A major objective of this study was to assess the feasibility of a home-based coaching intervention that targeted the home environments of rural adults. The few prior studies targeting home environments for obesity prevention have focused on children.9
Recruitment efforts were generally successful, although 25% of those enrolled did not initiate study activities. About half of these could not be reached by telephone (original recruitment was in-person), and the other half changed their minds about participating. This suggests the intervention may appeal to many people, but a subset will have limited interest in or availability to schedule home visits with a coach. Those who participated in intervention activities were very pleased with the coaching process. Additionally, once people began the intervention, participation was fairly high, with over three quarters of primary participants completing all home visits and coaching calls. Engaging a second member of each household was more challenging than expected, perhaps because the initial recruitment focused on just one member of the household. Targeting only the meal preparer and/or food shopper as the primary change agent may be a more efficient approach for changing the home environment and should be explored in future research.
Despite the fact the study was not powered to detect environmental or behavioral outcomes, we observed significant improvements in the home food environment and a trend toward weight loss. There were also some improvements in home activity environment indicators. There is little precedent in published research against which to compare these findings.
Of the behavioral outcomes, only fat intake decreased significantly. The clinical significance of this decrease is difficult to ascertain given the short timeframe of the study. A limitation of this study is the heavy reliance on self-reported measures. Even with a possible social desirability bias, however, the results are sufficiently positive to warrant additional research. Future research should include more objective instruments, such as the use of accelerometers to assess physical activity and 24-hour dietary recalls to assess caloric intake, along with longer term follow-up.
A 6-week intervention is quite brief relative to other interventions to prevent weight gain. A recent review showed that weight gain prevention interventions ranged from 13 weeks to 5 years.5
Results suggest the Healthy Homes/Healthy Families intervention is promising, but that the intervention might be lengthened to solidify and/or deepen the environmental changes triggered by the coaching. A longer and/or more intense intervention may also increase the likelihood that changes in the home environment lead to increased energy expenditure and decreased energy consumption over time.
The study findings were shared with the CAB and used to formulate the partnership’s next research project. CAB members were enthused about the study findings and decided to collaboratively conduct a large, randomized controlled trial of a similar but more intensive intervention targeting women as gatekeepers of the home environment. Three community health centers were represented on the CAB and they suggested that recruitment be done by providers at their centers. Another work group was formed to expand and enhance the intervention strategies, and the new trial is currently underway in partnership with three community health centers. Primary outcomes for the current trial are assessed through accelerometers and two 24-hour dietary recalls.
Ultimately, the dissemination potential of these types of interventions is critical for their ability to make an impact on population health.40
Even when interventions are proven effective, they must be compatible with organizational missions and contexts to be adopted by sufficient numbers of organizations to make a difference. Therefore, it is important to design interventions that can be adopted by existing organizational structures in communities. A major advantage of using CBPR in the progression of studies described herein is that the intervention was designed to address a health issue of major local concern, local leaders were committed to and excited about the research, and the intervention is consistent with local values and community structures. Coupling the Healthy Homes/Healthy Families intervention with a clinic-based screening and referral system, such as we are currently testing, has the potential for widespread dissemination. This approach has the added benefit of resolving the issue of how to recruit participants into this type of intervention.
The health coach has the potential to be a low-cost bridge between the patient-centered medical home and the actual patient home. As healthcare reform provides medical homes for a greater proportion of the population, a complementary strategy would be to improve actual home environments to support healthy lifestyles. Physicians could refer patients to home-based coaching interventions to prevent obesity in their patients. The “home visit” was a traditional part of public health—originally for maternal and child health services—and could be adapted for the twenty-first century to address chronic disease prevention and management. One of the major challenges of the patient-centered medical home is that of achieving behavioral changes, especially concerning diet and physical activity. A recent article by Lianov and Johnson discusses41
how physicians must increase their competence level in promoting lifestyle change in their patients. They recommend routine assessment of health behaviors, followed by evidence-based counseling and use of community resources. Ecologic models of obesity prevention highlight the need for multiple intervention strategies in multiple sectors of the community.42
Intervention research that links the medical home with the actual home via a community-based intervention developed through community-engaged research is an important step in this direction.