Section

5

Outcome Measures

What are outcome measures?

Outcome measures are those that show the impact of your intervention on, for example, a health metric.

Outcome measures will help you determine the impact of your program’s intervention on the children and families who are enrolled.¹⁸ Outcome measures enhance your understanding of the impact of your program on participants, whether positive or negative, by looking at measures such as those related to anthropometry, physiology, and lifestyle and behavior changes. When interested parties think of program evaluation, they are often focused on outcome measures such as weight status improvement, but it is important to remember these measures are only one piece of your evaluation. Some outcome measures, such as change in medication use or health care costs, may not be feasible to assess when programs last a few weeks or even a few months.

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What types of outcome measures are appropriate for CHWPs?

Community-based CHWPs usually have a goal of improving children’s weight status or preventing excessive weight gain through changes in diet, physical activity, and sedentary behavior. While weight-based outcomes are important, consider other outcomes as well, which may have an important impact on the health and quality of life of the participants and their families. Some CHWPs also aim to have a favorable impact on physiologic or metabolic, behavioral, or psychosocial outcomes. Funders or other interested parties may also want to see how the program affects other outcomes, such as health care costs.

Anthropometric measures will provide you with information on weight, body size, and body composition. Methods to assess anthropometry commonly include the measurement of height and weight to calculate body mass index (BMI). When deciding which anthropometric measures to include, you may wish to consider:

• Staff training
• Cost of equipment
• Time to conduct measurements
• Frequency of measurement
• Privacy
• Acceptability of measurements
• Considerations when measuring children with severe obesity or disabilities

For a review of the procedures and considerations when collecting anthropometric measures using the aforementioned methods, refer to A Guide to Methods for Assessing Childhood Obesity.

NCCOR designed this User Guide to assist users in selecting the most appropriate method of measuring adiposity in children when conducting population-level research and/or evaluation on obesity.

Physiological and metabolic measures may include blood pressure, lipids, glucose, or hemoglobin A1c, as well as effort-based measures such as resting heart rate or heart rate recovery from exercise. Also included are measures of fitness, strength, and motor skill development. Similar to choosing anthropometric measures, your choice of physiological and metabolic measures will require you to consider issues relating to training and equipment.

Measures of fitness are evaluated because they can help with setting and achieving fitness goals and priorities.²⁸

• 12-minute walk
• Fitness Gram Pacer Assessment
• Heart rate recovery

Measures of strength in children are evaluated to monitor how strength is developed.²⁹ Examples of strength tests commonly used with children are noted below.³⁰

• Grip strength test
• Push-up test
• Plank test

When conducting any effort-based testing, it is important to assess improvements from baseline. It is also important to keep in mind that in many CHWPs, most participants may have normal physiological and metabolic measures at baseline. This could make it more difficult to detect improvements in these measures in a group of children and adolescents during the program or intervention. In some cases, changes in associated health conditions such as asthma, sleep apnea, or diabetes can be assessed. However, it may not be feasible to assess such conditions unless the CHWP has an existing relationship with a primary care office or other health care setting.

Lifestyle or behavioral change measures include changes in nutrition, physical activity, screen time, and sleep. These measures can be evaluated via self-report questionnaires, direct observation, or devices (e.g., accelerometers or pedometers for physical activity). Self-report tools, particularly for diet and physical activity, have limitations that may affect their validity. If using a questionnaire or survey, consider using one that has already been developed and validated.

Psychosocial measures consider the possible impact of your CHWP on domains of psychological and social functioning among children or teens with overweight or obesity. Self-report measures such as treatment satisfaction that document where the CHWP may have a particular strength or a need for potential improvement may be used as process measures. Psychosocial measures require consideration of who is best suited to report on the outcomes of interest. For younger children (<7 years of age), caregiver report is preferable because child reading levels are limited. Self-report, caregiver proxy, or both may be appropriate for older children, depending on the domains measured.

Health-related quality of life (HRQoL) is a common psychosocial measure. HRQoL examines functioning in the physical, social, emotional, and school domains. Studies report that children and teens with overweight and obesity report significant impairments in functioning relative to healthy weight peers.^33,34 Data suggest that improvements in HRQoL are associated with participation in weight control interventions.³⁵

Self-esteem is broadly defined as thoughts, concepts, and feelings about oneself.³⁶ Studies using measures of self-esteem have shown that children with overweight or obesity have lower self-esteem.³⁷ Low self-esteem is in turn associated with a lower likelihood of successful outcomes after participation in weight management programs. Efforts to improve self-esteem during participation in healthy weight interventions have been found to be associated with improved weight outcomes.^38,39

Other psychosocial measures that can be assessed include weight-related teasing, depression, anxiety, and concerns with weight, shape, or body image. Weight-related teasing is commonly reported by youth with overweight or obesity. Lastly, weight and body shape are different from body image. Body image is defined as the extent to which weight influences overall feelings about oneself. Evaluating concerns with weight, shape, or body image may be more appropriate for older children and teens.

When using psychosocial measures, baseline measurement as well as changes over time should be assessed. Also, consider the implications of your assessments from a safety perspective. That is, if the measures you chose provide diagnostic information or assess a specific risk, such as disordered eating patterns, you will need to ensure you have an appropriate plan, staff, and resources for responding in real-time. If you do not, consider not using those measures at all.

Cost-related measures include those deriving from cost analyses and cost-effectiveness analyses. Cost analyses capture the costs included in delivering the intervention (e.g., facilitator or coach time, and space) as well as costs to participants (e.g., travel time, transportation costs, and opportunity costs for lost wages). Cost analyses can be important measures because they will help you and your partners describe what it takes to implement your program. Cost effectiveness analyses assess whether an intervention provides value relative to an existing intervention, such as usual care.

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How should outcome measures be chosen?

You should identify the outcomes of interest to your CHWP. Selecting the best outcome measures to evaluate your program will depend on a variety of factors, including what you and program partners, including funders, participants, and families, would consider as useful outcomes. Once you’ve identified your outcomes, take the time to evaluate what would constitute “successful outcomes” in your program for involved parties, as this can help you in your deliberations. Finally, try and balance the feasibility and validity of your chosen outcome measures. Practical considerations, including feasibility, participant and program/interventionist burden, and costs of collecting the measures, can also be important considerations when planning measures for evaluating your study.

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If I had to choose, what outcome measures are ideal for all CHWPs to evaluate?

In summary, CHWPs can prioritize evaluating outcome measures such as:

• Height and weight
• Lifestyle behaviors (healthier food, physical activity, and sleep patterns)

Measures that may require more time and training or have associated costs but are worth consideration include those relating to:

• Blood pressure
• Fitness (resting heart rate, 12-minute walk/run with resting heart rate recovery assessment)
• Brief assessments that are available at no-cost and are likely to show improvement:
  • HRQoL
  • Self-esteem domains
• Weight-related teasing and perceptions of body image

Please see Appendix 2 for a summary of these measures. This Appendix presents Level 1 and Level 2 measures to facilitate your choice of measure, depending on your capacity and familiarity with evaluation.

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Summary

Not all potential outcome measures will be relevant for every program. Practical considerations, including feasibility and costs of collecting the measures, can be important when planning measures for evaluating your study. There is a need to balance feasibility and validity in the measures chosen—sometimes methods that are more valid are unavailable, too expensive, or too time consuming to include.

Be sure to set appropriate expectations for your CHWPs leadership and staff, as well as your partners. Your program’s goal (e.g., weight gain prevention vs obesity treatment), size, duration, and intensity can also help you to choose appropriate outcome measures. For example, a small treatment-focused program of moderate to high intensity (i.e., >26 contact hours over 2–12 months) may expect to have a greater impact on weight and other anthropometric outcomes as well as biomedical outcomes such as blood pressure and lipids than a large community-based recreational program targeting obesity prevention.

You may wish to consider intermediate outcomes for which you will be able to detect changes in dietary intake and physical activity levels in addition to changes in weight. Also consider time points at which outcomes will be measured. Often this takes place at the start and end of a program, but it may vary by the type of measure and the goals of the program. Not all outcome measures need to be assessed at all timepoints.

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