Assessing the Feasibility of Partnering with a Home Visiting Program for Early Childhood Obesity Prevention

The obesity prevention framework (OPF) for translating evidence into action (Swinburn et al., 2005) defines five issues: (I) building a case for action; (II) identifying points of intervention; (III) defining opportunities for action; (IV) evaluating potential interventions; and (V) selecting specific policies, programs, and actions.

The case for addressing the U.S. obesity crisis is overwhelmingly clear given 74% of U.S. adults ≥ 20 years have overweight or obesity (Centers for Disease Control and Prevention & National Center for Health Statistics, 2021), and an estimated 86% will by 2030 (Hruby & Hu, 2015; Wang et al., 2008).

Evidence supports addressing obesity in the earliest stages of life (Taveras, 2016). Healthy People 2030 set a goal of reducing the proportion of U.S. children and adolescents with obesity ages 2–19 years from 17.8% in 2013–2016 to 15.5% by 2030 (Healthy People, 2030). By 2017–2018, however, the proportion increased to 19.3%, with an additional 16.1% overweight (Fryar et al., 2020). There is no evidence of a decline in childhood obesity, rather there is a significant increase in obesity among children, including aged 2–5 years (Hu & Staiano, 2022).

Childhood obesity prevention efforts have had limited success, especially among vulnerable populations, but home visiting programs reach families of young children at risk for obesity and offer potential for large-scale implementation (Salvy et al., 2017). Studies regarding the feasibility, acceptability, and efficacy of implementing early childhood obesity prevention content into home visitation programs are lacking (Zeldman et al., 2023).

Parents as Teachers (PAT) (https://​parentsasteacher​s.​org/​) is an established, federally recognized evidence-based home visiting model with the potential to inform these efforts. PAT serves families with children prenatal through kindergarten via personal visits delivered primarily at home. PAT services include group connections, screenings and assessments with validated instruments, and referrals for basic needs such as housing and education. A family can enroll regardless of need or risk. PAT goals are to: (1) increase parent knowledge of early childhood development, (2) provide early detection of developmental delays and health issues, (3) prevent child abuse and neglect, and (4) increase children’s school readiness and success. In 2020–2021, PAT’s model was implemented across 966 affiliate sites in the U.S. and 4 other countries through 971,779 personal visits to 82,511 families and 101,173 children.

We developed, implemented, and tested a proof-of-concept protocol for collecting child anthropometric data through PAT. We previously reported on the formative and process evaluation measures of that implementation, including the acceptability to stakeholders, percentage of data that met eligibility criteria, and percentage of measurement goals reached (Kapp et al., 2020). Guided by the RE-AIM framework, the objective of this study was to evaluate the reach of our proof-of-concept effort in measuring vulnerable children, i.e. with overweight or obesity, and with diversity of socioeconomic status (SES), ethnicity, locality, and gender. This informs the likelihood of an intervention reaching the known inequities in the distribution of obesity (Swinburn et al., 2005).

We included an assessment of adverse family experiences (AFEs), given emerging evidence suggesting AFEs [and adverse childhood experiences (ACEs)] in childhood or adolescence are associated with obesity development (Gardner et al., 2019; Lynch et al., 2016; McKelvey et al., 2019). AFEs are a category of ACEs; ACEs traditionally include psychological abuse; physical abuse; and sexual abuse; as well as household dysfunction including substance abuse, mental illness, violence toward the mother, and other criminal behavior (Felitti et al., 1998; National Center for Injury Prevention and Control Division of Violence Prevention, 2019). An estimated 61% of U.S. adults experience ≥ 1 ACE category and 15.6% experience ≥ 4 categories (Merrick et al., 2019). ACEs increase the risk of obesity via chronic stress and coping behaviors such as overeating (Felitti et al., 1998; Merrick et al., 2019). To date, we know of no articles that have examined ACEs or AFEs and early childhood obesity in a home visiting setting, particularly with robust measurement of the family context. We hypothesize that AFEs are associated with early childhood obesity.

We previously reported on our methodology and findings from the formative and process evaluation (Kapp et al., 2020), which is repeated here in brief. PAT’s National Center (PATNC) offers to sites a robust data management system nicknamed “Penelope” to track families’ services and outcomes. Site eligibility for our study required that sites: were using Penelope for ≥ 12 months; were accredited to implement the evidence-based model; met PATNC’s endorsement for quality; were implementing the Life Skills Progression (LSP) instrument (Wollesen, 2006); and had a robust number of eligible children. The LSP was developed to collect clinical and outcomes measures through home visiting. LSP has a reported construct validity ranging from α of 0.64–0.99 across scales, and interrater reliability estimated at 70–90%. LSP has a test–retest reliability reported at 0.90 for average inter-item correlation scores.

The four participating sites (a school district, federally qualified health center, and two non-profit organizations) were in South Carolina, Texas, Illinois, and Florida. Sites employed 5–50 home visitors. We shipped equipment to sites, and PATNC provided sites lists of eligible children. Training included measuring children 2–3 times for accuracy at a single visit. Sites received compensation for meeting measurement goals.

Child eligibility included: ages ≥ 6 months to < 5 years as of September 1, 2019, and active enrollment in PAT, with a completed child health record. Mother eligibility included a baseline LSP assessment.

Some sites incorporated measurements into the next scheduled home visit or group connections designed to bring families and children together to share information about parenting issues and child health and development. Sites recorded 260 child measurements, reaching 91% of their goals, over a 6-week period ending in November 2019.

For a child < 24 months, weight-for-length (WFL) is the recommended measure as compared to the World Health Organization (WHO) sex-specific growth standards. For children ages ≥ 24 months, body mass index (BMI) is recommended using the Centers for Disease Control and Prevention (CDC) growth charts. CDC’s SAS code calculates WFL and BMI measures and flags extreme values (Division of Nutrition; Physical Activity; and Obesity; National Center for Chronic Disease Prevention and Health Promotion, 2019a, 2019b). Our outcome is child anthropometric measurements as yes/no for overweight or obesity at the ≥ 85th (overweight) and ≥ 95th (obese) percentiles. We previously reported 214/260 records after exclusions and flagged data (Kapp et al., 2020). For this analysis the final sample included 248 children after 12 were excluded for being outside of the age eligibility criteria, and we were able to review and correct flagged data to centimeters instead of inches.

This analysis defines the presence of AFEs through the mother’s baseline LSP assessment (scores of 1–2 on scales suggest needs or dangerous conditions) and other PAT variables or assessments. PAT assessments are typically completed within 90–120 days of family enrollment. We label these as AFEs instead of ACEs given they reflect the child’s contextual environment and are not self-reported by the child.

Psychological abuse was identified from the LSP nurturing scale. Physical abuse was defined from the LSP discipline scale or PAT indication of child abuse or neglect reported or substantiated. Substance abuse was defined from the LSP substance use/abuse scale, or PAT indication of the parent’s persistent use of substances despite negative social, interpersonal, legal, medical, or other consequence at any point during the child’s lifetime (including prenatal). Mental illness in the home was defined from the mother’s LSP depression/suicide and mental illness scores; PAT indication of a parent with mental health issues (i.e., a thought, mood, or behavioral disorder associated with distress and/or impaired functioning determined by parent report or diagnosis); or the mother screened positive for depression (score of ≥ 13 on the Edinburgh Postnatal Depression Scale or ≥ 10 on the Patient Health Questionnaire-9) (Traube et al., 2022). Mother has been treated violently was identified from the LSP family/extended family scale; boyfriend, father of baby, or spouse scale; friends/peers scale; or PAT indication that the female parent is a survivor of intimate partner violence per self-report, positive screening, or court proceedings during the child’s lifetime. Family history of criminal behavior was identified by PAT questions indicating a parent was incarcerated in federal or state prison or local jail, halfway house, part of a boot camp or weekend program during the child’s lifetime, or a family member had been involved with the correctional system. Our AFEs index sums the child’s identified AFEs.

We created a “structural and household stressors” (SHS) index to sum additional stressors. Caregiver low education was identified from LSP < 12th grade education/education scales or PAT indicated a high school diploma or equivalency was not attained and the parent was not enrolled. Low income was defined from the LSP income scale or PAT indicated that the family was eligible for free and reduced lunches; public housing; childcare subsidy; Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); food stamps/Supplemental Nutrition Assistance Program (SNAP); Temporary Assistance for Needy Families; Head Start/Early Head Start; and/or Medicaid. Underemployment was defined from the LSP employment scale or PAT indicated the mother as primary parent was not employed. Immigration needs were defined from the LSP immigration scale or PAT identified the family as a recent immigrant or refugee family (≥ 1 parents foreign born and entered the U.S. ≤ 5 years prior). Unstable housing was defined from the LSP housing scale or PAT identified the family as lacking a fixed, regular, or adequate nighttime residence, living in motels, residing in shelters or in public or private places not designated for sleeping; or the mother as primary parent was homeless and sharing housing, homeless in some other arrangement, or living in public housing. Childcare needs were identified from the LSP childcare scale. Single parent was identified by PAT. PAT identified a young parent as pregnant or parenting < age 21 years. PAT defined a parent with a disability or chronic health condition as having a physical or cognitive impairment that substantially limits the ability to parent. PAT defined a child with a disability or chronic health condition as a child with a significant delay, disability, or condition that affects developmental domains and/or overall family well-being.

Community type included major city (population ≥ 500,000) or urban (densely settled area with a population of ≥ 50,000); suburban (an identifiable community as part of a larger urban area); or small town (population ≥ 2500) or rural (population < 2500). Follow-up time was defined as years from the family’s PAT start to the child’s anthropometric measurement date.