What are contextual factors?
Contextual factors can have an impact on your CHWP’s outcomes but are not necessarily part of the intervention.
Contextual factors can be specific to the program itself, to program participants and their families, and even to the communities where participants live. Contextual factors for childhood obesity can be quite complex and encompass all of the individual, societal, and systemic factors that impact a child’s weight. Often there are several contextual factors to keep in mind as you evaluate your program. In this section, we’ll detail several contextual factors that commonly impact healthy weight programs.
What types of contextual factors are appropriate for CHWPs to consider?
Research on contextual factors across CHWPs is limited, but a few studies have shown where some opportunities may exist to help facilitate program attendance and completion.40,41,42,43 Attendance is one key factor to help participants in your program meet their goals and ultimately for your program to achieve its outcomes. If participants do not show up, then chances are the program will not be very successful. If attendance is a troublesome spot for your program, look at the barriers to attendance to determine if any may need to be addressed by your program. Other common barriers may be identified and addressed by your CHWP in similar ways (Figure 3).
Individual-level contextual factors, or those specific to participants or their parents, are numerous and may include factors such as access to healthy foods and safe places to exercise. Additionally, there may be specific facilitating contextual factors that you may wish to consider since these may help children and families to benefit from your program (Figure 3).
Figure 3: Categorization of contextual factors
- Time availability to attend CHWP
- Conflicting schedules and work hours
- Parent attendance
- Parent engagement in behavior change
- Conflicting commitments with school and extracurricular activities
- Hesitancy to attend because of prior unsuccessful weight loss attempts
- Lack of transportation or public transportation
- Need for reimbursement for transportation
- Inadequate transportation to safe physical activity outlets for youth
Potential Attendance Facilitators
- Offering program session scheduling far in advance
- Providing transportation assistance
- Mapping the frequency and duration of the program onto the academic school year
- Convenient local program location
- Virtual delivery of program can facilitate attendance, scheduling
- Motivational program leader
- Monetary incentives or small rewards from program leaders/parents/guardians
- Program structure
- Smaller groups
- Modality, including phone, text or virtual
- Include the whole family
- Must be fun to encourage child participation
- Cultural relevance
Common Individual-Level Contextual Factors
- Readiness to change
- Importance or concern
- Demographic characteristics
- Health-Related Social Needs
- Housing instability
- Food insecurity
- Education and health literacy
- Employment status
- Neighborhood/community factors
- Immigration status and legal factors
- Cultural acceptability
- Mental health
- Adverse childhood experiences
- Executive functioning or problem-solving ability
- Social support (informational, emotional, functional)
- Family functioning and connectedness
- Social connection with
- Group leaders and behavioral/health coaches
- Other group members
- Alignment of program expectations
- Technology for virtual programs
- Bandwidth/internet access
- Ability to use program/engage
Common Barriers–Access to Healthy Foods:
- Cost of fresh produce
- Expiration of fresh produce before use
- Family/child exposure and acceptability to variety of foods
- Cost of childcare
- Parents/guardians must pay for childcare for younger siblings in order to take an older child to the gym or other organized activities
- Community factors/safety
- Accessibly to physical activity resources
How should contextual factors be chosen for evaluation?
Although contextual factors may play a role in the overall success of your program, some of the contextual factors listed in Figure 3 may not be appropriate for your program to address. Think about the factors that are most important to your program and then determine which ones you can do something about. If there are factors not in your purview to address, consider connecting participants and their families to services you are aware of within your community instead of taking them on within your program. In this section we share some examples of potential opportunities to assess several personal contextual factors.
What are opportunities for CHWPs to address contextual factors?
If you conduct an assessment at some point during your program, it may be helpful to ask specific questions vs more open-ended questions and to limit the number of questions you ask. This will help you to focus your questions on factors you can address and help lower participant burden. For example, asking parents “What is it about the program that has been difficult for you?” may lead to answers you can do little or nothing about. However, asking parents something along the lines of “What about this program has been most difficult: transportation, timing, or location?” may provide you greater opportunity to address these factors for future programming. Perhaps if you learn timing is an issue, you will work to provide your program at more times during the week or you might offer services like childcare for younger children, so parents do not feel conflicted when taking older children to your program. You may also be able to connect families to a ride-service or other transportation resources in the community to facilitate transportation to and from your program. If you cannot change the timing of your program or offer transportation options, then these items may not be reasonable to ask about; however, understanding these issues may help you engage your partners to identify resources and solutions to address them. Lastly, it is important to identify potential facilitators to any identified barriers. For example, if the cost of transportation or fresh foods is identified, then your program and partners can facilitate connecting participants to voucher or reimbursement programs.
Social determinants of health (SDoH) and health equity are important areas to consider incorporating into evaluation efforts. SDoH encompass both the conditions in which people are born, grow, live, work, and age44 and the social and economic context that shapes these conditions.45 Health equity aims to eliminate disparities in health by aiming to ensure disadvantages based on social position or other socially determined circumstances do not exist.46 In this regard, addressing obesity is an important health equity goal. There are many resources to help your program identify ways to include a healthy equity lens into your CHWP evaluation. For example, a policy statement by the American Academy of Pediatrics offers strategies to screen and identify children at risk for food insecurity and provides recommendations on how to connect families to appropriate community resources.47 Additionally, the Centers for Medicare and Medicaid Services developed the Accountable Health Communities Health-Related Social Needs Screening Tool, the first 10 items of which relate to several social determinant of health domains: housing, food insecurity, transportation, utility help needs, and interpersonal safety. Additional domains include employment and physical activity. This tool can be used as an action item (CHWPs can act on these contextual factors) as well as a data collection tool for evaluation to create supports for future iterations. You will find several resources in Table 1 that can help your program think about addressing SDoH and health equity issues.
Table 1: Select Resources to Help Address Social Determinants of Health and Health Equity
- The Accountable Health Communities Health-Related Social Needs Screening Tool was developed by the Centers for Medicare & Medicaid Services to help providers conduct assessments to inform patients’ treatment plans and make referrals to community services. The first 10 items in the tool are related to SDoH.
- Addressing Health Equity in Evaluation Efforts helps users integrate health equity considerations into each step of an evaluation.
- Getting to Equity in Obesity Prevention: A New Framework is a discussion paper that proposes using a framework with a deliberate focus on equity when designing and implementing strategies for obesity prevention.
- Health Equity Resource Toolkit for State Practitioners Addressing Obesity Disparities aims to increase the capacity of state health departments and their partners to implement effective responses to obesity in populations that are facing health disparities.
- Promoting Food Security for All Children was developed by the American Academy of Pediatrics and the Food Research & Action Center to help providers learn how they can play a critical role in addressing food insecurity. The toolkit includes a validated two-question food insecurity screening tool and provides guidance on how providers can address food insecurity among their patients and families.
- Screen and Intervene: A Toolkit for Pediatricians to Address Food Insecurity was developed by the American Academy of Pediatrics and the Food Research & Action Center to help providers learn how they can play a critical role in addressing food insecurity. The toolkit includes a validated two-question food insecurity screening tool and provides guidance on how providers can address food insecurity among their patients and families.
- Social Determinants of Health 101 for Health Care: Five Plus Five is a discussion paper that provides readers with five things to know about SDoH in health care.
Assessing parents’ readiness to change or parents’ self-efficacy to address obesity-related behaviors is possible, although it can be difficult to assess. A simple 10-point scale is common and can easily be used in your program. Questions can vary and may include:
- How motivated are you to make healthy changes to support your child’s/family’s health?
- How important is it for you to make those changes?
- How confident are you to make those changes?
You can also review the following resources on parental support and self-efficacy and determine if they are appropriate for you to incorporate in your program evaluation:
- Validation of five stage of change measures for parental support of healthy eating and activity
- Lifestyle Behaviour Checklist
- Development and preliminary validation of the Parent Efficacy for Child Healthy Weight Behaviour Scale
- Parent Efficacy for Child Healthy Weight Behavior Scale (PECHWB)
Evaluating contextual factors is complicated, given the different levels at which they can impact program success. Given the numerous contextual factors that can be evaluated, and taking time and costs into consideration, not all factors discussed in this section can be feasibly collected by your program. Contextual factors will be different for every program and can differ among cohorts in the same program. Therefore, ways to address contextual factors will vary. We outlined several key contextual factors for your consideration, but there may be other contextual factors that can impact the success of your program. You may find yourself asking, “How do I address all the potential factors that may affect my program’s outcomes?” but do not despair. Instead prioritize one or two contextual factors that your program may be able to address and determine the best time during the course of your program to ask these questions. This will also help limit the number of questions you ask of program participants and reduce participant burden. Ultimately, the goal is to assess potentially malleable contextual factors that your program may be able to address.
For more information:
The Institute for Medicaid Improvement conducted a learning collaborative for Medicaid-managed care plans that were running weight management programs. The collaborative produced two toolkits—Changing the Culture of Health in Childhood Obesity: Implementation Toolkit for Medicaid Health Plans and Building a Culture of Health in Childhood Obesity: Overview & Action Plan for Medicaid Health Plans—which may be helpful to your organization when thinking about contextual factors.