Home Uncategorized Module 4 Case-fighting chronic disease and community nutrition intervention

Uncategorized

Module 4 Case-fighting chronic disease and community nutrition intervention

BEFORE BEGINNING ASSIGNMENT. PLEASE READ THE REQUIRED READING IN THE ATTACHMENTS.

HOMEWORK ASSIGNMENT

Case Assignment-Fighting Chronic Disease and Community Nutrition Intervention

For this Case Assignment you will expand your understanding of core public health roles; specifically nutrition. Please answer these questions:

1. Discuss the differences in the role of public health in the prevention of infectious diseases and chronic diseases. In your opinion, which will be more important to the health of our nations over the next 20 to 30 years?

2. Discuss and explain the role of prevention in fighting and controlling the spread of chronic diseases and the impact of chronic diseases on health care spending.

3. Discuss the core public health responsibilities and how they have had an impact on nutritional issues in America, including obesity and diabetes. Do you believe that they have been effectively or ineffectively managed by public health agencies? Define and discuss the role of State government in this area and how it differs from that of the Federal government.

4. How do community nutritionists, public health nutritionist, and clinical nutritionist differ?

5. Why is nutrition important in health and disease treatment, control and prevention and how is nutrition related to any of the Social Determinants of Health?

6. Which organizations are involved in public health nutrition? Of the organizations identified which one has the most influence over public policy for public health nutrition? Please justify your response.

Please submit your Case Assignment at the end of Module 4. Please refer to the Trident calendar for exact due dates. Please contact me at any time should you have any questions.

Assignment Expectations

1. You are expected to consult the scholarly literature in preparing your paper; you are also expected to incorporate relevant background readings.

2. Your paper should be written in your own words. This will enable your instructor to assess your level of understanding.

3. In order to earn full credit, you must clearly show that you have read ALL required Background materials.

4. Be sure to cite your references in the text of all papers and on the reference list at the end. For examples, look at the way the references are listed in the modules and on the Background reading list. Remember, any statement that you make that is not common knowledge or that originates from your synthesis or interpretation of materials you have read must have a citation associated with it. For guidelines on in-text citations, visit the following website:

https://owl.english.purdue.edu/owl/resource/560/02/

5. Proofread your paper to be sure grammar and punctuation are correct and that each part of the assignment has been addressed clearly and completely.

6. Your assignment will not be graded until you have submitted an Originality Report with a Similarity Index (SI) score <15% (excluding direct quotes, quoted assignment instructions, and references). Papers not meeting this requirement by the end of the session will receive a score of 0 (grade of F). Papers with a lower SI score may be returned for revisions. For example, if one paragraph accounting for only 10% of a paper is cut and pasted, the paper could be returned for revision, despite the low SI score. Please use the report and your SI score as a guide to improve the originality of your work.

Length: Your paper should be 5-7 pages (double-spaced) in length, and include 5-7 peer-reviewed reference citations (excluding title page and references)

Note: Wikipedia is not an acceptable source of information.

Module 4 – Background – Reading Requirement

kim woodskim woods

RESEARCH ARTICLE

Implementation of Patient-Centered

Education for Chronic-Disease Management

in Uganda: An Effectiveness Study

Trishul Siddharthan1,2*, Tracy Rabin2, Maureen E. Canavan3, Faith Nassali4,
Phillip Kirchhoff5, Robert Kalyesubula4, Steven Coca2,6, Asghar Rastegar2, Felix Knauf2,7

1 Division of Pulmonary and Critical Care, Johns Hopkins University, Johns Hopkins School of Medicine,

Baltimore, Maryland, United States of America, 2 Department of Medicine, Yale School of Medicine, Yale

University, New Haven, Connecticut, United States of America, 3 Global Health Leadership Institute, Yale

University, New Haven, Connecticut, United States of America, 4 College of Health Sciences, Makerere

University, Kampala, Uganda, 5 Department of Surgery, University Hospital Basel, Basel, Switzerland,

6 Department of Nephrology, Mt. Sinai Hospital, Mount Sinai School of Medicine, New York, New York,

United States of America, 7 Department of Nephrology, Friedrich-Alexander-Universität Erlangen-Nürnberg,

Erlangen, Germany

* Tsiddha1@jhmi.edu

Abstract

Background

The majority of non-communicable disease related deaths occur in low- and middle-income

countries. Patient-centered care is an essential component of chronic disease management

in high income settings.

Objective

To examine feasibility of implementation of a validated patient-centered education tool

among patients with heart failure in Uganda.

Design

Mixed-methods, prospective cohort.

Settings

A private and public cardiology clinic in Mulago National Referral and Teaching Hospital,

Kampala, Uganda.

Participants

Adults with a primary diagnosis of heart failure.

Interventions

PocketDoktor Educational Booklets with patient-centered health education.

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 1 / 12

a11111

OPENACCESS

Citation: Siddharthan T, Rabin T, Canavan ME,

Nassali F, Kirchhoff P, Kalyesubula R, et al. (2016)

Implementation of Patient-Centered Education for

Chronic-Disease Management in Uganda: An

Effectiveness Study. PLoS ONE 11(11): e0166411.

doi:10.1371/journal.pone.0166411

Editor: Christophe Leroyer, Universite de Bretagne

Occidentale, FRANCE

Received: June 15, 2016

Accepted: October 29, 2016

Published: November 16, 2016

the Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: Data has been

uploaded as Supporting Information.

Funding: Trishul Siddharthan received funding in

part from a Fulbright Scholar Award and from the

Fogarty International Center of the National

Institutes of Health under Award No.

5R25TW009340. Felix Knauf, Trishul Siddharthan,

Tracy Rabin, Robert Kalyesubula and Asghar

Rastegar are supported by the Else Kröner-

Fresenius-Stifung to establish a center of

excellence for patient-centered care and non-

communicable disease management in Uganda

http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0166411&domain=pdf

http://creativecommons.org/licenses/by/4.0/

Main Measures

The primary outcomes were the change in Patient Activation Measure (PAM-13), as well as

the acceptability of the PocketDoktor intervention, and feasibility of implementing patient-

centered education in outpatient clinical settings. Secondary outcomes included the change

in satisfaction with overall clinical care and doctor-patient communication.

Key

Results

A total of 105 participants were enrolled at two different clinics: the Mulago Outpatient

Department (public) and the Uganda Heart Institute (private). 93 participants completed fol-

low up at 3 months and were included in analysis. The primary analysis showed improved

patient activation measure scores regarding disease-specific knowledge, treatment options

and prevention of exacerbations among both groups (mean change 0.94 [SD = 1.01], 1.02

[SD = 1.15], and 0.92 [SD = 0.89] among private paying patients and 1.98 [SD = 0.98], 1.93

[SD = 1.02], and 1.45 [SD = 1.02] among public paying patients, p<0.001 for all values) after exposure to the intervention; this effect was significantly larger among indigent patients.

Participants reported that materials were easy to read, that they had improved knowledge of

disease, and stated improved communication with physicians.

Conclusions

Patient-centered medical education can improve confidence in self-management as well as

satisfaction with doctor-patient communication and overall care in Uganda. Our results

show that printed booklets are locally appropriate, highly acceptable and feasible to imple-

ment in an LMIC outpatient setting across socioeconomic groups.

Introduction

Greater than 80% of non-communicable disease (NCD) related deaths occur in low- and mid-

dle-income countries (LMICs) [1]. The vast majority of these deaths are attributable to cardio-

vascular diseases, cancer, chronic respiratory conditions, and/or diabetes which are related to

four largely modifiable risk factors–tobacco, unhealthy diet, physical inactivity and alcohol [1].

Beyond the human toll, the economic burden of NCDs is expected to be crippling for LMICs,

potentially reversing all gains that have been achieved by poverty reduction efforts [2]. It is

estimated that $47 trillion in global economic output will be lost due to NCDs by 2030 and,

thus, that the cost of inaction would exceed that of proposed interventions for NCDs [2]. As a

consequence, chronic disease management has been identified by the WHO as a key priority

and “best buy” for combating the epidemiologic transition to NCDs in LMIC settings [1–3].

Patient-centered education is an essential component in chronic disease management [4].

Defined as a partnership between health care providers, patients, and families, patient-cen-

tered education provides patients with the information necessary to participate in medical

decision-making. Medical care that is sensitive to patient dignity has been demonstrated to

enhance information sharing between all members of a treatment team [4, 5]. Patient-centered

education has been shown to a) foster communication [4], b) improve medication adherence

[6, 7], c) decrease hospitalization [6], and d) affect positive changes in health habits for patients

with chronic diseases in high-income settings [8, 9]. Among hospitalized patients, those who

understand their discharge instructions—including how to take their medications—are 30%

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 2 / 12

(2016_HA44). The content is solely the

responsibility of the authors and does not

necessarily represent the official views of the

National Institutes of Health or respective

government or non-governmental organizations.

The funders had no role in study design, data

collection and analysis, decision to publish, or

preparation of the manuscript.

Competing Interests: Felix Knauf and Phillip

Kirchhoff are co-founders of PocketDoktor Medical

Booklets. This does not alter our adherence to

PLOS ONE policies on sharing data and materials.

less likely to be readmitted [6]. Numerous studies have documented inadequate patient-cen-

tered care in high-income settings [4, 5, 9, 10]. Patient discontent has been demonstrated even

when doctors considered communication adequate [10]. Poor communication between

patients and providers has been associated with adverse health outcomes [11]. Although a

number of single-center studies have shown low levels of patient satisfaction with care and

communication in LMICs, as well as the potential for improved health outcomes, limited data

exists regarding patient-centered communication in these settings [7, 12–14].

Public health interventions aimed at combating NCDs will require novel approaches as well

as implementation of strategies which have been previously validated in high-income settings

[15]. We describe the implementation of a previously validated patient-centered health tool

among an outpatient population with primary diagnosis of heart failure in Uganda. Uganda is

representative of many LMIC, as it is undergoing a transition in the relative burden of commu-

nicable to non-communicable diseases [16]. We examined patient-centered care among those

with heart failure, as it is a disease process requiring complex health management with longitu-

dinal follow up and has been previously studied to assess the role of doctor-patient communi-

cation in health outcomes [17, 18]. We assessed efficacy of this intervention in public and

private clinical environments as well as adaptability, acceptability and feasibility of implement-

ing patient-centered care in an LMIC setting.

Materials and Methods

Study Design, Setting and Participants

We conducted a mixed-methods, feasibility-implementation study to assess whether a patient-

centered instrument, PocketDoktor, could be incorporated into patient counseling during out-
patient visits for those with an established diagnosis of heart failure. We selected established

patients, as these individuals had already undergone the necessary diagnostic testing and

should have had some discussion of their diagnosis with a physician prior to enrollment in the

study. The study location was the outpatient department of the Mulago National Referral and

Teaching Hospital in Kampala, Uganda, which has over 400,000 outpatient visits annually

amongst the specialty clinics [12]. To assess the role of socioeconomic factors in patient-cen-

tered care and satisfaction among patients with heart failure, we conducted sampling within

an indigent patient population at the Mulago Outpatient Department (MOPD) Heart Failure

Clinic, as well as among the outpatient clinic at the Uganda Heart Institute (UHI), a private-

pay institution at the same physical location. While services are free at MOPD, UHI requires a

consultation fee of 20,000 USh ($6), as well as fees for additional diagnostic testing and medi-

cations. This study was approved by the Yale University Institutional Review Board, Mulago

Hospital Institutional Review Board and the Uganda National Council for Science and Tech-

nology. Written consent was obtained in English or Luganda for each participant and consent

forms were approved by IRBs.

PocketDoktor

PocketDoktor is a patient-centered education tool that facilitates provider and patient commu-
nication by describing diseases in short, illustrated booklets with accompanying text in layper-

son prose and associated pictograms. The booklets describe disease processes, diagnosis,

treatment and long-term management. PocketDoktor contains interactive features that are
designed to prompt patients to ask questions at each point of discussion, facilitating conversa-

tion about disease. To date the booklets have been evaluated for acceptability and satisfaction

among European patients, showing high levels of satisfaction and an increase in self-reported

disease-specific knowledge [19].

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 3 / 12

We integrated PocketDoktor booklets and health education within existing outpatient clinic
visits at MOPD and UHI. The intervention consisted of a 20–30 minute appointment with a

study health educator who went through the PocketDoktor booklets after the physicians dis-
cussed disease management with the patients. The health educator was trained in disease pro-

cess, diagnosis and management of heart failure. The patient-centered education occurred in

the same clinical space to facilitate discussion between patients, caregivers and providers. For

those patients who were illiterate, the health educator utilized included pictograms to convey

key concepts and engaged family members/caregivers in the discussion. Patients were given

booklets to take home and encouraged to make note of questions for their next appointment.

Formative Phase

A formative phase involving semi-structured interviews was conducted prior to initiation of

the study with local providers and patients from the outpatient ward of Mulago Hospital. Pock-
etDoktor booklets were translated from English to Luganda by certified translators. We part-
nered with three local physicians to rephrase complex medical terminology and redesign

pictograms. Semi-structured interviews consisting of a convenience sample of 10 patients

(equal distribution of males and females) and associated caretakers was conducted to assess

adaptation, content, length and format. Comments were coded and content was updated

accordingly. PocketDoktor booklets were back-translated for accuracy.

Efficacy Trial

The efficacy trial consisted of a prospective-cohort study conducted between November 2014

and April 2015. Clinic physicians at UHI and MOPD were informed of the study on days of

recruitment and were asked to refer all patients with a known diagnosis of heart failure. Inclu-

sion criteria for the study included a primary diagnosis of heart failure (confirmed by echocar-

diography), plans for future follow up visits, and age greater than eighteen years. We defined

heart failure as the presence of symptoms and signs of disease with objective evidence of car-

diac dysfunction by echocardiography using the European Society of Cardiology Guidelines

[20]. Exclusion criteria included lack of fluency in Luganda or English. Demographic informa-

tion including gender, residence, occupation, income, level of education, literacy, marital sta-

tus and self-reported health status was collected from those who consented.

Outcome Measures

Quantitative questionnaires concerning patient activation and satisfaction as well as qualitative

interviews were applied before and after intervention. The primary outcome of the feasibility

study was change in level of patient activation after administration of PocketDoktor interven-
tion. The Patient-Activation Measures (PAM-13) is a 13-item questionnaire designed to elicit

responses from a person about his or her attitudes toward confidence, knowledge and ability

to self-managing health and has been utilized to assess patient-centered care among those with

chronic diseases [21]. The scale is based on the Guttman technique with items ordered accord-

ing to level of difficulty and has been validated in numerous settings to assess doctor-patient

communication and health outcomes [21–23]. We assessed patient activation in three domains

(knowledge of condition, medical treatment options available, and ways to prevent further

problems with health condition). Secondary outcomes included satisfaction with materials as

well as satisfaction with doctor-patient communication. A patient satisfaction questionnaire,

which was validated by Nabbuye-Skeandi et al. in the same hospital setting, was adapted for

this study [12, 24]. The responses were recorded on a five-point Likert-type scale of response

options, ranging from strongly disagree to strongly agree to elicit endorsement of a particular

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 4 / 12

statement. In addition, we collected data concerning satisfaction with PocketDoktor materials,
patient-physician communication and overall satisfaction with care. Semi-structured inter-

views were conducted examining the patient’s understanding of heart failure (including signs

and symptoms, diagnosis and management), patient-doctor communication and overall satis-

faction. Patients were followed up at their next appointment (3 months later, on average) and

repeat questionnaires were administered and qualitative interviews were conducted.

Data Analysis

Mean scores were calculated as a composite measure of satisfaction using each of the items in

the general satisfaction indicator by clinic type with lower scores indicating greater satisfac-

tion. Also, mean scores for the three dimensions of patient activation were calculated for each

subject. In descriptive analysis frequencies and proportions were obtained for categorical vari-

ables, while means and standard deviations (SDs) were calculated for continuous variables. All

associations were considered statistically significance at P-values of�0.05. Data were entered
into Epidata software and analyzed using the STATA version 12.0.

Qualitative data was analyzed using grounded theory with a constant comparative approach

[25]. Two separate investigators analyzed data (TS, FN), independently labelling concepts and

generate codes based on the concepts until theoretical saturation was reached and no new

codes were bring introduced in the interviews. Coded lines were then compared and applied

based on group consensus among the investigators. This paper describes the results of the for-

mative phase as well as the quantitative portion of the study; we anticipate disseminating the

qualitative outcomes in a separate manuscript.

Results

105 participants were referred to the health educator by the attending physician and all con-

sented to participate in the study. 93 completed baseline and follow up surveys. Of those who

were lost to follow up, 1 participant died and 11 did not follow up for the duration of recruit-

ment. Participants with heart failure seen in the clinic were predominantly female (65%

[n = 61]). 48% (n = 45) of those who were included in analysis were seen in the private clinic

(UHI) while the rest were seen in the general public outpatient clinic (MOPD) (Table 1).

Lower levels of formal employment were observed in the public clinics compared to private

clinics. Participants in the public clinics stated lower levels of income compared to those seen

in private clinics. In addition, those followed in the public clinics reported lower levels of edu-

cation and literacy compared to those in the private setting. There were no significant differ-

ences in self-reported health status between public and private clinics, with the majority in

both settings reporting poor or fair health status.

Few participants stated strong baseline levels of satisfaction with doctor-patient communi-

cation and overall care in both public and private clinical settings at baseline, (2.3% [n = 1]

and 28.6% [n = 14] respectively). Levels of satisfaction with doctor-patient communication

and overall care were lower among those followed in public clinics compared to private set-

tings (6.8% [3] vs 24.5% [12], p = 0.005 (Table 2).

Patient Activation Measure Outcomes

At baseline participants in both private and public outpatient clinics reported low levels of

patient activation in regards to their condition, treatment options, and ways to prevent exacer-

bation, though those seen in public outpatient settings reported lower levels compared to

those in the private settings (Table 3). At follow up, participants in both clinic settings reported

improvement in activation measure for each respective category (80% stated improvement in

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 5 / 12

disease knowledge, 80% stated improved knowledge of treatment options, and 83% stated

improved knowledge of ways to present worsening of condition, p<0.001). Greater improve-

ment in activation measures were noticed among participants followed in public clinics versus

private ones with 70.5% and 75.5% stating, respectively, that they strongly agreed with the

statements, “I understand the nature and causes of my health condition.” (Tables 4 & 5).

Appropriateness, Acceptability and Feasibility

PocketDoktor booklets were found to be locally appropriate and accepted through satisfaction
surveys (Table 6). All participants expressed being satisfied to some extent with the education

materials. They also felt that the writing and information had moderate or extreme clarity with

Table 1. Distribution of sociodemographic variable by clinic status (N = 93).

Variable Private N = 49 (%) Public N = 44 n (%)

p-value

Gender 0.388

Male 19 (38.8) 13 (29.6)

Female 30 (61.2) 31 (70.4)

Occupation 0.292

Employed 12 (24.5) 6 (13.6)

Unemployed 25 (51.0) 29 (65.9)

Self-employed 12 (24.5) 9 (20.5)

Average Monthly Income 0.001

150,000USH 34 (69.4) 40 (90.9)

150,000–500,000 USH 6 (12.2) 3 (6.8)

500,000-1million USH 6 (12.2) 1 (2.3)

1million-2million USH 1 (2.0) 0 (0.0)

>2 million USH 2 (4.1) 0 (0.0)
Level of Education 0.072

No study 7 (14.3) 10 (22.7)

Primary 12 (24.5) 17 (38.6)

Secondary 16 (32.7) 13 (29.6)

University 14 (28.6) 4 (9.1)

Level of Reading/Writing <0.001 Illiterate 1 (2.0) 12 (27.3)

Some reading/writing 24 (49.0) 23 (52.3)

Fully literate 24 (50.0) 9 (20.5)

Marital Status 0.196

Married 34 (69.4) 22 (50.0)

Divorced 4 (8.2) 2 (4.6)

Widowed 5 (10.2) 10 (22.7)

Single 4 (8.2) 8 (18.2)

Separated 2 (4.1) 2 (4.6)

Self-Reported health status 0.203

Poor 17 (34.7) 19 (43.2)

Fair 25 (51.0) 24 (54.6)

Good 6 (12.2) 1 (2.3)

Excellent 1 (2.0) 0 (0.0)

N and column percent reported. P-values are from χ2 tests. Percentages may not sum to 100 due to

rounding

doi:10.1371/journal.pone.0166411.t001

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 6 / 12

the materials being at least moderately appealing and looking at least moderately professional.

All respondents also reported being between moderately and extremely likely to recommend

the contents of the educational materials. The intervention was feasible to implement in this

setting with minimal burden to providers stated, although for the purposes of this investigation

health education was provided by a study health educator. Participants reported that they were

talked with about their disease and that pictures were used as part of the explanation. They

noted that this information generated questions and they would talk to friends and family

about the materials.

Discussion

In this mixed-methods study we examined the effect of patient-centered health education on

health activation measures among those with heart failure in outpatient settings in Uganda and

assessed the implementation of the PocketDoktor booklets with regards to appropriateness,
acceptability and feasibility of intervention. Furthermore, we described concrete differences

between public and private clinical settings, adding to the understanding of patient preferences

between different payer groups. While a number of studies have examined the effects of patient-

centered care in high-income settings, this is one of the first examining patient-centered care in

a low-income setting and informs strategies for chronic disease management in other LMICs.

Similar to prior studies, we found low levels of baseline satisfaction with care and patient-

physician communication among patients in our setting [12]. An understanding of patient

Table 2. Distribution of baseline satisfaction items by clinic status (N = 93).

Private

N = 49

Public

N = 44

p-value

Satisfaction with patient education in Mulago <0.001 Extremely satisfied 14 (28.6) 1 (2.3)

Moderately satisfied 32 (65.3) 27 (61.4)

Neither satisfied or dissatisfied 0 (0.0) 2 (4.6)

Moderately dissatisfied 3 (6.1) 12 (27.3)

Extremely dissatisfied 0 (0.0) 2 (4.6)

I am satisfied that my doctor told me about my condition, the

treatment options and how I can stay healthy.

0.005

Strongly agree 12 (24.5) 3 (6.8)

Agree 31 (63.3) 26 (59.1)

Neither agree/disagree 1 (2.0) 0 (0.0)

Disagree 5 (10.2) 15 (34.1)

Strongly disagree NA NA

doi:10.1371/journal.pone.0166411.t002

Table 3. Mean baseline PAM 13 measures

by clinic type (N = 93).

Private Mean

(SD)

Public Mean

(SD)
p-value

I understand the nature and causes of my health condition 3.82 (0.93) 2.72 (0.95) <0.001 I know the different medical treatment options available for

my health

condition

3.82 (1.03) 2.80 (0.95) <0.001

I know how to prevent further problems with my health

condition

4.02 (0.80) 3.32 (0.98) 0.003

p-values are from t-tests

doi:10.1371/journal.pone.0166411.t003

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 7 / 12

confidence in self-management is a critical step in assessing the role of a patient-centered

intervention in health outcomes. While no authors have examined patient-activation in LMIC

settings, one study found significant improvements in self-reported medication adherence and

blood pressure among a private paying population of Nigerian patients with a similar interven-

tion, consistent with our findings [14]. Our study differed from previous ones by specifically

examining the efficacy of our intervention in relation to patient-centered outcomes, as well as

feasibility of implementing the intervention among mixed-payer populations. While a signifi-

cant portion of the health-seeking population in LMIC settings is indigent, the private health

care market is substantial, and understanding differences between groups will be critical for

effective systemic strategies to manage NCDs [26].

Patient activation is a complex outcome including patient literacy, socioeconomic status

and patient-doctor communication [27, 28]. Lower levels of patient activation were observed

among participants seen in public clinics, consistent with the differences seen between public

and private patients in the patient activation component factors. Intervention with PocketDok-
tor resulted in greater improvement in activation measures among this group, possibly as a
result of the pictograms that allowed for use of the tool with patients that have limited literacy,

though these results may also represent a ceiling effect, as private paying patients had higher

baseline scores. Additionally the improvement in activation scores across domains may be a

consequence of a social acceptability response bias which have been noted in previous studies

in the region. The intervention was found to be locally appropriate and feasible. The average

time of administration was 15 minutes by the end of the study and was well received by

patients and providers alike. Of note, for the purposes of this study the intervention required

the addition of a dedicated health educator. Further research will need to be conducted to

Table 4. Change in PAM 13 measures from baseline to follow-up, stratified by clinic type.

Private N = 49 Public N = 44

Change Mean (SD) p-value Change Mean (SD) p-value

I understand the nature and causes of my health condition 0.94 (1.01) <0.001 1.98 (0.98) <0.001 I know the different medical treatment options available for my health condition 1.02 (1.15) <0.001 1.93 (1.02) <0.001 I know how to prevent further problems with my health condition 0.92 (0.89) <0.001 1.45 (1.02) <0.001

p-values are from χ2 test. PAM 13 scale (1–5)

doi:10.1371/journal.pone.0166411.t004

Table 5. Baseline and follow-up proportion of respondents that strongly agree with PAM 13 measures

by clinic type (N = 93).

Baseline Private n

(%)

Public n

(%)
p-value

I understand the nature and causes of my health condition 9 (18.4%) 0 (0.0%) 0.003

I know the different medical treatment options available for my health

condition

11 (22.5%) 0 (0.0%) <0.001

I know how to prevent further problems with my health condition 11 (22.5%) 1 (2.3%) 0.004

Follow-up

I understand the nature and causes of my health condition 37 (75.5%) 31 (70.5%) 0.583

I know the different medical treatment options available for my health
condition

41 (83.7%) 32 (72.7%) 0.200

I know how to prevent further problems with my health condition 46 (93.9%) 34 (77.3%) 0.022

p-values are from χ2 test. PAM 13 scale (1–5)

doi:10.1371/journal.pone.0166411.t005

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 8 / 12

assess the implementation of this model by existing members of the healthcare team (e.g. phy-

sicians, nurses, or community health workers). Given the relative low-cost of booklets, the

intervention has the potential to be scaled with limited resource burden.

Limitations of this study included the study setting. Mulago National Referral and Teaching

Hospital is a large tertiary hospital in the capital of Uganda. Although it is representative of

other LMIC hospitals in regards to limited resources, inadequate ratio of physicians to

patients, and long waits, the majority of patients with chronic disease typically receive care in

rural health settings; 80% of Uganda is rural and patients typically receive care at local health

centers or regional hospitals if at all [12, 29]. Additional investigations will need to examine

the implementation of PocketDoktor at the regional and community levels. While this pilot
aimed to assess efficacy and feasibility of implementation, larger trials assessing health out-

comes could provide necessary data to assess cost-effectiveness of patient-centered care.

Table 6. Distribution of satisfaction with educational materials at follow-up by clinic type (N = 93).

Private N = 49 Public N = 44 p-value

n (%) n (%)

Satisfaction with education materials 0.085

Extremely satisfied 43 (87.8) 32 (72.7)

Moderately satisfied 6 (12.2) 11 (25.0)

Slightly satisfied NA 1 (2.3)

Neither satisfied or dissatisfied NA NA

Slightly dissatisfied NA NA

Moderately dissatisfied NA NA

Extremely dissatisfied NA NA

Clarity of writing and information on the educational materials 0.704

Extremely clear 46 (93.9) 40 (90.9)

Moderately clear 3 (6.1) 4 (9.1)

Slightly clear NA NA

Not at all clear NA NA

Visual appeal of educational materials 0.222

Extremely appealing 48 (98.0) 40 (90.9)

Very appealing 1 (2.0) 3 (6.8)

Moderately appealing NA 1 (2.3)

Slightly appealing NA NA

Not at all appealing NA NA

Professionalism of look and feel of the educational materials 0.058

Extremely professional 44 (89.8) 32 (72.7)

Very professional 5 (10.2) 11 (25.0)

Moderately professional NA 1 (2.3)

Slightly professional NA NA

Not at all professional NA NA

Likelihood of recommending the content of the educational materials to others 0.363

Extremely likely 46 (93.9) 38 (86.4)

Very likely 3 (6.1) 5 (11.4)

Moderately likely NA 1 (2.3)

Slightly likely NA NA

Not at all likely NA NA

p-values are from Fishers exact test

doi:10.1371/journal.pone.0166411.t006

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 9 / 12

Given the rising burden of global NCD morbidity and mortality, LMIC health systems

will need to address this epidemiologic transition from the angle of both chronic disease

management and lifestyle-based shared risk factor reduction. Patient-centered approaches

will be key components of any chronic-disease management strategy [3]. Interventions

aimed at incorporating patient-centered NCD management within existing community-

based health efforts, traditionally oriented towards infectious disease and malnutrition, may

prove to be both cost-effective and transformative [30]. New technologies such as m-health

(mobile phone-based health technology) may allow for implementation of patient-centered

care directly in rural communities [31, 32]. As with any new health system intervention,

the ideal program should be low-cost, require minimal input of new resources, culturally

acceptable, and scalable.

Conclusion

This feasibility-implementation study marks an initial step toward implementing patient-cen-

tered education to address chronic illness in Uganda. Although the numbers are small, this

data also suggests that a patient-centered education strategy may even have a greater impact

on those patients who are most socially or economically disadvantaged; these are the same

individuals who, together with their families, are likely to bear the greatest burden of the loom-

ing NCD crisis.

Supporting Information

S1 File. PocketDoktor Booklet Luganda.

(PDF)

S2 File. Study Questionnaires.

(DOC)

S3 File. Baseline and Follow-up Data.

(XLSX)

Author Contributions

Conceptualization: TS FK RK SC TR AR.

Data curation: TS FN.

Formal analysis: TS SC MC.

Funding acquisition: TS FK.

Investigation: TS FN RK.

Methodology: TS FK SC TR.

Resources: FK PK.

Supervision: FK TR RK.

Visualization: TS MC SC FK.

Writing – original draft: TS FK TR.

Writing – review & editing: TS TR MC FN RK AR FK.

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 10 / 12

http://www.plosone.org/article/fetchSingleRepresentation.action?uri=info:doi/10.1371/journal.pone.0166411.s001

http://www.plosone.org/article/fetchSingleRepresentation.action?uri=info:doi/10.1371/journal.pone.0166411.s002

http://www.plosone.org/article/fetchSingleRepresentation.action?uri=info:doi/10.1371/journal.pone.0166411.s003

References
1. World Health Organization. Global status report on noncommunicable diseases 2014. Available: http://

www.who.int/nmh/publications/ncd-status-report-2014/en/

2. Bloom DE, Cafiero E, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, et al. The global eco-

nomic burden of noncommunicable diseases. Program on the Global Demography of Aging; 2012.

Available: http://www3.weforum.org/docs/WEF_Harvard_HE_

GlobalEconomicBurdenNonCommunicableDiseases_2011

3. World Health Organization. People-centred care in low-and middle-income countries. Proceedings of

Third Geneva Conference on People-Centred Care. 2010 May 5; Geneva, Switzerland. Available:

http://www.personcenteredmedicine.org/doc/genevathree/geneva2011i

4. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary

care settings: A systematic review. Prev Chronic Dis 2013; 10

5. Houle J, Beaulieu M-D, Lussier M-T, Del Grande C, Pellerin J-P, et al. Patients’ experience of chronic ill-

ness care in a network of teaching settings. Canadian Family Physician. 2012; 58(12):1366–73. PMID:

23242897

6. Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hos-

pital discharge program to decrease rehospitalization: a randomized trial. Annals of Internal Medicine.

2009; 150(3):178–87. PMID: 19189907

7. Roberts KJ. Physician-patient relationships, patient satisfaction, and antiretroviral medication adher-

ence among HIV-infected adults attending a public health clinic. AIDS Patient Care and STDs. 2002; 16

(1):43–50. doi: 10.1089/108729102753429398 PMID: 11839218

8. Lorig KR, Sobel DS, Stewart AL, Brown BW, Bandura A, Ritter P, et al. Evidence suggesting that a

chronic disease self-management program can improve health status while reducing hospitalization: a

randomized trial. Medical Care. 1999; 37(1):5–14. PMID: 10413387

9. Ratanawongsa N, Karter AJ, Parker MM, Lyles CR, Heisler M, Moffet HH et al. Communication and

medication refill adherence: the Diabetes Study of Northern California. JAMA Internal Medicine. 2013;

173(3):210–8. doi: 10.1001/jamainternmed.2013.1216 PMID: 23277199

10. Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a sys-

tematic review. The Journal of the American Board of Family Practice. 2002; 15(1):25–38. PMID:

11841136

11. Baker A. Crossing the quality chasm: A new health system for the 21st century. BMJ. 2001 Nov 17; 323

(7322):1192.

12. Nabbuye-Sekandi J, Makumbi FE, Kasangaki A, Kizza IB, Tugumisirize J, Nshimye E, et al. Patient sat-

isfaction with services in outpatient clinics at Mulago hospital, Uganda. International Journal for Quality

in Health Care. 2011; 23(5):516–23. doi: 10.1093/intqhc/mzr040 PMID: 21775313

13. Baltussen R, Yé Y, Haddad S, Sauerborn RS. Perceived quality of care of primary health care services

in Burkina Faso. Health policy and planning. 2002; 17(1):42–8. PMID: 11861585

14. Odusola AO, Nelissen H, Hendriks M, Schultsz C, Wit F, Bolarinwa OA, et al. How group-based cardio-

vascular health education affects treatment adherence and blood pressure control among insured

hypertensive nigerians: A pre-test, post-test study. World Journal of Cardiovascular Diseases. 2015; 5

(07):181.

15. Ebrahim S, Pearce N, Smeeth L, Casas JP, Jaffar S, Piot P. Tackling non-communicable diseases in

low-and middle-income countries: is the evidence from high-income countries all we need? PLoS Med.

2013; 10(1):e1001377. doi: 10.1371/journal.pmed.1001377 PMID: 23382655

16. Siddharthan T, Ramaiya K, Yonga G, Mutungi GN, Rabin TL, List JM, et al. Noncommunicable Dis-

eases In East Africa: Assessing the gaps in care and identifying opportunities for improvement. Health

Affairs. 2015; 34(9):1506–13. doi: 10.1377/hlthaff.2015.0382 PMID: 26355052

17. Griffin SJ, Kinmonth A-L, Veltman MW, Gillard S, Grant J, Stewart M. Effect on health-related outcomes

of interventions to alter the interaction between patients and practitioners: a systematic review of trials.

The Annals of Family Medicine. 2004; 2(6):595–608. doi: 10.1370/afm.142 PMID: 15576546

18. Roger VL. Epidemiology of heart failure. Circulation research. 2013; 113(6):646–59. doi: 10.1161/

CIRCRESAHA.113.300268 PMID: 23989710

19. PocketDoktor 2016 [Available: http://pocketdoktor.de/en/.

20. Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M. Guidelines for the diagnosis and

treatment of chronic heart failure: executive summary (update 2005). European heart journal. 2005; 26

(11):1115–40. doi: 10.1093/eurheartj/ehi204 PMID: 15901669

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 11 / 12

http://www.who.int/nmh/publications/ncd-status-report-2014/en/

http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011

http://www.personcenteredmedicine.org/doc/genevathree/geneva2011i

http://www.ncbi.nlm.nih.gov/pubmed/23242897

http://www.ncbi.nlm.nih.gov/pubmed/19189907

http://dx.doi.org/10.1089/108729102753429398

http://www.ncbi.nlm.nih.gov/pubmed/11839218

http://www.ncbi.nlm.nih.gov/pubmed/10413387

http://dx.doi.org/10.1001/jamainternmed.2013.1216

http://www.ncbi.nlm.nih.gov/pubmed/23277199

http://www.ncbi.nlm.nih.gov/pubmed/11841136

http://dx.doi.org/10.1093/intqhc/mzr040

http://www.ncbi.nlm.nih.gov/pubmed/21775313

http://www.ncbi.nlm.nih.gov/pubmed/11861585

http://dx.doi.org/10.1371/journal.pmed.1001377

http://www.ncbi.nlm.nih.gov/pubmed/23382655

http://dx.doi.org/10.1377/hlthaff.2015.0382

http://www.ncbi.nlm.nih.gov/pubmed/26355052

http://dx.doi.org/10.1370/afm.142

http://www.ncbi.nlm.nih.gov/pubmed/15576546

http://dx.doi.org/10.1161/CIRCRESAHA.113.300268

http://www.ncbi.nlm.nih.gov/pubmed/23989710

http://pocketdoktor.de/en/

http://dx.doi.org/10.1093/eurheartj/ehi204

http://www.ncbi.nlm.nih.gov/pubmed/15901669

21. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the patient activation measure (PAM):

conceptualizing and measuring activation in patients and consumers. Health Services Research. 2004;

39(4p1):1005–26.

22. Greene J, Hibbard JH. Why does patient activation matter? An examination of the relationships

between patient activation and health-related outcomes. Journal of General Internal Medicine. 2012; 27

(5):520–6. doi: 10.1007/s11606-011-1931-2 PMID: 22127797

23. Hibbard JH, Mahoney ER, Stockard J, Tusler M. Development and testing of a short form of the patient

activation measure. Health Services Research. 2005; 40(6p1):1918–30.

24. Grogan S, Conner M, Norman P, Willits D, Porter I. Validation of a questionnaire measuring patient sat-

isfaction with general practitioner services. Quality in Health Care. 2000; 9(4):210–5. doi: 10.1136/qhc.

9.4.210 PMID: 11101705

25. Glaser BG, Strauss AL. The discovery of grounded theory: Strategies for qualitative research. 7th ed.

New Brunswick: Transaction Publishers; 2012.

26. Saksena P, Xu K, Elovainio R, Perrot J. Utilization and expenditure at public and private facilities in 39

low-income countries. Tropical Medicine & International Health. 2012; 17(1):23–35.

27. Smith SG, Curtis LM, Wardle J, von Wagner C, Wolf MS. Skill set or mind set? Associations between

health literacy, patient activation and health. PloS one. 2013; 8(9):e74373. doi: 10.1371/journal.pone.

0074373 PMID: 24023942

28. Oi K. Understanding the Role of Patient Activation in the Association between Patient Socio-Economic

Demographics and Patient Experience. 2012.

29. World Bank. Population Data 2015. Available: http://data.worldbank.org/indicator/SP.POP.TOTL.

30. Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income coun-

tries: an overview of their history, recent evolution, and current effectiveness. Annual review of public

health. 2014; 35:399–421. doi: 10.1146/annurev-publhealth-032013-182354 PMID: 24387091

31. Otero C, Luna D, Marcelo A, Househ M, Mandirola H, Curioso W, et al. Why Patient Centered Care

Coordination Is Important in Developing Countries?: Contribution of the IMIA Health Informatics for

Development Working Group. Yearbook of medical informatics. 2015; 10(1):30. doi: 10.15265/IY-2015-

013 PMID: 26123907

32. Praveen D, Patel A, McMahon S, Prabhakaran D, Clifford GD, Maulik PK, et al. A multifaceted strategy

using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardio-

vascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled

trial. communities. 2013; 5(6).

Patient-Centered Education for Chronic-Disease Management

PLOS ONE | DOI:10.1371/journal.pone.0166411 November 16, 2016 12 / 12

http://dx.doi.org/10.1007/s11606-011-1931-2

http://www.ncbi.nlm.nih.gov/pubmed/22127797

http://dx.doi.org/10.1136/qhc.9.4.210

http://www.ncbi.nlm.nih.gov/pubmed/11101705

http://dx.doi.org/10.1371/journal.pone.0074373

http://www.ncbi.nlm.nih.gov/pubmed/24023942

http://data.worldbank.org/indicator/SP.POP.TOTL

http://dx.doi.org/10.1146/annurev-publhealth-032013-182354

http://www.ncbi.nlm.nih.gov/pubmed/24387091

http://dx.doi.org/10.15265/IY-2015-013

http://www.ncbi.nlm.nih.gov/pubmed/26123907

What will it take to improve prevention of chronic diseases
in Australia? A case study of two national approaches

Sonia Wutzke1,2,4 BSc (Psych) Hons, MPH, PhD Deputy Director

Emily Morrice1,2 BIGS(Hons), Research Assistant

Murray Benton3 BSocSci, Director

Andrew Wilson1,2 BMedSci, MBBS(Hons), PhD, FRACP, FAFPHM, Director

1The Australian Prevention Partnership Centre, Ultimo, NSW 2007, Australia.
Email: preventioncentre@saxinstitute.org.au

2Menzies Centre for Health Policy, University of Sydney, NSW 2006, Australia. Email: a.wilson@sydney.edu.au
3Inca Consulting Pty Ltd, Sydney, NSW 2000, Australia. Email: mbenton@incaconsulting.com.au
4Corresponding author. Email: sonia.wutzke@saxinstitute.org.au

Abstract
Objective. Despite being a healthy country by international standards, Australia has a growing and serious burden

from chronic diseases. There have been several national efforts to tackle this problem, but despite some important
advances much more needs to be done. From the viewpoint of diverse stakeholders, the present study examined two
approaches to controlling chronic disease in Australia: (1) the 2005 National Chronic Disease Strategy (NCDS); and
(2) the 2008 National Partnership Agreement on Preventive Health (NPAPH).

Methods. Individual and small group semistructured interviews were undertaken with 29 leaders across Australia,
reflecting a diverse cross-section of senior public health managers and program implementation staff from state and
territory health departments, as well as academics, thought leaders and public health advocates. A grounded theory
approach was used to generate themes relevant to the research.

Results. There is general support for national approaches to the prevention of chronic disease. The NCDS was viewed
as necessary and useful for national coordination, setting a common agenda and serving as an anchor to align jurisdictional
priorities and action. However, without funding or other infrastructure commitments or implementation plans, any
expectations as to what could be meaningfully achieved were limited. In contrast, although jurisdictions welcomed the
NPAPH, its associated funding and the opportunity to tailor strategy to their unique needs and populations, there were
calls for greater national leadership as well as guidance on the evidence base to inform decision making. Key aspects of
successful national action were strong Australian Government leadership and coordination, setting a common agenda,
national alignment on priorities, evidence-informed implementation strategies, partnerships within and across governments,
as well as with other sectors, and funding and infrastructure to support implementation.

Conclusions. Both the NCDS and NPAPH were seen to have overlapping strengths and weaknesses. A key need
identified was for future approaches to focus on generating more sustainable, system-wide change.

What is known about the topic? Despite some important advances, chronic diseases remain Australia’s greatest health
challenge. In efforts to tackle this increasing burden from chronic diseases, several large-scale, national initiatives have
been released in Australia over recent years, including the 2005 NCDS and the 2008 NPAPH.
What does this paper add? From the viewpoint of practitioners, policy makers, advocates, researchers and public
health thought leaders, this paper examines the usefulness and significance of the NCDS and NPAPH as national initiatives
for achieving improvements to the prevention of chronic disease.
What are the implications for practitioners? By better understanding how previous countrywide chronic disease
initiatives were viewed and used at national, state and local levels, this research is well placed to inform current, planned
and future large-scale, population-level health initiatives.

Received 6 January 2016, accepted 20 April 2016, published online 16 June 2016

Journal compilation � AHHA 2017

www.publish.csiro.au/journals/ahr

CSIRO PUBLISHING

Australian Health Review, 2017, 41, 176–181
http://dx.doi.org/10.1071/AH16002

HEALTH SERVICE RESEARCH

mailto:preventioncentre@saxinstitute.org.au

mailto:a.wilson@sydney.edu.au

mailto:mbenton@incaconsulting.com.au

mailto:sonia.wutzke@saxinstitute.org.au

Introduction

Australia is, by international standards, a very healthy country.1

But this status is increasingly at risk from the growing epidemic
of chronic diseases that affect almost half of all Australians2 and
are responsible for 85% of the total burden of disease.3

In efforts to control the increasing burden of chronic diseases,
including heart disease, stroke and heart failure, chronic kidney
disease, lung disease and Type 2 diabetes, the Australian
Government has over the past decade released several strategies,
including the Australian Better Health Initiative,4 Type 2
Diabetes Initiative5 and the National Healthcare Agreement,6 all
of which fundamentally aimed to improve health outcomes and
reduce pressure on the Australian health system. Several strate-
gies specifically focusing on prevention were also released over
this period, including, but not limited to, Eat Well Australia
(EWA): An Agenda for Public Health Nutrition 2000–2010,7

National Tobacco Strategy 2004–2009: The Strategy,8 Be Active
Australia: A Framework for Health Sector Action for Physical
Activity 2005–20109 and Healthy Weight 2008 – Australia’s
Future: The National Action Agenda for Children and Young
People and Their Families.10 Importantly, across this period two
large-scale national initiatives, the National Chronic Disease
Strategy (NCDS)11 and the National Partnership Agreement on
Preventive Health (NPAPH),12 were also released, both with
overarching, country-wide approaches to addressing chronic
disease.

The current landscape of national preventive health strategy
and action looks comparatively bare compared with previous
years. Arguably, the NCDS has lost currency and programs made
possible through the NPAPH have lost momentum or ceased
following its cancellation in 2014. However, chronic diseases
remain Australia’s greatest health challenge.13 As such, the
current Australian Government is embarking on a new national
strategy for chronic diseases.14

To ensure current, planned and future population preventive
health initiatives, including the new national strategy, are in-
formed by past experiences, it is important to better understand
how the previous NCDS was used, whether it was relevant
and whether it informed governments across Australia. In
addition, it is important to consider how the NCDS and the
NPAPH may have worked together as two different but comple-
mentary approaches to chronic disease prevention.

By analysing the NCDS and the NPAPH as a case study of
national approaches to driving the preventive health agenda in
Australia, the purpose of the present study was to explore the
views of practitioners, policy makers, advocates, thought leaders
and researchers with regard to: (1) the significance of the 2005
NCDS and its potential for achieving improvements to the
prevention of chronic disease; (2) the approach to future national
chronic disease strategies; and (3) the significance of the NPAPH
and its potential for achieving improvements to the prevention of
chronic disease.

Methods

Data collection consisted of individual and small group semi-
structured interviews undertaken by an independent consultant
recruited to minimise potential bias due to existing professional
relationships between the research team and respondents.

Published standards for designing, undertaking and reporting
qualitative research guided the methods and reporting of the
research, including elements such as who the research team were,
what the context of the study was, how participants were
recruited, the use of a discussion guide and the reporting of
quotations in the results.15

Participants were recruited using a combination of purpo-
sive and snowballing sampling techniques, whereby invitees
were individually identified by the research team on the basis
of their likely ability to provide an informed contribution to the
study, or to nominate other suitable candidates from their
organisation. Participants included senior public health man-
agers and program implementation staff from state and terri-
tory health departments senior academics; as well as thought
leaders and public health advocates from key agencies across
the country.

In all, 33 individuals were invited to participate through a
personally addressed email from the Director of the Australian
Prevention Partnership Centre (http://www.preventioncentre.
org.au, accessed 5 January 2016), a national centre investi-
gating approaches to building an effective, efficient and eq-
uitable system for the prevention of lifestyle-related chronic
disease. The email invitation was followed-up by the research
team. To ensure the study captured informed perspectives, all
respondents needed to have relevant experience of at least
2 years. Further, all respondents were �18 years of age and
provided informed verbal consent for both their participation
in the research and for the recording of the interviews before
participation. Interviews were undertaken between June and
August 2015 and, where possible, were conducted face to face
and audio recorded.

Interviews were supported by a semistructured discussion
guide, developed to elicit views across three broad themes: (1)
perceptions on the 2005 NCDS, in particular its significance to
the prevention of chronic disease; (2) views on future national
strategies; and (3) perceptions on the NPAPH and its signif-
icance for achieving improvements to the prevention of chron-
ic disease. The discussion guide was developed initially by the
research team and then revised following feedback from a
Project Steering Committee, academics, practitioners and pol-
icy makers with extensive awareness of and experience in
Australia’s chronic disease prevention environment.

Consistent with a grounded theory approach responses were
anonymised and reviewed by the research team, and analysis
of the text undertaken to generate themes and subthemes. The
research was reviewed and approved by the Sax Institute low-
risk research assessment committee (R2015/05/03).

Results

In all, 29 individuals participated in the research. This included
17 people who were sent the invitation email and 12 others
who responded in place of the original invitee or else alongside
the original invitee. Interviews were approximately 1 h in
duration and were conducted face to face and by telephone.
All eight of Australia’s state or territory health jurisdictions
participated in the research, along with an additional 10
individuals (four researchers and six advocates or thought
leaders).

National strategies for chronic disease prevention Australian Health Review 177

Home

National Chronic Disease Strategy

Endorsed by Australian Health Ministers in 2005, the NCDS
provided high-level policy guidance for action at every level of
government and all parts of the healthcare system for the pre-
vention and management of chronic disease. Based on overarch-
ing best-practice approaches that recognised the importance of
prevention and integrated care, the document identified key
guiding principles and identified four action areas: prevention
across the continuum; early detection and early treatment; inte-
gration and continuity of prevention and care; and self-manage-
ment. Five disease-specific National Service Improvement
Frameworks (NSIFs) were also produced to accompany the
Strategy. For both the Strategy and the NSIFs, implementation
was the responsibility of each jurisdiction according to local
priorities and needs. No specific funding was provided to jur-
isdictions for implementation.

Policy impact of the 2005 NCDS

Almost all respondents were aware of the 2005 NCDS. When
asked about the use they had made of it and its centrality to a
national approach to chronic disease, particularly chronic disease
prevention, views varied. A few respondents, particularly those
from smaller jurisdictions, reported that the NCDS was quite
central in guiding state or territory strategy. Other respondents,
however, thought that the NCDS had served only little function in
the work of policy makers and practitioners, as the following
comments illustrate:

I’ve given it as close to zero consideration as you can get.
(Advocate/thought leader)

Never looked at it. (Advocate/thought leader)

The 2005 strategy was virtually entirely irrelevant to our
work. There was a failure to include, recognise or engage
the [non-governmental organisation (NGO)] sector as pro-
viders of health services. (Practitioner/policy maker)

Although some respondents saw value in high-level strategic
statements of intent, for those critical of the 2005 NCDS the most
common observations were that it made no funding or other
infrastructure commitments,hadnoimplementationplanandwas
not binding in any way. The following quotes are typical of this
view:

A national strategy is only as good as the dollars attached
to it. It failed to provide resources, an implementation
strategy, an accountability framework, and goals and
targets. (Practitioner/policy maker)

National strategies are pretty useless unless they come with
financial muscle – otherwise why would the states and
territories do anything, let alone convince other portfolios
to do anything. (Advocate/thought leader)

Despite the cynical views raised throughout the discussions
with regard to the 2005 NCDS, most respondents agreed that
there is value in having a national strategy. As one informant
aptly noted:

When they’re well put together they serve as an anchor
for everything that happens. It helps to prioritise research

and programs – everything can be tied back to the Strategy.
(Researcher)

In terms of prevention, informants were asked about the
prominence that prevention was given in the 2005 NCDS and
the way that prevention was ‘oriented’. Generally, it was ac-
knowledged that although prevention was recognised as impor-
tant in the document, like other aspects of the Strategy it lacked
detail and specified actions. Inother words, the document ‘said all
the right things’ about the importance of prevention but provided
no clear direction (and did not earmark funds) for the pursuit of
national prevention initiatives.

Perspectives on a new national strategy for chronic
diseases

Repeatedly, the comments raised by respondents echoed
views that: (1) the new strategy should genuinely underpin a
coordinated effort to meaningfully address chronic disease; and
(2) the process for its development should be significantly
different to earlier efforts, otherwise it is likely to yield similar
results to previous strategies. As two informants said:

The Commonwealth has been absent on health prevention
and now they want to develop a national strategy?
(Advocate/thought leader)

The risk is that the next strategy is just a set of motherhood
statements without any implementation plans. It needs to
be funded, planned and coordinated with the states and
territories. (Practitioner/policy maker)

It was clear that informants, whether they were practitioners,
policy makers, advocates, researchers or thought leaders, wanted
to see a chronic disease strategy that would guide a genuine
effort to address the root causes of chronic disease. They wanted
to see government leadership to drive environmental or systemic
change, for example in reducing the amount of sugar, salt and
fat in food and drink and addressing the social acceptability of
alcohol consumption. It was commonly noted that there had
been some ‘good wins’ in terms of tobacco control, plain pack-
aging and widening no smoking areas for example, but that the
same leadership had not been directed to addressing other root
causes of chronic disease.

Several respondents also expressed frustration that govern-
ments tended to adopt a ‘personal responsibility’ approach to
chronic disease prevention. Rather than addressing environmen-
tal or systemic factors, it was felt that governments often take the
view that ‘people should be able to choose’ and that prevention
activities should be aimed at ‘encouraging people to make
healthierchoices’.Itwasnotedbyseveralrespondentsthatpeople
arenotalwaysabletomake‘healthy’choices,whetherduetotheir
knowledge, social background, geographic location or available
income. Government has an important role, it was thought, in
addressing environmental factors to make it easier for people to
make healthier choices. The following are indicative comments
from respondents:

It’s important to have national strategies but they usually
don’t have a systemic foundation. They’re usually based
on what people think the strategy should be. (Researcher)

178 Australian Health Review S. Wutzke et al.

It’s inequitable to simply say that individuals
should take responsibility. Clearly, not everyone is
equal in their ability to stay healthy. (Advocate/
thought leader)

You need governance and leadership to address
systemic issues – unless that’s there, there’s no point.
(Practitioner/policy maker)

National Partnership Agreement on Preventive Health

With funding in the vicinity of A$645 million allocated by the
Australian Government to states and territories across Australia,
the NPAPH was an unprecedented, national, coordinated frame-
work to tackle the growing burden of chronic disease through
prevention. Initially covering the period 2008–14, but in 2012
extended until June 2018, and then in 2014 cancelled premature-
ly,16 the NPAPH broadly set out to improve the prevention of
chronic disease through a collection of policy priorities and
funding arrangements across four distinct components: (1) set-
tings-based programs, including the Healthy Children Initiative,
the Healthy Workers Initiative and the Healthy Communities
Initiative; (2) whole-of-population social marketing strategies;
(3) the establishment of partnerships across sectors; and (4) en-
abling infrastructure to support the partnership.

Effect of the NPAPH on government-led preventive
health policy and practice across Australia

When asked about the potential of the NPAPH, respondents
overwhelmingly agreed that it created a strong platform for the
national roll-out of programs supporting healthy lifestyles. The
strength of this platform was described in three main ways
by respondents: (1) supporting multiple and layered strategies;
(2) allowing for the expansion and scaling up of existing
programs; and (3) creating opportunities for developing and
testing innovative ideas.

All respondents also agreed that core infrastructure was
developed under the NPAPH, which elevated the rigour and
sophistication of their preventive health activities. The key themes
that arose throughout the interviews focused on achieving stron-
ger governance, creating enhanced data collection capabilities,
establishing a more skilled workforce and implementing
improved program evaluation standards and accountabilities.
Comments reflecting these views included:

Having access to that data is embedded now in people’s
expectations. So yes, the money was useful to us in
advancing our collections program. (Practitioner/policy
maker)

The focus on evaluation was a significant thing – to have
it formalised as it was in the NPAPH was very good.
(Practitioner/policy maker)

We’ve ended up with a large workforce of people who
now understand how the systems approach works and
how to make it work. (Practitioner/policy maker)

Respondents had mixed views about the extent to which
the NPAPH was successful in building partnerships. Some
respondents felt that the NPAPH created positive opportunities

for them to better collaborate with other state and territory
government agencies, primarily within health, but occasionally
outside of health. Two comments indicative of this view were:

The technical network was really useful. . .there’s no other
forum. (Practitioner/policy maker)

There is definitely a legacy of continued cross-government
communications. The development of some personal
working relationships has been a real benefit. (Practition-
er/policy maker)

Other respondents questioned the extent to which the
NPAPH facilitated a partnership between state and territory
governments and the Commonwealth Government. Some felt
the NPAPH improved these communications, yet others were of
the view that the NPAPH had never truly built a partnership
between the levels of government.

When asked about the degree of national coordination of
chronic disease prevention activities, most informants were of
the view that during the time of the NPAPH there was a greater
degree of coordination. Informants particularly valued the ability
to share information and ideas through the prevention managers’
forum, facilitated at the time by the Australian National Preven-
tive Health Agency(ANPHA). This wasputforward as providing
a real practical benefit. Following are some indicative quotes
illustrating the value placed on this national coordination and its
loss following abolishment of the NPAPH:

The main thing we lost was the ability to interact directly
with the Commonwealth. We have to be talking to one
another. (Practitioner/policy maker)

The national structure and the sharing that occurred under
the NPAPH is a big loss. (Practitioner/policy maker)

Discussion

With Australia a signatory to the World Health Organization’s
global action plan for the prevention and control of non-com-
municable diseases with a global target of achieving 25% reduc-
tion in the burden of chronic disease by 2025,17 it is timely, and
indeed imperative, that Australia takes substantive action.

Through semistructured, qualitative interviews with practi-
tioners, policy makers, advocates, researchers and thought
leaders from a diverse cross-section across Australia, including
input from all sate and territory health departments across
Australia, the present study demonstrated consistent support
for the Australian Government taking a leadership role in
driving the preventive health agenda across Australia. How-
ever, comments reflected quite marked differences in views
to the 2005 NCDS and the 2008 NPAPH, both national
approaches with the same overarching aim of controlling
chronic diseases.

In summary, although there was some cynicism as to the
value of the 2005 NCDS and possible future incarnations of it,
overall national strategies of this nature were viewed by
respondents as necessary and useful for national coordination,
setting a common agenda and serving as an anchor to align
jurisdictional priorities and action. However, without funding

National strategies for chronic disease prevention Australian Health Review 179

or other infrastructure commitments or implementation plans,
any expectations as to what could be meaningfully achieved
were limited.

Conversely, with the NPAPH there was near universal
agreement among respondents that this approach was achiev-
ing or on the way to achieving its overarching desired outputs,
including programs to build foundations for healthy beha-
viours, enabling infrastructure for evidence-based policy and
partnerships for sustainable national action, across and be-
tween levels of government as well as with other sectors.
Supported by available evidence for achieving large-scale,
health system change, with the NPAPH there was national
leadership,18 a focus on partnerships19 and significant funding
commitment with reward payments to incentivise jurisdic-
tions.20 However, there was little national direction and
although jurisdictions appeared to welcome the opportunity
to tailor strategy to their unique needs and populations, there
were commonly calls for some level of guidance and evidence
base at the national level to inform decisions.

Both the 2005 NCDS and the 2008 NPAPH are consistent
with the growing literature on the value of considering country
health systems in their totality rather than emphasising dis-
ease-focused programming.21 In essence, health system
strengthening approaches differ from disease-focused pro-
gramming in that the focus is on the underlying infrastructure
needed to effect change.20 However, standing alone, the
NCDS lacked any mechanism for implementation and the
NPAPH itself had little strategy to drive action. The combi-
nation of these two approaches perhaps was what was needed
to meaningfully effect system-wide, sustainable chronic dis-
ease prevention.

Consistent with this notion of whole-of-system strengthening
espoused in the literature, and taking into account the views
elicited through this study, it is the opinion of the authors that
within the limits of the current legislative and policy environ-
ments any forthcoming national approaches to the prevention of
chronic diseases should:

* acknowledge and build on previous work in the space, with a
recognition of the current political, financial and technical
environment and what realistically can be aimed for

* takealong-termviewthatextendsmorethanoneelectoralcycle
* provide funding and other infrastructure commitments
* address the complex and interdependent root causes of chronic
disease and accommodategeographical and cultural contexts to
avoid ‘one-size-fits-all’ approaches

* use, link and sequence evidence-based interventions over a
person’s life course

* identify and articulate the interests and roles that can be played
by all actors in the system, including individuals, health pro-
fessionals, governments, researchers, NGOs and private sector
organisations, with a view to aligning interests and ‘buy-in’

* create mechanisms for cross-sectoral engagement and coordi-
nation, especially where there are opportunities to make use of
the expertise or capabilities from different sectors (e.g. the
marketing expertise within the private sector)

* identify how interventions can affect the system, not just
individuals, with a focus on changing social norms rather than
just individual behaviour

* rather than rely on health outcomes alone, establish indicators
to reflect broader system change, like change in policy direc-
tion, volume of prevention activity and social norms.

Conclusions

The views of policy makers and thought leaders on the
Australian Government’s two national policy approaches to
the control of chronic disease indicate that both approaches
were useful, practical and set in motion potential gains for the
health system. Future national approaches to control chronic
diseases in Australia should draw on the experience of these
approaches. The NCDS was seen as an important agenda-
setting document, but it lacked transformative power due to the
absence of funding or concrete implementation plans. Simi-
larly, in many jurisdictions the NPAPH did not transform the
chronic disease prevention field or offer any particular cohe-
sive strategy for how best to control chronic diseases, but it did
enable an expansion of existing efforts and a coalition among
governments across Australia that was important for building
policy momentum. Combined, the NPAPH and the NCDS
provided a step forward in prioritising chronic disease pre-
vention in Australia in terms of both strategic direction and
programs on the ground. Our research suggests that future
approaches should focus on generating more sustainable,
system-wide change. That is, change across the people, pro-
cesses, activities, settings and structures (and the dynamic
relationships between them) that facilitate or hinder chronic
condition prevention efforts. With a new chronic disease
strategy on the horizon (see http://www.health.gov.au/inter-
net/main/publishing.nsf/Content/nsfcc, accessed 5 January
2016), these results indicate that this new strategy will be
important for helping to reset the direction for preventative
health, but that it should be accompanied by an implementation
mechanism to ensure that change happens.

Competing interests

No authors have any conflicts of interest to declare.

Acknowledgements

This research was supported by the Australian Prevention Partnership
Centre through the National Health and Medical Research Council Partner-
ship Centre grant scheme (Grant ID: GNT9100001) with the Australian
Government Department of Health, the NSW Ministry of Health, ACT
Health, HCF and the HCF Research Foundation. The authors are grateful
to the Project Steering Committee for advice on study design and focus: Bill
Bellew, Maria Gomez, Lesley King, Andrew Milat and Penny Tolhurst.

References

1 National Preventative Health Taskforce. Australia: healthiest country
by 2020 – National Preventative Health Strategy – Overview. Canberra:
Commonwealth of Australia; 2009.

2 Australian Institute of Health and Welfare (AIHW). Australia’s welfare
2015. Australia’s welfare series no. 12. Catalogue no. AUS 189.
Canberra: AIHW; 2015.

3 Institute for Health Metrics and Evaluation. DALY estimates for
Australasia. 2014. Available at: http://www.healthmetricsandevalua-
tion.org [verified 5 January 2016].

4 Council of Australian Governments. Better health for all Australians.
Action plan. Canberra (AUST): COAG; 2006].

180 Australian Health Review S. Wutzke et al.

http://www.health.gov.au/internet/main/publishing.nsf/Content/nsfcc

http://www.healthmetricsandevaluation.org

5 Australian Government Department of Health and Ageing. COAG –
Reducing the risk of type 2 diabetes. 2007. Available at: https://www.
health.gov.au/internet/budget/publishing.nsf/Content/BC9E49EDBCE
FB951CA257CA0003FF4CC/$File/hfact31 [verified 5 January
2016].

6 Council of Australian Governments. National Healthcare Agreement
2012. 2012. Available at: http://www.federalfinancialrelations.gov.
au/content/npa/healthcare/national-agreement [verified 5 January
2016].

7 Australian Government, Department of Health. National Public Health
Partnership’s Nutrition Strategy and Action Plan – Eat Well Australia,
2000–2010.2000.Availableat:http://www.health.gov.au/internet/main/
publishing.nsf/content/health-pubhlth-strateg-food-nphp.htm [verified 5
January 2016].

8 Commonwealth of Australia. National Tobacco Strategy, 2004-2009:
The Strategy. 2004. Available at: http://apps.who.int/fctc/reporting/
Australia_annex7_national_tobacco_strategy2004_2009 [verified
5 January 2016].

9 National Public Health Partnership. Be Active Australia: A Framework
for Health Sector Action for Physical Activity. 2005. Available at: http://
www.hnehealth.nsw.gov.au/hneph/physical%20activity/Documents/be-
active-australia [verified 5 January 2016].

10 Commonwealth of Australia. Healthy Weight 2008. Australia’s Future:
The National Action Agenda for Children and Young People and
their Families. 2003. Available at: http://www.healthyactive.gov.au/
internet/healthyactive/publishing.nsf/Content/healthy_weight08 /$
File/healthy_weight08 [verified 5 January 2016].

11 National Health Priority Action Council. National chronic disease
strategy. Canberra: Australian Government Department of Health and
Ageing; 2006.

12 Council of Australian Governments. National partnership agreement
on preventive health. Canberra: Commonwealth of Australia; 2008.

13 Australian Institute of Health and Welfare (AIHW). Australia’s health
series no. 14. Catalogue no. AUS 178. Canberra: AIHW; 2014.

14 Australian Government, Department of Health. National Strategic
Framework for Chronic Conditions Available at: http://www.health.
gov.au/internet/main/publishing.nsf/content/nsfcc [verified 5 January
2016].

15 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qual-
itative research (COREQ): a 32-item checklist for interviews and focus
groups. Int J Qual Health Care 2007; 19: 349–57. doi:10.1093/intqhc/
mzm042

16 Biggs A. Budget review 2014–2015: health funding agreements: Parlia-
ment of Australia. 2014. Available at: http://www.aph.gov.au/about_
parliament/parliamentary_departments/parliamentary_library/pubs/rp/
budgetreview201415/healthfunding [verified 5 January 2016].

17 WorldHealthOrganization(WHO).Globalactionplanfortheprevention
and control of noncommunicable diseases 2013–2020. Geneva: WHO;
2013.

18 Best A, Greenhalgh T, Lewis S, Saul JE, Carroll S, Bitz J. Large-system
transformation in health care: a realist review. Milbank Q 2012; 90:
421–56. doi:10.1111/j.1468-0009.2012.00670.x

19 Swanson RC, Cattaneo A, Bradley E, Chunharas S, Atun R, Abbas KM,
Katsaliaki K, Mustafee N, Meier BM, Best A. Rethinking health
systems strengthening: key systems thinking tools and strategies for
transformational change. Health Policy Plan 2012; 27(Suppl. 4):
iv54–61. doi:10.1093/heapol/czs090

20 Best A, Saul J. Complexity and lessons learned from the health sector
for country system strengthening. Background paper for the USAID
Experience Summit on strengthening country systems. West Vancouver:
InSource Research Group; 2012.

21 Spicer N, Walsh A. 10 best resources on the current effects of global
health initiatives on country health systems. Health Policy Plan 2012;
27: 265–9. doi:10.1093/heapol/czr034

National strategies for chronic disease prevention Australian Health Review 181

www.publish.csiro.au/journals/ahr

https://www.health.gov.au/internet/budget/publishing.nsf/Content/BC9E49EDBCEFB951CA257CA0003FF4CC/$File/hfact31

http://www.federalfinancialrelations.gov.au/content/npa/healthcare/national-agreement

http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-food-nphp.htm

http://apps.who.int/fctc/reporting/Australia_annex7_national_tobacco_strategy2004_2009

http://www.hnehealth.nsw.gov.au/hneph/physical%20activity/Documents/be-active-australia

http://www.healthyactive.gov.au/internet/healthyactive/publishing.nsf/Content/healthy_weight08 /$File/healthy_weight08

http://www.health.gov.au/internet/main/publishing.nsf/content/nsfcc

dx.doi.org/10.1093/intqhc/mzm042

http://www.aph.gov.au/about_parliament/parliamentary_departments/parliamentary_library/pubs/rp/budgetreview201415/healthfunding

dx.doi.org/10.1111/j.1468-0009.2012.00670.x

dx.doi.org/10.1093/heapol/czs090

dx.doi.org/10.1093/heapol/czr034

Reproduced with permission of copyright owner.
Further reproduction prohibited without permission.

Research Article
ACommunity-Based Nutrition and Physical Activity Intervention
for Children Who Are Overweight or Obese and Their

Caregivers

FurongXu,1 StephanieMarchand,2 Celeste Corcoran,3 HeatherDiBiasio,4 Rachel Clough,5

Christopher S. Dyer,1 Jennifer Nobles,6 Jade White,6 Mary L. Greaney,1 and
Geo2rey W. Greene6

1Department of Kinesiology, University of Rhode Island, Independence Square II, Kingston, RI 02881, USA
2KinderHealthRI, LLC, 10 High Street, Wake&eld, RI 02879, USA
3Coastal Medical Narragansett Bay Pediatrics, 65 Village Square Drive, South Kingstown, RI 02879, USA
4Wake&eld Pediatrics, LLC, 46 Holley Street, Wake&eld, RI 02879, USA
5Busy Bodies Studio, 12 High Street, South Kingstown, RI 02879, USA
6Department of Nutrition and Food Sciences, University of Rhode Island, Fogarty Hall, Kingston, RI 02881, USA

Correspondence should be addressed to Furong Xu; fxu2007@uri.edu

Received 10 May 2017; Revised 12 September 2017; Accepted 17 September 2017; Published 8 October 2017

Academic Editor: Aron Weller

Copyright © 2017 Furong Xu et al. (is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

(ere is a need for e-cacious interventions to reduce the prevalence of childhood obesity, and a limited body of research suggests
that collaborative community-based programs designed for children and their caregivers may be e/ective in reducing obesity
rates. (is paper reports the results of a community-based obesity intervention, South County Food, Fitness and Fun (SCFFF),
designed for preadolescent children who are overweight or obese and their caregivers. SCFFF was developed in response to
community concerns. Families were referred to the program by their physician and participated in the program at no cost. (e
16-week intervention includes weekly group nutrition and physical activity sessions. Analyses determined that 65 out of the 97
children who completed SCFFF provided 2-year follow-up data and had reduced BMI z-scores over 2 years following the
intervention. (ese participants decreased their energy, fat, carbohydrate, saturated fat, and sodium intake and increased co

body strength and endurance from baseline to the end of the intervention. SCFFF was e/ective in reducing relative weight and
improving diet and core muscle strength and endurance in children who are overweight or obese.

1. Introduction

Obesity is a major health concern among children in the
United States [1]. Recent data indicate that 17.9% of children
aged 6–11 years have obesity (body mass index (BMI) greater
than or equal to the 95th percentile for children of the same
age) [2]. Childhood obesity is associated with a number of
adverse health risks, including increased risk of coronary
heart disease, dyslipidemia, insulin resistance, hypertension,
and weight-related psychological stress [3, 4]. Obesity in
childhood often persists into adulthood [1, 3]. In addition, it
poses signiAcant economic burdens: medical costs are 30%
higher for children who have obesity than children who stay
at a healthy weight [5, 6]. Despite e/orts to reduce childhood

obesity, the percentage of children who are overweight or
obese is remaining high [7].

Childhood obesity is a result of chronic positive energy
balance with intake exceeding expenditure required for
growth, homeostatic maintenance, and physical activity [8].
Pediatric weight management is a complex issue as obesity is
a multifactorial condition due to environmental, social, and
behavioral factors [9, 10]. Spear and colleagues recommend
a four-stage pediatric obesity treatment approach that begins
with prevention e/orts plus structural weight management
(stages 1 and 2) provided by primary care practitioners. If
these e/orts are not successful in changing the direction of
relative weight gain, the next stage is a comprehensive
multidisciplinary intervention to modify the child’s behaviors

Hindawi
Journal of Obesity
Volume 2017, Article ID 2746595, 9 pages
https://doi.org/10.1155/2017/2746595

mailto:fxu2007@uri.edu

https://doi.org/10.1155/2017/2746595

and the home environment (stage 3). If the multidisciplinary
intervention is unsuccessful or serious comorbidities exist,
stage 4 interventions that include strenuous diet restriction,
drug, or surgical treatment are recommended [11]. Although
severe dietary restrictions and surgical interventions can
reduce obesity among older adolescents and adults, neither
approach is recommended for preadolescent children due to
their nutritional and physiological needs as well as the risk of
eating disorders [11, 12]. For preadolescent children with
obesity, the goal is to reduce the rate of weight gain to allow
adolescent maturation and physical growth to normalize
body weight. Given the prevalence of childhood obesity,
there is a clear need for primary care stage 1 and 2 in-
terventions, but there are limited models of successful
community-based stage 3 interventions for preadolescents
who are overweight or obese to prevent obesity in adoles-
cence [11, 13].

Numerous interventions have focused on improving
dietary intake and increasing physical activity to reduce
obesity in children [3, 14–16]. However, many of these in-
terventions are school-based andmay not consider the home
setting [17]. Parents and guardians (henceforth referred to as
caregivers) play an important role in determining what
foods are available for their children and shaping their eating
and physical activity behaviors [18]. Additionally, because
children model physical activity and nutrition behaviors of
family members, it is important to include caregivers in
intervention e/orts [18]. As a result, obesity prevention
programs that include caregivers have a greater impact than
those that do not involve them [19]. Nonetheless, there is still
limited understanding of the e/ectiveness of community-
based interventions (stage 3) that include caregivers in re-
ducing relative weight with follow-up exceeding one year.

(us, the primary aim of this study was to assess the
e/ects of a community-based comprehensive stage 3,
multidisciplinary intervention on BMI z-scores and BMI in
children who are overweight or obese aged 6–10 years two
years following the intervention. Secondary aims were to
examine the e/ects of this intervention on children’s dietary
intake, physical Atness, and psychosocial functioning from
baseline to postintervention.

2. Methods

2.1. Study Design and Participants. (is was a single-group,
longitudinal study examining the impact of South County
Food, Fitness and Fun (SCFFF), a stage 3, multidisciplinary
obesity intervention (described below). SCFFF was de-
veloped using social cognitive theory [20], and intervention
activities were designed to facilitate and encourage chil-
dren’s healthy behaviors through positive interaction with
their caregivers [20]. In total, 146 overweight (BMI greater
than or equal to the 85th percentile but less than the 95th
percentile for children of the same age, n� 21) or obese (BMI
greater than or equal to the 95th percentile for children of
the same age, n� 125) children between 6 and 10 years of age
and their caregivers were recruited to participate in one of
the fourteen 16-week SCFFF programs o/ered between
February 2009 and December 2016 in Rhode Island [2].

Children and their caregivers were referred to SCFFF by
their child’s primary care physicians who determined that
(1) they were free from medical conditions (e.g., severe heart
disease) that limited eligibility, (2) they had not responded to
stage 1 and stage 2 interventions in the primary care o-ce,
and (3) their family lacked resources for fee-based obesity
prevention programs [11]. After attending an SCFFF ori-
entation session, 118 children and their caregivers enrolled in
the program, and 97 (82%) completed the intervention (see
Figure 1 for study Jowchart). Caregivers signed informed
consent forms, and children signed assent forms. Caregivers
also completed the Health Insurance Portability and Ac-
countability Act (HIPAA) release forms that allowed re-
ferring physicians to release the anthropometric measures of
participating children. (is study was approved by the
University of Rhode Island Institutional Review Board.

2.2. Intervention. SCFFF was created in response to local
healthcare practitioners and community members identi-
fying a need for e/ective obesity prevention programs for
preadolescents [21, 22]. Pediatricians, dietitians, a child
activity specialist, and nutrition and kinesiology faculty and
students from a local university developed SCFFF using
social cognitive theory [22]. In response to community
concerns, SCFFF was provided at no cost to eligible families.
Although initially funded by a local community hospital, the
program is currently supported by grants from Blue Cross &
Blue Shield of Rhode Island, fundraising activities, donations
from the medical community, and volunteers from the
university and community. Funding was secured to pay for
program materials, the space, a pediatric dietitian, and a child

Total referrals
n = 146

Participants
n = 118

(i) 7 children missing 2-year
follow-up
(ii) 3 children had not completed
2 years at the time of analysis

Noncompleters
n = 21

Completers
n = 97

Completers with
1-year follow-up

n = 75

Completers with
2-year follow-up

n = 65

Nonparticipants
n = 28

Figure 1: Study Jowchart.

2 Journal of Obesity

activity specialist for 32 hours for each SCFFF cohort to-
taling 448 hours. Eight SCFFF board members (dietitians,
pediatricians, university faculty, and community members)
and over 50 university students volunteered about 3500
hours to SCFFF since 2009 with an average of 250 vol-
unteered person-hours for each SCFFF cohort.

SCFFF took place at a community exercise and dance
center for youth. (e program included 16 weekly sessions
(Table 1); each session lasted approximately 75 minutes and
was attended by the child and at least one of their caregivers.
At the Arst and last sessions, children completed physical
assessments and parents completed self-administered sur-
veys. (e remaining 14 sessions focused on education and
skill building and included nutrition and physical activity
segments. Nutrition segments were led by a pediatric di-
etitian, and physical activity segments were led by a child
activity specialist with 30 years of experience teaching
children physical activity at the community level. (e nu-
trition components of SCFFF encouraged substituting more
healthful foods for foods with added sugar, processed foods,
and fast foods without energy restriction. Physical activity
was encouraged through games and fun activities that could
be completed with equipment available at home. Caregivers
and children met separately as groups for the nutrition and
physical activity segments. Information was presented to
caregivers in a round-table format that encouraged ques-
tions and sharing of ideas (e.g., strategies for overcoming

barriers). Sessions for caregivers emphasized the importance
of healthful eating for the whole family and of increasing the
family’s daily physical activity for health and well-being.
Caregivers were provided handouts such as recipes and
exercise tips. Nutrition and physical activity information was
provided to children through interactive activities. At the
end of each SCFFF session meeting, children and caregivers
met for a 15 minutes of family physical activity. Student
volunteers provided assistance at sessions under faculty
supervision.

2.3. Outcome Measures

2.3.1. Demographic and Anthropometric Measures. Caregivers
reported the date of birth and sex of their participating
children on a survey completed at the Arst session. (e same
pediatrician took anthropometric measurements on-site at
both the Arst (week 1) and last (week 16) sessions. Children’s
height was measured to the nearest 0.25 inches with shoes
removed using a Tanita stadiometer (model WB3000,
Arlington Heights, Illinois), and weight in light clothing was
measured to the nearest 0.1 lb on a balance-beam scale
(model WB300731, Arlington Heights, Illinois). In addition,
height, weight, and date of measurement were abstracted
from the children’s medical records at one and two years
prior to SCFFF enrollment and for one and two years post
intervention. Height and weight were used to determine

Table 1: Description of the SCFFF program.

Audience Nutrition segment Physical activity segment

Child

Nutrition (30 minutes)
(1) Games focusing on Food Guide Pyramid/
Choose MyPlate food groups and serving sizes
(topic of the week)
(2) Food tasting games
(3) Importance of fruits, vegetables, and whole grains
(4) Awareness of foods high in added sugar,
sodium, and fats
(5) Snacks versus treats
(6) Meals, fast foods, and beverages
(7) Weekly Nutrition Challenge: making recipe with
caregivers or arts and crafts related to topic of theweek

Physical Activity (30 minutes of moderate to
vigorous activity)
(1) Description and demonstration of target activity
(2) Weekly activity (rope jumping, ball playing, team
games, yoga, hand-eye coordination) engages children
fully (e.g., breathing quickens or sweating) for the
entire 30 minutes with appropriate verbal cues to
keep them on task or maintain pace
(3) Weekly activity challenge

Caregivers

Nutrition (30 minutes)
(1) Review the previous week’s Nutrition Challenge
and recipe tasting
(2) FoodGuidePyramid/ChooseMyPlate foodgroups
and serving sizes
(3) Foods high in added sugar, fats, and sodium
(4) Snacks versus treats
(5) Meals, fast foods, and beverages
(6) Changing eating behaviors as a family
(7) Importance of fruits, vegetables, and whole grains
(8) Challenges in changing a child’s eating behavior
(9) Caregivers as role models for healthful eating
(10) Weekly Nutrition Challenge recipe

Physical Activity (30 minutes)
(1) Review the previous week’s physical activity
challenge, address barriers, and suggest resolutions for
being physically active
(2) Types of physical activities and activity
intensity levels
(3) Importance of physical activity for health
(4) Increasing physical activity in daily life using
available neighborhood resources (e.g., bike paths)
(5) Parents as role models for active living
(6) Child’s weekly physical activity challenge

Child and caregiver —
Interactive physical activity (15 minutes)
(1) Child teaches caregiver how to do activity
(2) Joint activity based on targeted physical activity

Note. SCFFF� South County Food, Fitness and Fun.

Journal of Obesity 3

BMI based on the Centers for Disease Control and Pre-
vention growth chart [23]. BMI z-scores were computed
using the Children’s Hospital of Philadelphia Research In-
stitute BMI z-score calculator for children [24]. BMI z-scores
(deviation from normal BMI) were based on the partici-
pants’ height, weight, sex, date of birth, and date of mea-
surement. Change in BMI z-score was used as the study’s
primary outcome measure as they are age-related and are
sensitive to changes in weight in children who are over-
weight or obese [25].

2.3.2. Other Measures. Dietary intake was measured using
the 152-item Youth Adolescent Food Frequency Ques-
tionnaire (YAQ, Harvard School of Public Health, Boston,
Massachusetts, 1995) for the Arst nine SCFFF cohorts [26]. It
was replaced by the 45-item Block Kids Food Screener
(BKFS) for later cohorts based on participants’ feedback
about the lengthy questionnaire [27]. Both are valid and
reliable methods of dietary assessment speciAcally designed
for children and adolescents and widely used in research
[28, 29]. Both YAQ and BKFS measure the same macro- and
micronutrients that contribute to overall health (calories,
protein, fat, carbohydrate, saturated fat, sodium, and added
sugar) [26, 27]. YAQ data were analyzed by the Harvard
School of Public Health following standard procedures, and
data for the BKFS also were analyzed using standard pro-
cedures [29].

Physical Atness was measured using selected compo-
nents of the FITNESSGRAM, a valid and reliable compre-
hensive Atness assessment in children aged 5–18 years [30].
(e examined components included curl-ups, push-ups,
trunk lifts, shoulder stretch, and back-saver sit and reach.
Curl-ups, push-ups, and trunk lifts measure abdominal,
trunk extensor, and upper body muscle strength and en-
durance while shoulder stretch and back-saver sit-and-reach
components measure Jexibility. All tests were implemented
using existing protocols [30].

Psychosocial functioning was measured utilizing the
35-item Pediatric Symptom Checklist (PSC) for the initial
eight cohorts, a valid and reliable approach to identifying
psychosocial dysfunction [31].(e questionnaire uses a 3-point
Likert scale (never� 0, sometimes� 1, and often� 2) and is
summed to create an overall score of psychosocial impair-
ment. In addition, three subscales were calculated: in-
ternalizing problems (5 items), externalizing problems
(7 items), and attention problems (5 items) [32]. A summary
score of 28 or higher or subscale scores of 5 or higher on
internalizing, 7 or higher on externalizing, and 7 or higher
on attention, respectively, suggest impairment in psycho-
logical functioning [32]. (e PSC was replaced by the Pe-
diatric Quality of Life Inventory (PedsQL 4.0) based on
feedback from caregivers. (e PedsQL is a 23-item survey
and comprised four domains: physical functioning (8 items),
emotional functioning (5 items), social functioning (5 items),
and school functioning (5 items). It is a valid instrument
to assess children’s psychosocial health (mean of emotional,
social, and school functioning subscales) and physical
health (physical functioning subscale) through children’s

perception (self-report) and their parents’ perception (parent
report) [33]. Items were scored following standardized
scoring procedures, with a higher score indicating a better
health status [33].

2.4. Data Analysis. Program completers were deAned as
participants who attendedmore than half of o/ered sessions.
Baseline di/erences between completers and noncompleters
were analyzed using the Kruskal-Wallis or chi-square test.
Pre- and postintervention di/erences in outcome measures
for SCFFF program completers were determined by the
paired t- or McNemar’s test. Mixed models were used to
analyze changes in BMI z-score and BMI from baseline to
the Anal SCFFF session (week 16) and to 1 year and to 2 years
following SCFFF participation in program completers. (e
sample size of noncompleters with 1-year (n� 3) or 2-year
(n� 1) postdata did not allow for stable comparisons with
completers; thus, all pre- and postintervention analyses
include only completers. Missing follow-up data were im-
puted if data existed for adjacent points (4 values imputed).
All analyses were performed using the SAS statistical analysis
system (Version 9.3, SAS Institute, Cary, NC), and p< 0.05 was considered statistically signiAcant.

3. Results

3.1. Characteristics of Study Participants. One hundred
eighteen participants (50 boys, 68 girls), with a mean age of
8.4± 1.3 years and an average BMI z-score at baseline of
2.04± 0.46, enrolled in SCFFF, and 97 (82%) were classiAed
as completers. BMI z-scores did not change in the two years
prior to SCFFF participation (β� 0.021, 95% CI: −0.017,
0.058; p � 0.277). Completers attended an average of 82% of
sessions (SD� 17.6), and noncompleters attended an average
of 30% of sessions (SD� 16.8). (ere were no di/erences in
demographic or anthropometric characteristics between
completers and noncompleters (Table 2).

3.2.Baseline toPostinterventionComparisonsamongProgram
Completers. Although BMI did not change from baseline to
the last SCFFF session, BMI z-score decreased while height
and weight increased over the course of the 16-week in-
tervention (Table 3). Children decreased their intake of
calories, carbohydrate, fat, saturated fat, and sodium over
the intervention period when accessed via the YAQ or BKFS;
changes in protein and added sugar intake were found in the
BKFS assessment, not in the YAQ (Table 3). Participants
(n� 97) increased their curl-up, push-up, and trunk lift
scores, but shoulder stretch and sit-and-reach scores did not
change (Table 3). Among participants with PSC data
(n� 65), the mean summary PSC score and subscale scores
decreased, but these changes were not statistically signiA-
cant. (ere were Ave participants (8.3%) whose PSC scores
suggested functional psychological impairment based on the
standard scoring [31]. Among participants with PedsQL
score (n� 28), the mean summary scores increased, but this
was not statistically signiAcant. (e only change in subscale
scores was the parental report of their child’s emotional

4 Journal of Obesity

Table 2: Comparison of the baseline information (preintervention) by participation status.

Total n� 118 Completers n� 97 Noncompleters n� 21 p value
Age (years) 8.4± 1.3 8.5± 1.3 8.1± 1.4 0.204
Height (cm) 54.3± 3.9 137.9± 9.4 137.6± 10.9 0.368
Weight (kg) 105.9± 28.4 47.5± 12.2 47.6± 16.4 0.08

BMI (kg/m2) 24.9± 4.4 24.9± 4.0 25.1± 5.8 0.690
BMI z-score 2.04± 0.47 2.04± 0.46 2.07± 0.50 0.775
Sex, male [n (%)] 50 (42.4) 39 (40.2) 11 (52.4) 0.047∗

Note. Values are mean± SD unless otherwise speciAed; p values were obtained by performing the Kruskal-Wallis test or chi-square test. ∗p< 0.05.

Table 3: Comparison between post- and premeasures for SCFFF program completers (n� 97).

Variables n Pre Post Di/erence between post andpre (post− pre, 95% CI) p value
E/ect
size

BMI (kg/m2) 97 24.9± 4.0 24.7± 3.7 −0.20 (−0.59 to 0.20) 0.117 −0.055
BMI z-score 97 2.04± 0.46 1.97± 0.45 −0.08 (−0.11 to −0.04) <0.001∗ −0.150 Height (cm) 97 137.9± 9.4 140.0± 10.3 1.99 (1.30 to 2.70) <0.001∗ 0.585 Weight (kg) 97 47.5± 12.2 48.6± 12.4 1.11 (0.59 to 1.63) <0.001∗ 0.463 YAQ 65a

Calories (kcal) 2105.6± 484.8 1888.5± 429.3 −217.15 (−316.49 to −117.81) <0.001∗ −0.542 Protein (grams) 91.9± 21.8 89.4± 21.3 −2.50 (−7.03 to 2.02) 0.273 −0.137 Fat (grams) 70.2± 19.0 60.2± 14.9 −10.04 (−14.15 to −5.94) <0.001∗ −0.606 Carbohydrate (grams) 283.4± 71.6 254.5± 66.6 −28.94 (−43.26 to −14.62) <0.001∗ −0.501 Saturated fat (grams) 24.2± 7.0 20.8± 5.9 −3.35 (−4.81 to −1.89) <0.001∗ −0.567 Sodium (mg) 2637.5± 679.5 2340.0± 523.2 −297.45 (−443.4 to −151.49) <0.001∗ −0.505 Added sugar (tsp) 63.3± 26.9 57.3± 29.9 −5.99 (−12.43 to 0.44) 0.067 −0.231

BKFS 18b

Calories (kcal) 1241.1± 448.2 910.3± 294.6 −330.78 (−565.21 to −96.35) 0.009∗ −0.705
Protein (grams) 57.4± 20.5 43.5± 13.7 −13.92 (−24.72 to −3.12) 0.015∗ −0.644
Fat (grams) 52.8± 22.6 35.0± 13.5 −17.74 (−28.61 to −6.86) 0.003∗ −0.815
Carbohydrate (grams) 138.6± 43.3 110.3± 33.1 −28.37 (−53.03 to −3.70) 0.027∗ −0.575
Saturated fat (grams) 18.4± 8.0 12.0± 4.5 −6.38 (−10.14 to −2.62) 0.002∗ −0.849
Sodium (mg) 2066.3± 774.4 1449.7± 442.3 −616.57 (−1027.47 to −205.68) 0.006∗ −0.750
Added sugar (tsp) 5.7± 3.2 3.2± 2.0 −2.57 (−4.37 to −0.76) 0.008∗ −0.711

PSC total score 65c 12.4± 8.3 11.2± 9.0 −1.20 (−2.67 to 0.27) 0.108 −0.202
PedsQL total (self) 28d 73.1± 18.0 74.6± 14.8 1.51 (−3.51 to 6.54) 0.542 0.09

Psychosocial health 67.6± 23.8 70.7± 17.2 3.10 (−3.21 to 9.40) 0.323 0.190
PedsQL total (parent) 28e 68.8± 13.2 72.8± 15.8 2.97 (−1.17 to 7.11) 0.152 0.20

Psychosocial health 66.1± 13.7 68.9± 18.3 2.86 (−1.96 to 7.68) 0.235 0.230
FITNESSGRAM 97

Curl-up 9.67± 10.59 12.48± 8.96 2.72 (0.76 to 4.68) 0.007∗ 0.280
Trunk lift (inches) 7.09± 2.90 8.23± 3.81 1.07 (0.43 to 1.72) 0.001∗ 0.333
Push-up 5.22± 5.89 6.42± 5.67 1.30 (0.36 to 2.25) 0.015∗ 0.279
Sit and reach (R) (inches) −1.27± 3.22 −1.01± 2.93 0.27 (−0.21 to 0.74) 0.264 0.114
Sit and reach (L) (inches) −1.21± 2.92 −1.23± 2.96 −0.02 (−0.53 to 0.49) 0.936 −0.008
Shoulder stretch (R) [n (%)] 56 (57.7) 63 (65.0) 61.8% (46.0 to 77.6)f 0.089g 0.618
Shoulder stretch (L) [n (%)] 44 (45.4) 50 (51.6) 72.0% (58.5 to 85.6)f 0.109g 0.720

Note. SCFFF� South County Food, Fitness and Fun. YAQ�Youth Adolescent Food Frequency Questionnaire. BKFS�Block Kids Food Screener.
PSC�Pediatric SymptomChecklist. PedsQL�Pediatric Quality of Life Inventory. Values aremean± SD unless otherwise speciAed; p values were obtained by
performing the paired t-test except for the note. aData were collected from 1–9 cohorts. bData were collected from 10–14 cohorts. cData were collected from
1–8 cohorts. d, eData were collected from 9–14 cohorts. f(e risk di/erence� (proportion of post-Yes among all pre-Yes) – (proportion of post-Yes among all
pre-No). gp value was calculated by McNemar’s test (binary variables). ∗p< 0.05.

Journal of Obesity 5

functioning, which increased signiAcantly from 61.4± 17.2 at
baseline to 68.9± 19.6 at postintervention (β� 7.90, 95% CI:
2.70, 13.11; p � 0.004).

3.3. Changes in BMI z-Score and BMI in Program Completers
withFollow-UpData. (emean BMI z-score andmean BMI
for program completers (n� 65) with 2-year follow-up data
are presented in Figure 2 and Table 4. Among completers
with 1-year follow-up (n� 75), BMI z-score decreased from
2.04± 0.44 at baseline to 2.01± 0.47 at one year, but
this change did not reach signiAcance (β�−0.017, 95% CI:
−0.043, 0.010; p � 0.216). Among completers with 2-year
follow-up (n� 65; overweight� 10, obese� 55), BMI in-
creased steadily (β� 0.87, 95% CI: 0.65, 1.08; p< 0.001), but BMI z-score decreased (β�−0.031, 95% CI: −0.054, −0.009; p � 0.007) throughout the two-year period.

4. Discussion

(is study found that SCFFF, a 16-week community-based
obesity prevention program designed for children and their
caregivers, was associated with a reduction in BMI z-score
and energy intake. Analysis also determined that core body
strength and endurance increased among SCFFF com-
pleters. (e decrease in BMI z-score during the two years
following the program indicates that the intervention
e/ect was sustained for two years. (is downward trajectory
of BMI z-scores is likely related to caregivers’ support
and positive interaction with their child, which suggests
that community-based interventions that include care-
givers are a successful model for stage 3 multidisciplinary
interventions. (e long-term success of this type of program
requires the collaborative community e/orts of pediatri-
cians, nutritionists, families, and others invested in the
community [34].

Children were referred to SCFFF after stage 1 and stage 2
interventions were not successful, and they had demon-
strated a persistently high relative weight for two years
[35, 36].(e consistently high BMI z-score prior to participation
in SCFFF may have been a precipitating factor in families’

decision to participate, but motivations for enrolling in
SCFFF were not assessed. Although the existing research
indicates that not all parents perceive their children’s weight
status accurately [37–39], studies have determined that
parents are motivated to enroll their children in intervention
programs due to concerns about their children’s weight
especially if recommended by their primary care physician
[11, 40, 41]. In our study, parental concern may have con-
tributed to participants’ relatively high completion rate
(82%), which is consistent with Towey et al.’s study [42].
Completers had reduced BMI z-scores over the 16-week
intervention and at 2-year follow-up with a downward
trajectory.(e e/ect size for change in BMI z-score (−0.15) is
similar to that found in other family-based programs such as
Fagg et al. and Trinh et al. [43, 44] but greater than that
found by Kothandan [45].

(e SCFFF nutrition education messages emphasized
the need to increase nutrient-rich, non–energy dense foods
such as fruits, vegetables, and whole grains and to limit
consumption of energy-rich foods with added fats, salt, and
sugars. Observed dietary changes indicate that children
reduced fat and sodium intake, which suggests improve-
ments in dietary quality. (ese dietary changes are consis-
tent with those observed in other studies [46, 47]. It is
important to note that SCFFF did not advocate energy re-
striction. (e observed reduction in energy intake and BMI
z-score was not associated with a reduction in weight or
stature, both of which increased over the course of the
program due to natural growth and development in youth at
this age. Dietary assessment was initially measured by the
YAQ and later switched to the BKFS to reduce participants’
burden. Although both are valid instruments [28, 29], self-
reported food frequency instruments are likely better for
ranking than validity; thus, reported energy intake may not
reJect true intake. (e substantial di/erences in energy
intake between these two instruments reinforce concerns
about validity. Although caregivers were asked to complete
the instruments with their children, it is possible that energy
dense foods eaten away from home were underreported,
although results of both the YAQ and BKFS are highly
correlated with actual intake when compared to results of
a 24-hour dietary recall [28, 48].

(e SCFFF intervention was designed to improve
children’s physical Atness by having them develop skills to
participate in fun physical activities that could be continued
at home. (e FITNESSGRAM assessment utilized assesses
physical Atness, an indication of frequent participation in

2.12

2.08

2.04

1.96

1.92

BM
I z

-s
co

pre post 1-year 2-year
Time point

Figure 2: Overall change in BMI z-score in completers with
2-year follow-up data (n� 65). Note. Pre � baseline/premeasure;
post � postmeasure; 1-year � 1 year following the intervention;
2-year � 2 years following the intervention.

Table 4: Relative weight for SCFFF completers with 2-year follow-
up (n� 65).

Time points n BMI (kg/m2) BMI z-score
Pre 65 25.0± 3.6 2.06± 0.42
Post 65 24.8± 3.3 2.00± 0.41
1-year 65 26.5± 4.3 2.02± 0.47
2-year 65 27.3± 4.5 1.95± 0.57
Note. Values are mean± SD. SCFFF� South County Food, Fitness and Fun.
1-year� 1 year following the intervention; 2-year� 2 years following the
intervention.

6 Journal of Obesity

physical exercises with certain intensity level [49]. Program
completers increased the number of curl-ups, trunk lifts, and
push-ups they completed which reJect core strength and
endurance. (ese results are similar to those found by Farris
et al. who have examined the impact of a 12-week multi-
disciplinary intervention on the physical performance of
children who are obese [50]. However, unlike Farris and
colleagues’ Andings [50], participants in the present study
did not show improvement in sit and reach (Jexibility
measures). (is di/erence could be due to di/erences in
the type of physical activity selected for the program. Farris
and colleagues utilized traditional exercise approaches in-
cluding warm-up, resistance exercises, aerobic activity, and
stretching exercises in each session [50], whereas SCFFF was
more focused on lifetime physical activities instead of
addressing speciAc activities that improve Jexibility. (ough
the measures assessed in this study do not directly assess
physical activity, results suggest that making physical activity
fun and facilitating family support may lead to improved
physical Atness.

(e slight but not statistically signiAcant decrease in
the PSC total scores and increase in the PedsQL total
scores suggest that participating in SCFFF may have had
a beneAcial impact on children’s psychological condition.
However, only a few of children in this study (n � 5) were
classiAed at risk using the PSC. Nonetheless, the positive
changes in scores were consistent with previous research
that determined that overall psychosocial health was
inJuenced by internal factors of physical health [51]. (e
signiAcant increase in children’s emotional functioning as
reported by parents on the PedsQL suggests that parents
perceived their children were feeling better about them-
selves. It is worth noting that participants’ mean PedsQL
baseline psychosocial scores (<70, n � 28) were much lower than those of healthy children (>81, n � 5480) re-
ported in other studies [52, 53]. (e prevalence rate for
psychological dysfunction is higher among children who
are overweight or obese [54–56]. Further research is
needed to assess the psychological e/ect of stage 3 in-
tervention programs.

Given the importance of families in shaping dietary- and
nutrition-related behaviors [18], the sustained participation
of caregivers is an important study Anding. (e need to
include caregivers in obesity intervention programs has been
recognized as an important strategy to address childhood
obesity, yet few programs actively engage caregivers and
those generally have high rates of attrition [57, 58]. (e 18%
attrition rate in this study suggests that the intervention
designed to be fun for children and engaging for caregivers
was e/ective, although there is room for improvement.

Study strengths include the use of standardized and
validated instruments and two-year follow-up. Never-
theless, the study is not without limitations. Dietary and
physical activity behaviors and BMI of siblings and par-
ents were not assessed. In addition, parents’ facilitation of
child and family activity outside of the intervention were
not assessed. Parental income and education data were
not collected; thus, comparisons with other studies are not
possible. However, some degree of economic challenge

can be assumed because children and their caregivers were
referred to this no-cost program by their pediatrician who
perceived that they did not have su-cient resources to pay
for such a program. Participants were from a suburban
area that is predominately white, which limits general-
izability. Results cannot be applied to di/erent pop-
ulations, particularly minority and populations without
regular primary care physicians. Moreover, this study
employed a nonexperimental design with a single group
and did not include a control group; thus, the anthro-
pometric changes may be due to additional factors beyond
the intervention.

5. Conclusion

Results of this study indicate that a community-based stage
3 intervention program for children and caretakers that
focused on nutrition and physical activity can reduce
relative weight in overweight and obese children. Future
interventions should be tested using randomized con-
trolled trials with more diverse sample and should assess
caregiver and sibling behavior changes. Given the lifelong
adverse health consequences of pediatric obesity, in-
terventions that change the relative weight trajectory, such
as the current study, should be widely implemented in
community settings. Future studies need to address family
involvement and collaboration within the community as it
is crucial for the program e/ectiveness and long-term
sustainability.

Conflicts of Interest

(e authors declare that there are no conJicts of interest
regarding the study results or the publication of this
paper.

Acknowledgments

(e authors thank all program participants and their
caretakers/guardians for participating in South County
Food, Fitness and Fun (SCFFF). (e authors would also like
to thank all student volunteers and community members
who have donated their time and expertise to support
SCFFF.

References

[1] N. F. Krebs, M. S. Jacobson, and American Academy of
Pediatrics Committee on Nutrition, “Prevention of pediatric
overweight and obesity,” Pediatrics, vol. 112, no. 2, pp. 424–430,
2003.

[2] National Center for Health Statistics, Health, United States,
2014, NCHS, Hyattsville, MD, USA, 2015, http://www.ncbi.nlm.
nih.gov/books/NBK299348/.

[3] A. D. Christodoulos, A. D. Flouris, and S. P. Tokmakidis,
“Obesity and physical Atness of pre-adolescent children
during the academic year and the summer period: e/ects of
organized physical activity,” Journal of Child Health Care,
vol. 10, no. 3, pp. 199–212, 2006.

[4] G. D. C. Ball, K. A. Ambler, R. A. Keaschuk et al., “Parents as
Agents of Change (PAC) in pediatric weight management: the

Journal of Obesity 7

http://www.ncbi.nlm.nih.gov/books/NBK299348/

protocol for the PAC randomized clinical trial,” BMC Pedi-
atrics, vol. 12, no. 1, p. 114, 2012.

[5] Y. C. Wang, K. McPherson, T. Marsh, S. L. Gortmaker, and
M. Brown, “Health and economic burden of the projected
obesity trends in the USA and the UK,” Lancet, vol. 378,
no. 9793, pp. 815–825, 2011.

[6] E. A. Finkelstein, J. G. Trogdon, J. W. Cohen, and W. Dietz,
“Annual medical spending attributable to obesity: payer- and
service-speciAc estimates,” Health A:airs, vol. 28, no. 5,
pp. w822–w831, 2009.

[7] C. L. Ogden, M. D. Carroll, B. K. Kit, and K. M. Flegal,
“Prevalence of childhood and adult obesity in the United
States, 2011-2012,” JAMA, vol. 311, no. 8, pp. 806–814, 2014.

[8] U.S. Department of Health and Human Services, ;e Surgeon
General’s Call To Action To Prevent and Decrease Overweight
and Obesity, U.S. Department of Health and Human Services,
Public Health Service, O-ce of the SurgeonGeneral, US GPO,
Washington, Rockville, MD, USA, 2001.

[9] R. P. Troiano and K. M. Flegal, “Overweight prevalence
among youth in the United States: why so many di/erent
numbers?,” International Journal of Obesity, vol. 23, no. 2,
pp. S22–S27, 1999.

[10] N. I. Larson, M. T. Story, and M. C. Nelson, “Neighborhood
environments: disparities in access to healthy foods in the
U.S.,” American Journal of Preventive Medicine, vol. 36, no. 1,
pp. 74–81, 2009.

[11] B. A. Spear, S. E. Barlow, C. Ervin et al., “Recommendations
for treatment of child and adolescent overweight and obesity,”
Pediatrics, vol. 120, no. 4, pp. S254–S288, 2007.

[12] Y. Latzer, L. Edmunds, S. Fenig et al., “Managing childhood
overweight: behavior, family, pharmacology, and bariatric
surgery interventions,” Obesity, vol. 17, no. 3, pp. 411–423,
2008.

[13] P. Boonchaya-anant, M. F. Holick, and C. M. Apovian,
“Serum 25-hydroxyvitamin D levels and metabolic health
status in extremely obese individuals,” Obesity, vol. 22, no. 12,
pp. 2539–2543, 2014.

[14] A. K. Chen, C. K. Roberts, and R. J. Barnard, “E/ect of a short-
term diet and exercise intervention on metabolic syndrome in
overweight children,”Metabolism: Clinical and Experimental,
vol. 55, no. 7, pp. 871–878, 2006.

[15] L. H. Shriver, A. W. Harrist, L. Hubbs-Tait, G. Topham,
M. Page, and A. Barrett, “Weight status, physical activity, and
Atness among third-grade rural children,” Journal of School
Health, vol. 81, no. 9, pp. 536–544, 2011.

[16] A. Eliakim, G. Kaven, I. Berger, O. Friedland, B. Wolach, and
D. Nemet, “(e e/ect of a combined intervention on body
mass index and Atness in obese children and adolescents—a
clinical experience,” European Journal of Pediatrics, vol. 161,
no. 8, pp. 449–454, 2002.

[17] J. A. Snethen, M. E. Broome, P. Treisman, E. Castro, and
S. T. Kelber, “E/ective weight loss for children: a meta-
analysis of intervention studies 2002-2015,” Worldviews on
Evidence-Based Nursing/Sigma ;eta Tau International,
Honor Society of Nursing, vol. 13, no. 4, pp. 294–302, 2016.

[18] K. E. Rhee, C. W. de Lago, T. Arscott-Mills, S. D. Mehta, and
R. K. Davis, “Factors associated with parental readiness to
make change for overweight children,” Pediatrics, vol. 116,
no. 1, pp. e94–e101, 2005.

[19] J. D. Anderson, R. Newby, R. Kehm, P. Barland, and
M. O. Hearst, “Taking steps together: a family- and
community-based obesity intervention for urban, multiethnic
children,” Health Education & Behavior, vol. 42, no. 2,
pp. 194–201, 2014.

[20] A. Bandura, “Social cognitive theory,” in Handbook of ;eories
of Social Psychology, vol. 1, pp. 416–438, SAGE publications
Inc., (ousand Oaks, California, USA, 2012.

[21] Rhode Island Kids Count, Childhood Obesity, Rhode
Island KIDS COUNT Factbook, Providence, RI, USA, 2012,
http://rikidscount.org.

[22] P. Elsworth, “Free South Kingstown program teaches parents,
children to be active, eat better,” Providence Journal, 2013,
http://www.providencejournal.com/features.

[23] R. J. Kuczmarski and K. M. Flegal, “Criteria for deAnition of
overweight in transition: background and recommendations
for the United States,” American Journal of Clinical Nutrition,
vol. 72, no. 5, pp. 1074–1081, 2000.

[24] Children’s Hospital of Philadelphia Research Institute, “Pedi-
atric Z-score calculator,” 2013, http://zscore.research.chop.edu/.

[25] L. M. Whetstone, K. M. Kolasa, and D. N. Collier, “Partici-
pation in community-originated intervention is associated
with positive changes in weight status and health behaviors in
youth,” American Journal of Health Promotion, vol. 27, no. 1,
pp. 10–16, 2012.

[26] H. R. Rockett and G. A. Colditz, “Assessing diets of children
and adolescents,” American Journal of Clinical Nutrition,
vol. 65, no. 4, pp. 1116S–1122S, 1997.

[27] K. W. Cullen, K. Watson, and I. Zakeri, “Relative reliability
and validity of the Block Kids Questionnaire among youth
aged 10 to 17 years,” Journal of the American Dietetic
Association, vol. 108, no. 5, pp. 862–866, 2008.

[28] H. R. Rockett, M. Breitenbach, A. L. Frazier et al., “Validation
of a youth/adolescent food frequency questionnaire,”
Preventive Medicine, vol. 26, no. 6, pp. 808–816, 1997.

[29] G. Block, A. M. Hartman, C. M. Dresser, M. D. Carroll,
J. Gannon, and L. Gardner, “A data-based approach to diet
questionnaire design and testing,” American Journal of
Epidemiology, vol. 124, no. 3, pp. 453–469, 1986.

[30] J. R. Morrow Jr., S. B. Martin, and A. W. Jackson, “Reliability
and validity of the FITNESSGRAM: quality of teacher-collected
health-related Atness surveillance data,” Research Quarterly for
Exercise and Sport, vol. 81, no. 3, pp. S24–S30, 2010.

[31] M. S. Jellinek, J. M. Murphy, J. Robinson, A. Feins, S. Lamb,
and T. Fenton, “Pediatric Symptoms Checklist: screening
school-age children for psychosocial dysfunction,” Journal of
Pediatrics, vol. 112, no. 2, pp. 201–209, 1988.

[32] W. Gardner, M. Murphy, G. Childs et al., “(e PSC-17: a brief
pediatric symptoms checklist including psychosocial problem
subscales: a report from PROS and ASPN,” Ambulatory Child
Health, vol. 5, no. 3, pp. 225–236, 1999.

[33] J. W. Varni, M. Seid, and P. S. Kurtin, “PedsQL 4.0: reliability
and validity of the Pediatric Quality of Life Inventory version
4.0 generic core scales in healthy and patient populations,”
Medical Care, vol. 39, no. 8, pp. 800–812, 2001.

[34] H. M. Grow, P. Hencz, M. J. Verbovski et al., “Partnering for
success and sustainability in community-based child obesity
intervention: seeking to help families ACT,” Family &
Community Health, vol. 37, no. 1, pp. 45–59, 2014.

[35] S. E. Barlow and W. H. Dietz, “Obesity evaluation and
treatment: Expert Committee recommendations: the Mater-
nal and Child Health Bureau, Health Resources and Services
Administration and the Department of Health and Human
Services,” Pediatrics, vol. 102, no. 3, p. e29, 1998.

[36] J. H. Himes and W. H. Dietz, “Guidelines for overweight in
adolescent preventive services: recommendations from an expert
committee: the Expert Committee on Clinical Guidelines for
Overweight in Adolescent Preventive Services,” American
Journal of Clinical Nutrition, vol. 59, no. 2, pp. 307–316, 1994.

8 Journal of Obesity

http://rikidscount.org

http://www.providencejournal.com/features

http://zscore.research.chop.edu/

[37] K. C. Eckstein, L. M. Mikhail, A. J. Ariza et al., “Parents’
perceptions of their child’s weight and health,” Pediatrics,
vol. 117, no. 3, pp. 681–690, 2006.

[38] E. Hudson, A. McGloin, and A. McConnon, “Parental weight
(mis)perceptions: factors inJuencing parents’ ability to cor-
rectly categorise their child’s weight status,” Maternal and
Child Health Journal, vol. 16, no. 9, pp. 1801–1809, 2012.

[39] T. Remmers, A. van Grieken, C. M. Renders, R. A. Hirasing,
S. M. Broeren, and H. Raat, “Correlates of parental mis-
perception of their child’s weight status: the “be active, eat
right” study,” PLoS ONE, vol. 9, no. 2, p. e88931, 2014.

[40] A. Dhingra, L. Brennan, and J. Walkley, “Predicting treatment
initiation in a family-based adolescent overweight and obesity
intervention,” Obesity, vol. 19, no. 6, pp. 1307–1310, 2011.

[41] H. Grow, C. Hsu, L. L. Liu et al., “Understanding family
motivations and barriers to participation in community-based
programs for overweight youth: one program model does not
At all,” Journal of Public Health Management and Practice,
vol. 19, no. 4, pp. e1–e10, 2013.

[42] M. Towey, R. Harrell, and B. Lee, “Evaluation of “one body,
one life”: a community-based family intervention for the
prevention of obesity in children,” Journal of Obesity,
vol. 2011, p. 7, 2011.

[43] J. Fagg, P. Chadwick, T. J. Cole et al., “From trial to pop-
ulation: a study of a family-based community intervention for
childhood overweight implemented at scale,” International
Journal of Obesity, vol. 38, no. 10, pp. 1343–1349, 2014.

[44] A. Trinh, M. Campbell, O. C. Ukoumunne, B. Gerner, and
M. Wake, “Physical activity and 3-year BMI change in
overweight and obese children,” Pediatrics, vol. 131, no. 2,
pp. e470–e477, 2013.

[45] S. K. Kothandan, “School based interventions versus family
based interventions in the treatment of childhood obesity—a
systematic review,” Archives of Public Health, vol. 72, no. 1,
p. 3, 2014.

[46] T. Reinehr, A. Schaefer, K. Winkel, E. Finne, A. M. Toschke,
and P. Kolip, “An e/ective lifestyle intervention in overweight
children: Andings from a randomized controlled trial on
“Obeldicks light”,” Clinical Nutrition, vol. 29, no. 3,
pp. 331–336, 2010.

[47] M. Waling, T. Lind, O. Hernell, and C. Larsson, “A one-year
intervention has modest e/ects on energy and macronutrient
intakes of overweight and obese Swedish children,” Journal of
Nutrition, vol. 140, no. 10, pp. 1793–1798, 2010.

[48] M. Hunsberger, J. O’Malley, T. Block, and J. C. Norris,
“Relative validation of block kids food screener for dietary
assessment in children and adolescents,” Maternal & Child
Nutrition, vol. 11, no. 2, pp. 260–270, 2015.

[49] A. Rauner, F. Mess, and A. Woll, “(e relationship between
physical activity, physical Atness and overweight in adoles-
cents: a systematic review of studies published in or after
2000,” BMC Pediatrics, vol. 13, p. 19, 2013.

[50] J. W. Farris, L. Taylor, M. Williamson, and C. Robinson,
“A 12-week interdisciplinary intervention program for children
who are obese,” Cardiopulmonary Physical ;erapy Journal,
vol. 22, no. 4, pp. 12–20, 2011.

[51] D. P. Steinbaum, C. Chemtob, J. A. Boscarino, and
D. Laraque, “Use of a psychosocial screen to detect children
with symptoms of posttraumatic stress disorder: an explor-
atory study,” Ambulatory Pediatrics, vol. 8, no. 1, pp. 32–35,
2008.

[52] J. W. Varni, M. Seid, T. Smith Knight, T. Burwinkle, J. Brown,
and I. S. Szer, “(e PedsQL™ in pediatric rheumatology:
reliability, validity, and responsiveness of the Pediatric

Quality of Life Inventory™ Generic Core Scales and Rheu-
matology Module,” Arthritis and Rheumatism, vol. 46, no. 3,
pp. 714–725, 2002.

[53] I. Wilmot, C. E. Cephus, A. Cassedy, I. Kudel, B. S. Marino,
and J. L. Je/eries, “Health-related quality of life in children
with heart failure as perceived by children and parents,”
Cardiology in the Young, vol. 26, no. 5, pp. 885–893, 2016.

[54] E. J. Costello, S. Mustillo, A. Erkanli, G. Keeler, and
A. Angold, “Prevalence and development of psychiatric dis-
orders in childhood and adolescence,” Archives of General
Psychiatry, vol. 60, no. 8, pp. 837–844, 2003.

[55] Y. Latzer and D. Stein, “A review of the psychological and
familial perspectives of childhood obesity,” Journal of Eating
Disorders, vol. 1, no. 1, p. 7, 2013.

[56] O. Pinhas-Hamiel, S. Singer, N. Pilpel, A. Fradkin, D. Modan,
and B. Reichman, “Health-related quality of life among
children and adolescents: associations with obesity,” In-
ternational Journal of Obesity, vol. 30, no. 2, pp. 267–272,
2006.

[57] A. C. Lindsay, K. M. Sussner, J. Kim, and S. Gortmaker, “(e
role of parents in preventing childhood obesity,” Future of
Children, vol. 16, no. 1, pp. 169–186, 2006.

[58] J. A. Skelton and B. M. Beech, “Attrition in paediatric weight
management: a review of the literature and new directions,”
Obesity Reviews, vol. 12, no. 5, pp. e273–e281, 2011.

Journal of Obesity 9

Turn in your highest-quality paper
Get a qualified writer to help you with

“ Module 4 Case-fighting chronic disease and community nutrition intervention ”

Get high-quality paper

NEW! AI matching with writer

Hire a Writer

Client Reviews

4.9

Sitejabber

4.6

Trustpilot

4.8

Our Guarantees

100% Confidentiality

Information about customers is confidential and never disclosed to third parties.

Original Writing

We complete all papers from scratch. You can get a plagiarism report.

Timely Delivery

No missed deadlines – 97% of assignments are completed in time.

Money Back

If you're confident that a writer didn't follow your order details, ask for a refund.

New to Your Trusted Assignment Help Service? Sign up & Save

Calculate the price of your order

Type of paper needed:

Pages:

You will get a personal manager and a discount.

Academic level:

We'll send you the first draft for approval by at

Total price:

$0.00

Power up Your Academic Success with the
Team of Professionals. We’ve Got Your Back.

Power up Your Study Success with Experts We’ve Got Your Back.

Order Now Order Now