High Five For Kids Toolkit

Investigators in the Department of Population Medicine (DPM) and Harvard Vanguard Medical Associates received a grant from the National Institute of Health to address the prevalence of obesity in young children. The study was carried out within Harvard Vanguard’s pediatric practices targeting children two to six years old who exceed body mass index recommendations for their age and sex. The program incorporated elements of the chronic care model and behavior change theory -- attempting to change parental behavior and then the child’s behavior. Advanced Practice Clinicians engaged parents with motivational interviews, goal setting, and advice about healthful dietary practices and physical activity. In addition, the program attempts to reduce TV viewing and consumption of sugary beverages and fast food. The program's innovative thinking could eventually become a national model for preventing obesity in young children.



Use of the High Five for Kids program materials is permissable with adequate citation. Please use the following citation text: Used with permission (or adapted) from the High Five for Kids study (NIH funded 5R01HD050966; PI: Matthew Gillman, MD, SM).
To request clean copies of any of the materials, please email: highfiveforkids@hphc.org

Table of Contents

    Clinician and Staff Training
    Study Protocols
    Clinic Forms
    Clinician Visit Tools
    Visit Materials
    Surveys, FAQs, Protocols
    Quality Assurance



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Overview of High Five for Kids
This brief overview offers a synopsis of the study and an introduction to Boingo, the High Five for Kids mascot.

Roles of practice team members in High Five for Kids
All levels of pediatric practice team members played a role in High Five for Kids. This page outlines their distinct responsibilities in implementing the program.

High Five for Kids participant eligibility
This page reviews the eligibility criteria for participating in High Five for Kids.

High Five for Kids participant visit timeline
The study schedule of clinic visits and follow-up for both intervention and usual care participants is included in the timeline of visits.

APC visit timeline
The APC's study schedule of clinic visits and follow-up for intervention participants. It was updated during the course of the study to reflect a change in the end point of follow-up from 2.5 years to 2 years.


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Survey of practices
Prior to the development of the High Five for Kids intervention, study staff conducted exploratory visits to each of the participating sites to learn about the practice’s department operations and patient populations. This survey was completed at these onsite visits in meetings with department chiefs and supervisors.

Approach for Prevention & Management of Overweight in Children 2-12 years
Developed by the National Initiative for Children’s Healthcare Quality (NICHQ), this algorithm of care was included in the toolkit for High Five clinicians.


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Clinician and Staff Training

APC Training Agenda
This was the agenda for the 2-day training of the intervention Advanced Practice Clinicians (APCs). Clinicians received CNE/CME credits for participating in the training.

Counseling Script and MI Roadmap
A one-page script/study visit overview, this is a condensed version of the study scripts.

Talking points to overcome barriers to behavior change
This document was given to APCs to aid them in helping parents overcome barriers to behavior change.

Cross-cultural education primer
A brief primer on the key concepts of cross-cultural care, this educational packet was developed by the Culturally Competent Care Education Committee of Harvard Medical School.

Height and weight measurement training
This instructor’s guide outlines the training for medical assistants to take research-level height and weight measurements of pediatric patients. There is also a handout on how to accurately record measurements, which was given to the MAs as part of the training.

Consent Form
The research consent form was mailed to study participants following verbal consent to complete the baseline survey, and confirmation of eligibility. Study participants were then required to mail back a signed copy of the form.


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Study Protocols

Intervention site workflow
This is the protocol for clinic staff at intervention sites, detailing what to do when study participants come in for appointments, as well as non-study patients within the target age group. It was given to clinic supervisors prior to the start of the study.

Usual Care site workflow
This is the protocol for clinic staff at usual care sites, detailing what to do when study participants come in for study height and weight checks. It was given to clinic supervisors prior to the start of the study.


CDM Study Visits
Initial Visit

  • Outline

  • This outline was included in the APC toolkit to offer a look at the initial study visit.
  • Guide

  • This complete guide to conducting the initial study visit, including sample scripts, was included in the APC toolkit.
  • Cue Card

  • This cue card gave a brief outline of conducting the initial study visit.

Follow-up Call

  • Outline

  • This outline was included in the APC toolkit to offer a look at the follow-up calls that came between each of the first three study visits.
  • Guide

  • A complete guide for the APCs in conducting the follow-up calls that came between each of the first three study visits.

Follow-up Visit

  • Outline

  • This outline was included in the APC toolkit to offer a look at the follow-up study visits.
  • Guide

  • This complete guide for the APCs detailed the follow-up study visits.


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Clinic Forms

Referral for High Five visits
Following patient enrollment in High Five for Kids, MDs/NPs completed this referral form at the well-child visit, and asked the parent to schedule a High Five visit with the intervention APC.

Well child visit survey
This survey was to be given to the parents/caretakers of all 2-6.9 year old patients upon arrival at the intervention clinic for a well-child visit (regardless of weight status or study enrollment). It was intended to be a conversation starter to address healthy behaviors and readiness for change,

Intake form
This form was to be completed by the MA recording height and weight measurements for a child in for a study visit.

SonneWheel (BMI assessment tool)
The SonneWheel is a BMI wheel that gives a child’s BMI based on height and weight, and then identifies BMI percentile range and classifies the child as Normal, At Risk, or Overweight. The calculations are separate for boys and girls.

CDC BMI chart for boys
CDC BMI chart for girls

Coding reference sheet
A list of codes and explanations to assist sites in billing for High Five for Kids study visits.


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Clinician Visit Tools

Visit Smart Text
In the EpicCare electronic medical record used at Harvard Vanguard Medical Associates, Smart Text templates are used in visit notes. The Smart Text provides a place for the APCs to record patient history with regard to the High Five behaviors.

Reference cards APC set Pediatrician set
The documents included in this section were made into 6”x3.5” laminated cards, hole-punched, and held together on a metal ring.

  • Core values
    • This card is intended to be used with parents to help them reflect on their own values and how those values might affect, or be affected by, their child’s health behaviors.


  • Confidence & Interest
    • The confidence and interest scale is used to help participants move forward their thinking about changing a behavior. Showing them the scale and asking the prompts encourages them to voice the reasons why they think they can make the change, as well as the reasons why it might be difficult. Identifying these barriers and facilitators can further their thoughts on how to be successful in making a change.


    • FRAMES is an acronym to help clinicians structure behavior change conversations with patients. It instructs clinicians to give feedback, to know that the decision to change is ultimately up to the patient, to offer advice, to provide a menu of options for change, and to be empathic and encouraging.


  • MI Road Map reminder
    • An additional tool to aid clinicians in structuring behavior change conversations with patients, this is a simple outline of a Motivational Interviewing encounter.


  • Overweight sensitivity
    • This is a list of recommended ways for clinicians to be sensitive in the words they use to discuss overweight and related behaviors with their patients.


  • Assess readiness
    • This card can help clinicians identify a patient’s readiness to change, and then guide them through how to respond and help patients move forward towards changing behavior, depending on the patient’s stage of readiness.


  • Non-High Five visits
    • This card offered clinicians tools to address High Five behaviors when seeing patients during non-High Five visits.


Prescription Pad
A tool for APCs to prescribe the High Five behaviors to their patients.


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Visit Materials

Poster for exam/waiting rooms
This poster serves as a conversation starter, sparking parents and children to think and talk about healthy behaviors even before seeing the clinician.

Menu of High Five behaviors
A key tool for study visits, the APC shows parents and children the menu of behaviors, identifies where the child has room to improve and where s/he is doing well (based on history taken), and then asks, “What are you interested in starting to work on?”

For Kids
Coloring pages (Set 1 and Set 2)
APCs gave kids these coloring sheets along with crayons to help entertain them while their parent(s) talked with the APC at study visits.

For Parents: (distributed by clinicians)

High Five Schedule
This fun chart helps families track their High Five for Kids visits and know what to expect over the course of the program.

Physical activity resources (example)
To help families find opportunities for physical activity, the APCs gave participants a list of parks and recreation organizations in and around their clinic community.

Tracking Calendar
Spanish version
Participants who set a behavioral goal at a High Five visit received a tracking calendar and a set of stickers. The calendar was designed to engage the child in their progress towards the goal and to offer a visual to follow how they are doing.

Stage-matched educational handouts
Spanish version
For most of the behavioral targets there are three handouts, each designed to address the needs of families at different stages of readiness to change. The three categories are Did you know?, Let’s get started…, and Keep it up! There are only two stages of handouts for TV-Free Bedrooms: Did you know? and Keep it up!, since the action step for removing TV from a child’s bedroom is primarily the physical process of moving a TV.

Did you know?
These handouts are for patients who are not meeting a behavioral goal, and do not indicate readiness to think about making a change to the behavior. It offers information that might help move someone to start to recognize that there could be a reason to change their behavior.

Let’s get started…
These handouts offer action steps and tips for families who have expressed that they would like to work on the behavior.

Keep it up!
For patients who are meeting the behavior target, these handouts offer tips and encouragement to maintain it.

  • Healthy Drinks Did you know?
  • Healthy Drinks Let’s get started…
  • Healthy Drinks Keep it up!
  • TV-Free Bedrooms Did you know?
  • TV-Free Bedrooms Keep it up!
  • Limit TV Did you know?
  • Limit TV Let’s get started…
  • Limit TV Keep it up!
  • Active Play Did you know?
  • Active Play Let’s get started…
  • Active Play Keep it up!
  • Five-A-Day Did you know?
  • Five-A-Day Let’s get started…
  • Five-A-Day Keep it up!
  • Healthy Meals Did you know?
  • Healthy Meals Let’s get started…
  • Healthy Meals Keep it up!

Additional handouts to support the stage-matched educational handouts:
Spanish version

  • Milk for High Five Kids
  • Healthy Snacking for High Five Kids
  • Healthy Snack Ideas for High Five Kids
  • Drink Ideas for High Five Kids
  • TV-Free Activities for High Five Kids
  • Healthy meal Ideas for High Five Kids
  • More Healthy Meals for High Five Kids
  • Fruits and Vegetables for High Five Kids
  • Finding Healthy Drinks for High Five Kids
  • High Five Facts about TV & Advertising
  • Children's Media Use and Weight
  • Healthy Portions for High Five Kids

Black and white materials
These handouts were intended to be stand-alone documents that were not stage-matched, as they were distributed by clinicians to non-High Five patients at intervention sites. They were printed in black and white.

  • Healthy Drinks Did you know?
  • Healthy Drinks Let’s get started…
  • TV-Free Bedrooms Did you know?
  • Limit TV Did you know?
  • Limit TV Let’s get started…
  • Active Play Did you know?
  • Active Play Let’s get started…
  • Five-A-Day Did you know?
  • Five-A-Day Let’s get started…
  • Healthy Meals Did you know?
  • Healthy Meals Let’s get started…

TV Allowance

  • TV Allowance Guidelines

  • This is a guideline for the APCs around when and how to introduce the TV Allowance monitor to parents.
  • TV Allowance Q & A

  • This question and answer form addressed anticipated APC questions about distributing TV Allowance.
  • Setting up TV Allowance

  • To make the process as simple as possible, we included these detailed directions with each TVA to help parents connect the monitor to their home television.


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Based on the Menu of Behaviors, this laminated placemat is directed towards kids, encouraging them in each of the target behaviors.

Printed front and back on heavy cardstock, the bookmarks offer a list of activities to do instead of watching TV.

Shopping list
Spanish version
This shopping list is a notepad with tear-off sheets. The back has a magnet so it can be mounted on the refrigerator.

Appointment-making gift bags
These bags were kept at the clinic reception desk for front desk staff to give to participants upon scheduling a High Five visit. There were four bags, each with a different message included on a card, and as little “gift” inside.

  • Snack bags are great for grab-and-go snacking. Inside was a recipe for trail mix.
  • Boingo likes to color, you can too! This bag included a small box of crayons and a Boingo coloring page.
  • Go outside and get dirty. We’ll help you clean up! Enclosed was a page of instructions for creating an obstacle course, and a packet of hand sanitizing wipes.
  • Put up a picture of your High Five hero! This came with a magnetic picture frame.


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Surveys, FAQs, Protocols

Baseline survey

  • Script

  • Research assistants used this phone script when calling potential participants to first determine eligibility and then, if eligible, to obtain baseline data, contact information, etc.
  • Refusal survey

  • Anyone deemed ineligible by the baseline survey, or who refused participation, was asked these follow-up questions.

Year 1 follow-up survey

  • Script

  • Research assistants followed this phone script to complete the year 1 follow-up surveys with all participants. Intervention participants only were asked addendum questions specific to program components and participant experiences with the program.

Year 2 final survey

  • Script

  • Research assistants followed this phone script to complete the final survey with all participants. Intervention participants only were asked addendum questions specific to program components and participant experiences with the program.


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Quality Assurance (QA)

QA protocol
Written for the APCs, this is an overview of the quality assurance process and the steps involved to complete it.

QA review for initial visit
This form was used by the expert reviewer to evaluate tape-recorded initial study visits, as well as by the APC to self-evaluate the recoded visits. The APC and the reviewer each kept their own copy to refer to when together discussing the visit.

QA review for follow-up visits
This form was used to assess recorded follow-up visits in the same way that the QA review form for initial visits was used.


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Retention (acquiring measurements and maintaining appointments)

Update on study visit appointment scheduling (sample)
Sent to each of the intervention sites, this individualized “report card” offered feedback on the number of study visits scheduled at that site that should have been scheduled at that point in time. It also includes tips for getting visits scheduled.

Moved out of HVMA follow-up
While participant eligibility was dependent on planning to stay with their current pediatric practice for the full two years of the study, a handful did move while enrolled. In order to obtain updated BMIs from these individuals, we asked them to authorize us to contact their new pediatrician, or if they didn’t have one yet, their school, to try to obtain a recent height and weight measurement. Following are the forms and letters used to complete this process:

Birthday card (sample)
This is an example of a birthday card sent to study participants. All participants were sent birthday cards during the two years of their study enrollment.

Art contest
All enrolled intervention participants were sent this art contest page and encouraged to mail back their own drawings about growing healthy.

Intervention newsletters
Over the course of the study, five newsletters were mailed to intervention participants, each addressing a different High Five target behavior. The “Keep in touch!” insert was included in each newsletter, highlighting the APC(s) and contact information specific to the pediatric office where the participant receives his or her care.

All-participant newsletter
This version of High Five News addressed general health, wellness, and family fun. It was mailed to all participants (both intervention and usual care).

  • High Five News: Fall (reading, bike safety, poison prevention, fall family activities, kids' insert)
  • High Five News: Spring (make a kite, sun safety, water safety, spring family activities, kids' insert)
  • High Five News: Summer (car safety seats, internet safety, beach crafts, summer family activities, kids' insert)

Clinician newsletter
Mailed to all intervention site clinicians, each In the Spotlight… newsletter focused on one of the five primary behavioral targets of High Five for Kids. Each includes snippets from the research literature about the targeted behavior, as well as talking points for discussing the behavior with parents, and a list of High Five study materials that address the behavior and were available to intervention families.