|Beno et al. (2005) (26).|
Design and implementation of training to improve management of paediatric overweight.
Kaiser Permanente of Georgia.
|Pre-test/post-test (baseline and 3 months).|
Descriptive statistics with results reported in percentages.
|n = 76 paediatric healthcare team members.|
75% participation rate.
Training group size ranged from 3–18 participants.
6 PAs and nurse practitioners.
18 registered nurses.
33 licensed practical nurses and medical assistants.
|Two 60-min interactive continuing medical education seminars.|
Interventions delivered by one trained physician and either one registered dietitian or behavioural health professional.
Sessions contained: education, assessment or counselling tools overview and interactive exercises.
|At 3 months:|
More than 40% of providers reported that all of the tools were useful.
Concerns were raised about addressing all of the history information in one counselling session.
Clinician motivation and attitudes were found to hinder acceptance of the tools in practice.
Tools included self-history form, Rx Pad and counselling guide.
Based on motivational interviewing (MI).
Training of entire staff.
Lack of diversity in practitioners.
Too many tools introduced at one time to staff.
Results would have been strengthened with use of t-tests.
|Hinchman et al. (2005) (44).|
Evaluation of a training to improve management of paediatric overweight.
Kaiser Permanente of Georgia.
Chart abstractions at baseline, 3 and 6 months.
Delayed-controlled design: start times for the two groups were 4 months apart.
Descriptive statistics, χ2.
|Nine paediatric clinics stratified into two groups:|
Group 1: four clinics and 33 nursing staff and 19 clinicians.
Group 2: five clinics and 31 nursing staff and 18 clinicians.
|n = 220 charts (110 in each group) were abstracted at each time point as a random sample of paediatric patients ages 5–18 years.|
Charts: 65% normal weight; 17% overweight and 17% obese; 51% female; 33% preteen.
|Paediatric healthcare team members received training by professionals stated above in the Beno et al. (2005) study (26).|
Session 1: education about obesity trends, assessment.
Session 2: counselling model and tools for counselling techniques, patient motivation and clinician time.
|No charted body mass index (BMI) or BMI% at baseline.|
Group 1: BMI recorded 40.7% at 3 months and 35.2% at 6 months; BMI% 12% at 3 months and 16.2% at 6 months. Values represent significant increases over baseline.
Group 2: BMI 43.0% at 3 months and 38.3% BMI%. Both with significantly increased reporting.
All tools except the Rx pad with statistically increased use over baseline.
Overweight patients had significantly more completed.
Brief in-service training for both staff and providers.
Attendance at both training sessions was 42% for group 1 and 29% for group 2.
Total of 36% of eligible participants attend both training sessions.
No discussion of why adherence to training continued to be so low after the intervention.
|McCallum et al. (2005) (50).|
Can Australian general practitioners (GPs) tackle childhood overweight/obesity? Methods and processes from the LEAP (Live, Eat and Play) randomized controlled trial (RCT).
Design for GP knowledge, skills and attitudes to childhood obesity embedded within a feasibility and efficacy RCT intervention trial.
Cross-sectional BMI survey recruited eligible overweight/obese children.
|General practitioners (n = 34) from 598 GPs contacted by letter.|
General practitioners attended at least two of three training sessions (75%) (2.5 h each) on management of childhood overweight.
28 (82%) of GPs completed baseline and follow-up questionnaires.
|29 family medical practices.|
Survey of 5- to 9-year-old BMIs.
Overweight/obese children attending these practices (n = 163) which represents 40% of eligible children.
82 (50%) randomized to intervention group and 81 (50%) to control group.
|Intervention focused on achievable goals in nutrition, physical activity and sedentary behaviour.|
Education sessions based on the Stage of Change Model.
Intervention was delivered in four consultations over 12 weeks to both child and parent.
|All 34 GPs recruited were retained throughout the study period.|
27 (79%) expressed competence in managing obesity after training compared with 12 (35%) before training.
No significant BMI differences between groups post intervention.
Medical practices represented a broad socioeconomic status demographic.
Trained office staff.
Not all GPs attended all of the training sessions.
Unknown how many children each GP intervened with.
|Gee et al. (2006) (42).|
Overweight children: a comprehensive approach to address the epidemic.
Kaiser Permanente Northern California.
|Presumed pre-test/post-test but not explicitly stated.|
Utilized comprehensive health questionnaire that included nutrition and physical activity questions.
|Children (7–15 years) and parents.|
n = 138 for 1–4 low intensity intervention sessions.
n = 81 for 6–8 moderate intensity 9-week intervention sessions.
n = 26 for 6–8 moderate intensity 6-week intervention sessions.
n = 73 for 20 high intensity sessions over a 6-month period.
|Physician and staff on site training at 38 Kaiser Permanente facilities.||Practice Guidelines for Kaiser:|
Physician Training Options:
1. Basic training: BMI, assessment, advice, treatment;
2. Communication skills: brief negotiation, cognitive behaviour skills;
3. Health professional advocacy.
Physical assessment, goals, lab tests, focused advice, follow-up, MI.
Low intensity: reported significant change in dietary, physical activity and TV/video behaviours.
Moderate intensity (9 weeks): significant decrease in mean daily servings of high-fat foods, high-sugar foods, servings of soda and TV viewing.
Moderate intensity (6 weeks): significant improvement in fruits and vegetable intake, drinking soda and physical activity.
High intensity: significant decrease in mean BMI.
Interventions targeted nutrition, education, exercise and behaviour change.
Health system support for physicians participating in community advocacy.
High family completion rate. High level of parent and child satisfaction.
Study design not published.
Little information concerning provider outcomes or intervention training length.
|Gonzalez & Gilmer|
Obesity prevention in paediatrics: a pilot paediatric resident curriculum intervention on nutrition and obesity education and counselling.
Attitudinal and knowledge questionnaires, examinations, and a checklist of desired provider skills and behaviours.
Questionnaires were also administered when the second-year residents completed their third-year residency.
Sign and Wilcoxon signed rank tests.
|n = 6 second-year residents received new curriculum.|
n = 3 third-year residents served as control.
Unknown number of first-year residents also surveyed for baseline data on attitudes and knowledge.
|Postgraduate second-year residents participating in an ‘Obesity Prevention in Pediatrics’ curriculum during a 1-month out-patient community rotation.||Intervention consisted of (i) 20 min written lecture on obesity; (ii) pre-lecture review of curriculum goals, objectives, instructional strategies and evaluation methods; (iii) assigned readings on paediatric obesity; (iv) obesity clinic experience with paediatric nutritionist; (v) 1-h small group discussion of cases with nutritionist; and (vi) Resident observed and evaluated during clinic interaction.||Control residents' knowledge and counselling skills on obesity prevention and management were well below expectation.|
Following participation, second-year residents' knowledge (per cent correct on examination) and comfort in counselling overweight and obese patients improved.
Mean attitudinal scores also increased by 45%.
Intervention targeted both prevention and treatment strategies.
Curriculum included counselling skills in nutrition and physical activity.
Small sample size because of residency cohort size.
No data reported on first-year residents.
|Dunlop et al. (2007) (59).|
Improving Provider's Assessment and Management of Childhood Overweight: Results of an Intervention
Emory University School of Medicine.
|Pre-test/post-test medical record abstraction of all records of well-child visits for patients 2–17 years of age.|
Compared provider training alone or in conjunction with office-based tool dissemination.
Data obtained 3 months prior to training, 1–3 months after the training and 4–6 months after the distribution of the tools.
|n = 38 of 44 primary care providers (86%).|
6 community-based primary care clinics affiliated with an academic medical centre.
466 medical abstractions at baseline.
538 abstractions at 1–3 months.
344 abstractions at 4–6 months.
|17 family medicine physicians and paediatric physicians.|
19 family medicine residents and paediatric physicians.
2 nurse practitioners and staff (receptionists, medical assistants, nurses).
|Two 1-h training sessions delivered by a physician.|
Expert Committee Recommendations;
Use of assessment tools;
Advise, identify, motivate counselling model; and
3 months later tools were distributed to clinics and placed in every patient's chart at well visits.
Outcomes: Documentation of BMI%, nutrition-activity history; nutrition-activity counselling.
|Non-significant increases in documentation in all outcomes at 1–3 months.|
Significant increases in all three outcomes at 4–6 months after the introduction of office-based tools in each chart.
Baseline and post-training rates were lower for residents.
Odds of provider documentation of all three outcomes increased with patient BMI.
Office-based tools provided for clinic use.
Intervention based on the advise-identify-motivate counselling model.
Relied on ‘checked box’ on medical record to indicate that nutritional or activity counselling took place at baseline.
No changes noted until tools added to protocol 3 months after initial training.
|Schwartz et al. (2007) (45).|
Office-based MI to prevent childhood obesity.
Private paediatric offices belonging to the American Academy of Pediatrics, Pediatric Research in Office Settings group.
|Non-randomized clinical trial.|
Feasibility study to determine if physicians and registered dietitians can implement an office-based MI intervention.
anova, paired t-tests
|n = 15 paediatricians (0.7%) from separate private paediatric practices.|
n = 5 registered dietitians.
n = 5 practices non-randomly assigned to each arm recruited 10 patients each.
|Paediatricians chosen to represent diversity of patients and provide geographical dispersion.|
Child (3 to 7 years of age) participants were assigned within clinics to: (i) control; (ii) minimal intervention (10- to 15-min MI session with paediatrician only); or (iii) intensive intervention (10- to 15-min MI session with paediatrician and 45- to 50-min MI session with registered dietitian).
|Intervention: paediatricians and registered dietitians attended a study orientation and completed a 2-day MI training session. Another 2-d training session occurred 1 year later because of delay in start of recruitment.|
Control paediatricians and registered dietitians received anthropometry training via telephone.
Outcomes: BMI, nutrition, physical activity.
|Enhanced motivational and counselling skills for obesity management occurred with both the paediatricians and the dietitians.|
Parents were highly satisfied with the MI counselling session(s).
No significant BMI differences between groups.
Significant decrease in dining out in intensive group.
Significant decrease in snacking in minimal intervention group.
Feasibility pilot study enabled researchers to obtain suggestions from participants in order to plan for a larger full-scale trial of the intervention.
No practice recruited required number of study child participants.
Large number of families dropped out of the study before the 6-month follow-up, especially in the intensive intervention group.
|Dennison et al. (2008) (43).|
Training healthcare professionals to manage overweight adolescents: Experience in rural Georgia communities.
|Post-test medical chart abstraction to assess practitioner compliance after training.|
|n = 58 providers (nurses, nurse practitioners, physicians).||10 rural paediatric clinics.|
97% of providers had not previously utilized BMI or BMI% to assess overweight patients.
85 overweight or obese adolescents, 13–18 years of age, were assessed.
49 (57%) adolescents completed the scheduled 16-week follow-up visit.
90-min adolescent overweight assessment and management training session.
Utilized Beno et al. (2005) and Hinchman et al. (2005) paediatric training protocol (26,44).
Included Centers for Disease Control (CDC) interactive case studies in growth chart training modules.
|Practitioners complied with protocol and discovered risk factors in many overweight patients that had not been previously diagnosed.|
After training, all but one chart had recorded BMI, and appropriate lab work ordered.
Targeted training to providers in a rural area with high incidence of obesity.
Compliance of adolescents/families to recommended management was not high despite reminder phone calls and monetary incentive. This may be a reflection of the lack of MI in the training content.
No direct measure of provider knowledge and assessment skills post intervention.
|Kopp & Hornberger (2008) (60).|
Proper Exercise and Nutrition Kit: Use of Obesity Screening and Assessment Tools with Underserved Populations.
KAN Be Healthy (KBH) registered nurse training programme.
Pre-survey concerning current practice, knowledge screening and assessment skills of nurses.
Proper Exercise and Nutrition (PEN) tool kits to incorporate revised curriculum of KBH.
Telephone interview utilized as a follow-up to the survey.
|n = 500 public health, school and clinic-based paediatric nurses were mailed surveys with 32% return (n = 159).||Public Health Nurses performing KBH health assessments in 77 counties in Kansas.|
Initial 46% pass rate on pre-survey KBH questionnaire.
4-h expanded training curriculum on growth, nutrition, obesity (BMI), client education, anticipatory guidance, and counselling and assessment tools.
Each nurse was mailed the PEN tool kit.
BMI chart wheel and educational materials use.
Plotting on the CDC growth chart, CDC BMI chart, nutrition intake and physical appearance.
|Strong nurse support for this intervention (92%).|
Results indicated that of 10 000 KBH clients each year, 53% would benefit from the Pen tool kit.
Results indicated increased identification of overweight and obesity and increased use of screening tools and referrals.
Comprehensive educational components for intervention.
Significant sample size.
Lack of educational materials in Spanish.
Post-evaluation via telephone interview not chart abstraction.
|Perrin et al. (2008) (49).|
Bolstering confidence in obesity prevention and treatment counselling for resident and community paediatricians.
North Carolina, USA.
Intervention to improve self-efficacy and frequency of obesity management and counselling.
‘Promoting Healthy Weight’ tools.
Signed Rank Test for ordinal data and the McNemar's test for dichotomous data.
|n = 49 of 52 (94%) paediatric resident physicians.|
n = 18 of 27 (90%) of community physicians.
|80% female; 88% Caucasian.|
University of North Carolina at Chapel Hill Pediatrics Continuity Clinic and four rural community practice sites.
Residents used the tools with an average of five patients each. Community physicians used the tools with an average of 23 patients.
|1-hour training included: assessment, communication, and counselling to improve diet and activity, follow-up, and use of screening and management tools.|
Resident physicians used tools a total of 9 months.
Community physicians used tools 2–4 months.
Residents used tools longer because of shorter scheduled clinic time.
Outcomes: confidence and use of tools.
|Confidence improved significantly in both the resident and community physician groups after training.|
Ease and frequency of counselling about healthy eating, physical activity and healthy weight significantly increased.
More than 50% of respondents reported that the tool utilization increased the length of the well visit.
Utilized social cognitive theory, transtheoretical model and MI.
Developed confidence (self-efficacy) questionnaire with Cronbach's alpha of 0.86.
Number of encounters and duration of the intervention varied between types of sites.
Small convenience sample.
No control group.
|Ewing et al. (2009) (51).|
Translating an evidence-based intervention for paediatric overweight to a primary care setting.
Kids Striving to Improve Diet and Exercise (KidSTRIDE)
University of Pittsburgh.
Descriptive statistics and anova.
|10 paediatricians and a paediatric nurse practitioner at each participating site (n = 22).|
Eligible 8- to 12-year-old children were referred to an 11 session group behavioural intervention (KidSTRIDE) which was adapted from Epstein et al. (1994) (61) and delivered by trained office nurses and nurse practitioners.
|One participating paediatric practice located in an urban setting.|
One paediatric practice located in a rural county.
|Provider training included a 30-min self-study packet and 2, 1-h face-to-face skills training session with one of the investigators as the trainer.|
Counselling skills included Stages of Change approach to behaviour change and MI.
Follow-up occurred 1 month later to reinforce skills and provide practice and discussion of materials.
|Primary care providers increased skills and confidence in assessing and communicating with overweight/obese children and their families.|
Sustainability of intervention promoted with training of office nurses to deliver the intervention.
Combined training of healthcare providers with staff.
No descriptive information given about providers.
Unknown how many contacts providers had with identified and referred children as intervention was delivered by office nurses.
No data presented to document provider increase in knowledge and skills.
|Gance-Cleveland et al. (2009) (62).|
Changes in nurse practitioners knowledge and behaviours following brief training on the Healthy Eating and Activity Together (HEAT) guidelines.
National Association of Pediatric Nurse Practitioners (NAPNAP) Annual Conference 2006.
One group design.
Programme to improve primary care providers' behaviour and efficacy in preventing paediatric overweight and obesity.
17-question questionnaire to tap knowledge, practice behaviours and identify barriers to success.
Descriptive statistics; t-tests; χ2.
|n = 35 nurse practitioners attending the NAPNAP 2006 Annual Conference.||89% (n = 31) of participants worked in paediatrics; and one participant in each of the following specialties: family practice, endocrinology, ear/nose/throat, and paediatric and adolescent diabetes.|
85% (n = 30) had been in practice >5 years; 9% (n = 3) were in practice 3–5 years; 3% (n = 1) and 3% (n = 1) had been in practice 1–3 years and 1 year of less respectively.
Intensive 4-h HEAT Clinical Practice Guideline training session (see NAPNAP, 2006).
|Significant improvements in practitioner assessment skills, knowledge, intent to follow guidelines using MI and behaviour modification techniques and to engage the family in the discussion of healthy practices.|
Proficiency and confidence in their ability to address child and family barriers to healthier lifestyles did not reach significance.
Nationally representative sample.
Provided training in an intensive 4-h intervention.
Limited evidence to equate increased knowledge to change in practice with use of guidelines to identify and manage overweight and obesity.
Small sample size.
Survey data without follow-up.
|Nicholas et al. (2009) (48).|
Randomized controlled trial of a mailed toolkit to increase use of BMI percentiles to screen for childhood obesity.
New York State.
|Randomized controlled trial.|
Mailed self-report survey at baseline and 5 months after toolkit introduction.
χ2 for categorical variables; non-parametric Wilcoxon rank-sum tests for ordered variables; t-tests for continuous variables; multivariate logistic regression models for differences in paediatric age groups.
|n = 402 physicians returned baseline surveys (40%).|
n = 211 physicians returned follow-up surveys (21%).
|Control and intervention group physicians did not differ on any measured variables.|
Similar exposure to public and private education on childhood obesity during the study in both groups.
|Intervention group: Toolkit promoted use of BMI percentiles to screen youths aged 2–20 years of age.|
Included BMI calculator, growth charts, instructions for calculating BMI, printed recommendations from the AAP, links to CDC training modules, links to Bright Futures in Practice, patient and family questionnaires on nutrition.
Control group: attention control.
|Recently trained physicians (post-1998 guideline publication) reported increased BMI screening at baseline. Urban physicians utilized BMI screening more frequently than those in rural or suburban settings.|
Intervention group increased use of BMI percentiles across the three age groups significantly in children aged 2–5 years.
72% found the toolkit helpful and 67% found that it influenced practice.
Simple, inexpensive intervention demonstrating modest effect.
Self-report data may measure intention to change practice.
No information available on non-responders.
Low response rate.
Office staff involvement to varying degrees within practices.
|Polacsek et al. (2009) (47).|
Impact of a primary care intervention on physician practice and patient and family behaviour: Keep ME Healthy The Maine Youth Overweight Collaborative
Pre-test/post-test provider surveys.
|Paediatric residency programme (n = 1).|
Family practice residency programme (n = 1).
Primary care paediatric practices (n = 9).
Family practice (n = 1).
|12 practice teams made up of clinical experts, primary care practices and community partners.||Intervention targeted specific changes in office practice:|
Healthcare system support; Self-management support; Healthcare system redesign.
Intervention length = 3 1.5-day learning sessions for each 3-member team. Followed in the next 18 months with two additional learning sessions, bimonthly conference calls, site visits and information emails.
Outcomes: provider counselling, BMI utilization.
|Teams showed improved knowledge of BMI and efficacy in addressing lifestyle issues.|
Improvement in providers' knowledge of community resources.
Patients and families heard more messages about nutrition, television, physical activity and sweetened beverages.
Chart reviews demonstrated more use in BMI, BMI percentiles for age and gender.
Providers also demonstrated more diverse goal setting with patients in chart reviews.
Increased follow-up appointments made.
Office systems improved significantly.
Based on the Chronic Care Model (CCM).
No comparison data.
Instruments modified by researchers in this study without extensive pilot testing.
|Pomietto et al. (2009) (52).|
Small steps to health: Building sustainable partnerships in paediatric obesity care.
Steps to Health King County programme.
Seattle Children's Hospital in Seattle, Washington partnering with Public Health and King County.
|One group pre-test/post-test design.|
Chart reviews: ∼20/month.
|Pilot phase 1: n = 3 participating practices.|
Pilot phase 2: n = 5 Medicaid managed care plans and n = 20 medical practices of which eight clinics worked on improving care for paediatric obesity.
Phase 3: no number of healthcare providers or number of clinic participating reported. Stated as statewide involvement.
|Within all three phases of the collaborative, collaboration occurred with numerous (n = 75) community partners representing schools, health plans, hospitals, healthcare providers, health departments and universities.||Components of the intervention:|
Three 8-h learning sessions, monthly conference calls, site visits, coaching and support as needed.
Establishment of a registry and clinical assessment of basic processes of care.
Intervention content responsive to community assessed needs.
Focused on cultural competency in content.
|Outcome measures by chart review: per cent of overweight and obese patients, per cent of BMI measured, per cent receiving healthy lifestyle messages; assessment of readiness to change and/or self-management goals discussed, documented race and ethnicity and planned follow-up.|
Specific statistics not reported.
Two prior pilot studies to test the intervention.
Content based on the Socioecological Model of health.
Collaboration process based on the CCM which increased the programme's sustainability.
Inherent flexibility of implementing community specific interventions hampers ability to evaluate outcomes for efficacy.