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Flattum et al. International Journal of Behavioral Nutrition and Physical Activity (2015) 12:53 DOI /s RESEARCH Open Access HOME Plus: Program design and implementation of a family-focused,
Flattum et al. International Journal of Behavioral Nutrition and Physical Activity (2015) 12:53 DOI /s RESEARCH Open Access HOME Plus: Program design and implementation of a family-focused, community-based intervention to promote the frequency and healthfulness of family meals, reduce children s sedentary behavior, and prevent obesity Colleen Flattum 1*, Michelle Draxten 2, Melissa Horning 1, Jayne A Fulkerson 1, Dianne Neumark-Sztainer 3, Ann Garwick 1, Martha Y Kubik 1 and Mary Story 4 Abstract Background: Involvement in meal preparation and eating meals with one s family are associated with better dietary quality and healthy body weight for youth. Given the poor dietary quality of many youth, potential benefits of family meals for better nutritional intake and great variation in family meals, development and evaluation of interventions aimed at improving and increasing family meals are needed. This paper presents the design of key intervention components and process evaluation of a community-based program (Healthy Home Offerings via the Mealtime Environment (HOME) Plus) to prevent obesity. Methods: The HOME Plus intervention was part of a two-arm (intervention versus attention-only control) randomized-controlled trial. Ten monthly, two-hour sessions and five motivational/goal-setting telephone calls to promote healthy eating and increasing family meals were delivered in community-based settings in the Minneapolis/ St. Paul, MN metropolitan area. The present study included 81 families (8-12 year old children and their parents) in the intervention condition. Process surveys were administered at the end of each intervention session and at a home visit after the intervention period. Chi-squares and t-tests were used for process survey analysis. Results: The HOME Plus program was successfully implemented and families were highly satisfied. Parents and children reported that the most enjoyable component was cooking with their families, learning how to eat more healthfully, and trying new recipes/foods and cooking tips. Average session attendance across the ten months was high for families (68%) and more than half completed their home activities. Conclusions: Findings support the value of a community-based, family-focused intervention program to promote family meals, limit screen time, and prevent obesity. Trial registration: NCT Keywords: Family meals, Dietary quality, Behavioral intervention, Motivational Interviewing, Obesity prevention * Correspondence: 1 School of Nursing, University of Minnesota, Weaver-Densford Hall, 308 Harvard St. SE, Minneapolis, MN 55455, USA Full list of author information is available at the end of the article 2015 Flattum et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Flattum et al. International Journal of Behavioral Nutrition and Physical Activity (2015) 12:53 Page 2 of 9 Background Diet quality of children and adolescents has long been a concern for health professionals and researchers. Despite recommendations of the 2010 Dietary Guidelines for Americans, youth typically have inadequate intakes of fruits, vegetables and whole grains and excessive intake of added sugar and fat [1-3]. Involvement in meal preparation and eating meals with one s family are associated with better dietary quality and healthy body weight for youth [4-8], making the promotion of family meals a possible nutrition- and weight-related health promotion strategy [7,9-14]. Interventions that strive to teach youth about the importance of healthful eating have been conducted across communities with varying success [15-17]. Creative and innovative programs such as hands-on cooking classes and gardening programs for youth [18-20] continue to be designed and delivered to children and adolescents to promote healthful eating. Current research suggests that involving youth in food preparation is associated with a preference for healthy eating [13,21,22]. However, detailed information beyond general statements about promotion of food preparation involvement and frequency is typically unavailable. Given the poor dietary intake of many youth [2,3], potential benefits of family meals for better nutritional intake [4,9,10,23] and great variation in family meals, it is crucial to develop interventions aimed at improving and increasing family meals and evaluate their potential impact on diet quality and obesity. However, little research has evaluated intervention programs from a familyfocused, behavior change perspective. Therefore, this paper presents an overview of key components of the Healthy Home Offerings via the Mealtime Environment (HOME) Plus program, a family-focused program to promote family meal frequency and healthful meals and snacks among 8 12 year-old children and their families. The theoretical model, guiding principles, intervention session components, and important process evaluation components [24,25] such as intervention fidelity, delivery and receipt dosage (attendance), responsiveness and use (parent and child satisfaction and homework completion) and self-evaluation of change are discussed. Methods Study design and participants The HOME Plus program is currently being evaluated in a randomized controlled trial with160 families (one target 8 12 year old child per family and the primary meal-preparing parent/guardian) with three data collection periods: baseline (2011, 2012), post-intervention (post-intervention) and follow-up (9 months postintervention). After baseline assessment, families were randomized to an intervention group (n = 81) and attended 10-monthly group sessions (Oct 2011-Jul 2012 and Oct 2012-Jul 2013, respectively for cohorts 1 and 2) or an attention-only control group (n = 79) that received 10-monthly newsletters. A staggered cohort design was used to accommodate the capacity of community centers and staff within funding limits. Families were recruited from community centers in six geographic locations of Minneapolis/St. Paul, Minnesota s metropolitan area. Recruitment efforts were targeted to primary meal-preparing parents of 8 12 year old children to increase the likelihood of accurate reporting related to food preparation and making changes in the home food environment. Effective methods such as flyers and small group presentations used successfully in the pilot study were used for recruitment [18]. Community center staff assisted with recruitment and facilitated logistics during intervention sessions. Parent and child participants signed informed consent or assent forms, respectively, and completed assessments including psychosocial surveys, anthropometric measures, dietary recall interviews (child only) and home food environmental measures. All procedures were approved by the University of Minnesota s Human Subjects Review Board. Study design, methods, eligibility and detailed data collection information is published elsewhere [26]. Children participating in the intervention were 8 12 years old (M = 10.5 years, SD = 1.5); 69% were white, 16% African American/Black and 15% mixed race/ethnicity; 46% were female; and 41% were overweight/obese ( 85%BMI percentile). Most participating parents in the intervention were female (94%); 78% of parents were white, 15% African American and 7% mixed race/ethnicity. Many parents were college educated (70%) and 48% were working full-time. Because income level is dependent upon household size, receipt of economic assistance (free and/or reduced lunch for child at school and/or public assistance through food support/stamps, EBT, WIN, TANF, SSI or MFIP) was used to measure household economic status; almost half of parents (45%) reported receiving economic assistance. The parent average age was 41 years (SD = 8.0) and 46% were overweight/obese. Program description A stepwise approach to designing and developing the HOME Plus intervention was used to maximize the program s likely effect [27]. The formative steps included: 1) targeted behavior validation, (i.e., obesity prevention of 8 12 year old children); 2) targeted mediator validation (i.e., Social Cognitive Theory (SCT) (personal, behavioral, and environmental factors)); 3) intervention procedure validation, (i.e., skill development and education); and 4) pilot/feasibility of the intervention. Process evaluation Flattum et al. International Journal of Behavioral Nutrition and Physical Activity (2015) 12:53 Page 3 of 9 was conducted throughout the intervention to assess fidelity, dosage, responsiveness and satisfaction. HOME Plus was based on a family meal program (HOME) previously developed and pilot tested for feasibility and acceptability by our team in [18], with the addition of a component to reduce sedentary behavior (mainly screen time). HOME Plus was guided by Social Cognitive Theory (SCT) and a socio-ecological framework [28-30]. As shown in Table 1, the intervention had three overarching goals associated with behavioral messages related to the planning, frequency and healthfulness of family meals and snacks. Sessions incorporated concepts of SCT, such as increasing self-efficacy of both parents and children (e.g., through hands-on cooking activities designed to increase skills/ confidence), increasing the outcome expectation of eating healthful food (e.g., by being given the opportunity to consume healthful foods created at the intervention) and enhancing parental skill development (e.g., parents learn and practice how to praise children for trying new foods, limit screen time at meals, and avoid mixed messages about food, activity and weight). Intervention delivery Intervention messages were addressed in a participant guidebook, Let s Eat Together Your Family s Guide to HOME Plus, given to each family and utilized throughout the sessions. The guidebook included session topics, strategies to help meet session goals, recipes and resources (e.g., list of local farmer s markets). Intervention sessions were delivered monthly to multiple family groups at community park and recreation centers in the Minneapolis area in the early evening to accommodate family schedules. All family members were encouraged to attend. Childcare for children ( 8 years) and transportation were available, as needed, to enhance retention and adherence. Each session was offered twice a month at each location, to allow for scheduling flexibility. Five brief goal-setting telephone calls were conducted by lead facilitators with intervention parents over the 10- month intervention. Details of intervention components are described below. Intervention components Family group sessions Lead facilitators used a set curriculum for intervention delivery (see Table 2 for brief content summaries). Sessions consisted of nutrition education and hands-on skill development to provide parents and children with new knowledge and practical application. Each session included 1) introduction of a new topic and review of prior month s topic and goals (family); 2) meal preparation (family); 3) taste testing a seasonal fruit/vegetable (separate parent and child groups); 4) small break-out groups with discussion and activity (separate parent and child groups); 5) eating a family meal (family); and 6) summary of session (family). Some details of a typical session are described below. Upon session arrival, each family selected one of four featured recipes to prepare (meat entree, vegetarian entree, salad, or fruit-based dessert). Parents and children were introduced to new recipes, developed basic knife skills, and practiced reading a recipe and measuring ingredients. These skills were targeted to promote meal planning and preparation self-efficacy. Recipes were selected based on the Dietary Guidelines for Americans (i.e., recipes contained 30% or less of calories from fat/serving and Table 1 HOME Plus goals and behavioral messages for intervention families Goals Behavioral Messages 1. Plan healthy meals and snacks with your family more often Get kids involved with shopping at least three times a month Plan and prepare healthy meals and snacks together at least three times a week Plan family meals and snacks using portion size guidelines Creatively involve kids in trying new fruits and vegetables Make half your plate fruits and vegetables at meals 2. Have meals with your family at home more often Make regular family meals a priority Enjoy your food, but don t overeat Sit together during meal time Promote positive conversation at meal time Eliminate electronics at meal time 3. Improve the healthfulness of the food available at home Increase the amount and variety of fruits and vegetables in the home Make fruits and vegetables more visible and easily accessible in the home Reduce the number of high fat and high sugar snacks in the home by at least half Replace sugar-sweetened beverages with water Rely less on highly processed foods in the home Flattum et al. International Journal of Behavioral Nutrition and Physical Activity (2015) 12:53 Page 4 of 9 Table 2 HOME Plus Session Topics with Parent and Child Ratings of Each Session Session Topics Mean rating of session (1 = didn t like, 5 = loved it) 1-Let s get started Best family meal ever Parent = 4.4 Child = 4.2 Wash, chop, slice and safety kitchen basics 2-Ready, Set, Goal Goal setting breaking it into bite-size pieces Parent = 4.4 Child = 4.1 Let s give them something to talk about conversation starters Recipe revolution common abbreviations 3-Thinking outside the box Switch it up: meal planning makeovers Parent = 4.4 Child = 4.3 Go! Slow! Whoa! Successful recipes = accurate measures 4- What s for dinner 2night? Cook today, eat tomorrow or freeze for another day Parent = 4.4 Child = 4.0 READ it before you EAT it A dash of this, a pinch of that measuring ingredients 5-Too much? Not enough? Portion distortion helpings, portions and servings Parent = 4.6 Child = 4.3 Are you hungry? Full? Listening to your body s cues Get creative-colorful, fresh and nutritious salads 6-Keep it under wraps Fast, fun and full of acceptance ideas for picky eaters Parent = 4.4 Child = 4.1 Making sense of advertising Wrap it up-quick and easy meals 7-Balance, balance, keep the balance Healthy snacks-beyond apples and oranges Parent = 4.6 Child = 4.3 The race is on choosing healthy snacks Peel! Chop! Fruits! 8-Less sugar and fat a sweet deal Sip smarter the bottom line on sugary drinks Parent = 4.6 Child = 4.4 Which snack or beverage? Check the facts! Peel! Chop! Vegetables! 9-AGREENable meals and snacks Why your choices matter Parent = 4.5 Child = 4.3 Celebrate seasons picking produce that s fresh & less expensive 10-The future is bright planning ahead The Celebrity Chef is you! Parent = 4.7 Child = 4.5 Kids can do it families can do it promoted fruits/vegetables). For simplicity, recipes had few overall ingredients and emphasized highly-available and low-cost ingredients. All participating family members sampled a seasonal fruit/vegetable in a Taster s Choice activity to increase their exposure to a variety of fruits/vegetables. Fruits/ vegetables selected for this activity were those that children rated during baseline data collection as ones they had not tried or did not like. Families were encouraged to try, on their own, the fruit/vegetable of the month before the next session as their Take HOME activity, which targeted the behavioral goal of increasing the number of fruits/vegetables available in the home and served at family meals and snacks. To encourage session attendance and completion of Take HOME activities, families received entries for a final session drawing for a personal home visit by a local chef. Small group discussions and activities Parent session activities focused on reducing barriers and strategies for behavior change related to program messages. For example, parents discussed mealtime stress, ways to increase the frequency and healthfulness of family meals, and strategies to increase healthful snacks at home through role-play and case scenarios. Children s group topics paralleled those of the parent but were more gamelike to educate them in a developmentally-appropriate and engaging manner. Sessions concluded with family-style meals where families tried the foods made by the group. A pre-portioned plate was on display at every meal to demonstrate appropriate serving sizes. All participants were encouraged to try at least a sample of each food. Following dinner, parents and children completed session evaluations and selected family-level goals, i.e., a goal that all members of Flattum et al. International Journal of Behavioral Nutrition and Physical Activity (2015) 12:53 Page 5 of 9 the family agreed they could work toward, for the next month (for example, increase the amount of fruits and vegetables as snacks). Families unable to attend a session received a telephone call from their facilitator who recapped the session and mailed them pertinent handouts. Parent goal-setting telephone calls Five brief (~20 minute) tailored goal-setting telephone calls were conducted by lead facilitators, who were trained in Motivational Interviewing (MI), with parents over the 10-month intervention. Often during the calls, parents selected new goals to complement the family-selected goal at sessions and tended to be focused on parental strategies for feeding picky eaters or eliminating junk food from the home. Parents had the option of working on the same goal throughout the intervention or choosing a new goal at any point. Each call followed a counseling protocol based on MI principles, including a participant-focused, collaborative, decision-making approach, giving nonjudgmental feedback, allowing for resistance, and encouraging the participant to make a case for change [31,32]. The facilitators relied on open-ended questions and reflections to bring about the participant s motivation and desire for change. Intervention staff held weekly case management meetings to discuss and address problem areas. Program cost Cost estimates were broken down to include training of intervention personnel, one-time program materials and costs associated with intervention delivery by family. Costs per family were as follows: One-time cost of $20 for personnel training (first aid and food safety training, study t-shirt and chef hat (as uniform)), one-time cost of $49 for program materials for participants at the beginning of the program (guidebook, recipe book, chef hat and canvas bag), and $44 per session for intervention delivery (staff time ($27 per family), food ($8 per family), small incentives ($3 per family), room rental ($6 per family)). In addition, childcare cost $20 per session for up to 6 kids and transportation cost $12.50 per session for families (n = 6) requiring cab or bus transportation. It is important to note that at least three college students volunteered to assist with session logistics at each session as well. Intervention process evaluation Fidelity of program delivery All intervention staff members were trained to study protocols and food safety practices; lead staff was also trained in basic first aid. Group sessions were facilitated by Registered Dietitians and a Registered Nurse. Lead staff that conducted the goal-setting phone calls were trained in MI prior to program start up. The program assistant supervised university-level student volunteers (usually 3 per session) in setting-up cooking stations. All team members assisted families during meal preparation and service. Observations of session curriculum delivery were regularly conducted to monitor and enhance program f
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