Part 1: Needs Assessment

  • Describe in detail the population and setting with which you will work. Identify the public health problem. Use surveillance data to support the needs of the community. As appropriate, discuss the health disparities of your target community. (20 points)

Population and setting: the intervention will be conducted in urban Shanghai overweight (BMI>24.9) but otherwise healthy men age between 40 to 74, who have been enrolled in the The shanghai men’s health study (SMHS).

According to the study, the prevalence of overweight and obesity among men aged between 40 to 74 in urban Shanghai, China was 33.1% and 2.6%, respectively (Shu et al., 2015).

The numbers from the study are highly likely to increase due to rapid development in economy and urbanization. Two major risks overweight and obesity pose to health are cardiovascular diseases (CVD) and type II diabetes mellitus(T2DM).  The financial burdens from either disease are huge for Chinese residents because of the medical system in China, which is reliant on patients paying for services. There is no fixed scheme of medical reimbursement for the majority of people and medical insurance is in its infancy (Perk et al., 2007). For example, a domestic heart stent normally costs more than 9,000 RMB, while the average annual income is 28,752 RMB (about $4,755). Regular exercise can help manage body weight, regulate blood glucose and lipid, lower blood pressure, and prevent metabolic syndrome. All these effects lower the risks of developing CVD. The costs of regular exercise, compared to medical cost of managing CVD and T2DM, are minimal.

In the same study, only 35.5% of all subjects,  representing men between 40 to 74 in urban Shanghai, reported regular exercise. The number for overweight/obese subjects was not given in the study, but it is possibly lower than that for all subjects. Because of the  cost-effectiveness of exercise in preventing obesity-led diseases, along with the concerning size of overweight and sedentary population, the exercise intervention in our target population is well needed.

 

References:

Shu, X. O., Li, H., Yang, G., Gao, J., Cai, H., Takata, Y., … & Xiang, Y. B. (2015). Cohort profile: The shanghai men’s health study. International journal of epidemiology, 44(3), 810-818.

Perk, J., Gohlke, H., Hellemans, I., Mathes, P., McGee, H., Monpère, C., … & Sellier, P. (Eds.). (2007). Cardiovascular prevention and rehabilitation. London: Springer.

 

  • What stakeholders may be needed along the way? Describe the role of each stakeholder, and the questions they may want answered about the intervention. Also briefly describe how a successful intervention would impact that stakeholder, and how an unsuccessful program might impact that stakeholder. Stakeholders may be individuals, groups, or organizations. (20 points)
Stakeholder Role in Intervention Questions from Stakeholder Effect on Stakeholder of a Successful Program Effect on Stakeholder of an Unsuccessful Program
 Me  Design the intervention; employ program coordinators; and analyze data Goals of the study?

How likely is it going to be successful?

 Respect in the field; experience in how to conduct a successful intervention program. Less likely to be sponsored in the future; bad reputation in the field;
 Shanghai Government Provide fundings Goal and economic effectiveness?

What theory is the intervention based upon?

  Healthier workforce and trust from people; Positive reputation and public image.  Money wasted; Harms to public image and citizen trust; less participation in future program sponsored by the government.
 Program Coordinator(s)  Recruit qualified participants; communicate program design with other stakeholders; Implementing the program; collect data. How to successfully implement the program as designed? Any standards and procedures to follow? Experience in a successful health intervention research and improved resume quality; Frustration from working  for an unsuccessful health intervention research; failure in improving their resume quality.
 Authors of the cohort study Provide participant contact information and more details of the study relevant to current intervention  What benefit the participants are likely to get?

How does that influence our future study on this population?

  Contribution to a successful study;

Likelihood in publishing a follow-up study focusing on this population’s BMI and metabolic profile.

  

Unlikely future collaboration;

Failure to get any benefit from providing sensitive information.

 
Participants Participate in the program as guided by program coordinators; communicate  progress with coordinators; attend baseline and post-intervention evaluations. Why would I want to participate and stick to the program?

What’s the cost?

How long does it last?

 Successfully lose weight and improve fitness; Positive lifestyle change and confidence in exercise; Decreased risk in developing CVD, T2DM or metabolic syndrome.  Don’t achieve goal weight and lose their belief in exercise and trust in government. Little improvement in metabolic profile; Unchanged CVD and T2DM risk factors.
 Fitness Instructor, Trainers or Exercise Physiologists Provide initial assessments of the subjects; educate participants in exercise frequency, intensity, duration and types; provide individualized exercise prescription and follow up using chosen technology-supported apps; report to program coordinators periodically. The goal of the study?

How to prescript exercise and how often do we follow up with the subject?

How and what to communicate with program coordinators?

 Increased recognition from industry and increased clientele, possibly from participants; Successful experience working with older population.  Unsuccessful experience working with older population; decreased recognition from industry and decreased clientele.
 App Developers Developing an App (for web, android, ios) for the program that allows participants, instructors, program coordinators to communicate exercise, nutrition plans and any concerns. The App will be the main tool used for this program.

Maintenance of the app throughout the program.

  

What features does the app need to include?

How much will you be willing to pay?

 Increased recognition from industry.

Can further develop the app into a popular weight-management app that attract more users and investors.

Money compensation.

 Money compensation.

Failure to improve reputation.

Part 2: Intervention Identification

  • State and define the intervention strategy – what does it mean? What populations has this strategy been used with? What settings has it been used in? How are your community characteristics similar or different to those of the communities in which the strategy has been effective? (20 points)

The intervention strategy is  Technology-Supported Multicomponent Coaching or Counseling Interventions To Reduce Weight. As the name suggest, the multicomponent coaching or counseling  intervention uses modern technological components such as computers, internet and computerized telephone system to facilitate the communication between coaches/counselors and subjects. Its goal is to influence many factors contributing to and resulting from ones’ weight status. The intervention may also incorporate non-technology components such as in-person counseling, manual tracking, printed lessons and written feedback.

The strategy has been used effectively in many U.S. home and community settings, with subjects usually overweight/obese adults recruited through flyers, newspaper and emails. Bond, 2007 also applied this strategy to diabetics in Seattle, WA. Follow-up time ranges from 2 months to 24 months, with the majority of the studies used 3 to 6 months. Interventions were usually delivered by counselors and other types of healthcare providers, with assorted technologies being utilized in facilitating interaction.

The target population for the current study is overweight but otherwise healthy men age between 40 to 74, who have been enrolled in the The shanghai men’s health study (SMHS). The intervention will take place in urban Shanghai communities, where the participants originally live. It is an overweight and adult population, but is not within U.S. or Canada, so there is a lot cultural (trust between participants and coaches, diet, patience, motivation, etc.) and socioeconomic differences (availability of gyms, parks, time,etc.) compared to the populations among which the strategy has already been successfully evaluated. The target population, while overweight, are significantly less obese than populations involved in previously successful studies, for the average BMI and percentage of overweight/obese are significantly lower than those in the U.S. The participants, especially the younger portion of them, may be harder to approach because many of them believe more in traditional Chinese medicine than exercise/diet. Availability of gyms is poor, considering the huge population. Memberships are too expensive for an average, retired man. Because of the reasons above, the exercise programs have to be tailored to resources each individual has.

  • Is the strategy recommended by the Task Force? Why or why not? (10 points)

The strategy is recommended by the Task Force on the basis of sufficient evidence that they are effective in improving weight-related behaviors or weight-related outcomes. The task force listed 18 studies that examined technology-supported multicomponent coaching or counseling interventions relevant to weight loss, all of the them reported reductions in weight. However, comparison groups in many studies received some sort of interventions as well. For example, one comparison group in McKay, 2002 had access to the web “conference area” and to articles online, while the treatment group had Internet access to a diabetes diet coach twice weekly, plus web self-monitoring of blood glucose and access to articles online. Because the heterogeneity among the treated comparison groups added uncertainty to the effect estimates, the Task Force considered these studies to provide sufficient rather than strong evidence of intervention effectiveness.  No evidence of harms from these interventions were found.

  • Provide at least 3 examples from existing articles (peer-reviewed preferably, but could come from other places). These should be different than the research-tested intervention programs(RTIP) listed already. You can include or link to this information, but you should provide different examples. (45 points total)
    1. Describe the intervention – what did the authors do? What was the procedure? How long was the intervention? Please describe individual components as well as the broader intervention plan.
    2. What were the outcomes measured?
    3. What amount of change did they find?

Article 1: Harvey-Berino, J., West, D., Krukowski, R., Prewitt, E., VanBiervliet, A., Ashikaga, T., & Skelly, J. (2010). Internet delivered behavioral obesity treatment. Preventive medicine, 51(2), 123-128.

  • The goal is to evaluate the efficacy of an Internet behavioral weight loss program; and determine if adding periodic in-person sessions to an Internet intervention improves outcomes.The weight loss treatment program focused on the modification of eating and exercise habits through the use of behavioral strategies and self-management skills. The authors recruited 481 healthy overweight adults (28% minority) who have access to Internet and are between 25 to 50 years old. Height and weight were recorded and they are randomized to 3 groups: InPerson, Internet and Hybrid. All conditions received a 6-month manualized comprehensive behavioral weight loss program that met weekly in face-to-face groups (for InPerson) or online via a synchronous chat group (for Internet and Hybrid).  Participants in the InPerson or Internet condition met weekly in small groups of 15 to 20 individuals in person or through a secured chatroom online. The Hybrid group met in person and once a month they substituted an in-person group meeting for an online chat. The content of the meetings for all groups were identical behavioral lessons based on a written protocol and individualized counselor feedback on progress toward meeting exercise and dietary intake goals were given. . Homework assignments  were provided weekly, including a prescribed calorie restricted diet, exercise and behavioral management. Subjects were instructed to record their dietary intake, minutes of physical activity and weight daily in either an online journal (for Internet and Hybrid) or a paper journal (InPerson) and to submit journals weekly.
  • The primary dependent measure was changes in body weight. Other outcomes include BMI, behavioral changes (dietary intake and physical activity). To assess the study process, attendance to in-person or online meetings was recorded and data on social support were collected at 6 months.
  • Weight losses differed significantly between conditions [8.0 (6.1)kg vs. 5.5 (5.6)kg vs. 6.0 (5.5)kg], for InPerson, Internet, and Hybrid respectively, p=0.01];  mean weight loss achieved InPerson was significantly greater than mean weight loss achieved by either the Internet and Hybrid conditions. No difference by condition in the change calories consumed were found, although all conditions reported reduced calorie intake.

Article 2: Polzien, K. M., Jakicic, J. M., Tate, D. F., & Otto, A. D. (2007). The Efficacy of a Technology‐based System in a Short‐term Behavioral Weight Loss Intervention. Obesity, 15(4), 825-830.

  • The objective was to examine the efficacy of adding a technology-based program to an in-person, behavioral weight loss intervention. Subjects were 57 individuals whose BMIs were between 25 to 39.9. They all had computer and Internet access, and demonstrated adequate computer skills before participation. Participants received a 12-week behavioral weight loss intervention composed of reduced caloric intake, increased physical activity, and behavior therapy. Three randomized groups were: 1) Standard In-Person Behavioral Weight Control Program (SBWP),  2) Intermittent Technology-Based Behavioral Weight Control Program (INT-TECH), or 3) Continuous Technology-Based Behavioral Weight Control Program (CON-TECH). SBWP participants received 7 in-person individualized counseling sessions, held weekly during month 1, twice during month 2, and once during month 3. CON-TECH participants received all components of SBWP, in addition to a wearable body monitor for objective energy expenditure measurement, Internet monitoring of energy intake, and feedback related to energy balance. INT-TECH participants received all components of CON-TECH, but the use of technology-based components was restricted to only 3 weeks (1, 5, and 9) during the 12-week intervention.

  • Outcomes measured were body weight, height, BMI, leisure-time physical activity (LTPA), and dietary intake. Process data was also collected, including in-person session attendance, Total armband time on body (TOB), and number of meals reported.
  • ITT analysis revealed weight loss of 4.1 (2.8 )kg, 3.4 (3.4) kg, and 6.2 (4.0) kg, for SBWP, INT-TECH, and CON-TECH groups, respectively (p=0.04, interaction effect). Relative weight loss was 4.6(3.2)%, 3.8 (3.8)%, and 7.1 (4.6)%, for SBWP, INT-TECH, and CON-TECH groups, respectively (p=0.03). Absolute and relative weight loss was significantly greater in CON-TECH vs. INT-TECH groups (p <= 0.05). LTPA significantly increased, and dietary intake significantly decreased from 0 to 12 weeks in all groups with no significant difference between groups.

Article 3: Morgan, P. J., Lubans, D. R., Collins, C. E., Warren, J. M., & Callister, R. (2009). The SHED‐IT Randomized Controlled Trial: Evaluation of an Internet‐based Weight‐loss Program for Men. Obesity, 17(11), 2025-2032.

  • The aim of this 3-month study was to evaluate the efficacy of an Internet-based weight-loss program for men in an assessor blinded randomized controlled trial. Participants were 65 overweight/obese male staff and students at the University of Newcastle (mean (s.d.) age = 35.9 (11.1) years; BMI = 30.6 (2.8)) recruited through university notice board. After pre-participation screening and signing the informed consent, they were randomly assigned to either the SHED-IT (Self-Help, Exercise and Diet using Information Technology) Internet group or a control group. SHED-IT participants received one face-to-face information session (75 min) led by one of the male researchers (P.J.M.) in September
    2007 plus 3 months of online support. The first 60 min of the information session covered instruction relating to the modification of diet and physical activity habits and behavior change strategies including self-monitoring, goal setting, and social support, based on Bandura’s Social Cognitive Theory. The second part of the information session was a 15-min technical orientation session to familiarize and teach participants how to use a publicly accessible, free website (www.calorieking.com.au) utilized in the study. All participants were also provided with a program booklet, which outlined nine key messages for weight loss tailored for men. Participants were asked to submit daily diaries for the first 4 weeks, for 2 weeks in the second month and for 1 week in the third and last month. Participants were also asked to enter their weight (in kg) each week. They received feedback based on their entries. The control group only attended the first part of the information session, separately from SHED-IT group. They received the same program booklet, too.
  • Outcome measures were obtained from all participants at baseline (September 2007) and then 3 months (December 2007) and 6 months (March, 2008) after the start of treatment. The primary outcome measure was change in body weight (kg and percent change from baseline). Secondary outcome measures were BMI, waist circumference, blood pressure, dietary intake, physical activity and process measures.
  • Weight decreased significantly in the Internet  group from baseline to 3 months (P < 0.001) and baseline to 6 months (P < 0.001) and also decreased significantly in the control group from baseline to 3 months (P < 0.001) and baseline to 6 months (P < 0.001). The difference between the Internet and control groups for changes in weight from baseline to 6 months (P = 0.228) was not statistically significant. Similar findings were reported for relative weight loss.

Part 3: Intervention Fit

  • Provide a logic model and SMART Objectives for your intervention. You should have a SMART objective for each behavior you anticipate changing. (35 points; 10 points for SMART objectives, 25 points for the logic model)

1. Participation in the program:

  • Overall, 66% of the scheduled exercise sessions and 66% of diet logs are completed (for example, 100 participants were scheduled to exercise 3x/wk for 24 weeks, then the goal is to have at least 5400 completed sessions at 12 weeks ).
  • Among the completed sessions, 50% of them achieve the targeted intensity according to RPE scale.
  • At least 50% of electronic hand-outs sent are received by participants, both at mid-term and the end.

2.  PA levels and calorie intakes

  • By mid-term (3-month), 75% of participants’ current PA meet the PA guidelines ( at least 150min of Mod.exercise/wk) and by the end of the study, 50%  of participants’ current PA meet PA guidelines. (the adherence by the end of study is lower than mid-term because of waning of interest and some of the participant lost enough weight and stop following the program)
  • At mid-term and the end of study, the average calorie intake of the sample is at least 400 kcals/day lower than the initial number. For example, all subjects’ average intake was 2200kcals/day initially and is 1750 kcals/day at midterm and the end.

3. Knowledge in Exercise and Nutrition

  • Average score of  a 20-question quiz on exercise and nutrition is improved by at least 30% at mid-term and average score is above 80% at the end of study.

4. Weight

  • Average body weight is reduced by at least 5% at the end of study, with 50% of the participant lost 5% of their initial weight at the end of study.

5. Five-year all-cause mortality

  • Participants who achieved and maintained goal weight loss have a significantly lower all-cause mortality rate than those who didn’t.

 

Inputs/Resources Activities Outputs Short-term Outcomes Intermediate Outcomes Long-term Outcomes
For example, funding sources, space, personnel What are your intervention activities or the things you will do that are part of your intervention strategy from the Community Guide For example, # of brochures or pamphlets distributed, # of educational sessions, # of lay health outreach workers trained, distance of sidewalks created What are the most immediate changes in awareness, attitudes, behavior, etc. that you expect from your intervention activities Usually your health behavior(s) of interest The mortality, infectious or chronic disease outcomes associated with the health behavior(s) of interest; may also include quality of life indicators
Personnel

Fitness Instructor, Trainers or Exercise Physiologists

Program Coordinators

App Developers

Funding Sources

Shanghai Government

Facilities

Fitness center and office used to conduct initial, mid-term and final assessments.
  • Launch the app that enables check-in, check-out and detailed exercise plans. Should be like a combination of TeamBuildr and MyFitnessPal, with the additional feature of online chat.

 

  • Conduct initial and mid-term (3-month) and final (6-month) assessments of participants.

 

  • Design individualized exercise plans and inform them through the App.

 

  • Monitor participation and progression of each participants.

 

  • Answer questions from participants about training and eating, or any concerns about the program.

 

  • Communicating with program coordinators on program implementation and participation or any concerns.
  • Scheduled  and finished exercise sessions and volumes

 

  • Target and actual calorie intakes

 

  • Numbers of electronic hand-outs sent and received

 

  • Chat history with participants

 

  • Progression of training and eating

 

  • Weight, body composition, BMI, knowledge and PA levels in three assessments of each patients.
  

  • Increase in PA level and decrease calorie intakes
  • Improved awareness of negative influence of excessive weight and fat on health
  • Increased knowledge in exercise and nutrition
  • Decreases in body weight and LDL
  • Increased knowledge in exercise and nutrition
  • Increase in PA levels and decrease in calorie intake
 Decreased all-cause mortality in five years in participants that achieved and maintained goal weight loss
  • Explain the logic of why this intervention may work. For example, why would teaching children about healthy eating change their actual eating behaviors? Or why would adding sidewalks increase physical activity for transportation or recreation? (15 points)

The main component of this intervention are individualized assessment and program design, and information delivery/communication utilizing an App specifically developed to facilitate receipt of content and interaction between fitness instructors and participants. Everything a participant needs to know can be found in the app and the information is displayed in a clear, organized way. This ensures receipt of content and saves time and money. Participants check-in every time they exercise and follow the detailed plan displayed on the screen. This helps researchers track progression and participation of each participants, and also provide accountability that motivates participants to follow the program. The online-chat feature makes interaction between instructors and participants very quick and easy, which further helps participants in building their knowledge and skill. According to the analytic framework of the strategy, improved knowledge, attitude and skill will lead to increased PA, improved nutrition and thus improved weight-related outcomes.

  • Discuss limitations of the selected strategy, and things to look out for/be mindful of along the way. Examples may be limitations of resources, community capacity, or anticipated effect of the intervention. (15 points)
  1. The age range of the participants in this study is very broad, from 40 to 74 years old, and will likely result in different usage of the designated app. For example, the 40-55 subgroup may learn how to use the app faster than older subgroup and thus show better results of intervention, while the older participants may have trouble using the app and can’t benefit as expected. (community characteristics)
  2. Intensities of training sessions are not very reliable. They are monitored through RPE scale instead of objective measures such as HR, walking speed,  or work rate (watt) because it is not realistic to do an exercise test on every participant. (limited resources)
  3. The success of the program is depending on the participants’ integrity (only record what they really did), so a monitoring strategy may be needed to determine the how honest the participants are in reporting their diet and exercise.
  • What data would you collect to know if you are implementing the strategy the way it was intended (process evaluation/implementation monitoring)? Refer back to your logic model and the Logic Model module as needed. Be sure to cover dose, reach, fidelity, and implementation. (40 points)

Dose:

  • Number of scheduled exercise sessions and diet logs required on the app, completed exercise sessions and diet logs, and percentages finished.
  • Number of electronic hand-outs delivered and received.
  • Number of assessments completed.
  • Characteristics of participants who meet the participation goal of the program.

Reach:

  • Number of participants who are actually using the app and getting up-to-date content on their app as delivered.
  • Number of sent electronic hand-outs that actually readable on the app.
  • Percentage of participants in control group who have access to the app.
  • Average PA and calorie intakes of the participants before intervention. Percentage of participants not meeting PA guidelines. Percentage of participants not eating calories than expected based on basic metabolic rate and PAL.

Fidelity:

  • Number of exercise sessions determined in program protocol and number of exercise sessions prescribed to participants.
  • Exercise intensity determined in program protocol and number of exercise intensity prescribed to participants.
  • Number of calorie reduction determined in program protocol and number of calorie reduction recommended to participants.
  • Number of electronic hand-outs determined in program protocol and number of number of electronic hand-outs sent to participants.
  • All characteristics of assessments planed by researchers and assessments performed by fitness instructors/trainers/exercise physiologist.
  • Program duration planed and actual duration.
  • Consistency of content delivery (Ex Rx, nutrition advice, motivation) across different trainers.

Implementation:

  • Differences in primary outcomes (PA levels, calorie intakes and body weight ) between treatment group and control group. Also eveluate differences between those who meet participation objectives and who don’t in treatment group.

Part 4: Reflection

  • Oftentimes when working with communities, the initial plan is not what ultimately happens. What would your second choice strategy be for your identified behavior and community? Why would you choose this strategy? In other words, in what ways would this strategy also address the needs of the community based on your assessment for Part 1? (25 points)

My second choice strategy is Obesity: Provider Education with a Patient Intervention. The goal of this strategy is to reduce and control obesity, which fits the target population’s need in increasing their awareness of health outcomes of overweight/obesity, knowledge in how to manage weight and their need to be hold accountable for their progression. In this two-part intervention, healthcare providers are first educated to increase knowledge, improve attitudes and change how they help patients address overweight and obesity. Then healthcare providers actually use a method to help their patients lose weight.

Healthcare providers, compared to fitness trainer, have better opportunities seeing older populations and thus have better chances in identifying subjects who can potentially benefit from intervention. The can interview the subjects on their health backgrounds naturally as part of the appointment. Target population is much more easily convinced by doctors and nurses than being approached on telephone by researchers. The situation is especially true in China because scams are everywhere. Upon successful assessment of patients, healthcare can provide brochures and notes to address the knowledge part and suggest diet/exercise based accordingly. Adherence and outcomes can be assessed during follow-up appointments, which the patients are more likely to attend.

While the strategy has its obvious strength, the education provided to healthcare providers is the key to its effectiveness. It’s not realistic expect one healthcare provider to master nutrition exercise and behavioral intervention skills. The quality of the intervention the patients receive is likely not as good as in the first choice. However, it does address the population’s needs and may provide better adherence and reach.

  • Reflect on how you may use the Community Guide, Nutrition Education Library, and other resources in the future. What did you like about these resources? What didn’t you like? Provide suggestions on how you would make the sites easier for practitioners to use. (20 points)

I may use Community Guide in educating my patients and clients in my future career as a cardiac rehab exercise physiologist. The strategies listed on website are not limited to managing obesity and increasing physical activity. Strategies on diabetes control and high blood pressure would also be useful, considering the patients conditions in cardiac rehabilitation.

The Community Guide is generally easy to use, especially after the upgrade. I like the comparison tool that allows the comparison of different strategies and makes it easy to find out which strategy fits better according to selected criteria. The summary of evidence is excellent in showing readers what has already been done. The features of strategies are clear on the new website. However, I think the descriptions of strategies can be more detailed, especially on the rationale or theory. This will make it easier for researchers and practitioners when they are writing a paper. For those strategies the task force doesn’t have enough evidence to recommend, it would be helpful to point out what else needs to be done.

Reference: Community Preventative Services Task Force (2014). “Obesity Prevention and Control: Provider Education with a Patient Intervention” retrieved from https://www.thecommunityguide.org/findings/physical-activity-creation-or-enhanced-access-places-physical-activity-combined .