HOME Plus: Program design and implementation of a family-focused, community-based intervention to promote the frequency and healthfulness of family meals, reduce children’s sedentary behavior, and prevent obesity | International Journal of Behavioral Nutrition and Physical Activity

Study design and participants

The HOME Plus program is currently being evaluated in a randomized controlled trial with160 families (one target 8–12 year old child per family and the primary meal-preparing parent/guardian) with three data collection periods: baseline (2011, 2012), post-intervention (post-intervention) and follow-up (9 months post-intervention). After baseline assessment, families were randomized to an intervention group (n = 81) and attended 10-monthly group sessions (Oct 2011-Jul 2012 and Oct 2012-Jul 2013, respectively for cohorts 1 and 2) or an attention-only control group (n = 79) that received 10-monthly newsletters. A staggered cohort design was used to accommodate the capacity of community centers and staff within funding limits.

Families were recruited from community centers in six geographic locations of Minneapolis/St. Paul, Minnesota’s metropolitan area. Recruitment efforts were targeted to primary meal-preparing parents of 8–12 year old children to increase the likelihood of accurate reporting related to food preparation and making changes in the home food environment. Effective methods such as flyers and small group presentations used successfully in the pilot study were used for recruitment [18]. Community center staff assisted with recruitment and facilitated logistics during intervention sessions. Parent and child participants signed informed consent or assent forms, respectively, and completed assessments including psychosocial surveys, anthropometric measures, dietary recall interviews (child only) and home food environmental measures. All procedures were approved by the University of Minnesota’s Human Subjects Review Board. Study design, methods, eligibility and detailed data collection information is published elsewhere [26].

Children participating in the intervention were 8–12 years old (M = 10.5 years, SD = 1.5); 69% were white, 16% African American/Black and 15% mixed race/ethnicity; 46% were female; and 41% were overweight/obese (>85%BMI percentile). Most participating parents in the intervention were female (94%); 78% of parents were white, 15% African American and 7% mixed race/ethnicity. Many parents were college educated (70%) and 48% were working full-time. Because income level is dependent upon household size, receipt of economic assistance (free and/or reduced lunch for child at school and/or public assistance through food support/stamps, EBT, WIN, TANF, SSI or MFIP) was used to measure household economic status; almost half of parents (45%) reported receiving economic assistance. The parent average age was 41 years (SD = 8.0) and 46% were overweight/obese.

Program description

A stepwise approach to designing and developing the HOME Plus intervention was used to maximize the program’s likely effect [27]. The formative steps included: 1) targeted behavior validation, (i.e., obesity prevention of 8–12 year old children); 2) targeted mediator validation (i.e., Social Cognitive Theory (SCT) (personal, behavioral, and environmental factors)); 3) intervention procedure validation, (i.e., skill development and education); and 4) pilot/feasibility of the intervention. Process evaluation was conducted throughout the intervention to assess fidelity, dosage, responsiveness and satisfaction.

HOME Plus was based on a family meal program (HOME) previously developed and pilot tested for feasibility and acceptability by our team in 2006–2008 [18], with the addition of a component to reduce sedentary behavior (mainly screen time). HOME Plus was guided by Social Cognitive Theory (SCT) and a socio-ecological framework [28-30]. As shown in Table 1, the intervention had three overarching goals associated with behavioral messages related to the planning, frequency and healthfulness of family meals and snacks.

Sessions incorporated concepts of SCT, such as increasing self-efficacy of both parents and children (e.g., through hands-on cooking activities designed to increase skills/confidence), increasing the outcome expectation of eating healthful food (e.g., by being given the opportunity to consume healthful foods created at the intervention) and enhancing parental skill development (e.g., parents learn and practice how to praise children for trying new foods, limit screen time at meals, and avoid mixed messages about food, activity and weight).

Intervention delivery

Intervention messages were addressed in a participant guidebook, Let’s Eat Together–Your Family’s Guide to HOME Plus, given to each family and utilized throughout the sessions. The guidebook included session topics, strategies to help meet session goals, recipes and resources (e.g., list of local farmer’s markets).

Intervention sessions were delivered monthly to multiple family groups at community park and recreation centers in the Minneapolis area in the early evening to accommodate family schedules. All family members were encouraged to attend. Childcare for children (<8 years) and transportation were available, as needed, to enhance retention and adherence. Each session was offered twice a month at each location, to allow for scheduling flexibility. Five brief goal-setting telephone calls were conducted by lead facilitators with intervention parents over the 10-month intervention. Details of intervention components are described below.

Intervention components

Family group sessions

Lead facilitators used a set curriculum for intervention delivery (see Table 2 for brief content summaries). Sessions consisted of nutrition education and hands-on skill development to provide parents and children with new knowledge and practical application. Each session included 1) introduction of a new topic and review of prior month’s topic and goals (family); 2) meal preparation (family); 3) taste testing a seasonal fruit/vegetable (separate parent and child groups); 4) small break-out groups with discussion and activity (separate parent and child groups); 5) eating a family meal (family); and 6) summary of session (family). Some details of a typical session are described below.

Upon session arrival, each family selected one of four featured recipes to prepare (meat entree, vegetarian entree, salad, or fruit-based dessert). Parents and children were introduced to new recipes, developed basic knife skills, and practiced reading a recipe and measuring ingredients. These skills were targeted to promote meal planning and preparation self-efficacy. Recipes were selected based on the Dietary Guidelines for Americans (i.e., recipes contained 30% or less of calories from fat/serving and promoted fruits/vegetables). For simplicity, recipes had few overall ingredients and emphasized highly-available and low-cost ingredients.

All participating family members sampled a seasonal fruit/vegetable in a Taster’s Choice activity to increase their exposure to a variety of fruits/vegetables. Fruits/vegetables selected for this activity were those that children rated during baseline data collection as ones they had “not tried” or “did not like.” Families were encouraged to try, on their own, the fruit/vegetable of the month before the next session as their Take HOME activity, which targeted the behavioral goal of increasing the number of fruits/vegetables available in the home and served at family meals and snacks. To encourage session attendance and completion of Take HOME activities, families received entries for a final session drawing for a personal home visit by a local chef.

Small group discussions and activities

Parent session activities focused on reducing barriers and strategies for behavior change related to program messages. For example, parents discussed mealtime stress, ways to increase the frequency and healthfulness of family meals, and strategies to increase healthful snacks at home through role-play and case scenarios. Children’s group topics paralleled those of the parent but were more game-like to educate them in a developmentally-appropriate and engaging manner.

Sessions concluded with family-style meals where families tried the foods made by the group. A pre-portioned plate was on display at every meal to demonstrate appropriate serving sizes. All participants were encouraged to try at least a sample of each food. Following dinner, parents and children completed session evaluations and selected family-level goals, i.e., a goal that all members of the family agreed they could work toward, for the next month (for example, increase the amount of fruits and vegetables as snacks). Families unable to attend a session received a telephone call from their facilitator who recapped the session and mailed them pertinent handouts.

Parent goal-setting telephone calls

Five brief (~20 minute) tailored goal-setting telephone calls were conducted by lead facilitators, who were trained in Motivational Interviewing (MI), with parents over the 10-month intervention. Often during the calls, parents selected new goals to complement the family-selected goal at sessions and tended to be focused on parental strategies for feeding picky eaters or eliminating junk food from the home. Parents had the option of working on the same goal throughout the intervention or choosing a new goal at any point. Each call followed a counseling protocol based on MI principles, including a participant-focused, collaborative, decision-making approach, giving nonjudgmental feedback, allowing for resistance, and encouraging the participant to make a case for change [31,32]. The facilitators relied on open-ended questions and reflections to bring about the participant’s motivation and desire for change. Intervention staff held weekly case management meetings to discuss and address problem areas.

Program cost

Cost estimates were broken down to include training of intervention personnel, one-time program materials and costs associated with intervention delivery by family. Costs per family were as follows: One-time cost of $20 for personnel training (first aid and food safety training, study t-shirt and chef hat (as uniform)), one-time cost of $49 for program materials for participants at the beginning of the program (guidebook, recipe book, chef hat and canvas bag), and $44 per session for intervention delivery (staff time ($27 per family), food ($8 per family), small incentives ($3 per family), room rental ($6 per family)). In addition, childcare cost $20 per session for up to 6 kids and transportation cost $12.50 per session for families (n = 6) requiring cab or bus transportation. It is important to note that at least three college students volunteered to assist with session logistics at each session as well.

Intervention process evaluation

Fidelity of program delivery

All intervention staff members were trained to study protocols and food safety practices; lead staff was also trained in basic first aid. Group sessions were facilitated by Registered Dietitians and a Registered Nurse. Lead staff that conducted the goal-setting phone calls were trained in MI prior to program start up. The program assistant supervised university-level student volunteers (usually 3 per session) in setting-up cooking stations. All team members assisted families during meal preparation and service.

Observations of session curriculum delivery were regularly conducted to monitor and enhance program fidelity [24,27,33]. Session observations were conducted at months 3, 6 and 9 by trained university-level students using a standardized checklist. The principal investigator monitored the checklists and reviewed them with staff.

Participant receipt dosage and responsiveness/use

Session attendance and goal-setting telephone call completion were the measures of program dosage. Study staff documented attendance of all family members at sessions and all telephone call attempts and completions. Homework completion of the Take HOME activity measured participant responsiveness/use. Additionally, we assessed if participants used their Family Guidebook and/or if they made session recipes at home. Lastly, parents and children self-evaluated any behavioral changes they attributed to HOME Plus.

Participant satisfaction

Parents and children completed satisfaction measures of the overall HOME Plus program. They were also asked if they would recommend the program to friends/family and to provide reasons for participation in the program.