Applications of equity frameworks in theory-based health behavior interventions: a scoping review

BACKGROUND

Health behavior theories are scientific frameworks used to inform health behavior interventions to address health-related issues, given their use in understanding and modifying behavior change.

PURPOSE

We aimed to assess how theory-informed health behavior interventions utilize health equity frameworks and methods.

METHODS

Using the PRISMA guidelines, we conducted a scoping review of ten often taught health behavior theories found in health behavior textbooks. We identified 656 intervention papers, and after the title and abstract screening and full-text review, we extracted data from 26 studies. We conducted a thematic analysis to examine 1) the prevalence and quality of behavior interventions informed by health equity frameworks and 2) the application of health equity frameworks in the design and implementation of health behavior interventions.

RESULTS

Theory-informed health behavior interventions incorporating equity frameworks predominately focused on two strategies. First, by incorporating multilevel frameworks via the socioecological model to influence behavior at multiple levels of risk. The second was utilizing community-based participatory methods to integrate the community's cultural, social, and lived experiences into the interventions. Creating practices and policies rooted in lived experiences, such as recording meetings, having childcare, and processes for inclusion of feedback served to embed equity into the intervention design and implementation. Studies that were more dedicated to community involvement showed greater community acceptance and improved intervention outcomes.

CONCLUSIONS

Our scoping review identified that incorporating equity into health behavior interventions is essential yet not widely practiced and poorly understood regarding how to "bake in equity." Enhanced training on incorporating equity into theory-informed behavioral interventions could improve health behavior and health education training, research, and practice.

Nutritional interventions for indigenous adults in Canada - opportunities to sustain health and cultural practices: a scoping review

Indigenous People in Canada possess rich cultural traditions, intertwined with a strong connection to nature. However, colonisation and contemporary challenges have given rise to changes in lifestyle and culture, resulting in health and nutrition disparities within these communities. The goal of this review was to explore the available literature of existing Indigenous nutrition programs for adults in Canada. Arksey and O'Malley's scoping review protocol was used to conduct the search between July 2020 and February 2023. Articles were obtained from MEDLINE (Ovid), PsycInfo, Embase (Ovid), CINAHL (EBSCO), Web of Science, Scopus (Elsevier), Canadian Business and Current Affairs (Proquest), and Google Scholar. We identified 24 publications, with 19 being unique interventions. Common themes among programs included integrating traditional foods and cultural values, adapted programming to local needs, empowering community members, using a multidisciplinary collaboration, and leveraging social activities, all of which highlight the need for holistic strategies amid complex historical, social, and environmental factors. Overall, this review emphasises the need for continued support and development of Indigenous-led nutritional initiatives to promote health and well-being among Indigenous adults in Canada. Ensuring culturally relevant and sustainable solutions is crucial for addressing nutritional health disparities and fostering long-term positive outcomes.

Whole systems approaches to diet and healthy weight: A scoping review of reviews

BACKGROUND

Obesity is a global epidemic affecting all age groups, populations, and income levels across continents, though is known to disproportionately affect socioeconomically disadvantaged populations. The causes of obesity are complex, informed by diet and weight practices, but shaped by social, commercial, and environmental factors and government policy. Consequently, a Whole System Approach (WSA)-which considers the many causes of obesity and shifts the focus away from individuals as points of intervention and puts an emphasis on understanding and improving the system in which people live-is required. This scoping review of reviews aims to: determine how WSAs to diet and healthy weight have been implemented and evaluated nationally and internationally; to determine what models or theories have been used to implement WSAs; describe how WSAs have been evaluated; determine if WSAs are effective; and to identify the contribution of the public and/or service users in the development of WSAs.

METHOD

Systematic searches were carried out using CINAHL, Scopus, PsycINFO (ProQuest), the Cochrane Library, and MEDLINE. Included review papers were those that focused on the application of a whole system approach to diet and/or healthy weight, and/or reported the theory/model used to implement or simulate this approach. Databases were searched from 1995 to March 2022 using a combination of text and Medical Subject Headings (MeSH terms). In addition, reference sections of identified articles were examined for additional relevant articles. Covidence software was used to screen titles and abstracts from the electronic databases and resolve conflicts.

RESULTS

A total of 20,308 articles were initially retrieved; after duplicate removal 7,690 unique title and abstracts were reviewed, and 110 articles were selected for full text review. On completion of full text review, 8 review articles were included for data extraction. These included: one umbrella review, four systematic reviews, a rapid review, and two literature reviews (one of which was on strategic reports written for government and public health policy). Evaluations of WSA were mainly process evaluations although health outcomes were assessed in some studies. Several conceptual frameworks or mathematical modelling approaches have been applied to WSAs for diet, healthy weight, and obesity to inform their planning or delivery, and to understand/map the associated systems. Common mathematical approaches include agent based or System Dynamic Modelling. Underlying both conceptual and mathematical models is an understanding how the elements of the complex systems impact each other to affect diet, healthy weight, and obesity. WSA implementations have reported some success in positively impacting health outcomes including reducing Body Mass Index, reducing sugary food intake, and increasing physical activity. Public and user involvement in WSA was not widely reported.

CONCLUSION

The application of WSA to diet and healthy weight shows promise, yet the research is lagging behind their implementation. Further robust evidence for using WSA to address diet and healthy weight are required, including incorporating process and outcome evaluations (perhaps using established approaches such as Systems Dynamic Modelling). Furthermore, the analysis of epidemiological data alongside longitudinal process and outcome evaluation regarding the implementation of a WSA is required.

Dietary Intake Estimated From a 24-Hour Recall Questionnaire in the Dene and Métis Communities of the Northwest Territories, Canada

Background

Food security and nutrient deficiencies are frequent issues for people living in northern remote regions of Canada.

Objective

The objective of this study is to describe the nutrient intake of residents living in the Dene/Métis communities of the Dehcho and Sahtú regions of the Northwest Territories.

Methods

A 24-h dietary recall survey was used to collect information from participants of a study completed in 9 communities during the winter seasons of January 2016 to March 2018. Intakes for food groups, vitamins, macroelements, and microelements were calculated. Nutrient intakes were compared with the available DRIs.

Results

In total, there were 197 participants. On average, 37% of their energy was consumed from fat, and fruit/vegetable consumption was low (2.8 servings). Some vitamin levels (i.e., folate and vitamins A, B-6, C, and D) indicated a risk of nutritional deficiency for at least half of the participants. Of the nutrients examined, the nutrients least likely to meet the DRIs, according to the age/sex category of respondents were vitamin D (6%-20%), fiber (0%-11%), and calcium (4%-30%). Males tended to have a higher rate of nutrient adequacy above the DRIs. Importantly, 52% of the childbearing age female participants appeared deficient in folate, 48% deficient in zinc, 41% deficient in B12, and 22% deficient in iron, which might affect pregnancy and children's development.

Conclusions

A focus on supporting a higher intake of nutrient-dense foods would benefit the health of these communities. Nutrition and health promotion programs should be implemented to improve public health efforts in the region.

Assessing the Use of Social Cognitive Theory Components in Cooking and Food Skills Interventions

Increased cooking skill development may reduce the risk of disease and promote healthy eating behaviors in the home. The social cognitive theory (SCT) is one of the most common theories used in cooking and food skill interventions. This narrative review aims to understand how commonly each SCT component is implemented in cooking interventions, as well as identifying which components are associated with positive outcomes. The literature review was conducted using three databases: PubMed, Web of Science (FSTA and CAB), and CINHAL, yielding thirteen included research articles. None of the studies in this review comprehensively included all SCT components; at most, five of the seven were defined. The most prevalent SCT components were behavioral capability, self-efficacy, and observational learning, and the least implemented component was expectations. All studies included in this review yielded positive outcomes for cooking self-efficacy and frequency, except for two studies with null outcomes. Findings from this review suggest that the SCT may not be fully realized, and future studies should continue to define how theory influences intervention design for adult cooking interventions.

Shifting paradigm from biomedical to decolonised methods in Inuit public health research in Canada: a scoping review

BACKGROUND

The National Inuit Strategy on Research focuses on advancing Inuit governance in research, increasing ownership over data and building capacity. Responding to this call for Inuit self-determination in research, academic researchers should consider cultural safety in research and ways to promote Inuit-led methods.

METHODS

This scoping review collated academic literature on public health research in Inuit communities in Canada between 2010 and 2022. A critical assessment of methods used in public health research in Inuit communities examined cultural safety and the use of Inuit-attuned methods. Descriptive and analytical data were summarised in tables and figures. Knowledge user engagement in the research process was analysed with thematic analysis.

RESULTS

356 articles met the inclusion criteria. Much of the published research was in nutrition and mental health, and few initiatives reported translation into promotion programmes. Almost all published research was disease or deficit focused and based on a biomedical paradigm, especially in toxicology, maternal health and chronic diseases. Recent years saw an increased number of participatory studies using a decolonial lens and focusing on resilience. While some qualitative research referred to Inuit methodologies and engaged communities in the research process, most quantitative research was not culturally safe. Overall, community engagement remained in early stages of co-designing research protocols and interventions. Discussion on governance and data ownership was limited. Recent years saw emerging discussions on these issues. Knowledge user capacity-building was limited to brief training on conventional data collection methods.

CONCLUSIONS

The last decade of published public health research has not responded to the National Inuit Strategy on Research. Participatory research is gaining ground, but has not reached its full potential. A shift from biomedical to decolonised methods is slowly taking place, and public health researchers who have not yet embraced this paradigm shift should do so.

Health promotion interventions supporting Indigenous healthy ageing: a scoping review

Aging well is a priority in Canada and globally, particularly for older Indigenous adults experiencing an increased risk of chronic conditions. Little is known about health promotion interventions for older Indigenous adults and most literature is framed within Eurocentric paradigms that are not always relevant to Indigenous populations. This scoping review, guided by Arksey and O'Malley's framework and the PRISMA-ScR Checklist, explores the literature on Indigenous health promoting interventions across the lifespan, with specific attention to Indigenous worldview and the role of older Indigenous adults within these interventions. To ensure respectful and meaningful engagement of Indigenous peoples, articles were included in the Collaborate or Shared Leadership categories on the Continuum of Engagement. Fifteen articles used Indigenous theories and frameworks in the study design. Several articles highlighted engaging Elders as advisors in the design and/or delivery of programs however only five indicated Elders were active participants. In this scoping review, we suggest integrating a high level of community engagement and augmenting intergenerational approaches are essential to promoting health among Indigenous populations and communities. Indigenous older adults are keepers of essential knowledge and must be engaged (as advisors and participants) in intergenerational health promotion interventions to support the health of all generations.

A multi-level, multi-component obesity intervention (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans) decreases soda intake in Native American adults

OBJECTIVE

To evaluate the impact of a multi-level, multi-component (MLMC) adult obesity intervention on beverage intake in Native American adults living in five geographically and culturally diverse tribal communities.

DESIGN

A 14-month, community-randomised, MLMC design was utilised, with three communities randomised to Intervention and two communities randomised to Comparison. FFQ were administered pre- and post-interventions, and difference-in-differences (DiD) analysis was used to assess intervention impact on beverage intake.

SETTING

The intervention took place within food stores, worksites, schools and selected media outlets located in the five communities. Key activities included working with store owners to stock healthy beverages, display and dispersal of educational materials, support of policies that discouraged unhealthy beverage consumption at worksites and schools and taste tests.

PARTICIPANTS

Data were collected from 422 respondents between the ages of 18 and 75 living in the five communities pre-intervention; of those, 299 completed post-intervention surveys. Only respondents completing both pre- and post-intervention surveys were included in the current analysis.

RESULTS

The DiD for daily servings of regular, sugar-sweetened soda from pre- to post-intervention was significant, indicating a significant decrease in Intervention communities (P < 0·05). No other changes to beverage intake were observed.

CONCLUSIONS

Large, MLMC obesity interventions can successfully reduce the intake of regular, sugar-sweetened soda in Native American adults. This is important within modern food environments where sugar-sweetened beverages are a primary source of added sugars in Native American diets.

Trends in the Number of Behavioural Theory-Based Healthy Eating Interventions Inclusive of Dietitians/Nutritionists in 2000-2020

Nutrition interventions developed using behaviour theory may be more effective than those without theoretical underpinnings. This study aimed to document the number of theory-based healthy eating interventions, the involvement of dietitians/nutritionists and the behaviour theories employed from 2000 to 2020. We conducted a review of publications related to healthy eating interventions that used behaviour change theories. Interventional studies published in English between 2000 and 2020 were retrieved from searching Medline, Cinahl, Embase, Psycinfo and Cochrane Central. Citation, country of origin, presence or absence of dietitian/nutritionist authors, participants, dietary behaviours, outcomes, theories and any behaviour change techniques (BCTs) stated were extracted. The publication trends on a yearly basis were recorded. A total of 266 articles were included. The number of theory-based interventions increased over the two decades. The number of studies conducted by dietitians/nutritionists increased, but since 2012, increases have been driven by other researchers. Social cognitive theory was the most used behaviour theory. Dietitians/nutritionists contributed to growth in publication of theory-based healthy eating interventions, but the proportion of researchers from other professions engaged in this field increased markedly. The reasons for this growth in publications from other professions is unknown but conjectured to result from greater prominence of dietary behaviours within the context of an obesity epidemic.

A Critical Review on New Approaches for Chronic Disease Prevention in Brazil and Canada: From Wholistic Dietary Guidelines to Physical Activity Security

In light of new evidence on the prevention of chronic diseases and the elevated rates of overweight and obesity in Brazil and Canada, this critical review aims to interpret and synthesize current aspects regarding dietary and physical activity initiatives in both countries and make future recommendations. The pioneering work presented in the last Brazilian dietary guidelines has been called a model that can be applied globally, given its conceptualization of healthy eating that translates easily to practical guidance. The new Canadian Food Guide has incorporated similar aspects, also putting the country as a leader in dietary guidance. With these new recommendations, citizens in both Brazil and Canada have access to impactful evidence-informed nutritional guidelines. Both documents propose eating patterns that focus not only on health benefits, such as chronic disease prevention, but also incorporate well-being concerning cultural, economic, sociodemographic, biological, and ecological dimensions. A similar approach is required for physical activity to allow individuals to have attainable health and life goals and thereby fully enjoy their lives, regardless of geographical location, health status, and socioeconomic condition, a concept recently described as physical activity security. The wholistic dietary guidelines from both countries represent a change in paradigm in public health. Likewise, national evidence-based policies are warranted to reduce disparities in physical activity, allowing healthier and more active lifestyles for everyone.

"I was eating more fruits and veggies than I have in years": a mixed methods evaluation of a fresh food prescription intervention

Background

Food insecurity is associated with poor nutritional health outcomes. Prescribing fresh fruits and vegetables in healthcare settings may be an opportunity to link patients with community supports to promote healthy diets and improve food security. This mixed methods study evaluated the impacts of a fresh food prescription pilot program.

Methods

The study took place at two Community Health Centre locations in Guelph, Ontario, Canada. Sixty food insecure patients with ≥1 cardio-metabolic condition or micronutrient deficiency participated in the intervention. Participants were prescribed 12 weekly vouchers to Community Food Markets. We conducted a one-group pre-post mixed-methods evaluation to assess changes in fruit and vegetable intake, self-reported health, food security, and perceived food environments. Surveys were conducted at baseline and follow-up and semi-structured interviews with participants were conducted following the intervention.

Results

Food security and fruit and vegetable consumption improved following the intervention. Food security scores increased by 1.6 points, on average (p < 0.001). Consumption of fruits and 'other' vegetables (cucumber, celery, cabbage, cauliflower, squashes, and vegetable juice) increased from baseline to follow-up (p < 0.05). No changes in self-reported physical or mental health were observed. Qualitative data suggested that the intervention benefited the availability, accessibility, affordability, acceptability, and accommodation of healthy foods for participating households.

Conclusions

Fresh food prescription programs may be a useful model for healthcare providers to improve patients' food environments, healthy food consumption, and food security.

A Scoping Review of the Use of Indigenous Food Sovereignty Principles for Intervention and Future Directions

Indigenous food sovereignty (IFS) represents a community-led movement with potential to reduce health inequities, but no scoping review of the impact of taking an IFS approach on intervention research has been conducted. This review sought to: 1) describe intervention studies that employ IFS principles, and 2) describe the impact of studies using IFS principles on food access, eating patterns, diet quality, physical activity, and health. Through a literature review, 4 IFS principles were identified: 1) community ownership, 2) inclusion of traditional food knowledge, 3) inclusion and promotion of cultural foods, and 4) environmental/intervention sustainability. Twenty intervention studies published between January 1, 2000 and February 5, 2020 were included. Most of the studies that scored high in IFS principles saw a positive impact on diet. This review found evidence supporting the value of IFS principles in the development, implementation, and evaluation of health interventions for Indigenous communities.

Drivers and health implications of the dietary transition among Inuit in the Canadian Arctic: a scoping review

OBJECTIVE

The current study undertook a systematic scoping review on the drivers and implications of dietary changes among Inuit in the Canadian Arctic.

DESIGN

A keyword search of peer-reviewed articles was performed using PubMed, Web of Science, CINAHL, Academic Search Premier, Circumpolar Health Bibliographic Database and High North Research Documents. Eligibility criteria included all full-text articles of any design reporting on research on food consumption, nutrient intake, dietary adequacy, dietary change, food security, nutrition-related chronic diseases or traditional food harvesting and consumption among Inuit populations residing in Canada. Articles reporting on in vivo and in vitro experiments or on health impacts of environmental contaminants were excluded.

RESULTS

A total of 162 studies were included. Studies indicated declining country food (CF) consumption in favour of market food (MF). Drivers of this transition include colonial processes, poverty and socio-economic factors, changing food preferences and knowledge, and climate change. Health implications of the dietary transition are complex. Micro-nutrient deficiencies and dietary inadequacy are serious concerns and likely exacerbated by increased consumption of non-nutrient dense MF. Food insecurity, overweight, obesity and related cardiometabolic health outcomes are growing public health concerns. Meanwhile, declining CF consumption is entangled with shifting culture and traditional knowledge, with potential implications for psychological, spiritual, social and cultural health and well-being.

CONCLUSIONS

By exploring and synthesising published literature, this review provides insight into the complex factors influencing Inuit diet and health. Findings may be informative for future research, decision-making and intersectoral actions around risk assessment, food policy and innovative community programmes.

Evaluating the implementation and impact of a healthier checkout programme at a regional convenience store chain

OBJECTIVE

To test the feasibility of implementing and evaluating a healthier checkout pilot study in a convenience store chain.

DESIGN

A quasi-experimental study was conducted comparing a 3-month 'healthier checkouts' intervention in ten convenience stores which stocked eight healthier items in the checkout space and ten comparison stores assigned to continue stocking their current checkout space product mix. All aspects of the intervention were implemented by the retailer. The research team conducted in-person fidelity checks to assess implementation. Sales data were collected from the retailer in order to compare mean baseline to intervention sales of the eight healthier items in intervention and comparison groups while controlling for overall store sales.

SETTING

Convenience store chain.

PARTICIPANTS

Twenty convenience stores in New Hampshire.

RESULTS

The increases in sales of healthier items between the baseline and intervention periods among the intervention and comparison stores were not statistically significant; however, the overall pattern of the results showed promising changes that should be expanded on in future studies. Intervention fidelity checks indicated that results may have been attenuated by variability in intervention implementation.

CONCLUSIONS

This study advances the evidence for effective promotion of healthier food purchases in the convenience store chain setting and adds to the current literature on retail checkout space interventions. Additional research is needed to confirm and expand these results.

Nutrition Interventions in Low-Income Rural and Urban Retail Environments: A Systematic Review

BACKGROUND

Nutrition interventions promoting healthy food choices aim to address health challenges of residents in low-income environments. Research about the effectiveness of nutrition interventions in low-income populations is limited, particularly for those in rural areas. Behavioral economics (BE) strategies demonstrate effectiveness for improving eating behaviors in some settings. However, the efficacy of BE interventions in retail food stores serving low-income populations residing in rural and urban geographies is nascent.

OBJECTIVE

This systematic literature review aims to identify and compare nutrition interventions implemented in rural and urban low-income retail food stores, including BE strategies when applied.

METHODS

This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Reviewers searched five databases for peer-reviewed publications from October 2010 to October 2019. Included studies implemented a nutrition intervention in low-income retail food stores and provided a quantitative outcome evaluation with results separated by rural and urban geography. BE interventions were analyzed based on the MINDSPACE framework for behavior change.

RESULTS

Forty-six separate publications (n = 20 rural, n = 26 urban) in the United States, Canada, Europe, New Zealand, and Australia were included. Researchers independently rated publications as low risk of bias (n = 4), moderate (n = 18), or high risk of bias (n = 24) using the Quality Assessment Tool for Quantitative Studies. Studies (n = 18) demonstrated positive outcomes for customer purchases, store sales, or participant intake of targeted healthy foods. Overall, most effective interventions included point-of-purchase signage (n = 16) and product placement strategies (n = 4 urban). Rural studies included financial incentives combined with participant education (n = 2) and incorporated culturally appropriate messengers and/or symbols (n = 5) to improve healthy food purchases and intake.

CONCLUSIONS

Improved research quality and tailored evidence-based interventions, including BE strategies, are necessary in retail food environments to promote healthy eating behaviors in low-income populations.

Understanding Barriers to Implementing and Managing Therapeutic Diets for People Living with Chronic Kidney Disease in Remote Indigenous Communities

Indigenous peoples in Canada, and globally, experience a disproportionate burden of chronic kidney disease (CKD) and end-stage renal disease (ESRD) ESRD patients in remote Indigenous communities might experience significant challenges in adhering to dietary guidelines. Much research has documented the poor quality, high cost, and limited availability of healthy foods in remote, Indigenous communities. Food quality and availability are poor in remote communities, indicating that persons with ESRD and CKD might have limited ability to adhere to dietary guidelines. This article reports on research designed to understand food-access barriers in remote First Nations for persons living with stage 4 and 5 CKD/ESRD. The study involved semi-structured interviews with 38 patients in remote communities. It concludes with some reflections on the significance of this issue in the context of dietetic practice.

The Retail Food Sector and Indigenous Peoples in High-Income Countries: A Systematic Scoping Review

Indigenous Peoples in high-income countries experience higher burdens of food insecurity, obesity, and diet-related health conditions compared to national averages. The objective of this systematic scoping review is to synthesize information from the published literature on the methods/approaches, findings, and scope for research and interventions on the retail food sector servicing Indigenous Peoples in high-income countries. A structured literature search in two major international databases yielded 139 relevant peer-reviewed articles from nine countries. Most research was conducted in Oceania and North America, and in rural and remote regions. Several convergent issues were identified across global regions including limited grocery store availability/access, heightened exposure to unhealthy food environments, inadequate market food supplies (i.e., high prices, limited availability, and poor quality), and common underlying structural factors including socio-economic inequality and colonialism. A list of actions that can modify the nature and structure of retailing systems to enhance the availability, accessibility, and quality of healthful foods is identified. While continuing to (re)align research with community priorities, international collaboration may foster enhanced opportunities to strengthen the evidence base for policy and practice and contribute to the amelioration of diet quality and health at the population level.

Dissemination of an American Indian Culturally Centered Community-Based Participatory Research Family Listening Program: Implications for Global Indigenous Well-Being

We introduce a culture-centered indigenous program called the Family Listening Program (FLP), which was developed through a long-standing community-based participatory research (CBPR) partnership involving tribal research teams (TRTs) from three American Indian communities (Apache, Navajo, and Pueblo) with the University of New Mexico’s Center for Participatory Research (UNM-CPR). This paper provides background information on the TRT/UNM-CPR multi-generational FLP intervention funded by the National Institute on Drug Abuse and how it is poised to take the next steps of dissemination and implementation (D&I). In preparing for the next steps, the TRT/UNM-CPR team piloted two FLP dissemination activities, first at the state-level and then nationally; this paper describes these activities. Based on the learnings from the pilot dissemination, the TRT/UNM-CPR team developed an innovative D&I model by integrating a community-based participatory research culture-centered science (CBPR-CCS) approach with the Interactive Systems Framework (ISF) to examine the uptake, cultural acceptance, and sustainability of the FLP as an evidence-based indigenous family program.

What are the elements of a whole system approach to community-centred public health? A qualitative study with public health leaders in England's local authority areas

OBJECTIVES

The aim of the study was to identify key elements of whole system approaches to building healthy communities and putting communities at the heart of public health with a focus on public health practice to reduce health inequalities.

DESIGN

A mixed-method qualitative study was undertaken. The primary method was semi-structured interviews with 17 public health leaders from 12 local areas. This was supplemented by a rapid review of literature, a survey of 342 members of the public via Public Health England's (PHE) People's Panel and a round-table discussion with 23 stakeholders.

SETTING

Local government in England.

RESULTS

Eleven elements of community-centred public health practice that constitute taking a whole system approach were identified. These were grouped into the headings of involving, strengthening, scaling and sustaining. The elements were underpinned by a set of values and principles.

CONCLUSION

Local public health leaders are in a strong position to develop a whole system approach to reducing health inequalities that puts communities at its heart. The elements, values and principles summarise what a supportive infrastructure looks like and this could be further tested with other localities and communities as a framework for scaling community-centred public health.

Effects of food policy actions on Indigenous Peoples' nutrition-related outcomes: a systematic review

INTRODUCTION

Indigenous Peoples worldwide endure unacceptable health disparities with undernutrition and food insecurity often coexisting with obesity and chronic diseases. Policy-level actions are required to eliminate malnutrition in all its forms. However, there has been no systematic synthesis of the evidence of effectiveness of food and nutrition policies for Indigenous Peoples around the world. This review fills that gap.

METHODS

Eight databases were searched for peer-reviewed literature, published between 2000 and 2019. Relevant websites were searched for grey literature. Articles were included if they were original studies, published in English and included data from Indigenous Peoples from Western colonised countries, evaluated a food or nutrition policy (or intervention), and provided quantitative impact/outcome data. Study screening, data extraction and quality assessment were undertaken independently by two authors, at least one of whom was Indigenous. A narrative synthesis was undertaken with studies grouped according to the NOURISHING food policy framework.

RESULTS

We identified 78 studies from Canada, Australia, Aotearoa/New Zealand and the USA. Most studies evaluated targeted interventions, focused on rural or remote Indigenous communities. The most effective interventions combined educational strategies with policies targeting food price, composition and/or availability, particularly in retail and school environments. Interventions to reduce exposure to unhealthy food advertising was the only area of the NOURISHING framework not represented in the literature. Few studies examined the impact of universal food policies on Indigenous Peoples' diets, health or well-being.

CONCLUSION

Both targeted and universal policy action can be effective for Indigenous Peoples. Actions that modify the structures and systems governing food supply through improved availability, access and affordability of healthy foods should be prioritised. More high-quality evidence on the impact of universal food and nutrition policy actions for Indigenous Peoples is required, particularly in urban areas and in the area of food marketing.

Complexity and Community Context: Learning from the Evaluation Design of a National Community Empowerment Programme

Community empowerment interventions, which aim to build greater individual and community control over health, are shaped by the community systems in which they are implemented. Drawing on complex systems thinking in public health research, this paper discusses the evaluation approach used for a UK community empowerment programme focused on disadvantaged neighbourhoods. It explores design choices and the tension between the overall enquiry questions, which were based on a programme theory of change, and the varied dynamic socio-cultural contexts in intervention communities. The paper concludes that the complexity of community systems needs to be accounted for through in-depth case studies that incorporate community perspectives.

Systematic review: a systems innovation perspective on barriers and facilitators for the implementation of healthy food-store interventions

BACKGROUND

Due to their central position in the modern food system, food stores present a unique opportunity to promote healthy dietary behaviour. However, there is a lack of insight into the factors that impede or enhance the implementation of nutritional interventions in food stores. We applied a systems innovation and implementation science framework to the identification of such barriers and facilitators.

METHODS

We conducted a systematic literature review. A search string was developed to identify qualitative and quantitative articles on environmental nutritional interventions in the food store. Four databases were systematically searched for studies published between 2000 and 2018. Eligible publications described study designs or original studies, focused on stimulating healthier dietary behaviour through environmental changes in retail settings and contained information on the perceptions or experiences of retailers or interventionists regarding the implementation process of the intervention. Context-descriptive data was extracted and a quality assessment was performed.

RESULTS

We included 41 articles, of which the majority was conducted in the USA and involved single stores or a mix of single and multi-store organisations. We categorized barriers and facilitators into 18 themes, under five domains. In the 'outer setting' domain, most factors related to consumers' preferences and demands, and the challenge of establishing a supply of healthy products. In the 'inner setting' domain, these related to conflicting values regarding health promotion and commercial viability, store lay-out, (insufficient) knowledge and work capacity, and routines regarding waste avoidance and product stocking. In the 'actors' domain, no major themes were found. For the 'intervention 'domain', most related to intervention-context fit, money and resource provision, material quality, and the trade-offs between commercial costs and risks versus commercial and health benefits. For the 'process' domain, most factors related to continuous engagement and strong relationships.

CONCLUSIONS

This review provides a comprehensive overview of barriers and facilitators to be taken into account when implementing nutritional interventions in food stores. Furthermore, we propose a novel perspective on implementation as the alignment of intervention and retail interests, and a corresponding approach to intervention design which may help avoid barriers, and leverage facilitators.

TRIAL REGISTRATION

PROSPERO; CRD42018095317.

Barriers and facilitators to the implementation of brief interventions targeting smoking, nutrition, and physical activity for indigenous populations: a narrative review

Objective

This narrative review aimed to identify and categorize the barriers and facilitators to the provision of brief intervention and behavioral change programs that target several risk behaviors among the Indigenous populations of Australia, Canada, and New Zealand.

Methods

A systematic database search was conducted of six databases including PubMeD, Embase, CINAHL, HealthStar, PsycINFO, and Web of Science. Thematic analysis was utilized to analyze qualitative data extracted from the included studies, and a narrative approach was employed to synthesize the common themes that emerged. The quality of studies was assessed in accordance with the Joanna Briggs Institute’s guidelines and using the software SUMARI – The System for the Unified Management, Assessment and Review of Information.

Results

Nine studies were included. The studies were classified at three intervention levels: (1) individual-based brief interventions, (2) family-based interventions, and (3) community-based-interventions. Across the studies, selection of the intervention level was associated with Indigenous priorities and preferences, and approaches with Indigenous collaboration were supported. Barriers and facilitators were grouped under four major categories representing the common themes: (1) characteristics of design, development, and delivery, (2) patient/provider relationship, (3) environmental factors, and (4) organizational capacity and workplace-related factors. Several sub-themes also emerged under the above-mentioned categories including level of intervention, Indigenous leadership and participation, cultural appropriateness, social and economic barriers, and design elements.

Conclusion

To improve the effectiveness of multiple health behavior change interventions among Indigenous populations, collaborative approaches that target different intervention levels are beneficial. Further research to bridge the knowledge gap in this topic will help to improve the quality of preventive health strategies to achieve better outcomes at all levels, and will improve intervention implementation from development and delivery fidelity, to acceptability and sustainability.

OPREVENT (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans): Design of a Multilevel, Multicomponent Obesity Intervention for Native American Adults and Households

Obesity prevalence is high in Native American (NA) adults, and there is a critical need to establish and implement evidence-based social, behavioral, and policy interventions that are theoretically informed. The use of multilevel, multicomponent (MLMC) interventions has been shown to be an effective strategy for comprehensive health behavior change; however, there is little guidance available in the literature to facilitate implementation in this underserved and understudied population. To decrease obesity and related comorbidities in NA adults, an MLMC intervention called OPREVENT (Obesity Prevention and Evaluation of InterVention Effectiveness in NaTive North Americans) was implemented in 5 rural NA communities to modify the food-purchasing environment, improve diet, and increase physical activity (PA). Five NA communities across the Upper Midwest and Southwest United States were randomly assigned to Immediate (n = 3) or Delayed (n = 2) Intervention. OPREVENT was implemented in Immediate Intervention community food stores, worksites, schools, and media over 1 y. A community-randomized controlled trial was used to evaluate intervention impact in adults at the individual and institutional levels, with individual-level data being collected on diet, PA, and psychosocial variables at baseline and follow-up; and institutional-level data being collected on food stores, worksites, and schools, media, and process measures. The OPREVENT intervention was one of the first MLMC obesity interventions in this population and provides evidence-based practices for future program development. The purpose of this article is to describe the design, implementation, and evaluation of OPREVENT. This trial was registered at isrctn.com as ISRCTN76144389.

Whole systems approaches to obesity and other complex public health challenges: a systematic review

BACKGROUND

Increasing awareness of the complexity of public health problems, including obesity, has led to growing interest in whole systems approaches (WSAs), defined as those that consider the multifactorial drivers of overweight and obesity, involve transformative co-ordinated action across a broad range of disciplines and stakeholders, operate across all levels of governance and throughout the life course. This paper reports a systematic review of WSAs targeting obesity and other complex public health and societal issues, such as healthy lifestyles for prevention of non-communicable disease.

METHODS

Seven electronic databases were searched from 1995 to 2018. Studies were included if there had been an effort to implement a WSA. Study selection was conducted by one reviewer with a random 20% double checked. Data extraction and validity assessment were undertaken by one reviewer and checked by a second reviewer. Narrative synthesis was undertaken.

RESULTS

Sixty-five articles were included; 33 about obesity. Most examined multicomponent community approaches, and there was substantial clinical and methodological heterogeneity. Nevertheless, a range of positive health outcomes were reported, with some evidence of whole systems thinking. Positive effects were seen on health behaviours, body mass index (BMI), parental and community awareness, community capacity building, nutrition and physical activity environments, underage drinking behaviour and health, safety and wellbeing of community members, self-efficacy, smoking and tobacco-related disease outcomes. Features of successful approaches reported in process evaluations included: full engagement of relevant partners and community; time to build relationships, trust and capacity; good governance; embedding within a broader policy context; local evaluation; finance.

CONCLUSIONS

Systems approaches to tackle obesity can have some benefit, but evidence of how to operationalise a WSA to address public health problems is still in its infancy. Future research should: (a) develop an agreed definition of a WSA in relation to obesity, (b) look across multiple sectors to ensure consistency of language and definition, (c) include detailed descriptions of the approaches, and (d) include process and economic evaluations.

Work, worksites, and wellbeing among North American Indian women: a qualitative study

The purpose of this study was to understand what factors influenced work-family balance and related health behaviors among a sample of rural North American Indian women. We interviewed 89 women through both in-depth interviews and focus groups across four tribal communities in the American Southwest and Upper Midwest between July 2010 and August 2011. Interviews were transcribed, coded, and analyzed for emerging themes related to work- family demands placed on women and resources available to cope with those demands. Three prominent themes emerged: structural characteristics (the context of rural reservation life), role stressors (women's multiple and conflicting roles) and the influence of social support (communal nature of care in the family and institutional support in the workplace). We found that women in participating rural reservation communities often acted as primary caregivers for both immediate and extended family, and often placed the needs of others before themselves. The context of rural reservations, with high rates of unemployment, poverty, and chronic illnesses associated with the collective trauma of colonization, placed high demands on female caregivers. Social support from within the workplace, family, and cultural traditions helped some female caregivers balance the demands of home and work. Tribal worksites could be a resource for promoting health and work-life balance by being responsive to the particular demands placed on women that often interfere with engaging in positive health behaviors in general and tribal wellness programs in particular.

Using unfolding case studies to better prepare the public health nutrition workforce to address the social determinants of health

OBJECTIVE

The public health nutrition workforce has been reported to be underprepared for practice. The present study aimed to test the ability of an unfolding case study approach to support the public health nutrition workforce for the workplace, with a focus on improved access to nutritious food.

DESIGN

Two unfolding case studies were trialled with undergraduate students in two-hour workshops to enhance their capability to address access to nutritious food as a social determinant of health. The approach provided information about the case using a staged approach that supported learners to review and reply to information and then continue this process as the case became increasingly complex.

SETTING

Melbourne, Australia.ParticipantsThirty-eight undergraduate nutrition and dietetics students.

RESULTS

The analysis revealed that the unfolding case study approach provided a place to challenge and deepen knowledge and think about the application of theory. As the cases developed and became more challenging, students were supported to consider appropriate approaches and recognised the constant evolution and dynamic nature of practice.

CONCLUSIONS

This learning activity challenged students and supported deep learning about possible solutions. It may also be useful at a graduate level and for continuous education of nutritionists and/or dietitians to empower the workforce to address the social determinants of health, rather than just acknowledging them as a set of barriers that prevent people and communities from achieving optimal health. Further work is required to investigate how unfolding case studies in curricula shape preparedness for practice of public health nutrition.

Who is research serving? A systematic realist review of circumpolar environment-related Indigenous health literature

BACKGROUND

Addressing factors leading to health disparities in the Circumpolar North require approaches that consider and address the social determinants of health including on-going colonization. Today, colonization and related policies and processes, continue to manifest in the marginalization of Indigenous knowledge, particularly its use in research; however, Indigenous populations have moved from being research subjects to leaders and consumers of environmental health research. Given the tensions that exist between how health research is conducted, how the results are mobilized, and who has control and access to the results, we examine how peer-reviewed environment-related Indigenous health research in the Circumpolar North is serving the needs of Indigenous communities, governments, and organizations.

METHODS

A modified systematic-realist literature review was conducted. Three databases were searched for peer-reviewed literature published from 2000 to 2015. Articles were included if the research focused on the intersection of the environment and health in Northern Canada and/or Alaska. A total of 960 unique records were screened for relevance, and 210 articles were analysed.

RESULTS

Of these relevant articles, 19% discussed how Indigenous peoples were engaged in the research. There was a significant increase in reporting participatory, community-based methods over time; the proportion of articles reporting community-engagement varied by research topic; quantitative research articles were significantly less likely to report community-engaged methods; and most articles did not clearly report how the results were shared with the community.

CONCLUSION

The results raise a number of questions for the field of Circumpolar environment-related Indigenous health research, including whether or how authors of peer-reviewed literature should (or should not) be obliged to describe how research is serving Northern Indigenous communities. The results are intended to stimulate further conversations and bridge perceived dichotomies of quantitative/qualitative, Western/Indigenous, and empirical/community driven research approaches, as well as underlying assumptions that frame health research.

The piloting of a culturally centered American Indian family prevention program: a CBPR partnership between Mescalero Apache and the University of New Mexico

The Mescalero Apache Family Listening Program (MAFLP) is a culturally centered family prevention program with third, fourth, and fifth graders; a parent/caregiver; and a family elder. The program follows a positive youth development model to develop stronger communication and shared cultural practices between elders, parents, and youth in the tribe to reduce substance initiation of use among the youth. The MAFLP was created using a community-based participatory research (CBPR) approach in partnership with the University of New Mexico. The research focus of MAFLP is centered on the adaptation of a family curriculum from a Navajo and Pueblo version of the Family Listening Program to an Apache version, the establishment of a (Apache) Tribal Research Team, and the piloting of the curriculum with Apache families. MAFLP was piloted twice, and evaluation measures were collected focused on formative and impact evaluation. This article provides a background on Mescalero Apache then introduces the Navajo and Pueblo version of a Family Listening and Family Circle Program, respectively, next, the CBPR research partnership between Mescalero Apache and the University of New Mexico and the creation of a Mescalero Apache Tribal Research Team followed by the development and adaptation of a Mescalero Apache Family Listening Program including implementation and evaluation, and concluding with preliminary findings.

An innovative team-based weightloss competition to reduce cardiovascular and diabetes risk among Māori and Pacific people: rationale and method for the study and its evaluation

Background

Obesity rates for New Zealand (NZ) Pacific and Māori (NZ indigenous people) are among the highest in the world. Long-term results of weight management programmes for adults have been modest but primarily focused on individuals. This paper describes the rationale and methodology for a trial of a culturally tailored team-based weightloss competition conducted online with community level support.

Methods/Design

A quasi-experimental design was used to compare an intervention and control group. Three six-month competitions with seven teams of seven Māori or Pacific people (N = 147) were run. Eligible participants were: Māori or Pacific, 16 years of age and above, obese (BMI ≥30 kg/m²) and either at risk of or already diagnosed with type 2 diabetes (HbA1c >50 mmol/mol) or cardiovascular disease.

The intervention facilitated group use of an internet-based competition offering financial incentives, education and support. The primary outcome was percentage of individual weight lost at 12-months. Secondary outcomes were percentage reduced total cholesterol and glycated haemoglobin (HbA1c). Data collected at baseline, 6-months and 12-months included: height, body weight, blood lipids and HbA1c, eating and dieting habits, family support, food access, alcohol use, nutrition literacy, activity levels, perceptions of weight, stress and sleep, and, perceived contagion effect. Process evaluation tasks will inform acceptability.

Discussion

An attractive, easy to understand weight change programme that effectively reduces disease risk among Māori and Pacific is desperately needed. Web-based delivered support and information to largely self-directed teams could also ease exponential rises in costs to the health system.

Trial registration

Trial Id: ACTRN12617000871347.

Targeted mass media interventions promoting healthy behaviours to reduce risk of non-communicable diseases in adult, ethnic minorities

BACKGROUND

Physical activity, a balanced diet, avoidance of tobacco exposure, and limited alcohol consumption may reduce morbidity and mortality from non-communicable diseases (NCDs). Mass media interventions are commonly used to encourage healthier behaviours in population groups. It is unclear whether targeted mass media interventions for ethnic minority groups are more or less effective in changing behaviours than those developed for the general population.

OBJECTIVES

To determine the effects of mass media interventions targeting adult ethnic minorities with messages about physical activity, dietary patterns, tobacco use or alcohol consumption to reduce the risk of NCDs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, ERIC, SweMed+, and ISI Web of Science until August 2016. We also searched for grey literature in OpenGrey, Grey Literature Report, Eldis, and two relevant websites until October 2016. The searches were not restricted by language.

SELECTION CRITERIA

We searched for individual and cluster-randomised controlled trials, controlled before-and-after studies (CBA) and interrupted time series studies (ITS). Relevant interventions promoted healthier behaviours related to physical activity, dietary patterns, tobacco use or alcohol consumption; were disseminated via mass media channels; and targeted ethnic minority groups. The population of interest comprised adults (≥ 18 years) from ethnic minority groups in the focal countries. Primary outcomes included indicators of behavioural change, self-reported behavioural change and knowledge and attitudes towards change. Secondary outcomes were the use of health promotion services and costs related to the project.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the references to identify studies for inclusion. We extracted data and assessed the risk of bias in all included studies. We did not pool the results due to heterogeneity in comparisons made, outcomes, and study designs. We describe the results narratively and present them in 'Summary of findings' tables. We judged the quality of the evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology.

MAIN RESULTS

Six studies met the inclusion criteria, including three RCTs, two cluster-RCTs and one ITS. All were conducted in the USA and comprised targeted mass media interventions for people of African descent (four studies), Spanish-language dominant Latino immigrants (one study), and Chinese immigrants (one study). The two latter studies offered the intervention in the participants' first language (Spanish, Cantonese, or Mandarin). Three interventions targeted towards women only, one pregnant women specifically. We judged all studies as being at unclear risk of bias in at least one domain and three studies as being at high risk of bias in at least one domain.We categorised the findings into three comparisons. The first comparison examined mass media interventions targeted at ethnic minorities versus an equivalent mass media intervention intended for the general population. The one study in this category (255 participants of African decent) found little or no difference in effect on self-reported behavioural change for smoking and only small differences in attitudes to change between participants who were given a culturally specific smoking cessation booklet versus a booklet intended for the general population. We are uncertain about the effect estimates, as assessed by the GRADE methodology (very low quality evidence of effect). No study provided data for indicators of behavioural change or adverse effects.The second comparison assessed targeted mass media interventions versus no intervention. One study (154 participants of African decent) reported effects for our primary outcomes. Participants in the intervention group had access to 12 one-hour live programmes on cable TV and received print material over three months regarding nutrition and physical activity to improve health and weight control. Change in body mass index (BMI) was comparable between groups 12 months after the baseline (low quality evidence). Scores on a food habits (fat behaviours) and total leisure activity scores changed favourably for the intervention group (very low quality evidence). Two other studies exposed entire populations in geographical areas to radio advertisements targeted towards African American communities. Authors presented effects on two of our secondary outcomes, use of health promotion services and project costs. The campaign message was to call smoking quit lines. The outcome was the number of calls received. After one year, one study reported 18 calls per estimated 10,000 targeted smokers from the intervention communities (estimated target population 310,500 persons), compared to 0.2 calls per estimated 10,000 targeted smokers from the control communities (estimated target population 331,400 persons) (moderate quality evidence). The ITS study also reported an increase in the number of calls from the target population during campaigns (low quality evidence). The proportion of African American callers increased in both studies (low to very low quality evidence). No study provided data on knowledge and attitudes for change and adverse effects. Information on costs were sparse.The third comparison assessed targeted mass media interventions versus a mass media intervention plus personalised content. Findings are based on three studies (1361 participants). Participants in these comparison groups received personal feedback. Two of the studies recorded weight changes over time. Neither found significant differences between the groups (low quality evidence). Evidence on behavioural changes, and knowledge and attitudes typically found some effects in favour of receiving personalised content or no significant differences between groups (very low quality evidence). No study provided data on adverse effects. Information on costs were sparse.

AUTHORS' CONCLUSIONS

The available evidence is inadequate for understanding whether mass media interventions targeted toward ethnic minority populations are more effective in changing health behaviours than mass media interventions intended for the population at large. When compared to no intervention, a targeted mass media intervention may increase the number of calls to smoking quit line, but the effect on health behaviours is unclear. These studies could not distinguish the impact of different components, for instance the effect of hearing a message regarding behavioural change, the cultural adaptation to the ethnic minority group, or increase reach to the target group through more appropriate mass media channels. New studies should explore targeted interventions for ethnic minorities with a first language other than the dominant language in their resident country, as well as directly compare targeted versus general population mass media interventions.

Diabetes and obesity prevention: changing the food environment in low-income settings

Innovative approaches are needed to impact obesity and other diet-related chronic diseases, including interventions at the environmental and policy levels. Such interventions are promising due to their wide reach. This article reports on 10 multilevel community trials that the present authors either led (n = 8) or played a substantial role in developing (n = 2) in low-income minority settings in the United States and other countries that test interventions to improve the food environment, support policy, and reduce the risk for developing obesity and other diet-related chronic diseases. All studies examined change from pre- to postintervention and included a comparison group. The results show the trials had consistent positive effects on consumer psychosocial factors, food purchasing, food preparation, and diet, and, in some instances, obesity. Recently, a multilevel, multicomponent intervention was implemented in the city of Baltimore that promises to impact obesity in children, and, potentially, diabetes and related chronic diseases among adults. Based on the results of these trials, this article offers a series of recommendations to contribute to the prevention of chronic disease in Mexico. Further work is needed to disseminate, expand, and sustain these initiatives at the city, state, and federal levels.

Store owners as potential agents of change: energy drinks in the interior of Alaska

Childhood obesity disproportionately impacts disadvantaged communities, including Alaska Native children. In part, lack of access to fresh fruits and vegetables and over consumption of sugar sweetened beverages including energy drinks contribute to excessive weight gain in Alaska Native youth. This commentary reports the possibility of storeowners and workers partnering with community members to limit sales of nutrient-poor energy drinks through point-of-sale counselling in rural communities in the interior of Alaska. This model of intervention may be useful to implement in areas where there are limited health workers or others that can serve as health educators. This study reports preliminary evidence from rural Alaska and from other Arctic communities that store workers may effectively improve community health status by limiting or promoting specific products. Storeowners or workers may be helpful partners in the fight against childhood obesity as they are present at the point of sale of high-risk beverages to Alaska Native youth.

A primary care lifestyle programme suitable for socioeconomically vulnerable groups - an observational study

OBJECTIVE

To explore whether a primary health care (PHC) health promotion programme reaches and engages socioeconomically vulnerable groups in a community to the same extent as higher socioeconomic groups.

DESIGN

Comparison of level of engagement and lifestyle improvements stratified by socioeconomic vulnerability level.

SETTING

Hisingen PHC catchment area (130,000 inhabitants) Gothenburg, Sweden.

PARTICIPANTS

Men and women aged 18-79, visiting any of the eight public PHC centres during an eight-month period 2007-2008, were presented with a short intervention health questionnaire and offered a health dialogue with a nurse, including a health profile, p-glucose and blood pressure check. Participants were classified according to four socioeconomic vulnerability factors: education, employment, ethnicity and living situation.

RESULTS

Out of 3691 participants, 27% had low education (Hisingen community level 23%), 18% were unemployed (community level 22%), and 16% were born outside Scandinavia (community level 22%). At the one-year follow-up, 2121 (57%) attended. At baseline, 3% of the individuals in the sample had three out of four socioeconomic vulnerability factors, 17% had two vulnerability factors, 43% had one vulnerability factor, and 37% had no vulnerability factors. Improved biological markers were seen in all vulnerability groups (1-3) and odds ratios for improvement were significantly higher in the most socioeconomically vulnerable group for smoking and stress compared to the group with no vulnerability factors.

CONCLUSION

Socioeconomically vulnerable groups were reached and lifestyle changes were accomplished to the same extent as in the higher socioeconomic groups in a PHC lifestyle intervention programme. KEY POINTS Primary care plays a major part in prevention of chronic diseases. However, non-pharmacological primary and secondary prevention is often less successful, especially concerning socioeconomically vulnerable groups. The health promoting intervention programme "Pro-Health" reached and engaged socioeconomically vulnerable groups. Participants from the socioeconomically vulnerable groups had comparable odds for lifestyle improvements after one year, compared to participants without vulnerability factors.

Promoting physical activity in a low-income neighborhood of the Paris suburb of Saint-Denis: effects of a community-based intervention to increase physical activity

Background

Physical activity (PA) is a key factor for facing the increasing prevalence of obesity and overweight, and should be part of every public health programs. In this context, a community-based public health program promoting PA was developed in a low-income neighborhood of the city of Saint-Denis (France).

Methods

This work aimed at assessing the effectiveness of a 2-year PA promotion program.

A quasi-experimental study was carried out using a pre/post design, with an assessment before (2013) and after (2015) the program. The interviewees were selected using a stratified random cluster sampling. The primary outcome was the proportion of participants practicing sufficient PA (WHO guidelines), and was measured using the RPAQ questionnaire. External interventions (on both neighborhood environment and inhabitants) were listed.

Results

We collected 199 questionnaires at baseline and 217 in 2015. There was a majority of women in both samples: 64.3 % in 2013 and 58.2 % in 2015. The average age of participants was 38.1 years (+/−1.1) and 40.6 (+/−1.1) respectively. The proportion of people practicing sufficient PA was modified from 48.1 % in 2013 to 63.5 % in 2015 (p = 0.001). This was mainly driven by women whose level of PA, increased from 40.3 % to 60.3 % (p = 0.002), reaching the average national French estimation of PA level among adults (63.5 %).

Conclusions

This work showed a significant increase of the proportion of people practicing PA in a disadvantaged neighborhood where a community-based program promoting PA was developed. Simultaneous external interventions contributed to the results, showing the necessity of synergic interventions to reach efficiency.

CVD Prevention Through Policy: a Review of Mass Media, Food/Menu Labeling, Taxation/Subsidies, Built Environment, School Procurement, Worksite Wellness, and Marketing Standards to Improve Diet

Poor diet is the leading cause of cardiovascular disease in the USA and globally. Evidence-based policies are crucial to improve diet and population health. We reviewed the effectiveness for a range of policy levers to alter diet and diet-related risk factors. We identified evidence to support benefits of focused mass media campaigns (especially for fruits, vegetables, salt), food pricing strategies (both subsidies and taxation, with stronger effects at lower income levels), school procurement policies (for increasing healthful or reducing unhealthful choices), and worksite wellness programs (especially when comprehensive and multicomponent). Evidence was inconclusive for food and menu labeling (for consumer or industry behavior) and changes in local built environment (e.g., availability or accessibility of supermarkets, fast food outlets). We found little empiric evidence evaluating marketing restrictions, although broad principles and large resources spent on marketing suggest utility. Widespread implementation and evaluation of evidence-based policy strategies, with further research on other strategies with mixed/limited evidence, are essential “population medicine” to reduce health and economic burdens and inequities of diet-related illness worldwide.

Best Practices for the Prevention and Management of Diabetes and Obesity-Related Chronic Disease among Indigenous Peoples in Canada: A Review

OBJECTIVES

To carry out a systematic review of interventions that have aimed at improving screening, treatment, prevention and management of type 2 diabetes and obesity-related chronic disease in Indigenous communities in Canada from 2008 to 2014, with the aim of identifying current best practices.

METHODS

A comprehensive literature review was carried out through an electronic database search using Medline, EMBASE, PubMED and Google scholar.

RESULTS

We identified 17 publications, comprising 13 evaluated interventions. Of them, 7 were school-based programs focused on children, 5 focused on adults, and 1 included both adults and children. Most interventions aimed at encouraging behaviour change, especially dietary change, but did little to address the underlying context of systemic marginalization and colonialism experienced in many Indigenous communities. Interventions focused on improving fitness were more effective than those aimed at dietary change. Overall, we found a range of successes among these interventions. Those that met with limited success reported that complex social issues and poverty presented challenges to effective intervention work in these communities. Participatory action research methods and community ownership of the intervention were found to be essential for project success.

CONCLUSIONS

Diabetes-focused intervention research in Indigenous communities appears to be a low priority for Canadian funders and policymakers. More intervention research is urgently needed in these communities. To be effective, this work must take an approach that is historically deep and sufficiently broad as to enable the ideologic, policy and institutional changes necessary in order to achieve true equity. This will involve addressing colonialism, racism and social exclusion as broader determinants of health.

Process Evaluation of a Comprehensive Supermarket Intervention in a Low-Income Baltimore Community

Supermarket-based interventions are one approach to improving the local food environment and reducing obesity and chronic disease in low-income populations. We implemented a multicomponent intervention that aimed to reduce environmental barriers to healthy food purchasing in a supermarket in Southwest Baltimore. The intervention, Eat Right-Live Well! used: shelf labels and in-store displays promoting healthy foods, sales and promotions on healthy foods, in-store taste tests, increasing healthy food products, community outreach events to promote the intervention, and employee training. We evaluated program implementation through store environment, taste test session, and community event evaluation forms as well as an Employee Impact Questionnaire. The stocking, labeling, and advertising of promoted foods were implemented with high and moderate fidelity. Taste test sessions were implemented with moderate reach and low dose. Community outreach events were implemented with high reach and dose. Supermarket employee training had no significant impact on employees' knowledge, self-efficacy, or behavioral intention for helping customers with healthy purchasing or related topics of nutrition and food safety. In summary, components of this intervention to promote healthy eating were implemented with varying success within a large supermarket. Greater participation from management and employees could improve implementation.

Developmental origins, behaviour change and the new public health

A developmental approach to public health focuses attention on better nourishing girls and young women, especially those of low socio-economic status, to improve mothers' nutrition and thereby the health of future generations. There have been significant advances in the behavioural sciences that may allow us to understand and support dietary change in young women and their children in ways that have not previously been possible. This paper describes some of these advances and aims to show how they inform this new approach to public health. The first of these has been to work out what is effective in supporting behaviour change, which has been achieved by careful and detailed analysis of behaviour change techniques used by practitioners in intervention, and of the effectiveness of these in supporting change. There is also a new understanding of the role that social and physical environments play in shaping our behaviours, and that behaviour is influenced by automatic processes and 'habits' as much as by reflective processes and rational decisions. To be maximally effective, interventions therefore have to address both influences on behaviour. An approach developed in Southampton aims to motivate, support and empower young women to make better food choices, but also to change the culture in which those choices are being made. Empowerment is the basis of the new public health. An empowered public demand for better access to better food can go a long way towards improving maternal, infant and family nutrition, and therefore the health of generations to come.

Determinants of dietary behavior and physical activity among Canadian Inuit: a systematic review

Background

Increased dependence on Western diets and low physical activity have largely contributed to weight gain and associated chronic diseases in the Canadian Inuit population. The purpose of this study was to systematically review factors influencing dietary and physical activity behaviors to guide health promotion interventions and provide recommendations for future studies.

Method

We conducted a systematic literature review to identify relevant articles. Searches were conducted between May 2014 and July 2014, and inclusive of articles published up until July 2014. Articles were searched using four databases: PubMed, PsycINFO, SocINDEX, and Psychology and Behavioral Sciences Collection. Eligible studies focused on diet and/or physical activity or determinants of diet and/or physical activity in Canadian Inuit population, and were published in English.

Results

A total of 45 articles were included in the analysis. A detailed appraisal of the articles suggested that many Inuit have disconnected from the traditional ways of life, including harvesting and processing of traditional food species and the associated physical activity. In the last two decades there has been a significant shift from consumption of healthy traditional foods to energy-dense store-bought foods particularly among younger Inuit (<50 years of age). Additionally, low socioeconomic status (SES) and high transportation cost affect food accessibility and contribute to poor dietary choices in the population. However, a few articles that described the mediating role of psychosocial factors reported that higher SES, increased healthful food knowledge, and self-efficacy towards healthy dietary behavior, were associated with greater intentions to make healthier food choices and participate in physical activity.

Conclusion

It is evident that the rapid social, cultural, and environmental changes in the Arctic have altered dietary and physical activity behaviors of Canadian Inuit. However, our understanding is limited on how these behaviours might be influenced in the face of these changes. Prospective studies are needed to advance our knowledge of cognitive and environmental determinants of Inuit energy balance-related behaviours. These studies can inform the development of health promotion interventions in the population.

Nutrition-related policy and environmental strategies to prevent obesity in rural communities: a systematic review of the literature, 2002-2013

INTRODUCTION

Residents of rural communities in the United States are at higher risk for obesity than their urban and suburban counterparts. Policy and environmental-change strategies supporting healthier dietary intake can prevent obesity and promote health equity. Evidence in support of these strategies is based largely on urban and suburban studies; little is known about use of these strategies in rural communities. The purpose of this review was to synthesize available evidence on the adaptation, implementation, and effectiveness of policy and environmental obesity-prevention strategies in rural settings.

METHODS

The review was guided by a list of Centers for Disease Control and Prevention Recommended Community Strategies and Measurements to Prevent Obesity in the United States, commonly known as the "COCOMO" strategies. We searched PubMed, Cumulative Index of Nursing and Allied Health Literature, Public Affairs Information Service, and Cochrane databases for articles published from 2002 through 2013 that reported findings from research on nutrition-related policy and environmental strategies in rural communities in the United States and Canada. Two researchers independently abstracted data from each article, and resolved discrepancies by consensus.

RESULTS

Of the 663 articles retrieved, 33 met inclusion criteria. The interventions most commonly focused on increasing access to more nutritious foods and beverages or decreasing access to less nutritious options. Rural adaptations included accommodating distance to food sources, tailoring to local food cultures, and building community partnerships.

CONCLUSIONS

Findings from this literature review provide guidance on adapting and implementing policy and environmental strategies in rural communities.

Community wide interventions for increasing physical activity

BACKGROUND

Multi-strategic community wide interventions for physical activity are increasingly popular but their ability to achieve population level improvements is unknown.

OBJECTIVES

To evaluate the effects of community wide, multi-strategic interventions upon population levels of physical activity.

SEARCH METHODS

We searched the Cochrane Public Health Group Segment of the Cochrane Register of Studies,The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, LILACS, PsycINFO, ASSIA, the British Nursing Index, Chinese CNKI databases, EPPI Centre (DoPHER, TRoPHI), ERIC, HMIC, Sociological Abstracts, SPORT Discus, Transport Database and Web of Science (Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index). We also scanned websites of the EU Platform on Diet, Physical Activity and Health; Health-Evidence.org; the International Union for Health Promotion and Education; the NIHR Coordinating Centre for Health Technology (NCCHTA); the US Centre for Disease Control and Prevention (CDC) and NICE and SIGN guidelines. Reference lists of all relevant systematic reviews, guidelines and primary studies were searched and we contacted experts in the field. The searches were updated to 16 January 2014, unrestricted by language or publication status.

SELECTION CRITERIA

Cluster randomised controlled trials, randomised controlled trials, quasi-experimental designs which used a control population for comparison, interrupted time-series studies, and prospective controlled cohort studies were included. Only studies with a minimum six-month follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted the data and assessed the risk of bias. Each study was assessed for the setting, the number of included components and their intensity. The primary outcome measures were grouped according to whether they were dichotomous (per cent physically active, per cent physically active during leisure time, and per cent physically inactive) or continuous (leisure time physical activity time (time spent)), walking (time spent), energy expenditure (as metabolic equivalents or METS)). For dichotomous measures we calculated the unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk. For continuous measures we calculated percentage change from baseline, unadjusted and adjusted.

MAIN RESULTS

After the selection process had been completed, 33 studies were included. A total of 267 communities were included in the review (populations between 500 and 1.9 million). Of the included studies, 25 were set in high income countries and eight were in low income countries. The interventions varied by the number of strategies included and their intensity. Almost all of the interventions included a component of building partnerships with local governments or non-governmental organisations (NGOs) (29 studies). None of the studies provided results by socio-economic disadvantage or other markers of equity. However, of those included studies undertaken in high income countries, 14 studies were described as being provided to deprived, disadvantaged or low socio-economic communities. Nineteen studies were identified as having a high risk of bias, 10 studies were unclear, and four studies had a low risk of bias. Selection bias was a major concern with these studies, with only five studies using randomisation to allocate communities. Four studies were judged as being at low risk of selection bias although 19 studies were considered to have an unclear risk of bias. Twelve studies had a high risk of detection bias, 13 an unclear risk and four a low risk of bias. Generally, the better designed studies showed no improvement in the primary outcome measure of physical activity at a population level.All four of the newly included, and judged to be at low risk of bias, studies (conducted in Japan, United Kingdom and USA) used randomisation to allocate the intervention to the communities. Three studies used a cluster randomised design and one study used a stepped wedge design. The approach to measuring the primary outcome of physical activity was better in these four studies than in many of the earlier studies. One study obtained objective population representative measurements of physical activity by accelerometers, while the remaining three low-risk studies used validated self-reported measures. The study using accelerometry, conducted in low income, high crime communities of USA, emphasised social marketing, partnership with police and environmental improvements. No change in the seven-day average daily minutes of moderate to vigorous physical activity was observed during the two years of operation. Some program level effect was observed with more people walking in the intervention community, however this result was not evident in the whole community. Similarly, the two studies conducted in the United Kingdom (one in rural villages and the other in urban London; both using communication, partnership and environmental strategies) found no improvement in the mean levels of energy expenditure per person per week, measured from one to four years from baseline. None of the three low risk studies reporting a dichotomous outcome of physical activity found improvements associated with the intervention.Overall, there was a noticeable absence of reporting of benefit in physical activity for community wide interventions in the included studies. However, as a group, the interventions undertaken in China appeared to have the greatest possibility of success with high participation rates reported. Reporting bias was evident with two studies failing to report physical activity measured at follow up. No adverse events were reported.The data pertaining to cost and sustainability of the interventions were limited and varied.

AUTHORS' CONCLUSIONS

Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings in the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that the multi-component community wide interventions studied effectively increased physical activity for the population, although some studies with environmental components observed more people walking.

Impact of the Healthy Foods North nutrition intervention program on Inuit and Inuvialuit food consumption and preparation methods in Canadian Arctic communities

Background

The 12-month Healthy Foods North intervention program was developed to improve diet among Inuit and Inuvialuit living in Arctic Canada and assess the impact of the intervention established for the communities.

Methods

A quasi-experimental study randomly selected men and women (≥19 years of age) in six remote communities in Nunavut and the Northwest Territories. Validated quantitative food frequency and adult impact questionnaires were used. Four communities received the intervention and two communities served as delayed intervention controls. Pre- and post-intervention changes in frequency of/total intake of de-promoted food groups and healthiness of cooking methods were determined. The impact of the intervention was assessed using analysis of covariance (ANCOVA).

Results

Post-intervention data were analysed in the intervention (n = 221) and control (n = 111) communities, with participant retention rates of 91% for Nunavut and 83% for the Northwest Territories. There was a significant decrease in de-promoted foods, such as high fat meats (−27.9 g) and high fat dairy products (−19.8 g) among intervention communities (all p ≤ 0.05). The use of healthier preparation methods significantly increased (14.7%) in intervention communities relative to control communities.

Conclusions

This study highlights the importance of using a community-based, multi-institutional nutrition intervention program to decrease the consumption of unhealthy foods and the use of unhealthy food preparation methods.