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.

8. Kok G, Schaalma H, Ruiter RAC, Empelen PV, Brug J. Intervention Mapping: A Protocol for Applying Health Psychology Theory to Prevention Programmes. J Health Psychol. 2004;9(1):85-98.

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.