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Background Few children meet physical activity and screen-time guidelines. Parents play a key role in supporting children’s physical activity and limiting child screen-time, but their own stress, management of stress (i.e., coping), and mood may impact their ability to do so. Ecological momentary assessment (EMA) is a methodology that can be used to assess the temporality of parental state (i.e., stress, mood) and subsequent child behavior. This study aimed to examine the relationship between parental stress, coping, and mood with child physical activity and screen-time, and whether there were differences by child sex. Methods Parents and their children ( n  = 436, 5–9 y) participated in an EMA study that used signal-contingent and end-of-day surveys. Parents received three signal-contingent surveys during fixed 3-hour windows and one end-of-day survey over 7-days via smartphone notifications. Parents reported their current stress, ability to manage stress, and depressive mood at the first signal-contingent survey. Parents also reported the frequency of their child’s physical activity and screen-time across the day during the end-of-day survey. Conditional fixed effects regression was fitted to examine current and lagged day stress, coping, and mood relationships on change in child physical activity and screen-time. Results Children were girls (53.7%), mainly non-white (64.3%), and with a household income of less than $50,000 USD (54.1%). Overall, parent’s current day stress was negatively related to the frequency of child physical activity ( p  = 0.001), but not screen-time. Among girls, higher parent current-day stress and lower coping were related to less frequent girl’s physical activity ( p s < 0.05). Parent’s lagged day stress was then associated with more frequent girl physical activity the next day ( p  = 0.018). There were no associations among parent mood or in models with only boys. Conclusions This study found parent’s stress may negatively impact child’s physical activity that day, but may positively impact physical activity the next day, namely girls. Findings suggest that reducing parental stress and improving coping abilities may improve girl’s physical activity, but other approaches are needed to reduce child screen-time at this age.

Background Prior research has shown associations between controlling food parenting practices (e.g., pressure-to-eat, restriction) and factors that increase risk for cardiovascular disease in children (e.g., low diet quality, obesity). This study aimed to examine associations between real-time parental stress and depressed mood, food parenting practices, and child eating behaviors in a longitudinal cohort study. Methods Children ages 5–9 years and their families ( n  = 631) from six racial/ethnic groups (African American, Hispanic, Hmong, Native American, Somali/Ethiopian, White) were recruited for this study through primary care clinics in a large metromolitan area in the US (Minneapolis/St. Paul, MN) in 2016–2019. Ecological momentary assessment was carried out over seven days with parents at two time points, 18 months apart. Adjusted associations between morning stress and depressed mood of parents on food parenting practices and child eating behaviors at the evening meal were examined. Interactions tested whether food security, race/ethnicity and child sex moderated associations. Results High levels of parental stress and depressed mood experienced earlier in the day were associated with controlling food parenting practices and child food fussiness at dinner the same night. Results were dependent on food security status, race/ethnicity, and child sex. Conclusions Health care professionals may want to consider, or continue, screening parents for stress, depression, and food insecurity during well-child visits and discuss the influence these factors may have on food parenting practices and child eating behaviors. Future research should use real-time interventions such as ecological momentary intervention to reduce parental stress and depressed mood to promote healthy food parenting practices and child eating behaviors.

Although prior research suggests that stress may play a role in parent's use of food-related parenting practices, it is unclear whether certain types of stress (e.g., transient, chronic) result in different food-related parenting practices. Identifying whether and how transient (i.e., momentary; parent/child conflict) and chronic (i.e., long-term; unemployment >6 months) sources of stress are related to parent food-related parenting practices is important with regard to childhood obesity. This is particularly important within racially/ethnically diverse parents who may be more likely to experience both types of stress and who have higher levels of obesity and related health problems. The current study examined the association between transient and chronic stressors and food-related parenting practices in a racially/ethnically diverse and immigrant sample. The current study is a cross-sectional, mixed-methods study using ecological momentary assessment (EMA). Parents (mean age = 35; 95% mothers) of children ages 5-7 years old (n = 61) from six racial/ethnic groups (African American, American Indian, Hispanic, Hmong, Somali, White) participated in this ten-day in-home observation with families. Transient stressors, specifically interpersonal conflicts, had significant within-day effects on engaging in more unhealthful food-related parenting practices the same evening with across-day effects weakening by day three. In contrast, financial transient stressors had stronger across-day effects. Chronic stressors, including stressful life events were not consistently associated with more unhealthful food-related parenting practices. Transient sources of stress were significantly associated with food-related parenting practices in racially/ethnically diverse and immigrant households. Chronic stressors were not consistently associated with food-related parenting practices. Future research and interventions may want to assess for transient sources of stress in parents and target these momentary factors in order to promote healthful food-related parenting practices.

Social determinants of health (SDoH), such as food and financial insecurity and food assistance, are potentially modifiable factors that may influence breastfeeding initiation and duration. Knowledge gaps exist regarding the relationship between these SDoH and infant feeding practices. We explored the relationships of food and financial insecurity and food assistance with the continuation of breastfeeding at four months postpartum among mothers and whether race and ethnicity modified these associations. Mothers retrospectively reported food and financial insecurity and receipt of food assistance (e.g. Women, Infants and Children and Supplemental Nutrition Assistance Program) during pregnancy with their first child and infant feeding practices (exclusive/mostly breastfeeding . exclusive/mostly formula feeding) following the birth of their first child. Sociodemographic-adjusted modified Poisson regressions estimated prevalence ratios and 95 % CI. Minneapolis-St. Paul, Minnesota. Mothers who participated in the Life-course Experiences And Pregnancy study (LEAP) ( 486). Ten percent of mothers reported food insecurity, 43 % financial insecurity and 22 % food assistance during their pregnancies. At four months postpartum, 63 % exclusively/mostly breastfed and 37 % exclusively/mostly formula-fed. We found a lower adjusted prevalence of breastfeeding at four months postpartum for mothers who reported experiencing food insecurity (0·65; 0·43-0·98) and receiving food assistance (0·66; 0·94-0·88) relative to those who did not. For financial insecurity (aPR 0·92; 0·78, 1·08), adjusted estimates showed little evidence of an association. We found a lower level of breastfeeding among mothers experiencing food insecurity and using food assistance. Resources to support longer breastfeeding duration for mothers are needed. Moreover, facilitators, barriers and mechanisms of breastfeeding initiation and duration must be identified.

The COVID-19 pandemic and the subsequent need for social distancing required the immediate pivoting of research modalities. Research that had previously been conducted in person had to pivot to remote data collection. Researchers had to develop data collection protocols that could be conducted remotely with limited or no evidence to guide the process. Therefore, the use of web-based platforms to conduct real-time research visits surged despite the lack of evidence backing these novel approaches. This paper aims to review the remote or virtual research protocols that have been used in the past 10 years, gather existing best practices, and propose recommendations for continuing to use virtual real-time methods when appropriate. Articles (n=22) published from 2013 to June 2023 were reviewed and analyzed to understand how researchers conducted virtual research that implemented real-time protocols. \"Real-time\" was defined as data collection with a participant through a live medium where a participant and research staff could talk to each other back and forth in the moment. We excluded studies for the following reasons: (1) studies that collected participant or patient measures for the sole purpose of engaging in a clinical encounter; (2) studies that solely conducted qualitative interview data collection; (3) studies that conducted virtual data collection such as surveys or self-report measures that had no interaction with research staff; (4) studies that described research interventions but did not involve the collection of data through a web-based platform; (5) studies that were reviews or not original research; (6) studies that described research protocols and did not include actual data collection; and (7) studies that did not collect data in real time, focused on telehealth or telemedicine, and were exclusively intended for medical and not research purposes. Findings from studies conducted both before and during the COVID-19 pandemic suggest that many types of data can be collected virtually in real time. Results and best practice recommendations from the current protocol review will be used in the design and implementation of a substudy to provide more evidence for virtual real-time data collection over the next year. Our findings suggest that virtual real-time visits are doable across a range of participant populations and can answer a range of research questions. Recommended best practices for virtual real-time data collection include (1) providing adequate equipment for real-time data collection, (2) creating protocols and materials for research staff to facilitate or guide participants through data collection, (3) piloting data collection, (4) iteratively accepting feedback, and (5) providing instructions in multiple forms. The implementation of these best practices and recommendations for future research are further discussed in the paper. DERR1-10.2196/53790.

Background Numerous observational studies show associations between family meal frequency and markers of child cardiovascular health including healthful diet quality and lower weight status. Some studies also show the “quality” of family meals, including dietary quality of the food served and the interpersonal atmosphere during meals, is associated with markers of child cardiovascular health. Additionally, prior intervention research indicates that immediate feedback on health behaviors (e.g., ecological momentary intervention (EMI), video feedback) increases the likelihood of behavior change. However, limited studies have tested the combination of these components in a rigorous clinical trial. The main aim of this paper is to describe the Family Matters study design, data collection protocols, measures, intervention components, process evaluation, and analysis plan. Methods/design The Family Matters intervention utilizes state-of-the-art intervention methods including EMI, video feedback, and home visiting by Community Health Workers (CHWs) to examine whether increasing the quantity (i.e., frequency) and quality of family meals (i.e., diet quality, interpersonal atmosphere) improves child cardiovascular health. Family Matters is an individual randomized controlled trial that tests combinations of the above factors across three study Arms: (1) EMI; (2) EMI + Virtual Home Visiting with CHW + Video Feedback; and (3) EMI + Hybrid Home Visiting with CHW + Video Feedback. The intervention will be carried out across 6 months with children ages 5–10 ( n  = 525) with increased risk for cardiovascular disease (i.e., BMI ≥ 75%ile) from low income and racially/ethnically diverse households and their families. Data collection will occur at baseline, post-intervention, and 6 months post-intervention. Primary outcomes include child weight, diet quality, and neck circumference. Discussion This study will be the first to our knowledge to use multiple innovative methods simultaneously including ecological momentary intervention, video feedback, and home visiting with CHWs within the novel intervention context of family meals to evaluate which combination of intervention components are most effective in improving child cardiovascular health. The Family Matters intervention has high potential public health impact as it aims to change clinical practice by creating a new model of care for child cardiovascular health in primary care. Trial registration This trial is registered in clinicaltrials.gov (Trial ID: NCT02669797). Date recorded 5/02/22.

Background Parents are an important influence on children’s dietary intake and eating behaviors. However, the lack of a conceptual framework and inconsistent assessment of food parenting practices limits our understanding of which food parenting practices are most influential on children. The aim of this study was to develop a food parenting practice conceptual framework using systematic approaches of literature reviews and expert input. Method A previously completed systematic review of food parenting practice instruments and a qualitative study of parents informed the development of a food parenting practice item bank consisting of 3632 food parenting practice items. The original item bank was further reduced to 110 key food parenting concepts using binning and winnowing techniques. A panel of 32 experts in parenting and nutrition were invited to sort the food parenting practice concepts into categories that reflected their perceptions of a food parenting practice conceptual framework. Multi-dimensional scaling produced a point map of the sorted concepts and hierarchical cluster analysis identified potential solutions. Subjective modifications were used to identify two potential solutions, with additional feedback from the expert panel requested. Results The experts came from 8 countries and 25 participated in the sorting and 23 provided additional feedback. A parsimonious and a comprehensive concept map were developed based on the clustering of the food parenting practice constructs. The parsimonious concept map contained 7 constructs, while the comprehensive concept map contained 17 constructs and was informed by a previously published content map for food parenting practices. Most of the experts (52%) preferred the comprehensive concept map, while 35% preferred to present both solutions. Conclusion The comprehensive food parenting practice conceptual map will provide the basis for developing a calibrated Item Response Modeling (IRM) item bank that can be used with computerized adaptive testing. Such an item bank will allow for more consistency in measuring food parenting practices across studies to better assess the impact of food parenting practices on child outcomes and the effect of interventions that target parents as agents of change.

Background A better understanding of the optimal “dose” of behavioral interventions to affect change in weight-related outcomes is a critical topic for childhood obesity intervention research. The objective of this review was to quantify the relationship between dose and outcome in behavioral trials targeting childhood obesity to guide future intervention development. Methods A systematic review and meta-regression included randomized controlled trials published between 1990 and June 2017 that tested a behavioral intervention for obesity among children 2–18 years old. Searches were conducted among PubMed (Web-based), Cumulative Index to Nursing and Allied Health Literature (EBSCO platform), PsycINFO (Ovid platform) and EMBASE (Ovid Platform). Two coders independently reviewed and abstracted each included study. Dose was extracted as intended intervention duration, number of sessions, and length of sessions. Standardized effect sizes were calculated from change in weight-related outcome (e.g., BMI-Z score). Results Of the 258 studies identified, 133 had sufficient data to be included in the meta-regression. Average intended total contact (# sessions x length of sessions) was 27.7 (SD 32.2) hours and average duration was 26.0 (SD 23.4) weeks. When controlling for study covariates, a random-effects meta-regression revealed no significant association between contact hours, intended duration or their interaction and effect size. Conclusions This systematic review identified wide variation in the dose of behavioral interventions to prevent and treat pediatric obesity, but was unable to detect a clear relationship between dose and weight-related outcomes. There is insufficient evidence to provide quantitative guidance for future intervention development. One limitation of this review was the ability to uniformly quantify dose due to a wide range of reporting strategies. Future trials should report dose intended, delivered, and received to facilitate quantitative evaluation of optimal dose. Trial registrations The protocol was registered on PROSPERO (Registration # CRD42016036124 ).

Ecological momentary assessment (EMA) has become a popular mobile health study design to understand the lived experiences of dynamic environments. The numerous study design choices available to EMA researchers, however, may quickly increase participant burden and could affect overall adherence, which could limit the usability of the collected data. This study quantifies what study design, participant attributes, and momentary factors may affect self-reported burden and adherence. The EMA from the Phase 1 Family Matters Study (n=150 adult Black, Hmong, Latino or Latina, Native American, Somali, and White caregivers; n=1392 observation days) was examined to understand how participant self-reported survey burden was related to both design and momentary antecedents of adherence. The daily burden was measured by the question \"Overall, how difficult was it for you to fill out the surveys today?\" on a 5-item Likert scale (0=not at all and 4=extremely). Daily protocol adherence was defined as completing at least 2 signal-contingent surveys, 1 event-contingent survey, and 1 end-of-day survey each. Stress and mood were measured earlier in the day, sociodemographic and psychosocial characteristics were reported using a comprehensive cross-sectional survey, and EMA timestamps for weekends and weekdays were used to parameterize time-series models to evaluate prospective correlates of end-of-day study burden. The burden was low at 1.2 (SD 1.14) indicating \"a little\" burden on average. Participants with elevated previous 30-day chronic stress levels (mean burden difference: 0.8; P=.04), 1 in 5 more immigrant households (P=.02), and the language primarily spoken in the home (P=.04; 3 in 20 more non-English-speaking households) were found to be population attributes of elevated moderate-high burden. Current and 1-day lagged nonadherence were correlated with elevated 0.39 and 0.36 burdens, respectively (P=.001), and the association decayed by the second day (β=0.08; P=.47). Unit increases in momentary antecedents, including daily depressed mood (P=.002) and across-day change in stress (P=.008), were positively associated with 0.15 and 0.07 higher end-of-day burdens after controlling for current-day adherence. The 8-day EMA implementation appeared to capture momentary sources of stress and depressed mood without substantial burden to a racially or ethnically diverse and immigrant or refugee sample of parents. Attention to sociodemographic attributes (eg, EMA in the primary language of the caregiver) was important for minimizing participant burden and improving data quality. Momentary stress and depressed mood were strong determinants of participant-experienced EMA burden and may affect adherence to mobile health study protocols. There were no strong indicators of EMA design attributes that created a persistent burden for caregivers. EMA stands to be an important observational design to address dynamic public health challenges related to human-environment interactions when the design is carefully tailored to the study population and to study research objectives.

Background People with diabetes, vascular disease, and asthma often struggle to maintain stability in their chronic health conditions, particularly those in rural areas, living in poverty, or racially or ethnically minoritized populations. These groups can experience inequities in healthcare, where one group of people has fewer or lower-quality resources than others. Integrating behavioral healthcare services into primary care holds promise in helping the primary care team better manage patients’ conditions, but it involves changing the way care is delivered in a clinic in multiple ways. Some clinics are more successful than others in fully integrating behavioral health models as shown by previous research conducted by our team identifying four patterns of implementation: Low, Structural, Partial, and Strong. Little is known about how this variation in integration may be related to chronic disease management and if IBH could be a strategy to reduce healthcare inequities. This study explores potential relationships between IBH implementation variation and chronic disease management in the context of healthcare inequities. Methods Building on a previously published latent class analysis of 102 primary care clinics in Minnesota, we used multiple regression to establish relationships between IBH latent class and healthcare inequities in chronic disease management, and then structural equation modeling to examine how IBH latent class may moderate those healthcare inequities. Results Contrary to our hypotheses, and demonstrating the complexity of the research question, clinics with better chronic disease management were more likely to be Low IBH rather than any other level of integration. Strong and Structural IBH clinics demonstrated better chronic disease management as race in the clinic’s location became more White. Conclusions IBH may result in improved care, though it may not be sufficient to resolve healthcare inequities; it appears that IBH may be more effective when fewer social determinants of health are present. Clinics with Low IBH may not be motivated to engage in this practice change for chronic disease management and may need to be provided other reasons to do so. Larger systemic and policy changes are likely required that specifically target the mechanisms of healthcare inequities.