Implementing NutriSTEP Ontario - June 09 Webinar
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We would like to tell you about NutriSTEP®. This work has been led by dietitian researchers from the Sudbury & District Health Unit Public Health, Research, Education & Development (PHRED) program, NRC and the University of Guelph, Dr Heather Keller and Dr Janis Randall Simpson. As of spring 2007, NutriSTEP® has been a program of the Nutrition Resource Centre of the Ontario Public Health Association. NutriSTEP® is of interest to a number of programs and agencies that service young children and their families.
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Implementing NutriSTEP Ontario - June 09 Webinar
- 5. Caregiver Resources - Education Booklets
- 35. © 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.
Editor's Notes
- We would like to tell you about NutriSTEP ® . This work has been led by dietitian researchers from the Sudbury & District Health Unit Public Health, Research, Education & Development (PHRED) program, NRC and the University of Guelph, Dr Heather Keller and Dr Janis Randall Simpson. As of spring 2007, NutriSTEP ® has been a program of the Nutrition Resource Centre of the Ontario Public Health Association. NutriSTEP ® is of interest to a number of programs and agencies that service young children and their families.
- Early surveillance and prevention of nutrition problems begins with valid and reliable screening tools and data . NutriSTEP ® is a valid and reliable bilingual (English and French) nutrition risk screening questionnaire now available for children 3 to 5 years old. NutriSTEP ® stands for Nutrition Screening Tool for Every Preschooler . It takes approximately five minutes to complete, and has been designed for administration by parents , caregivers or community professionals in a variety of settings.
- Each question has up to five possible responses and each response has a score from 0 to 4. Parents check off which answer best suits their child’s typical nutrition habits. Once the questionnaire is completed, the nutrition risk score must be determined by adding the scores for the 17 questions to receive a total score. The higher the score, the greater the nutrition risk. There are three levels of nutrition risk: low, moderate and high . For each risk level, there are guidelines for parents on their next steps: If the total score is 20 or less (low risk) : Your child’s nutrition habits are quite good. There may be things that you want to work on. Check out the educational booklets for tips. If the total score is 21 to 25 (moderate risk): You can improve your child’s nutrition habits by making some small changes. Contact your public health unit or community health centre for educational materials or community programs. If the total score is 26 and greater (high risk): You can improve your child’s nutrition habits by making changes. Talk with a health care professional, such as a registered dietitian or your family doctor or pediatrician. Based on the validation work, it is anticipated that the high risk nutrition referrals will be 10 -15% of the children screened. This is similar to the number of children identified at risk in the HBHC and Dental screening programs. The moderate risk referrals will be 23-33 % of the children screened with the remaining children, about 50% being identified as low risk .
- There has been a strong focus on community based practice during the development of NutriSTEP. Throughout the tool development, nutrition education was a priority. Hundreds of parents and caregivers learned about the importance of nutrition for their child, and children identified as having nutrition problems received nutritional assessments and referrals. Two consumer nutrition education booklets in English and French were also developed and evaluated. These booklets filled an identified gap in available nutrition education materials for this age group. Research has demonstrated that these resources can change parents’ nutrition knowledge and attitudes. These booklets, “The ABCs of Feeding Preschoolers” and “How to Build a Healthy Preschooler”, have been available through the Ontario Best Start Resource Centre. The original NutriSTEP booklet called “ABCs of Feeding Preschoolers” has recently been replaced with an updated MHP resource called “Eat Right. Be Active”.
- To determine if a preschooler has nutrition problems, there are two methods that can be used: a nutrition screen or a nutrition assessment. Nutrition screening is the first step in identifying nutrition problems, it is a form of early detection. Screening helps ensure those who need a full nutritional assessment receive one, and that skilled professionals are best utilized for those individuals who could most benefit from their services. A nutrition assessment is a very comprehensive approach to determine the nutritional status of a person. It involves medical, nutrition and medication histories, physical examinations, anthropometric measurements (such as weight and height) and laboratory data. Nutritional assessments are done by a qualified nutrition professional and require more time and resources to carry out than does nutrition risk screening.). NutriSTEP ® isn’t just Screening. Screening is the means to an end, in that the Program ethically includes parent education and skill building follow up. Nutrition screening can benefit children and their families, child and health care providers and communities by: Raising awareness and knowledge about healthy eating, healthy weights and physical activity Promoting early intervention and decreasing the risk of serious consequences of malnutrition such as anemia and overweight/obesity Targeting children at risk for further assessment and treatment Streamlining the referral process Prioritizing services to those most in need Identifying the needs in a priority population group to integrate services and target nutrition programs
- Ethical nutrition screening’ means that a preschooler is not only screened for nutritional risk but the family is provided with opportunities to improve their child’s eating and activity habits . Ethical screening involves voluntary participation in a screening process. It also includes a responsibility to: 1) Target people in need of resources or education through the consistent use of a valid and reliable screening tool. 2) Provide those identified to be at risk with reasonable options for assessment and treatment through resources, services or education. 3) Follow-up with these individuals to ensure that their nutritional needs are met with the intervention. Those who screen positive or higher risk can be referred for a nutritional assessment and treatment if necessary. There may be other professionals and services which are more appropriate such as a social worker, family counsellor or family physician/nurse practitioner.
- Sample referral map template shows the three risk levels and types of referral sources for each risk level.
- Screening models identify: 1) How screening happens 2) The appropriate and feasible referrals 3) How referrals would occur 4) How follow-up would be completed to ensure that the client’s needs will be met There are few models available describing best practices for nutrition risk screening within a community. Work has begun to build capacity using ethical nutrition screening that is both feasible and sustainable by communities. In 2006, a National CIHR Think Tank was held with 12 stakeholders and the NutriSTEP research team to discuss implementation models that were likely to be useful approaches to preschool nutrition screening across the country. This group suggested the following models for preschool nutrition screening: -screening fairs -day cares -school introduction/preschool wellness programs -doctors’/primary care offices -parent education programs
- With additional funds received from a Danone Institute Grant-in-Aid, a targeted implementation and process evaluation study was led by the University of Guelph using different nutrition risk screening and referral models in select Ontario sites from June 2007 to June 2009. A self-referral model (school board kindergarten registration package) was coordinated through York Region Health Department. An assisted-referral model was coordinated through the Thunder Bay District Health Unit via their established Fair Start preschool screening Program. At the Sudbury & District Health Unit a new screening program was tested via the Ontario “Best Start hubs” model.
- September 2007 to July 2008- Facilitator assisted scoring and referral model Thunder Bay-Fair Start screening program ( n=300 ) Sudbury- new “Best Start” hubs ( n=200 ) Data collection: Parent level; Facilitator level; Site level; and, Community level In Thunder Bay and Sudbury, parents filled out NutriSTEP at preschool screening fairs. Facilitators assisted parents in scoring the questionnaire and directed parents to the most appropriate community services using the referral map for their community. To evaluate this process, information was collected from both parents and facilitators on the screening process. January 2008 to July 2008-JK/SK registration via a self-referral model NutriSTEP ® packages sent to 137 schools 1400 packages sent – goal 500 returns Data collection: Parent level; Site level; and, Community level
- Approximately half (51%) of the children screened were males and 64% were aged 3 years. Most (86%) of the children spoke English as their first language and 96% were born in Canada. Most children came from homes where the parents were either married or living common-law (93%). Seventy-one percent of parents had graduated from either college or university and 69% had a family income greater than $60,000.
- 164 interviews with parents on their perceptions of the preschool screening done in Thunder Bay, Sudbury, and North York. Parent Demographics: Parental Age: Mean=34 ±5 yrs Range=20-48 yrs Parental Gender: 94% Female Parental Education: 76% Graduated U/C Marital Status: 94% Married/Common Law Income: $60K and Above =70% Ethnicity: Mother: Caucasian (26%), European (53%), Other (21%) Father: Caucasian (30%), European (50%), Other (20%)
- Overall most parents found that the screening process increased awareness in nutrition/preschooler diets
- Screen facilitators in both Thunder Bay and Sudbury completed a self-administered questionnaire and also had a debriefing session with the Site Coordinators. In Thunder Bay , 8 facilitators completed evaluation forms. In Sudbury , 9 completed evaluation forms. In addition, site coordinators provided detailed reports summarizing the planning, implementation and follow up process in their site. See background document, June 2009 for more details. Overall, nutrition risk screening for preschoolers using NutriSTEP® has been demonstrated to be not only feasible, but sustainable, in self-referral and assisted referral models in Ontario.
- We must not get discouraged since many other health screening programs and public health interventions are created and well resourced before true health status outcome data are available. Adequate resources and integrated systems/data sets are required to track outcomes to illustrate effectiveness.
- Implementing a provincial program requires numerous partners and collaborations. NRC and U of Guelph have been instrumental in moving this along with support from the PHRED program particularly around advocacy and awareness building and NutriSTEP’s inclusion in the Ontario Public Health Standards. Further implementation and referral support and accessibility of resources has been achieved with ERO and Service Ontario.
- OPHS=Ontario Public Health Standards Chronic Disease Prevention The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current) , in the areas of: Healthy eating; Healthy weights; Comprehensive tobacco control; Physical activity; MOHLTC OPHS website – Support Manual - Child Health Logic Model. Board of Health: Child Health Outcomes Health Promotion and Policy Development, Disease Prevention Requirements # 4 - 9, 11: Children at risk of poor health and developmental outcomes are supported and referred to services prior to school entry. Priority populations are linked to child/family health information, programs and services. Community partners and the public are aware of the importance of creating safe and supportive environments that promote healthy child development. The public is aware of the factors associated with positive parenting. Policy-makers have the information required to enable them to amend current policies that would have an impact on the promotion of healthy child development. Assessment & Surveillance Requirement # 1: The BOH is aware and uses epidemiology to influence the development of healthy public policy and its programs and services for the promotion of healthy child development. NutriSTEP ® provides an excellent basis for a nutrition surveillance system for nutrition risk in preschool children across Canada. - tool with or without score can be used at local, regional and provincial levels for preschool population nutritional health assessment, surveillance and monitoring - tool can be used as pre-post test for parent nutrition intervention/program to assess changes in parent perception of their preschooler’s nutrition risk
- Requirement # 11 reads: 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. *Screening tools will include those that are part of the HBHC program (e.g. Nipissing District Developmental Screen) as well as other reliable, valid screening tools that may be identified, such as NutriSTEP and the Paediatric Dental Screening Instrument. Child Health: Assessment and Surveillance The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current), in the areas of: Positive parenting; Breastfeeding; Healthy family dynamics; Healthy eating, healthy weights, and physical activity; Growth and development; and Oral health
- HBHC= Healthy Babies Healthy Children Program FHTs= Family Health Teams EDI= Early Developmental Index
- For further information on NutriSTEP, start with the website at www.nutristep.ca.
- NutriSTEP Online www.nutristep.ca
- “ How to Build a Healthy Preschooler” has also been updated; professionally designed and printed and will be available through Service Ontario this spring. This resource has also been culturally adapted and is being updated this spring and will be available in Punjabi, Vietnamese, traditional and simplified Chinese. Other NRC resources we use: Busy Bodies and the ERBA Guide for children 6-8 years.
- Obtain the free Implementation Toolkit. The NutriSTEP ® toolkit includes supporting materials and will continue to undergo revisions and additions based on the practice-based research in the various sites just described. The toolkit is also translated into French. Consider the Implementation Toolkit like a combined Protocol and Guidance Document for NutriSTEP ® . A community or service provider interested in implementing a screening program needs to consider the capacity of the community. This will include: -A site coordinator to oversee the program and its evaluation. - Training for screen administrators, and the individuals in the referral process - Individualize resources for those who will benefit from the program -Know the issues with data collection and management -Develop referral maps or a process for ethically meeting the needs of groups identified to be at: Low risk: no nutrition problems or concerns Moderate risk: some nutritional problems or concerns High risk: requires a referral -A site coordinator can monitor the process to inform current practices and support changes to programs and services if appropriate.
- NutriSTEP ® provides an excellent basis for a nutrition surveillance system for nutrition risk in preschool children across Canada. - tool with or without score can be used at local, regional and provincial levels for preschool population nutritional health assessment, surveillance and monitoring - tool can be used as pre-post test for parent nutrition intervention/program to assess changes in parent perception of their preschooler’s nutrition risk - an abbreviated tool is being created which can also be considered for these purposes, including the development of a NutriSTEP RRFSS module .) There are requests to validate NutriSTEP ® for other age groups as well as other ethnicities e.g. Spanish in the US. The overall goal of the NutriSTEP ® program is to improve the health status of young Canadian children.