CAN SCHOOL-BASED HEALTH PROMOTION INTERVENTIONS PREVENT CHILDHOOD - PowerPoint PPT Presentation

CAN SCHOOL-BASED HEALTH PROMOTION INTERVENTIONS PREVENT CHILDHOOD OBESITY IN LMICS ? Roos Verstraeten Institute of Tropical Medicine (ITM) Antwerp, Belgium August 27, 2015

INTRODUCTION Defining and understanding the problem of chronic diseases and childhood obesity in low- and middle- income countries (LMICs)

Did you know? Global Individual and Intermediate distribution of environmental risk factors chronic disease risk factors deaths SOCIO- CULTURAL ∆ HICs OBESITY DIET LMICs IN LMICS PA *2 80% ECONOMIC ∆

Overweight and obesity prevalence HICs Ecuador Global LMICs BOYS GIRLS Source: The Lancet (DOI:10.1016/S0140-6736(14)60460-8)

Did you know? 25% (51.8 million) children and adolescents are overweight or obese in Latin-America

Did you know? Global Individual and Intermediate distribution of environmental risk factors chronic disease risk factors deaths SOCIO- CULTURAL ∆ HICs OBESITY DIET LMICs *2 PA 80% ECONOMIC ∆

Ecuador Diet PA • High intake of refined CH, • Low PA and fitness excessive unhealthy levels snacks and sugary drinks • Low fruit and vegetable • High sedentary intake behaviour • Skipping breakfast 34% dyslipidemia, 6% high blood pressure, 20% abdominal obesity

Did you know? Life expectancy Health care costs PREVENTION = URGENTLY NEEDED

Research objective Systematic and stepwise planning, development and evaluation of preventive interventions in LMICs Case study School-based Diet and PA Ecuadorian Adolescents (11-15 yrs) Cluster randomised-controlled study

QUESTION 2: QUESTION 3: VALID CONTEXTUAL TOOLS FACTORS QUESTION 1: QUESTION 4: EVIDENCE IN VALID LMICs MODELS NEEDS ASSESSMENT INTERVENTION DEVELOPMENT

NEEDS ASSESSMENT An epidemiological analysis of the health problem in LMICs and in the context of Ecuador to inform intervention development

Question 1 Can a school-based ∆ intervention prevent childhood obesity in a LMIC? Verstraeten R et al. AJCN. 2012 Aug;96(2):415-38

Systematic review – PICO model Healthy children (6-18 yrs old) in P Population LMICS School-based interventions targeting I Intervention diet and PA to prevent obesity C C omparison Controlled trial Dietary and/or PA behaviour and O Outcome anthropometry

Design PROTOCOL SEARCH (n = 7218 references) STUDY SELECTION (n = 22 studies) DATA EXTRACTION DATA SYNTHESIS QUALITY APPRAISAL

Results Number of studies (n = 22) Number of studies (n = 22) 4 • Changed 2 18 behaviour and/or BMI BMI 8 Characteristics of effectiveness: Diet and PA/multi-component/integrated in the curriculum

Methodological and conceptual challenges • Low quality of evidence • Lack of valid and reliable instruments • Lack of theory • No information on contextual factors • No details on intervention strategies and processes: ? Start Finish Process evaluation

Question 1 Can a school-based ∆ intervention prevent childhood obesity in a LMIC? Yes, when…

Key messages for intervention development • Contextual influences of behaviour • Valid tools • Systematic and theory-based approach • Local evidence and participation • Rigorous evaluation + process evaluation

Question 2 Can a 7 day PA record provide good ∆ estimates of PA levels in Ecuadorian adolescents? Verstraeten R et al. BMC Pub Health 2013;13:1109

Validation study Time spent on different PA levels was estimated Perceived difficulty/socio- demographics (BMI, age, sex, setting) 7 d VALIDITY • Urban and rural adolescents (11-15 yrs) 3 wks • N = 302 RELIABILITY

Results Validity Reliability Fair measurement agreement Modest measurement agreement

Results Validity Reliability • Sex • Perceived difficulty of completing the PA record Girls > LPA than boys Girls < SED/VPA than boys Reliability • Setting Rural > LPA than urban Perceived difficulty Rural < VPA than urban

Question 2 Can a 7 day PA record provide good ∆ estimates of PA levels in Ecuadorian adolescents? Yes, but…

Key messages for intervention development Fair measurement agreement Too strenous (high participant burden) Use objective measure (accelerometer) to evaluate PA behaviour

Question 3 What are the factors that influence dietary ∆ and PA behaviour in Ecuadorian adolescents? Verstraeten R et al. Plos One. 2014:e87183.doi:10.1371/journal.pone.008718 Van Royen K et al. JPAH 2013 DOI:10.1123/jpah.2013-0288

Focus group discussions Adolescents Parents School staff N = 12 N = 4 N = 4 144 participants Urban Rural Understand individual and environmental influences Theoretical framework

Conceptual framework for dietary behaviour

Conceptual framework for PA behaviour

Question 3 What are the factors that influence dietary ∆ and PA behaviour in Ecuadorian adolescents? Factors known, and…

Key messages for intervention development Recommended to include: • Contextual factors • Individual influences + physical school environment + social and the built environment • Parents and school staff • SES and setting to evaluate their influence Evaluate conceptual frameworks quantitatively

Question 4 Is the culture-specific ∆ framework for dietary behaviour a valid model?

Validity of conceptual framework Accessibility/ parental Environment permissiveness/ school support Self- efficacy/barriers/ Individual benefits/ habit factors • Urban and rural strength/food adolescents safety (11-15 yrs old) • N = 784 • SES/dietary behaviour/ influencing factors Dietary behaviour operationalized

Direct effects on behaviour Environmental factors Individual factors Perceived food safety Parental School Perceived permissiveness support benefits Perceived benefits

Indirect effects on behaviour High accessibility to healthy High accessibility to healthy food food Supportive Supportive school school environment environment Healthy food Perceived Perceived perceived as benefits benefits safe

Question 4 Is the culture-specific ∆ framework for dietary behaviour a valid model? Yes, and…

Key messages for intervention development Different pathways  different behaviours Environmental + social + individual changes

QUESTION 2: QUESTION 3: VALID CONTEXTUAL TOOLS FACTORS QUESTION 1: QUESTION 4: EVIDENCE IN VALID LMICs MODELS NEEDS ASSESSMENT INTERVENTION DEVELOPMENT

INTERVENTION DEVELOPMENT Based on needs assessment and using theory, local evidence, and a participatory approach

Systematic intervention development Needs assessment Intervention development Theory and Intervention 4Q: evidence-based strategies approach (IM) matching the QUALITATIVE AND social and Participatory QUANTITATIVE cultural approach DATA realities (CPPE)

Intervention objectives Dietary behaviour PA behaviour Schools: healthy foods Schools: PA opportunities

Intervention programme Individual classroom-based Environment-based component component (individual level) (school and family level) Interactive educational toolkit on • Parents: interactive sessions diet and PA • Schools: • ∆ physical environment • Training food tuck shop personnel • Social events

DURATION: 3 YEARS P 1430 Ecuadorian adolescents (11-15 Population yrs) School-based health promotion I Intervention intervention targeting diet and PA Cluster randomised-controlled trial in C C omparison 20 schools (I= 10; C=10) O Primary: dietary and/or PA behaviour Outcome Secondary: anthropometry PROCESS AND IMPACT EVALUATION

Intervention programme 2009 Intervention 2011 Baseline + package preparatory 1+Process Follow-up 1 workshops evaluation Intervention 2012 package Follow-up 2 2+Process evaluation

Intervention effects – dietary intake Added sugar intake ↓ 6 grams (P=0.005) Processed food intake during snacking ↓ 23 grams (P=0.037) Fruit and vegetable intake ↑ 23 grams (P=0.005)

Intervention effects - PA No effect Minimized decline in PA in the intervention group Physical fitness improved

Intervention effects – metabolic risk factors Waist circumference ↓ 1 cm (P=0.005) Systolic blood pressure ↓ 4 mmHg Diastolic blood pressure ↓ 2 mmHg (P<0.001)

CONCLUSION Systematic and stepwise development of an intervention in Ecuadorian adolescents is effective

Conclusion: needs assessment School-based interventions have the potential Q1 to improve dietary and PA behaviour in LMICs and prevent unhealthy body weight It is important to evaluate tools measuring Q2 behaviour Examining contextual influences on dietary and Q3 PA behaviour is important Q4 Conceptual frameworks help in developing interventions and can further theory development

Conclusion: intervention development A comprehensive, culturally-appropriate C1 intervention package was developed New insight into the processes of intervention C2 development in LMICs is provided C3 Help in identification of effective and ineffective strategies Allow for replication, adoption or dissemination of C4 useful strategies

And now? ?