Implementing NutriSTEP Ontario - June 09 Webinar

Implementing NutriSTEP®

in OntarioJune 24, 2009

Provincial Webinar

Lee Rysdale, Joanne Beyers,

Dr. Janis Randall Simpson and Dr. Heather Keller

What We Will Cover

What is the NutriSTEP® Program Research background - validation of NutriSTEP®

Where NutriSTEP® is being implemented right now and ongoing evaluation

Natural fit as screening and/or surveillance tool with public health, education, primary health care

Opportunities, challenges and next steps

NutriSTEP® Program is … Parent-focused nutrition education

and skill building program that starts with: Nutrition risk screening index

for preschoolers (3-5 years) Multi-ethnic English and French Parent-administered - 5 minutes to complete

On-going collaborative practice-based research with University of Guelph, PHRED and others

Implementation Toolkit and resources NutriSTEP® Online Community

What NutriSTEP® Measures:Construct of Nutritional Risk

Physical growth/weight concern Food and fluid intake Physical activity and screen time Factors affecting food intake (food

security; psychosocial feeding environment)

Caregiver Resources - Education Booklets

Why NutriSTEP® Program?Canary in the Coal Mine

Screening, Parent Education and Skill Building… Leads to early identification and prevention of

nutrition problems in priority populations Increases nutrition awareness with families and

providers Means treatment can occur, reducing serious

consequences Helps manage scarce community resources Screening data can be used to monitor trends over

time (surveillance)

Refer

ProvideInfo

Monitor

Parent fills in tool

Child not at

nutritional risk

Provide nutrition

info

Child at nutrition risk (mod or high)

PhysicianAssessTreat

Dietitian

AssessCounsel

OtherCommunity

Parent Programs/Workshops/Services

Ethical Screening…

Referral Mapping®

Primary Sites for Screening…

CIHR Think Tank 2006

Screening fairs Day cares Kindergarten registration packages Doctors’ and primary health care offices Outpatient clinics Parent education programs

Evaluating Targeted SitesJune 2007-2009

Funded by NRC and Danone Institute grant Two feasible models for public health

Self-scoring and self-referral Administrator assisted scoring and referral

Ontario sites York Region-JK/SK registration packages Thunder Bay-Fair Start screening program, JK/SK

registration events Sudbury- new “Best Start” hubs in schools

Implementation Study Goal and Objectives

Goal To determine the resources required as well as the

feasible and appropriate processes for implementing NutriSTEP® in the Public Health system in Ontario

Objectives Implement NutriSTEP® screening based on the

proposed models Evaluate the targeted implementation of NutriSTEP®

Overall Results York Region-131(9.5%) were returned Thunder Bay-153 children were screened Sudbury-80 children were screened Only 2 parents in Thunder Bay and Sudbury

declined screening process Total: 364 NutriSTEP® and demographic

questionnaires returned Nutritional risk levels:

6% high risk 13% moderate risk 81% low risk

Low Risk Mod/ High Risk

Total %

Thunder Bay 58 13 71 43.3%

York Region 48 10 58 35.4%

Sudbury 26 9 35 21.3%

Total 132 32 164 100.0%

% 80% 20% 100% -----

Parent Phone Interviews Total Packages Received: 364 (consent: 264) Interviews conducted: 164 Participation Rate: 62%

Parent Thoughts on Score Low Risk

Reassured, happy, relieved, useful confirmation Moderate or High Risk

Often a chronic health or health history issue (e.g. anemia)

Confirmation of issues that were suspected Screening helped to see changes can be made and

reinforced importance of good eating habits Increased awareness of less healthful behaviours

(e.g. TV watching) Got caregiver resources

Parent Thoughts on Site Assisted Referral Model-Screening Fairs and Hubs

Good place, convenient, self-selection, missing those who need most

Multiple screens, some steps can get missed Concern about follow-up Lack of space, time, environmental issues for completion Site needs to be flexible-drop-in is not ideal for screening

Self Referral Model School is for everyone Being part of school entry package reinforced importance

and relevance Parents liked being able to take questionnaire home Increased awareness of nutrition issues

Parent Conclusions

Main Benefit Screening increased parent awareness

Barriers to Referrals/Screening Already aware Other situations take precedence No time to make changes

Need to ensure adequate follow-up of ‘at risk’ families

What We Found Out After Evaluating Three Sites

Assisted Referral Model Feasible, need for training of facilitators,

communication with numerous community partners Self Referral Model

Would likely work better if not part of a research project

Can reach a large number Good partnership opportunity for public health,

schools Did not overwhelm follow-up services Training about preschool nutrition for follow up by health

professionals may be needed

Key Learnings

Study settings and procedures may not be typical/usual

Nutrition concerns are complex to address We can screen, ID, refer and gather data well Ethical practice hard to do - follow-up with

parents is critical Measuring efficacy and effectiveness requires

long term evaluation efforts

Preschool Nutrition Modules “Primers”

Front line health professionals require extra training on preschool nutrition

Top five preschool nutrition issues identified as learning opportunities for Registered Dietitians (RDs): 1) growth assessment (part 1) – theoretical and

background information 2) growth assessment (part 2) - abnormal growth (failure to

thrive, overweight and obesity) and body image/self-esteem

3) nutritional assessment - developmental stages, parenting and the feeding environment

4) nutrient deficiencies - iron and vitamin D 5) food allergies and intolerances

RD Primers

March and April 2009- updated and refined; translated into French

English and French Primers posted on the NutriSTEP® website (www.nutristep.ca)

Ideally need to host a series of 5 web casts for Ontario RDs and their health care team members (public health, community, and clinical) - additional funds are required

Implementing NutriSTEP® in Ontario

Nutrition Resource Centre (NRC) University of Guelph / www.Flintbox.com PHRED Eat Right Ontario (ERO) Call Centre Ontario Public Health Standards (OPHS) Service Ontario

Eat Right Ontario Call Centre Parents

Standardized counseling tool covers low, moderate and high risk

Contact referral database-general, provincial, site specific

Will redirect parents to local health units and other referral sources

Practitioners Direct callers to Flint Box and NutriSTEP® website Future Role- a resource to assist agencies in setting

up a screening program

1- 877- 510- 510- 2

Fit with OPHS: Screening, Surveillance & Requirements

Related to Children

Foundational Standard: 1, 2, 3, 4, 5, 6

Chronic Disease Prevention: 1, 3, 7, 11

Child Health: 1, 4, 5, 6, 7, 8, 9,

11

NutriSTEP® and New Ontario Public Health Standards

Child Health Requirement # 11: The BOH shall facilitate access and support for families to complete screening tools(*19) to monitor their child’s health and development, and provide a contact for families to discuss results and arrange follow-up.

* …such as NutriSTEP®

School Readiness…if nutritionally well, ready to learn Where NutriSTEP® fits

JK/SK registration (York Region and TBay) Immunization/well child clinics (Calgary);

developmental screening fairs HBHC Program FHTs EDI for JK/SK (dovetail with parent survey

component – logical fit for NutriSTEP®) Local communities data available for surveillance and

planning Dental screening

Steps to Implementation NutriSTEP® Online www.nutristep.ca

Background, FAQs, Collaborative 3rd party site Implementation Toolkit, supportive resources

Flintbox www.flintbox.com Electronic questionnaire and license; online toolkit

Service Ontario www.serviceontario.ca/publications Print questionnaires (password protected side only) Electronic and print educational booklets

Nutrition Resource Centre www.nutritionrc.ca Provincial Program Coordinator:

Lee Rysdale: [email protected]

Implementation Toolkit English and French Online version

www.nutristep.ca www.flintbox.com

Binder/CD version NRC order form Provided on this

webcast Ontario only

NutriSTEP® Questionnaire

Electronic versions www.flintbox.com

Print versions www.serviceontario.ca/

publications (Ontario Health Units; password

protected side only)

www.serviceontario.ca/publications

Electronic and print Print versions from

ServiceOntario only English and French Cultural Adaptations

Summer/fall 2009 Chinese

Simplified Traditional

Vietnamese Punjabi

Steps Towards Implementation

Obtain the NutriSTEP® Implementation Toolkit Select a Site Coordinator Train those involved in the process Identify resources to meet needs including Eat

Right Ontario and the Call Centre Develop referral maps for services Monitor and evaluate process and outcomes Use results to inform practice and service

delivery

Some Next Steps Work towards a “one stop data shop” for

NutriSTEP® (for screening and surveillance purposes at all levels - national, provincial, regional and local)

NutriSTEP® validation with other age groups of children e.g. 18 months

NutriSTEP® validation in other languages

Long-term: Testing of effectiveness of preschool nutrition screening and outcomes

Take away Valid and reliable questionnaire-English and French Fills need for simple index for preschool screening Just completing the tool increases parent food and

nutrition awareness Caregiver resources well developed Integrates into existing programs with many different

partners e.g. ERO, HBHC, school readiness Reaches at risk, priority populations Can be used for screening and surveillance Requires enhanced capacity for provincial

coordination and evaluation

Acknowledgements University of Guelph

Researchers: Janis Randall Simpson: [email protected] Heather Keller: [email protected]

SDHU PHRED Program Past project updates and documents: www.sdhu.com Researcher:

Joanne Beyers: [email protected] Nutrition Resource Centre

Provincial Program Coordinator: Lee Rysdale: [email protected]

© 1998-2008. Sudbury & District Health Unit, Janis Randall Simpson, and Heather Keller. All Rights Reserved. The NutriSTEP® mark and Bear Logo are owned by the Sudbury & District Health Unit.

Refer to www.nutristep.ca for more information.