The children's health and activity modification program (C.H.A.M.P.): a community-based lifestyle program for children with obesity and their families

To answer our primary research question—that is, whether C.H.A.M.P. represented a feasible treatment option for children with obesity and their caregivers—data were collected in relation to the RE-AIM Framework, an evaluation tool for community-based health interventions. The following represents an overview of the RE-AIM dimensions, the methods used to measure each outcome in our study, and the time points at which each outcome was measured.
1.REACH: Participant demographics were compared to census demographics in London, Canada, to assess representativeness, and records of inquiries about the program were used to analyze the participation rate as well as the most effective recruitment methods.
2. EFFECTIVENESS AND INDIVIDUAL-LEVEL MAINTENANCE: Effectiveness data were reported as part of RE-AIM and within the context of the feasibility study given that C.H.A.M.P. was offered in a ‘real world’ setting. In addition, whereas the short-term impact of the intervention (i.e., pre-post data) represented the effectiveness dimension of RE-AIM in the current project, the longer-term data (i.e., 3, 6, and/or 12 month) represented the individual-level maintenance element of RE-AIM in our study. Individual-level maintenance was also assessed using participant attrition. Measurements on specific outcomes (representing the secondary objectives, outlined below) were collected at baseline, post-intervention (i.e., approximately one week following the 4-week intervention), 3-month (in some cases), 6-month, and 12-month follow-up assessments. The impact of the intervention on these outcomes were assessed via a series of repeated measures ANOVAs to examine changes across time and post-hoc analyses were conducted to determine whether there were statistical differences in the variables of interest (physical activity behaviour, physiological outcomes, and psychological outcomes). Effect size values (η2) were also calculated
3. ADOPTION: As outlined by Burke et al. (under review), adoption of C.H.A.M.P. was addressed by: (a) describing the delivery settings, the use of these settings over the 2-year period, and their potential for translating the research program into practice; and (b) calculating and reporting on the number of individuals and/or community organizations in the community that were involved in the implementation of the program.
4. IMPLEMENTATION: Again, as outlined by Burke and colleagues (under review), four steps were completed to analyze and explore the implementation of C.H.A.M.P.: 4.1. The original C.H.A.M.P. schedules (i.e., for both the child and caregiver sessions), in addition to revisions and notes made by research staff and program counselors, were analyzed to determine the percentage of the planned intervention that was actually implemented
4.2. At the end of each week/family session, the children and parents completed fidelity checks (i.e., small quizzes pertaining to the information provided during the educational sessions) to evaluate the degree to which the material being disseminated was retained.
4.3. A comparison between the original budgeted costs and the actual costs of running the program was calculated; and (d) Attendance was monitored using researcher records for the child and caregiver portions of the program.
5. SETTING-LEVEL MAINTENANCE: In the present study, we calculated the percentage of community organizations (who participated in the first year of the intervention) that were asked and agreed to participate in the second year of the program as an indicator of setting-level maintenance.

Numerous variables of interest were considered to be secondary outcomes in the C.H.A.M.P. project. The following provides an overview of these outcomes, along with information about the method used to measure the outcome and the time points at which they were measured:
1. PHYSICAL ACTIVITY (CHILDREN):
1.1. As outlined in Burke, Vanderloo, Gaston, Pearson, and Tucker (in press), self-reported physical activity was assessed at five time points (i.e., baseline, 1-week post-intervention, 3-, 6-, and 12-months post-intervention) using the Physical Activity Questionnaire for Older Children (PAQ-C). The PAQ-C is a commonly used 7-day recall tool. The PAQ-C is comprised of nine items which assess the frequency and intensity of spare time exercise, school-based exercise, and participation in sports after school, in the evenings, and on weekends, as well as perceived general activity level. Each item is scored on a 5-point Likert-type scale (i.e., 1 = no activity and 5 = the highest level of activity), whereby higher values are reflective of greater levels of physical activity. Because the PAQ-C is intended to be used during the school year and the present study included two assessments that took place during summer months (i.e., baseline and 12-months post-intervention), only the four items which referred to home-based physical activity were used in subsequent analyses.
1.2. Objective physical activity was assessed using the Actical® (MiniMitter, Oregon), which is a small durable (approximately 2.8 x 2.7 x 1.0cm3), lightweight (17g), and water resistant omnidirectional accelerometer easily worn on the child’s hip. The Actical® sensors were programmed with the participant’s personal information (e.g., age, weight, and height) to provide an estimate of activity-related energy expenditure. Children were asked to wear the accelerometer during waking hours for one week (7-day) periods at weeks 1 and 4 of the 4-week program, at 3, 6, and 12 months post-intervention (if possible).
2.PHYSIOLOGICAL MEASURES (CHILDREN):
2.1. Body composition was measured using a Dual Energy X-Ray Absorptiometry (DXA) scanner (GE Lunar), located in the Exercise and Health Psychology Laboratory at The University of Western Ontario. Body composition was measured at the baseline, post-intervention, 6 month, and 12 month follow-up assessments. The DXA machine differentiates between absolute and relative amounts of fat mass, muscle mass, and bone mass. It is considered to be an accurate criterion reference for quantifying fat and muscle mass in children. To determine standardized body mass index (BMI-z) scores for the children, weight was also measured on the DXA, while height was measured using a standard height and weight scale. Standardized BMI was calculated using the LMS method with an online calculator from the Children’s Hospital of Philadelphia (The Children’s Hospital of Philadelphia, 2008). Finally, using the umbilicus as the vertical landmark, waist circumference was measured by the C.H.A.M.P. paediatrician using a standard measuring tape, as another means of evaluating body composition.
2.2. Fasting blood sample measurements yielded values for total cholesterol, high density lipoprotein cholesterol (HDL-c), low density lipoprotein cholesterol (LDL-c), triglycerides, insulin, serum glucose, and HOMA-IR. Children had blood work drawn to determine metabolic status at baseline, week 4, and at 6 and 12 month follow-ups. Blood samples were taken by nurses specializing in paediatrics at the Paediatric Medical Day Unit (PMDU) located at the Children’s Hospital of Western Ontario. The PMDU had a comfortable waiting room with toys, games, and books for children. A nearby Child Life Room was staffed with Child Life Specialists who integrated emotional support into play in order to minimize any stress that might have been associated with the procedures/hospital experience.
2.3. Vessel wall imaging (VWI) was conducted on all children to monitor plaque formation, vessel elasticity, and capillary function, thus providing an estimate of cardiovascular health. A small probe that emits ultrasound waves was held against the child’s skin to obtain images of the heart, brachial artery (inner side of elbow), and carotid artery (neck). This probe was utilized to record blood flow through the brachial and carotid artery. An additional ultrasound probe was placed in the suprasternal notch (lower part of neck, between the collar bones) to record the flow of blood as it leaves the heart. Assessments were taken at baseline, post-intervention, and at 6 and 12 month follow-up time points.
2.4. Blood pressure was taken via a cuff that was placed around the participant’s upper arm and inflated periodically in the same manner as blood pressure measurements taken by a physician at baseline, post-intervention, and 6 and 12 months post-intervention.
2.5. Children’s resting heart rate, exercise heart rates, and distance run/walked (in metres) were measured by the Cooper 12-minute walk/run test. The Cooper test is a field-based, self-paced 12-minute walk or run test. This particular assessment is a self-paced test, thus it allowed the children to choose a pace with which they felt most comfortable. It also has minimal opportunity for embarrassment as participants finish at the same time and location (i.e., rather than a race whereby one child might be an obvious ‘winner’). Children completed the Cooper 12 minute walk/run fitness test on the first and last days of camp, and at the 6 and 12 month follow-up time points. Children were read instructions as to how to complete the test, and were instructed to choose a fast walking or jogging pace that they could maintain for 12 minutes. The length of the track was 25 meters, marked with a pylon every 5 meters for accurate recording of distance. Children were equipped with a Polar heart rate monitor comprised of two electrodes that were placed above the diaphragm. These electrodes transmitted the heart rate signal to a watch worn on the wrist. Resting heart rate was recorded prior to the test, while the children were seated. Exercise heart rates were recorded at 3-, 6-, 9- and 12-minute time points. Distance run/walked during the test was also used as a measure of fitness status, and was determined by counting the number of laps each child completed.
3. PSYCHOLOGICAL MEASURES (CHILDREN):
3.1. As outlined in Burke, Vanderloo, Gaston, Pearson, and Tucker (in press), physical activity-related task and barrier self-efficacy were assessed at baseline, 1-week post-intervention (i.e., 5 weeks), and at 3, 6, and 12 months post-intervention. An adapted version of the Self-Efficacy Scale was used to assess task self-efficacy; children were asked to identify how confident they were in their ability to complete regular physical activity for increasing amounts of time (10, 30, and 60 minutes) at three intensities (light, moderate, and hard). A color-coded scale with response options ranging from 0% (no confidence at all) to 100% (completely confident) was used, and verbal, written, and pictorial examples of mild, moderate, and hard physical activities were provided. Higher scores reflected greater efficacy to engage in physical activity for increasing durations and intensities. Barrier self-efficacy was assessed using a modified version of the Barrier Efficacy Scale. Again, using a color-coded scale ranging from 0% (no confidence at all) to 100% (completely confident), children evaluated their confidence in their ability to perform physical activity, for 60 minutes per day on most days, in the presence of six common barriers (e.g., “If I have a lot of activities to do with my friends and/or family”, “If I am tired”) presented verbally, in text, and via illustrations.
3.2. The Pediatric Quality of Life Inventory 4.0 (PEDS-QL 4.0), a reliable and valid measure of health-related quality of life (QOL) for children ages 8 to 12, was administered to children at baseline, 1-week post-intervention (i.e., 5 weeks), and at 3, 6, and 12 months post-intervention. The questionnaire included one document that was completed by the child and one proxy report that one parent/guardian completed based on his or her perceptions of the child’s QOL. Both the child and parent proxy questionnaires consisted of the following subscales: 1) physical (n = 8 items); 2) emotional (n = 5 items); 3) social (n = 5 items); 4) and school (n = 5 items) functioning. Because C.H.A.M.P. took place when children were not in school, the school subscale was not included in subsequent analyses.
3.3. A short questionnaire containing questions pertaining to the Theory of Planned Behavior constructs was also administered to children. Specifically, items related to children’s attitudes towards physical activity, subjective norms, perceived behavioural control, and intention were asked using a paper-and pencil survey completed by children at baseline, post-intervention, and 3, 6, and 12 months post-intervention.
3.4. Cohesion (i.e., perceptions of belonging and friendships) was assessed 2 weeks into the program (to allow cohesion to develop), the end of the 4-week program, and three months after the camp experience. The 18 item questionnaire was developed for the program and contained a five-point response scale (1 = highest, 5 = lowest).
4. PERCEPTIONS OF THE PROGRAM (CHILDREN AND CAREGIVERS):
4.1. Within one month following the intervention, focus groups were conducted with children and caregivers related to the impact of the intervention. Each session was audio-recorded and transcribed verbatim, and inductive content analysis was conducted using guidelines. Member checking took place and strategies were used to ensure data trustworthiness (i.e., credibility, dependability, confirmability, and transferability).