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104 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2011 vol. 35 no. 2© 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia
Editorials
doi: 10.1111/j.1753-6405.2010.00688.x
A settings-based theoretical framework for obesity prevention community interventions and research Lisa Gibbs, Elizabeth Waters
Jack Brockhoff Child Health and Wellbeing Program, The McCaughey Centre, University of Melbourne, Victoria
Lawrence St LegerSchool of Health and Social Development, Deakin University, Victoria
Julie GreenRoyal Children’s Hospital and Murdoch Childrens Research Institute, Victoria, and Department of Paediatrics and Melbourne Graduate School of Education, The University of Melbourne, Victoria
Lisa GoldDeakin Health Economics, Deakin University, Victoria
Boyd SwinburnWHO Collaborating Centre for Obesity Prevention, Deakin University, Victoria
Childhood obesity presents one of the greatest challenges
to the public health community because the drivers of obesity
can be located at the level of individual, community, social and
justice systems. The depth of complexity often gives rise to
opportunities for trivial, competing, opaque, ‘homeopathic’ and
indeed, potentially harmful and ineffective solutions. One of the
unresolved issues in the polarity of these debates is the level at
which prevention efforts should be targeted. Articulation of the
most appropriate theoretical frameworks to guide prevention
efforts is urgently called for.
It is often argued that theoretical frameworks can provide an
important structure for researching and understanding a public
health problem or intervention.1 Well-developed theories can
be used in problem-driven research to provide a conceptual
framework for a study.2 They can contribute to an understanding
and interpretation of the problem or issue being studied and can
inform the selection of models or frameworks to guide action.
Theoretical frameworks are, however, often under-utilised and
implicit rather than clearly articulated, and rarely evaluated for
their value and appropriateness.3
We argue that selecting, using, articulating and testing the
choice of theoretical framework is an important component
of rigorous population health intervention research; and aim
to illustrate this point from the perspective of experience in
developing, implementing and evaluating more than 14 system and
community-based intervention studies in the field of childhood
obesity prevention.
The role of theory in research and intervention design
There is no single, correct or universal theoretical framework for
a particular area of study. In a complex endeavour such as obesity
prevention, it is likely that several theoretical frameworks will
need to be used to guide the interventions and the understanding
of the results. The more important consideration is that the choice
of theory or theories is driven by the research question or problem.
In intervention or program-oriented research, there will be several
theories that could make up a framework, so researchers have
some flexibility in selecting the ‘best fit’ with the context and the
outcomes sought. Careful consideration of alternative frameworks
strengthens intervention thinking and design by highlighting the
areas of consensus (i.e. where program design would be similar
under any theoretical framework) and the areas of disagreement.
The rigour of this approach enables and strengthens opportunities
for reflective analysis of the attribution of measured success or
failure to the success or failure of intervention and/or of theory.4
Commonly used theoretical frameworksHistorically, interventions for obesity prevention have
predominantly used behaviour-change theoretical frameworks to
both understand what causes weight gain and to guide the models
for healthy eating and physical activity behaviours (thus addressing
the imbalance that leads to weight gain).4 While the relevance
of this approach for treatment programs is more compelling,
its appropriateness to the complex socio-political context of
regulation, legislation, social norms, environmental contexts,
community and individual behaviours, is of significant concern.
The recommendation in some of the current literature that obesity
prevention programs be based on behavioural theories is at best
naïve and at worst unethical, and a significant waste of resources.5
Even more dramatically, a range of alternative ways of
conceptualising the theories underpinning weight gain behaviours
and solutions include genetic factors and biological variables, such
as gender and age. Social ecological theories are only starting to be
used to explore the influence of the environment on weight status
and physical activity and eating behaviours.6,7,4 In some research
studies these theoretical principles have been applied as models
for action by targeting the behaviour of the decision makers for
environmental change.2,4,8,9 In some cases, they are still primarily
driven by a focus on individual behaviour change as a way of
changing environments.
A broader understanding of socioenvironmental theories can
increase understanding of social and environmental trends that
maximise opportunities for weight gain and minimise healthy
lifestyle options, creating ‘obesogenic’ macro- and micro-
environments10. This shifts our understanding of the obesity
epidemic from a focus on the influence of individual health
behaviours and genetic profile to a recognition that there are
broader influences on health status, including sociocultural
influences on health behaviours,4,11 that are now being reflected
in population increases in weight.
2011 vol. 35 no. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 105© 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia
Editorials
Matching theoretical frameworks to current understanding
Given the abject failures of short-term behavioural interventions
in addressing the population-wide, intergenerational challenges
of obesity, there is increasing recognition of the need for
comprehensive, multi-level, system-integrated or community-
based interventions. However, the evidence is still in the field
and we remain some years off understanding what will constitute
an effective approach.12 This uncertainty strengthens the case
for greater articulation of the theoretical framework employed
in intervention design and implementation, and supports the
application of models for action based on theoretical frameworks
that incorporate multiple theories to address the complexity of
the intervention.2,8
Clearly, there are a number of factors influencing the observed
health outcomes. For example, if the focus of an intervention is
on individuals, then a behaviour change model is likely to be
an appropriate approach. Alternatively, a socioenvironmental
theoretical framework should clearly be selected for population-
based obesity prevention initiatives if the concept of an
‘obesogenic’ environment and its impact on population obesity
levels is accepted. In this context, theoretical models that
primarily address physical, policy, economic and socio-cultural
environments, in addition to targeting psychosocial and
behavioural factors, should be considered as a guide for action,
i.e. primarily targeting environmental change in order to achieve
population behaviour change.13,14 This approach aligns with the
Ottawa Charter for Health Promotion, which includes a strategy
for ‘Creating supportive environments’ as one of its core foci.15
A settings-based approach is well established in health
promotion as a way of creating supportive environments, as
evidenced by the success of the Healthy Cities model for action
which started as a small-scale project and expanded into a major
global movement.16 In the context of child obesity prevention, the
most relevant and well-established version of the healthy settings
approach is the Health Promoting Schools Framework (HPSF).
This model for action is based on health promotion theory and
is consistent with a socioenvironmental theoretical framework. It
has been widely used and developed to assist schools to address
health issues over the past decade.17
The advantage of the HPSF is that it is designed to guide
multilevel interventions. It not only addresses environmental
change but also advocates for engagement of the community and
programs to address skills and behaviours. In doing so, it accounts
for environmental, sociocultural and individual influences on
health behaviours. Layering of additional models for action
operating within the broader theoretical framework can also be
applied to suit the setting and population context. For example,
in an intervention involving multiple customised strategies in
multiple settings, application of a community participatory
based approach will also enhance community engagement and
sustainability.18,19 Community-based participatory research
involves the community as active partners at all stages of the
research process.20 In a culturally diverse community, it may also
be helpful to draw on models of cultural competence.21,22 “Cultural
and linguistic competence is a set of congruent behaviours,
attitudes, and policies that come together in a system, agency, or
among professionals that enables effective work in cross-cultural
situations.”23 In this way, application of multiple theoretical models
for action, via a coherent theoretical framework, can support
the development, implementation and evaluation of complex
community-based interventions.
As noted previously, inappropriate selection of a theoretical
framework is likely to contribute to ineffective or negative
outcomes. For example, addressing environmental change as part
of an obesity treatment program may be beyond the resources and
scope of the program and may neglect the immediate health needs
of the participants. Similarly, applying a behaviour change model
in a school based obesity prevention program by targeting children
who are overweight or obese, could result in stigmatisation, loss
of self esteem and subsequent weight gain. In summary, it is vital that public health practitioners and
researchers recognise the importance of articulating and applying
theoretical frameworks and related models for action to the design,
implementation and evaluation of obesity prevention interventions.
For the purposes of population level obesity prevention research
and interventions, increasing our understanding of the complexity
of the shifting environmental and socio-cultural influences on child
obesity requires a shift from a reliance on mainly behaviour change
models to a socioenvironmental theoretical framework. In taking a
healthy settings approach, the HPSF is an example of a model for
action that is consistent with the socioenvironmental focus while
still providing scope for targeting health behaviours. It provides
an appropriate primary model for guiding the development,
implementation and evaluation of complex school-based obesity
prevention interventions.
Acknowledgements Elizabeth Waters and Lisa Gibbs acknowledge the Jack
Brockhoff Foundation for salary and operational funding
support. Elizabeth Waters acknowledges the support of
a VicHea l th Publ i c Hea l th Resea rch Fe l lowsh ip .
Lisa Gibbs, Lisa Gold and Julie Green acknowledge NHMRC
salary support.
Correspondence to: Dr Lisa Gibbs, Jack Brockhoff Child Health and Wellbeing Program, The McCaughey Centre, School of Population Health, University of Melbourne, Level 5, 207 Bouverie Street, Carlton, Victoria 3053; e-mail: lgibbs@unimelb.edu.au
References1. Daly J, Willis K, Small R, Green J, Welch N, Kealy M, et al. Assessing qualitative
research in health – a hierarchy of evidence-for-practice. J Clin Epidemiol. 2007;60:43-9.
2. Brug J, Oenema A, Ferreira I. Theory, evidence and Intervention Mapping to improve behavior nutrition and physical activity interventions. International Journal of Behavioral Nutrition and Physical Activity. 2005;2(1):2.
3. Summerbell C, Waters E, Edmunds L, Kelly S, Brown T, Campbell K. Interventions for preventing obesity in children (Cochrane Review). In: The Cochrane Database of Systematic Reviews; 3, 2005. Oxford (UK): Update Software; 2005.
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4. Baranowski T, Cullen K, Micklas T, Thompson D, Baranowski J. Are Current Health Behavioral Change Models Helpful in Guiding Prevention of Weight Gain Efforts? Obes Res. 2003;11 Suppl:23-43.
5. Sharma M. School-based interventions for childhood and adolescent obesity. Obes Rev. 2006;7(3):261-9.
6. Green LW, Kreuter MW. Health Promotion Planning: An Educational and Ecological Approach. Montain View (CA): Mayfield; 1999.
7. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education Quarterly. 1988;15:351-77.
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9. Baranowski T, Cullen K, Nicklas T, Thompson D, Baranowski J. School-Based Obesity Prevention: A Blueprint for Taming the Epidemic. Am J Health Behav. 2002;26(6):486-93.
10. Swinburn B, Egger GJ, Raza F. Dissecting obesogenic environments: The development and application of a framework for identifying and prioritising environmental interventions for obesity. Prev Med. 1999;29:563-70.
11. Renzaho A. Fat, rich and beautiful: changing socio-cultural paradigms associated with obesity risk, nutritional status and refugee children from sub-Saharan Africa. Health Place. 2004;10(1):105-13.
12. Summerbell C, Waters E, Edmunds L, Kelly S, Brown T, Campbell K. Interventions for preventing obesity in children (Cochrane Review). In: The Cochrane Database of Systematic Reviews; 3, 2005. Oxford (UK): Update Software; 2005.
13. Swinburn B, Egger G. Preventive strategies against weight gain and obesity. Obes Rev. 2002;3:289-301.
14. Lynch J. Social epidemiology: some observations about the past, present and future. Australasian Epidemiologist. 2000;7(3):3.
15. World Health Organisation. Ottawa Charter for Health Promotion. Ottawa (CAN): Department of Health and Welfare, WHO; 1986.
16. Dooris M. Joining up settings for health: a valuable investment for strategic partnerships? Critical Public Health. 2004;14(1):49-61.
17. The International Union for Health Promotion and Education (IUHPE). Protocols and Guidelines for Health Promoting Schools. Promotion and Education. 2005;12(3-4):145-7.
18. Israel B, Schulz A, Parker E, Becker A. Review of Community-Based Research: Assessing Partnership Approaches to Improve Public Health. Annu Rev Public Health. 1998;19:173-202.
19. Gibbs L, Gold L, Kulkens M, Riggs E, Van Gemert C, Waters E. Are the benefits of a community-based participatory approach to public health research worth the costs? Just Policy. 2008;47:52-9.
20. Goodman RM, Yoo S, Jack LJ. Applying comprehensive community-based approaches in diabetes prevention in diabetes prevention: rationale. principles and models. J Public Health Manag Pract. 2006;12;545-54.
21. Cross T, Bazron B, Dennis K, Isaacs M. Towards a Culturally Competent System of Care. Vol I. Washington (DC): National Technical Assistance Centre for Children’s Mental Health, Georgetown University Child Development Centre;1989.
22. National Health and Medical Research Council. Cultural Competence in Health: A Guide for Policy, Partnerships and Participation. Canberra (AUST): Commonwealth of Australia; 2006.
23. Office of Disease Prevention and Health Promotion, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care. Washington (DC): U.S. Department of Health and Human Services; 2001.
doi: 10.1111/j.1753-6405.2010.00689.x
Planning for population health in Australia’s health reformsHelen Keleher
Professor and Head, Department of Health Social Science, Monash University, Victoria and President, Public Health Association of Australia
One of the major health reforms under way in Australia is
the development of Medicare Locals,1 which are intended to be
a national network of highly functioning primary health care
organisations. Medicare Locals are intended to be a different
model to that of Divisions of General Practice with the integration
of community health promotion and population health programs.
These will be sweeping changes that require not just new
governance and functional arrangements, but also a level of
population health planning not undertaken before in Australia.
Medicare Locals policy documents briefly refer to ‘Healthy
Communities Plans’ for which each Medicare Local will have
responsibility: “Over time, detailed local population health
and service plans will be developed to inform the planning and
coordination activities undertaken by Medicare Locals”1 (p5).
However there is little, if any, guidance from the Commonwealth
on how those plans should be developed or the extent of planning
needed to drive effective and equitable health promotion and
prevention work of Medicare Locals, or even what population
health and population health planning mean in the context of
Medicare Locals. The Department of Health and Ageing has said
that Healthy Communities Plans will include “identification of the
health needs of local areas and development of locally focused
and responsive services”, and that “decisions and processes
based on evidence and strong population health data will enable
a stronger focus on prevention and early intervention, result in
more appropriate service utilisation, improved patient access and
greater clinical and administrative efficiency”1 (p5). The government
has stated its intentions that Medicare Locals will be efficient,
effective and meet equity goals.2,3
Even in a country as relatively rich as Australia, there are
rising inequities in the people’s health. At least 1 in 10 of us, that
is 2 million Australians, now live in poverty4. The proportion of
children living in relative poverty has risen from 2.9% in 2001 to
12% in 20105 – Australia has the 14th highest child poverty rate
on OECD rankings6. Clear links have been established between
income and health, and models to explain the relationship between
social conditions and health are well-developed.7,8 Because the
socio-economic gradient predicts health status in every society9,
narrowing health gaps means raising the health of the poorest,
and doing so at a rate which outstrips that of the wider population.
Population health is a conceptual framework to identify why
some populations are healthier than others and promote thinking
about what can be done to make health outcomes more equitable.9
In other words, population health is about determinants of
health among populations and their characteristics. Effective
Editorials represent the views of the authors and not necessarily the views of this Journal or the Public Health Association of Australia.