Translating Science into Action in Community Settings

6-8-12

Special ConsiderationsShari Barkin, MD, MSHS

Marian Wright Edelman Professor of PediatricsDivision Director General Pediatrics

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Translational Research

T1: applying discoveries generated during research in the laboratory, and in preclinical studies, to trials and studies in human subjects.

T2: enhances the development and adoption of prevention and treatment strategies in clinical and community settings to improve the public’s health.

T2 Translational Research

bedside → communityevidence → practice

Identifies community, patient, doctor, & organizational factors that serve as barriers & facilitators to translation;

Develops new intervention & implementation strategies to increase translation, such as quality improvement programs or policies;

Evaluates the impact of strategies to increase translation of healthy behaviors & processes of care.

Community Engaged Research Includes: Community Based Research:

[as opp. to Community Placed Research] Some collaboration with community partners (e.g., an advisory board), but all important decisions made by researchers

Community Based Participatory Research: A "collaborative approach to research that equitably

involves all partners … and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community and has the aim of combining knowledge with action and achieving social change to improve health outcomes and eliminate health disparities." Kellogg Foundation Community Health Scholars Program

Emphasizes meaningful consultation & participation from community stakeholders in all phases of a project

Community Driven Research: All important decisions made by community representatives

or organization

Why the increasing emphasis on Community Engaged Research?

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In Social Research: Greater recognition of issues of external validity and the value of collaboration Community involvement can increase application & its success Ethical considerations of participant community voice and control

In Health Research: Need for translational research

US health outcomes are no better than outcomes for other industrialized countries Even though the US is a leader in biomedical research, there is a gap between this research and practice, and ultimately health outcomes

NIH Roadmap – http://nihroadmap.nih.gov Long-term plan to strengthen linkages between research and practice and practice and communities One strategy – community engaged research

Added Ethical Concerns in Reviewing CER

Same principals, different level of application Respect for community, culture, and the

individuals who make up that community. Special attention given to communities that have suffered discrimination, marginalization, and exploitation

Beneficence means doing no harm to individuals, community groups, and cultural institutions

Justice means all partners in the research share the benefits, and the work is fair to the whole community, including those not represented by the working coalition

Being sensitive to time frames It is death to a study funded for a year to spend

the first six months trying to get IRB approval Allow activities to start (e.g., needs assessment)

before details are ready for later activities (e.g., interventions)

Expedite review of amendments and new studies (under an umbrella) when timing is critical

Invite investigators to committee meetings early in the review process to allow a dialogue with the committee to occur and to avoid repeated deferrals

The Nashville Collaborative: A Partnership To Develop and Test Community-

based, Family-centered Programs that Measurably Reduce Childhood Obesity

• Metro Parks Board approval in May 2008• Official launch on June 28, 2008• 7 grants obtained to test programs:

– Family-based

– Community-centered

– Measureable

– Sustainable

Mr. Paul Widman and Dr. Shari Barkin, Co-Directors

I. What: Benefits of Academic–Community Partnership

Community benefits from

evidence-based, sustainable

program

Improved child healthoutcomes

Science benefits from practical

research

Why: Childhood Obesity

Childhood Obesity

Childhood ObesityDisproportionate Effect on Minorities

Of 2-5 year olds:

Childhood ObesityDisproportionate Effect on Minorities

Of 2-5 year olds:

4-5%

12-15%

24-27%

AchievementsAn Overview of Nashville Collaborative Projects:•Salud con la Familia•Salud America!•Coleman Afterschool Program•Growing Right Onto Wellness (GROW)

Project 1: Salud con la Familia (Health with the Family)

• Goal: To examine a family-based, community centered intervention to prevent/treat obesity for Latino parent-preschool child pairs.

• Enrolled 100 Latino families with preschool-age children in 12 week sessions.

• Results: – 41% of Latino preschoolers started overweight – Intervention group was 2x as likely to change

their weight category to normal in 3 months

Funders: State of Tennessee; Vanderbilt Institute of Clinicaland Translational Research; 2008-2010

Salud con la Familia Results: BMI % Change

Project 2: Salud America!

• Goal: To evaluate the impact of a community engaged research study (Salud con la Familia) on:– Latino family use of a recreation center for routine

physical activity (134 families surveyed) one year after specific programming ended.

– Metro Parks and Recreation programs and policies for Latino families with young children (89 staff surveyed)

Funder: Robert Wood Johnson Foundation; 2009-2011

Salud America!Results: Use of Recreation Center

Survey Results Unexposed (n=65) Exposed (n=66)

Adult Use (%)

Once a month or less 66.15 34.85

More than once a month 33.85 65.15

Adult Use With Child (%)

Once a month or less 75.38 37.88

More than once a month 24.62 62.12

Salud America!Results: Use of Recreation Center by Latino

families with their childrenHow often parents use the recreation center with their child Unexposed (%) Exposed (%)

Everyday 1.5% 1.5%> 1/week 13.9% 24.2%Once/week 7.7% 19.7%>1/month 1.5% 16.7%Once/month 4.6% 27.2%Never 70.8% 10.6%

p<0.000* Chi-square test

Project 3: Coleman Afterschool Program

• Goal: To see if children in parks-based afterschool programs were more active than children in usualafter-school programs.

• 100 school-age children enrolled• Results:

– Saw a 12% increase in activity over 3 months - 10% was in high-intensity activity

– Reduced the gender gap – girls in Coleman program more active than control girls

Funders: Vanderbilt CTSA and Institute for Obesity and Metabolism; 2010

Coleman Afterschool ProgramResults: Percent Change in Physical Activity

• Children in parks-based program began ~10% more active than the control group.

• After 3 months, they were ~20% more active than the control group.

Project 4: GROWGrowing Right Onto Wellness (GROW)

• Vanderbilt University School of Medicine Department of Pediatrics working with Metro Parks and Recreation was awarded $12 Million to prevent childhood obesity over 7 years.

• Develop and test a multi-ethnic, community-based, family-centered healthy lifestyle intervention with 600 families with preschool-age children over three years

The GROW Timeline

Oct. – Jun. 2010

Jul. – Dec. 2011

August. 2012 – Dec. 2016

• 7 years total: Aug. 2010 – Aug. 2017

The GROW Program

*300 dyads split into 3 waves of 100 dyads = 50 per community center (further split into multiple session times)

Who?

Where?

What?

The Goals of GROW

Broader Impact

• Focus Groups: 6 Parent Groups (N=50); 4 Metro Parks and Recreation Staff Groups (N=17)• Activity Testing: Conducted classes at intervention sites to test parent-child programming• Curriculum Development: Developed materials; involved expert review and cognitive interviews

(N=60)• PhotoVoice: Assessed barriers around healthy eating and nutrition (N=6)• Pilot Study:

– Tested RCT screening processes and intervention curriculum in the East Park area (N=50)– Updated curriculum and processes and tested with additional group in East Park area (N=11)

Formative ResearchDemographics

Child

Age, mean (SD) 4.69(0.74)

Gender, No. (%)

Female 30(60.0)

Male 20(40)

Absolute BMI, mean (SD) 16.39(0.76)

Waist circumference (cm) 51.94(2.43)

Tricep skinfold (mm) 14.22(3.61)

Race, No. (%)

Black 26(52)

White 15(30)

Multi/Other 9(18)

Hispanic or Latino/Latina 2(4)

Adult

Age, mean (SD) 35.92(9.36)

BMI (kg/m^2), mean (SD) 35.39(12.46)

Waist (cm), mean (SD) 109.13(22.13)

Tricep (mm), mean (SD) 40.18(13.89)

Gender, No. (%)

Female 48(96)

Male 2(4)

Race/Ethnicity, No. (%)

Black 28(56)

White 19(38)

Hispanic or Latino/Latina 2(4)

Multi/Other 3(6)

Total Household Income, No. (%)

$24,999 or less 29(58)

$25,000 - $34,999 4(8)

$35,000 - $49,999 2(4)

$50,000 - $74,999 5(10)

$75,000 - $199,999 9(18)

I prefer not to answer 1(2)

Formative ResearchDemographics

• Target community highly gentrified resulting in participant income ranging from ≤ $14,999 to $100,000-$199,999

• New screening tool respectfully determines underserved status through participation in federal assistance programs.

Survey Question Pilot 1 (N=50) Pilot 2 (N=11)Income under $25,000 58.0% (29) 72.7% (8)

WIC Participation 14.0% (7) 36.4% (4)SNAP Participation 50.0% (25) 90.9% (10)

Addition of federal assistance program

participation question

Formative ResearchRecruitment Changes

Formative ResearchDiet Recall Data

Formative ResearchAccelerometry

● Baseline data were collected from 45 children 3 to 5 years of age who were participating in a healthy lifestyle pilot study.

● Physical activity was assessed using an accelerometer.

● Data were analyzed in 15-second epochs.

● Validated threshold values were used to derive time spent in sedentary, light, moderate, and vigorous activity.1

1Pate RR, Almeida MJ, McIver KL, Pfeiffer KA, Dowda M. Validation and calibration of an accelerometer in preschool children. Obesity (Silver Spring). 2006;14(11):2000 –2006

Demographic and Baseline Results● N=24 girls, 21 boys

● Ethnicity: 51% black, 31% white, 13% biracial ● 34 normal weight, 11 overweight● Average age: 4.4 (SD 0.7) years

● On average, participants wore accelerometers for 23.3 (SD 1.1) hours a day for 6.7 (0.8) days.

● Children spent 8.8% (SD 2.2) of their wear time in MVPA.

ActiGraph GT3X+ Accelerometer

Sample 24-Hour Activity Recording

● On average, children completed 90% of their daily MVPA in 11.3 hours (SD 1.3 hours).

● Young children are active throughout the majority of their waking hours.

MPA napsleep sleep

VPA

LPA

Phys

ical

act

ivity

thre

shol

d

12 AM 6 AM 12 PM 6 PM 12 AM

Sedentary

LPA

Number of 15-second Epochs

≤ 4 epochs

> 4 epochs > 4 epochs

420 (MPA)

842 (VPA)

PA

thre

shol

d va

lues

# o

f cou

nts/

15 s

ec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Isolated Spurt A single MVPA period ≤ 4 epochs in length with > 4 epochs of non-MVPA before and after it

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Sedentary

LPA

420 (MPA)

842 (VPA)

Number of 15-second Epochs

PA

thre

shol

d va

lues

# o

f cou

nts/

15 s

ec

> 4 epochs> 4 epochs

> 4 epochs

Isolated Sustained ActivityA single MVPA period > 4 epochs in length with > 4 epochs of non-MVPA before and after it

Sedentary

LPA

Number of 15-second Epochs

> 4 epochs

> 4 epochs

≤ 4 epochs

420 (MPA)

842 (VPA)

PA

thre

shol

d va

lues

#of

cou

nts/

15 s

ec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Clustered Sustained ActivityAn event comprised of a series of MVPA periods that average >4 epochs, where there are no periods ≥ 4 epochs of non-MVPA

Clustered SpurtAn event comprised of a series of MVPA periods that average ≤4 epochs, where there are no periods ≥4 epochs of non-MVPA

842 (VPA)

Sedentary

LPA

Number of 15-second Epochs

≤ 4 epochs

≤ 4 epochs

≤ 4 epochs> 4 epochs

420 (MPA)

PA

thre

shol

d va

lues

#of

cou

nts/

15 s

ec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

MVPA Category Duration Among MVPA Category Duration Among ParticipantsParticipants

Time in MVPA within Activity Block

Length of Activity Block

MVPA Category Distribution

MVPA Category Distribution as a Percentage of Total MVPA

Girls% (SD)

Boys% (SD) P-value1

Isolated Spurt 16.9 (4.8) 13.8 (2.9)  0.0123Isolated Sustained Activity 2.6 (1.2) 2.0 (0.7) 0.0842

Clustered Spurt 63.5 (5.5) 60.6 (7.7) 0.1503Clustered Sustained Activity 17.1 (7.8) 23.6 (8.7)  0.0113

1two-tailed t-test

62%

20% 16% 2%

Formative Phase Conclusion● Young children appear to participate in MVPA throughout

most of their waking hours in 4 varied patterns: ● Isolated spurts● Isolated sustained activity● Clustered spurts● Clustered sustained activity

● Children spend the majority of their MVPA in clustered spurts.

● Applying these MVPA categories may help inform preschool activity programs and policies to promote developmentally appropriate physical activity for young children.

Conclusions

• Clinical and Translational Research includes multiple settings

• Community settings require additional scientific rigor to test interventions in real-world settings (efficacy and effectiveness)

• Findings can directly affect health and research

References

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