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Using Evidence to Inform
Efforts to Confront Childhood Obesity
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Brief Notes about Technology
A u d i o
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2
Technology Notes Cont.
Re c o rd i n g
• Today’s webinar will be recorded
• The recording will be available on the AMCHP website at
www.amchp.org
3
Objectives
• Highlight state examples using ‘evidence based practice’ and ‘data to action’ techniques for childhood obesity prevention initiatives.
• Provide information resources and references to promote evidence based practice in public health.
• Provide an overview of the Community Guide and describe its intended use and relevance for state Title V programs.
• Provide resources to participants that describe the optimal use of the Community Guide findings in the area of childhood obesity prevention.
Featuring:
• Robin Stanton, MA, RD, LD
Nutrition Consultant
Maternal and Child Health Program, Oregon Health Authority
• Wendy Rankin, MPA
Oregon Public Health Institute
• Shawna L. Mercer , MSc, PhD
Branch Chief and Director
The Community Guide Branch, US Centers for Disease
Control and Prevention
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EARLY CHILDHOOD OBESITY
PREVENTION: OREGON'S PATH From Data to Action
July 10, 2012
PRESENTED BY:
Robin Stanton, MA, RD, LD
Nutrition Consultant
Oregon Health Authority,
Public Health Division
Wendy Rankin, MPA
Project Manager
Oregon Public Health Institute
YOUR LOGWENDY—
PLEASE INSERT O!
OBJECTIVES:
Describe development of a novel survey and use
of data findings to develop a screen-time
reduction intervention in early care & education.
Describe a screen-time reduction intervention
process and outcomes.
Understand how collaborations are leading to
early care & education system improvements in
Oregon.
OVERVIEW
Oregon’s commitment to promoting children’s
healthy weight and preventing obesity has led to
multiple partnerships and cross system
collaborations in early care & education.
Collaborations have resulted in:
Assessment of healthy weight practices
Planning and policy development
Professional development opportunities
Resource development
Funding
NATIONAL LANDSCAPE
Initiatives on the national level have bolstered Oregon’s efforts through:
Promotion of evidence-based practices and research E.g. The Community Guide, Institute of Medicine Early
Childhood Obesity Prevention Policies, Caring for Our Children National Health and Safety Performance Standards
Policy improvements E.g. CACFP guidelines
Initiatives and resources for child care providers and parents E.g. Let’s Move Child Care; I am Moving, I am Learning,
Farm to Preschool
Professional development E.g. Tiered Quality Rating and Improvement System
RIGHT FROM THE START
Survey-based
assessment of all
licensed child care
providers during
spring 2010, in
Multnomah County,
Oregon’s largest
metropolitan area
Sent to all English &
Russian-speaking
home and center
providers
RIGHT FROM THE START: PURPOSE
To examine the role of child care providers in
prevention of childhood obesity
59 questions about provider practices, the
guidelines they followed, their training, and their
attitudes and beliefs regarding:
Nutrition and eating habits
Physical activity
Screen time
Breastfeeding accommodation
RIGHT FROM THE START: DEVELOPMENT
Relied on evidence-based resources, policy
briefs, research, and existing assessment
tools to inform the survey development
A few selected resources available in 2009:
Preventing Childhood Obesity, Institute of Medicine,
2005
Robert Wood Johnson online Child Care Toolkit
NAP SACC
COLLABORATIONS
25 individuals representing 18 different programs and agencies, including:
Oregon Public Health Institute
OR Public Health Division, MCH Program
Multnomah Co. Health Dept.
OR Child Care Division
Child Care Resource & Referral, Multnomah Co.
Kaiser Permanente NW
Child Care Providers
RIGHT FROM THE START: RESPONDENTS
Overall response rate 58%
511 surveys completed (492 valid surveys)
English registered FCC Homes—59.5%
Russian registered FCC Homes—53%
English certified FCC Homes—59.9%
Child Care Centers—57.8%
SCREEN TIME FINDINGS
There are high rates of screen time exposure in
home-based child care settings.
SCREEN TIME USE
Missed opportunities for interaction with environment and people
Increased risk for:
obesity
aggression & behavior problems
altered sleep
reduced literacy
exposure to substance use/abuse, violence and sex
pervasive marketing influence
SCREEN TIME RECOMMENDATIONS
No screen media under 2 years of age
2 years and older:
total media not more than 30 minutes per week in
child care
educational and physical activity use only (“quality
programming”)
some guidelines state less than 30 min per day in
half-day/less than 1 hr in full day care
computer use only in 15 minute increments (except in
school age for homework)
No screen use at mealtime
Do not use screen media as reward
SCREEN TIME FINDINGS
Registered FCC Homes
Allow children under 2 to watch TV or videos—45%
Allow screen time for children over 2—79%
Certified FCC Homes
Allow children under 2 to watch TV or videos—18%
Allow screen time for children over 2—29%
Centers
Allow children under 2 to watch TV or videos—3%
Allow screen time for children over 2—34%
SCREEN TIME FINDINGS
Kids under age 2 Kids age 2 years and older
Typical hours of screen time per day by setting
type
GUIDELINES BY SETTING TYPE
While most settings have nutrition guidelines,
most lack guidelines for physical activity, screen
time exposure and appropriate handling and
storage of breast milk.
GUIDELINES BY SETTING TYPE
Full report of the
Right From the Start Project is available online:
www.orphi.org
SCREEN TIME REDUCTION FOR
CHILDREN PROJECT (SCRCH)
SCRCH: DEVELOPMENT
Right From the Start stimulated collaborative
efforts to improve healthy weight practices in
child care settings
Collaborations were expanded
E.g. 11 organizations/programs
Funding was leveraged
E.g. Multnomah County ESD LAUNCH & significant in-
kind support
STAR coalition developed a clearly defined screen
time reduction project:
Develop training materials and coaching
Qualitative data collection
SCRCH: INTERVENTION
Training and skill building on screen time reduction and policy development for registered family child care providers
Individual site-based consultation to coach providers on applying the information in caring for children
Incentives of $400 for materials, contract to participate in both quantitative and qualitative evaluation, & $100 for participation in evaluation
Credit for Level 1 training
PROJECT MODEL
Deep change
Screen time reduction
Orientation and policy training
Screen time concerns training,
challenges identified
On-site observation,
coaching, action plan
Facilitated discussion
Materials purchased
and implemented
Focus Group Feedback,
pre/post self assessment
PROVIDER FEEDBACK
“The help with setting up my environment to keep
screen time out of my childcare has been great.”
“The information that was given to me by my
coach was helpful in selecting activities to keep
the children busy and entertained.”
“Children will learn more [with less screen time].”
“As leaders in our homes, we can model better
behavior for daycare children, and broaden their
horizons with all the exciting activities we can
spend our time on that don't involve screens.”
“I'm learning if I have to
use screen time, to use it
in an educational way to
inform children and
educate them about a
subject."
SCRCH: KEY FINDINGS
Providers are under-informed on the health effects of screen time on children & believe that parents are under-informed as well
There are complex underlying issues which drive screen time use—unique to each care setting and provider
Providers need: Resource materials for themselves and for the parents
Support to make changes in their screen time practices, including home visits with coaching, ongoing training & support in policy development
Ongoing opportunities to talk with each other about the challenges of maintaining screen free settings
Considerable effort will be needed to support child care providers in communicating with parents about controversial issues such as screen time reduction.
NEXT STEPS
Through strong
collaborations and
funding from
Multnomah County
Health Department,
this model will be
applied to the area of
breastfeeding in
childcare settings
SELECTED RESOURCES
Let’s Move Child Care http://www.healthykidshealthyfuture.org/welcome.html
Preventing Childhood Obesity in Early Care and Education Programs, Selected Standards from Caring for our Children National Health & Safety Performance Standards http://nrckids.org/CFOC3/PDFVersion/preventing_obesity.pdf
Institute of Medicine Early Childhood Obesity Prevention Policies http://www.rwjf.org/childhoodobesity/product.jsp?id=72539&cid=XEM_205602
Campaign for a Commercial Free Childhood—Screen-Free Week http://www.commercialfreechildhood.org/actions/screenfreeweek2012.html
CD Summary, Oregon Public Health Division. Screen Media—Unplug It For Children, 2009. http://public.health.oregon.gov/diseasesconditions/communicabledisease/cdsummarynewsletter/documents/2009/ohd5819.pdf
Questions?
To s u b m i t a q u e s t i o n :
• Type your question in the chat box at the lower left-hand side of your screen. – Send questions to the Chairperson (AMCHP)
– Be sure to include to which presenter/s you are addressing your question.
33
Evidence Based MCH Programs
http://www.amchp.org/PROGRAMSANDTOPICS/BESTPRACTICES/INNOVATIONSTATION/
Evidence-Based Resources for Public Health Practice
http://www.amchp.org/programsandtopics/BestPractices/Pages/Resources.aspx
The Community Guide and Childhood Obesity
Shawna L. Mercer, MSc, PhD, Director
The Guide to Community Preventive Services
(Community Guide),
Centers for Disease Control and Prevention (CDC)
July, 2012
Evidence-Based Approaches:
The Community Guide as a Tool to Inform
Childhood Obesity Prevention Efforts
Office of Surveillance, Epidemiology, and Laboratory Services
Epidemiology and Analysis Program Office
Outline
Setting the Stage
Why Use an Evidence-Based Approach in Public Health?
Overview of the Community Guide
Using the Community Guide to Improve Health
Navigating the Community Guide Website
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Setting the Stage
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Health Improvement Planning Steps
Planning & Assessment
What’s the problem?
Setting Objectives
What do we want to achieve?
Selecting Interventions
What works?
Implementing
How do we do it?
Evaluating
Did it work? How well?
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Public Health Improvement Planning Steps
Planning & Assessment
What’s the problem?
Setting Objectives
What do we want to achieve?
Selecting Interventions
What works?
Implementing
How do we do it?
Evaluating
Did it work? How well?
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What is the value of using an evidence-based
approach to select interventions?
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“Evidence” in Public Health
A wild guess (“something must be done!”)
An educated guess
Word of mouth (what others are doing)
Case report (before-after experience)
An evaluation of one study or program
One group gets the intervention
A second group acts as a comparison
A narrative review of multiple studies or programs
A systematic review of multiple studies/programs
“Truth”
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Why Evidence-Based?
Evidence-based programs or policies are approaches that
have been found to be effective
Using an evidence-based approach allows for scarce
resources to be used wisely
Funders are requiring more accountability
Shorten the time that it takes to develop a program or
policy
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The Community Guide:
An Important Evidence Base for Public Health
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The Community Guide
State-of-the-science
systematic reviews that:
Analyze all available
evidence on the effectiveness
of community-based
interventions in public health
Assess the economic benefit
of all effective interventions
Highlight critical evidence
gaps
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The Community Guide
These systematic review findings form the basis for
evidence-based recommendations
About effective programs and policies for
• Communities,
• Worksites,
• Schools,
• Healthcare systems
• Etc.
Developed by the
Community Preventive
Services Task Force
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Community Preventive Services Task Force (Task Force)
A non-federal, independent, rotating body
Internationally renowned experts in public health research,
practice, policy
Always have members with state and local health department
experience
Nomination process includes broad input from throughout
public health, healthcare
Members are appointed by CDC Director
Serve without payment
CDC provides scientific, technical and administrative support for
the Task Force
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Complementarity of the
US Preventive Services Task Force (USPSTF) and
Community Preventive Services Task Force (CPSTF)
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Community Preventive Services?
Evaluating the effectiveness of interventions that are typically delivered:
At the group level
Community or population-based
Demographic • State/province, city, neighborhood
• Age, gender, race/ethnicity, economic status
Organization • Health care system
• Schools
• Worksites
By a wide range of “providers”
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Community Preventive Services can be
Informational
Education programs when used alone for increasing use of child
safety seats
Community-wide campaigns to increase physical activity
Behavioral, Social
Enhanced school-based physical education to increase physical
activity
Behavioral interventions to reduce screen time
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Community Preventive Services can be
Environmental, Policy
Street scale urban design (lighting, improved safety, ease of
walking) in increasing physical activity
Point-of-decision prompts to encourage use of stairs
Health System
Vaccination programs in WIC settings
Collaborative care for the management of depressive disorders
All: Guide to Community Preventive Services
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Over 210 Task Force Findings & Recommendations
The Environment
Social Environment Health Equity
Settings
States Worksites Healthcare system
Communities Schools Organizations
Risk Behaviors Specific Conditions
Tobacco Use
Alcohol Abuse/Misuse
Other Substance Abuse
Poor Nutrition
Inadequate Physical Activity
Unhealthy Sexual Behaviors
Current reviews
Vaccine-Preventable Disease
Pregnancy Outcomes
Violence
Motor Vehicle Injuries
Depression/Mental Health
Cancer
Diabetes
Oral Health
Obesity
Asthma
Cardiovascular disease
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Community Guide: How is it Used?
To inform decision making around:
Practice (initiatives, programs)
Policy
Research
Funding for research and programs
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Challenge #1: A Typical Approach to Developing and Disseminating Evidence Based Recommendations: A Push Model
Systematic
Review
of the
Scientific
Evidence By researchers
Practice, Policy Dissemination
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Addressing Challenge #1
By actively engaging in conducting and disseminating the systematic review those who are expected to be the users and beneficiaries of the research, it is more likely the findings and recommendations will be relevant to their needs
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Challenge #2
Most decision makers considering community preventive
services, programs, and policies want to know:
Are the findings generalizable across all the settings, situations
and populations for which I am responsible?
Are the findings applicable to my specific setting, situation, or
population?
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Community Guide Places Equal Weight on
The quality of the systematic review methods and analysis
The group processes
Participation and collaboration
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The CG Seeks to Answer Key Questions about Interventions
Do they work?
How well?
For whom?
Under what circumstance are they
appropriate (applicability)?
What do they cost?
Do they provide value?
Are there barriers to their use?
Are there any harms?
Are there any unanticipated outcomes?
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Formal Review of Applicability
Information is explicitly provided to Task Force on
applicability
Considered when they make recommendations
Information is provided to users in a refined Rationale
Statement accompanying the Task Force
Recommendation Statement
Remaining challenge: information is often limited
Critical role for program evaluation of real world programs,
services, and policies!!!
Information can be incorporated into updates of Task Force
recommendations!
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Task Force Recommendation Options
Recommend
Strong Evidence
Sufficient Evidence
Recommend against
Strong Evidence
Sufficient Evidence
Insufficient evidence to
recommend for or against
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What Does Insufficient Evidence Mean?
This does NOT mean that the evidence does not work
Insufficient evidence means that additional research is
needed to determine whether or not the intervention is
effective
In some cases there are not enough studies to draw
firm conclusions
In other cases, the available studies have inconsistent
findings
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If “Insufficient Evidence,” then what?
If the intervention is currently being used
May want to continue using it if there are no associated harms
May choose to stop due to issues such as cost
If the intervention is not being used
May not want to begin using it
May choose to cite the IE finding in your funding proposal
Consider:
Are there better documented alternatives
for reaching the same goals?
If you undertake a practice-based innovation:
Collect sufficient data so your experience can
contribute to the evidence base!
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What to Do with a Recommendation
“Even if it is evidence-based,
it is not certainty.”
McGinnis and Foege
Not a cookbook or a one-size-fits-all solution
Users must combine scientific information
(e.g., effectiveness, cost) with other information (e.g.,
needs, values, capacities, resources, preferences)
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How Can You Use the Community Guide to Improve Child Obesity Prevention?
In support of policy:
Identify policies, laws for which there is evidence of their
effectiveness in achieving important public health outcomes
Learn what magnitude of effect might be possible from
implementation of specific policies
Inform interface with governmental agencies, organizations, and
other stakeholders in support of:
• Health policies
• Policies in other sectors with maternal and child health implications
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How Can You Use the Community Guide to Improve Child Obesity Prevention (cont’d)?
In support of agency programmatic initiatives:
Plan and evaluate programs
Strengthen applications for programmatic funding
Justify program support/funding
Plan/modify systems
Learn what magnitude of effect might be possible from
implementation of specific programs
Inform interface with the health care system to support delivery of
effective clinical services
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Navigating The Community Guide Website
The Community Guide Website
www.thecommunityguide.org 68
The Community Guide Website
www.thecommunityguide.org 69
The Community Guide Website
www.thecommunityguide.org 70
Complete List of Task Force Findings
www.thecommunityguide.org 72
Home Page: Topics
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Topic Page
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Topic Page
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Web Intervention Summary Page
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Intervention Summary Page (lower half)
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Task Force Finding and Rationale Statement
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Analytic framework
Kahn EB, Ramsey LT, Brownson R, et al. (2002) The effectiveness of interventions to increase physical activity: a systematic
review Am J Prev Med 2002;22(4S):73-107
Office of Surveillance, Epidemiology, and Laboratory Services
Epidemiology and Analysis Program Office 80
For more information
Shawna Mercer [email protected]
www.thecommunityguide.org
The findings and conclusions in this presentation are those of the
presenters and do not necessarily represent the views of CDC
Questions?
To s u b m i t a q u e st i o n :
• Type your question in the chat box at the lower left-hand side of your screen. – Send questions to the Chairperson (AMCHP)
– Be sure to include to which presenter/s you are addressing your question.
81
Healthy Children. Healthy Families. Healthy Communities.
WWW.AMCHP.ORG
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