London Childhood Obesity Exchange Cultural Insights and the - - PowerPoint PPT Presentation

ADPH London

London Childhood Obesity Exchange

Cultural Insights and the Normalisation of Obesity

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Outline– 14th June

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Introductory Presentation 9.30 Welcome and Introduction to the event 9.40 Understanding our audiences 10.00 Using Behavioural Insights to Tackle childhood obesity 10.30 Cultural Insights and Application in Lambeth 11.00 Q&A and sharing of insights & projects in the room 11.15 Coffee and Exchange of Knowledge and Ideas Facilitating Action... 11.30 Working together to understand levers and challenges for communities. 12.00 Developing ideas and commitments to make small changes to make a big difference. 12.20 Into Action ... Resources and support to implement change 12.30 Close and Ideas Exchange

ADPH London

Introducing the Issue Sarah Cork – Brilliant Futures & iPiP

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What’s the problem?

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A Health Survey for England finding that 9/10 mothers and 8/10 fathers of an overweight child described them as being about the right weight. And with increase in overweight and obesity rising, we are normalising the Issue, with a rising % unable to recognise when someone is overweight or Obese and not as concerned.

It’s a complex problem, with many cultural and attitudinal influences and influencers...

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• People tend to overestimate what obesity means in terms of adult body

size.

• People who are obese are often the object of stigmatising attitudes.
• The majority (80%) said that those who are obese themselves should

take responsibility, 53% agree that “most overweight people could lose weight if they tried”

• In relation to the causes of obesity; Overall, 82% feel that modern

lifestyles are too sedentary, while 91% feel that fast food is too easily available.

• Younger respondents and those from a black or minority ethnic (BME)

background were more likely to feel that healthy food is too expensive and that people have too little time to make healthy meals

British Social Attitudes Survey, 2015, Public Health England

We need to understand where people ‘are at’... ... Get into their world...

6 Great Weight Debate 2016

Motivations Aspirations Feelings Values Fears

Knowledge? Facts? Where from? Beliefs Attitudes Benefits & Buts  Barriers Who & what influences? Lifestyle, social norms, messengers….? What

Do? Where Go?

The commercial world sells food through emotional appeal... We need to get into their world too.

7 Great Weight Debate 2016

Motivations Aspirations Feelings Values Fears

Benefits & Buts  Barriers

And understand different cultural behaviours and influences – the ‘System’ is different for different populations...

• The graph presents national data on
• besity prevalence by ethnicity from

the NCMP.

• The gap between obesity rates in

White British and most other ethnic groups is widening nationally.

• In London, 41.8% of the population

are from BAME groups, which is almost 3 times higher than the England average (14.6%).

• Although there is variation across

London - The proportion of the population from BAME groups ranges from 13.6% in Havering to 72.4% in Newham.

Healthy Weight, Healthy Lives

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Ethnic Minority Communities: Bangladeshi and Pakistani Families

“My mother-in-law is

• bsessed about feeding

my child. She keeps saying he is too thin when I know he is healthy and has a good weight” “I would love to be able to go swimming or take the kids but there is so much else to do. There’s the cooking for the mother-in- law, looking after my sister who is disabled and after running around after four children, I’m exhausted.” “The problem isn’t our home food. Now you have these halal chicken and chip places on every

• corner. It’s just too easy

when you come home on a Friday night to grab something from these places as a treat for all the family.” “I just don’t let him out. I worry about him going

• ut on his bike and

then hanging around the shops with his

• friends. You just don’t

know what they will be tempted to get into. That’s when they go bad.”

“I never really thought about it. Now that you mention it, it just makes you think about how many people and how many children there are in my family who have a weight problem.”

Being ‘big’ is seen as a sign of health and wealth Scratch cooking of traditional meals is widespread but not all cooking practices are healthy Parents do not control children’s consumption of Western convenience foods Parents place a high priority on their children’s educational attainment and

• n the maintenance of cultural and

religious values Physical activity is not a cultural norm Mothers and children do not have time to be physically active Great importance is placed on the provision of sufficient quantities of food

Cultural Insights from Literature

Study with children from ethnically diverse sample of young children and parents in London:

• Dislike of school meals
• Lack of knowledge of guidelines and negativity towards physical activity

education at school among girls.

• Parents feel physical activity is role of schools.
• Influence of neighbourhood (lack of safety – gangs & dogs, fast food outlets).
• Places of workshop key focal points for social support.
• Want to retain traditional practices.
• Family roles and responsibilities and religion as facilitators and barriers:
• importance of family meals
• reliance on convenience stores for traditional foods.
• In South Asian families homework prioritised over physical activity.
• Black Caribbean and Black African families reporting dads associated with treats

/ fast food / takeaways and influence of wider family.

• Needing to study food labels for halal ingredients for example as opportunity.
• Places of worship as focal point and often ‘food point’. – more focus between

healthy eating and religion than physical activity and religion.

Rawlins et l, 2012 10

Working with different beliefs, values, attitudes in different communities...

JOGG Rotterdam carried out research on how to encourage Turkish and Moroccan mothers increase childrens’ water

• consumption. Based on

qualitative research they developed the message ‘You are a good and strong mum when you give your children water at least twice a day’

www.epode-international-network.com

www.brilliantfutures.org

An Insight Driven Approach in Action: White working class families – working full time, time-poor, ‘just managing’. Reliant on freezer. Were ‘cooking’ meals every night – take something from freezer, put in oven – therefore ‘cooking’ messages not getting through. All shopped at same supermarket – ASDA. Therefore... Promotion with local ASDA – using existing offers on frozen food to shift ‘up a traffic light’ and then make meal from scratch to freeze.

Working with different beliefs, values, attitudes in different communities...

Giving people a healthy version of what they want... In their world..

#FDPHwebinars

Tasty Buds Carribean Takeaway https://vimeo.com/108575962

ADPH London

Using Behavioural Insights to Tackle Childhood Obesity The Opportunity Sarah Golding Public Health England, Behavioural Insights Team

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Using behavioural insights to enhance NCMP feedback: a randomised controlled trial

London Childhood Obesity Exchange, May & June 2017

Sarah Golding ESRC Research Fellow PHE Behavioural Insights Team

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‘Behavioural Insights’

Behaviour Capability

Psychological capability Physical capability

Motivation

Reflective motivation Automatic motivation

Opportunity

Social opportunity Physical

• pportunity

COM-B Model of Behaviour

Michie et al. (2012) 17

18 Behavioural Insights in Public Health England. 18

Methods: Developing a behaviourally enhanced NCMP feedback letter

Study Design

Cluster Randomisation 283 Schools (10,661 Yr 6 pupils) Control Routine (2014/15) feedback letter Intervention Behaviourally enhanced feedback letter (i) Uptake of WMS

Study Design

Cluster Randomisation 283 Schools (10,661 Yr 6 pupils) Control Routine (2014/15) feedback letter Intervention Behaviourally enhanced feedback letter (i) Uptake of WMS

Control

Feedback letter Family Lifestyle Club (FLiC) flyer (OW / VOW) Local activities leaflet Change4Life tips sheet

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+ FLiC flyer + A local activities leaflet

Control letter: Overweight and very overweight

+ Change4Life tips sheet

Control Intervention

Feedback letter Family Lifestyle Club (FLiC) flyer (OW / VOW) Local activities leaflet Change4Life tips sheet Behaviourally enhanced feedback letter (incl. social norms statement) FliC flyer (OW / VOW) Local activities leaflet Chang4Life tips sheet ‘Map Me’ images (OW / VOW) Pre-populated booking form (VOW)

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Intervention letter: Overweight

+ FLiC flyer + Map Me body image scales + A local activities leaflet + Change4Life tips sheet + A call to action to look at the images

• ver the page and an

explanation about the images.

GIRLS

+ Social norms statement about

• verweight and very
• verweight children

being in the minority.

Intervention letter: Overweight

+ FLiC flyer + Map Me body image scales + A local activities leaflet + Change4Life tips sheet

+ A pre-populated booking form with a freepost envelope.

Intervention letter: Very overweight

+ FLiC flyer + A local activities leaflet + Change4Life tips sheet + Map Me body image scales + Social norms statement

Pre-populated booking form with FREEPOST envelope

+ Includes child's name, address and school. + Parent to provide details on preferred contact times and format

30 Behavioural Insights in Public Health England. 30

31 Behavioural Insights in Public Health England. (http://energyskeptic.com/2013/cognitive-bias/) 31

Findings: Impact of intervention on uptake of weight management services

NCMP measurements, Year 6: Leicester City, Leicester County & Rutland

Population Monitoring Weight Status Frequency % Underweight 231 2.17% Healthy weight 7039 66.03% Overweight 1436 13.47% Very overweight 1955 18.34% Totals 10661 100.00%

Ethnicity – OW & VOW, Year 6: Leicester City, Leicester County & Rutland

Ethnicity (ONS Categories) Control (%) Intervention (%) White 858 (65.3) 857 (68.5) Black 73 (5.4) 65 (5.2) Asian 306 (22.6) 246 (19.7) Mixed 88 (6.5) 59 (4.7) Other 23 (1.7) 12 (1.0) Unknown 8 (0.6) 12 (1.0)

Main Outcome: Uptake of WMS

2.4% 2.2% 1.0% 4.8% 4.3% 1.9% First Contact Enrollment Attendance Uptake of Weight Management Services Control Intervention

Conclusions & recommendations

Conclusions

WMS uptake can be improved by making low-cost, behaviourally informed changes to feedback letter. No differential effects for any sub-group Cannot say for certain which aspects of intervention were most effective:

• Social norms statement?
• Map me images?
• Pre-populated form?

Recommendation would be to replicate letter & materials in their entirety

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ADPH London

Using Cultural Insights in Lambeth Bimpe Oki & Vida Cunningham

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Insight into Overweight and Obesity amongst Lambeth Ethnic Minority Mothers

Bimpe Oki - Consultant in Public Health Vida Cunningham – Public Health Specialist London Borough of Lambeth

Ethnic Insight Aims

• To understand knowledge and awareness of overweight

and obesity

• To identify attitudes towards overweight and obesity
• To understand knowledge and awareness of healthy eating

and physical activity

• To provide insight into behavioural choices related to
• verweight and obesity
• To identify barriers to healthy behaviour change

Mothers of Primary School Aged Children Black Caribbean Black West African White British (C2DE) Somali Portuguese

Understanding of Overweight and Obesity

• Very few understand overweight and obesity in terms of

BMI

• Most define overweight in aesthetic terms and obesity in

health and functional terms

• Obesity is equated with morbid levels of obesity

Overweight Obesity “I think it’s from size 18, from size 18 upwards it’s overweight.” (Black Caribbean) “Overweight is when you can’t fit into proper clothes and you have to wear those great big tent like things.” (White British) “I think an obese person is one of them people who can’t get out of bed or off their chair, you know when their legs is full of rolls of fat.” (White British) “They’re housebound and they can’t get out of bed and wash themselves so they have to have somebody to clean

• them. That is obese when you cannot do anything for

yourself.” (West African) “They cannot pray as they are obese.” (Somali)

• Portuguese women had a relative better understanding of
• verweight and obesity
• West Africans dismiss the concept of overweight
• Some respondents were shocked

to learn from their doctor that they are obese

“Five kilos over is overweight but 20 kilos over is obese.” (Portuguese) “When I see somebody like this (fellow respondent) I never call her overweight, I would call her a healthy lady.” (West African) “We are not overweight. Overweight people are the ones you push in a wheelchair, they are helpless, they can’t breathe, they can’t move. They are overweight.” (West African) “I thought I was overweight but when my doctor told me I am obese I thought

• h my God, I didn’t know that. I was
• shocked. I was like oh my God I am

clinically obese.” (Black Caribbean) “Well my doctor said I was clinically obese. I can breathe, I can wash myself but apparently for my height I have got too much weight so I am obese. But I can move.” (White British)

Understanding of Overweight and Obesity

Portuguese Somali White British Black Caribbean West African

Perception of Ideal Body Size

Portuguese Somali White British Black Caribbean West African

Perception of Ideal Body Size

Perception of Overweight Body Size

Portuguese Somali White British Black Caribbean

West African (Heavier)

Perceptions of, and Identification with, Healthy Lifestyles

Vignate “I would like you to picture in your mind a [vary ethnicity] family, with a father, a mother and three children - two boys and a girl – aged between 5 and 10 years-old. They live in Lambeth. They each eat at least five fruits and vegetables a day as part of their diet, and everyone in the family does at least half an hour of exercise every day.”

Perceptions of the Healthy Family

• All Somalis and West Africans felt the family could

not be from their community. It had to be a White, middle-class family.

• None (except the Portuguese) thought they

themselves could have such a lifestyle. Main reasons given were:

• Leading stressful lives
• Having little time
• Being unable to afford this healthy lifestyle
• Children refusing to eat fruit/vegetables

Barriers: Lack of identification - “Not me”

White British Black Caribbean West African

“I can see the kids probably doing half an hour of exercise a day because they go to school, but I’ve never known a kid to eat five fruits and veg I’m sorry.” (White British) “The two adults and the three kids all eat five lots of fruit and veg. No. That’s impossible!” White British) “For a Caribbean I don’t see that going on

• here. We Caribbean people love our meals.

We tend to eat a lot of meat, meat with carbohydrates like rice, yam, dumplings, bananas.” (Black Caribbean) “If that’s a Black family they have had to have lived here a very long

• time. And they have got to be

well off.” (Black Caribbean) “You’re eating vegetables and you’re working out, the kids are working out. These guys have got time. I have to go to work, the kids come back, what time do we have to do this routine of exercise and all? You look at this family and either the mum is White and the dad is African because 99.9% of Africans don’t do this.” (West African) “I look at this family and they can’t be Africans.” (West African)

Barriers: Lack of identification – “Not me”

Somali Portuguese

“This is not a Somali family. Somali family cooks rice and meat and little

• salad. Somali family does not do a lot
• f physical activity.” (Somali)

“This family is raised in homes that value healthy eating and exercise and they just continue to do what they were taught in their

• childhood. Somalis are not raised in that way

and do not care about healthy eating or exercising.” (Somali) “That is a good way to live if you have the time.” (Portuguese) “We already eat that amount of fruit and vegetables so that doesn’t seem

• difficult. Doing exercise everyday

would be difficult.” (Portuguese) “They are not a poor White family either because poor White people do not care about healthy eating.” (Somali)

Perception of Children’s Body Image - Overweight

Portuguese Somali Black Caribbean West African White British

Children’s body size is perceived to be strongly associated with their health. With the exception of the Portuguese, all communities regarded ‘large’ children as healthy children and ‘thin’ children as unhealthy children. Many parents believe that obese children would grow out of it. Some parents were concerned about their children being underweight and not eating enough. No one thought their children ate too much.

How Learning from Insight Informed Local Work – Lambeth Level 1 Multi- agency Healthy Weight Training

Informed the Bespoke Training which was designed, amongst

• ther objectives, to empower practitioners to be able to:
• Challenge widespread misunderstandings around obesity, in

particular association of overweight and obesity with morbid levels of obesity.

• Challenge the view that ‘large’ children are healthy children.

Emphasise the association of childhood obesity with adult

• besity.
• Disentangle diet from body image: focus messages on

improving health, not (primarily) reducing weight.

• Ensure that health advice is not seen to be exclusive to a

small section of the population: White and middle-class.

How Learning from Insight Informed Local Work – Levels 2 & 3 Weight Management Services

Techniques in the delivery of the services:

• Acknowledge lifestyle and cultural barriers

and tailor health advice accordingly. Make health promoting actions relevant to people’s lives.

• Include a range of local cultural foods when

promoting healthy eating

• Incorporate cultural parenting skills to

support parents to support positive behaviour change amongst their children.

More in information?

Bim impe Oki i - boki@lambeth.g .gov.uk Vid ida Cunningham – vcunningham@lambeth.g .gov.uk

Lambeth Public Health Team

ADPH London

So how can we work with social norms and cultural insights?

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ADPH London

Activities

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ADPH London

Wrap Up and Into Action

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Into Action

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Key learnings we can put in practice:

• Small changes across the system, by all players can make a big difference and

achieve the tipping point needed to reverse norms.

• Consider ‘what’s in it for me?’ for all stakeholders, we have a role in tackling

childhood obesity, and also that childhood obesity has a role in our priorities.

• Consider the changes made and adapt, based on intended and unintended
• utcomes.
• Make sure we can measure changes and see what is working and isn’t

working...

• No blame..... Work together to make the system better...
• And believe it’s possible......

What’s next...

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Make the Change....Obesity leads co-ordinate action from today’s event... Access the Website ..(www.....) after election June 9th... . With presentations, resources, posters examples, toolkit Feedback progress, challenges and experiences at Ideas Exchange Wednesday July 12 Share knowledge, examples and activities with wider teams across Boroughs with materials available on the website.