Lessons fromLessons from

Obesity Prevention in Obesity Prevention in Public HealthPublic HealthUNC-Chapel Hill, August 2008UNC-Chapel Hill, August 2008

Best Practices in Obesity Prevention

1. Putting “Best Practice” into perspective

2. Finding “evidence-based” programs

3. A model for achieving the greatest impact for programs

4. Reframing media advocacy

Environmental & Policy approachesENORMOUS potential

Yet, the amount of well done policy research/evaluation in “real world” settings is small compared with the reach and potential.

Environmental & Policy approaches

What constitutes acceptable evidence?

Remember: lack of or insufficient evidence doesn’t mean it should not be done…just that we don’t yet know if it is effective.

Sage advice

We need evidence from both research and practice There are MANY research and practice efforts

currently underway in NC and nationally We can’t afford to wait until all the evidence is in, but

we can make informed choices of where to spend time and resources

“Based on the best available evidence, as opposed to waiting for the best possible evidence” Preventing Childhood Obesity, Institute of Medicine

NC Programs – NAP SACC

NC Programs – NAP SACC

Research findings to date 96 child care centers across 33 NC Counties. 3

evaluation groups: intervention, minimal intervention and control Shows promise as a environmental intervention Web training may be used in conjunction with or in place

of in-person training Self-assessment instrument can be used as an outcome

measure Results in modest behavior change among children

Kids Eating Smart Moving More (KESMM) Pediatric obesity intervention study funded by NICHD

(built on 4 years of pilot work) 24 primary care practices serving Medicaid families

throughout the state of North Carolina will participate Focuses on improving primary care providers and case

managers abilities to: identify and assess children at risk for or already overweight communicate effectively with families/link them to community

resources influence local policies related to improved nutrition and

opportunities for physical activity. Intervention materials include:

Provider and case manager toolkits and training Color-coded BMI charts Starting the Conversation Nutrition and Physical Activity

evidence-based tools Self-Monitoring logs Families Eating Smart and Moving More toolkit materials

Primary care community partnership advocacy workshops

Dates of funding: September 1, 2005- June 30, 2010

Public Health Impact

Translating evidence into practiceThe RE-AIM Model Purpose

To assess the potential for a given intervention to have a public health impact

Which is Better?

Program A Program B

16 sessions 16 sessions

150 minute PA 150 minute PA

Effective in 8 of 10 Effective in 2 of 10

It Depends

Who delivers? Program A: Trained master’s level health

educators What resources?

Program A: Group exercise area and counseling rooms

How easy is it to implement? Program A: Moderately difficult

It Depends

Who delivers? Program B: Administrative assistants in

community health center What resources?

Program B: Email access and participants can do activities at home or in neighborhood

How easy is it to implement? Program B: Moderately easy

It still depends

How Scalable is it? Program A: 20 people per

class session, (90-minute counseling session and 3 one-hour classes each week)

Program B: 100 people per session (includes monitoring of physical activity and sending out weekly newsletters)

What does it Cost? Program A: 33 hours per

week for 6 months from health educator for every 16 successes (20 people per group)

Program B: 8 hours per week for 6 months from administrative assistant for every 20 successes.

How can we use RE-AIM in practice? Developing a new intervention Adapting an existing intervention Choosing between alternative

interventions Assessing an intervention as

part of quality improvement Framing questions for evaluation

purposes

Why RE-AIM

Reach large numbers of people, especially those who can most benefit

Be widely adopted by different settings Be consistently implemented by staff

members with moderate levels of training and expertise

Produce replicable and long-lasting effects and be maintained at reasonable cost

Dimension Issues to Consider Population Policy Ex.

Reach -Number of people influenced-Representativeness of those involved -Inclusion of those most at-risk

-Extent that risk-exposed groups are reached -Representative of catchment area

Effectiveness -Impact on risk reduction-Impact on health outcome-Robustness -Impact on quality of life-Unanticipated consequences

-Consistent effects across risk groups-Impact on other environmental outcomes-Approach “tolerates” adaptation, effects aren’t diminished

Adoption -Number and proportion of target settings involved-Diffusion/adoption curves for the innovation approach

-Large number and representative settings are involved-Settings adopting are relevant to policy decisions

Implementation -Approach enacted as intended-Cost of enactment-Level of enforcement or delivery variability

-Adherence over time-Costs of program/policy implementation

Maintenance -Policy/program sustained over time-Long-term monitoring of population

-Long-term impact on health -Large number of relevant settings sustain the innovation-Extent policy is adapted or program re-invented

RE-AIM Perspectives on Generating Relevant Evidence

If we want more evidence-based practice, we need more practice-based evidence.

L. W. Green, 2004

Media Advocacy

It is now clear that standards of population health are overwhelmingly affected not so much by medical care as by the social and economic circumstances in which people live and work.

Richard Wilkinson (2000)

Land of Controversy: the Upstream Territory Distant from perceived

immediate causes Perceived as minimizing

individual responsibility Addresses issues of social

or public policy Often confronts well-

financed corporate interests Few short term indicators of

success

The definition of downstream!It’s almost as though the system

encourages people to get sick and then people get paid to treat them.

Dr. Matthew E. Fink, Former president of Beth Israel In “The treatment of diabetes, success often does not pay”

New York Times, January 11, 2006

Basic Public Health Question

Will the public’s health improve primarily as a result of individuals getting more and better

knowledge about personal factors

Or

Groups getting more skills and opportunities to participate in changing public policies?

Media Advocacy & Reframing the Issue

Frames are mental structures that help people understand the world, based on particular cues from outside themselves that activate assumptions and values they hold within themselves.

Berkley Media Studies Group

Frames

People interpret words, images, actions or text by fitting them into an existing conceptual systems that gives them order and meaning. Just a few cures, words, images, trigger whole conceptual frames. Often expressed in metaphors

Horse races in political campaigns, War metaphors in health threats Sports and business metaphors

BIJVSJGAI AGTJVJTV

Framing & Media Advocacy Framing battles in public health Illustrate the

tension between individual freedom and collective responsibilities.

The two frames of market justice and social justice influence public dialogue on the health consequences of corporate practices.

Frame support for public health as social justice A shift to social justice “frame” demands a

rebalancing these values with others that Americans also hold.

How an issue is described or framed can determine the extent to which it has popular or political support.

We must articulate the social justice values motivating the changes we seek in specific policy battles that will be debated in the context of news coverage.

Market Justice vs. Social Justice Values Self-determination and self

discipline Rugged individualism and

self-interest Benefits based solely on

personal effort Limited government

intervention Voluntary and moral nature

of behavior

Shared responsibility Interconnection and

cooperation Basic benefits should be

assured Strong obligation to the

collective good Government involvement is

necessary Community well-being

supersedes individual well-being

Pew Center poll of 44 countries found that US residents We are more likely to believe that twe are in control

of our lives than to see our lives as subject to external forces. Dominant factors: self determination, personal discipline

and hard work Reinforcing individualism.

How is Obesity Being Framed Center around appearance and health Include the idea that the direct cause of obesity is

overeating and that overeating is bad for health and bad for appearance.

But frames evoke more Expressed in terms of character, people become

obese when they lack will power More deeply imbedded…those who lack willpower are

of poor characterThese underlying assumptions about obesity can be

evoked whenever obesity is referred to.

The Need for Re-Framing

We need to quit using the word! Obesity is a bodily condition, NOT a social

condition –people are obese, communities and neighborhoods are not.

Using the term makes it harder to illustrate the conditions that inhibit healthy eating and activity.

The Need for Re-Framing

Obesity narrows the problem, elevating one risk factor above others.

Obesity is stigmatizing. A focus on obesity favors powerful

stakeholders like the food, pharmaceutical and diet industries.

Obesity moves the conversation “downstream”.

The Need for Re-Framing

With news we are NOT trying to reach the mass public, but Policy Makers!

80 % of media stories focus on individual accountability.

Key Functions of the News

Setting the Agenda what we think about

Shaping the Debate how we thing about it

Reaching Opinion Leaders what we do about it

The Need for Re-Framing

Pitch stories that widen the frame to include environmental factors root causes the need for policy solutions.

Framing for Content

Translate individual problem to social issue Assign primary responsibility Articulate shared values Present a policy solution Develop story elements

Message Development What’s wrong?

Fast food is widespread on high school campuses Why does it matter?

This endangers the health of the next generation. We owe our children a fair change to be strong and successful

What should be done? Schools must promote appealing, affordable healthy

options The legislature must provide adequate funds for food

service.

What you already know

Use compelling visuals Develop media bites Calculate social math Identify authentic voices

Media bites

Smoking a “safer” cigarette is like jumping out of a 10th floor window rather than a 12th floor window.

Having a no-smoking section in a restaruant is like having a no-peeing section in a swimming pool.

Tobacco is a pediatric disease

Media bites

Kids need sports, not sports drinks.Nicholas Kristof

Commenting on the negative health effects of high-fructose corn syrup

The New York Times, April 11, 2006.