Victoria W. Rogers

Impact of a Primary Care Intervention on Physician Practice and Patient and Family Behavior: Keep ME Healthy—The Maine Youth Overweight Collaborative

OBJECTIVE. To evaluate the effect of a pediatric primary care–based intervention, on improved clinical decision support and family management of risk behaviors for childhood overweight. METHODS. An experimental field trial was conducted with 12 intervention sites in urban and rural areas of Maine and nonrandomized control sites. Change was assessed by using clinical and parent measures from 9 intervention and 10 control sites before and during the Maine Youth Overweight Collaborative intervention. Longitudinal information was collected from chart audits of patients aged 5–18 years (n = 600), systematic samples of parents collected before (n = 346) and during (n = 386) the intervention in 12 sites, and systematic samples of parents in 9 intervention (n = 235) and 10 control (n = 304) sites collected during the intervention. Surveys of health care providers (n = 14 and 17) before and during the intervention were also collected. Teams worked over 18 months to implement improvements in clinical decision support, including tracking BMI percentiles, identification of overweight patients, appropriate laboratory tests, counseling of families and patients use of a behavioral screening tool, and other improvements following the chronic-care model targeting patients aged 5 to 18 and their families. RESULTS. Large changes occurred in clinical practice from before to during the Maine Youth Overweight Collaborative: increases in assessment of BMI (38%–94%), BMI percentile for age and gender (25%–89%), use of the 5-2-1-0 behavioral screening tool (0%–82%), and weight classification (19%–75%). Parent surveys indicated improvements in providers’ behavior and rates of counseling. Intervention providers reported improvements in knowledge, attitudes, self-efficacy, and practice. CONCLUSIONS. The Maine Youth Overweight Collaborative intervention improved clinical decision support and family management of risk behaviors, indicating a promising primary care–based approach to address overweight risk among children and youth.

Impact of Let’s Go! 5-2-1-0: A Community-Based, Multisetting Childhood Obesity Prevention Program

OBJECTIVE Document the impact of Lets Go!, a multisetting community-based childhood obesity prevention program on participants in 12 communities in Maine. METHODS The study used repeated random telephone surveys with 800 parents of children to measure awareness of messages and child behaviors. Surveys were conducted in schools, child care programs, and afterschool programs to track changes in policies and environments. RESULTS Findings show improvements from 2007 to 2011: Children consuming fruits and vegetables increased from 18%, 95% CI [15, 21], to 26% [23, 30] (p < .001); children limiting sugary drinks increased from 63% [59, 67] to 69% [65, 73] (p = .011); and parent awareness of the program grew from 10% [7, 12] to 47% [43, 51] (p < .001). Participating sites implemented widespread changes to promote healthy behaviors. CONCLUSIONS A multisetting, community-based intervention with a consistent message can positively impact behaviors that lead to childhood obesity.

5-2-1-0 Goes to School: A Pilot Project Testing the Feasibility of Schools Adopting and Delivering Healthy Messages During the School Day

OBJECTIVE. Our goal was to determine the feasibility of school staff voluntarily adopting strategies to deliver health-promotion messages to primary and middle school students during the school day. METHODS. During the 2006–2007 school year, we provided a resource kit with strategies for promoting physical activity and healthy eating through use of the 5-2-1-0 message (encouraging ≥5 servings of fruits and vegetables daily, limiting screen time to ≤2 hours per day, promoting ≥1 hour of physical activity daily, and avoiding sugar-sweetened beverages) to 7 primary schools and 2 middle schools in southern Maine. Teachers and administrators voluntarily implemented resource-kit strategies in classrooms and schools. The resource kit included educational handouts that could be sent home to parents. Administrators, teachers, and parents were surveyed at the end of the school year to ascertain their level of awareness of the project, ease of implementation, and perceived usefulness of the resource kit. In small discussion groups with students, we assessed their level of awareness of and attitude toward the 5-2-1-0 message. RESULTS. Most administrators and teachers and half of the parents reported being more aware of the 5-2-1-0 message as a result of the project. Eighty percent of the teachers who reported using the resource kit found it easy or extremely easy to use. Ninety percent of the teachers reported that they would be willing to continue implementing strategies in the future; of those who would not, a lack of time was cited as the reason. All administrators reported that the project had been worthwhile for their district. Parents were less aware of the message than teachers and administrators; 2 in 5 parents reported receiving educational handouts. Most students responded positively to the messages. CONCLUSIONS. It is feasible for primary and middle schools to voluntarily deliver health-promotion messages during the school day through implementing strategies from the 5-2-1-0 resource kit. For school staff to fully implement the strategies, time constraints, both real and perceived, need to be addressed.

The impact of implementing a chronic care residency training initiative on asthma outcomes.

Purpose To examine the impact of a chronic care residency training intervention on continuity clinic patients’ asthma-related emergency department use and primary care residents’ application of key elements of the Chronic Care Model (CCM). Method In 2002 and 2003, the authors conducted a pre- and posttraining survey of 41 intervention residents at Maine Medical Center to assess residents’ implementation of the CCM. The change in implementation for intervention residents was compared with that of 77 primary care residents not receiving CCM training. Asthma-related emergency department (ED) use by 441 patients cared for by intervention residents was compared with that of other asthma patients at Maine Medical Center using hospital billing records. Results At baseline, residents in both groups reported sporadic application of key elements of the CCM. At posttest, Maine Medical Center residents reported significantly greater increases in CCM implementation than the comparison group for 4 out of the 12 items. The greatest increases were in residents’ access to asthma guidelines, the proportion of patients receiving written asthma management plans, and residents’ access to information on community asthma programs. The number of asthma-related ED visits dropped significantly among patients treated by intervention residents (pediatric patients 42%, adults 44%). There was a slight increase in asthma ED use for nonintervention pediatric patients at the hospital (8%) and a very small decrease for adults (3%). Conclusions Chronic care training programs for residents may influence the health outcomes of patients treated in their continuity clinics while simultaneously offering an important educational experience in an underemphasized area of medicine.

Let's Go! School Nutrition Workgroups: Regional Partnerships for Improving School Meals

This report describes a regional approach for improving the nutritional quality of school meals and increasing the selection of healthier foods. Lets Go! is a childhood obesity prevention program that establishes regional workgroups to develop innovative solutions to improve school meal programs. Lets Go! fosters collaborative decision making, specifically addressing the feasibility of proposed strategies, differences in school environments, and level of readiness for change. This approach led to 77 schools achieving the HealthierUS School Challenge and 130 schools implementing Smarter Lunchrooms techniques in school year 2011-2012. Communities nationwide could use a similar approach to improve school meals.

Sustainability of Key Maine Youth Overweight Collaborative Improvements: A Follow-Up Study

BACKGROUND Primary care is an opportune setting to contribute to obesity prevention and treatment. However, there is limited evidence for effective and sustainable interventions in primary care. The Maine Youth Overweight Collaborative (MYOC) successfully affected office systems, provider behavior, and patient experience. The current study evaluates the effect of MYOC on provider knowledge, beliefs, practices, patient experience, and office systems, in 2012, three years postintervention. METHODS A quasi-experimental field trial was used with all seven original MYOC intervention sites that participated in MYOC between 2004 and 2009 and two non-MYOC control sites. Data from immediately post-MYOC in 2009 served as the baseline comparison. Main outcome measures included rates of recording of BMI percentile in chart, weight classification, use of the 5210 behavioral screening tool, parental reports of counseling received on 5210 topics, and clinician reports of changes in knowledge, beliefs, and practices. RESULTS Many key MYOC improvements were sustained or improved 3 years postintervention and demonstrated improvements, as compared to control sites. CONCLUSION In an environment where obesity has become a priority for healthcare providers and systems, we demonstrate sustainable improvements in clinical decision support and family management of risk behaviors within a primary-care-based approach to addressing overweight risk among children and youth. Some declines were observed for more-complex behavioral and system outcomes. Many opportunities for office system and provider improvements remain.

Evaluation of a primary care intervention on body mass index: the Maine Youth Overweight Collaborative.

BACKGROUND We evaluated the impact of a brief primary-care-based intervention, The Maine Youth Overweight Collaborative (MYOC), on BMI (kg/m(2)) z-score change among participants with obesity (BMI ≥95th percentile for age and sex), overweight (BMI ≥85th and <95th percentile), and healthy weight (≥50th and <85th percentile). METHODS A quasi-experimental field trial with nine intervention and nine control sites in urban and rural areas of Maine, MYOC focused on improvements in clinical decision support, charting BMI percentile, identifying patients with obesity, appropriate lab tests, and counseling families/patients. Retrospective longitudinal record reviews assessed BMI z-scores preintervention (from 1999 through October 2004) and one postintervention time point (between December 2006 and March 2008). Participants were youth ages 5-18 having two visits before the intervention with weight percentile greater than or equal to 95% (N=265). Secondary analyses focused on youths who are overweight (N=215) and healthy weight youth (N=506). RESULTS Although the MYOC intervention demonstrated significant provider and office system improvements, we found no significant changes in BMI z-scores in intervention versus control youth pre- to postintervention and significant flattening of upward trends among both intervention and control sites (p<0.001). CONCLUSIONS This brief office-based intervention was associated with no significant improvement in BMI z-scores, compared to control sites. An important avenue for obesity prevention and treatment as part of a multisector approach in communities, this type of primary care intervention alone may be unlikely to impact BMI improvement given the limited dosage-an estimated 4-6 minutes for one patient contact.

Policies and practices of high-performing Let’s Go! schools:

ABSTRACT Background: Let’s Go! is a Maine-based, nationally recognized childhood obesity prevention program. Purpose: The purpose of this study was to identify specific program and school characteristics, policies, and practices associated with schools achieving Let’s Go!’s priority strategies for increasing opportunities for healthy eating/active living in schools and suggest areas for program improvement. Methods: A serial cross-sectional design over 3 years was used to identify characteristics of higher-performing Let’s Go! schools and suggestions for program improvement. Logistic regressions used data from Let’s Go! school surveys and Common Core of Data. Results: Outcome variables were the 5 priority strategies for each year (2013, 2014, and 2015). Strongest predictors were having a Let’s Go! team at the school (P < .01), having enforced district policy on the priority strategy (P < .05), and educating families in adopting a lifestyle supporting healthy eating/active living (P < .01). Discussion: Enforced district wellness policies, school wellness teams, and family involvement are crucial components to the success of Let’s Go!. Translation to Health Education Practice: Child health programs must adjust to the context in which they will be administered and will be more successful when supported by additional efforts including district wellness policies, collaborative wellness teams, and strong communication between parents and teachers. A AJHE Self-Study quiz is online for this article via the SHAPE America Online Institute (SAOI) http://portal.shapeamerica.org/trn-Webinars