Childhood obesity remains a significant public health concern. While national health and nutrition examination survey (NHANES) reports suggest that obesity may have declined among children aged 2–5 years [
Additional findings from NHANES demonstrate that since 2003 there have been no changes in childhood obesity overall [
Childhood obesity is particularly prevalent among low-income children, as well as African American and Latino children [
The Institute of Medicine strongly recommends that obesity prevention intervention begins in early childhood [
Modifying the home/family environment and parent behaviors are crucial intervention components for the prevention of early childhood obesity [
Although there has been considerable growth in the number of childhood obesity prevention interventions with parents of preschool age children in a variety of settings [
Thus, the purpose of this intervention, healthy homes, healthy families (HHHF), is to address existing gaps in the literature by conducting a pilot feasibility and acceptability study of a parent-driven, home-based intervention to modify health lifestyle behaviors among low-income racially/ethnically diverse children aged 2 to 5 years. The findings from HHHF will inform the design and implementation of a future randomized controlled trial.
HHHF was an early childhood obesity intervention designed to encourage parents to improve healthy lifestyle behaviors related to eating and physical activity for themselves and their children. The study design was a prospective design with pretest/posttest measurement that combined telephone surveys and in-home visit measures collected at baseline and 4-month follow-up with 50 parent-child pairs. The study received approval from the Brown University Institutional Review Board. All participants received a financial incentive upon completion of each study visit.
The study recruitment occurred from 2009 to 2012, at twelve special supplemental nutrition program for women, infants and children (WIC) offices in low-income communities in Rhode Island. The research assistant approached WIC clients in the waiting room to tell them about the study and to ask if they would be interested in participating.
Interested participants were screened for eligibility. Study inclusion criteria required that participants were a parent or legal guardian of a child who was 2 to 5 years of age at the date of the baseline survey and had an age-sex specific body mass index (BMI) of 50th percentile or greater. The adult needed to be 18 years of age or older, live with the child at least 75 percent of the time, speak and read English, and be knowledgeable about the child’s diet and physical activity behaviors. Eligible participants were asked to complete a baseline phone survey administered by trained interviewers using a computer automated telephone interface (CATI) system. Upon completion, research assistants were scheduled to visit the home at the convenience of the participant parent and child to complete an in-person survey, anthropometric measures, and a home audit. Verbal informed consent was received for the baseline telephone survey and then written informed consent (and verbal assent for children aged 4 and over) was received at the home visit. Upon completion of the home visit, parent-child pairs were considered enrolled. This process was repeated four months later as a follow-up assessment.
HHHF included four sets of tailored written materials, three brief motivational interviewing (MI) telephone calls delivered by a trained lay counselor, a physical activity video tailored to the child’s age, and a TV time monitoring device (TV Allowance by MINDMASTER, INC) to help parents monitor/restrict child’s time spent on TV.
The intervention was informed by social cognitive theory (SCT) [
Healthy homes, healthy families intervention logic model.
SCT is based on reciprocal determinism where a person’s behavior, personal factors, and the environment interact constantly and where change in one domain affects changes in the other two domains [
After the baseline home assessment, study staff installed the TV monitor on the TV that the child used most often. Since the primary goal of the TV monitor was as an intervention tool to increase parents’ self-efficacy for setting TV restrictions and limiting the child’s time spent watching TV, we did not collect any data from this device. Approximately 1-2 weeks later, participants received their first package of tailored written intervention materials. The tailored written materials were mailed out in four stages over a 20-week period (approximately every 4 weeks), and the lay counselor MI calls occurred approximately 2 weeks after the mailing of each set of materials. A final set of tailored materials were mailed 1-2 weeks after the final counseling phone call. Materials were microtailored (tailored messages embedded into a page) or macrotailored (entire pages chosen or not). We accomplished the tailoring by using algorithms based on parents’ answers to survey questions and home audit results as well as parent choice. We generated tailored feedback reports for each family on all target child behaviors, the home environment, and parent role modelling behaviors. We also personalized materials with the participant’s and child’s name.
The tailored printed materials focused on eight target behaviors found to be associated with obesity in children and families. These behaviors (increasing fruits and vegetables, reducing sugary drinks, limiting juice, low-fat instead of high fat milk, increasing physical activity, limiting fast food, removing TV from the child’s bedroom, and limiting screen time) were all within control of the parent. If the family was not meeting the guideline for a target behavior, the computer populated a list of choices. We then presented the list to parents as areas where change was possible. Parents then chose a topic for each mailing from this list of primary target behaviors that were an issue for their family. We conducted a similar process for barriers that parents identified as problem areas such as the cost of healthy eating, cost of physical activity, children upset about changing foods or household rules, picky eaters, time for healthy eating, time for PA, children’s choices/habits, lack of knowledge/skill, and lack of social support. Parents could receive up to a total of five barriers pages. In addition, parents could choose up to four tailored recipe pages.
In between each of the four tailored mailings, parents received a brief motivational interviewing (MI) call designed to support their efforts to make changes to the social and physical home environment [
We recruited four women to serve as lay MI counselors for the enrolled parents/guardians (one dropped out early due to the time commitment). We selected counselors who resided in Rhode Island and who had some experience with behavior change interventions but not specifically with MI. One counselor was Hispanic and three were non-Hispanic white and all had experience working with low-income populations. A facilitator, Dr. Drenner, trained through the motivational interviewing network of trainers (MINT), trained the lay counselors over seven evenings for a total of 12 hours. The MI training focused on the primary principles and techniques of the overall MI style and also on how these elements related to the specific behavior change targets of HHHF.
Once the telephone counseling began, Dr. Drenner monitored a random sample of the recorded telephone counseling sessions and continued coaching the counselors in group meetings and in individual sessions. She held group coaching meetings approximately biweekly both in-person and via conference call. Additionally, she held individual coaching sessions via telephone that focused on feedback on one or more of the digitally recorded telephone calls. Coaching was an opportunity for counselors to get consultation on both the content of the calls and specific behaviors related to MI. Dr. Drenner coded random counselor telephone calls using elements of the Motivational Interviewing Treatment Integrity Scale on global scores of empathy, behavior counts of reflections, and open and closed questions [
Intervention adherence assessment included counselor’s focus on (1) a specific target behavior, (2) assessment of importance and confidence of the chosen behavior, (4) goal setting, and (5) on calls 2 and 3, checking with the parent to see if they had met the set goal. Counselors elicited parents’ own desire, ability, reason, and need for change and self-efficacy for change through reflection and affirmation of parents’ effort to create a healthy environment for their child and family. Each participant received a tailored MI feedback page in the subsequent mailing summarizing the importance and confidence regarding the topic they discussed as well as the next step that the participant said they would take. If the counselor was unable to complete the call (after 3 phone call attempts), the participant received an MI feedback page informing them of the missed call as well as when they would receive the next call and a set of tailored materials based on the last contact.
We also obtained questions used in the Fit WIC [
We examined parental support for child physical activity using three items from the Aventuras Para Niños study to inquire about parents/family activity together and transportation [
Demographic variables were collected for parent, as well as the child, and categorized as follows: gender (male versus female), race (White, Black, Asian, Native Hawaiian or other Pacific Island, American Indian or Alaska Native, mixed race, other), and ethnicity (Hispanic versus non-Hispanic). Mean age and BMI were determined and treated as continuous variables. Descriptive statistics were computed with frequencies and proportions for categorical variables and means for continuous variables. Chi square tests were used to compare categorical psychosocial data and categorical demographic variables. General linear models were constructed to compare mean differences of dietary intake, physical activity, sedentary behaviors, child BMI, and parent behaviors pre-/posttest. Significance criterion was set at
Figure
Healthy homes, healthy families intervention recruitment flow diagram.
Baseline demographic and BMI characteristics of the participating children and parents/guardians are presented in Table
Demographic characteristics of the 50 parent-child pairs in healthy homes, healthy families.
Variable | Mean ± SD or |
---|---|
Parent gender (female) | 49 (98) |
Relationship to child | |
Mother | 49 (98) |
Father | 1 (2) |
Percent Hispanic or Latino? (parent) | 20 (40) |
Percent Hispanic or Latino? (child) | 25 (50) |
Race (parent) | 24 (48) |
White | 7 (14) |
Black | 1 (2) |
Asian | 1 (2) |
Native Hawaiian or other Pacific Island | 3 (6) |
American Indian or Alaska Native | 4 (2) |
Mixed race | 12 (24) |
Other | 24 (48) |
Race (child) | |
White | 19 (38) |
Black | 7 (14) |
Asian | 1 (2) |
Native Hawaiian or other Pacific Island | 1 (2) |
American Indian or Alaska Native | 3 (6) |
Mixed race | 7 (14) |
Other | 12 (24) |
Marital status | |
Single | 27 (54) |
Married | 18 (36) |
Divorced | 1 (2) |
Separated | 4 (8) |
Employment status | |
Employed full time | 12 (24) |
Employed part time | 13 (26) |
Unemployed | 12 (24) |
Disabled | 2 (4) |
Student | 5 (10) |
Homemaker | 6 (12) |
Education | |
Less than high school | 4 (8) |
High school or general educational development credential (GED) | 26 (46) |
Vocational or technical school or |
19 (38) |
Bachelor's degree | 3 (6) |
Postgraduate degree | 1 (2) |
Number of other children living in household | |
0 | 17 (34) |
1 | 13 (26) |
2 | 12 (24) |
3 | 5 (10) |
4 | 2 (4) |
5 | 1 (2) |
Number of adults (including yourself) living in household | |
1 | 18 (36) |
2 | 21 (42) |
3 | 6 (12) |
4 | 3 (6) |
5 | 1 (2) |
6 | 1 (2) |
Worried about not having enough food (yes) | 14 (28) |
Annual household income | |
<$6,000 | 7 (14) |
$6,000 to $11,999 | 10 (20) |
$12,000 to $17,999 | 4 (8) |
$18,000 to $23,999 | 10 (20) |
$24,000 to $29,999 | 5 (10) |
$30,000 to $35,999 | 2 (4) |
$36,000 | 7 (14) |
Don’t know or refused | 5 (10) |
BMI category (parent) | |
Underweight | 4 (2) |
Healthy weight | 14 (28) |
Overweight | 10 (20) |
Obese | 24 (48) |
BMI category (child) | |
Underweight (<5th percentile) | 0 |
Within range (5th to <85th percentile) | 36 (72) |
Overweight (85th to <95th percentile) | 7 (14) |
Obese ( |
7 (14) |
Mean Age | |
Parent or guardian | 28.38 ± 6.18 |
Child (age in months) | 43.12 ± 11.88 |
Mean BMI | |
Parent or guardian | 29.81 ± 8.21 |
Mean BMI %ile for age and sex | |
Child | 65.36 ± 27.48 |
The average BMI of the children enrolled in HHHF was at the 65th percentile for age and sex. The recruited children were mostly within the range of 50th–85th percentile (72%), with an additional 14% each in the overweight (≥85th, <95th %ile) and obese (≥95th %ile) categories. The parents/guardians averaged a BMI of 29 kg/m2. The highest proportion of adult participants were obese (48% with BMI ≥ 30), 20% were overweight (BMI ≥ 25, <30), 28% were normal weight, and 4% were underweight.
Process evaluation measures are presented in Table
Process evaluation data.
Variable |
|
|
|
|
|
---|---|---|---|---|---|
Health coach overall | |||||
|
|||||
None | One | Two | Three | Other | |
|
|||||
How many phone calls did you receive from the health coach (reported by participants) | 0 (0) | 1 (2.78) | 7 (19.44) | 26 (72.22) | 2 (5.56) |
Actual calls completed according to counselors | 4 (8) | 13 (26) | 25 (50) | 8 (16) | |
|
|||||
Not at all | A little bit | Some | A lot | ||
|
|||||
How much did the health coach make you think about your child's health | 1 (2.56) | 2 (5.13) | 9 (23.08) | 27 (69.23) | |
How much did you feel understood by the health coach | 0 (0) | 1 (2.56) | 9 (23.08) | 29 (74.36) | |
|
|||||
Agree a lot | Agree a little | Neither agree nor disagree | Disagree a little | Disagree a lot | |
|
|||||
|
|||||
Made it comfortable for me to talk about my child’s health | 34 (87.18) | 1 (2.56) | 4 (10.26) | 0 (0) | 0 (0) |
Respected me | 36 (92.31) | 0 (0) | 3 (7.69) | 0 (0) | 0 (0) |
Helped me to think about why health changes might be important to my child | 30 (76.92) | 4 (10.26) | 3 (7.69) | 1 (2.56) | 1 (2.56) |
Expressed caring and understanding when talking with me about my child’s health | 35 (89.74) | 1 (2.56) | 2 (5.13) | 0 (0) | 1 (2.56) |
Addressed my concerns about my child’s health | 33 (84.62) | 2 (5.13) | 2 (5.13) | 1 (2.56) | 1 (2.56) |
Helped me to set a goal for positive changes in my child's health | 28 (71.79) | 7 (17.95) | 3 (7.69) | 1 (2.56) | 0 (0) |
I felt pressured by the health coach to make changes in my child’s health | 2 (5.13) | 0 (0) | 3 (7.69) | 2 (5.13) | 32 (82.05) |
|
|||||
Were written specifically for you | 26 (68.42) | 4 (10.53) | 5 (13.16) | 3 (7.89) | 0 (0) |
Had information you could use | 31 (81.58) | 4 (10.53) | 1 (2.63) | 1 (2.63) | 1 (2.63) |
Had information you could believe | 27 (71.05) | 8 (21.05) | 3 (7.89) | 0 (0) | 0 (0) |
Were easy to read | 36 (94.74) | 2 (5.26) | 0 (0) | 0 (0) | 0 (0) |
|
|||||
Was easy to use | 17 (73.91) | 2 (8.70) | 0 (0) | 1 (4.35) | 3 (13.04) |
Was useful | 10 (43.48) | 4 (17.39) | 2 (8.70) | 2 (8.70) | 5 (21.74) |
Is a great tool for parents because it is a “set it and forget it” device for them | 13 (56.52) | 4 (17.39) | 3 (13.04) | 1 (4.35) | 2 (8.70) |
Helped your child spend more time doing physically active things | 11 (47.83) | 2 (8.70) | 4 (17.39) | 2 (8.70) | 4 (17.39) |
Changes in child outcomes from baseline to month 4 and change scores for healthy homes, healthy families participants.
Variable | BL |
M4 |
Change (BL to M4) |
|
---|---|---|---|---|
|
||||
Child BMI for age | 65.36 ± 27.48 |
63.82 ± 29.73 |
−1.77 ± 10.93 |
0.319 |
|
||||
Servings of vegetables/day | 0.28 ± 0.34 |
0.54 ± 0.64 |
0.28 ± 0.53 |
0.001* |
Servings of fruit/day | 0.96 ± 1.13 |
1.17 ± 1.17 |
0.21 ± 1.04 |
0.222 |
Ounces of 100% fruit juice/day | 16.01 ± 15.10 |
11.94 ± 11.14 |
−3.92 ± 11.27 |
0.036* |
Ounces of sweetened drinks and soda/day | 8.80 ± 18.52 |
5.06 ± 12.77 |
−4.23 ± 19.65 |
0.198 |
Oz/day child drinks water | 13.98 ± 13.47 |
13.42 ± 8.52 |
0.61 ± 9.31 |
0.691 |
Oz/day child drinks milk | 15.40 ± 9.78 |
13.44 ± 6.88 |
−0.46 ± 8.20 |
0.727 |
Times/week child eats fast food | 1.16 ± 1.23 |
0.86 ± 0.83 |
−0.29 ± 1.06 |
0.091 |
|
||||
Weekday child exercises | 194.98 ± 171.56 |
164.21 ± 170.42 |
−13.35 ± 138.86 |
0.562 |
Weekend day child exercises | 206.02 ± 185.71 |
182.90 ± 169.28 |
5.74 ± 132.50 |
0.791 |
Weekday child spends playing outside | 96.80 ± 107.49 |
59.51 ± 58.14 |
−22.28 ± 59.33 |
0.024* |
Weekend day child spends playing outside | 136.40 ± 126.76 |
70.67 ± 73.91 |
−41.13 ± 91.99 |
0.008* |
|
||||
Weekday child spends watching TV | 146.90 ± 98.71 |
110.77 ± 81.19 |
−49.87 ± 99.88 |
0.003* |
Weekend day child spends watching TV | 149.00 ± 96.27 |
133.72 ± 91.16 |
−20.38 ± 119.80 |
0.294 |
Parents/guardians reported that the health coach made them “think about their child’s health a lot” (69%) and “felt understood by the health coach a lot” (74%). A very high proportion of parents/guardians agreed a lot that “they felt respected” (92%), that “the health coach expressed caring and understanding when discussing their child’s health” (89%), and that “the health coach made it comfortable for [the parent] to talk about their child’s health” (87%). Also, the parents/guardians agreed a lot that “the health coach addressed concerns about the child’s health” (84%), “helped [the parent] to think about why health changes might be important to the child” (77%), and “helped [the parent] to set goals for positive change in the child’s life” (71%).
Most parents reported receiving three (45%) or four (42%) mailings, and the majority read all or most of them (82%). Most parents found the materials somewhat (34%) or very (55%) interesting and 95% reported that “they were very clearly written.” Parents agreed a lot that “the materials were easy to read” (95%), “had information they could use,” (82%) or believe (71%), and “were written especially for [the parent]” (68%). At the time of the four-month follow-up, 87% were still using the written materials and 71% had shared the materials with others.
The TV monitor received somewhat mixed results. The monitor was used always or often (33%), sometimes (13%), but also rarely or never (35%), or the parents/guardians chose not to have a TV monitor (18%). Most parents/guardians (74%) agreed a lot that “the device was easy to use.” However, only about half of participating parents/guardians agreed a lot that “the monitor was useful” (43%) and “was a great tool because they could set it and forget it” (57%) and that “the device helped the child spend more time doing physically active things” (48%). Most parents disagreed a lot (52%) or a little (9%) that “the child would get upset when the TV monitor was turned on.”
Baseline and change in child outcome measures are presented in Table
Although mean BMI percentile did decrease (−1.77 kg/m2) from baseline to month 4, this change was not significant. However, significant change was found in children’s daily vegetable intake. Higher intake was reported at month 4 of follow-up (0.54 cups) compared with baseline (0.28 cups,
While there were no significant changes in intakes for other beverages, all changes were in the direction expected with 4-ounce reductions in sweetened beverage intakes per day and a 0.6-ounce increase in water intake per day. Also, the reduction in the number of times in which children consume fast food each week approached statistical significance (
Baseline and 4-month change in parent behaviors related to parent role modelling, the home food environment, family support for PA, family encouragement for PA/diet, and parent household rules are presented in Table
Changes in parent behaviors from baseline to month 4 and change scores for healthy homes, healthy families participants.
Variable | BL |
M4 |
Change BL to M4 |
|
---|---|---|---|---|
|
||||
Times/day child saw you eat fruit or vegetables w/meal | 2.44 ± 2.03 |
2.42 ± 2.05 |
0.11 ± 3.22 |
0.8414 |
Times/day child saw you eat fruit or vegetables as a snack | 1.90 ± 2.01 |
1.77 ± 1.51 |
−0.03 ± 2.42 |
0.9476 |
Days child saw you drink low-fat milk | 1.74 ± 2.62 |
2.41 ± 2.90 |
0.87 ± 2.45 |
0.0324* |
Days child saw you eating fast food | 1.30 ± 1.37 |
0.90 ± 1.33 |
−0.33 ± 1.03 |
0.0513 |
Times/day child saw you drink sweetened drinks | 1.84 ± 1.60 |
1.49 ± 1.32 |
−0.15 ± 1.91 |
0.6184 |
|
||||
Days child saw you walk from place to place | 1.41 ± 2.21 |
1.77 ± 2.38 |
0.71 ± 1.93 |
0.0292* |
Days child saw you exercising | 0.73 ± 1.45 |
1.54 ± 2.16 |
0.72 ± 1.64 |
0.0094* |
Min/day child saw you watching TV | 131.90 ± 100.58 |
88.08 ± 58.62 |
−47.18 ± 116.61 |
0.0158* |
Min/day child saw you playing on computer | 73.60 ± 109.44 |
50.38 ± 77.75 |
−17.05 ± 68.86 |
0.1303 |
|
||||
Days you did physically active things w/your child | 2.20 ± 2.15 |
2.46 ± 2.17 |
0.28 ± 2.65 |
0.5095 |
Days you did physically active things as a family | 1.80 ± 1.82 |
1.33 ± 1.80 |
−0.41 ± 2.05 |
0.2187 |
Days/week you took child to be physically active | 3.40 ± 2.09 |
2.97 ± 2.24 |
−0.38 ± 3.01 |
0.4305 |
Days/week you suggested child to play outside | 3.46 ± 2.62 |
2.44 ± 2.01 |
−0.79 ± 3.06 |
0.1133 |
|
||||
Times/day you gave child fruit to eat | 1.86 ± 1.22 |
2.21 ± 1.49 |
0.47 ± 1.62 |
0.0802 |
Times/day you gave child vegetables to eat | 1.78 ± 1.52 |
1.64 ± 1.22 |
−0.05 ± 1.69 |
0.8503 |
Days/week you have cut up fv for child to eat | 3.88 ± 2.60 |
3.81 ± 2.22 |
0.22 ± 2.71 |
0.6510 |
Days per week the child consumed low-fat milk | 3.84 ± 3.21 |
4.64 ± 3.14 |
1.13 ± 3.22 |
0.0350* |
Days/week had soda in your home for child to drink | 0.82 ± 1.84 |
0.90 ± 1.70 |
−0.05 ± 2.03 |
0.8752 |
Days/week you had sweetened drinks in your home for child to drink | 2.90 ± 2.87 |
2.85 ± 2.87 |
−0.31 ± 3.13 |
0.5429 |
Days/week you had sweets for child to eat | 3.94 ± 2.67 |
3.74 ± 2.59 |
−0.64 ± 2.99 |
0.1881 |
Days/week you had salty snack for child to eat | 2.88 ± 2.50 |
3.36 ± 2.45 |
0.13 ± 2.68 |
0.7665 |
|
||||
Days/week you praised child for drinking low-fat milk | 0.92 ± 2.13 |
2.23 ± 3.14 |
1.26 ± 3.18 |
0.0181* |
Days/week you praised child for eating fv | 2.63 ± 2.58 |
4.51 ± 2.58 |
1.85 ± 2.42 |
<0.0001* |
Days/week you praised child for not drinking sweetened drinks | 1.06 ± 2.26 |
1.51 ± 2.43 |
0.53 ± 2.48 |
0.1988 |
Days/week you encouraged child to watch less TV | 2.40 ± 2.60 |
4.31 ± 2.24 |
1.35 ± 2.48 |
0.0105* |
Days/week you praised child for being physically active | 2.88 ± 2.90 |
3.54 ± 2.78 |
0.49 ± 2.99 |
0.3153 |
|
||||
Limit number of days child spends watching TV/videos | 3.22 ± 1.28 |
3.51 ± 1.32 |
0.46 ± 1.25 |
0.0271* |
Limit number of days child plays video games | 4.48 ± 1.76 |
4.56 ± 1.70 |
0.31 ± 1.70 |
0.2665 |
Limit number of days child spends on computer | 4.54 ± 1.80 |
5.00 ± 1.54 |
0.56 ± 1.94 |
0.0779 |
Limit number of days child drinks 100% juice | 2.50 ± 1.39 |
3.15 ± 1.44 |
0.62 ± 1.14 |
0.0017 |
Limit number of days child eats fast food | 3.82 ± 1.22 |
4.44 ± 1.05 |
0.69 ± 1.59 |
0.0099 |
The main objective of this study was to examine the feasibility of a home-based early childhood obesity intervention to modify parent and child health behaviors. This pilot intervention showed great promise in demonstrating that a home-based intervention could be successful in changing some parental behaviors as well as dietary and sedentary behaviors of children. Many changes were either statistically significant or in the posited direction, which is impressive given that the sample size was only 50 parent-child pairs and the intervention was monthly for only four months in duration. Overall, participating parents/guardians reported positively on the components of the intervention. The telephone counselors were well received and the tailored written materials were well used. While there were some discrepancies in parent reports of receipt of MI counseling calls, we think this could be due to the parents confusing the counseling calls with the baseline and follow-up evaluation calls or confusing attempts to reach them with actual MI calls. However, the response to the TV monitor was somewhat mixed; though some parents/guardians seemed to fully use the device others did not report using it at all. The overall pilot feasibility, intervention findings, and parent reported acceptability demonstrate significant potential for HHHF to be implemented as a future randomized controlled trial for the prevention of childhood obesity. Additionally, we had good participant retention at four-month follow-up.
The current study also found significant improvements in children’s daily servings of vegetables and reductions in 100% juice intake, but no statistically significant changes in sweetened beverage, water, milk intake, or fast food consumption were evidenced. On average, children’s total servings of vegetables almost doubled over the course of the intervention. However, these intake levels are still lower than recommendations for children of this age (1 to 1.5 cups each of fruits and vegetables per day) [
It is important to note that more than one-fourth of HHHF participating parents identified food insecurity as a key concern, which may have affected intervention efficacy. The finding of high levels of parent reported food insecurity is similar to reports from other interventions with low-income parents of young children [
Contrary to our hypotheses, we found unexpected declines in parent reports of children’s outdoor playing time on both weekdays and weekend days. On average, parents reported that children participated in one hour less of total daily outdoor physical activity at the four-month follow-up assessment. These findings are disconcerting because early childhood physical activity patterns track into adulthood and high levels of physical activity in early childhood mitigate physical activity declines evidenced during adolescence [
We also tested the hypothesis that seasonality may have influenced changes in outdoor physical activity from baseline to four months. There were no significant differences in baseline physical activity (weekday or weekend) between summer/early fall relative to fall/winter group participants. Also, seasonality did not significantly affect changes in weekday outdoor physical activity (
Regarding children’s sedentary behaviors, time spent watching television was significantly reduced during the weekday and somewhat declined on weekend days. Children decreased their weekday television time by almost 50 minutes from baseline to four-month follow-up but did not decrease TV time as much on weekend days. This significant reduction in TV screen time resulted in children meeting the guidelines recommended by The American Academy of Pediatrics [
The findings from HHHF provide mixed support for changes in parent behaviors associated with children’s health behaviors. The study demonstrates favorable improvements in some of the parent behaviors related to parent role modelling, the home food environment, family encouragement for PA/diet, and household rules. Contrary to other intervention results [
While informative, this study is not without some limitations. The study recruited children at all levels of obesity risk, which included many children at a healthy weight and potentially more motivated parents/guardians. Additionally, as this was a pilot intervention and was underpowered to detect differences in key outcomes, the sample size was small and effect size estimates with small samples have large standard errors and wide confidence intervals. The pretest/posttest design was a limitation which might have affected the validity and generalizability of study findings [
Despite the limitations, this study has a number of strengths and is one of few home-based early childhood obesity prevention interventions specifically designed for low-income diverse racial/ethnic populations. This study recruited directly from WIC clinics, thus ensuring recruitment of families who were eligible to receive income based support from federal programs. The sample was predominantly low-income and ethnically and racially diverse thus reaching populations who are at significantly higher risk for future obesity and related comorbidities. There was also good participant retention at four-month follow-up. Additionally, the goals of this intervention were aligned with current recommendations and focused on changing health behaviors for the long term instead of weight loss.
HHHF was a parent-driven home-based intervention that incorporated tailored written materials and video, nutrition information, and MI along with TV monitors and an age-matched children’s exercise video. This intervention appeared to be effective in changing some aspects of children’s behavior and their home environments through changes made by parents. However, a randomized trial is necessary to truly test the efficacy of this intervention. Such trial will be planned in the near future. We will also analyze correlates of children’s BMI, diet, PA, and sedentary behavior as well as predictors of change, which will aid in future intervention development. Furthermore, to broaden the reach of the intervention to a larger population, we would like to be able to offer the intervention in Spanish as well as English. It may also be worthwhile to test other channels in addition to print mailings for providing tailored messages, that is, tailored video, internet, text messaging, smart phones, and etcetera. It might also be interesting to study the effectiveness of combining a home-based intervention like HHHF with a pediatric health care provider intervention or an intervention in child care settings.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Healthy homes, healthy families was funded by Grant no. R21DK080396 (developing tailored home environment interventions to address childhood obesity), from the National Institute for Diabetes, Digestive and Kidney Diseases. Support for completing this paper was also provided by Grant no. 3R01CA134903-05S1, from the National Cancer Institute. The authors would like to acknowledge the following individuals for their help with the study and/or with the preparation of this paper: Lizette Muriel, Yasmil Montes, Shannon Whittaker, Robin Scheer, and Jennifer Mello.