Margaret B. Hargreaves

Expanding the Role of Primary Care in the Prevention and Treatment of Childhood Obesity: A Review of Clinic- and Community-Based Recommendations and Interventions

Although pediatric providers have traditionally assessed and treated childhood obesity and associated health-related conditions in the clinic setting, there is a recognized need to expand the provider role. We reviewed the literature published from 2005 to 2012 to (1) provide examples of the spectrum of roles that primary care providers can play in the successful treatment and prevention of childhood obesity in both clinic and community settings and (2) synthesize the evidence of important characteristics, factors, or strategies in successful community-based models. The review identified 96 articles that provide evidence of how primary care providers can successfully prevent and treat childhood obesity by coordinating efforts within the primary care setting and through linkages to obesity prevention and treatment resources within the community. By aligning the most promising interventions with recommendations published over the past decade by the Institute of Medicine, the American Academy of Pediatrics, and other health organizations, we present nine areas in which providers can promote the prevention and treatment of childhood obesity through efforts in clinical and community settings: weight status assessment and monitoring, healthy lifestyle promotion, treatment, clinician skill development, clinic infrastructure development, community program referrals, community health education, multisector community initiatives, and policy advocacy.

Intermediate Outcomes, Strategies, and Challenges of Eight Healthy Start Projects

Site visits were conducted for the evaluation of the national Healthy Start program to gain an understanding of how projects design and implement five service components (outreach, case management, health education, depression screening and interconceptional care) and four system components (consortium, coordination/collaboration, local health system action plan and sustainability) as well as program staff’s perceptions of these components’ influence on intermediate outcomes. Interviews with project directors, case managers, local evaluators, clinicians, consortium members, outreach/lay workers and other stakeholders were conducted during 3-day in-depth site visits with eight Healthy Start grantees. Grantees reported that both services and systems components were related to self-reported service achievements (e.g. earlier entry into prenatal care) and systems achievements (e.g. consumer involvement). Outreach, case management, and health education were perceived as the service components that contributed most to their achievements while consortia was perceived as the most influential systems component in reaching their goals. Furthermore, cultural competence and community voice were overarching project components that addressed racial/ethnic disparities. Finally, there was great variability across sites regarding the challenges they faced, with poor service availability and limited funding the two most frequently reported. Service provision and systems development are both critical for successful Healthy Start projects to achieve intermediate program outcomes. Unique contextual and community issues influence Healthy Start project design, implementation and reported accomplishments. All eight projects implement the required program components yet outreach, case management, and health education are cited most frequently for contributing to their perceived achievements.

Advancing Systems Thinking in Evaluation: A Review of Four Publications

This article reviews four books published in 2010 and 2011 on the topic of systems thinking in evaluation: Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use by Michael Q. Patton; Purposeful Program Theory: Effective Use of Theories of Change and Logic Models by Sue Funnell and Patricia Rogers; Systems Concepts in Action: A Practitioners Toolkit by Bob Williams and Richard Hummelbrunner, and Evaluation in the Face of Uncertainty: Anticipating Surprise and Responding to the Inevitable by Jonathan Morell. These books describe the interdisciplinary landscape of systems theories, encompassing general systems theory, systems dynamics, complexity theory, network theory, and learning systems, and how they can be used to improve evaluation practice. The books appeal to many different and sometimes overlapping audiences. Separately, they address specific information needs about how to incorporate systems concepts into different aspects of evaluation design, data collection, analysis, and reporting. Together, the books complement and reinforce each other, creating a cohesive picture of the state of the art of systems thinking by encouraging thinking about situational dynamics in an often complicated and complex world. The books’ authors also advance systems thinking in evaluation by inviting their readers to test out the books’ ideas and methods in their own evaluation work.

Linkages to Care for Newly Diagnosed Individuals Who Test HIV Positive in Nonprimary Care Settings

Linkage services are an increasingly important component of the continuum of care for people living with HIV, particularly for individuals diagnosed in nonprimary care settings who are less likely than those identified in primary care settings to have a usual source of care. This study examines successful models used by hospital emergency departments, health department outpatient clinics, and other nonprimary care providers for testing, linking, and engaging newly diagnosed HIV-positive racial and ethnic minorities into medical care. Based on studies of five mature linkage-to-care (LTC) programs implemented in geographically and institutionally diverse settings, we identify five key characteristics that make them viable. Effective linkage programs are low cost, intensive, time limited, unique, and flexible. We also identify four core components of successful LTC protocols: directly employed linkage workers, active referral to medical care, person-centered linkage case management, and cultural and linguistic concordance. Finally, we develop a set of operational strategies to help providers address barriers at all levels of the health care system to help promote the effective linkage of newly diagnosed patients to care. We organize the strategies around four key areas: adherence to LTC protocols, selection of linkage workers, execution of linkage programs, and sustainability of linkage programs. The findings presented in this study provide a practical and operational guide for developing and implementing policies and procedures for linking newly diagnosed individuals who test HIV positive in nonprimary care settings into ongoing care for HIV infection.

The Healthy Weight Collaborative: Using Learning Collaboratives to Enhance Community-based Prevention Initiatives Addressing Childhood Obesity

This report from the field describes the design, implementation, and early evaluation results of the Healthy Weight Collaborative, a federally-supported learning collaborative to develop, test, and disseminate an integrated change package of six promising, evidence-based clinical and community-based strategies to prevent and treat obesity for children and families.

Aligning Community Capacity, Networks, and Solutions to Address Adverse Childhood Experiences and Increase Resilience

From Community Science, Gaithersburg, Md (Dr Hargreaves); Research Services, Casey Family Programs, Seattle, Wash (Dr Pecora); School of Social Work, University of Washington, Seattle, Wash (Dr Pecora); and Partnerships and Collaboration, Washington State Department of Early Learning, Olympia, Wash (Mr Williamson) The authors have no conflicts of interest to disclose. Address correspondence to Margaret B. Hargreaves, PhD, MPP, Principal Associate, Community Science, 438 N Frederick Ave, Suite 315, Gaithersburg, MD 20877 (e-mail: mhargreaves@communityscience.com).

Addressing Childhood Obesity Through Multisector Collaborations: Evaluation of a National Quality Improvement Effort

The Healthy Weight Collaborative (HWC) represents a national quality improvement effort to increase uptake of evidence-based community-based interventions to address obesity among children. Implemented from 2011 to 2013, the HWC built the capacity of 49 community-based multisector teams (10 teams in the Phase 1 pilot, 39 teams in Phase 2), delivered services to support health behavior changes in children and families, and implemented sustainable social and environmental policy change at the organizational and community levels. Phase 2 teams participated in three virtual collaborative learning sessions interspersed with three “action periods” during which teams implemented the HWC “change package” while receiving tailored coaching and peer-support. All of the teams participating in Phase 2 adopted a healthy weight message, 59% implemented community-wide healthy weight assessments and healthy weight plans, and 31% made progress toward developing and implementing policies to promote healthy weight. By the end of the project, one-third of teams had developed sustainability plans to continue working with this approach. The HWC offers a collaborative team model with the potential to effectively address other public health challenges.