The Community-based Healthy-lifestyle Intervention for Rural Preschools (CHIRP) study: Design and methods

The CHIRP study is a two-arm, pilot randomized controlled trial assessing the effectiveness of a behavioral family weight management intervention in an important and at-risk population, overweight young children, 3 to 6 years of age, and their parents from underserved rural counties. Participants will include 96 parent–child dyads living in rural counties in north central Florida. Families will be randomized to one of two conditions: (a) behavioral family based intervention or (b) a waitlist control. Child and parent participants will be assessed at baseline (month 0), post-treatment (month 4), and follow-up (month 10). Assessments and intervention sessions will be held at the Cooperative Extension office in each participating rural county. The primary outcome measure is change in child body mass index (BMI) z-score. Additional key outcome measures include child dietary intake, physical activity, and parent BMI.This study is unique because (1) it is one of the few randomized controlled trails examining a behavioral family intervention to address healthy habits and improved weight status in young overweight and obese children, (2) addresses health promotion in rural settings, and (3) examines intervention delivery in real world community settings through the Cooperative Extension Service offices. If successful, this research has potential implications for medically underserved rural communities and preventative health services for young children and their families.     

Crisis child care: an intervention for at-risk families.

Crisis child care programs provide parents in crisis with a break from the stresses of childrearing and provide at-risk children with a safe environment. This study describes parenting stress as the construct of measurement in a pilot project in a predominantly rural midwestern state. The Parenting Stress Index/Short Form (PSI/SF) was used to measure the amount of stress experienced by the parent as a result of the parenting role. Comparisons of the mothers' PSI/SF pretest and posttest scores indicated significant improvement in the construct areas of Total Stress. Parental Distress. Difficult Child, and Life Stress. Comparison of child maltreatment rates indicated that there was a significant decrease (X2 = 16.91, p < 0.0001) in the reported incidence of child maltreatment in the rural counties with a crisis child care program compared with counties that did not offer this intervention. Overall, these findings indicate that crisis child care is an effective preventive intervention for at-risk families. The investigator suggests that nurses enhance their collaborative relationships with these programs to provide a more seamless avenue for both receiving and providing referrals.     

Addressing the wicked problem of childhood trauma through a nursing and cooperative extension system collaboration

The purpose of this clinical concept report is to describe a public health project in rural Indiana that addressed the complex social issue or “wicked problem” of childhood trauma. The project was implemented through a unique partnership between nursing faculty and Cooperative Extension Educators, community‐based workers who are associated with fulfilling the mission of Land Grant Universities. The core focus of the project entailed a nurse and a Cooperative Extension Educator co‐teaching trauma‐informed parenting classes to rural dwelling, kinship caregivers. Kinship caregivers are often grandparents who assume the parenting role after the child has been removed from the birth parents’ care. The trauma‐informed curriculum was developed by experts in child trauma and is available through the National Child Traumatic Stress Network. The unique partnership provided insight into the different missions of the two organizations, different values and workflow metrics, and different schedules, which at times proved to be barriers to implementation. This discussion focuses on deconstructing the goals and objectives of the project and retrospectively, describing recommendations so that public health nurses may partner with Extension Educators in their communities for optimal project success.     

The role of chiropractic in primary care: findings of four community studies

OBJECTIVE: To assess, through qualitative studies of 4 medically underserved communities, the receptivity of chiropractors, other health care providers, and consumers to the idea of chiropractors' assuming a focal role in primary care. METHOD: Visits by a team of 2 researchers to 4 medically underserved communities: (1) rural towns in eastern Oregon; (2) rural towns in Iowa; (3) underserved areas of Miami, Fla; and (4) underserved areas of Chicago, Ill. Each site visit included interviews with chiropractors, other health care providers, and managers of health facilities as well as with focus groups of consumers. RESULTS: If chiropractors were to pursue a primary care role based on an allopathic model of primary care, there would not be widespread consumer receptivity. Those consumers who are most likely to use chiropractors as primary care providers are those who prefer health care models that have a close affinity with lay conceptualizations of illness and health care. CONCLUSIONS: The community studies suggested that chiropractors and consumers might prefer that chiropractors not be primary care providers in a conventional way and that the allopathic community might be indifferent or even hostile to the idea of chiropractors and other non-MDs as major primary care providers. Current practice models of chiropractors do not include a strong allopathic model of primary care, although they are consistent with consumer preferences and satisfying to chiropractors.     

Design of the Rural LEAP randomized trial: An evaluation of extended-care programs for weight management delivered via group or individual telephone counseling

Obesity is a major contributor to the greater prevalence of chronic disease morbidity and mortality observed in rural versus nonrural areas of the U.S. Nonetheless, little research attention has been given to modifying this important driver of rural/urban disparities in health outcomes. Although lifestyle treatments produce weight reductions of sufficient magnitude to improve health, the existing research is limited with respect to the long-term maintenance of treatment effects and the dissemination of services to underserved populations. Recent studies have demonstrated the feasibility of delivering lifestyle programs through the infrastructure of the U.S. Cooperative Extension Service (CES), which has >2900 offices nationwide and whose mission includes nutrition education and health promotion. In addition, several randomized trials have shown that supplementing lifestyle treatment with extended-care programs consisting of either face-to-face sessions or individual telephone counseling can improve the maintenance of weight loss. However, both options entail relatively high costs that inhibit adoption in rural communities. The delivery of extended care via group-based telephone intervention may represent a promising, cost-effective alternative that is well suited to rural residents who tend to be isolated, have heightened concerns about privacy, and report lower quality of life. The Rural Lifestyle Eating and Activity Program (Rural LEAP) is a randomized trial, conducted via CES offices in rural communities, targeted to adults with obesity (n = 528), and designed to evaluate the effectiveness and cost-effectiveness of extended-care programs delivered via group or individual telephone counseling compared to an education control condition on long-term changes in body weight.     

Acceptance of Nurse Practitioners and Physician Assistants in Meeting the Perceived Needs of Rural Communities

ABSTRACT Nurse practitioners and physician assistants have provided a partial solution to the shortage of primary care services in medically underserved rural areas. This paper describes the results of a study exploring community acceptance of nurse practitioners and physician assistants in rural medically underserved areas. Community acceptance in the context of this study implies not only satisfaction with care received, but also willingness of the community to support NP/PA practice through its infrastructure and encourage members to initially seek and continue to receive care from an NP or PA. Five focus groups were conducted in each of five rural medically underserved communities. The two most pervasive findings were the lack of previous exposure to NPs and PAs and the general belief that NPs and PAs would be accepted in these communities if certain conditions could be met. The theme of conditional acceptance included both personal and system factors. Personal factors included friendliness, competence, willingness to enter into the life of the community, and the ability to keep information confidential. System factors considered critical for acceptance included service type, integration with the existing health care system, cost, geographic proximity, and availability. The results of this study offer insight into community attitudes and suggest marketing strategies for those who plan to introduce NP or PA services into rural communities.     

A randomized clinical trial of the effects of parent mentors on early childhood obesity: Study design and baseline data

BackgroundFew effective community-based interventions exist for early childhood obesity. Parent mentors have been successful as an intervention for other conditions, but have not been used in childhood obesity. We designed an intervention for early childhood obesity using parent mentors and a positive outlier approach to assess potential efficacy, feasibility, and acceptability.MethodsThis trial enrolled obese (≥ 95th BMI percentile for age and gender) 2–5-year-old children in a Head Start program and their parents, with allocation to either parent mentors trained in positively deviant behaviors regarding childhood obesity, or community health workers delivering health education on obesity-related behaviors. The primary outcome is body mass index z-score change at the six-month follow-up assessment. Secondary outcomes include feeding behaviors and practices, health-related quality of life, dietary intake, and participation levels.ResultsWe enrolled three parent mentors and 60 parent–child dyads. The population is 100% Hispanic; 44% of parents speak Spanish as their primary language and 45% were not high-school graduates. Children had a reported median vegetable and fruit intake of 0.3 and 1.1 cups per day, respectively, at baseline, and a median daily screen time of three hours. There was no intergroup difference in quality-of-life scores at baseline. Retention has been high, at 90% in three months.ConclusionsIn this randomized trial of the effects of parent mentors on early childhood obesity, parent–child dyads from an underserved, Hispanic population were successfully enrolled through a partnership with a Head Start organization, with a high retention rate.     

Facilitating Self-Management of Substance Use Disorders with Online Counseling: The Intervention and Study Design

This paper describes a pilot study using online counseling for court-involved parents who have been charged with child abuse and neglect related to substance use. All families resided in the medically underserved area of Newark, New Jersey and were recruited from halfway houses and the Family Court. The sample consisted of 30 participants randomly assigned to control (n = 15) and experimental (n = 15) groups. Of the participants, 83% were Black, 13% were White, and 3% were Hispanic. The control group had access to usual face-to-face treatment at a local treatment center where typical court-ordered offenders were referred. Usual face-to-face treatment often involved being wait-listed for periods of months even for a detox bed. The experimental group had immediate access to the online counseling intervention. The online counseling software and the live counseling components of the intervention were developed with a stages of change theoretical framework. Preliminary findings show promise for the feasibility of online interventions for underserved populations.     

The Kansas Health Education Training Center: caring for the underserved

The State of Kansas was awarded Health Education Training Centers (HETC) DHHS/HRSA, BrHPr Federal funds for the first time in 2002 through 2005. The three-year grant award was under the leadership of the Nurse-Midwifery Education faculty of the University of Kansas (KU) School of Nursing. Federal objectives included: 1. To facilitate interdisciplinary clinical training for health professions students from nursing, medicine, and allied health at targeted underserved communities. 2. To deliver culturally appropriate health care information to underprivileged populations at targeted underserved communities. 3. To conduct continuing education activities for community health workers and health professionals serving vulnerable urban and rural populations. 4. To recruit and mentor high school students from disadvantaged populations to pursue health professions. This three-year state-wide program addressed access to quality health care for underprivileged and underserved populations in select communities to improve health status, through community-based care that is culturally competent, multidisciplinary, sensitive to needs of special populations and augmented by health professions students. This article provides a review of two selected community-based interventions in Sedgwick and Wyandotte counties (addressing BrHPr federal objectives one and two) implemented to enhance care for immigrant pregnant women and underserved patients diagnosed with diabetes, respectively. Also included is a review of literature related to the efficacy and utilization of community based health workers (CHWs) in caring for vulnerable populations.     

Enhancing breast health in rural populations: clinical nurse specialist as the key

Four clinical nurse specialists (CNSs) were funded for a project to increase breast cancer (BC) screening practices and the knowledge of BC risk factors for women in 4 medically underserved rural counties. The goal was to implement a program to increase knowledge of breast health practices, increase access to mammography, establish linkages among CNSs and community organizations, and increase resources for breast health education and screening. Phase I: A training program (focusing on breast health, breast cancer, and screening) was presented to public health nurses from each of the 4 counties. Phase II: Project and public health nurses teamed to provide an education and screening program for rural area women. The program involved making mammograms available at no cost through a mobile mammography unit that was brought to each county. Mammograms and educational programs were provided to 141 women. The project team was clearly able to function as both clinical experts and clinical leaders. The spheres of influence for these 4 CNSs included patient/client (rural women), nursing personnel (county health department nurses), and organization/network (state health department and governmental bodies). This project, based on the Logic Model, can serve as a framework for delivering care in underserved, rural populations.     

Exploring Relationships Among Maternal BMI,Family Factors,and Concern for Child's Weight

PROBLEM: In an effort to better understand child obesity, this study examined the association between family living location, family function, mother's body mass index (BMI), and mothers' attitudes and behaviors concerning child feeding. Recent research on obesity has shown there is limited information on family influence and parental perceptions and attitudes. METHODS: A cross-sectional analysis was performed on data from 47 mothers of school-aged children. FINDINGS: Urban African-American mothers had higher BMIs and were significantly more concerned about their child's weight status than rural white mothers. Additionally, maternal BMI was associated with the total number of individuals in the household. CONCLUSION: Results suggest the importance in understanding the family and community and its influence on childhood obesity. Armed with knowledge about family factors and parents' beliefs and perceptions, nurses can develop interventions that can assist families and communities to focus on healthy children feeding and weight management.     

PS2-25: An Adaptation of Behavioral Pediatric Obesity Treatment for the Real World: Results from the Group Health Family Wellness Program Pilot Trial

Background/Aims The US Preventive Service Task Force recommends intensive behavioral treatment for children with BMI >85th percentile, but these programs typically rely on individual contact, making them costly and infeasible in health care. In response, we developed a group-based program, the Family Wellness Program (FWP), and piloted it in a primary care setting as a proof-of-concept. Methods The single-arm FWP pilot teaches behavioral skills such as monitoring, goal setting, problem solving, contingency management, environmental control, and relapse prevention in separate parent and child groups. Pediatricians referred eligible families-a child aged 6-12 years with BMI ≥ the 85th percentile and a parent with BMI ≥ 25-and FWP staff followed up by phone for recruitment. Masters-level interventionists facilitated the weekly group sessions. Contact hours were 13 (over 12 weeks) for the first four cohorts and increased to 20 (16 weeks) for the last two cohorts. Primary outcomes were attendance and child and parent BMI. We present results from the first five cohorts, with a sixth underway. Results Thirty-seven families enrolled, representing 33.6% (37 of 110) of those invited. Of families enrolled, 46.0% (17 of 37) completed the program (i.e., attended at least 75% of sessions); they constitute the study sample. All children (17 of 17, 100%) and most parents (12 of 17, 70.6%) were obese at baseline (BMI ≥ 95%ile for children, BMI ≥ 30 for adults). Immediately post-treatment, mean change in child BMI z-score was -0.11 (SD=0.12). BMI z-score decreased by .05-.10 in 6 children (35.3%) and by .10-.50 in another 6 (35.3%). In 5 children (29.4%), BMI z-score was unchanged (decrease of 0-.05). Mean change in parent BMI was -1.09 (SD=1.42), with 76.5% (13 of 17) having reduced BMI post-FWP. Conclusions A group program for family-based behavioral pediatric weight management is feasible; however recruitment and retention are major challenges. Despite the FWP's low intensity, child and parent BMI changes among completers are promising. A next step will be to increase the program's intensity to that recommended by the USPSTF (>25 contact hours). Group-based treatment may represent a promising strategy for addressing pediatric obesity in health delivery systems.     

The WORD (Wholeness,Oneness, Righteousness,Deliverance): design of a randomized controlled trial testing the effectiveness of an evidence-based weight loss and maintenance intervention translated for a faith-based,rural, African American population using a community-based participatory approach

BackgroundThe positive effects of weight loss on obesity-related risk factors diminish unless weight loss is maintained. Yet little work has focused on the translation of evidence-based weight loss interventions with the aim of sustaining weight loss in underserved populations. Using a community-based participatory approach (CBPR) that engages the strong faith-based social infrastructure characteristic of rural African American communities is a promising way to sustain weight loss in African Americans, who bear a disproportionate burden of the obesity epidemic.ObjectivesLed by a collaborative community–academic partnership, The WORD aims to change dietary and physical activity behaviors to produce and maintain weight loss in rural, African American adults of faith.DesignThe WORD is a randomized controlled trial with 450 participants nested within 30 churches. All churches will receive a 16-session core weight loss intervention. Half of the churches will be randomized to receive an additional 12-session maintenance component.MethodsThe WORD is a cultural adaptation of the Diabetes Prevention Program, whereby small groups will be led by trained church members. Participants will be assessed at baseline, 6, 12, and 18 months. A detailed cost-effectiveness and process evaluation will be included.SummaryThe WORD aims to sustain weight loss in rural African Americans. The utilization of a CBPR approach and the engagement of the faith-based social infrastructure of African American communities will maximize the intervention's sustainability. Unique aspects of this trial include the focus on weight loss maintenance and the use of a faith-based CBPR approach in translating evidence-based obesity interventions.     

Early intervention in psychosis: a rural perspective

Over the past decade, there has been great interest in both the development and delivery of early intervention in psychosis services in the United Kingdom, supported by national policy and a Policy Implementation Guide (PIG). Despite this, the PIG fails to distinguish the delivery of early intervention services to different population groups. The paper aims to augment available literature with the range of complex issues that practitioners may face when working in rural settings and link this to the development of early intervention services in rural communities. This paper will also outline some of the fundamental factors that challenge delivery of early intervention to individuals with a first episode of psychosis and their families in rural communities. Important key areas for consideration will be highlighted for both the planning and delivery of early intervention to rural communities.     

Effectiveness of a school-based intervention to increase health knowledge of cardiovascular disease risk factors among rural Mississippi middle school children

BACKGROUND: Few school-based interventions have been evaluated to assess health awareness among children in rural southern areas. The purpose of this controlled investigation was to increase health awareness among middle school-aged children residing in a racially diverse rural community in Mississippi. METHODS: This investigation assessed health knowledge before and after a 16-week school-based intervention in 205 fifth-grade students. Height, weight, BMI, body composition, waist circumference, dietary intake, blood lipids and lipoprotein concentrations, blood glucose concentrations, and resting blood pressure were measured to enhance student awareness of cardiovascular disease risk factors. Values in the intervention school were compared with those obtained simultaneously in a control school within the same community. RESULTS: The school-based intervention was effective in increasing health knowledge in the intervention as compared with the control school. Secondarily, it was effective in improving certain dietary behaviors. Utilizing health care professionals in the classroom to teach students appropriate lifestyles and actually measuring cardiovascular risk factors to increase awareness among students was effective in increasing overall health knowledge. CONCLUSIONS: Health knowledge of rural adolescents can be increased through partnerships with schools and multidisciplinary teams of health care professionals. Ongoing efforts to reduce childhood obesity and cardiovascular disease risk factors are urgently needed, and information obtained during this investigation may be used in planning school-based interventions in other diverse, rural communities.     

The management of diabetes in everyday life study: Design and methods for a pragmatic randomized controlled trial comparing the effectiveness of text messaging versus health coaching

BackgroundAfrican American patients with uncontrolled diabetes living in medically underserved areas need effective clinic-based interventions to improve self-care behaviors. Text messaging (TM) and health coaching (HC) are among the most promising low-cost population-based approaches, but little is known about their comparative effectiveness in real-world clinical settings.ObjectiveUse a pragmatic randomized controlled trial design to determine the comparative effectiveness of TM and HC with enhanced usual care (EC) in African American adults with uncontrolled diabetes and multiple chronic health conditions.Methods/designThe Management of Diabetes in Everyday Life (MODEL) study is randomizing 646 patients (n = 581with anticipated 90% retention) to 3 intervention arms: TM, HC, and EC. Participants are African American adults living in medically underserved areas of the Mid-South, age ≥ 18, with uncontrolled diabetes (A1c ≥ 8), one or more additional chronic conditions, and who have a phone with texting and voicemail capability. Primary outcome measures: the general diet, exercise, and medication adherence subscales of the revised Summary of Diabetes Self-Care Activities questionnaire assessed at one year. Secondary outcomes: diabetes-specific quality of life, primary care engagement, and average blood sugar (A1c). The study will also assess heterogeneity of treatment effects by six key baseline participant characteristics.ConclusionsWe describe the design and methods of the MODEL study along with design revisions required during implementation in a pragmatic setting. This trial, upon its conclusion, will allow us to compare the effectiveness of two promising low-cost primary care-based strategies for supporting self-care behaviors among African Americans individuals with uncontrolled diabetes.ClinicalTrials.gov registration number: NCT02957513     

Family Networks of Obesity and Type 2 Diabetes in Rural Appalachia

The prevalence of obesity and diabetes has been studied in adolescent and adult populations in poor, medically underserved rural Appalachia of West Virginia. A web‐based questionnaire about obesity and diabetes was obtained in 989 family members of 210 Community Based Clinical Research (CBPR) trained adolescent members of a network of 18 science clubs, incorporating 142 families. After age‐correction in < 20 years old, 50% of both adolescents and adults were obese. The frequency distribution of obesity was trimodal. In the overall population 10.4% had type 2 diabetes, while 24% of adult, obese subjects had type 2 diabetes. A new metric, the family diabetes risk potential, identified a trimodal distribution of risk potential. In the lowest most common distribution 43% of families had a diabetic family member. In the intermediate distribution, 69% had a diabetic family member, and in the distribution with highest scores all the families had a diabetic member. In conclusion, the poorest counties of rural Appalachia are at crisis level with the prevalence of obesity and diabetes. The distribution of age‐corrected obesity and family diabetes risk potential are not normally distributed. We suggest that targeting individual family units at greatest risk offers the most efficient strategy for ameliorating this epidemic.     

Community Empowerment in Rural Health Care

Abstract The Healthy Communities 2000 mandate calls for public health leaders to involve community members in setting health priorities and implementing programs in response to the national health objectives for the year 2000 (American Public Health Association, 1991). This paper describes community involvement through a community empowerment nursing intervention and evaluates its application in a rural community. A community health nursing project (AHCPR, Grant No. HS06801) with three interventions, one of which was community empowerment, was designed to address the health needs of small, rural, underserved, primarily Mexican American communities in Arizona. Community empowerment in this project was based on the community-development approach to community organization, and involved community health nurses and lay health workers, called promotoras , who are key persons in community development. The implementation of two health fairs, one the result of the community-empowerment intervention, is described and evaluated in relation to community health. The community-empowerment intervention was based on community participation and responsibility, hallmarks of the second health fair, reflecting lay expertise and cooperation among various levels of the community. Successes and limitations of the health fairs provide feedback for developing a community-empowerment intervention.     

Growing Right Onto Wellness (GROW): A family-centered,community-based obesity prevention randomized controlled trial for preschool child–parent pairs

Growing Right Onto Wellness (GROW) is a randomized controlled trial that tests the efficacy of a family-centered, community-based, behavioral intervention to prevent childhood obesity among preschool-aged children. Focusing on parent–child pairs, GROW utilizes a multi-level framework, which accounts for macro (i.e., built-environment) and micro (i.e., genetics) level systems that contribute to the childhood obesity epidemic.Six hundred parent–child pairs will be randomized to a 3-year healthy lifestyle intervention or a 3-year school readiness program. Eligible children are enrolled between ages 3 and 5, are from minority communities, and are not obese. The principal site for the GROW intervention is local community recreation centers and libraries.The primary outcome is childhood body mass index (BMI) trajectory at the end of the three-year study period. In addition to other anthropometric measurements, mediators and moderators of growth are considered, including genetics, accelerometry, and diet recall.GROW is a staged intensity intervention, consisting of intensive, maintenance, and sustainability phases. Throughout the study, parents build skills in nutrition, physical activity, and parenting, concurrently forming new social networks. Participants are taught goal-setting, self-monitoring, and problem solving techniques to facilitate sustainable behavior change. The GROW curriculum uses low health literacy communication and social media to communicate key health messages. The control arm is administered to both control and intervention participants.By conducting this trial in public community centers, and by implementing a family-centered approach to sustainable healthy childhood growth, we aim to develop an exportable community-based intervention to address the expanding public health crisis of pediatric obesity.