Web 240 Week 2 Individual Assignment Mgmt

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29.

Abstract

Objectives  Usability and pilot testing of a web intervention (BeInCharge.org [BIC]) of behavior plus nutrition intervention for children with cystic fibrosis (CF) ages 4–9 years.  Methods  Think Aloud methodology was used with five mothers to assess usability and refine the intervention. A pilot trial was then conducted with 10 mothers of children with CF ages 4–9 years randomized to the web-based BIC or a Standard Care Control (STC). Change in weight gain for each group was compared in a pre-to-post design.  Results  Mothers rated the usability and clarity of BIC highly. The pilot trial showed children of mothers who received BIC had a significant change in weight pre-to-post-treatment (0.67 kg, p  = .04). Change for the STC was not significant (0.41 kg, p  = .10).  Conclusions  A web-based behavior plus nutrition intervention appears promising in increasing weight gain in children with CF.

behavioral intervention, cystic fibrosis, nutrition, web intervention

Optimizing nutritional status and growth improves health outcomes and survival in children with cystic fibrosis (CF) ( Yen, Quinton, & Borowitz, 2013 ). A body mass index (BMI) at or above the 50th percentile for age and gender is associated with better pulmonary function, as measured by forced expiratory volume in 1 s (FEV 1 ), for children with CF ( Stallings, Stark, Robinson, Feranchak, & Quinton, 2008 ). Evidence-based practice guidelines recommend that nutritional treatment for children with CF ages 2–20 years should aim to achieve and maintain a BMI ≥ 50th percentile ( Stallings et al., 2008 ); however, across 117 CF centers in the United States, 57% of girls and 56% of boys failed to meet this recommendation ( Stallings et al., 2008 ).

To achieve optimal nutritional status, it is recommended that children with CF consume 120–150% of the estimated energy requirement (EER) a day based on sex, age, and activity level with 40% of calories derived from fat ( Borowitz, Baker, & Stallings, 2002 ). Studies of dietary intake show that most children with CF do not achieve these recommendations ( Kawchak et al., 1996 ; Powers et al., 2002 ; Stark et al., 1995 , 1997 ). Across a series of studies, a behavior plus nutrition intervention delivered in face-to-face format (Be In Charge) has consistently demonstrated the ability to increase calorie consumption approximately 900 calories a day and weight gain approximately 1.5 kg over an 8- to 9-week period for children with CF ages 4–12 years ( Stark, Bowen, Tyc, Evans, & Passero, 1990 ; Stark et al., 1993 , 1996 , 2003 ; Stark, Powers, Jelalian, Rape, & Miller, 1994 ). Children receiving this intervention demonstrated better calorie intake and weight gain as compared with a standard care waitlist control ( Stark et al., 1996 ) or nutrition education alone ( Stark et al., 2003 , 2009 ), and gains were maintained 1 and 2 years posttreatment.

Despite the CF Foundation recommendation for the use of behavior plus nutrition intervention in CF care for children ages 1–12 years ( Stallings et al., 2008 ), this recommendation has not been implemented owing to multiple barriers, including lack of trained clinicians (most CF Centers do not have access to a pediatric psychologist), cost, time, and distance from providers. Thus, there is a clear need for alternative methods of delivering this efficacious treatment to patients with CF. Increasing the accessibility of behavior plus nutrition intervention would also allow CF providers to recommend it earlier in the course of treatment, which data suggest will yield the best outcomes ( Opipari-Arrigan, Powers, Quittner, & Stark, 2010 ).

Internet treatment delivery provides an excellent alternative, addressing access barriers, circumventing problems of limited providers, geography, time, and costs ( Barlow & Ellard, 2004 ), and offering great potential for dissemination of interventions. Seventy percent of adults have high-speed Internet at home ( Pew Research, 2015 ), 84% of American adults use the Internet ( Perrin & Duggan, 2015 ), the Internet is increasingly used by patients and families to access health information ( Bensley et al., 2004 ; Cussler et al., 2008 ; Fox & Duggan, 2013 ; Oenema, Brug, Dijkstra, de Weerdt, & de Vries, 2008 ), and is an efficacious mode of delivery for behavior health interventions ( Cushing & Steele, 2010 ; Stinson, Wilson, Gill, Yamada, & Holt, 2009 ).

We followed the nine steps outlined by Ritterband for the development of web-based interventions ( Ritterband et al., 2003 ): (1) identify the problem area, (2) identify an effective face-to-face intervention to translate, (3) operationalize the intervention (identify critical ingredients), (4) consider legal and ethical issues (e.g., privacy, confidentiality), (5) incorporate multimedia (e.g., video, graphics), (6) personalize and tailor content, (7) incorporate feedback to the user, (8) build the Web site, and (9) test the intervention (e.g., usability testing, pilot trials, randomized trials). This report describes Step 9 usability testing (Phase 1) followed by the conduct of a small pilot trial of the web-based intervention (Phase 2).

We hypothesized that parents of children with CF, ages 4–9 years, would be able to successfully interact and engage with the BeInCharge.org (BIC) Web site and that acceptability of content and mode of delivery would be high. For the pilot test, 10 families were randomly assigned to the refined (from usability testing) BIC or a Standard Care control (STC). Because of the small sample size, we did not have power to compare the two conditions on the primary outcome of change in weight pre- to posttreatment; thus, we compared change in weight gain within each group pre- to posttreatment. We hypothesized that the children whose parents participated in BIC would show a significant increase in weight pre- to posttreatment, while the STC would not show significant change.

Methods

Phase 1. Development of BIC

The program was designed to promote normal weight gain and growth by providing strategies to meet the CF dietary recommendations of 140% of the EER a day based on sex, age, and activity level. Program content was developed from the evidence-based behavior plus nutrition intervention Be In Charge face-to-face protocol ( Stark et al., 2009 ) using an iterative process that used content expertise from psychologists, dietitians, and web designers. As such, BIC has two components: a seven-module web-based intervention and a linked DietTracker app. Each web module includes both nutrition education and child behavior management components and takes 45–60 min to complete (see Table I for overview). Each module targets one snack/meal and teaches a child behavior management strategy. Modules are designed to be completed every 7–10 days. The accompanying DietTracker app requires daily input with a minimum of 5 days of dietary tracking necessary to proceed to the next web module.

Table I.

Topic and Content Outline of the Seven BeInCharge.org Modules

Module topics Module content 
  • 1. Education about CF and nutrition

  • Introduction to keeping a food diary

Provide overview of treatment, rational for the need for additional calories for children with cystic fibrosis, and the need to establish a record of what the child typically eats. 
  • 2. Getting more energy from snack

  • Attention Part I: The power of parent attention

  • Provide specific overall calorie goal for treatment based on 140% EER for age and gender.

  • Explain why starting with snack.

  • How parents typically try to get their children to eat and why that does not work.

  • Introduce concept of parent attention as reward and teach complimenting and praising of desired eating behavior.

  • Snack foods that will meet the calorie goals.

  • 3. Boosting breakfast

  • Attention Part II: Using attention to change child behavior at meals

  • Review progress on snack and total calories and set breakfast calorie goals.

  • Review the use of attention in changing behavior (praising and compliments).

  • Teach ignoring, the necessary counterbalance that makes praise more powerful.

  • Breakfast foods that will meet the calorie goals.

4. Assimilating calorie gains, no meal target Using privileges and setting time limits on meals to be most effective Review progress on total calories, snack and breakfast (no increase in calorie goal this week). Review use of praising and ignoring.Teach new skills of using privileges and sticker charts to motivate kids even more. Explaining why meals should only be 20 min (more time at a meal does not lead to higher caloric intake). 
  • 5. How to solve the lunch dilemma

  • Applying behavioral skills to lunch

  • Review progress on total calories, snack and breakfast and set lunch goals.

  • Perfecting behavioral skills.

  • Introduction of shaping to introducing new foods.

  • Lunch foods that will meet the calorie goal.

  • Lunch at school or daycare—how to achieve the cystic fibrosis energy needs when others are feeding.

  • 6. Dinner

  • Bringing all the behavioral skills together

  • Review progress on total calories, snack, breakfast, and lunch and set dinner goals.

  • Review of behavioral skills and how to apply to the challenge of dinner.

  • How to add calories to child’s dinner without blowing parent diet or making a separate meal.

  • Continue introduction of new foods.

  • 7. Graduation

  • Planning for maintenance of calorie gains and behavior skills

  • Review progress.

  • Develop plan for continuing to achieve calorie goal after intervention.

  • Plan for sick days and getting back to optimal calorie intake after an illness.

  • Review of how to incorporate praising, ignoring, and using privileges for the long term.

Module topics Module content 
  • 1. Education about CF and nutrition

  • Introduction to keeping a food diary

Provide overview of treatment, rational for the need for additional calories for children with cystic fibrosis, and the need to establish a record of what the child typically eats. 
  • 2. Getting more energy from snack

  • Attention Part I: The power of parent attention

  • Provide specific overall calorie goal for treatment based on 140% EER for age and gender.

  • Explain why starting with snack.

  • How parents typically try to get their children to eat and why that does not work.

  • Introduce concept of parent attention as reward and teach complimenting and praising of desired eating behavior.

  • Snack foods that will meet the calorie goals.

  • 3. Boosting breakfast

  • Attention Part II: Using attention to change child behavior at meals

  • Review progress on snack and total calories and set breakfast calorie goals.

  • Review the use of attention in changing behavior (praising and compliments).

  • Teach ignoring, the necessary counterbalance that makes praise more powerful.

  • Breakfast foods that will meet the calorie goals.

4. Assimilating calorie gains, no meal target Using privileges and setting time limits on meals to be most effective Review progress on total calories, snack and breakfast (no increase in calorie goal this week). Review use of praising and ignoring.Teach new skills of using privileges and sticker charts to motivate kids even more. Explaining why meals should only be 20 min (more time at a meal does not lead to higher caloric intake). 
  • 5. How to solve the lunch dilemma

  • Applying behavioral skills to lunch

  • Review progress on total calories, snack and breakfast and set lunch goals.

  • Perfecting behavioral skills.

  • Introduction of shaping to introducing new foods.

  • Lunch foods that will meet the calorie goal.

  • Lunch at school or daycare—how to achieve the cystic fibrosis energy needs when others are feeding.

  • 6. Dinner

  • Bringing all the behavioral skills together

  • Review progress on total calories, snack, breakfast, and lunch and set dinner goals.

  • Review of behavioral skills and how to apply to the challenge of dinner.

  • How to add calories to child’s dinner without blowing parent diet or making a separate meal.

  • Continue introduction of new foods.

  • 7. Graduation

  • Planning for maintenance of calorie gains and behavior skills

  • Review progress.

  • Develop plan for continuing to achieve calorie goal after intervention.

  • Plan for sick days and getting back to optimal calorie intake after an illness.

  • Review of how to incorporate praising, ignoring, and using privileges for the long term.

View Large

DietTracker App

A robust literature supports that dietary self-monitoring is a critical ingredient of behavioral weight control programs ( Foreyt & Goodrick, 1993 ; Yon, Johnson, Harvey-Berino, Gold, & Howard, 2007 ) and it has been a cornerstone of the face-to-face behavior plus nutrition intervention ( Stark et al., 1990 , 1993 , 1996 , 2003 , 2009 ). We created a DietTracker app for iPodTouch TM and iPhone TM (also accessible via the web) based on the USDA database that allows real-time data entry and calorie feedback. The DietTracker app syncs with the BIC Web site to populate calorie graphs and create personalized calorie goals and feedback.

Nutrition Education

Necessary educational components of any intervention to increase caloric intake include knowledge of CF dietary recommendations and the foods/calorie boosters (e.g., cream, butter) that support achieving those recommendations, as well as a rationale for the increased calorie requirement for children with CF ( Stark et al., 2009 ). BIC sets personalized calorie goals to achieve 140% of the EER a day by the end of treatment based on sex, age, and moderately high physical activity level. If a child is already achieving 140% EER, then the goal is created by increasing baseline caloric intake by 25%. The difference between the baseline caloric intake and personalized goal to be achieved by the end of the intervention is then divided by 4 to set a goal for snack and three meals. One snack/meal is targeted per module, in Modules 2, 3, 5, and 6, starting with snack and proceeding across breakfast, lunch, and dinner. Parents are presented with a rationale for the calorie goals, provided with learning opportunities to boost calories through interactive games, and allowed to create and print a personalized list of high-calorie food choices.

Child Behavioral Management

The child behavior management components of treatment are based on the well-established principles developed by Forehand and McMahon ( Forehand & McMahon, 1981 ) and include differential attention, contingency management, and shaping. Previous research with children with CF and their parents shows that teaching parents these skills increases calorie intake and weight gain for their children, as well as improving parent and child mealtime interactions ( Stark et al., 1994 ). There is evidence that behavioral child management techniques can be taught to parents via videotaped demonstrations of skills ( Taylor et al., 2008 ). In BIC, behavioral child management concepts are taught via didactics, cartoons, video testimonials and demonstrations, and interactive, animated role-plays.

Usability Testing

Five mothers of children with CF, who had completed a randomized trial of the face-to-face behavior plus nutrition intervention within the prior 2 years, were recruited to provide end user feedback. The first five mothers contacted agreed to participate. These mothers ranged from 27 to 41 years in age, with an average age of 33 years. All were married, non-Hispanic White. Two had private insurance and three received Medicaid. Two were high school graduates, two had some college, and one was a college graduate. They reported annual income across all levels: $15,000–$24,900; $25,000–$34,000; $35,000–$49,000; and $75,000–$99,000. Household size was 4 for four of the families and 3 for one family. The institutional review board at the academic medical center where the study was conducted approved this study, and written informed consent was obtained before participation.

Procedures

Mothers reviewed four BIC modules over two in-person sessions lasting 90 min each that were audio and video recorded. The “Think Aloud” methodology, widely used to evaluate thought process while performing electronic tasks ( Kushniruk, 2002 ), was used to solicit feedback regarding content, format, design, and functionality, and mothers completed a web-based survey following each module. Between the two review sessions, mothers used the DietTracker app for 7 days. Mothers were paid $100 per review session and up to $100 for dietary recording ($10 per full day, plus a $30 bonus if they completed the seven full days).

Measures

Self-Report Survey Data

Quantitative data were obtained via web-based survey at the end of each module. The survey asked participants to rate “How useful or relevant was the website/module content?” and “How easy was it to use and navigate?” on a Likert scale ranging from 0 ( not at all ) to 5 ( very useful or easy ), and to rate the likability of the Web site appearance and theme on a Likert scale ranging from 0 ( did not like ) to 5 ( liked very much ).

Think Aloud Data

The Think Aloud review sessions were transcribed verbatim and summarized separately by three coders for each module. Coders read the transcript from each module, used thematic analysis to independently categorize feedback into themes, and then met as a group to derive a final list of themes and participant suggestions for improvement. Disagreements were resolved by consensus.

Results

Survey Results

Overall Web site and module-specific survey results indicated positive ratings for site attractiveness ( M  = 4.75, SD  = 0.50, N  = 5), balance of graphics versus text ( M  = 4.75, SD  = 0.50, N  = 5), and ease of navigation ( M  = 4.75, SD  = 0.50, N  = 5). All mothers rated the information as highly relevant to their needs ( M  = 4.75, SD  = 0.50, N  = 5) and felt that the content would keep them invested in the program ( M  = 4.5, SD  = 0.58, N  = 5).

Think Aloud Themes

Six major themes were identified from the feedback during the Think Aloud review sessions.

Theme 1

Web Site Design: A majority of mothers ( n  = 4) liked and understood the Web site design which incorporated a theme of growing a garden for visual interest. One mother responded, “Growing the vegetable garden and you’re growing kids, I think that’s a pretty good idea.”

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