Creating community action plans for obesity prevention using the ANGELO (Analysis Grid for Elements Linked to Obesity) Framework

Developing and Evaluating a Data-Driven and Systems Approach to Health Promotion Among Vocational Students: Protocol for the Data Health Study

BACKGROUND

Vocational school students exhibit significant risk behaviors in terms of poor diet, frequent use of nicotine products, inadequate fruit and vegetable intake, low levels of physical activity, and poor mental health. This makes vocational students vulnerable to the development of noncommunicable diseases. Therefore, effective health promotion programs targeting vocational students are required.

OBJECTIVE

The Danish study "Data-driven and Systems Approach to Health Promotion Among Vocational Students" (Data Health) aims to develop, implement, and evaluate a systems approach to support vocational schools, municipalities, and local communities in implementing locally relevant health promotion actions among and for vocational students. This paper describes the Data Health program and how implementation and preliminary effectiveness will be evaluated.

METHODS

The Data Health program offers an iterative 5-step process to develop changes in the systems that shape health behavior and well-being among vocational students. The program will be implemented and evaluated in 8 Danish vocational schools in 4 municipalities. The implementation of the process and actions will be explored using a systems-based evaluation design that assesses contextual differences and the mechanisms through which the program leads to changes in the systems. Preliminary effectiveness at the individual level (students' self-reported health behavior and well-being) and organizational level (school organizational readiness reported by school staff) will be assessed using a quasi-experimental design, and cross-sectional data will be collected at all 8 schools simultaneously 4 times during the 2-year study period.

RESULTS

This study was launched in 2021, and data collection is expected to be completed in June 2024. The first results are expected to be submitted for publication in January 2024.

CONCLUSIONS

We expect that the Data Health study will make significant contributions to complex intervention research by contributing to the paucity of research studies that have used systems approaches in school settings. The study will also provide evidence of successful elements for systems change and effectiveness to determine whether a national scale-up can be recommended.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05308459; https://clinicaltrials.gov/study/NCT05308459.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52571.

Scanning for Obesogenicity of Primary School Environments in Tshwane, Gauteng, South Africa

The purpose of this study was to scan for the obesogenicity of primary school environments in Tshwane, Gauteng, South Africa. This study was carried out in ten public primary schools in the Tshwane West district of the Gauteng province. An observational design was used to collect the data. Data collection was conducted using an observational checklist guided by the Analysis Grid for Environments Linked to Obesity (ANGELO) framework. The findings revealed that although a nutrition policy was available in most schools, few schools were communicating the policy. Despite all the schools having sports fields, children were not exercising. Most schools also had a school nutrition programme. Most primary schoolchildren's lunchboxes contained sweets, sugar-sweetened beverages, and snacks. A few lunchboxes contained fruits and vegetables. Primary schools in Tshwane West did not comply with most aspects of the school mapping environment, indicating that the school environments were obesogenic. It is therefore essential to scan for obesogenicity in all South African schools so that tailor-made interventions can be implemented to rectify and further prevent obesogenic school environments.

Non-traditional data sources in obesity research: a systematic review of their use in the study of obesogenic environments

BACKGROUND

The complex nature of obesity increasingly requires a comprehensive approach that includes the role of environmental factors. For understanding contextual determinants, the resources provided by technological advances could become a key factor in obesogenic environment research. This study aims to identify different sources of non-traditional data and their applications, considering the domains of obesogenic environments: physical, sociocultural, political and economic.

METHODS

We conducted a systematic search in PubMed, Scopus and LILACS databases by two independent groups of reviewers, from September to December 2021. We included those studies oriented to adult obesity research using non-traditional data sources, published in the last 5 years in English, Spanish or Portuguese. The overall reporting followed the PRISMA guidelines.

RESULTS

The initial search yielded 1583 articles, 94 articles were kept for full-text screening, and 53 studies met the eligibility criteria and were included. We extracted information about countries of origin, study design, observation units, obesity-related outcomes, environment variables, and non-traditional data sources used. Our results revealed that most of the studies originated from high-income countries (86.54%) and used geospatial data within a GIS (76.67%), social networks (16.67%), and digital devices (11.66%) as data sources. Geospatial data were the most utilised data source and mainly contributed to the study of the physical domains of obesogenic environments, followed by social networks providing data to the analysis of the sociocultural domain. A gap in the literature exploring the political domain of environments was also evident.

CONCLUSION

The disparities between countries are noticeable. Geospatial and social network data sources contributed to studying the physical and sociocultural environments, which could be a valuable complement to those traditionally used in obesity research. We propose the use of information available on the Internet, addressed by artificial intelligence-based tools, to increase the knowledge on political and economic dimensions of the obesogenic environment.

How do we best engage young people in decision-making about their health? A scoping review of deliberative priority setting methods

INTRODUCTION

International organisations have called to increase young people's involvement in healthcare and health policy development. We currently lack effective methods for facilitating meaningful engagement by young people in health-related decision-making. The purpose of this scoping review is to identify deliberative priority setting methods and explore the effectiveness of these in engaging young people in healthcare and health policy decision-making.

METHODS

Seven databases were searched systematically, using MeSH and free text terms, for articles published in English before July 2021 that described the use of deliberative priority setting methods for health decision-making with young people. All titles, abstracts and full-text papers were screened by a team of six independent reviewers between them. Data extraction followed the Centre for Reviews and Dissemination guidelines. The results are presented as a narrative synthesis, structured around four components for evaluating deliberative processes: 1) representation and inclusion of diverse participants, 2) the way the process is run including levels and timing of participant engagement, 3) the quality of the information provided to participants and 4) resulting outcomes and decisions.

FINDINGS

The search yielded 9 reviews and 21 studies. The more engaging deliberative priority setting tools involved young people-led committees, mixed methods for identifying and prioritising issues and digital data collection and communication tools. Long-term and frequent contact with young people to build trust underpinned the success of some of the tools, as did offering incentives for taking part and skills development using creative methods. The review also suggests that successful priority setting processes with young people involve consideration of power dynamics, since young people's decisions are likely to be made together with family members, health professionals and academics.

DISCUSSION

Young people's engagement in decision-making about their health is best achieved through investing time in building strong relationships and ensuring young people are appropriately rewarded for their time and contribution. If young people are to be instrumental in improving their health and architects of their own futures, decision-making processes need to respect young people's autonomy and agency. Our review suggests that methods of power-sharing with young people do exist but that they have yet to be adopted by organisations and global institutions setting global health policy.

Maintenance Outcomes of the Children's Healthy Living Program on Overweight, Obesity, and Acanthosis Nigricans Among Young Children in the US-Affiliated Pacific Region: A Randomized Clinical Trial

Importance

Few obesity prevention trials among children have demonstrated sustainable outcomes in the long term.

Objectives

To sustain a community-wide decrease in the prevalence of overweight and obesity among young children in the US-affiliated Pacific region.

Design, Setting, and Participants

In the Children's Healthy Living community-randomized clinical trial, hierarchical modeling comparing the change in intervention and control communities accounted for community randomization (community clustering with jurisdictions), and adjusted for the age and sex distribution of the assessed children in a cross-sectional design. The outcome measures were repeated in communities rather than among individual children. A total of 27 communities in 5 jurisdictions (Hawai'i, Alaska, Commonwealth of the Northern Mariana Islands, American Samoa, and Guam) of the US-affiliated Pacific region were included. Participants included children aged 2 to 8 years in the 27 selected communities from October 1, 2012 (4329 in time 1 [baseline]) to August 31, 2015 (4043 in time 2 [intervention end]) and from January 1, 2019, to April 30, 2020 (1469 in time 3 [maintenance period]). Study analysis was completed March 25, 2022.

Interventions

Nineteen activities addressed training, policies, systems, and environments of communities and 6 target behaviors of children (consumption of fruit and vegetables, water, and sugar-sweetened beverages; sleep; physical activity; and screen time) during a 2-year intervention period. Continued partnership with community coalitions, ongoing academic training of community partners, and use of trial data during a 6-year maintenance period.

Main Outcomes and Measures

The primary outcome was measured anthropometry; secondary outcomes were the presence of acanthosis nigricans, dietary intake derived from 2 days of food records, and survey questions on screen time and sleep disturbance.

Results

Among the 9840 children included in the analysis (4866 girls [49.5%] and 4974 boys [50.5%]; 6334 [64.4%] aged 2-5 years), the intervention group showed significant improvements compared with the control group from times 1 to 3 in prevalence of overweight plus obesity (d = -12.60% [95% CI, -20.92% to -4.28%]), waist circumference (d = -1.64 [95% CI, -2.87 to -0.41] cm), and acanthosis nigricans prevalence (d = -3.55% [95% CI, -6.17% to -0.92%]). Significant improvements were also observed from times 2 to 3 in prevalence of overweight plus obesity (d = -8.73% [95% CI, -15.86% to -1.60%]) but not in waist circumference (d = -0.81 [95% CI, -1.85 to 0.23] cm).

Conclusions and Relevance

This randomized clinical trial found that the outcomes of the Children's Healthy Living intervention were maintained and enhanced 6 years after the intervention among young children in the US-affiliated Pacific region. The prevalence of overweight, obesity, and acanthosis nigricans was further reduced in communities, suggesting that multilevel multicomponent interventions may help reduce child overweight and obesity in this region.

Trial Registration

ClinicalTrials.gov Identifier: NCT01881373.

Factors influencing obesogenic behaviours of adolescent girls and women in low- and middle-income countries: A qualitative evidence synthesis

This systematic review synthesized the qualitative evidence on factors influencing obesogenic behaviours in adolescent girls and women of reproductive age in low- and middle-income countries (LMICs). This qualitative evidence synthesis followed the framework synthesis approach to extract, analyse and synthesize data. Electronic searches were conducted in the Web of Science, SCOPUS, CABI Abstracts, MEDLINE, PsycINFO and Google Scholar. Studies were eligible if they were conducted in LMICs, of qualitative nature, and reported obesogenic behaviours of female adolescents (10-19 years of age) or women of reproductive age (15-49 years of age). The review resulted in 71 included studies from 27 different countries. Thirty-two studies focused on dietary behaviours, 17 on physical activity and 22 on both behaviours. Gender norms and failures to recognize the importance of healthy behaviours across the life cycle were important factors. The abundance and promotion of affordable but unhealthy food, food safety concerns, taste preferences and social desirability of foods drive consumption of unhealthy foods. Busy lives and limited exercise spaces keep girls and women from being physically active. Obesogenic behaviours of adolescent girls and women of reproductive age are influenced by factors at individual, social, physical and environmental levels and require diverse solutions to address these factors in LMICs.

Global Health in Preconception, Pregnancy and Postpartum Alliance: development of an international consumer and community involvement framework

BACKGROUND

The goal of the Global Health in Preconception, Pregnancy and Postpartum (HiPPP) Alliance, comprising consumers and leading international multidisciplinary academics and clinicians, is to generate research and translation priorities and build international collaboration around healthy lifestyle and obesity prevention among women across the reproductive years. In doing so, we actively seek to involve consumers in research, implementation and translation initiatives. There are limited frameworks specifically designed to involve women across the key obesity prevention windows before (preconception), during and after pregnancy (postpartum). The aim of this paper is to outline our strategy for the development of the HiPPP Consumer and Community (CCI) Framework, with consumers as central to co-designed, co-implemented and co-disseminated research and translation.

METHOD

The development of the framework involved three phases: In Phase 1, 21 Global HiPPP Alliance members participated in a CCI workshop to propose and discuss values and approaches for framework development; Phase 2 comprised a search of peer-reviewed and grey literature for existing CCI frameworks and resources; and Phase 3 entailed collaboration with consumers (i.e., members of the public with lived experience of weight/lifestyle issues in preconception, pregnancy and postpartum) and international CCI experts to workshop and refine the HiPPP CCI Framework (guided by Phases 1 and 2).

RESULTS

The HiPPP CCI Framework's values and approaches identified in Phases 1-2 and further refined in Phase 3 were summarized under the following five key principles: 1. Inclusive, 2. Flexible, 3. Transparent, 4. Equitable, and 5. Adaptable. The HiPPP Framework describes values and approaches for involving consumers in research initiatives from design to translation that focus on improving healthy lifestyles and preventing obesity specifically before, during and after pregnancy; importantly it takes into consideration common barriers to partnering in obesity research during perinatal life stages, such as limited availability associated with family caregiving responsibilities.

CONCLUSION

The HiPPP CCI Framework aims to describe approaches for implementing meaningful CCI initiatives with women in preconception, pregnancy and postpartum periods. Evaluation of the framework is now needed to understand how effective it is in facilitating meaningful involvement for consumers, researchers and clinicians, and its impact on research to improve healthy lifestyle outcomes.

A System Dynamics and Participatory Action Research Approach to Promote Healthy Living and a Healthy Weight among 10-14-Year-Old Adolescents in Amsterdam: The LIKE Programme

This paper describes the design of the LIKE programme, which aims to tackle the complex problem of childhood overweight and obesity in 10–14-year-old adolescents using a systems dynamics and participatory approach. The LIKE programme focuses on the transition period from 10-years-old to teenager and was implemented in collaboration with the Amsterdam Healthy Weight Programme (AHWP) in Amsterdam-East, the Netherlands. The aim is to develop, implement and evaluate an integrated action programme at the levels of family, school, neighbourhood, health care and city. Following the principles of Participatory Action Research (PAR), we worked with our population and societal stakeholders as co-creators. Applying a system lens, we first obtained a dynamic picture of the pre-existing systems that shape adolescents’ behaviour relating to diet, physical activity, sleep and screen use. The subsequent action programme development was dynamic and adaptive, including quick actions focusing on system elements (quick evaluating, adapting and possibly catalysing further action) and more long-term actions focusing on system goals and/or paradigm change. The programme is supported by a developmental systems evaluation and the Intervention Level Framework, supplemented with routinely collected data on weight status and health behaviour change over a period of five years. In the coming years, we will report how this approach has worked to provide a robust understanding of the programme’s effectiveness within a complex dynamic system. In the meantime, we hope our study design serves as a source of inspiration for other public health intervention studies in complex systems.

Identifying social norms in physical aspects of food environments: A photo study

It is widely accepted that physical food environments can contribute to unhealthy eating, but less is known about how physical cues in these environments actually stimulate eating. Our study starts from the assumption that social norms are embedded in physical cues and aims to make an inventory of physical cues that communicate what is socially accepted as normal and/or appropriate to eat in a Dutch outside-the-home food context. In Study 1, we conducted a qualitative study in which photographs taken in self-service food environments were analyzed using strategies from photo documentation and semiology. Grounded theory was applied to identify a wide variety of specific physical cues that were ultimately grouped into 18 higher level categories of physical cues (e.g. consumption traces, product availability). Most cue categories were associated with either descriptive or injunctive social norms, but some were associated with both types. In Study 2, we aimed to quantitatively cross-validate the social norm interpretations among laypeople (N = 173) by focusing on two selected photographs. More than half of the physical cues that participants identified in these photographs as being influential had been identified in Study 1 as cues bearing a normative message. The results further indicated that other people's behavior is easier to recognize in physical food environments than signals about what ought to be done. Given the great variety of identified physical cues associated with social norms, we posit that social norms are widely embedded in food environments and might guide eating behavior. Further research should study the effects of these cues on behavior and test whether the underlying process can be attributed to social norm interpretations.

Participant engagement with a UK community-based preschool childhood obesity prevention programme: a focused ethnography study

BACKGROUND

Children's centres in the UK provide a setting for public health programmes; offering support to families living in the most disadvantaged areas where obesity prevalence is at its highest. Health, Exercise and Nutrition in the Really Young (HENRY) is an eight-week obesity prevention programme currently delivered in children's centres across the UK. However, low participant engagement in some local authorities threatens its potential reach and impact. This study aimed to explore the factors influencing participant engagement with HENRY to describe where local intervention may support engagement efforts.

METHOD

A focused ethnography study was undertaken in five children's centres delivering HENRY across the UK. One hundred and ninety hours of field observations, 22 interviews with staff (commissioners, HENRY co-ordinators, managers and facilitators) and six focus groups (36 parents), took place over five consecutive days in each centre. The Consolidated Framework for Implementation Research (CFIR) was used to guide the observations and analysis of the data.

RESULTS

Three overarching themes described the factors influencing participant engagement with HENRY: local authority decision making around children's centre programmes; children's centre implementation of HENRY; and the participant experience of HENRY. The results indicate that factors influencing participant engagement with public health programmes begin at the commissioning body level, influencing children's centre implementation and subsequently the experience of participants. Local authority funding priorities and constraints influence availability of places and who these places are offered to, with funding often targeted towards those deemed most at need. This was perceived to have a detrimental effect on participant experience of the programme.

CONCLUSION

In summary, participant engagement is affected by multiple factors, working at different levels of the children's centre and local authority hierarchy, most of which are at play even before participants decide whether or not they choose to enrol and maintain attendance. For programmes to achieve their optimal reach and impact, factors at the commissioning and local implementation level need to be addressed prior to addressing participant facing issues.

Effect of the Children's Healthy Living Program on Young Child Overweight, Obesity, and Acanthosis Nigricans in the US-Affiliated Pacific Region: A Randomized Clinical Trial

IMPORTANCE

Pacific Islanders have among the highest rates of obesity and type 2 diabetes in the world. Targeting children is critical for primary prevention.

OBJECTIVES

To prevent young child overweight and obesity and to improve health in the US-Affiliated Pacific region via the Children's Healthy Living Program.

DESIGN, SETTING, AND PARTICIPANTS

In this multijurisdictional, multilevel, multicomponent community randomized clinical trial, where all evaluable children were analyzed according to the random assignment of their community, hierarchical difference-in-difference models accounted for the community randomization, community clustering with jurisdictions, and these models were adjusted for the age and sex distribution of the community. The setting was 27 communities in 5 jurisdictions (Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, and Hawaii). Participants were 4329 children (time 1) and 4042 children (time 2) aged 2 to 8 years in 27 selected communities from October 7, 2012, to October 25, 2015. Data analysis was completed in June 2018.

INTERVENTIONS

Nineteen activities addressed policy, environment, messaging, training, and 6 target behaviors (sleep time, screen time, physical activity, fruits and vegetables, water, and sugar-sweetened beverages).

MAIN OUTCOMES AND MEASURES

Primary outcomes were body size measurements. Secondary outcomes were acanthosis nigricans, sleep quality and duration, dietary intake, physical activity, and other questionnaire reponses.

RESULTS

The study included 27 communities and 8371 evaluable children (mean [SD] age, 5.4 [1.8] years; 50.9% male [n = 4264]). Data analysis included 952 children in the intervention group and 930 children in the control group aged 2 to 5 years at time 1; 825 children in the intervention group and 735 children in the control group aged 2 to 5 years at time 2; 565 children in the intervention group and 561 children in the control group aged 6 to 8 years at time 1; and 517 children in the intervention group and 560 children in the control group aged 6 to 8 years at time 2. The intervention communities showed significant improvement compared with control communities in overweight and obesity prevalence (effect size [d] = -3.95%; 95% CI, -7.47% to -0.43%), waist circumference (d = -0.71 cm; 95% CI, -1.37 to -0.05 cm), and acanthosis nigricans prevalence (d = -2.28%; 95% CI, -2.77% to -1.57%). Age and sex subgroup analysis revealed greater difference among the intervention communities in acanthosis nigricans prevalence in the group aged 2 to 5 years (-3.99%) vs the group aged 6 to 8 years (-3.40%), and the interaction was significant (d = 0.59%, P < .001), as well as the smaller difference in the group aged 2 to 5 years (-0.10%) vs the group aged 6 to 8 years (-1.07%) in screen time (d = -0.97 hour per day, P = .01).

CONCLUSIONS AND RELEVANCE

The intervention reduced the prevalence of young child overweight and obesity and acanthosis nigricans. Comprehensive, effective, and sustainable interventions are needed to improve child health in the US-Affiliated Pacific region.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01881373.

School-based systems change for obesity prevention in adolescents: outcomes of the Australian Capital Territory 'It's Your Move!'

OBJECTIVE

The Australian Capital Territory 'It's Your Move!' (ACT-IYM) was a three-year (2012-2014) systems intervention to prevent obesity among adolescents.

METHODS

The ACT-IYM project involved three intervention schools and three comparison schools and targeted secondary students aged 12-16 years. The intervention consisted of multiple initiatives at individual, community, and school policy level to support healthier nutrition and physical activity. Intervention school-specific objectives related to increasing active transport, increasing time spent physically active at school, and supporting mental wellbeing. Data were collected in 2012 and 2014 from 656 students. Anthropometric data were objectively measured and behavioural data self-reported.

RESULTS

Proportions of overweight or obesity were similar over time within the intervention (24.5% baseline and 22.8% follow-up) and comparison groups (31.8% baseline and 30.6% follow-up). Within schools, two of three the intervention schools showed a significant decrease in the prevalence of overweight and obesity (p<0.05).

CONCLUSIONS

There was some evidence of effectiveness of the systems approach to preventing obesity among adolescents. Implications for public health: The incorporation of systems thinking has been touted as the next stage in obesity prevention and public health more broadly. These findings demonstrate that the use of systems methods can be effective on a small scale.

Feasibility of a novel participatory multi-sector continuous improvement approach to enhance food security in remote Indigenous Australian communities

Background

Food insecurity underlies and compounds many of the development issues faced by remote Indigenous communities in Australia. Multi-sector approaches offer promise to improve food security. We assessed the feasibility of a novel multi-sector approach to enhance community food security in remote Indigenous Australia.

Method

A longitudinal comparative multi-site case study, the Good Food Systems Good Food for All Project, was conducted (2009–2013) with four Aboriginal communities. Continuous improvement meetings were held in each community. Data from project documents and store sales were used to assess feasibility according to engagement, uptake and sustainability of action, and impact on community diet, as well as identifying conditions facilitating or hindering these.

Results

Engagement was established where: the community perceived a need for the approach; where trust was developed between the community and facilitators; where there was community stability; and where flexibility was applied in the timing of meetings. The approach enabled stakeholders in each community to collectively appraise the community food system and plan action. Actions that could be directly implemented within available resources resulted from developing collaborative capacity. Actions requiring advocacy, multi-sectoral involvement, commitment or further resources were less frequently used. Positive shifts in community diet were associated with key areas where actions were implemented.

Conclusion

A multi-sector participatory approach seeking continuous improvement engaged committed Aboriginal and non-Aboriginal stakeholders and was shown to have potential to shift community diet. Provision of clear mechanisms to link this approach with higher level policy and decision-making structures, clarity of roles and responsibilities, and processes to prioritise and communicate actions across sectors should further strengthen capacity for food security improvement. Integrating this approach enabling local decision-making into community governance structures with adequate resourcing is an imperative.

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A diverse group of stakeholders engaged in a continuous improvement process of community-led action to strengthen food security.

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Stakeholders collectively appraised the whole local food system and prioritised strategies to improve food security.

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Actions able to be directly implemented within available resources resulted from developing collaborative capacity.

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Positive shifts in community diet were associated with key areas where actions were implemented.

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Integrating the approach with higher level decision-making structures could further strengthen capacity for food system improvement.

Study Protocol of MINI SALTEN: a technology-based multi-component intervention in the school environment targeting healthy habits of first grade children and their parents

BACKGROUND

MINI SALTEN is a program developed to increase moderate to vigorous physical activity (PA) and improve eating habits at home and school in first grade children. It aims to assess the effects of a technology family-based and PA school-based intervention. The purpose of this manuscript is to describe the protocol design and the MINISALTEN intervention.

METHODS

This is cluster-randomized controlled trial designed to run from July 2015 to November 2016 in 12 public schools of the city of Buenos Aires, matched for socio-demographic characteristics. The intervention is based on two main components: (a) "active breaks" (AB): implemented during school breaks by a PA instructor; (b) "virtual" (V): web-based contents delivered to the families via a multiplatform application. Using a computer generated random sequence participants are allocated to one of four intervention conditions: (AB), (V), (AB + V), and control (C). Outcomes are measured at baseline and 12 months post intervention, and will include data collected from the child and her/his mother/father or guardian. Primary outcome measures are: PA and sedentary behaviour (measured with accelerometers). Secondary outcome measures related are: percentage of kilocalories (kcal) from added sugars, and from total and saturated fats; grams of fruits and vegetables; and number of snacks and kcal coming from their added sugars and total and saturated fats. Family socio-economic level, home environment, and school environment will also be assessed. Statistical analysis is on an intention-to-treat principle. Baseline characteristics are described using summary measures and mixed models (with school as random effect). The effect of the two interventions will be estimated using a generalized mixed linear model with link and distribution selected according to the type of outcome. Included random effects are: child (or mother/father or guardian) accounting for repeated measures; school accounting for cluster induced by school. The most parsimonious model for each outcome will be reported. The False Discovery Rate criterion will be used to correct for multiple testing in non-planned analyses.

DISCUSSION

It is a pioneer assessment of the impact of a technology-based virtual intervention and a school-based PA program, designed to prevent obesity, and involving the parents at public schools of Buenos Aires.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN58093412 . Registered March 14th, 2016 (retrospectively registered).

The outcomes of health-promoting communities: being active eating well initiative-a community-based obesity prevention intervention in Victoria, Australia

OBJECTIVE

The aim of this study is to evaluate the impact of the Health-Promoting Communities: Being Active Eating Well (HPC:BAEW, 2007-2010) initiative, which comprised community-based multi-component interventions adapted to community context in five separate communities. The intervention aimed to promote healthy eating, physical activity and stronger, healthier communities.

METHODS

A mixed method and multilevel quasi-experimental evaluation of the HPC:BAEW initiative captured process, impact and outcome data. The evaluation involved both cross-sectional (children and adolescents) and longitudinal designs (adults) with data collected pre- and post-intervention in intervention (n=2408 children and adolescents from 18 schools, n=501 adults from 22 workplaces) and comparison groups (n=3163 children and adolescents from 33 schools, n=318 adults from seven workplaces). Anthropometry, obesity-related behavioural and environmental data, information regarding community context and implementation factors were collected. The primary outcomes were differences in anthropometry (weight, waist, body mass index (BMI) and standardised BMI (BMI z-score)) over time compared with comparison communities. Baseline data was collected 2008/2009 and post-intervention collected in 2010 with an average intervention time frame of approximately 12 months.

RESULTS

The strategies most commonly implemented were related to social marketing, stakeholder engagement, network and partnership development, community-directed needs assessment and capacity building. Analysis of post-intervention data showed gains in community capacity, but few impacts on environments, policy or individual knowledge, skills, beliefs and perceptions. Relative to the comparison group, one community achieved a lower prevalence of overweight/obesity, lower weight, waist circumference and BMI (P<0.005). One community achieved a higher level of healthy eating policy implementation in schools; two communities achieved improved healthy eating-related behaviours (P<0.03); one community achieved lower sedentary behaviours; and one community achieved higher levels of physical activity in schools (P<0.05). All effect sizes were in the small-to-moderate range.

CONCLUSIONS

This was a complex and ambitious initiative, which attempted to expand a previously successful community-based intervention in Victoria into five new contexts and communities. Overall, project success was quite inconsistent, and some significant differences were in the unanticipated direction. However, there are many important learnings that should inform future health-promotion activities. The heterogeneity of outcomes of HPC:BAEW communities reflects the reality of life whereby effectiveness of intervention strategies is dependent on individual and community factors. Future health promotion should consider a systems approach whereby existing systems are modified rather than relying heavily on the addition of new activities, with longer time frames for implementation.

Analysis Grid for Environments Linked to Obesity (ANGELO) framework to develop community-driven health programmes in an Indigenous community in Canada

Indigenous First Nations people in Canada have high chronic disease morbidity resulting in part from enduring social inequities and colonialism. Obesity prevention strategies developed by and for First Nations people are crucial to improving the health status of this group. The research objective was to develop community-relevant strategies to address childhood obesity in a First Nations community. Strategies were derived from an action-based workshop based on the Analysis Grid for Environments Linked to Obesity (ANGELO) framework. Thirteen community members with wide-ranging community representation took part in the workshop. They combined personal knowledge and experience with community-specific and national research to dissect the broad array of environmental factors that influenced childhood obesity in their community. They then developed community-specific action plans focusing on healthy eating and physical activity for children and their families. Actions included increasing awareness of children's health issues among the local population and community leadership, promoting nutrition and physical activity at school, and improving recreation opportunities. Strengthening children's connection to their culture was considered paramount to improving their well-being; thus, workshop participants developed programmes that included elders as teachers and reinforced families' acquaintance with First Nations foods and activities. The research demonstrated that the ANGELO framework is a participatory way to develop community-driven health programmes. It also demonstrated that First Nations people involved in the creation of solutions to health issues in their communities may focus on decolonising approaches such as strengthening their connection to indigenous culture and traditions. External funds were not available to implement programmes and there was no formal follow-up to determine if community members implemented programmes. Future research needs to examine the extent to which community members can implement programmes on their own and whether community action plans, when implemented, lead to short- and long-term benefits in health outcomes.

Developing a Tool to Assess the Capacity of Out-of-School Time Program Providers to Implement Policy, Systems, and Environmental Change

BACKGROUND

Little is known about public health practitioners' capacity to change policies, systems, or environments (PSEs), in part due to the absence of measures. To address this need, we partnered with the Alliance for a Healthier Generation (Alliance) to develop and test a theory-derived measure of the capacity of out-of-school time program providers to improve students' level of nutrition and physical activity through changes in PSEs.

COMMUNITY CONTEXT

The measure was developed and tested through an engaged partnership with staff working on the Alliance's Healthy Out-of-School Time (HOST) Initiative. In total, approximately 2,000 sites nationwide are engaged in the HOST Initiative, which serves predominantly high-need children and youths.

METHODS

We partnered with the Alliance to conduct formative work that would help develop a survey that assessed attitudes/beliefs, social norms, external resources/supports, and self-efficacy. The survey was administered to providers of out-of-school time programs who were implementing the Alliance's HOST Initiative.

OUTCOME

Survey respondents were 185 out-of-school time program providers (53% response rate). Exploratory factor analysis yielded a 4-factor model that explained 44.7% of the variance. Factors pertained to perceptions of social norms (6 items) and self-efficacy to build support and engage a team (4 items) and create (5 items) and implement (3 items) an action plan.

INTERPRETATION

We report initial development and factor analysis of a tool that the Alliance can use to assess the capacity of after-school time program providers, which is critical to targeting capacity-building interventions and assessing their effectiveness. Study findings also will inform the development of measures to assess individual capacity to plan and implement other PSE interventions.

A community engagement process identifies environmental priorities to prevent early childhood obesity: the Children's Healthy Living (CHL) program for remote underserved populations in the US Affiliated Pacific Islands, Hawaii and Alaska

Underserved minority populations in the US Affiliated Pacific Islands (USAPI), Hawaii, and Alaska display disproportionate rates of childhood obesity. The region’s unique circumstance should be taken into account when designing obesity prevention interventions. The purpose of this paper is to (a), describe the community engagement process (CEP) used by the Children’s Healthy Living (CHL) Program for remote underserved minority populations in the USAPI, Hawaii, and Alaska (b) report community-identified priorities for an environmental intervention addressing early childhood (ages 2–8 years) obesity, and (c) share lessons learned in the CEP. Four communities in each of five CHL jurisdictions (Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Hawai‘i) were selected to participate in the community-randomized matched-pair trial. Over 900 community members including parents, teachers, and community leaders participated in the CEP over a 14 month period. The CEP was used to identify environmental intervention priorities to address six behavioral outcomes: increasing fruit/vegetable consumption, water intake, physical activity and sleep; and decreasing screen time and intake of sugar sweetened beverages. Community members were engaged through Local Advisory Committees, key informant interviews and participatory community meetings. Community-identified priorities centered on policy development; role modeling; enhancing access to healthy food, clean water, and physical activity venues; and healthy living education. Through the CEP, CHL identified culturally appropriate priorities for intervention that were also consistent with the literature on effective obesity prevention practices. Results of the CEP will guide the CHL intervention design and implementation. The CHL CEP may serve as a model for other underserved minority island populations.

Three-Year Improvements in Weight Status and Weight-Related Behaviors in Middle School Students: The Healthy Choices Study

INTRODUCTION

Few dissemination evaluations exist to document the effectiveness of evidence-based childhood obesity interventions outside the research setting.

OBJECTIVE

Evaluate Healthy Choices (HC), a multi-component obesity prevention program, by examining school-level changes in weight-related behaviors and weight status and the association of implementation components with odds of overweight/obesity.

METHODS

We compared baseline and Year 3 school-level behavioral and weight status outcomes with paired t-tests adjusted for schools' socio-demographic characteristics. We used generalized estimating equations to examine the odds of overweight/obesity associated with program components.

SETTING/PARTICIPANTS

Consecutive sample of 45 of 51 middle schools participating in the HC program with complete baseline and follow-up survey data including a subsample of 35 schools with measured anthropomentry for 5,665 7th grade students.

INTERVENTION

Schools developed a multi-disciplinary team and implemented an obesity prevention curriculum, before and after school activities, environmental and policy changes and health promotions targeting a 5-2-1 theme: eat ≥ 5 servings/day of fruits and vegetables (FV), watch ≤ 2 hours of television (TV) and participate in ≥ 1 hours/day of physical activity (PA) on most days.

MAIN OUTCOME MEASURES

1) School-level percent of students achieving targeted behaviors and percent overweight/obese; and 2) individual odds of overweight/obesity.

RESULTS

The percent achieving behavioral goals over three years increased significantly for FV: 16.4 to 19.4 (p = 0.001), TV: 53.4 to 58.2 (p = 0.003) and PA: 37.1 to 39.9 (p = 0.02), adjusting for school size, baseline mean age and percent female, non-Hispanic White, and eligible for free and reduced price lunch. In 35 schools with anthropometry, the percent of overweight/obese 7th grade students decreased from 42.1 to 38.4 (p = 0.016). Having a team that met the HC definition was associated with lower odds of overweight/obesity (OR = 0.83, CI: 0.71-0.98).

CONCLUSIONS AND RELEVANCE

The HC multi-component intervention demonstrated three-year improvements in weight-related behaviors and weight status across diverse middle schools. Team building appears important to the program's effectiveness.

Development of the good food planning tool: A food system approach to food security in indigenous Australian remote communities

Few frameworks exist to assist food system planning, especially for Indigenous Australian remote communities. We developed a Good Food Planning Tool to support stakeholders to collectively plan and take action for local food system improvement. Development occurred over a four-year period through an evolving four phase participatory process that included literature review, several meetings with representatives of various organisations and communities and application of the Tool with multi-sector groups in each of four Indigenous Australian remote communities. A diverse range of 148 stakeholders, 78 of whom were Indigenous, had input to its development. Five food system domains: (i) Leadership and partnerships; (ii) Traditional food and local food production; (iii) Food businesses; (iv) Buildings, public places and transport; (v) Community and services and 28 activity areas form the framework of the Tool. The Good Food Planning Tool provides a useful framework to facilitate collective appraisal of the food system and to identify opportunities for food system improvement in Indigenous Australian remote communities, with potential for adaptation for wider application.

A snapshot of the scope of obesity prevention practice in Australia

Community-based initiatives (CBIs) that build capacity and promote healthy environments hold promise for preventing obesity and non-communicable disease, however their characteristics remain poorly understood and lessons are learned in isolation. This limits understanding of likely effectiveness of CBIs; the potential for actively supporting practice; and the translation of community-based knowledge into policy. Building on an initial survey (2010), an online survey was launched (2013) with the aim to describe the reach and characteristics of Australian CBIs and identify and evaluate elements known to contribute to best practice, effectiveness and sustainability. Responses from 104 CBIs were received in 2013. Geographic location generally reflected population density in Australia. Duration of CBIs was short-term (median 3 years; range 0.2–21.0 years), delivered mostly by health departments and local governments. Median annual funding had more than doubled since the 2010 survey, but average staffing had not increased. CBIs used at least two strategy types, with a preference for individual behaviour change strategies. Targeting children was less common (31%) compared with the 2010 survey (57%). Logic models and theory were used in planning, but there was low use of research evidence and existing prevention frameworks. Nearly, all CBIs had an evaluation component (12% of budget), but dissemination was limited. This survey provides information on the scope and varied quality of the current obesity prevention investment in Australia. To boost the quality and effectiveness of CBIs, further support systems may be required to ensure that organizations adopt upstream, evidence-informed approaches; and integrate CBIs into systems, policies and environments.

The Healthy Migrant Families Initiative: development of a culturally competent obesity prevention intervention for African migrants

Background

Although obesity among immigrants remains an important area of study given the increasing migrant population in Australia and other developed countries, research on factors amenable to intervention is sparse. The aim of the study was to develop a culturally-competent obesity prevention program for sub-Saharan African (SSA) families with children aged 12–17 years using a community-partnered participatory approach.

Methods

A community-partnered participatory approach that allowed the intervention to be developed in collaborative partnership with communities was used. Three pilot studies were carried out in 2008 and 2009 which included focus groups, interviews, and workshops with SSA parents, teenagers and health professionals, and emerging themes were used to inform the intervention content. A cultural competence framework containing 10 strategies was developed to inform the development of the program. Using findings from our scoping research, together with community consultations through the African Review Panel, a draft program outline (skeleton) was developed and presented in two separate community forums with SSA community members and health professionals working with SSA communities in Melbourne.

Results

The ‘Healthy Migrant Families Initiative (HMFI): Challenges and Choices’ program was developed and designed to assist African families in their transition to life in a new country. The program consists of nine sessions, each approximately 1 1/2 hours in length, which are divided into two modules based on the topic. The first module ‘Healthy lifestyles in a new culture’ (5 sessions) focuses on healthy eating, active living and healthy body weight. The second module ‘Healthy families in a new culture’ (4 sessions) focuses on parenting, communication and problem solving. The sessions are designed for a group setting (6–12 people per group), as many of the program activities are discussion-based, supported by session materials and program resources.

Conclusion

Strong partnerships and participation by SSA migrant communities enabled the design of a culturally competent and evidence-based intervention that addresses obesity prevention through a focus on healthy lifestyles and healthy families. Program implementation and evaluation will further inform obesity prevention interventions for ethnic minorities and disadvantaged communities.

An obesogenic island in the Mediterranean: mapping potential drivers of obesity in Malta

OBJECTIVE

The prevalence of childhood and adult obesity in Malta is among the highest in the world. Although increasingly recognised as a public health problem with substantial future economic implications for the national health and social care systems, understanding the context underlying the burden of obesity is necessary for the development of appropriate counter-strategies.

DESIGN

We conducted a contextual analysis to explore factors that may have potentially contributed to the establishment of an obesogenic environment in Malta. A search of the literature published between 1990 and 2013 was conducted in MEDLINE and EMBASE. Twenty-two full-text articles were retrieved. Additional publications were identified following recommendations by Maltese public health experts; a review of relevant websites; and thorough hand searching of back issues of the Malta Medical Journal since 1990.

SETTING

Malta.

SUBJECTS

Whole population, with a focus on children.

RESULTS

Results are organised and presented using the ANalysis Grid for Elements Linked to Obesity (ANGELO) framework. Physical, economic, policy and socio-cultural dimensions of the Maltese obesogenic environment are explored.

CONCLUSIONS

Malta's obesity rates may be the result of an obesogenic environment characterised by limited infrastructure for active living combined with an energy-dense food supply. Further research is required to identify and quantify the strength of interactions between these potential environmental drivers of obesity in order to enable appropriate countermeasures to be developed.

Large reductions in child overweight and obesity in intervention and comparison communities 3 years after a community project

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Childhood obesity has been increasing over decades and scalable, population-wide solutions are urgently needed to reverse this trend. Evidence is emerging that community-based approaches can reduce unhealthy weight gain in children. In some countries, such as Australia, the prevalence of childhood obesity appears to be flattening, suggesting that some population-wide changes may be underway.

WHAT THIS STUDY ADDS

A community-based intervention project for obesity prevention in a rural town appears to have increasing effects 3 years after the end of the project, substantially reducing overweight and obesity by 6% points in new cohorts of children, 6 years after the original baseline. An apparent and unanticipated 'spillover' of effects into the surrounding region appeared to have occurred with 10%-point reductions in childhood overweight and obesity over the same time period. A 'viral-like' spread of obesity prevention efforts may be becoming possible and an increase in endogenous community activities appears to be surprisingly successful in reducing childhood obesity prevalence.

BACKGROUND

The long-term evaluations of community-based childhood obesity prevention interventions are needed to determine their sustainability and scalability.

OBJECTIVES

To measure the impacts of the successful Be Active Eat Well (BAEW) programme in Victoria, Australia (2003-2006), 3 years after the programme finished (2009).

METHODS

A serial cross-sectional study of children in six intervention and 10 comparison primary schools in 2003 (n = 1674, response rate 47%) and 2009 (n = 1281, response rate 37%). Height, weight, lunch box audits, self-reported behaviours and economic investment in obesity prevention were measured.

RESULTS

Compared with 2003, the 2009 prevalence of overweight/obesity (World Health Organization criteria) was significantly lower (P < 0.001) in both intervention (39.2% vs. 32.8%) and comparison (39.6% vs. 29.1%) areas, as was the mean standardized body mass index (0.79 vs. 0.65, 0.77 vs. 0.57, respectively) with no significant differences between areas. Some behaviours improved and a few deteriorated with any group differences favouring the comparison area. In 2009, the investment in obesity prevention in intervention schools was about 30 000 Australian dollars (AUD) per school per year, less than half the amount during BAEW. By contrast, the comparison schools increased from a very low base to over 66 000 AUD per school per year in 2009.

CONCLUSIONS

The 8%-point reduction in overweight/obesity in both areas over 6 years from baseline to 3 years post-intervention was substantial. While the benefits of BAEW increased in the intervention community in the long term, the surrounding communities appeared to have more than caught up in programme investments and health gains, suggesting a possible 'viral spread' of obesity prevention actions across the wider region.

Using the ANGELO model to develop the children's healthy living program multilevel intervention to promote obesity preventing behaviors for young children in the U.S.-affiliated Pacific Region

BACKGROUND

Almost 40% of children are overweight or obese by age 8 years in the US-Affiliated Pacific, inclusive of the five jurisdictions of Alaska, Hawaii, American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands. This article describes how the Children's Healthy Living (CHL) Program used the ANGELO (Analysis Grid for Environments/Elements Linked to Obesity) model to design a regional intervention to increase fruit and vegetable intake, water consumption, physical activity, and sleep duration and decrease recreational screen time and sugar-sweetened beverage consumption in young children ages 2-8 years.

METHODS

Using the ANGELO model, CHL (1) engaged community to identify preferred intervention strategies, (2) reviewed scientific literature, (3) merged findings from community and literature, and (4) formulated the regional intervention.

RESULTS

More than 900 community members across the Pacific helped identify intervention strategies on importance and feasibility. Nine common intervention strategies emerged. Participants supported the idea of a regional intervention while noting that cultural and resource differences would require flexibility in its implementation in the five jurisdictions. Community findings were merged with the effective obesity-reducing strategies identified in the literature, resulting in a regional intervention with four cross-cutting functions: (1) initiate or strengthen school wellness policies; (2) partner and advocate for environmental change; (3) promote CHL messages; and (4) train trainers to promote CHL behavioral objectives for children ages 2-8 years. These broad functions guided intervention activities and allowed communities to tailor activities to maximize intervention fit.

CONCLUSIONS

Using the ANGELO model assured that the regional intervention was evidence based while recognizing jurisdiction context, which should increase effectiveness and sustainability.

Process evaluation of a community-based intervention program: Healthy Youth Healthy Communities, an adolescent obesity prevention project in Fiji

Nearly one-half of the adult population in Fiji between the ages of 15-64 years is either overweight or obese; and rates amongst school children have, on average, doubled during the last decade. There is an urgent need to scale up the promotion of healthy behaviors and environments using a multi-sectoral approach. The Healthy Youth Healthy Community (HYHC) project in Fiji used a settings approach in secondary schools and faith-based organizations to increase the capacity of the whole community, including churches, mosques and temples, to promote healthy eating and regular physical activity, and to prevent unhealthy weight gain in adolescents aged 13-18 years. The team consisted of a study manager, project coordinator and four research assistants (RAs) committed to planning, designing and facilitating the implementation of intervention programs in collaboration with other stakeholders, such as the wider school communities, government and non-governmental organizations and business partners. Process data were collected on all intervention activities and analyzed by dose, frequency and reach for each specific strategy. The Fiji Action Plan included nine objectives for the school settings; four were based on nutrition and two on physical activity in schools, plus three general objectives, namely capacity building, social marketing and evaluation. Long-term change in nutritional behavior was difficult to achieve; a key contributor to this was the unhealthy food served in the school canteens. Whilst capacity-building proved to be one of the best mechanisms for intervening, it is important to consider the cultural and social factors influencing health behaviors and affecting specific groups.

Eating for the better: a social marketing review (2000-2012)

OBJECTIVE

The present study sought to identify both the ingredients for success and the potential impediments to social marketing effectiveness for healthy eating behaviour, focusing on studies conducted over the last 10 years.

DESIGN

A comprehensive literature review was undertaken examining seventeen databases to identify studies reporting the use of social marketing to address healthy eating. Thirty-four empirical studies were analysed to examine the effectiveness of social marketing interventions to improve healthy eating behaviour using Andreasen's (2002) social marketing benchmark criteria. Statistical analysis was undertaken to quantitatively evaluate whether effectiveness varied between study categories (subsets).

SETTING

Healthy eating empirical studies published from 2000 onwards.

SUBJECTS

Empirical studies that self-identified as social marketing.

RESULTS

Sixteen social marketing studies (subset 1) were identified in the review. These were systematic studies which sought to change behaviour through tailored solutions (e.g. use of marketing tools beyond communication was clearly evident) that delivered value to the target audience. For these sixteen studies, the mean number of criteria identified was five. Six studies met all six criteria. Positive change to healthy eating behaviour was found in fourteen of sixteen studies. The sixteen studies that met the definition of social marketing used significantly more of Andreasen's (2002) criteria and were more effective in achieving behavioural change than the eighteen studies in subset 2.

CONCLUSIONS

Social marketing is an involved process and it is important that studies identifying as social marketing adopt social marketing benchmark criteria. Social marketing when employed to its full extent offers the potential to change healthy eating.

Exploring obesogenic environments: the design and development of the migrant obesogenic perception of the environment questionnaire (MOPE-Q) using a sample of Iranian migrants in Australia

Background

Although there are a number of studies examining the effect of migration on obesity, these studies tend to focus on the role of acculturation in this relationship. However, there are indications that the change in environment may also be an important factor. Indeed, there is a considerable lack of psychometric tools designed to assess the association between environment and migrant health behaviour. The current study aimed to assess the literature on the link between environment and health for migrants, and on the basis of this information, design and develop the Migrant Obesogenic Perception of the Environment questionnaire (MOPE-Q). The MOPE-Q is the first comprehensive measure of the impact of environmental factors on migrant health behaviour related to physical activity, food habits and body image concern, as well as weight change.

Methods

Using a systematic approach, an initial pool of items for the questionnaire was developed and refined on the basis of rigorous content and face validity assessments and factor analysis. Further, reliability tests and test re-test studies were undertaken. Differences between Iranian and Australian environmental factors as they relate to obesogenic behaviour were explored using the developed measure.

Results

A total of 36 items were developed for the MOPE-Q. Principal factor analysis identified three similar factor structures of environmental factors related to obesity (categorized in terms of facilitators, barriers and pressures) for each country. The final questionnaire consisted of four distinct subscales pertaining specifically to the Australian environment and five subscales pertaining to the Iranian environment, accounting for 59% and 63%, respectively, of the total variance in obesity rates. Data suggests that the MOPE-Q is a reliable and valid self-report measure for assessing the relationship between environmental factors linked to obesity and obesogenic behaviour for this particular migrant group.

Conclusion

The variations in environmental factors linked to obesity behaviour between home (Iran) and host (Australia) countries have been incorporated into the MOPE-Q instrument which has shown good psychometric properties. The MOPE-Q can be adapted and applied to other environments and populations to help explain changes in diet, physical activity patterns and body weight in migrant groups as they acculturate.

Obesity Interventions in the Community : Engaged and Participatory Approaches

Obesity is a pervasive global public health concern of utmost priority. Effective and efficient interventions are urgently needed to reverse current trends, especially among children. The past decade has witnessed increasing adoption and implementation of community-engaged and -participatory interventions that employ a bottom-up approach to identifying and realizing sustainable solutions within communities. It is argued herein that community-based approaches are most effective when implemented via a systems perspective that integrates across societal sectors. This approach seizes upon the synergistic effects that result from simultaneously mobilizing community assets at multiple levels. This paper provides an overview of the evolution and theory behind community-engaged, community-participatory, and systems-level interventions, discusses recent findings in the field, offers reflections based on first-hand experience, outlines advances in relevant resources, and lays forth potential and promising directions for future research. It emphasizes the centrality and necessity of community-engaged systems-level interventions in halting and reversing the obesity epidemic.

Developing programs for African families, by African families: engaging African migrant families in Melbourne in health promotion interventions

Obesity is an emerging problem for African migrants in Australia, but few prevention programs incorporate their cultural beliefs and values. This study reports on the application of community capacity-building and empowerment principles in 4 workshops with Sudanese families in Australia. Workshop participants prioritized health behaviors, skill and knowledge gaps, and environments for change to identify culturally centered approaches to health promotion. The workshops highlighted a need for culturally and age-appropriate interventions that build whole-of-family skills and knowledge around the positive effects of physical activity and nutrition to improve health within communities while reducing intergenerational and gender role family conflicts.

Healthy Alberta Communities: impact of a three-year community-based obesity and chronic disease prevention intervention

OBJECTIVE

To assess the impact of a 3 year (2006-2009) community-based intervention for obesity and chronic disease prevention in four diverse "Healthy Alberta Communities" (HAC).

METHODS

Targeted intervention development incorporated the ANGELO conceptual framework to help community stakeholders identify environmental determinants of obesity amenable to intervention. Several inter-related initiatives were implemented. To evaluate, we surveyed separate samples of adults in HAC communities before and after the interventions and compared responses to identical survey questions asked of adults living in Alberta in two waves of the Canadian Community Health Survey (CCHS).

RESULTS

The HAC sample included 4761 (2006) and 4733 (2009) people. The comparison sample included 9775 and 9784 respondents in 2005 and 2009-10 respectively. Self-reported body mass index showed no change, and neither were there significant changes in behaviors relative to secular trends. Most significant outcomes were relevant to social conditions, specifically sense of belonging to community in the intervention communities.

CONCLUSION

Health outcome indicators at the community level may not be sufficiently sensitive to capture changes which, over a relatively short term, would only be expected to be incremental, given that interventions were directed primarily to creating environmental conditions supportive of changes in behavioral outcomes rather than toward health outcome change directly.

Increasing community capacity and decreasing prevalence of overweight and obesity in a community based intervention among Australian adolescents

BACKGROUND

Community capacity building is a promising approach in reducing childhood obesity. The objective was to determine changes in capacity over a 3 year intervention (2005-2008) in schools and whether greater increases in capacity were associated with greater decreases in overweight/obesity.

METHODS

"It's your Move!" (IYM) was an obesity prevention project, in 12 Australian secondary schools (5 intervention; 7 comparison), that aimed to increase community capacity to promote healthy eating and physical activity. Capacity was assessed pre/post intervention using the 'Community Readiness to Change (RTC)' tool. Comparisons from baseline to follow-up were tested using Wilcoxon Signed-Ranks and results plotted against changes (Newcombe's paired differences) in prevalence of overweight/obesity (WHO standards).

RESULTS

RTC increased in intervention schools (p=0.04) over time but not for comparison schools (p=0.50). The intervention group improved on 5 of 6 dimensions and the three intervention schools that increased three levels on the RTC scale each had significant reductions in overweight/obesity prevalence.

CONCLUSION

There were marked increases in capacity in the intervention schools and those with greater increases had greater decreases in the prevalence of overweight/obesity. Community-based obesity prevention efforts should specifically target increasing community capacity as a proximal indicator of success.

Community action to prevent childhood obesity: lessons from three US case studies

BACKGROUND

A 2005 Institute of Medicine report argues that "prevention of obesity in children and youth is, ultimately, about community," yet the literature lacks empirical research on what communities are doing to prevent childhood obesity. This research helps fill this gap and highlights promising practices.

CASES

This research entailed exploratory analysis of three descriptive case studies of community efforts to prevent childhood obesity in the northeastern United States: Shape Up Somerville in Massachusetts, MA (urban), Whole Community Project in New York, NY (semiurban), and Eat Well Play Hard Chemung in NY (semirural). Data included stakeholder interviews (n=23), participant observation (n ≥ 7 events and meetings/case), and document analysis (n≈100/case) from project inceptions until March, 2010. Meeting participation was tracked. Data were coded for actions and strategies. Actions were mapped to an adapted version of the ANalysis Grid for Environments Linked to Obesity (ANGELO) framework.

DISCUSSION

These three projects were successful in changing physical environments for food and activity through program and event offerings. The projects were less active in generating policy and economic change. The scale and scope of actions related to project longevity. Demographics of key project stakeholders may have hinged on individual and institutional identities of project facilitators and on intentionality of inclusion strategies.

CONCLUSION

Such projects could likely generate greater scope and scale of environmental changes to prevent childhood obesity if funding agencies provided long-term financial support and technical assistance, even if at lower levels. Diversity of participation would also benefit from stable support and from dispersal of decision-making powers, including through distributed funding.

Identifying important and feasible policies and actions for health at community sports clubs: a consensus-generating approach

OBJECTIVES

Children's high participation in organised sport in Australia makes sport an ideal setting for health promotion. This study aimed to generate consensus on priority health promotion objectives for community sports clubs, based on informed expert judgements.

DESIGN

Delphi survey using three structured questionnaires.

METHODS

Forty-six health promotion, nutrition, physical activity and sport management/delivery professionals were approached to participate in the survey. Questionnaires used an iterative process to determine aspects of sports clubs deemed necessary for developing healthy sporting environments for children. Initially, participants were provided with a list of potential standards for a range of health promotion areas and asked to rate standards based on their importance and feasibility, and any barriers to implementation. Subsequently, participants were provided with information that summarised ratings for each standard to indicate convergence of the group, and asked to review and potentially revise their responses where they diverged. In a third round, participants ranked confirmed standards by priority.

RESULTS

26 professionals completed round 1, 21 completed round 2, and 18 completed round 3. The highest ranked standards related to responsible alcohol practices, availability of healthy food and drinks at sports canteens, smoke-free club facilities, restricting the sale and consumption of alcohol during junior sporting activities, and restricting unhealthy food and beverage company sponsorship.

CONCLUSIONS

Identifying and prioritising health promotion areas that are relevant to children's sports clubs assists in focusing public health efforts and may guide future engagement of sports clubs. Approaches for providing informational and financial support to clubs to operationalise these standards are proposed.

A socio-ecological perspective on behavioural interventions to influence food choice in schools: alternative, complementary or synergistic?

Objective

An increasing focus on legislation, policy and guidance on the nutritional content of school food has in part been in response to the limited impact of more behavioural or educational approaches. However, there is a risk that a sole focus on policy-level action may lead to neglect of the important contribution that more behavioural approaches can make as components of effective, coordinated, multilevel action to improve the dietary intake of schoolchildren. The current paper aims to highlight the potential importance of viewing alternative approaches as complementary or synergistic, rather than competing.

Design

The socio-ecological and RE-AIM frameworks are used to provide a theoretical rationale and demonstrate the importance of explicitly identifying the interdependence of policies, interventions and contextual structures and processes. School food case study evidence is used to exemplify how understanding and exploiting these interdependencies can maximise impact on dietary outcomes.

Setting

Case studies of trials in schools in the UK (South West England and Wales) and Australia (Victoria).

Subjects

Schoolchildren.

Results

The case studies provide examples to support the hypothesis that the reach, effectiveness, adoption, implementation and maintenance of school food policies and interventions can be maximised by understanding and exploiting the interdependence between levels in the socio-ecological framework.

Conclusions

Rather than being seen as competing alternatives, diverse approaches to improving the diets of schoolchildren should be considered in terms of their potential to be complementary and synergistic, acting at multiple levels to improve acceptability, fidelity, effectiveness and sustainability.

Implementing a community-based obesity prevention programme: experiences of stakeholders in the north east of England

Recent literature indicates the potential of community-based obesity prevention programmes in the endeavour to reduce the prevalence of obesity in developed nations. Considerable suggestion and advocacy come from theoretical standpoints and little is known on actual practical application of this type of multi-component health promotion programme. This article explores the experiences of 'implementation' by stakeholders of a large community-based obesity prevention programme, facilitated by a National Health Service Care Trust in the north-east of England, UK. Three stakeholder groups (senior health officials, public health workers and community members) who had administrated and experienced the programme since its conception in 2006 provide perspectives on the aspects of local delivery and receipt. Semi-structured interviews and focus groups were conducted with stakeholders (28 participants in total). The participants felt there were three broad aspects which shaped and constrained the delivery and receipt of the programme, namely partnership working, integration of services and quality issues. Data indicated that it had taken time to establish working partnerships between the multi-agencies involved in the community-based obesity programme. Strategic management would aid the processes of communication and collaboration between agencies and also the local community involved in the administration, delivery and participation of interventions in the programme. Secondly, the way in which the programme is justified and sustained will have to be reviewed, with the intention of using a suitable evaluative framework or tool for monitoring purposes.

Promoting health at the community level: thinking globally, acting locally

Prevention of childhood obesity is a societal priority. Despite our knowledge about the scope of the problem and the determinants that lead to it, we have yet to produce meaningful declines in obesity rates. Recent attention has been given to interventions that employ multiple strategies across multiple settings involving whole communities given their promising results. The next era of science calls for interdisciplinary teams who will envision a whole system approach to advance the community-based obesity prevention model. This perspective describes some of the more recent discussions of community-based methodologies such as the ANGELO (Analysis Grid for Environments Linked to Obesity) framework, best-practice principles, and a whole system intervention approach to obesity prevention. The proposed required elements to advance community-based research to address childhood obesity are: A systems perspective and approach, training of future leaders in community research methodology and social change, applying transdisciplinary strategies, funding to conduct rigorous trials to determine efficacy and effectiveness, enhanced design and analysis approaches, new and improved tools and methodologies to collect quantitative and qualitative data, enhanced community engagement models and sustainability frameworks, advancement of a bold public policy agenda, economic modeling, and acknowledgment of the approach as viable. To reverse childhood obesity, we need to embrace and integrate complex strategies at multiple levels within communities across the globe.

Experiences and challenges in implementing complex community-based research project: the Pacific Obesity Prevention in Communities project

Policy makers throughout the world are struggling to find effective ways to prevent the rising trend of obesity globally, particularly among children. The Pacific Obesity Prevention in Communities project was the first large-scale, intervention research project conducted in the Pacific aiming to prevent obesity in adolescents. The project spanned four countries: Australia, New Zealand, Fiji and Tonga. This paper reports on the strengths and challenges experienced from this complex study implemented from 2004 to 2009 across eight cultural groups in different community settings. The key strengths of the project were its holistic collaborative approach, participatory processes and capacity building. The challenges inherent in such a large complex project were underestimated during the project's development. These related to the scale, complexity, duration, low research capacity in some sites and overall coordination across four different countries. Our experiences included the need for a longer lead-in time prior to intervention for training and up-skilling of staff in Fiji and Tonga, investment in overall coordination, data quality management across all sites and the need for realistic capacity building requirements for research staff. The enhanced research capacity and skills across all sites include the development and strengthening of research centres, knowledge translation and new obesity prevention projects.

Reducing unhealthy weight gain in Fijian adolescents: results of the Healthy Youth Healthy Communities study

Obesity is a significant problem among adolescents in Pacific populations. This paper reports on the outcomes of a 3-year obesity prevention study, Healthy Youth Healthy Communities, which was part of the Pacific Obesity Prevention in Communities project, undertaken with Fijian adolescents. The intervention was developed with schools and comprised social marketing, nutrition and physical activity initiatives and capacity building designed to reduce unhealthy weight, and the individual exposure period was just over 2-year duration. The evaluation incorporated a quasi-experimental, longitudinal design in seven intervention secondary schools near Suva (n=874) and a matched sample of 11 comparison secondary schools from western Viti Levu (n=2,062). There were significant differences between groups at baseline; the intervention group was shorter, weighed less, had a higher proportion of underweight and lower proportion of overweight, and better quality of life (Pediatric Quality of Life Inventory only). At follow-up, the intervention group had lower percentage body fat (-1.17) but also a lower increase in quality of life (Assessment of Quality of Life instrument: -0.02; Pediatric Quality of Life Inventory: -1.94) than the comparison group. There were no other differences in anthropometry, and behaviours' changes showed a mixed pattern. In conclusion, this school-based health promotion programme lowered percentage body fat but did not reduce unhealthy weight gain or influence most obesity-promoting behaviours among Fijian adolescents. Despite growing evidence supporting the efficacy of community-based approaches to reduce obesity among children of European descent, findings from this study failed to demonstrate the efficacy of a community capacity-building approach among an adolescent sample drawn from a different sociocultural, economic and geographical context. Additional 'top-down' or other innovative approaches may be needed to reduce adolescent obesity in the Pacific.

The Pacific Obesity Prevention in Communities project: project overview and methods

Obesity is increasing worldwide with the Pacific region having the highest prevalence among adults. The most common precursor of adult obesity is adolescent obesity making this a critical period for prevention. The Pacific Obesity Prevention in Communities project was a four-country project (Fiji, Tonga, New Zealand and Australia) designed to prevent adolescent obesity. This paper overviews the project and the methods common to the four countries. Each country implemented a community-based intervention programme promoting healthy eating, physical activity and healthy weight in adolescents. A community capacity-building approach was used, with common processes employed but with contextualized interventions within each country. Changes in anthropometric, behavioural and perception outcomes were evaluated at the individual level and school environments and community capacity at the settings level. The evaluation tools common to each are described. Additional analytical studies included economic, socio-cultural and policy studies. The project pioneered many areas of obesity prevention research: using multi-country collaboration to build research capacity; testing a capacity-building approach in ethnic groups with very high obesity prevalence; costing complex, long-term community intervention programmes; systematically studying the powerful socio-cultural influences on weight gain; and undertaking a participatory, national, priority-setting process for policy interventions using simulation modelling of cost-effectiveness of interventions.

[Juvenile obesity with a focus on health promotion: integrative review]

This integrative review summarizes nursing researches that contribute to study juvenile obesity with a focus on health promotion. 20 articles were identified in a bibliographical survey that followed the criteria: date, language, and the descriptors: nursing, adolescent, obesity and health promotion. The Pediatric Nursing Journal published seven of these papers (35%). Indexed papers were published in the last ten years in Portuguese and English. Results showed the construction of scientific knowledge in nursing that developed health promotion strategies in cases of juvenile obesity, thus contributing to the development of the profession. Showing the cumulative risk that juvenile obesity presents of turning subjects into obese adults is a precious resource to plan nursing actions for this population, and for these actions to achieve effective results.

Process evaluation of a community-based adolescent obesity prevention project in Tonga

Background

The rising burden of obesity in Tonga is alarming. The promotion of healthy behaviours and environments requires immediate urgent action and a multi-sectoral approach. A three-year community based study titled the Ma'alahi Youth Project (MYP) conducted in Tonga from 2005-2008 aimed to increase the capacity of the whole community (schools, churches, parents and adolescents) to promote healthy eating and regular physical activity and to reduce the prevalence of overweight and obesity amongst youth and their families. This paper reflects on the process evaluation for MYP, against a set of Best Practice Principles for community-based obesity prevention.

Methods

MYP was managed by the Fiji School of Medicine. A team of five staff in Tonga were committed to planning, implementation and evaluation of a strategic plan, the key planks of which were developed during a two day community workshop. Intervention activities were delivered in villages, churches and schools, on the main island of Tongatapu. Process evaluation data covering the resource utilisation associated with all intervention activities were collected, and analysed by dose, frequency and reach for specific strategies. The action plan included three standard objectives around capacity building, social marketing and evaluation; four nutrition; two physical activity objectives; and one around championing key people as role models.

Results

While the interventions included a wide mix of activities straddling across all of these objectives and in both school and village settings, there was a major focus on the social marketing and physical activity objectives. The intervention reach, frequency and dose varied widely across all activities, and showed no consistent patterns.

Conclusions

The adolescent obesity interventions implemented as part of the MYP program comprised a wide range of activities conducted in multiple settings, touched a broad spectrum of the population (wider than the target group), but the dose and frequency of activities were generally insufficient and not sustained. Also the project confirmed that, while the MYP resulted in increased community awareness of healthy behaviours, Tonga is still in its infancy in terms of conducting public health research and lacks research infrastructure and capacity.

Selection of priority groups for obesity prevention: current approaches and development of an evidence-informed framework

Resources for obesity prevention interventions are inevitably limited, necessitating the selection of priority groups to ensure effective and equitable use of funds. This paper aims to review published approaches to selection of priority groups ('target populations') for obesity prevention, and to present the development of a new systematic framework for organizing and assessing evidence for selecting priority groups. A review was conducted of the process and justification described for selecting priority groups in a sample of obesity prevention publications. Using the results of this review and adaptation of theory and frameworks in both the obesity prevention and health promotion priority-setting literature, a framework was developed for assessment of potential priority groups for obesity prevention. The published literature lacks discussion of and explicit processes for selection of priority groups for obesity prevention intervention. The new framework describes specific types of evidence that should be considered in the assessment of a potential priority group for obesity prevention and has applications for funding and implementing community-based or settings-level obesity prevention interventions and research. Application of this framework has the potential to enhance the effective use of limited obesity prevention resources and to identify areas in need of additional research evidence.

Reflections on community-based population health intervention and evaluation for obesity and chronic disease prevention: the Healthy Alberta Communities project

OBJECTIVES

To reflect upon a population health intervention for obesity and chronic disease prevention, with specific attention to the processes of change and developing, implementing and evaluating an intervention in a community-university-government partnership context.

METHODS

To capture the value, process and context of our interventions, we employed a multi-layered, mixed methods research and evaluation design. Guided by assumptions of community-based participatory research, and using a validated capacity-building tool, the investigators described and reflected critically upon the level and nature of capacity built (for both research and intervention) as indicators of the process and contextual influences on intervention success.

RESULTS

Capacity was built in communities through collaborative approaches. We captured complexity of change in social context to advance understanding of how to intervene to transform environments. Developing novel community evaluation strategies can help to advance understanding of how environmental interventions affect health before health outcomes data demonstrate change.

CONCLUSIONS

Our experience provides an example of operationalizing an ecological framework. As a community-university-government partnership, Healthy Alberta Communities provides an opportunity for developing promising practices for the health of communities, as well as a unique research platform for evaluating the process and establishing effectiveness of population health interventions.

Increasing community capacity to prevent childhood obesity: challenges, lessons learned and results from the Romp & Chomp intervention

Background

Obesity is a major public health issue; however, only limited evidence is available about effective ways to prevent obesity, particularly in early childhood. Romp & Chomp was a community-wide obesity prevention intervention conducted in Geelong Australia with a target group of 12,000 children aged 0-5 years. The intervention had an environmental and capacity building focus and we have recently demonstrated that the prevalence of overweight/obesity was lower in intervention children, post-intervention. Capacity building is defined as the development of knowledge, skills, commitment, structures, systems and leadership to enable effective health promotion and the aim of this study was to determine if the capacity of the Geelong community, represented by key stakeholder organisations, to support healthy eating and physical activity for young children was increased after Romp & Chomp.

Methods

A mixed methods evaluation with three data sources was utilised. 1) Document analysis comprised assessment of the documented formative and intervention activities against a capacity building framework (five domains: Partnerships, Leadership, Resource Allocation, Workforce Development, and Organisational Development); 2) Thematic analysis of key informant interviews (n = 16); and 3) the quantitative Community Capacity Index Survey.

Results

Document analysis showed that the majority of the capacity building activities addressed the Partnerships, Resource Allocation and Organisational Development domains of capacity building, with a lack of activity in the Leadership and Workforce Development domains. The thematic analysis revealed the establishment of sustainable partnerships, use of specialist advice, and integration of activities into ongoing formal training for early childhood workers. Complex issues also emerged from the key informant interviews regarding the challenges of limited funding, high staff turnover, changing governance structures, lack of high level leadership and unclear communication strategies. The Community Capacity Index provided further evidence that the project implementation network achieved a moderate level of capacity.

Conclusions

Romp & Chomp increased the capacity of organisations, settings and services in the Geelong community to support healthy eating and physical activity for young children. Despite this success there are important learnings from this mixed methods evaluation that should inform current and future community-based public health and health promotion initiatives.

Trial Registration Number

ANZCTRN12607000374460

The process evaluation of It's Your Move!, an Australian adolescent community-based obesity prevention project

BACKGROUND

Evidence on interventions for preventing unhealthy weight gain in adolescents is urgently needed. The aim of this paper is to describe the process evaluation for a three-year (2005-2008) project conducted in five secondary schools in the East Geelong/Bellarine region of Victoria, Australia. The project, 'It's Your Move!' aimed to reduce unhealthy weight gain by promoting healthy eating patterns, regular physical activity, healthy body weight, and body size perception amongst youth; and improve the capacity of families, schools, and community organisations to sustain the promotion of healthy eating and physical activity in the region.

METHODS

The project was supported by Deakin University (training and evaluation), a Reference Committee (strategic direction, budgetary approval and monitoring) and a Project Management Committee (project delivery). A workshop of students, teachers and other stakeholders formulated a 10-point action plan, which was then translated into strategies and initiatives specific to each school by the School Project Officers (staff members released from teaching duties one day per week) and trained Student Ambassadors. Baseline surveys informed intervention development. Process data were collected on all intervention activities and these were collated and enumerated, where possible, into a set of mutually exclusive tables to demonstrate the types of strategies and the dose, frequency and reach of intervention activities.

RESULTS

The action plan included three guiding objectives, four on nutrition, two on physical activity and one on body image. The process evaluation data showed that a mix of intervention strategies were implemented, including social marketing, one-off events, lunch time and curriculum programs, improvements in infrastructure, and healthy school food policies. The majority of the interventions were implemented in schools and focused on capacity building and healthy eating strategies as physical activity practices were seen by the teachers as already meeting students' needs.

CONCLUSIONS

While substantial health-promoting activities were conducted (especially related to healthy eating), there remain further opportunities for secondary schools to use a whole-of-school approach through the school curriculum, environment, policies and ethos to improve healthy eating, physical activity and healthy body perceptions in youth. To achieve this, significant, sustained leadership will be required within the education sector generally and within schools specifically.

The process evaluation of It's Your Move!, an Australian adolescent community-based obesity prevention project

BACKGROUND

Evidence on interventions for preventing unhealthy weight gain in adolescents is urgently needed. The aim of this paper is to describe the process evaluation for a three-year (2005-2008) project conducted in five secondary schools in the East Geelong/Bellarine region of Victoria, Australia. The project, 'It's Your Move!' aimed to reduce unhealthy weight gain by promoting healthy eating patterns, regular physical activity, healthy body weight, and body size perception amongst youth; and improve the capacity of families, schools, and community organisations to sustain the promotion of healthy eating and physical activity in the region.

METHODS

The project was supported by Deakin University (training and evaluation), a Reference Committee (strategic direction, budgetary approval and monitoring) and a Project Management Committee (project delivery). A workshop of students, teachers and other stakeholders formulated a 10-point action plan, which was then translated into strategies and initiatives specific to each school by the School Project Officers (staff members released from teaching duties one day per week) and trained Student Ambassadors. Baseline surveys informed intervention development. Process data were collected on all intervention activities and these were collated and enumerated, where possible, into a set of mutually exclusive tables to demonstrate the types of strategies and the dose, frequency and reach of intervention activities.

RESULTS

The action plan included three guiding objectives, four on nutrition, two on physical activity and one on body image. The process evaluation data showed that a mix of intervention strategies were implemented, including social marketing, one-off events, lunch time and curriculum programs, improvements in infrastructure, and healthy school food policies. The majority of the interventions were implemented in schools and focused on capacity building and healthy eating strategies as physical activity practices were seen by the teachers as already meeting students' needs.

CONCLUSIONS

While substantial health-promoting activities were conducted (especially related to healthy eating), there remain further opportunities for secondary schools to use a whole-of-school approach through the school curriculum, environment, policies and ethos to improve healthy eating, physical activity and healthy body perceptions in youth. To achieve this, significant, sustained leadership will be required within the education sector generally and within schools specifically.