Source: VANDERBILT UNIVERSITY MEDICAL CENTER submitted to
CHILDREN EATING WELL (CHEW) SMARTPHONE APPLICATION FOR WIC FAMILIES
Sponsoring Institution
National Institute of Food and Agriculture
Project Status
NEW
Funding Source
AFRI COMPETITIVE GRANT
Reporting Frequency
Annual
Accession No.
1011962
Grant No.
2017-68001-26352
Project No.
TENW-2016-10801
Proposal No.
2016-10801
Multistate No.
(N/A)
Program Code
A2101
Project Start Date
Apr 15, 2017
Project End Date
Apr 14, 2018
Grant Year
2017
Project Director
Hull, P.
Recipient Organization
VANDERBILT UNIVERSITY MEDICAL CENTER
1161 21ST AVE S STE D3300 MCN
NASHVILLE,TN 37232
Performing Department
Medicine/Epidemiology
Non Technical Summary
Childhood obesity has increased rapidly in recent decades. Risk for obesity increases sharply after age 5 and is greater in limited-resource families. USDA's Special Supplemental Nutrition Program for Women, Infants, and Children ("WIC Program") serves 9.3 million limited-resource, nutritionally at-risk mothers, infants, and children under age 5 in the U.S. WIC provides free supplemental healthy foods, nutrition education, breastfeeding support, and healthcare referrals. WIC improves diet quality among low-income children, but participation in the program drops as children age, particularly at ages 2-4. New strategies are needed to increase the use of WIC benefits and consumption of WIC foods, to reinforce WIC nutrition education between quarterly visits, and to effectively use technology in WIC nutrition education. The Children Eating Well (CHEW) smartphone application ("app") developed by our team addresses these needs. The vast majority of WIC participants use smartphones. The CHEW app is designed to increase use of WIC benefits through easy-to-use WIC shopping tools and to increase consumption of WIC foods through built-in nutrition education tools. In addition, the app could potentially help encourage families to stay in the WIC program longer.When we tested a prototype version of the CHEW app, it was positively received by WIC participants. The Tennessee WIC program now wants to use the CHEW app in WIC clinics across the state. We first plan to enhance the features of the CHEW app, then we will roll it out in WIC clinics across the state of Tennessee, reaching over 70,000 families with 2-4 year-old children. The overall goal for this five-year project is to evaluate the impact of the CHEW app on increasing the use of WIC benefits, improving diet quality, and reducing other obesity risk factors among preschool-aged children from limited-resource families. In addition, we will estimate the costs of implementing the CHEW app and how cost-effective it is for the WIC program to use it. Our long-term goal is to later adapt the CHEW app for WIC programs to use in other states across the country. In addition, we will train high school, undergraduate, and graduate students and postdoctoral fellows to become the next generation of childhood obesity prevention researchers and professionals.
Animal Health Component
0%
Research Effort Categories
Basic
(N/A)
Applied
80%
Developmental
20%
Classification

Knowledge Area (KA)Subject of Investigation (SOI)Field of Science (FOS)Percent
7036020101015%
7246020101015%
8036020101010%
9026050303020%
9036050303020%
9036010302020%
Knowledge Area
703 - Nutrition Education and Behavior; 903 - Communication, Education, and Information Delivery; 902 - Administration of Projects and Programs; 803 - Sociological and Technological Change Affecting Individuals, Families, and Communities; 724 - Healthy Lifestyle;

Subject Of Investigation
6010 - Individuals; 6050 - Communities, areas, and regions; 6020 - The family and its members;

Field Of Science
3020 - Education; 1010 - Nutrition and metabolism; 3030 - Information and communication;
Goals / Objectives
The Children Eating Well (CHEW) smartphone application ("app") was developed for prototype testing under a previous AFRI-funded grant. Leveraging our existing unique collaboration among Tennessee (TN) Cooperative Extension, the TN WIC program, multidisciplinary researchers, and student training programs, we will extend the CHEW app to the next phase of dissemination and implementation using an integrated approach that combines extension, research, and education. Our long-term goal is to eventually disseminate the CHEW app to state WIC programs across the country, reinforcing standard WIC nutrition education, to reduce risk of childhood obesity among limited-resource, preschool aged children. The overall project goal is to adapt, disseminate, implement, and evaluate the CHEW app designed to increase WIC family benefit redemption and improve diet quality and other obesity risk factors among preschool-aged children, while training the next generation of researchers and professionals. The objectives are to: (1) Develop and maintain version 2.0 of the CHEW app in English and Spanish, and disseminate it to the WIC program to implement in WIC clinics across TN (Extension); (2) Conduct process, outcome, and economic evaluation of the CHEW app implementation in the TN WIC program (Research); and (3) Train high school, undergraduate, and graduate students and post-doctoral fellows in the use of technologies for childhood obesity prevention (Education).
Project Methods
OBJECTIVE 1:The CHEW Community Advisory Board (CAB) will continue to serve as the stakeholder advisory body for this project and will give input throughout all phases of the project.During the first year, the App Design Committee will coordinate an iterative and user-centered design process to upgrade the CHEW app prototype into Version 2.0.We will collect user feedback from around 100 WIC participants through individual cognitive interviews, focus groups, and individual prototype field-testing to provide qualitative feedback.We will invite a random samples of 250 WIC program staff to respond to brief online surveys to gather feedback on the app and to guide preparation of the implementation plan.The App Design Committee will work with software developers and designers will enhance the overall app functioning and shopping tools to work with the state's forthcoming EBT WIC system.The App Content Committee (including the Cooperative Extension Program (CEP) and students/fellows) will expand the app's nutrition education content to add research-based information, actionable advice, and tools drawn from USDA, EFNEP, SNAP-Ed, eXtension, and other sources.The Measurement Committee will prepare mobile data collection tools to gather data from users both passively (app analytics) and actively (surveys) for evaluation purposes.The Implementation Committee/CEP will prepare training modules and train WIC staff on how to implement the app with WIC participants in WIC clinics.During Years 2-5, the CHEW 2.0 will undergo continuous maintenance and periodic updates of nutrition education content and WIC shopping tools developed by CEP and students/fellows.OBJECTIVE 2:The app will gradually be rolled out to all 95 counties on a staggered schedule during Years 2-5.We will use a two-arm, cluster randomized design, with counties randomized to an Intervention Arm (standard WIC education plus the CHEW 2.0 app) or Wait-List Control Arm (standard WIC education only).We hypothesize that the outcomes will be significantly more favorable among participants in the Intervention counties versus Wait-List Control counties.Process evaluation will assess staff implementation fidelity and satisfaction, uptake of the app by WIC participants (reach), user engagement, and user satisfaction.Outcome evaluation will compare intervention and wait-list control counties on primary outcomes (WIC benefit redemption rate, all participants; dietary intake, N=600) and secondary outcomes (WIC retention rate, all participants; WIC shopping ease, home food environment, child feeding strategies, and obesity risk factors, N=1,000).The economic evaluation will estimate implementation costs, conduct cost-effectiveness analysis, and prepare an economic sustainability plan for TN and future dissemination to other states.OBJECTIVE 3:a) Formal Classroom Instruction:The Curriculum Committee will develop a new module focused on use of technologies for obesity prevention, to implement in three existing TSU and VU courses.The new curriculum module will incorporate the CHEW app as a case study and engage students in hands-on activities to create new content and tools for the app.Process Evaluation (Outputs): The deliverables for the module include unit learning objectives and competencies, PowerPoint presentation, recommended readings, an in-class and/or out-of-class learning activity, and exam questions. Milestones: (a) Completion of module and materials in Year 1, (b) Annual update of modules and materials in Years 2-5, (c) Delivery of module to target number of students in Years 1-5, and (d) Complete evaluation of module each semester.Process Target: 195 students per year x 5 years = 975 students (850 undergrad, 125 grad)Outcome Evaluation: Exam questions will be developed for each course to assess student mastery of competencies.Outcome Target: 90% of students in each course will achieve mastery of the concepts (>80% correct).b) Mentored Training Experiences:The CHEW project will host mentored training experiences in childhood obesity prevention, technology, research, and extension to high school, undergraduate, and graduate students and post-doctoral fellows.The goal is to encourage students to pursue further education and/or careers relevant to public health nutrition and obesity prevention.Both grant-supported trainees (2 undergraduate students and 1 post-doctoral fellow per year) and unpaid interns (2-3 per year) will receive hands-on experiential training through being immersed in the various CHEW project activities.Process Evaluation (Outputs): We will track the number of students trained at each institution and level (high school to postdoctoral), and we will document their research products.Process Targets: 1) 5+ students per year x 5 years = 25+ students, 2) 4+ student poster/oral presentations per year x 5 years = 20+ presentations, and 3) 10+ summary papers from unpaid interns.Outcome Evaluation: The measure of success of the training experiences is for trainees to pursue further education and/or careers relevant to public health nutrition and obesity prevention. Trainees will complete an exit survey with future plans and contact information after graduation. We will send them an annual online survey to track academic programs and career choices. We will evaluate the presentations/papers, and document when students earn prizes for presentations.

Progress 04/15/17 to 04/14/18

Outputs
Target Audience: Low-income and ethnically-diverse WIC participants with 2-4 year-old children WIC program staff High school, undergraduate, and graduate students and post-doctoral fellows Changes/Problems:After we submitted the grant proposal, the Tennessee WIC program pushed back their timeline for EBT implementation. Therefore, given that launching implementation of the CHEW app depends on the new WIC EBT system being in place and fully functional, we had to slightly modify our timeline for starting implementation of the app later in Year 2 than originally planned. However, this slight delay in launching the app will not adversely affect the project. In fact, it will give us more time for pilot testing to ensure successful implementation. We will still have sufficient time to recruit participants and collect data for the evaluation of the app. Please note: The "Interim" financial report only captures expenses ending 12/31/2017. Invoices from our subawards (TSU and VU) and invoices from vendors performing the software development and user design, all of which constitute a large proportion of the overall budget for Year 1, will be processed before the end of the budget period. We anticipate spending down the funds before the end of the current budget period. What opportunities for training and professional development has the project provided? The study coordinators, postdoctoral fellow, and students have attended 19 seminar presentations, trainings and workshops at Vanderbilt and neighboring institutions on research-related topics. The postdoctoral fellow attended the WIC Technology, Program Integrity, and Vendor Management Education & Networking Conference in fall 2017 to understand the current and future trajectory of technology in the WIC program. The postdoctoral fellow is taking a 3-credit course at Vanderbilt this semester called Measurement and Analysis for Healthcare Improvement to enhance her skills in data collection and analysis to evaluation the implementation of programs. The postdoctoral fellow has also served as the preceptor for the two undergraduate unpaid student interns majoring in public health and health education, giving her valuable experience in student mentorship. How have the results been disseminated to communities of interest?An overview of plans for version 2.0 of the CHEW app was presented in an oral presentation and poster presentation at the 2017 conference of the Society for Nutrition Education and Behavior. Plans for the CHEW 2.0 app dissemination and evaluation are also described on our website, www.nashvillechew.org. What do you plan to do during the next reporting period to accomplish the goals?Objective 1: We will continue with additional user testing and modifications to the app during the first half of Year 2. Then we will field test the app while WIC starts transitioning to EBT in summer/fall 2018 to troubleshoot any EBT-related bugs in the app. We will submit one or more manuscripts reporting on analysis of user testing interview data. Objective 2: We will continue with additional user testing and modifications to the data collection tools and procedures during the first half of Year 2. We will also finalize data collection and analysis plans for the economic evaluation. In summer 2018, we will randomize the counties and conduct a pilot study of the app implementation and data collection procedures. In late 2018/early 2019, we will begin to roll out full-scale implementation of the app and data collection. Objective 3: We will update of the curriculum module and deliver it again in the four courses. We will expand outcome evaluation of module. In some of the activities the students create ideas for possible new recipes, content, and tools for the CHEW app. The CHEW team will review their ideas each semester and select the best ideas for consideration to be included in future enhancements of the app.

Impacts
What was accomplished under these goals? Objective 1: Develop and maintain version 2.0 of the CHEW app in English and Spanish, and disseminate it to the WIC program to implement in WIC clinics across TN (Extension) We are on schedule to complete development of the app prototype by the end of the Year 1 with additional user testing and modifications during the first part of Year 2. WIC Shopping Tools: We have met several times with the Tennessee WIC Program to coordinate logistics for how the app will synchronize with WIC management information system (MIS) and Electronic Benefits Transfer (EBT) systems for users to check their current balance of monthly WIC benefits and use the app while shopping. We are guiding the software development vendor on enhancements to the WIC shopping tools. Recipes: We developed recipe standards to guide the selection, modification, and creation of recipes for inclusion in the CHEW app. We have compiled 39 new recipes to date to add to the existing 35 snack recipes from the CHEW prototype. Detailed nutrient analysis is underway to provide a nutrition label for each recipe. Additional recipes will be added from Cooking Matters (see below). The recipes will include tags to to tailor recommendations to specific users. Educational Tips: We have been preparing the topic areas of educational advice to align with the self-assessment and goal-setting tools (see below) and to align with WIC nutrition education. The tips will also include tags to be able to tailor tips to specific users. Shopping/Meal Planning: We formed a partnership with Share Our Strength, a non-profit organization that developed the Cooking Matters app targeting low-income SNAP families, which includes recipes, a meal planner, and a shopping list. Cooking Matters is providing their app programming code to adapt it into the CHEW app. Assessment and Goal Setting: We formed a partnership with the University of California-Davis (Marilyn Townsend and colleagues) to incorporate their self-assessment (obesity risk and parent feeding) and goal-setting tools into the CHEW app. We are also adapting a goal progress tracking tool previously developed by one of our team members. Mapping Function: Students in the Vanderbilt course created a prototype of a mapping function for users to find WIC clinics and WIC-authorized grocery stores. Objective 2: Conduct process, outcome, and economic evaluation of the CHEW app implementation in the TN WIC program (Research) We are on track with preparations for the implementation and evaluation activities that will start in Year 2. Implementation planning: We met with the Tennessee WIC program leadership several times to update the timeline for app implementation based on the WIC program's timeline for transitioning WIC from paper vouchers to EBT. They have also provided input on the process and outcome evaluation methods. County-level database: For outcome evaluation, we plan to randomize counties to two study arms. Counties will be matched based on similar demographic characteristics. We compiled a database of county-level indicators, including age group, race/ethnicity, income, poverty, food insecurity, SNAP participation, SNAP and WIC grocery stores, access to a motor vehicle, limited English proficiency, and WIC participation by enrollment category. Data collection: We have been preparing the procedures for collecting data from WIC participants via the CHEW app, a separate mobile survey app, and telephone-based dietary recalls; and collecting data from WIC staff using online surveys. The software development vendor is programming the app to collect analytics data and programming the separate mobile survey app. Economic evaluation: A literature review was performed to guide identification of time allocation in WIC services as well as cost structures in adopting and implementation of technologies for similar uses. The information is being used to design survey questions and will be used to model cost estimation next year. Objective 3: Train high school, undergraduate, and graduate students and post-doctoral fellows in the use of technologies for childhood obesity prevention (Education). a) Formal Classroom Instruction We developed a new curriculum module focused on use of technologies for obesity prevention to enhance existing undergraduate Nutrition and Food Science courses at TSU and a cross-disciplinary undergraduate course at Vanderbilt. The module provides a flexible menu of instructional materials and assessments for the instructor to select the specific set of materials that fit best for each course, based on the level/experience of students and overall course objectives. The module incorporates the CHEW app as a case study and engages students in hands-on activities. In some of the activities the students create ideas for possible new recipes, content, and tools for the CHEW app. Learning objectives: Increase knowledge about the WIC program, childhood obesity, and nutrition-related technology Evaluate nutrition-related technology using the application of current health behavior theories and techniques established in the scientific literature Create easy recipes using WIC foods for children that meet the Dietary Guidelines for Americans Generate ideas or prototypes for new content and features that could be added to the CHEW app Didactic content: Three PowerPoint slide decks were created for the instructors with instructional information on the following topics: Digital Technology and Nutrition Behavior, WIC Program Overview, Introduction to CHEW App. Recommended readings: A literature review was conducted and eight journal articles selected as readings to complement the didactic content and assignments. Assignments: Digital Technology Review: Select, use, and evaluate a popular nutrition app and its features WIC Food Package Awareness: Analyze WIC food packages and "go shopping" for the items at an approved WIC grocery store New Recipes: Create or modify a recipe using WIC foods, based on the Dietary Guidelines for Americans Idea for New CHEW App Tool: In-class activity to analyze and discuss feasibility and possible ways to develop a new tool for the CHEW app Prototype of New CHEW App Tool: Group project to create a working prototype of a new tool for the CHEW app, using computer programming Exam questions: Multiple-choice exam questions were developed to assess knowledge of common features of nutrition apps and the benefits of using digital technology for health behaviors and health outcomes. Students reached (138): 1. NUFS 2010 Basic Nutrition (Faculty: Elyse Shearer): 33 students Majors: 25 Dental Hygiene/Nursing/Health Science, 6 Fashion Merchandising, 2 Biology 2. NUFS 3120 Nutrition in the Global Community (Faculty: Veronica Oates): 13 students Majors: 6 Food and Nutritional Science, 2 Food Service Management, 5 other 3. NUFS 3330 Maternal and Child Nutrition (Faculty: Sandria Godwin): 40 students Majors: 40 non-nutrition 4. UNIV 3278 / CS 4278: Tackling Big Questions with Mobile Cloud Computing (Faculty: Doug Schmidt and Jules White): 52 students Majors: 40 computer science, 12 non-computer science b) Mentored Training Experiences: The CHEW project hosts mentored training experiences focused on childhood obesity prevention, technology, research, and extension. Trainees receive hands-on experiential training through being immersed in the various CHEW project activities. Learning Objectives: Increase knowledge, skills, and competencies in mobile health and obesity prevention research and extension Apply knowledge, skills, and competencies in mobile health and obesity prevention research and extension Consider educational and career opportunities relevant to public health nutrition and obesity prevention Trainees (5): Grant-supported Trainees: 2 undergraduate students and 1 post-doctoral fellow Unpaid Interns: 2 undergraduate students

Publications

  • Type: Journal Articles Status: Published Year Published: 2017 Citation: Hull PC, Emerson JS, Quirk ME, Canedo JR, Jones JL, Vylegzhanina V, Schmidt DC, Mulvaney SA, Beech BM, Briley C, Harris C, Husaini BA. A Smartphone App for Families with Preschool-Aged Children in a Public Nutrition Program: Prototype Development and Beta-Testing. JMIR mHealth uHealth. 2017; 5(8):e102. doi:10.2196/mhealth.7477
  • Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Hull PC. Children Eating Well (CHEW) Smartphone Application for WIC-Participating Families. Invited presentation at annual meeting of Society for Nutrition, Education and Behavior, Washington (DC), July 2017.
  • Type: Journal Articles Status: Published Year Published: 2017 Citation: Hull PC, Briley C, Schmidt D, Mulvaney S, Silver H, Illukpitiya P, Koyama T, Jones J, McAfee C. CHEW 2.0: Expansion of the Children Eating Well (CHEW): Smartphone application for WIC-participating families. J Nutr Educ Behav. 2017; 49(7): S115-116. (Abstract) doi: http://dx.doi.org/10.1016/j.jneb.2017.05.097