Topic: Screen & TV Time

Strategy Profile: Program in Early Care and Education Settings to Reduce TV Viewing

Posted on September 22, 2023

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.

  • Program to reduce television viewing among young children ages 2-5 in licensed early care and education centers by training educators in an evidence-based curriculum and engaging families in reducing television time at home

What population benefits?

Children ages 2-5 attending licensed early care and education centers.

What are the estimated benefits?

Relative to not implementing the strategy
Reduce child daily television time which can help promote healthy child weight.

What activities and resources are needed?

Activities Resources Who Leads?
Train early care and education directors and staff on an evidence-based curriculum (Fit5Kids) to reduce television time • Time for state early care and education agency training consultant to prepare for and lead trainings
• Time for early care and education program directors and staff to attend trainings
• Travel costs		 State early care and education training consultant
Provide training materials for early care educators and administrators to engage children and families in reducing television time • Cost of training materials State government
Provide materials to children and families to promote reduced TV time • Cost of materials for children and families
• Cost of the book “The Berenstain Bears and Too Much TV”		 Early care and education programs

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.

Suggested Citation

CHOICES Strategy Profile: Program in Early Care and Education Settings to Reduce TV Viewing. 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

← Back to Resources

Strategy Profile: Creating Healthier Early Care and Education Environments

Posted on September 22, 2023

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.

  • Improving nutrition, physical activity, & screen time policies & practices for children ages 3-5 by incorporating the Nutrition & Physical Activity Self-Assessment for Child Care (NAP SACC) Program into state’s Quality Rating and Improvement Systems (QRIS) for early care and education programs.

What population benefits?

Children ages 3-5 attending licensed early care and education programs that participate in their state’s Quality Rating and Improvement Systems (QRIS).

What are the estimated benefits?

Relative to not implementing the strategy
Promote healthy child weight.

What activities and resources are needed?

Activities Resources Who Leads?
Train early care and education health professionals to work with early care and education programs • Time of state training consultant to train early care and education health professionals
• Time of early care and education health professionals to be trained		 State QRIS administrators
Provide consultation to early care and education program directors and staff for conducting self-assessments of program policies and practices, completing action plans, and implementing changes to improve nutrition, physical activity, and screen time environments in programs • Time of early care and education health professionals to provide consultation to early care and education programs
• Time of early care and education program directors and staff to participate in consultation		 Early care and education health professionals
Provide materials and equipment for implementing NAP SACC program • Cost for GO NAP SACC online license
• Physical activity equipment costs		 State QRIS administrators
Implement changes in early care and education programs to improve nutrition, physical activity, and screen time environments • Time of early care and education program directors to implement changes Early care and education program directors
Improve nutritional quality of meals served in early care and education programs • Food costs for improving nutritional quality of meals Early care and education program directors
Monitor compliance with NAP SACC program • Time of state-level QRIS Administrators to monitor compliance State QRIS administrators
Strategy Modification

In states where NAP SACC is already being implemented, the strategy could be modified to focus on increasing the number of early care and education programs that participate in NAP SACC. With this modification, the cost for the GO NAP SACC online license would not be needed, since it is a fixed annual cost paid per state (i.e., it does not depend on the number of participating programs). With this modification, the impact on health is expected to be similar, and the impact on reach and cost would vary according to the number of programs reached.

FOR ADDITIONAL INFORMATION

Gortmaker SL, Wang YC, Long MW, Giles CM, Ward ZJ, Barrett JL, Kenney EL, Sonneville KR, Afzal AS, Resch SC, Cradock AL. Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Aff (Millwood). 2015 Nov;34(11):1932-9. doi: 10.1377/hlthaff.2015.0631. Supplemental Appendix with strategy details available at: https://www.healthaffairs.org/doi/suppl/10.1377/hlthaff.2015.0631/ suppl_file/2015-0631_gortmaker_appendix.pdf

Selected CHOICES research brief including cost-effectiveness metrics:

Adams B, Sutphin B, Betancourt K, Balamurugan A, Kim H, Bolton A, Barrett J, Reiner J, Cradock AL. Arkansas: Creating Healthier Child Care Environments: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) in the Quality Rating Improvement System (QRIS) {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. Available at: https://choicesproject.org/publications/brief-napsacc-arkansas

Kenney EL, Giles CM, Flax CN, Gortmaker SL, Cradock AL, Ward ZJ, Foster S, Hammond W. New Hampshire: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) Intervention {Issue Brief}. New Hampshire Department of Health and Human Services, Concord, NH, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2017. Available at: https:// choicesproject.org/publications/brief-napsacc-intervention-new-hampshire

Suggested Citation

CHOICES Strategy Profile: Creating Healthier Early Care and Education Environments. 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

← Back to Resources

Strategy Profile: Home Visits to Reduce TV Time

Posted on September 15, 2023

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

← Back to Resources

Strategy Profile: Counseling in WIC Visits to Reduce TV Viewing

Posted on August 9, 2023

Loving Mother Holding Newborn Baby At Home In Loft Apartment

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.

  • Incorporating television time counseling into required Special Supplemental Nutrition program for Women, Infants, and Children (WIC) certification visits among WIC participants with children ages 2-4 through the inclusion of relevant assessment items within the existing screening assessment tools regularly used by WIC clinical staff.

What population benefits?

Children ages 2-4 who participate in the WIC program.

What are the estimated benefits?

Relative to not implementing the strategy
Reduce child daily television time which can help promote healthy child weight.

What activities and resources are needed?

Activities Resources Who Leads?
Coordinate planning and delivery of virtual training and educational materials for WIC clinicians and monitor program status • Time for National WIC Coordinator to coordinate and monitor the program National WIC Coordinator
Develop virtual training and educational materials for WIC clinicians • Time for national WIC agency staff to develop virtual training and educational materials National WIC Agency Staff
Add relevant assessment items to measure television viewing within tools, tracking, and monitoring systems regularly used by WIC clinicians • Time to update database, tools, and tracking systems State WIC Agency Information Systems Staff
Train WIC clinicians in using relevant screening tools and motivational interviewing techniques • Time for state WIC agency staff to prepare for and deliver trainings
• Time for state WIC clinicians to attend trainings		 State WIC Program Staff

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:

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. Available at: https://choicesproject.org/ publications/brief-wic-st-arkansas

Suggested Citation

CHOICES Strategy Profile: Counseling in WIC Visits to Reduce TV Viewing. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; August 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

← Back to Resources

Brief: Creating Healthier Afterschool Environments (OSNAP) in Boston, MA

Posted on July 28, 2023

Three kids at the playground

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

This brief summarizes a CHOICES Learning Collaborative Partnership model examining the implementation of the Out of School Nutrition and Physical Activity (OSNAP) initiative that helps afterschool programs improve practices and policies that increase physical activity and consumption of healthy snacks.

The Issue

Every child should have opportunities to grow up healthy. Regular physical activity, healthy eating, and adequate hydration can help children maintain a healthy weight. Over 6,000 students in kindergarten to fifth grade participate in afterschool programs in Boston.1 These educational settings can provide essential opportunities for children to learn healthy eating habits and promote physical activity and wellness. However, not all programs offer the same opportunities for healthy eating and physical activity.2 Helping more afterschool programs adopt policies and practices that incorporate more physical activity, healthier snacks, and improved water access during program time can help ensure that all children in Boston’s afterschool programs have opportunities to grow up healthy.

About Creating Healthier Afterschool Environments

OSNAP is a proven initiative implemented in multiple communities that helps afterschool programs create environments that promote increased physical activity and consumption of healthy snacks.3-6 Creating healthier afterschool environments can contribute to higher quality afterschool programming. 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 assess7 and modify their programs’ practices and policies3 to meet the OSNAP nutrition and physical activity goals. The Boston Public Health Commission would supply program leaders with materials to support implementation and offer continuing education units for their participation.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2029) of implementing the OSNAP program with the costs and outcomes associated with not implementing the program.

Creating healthier afterschool environments is an investment in the future. By the end of 2029:
If creating healthier afterschool environments (OSNAP) was implemented in Boston, 10,800 children would be reached over 10 years, $34,100 would be saved in health care costs, and it would cost $18.30 per child per year to implement.

Conclusions and Implications

Opportunities for physical activity and access to healthy foods in afterschool programs are important to parents2 and can help enhance the quality of afterschool programing. Over 10 years, this strategy could train more than 600 afterschool teachers and directors. By equipping afterschool leaders with these skills and resources, afterschool programs could adopt healthier practices and policies and we project that 10,800 children would benefit from more physical activity and improved diet. We project that 37 cases of obesity would be prevented and $34,100 in healthcare costs related to excess weight would be saved in 2029. We expect this strategy would cost $18.30 per child per year to implement in Boston and is projected to be cost-effective at commonly accepted thresholds8 based on net population health improvement related to excess weight ($72,100 per quality-adjusted life year gained).

In addition to promoting healthy weight, this strategy may also support children’s health in 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.9 These healthy behaviors can also strengthen students’ attention, memory,10,11 and cognitive functioning,10 all important components for learning and academic performance. Incorporating physical activity and healthy snacks in afterschool programs can help children nurture healthy habits and lay a strong foundation for overall health and well-being.

This strategy builds upon Boston Public Health Commission’s demonstrated success where, in 2015, more than 120 programs took steps to improve their screen time, physical activity, and nutrition practices through OSNAP, creating higher quality afterschool programs across Boston.11 Broader implementation could reach all afterschool programs in Boston, improving practices and policies that promote increased physical activity and consumption of healthy snacks, furthering the Boston Public Health Commission’s goal of creating policy and systems changes in childcare to promote the health of all Boston residents.

References

  1. Boston AfterSchool & Beyond. SY 21-22 Programs. In. Boston, MA: Boston AfterSchool & Beyond; 2021.

  2. Kids on the Move: Afterschool Programs Promoting Healthy Eating and Physical Activity. Washington, D.C.: America After 3pm, Afterschool Alliance; 2015.

  3. 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

  4. Cradock AL, Barrett JL, Giles CM, et al. Promoting Physical Activity With the Out of School Nutrition and Physical Activity (OSNAP) Initiative: A Cluster-Randomized Controlled Trial. JAMA Pediatr. 2016;170(2):155-162.

  5. Lee RM, Giles CM, Cradock AL, Emmons KM, Okechukwu C, Kenney EL, Thayer J, Gortmaker SL. Impact of the Out-of-School Nutrition and Physical Activity (OSNAP) Group Randomized Controlled Trial on Children’s Food, Beverage, and Calorie Consumption among Snacks Served. J Acad Nutr Diet. 2018 Aug;118(8):1425-1437. doi: 10.1016/j.jand.2018.04.011.

  6. Lee RM, Barrett JL, Daly JG, Mozaffarian RS, Giles CM, Cradock AL, Gortmaker SL. Assessing the effectiveness of training models for national scale-up of an evidence-based nutrition and physical activity intervention: a group randomized trial. BMC Public Health. 2019 Nov 28;19(1):1587. doi: 10.1186/s12889-019-7902-y.

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. Blanding N. Afterschool Programs in Boston, MA, Expand Opportunties for Obesity Prevention. Centers for Disease Control and Prevention; 2016. http://nccd.cdc.gov/nccdsuccessstories

Suggested Citation:

Carter S, Bovenzi M, Clarke J, Bolton AA, Reiner JF, Barrett JL, Cradock AL, Gortmaker SL. Boston, MA: Creating Healthier Afterschool Environments (OSNAP) {Issue Brief}. Boston Public Health Commission, Massachusetts, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; July 2023.

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.

← Back to Resources

Strategy Profile: Creating Healthier Afterschool Environments

Posted on October 6, 2022

Young boy eating a green apple

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.

  • Creating healthier afterschool environments is a strategy to improve nutrition and physical activity policies & practices through the Out of School Nutrition and Physical Activity (OSNAP) initiative for children in grades K-5 attending state-administered 21st Century Learning afterschool programs.

What population benefits?

Children in grades K-5 attending state-administered 21st Century Learning afterschool programs.

What are the estimated benefits?

Relative to not implementing the strategy
Increase vigorous physical activity and improve nutritional quality of snacks and beverages offered in afterschool programs, and, in turn, promote healthy child weight.

What activities and resources are needed?

Activities Resources Who Leads?
Issue regulations to improve nutrition and physical activity policies and practices in afterschool programs • Time to issue and communicate regulations State government
Provide training and technical assistance to regional Healthy Afterschool trainers on how to lead learning collaborative sessions • Time for state Healthy Afterschool coordinator to lead trainings
• Time for regional Healthy Afterschool trainers to be trained and receive technical assistance
• Travel costs
• Training material costs		 State healthy afterschool coordinator
Conduct regional learning collaboratives with afterschool program staff including training and technical assistance on goals and implementation activities • Time for regional Healthy Afterschool trainers to lead learning collaboratives and provide technical assistance
• Time for afterschool program staff to attend learning collaboratives and receive technical assistance
• Training material costs
• Travel costs		 Regional healthy afterschool trainer
Assess and implement actions to change program practices to meet Healthy Afterschool standards • Time for afterschool program staff to conduct program practice self-assessments and implement changes at their program
• Increase in food costs to provide snacks in compliance with nutrition standards to children attending Healthy Afterschool programs		 Afterschool program director
Develop CEU-accredited course for local program staff • Cost to create a CEU-accredited course State healthy afterschool coordinator
Provide educational materials and incentives to local program staff • Material and incentive costs State government
Monitor compliance to ensure afterschool programs are following programmatic requirements • Time for state monitoring and compliance staff to monitor compliance
• Travel costs		 State government monitoring and compliance staff
Establish a Healthy Afterschool recognition and monitoring website • Time to create and maintain website State government website developer
Strategy Modification

This strategy could be modified to benefit children who participate in out-of-school programs administered by other organizations (e.g., YMCA or Boys and Girls Club of America). With this modification, the activities necessary to carry out the voluntary recognition program may not be included (e.g., issuing regulations, creating a healthy afterschool nutrition website, and monitoring compliance). With this modification, the impact on health is expected to be similar, and the impact on reach and cost may vary.

FOR ADDITIONAL INFORMATION

Cradock AL, Barrett JL, Kenney EL, Giles CM, Ward ZJ, Long MW, Resch SC, Pipito AA, Wei ER, Gortmaker SL. Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood. Prev Med. 2017 Feb;95 Suppl: S17-S27. doi: 10.1016/j.ypmed.2016.10.017. Supplemental Appendix with strategy details available at: https://ars.els-cdn.com/ content/image/1-s2.0-S0091743516303395-mmc1.docx

Suggested Citation

CHOICES Strategy Profile: Creating Healthier Afterschool Environments. CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; May 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

← Back to Resources

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

Posted on May 31, 2022

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.

← Back to Resources

Brief: Reducing Screen Time in Early Child Care Settings in Boston, MA

Posted on September 20, 2021

Teacher playing with kids

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

Versions of this brief were published in September 2021 and January 2023. The January 2023 update was to reflect revised projections for Boston’s population. This brief was updated again in October 2023 to more accurately represent the model period.

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy to reduce screen time in early child care settings in Boston. This strategy provides voluntary training to early child care educators and resources to families to limit noneducational television time at child care and home.

The Issue

Every child should have opportunities to grow up at a healthy weight. Too much screen time in early childhood is linked to overweight and obesity, as it reduces opportunities for children to be active and advertisement exposure can lead children to eat and drink more unhealthy foods.1 The American Academy of Pediatrics recommends limiting screen time to one hour of quality programming per day in child care and at home for children over 2 years old.2 Less than half of children ages 2-5 met this guideline.3

Limiting screen time at child care and home would support children’s healthy growth. In 2017, about three in 10 first graders in Boston had overweight or obesity.4 Reducing young children’s screen time will ensure more children grow up at a healthy weight and enter school ready to learn.

About the Strategy to Reduce Screen Time in Early Child Care Settings

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.5,6 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.

NOTE: The data that informed these estimates were collected after the program closures prompted by the COVID-19 pandemic. As programs reopen and demand continues to increase, this strategy could reach more children.

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of implementing a strategy to reduce screen time in Boston early child care settings with the costs and outcomes associated with not implementing the strategy over 10 years (2020-2029).

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 would be reached over 10 years; 125 cases of childhood obesity would be prevented in 2029; this strategy would cost $16 per child to implement; children reached by this strategy would experience 33 fewer minutes of screen time per child per day

Conclusions and Implications

If the strategy were implemented, we estimate that over 10 years, 18,200 children ages 3-5 would attend programs that support reducing screen time (based on the number of programs open during the COVID-19 pandemic). This strategy would prevent 125 cases of obesity in 2029 alone, saving $138,000 in obesity-related health care costs over 10 years. The average annual cost to implement this strategy would be $161 per program, or $16 per child.

Expanding training opportunities for early child care educators will also help support quality care. Ensuring access to quality care is essential for families and employers.7 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.

Besides promoting a healthy weight, viewing less screen time benefits children in other ways. Too much screen use is associated with less sleep and can negatively impact social well-being.1 We estimate that, on average, each child attending a program implementing the strategy would view 33 fewer minutes of screen time per day. This allows more time for developmentally appropriate play activities, helping to form a strong foundation for overall well-being. 

This strategy would train and provide technical assistance to early childhood educators on reducing screen time. As programs reopen post-pandemic and demand for child care continues to increase, the strategy could reach even more children. This strategy would enable early child care programs in Boston to support healthy growth because every child deserves a healthy start. 

References

  1. Li C, Cheng G, Sha T, Cheng W, Yan Y. The Relationships between Screen Use and Health Indicators among Infants, Toddlers, and Preschoolers: A Meta-Analysis and Systematic Review. International Journal of Environmental Research and Public Health. 2020;17(19):7324. 

  2. COUNCIL ON COMMUNICATIONS AND MEDIA. Media and Young Minds. Pediatrics. 2016;138(5):e20162591. 

  3. Healthy People 2030. Increase the proportion of children aged 2 to 5 who get no more than 1 hour of screen time a day – PA-13. 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 July 20, 2021. https://health.gov/healthypeople/objectives-and-data/browse-objectives/physical-activity/increase-proportion-children-aged-2-5-years-who-get-no-more-1-hour-screen-time-day-pa-13/data 

  4. 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 July 23, 2021. https://www.mass.gov/doc/the-status-of-childhood-weight-in-massachusetts-2017

  5. 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. 

  6. 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. 

  7. Campbell F, Patil P, McSwain K. Boston’s Child-Care Supply Crisis: What a Pandemic Reveals. November 2020. https://www.bostonopportunityagenda.org/-/media/boa/early-ed-census-2020-pt-1-202011.pdf

Suggested Citation:

Bovenzi M, Carter S, Sabir M, Bolton AA, Barrett JL, Reiner JF, Cradock AL, Gortmaker SL. Boston, MA: Reducing Screen Time in Early Child Care Settings {Issue Brief}. Boston Public Health Commission and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2023. For more information, please visit www.choicesproject.org

Versions of this brief were published in September 2021 and January 2023. The January 2023 update was to reflect revised projections for Boston’s population. This brief was updated again in October 2023 to more accurately represent the model period.

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.

← Back to Resources

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

Posted on May 17, 2021

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.

← Back to Resources

Brief: Creating Healthier Child Care Environments: NAPSACC in the Quality Rating Improvement System in Arkansas

Posted on May 17, 2021

Young kids playing in an early care setting

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

This brief summarizes a CHOICES Learning Collaborative Partnership model examining a strategy incorporating the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) assessment tools into Better Beginnings, Arkansas’ Quality Rating and Improvement System, to support quality early child care program opportunities and promote child health. 

The Issue

In Arkansas, three out of 10 kindergarteners entering school in 2018 had overweight or obesity.1 The majority of today’s children will have obesity at age 35 if we don’t act.2 Making sure children are growing up at a healthy weight from their very first days is a critical way to prevent obesity and future risk for obesity-related diseases like diabetes as adults. Conditions linked to obesity, previously only seen in adults, are appearing in Arkansas’ Medicaid-enrolled children.3 Early child care programs that support healthy nutrition and physical activity habits show great promise in promoting healthy weight.4

In Arkansas, more than half of children ages 2-5 attend a licensed child care program.5 Providing licensed child care programs with training opportunities and resources through Better Beginnings may be an effective strategy to improve the quality of child care programs and to ensure that the majority of children in Arkansas are off to a healthy start.

About NAP SACC

NAP SACC is an evidence-based, trusted strategy enabling child care centers to attain best practices regarding nutrition, active play, and screen time.4 To date, NAP SACC shows the best evidence for reducing childhood obesity risk in children under age 5.6 Early education program directors and staff complete self-assessments and receive training and technical assistance to implement practices, policies, and changes supporting healthy outcomes. Better Beginnings is designed to improve child care environments to support child health and development. Integrating NAP SACC into Better Beginnings can improve the quality of child care programs and ensure more children grow up healthy in Arkansas.

Comparing Costs and Outcomes

A CHOICES cost-effectiveness analysis compared the costs and outcomes over a 10-year time horizon (2020-2030) of implementing NAP SACC with the costs and outcomes of not implementing the program.

Implementing NAP SACC into Better Beginnings in Arkansas is an investment in child health. By the end of 2030:

If NAP SACC was incorporated into Better Beginnings in Arkansas, then 116,000 children would be reached over 10 years with more active play, less screen time, and healthier food and drinks. 1,320 early care directors and staff would be trained in the first year. It would cost $18 per child per year to implement. 8,720 years with obesity would be prevented over 10 years.

Conclusions and Implications

Every child should have opportunities for a healthy start. A state-level initiative integrating NAP SACC into training and quality improvement through Better Beginnings could create healthier nutrition and physical activity environments in child care programs for 116,000 children over 10 years. This strategy would benefit 1,320 early care directors and staff with training and technical assistance to support using nutrition, active play, and screen time best practices at 659 child care programs. Over 10 years, children in Arkansas would have 8,720 more years lived at a healthy weight and 1,130 fewer children would have obesity in 2030 alone.

Many prevention strategies targeting children require an upfront investment because costly obesity-related health conditions generally present later in adulthood.7 While we project this strategy would cost $18 per child per year, shortchanging early prevention efforts may lead to costly and complicated treatment in the future. Already, the total annual costs of having obesity are estimated to be $6 million for the 30,000 25- to 29-year-olds enrolled in Medicaid—inclusive of Arkansas’ expansion population. This represents an excess annual cost of $200 per person due to obesity.3

Early child care programs also play a critical role in supporting healthy child development and children’s academic readiness.8 Investing in a strategy for quality improvement that provides the necessary training, technical assistance, and resources supports early educators in providing high-quality child care that nurtures healthy habits. Enabling early education leaders in Arkansas to use the best available evidence to prevent excess weight gain in children will support children’s healthy growth and development.

References

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

  2. Ward Z, Long M, Resch S, Giles C, Cradock A, Gortmaker S. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. New England Journal of Medicine. 2017; 377(22): 2145-2153.

  3. ACHI, Arkansas Medicaid. Comorbid Conditions and Medicaid Costs Associated with Childhood Obesity in Arkansas. 2019.

  4. Alkon A, Crowley AA, Neelon SE, Hill S, Pan Y, Nguyen V, Rose R, Savage E, Forestieri N, Shipman L, Kotch JB. Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health. 2014;14:215.

  5. Arkansas Department of Human Services, Division of Child Care and Early Childhood Education, Child Care Facilities Database. Unpublished data. 2020.

  6. Kenney E, Cradock A, Resch S, Giles C, Gortmaker S. The Cost-Effectiveness of Interventions for Reducing Obesity among Young Children through Healthy Eating, Physical Activity, and Screen Time. Durham, NC: Healthy Eating Research; 2019. Available at: http://healthyeatingresearch.org

  7. Gortmaker SL, Wang YC, Long MW, Giles CM, Ward ZJ, Barrett JL, …Cradock, AL. Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Affairs. 2015; 34(11), 1932–1939.

  8. Morrisey T. The Effects of Early Care And Education on Children’s Health. Health Affairs Health Policy Brief. 2019

Suggested Citation:

Adams B, Sutphin B, Betancourt K, Balamurugan A, Kim H, Bolton A, Barrett J, Reiner J, Cradock AL. Arkansas: Creating Healthier Child Care Environments: Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) in the Quality Rating Improvement System (QRIS) {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.

← Back to Resources