Setting: Clinical

Strategy Report: Electronic Decision Support for Pediatric Medical Providers

Toddler girl laughing while doctor examines

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose.

Overview

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics. This strategy report describes the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for an effective strategy to improve child health. This information can help inform decision-making around promoting healthy weight. To explore and compare additional strategies, visit the CHOICES National Action Kit 2.0.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu for an accessible version of this report.

Suggested Citation

CHOICES National Action Kit: Electronic Decision Support for Pediatric Medical Providers Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2023.

The design for this report and its graphics were developed by Molly Garrone, MA and partners at Burness.

Funding

This work is supported by the National Institutes of Health (R01HL146625), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders. The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose

For further information, contact choicesproject@hsph.harvard.edu

Strategy Report: Home Visits to Reduce TV Time

Mom and daughter meeting with counselor at home, while daughter is looking at a handheld screen

The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose.

Overview

CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics. This strategy report describes the projected national population reach, impact on health and health equity, implementation costs, and cost-effectiveness for an effective strategy to improve child health. This information can help inform decision-making around promoting healthy weight. To explore and compare additional strategies, visit the CHOICES National Action Kit 2.0.

Continue reading in the full report.

Contact choicesproject@hsph.harvard.edu for an accessible version of this report.

Suggested Citation

CHOICES National Action Kit: Home Visits to Reduce TV Time Strategy Report. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; December 2023.

The design for this report and its graphics were developed by Molly Garrone, MA and partners at Burness.

Funding

This work is supported by the National Institutes of Health (R01HL146625), The JPB Foundation, and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders. The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose

For further information, contact choicesproject@hsph.harvard.edu

Exploring the Cost-Effectiveness of Strategies to Improve Child Health in Boston, MA

The information in this brief is intended only to provide educational information.

The CHOICES Project at the Harvard T.H. Chan School of Public Health and the Boston Public Health Commission (BPHC) worked together as part of the Massachusetts-CHOICES Project (2019 – 2024), a training, technical assistance, and modeling initiative, to develop a playbook of strategies to promote healthy weight and advance health equity in addition to studying how cost-effectiveness metrics are used by partners throughout the state.

Methods & Strategies Modeled

CHOICES cost-effectiveness analysis examines: How many and what types of people would be affected by the policy or program? What the effect of the policy or program would be on health? What will be the implementation costs and the potential health care cost savings? How could the policy or program reduce health disparities and improve health equity?CHOICES uses cost-effectiveness analysis to compare the costs and outcomes of different policies and programs promoting improved nutrition or increased physical activity in schools, early care and education and out-of-school settings, communities, and clinics.

Using CHOICES cost-effectiveness analysis and local data, the BPHC team worked with CHOICES to create a virtual population that mirrors the current population of Boston, MA. Then, the teams examined the expected costs, health outcomes, and health care costs saved if the following strategies were implemented in Boston, Massachusetts over a 10-year timeframe (2020-2029):

Reducing Screen Time in Early Child Care Settings
More Movement Program in Early Child Care Settings
Home Visits to Reduce Screen Time
Movement Breaks in the Classroom
Creating Healthier Afterschool Environments (OSNAP)

Reducing Screen Time in Early Child Care Settings

The strategy to reduce screen time in early child care settings involves providing voluntary training to early child care educators and resources to families to limit noneducational television time at child care and home. This strategy could support Boston’s efforts to improve early child care quality through the Boston Healthy Child Care Initiative. It would include training opportunities for early child care educators, offering ongoing support and technical assistance, and providing parents with educational materials that may lead to reducing screen time in young children.1,2

Helping educators to implement practices shown to be effective in reducing television time can help the children in Boston’s early education and care settings engage in fewer minutes of screen time.

Implementing a strategy to reduce screen time in early child care settings is an investment in the future. By the end of 2029: 18,200 children reached over 10 years; 33 fewer minutes of screen time per child per day; $16 per child per year

Additional Key Findings

If a strategy to reduce screen time in early child care settings was implemented in Boston, 125 cases of obesity would be prevented in 2029, saving $138,000 in health care costs over 10 years.

In addition, this strategy would train and provide technical assistance to early childhood educators on reducing screen time. In the initial training series, this strategy would provide additional skills training and professional development for 1,380 educators and more opportunities to reduce screen time in 570 (100%) child care programs serving 3-5 year olds.

To learn more about this strategy, read the research brief.

References

1. Mendoza JA, Baranowski T, Jaramillo S, et al. Fit 5 Kids TV Reduction Program for Latino Preschoolers: A Cluster Randomized Controlled Trial. American Journal of Preventive Medicine. 2016;50(5):584-592.<
2. Dennison BA, Russo TJ, Burdick PA, Jenkins PL. An intervention to reduce television viewing by preschool children. Archives of Pediatrics and Adolescent Medicine. 2004;158(2):170-176.

More Movement Program in Early Child Care Settings

The more movement program provides training opportunities and resources for early child care educators to implement actions in their programs to encourage physical activity. This strategy could support Boston’s efforts to improve early child care quality through the Boston Healthy Child Care Initiative. It would include training opportunities for early child care educators in physical activity curricula, provide resources and instructional materials, and support technical assistance opportunities that may lead to higher physical activity levels among young children.1,2

Helping educators implement practices shown to be effective in increasing physical activity can help the children in Boston’s early education and care settings to move more.

Implementing the more movement program in early child care settings is an investment in the future. By the end of 2029: 18,200 children reached over 10 years; 7.4 additional minutes of moderate-to-vigorous physical activity per child per day; $16 per child per year

Additional Key Findings

If the more movement program in early child care settings was implemented in Boston, 94 cases of obesity would be prevented in 2029, saving $104,000 in health care costs over 10 years. Besides promoting a healthy weight, increasing physical activity is linked to improved bone and muscular health and better gross motor skills in young children.3-5

In addition, this strategy would train and provide technical assistance to early childhood educators. In the initial training series, the more movement program would provide additional skills training and professional development for 1,380 educators and more physical activity promotion opportunities in 570 (100%) child care programs serving 3-5 year olds.

To learn more about this strategy, read the research brief.

References

1. Fitzgibbon ML, Stolley MR, Schiffer LA, et al. Hip-Hop to Health Jr. Obesity Prevention Effectiveness Trial: Postintervention Results. Obesity (Silver Spring). 2011;19(5):994-1003.
2. Kong A, Buscemi J, Stolley MR, Schiffer LA, Kim Y, Braunschweig CL, Gomez-Perez SL, Blumstein LB, Van Horn L, Dyer AR, Fitzgibbon ML. Hip-Hop to Health Jr. Randomized Effectiveness Trial: 1-Year Follow-up Results. American Journal of Preventive Medicine. 2016 Feb;50(2):136-44.
3. U.S. Dept of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. U.S. Dept of Health and Human Services; 2018. Accessed Jul 23, 2021. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
4. Pate RR, Hillman CH, Janz KF, et al. Physical Activity and Health in Children Younger than 6 Years: A Systematic Review. Medicine & Science in Sports & Exercise. 06 2019;51(6):1282-1291.
5. Timmons BW, Leblanc AG, Carson V, et al. Systematic review of physical activity and health in the early years (aged 0-4 years). Applied Physiology, Nutrition, and Metabolism. Aug 2012;37(4):773-92.

Home Visits to Reduce Screen Time

The home visits to reduce screen time strategy aims to reduce the amount of screen time viewed at home by young children. Community health workers would provide counseling and resources on strategies to limit children’s screen time to children and families who participate in home visiting programs.

Through professional development training opportunities, community health workers would learn ways to support families and children in limiting their screen time. During a home visit, community health workers would share the importance of appropriate screen time limits and provide strategies and tools for families to use, including a screen time management device. Integrating this strategy through existing home visiting programs could help more children manage their screen time and grow up at a healthy weight.1Implementing the home visits to reduce screen time strategy is an investment in the future. By the end of 2029: 3,320 children reached over 10 years; 1.8 fewer hours of screen time per child per day; $44,600 saved in health care costs over 10 years

Additional Key Findings

If the home visits to reduce screen time strategy was implemented in Boston, 60 cases of childhood obesity would be prevented in 2029. Besides promoting a healthy weight, this strategy may also benefit children in other ways. Providing children and their families with strategies to move away from their screens allows for more time for activities like reading and active play.

By training and equipping 119 community health workers annually by ensuring that everyone has access to what they need to grow up healthy and strong, this strategy could help reach those families and children that may be at higher risk of having or developing obesity. Children in households with low income could see greater health benefits from this strategy.1

To learn more about this strategy, read the research brief.

References

1. Epstein LH, Roemmich JN, Robinson JL, et al. A randomized trial of the effects of reducing television viewing and computer use on body mass index in young children. Arch Pediatr Adolesc Med. Mar 2008;162(3):239-45. doi:10.1001/archpediatrics.2007.45

Movement Breaks in the Classroom

Movement breaks in the classroom is a strategy to promote physical activity during the school day by incorporating five-to-10-minute movement breaks in K-5 public elementary school classrooms. To implement the movement breaks strategy in Boston, teachers, Wellness Champions, and staff would receive training, equipment, and materials to incorporate short activity breaks in the classroom to help children move more.1,2

This aligns with Boston Public School’s (BPS) Physical Education and Physical Activity Policy that requires schools to offer physical activity opportunities during the school day,3 as well as BPS’ Whole School, Whole Community, Whole Child approach, which supports students’ holistic health by promoting positive classroom environments that foster physical activity and learning.

Implementing movement breaks in the classroom is an investment in the future. By the end of 2029: 29,400 students reached over 10 years; 25 additional minutes of moderate-to-vigorous physical activity per student per school week; $1.74 per child per year

Additional Key Findings

If movement breaks were incorporated into classrooms in Boston, 37 cases of childhood obesity would be prevented in 2029 and save $35,300 in health care costs related to excess weight over 10 years.

By training and equipping over 600 teachers and other school staff yearly to incorporate movement breaks in the classroom, this strategy could help all Boston Public Schools cultivate a positive school climate and improve social emotional learning.4 Participation in movement breaks are associated with students spending more time on task,5 and teachers report that students are more engaged, supportive of each other, and responsive to teacher instructions after participating in a movement break.6

To learn more about this strategy, read the research brief.

References

1. Erwin HE, Beighle A, Morgan CF, Noland M. Effect of a low-cost, teacher-directed classroom intervention on elementary students’ physical activity. J Sch Health. 2011;81(8):455-461.
2. Murtagh E, Mulvihill M, Markey O. Bizzy Break! The effect of a classroom-based activity break on in-school physical activity levels of primary school children. Pediatr Exerc Sci. 2013;25(2):300-307.
3. Boston Public Schools. Physical Education & Physical Activity Policy. 2020:8. Superintendent’s Circular. https://drive.google.com/file/d/1rSGwpFaa4LsPKxjhdsHxz2IaXg3ZFVtE/view?usp=embed_facebook
4. School-Based Physical Activity Improves the Social and Emotional Climate for Learning. Centers for Disease Control and Prevention,. Accessed March 9, 2022. https://www.cdc.gov/healthyschools/school_based_pa_se_sel.htm
5. The Community Preventive Services Task Force. Physical Activity: Classroom-based Physical Activity Break Interventions. The Community Guide. 2021:8.
Campbell AL, Lassiter JW. Teacher perceptions of facilitators and barriers to implementing classroom physical activity breaks. J Educ Res. 2020;113(2):108-119

 

Creating Healthier Afterschool Environments (OSNAP)

The Out of School Nutrition and Physical Activity (OSNAP) initiative helps afterschool programs improve practices and policies that increase physical activity and consumption of healthy snacks.

To implement this initiative, the Boston Public Health Commission would provide professional development opportunities for afterschool program leaders serving students in grades K-5. Afterschool staff leaders would participate in three learning collaborative sessions and receive technical assistance to assess1 and modify their programs’ practices and policies2  to meet the OSNAP nutrition and physical activity goals.

Creating healthier afterschool environments is an investment in the future. By the end of 2029: 10,800 children reached over 10 years; $34,100 saved in health care costs in 2029; $18.30 per child per year

Additional Key Findings

If the OSNAP initiative was implemented in Boston, 37 cases of obesity would be prevented in 2029. It is also projected to be cost-effective at commonly accepted thresholds3 based on net population health improvement related to excess weight ($72,100 per quality-adjusted life year gained).

This strategy may also support children’s health in a variety of other ways. Regular physical activity, healthy eating, and adequate hydration can improve children’s mental and emotional well-being and their heart, lung, and bone health.4 These healthy behaviors can also strengthen students’ attention, memory,5,6 and cognitive functioning,5 all important components for learning and academic performance.

To learn more about this strategy, read the research brief.

References

1. Lee RM, Emmons KM, Okechukwu CA, Barrett JL, Kenney EL, Cradock AL, Giles CM, deBlois ME, Gortmaker SL. Validity of a practitioner-administered observational tool to measure physical activity, nutrition, and screen time in school-age programs. Int J Behav Nutr Phys Act. 2014 Nov 28;11:145. doi: 10.1186/s12966-014-0145-5.
2. Kenney EL, Giles CM, deBlois ME, Gortmaker SL, Chinfatt S, Cradock AL. Improving nutrition and physical activity policies in afterschool programs: results from a group-randomized controlled trial. Prev Med. 2014;66:159-166. doi:10.1016/j.ypmed.2014.06.011
3. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. New England Journal of Medicine. 2014 Aug 28;371(9):796-7. DOI: 10.1056/NEJMp1405158. PMID: 25162885.
4. Health Benefits of Physical Activity for Children. Centers for Disease Control and Prevention. https://www.cdc.gov/physicalactivity/basics/adults/health-benefits-of-physical-activity-for-children.html. Published Jan 12, 2022. Updated 2022-01-12T05:06:09Z. Accessed Dec 7, 2022.
5. Childhood Nutrition Facts. Centers for Disease Control and Prevention. https://www.cdc.gov/healthyschools/nutrition/facts.htm. Published 2022. Updated 2022-08-05T03:49:26Z. Accessed Dec 12, 2022.
6. Blanding N. Afterschool Programs in Boston, MA, Expand Opportunities for Obesity Prevention. Centers for Disease Control and Prevention; 2016. http://nccd.cdc.gov/nccdsuccessstories


The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This document was developed at the Harvard T.H. Chan School of Public Health through the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This document is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.


Explore and compare these strategies and more using the CHOICES National Action Kit 2.0!

Strategy Profile: Home Visits to Reduce TV Time

Mom and daughter meeting with counselor at home, while daughter is looking at a handheld screen

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

  • Home visits to reduce TV time is a program to disseminate a screen time managing device to families through a home visiting program to reduce screen time among children ages 4-7.

What population benefits?

Children ages 4-7 with BMI >75th percentile who receive home visits.

What are the estimated benefits?

Relative to not implementing the strategy
Reduce child daily television time which can help improve dietary intake and, in turn, promote healthy child weight.

What activities and resources are needed?

Activities Resources Who Leads?
Coordinate the training rollout • Time for the director to coordinate the trainings Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program
Train community health workers who would implement the program • Time for community health workers to receive trainings
• Travel costs
• Material costs
Home Visiting Program Coordinator
Train registered nurses about referring children to home visits to reduce screen time • Time for registered nurses to receive trainings
• Travel costs
Home Visiting Program Coordinator
Purchase program materials • TV control device cost
• Posters cost
• Incentives for children cost
Home Visiting Programs
Coordinate patient referrals and provide counseling during home visits • Time for registered nurses to recruit and refer patients
• Time for community health workers to implement
Community health center registered nurses & community health workers
Strategy Modification

Some state and local health agencies added to this strategy by teaching about parental controls on other screen devices (e.g., tablets, smart phones, etc.). This could help parents limit all types of screen time for their children, not just on the television. This would require additional training and materials for families.

FOR ADDITIONAL INFORMATION

Kenney EL, Mozaffarian RS, Long MW, Barrett JL, Cradock AL, Giles CM, Ward ZJ, Gortmaker SL. Limiting television to reduce childhood obesity: cost-effectiveness of five population strategies. Child Obes. 2021 Oct;17(7):442-448. doi: 10.1089/chi.2021.0016.

Selected CHOICES research brief including cost-effectiveness metrics:

Carter S, Bovenzi M, Sabir M, Bolton AA, Reiner JR, Barrett JL, Cradock AL, Gortmaker SL. Boston, MA: Home Visits to Reduce Screen Time {Issue Brief}. Boston Public Health Commission, Boston, MA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; February 2023. Available at: https://choicesproject.org/publications/brief-home-visits-screen-time


Suggested Citation

CHOICES Strategy Profile: Home Visits to Reduce TV Time. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; September 2023.

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

©2015 President and Fellows of Harvard College. All rights reserved. The CHOICES name, acronym and logo are marks of the President and Fellows of Harvard College.

Brief: Home Visits to Reduce Screen Time in Boston, MA

Mom and daughter meeting with counselor at home, while daughter is looking at a handheld screen

The information in this brief is intended only to provide educational information.

A version of this brief was published in May 2022. This brief was updated in February 2023 to reflect revised projections for Boston’s population. 

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy to reduce the amount of screen time viewed at home by young children in Boston, MA. Community health workers would provide counseling and resources on strategies to limit children’s screen time to children and families who participate in home visiting programs.

The Issue

In 2017, three in 10 first graders in Boston had overweight or obesity.1 Access to healthy foods, beverages, and opportunities to participate in regular physical activity are key priorities for communities in supporting children growing up at a healthy weight. However, not all families have access to the same resources.

Limiting children’s screen time is also a high priority for communities.2 Food companies use television to market unhealthy foods and drinks to children, which can increase children’s food intake and their risk for excess weight gain.3 Moreover, food companies have disproportionately marketed fast food and sugary drinks to Black and Hispanic youth4 and children from lower income households watch more screen media than their peers,5 putting them at greater risk for unfavorable health outcomes.

Helping families manage screen time can promote a healthy weight and advance health equity. Home visiting programs engage community health workers to improve health behaviors and reduce the risk of chronic diseases for families with children. Home visiting programs specifically support children who are exposed to conditions that could negatively impact their health.6

About the Home Visits to Reduce Screen Time Strategy

This strategy supports the Boston Public Health Commission’s goal of preventing obesity and chronic disease using a health equity lens while also building and maintaining partnerships with home visiting programs across Boston. Through professional development trainings opportunities, community health workers would learn ways to support families and children in limiting their screen time. During a home visit, community health workers would share the importance of appropriate screen time limits and provide strategies and tools for families to use, including a screen time management device. Integrating this strategy through existing home visiting programs could help more children manage their screen time and grow up at a healthy weight.7

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2030) of implementing the home visits to limit screen time strategy with the costs and outcomes associated with not implementing the program.

Implementing the home visits to reduce screen time strategy is an investment in the future. By the end of 2030:
If home visits to reduce screen time was implemented in Boston, then by the end of 2030: 3,320 children would be reached over 10 years, 60 cases of childhood obesity would be prevented in 2030, each child would view 1.8 fewer hours of screen time each day, and $44,600 in health care costs would be saved over 10 years.

Conclusions and Implications

Incorporating counseling and providing resources to limit screen time through existing home visiting programs could reach 3,320 children ages 4-7. Over 10 years, we project that children whose families participated in the program would watch nearly two fewer hours of screen time per day, on average. This strategy could also prevent 60 cases of childhood obesity in 2030, saving $44,600 in health care costs related to excess weight over 10 years. It would cost $540 per child.

Community health workers play an important role in building healthier communities and promoting health equity. By training and equipping 119 community health workers annually by ensuring that everyone has access to what they need to grow up healthy and strong, this strategy could help reach those families and children that may be at higher risk of having or developing obesity. Children in households with low income could see greater health benefits from this strategy.7

In addition to promoting healthy weight, this strategy may also benefit children in other ways. Too much screen time can negatively impact children’s sleep and social wellbeing.8 Providing children and their families with strategies to move away from their screens allows for more time for developmentally appropriate activities like reading and active play. Strategies families can use to limit online video viewing and mobile device use may be particularly important as screen time from these sources has increased dramatically in recent years.5

Working with community health workers in Boston’s existing home visiting programs will help families build a foundation for overall health and wellbeing. These preventive strategies play a critical role in helping children establish healthy habits early on in life. 

References

  1. School Health Services, Dept of Public Health. Results from the Body Mass Index Screening in Massachusetts Public School Districts, 2017. School Health Services, Dept of Public Health; 2020. Accessed Feb 22, 2022. https://www.mass.gov/doc/the-status-of-childhood-weight-in-massachusetts-2017

  2. Healthy People 2030: Building a healthier future for all. Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services. Accessed Feb 4, 2022. https://health.gov/healthypeople

  3. Russell SJ, Croker H, Viner RM. The effect of screen advertising on children’s dietary intake: A systematic review and meta-analysis. Obes Rev. 2019;20(4):554-568. doi:10.1111/obr.12812

  4. UConn Rudd Center for Food Policy & Obesity. Fast Food Advertising: Billions in spending, continued high exposure by youth. 2021. Fast Food Fact, UConn Rudd Center for Food Policy & Obesity. https://www.fastfoodmarketing.org/media/FACTS%20Summary%20FINAL%206.15.pdf   

  5. Rideout V, Robb MB. The Common Sense Census: Media Use by Kids Age Zero to Eight. 2020. Common Sense Census. https://www.commonsensemedia.org/research/the-common-sense-census-media-use-by-kids-age-zero-to-eight-2020 

  6. Duffee JH, Mendelsohn AL, Kuo AA, Legano LA, Earls MF. Early Childhood Home Visiting. Pediatrics. Sep 2017;140(3). doi:10.1542/peds.2017-2150 

  7. Epstein LH, Roemmich JN, Robinson JL, et al. A randomized trial of the effects of reducing television viewing and computer use on body mass index in young children. Arch Pediatr Adolesc Med. Mar 2008;162(3):239-45. doi:10.1001/archpediatrics.2007.45 

  8. Tremblay MS, LeBlanc AG, Kho ME, et al. Systematic review of sedentary behaviour and health indicators in school-aged children and youth. Int J Behav Nutr Phys Act. Sep 21 2011;8:98. doi:10.1186/1479-5868-8-98

Suggested Citation:

Carter S, Bovenzi M, Sabir M, Bolton AA, Reiner JR, Barrett JL, Cradock AL, Gortmaker SL. Boston, MA: Home Visits to Reduce Screen Time {Issue Brief}. Boston Public Health Commission, Boston, MA, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; February 2023. For more information, please visit www.choicesproject.org

A version of this brief was published in May 2022. This brief was updated in February 2023 to reflect revised projections for Boston’s population. 

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Boston Public Health Commission through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Strategy Profile: Electronic Decision Support for Pediatric Medical Providers

Toddler girl laughing while doctor examines

The information in this resource is intended only to provide educational information. This profile describes the estimated benefits, activities, resources, and leadership needed to implement a strategy to improve child health. This information can be useful for planning and prioritization purposes.

  • Promoting recognition and recommended management of obesity among children ages 6-12 through electronic decision supports for pediatric medical providers during well-child visits.

What population benefits?

Children ages 6-12 years old with obesity (BMI>95th percentile) who are being seen by primary care providers with fully-functioning electronic health records systems.

What are the estimated benefits?

Relative to not implementing the strategy
Increase nutrition and physical activity health-promoting behaviors and, as a result, promote healthy child weight.

What activities and resources are needed?

Activities Resources Who Leads?
Oversee and implement electronic decision support for pediatric medical providers • Time for health system project coordinator to develop content for website, project dissemination plan, and training materials Health system project coordinator
Modify electronic health record system to prompt providers to recognize and manage obesity at clinics • Time for electronic health record system staff to update electronic health record system Electronic health record system staff
Develop and maintain a website to share local nutrition and physical activity resources to support healthy behaviors • Time to develop and maintain the website Health system website developer
and staff
Train in motivational interviewing and electronic health system changes and provide performance feedback to primary care providers • Time for health system project coordinator and/ or electronic health records system manager to lead trainings and to provide performance feedback to primary
care providers
• Time for primary care providers to attend trainings
• Training material costs
• Food costs to offer with trainings
Health system project
coordinator, electronic health records system manager,
practice coach, and/or operations
manager
Develop and deliver direct-to-parent communications • Time for the health systems project coordinator to develop content for communications materials for families
• Costs for printing and mailing materials
Health systems project coordinator
Additional time in clinics by primary care providers • Additional time for primary care clinicians to spend with patients in office Primary care clinicians
Material costs for primary care offices • Costs for printing posters to be displayed in primary care offices Health system
Strategy Modification

Some state and local health agencies replaced parent mailings with text messages, following a strategy modification that was shown to be effective in a research study. In the text messaging scenario, this strategy could reach children ages 2-12 and we estimate BMI would decrease (-0.3 units or about -1.24 lbs for a 9-year-old of average height). If a text messaging platform already exists in clinics, this could be less expensive than parent mailings.


FOR ADDITIONAL INFORMATION
Sharifi M, Franz C, Horan CM, Giles C, Long M, Ward Z, Resch S, Marshall R, Gortmaker S, Taveras E. Cost-Effectiveness of a Clinical Childhood Obesity Intervention. Pediatrics. 2017; 140(5): e20162998.

Selected CHOICES research brief including cost-effectiveness metrics:
Moreland J, Rosen J, Kraus E, Reiner J, Gortmaker S, Giles C, Ward Z. Denver: Study of Technology to Accelerate Research (STAR) {Issue Brief}. Denver Public Health and Denver Health, Denver, CO, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; July 2018. Available at: https://choicesproject.org/publications/brief-star-denver


Suggested Citation

CHOICES Strategy Profile: Electronic Decision Support for Pediatric Medical Providers. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; April 2022.

Funding

This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The information provided here is intended to be used for educational purposes. Links to other resources and websites are intended to provide additional information aligned with this educational purpose. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Adapted from the TIDieR (Template for Intervention Description and Replication) Checklist

©2015 President and Fellows of Harvard College. All rights reserved. The CHOICES name, acronym and logo are marks of the President and Fellows of Harvard College.

CHOICES Web Forum: How a clinical strategy in Denver could improve health and address health equity

The CHOICES Project at the Harvard T.H. Chan School of Public Health hosted this virtual Web Forum on July 14, 2021. Key leaders in the field discussed how cost-effectiveness analysis can be a useful decision-making tool to prioritize strategies that promote healthy eating, active living, and health equity.

Moderator:

  • William Dietz, MD, PhD, Director, Sumner M. Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, The George Washington University

Panelists:

  • Captain Heidi Blanck, PhD, MS, Branch Chief, Chronic Disease Nutrition/Obesity, Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention
  • Jennifer Moreland, MPH, Chronic Disease Manager, Denver Public Health –
  • Elsie Taveras, MD, MPH, Chief Community Health Equity Officer, Mass General Brigham, Executive Director, Kraft Center for Community Health at MGH, Conrad Taff Endowed Professor, Harvard Medical School

Brief: Women, Infants, and Children (WIC) Television Time Reduction in Arkansas

Mother playing with young child

The information in this brief is intended only to provide educational information.

This brief summarizes the findings from a CHOICES Learning Collaborative Partnership model examining a strategy to incorporate television time counseling into the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Arkansas. WIC staff would be trained to assess children’s television viewing and offer education on modifying television behaviors during WIC certification visits.

The Issue

In Arkansas, three out of 10 kindergarteners entering school in 2018 had overweight or obesity.1 However, limiting children’s television viewing may help them grow up at a healthy weight because product marketing on television can lead children to consume too many unhealthy foods and drinks.2

The American Academy of Pediatrics recommends children view a maximum of one hour per day of quality screen programming.3 Yet, in 2019, many children ages 2-4 participating in Arkansas’ WIC program viewed twice that amount, averaging nearly two hours per day. Just two out of every 10 children viewed the recommended level of daily screen time.4

In Arkansas, the WIC program offers nutrition education, referrals, and supplemental food support to low-income families (in households with income less than 185% of poverty levels). Identifying strategies to help these families achieve the recommended levels of television would support children’s growth and development. Ensuring children are growing up at a healthy weight also increases their likelihood of having a healthy weight in adulthood.

About Women, Infants, and Children (WIC) Television Time Reduction

This evidence-based strategy involves training WIC clinic staff to assess television viewing practices and provide opportunities for counseling to caregivers to reduce the amount of television their child watches.5 This strategy would require a modification within the existing assessment tool used to personalize nutrition education, referrals, and food package tailoring that would prompt staff to ask caregivers questions during recertification visits and provide relevant educational resources and guidance. WIC clinic staff would be trained to ask caregivers how much television their children view and then share ways to reduce it.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2030) of implementing WIC Television Time Reduction with the costs and outcomes associated with not implementing the strategy.

Implementing WIC Television Time Reduction in Arkansas is an investment in the future. By the end of 2030:

If WIC television time reduction was implemented in Arkansas, then 60,800 children would be reached over 10 years. It would cost $0.52 per child per year to implement, and save $92,400 in health care costs over 10 years. Children would view 18 fewer minutes of TV each day.

Conclusions and Implications

A state-level initiative that incorporates television viewing screening assessments and counseling practices into regular WIC visits could reach over 60,800 children and their families in Arkansas over 10 years. We project children would average 18 fewer minutes of television daily if these practices were incorporated. This strategy would prevent 314 cases of childhood obesity in Arkansas in 2030, at an average cost of $0.52 per child per year. Moreover, this investment in child health is estimated to pay off over 10 years. For every $1 spent on implementing this strategy, $1.06 in obesity-related health care costs would be saved over 10 years, saving $92,400 by 2030.

Children participating in WIC in Arkansas are in low-income households and are more likely to be Hispanic or Black than the general population of 2-4 year olds in Arkansas.4 CHOICES projected substantial reductions in cases of obesity among low-income children participating in WIC. Since this strategy is focused on populations with high risk of excess television viewing, and is not expected to impact obesity among higher income households not participating in WIC, it could lead to improvements in disparities in both television viewing and obesity risk.

The WIC program helps safeguard the health of children by providing supplemental foods, referrals, and nutrition education. These preventive strategies can play a critical role in helping children establish healthy habits early. Incorporating opportunities for skill-building to reduce television time into the WIC program is a low-cost and feasible strategy to ensure opportunities for more Arkansas children to grow up a healthy weight.

References

  1. ACHI. Assessment of Childhood and Adolescent Obesity in Arkansas: Year 16 (Fall 2018-Spring 2019). Little Rock, AR: Arkansas Center for Health Improvement; 2019.

  2. Russell SJ, Croker H, Viner RM. The effect of screen advertising on children’s dietary intake: A systematic review and meta-analysis. Obesity Reviews. 2019;20(4):554-568.

  3. Council on Communications and Media. Media and Young Minds. Pediatrics. 2016;138(5):e20162591.

  4. Arkansas Department of Health. WIC program 2019 data, unpublished report; accessed June 2020.

  5. Whaley S, McGregor S, Jiang L, Gomez J, Harrison G, Jenks E. A WIC-Based Intervention to Prevent Early Childhood Overweight. Journal of Nutrition Education and Behavior. 2010 Feb; 52(3S) S47-51

Suggested Citation:

Adams B, Sutphin B, Looney R, Rollins N, Balamurugan A, Kim H, Bolton A, Reiner J, Barrett J, Gortmaker SL, Cradock AL. Arkansas: Women, Infants, and Children (WIC) Television Time Reduction {Issue Brief}. Arkansas Department of Health, Little Rock, AR, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; May 2021. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with the Arkansas Department of Health through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by The JPB Foundation and the Centers for Disease Control and Prevention (U48DP006376). The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention or other funders.

Making CHOICES in a Health Department: Case 2 (Advanced)

People drawing on a whiteboard

In this advanced teaching case, which builds on Case 1, a fictional health department continues to work with the CHOICES Project’s Learning Collaborative Partnership to determine how to implement an evidence-based strategy that requires substantial investment, but they face a variety of additional challenges such as state politics and the complexities of health policy.


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Making CHOICES in a Health Department: Case 1 (Introductory)

In this introductory teaching case, a fictional health department engages with the CHOICES Project’s Learning Collaborative Partnership to help them narrow down a list of potential strategies to reduce childhood obesity in their county through a cost-effectiveness lens.


CHOICES Community of Practice
To browse more resources like this, check out our Community of Practice!