Preventing Childhood Obesity - Evidence Policy and Practice.pdf

Chapter 7
prevention efforts, particularly in children. 25,26
Controlled obesity prevention trials in childhood are
few in number, mostly short term (one year or less),
focused on only a single or a few strategies (education
or social marketing only) and settings (school- based
only) and largely showed little or no impact. 27 – 29 Until
recently, the studies that did show an impact tended
to be high - intensity, less sustainable approaches (e.g.,
extensive classroom time promoting individual
27 – 29
behavior change). It is clear that innovative
approaches that work at multiple levels and are flexible,
effective, cost - effective, equitable and sustainable
are urgently needed and, as discussed above, multi -
setting community - based interventions hold promise
as one such option. 2,25,26,29,30
The success of a multi - setting intervention approach
may be the result of a number of factors. An approach
such as this works within a framework which recognizes
that multiple factors affect a community ’ s function
and, in turn, the health of the individuals within
it. The socio - ecological model identifies five levels of
influence on an individual ’ s health: intrapersonal,
interpersonal, organizational, community and environment/policy.
This framework also recognizes that
these factors (environment, working conditions,
economy, education, culture and health systems),
affect an individual ’ s health in both direct and indirect
ways. Reviews of the intervention literature, particularly
in obesity prevention have shown that interventions
that use these frameworks to guide their design
are more likely to be successful. 29 This also appears to
hold true across a number of public health issues, as
discussed above.
Behavioral interventions have had limited success
at altering individual health outcomes. However, even
when shown to have some efficacy, the sustainability
of the modest changes in health behavior is low and
does not translate to population - level health improvements.
Limitations of this type of intervention are that
they largely ignore the social context that shapes
behaviors and that the complexity of the physiological
changes brought about by behavior change is often
not recognized. Interventions of this type treat individual
behaviors as separate from social context and
biology. 31
Community-based, and community-wide, interventions
can also address risk factors that are common
to a number of chronic diseases. The integrated
chronic disease prevention ( CDP ) model has developed
from a recognition of the preventable risk factors
shared by leading chronic diseases. 32 Key concepts in
the integrated CDP model include an ecological perspective,
intersectoral action, multi - level intervention,
and collaborative processes. The multiplicity and
complexity of this approach is captured in a definition
put forward by Shiell:
[Integrated chronic disease prevention is an
approach] … that targets more than one risk
factor or disease outcome, more than one level of
influence, more than one disciplinary perspective,
more than one type of research method,
or more than one societal sector, and which
targets populations —rather than individuals —as
a unit. 32
The influence of the ecological perspective is evident
in that integrated CDP frameworks consider the interdependence
between individuals and the broader
socio - environmental context. For example, a community
- wide intervention to improve the delivery of preventative
services to children in the United States
33
achieved far - reaching changes. The intervention
approach was based on systems theory, which suggests
that many opportunities for improvement exist in the
interactions between elements of a system. For this
intervention, the application of this theory resulted in
viewing care delivery as a series of processes extending
from the home to the primary care practice and other
community health and social services. The intervention
activities were directed at the community, practice
and family level. At the community level, positive
effects were seen in state and community policies,
which led to sustainable changes in organization practices
and funding approaches. At the practice level,
alignment and integration of services delivered by
multiple practices resulted in reduced duplication,
improved coordination and changes in service delivery.
At the family level, the intervention resulted in
improved child and maternal health outcomes. 33
An additional benefit of a multi - setting community
- wide approach is its potential to improve the
health and development of all children in the community.
Interventions that attempt to address at least
some of the social determinants of health have the
potential to address population - level determinants of
ill - health, rather than individual characteristics. They
60