childhood obesity prevention: Fiona Dickens Public Health Programme - - PowerPoint PPT Presentation

Putting research to work in childhood obesity prevention:

Fiona Dickens Public Health Programme Manager Swindon Borough Council

Challenges and priorities

• Evidence base: not clear what works,

what does not work or is less effective, cost effective or difficult to sustain.

• Translating evidence into action at

local level:

– Should we stop doing anything? – Should we start to build a better evidence base?

Challenges and priorities

Translating evidence into action at local level:

– Re-consider our overall approach: a life course approach or focus on specific projects in schools and/ or early years? – Should we focus on doing one thing really well that is most likely to work or do a number

• f small programmes e.g. focus on a

multicomponent school programme.

Challenges and priorities

Translating evidence into action at local level:

– What about health inequalities- will we end up increasing the gap if we go for quick wins? – Are there any projects we can work on across a wider area? – What if we do nothing at all at local level?

Geraldine Cooney Public Involvement Consultant University of Bath

Involving Parents & Children

Research is not just for researchers – it cannot lead to improvements unless the right people join in No matter how complicated the research or how brilliant the researcher, patients and the public always offer unique invaluable insights

Working ‘with’ people not ‘about’ or ‘for’ them

• Consultation
• Collaboration/ Co-production
• User/Community led

Parents Interviewing Parents (PIP project)

PIP Headlines

• Team of 4 trained interviewers
• Recruitment issues– ongoing
• Relaxed, comfortable interviews
• Context – parent/family perspective
• Support & help – practical, emotional

’Bottom up’ approach

• Avoids ‘us’ and ‘them’

‘We are helping our daughter…I resent the interference..’

• Reduces Negativity

‘..you are being heavily criticised as being an irresponsible parent’

• Creates Dialogue

‘I felt judged and unable to reply to anyone...’

• Identifies Solutions

‘I think a phone call would have been better…there wasn’t a comfortable chat.’ ‘I would like to see a weight range of where she should be for her height and age.. BMI does not mean a bean to the normal person..’

“There should be a place for people that have got issues to be able to talk to someone, like counselling. But at school. Where you could go…you know, just to help…I don’t think she [daughter] had the chance to have someone she could speak to.”

Fiona Gillison, Department for Health, University of Bath f.b.gillison@bath.ac.uk

Collaborators: Lou Atkinson, Coventry University (and Warks. Public Health) Sanne Gerrards & Stef Kremers, Maastricht University, NL Jeff Niederdeppe, Cornell University, USA

NCMP Research update

……a whistle-stop tour of recent relevant research

Talk Outline

• Research studies;

1. Parents’ views of the NCMP 2. Should we adjust for children’s level of maturity? 3. What are the risks of harm 4. Development of a health communication approach

• What does this research suggest?
• 1. Applying narrative messaging
• 2. Shifting formats

The challenge

• 75-83% UK parents of overweight children are

not aware their child is overweight

• Parents are essential in tackling childhood obesity
• Interventions/projects that involve parents significantly

more effective than those which don’t

• If the NCMP system isn’t

working for us – can research provide ideas of different approaches that may help?

What limits positive impact of NCMP?

• Parents’ priorities for judging a child’s health don’t

coincide with ours

• Consider well-being and lifestyle as a priority
• Some believe labelling children as overweight is ‘risky’
• Parents don’t have full trust in the measures
• Not convinced by BMI is valid (esp. around puberty)
• Not convinced by ‘1-off’ measures
• Parents’ don’t believe we (or they) can realistically do

anything to change their child’s weight

• Avoiding conflict (Lou Atkinson, Coventry University)

2 4 6 8 10 12 14 16 18 Weight not a health risk Healthy lifestyle mitigates risk Risk of harm BMI not valid /child is normal Puberty Will naturally resolve Parent-only responsibility

Why don’t parents believe it?

1 2

Gillison, Beck & Lewitt, 2014; Public Health & Nutrition

20 40 60 80 100

• verweight
• bese

Change in classification of overweight accounting for maturity in boys

Consistent classification Change in classification

20 40 60 80 100

• verweight
• bese

Change in classification of overweight accounting for maturity in girls

Consistent classification Change in classification

Should we take account of puberty?

N=407 Year 6 children in BANES & Wiltshire

11% of obese girls were no longer

• bese when

adjusting for maturity 32% of overweight girls were no longer

• verweight when

adjusting for maturity

Is it ‘risky’ for parents to tell their child they are

• verweight?
• Only 4 intervention studies – all unlike NCMP
• Interventions training parents to communicate positively;

Outcomes measured Effects Perceived pressure to be thin Body satisfaction Eating disorder symptoms Unhealthy weight loss behaviours

Is it ‘risky’ for parents to tell their child they are

• verweight?
• 40 studies reporting observations (from surveys);

Parent behaviour Child body dissatisfaction Child poorer wellbeing Child dysfunctional eating

Encouragement to lose weight 0.3 0.5 0.2 Criticism / teasing 0.2 0.2 0.2* Encouragement healthy lifestyle** improved satisfaction

• reduced ‘dieting’

* Stronger association in girls; ** only 2 studies

Conclusions so far…

• We may be inadvertently classifying some more

advanced children as overweight when they are not

• Anything we do that results in parents encouraging a

child to lose weight is not a neutral activity – even if it is not the cause, more encouragement is associated with poorer wellbeing Could acknowledging and adjusting for these concerns increase the impact of NCMP feedback?

Narratives and story telling

• How can we reduce ‘reactance’ so our message is

read?

• Narrative messages (stories) of ‘people like you’

with an embedded health message

• If constructed well, work by:
• Reducing reactance (counter-arguing)
• Reducing perceived invulnerability
• Increasing relevance
• Increasing self-efficacy of the required action
• Communicating complex ideas to people with lower levels of

education

Niderdeppe & Byrne, 2012

Can we put this research into practice?

• 1. Adjustments to the NCMP feedback
• more tailored letter (e.g., maturation status, activity level)
• advise on positive ways to talk to children about weight
• narrative message to reduce reactance and enhance self-efficacy

(sent with a letter or ahead, available online)

• 2. Achieve the same aims through other means
• work with schools raise the profile of the importance of a healthy

weight, ahead of NCMP

• facilitate face to face feedback
• e.g., health checks, health events, parents’ evenings
• involve parents in weighing and monitoring (e.g., between Reception

and Year 6)

Research Round-Up

• What works in childhood obesity prevention?
• School based initiatives
• Community based approaches
• Family based initiatives
• How do childhood obesity

prevention initiatives impact health inequalities?

Waters et al (Cochrane review), 2011

• 37 independent studies: average –0.15 kg.m2 (BMI points)
• bigger effect sizes for younger ages
• no evidence of adverse effects

FACTORS ASSOCIATED WITH BETTER OUTCOMES

• School curriculum including healthy eating, physical activity and body

image

• Increased PA opportunities in schools
• Improved nutrition within schools
• Supportive physical and cultural environments
• Educational support for teachers in relation to health promotion

activities

• Participation and awareness among families

Results of Systematic reviews

Results of Systematic reviews

Wang et al, 2015

• 139 intervention studies analysed (outcomes at 6 mo.)

Setting Outcome Support

School only (43%) Significant BMI Moderate (PA or diet) poor (combined) School + home (23%) Significant BMI High (PA only) Moderate (combined) School + home + community (7%) Significant BMI High (combined) School + community (4%) Significant BMI Poor (PA or diet) Moderate (combined) Home-based (4%) No effect Community-based (7%) Significant BMI Moderate (if incl. schools) Poor (if schools not incl.)

School-based interventions

Vasques et al, 2014

• 52 studies
• Very small sizes of effect

less than 0.1 – meaningful effect = 0.2

• Better results if including both

nutrition education and physical activity sessions

• No difference between in-school

and after-school projects

Content of interventions

Hendrie et al, 2012

• 15 studies delivered school- or community-based

interventions AND involved parents

• Components distinguishing effective interventions

were;

• provision of information about the behavior–

health link (providing knowledge),

• prompting practice (repeating behaviour

many times),

• planning for social support
• modelling useful in the home, not in school
• greater intensity of family involvement

Family-based initiatives

• Not well researched - but shows little promise
• e.g., Showell et al 2013 systematic review with 6 studies

reported no positive effects

• Not as effective as school-based interventions
• perhaps as relies solely on parents to be implemented?
• schools better placed to normalise activities and keep momentum
• Parenting skills / style strongly

associated with obesity – but evidence suggests it should not be a key focus

What about health inequalities?

• Children in lower SES families are more likely to be
• verweight by the age of 5
• 2 x chance of overweight, 4 x chance of obesity
• Lifestyle characteristics only account for 26% and 42% of

this difference

• Lower SES children more vulnerable to marketing effects
• Few studies report their impact on inequalities
• many targeted towards lower SES groups
• Interventions tend to be similarly effective with high and low

deprivation – but participation rates lower

EPODE methodology

• Used across Europe in 500 childhood obesity

prevention interventions

• Central aim = capacity building
• Positive approach, encouraging healthy lifestyle

adoption in local environments, children’s settings and families

• Incorporates;
• Social marketing
• Gaining political commitment
• Local steering committee of stakeholders
• Training and coaching a local project manager

Borys et al., 2012

EPHE study

Example uses:

• Study implemented in 7 European countries
• Core aim to reduce inequalities in prevalence
• Only baseline measures published so far;
• Confirmed some associations that can’t be changed
• mothers education higher child fruit & veg intake
• lower SES higher fruit juice/soft drink intake
• lower SES higher screen time
• Primary ‘changeable’ determinants (all countries); parental rules

and home availability (of food, equipment etc)

Mantziki et al., 2014

Summary

Evidence suggests we approach childhood obesity prevention by;

• School-based initiatives combining dietary and physical

activity components….

• That provide frequent opportunities for children to eat

well and get active….

• That link to families and the community…
• The more intensively families are involved the better…
• That provide support and education to teachers and

parents too.

Easy!

Talk Outline

• How can we improve engagement with
• besity interventions?
• Use Normalisation Process Theory
• Identify factors that inhibit & promote

engagement

Dr Charlotte Dack Department of Psychology, University of Bath c.n.dack@bath.ac.uk

Complex Interventions

Development

• Why? How? What?

Evaluation

• Efficacy &

Effectiveness

Implementation

• How to improve

engagement?

health Interventions

What happens after children are identified as

• verweight or obese?
• Nothing
• Information prompts BC within family
• Referral to obesity/health promotion intervention
• E.g. SHINE (Self Help Independence Nutrition & Exercise);

Alive & Kicking

• Something else?
• Public health impact depends on the proportion of the

target group that are exposed to the intervention

• How might we increase this proportion?

Do I want to take part? (Cognitive Participation Impact on work (Collective Action) Is it worth it? (Reflexive Monitoring) Fit with existing skill set and organisational goals and resource Impact on consultations and relationships Group processes and conventions Organizing structures and social norms Does it make sense? (Coherence)

May & Finch; Sociology 2009

Normalization Process Theory

http://www.normalizationprocess.org/

Is the intervention easy to describe?

• Is it distinct from other ways of working?
• Does it have a clear purpose for all relevant

participants?

• What benefits will the intervention bring and to

who?

• Are these benefits likely to valued?
• Will it fit with the overall goals and activity of the
• rganisation?

Factor 1: Does it make sense?

Are parents/schools etc. likely to think it’s a good idea?

• Will they see the point of the intervention easily?
• Will they be prepared to invest time time, energy

and work in it? Factor 2: Do I want to take part?

How will the intervention affect the work of nurses/teachers etc. and the lives of parents?

• What effect will it have on relationships?
• Will nurses/teachers/parents require training

before they can use it?

• How compatible is it with existing practices?
• What impact will it have on resources, power, &

responsibility between different groups. Factor 3: Impact on work

How are parents/schools likely to perceive the intervention once it has been in use for a while?

• Is it likely to be perceived as worthwhile?
• Will it be clear what effects the intervention has

had?

• Can parents/schools contribute feedback about

the intervention once it is in use?

• Can the intervention be adapted on the basis of

experience? Factor 4: Is it worth it?

Findings from an adult intervention (diabetes)

Does it make sense?

• Distinct from other diabetes education.
• Majority of staff and pts could see that it could be useful.
• Fit with CCG priorities.

Do I want to take part?

• For some staff & patients it was too much on top of

everything else

Findings from an adult intervention (diabetes)

Impact on work

• Potential to relieve some pressure in appt.
• Fit with existing learning (e.g. care planning) and

routines but not always skill set

• Staff and Pt training and support needed
• Lack of resource & time
• Problems with organisational structures

Was it worth it?

• Adapted intervention to save time/reach different groups
• Health Care Assistants/Patient Champions as

implementers

To think about

• Which settings/organisations might be the best fit to

deliver an intervention?

• Who are the implementers?
• Who are the participants?
• What is the intervention?
• Which components of NPT might need improving and

how could we do this?