A collaborative approach to developing sustainable behaviour change interventions for childhood obesity prevention: Development of the Choosing Healthy Eating for Infant Health (CHErIsH) intervention and implementation strategy

Outcome measurement instruments used to measure diet-related outcomes in infancy: A scoping review

INTRODUCTION

Supporting positive diet behaviours during infancy is essential to support child health and prevent childhood obesity. How infant diet-related outcomes are measured in trials is crucial to determining intervention effectiveness. This scoping review examined what and how outcome measurement instruments are currently used to measure 13 infant diet-related outcomes from a previously developed core outcome set.

METHODS

The databases EMBASE, MEDLINE, CINAHL and PsycINFO were searched from inception to September 2023. Eligible studies reported trials that included infants ≤1 year old and at least one diet-related outcome measurement instrument. Titles/abstracts and full texts were independently screened in duplicate. Data were narratively synthesised.

RESULTS

136 studies reporting 133 trials were included. Outcome measurement instruments used included 66 questionnaires (n = 70 studies), 65 individual questions (n = 45 studies), 24 food diaries/records (n = 21 studies), 11 24-hour dietary recall (n = 11 studies), and healthcare record data (n = 6 studies). Outcome measurement instruments were predominantly self-administered by researchers in participants homes. There was a lack of reporting for some outcome measurements used.

CONCLUSION

Review findings highlight the need to improve clarity and completeness of outcome reporting. The findings also provide an important first step to address heterogeneity in measurement of infant diet-related outcomes. Consistent measurement of diet-related outcomes is needed to improve synthesis and evaluation of obesity prevention interventions.

Barriers and Facilitators Influencing Parents' Willingness to Follow Healthcare Provider Guidance for Addressing Behaviors Linked to Early Childhood Obesity Risk: A Qualitative Descriptive Study

INTRODUCTION

This study aims to assess parents' willingness to modify behaviors associated with obesity risk upon a provider's recommendation in the first six months of life among non-Hispanic Black and Hispanic families.

METHOD

Twenty parents completed a survey about their current infant feeding, sleep, and nutritional behaviors that guided a tailored semistructured interview.

RESULTS

Barriers to parents' willingness to modify behaviors associated with obesity risk in infancy included prioritizing perception of infant hunger and relying on parental intuition. Facilitators included understanding the provider's reasoning and trusting the provider's motivations.

DISCUSSION

Health care providers are considered trusted sources by most parents and parents are willing to follow professional advice if providers share detailed explanations on the reasoning for behavior change recommendations. Future interventions created by trusted sources, like pediatric primary care providers, offer a promising mechanism for providing education on early life obesity prevention that is tailored to individual family needs.

Identifying behavior change techniques (BCTs) in responsive feeding interventions to prevent childhood obesity-A systematic review

BACKGROUND

Complex interventions that include responsive infant feeding components can potentially prevent childhood obesity. To develop a replicable responsive feeding intervention, an understanding of the most effective behavior change techniques (BCTs) and theory is needed.

OBJECTIVE

To identify the BCTs and theories used in interventions with responsive feeding components for caregivers of children ≤2 years.

METHODS

PsycINFO, CINAHL, Cochrane Library, EMBASE, and MIDIRS were searched from inception to May 2023. Studies of obesity prevention interventions with a responsive feeding component were included. BCT Taxonomy Version 1 and Michie and Prestwich theory coding method were applied.

FINDINGS

Eighteen interventions were identified; the number of BCTs ranged from 3 to 11 (mean = 5.5). The most used BCTs were "Instruction on how to perform a behaviour" (17/18) and "Adding objects to the environment" (13/18), which were commonly used in the nine trials demonstrating higher responsive feeding behaviours and the four trials reporting reduced likelihood of overweight or obesity, or rapid weight gain. Fifteen trials reported use of theory.

CONCLUSION

BCT use was low in interventions with responsive feeding components. BCTs are replicable; their use in interventions, alongside theory, will ensure that key determinants of responsive feeding behavior are included in future obesity prevention interventions.

Refining the Choosing Health Infant feeding for Infant Health intervention and implementation strategy: Re-CHErIsH Study Protocol

Background

Childhood obesity is a significant global public health challenge, with significant adverse effects on both mental and physical health outcomes. During the period from birth to one-year, modifiable caregiver behaviours, such as what, how and when infants are fed, can influence obesity development and prevention. The Choosing Healthy Eating for Infant Health (CHErIsH) intervention was developed to support healthy infant feeding practices to prevent childhood obesity in the first year. A feasibility study examined acceptability and feasibility of the CHErIsH intervention in primary care and identified key challenges and possible areas for refinement of the intervention and trial processes. The current project aims to refine delivery of the CHErIsH intervention and trial processes to maximise the likelihood of successful future implementation and evaluation.

Methods

This study will utilise a mixed-methods approach and will be conducted in three phases. In Phase 1 potential refinements to the CHErIsH intervention delivery and trial processes will be developed from a review of the feasibility study findings and input from the multidisciplinary team. An online mixed-methods survey will be conducted in Phase 2 to evaluate caregiver attitudes about the proposed refinements from Phase 1. Participants will be pregnant women, their partners, and/or parents/primary caregivers of infants up to 2-years of age, based in Ireland. Participants will be recruited using convenience and snowball sampling. In Phase 3 a stakeholder consensus meeting, using the nominal group technique, will be conducted to agree the refined intervention and trial processes. Stakeholders will include healthcare professionals, researchers, policymakers, and parents/caregivers, who will discuss and rate refinements in terms of preference.

Conclusions

Findings from this study will address uncertainties in the intervention delivery and trial processes of the CHErIsH intervention, with the potential to maximise the likelihood of successful future implementation and evaluation of a primary-care based obesity prevention intervention.

Healthier Together: Implementation and evaluation of a co-designed, culturally tailored childhood obesity community prevention program for Māori and Pacific Islander children and families

ISSUE ADDRESSED

Co-designed and culturally tailored preventive initiatives delivered in childhood have high potential to close the cross-cultural gap in health outcomes of priority populations. Māori and Pacific Islander people living in Australia exhibit a higher prevalence of overweight and obesity and higher rates of multimorbidity, including heart disease, cancer and diabetes.

METHODS

This mixed-methods, pilot implementation and evaluation study, aimed to evaluate the implementation of a community-based, co-designed and culturally tailored childhood obesity prevention program, using quantitative (pre-post anthropometric measurement, pre-post health behaviour questionnaire) and qualitative (semi-structured interview) methods. Sessions relating to healthy eating, physical activity and positive parenting practices were delivered to families residing in Brisbane (Australia) over 8-weeks.

RESULTS

Data were collected from a total of 66 children (mean age 11, SD 4) and 38 parents (mean age 40, SD 8) of Māori and Pacific Islander background, from July 2018 to November 2019. Anthropometric changes included a reduction in Body Mass Index (BMI) z-score among 59% of children (median change -0.02, n = 38, p = 0.17) and BMI among 47% of adults (median change +0.06 kg/m2, n = 18, p = 0.64). Significant improvements (p < 0.05) in self-reported health behaviours from pre- to post-program included increased vegetable consumption among children, decreased discretionary food intake of children, decreased discretionary drink consumption among both children and adults, increased minutes of daily physical activity among adults and increased parental confidence in the healthy diets of their children. Qualitative data revealed participants valued the inclusion of all family members, learning of practical skills and cultural tailoring delivered by the Multicultural Health Coaches.

CONCLUSIONS

This study provides preliminary evidence that the Healthier Together program improved self-reported health behaviours and physical activity levels among Māori and Pacific Islander children and their families in the short-term; however, due to the small sample size, these results must be interpreted carefully. The program empowered change via cultural tailoring and accessibility; however, long-term implementation and evaluation with a larger cohort is needed to validate the observed health behaviour improvements and their sustainability. SO WHAT?: The co-design framework that informed program development and key learnings of implementation will provide guidance to health practitioners, health workers, public health professionals and policy makers to develop inclusive and pragmatic co-design solutions for priority cultural populations in Australia. Health outcomes will improve as a result, promoting health equity for future generations.

Application of an Adapted Behaviour Change Wheel to Assistance Dog Puppy Raising: A Proposed Raiser-Centred Support Program

Puppy raising (PR) programs recruit volunteer community members (raisers) to raise assistance dog (AD) candidates from puppyhood until the dogs are ready for advanced training. Once qualified, ADs assist human handlers with a disability to live more independently. Unfortunately, about 50% of all puppies do not meet the behavioural standards required for further training after completing a PR program. This increases costs and lengthens the time taken for a handler to obtain an AD. Research has identified several factors that influence raisers' experiences. It has also shown that raisers' socialisation and training practices affect perceived puppy behaviour. Drawing on the argument that puppy raiser practices are central to improving overall puppy raising program outcomes, this paper interprets recent findings within the framework provided by the behaviour change wheel-an established behaviour change framework-to suggest a coordinated approach to supporting puppy raisers. The recommendations will allow future research to employ more objective measures and more rigorous experimental designs as the field attempts to corroborate existing findings and develop evidence-based models of practice.

A collaborative approach to develop an intervention to strengthen health visitors' role in prevention of excess weight gain in children

BACKGROUND

The high prevalence of childhood obesity is a concern for public health policy and practitioners, leading to a focus on early prevention. UK health visitors (HVs) are well-positioned to prevent excessive weight gain trends in pre-school children but experience barriers to implementing guideline recommended practices. This research engaged with HVs to design an intervention to strengthen their role in prevention of early childhood obesity.

METHODS

We describe the processes we used to develop a behaviour change intervention and measures to test its feasibility. We conducted a systematic review to identify factors associated with implementation of practices recommended for prevention of early childhood obesity. We carried out interactive workshops with HVs who deliver health visiting services in County Durham, England. Workshop format was informed by the behaviour change wheel framework for developing theory-based interventions and incorporated systematic review evidence. As intended recipients of the intervention, HVs provided their views of what is important and acceptable in the local context. The findings of the workshops were combined in an iterative process to inform the four steps of the Implementation Intervention development framework that was adapted as a practical guide for the development process.

RESULTS

Theoretical analysis of the workshop findings revealed HVs' capabilities, opportunities and motivations related to prevention of excess weight in 0-2 year olds. Intervention strategies deemed most likely to support implementation (enablement, education, training, modelling, persuasion) were combined to design an interactive training intervention. Measures to test acceptability, feasibility, and fidelity of delivery of the proposed intervention were identified.

CONCLUSIONS

An interactive training intervention has been designed, informed by theory, evidence, and expert knowledge of HVs, in an area of health promotion that is currently evolving. This research addresses an important evidence-practice gap in prevention of childhood obesity. The use of a systematic approach to the development process, identification of intervention contents and their hypothesised mechanisms of action provides an opportunity for this research to contribute to the body of literature on designing of implementation interventions using a collaborative approach. Future research should be directed to evaluate the acceptability and feasibility of the intervention.

Investigating group-based classes ('weaning workshops') to support complementary infant feeding in Irish primary care settings: a cross-sectional survey

OBJECTIVE

This study aims to (1) investigate current practice regarding 'weaning workshops' to support complementary infant feeding delivered within Irish primary care, (2) explore the experiences and opinions of community dietitians regarding optimal content and modes of delivery of weaning workshops and (3) identify the key factors to be considered in the development and implementation of weaning workshops delivered within primary care.

DESIGN

Cross-sectional survey.

SETTING

Irish primary care.

PARTICIPANTS

Forty-seven community-based dietitians.

RESULTS

Sixteen dietitians reported that workshops were run in their area with variable frequency, with ten reporting that workshops were never run in their area. Participants reported that mostly mothers of medium socio-economic status (SES) attended weaning workshops when infants were aged between 4 and 7 months, and that feedback from workshop attendees was predominantly positive. Dietitians identified that key factors to be considered in future development and delivery of weaning workshops are (1) workshop characteristics such as content, timing and venue, (2) organisational characteristics such as availability of resources and multidisciplinary involvement and (3) attendee characteristics such as SES.

CONCLUSIONS

This study highlights substantial variability regarding provision of weaning workshops in Ireland, and a lack of standardisation regarding the provider, content and frequency of workshops where workshops are being delivered. The study also provides unique insights into the experiences and opinions of primary care community dietitians regarding the development and delivery of weaning workshops in terms of optimal content and delivery options. These perspectives will make a valuable contribution given the dearth of evidence in this area internationally.

The impact of reducing the frequency of night feeding on infant BMI

BACKGROUND

Teaching caregivers to respond to normal infant night awakenings in ways other than feeding is a common obesity prevention effort. Models can simulate caregiver feeding behavior while controlling for variables that are difficult to manipulate or measure in real life.

METHODS

We developed a virtual infant model representing an infant with an embedded metabolism and his/her daily sleep, awakenings, and feeds from their caregiver each day as the infant aged from 6 to 12 months (recommended age to introduce solids). We then simulated different night feeding interventions and their impact on infant body mass index (BMI).

RESULTS

Reducing the likelihood of feeding during normal night wakings from 79% to 50% to 10% lowered infant BMI from the 84th to the 75th to the 62nd percentile by 12 months, respectively, among caregivers who did not adaptively feed (e.g., adjust portion sizes of solid foods with infant growth). Among caregivers who adaptively feed, all scenarios resulted in relatively stable BMI percentiles, and progressively reducing feeding probability by 10% each month showed the least fluctuations.

CONCLUSIONS

Reducing night feeding has the potential to impact infant BMI, (e.g., 10% lower probability can reduce BMI by 20 percentile points) especially among caregivers who do not adaptively feed.

IMPACT

Teaching caregivers to respond to infant night waking with other soothing behaviors besides feeding has the potential to reduce infant BMI. When reducing the likelihood of feeding during night wakings from 79% to 50% to 10%, infants dropped from the 84th BMI percentile to the 75th to the 62nd by 12 months, respectively, among caregivers who do not adaptively feed. Night-feeding interventions have a greater impact when caregivers do not adaptively feed their infant based on their growth compared to caregivers who do adaptively feed. Night-feeding interventions should be one of the several tools in a multi-component intervention for childhood obesity prevention.

Supporting self-management and clinic attendance in young adults with type 1 diabetes: development of the D1 Now intervention

BACKGROUND

Self-management of type 1 diabetes (T1D) is complex and can be particularly challenging for young adults. This is reflected in the high blood glucose values and rates of clinic non-attendance in this group. There is a gap for a theory-based intervention informed by key stakeholder opinions to support and improve self-management in young adults with T1D.

PURPOSE

The aim of the work was to systematically co-develop an evidence-based and stakeholder-led intervention to support self-management and clinic engagement in young adults living with T1D in Ireland. Co-development was led by the Young Adult Panel.

METHODS

The Behaviour Change Wheel was used to guide the development. Five evidence sources were used to inform the process. An iterative co-design process was used with the Young Adult Panel. Initial intervention components were refined and feasibility tested using qualitative methods.

RESULTS

Environmental restructuring, education and training were selected as appropriate intervention functions. The co-design process, along with qualitative refinement and feasibility work, led to the final intervention content which consisted of 17 behaviour change techniques. The final D1 Now intervention consists of three components: a support worker, an agenda setting tool and an interactive messaging service.

CONCLUSIONS

The D1 Now intervention is now at pilot evaluation stage. Its transparent and systematic development will facilitate evaluation and future replications.

Exploring healthcare professionals' views of the acceptability of delivering interventions to promote healthy infant feeding practices within primary care: a qualitative interview study

OBJECTIVE

Early-life nutrition plays a key role in establishing healthy lifestyles and preventing chronic disease. This study aimed to (1) explore healthcare professionals' (HCP) opinions on the acceptability of and factors influencing the delivery of interventions to promote healthy infant feeding behaviours within primary care and (2) identify proposed barriers/enablers to delivering such interventions during vaccination visits, to inform the development of a childhood obesity prevention intervention.

DESIGN

A qualitative study design was employed using semi-structured telephone interviews. Data were analysed using qualitative content analysis; findings were also mapped to the Theoretical Framework of Acceptability (TFA).

SETTING

Primary care in Ireland.

PARTICIPANTS

Twenty-one primary care-based HCP: five practice nurses, seven general practitioners, three public health nurses, three community dietitians and three community medical officers.

RESULTS

The acceptability of delivering interventions to promote healthy infant feeding within primary care is influenced by the availability of resources, HCP's roles and priorities, and factors relating to communication and relationships between HCP and parents. Proposed barriers and enablers to delivering interventions within vaccination visits include time constraints v. opportunistic access, existing relationships and trust between parents and practice nurses, and potential communication issues. Barriers/enablers mapped to TFA constructs of Affective Attitude, Perceived Effectiveness and Self-Efficacy.

CONCLUSIONS

This study provides a valuable insight into HCP perspectives of delivering prevention-focused infant feeding interventions within primary care settings. While promising, factors such as coordination and clarity of HCP roles and resource allocation need to be addressed to ensure acceptability of interventions to HCP involved in delivery.

Enhancing the Behaviour Change Wheel with synthesis, stakeholder involvement and decision-making: a case example using the 'Enhancing the Quality of Psychological Interventions Delivered by Telephone' (EQUITy) research programme

Background

Using frameworks such as the Behaviour Change Wheel to develop behaviour change interventions can be challenging because judgement is needed at various points in the process and it is not always clear how uncertainties can be resolved. We propose a transparent and systematic three-phase process to transition from a research evidence base to a behaviour change intervention. The three phases entail evidence synthesis, stakeholder involvement and decision-making. We present the systematic development of an intervention to enhance the quality of psychological treatment delivered by telephone, as a worked example of this process.

Method

In phase 1 (evidence synthesis), we propose that the capabilities (C), opportunities (O) and motivations (M) model of behaviour change (COM-B) can be used to support the synthesis of a varied corpus of empirical evidence and to identify domains to be included in a proposed behaviour change intervention. In phase 2 (stakeholder involvement), we propose that formal consensus procedures (e.g. the RAND Health/University of California-Los Angeles Appropriateness Methodology) can be used to facilitate discussions of proposed domains with stakeholder groups. In phase 3 (decision-making), we propose that behavioural scientists identify (with public/patient input) intervention functions and behaviour change techniques using the acceptability, practicability, effectiveness/cost-effectiveness, affordability, safety/side-effects and equity (APEASE) criteria.

Results

The COM-B model was a useful tool that allowed a multidisciplinary research team, many of whom had no prior knowledge of behavioural science, to synthesise effectively a varied corpus of evidence (phase 1: evidence synthesis). The RAND Health/University of California-Los Angeles Appropriateness Methodology provided a transparent means of involving stakeholders (patients, practitioners and key informants in the present example), a structured way in which they could identify which of 93 domains identified in phase 1 were essential for inclusion in the intervention (phase 2: stakeholder involvement). Phase 3 (decision-making) was able to draw on existing Behaviour Change Wheel resources to revisit phases 1 and 2 and facilitate agreement among behavioural scientists on the final intervention modules. Behaviour changes were required at service, practitioner, patient and community levels.

Conclusion

Frameworks offer a foundation for intervention development but require additional elucidation at each stage of the process. The decisions adopted in this study are designed to provide an example on how to resolve challenges while designing a behaviour change intervention. We propose a three-phase process, which represents a transparent and systematic framework for developing behaviour change interventions in any setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01122-2.

The Use of Fear versus Hope in Health Advertisements: The Moderating Role of Individual Characteristics on Subsequent Health Decisions in Chile

No studies have addressed the way the effectiveness of fear and hope advertisements differs across differently characterized individuals. The present study aims to find out in which situations related to different individual characteristics do fear and hope advertisements work as tools in generating healthy eating intention and physical activity intention. This study conducted an experiment using 283 adults from Chile. The results suggest that fear versus hope appeals in health advertisements have a more positive influence on healthy eating intention. The results suggest that the effect of fear advertisements on healthy eating intention is positively moderated by the frequency of fast food consumption and is negatively moderated by self-efficacy. The results suggest that fear versus hope appeals in health advertisements have no main effect on physical activity intention. However, the results suggest that the effect of fear advertisements on physical activity intention is positively moderated by perceived body weight and past healthy eating behavior and is negatively moderated by subjective norms. The results indicate that when making health advertising, homogenous messages are not persuasive for heterogeneous audiences. The present study results suggest that fear and hope advertisements should be delivered considering the individual characteristics identified in the present study.