Goals:
- To provide comprehensive medical services to children in emergency housing.
- To assist families in accessing important services including health insurance, primary care, and specialty care.
- To provide education and advocacy.
- To enhance healthcare providers’ knowledge of, and exposure to, homelessness and its impact on children’s lives and their health.
Collaboration, Partnerships & Replication
Prevalence
Challenges
Navigating systems
TRAUMA
Volunteers
Consistent participation
Coordination with shelter staff
Program evaluation
CHOICES
Next steps…
- We know that moms are motivated to make behavior changes
- Can now fine tune our program evaluation based on these results
- Catch moms when they're attending their first session with a pre-participation survey; use post participation survey after certain number of sessions.
- Elaborate on differences between agree and strongly agree.
Follow families through housing changes
Ashley's story (a case report)
Everyone wants and deserves
CHOICES!
Program Evaluation Setup
- Families
- Increasing physical activity
- Making & buying healthy snacks
- Shelter
- Food tastings
- Food committee
- Healthy snacks at meetings
- City
- Menu planning: offering options & involvement, more culturally appropriate, more child-friendly
- Empowering kitchen staff
- Initial/broadest goal of Operation CHOICES: to improve nutrition/fitness, prevent obesity in high risk population
- First step of behavior change is attitude change more realistic, potentially more measurable
- Program success = helping families move from one stage of change to the next
Change in Thinking
- More knowledge and awareness: able to recognize healthier options (and less healthy options, particularly in the shelter)
- Healthy foods can taste good
- Exercise can be fun, easy, and soothing
Reasons for Participating
Mom
Child
Change in Behavior
Food Choices
Stages of Change
Stages of Change (Transtheoretical Model)
Physical Activity
Ideal Program Evaluation
- More fruits and vegetables
- More water, less soda
- Saute instead of fry
- Reading labels at the grocery store
- Self-guided yoga
- Walking more
- Taking the stairs
- Exercise options for indoors
- Exercising together (mom with kids)
Evaluate how much of the change was due to program participation
Pre participation and post participation survey
- Theoretical model often used in examining and affecting behavior change
- 5 stages (precontemplation, contemplation, preparation, action, maintenance)
- Must move through each stage in order to successfully change behavior
- Rich literature of using this model in obesity treatment and prevention
Measure the change
What Moms Said about Operation CHOICES
Actual Program Evaluation
Evaluation Tools
Challenges in Implementation
Before I would just eat a starch. Now I eat a starch and a vegetable to make my meal more balanced.
When I'm done doing yoga I feel like I have no worries.
I enjoy yoga. I feel relaxed and calm and use the time to get ready for the next day.
To Address those Challenges
- Transiency
- Environment
- Inconsistent participation
- Differences across shelters
- Changes over tim
Self-guided yoga helps with my anxiety and panic attacks.
- Survey
- 8 questions, <2 minute completion time
- First 2 questions are participation characteristics (who participated and how many sessions)
- 1 question regarding anticipated housing status
- 2 questions regarding diet: importance and confidence
- 2 questions regarding fitness: importance and confidence
- Last questions regarding knowledge and skill
- Interview
- Why participate?
- Change in thinking
- Change in behavior
- Change in confidence (“more able”)
- Coordination with shelter staff
- Finding interviewers
- Social work interns from opposing sites
- Finding interviewees
- Used OC program time
- Brought healthy snacks
The kids are tired for bed. They enjoy it. They love famliar faces.
Dose-Response?
- Quantitative and qualitative components
- Quick
- Applicable to all three shelters
- Ask about how many sessions attended
Continue coming. The energy that you bring is needed. The kids like it.
Progression of Readiness to Change Score for 8 Individuals
Outcomes Overview
Who Participated?
Number of Program Sessions Attended
Anticipated Housing Status
in 30 Days
My daughter drags me down to participate.
My kids know more. They try to correct me. They say, "Mom, you shouldn't be eating that."
- 61 women completed written surveys
- 21 women participated in structured interviews
- High satisfaction with the program
- Already implementing new behaviors as a result of program
Survey
Interview
Priority and Ability
to Increase Exercise
Priority and Ability
to Change Diet
Themes
Is Dose of Program Associated with More Readiness to Change?
- 18 moms of the 21 interviewed participate in the mom part of the program, 14 of those gave specific reasons why they chose to participate
- 2 moms used the word “distraction”
- 2 moms specifically said “stress relief”
- 10 moms discussed their desire to gain knowledge and/or skills for making healthier diet and exercise decisions
- If you use a 2 by 2 chi-square model then yes
- Confidence in increasing physical activity significantly correlated with participation in 4 or more sessions (RR=1.45)
- Gain in knowledge/skill significantly correlated with participation in 4 or more sessions (RR=1.33)
- Statistics are limited by overall high degree of readiness to change
- Sample size too small to truly say, but encouraging
- Moms: interested in educating themselves on nutrition and fitness
- 7 moms said they wanted to learn more about healthy foods or try new healthy foods
- 3 moms specifically interested in trying yoga
- Kids: moms want them more engaged in physical activity
Ecological Model
Impact
Mothers
&
Children
Obesity & Homelessness
New York Children’s Health Project
- Basic Food Groups
- Nutrition Labels & Serving Sizes
- Vitamins & Minerals
- Go, Slow, Whoa Foods
- Health Consequences of Obesity
- Grocery Shopping
- Importance of physical activity
- Heart health
- Hydration
- Healthy lungs
- DANCE!
- Yoga
S.P.A.R.K.
(Safe Physical Activity & Recreation for Kids)
Grant, R., et al. (2007). The health of homeless children revisited. Advances in Pediatrics, 54, 173-178. Available at:
http://www.childrenshealthfund.org/sites/default/files/publications/HealthStatusofHomelessChildrenRevisited.pdf
FUN!!
- Flexibility
- Strengthening
- Endurance
- Balance, Coordination & Agility
- Go, Slow, Whoa! Foods
- Basic Food Groups
- Hydration
- Heart Health
- Teamwork
Children Served by HHI
Researchers from Johns Hopkins
University found a high prevalence of
obesity and overweight in homeless
Baltimore caregivers (77%)
and their children (23%)
Schwartz, Kathleen B., & et al. (2007). High prevalence of overweight and obesity in homeless Baltimore children and their caregivers: a pilot study. Medscape General Medicine , 9. Available at: http://www.medscape.com/viewarticle/551711
WOMEN'S WELLNESS
(Moms)
Cost
- 2 sessions per week at 2 shelters
- 1 session every other week at 1 shelter
Pre-school Nutrition Lessons
- Being Healthy
- Fruits
- Vegetables
- Milk Builds Strong Bones
- Healthy & Not-so-Healthy Food
- Making Healthy Meals
School Age Nutrition Lessons
- Being Healthy
- Go, Slow, Whoa Foods
- Food Pyramid
- Read it before you eat it
- Sugar
- Restaurant
Annual hospital costs related to obesity among children and adolescents increased from $35 million (1979) to $127 million (1999)
In 2006, obese individuals spent $1,400 more on medical care costs
NUTRITION & FITNESS
(children)
Operation CHOICES
Shelter Policies
- 4 sessions per week at 3 shelters
- 1 hour each week
- Year round!
Nutrition & Fitness TOGETHER
Moms & Children APART
Stress
In 2007, approximately 300,000 deaths per year may have been attributable to obesity
Garden
In 2008, annual healthcare cost of obesity in the US was estimated to be as high as $147 billion
Neighborhood
Finkelstein, EA, Trogdon, JG, Cohen, JW, and Dietz, W. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 2009; 28(5): w822-w831. Available at: http://www.cdc.gov/obesity/causes/economics.html
Office of the Surgeon General. (2007). Overweight and Obesity: What You Can Do. Available at: http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_whatcanyoudo.htm; CDC National Center for Chronic Disease Prevention and Health Promotion. (2009). Halting the epidemic by making health easier. Available at: http://www.cdc.gov/nccdphp/publications/AAG/pdf/obesity.pdf
On-site Nurse
Trauma
DVAEYC Education Coordinator
Menu Restrictions
The Problem
Community Pantry
Children's Cooking Classes
Trends in the US
Overweight = BMI at or above the 85%
and lower than 95%
Obesity = BMI at or above 95%
Obesity Among Adults
1997
1992
17% (12.5 million) children & adolescents (2-19 years) are obese
1985
2001
2009
Obesity prevalence among children & adolescents has almost tripled since 1980
2005
Children who are obese are more likely to be bullied
National Health and Nutrition Examination Survey (NHANES) 2007-2008. Available at: http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.pdf;
Lumeng, J.C., Forrest, P., Appugliese, D.P., Niko Kaciroti, Corwyn, R.F., & Bradley, R.H. (2010). Weight status as a predictor of being bullied in third through sixth grades. Pediatrics (125), 6, e1301-e1307. Available at: http://pediatrics.aappublications.org/content/125/6/e1301.long
Consequences
Obese children are more likely to have:
- High blood pressure and high cholesterol
- Increased risk of type 2 diabetes
- Breathing problems
- Joint problems and musculoskeletal discomfort
- Greater risk of social and psychological problems
- Fatty liver disease
- Gallstones
- Heartburn
More likely to become obese adults
2009 State Prevalence of Obesity
Among Low-Income Children (2-4 Years)
Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr. 2007;150(1):12—17.e2.; Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force. Pediatrics. 2005;116(1):e125—144.; Han JC, Lawlor DA, Kimm SY. Childhood obesity. Lancet. May 15 2010;375(9727):1737—1748; Sutherland ER. Obesity and asthma. Immunol Allergy Clin North Am. 2008;28(3):589—602, ix; Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complications of overweight in children and adolescents. Pediatrics. Jun 2006;117(6):2167—2174.; Dietz W. Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics 1998;101:518—525.; Swartz MB and Puhl R. Childhood obesity: a societal problem to solve. Obesity Reviews 2003; 4(1):57—71.
Later in life...
- Obesity in adulthood is likely to be more severe
- Adult obesity is associated with:
- Heart disease
- Diabetes
- Some cancers
- Decreased quality/length of life
1 of 7 (1.25 million) low-income, preschool-aged child (2-4 years) is overweight or obese
Among Children & Adolescents
2 to 19 years old
CDC US Obesity Trends by State 1985-2009. Available at: http://www.cdc.gov/obesity/data/trends.html#Race
Minority and low-income populations have a disproportionate burden of cardiovascular disease
Biro FM, Wien M. Childhood obesity and adult morbidities. Am J Clin Nutr. May 2010;91(5):1499S—1505S.; Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;37(13):869—873; Serdula MK, Ivery D, Coates RJ, Freedman DS. Williamson DF. Byers T. Do obese children become obese adults? A review of the literature. Prev Med 1993;22:167—177; National Institutes of Health. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: the Evidence Report. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 1998; Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood overweight to coronary heart disease risk factors in adulthood: The Bogalusa Heart Study. Pediatrics 2001;108:712—718.
Adults in the U.S.
CDC. Prevalence of Obesity Among Children and Adolescents: United States, Trends 1963-1965 Through 2007-2008 . Available at: http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.pdf
Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS data brief, no 82. Hyattsville, MD: National Center for Health Statistics. 2012. Available at: http://www.cdc.gov/NCHS/data/hestat/obesity_adult_07_08/obesity_adult_07_08.pdf
CDC Office of Minority Health & Health Disparities. (2012). Eliminate Disparities
in Cardiovascular Disease Factsheet. Available at: http://www.cdc.gov/omhd/amh/factsheets/cardio.htm#4
Among Male Adolescents by Race/Ethnicity
12 to 19 years old
Among Female Adolescents by Race/Ethnicity
12 to 19 years old
Operation CHOICES:
Evaluation of Obesity Prevention Programming for Families in Emergency Housing
CDC. Prevalence of Obesity Among Children and Adolescents: United States, Trends 1963-1965 Through 2007-2008 . Available at: http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.pdf
“Our brain is smarter than our stomach. The brain makes the decision to eat healthy food.”
- Consume high fat, calorie dense foods, especially at school
- Don’t enjoy many meals at the shelter
- Parents make decisions about the food they eat, but children know how to influence parents
- Some familiarity with nutrition & fitness concepts
- Want to learn more about nutrition & physical fitness with their moms
Melissa Berrios Johnson, MSW
Michelle Katzow, MD
Homeless Health Initiative
The Children’s Hospital of Philadelphia
MOTHERS
CHILDREN
Nutrition
& Physical Activity
- The food served in shelter is not nutritious or balanced
- Not accustomed to food served
- Sneak food into shelter
- Usually eat fast food outside of shelter
- Toddlers are served same food as adults
- Force children to eat or go to bed hungry
- Want to give children 100% juice
- Want to learn more about nutrition & fitness
- BARRIERS:
- No choice
- No fresh options
- Little to no money
- No access to kitchen
- Shelter rules
"When my children are sick, I can't even go out
and get some ginger ale and crackers.”
- Fresh options
- Healthier culture
- Empower families
- Creative meals
- Change menus
HHI
SHELTER STAFF
Focus group findings
Operation CHOICES Plan
- Conduct needs assessments & focus groups:
- Mothers
- Children
- Staff
- Readiness to Change
- Environmental Context
- Emergency Housing Facility
- Neighborhood
- Create program based on above findings