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 distribution of chronic disease deaths

HICs LMICs 80%

OBESITY IN LMICS

*2

DIET PA SOCIO- CULTURAL ∆ ECONOMIC ∆

Intermediate risk factors Individual and environmental risk factors

Source: The Lancet (DOI:10.1016/S0140-6736(14)60460-8)

Ecuador

HICs LMICs Global

BOYS GIRLS

Overweight and obesity prevalence

Did you know?

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

Did you know?

Global distribution of chronic disease deaths

HICs LMICs 80%

OBESITY

*2

DIET PA SOCIO- CULTURAL ∆ ECONOMIC ∆

Intermediate risk factors Individual and environmental risk factors

Ecuador

• Low PA and fitness

levels

• High sedentary

behaviour

PA Diet

• High intake of refined CH,

excessive unhealthy snacks and sugary drinks

• Low fruit and vegetable

intake

• 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

• f preventive interventions

in LMICs

Case study

School-based Diet and PA Ecuadorian Adolescents (11-15 yrs) Cluster randomised-controlled study

QUESTION 1: EVIDENCE IN LMICs QUESTION 4: VALID MODELS QUESTION 3: CONTEXTUAL FACTORS QUESTION 2: VALID TOOLS

INTERVENTION DEVELOPMENT

NEEDS ASSESSMENT

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

O

Outcome

I

Intervention

C

Comparison

P

Population School-based interventions targeting diet and PA to prevent obesity Controlled trial Dietary and/or PA behaviour and anthropometry Healthy children (6-18 yrs old) in LMICS

Design

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

Results

BMI

2

Number of studies (n = 22)

8

• Changed

behaviour and/or BMI

4

Number of studies (n = 22)

18

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

• Urban and

rural adolescents (11-15 yrs)

• N = 302

VALIDITY RELIABILITY 3 wks 7 d

Time spent on different PA levels was estimated Perceived difficulty/socio- demographics (BMI, age, sex, setting)

Results

Validity Reliability

Fair measurement agreement Modest measurement agreement

Results

Validity

• Sex

Girls > LPA than boys Girls < SED/VPA than boys

• Setting

Rural > LPA than urban Rural < VPA than urban

Reliability

• Perceived difficulty of

completing the PA record

Reliability Perceived difficulty

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

Understand individual and environmental influences Theoretical framework

School staff N = 4 Parents N = 4 Adolescents N = 12

Urban Rural

144 participants

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

• Urban and rural

adolescents (11-15 yrs old)

• N = 784
• SES/dietary

behaviour/ influencing factors

• perationalized

Individual factors Environment Accessibility/ parental permissiveness/ school support Self- efficacy/barriers/ benefits/ habit strength/food safety

Dietary behaviour

Direct effects on behaviour

Individual factors

Perceived benefits Perceived food safety Perceived benefits

Environmental factors

Parental permissiveness School support

Indirect effects on behaviour

High accessibility to healthy food Supportive school environment High accessibility to healthy food Supportive school environment Perceived benefits Healthy food perceived as safe Perceived benefits

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 1: EVIDENCE IN LMICs QUESTION 4: VALID MODELS QUESTION 3: CONTEXTUAL FACTORS QUESTION 2: VALID TOOLS

INTERVENTION DEVELOPMENT

NEEDS ASSESSMENT

INTERVENTION DEVELOPMENT

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

Systematic intervention development

Intervention development Participatory approach (CPPE) Theory and evidence-based approach (IM) Needs assessment

4Q: QUALITATIVE AND QUANTITATIVE DATA

Intervention strategies matching the social and cultural realities

Intervention objectives

Dietary behaviour PA behaviour

Schools: healthy foods Schools: PA opportunities

Intervention programme

Individual classroom-based component (individual level)

Interactive educational toolkit on diet and PA

Environment-based component (school and family level)

• Parents: interactive sessions
• Schools:
• ∆ physical environment
• Training food tuck shop

personnel

• Social events

O

Outcome

I

Intervention

C

Comparison

P

Population School-based health promotion intervention targeting diet and PA Cluster randomised-controlled trial in 20 schools (I= 10; C=10) Primary: dietary and/or PA behaviour Secondary: anthropometry 1430 Ecuadorian adolescents (11-15 yrs)

DURATION: 3 YEARS PROCESS AND IMPACT EVALUATION

Intervention programme

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

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 to improve dietary and PA behaviour in LMICs and prevent unhealthy body weight

Q1 Q2 Q3 Q4

It is important to evaluate tools measuring behaviour Examining contextual influences on dietary and PA behaviour is important Conceptual frameworks help in developing interventions and can further theory development

Conclusion: intervention development

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

C1 C2 C3 C4

And now?

?

And now?...

• NCD remain taboo for funders
• Nutrition summit – End 2016
• Government leadership?
• Evidence-informed policy-making in Ecuador to tackle NCDs:

conserted effort between policy-makers and researchers to design smart policies

• Wide range of stakeholders (public/private)
• SR of effective policies + contextualisation (health systems in

LMICs)

• matrix using intervention ladder

Intervention ladder

Policy option

• Eliminate choice
• Restrict choice
• Guide choice through disincentive
• Guide choice through incentive
• Guide choice through changing default policy
• Enable choice
• Provide information
• Do nothing

http://www.nuffieldbioethics.org/public-health/public-health-policy-process-and-practice

Increasing intrusion & conflict

FUNDING

GRAC ACIAS AS!!!