I Introduction – What is NutriSTEP®?
II Implementation of Nutritional Risk Screening
III Lessons Learned
--written by Michelle Manarina, an intern at the Nutrition Resource Centre and a graduate student in Public Health Nutrition at the University of California, Berkeley; submitted by Lee Rysdale, MEd, RD, Program Coordinator, Nutrition Resource Centre, Ontario Public Health Association
The development and review of this article were supported by the study investigators, Dr. Janis Randall Simpson, RD and Dr. Heather Keller, RD of the University of Guelph. Study site coordination was provided by Mary Turfryer, MHSc, RD, Nutrition Services, York Region Community and Health Services Department; Kim McKibbon, RD, Thunder Bay District Health Unit; and, Lee Rysdale, MEd, RD, Nutrition Resource Centre. Parent telephone interviews and data analysis was conducted by Eliana Witchell, MAN (candidate), University of Guelph.
Financial support for this study was provided by Danone Institute.
Study investigators were Dr. Janis Randall Simpson, RD and Dr. Heather Keller, RD, University of Guelph; Joanne Beyers, MA, RD, Sudbury& District Health Unit; Lee Rysdale, MEd, RD, Nutrition Resource Centre; and, Mary Turfryer, MHSc, RD, Nutrition Services, York Region Community and Health Services Department.
I Introduction – What is NutriSTEP®?
NutriSTEP® (Nutrition Screening Tool for Every Preschooler) is a fast and simple way to assess eating habits and identify nutrition problems early in young children 3–5 years of age. The NutriSTEP® questionnaire includes 17 items covering: food and nutrient intake, physical growth, developmental and physical capabilities, physical activity, food security and the feeding environment.  It is intended for use by community professionals and should be completed by the child’s parent or primary caregiver, whoever is most knowledgeable about the child’s eating and other health habits.
The NutriSTEP® questionnaire is scored according to three levels of nutrition risk with follow-up guidelines for parents:
Low Risk – Children whose score is less than 20 are low risk and require no immediate follow-up. Parents are encouraged to refer to the educational materials provided with the screening index.
Moderate Risk – Parents of children whose score is 21–25 are moderate risk and are encouraged to refer to the educational materials provided with the screening index. These parents are also directed to a number of community and provincial programs such as Eat Right Ontario (www.eatrightontario.ca) and the provincial toll-free Dietitian Call Centre (1-877-510-510-2) as well as their local public health unit.
High Risk – Parents of children whose risk score is 26 or greater are high risk and are encouraged to follow-up with appropriate community-based services such as a registered dietitian or family doctor.
Based on validation results, up to 14% of the preschool population will potentially be identified as high risk and in need of some form of primary prevention.  This proportion is comparable to other provincial public health screening initiatives in Dental Health and Healthy Babies, Healthy Children. The NutriSTEP® questionnaire is listed as a valid and reliable tool to be used in the Child Health Program, Requirement # 11 of the Ontario Public Health Standards, released November 2008. 
II Implementation of Nutritional Risk Screening
After the development and validation of NutriSTEP®, it was necessary to determine how to implement screening in an ethical manner. Without developing a process for identification, referral and follow-up, children would be labeled as “at risk” and the screening process may result in more harm than good.  Screening models should identify how screening happens, identification of appropriate and feasible referrals, how referrals should occur, and how follow-up is completed to ensure that needs are met. [4, 5]
A community or service provider interested in implementing screening needs to consider: the capacity of the community; the training needs of screen administrators ; reaching those who will benefit from the program ; issues with data collection and management ; and, the process for ethically meeting the needs of those at risk. [7, 8] Development and process evaluation of feasible models is the first step towards achieving these ends and thus the focus of the targeted implementation of NutriSTEP® in Ontario.
Study Goal and Objectives
With funds from a Danone Institute Grant-in-Aid, a targeted implementation and process evaluation study was led by the University of Guelph and the Nutrition Resource Centre using different nutrition risk screening and referral models in select Ontario sites from June 2007 to June 2009. The purpose of this NutriSTEP® study was to develop and implement models that could evaluate the successes in each site as well as the barriers that needed to be overcome so that screening, referral if necessary, and follow-up could occur.  The overall goal of this research was to determine the resources required and feasible and appropriate processes for implementing NutriSTEP® in an ethical manner. The specific objectives were:
1. To develop two feasible models for implementation of NutriSTEP® in public health.
2. To implement NutriSTEP® screening based on the proposed models.
3. To evaluate the targeted implementation of NutriSTEP®.
Study Design and Results
This study was a process evaluation of two models for targeted implementation of NutriSTEP® in three sites in Ontario: York Region, Thunder Bay and Sudbury. In York Region, a Self Referral Model was coordinated through York Region Health Department and included the NutriSTEP® screening tool in a school board kindergarten registration package. In Thunder Bay and Sudbury, an Assisted Referral Model was developed. In Thunder Bay, the Assisted Referral Model was coordinated through the Thunder Bay District Health Unit via their established Fair Start preschool screening program. In Sudbury, NutriSTEP® was implemented as part of a new screening program via the Ontario Best Start Hubs and coordinated by the Sudbury & District Health Unit. The goal was to screen 500, 300, and 200 preschoolers in York Region, Thunder Bay and Sudbury respectively. This decision was based on a projection that 50–100 children (10% of the sample size of 1000) would be at high risk and parents of these children were initially intended to be the focus of parent perception interviews to evaluate the screening and referral process.
In Thunder Bay and Sudbury, nutrition screening in English and French began in early November 2007 and was completed at the end of June 2008. By the end of the data collection period, 153 children were screened in Thunder Bay, and 80 children were screened in Sudbury. Only two parents in each of these locations declined the nutrition risk screening. In York Region, 1400 screening packages were distributed to 137 schools from January to May 2008 and 131 (9.5%) of the surveys were returned to the University of Guelph. A total of 364 NutriSTEP® and demographic questionnaires were completed in this study. The nutritional risk levels were as follows: 6% high risk, 13% moderate risk, and 81% low risk.
Of the 364 parents who completed the NutriSTEP® questionnaire, 264 agreed to be contacted by a University of Guelph research assistant. A total of 164 telephone interviews were conducted (151 English, 13 French) using a scripted questionnaire on parent perceptions of the screening venue, the screening process, nutritional risk, referrals, and usefulness of resources. Parents of low-risk children generally reported feeling reassured, happy, and relieved. They expressed that the questionnaire was a useful confirmation of their child’s nutritional status. Parents with children at moderate or high risk often reported a chronic health or health history issue, such as anemia, or expressed that the questionnaire provided confirmation of issues that were already suspected.
When asked about what they thought of the screening process, parents in all three locations had mainly positive opinions about the screening venue. For example, in Thunder Bay, most parents thought that the Fair Start screening fairs were good places for this because they were convenient. Some parents, however, felt that the setting was very busy, that the nutrition risk screening could get “lost” in the process, and that those who attend screening fairs are likely not those who really “need” to have nutrition risk screening. Parents from York Region were very positive about the distribution of the NutriSTEP® questionnaire through the schools as it had the potential to reach everyone and the importance and relevance of preschool nutrition issues was reinforced with the school’s involvement. At the Best Start Hub in Sudbury, parents felt that the screening process needed to be flexible as the primary purpose of these facilities was for drop-in, not screening.
Overall, the main benefit of screening was an increase in parent awareness of nutritional risk factors. Very few of the parents who had been referred to a health professional and who were interviewed actually followed through with the referral. Barriers to referrals/screening included already being aware of nutritional issues, other situations taking precedence, or a lack of time to make changes. The low uptake of referrals highlights the need to ensure adequate follow-up of ‘at risk’ families.
III Lessons Learned
As with any community-based research project, many practical lessons were learned behind the scenes. Site coordinator reports from the three regions identified the challenges associated with screening as part of a research study. All of the site coordinators noted difficulties with the research component of the project. The length of time parents needed to complete the screening process was significantly increased by the added requirements of completing the demographic and consent forms. Additionally, some sites experienced legal issues with reporting potential child welfare concerns. A few parents expressed concerns regarding the consent forms; one parent stated “[I had a concern about] the comment on the consent form about possibly contacting social services.”
Based on past early years screening experiences in Sudbury and Thunder Bay, these programs have targeted preschool age children; however, during the study period, parents of older infants and toddlers were more frequently registering for Fair Start or attending the Best Start Hubs. It would appear that parents are more aware and interested in these programs when their children are younger. Therefore, the programs recruited participants from Junior Kindergarten registration and Welcome to Kindergarten events to reach the preschool age children for whom NutriSTEP® is designed.
Other challenges in Sudbury were related to the staggered start dates of the hub sites during the data collection period and competing program priorities which delayed or discontinued study participation by some hub sites. In addition, program staff turnover resulted in the need for multiple training sessions for the research component at many of the sites. In both Sudbury and Thunder Bay, there was also difficulty providing additional training on preschool nutrition topics for screeners. In York Region, it was difficult to get packages to parents as schools reported not receiving them or forgetting to distribute them.
As a result of the feedback from parents and site coordinators, researchers have identified some key lessons from this study:
- Study settings and procedures may not be typical.
- Nutrition concerns are complex to address.
- We can screen, identify, refer and gather data well.
- Ethical practice is difficult to carry out – follow-up with parents is critical.
- Measuring efficacy and effectiveness requires long-term evaluation efforts.
Overall, nutrition risk screening for preschoolers using NutriSTEP® has been demonstrated to be not only feasible, but sustainable, in Self-Referral and Assisted Referral models in Ontario. Both Thunder Bay and York Region have continued the implementation of NutriSTEP® using the same as well as expanded referral models and settings. Plans are underway in Sudbury to continue the NutriSTEP® program. The success of this study has enabled implementation projects in Ontario primary health care settings including the Hamilton and Stratford family health teams and the Hospital for Sick Children through a number of community pediatrician practices and a large family medicine group. Furthermore, resources and findings from this project have been incorporated into the NutriSTEP® Implementation Toolkit and NutriSTEP® website.
The NutriSTEP® program will easily dovetail into existing provincial programs and reach at-risk preschoolers and their families in locations such as Best Start Hubs, parent education programs, school readiness programs, and primary health care settings such as Family Health Teams (FHTs). The Assisted Referral Model is feasible; however, there is a need for training of facilitators and communication with numerous community partners. The Self Referral Model can reach a large number of people and provides a good opportunity for partnerships between public health and schools.
- Randall Simpson JA, Keller HH, Rysdale LA, Beyers JE. Nutrition Screening Tool for Every Preschooler (NutriSTEP™): validation and test-retest reliability of a parent-administered questionnaire assessing nutrition risk of preschoolers. Eur J Clin Nutr (2007), 1-11 [online].
- Ministry of Health and Long Term Care. Ontario Public Health Standards 2008. Available at: http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_stan.... Accessed July 15, 2009.
- Rush D. Nutrition screening in old people: Its place in the coherent practice of preventive health care. Annu Rev Nutr 1997;17: 101-25.
- Keller HH, Brockest B, and Haresign H. Building Capacity for Nutrition Screening. Nutrition Today 41(4), 164-170. 2006.
- Weddle DO, Wellman NS, and Bates GM. Incorporating Nutrition Screening into Three Older Americans Act Elderly Nutrition Programs. Journal of Nutrition for the Elderly 17(1), 19-37. 1997.
- Bonnel W. Nutritional health promotion for older adults, where is the content? J Am Acad Nurse Pract 2003;15:224-9.Edington J. Problems of nutritional assessment in the community. Proc Nutr Soc 1999;58: 47-51.
- Shah C. Public Health and Preventive Medicine in Canada, 2003. Toronto: Elsevier Saunders, 2003.
- Edington J. Problems of nutritional assessment in the community. Proc Nutr Soc 1999; 58: 47-51.
- Ross EM, Rosenberg IH, Dawson-Hughes B, Col NF, Wong JB. Fitting nutrition into the medical model: the role of decision analytic cost-effectiveness techniques. Eur J Clin Nutr 1999;53 Suppl 2:S25-S28.