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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.

Population Challenges

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”)
  • Survey timing

  • 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

  • Motivated to change

  • 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

FUN, INTERACTIVE!

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

Interest

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

Challenges

1997

1992

Strengths

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

541,000 are 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
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