CAN SCHOOL-BASED HEALTH PROMOTION INTERVENTIONS PREVENT CHILDHOOD OBESITY IN LMICS?

Transcription

1 CAN SCHOOL-BASED HEALTH PROMOTION INTERVENTIONS PREVENT CHILDHOOD OBESITY IN LMICS? Roos Verstraeten Institute of Tropical Medicine (ITM) Antwerp, Belgium August 27, 2015

2 INTRODUCTION Defining and understanding the problem of chronic diseases and childhood obesity in low- and middleincome countries (LMICs)

3 Did you know? Global distribution of chronic disease deaths Intermediate risk factors Individual and environmental risk factors LMICs 80% HICs OBESITY IN LMICS *2 SOCIO- CULTURAL DIET PA ECONOMIC

4 Overweight and obesity prevalence HICs Ecuador Global LMICs BOYS GIRLS Source: The Lancet (DOI: /S (14) )

5 Did you know? 25% (51.8 million) children and adolescents are overweight or obese in Latin-America

6 Did you know? Global distribution of chronic disease deaths Intermediate risk factors Individual and environmental risk factors LMICs 80% HICs OBESITY *2 SOCIO- CULTURAL DIET PA ECONOMIC

7 Ecuador Diet PA High intake of refined CH, excessive unhealthy snacks and sugary drinks Low fruit and vegetable intake Skipping breakfast Low PA and fitness levels High sedentary behaviour 34% dyslipidemia, 6% high blood pressure, 20% abdominal obesity

8 Did you know? Life expectancy Health care costs PREVENTION = URGENTLY NEEDED

9 Research objective Systematic and stepwise planning, development and evaluation of preventive interventions in LMICs Case study School-based Diet and PA Ecuadorian Adolescents (11-15 yrs) Cluster randomised-controlled study

10 QUESTION 2: VALID TOOLS QUESTION 3: CONTEXTUAL FACTORS QUESTION 1: EVIDENCE IN LMICs QUESTION 4: VALID MODELS NEEDS ASSESSMENT INTERVENTION DEVELOPMENT

11 NEEDS ASSESSMENT An epidemiological analysis of the health problem in LMICs and in the context of Ecuador to inform intervention development

12 Question 1 Can a school-based intervention prevent childhood obesity in a LMIC? Verstraeten R et al. AJCN Aug;96(2):415-38

13 Systematic review PICO model P I Population Intervention Healthy children (6-18 yrs old) in LMICS School-based interventions targeting diet and PA to prevent obesity C Comparison Controlled trial O Outcome Dietary and/or PA behaviour and anthropometry

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

15 Results Number of studies (n = 22) 4 18 Changed behaviour and/or BMI Number of studies (n = 22) 2 8 BMI Characteristics of effectiveness: Diet and PA/multi-component/integrated in the curriculum

16 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

17 Question 1 Can a school-based intervention prevent childhood obesity in a LMIC? Yes, when

18 Key messages for intervention development Contextual influences of behaviour Valid tools Systematic and theory-based approach Local evidence and participation Rigorous evaluation + process evaluation

19 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

20 Validation study Time spent on different PA levels was estimated Urban and rural adolescents (11-15 yrs) 7d Perceived difficulty/sociodemographics (BMI, age, sex, setting) VALIDITY 3 wks N = 302 RELIABILITY

21 Results Validity Fair measurement agreement Reliability Modest measurement agreement

22 Results Validity Reliability Sex Girls > LPA than boys Girls < SED/VPA than boys Setting Rural > LPA than urban Rural < VPA than urban Perceived difficulty of completing the PA record Reliability Perceived difficulty

23 Question 2 Can a 7 day PA record provide good estimates of PA levels in Ecuadorian adolescents? Yes, but

24 Key messages for intervention development Fair measurement agreement Too strenous (high participant burden) Use objective measure (accelerometer) to evaluate PA behaviour

25 Question 3 What are the factors that influence dietary and PA behaviour in Ecuadorian adolescents? Verstraeten R et al. Plos One. 2014:e87183.doi: /journal.pone Van Royen K et al. JPAH 2013 DOI: /jpah

26 Focus group discussions Adolescents N = 12 Parents N = 4 School staff N = 4 Urban 144 participants Rural Understand individual and environmental influences Theoretical framework

27 Conceptual framework for dietary behaviour

28 Conceptual framework for PA behaviour

29 Question 3 What are the factors that influence dietary and PA behaviour in Ecuadorian adolescents? Factors known, and

30 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

31 Question 4 Is the culture-specific framework for dietary behaviour a valid model?

32 Validity of conceptual framework Accessibility/ parental Environment permissiveness/ school support Urban and rural adolescents (11-15 yrs old) N = 784 SES/dietary behaviour/ influencing factors operationalized Selfefficacy/barriers/ Individual benefits/ factors habit strength/food safety Dietary behaviour

33 Direct effects on behaviour Environmental factors Individual factors Parental permissiveness School support Perceived benefits Perceived food safety Perceived benefits

34 Indirect effects on behaviour High accessibility to healthy food High accessibility to healthy food Supportive school environment Supportive school environment Perceived benefits Healthy food perceived as safe Perceived benefits

35 Question 4 Is the culture-specific framework for dietary behaviour a valid model? Yes, and

36 Key messages for intervention development Different pathways different behaviours Environmental + social + individual changes

37 QUESTION 2: VALID TOOLS QUESTION 3: CONTEXTUAL FACTORS QUESTION 1: EVIDENCE IN LMICs QUESTION 4: VALID MODELS NEEDS ASSESSMENT INTERVENTION DEVELOPMENT

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

39 Systematic intervention development Needs assessment Intervention development 4Q: QUALITATIVE AND QUANTITATIVE DATA Theory and evidence-based approach (IM) Participatory approach (CPPE) Intervention strategies matching the social and cultural realities

40 Intervention objectives Dietary behaviour PA behaviour Schools: healthy foods Schools: PA opportunities

41 Intervention programme Individual classroom-based component (individual level) Environment-based component (school and family level) Interactive educational toolkit on diet and PA Parents: interactive sessions Schools: physical environment Training food tuck shop personnel Social events

42 P I Population Intervention DURATION: 3 YEARS 1430 Ecuadorian adolescents (11-15 yrs) School-based health promotion intervention targeting diet and PA C Comparison O Outcome Cluster randomised-controlled trial in 20 schools (I= 10; C=10) Primary: dietary and/or PA behaviour Secondary: anthropometry PROCESS AND IMPACT EVALUATION

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

44 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)

45 Intervention effects - PA No effect Minimized decline in PA in the intervention group Physical fitness improved

46 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)

47 CONCLUSION Systematic and stepwise development of an intervention in Ecuadorian adolescents is effective

48 Conclusion: needs assessment Q1 Q2 Q3 Q4 School-based interventions have the potential to improve dietary and PA behaviour in LMICs and prevent unhealthy body weight 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

49 Conclusion: intervention development C1 A comprehensive, culturally-appropriate intervention package was developed C2 C3 New insight into the processes of intervention development in LMICs is provided Help in identification of effective and ineffective strategies C4 Allow for replication, adoption or dissemination of useful strategies

50 And now??

51 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

52 Intervention ladder Increasing intrusion & conflict 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

53 GRACIAS!!! FUNDING

54