Best Practices in Obesity Prevention 1. Putting “Best Practice” into perspective 2. Finding “evidence-based” programs 3. A model for achieving the greatest impact for programs 4. Reframing media advocacy
Environmental & Policy approaches Questions What are EP approaches? What is the built environment Why might it matter? What do we know about interventions? What do we have yet to learn?
Environmental & Policy approaches Perhaps the largest impact on population health Learn from smallpox, tobacco, seat belts The Inverse Evidence Law Yet we may have the fewest skills Out of comfort zone Requires some new thinking and actions Evaluations can be messy Limitations in government agencies
Environmental & Policy approaches Aimed at changing the physical and sociopolitical environments Provide opportunities, support, and cues to help people develop healthier behaviors May directly affect behaviors or may alter social norms Influence of the price of foods on consumption Many physically active people in public spaces Often more permanent than many public health programs focused on individual-level behavior change Important complement to individual-level programs For policy intervention Much of the power held by states Local efforts in many areas related to the built environment
Environmental & Policy approaches ENORMOUS potential Yet, the amount of well done policy research/evaluation in “real world” settings is small compared with the reach and potential.
Environmental & Policy approaches What constitutes acceptable evidence?
The effectiveness of parachutes has not been subjected to rigorous evaluation by using randomized controlled trials…. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute. Smith and Pell, BMJ, 2004
Remember: lack of or insufficient evidence doesn’t mean it should not be done…just that we don’t yet know if it is effective.
Sage advice We need evidence from both research and practice There are MANY research and practice efforts currently underway in NC and nationally We can’t afford to wait until all the evidence is in, but we can make informed choices of where to spend time and resources “Based on the best available evidence, as opposed to waiting for the best possible evidence” Preventing Childhood Obesity, Institute of Medicine
“Promise” Table Increasing population impact Increasing evidence certainty PromisingMore promising Most promising Less promising PromisingMore promising Least promising Less promising Promising
Promising interventions within the families and community action area Very promising Promising Some promise – High gain, mod uncertainty Mod gain, mod uncertainty High gain, high uncertainty Mod gain, high uncertainty Family-focused weight management programs Parent skills training programs Community based programs Work with local governments to develop nutrition plans that address supply and demand Local food policy coalitions to improve access and supply systems Work with local governments to develop local physical activity plans that address availability and access
Research findings to date 96 child care centers across 33 NC Counties. 3 evaluation groups: intervention, minimal intervention and control Shows promise as a environmental intervention Web training may be used in conjunction with or in place of in-person training Self-assessment instrument can be used as an outcome measure Results in modest behavior change among children
NC Programs – NAP SACC Child Center improvements include Revising menus to meet “best practice” guidelines Moving vending machines to less visible areas Switching to low-fat milk for children over 2
Kids Eating Smart Moving More (KESMM) Pediatric obesity intervention study funded by NICHD (built on 4 years of pilot work) 24 primary care practices serving Medicaid families throughout the state of North Carolina will participate Focuses on improving primary care providers and case managers abilities to: identify and assess children at risk for or already overweight communicate effectively with families/link them to community resources influence local policies related to improved nutrition and opportunities for physical activity. Intervention materials include: Provider and case manager toolkits and training Color-coded BMI charts Starting the Conversation Nutrition and Physical Activity evidence-based tools Self-Monitoring logs Families Eating Smart and Moving More toolkit materials Primary care community partnership advocacy workshops Dates of funding: September 1, 2005- June 30, 2010
So what’s an obesity prevention practitioner to do? Don’t panic about what is evidence-based and what is not Step back, pull in other stakeholders, and take a careful look at the big picture Build a case for action on obesity Identify contributing factors Experiment with logic models Define the range of opportunities for action Consider the full socio-ecologic model
So what’s an obesity prevention practitioner to do? Evaluate potential interventions using a broad base of evidence Observational Experimental Extrapolated: modeling, cost effectivelness Experience: theory, parallel evidence, informed opinion Keep an eye on the community guide
Translating evidence into practice The RE-AIM Model Purpose To assess the potential for a given intervention to have a public health impact
Which is Better? Program AProgram B 16 sessions 150 minute PA Effective in 8 of 10Effective in 2 of 10
It Depends Who delivers? Program A: Trained master’s level health educators What resources? Program A: Group exercise area and counseling rooms How easy is it to implement? Program A: Moderately difficult
It Depends Who delivers? Program B: Administrative assistants in community health center What resources? Program B: Email access and participants can do activities at home or in neighborhood How easy is it to implement? Program B: Moderately easy
It still depends How Scalable is it? Program A: 20 people per class session, (90-minute counseling session and 3 one-hour classes each week) Program B: 100 people per session (includes monitoring of physical activity and sending out weekly newsletters) What does it Cost? Program A: 33 hours per week for 6 months from health educator for every 16 successes (20 people per group) Program B: 8 hours per week for 6 months from administrative assistant for every 20 successes.
Striking a Balance Who we intend to reach What works What is feasible given resources
How can we use RE-AIM in practice? Developing a new intervention Adapting an existing intervention Choosing between alternative interventions Assessing an intervention as part of quality improvement Framing questions for evaluation purposes
Why RE-AIM Reach large numbers of people, especially those who can most benefit Be widely adopted by different settings Be consistently implemented by staff members with moderate levels of training and expertise Produce replicable and long-lasting effects and be maintained at reasonable cost
RE-AIM and Socioecologic Model Behavior Change Individual Interpersonal Environmental Change Organizational Community Policy Change Organizational Societal
RE-AIM Dimensions and Definitions DimensionDefinition Reach 1. The absolute number and proportion of individuals who are willing to participate in a given initiative, intervention, or program. 2. Representativeness of participants. Individual Level
RE-AIM Dimensions and Definitions DimensionDefinition Efficacy/Effectiveness 1. Effects on primary outcome of interest 2. Impact on quality of life and negative outcomes Individual Level
RE-AIM Dimensions and Definitions DimensionDefinition Adoption 1. The absolute number and proportion of settings and staff who are willing to initiate a program. 2. Representativeness of participating settings. Setting Level
RE-AIM Dimensions and Definitions DimensionDefinition Implementation 1. Extent to which intervention delivered as intended (with fidelity) 2. Time and cost of intervention. Setting Level
RE-AIM Dimensions and Definitions DimensionDefinition Maintenance 1. (Individual) Long-term effects of intervention (>6 months). 2. (Setting) Extent of continuation or modification of intervention. Both Individual and Setting
DimensionIssues to ConsiderPopulation Policy Ex. Reach -Number of people influenced -Representativeness of those involved -Inclusion of those most at-risk -Extent that risk-exposed groups are reached -Representative of catchment area Effectiveness -Impact on risk reduction -Impact on health outcome -Robustness -Impact on quality of life -Unanticipated consequences -Consistent effects across risk groups -Impact on other environmental outcomes -Approach “tolerates” adaptation, effects aren’t diminished Adoption -Number and proportion of target settings involved -Diffusion/adoption curves for the innovation approach -Large number and representative settings are involved -Settings adopting are relevant to policy decisions Implementation -Approach enacted as intended -Cost of enactment -Level of enforcement or delivery variability -Adherence over time -Costs of program/policy implementation Maintenance -Policy/program sustained over time -Long-term monitoring of population -Long-term impact on health -Large number of relevant settings sustain the innovation -Extent policy is adapted or program re-invented RE-AIM Perspectives on Generating Relevant Evidence
If we want more evidence-based practice, we need more practice-based evidence. L. W. Green, 2004
Media Advocacy It is now clear that standards of population health are overwhelmingly affected not so much by medical care as by the social and economic circumstances in which people live and work. Richard Wilkinson (2000)
Land of Controversy: the Upstream Territory Distant from perceived immediate causes Perceived as minimizing individual responsibility Addresses issues of social or public policy Often confronts well- financed corporate interests Few short term indicators of success
The definition of downstream! It’s almost as though the system encourages people to get sick and then people get paid to treat them. Dr. Matthew E. Fink, Former president of Beth Israel In “The treatment of diabetes, success often does not pay” New York Times, January 11, 2006
Basic Public Health Question Will the public’s health improve primarily as a result of individuals getting more and better knowledge about personal factors Or Groups getting more skills and opportunities to participate in changing public policies?
Frames are mental structures that help people understand the world, based on particular cues from outside themselves that activate assumptions and values they hold within themselves. Berkley Media Studies Group
Frames are… “Labels the mind uses to find what it knows.” Composed of elements visuals, values, stereotypes, messengers which together trigger an existing idea. tell us what the communication is about, signal what to pay attention to (and what not to) Allow us to fill in or infer missing information Set up a pattern of reasoning that influences decision outcomes There is a translation process between incoming information and the pictures in our heads
Frames People interpret words, images, actions or text by fitting them into an existing conceptual systems that gives them order and meaning. Just a few cures, words, images, trigger whole conceptual frames. Often expressed in metaphors Horse races in political campaigns, War metaphors in health threats Sports and business metaphors
Framing & Media Advocacy Framing battles in public health Illustrate the tension between individual freedom and collective responsibilities. The two frames of market justice and social justice influence public dialogue on the health consequences of corporate practices.
Frame support for public health as social justice A shift to social justice “frame” demands a rebalancing these values with others that Americans also hold. How an issue is described or framed can determine the extent to which it has popular or political support. We must articulate the social justice values motivating the changes we seek in specific policy battles that will be debated in the context of news coverage.
Framing If they can get you asking the wrong questions, they don’t have to worry about the answers. Thomas Pynchon (2000)
Practitioners working in public health are now eyeing tobacco control enviously, wondering if similar tactics will work to advance fairer policy approaches to obesity. There is much to be learned from tobacco control. However, fundamentally the shift must be tied to a core set of values and for public health those values should reflect social justice.
Market Justice vs. Social Justice Values Self-determination and self discipline Rugged individualism and self-interest Benefits based solely on personal effort Limited government intervention Voluntary and moral nature of behavior Shared responsibility Interconnection and cooperation Basic benefits should be assured Strong obligation to the collective good Government involvement is necessary Community well-being supersedes individual well- being
Pew Center poll of 44 countries found that US residents We are more likely to believe that twe are in control of our lives than to see our lives as subject to external forces. Dominant factors: self determination, personal discipline and hard work Reinforcing individualism.
How is Obesity Being Framed Center around appearance and health Include the idea that the direct cause of obesity is overeating and that overeating is bad for health and bad for appearance. But frames evoke more Expressed in terms of character, people become obese when they lack will power More deeply imbedded…those who lack willpower are of poor character These underlying assumptions about obesity can be evoked whenever obesity is referred to.
The Need for Re-Framing We need to quit using the word! Obesity is a bodily condition, NOT a social condition –people are obese, communities and neighborhoods are not. Using the term makes it harder to illustrate the conditions that inhibit healthy eating and activity.
The Need for Re-Framing Obesity narrows the problem, elevating one risk factor above others. Obesity is stigmatizing. A focus on obesity favors powerful stakeholders like the food, pharmaceutical and diet industries. Obesity moves the conversation “downstream”.
Although language is crucial, it should never be an advocates’s first and foremost consideration. Before determing what to say, public health advocates must determine what they want to change in concrete terms, the more specific the better. The language public health educators use needs to grow out of policy that needs first to be rooted in social justice values. Once the steps to a solution for a given public health problem have been identified and the mechanisms for instituting them have been determined, then language should be developed to communicate the solution and why it matters. That language, the specifics of the message will then emerge from how the issue is being framed.
The Need for Re-Framing With news we are NOT trying to reach the mass public, but Policy Makers! 80 % of media stories focus on individual accountability.
The Need for Re-Framing Pitch stories that widen the frame to include environmental factors root causes the need for policy solutions.
Framing for Content Translate individual problem to social issue Assign primary responsibility Articulate shared values Present a policy solution Develop story elements
Message Development What’s wrong? Fast food is widespread on high school campuses Why does it matter? This endangers the health of the next generation. We owe our children a fair change to be strong and successful What should be done? Schools must promote appealing, affordable healthy options The legislature must provide adequate funds for food service.
What you already know Use compelling visuals Develop media bites Calculate social math Identify authentic voices
Media bites Smoking a “safer” cigarette is like jumping out of a 10 th floor window rather than a 12 th floor window. Having a no-smoking section in a restaruant is like having a no-peeing section in a swimming pool. Tobacco is a pediatric disease
Media bites Kids need sports, not sports drinks. Nicholas Kristof Commenting on the negative health effects of high-fructose corn syrup The New York Times, April 11, 2006.