less likely to be classified as overweight if they reported < or =1 hour of TV per day compared with those who watched > or =4 hours of TV. In general, youth who engaged in less physical activity watched more TV per week. DISCUSSION: Increased levels of physical activity are associated with a lower BMI and less TV watching. However, the relationship between TV watching and weight status is more pronounced.

How can primary concerns of school district superintendents guide school health efforts?

School-based research and health promotion interventions typically require upper administration support and acceptance to succeed. This paper focuses on a recently completed Delphi survey of the majority of school district superintendents in a frontier state. The survey examined superintendent district-level concerns at the elementary, middle/junior high, and high school levels. Primary concerns revolved around school funding, classroom education and student achievement, and teacher-centered issues. Implications for this research are discussed as are the importance of these data to those interested in working with schools to improve student health. The importance of this information for implementation of coordinated school health programs also is discussed.