Training and Reflective Supervision Emerge as Top Strategies to Bring Healthy Eating and Activity Support Into Home Visiting

When a nurse, social worker, or trained home visitor sits down with a young mother in her own living room, something happens that a clinic can rarely replicate. The visitor is trusted. The relationship is sustained over months or years. And the conversation can bend toward whatever matters most that day — food, stress, sleep, or a toddler’s tantrum. For researchers trying to prevent chronic disease, that living-room trust is a precious resource, and a new study published in Frontiers in Health Services shows how to use it deliberately. The work, led by Rachel G. Tabak of Washington University in St. Louis, mapped the practical strategies needed to embed a proven healthy eating and activity intervention inside Parents as Teachers, a national home visiting model serving families from pregnancy through kindergarten entry.

The intervention at the heart of the effort is HEALTH — Healthy Eating and Active Living Taught at Home. Its evidence base is not theoretical. In a 24-month group-randomized trial involving 230 mothers with overweight or obesity and their preschool children, mothers receiving HEALTH lost an average of 1.5 kilograms by the study’s end, while mothers in usual care gained 3.2 kilograms, a statistically significant difference with a p-value of .002. A second randomized trial adapted the program for pregnancy and postpartum: among 267 Black mothers enrolled in Parents as Teachers, 89 percent of whom participated in Medicaid, those receiving the adapted intervention retained 2.5 kilograms at one year postpartum compared with 5.7 kilograms among controls, a difference of 3.2 kilograms that reached significance at p = .01. These are clinically meaningful margins for a program delivered not by clinicians but by parent educators working within an existing community infrastructure.

The scale of the delivery platform is what makes the new analysis viral in its implications. Parents as Teachers operated 858 affiliates across the United States in 2024–2025, staffed by roughly 4,300 parent educators, reaching more than 77,000 families and 93,000 children. Eighty-two percent of the families served carry at least one stressor such as low income, low educational attainment, recent immigration, or unstable housing. These are precisely the populations that bear the greatest chronic disease burdens and face the steepest barriers to healthcare access. Healthcare systems structured around traditional medical care and billing struggle to build the kind of sustained, trusted relationships that home visiting organizations develop as a matter of routine. Yet community-based organizations were not originally designed to deliver health-related interventions, which is where implementation science enters the picture.

Implementation science is the discipline concerned with the deliberate spread and uptake of evidence-based programs into usual practice settings. It defines implementation strategies — methods designed to enhance adoption, implementation, and scale-up of evidence-based interventions — and provides frameworks for assessing the contextual determinants, the barriers and facilitators, that operate at individual, provider, and organizational levels. The research team used two complementary tools. The first is a Designing for Dissemination and Sustainability approach, which engages community organization partners from the earliest stages of intervention development and aligns the program with the organization’s usual practice and reimbursement structure. The second is the Implementation Strategies Applied in Communities compilation, or ISAC, a taxonomy of strategies specifically tailored to community-based organizations rather than clinical settings.

Rather than inventing entirely new implementation supports, the team conducted a series of iterative meetings with the Parents as Teachers National Center — drawing on staff from research and learning, implementation support, training, and curriculum — to match previously identified determinants with potential ISAC strategies. Eleven determinants had emerged from prior mixed-methods work: parent educator experience and comfort discussing weight, supervisor and peer support, perceived value, fit with workflow, relationships and trust, and mothers’ social needs, among others. The resulting strategy set deliberately leveraged structures already familiar to affiliates: reflective supervision, implementation support calls, professional development, peer learning opportunities, communities of practice, webinars, and conference-based learning. The goal was to maximize fit with existing organizational workflows while minimizing burden on local programs and parent educators.

The specified strategies are concrete. Parent educators within an affiliate meet to share successes and challenges implementing HEALTH. Communities of practice bring parent educators together across affiliates on a monthly basis after initial training. The National Center develops materials that supervisors use during reflective supervision meetings with parent educators to observe, provide feedback, and offer HEALTH supports. Brief online refresher trainings, each under twenty minutes, address common challenges and solutions on an ongoing basis. Implementation support team members and supervisors problem-solve on monthly HEALTH-focused calls. Parent educators themselves develop short messages and videos with implementation tips, which the National Center shares through social media at least quarterly. A podcast series about HEALTH and how to access training runs monthly, and webinars occur two to four times per year. Each strategy is mapped to the actors, actions, temporality, dose, and determinants it targets.

To test how these strategies land with the workforce, the team administered an anonymous five-item survey at the 2025 Parents as Teachers Annual Conference in San Juan, Puerto Rico. Participants scanned a QR code displayed during workshops, rated each strategy on perceived impact and feasibility using a five-point scale, and reported their role and community type. Forty-nine participants from 18 states responded; most were parent educators, and 77 percent served a mix of suburban, urban, and rural communities or only urban ones, while 23 percent served only rural or small-town communities. Responses were dichotomized, with ratings of extremely or considerably grouped together, and differences of at least 20 percent between respondent types were treated as substantively meaningful. No statistical testing was conducted due to the sample size and potential for multiple comparisons.

The results converge on a clear hierarchy. Training on implementing the intervention received the highest percentage of respondents — 89 percent — rating it as extremely or considerably impactful, and it also drew the second highest feasibility rating at 83 percent. Materials to support supervisors for reflective supervision earned the highest feasibility rating and the second highest impact rating. Communities of practice, parent educator team meetings, and resource connection supports were viewed as highly impactful but somewhat less feasible. At the bottom of the hierarchy were podcast series focused on the intervention and implementation support calls focused on the intervention. Ratings were broadly similar across rural and mixed or urban settings, suggesting the strategies were well aligned with existing organizational processes rather than requiring context-specific redesign.

Role differences, however, were pronounced. For short messages and videos about the intervention, 94 percent of supervisors and leaders rated it as extremely or considerably impactful, compared with only 65 percent of parent educators. The pattern reversed for podcasts and implementation support calls: 67 percent and 59 percent of parent educators rated these as extremely or considerably impactful, versus 41 percent and 39 percent of supervisors and leaders. Parent educators also rated podcasts and implementation support calls as more feasible than supervisors did — 62 percent and 72 percent versus 37 percent and 41 percent. For ongoing refresher training and better partnerships for resource connections, 88 percent of parent educators rated feasibility as extremely or considerably, compared with 59 percent and 65 percent among supervisors and leaders. The authors suggest that parent educators’ comfort with peer-level supports may reflect their day-to-day familiarity with the intervention content, while supervisors may need additional work to build support for strategies they perceive as less feasible.

The broader takeaway extends well beyond a single intervention. Organizations with established implementation supports — workforce development systems, reflective supervision, technical assistance, quality improvement structures — may be better positioned to integrate multiple evidence-based interventions over time by leveraging existing relationships rather than creating intervention-specific supports for each new initiative. Comparable studies reinforce this pattern: Knapp and colleagues found training and leadership support to be key strategies for implementing a pediatric hypertension guideline in community health centers, though they also identified medical-record strategies such as reminders and order sets that are more relevant to clinical contexts. Glasgow and colleagues found little difference in strategy preferences among primary care physicians based on rural or urban context, echoing the current study’s finding of similarity across community types. The study’s limitations are acknowledged: the convenience sample was self-selected, the cross-sectional design limits causal interpretation, and the conference setting may not be accessible to all programs. Still, the findings suggest that when a home visiting organization decides to embed health content, the most viral strategy may be the least glamorous one — train the workforce well, support the supervisors who support the educators, and let the existing infrastructure do the rest.

Subject of Research: Implementation strategies for embedding a healthy eating and activity intervention within community-based home visiting

Article Title: Strategies to support implementation of an intervention embedding healthy eating and activity content within community-based home visiting

Article References: Tabak, R. G., Gilbert, A., Morshed, A. B., Farabi, S. S., Schwarz, C. D., Kemner, A., & Haire-Joshu, D. (2026). Strategies to support implementation of an intervention embedding healthy eating and activity content within community-based home visiting. Frontiers in Health Services, 6, Article 1951390. https://doi.org/10.3389/frhs.2026.1951390

Image Credits: AI Generated

DOI: 10.3389/frhs.2026.1951390

Keywords: implementation science, home visiting, Parents as Teachers, healthy eating, physical activity, community health, maternal health, chronic disease prevention, Strategies, support, implementation, intervention