Original article
Parent preferences for telephone coaching to prevent and manage childhood obesity Rachel E Blaine,1 Lori Pbert,2 Alan C Geller,3 E Michael Powers,4 Kathleen Mitchell5 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ postgradmedj-2014-132928). 1
Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA 2 Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA 3 Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts, USA 4 Vanderbilt University School of Medicine, Nashville, Tennessee USA 5 Department of Pediatrics, Harvard Vanguard Medical Associates, Watertown, Massachusetts, USA Correspondence to Ms Rachel E Blaine, Department of Nutrition, Harvard School of Public Health, 677 Huntington Ave, Building 2, Room #320, Boston, MA 02115, USA; [email protected] Received 29 July 2014 Revised 8 January 2015 Accepted 8 February 2015 Published Online First 26 March 2015
ABSTRACT Objective To assess parent preferences for utilisation of a parent-focused, telephone-based coaching service, or ‘FITLINE,’ to prevent or manage childhood obesity. Methods A cross-sectional survey of parents of children aged 2–12 years was conducted at a paediatric practice in Greater Boston, Massachusetts, USA, between July 2012 and May 2013. Parents received questionnaires with clinic visit paperwork and opted-in to the study by returning them to clinic staff or by mail. The anonymous pen-to-paper questionnaire assessed parents’ potential FITLINE utilisation, preferences regarding educational content and logistics, and parent/ child demographics. Simple logistical regression was used to assess associations between parent and child factors and FITLINE interest. Results Among n=114 participants, most parents reported being very likely (n=53, 48%) or somewhat likely (n=44, 40%) to use a FITLINE-promoting healthy habits for children if it was made available. Interest in a FITLINE was greatest among overweight or obese parents (OR 3.12, CI 1.17 to 8.30) and those with children aged 50% report lacking referral resources.5 A recent call to action for primary care practice underscored the critical need for referral mechanisms to address childhood weight, citing few systems in place for individualised counselling and education for families.6 The AAP specifically identified the need for referral systems as an essential part of a comprehensive plan for addressing paediatric obesity.3 Responding to the need for more referral options for paediatricians, our team developed a conceptual framework for a telephonebased intervention. The telephone was chosen as a modality for reaching parents because of its documented efficacy in another large-scale, challenging public health issue—tobacco addiction. In the USA, >500 000 people per year call smoking cessation ‘quitlines,’ cost-effective and easily used systems to promote behaviour change.7 A few phone sessions with a quitline counsellor increases odds of abstaining from smoking by 34% in the short term and 20% in the long term.8 Quitlines for smokers have been successfully conducted using social learning theory (SLT) as a framework,8 and a ‘FITLINE,’ or phone-based approach to paediatric weight management for parents, could build upon a similar theoretical model. The key goals for a phone coach would follow the tenets of SLT, namely provide motivation for parents to make changes (eg, reasons to offer vegetables as snacks), increase self-efficacy of parents to make changes (eg, how to prepare vegetables in appealing ways) and provide parents with strategies to address anticipated challenges (eg, ways to respond when a child refuses to try a new food). Multiple phone calls can work to reinforce new skills and behaviours. Since parentfocused interventions have demonstrated both lifestyle change and weight loss in overweight and obese children,9 a FITLINE warrants exploration. The purpose of this study was to assess parent preferences for utilisation of a FITLINE to prevent childhood obesity among children aged 2–12 years in a Greater Boston area at paediatric practice. Parents were defined as adult primary caregivers to the child of interest. We sought to explore whether parents, if referred, would be likely to use an educational telephone-based coaching regarding child feeding, physical activity, sleep and screen time. The findings were used to inform the development and pilot testing of an intervention for parents in the clinic population (box 1).
Blaine RE, et al. Postgrad Med J 2015;91:206–211. doi:10.1136/postgradmedj-2014-132928
Original article Box 1 How a FITLINE could prevent and address childhood obesity ▸ A majority of paediatricians report having insufficient time and resources to counsel parents about inappropriate child weight gain5 ▸ Paediatric weight management services may be inaccessible to families due to issues of cost, transportation and time10 ▸ Phone-based tobacco control ‘quitlines’ have provided successful, accessible and cost-effective behaviour change counselling to adults who wish to quit smoking7 ▸ Similarly, a phone-based coaching service for parents (‘FITLINE’) which emphasises healthy family behaviours may be a viable large-scale public health referral option for paediatricians ▸ Parent-focused interventions have demonstrated both lifestyle change and weight loss in overweight and obese children9 METHODS Study setting and recruitment Between July 2012 and May 2013, we conducted a crosssectional survey of adult parents of children aged 2–12 years visiting an outpatient paediatric medical practice in Greater Boston, Massachusetts, USA (box 2). When parents arrived at the office, medical staff offered them a study packet with regular appointment check-in paperwork. The study packet included information about the survey, a consent form and an English language pen-to-paper questionnaire designed for selfadministration. Parents opted-in to the study by completing the anonymous questionnaires while waiting for their child’s appointment. Parents had the option to return questionnaires immediately to a box in the waiting room or receive a selfaddressed stamped envelope to mail them at a later date. No monetary incentives were provided for participation.
Primary outcome measure To assess parent interest in a FITLINE, we developed a survey questionnaire containing a brief description of the proposed intervention (figure 1), followed by questions regarding parent attitudes towards the service. Parents’ likelihood to use a FITLINE was our primary outcome measure. On a scale of ‘very likely’, ‘somewhat likely’ or ‘not at all likely’, parents were asked, “How likely do you think you would be to use this FITLINE if it was made available to you?” The online supplementary appendix contains the complete questionnaire.
Questionnaire development We developed a pen-to-paper questionnaire to facilitate understanding of parent preferences regarding FITLINE content and logistics. Parents read a brief description of the proposed
Box 2 Study setting ▸ Location: Waiting room of an outpatient paediatric office in Watertown, Massachusetts, an urban city in the Greater Boston area. ▸ Paediatric patients served during study period: 5000 ▸ Clinicians: Six paediatricians (2.5 Full-time equivalent) and one nurse practitioner (0.75 full-time equivalent)
FITLINE prior to reporting their preferences (figure 1). Parent preferences for educational topics (eg, healthy food shopping) were assessed by asking parents to rate their interest in each topic using a scale of ‘very interested’, ‘somewhat interested’ or ‘not at all interested’. Parent preferences for how likely they would be to use a FITLINE based on referral modality (eg, paediatrician, employer) was assessed on a scale of ‘much more likely’, ‘somewhat more likely’ and ‘no change’. Parent preferences for how likely they would be to use a FITLINE based on content delivery modality (eg, live phone calls, text message) were assessed on a scale of ‘much more likely’, ‘somewhat more likely’ and ‘no change.’ Finally, parents were asked about accessibility considerations such as preferred hours of operation, frequency of calls and timing of calls. To assess readability, we pilot tested these questionnaire items with a sample (n=9) of parents. Based on pilot testing feedback, the telephone-based service was called a FITLINE in the questionnaire to allow parents to visualise a concrete referral option. We assessed parent and child demographics to understand factors predictive of FITLINE utilisation: both parent and child age, sex, race/ethnicity and calculated BMI (kg/m2) using selfreported weights and heights. If there was more than one child, we asked the parent to report on their youngest child who was aged at least 2 years and no >12 years because we believed a FITLINE would likely attract parents of younger children, as influence and control over feeding and other activities are greatest in early childhood.11
DATA ANALYSIS We performed statistical analyses to identify FITLINE, parent and child factors associated with FITLINE utilisation, defining those with a self-reported interest level of ‘very likely’ as likely users. To describe parent and child characteristics of interest, we obtained frequencies for categorical variables and mean values and SDs for continuous variables. Simple logistical regression was used to assess associations between these factors and FITLINE interest. Age of youngest child appeared to be a significant modifier of parent interest, so adjusted ORs were obtained using multivariate logistical regression controlling for child age. To test for differences in parent preferences for educational topics and tools based on child age, we used χ2 tests. All analyses were conducted using Stata V.12.0 (Stata Corporation, College Station, Texas, USA).
RESULTS Participants Parent characteristics Among the 114 parents who participated in our study, the majority returned questionnaires in the waiting room (n=91, 80%) versus via mail using a prepaid envelope (n=23, 20%). Parents were primarily white, college educated and women (table 1). Parent ages ranged from 27 to 59 years, with a median age of 39 years. Many were either overweight or obese (n=43, 38%) based on BMI calculated from self-reported weight and height; however, there was insufficient data to calculate BMI for one in four parents (n=28, 25%). Most parents were married (n=76, 72%) and employed (n=63, 60%). One grandmother, a godmother and an aunt were included in the study as they fulfilled a parental role as primary caregivers of the child.
Child characteristics Parents reported on their youngest child aged 2–12 years, with a median age of 5 years. Parents reported on female children (59%) slightly more than male children. Based on BMI
Blaine RE, et al. Postgrad Med J 2015;91:206–211. doi:10.1136/postgradmedj-2014-132928
207
Original article Figure 1 Sample text from survey instrument introducing the FITLINE concept. After participants read statement A, they were asked a variety of questions regarding their level of interest using the FITLINE and their accessibility preferences (call length, frequency, and time). Statement B was used to illustrate potential topics that parents might discuss with a FITLINE coach and was followed by questions regarding participants’ level of interest in these topics.
Table 1 Parent likelihood* to use FITLINE based on parent and child† characteristics (n=114) Very likely to use FITLINE Total, n (%) Parent characteristics All Sex Female Male Age,§ years ≥39 College degree ≤College degree Body mass index (BMI) Normal (≤18.5 BMI
Parent preferences for telephone coaching to prevent and manage childhood obesity Rachel E Blaine,1 Lori Pbert,2 Alan C Geller,3 E Michael Powers,4 Kathleen Mitchell5 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ postgradmedj-2014-132928). 1
Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA 2 Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA 3 Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts, USA 4 Vanderbilt University School of Medicine, Nashville, Tennessee USA 5 Department of Pediatrics, Harvard Vanguard Medical Associates, Watertown, Massachusetts, USA Correspondence to Ms Rachel E Blaine, Department of Nutrition, Harvard School of Public Health, 677 Huntington Ave, Building 2, Room #320, Boston, MA 02115, USA; [email protected] Received 29 July 2014 Revised 8 January 2015 Accepted 8 February 2015 Published Online First 26 March 2015
ABSTRACT Objective To assess parent preferences for utilisation of a parent-focused, telephone-based coaching service, or ‘FITLINE,’ to prevent or manage childhood obesity. Methods A cross-sectional survey of parents of children aged 2–12 years was conducted at a paediatric practice in Greater Boston, Massachusetts, USA, between July 2012 and May 2013. Parents received questionnaires with clinic visit paperwork and opted-in to the study by returning them to clinic staff or by mail. The anonymous pen-to-paper questionnaire assessed parents’ potential FITLINE utilisation, preferences regarding educational content and logistics, and parent/ child demographics. Simple logistical regression was used to assess associations between parent and child factors and FITLINE interest. Results Among n=114 participants, most parents reported being very likely (n=53, 48%) or somewhat likely (n=44, 40%) to use a FITLINE-promoting healthy habits for children if it was made available. Interest in a FITLINE was greatest among overweight or obese parents (OR 3.12, CI 1.17 to 8.30) and those with children aged 50% report lacking referral resources.5 A recent call to action for primary care practice underscored the critical need for referral mechanisms to address childhood weight, citing few systems in place for individualised counselling and education for families.6 The AAP specifically identified the need for referral systems as an essential part of a comprehensive plan for addressing paediatric obesity.3 Responding to the need for more referral options for paediatricians, our team developed a conceptual framework for a telephonebased intervention. The telephone was chosen as a modality for reaching parents because of its documented efficacy in another large-scale, challenging public health issue—tobacco addiction. In the USA, >500 000 people per year call smoking cessation ‘quitlines,’ cost-effective and easily used systems to promote behaviour change.7 A few phone sessions with a quitline counsellor increases odds of abstaining from smoking by 34% in the short term and 20% in the long term.8 Quitlines for smokers have been successfully conducted using social learning theory (SLT) as a framework,8 and a ‘FITLINE,’ or phone-based approach to paediatric weight management for parents, could build upon a similar theoretical model. The key goals for a phone coach would follow the tenets of SLT, namely provide motivation for parents to make changes (eg, reasons to offer vegetables as snacks), increase self-efficacy of parents to make changes (eg, how to prepare vegetables in appealing ways) and provide parents with strategies to address anticipated challenges (eg, ways to respond when a child refuses to try a new food). Multiple phone calls can work to reinforce new skills and behaviours. Since parentfocused interventions have demonstrated both lifestyle change and weight loss in overweight and obese children,9 a FITLINE warrants exploration. The purpose of this study was to assess parent preferences for utilisation of a FITLINE to prevent childhood obesity among children aged 2–12 years in a Greater Boston area at paediatric practice. Parents were defined as adult primary caregivers to the child of interest. We sought to explore whether parents, if referred, would be likely to use an educational telephone-based coaching regarding child feeding, physical activity, sleep and screen time. The findings were used to inform the development and pilot testing of an intervention for parents in the clinic population (box 1).
Blaine RE, et al. Postgrad Med J 2015;91:206–211. doi:10.1136/postgradmedj-2014-132928
Original article Box 1 How a FITLINE could prevent and address childhood obesity ▸ A majority of paediatricians report having insufficient time and resources to counsel parents about inappropriate child weight gain5 ▸ Paediatric weight management services may be inaccessible to families due to issues of cost, transportation and time10 ▸ Phone-based tobacco control ‘quitlines’ have provided successful, accessible and cost-effective behaviour change counselling to adults who wish to quit smoking7 ▸ Similarly, a phone-based coaching service for parents (‘FITLINE’) which emphasises healthy family behaviours may be a viable large-scale public health referral option for paediatricians ▸ Parent-focused interventions have demonstrated both lifestyle change and weight loss in overweight and obese children9 METHODS Study setting and recruitment Between July 2012 and May 2013, we conducted a crosssectional survey of adult parents of children aged 2–12 years visiting an outpatient paediatric medical practice in Greater Boston, Massachusetts, USA (box 2). When parents arrived at the office, medical staff offered them a study packet with regular appointment check-in paperwork. The study packet included information about the survey, a consent form and an English language pen-to-paper questionnaire designed for selfadministration. Parents opted-in to the study by completing the anonymous questionnaires while waiting for their child’s appointment. Parents had the option to return questionnaires immediately to a box in the waiting room or receive a selfaddressed stamped envelope to mail them at a later date. No monetary incentives were provided for participation.
Primary outcome measure To assess parent interest in a FITLINE, we developed a survey questionnaire containing a brief description of the proposed intervention (figure 1), followed by questions regarding parent attitudes towards the service. Parents’ likelihood to use a FITLINE was our primary outcome measure. On a scale of ‘very likely’, ‘somewhat likely’ or ‘not at all likely’, parents were asked, “How likely do you think you would be to use this FITLINE if it was made available to you?” The online supplementary appendix contains the complete questionnaire.
Questionnaire development We developed a pen-to-paper questionnaire to facilitate understanding of parent preferences regarding FITLINE content and logistics. Parents read a brief description of the proposed
Box 2 Study setting ▸ Location: Waiting room of an outpatient paediatric office in Watertown, Massachusetts, an urban city in the Greater Boston area. ▸ Paediatric patients served during study period: 5000 ▸ Clinicians: Six paediatricians (2.5 Full-time equivalent) and one nurse practitioner (0.75 full-time equivalent)
FITLINE prior to reporting their preferences (figure 1). Parent preferences for educational topics (eg, healthy food shopping) were assessed by asking parents to rate their interest in each topic using a scale of ‘very interested’, ‘somewhat interested’ or ‘not at all interested’. Parent preferences for how likely they would be to use a FITLINE based on referral modality (eg, paediatrician, employer) was assessed on a scale of ‘much more likely’, ‘somewhat more likely’ and ‘no change’. Parent preferences for how likely they would be to use a FITLINE based on content delivery modality (eg, live phone calls, text message) were assessed on a scale of ‘much more likely’, ‘somewhat more likely’ and ‘no change.’ Finally, parents were asked about accessibility considerations such as preferred hours of operation, frequency of calls and timing of calls. To assess readability, we pilot tested these questionnaire items with a sample (n=9) of parents. Based on pilot testing feedback, the telephone-based service was called a FITLINE in the questionnaire to allow parents to visualise a concrete referral option. We assessed parent and child demographics to understand factors predictive of FITLINE utilisation: both parent and child age, sex, race/ethnicity and calculated BMI (kg/m2) using selfreported weights and heights. If there was more than one child, we asked the parent to report on their youngest child who was aged at least 2 years and no >12 years because we believed a FITLINE would likely attract parents of younger children, as influence and control over feeding and other activities are greatest in early childhood.11
DATA ANALYSIS We performed statistical analyses to identify FITLINE, parent and child factors associated with FITLINE utilisation, defining those with a self-reported interest level of ‘very likely’ as likely users. To describe parent and child characteristics of interest, we obtained frequencies for categorical variables and mean values and SDs for continuous variables. Simple logistical regression was used to assess associations between these factors and FITLINE interest. Age of youngest child appeared to be a significant modifier of parent interest, so adjusted ORs were obtained using multivariate logistical regression controlling for child age. To test for differences in parent preferences for educational topics and tools based on child age, we used χ2 tests. All analyses were conducted using Stata V.12.0 (Stata Corporation, College Station, Texas, USA).
RESULTS Participants Parent characteristics Among the 114 parents who participated in our study, the majority returned questionnaires in the waiting room (n=91, 80%) versus via mail using a prepaid envelope (n=23, 20%). Parents were primarily white, college educated and women (table 1). Parent ages ranged from 27 to 59 years, with a median age of 39 years. Many were either overweight or obese (n=43, 38%) based on BMI calculated from self-reported weight and height; however, there was insufficient data to calculate BMI for one in four parents (n=28, 25%). Most parents were married (n=76, 72%) and employed (n=63, 60%). One grandmother, a godmother and an aunt were included in the study as they fulfilled a parental role as primary caregivers of the child.
Child characteristics Parents reported on their youngest child aged 2–12 years, with a median age of 5 years. Parents reported on female children (59%) slightly more than male children. Based on BMI
Blaine RE, et al. Postgrad Med J 2015;91:206–211. doi:10.1136/postgradmedj-2014-132928
207
Original article Figure 1 Sample text from survey instrument introducing the FITLINE concept. After participants read statement A, they were asked a variety of questions regarding their level of interest using the FITLINE and their accessibility preferences (call length, frequency, and time). Statement B was used to illustrate potential topics that parents might discuss with a FITLINE coach and was followed by questions regarding participants’ level of interest in these topics.
Table 1 Parent likelihood* to use FITLINE based on parent and child† characteristics (n=114) Very likely to use FITLINE Total, n (%) Parent characteristics All Sex Female Male Age,§ years ≥39 College degree ≤College degree Body mass index (BMI) Normal (≤18.5 BMI
