Measuring the intensity of community programs and policies for preventing childhood obesity in a diverse sample of US communities: the Healthy Communities Study

Neighborhood environments underpin screen time intervention success in children: Evidence from a study of greenspace and community programming across 130 US communities

The goal of this study was to understand how neighborhood greenspace access may support or hinder the effectiveness of community programs and policies (CPPs) aimed at reducing racial and ethnic inequities in screen time among 4598 US children. We found higher CPP intensity was significantly associated with fewer screen time behaviors in high greenspace neighborhoods, but not neighborhoods with low or moderate greenspace. Moreover, there were significant differences in greenspace access by neighborhood-level race and ethnicity. Implementing CPPs without regard for racial and ethnic greenspace inequities may be an underlying cause in the perpetuation of inequities in childhood screen time.

Can a collective-impact initiative improve well-being in three US communities? Findings from a prospective repeated cross-sectional study

INTRODUCTION

Communities are seeking to learn if and how they can improve the well-being of their residents. We therefore examined the impact of a community-led, collective-impact initiative, deployed through Blue Zones Project by Sharecare, aimed at improving health and well-being in one set of US communities.

METHODS

We used data from cross-sectional surveys of the Well-Being Index (2010-2017) to assess how the Life Evaluation Index (LEI) in Hermosa Beach, Manhattan Beach and Redondo Beach in California (Beach Cities) changed over time and how this change compares with change for similar cities (Beach Cities-like) and for the USA as a whole. We examined types of interventions, perceived impacts, and relationships between intervention type and change in LEI.

RESULTS

The Beach Cities experienced greater increases in LEI than Beach Cities-like communities and the nation. The entire portfolio of interventions was positively associated with change in LEI in the Beach Cities (+1.12, p=0.012), with process-oriented interventions most closely associated with improvement.

CONCLUSIONS

Community-led collective action that leverages community engagement and activation, strategic use of programming and large-scale built-environment and policy change can improve health and well-being at scale.

Association between multi-component initiatives and physical activity-related behaviors: interim findings from the Healthy Schools Healthy Communities initiative

Background

Although successful, assessment of multi-component initiatives (MCIs) prove to be very challenging. Further, rigorous evaluations may not be viable, especially when assessing the impact of MCIs on long-term population-level behavior change (e.g., physical activity (PA) and health outcomes (e.g., childhood obesity). The purpose of this study was to use intensity scoring, to assess whether higher intensity MCIs implemented as part of Healthy Schools Healthy Communities (HSHC) were associated with improved physical activity and reduced sedentary behaviors among youth (dependent variables).

Methods

PA-related interventions were assigned point values based on three characteristics: 1) purpose of initiative; 2) duration; and 3) reach. A MCI intensity score of all strategies was calculated for each school district and its respective community. Multivariate longitudinal regressions were applied, controlling for measurement period, Cohort, and student enrollment size.

Results

Strategy intensity scores ranged from 0.3 to 3.0 with 20% considered “higher-scoring” (score > 2.1) and 47% considered “lower-scoring” (< 1.2). Average MCI intensity scores more than tripled over the evaluation period, rising from 14.8 in the first grant year to 32.1 in year 2, 41.1 in year 3, and 48.1 in year 4. For each additional point increase in average MCI intensity score, the number of days per week that students reported PA for at least 60 min increased by 0.010 days (p < 0.01), and the number of hours per weekday that students reported engaging in screen time strategies decreased by 0.006 h (p < 0.05). An increase of 50 points in MCI intensity score was associated with an average 0.5 day increase in number of weekdays physically active and an increase of 55 points was associated with an average decrease of 20 min of sedentary time per weekday.

Conclusions

We found a correlation between intensity and PA and sedentary time; increased PA and reduced sedentary time was found with higher-intensity MCIs. While additional research is warranted, practitioners implementing MCIs, especially with limited resources (and access to population-level behavior data), may consider intensity scoring as a realistic and cost effective way to assess their initiatives. At a minimum, the use of intensity scoring as an evaluation method can provide justification for, or against, the inclusion of an individual strategy into an MCI, as well as ways to increase the likelihood of the MCI impacting population-health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10312-y.

Association of Multisetting Community Programs and Policies With Child Body Mass Index: The Healthy Communities Study

Introduction

Expert opinion suggests that efforts to address childhood obesity should seek to transform the environments in which children operate. The objective of this study was to describe the extent to which multisetting programs and policies interact with community and child predictors and are associated with child body mass index (BMI) in the 130 US communities participating in the Healthy Communities Study.

Methods

For 2 years beginning in fall 2013, we collected data through key informant interviews on community programs and policies related to healthy weight among children that occurred in the 10 years before the interview. We characterized community programs and policies by intensity of efforts and the number of settings in which a program or policy was implemented. Child height and weight were measured during household data collection. We used multilevel modeling to examine associations of community programs and policies in multiple settings and child and community predictors with BMI z scores of children.

Results

The mean number of settings in which community policies and programs were implemented was 7.3 per community. Of 130 communities, 31 (23.8%) implemented community programs and policies in multiple settings. Higher-intensity community programs and policies were associated with lower BMI in communities that used multiple settings but not in communities that implemented programs and policies in few settings.

Conclusion

Efforts to prevent childhood obesity may be more effective when community programs and policies are both intensive and are implemented in multiple settings in which children live, learn, and play.

Community-level obesity prevention is not associated with dieting behaviours and weight dissatisfaction in children: The Healthy Communities Study

BACKGROUND

Within the context of high childhood obesity prevalence, there is a concern that community efforts intended to reduce childhood obesity may lead to unintended adverse outcomes.

OBJECTIVE

This analysis examined relationships between community programs, policies, and environmental changes (CPPs) for obesity prevention with unhealthy dieting behaviours and body weight satisfaction in children.

METHODS

Using the Healthy Communities Study 2013 to 2015 survey sample of 5138 US children aged 4 to 15 years old, multilevel models examined associations between standardized CPP intensity scores and child dieting behaviours and weight satisfaction, adjusting for community and child-level covariates and clustered study design.

RESULTS

In fully adjusted models, higher total, physical activity, and nutrition CPP intensity scores were associated with lower odds of dissatisfaction with weight (1 year total CPP odds ratio [OR]: 0.41, 95% confidence interval [CI], 0.22-0.73; 6 year total CPP OR: 0.48, 0.29-0.80). Higher physical activity CPP intensity over the past year was associated with greater odds of weight satisfaction (OR: 1.77, 95% CI, 1.10-2.84). No associations were observed with dieting behaviours.

CONCLUSIONS

Results suggest that community efforts focusing on nutrition and physical activity to prevent childhood obesity may be associated with weight satisfaction and not with unhealthy dieting behaviours.

Objectives of community policies and programs associated with more healthful dietary intakes among children: findings from the Healthy Communities Study

BACKGROUND

Rational planning of community policies and programs (CPPs) to prevent obesity requires an understanding of CPP objectives associated with dietary behaviours.

OBJECTIVE

The objective of the study is to identify objectives of CPPs associated with healthful dietary behaviours.

METHODS

An observational study identified 4026 nutrition CPPs occurring in 130 communities in the prior 6 years. Dietary intakes of fruits and vegetables, added sugar and sugar-sweetened beverages, among others, were reported among 5138 children 4-15 years of age from the communities, using a Dietary Screener Questionnaire with children age 9 years and older (parent assisted) or parent proxies for younger children. CPPs were documented through key informant interviews and characterized by their intensity, count, and objectives including target dietary behaviour and food environment change strategy. Associations between dietary intakes and CPP objectives were assessed using hierarchical statistical models.

RESULTS

CPPs with the highest intensity scores that targeted fast food or fat intake or provided smaller portions were associated with greater fruit and vegetable intake (0.21, 0.19, 0.23 cup equivalents/day respectively with p values <0.01, 0.04, 0.03). CPPs with the highest intensity scores that restricted the availability of less healthful foods were associated with lower child intakes of total added sugar (-1.08 tsp/day, p < 0.01) and sugar from sugar-sweetened beverages (-1.63 tsp/day, p = 0.04). Similar associations were observed between CPP count and dietary outcomes. No other significant associations were found between CPP target behaviours or environmental strategies and dietary intakes/behaviours.

CONCLUSION

CPPs that targeted decreases in intakes of less healthful foods and/or aimed to modify the availability of less healthful foods and portions were associated with healthier child dietary behaviours.

Community characteristics modify the relationship between obesity prevention efforts and dietary intake in children: the Healthy Communities Study

BACKGROUND

The influence of community characteristics on the effectiveness of childhood obesity prevention efforts is not well understood.

OBJECTIVE

Examine the interaction of community characteristics with the relationship between community programmes and policies (CPPs) and dietary intake.

METHODS

An observational study of 5138 children in grades K-8 in 130 US communities was conducted in 2013-2015. Key informant interviews identified and characterized CPPs. CPP scores were generated for the number of target behaviours (CPP-Behav) and the number of behaviour change strategies (CPP-Strat) addressed by all CPPs and CPPs with nutrition goals over the prior 6 years in each community. Dietary intake was assessed by dietary screener and included intake of sugar from sugar-sweetened beverages; energy-dense foods; fruits and vegetables; whole grains; and fibre. Multivariate statistical models assessed the interactions between US region, urbanicity, community-level income, and community-level race/ethnicity and CPP scores in relation to dietary intake.

RESULTS

CPP-Strat was positively associated with healthier dietary intakes in the Northeast and West, and in high Hispanic communities; the reverse was true in the South, and in high African-American and low-income communities. The CPP-Behav was positively associated with healthier dietary intakes in the South and rural areas, and the reverse was true in the West.

CONCLUSION

The relationships between CPP index scores and dietary intake were most strongly influenced by region and urbanicity and to a lesser extent by community-level race/ethnicity and income. Findings suggest that different considerations may be needed for childhood obesity prevention efforts in communities with different characteristics.

Associations between community programmes and policies and children's physical activity: the Healthy Communities Study

BACKGROUND

Community initiatives to promote physical activity in children are common, but evidence supporting their effectiveness is limited.

OBJECTIVES

The objective of this study is to examine the relationships between community programmes and policies and children's physical activity in a large and diverse sample of US communities.

METHODS

Programmes and policies to promote children's physical activity were assessed in 130 communities by key informant interviews, and physical activity behaviours were measured by self-report and parental report in samples of children in each community (total n = 5138). Associations between composite indices of community programmes and policies and indicators of total and moderate-to-vigorous physical activity were examined without and with adjustment for demographic factors.

RESULTS

An index reflecting the 6-year history of the number of behaviour change strategies used in community programmes and policies was positively associated with children's moderate-to-vigorous physical activity. This association was attenuated with adjustment for demographic factors. Effect modification analyses found that the association was positive among non-Hispanic children but was negative for Hispanic children.

CONCLUSIONS

Community initiatives to promote physical activity in children were positively associated with children's physical activity in non-Hispanic children. Such initiatives were negatively associated with physical activity in Hispanic children, suggesting that future research should consider unique cultural factors when designing community initiatives to promote activity in this population sub-group.

Supplement overview: what the Healthy Communities Study is telling us about childhood obesity prevention in U.S. communities

The Healthy Communities Study (HCS), conducted between 2010 and 2016, tells a real-world story of how childhood obesity prevention efforts have unfolded in 130 U.S. communities. The study documented nearly 10,000 current and past community policies and programs (CPPs) and assessed dietary and physical activity behaviors, weight, height, and waist circumference of more than 5,000, 4- to 15-year-old children. The articles in this HCS supplement describe the variables created to characterize the CPPs, CPP relationships with children's behavioral and weight status, other analyses of interest, and recruitment challenges. Findings suggest that many of the strategies being implemented work as intended to improve children's behaviors and weight status. However, of concern, findings also indicate lesser reach to children in demographic groups at highest risk of obesity. Overall, the HCS insights can guide the next phase of efforts to strengthen existing CPPs and motivate other, novel approaches to combating childhood obesity.

Associations of community programs and policies with children's dietary intakes: the Healthy Communities Study

BACKGROUND

The impact of community-based obesity prevention efforts on child nutrition has not been adequately studied.

OBJECTIVE

Examine relationships between number, type and intensity of community programs and policies (CPPs) and child nutrition.

METHODS

An observational study of 5138 children (grades K-8) in 130 U.S. communities was conducted in 2013-2015. CPPs were identified by 10-14 key informant interviews per community. CPPs were characterized based on: count, intensity, number of different strategies used and number of different behaviours targeted. Scores for the prior 6 years were calculated separately for CPPs that addressed primarily nutrition, primarily physical activity (PA) or total combined. Child intakes were calculated from a dietary screener and dietary behaviours were based on survey responses. Multi-level statistical models assessed associations between CPP indices and nutrition measures, adjusting for child and community-level covariates.

RESULTS

Implementing more types of strategies across all CPPs was related to lower intakes of total added sugar (when CPPs addressed primarily PA), sugar-sweetened beverages (for nutrition and PA CPPs) and energy-dense foods of minimal nutritional value (for total CPPs). Addressing more behaviours was related to higher intakes of fruit and vegetables (for nutrition and total CPPs) and fibre (total CPPs). Higher count and intensity (PA and total CPPs) were related to more consumption of lower fat compared with higher fat milk. A higher count (PA CPPs) was related to fewer energy-dense foods and whole grains. No other relationships were significant at P < 0.05.

CONCLUSION

Multiple characteristics of CPPs to prevent obesity appear important to improve children's diets.