Community Interventions: A Brief Overview and Their Application to the Obesity Epidemic

Jun 01, 04:30 AM

Current Headlines: By Economos, Christina D; Irish-Hauser, Sonya

Introduction

Defining "community" from a research perspective is difficult. Communities consist of environmental, social, and geographic components. In addition, race, ethnicity, socio-economic status (SES), and group memberships often play roles in community identity.1 Barry Wellman and Scot Wortley urge that to truly understand and influence a community, and most certainly to conduct research within communities, one must take into account the varied nature of relationships and networks and how they may work together synergistically to meet the needs of community members.2 Using the Social Ecological Model, with its delineation of multiple spheres of influence (individual-interpersonal-organizational-community-public policy), community-based research has attempted to reach this understanding. Although dramatic shifts have not yet been realized, many studies suggest improved health behaviors and healthy environments, which indicate a promising future for community intervention work.3 The discussion that follows reviews the theory and rationale for community-based interventions, the social- ecological approach to understanding and studying obesity, and the progress and promise of community interventions.

Theory and Rationale for Community-Based Interventions

Community-based interventions allow for the wealth of assets present in any community to be tapped and used with efficiency and direction. One of the most important assets found in communities is, naturally, the vast array of human resources. From vested community leaders, to service and information providers, to organizations and faith-based groups, to community members seeking employment, the opportunities to partner, collaborate, expand, and enrich initiatives are numerous. Additionally, the depth of community understanding possessed by its members cannot be matched by efforts made by individuals from the outside. Soliciting community input can be invaluable in shaping and implementing research and programmatic activity. Indeed, allowing community members to participate in the work offers several advantages to investigatordriven research and programming. Knowledge of the resources and dynamics existing within communities is best acquired directly from community members. Further, there are often recognized, official or unofficial, community leaders who may be best equipped to discuss relevant issues with influential politicians in a position to affect important policy changes. The nature of community structure and its human resources yields an innate ability for members to connect, organize, network, and share resources. Communities possess an inherent mechanism for efficiently bringing people together for a common cause. Many interventions leverage events such as festivals, harvest parties, and community field days to disseminate messages, model ideal nutrition and physical activity behaviors, and to foster community cooperation in these efforts.

Through the multiple linkages and interactions of community members, community norms develop. In many regards, individuals within a community share both proximity and a wide range of characteristics, both positive and negative. With sustained connections and continued conversations, participants in communities, regardless of degrees or modes of inclusion, develop emotional bonds, common intellectual pathways, and corporate methods of communication. Along with other commonalities such as proximity, cultural practices, and socio-economic status, community members also have common problems. The physical or built environment also exerts a powerful influence on the lives and health of community residents in various ways: some obvious, others subtle, some beneficial, and some pernicious.

It has been shown that the probability of being overweight or obese is significantly associated with land use and the layout of the community in which an individual lives.4 Known colloquially as suburban sprawl, many community layouts now cater primarily to motorists, leaving walking or biking to destinations either precarious or altogether impossible. While the emergence of large multi-purpose chain stores, fast food establishments, and the roadways that connect them to suburban neighborhoods offer convenience and efficiency to consumers, it has also produced unintended consequences. One explanation for the link between overweight and community layout is that more physical activity and healthier diets may be seen in communities with convenient, safe walking paths and accessible sources of fruits and vegetables.5 On the other hand, poor health in residents may be expected in communities where crime rates are high, numerous alcohol outlets exist, and access to open space and fresh food is limited. A recent report by the Prevention Institute identified 11 case studies highlighting local environmental changes that would improve the health of the communities. Examples of community changes enacted include bringing full-service grocery stores to areas that lack sufficient access (e.g., Rochester, New York); creating community gardens to foster not only healthy eating, but physical activity and social connections (e.g., Denver, Colorado); and improving community walkabilty through major infrastructure changes in the built environment (e.g., Boston, Massachusetts).6 Indeed, local governments and developers would do well to focus on improving sidewalks and street crossing safety, providing local venues for physical activity, and building stores and businesses within safe walking or biking distance of the communities they serve.

Genetics alone cannot account for the rising rates of overweight and obesity.7 The sudden international proliferation noted in recent decades suggest environmental more than genetic influences.8 Targeting the larger community environment to encourage healthful eating, increased levels of physical activity, and decreased sedentary behaviors is emerging as the only practical way to address this issue on a large scale.9 Furthermore, community-wide strategies directed at all ages and groups offer an up-stream behavioral solution to the problem, and thus a means of both treatment and prevention.

Behavior change in the areas of diet and physical activity has been successful to some degree on an individual basis,10 but in order for individual behaviors to be sustained, they must be able to be carried out in an environment that supports healthy choices. From a public health perspective, individual behaviors must be addressed in the context of societal and environmental influences at the community level where individuals live.11 This is especially true for children, who have very little control over their environments, particularly in current obesigenic settings that promote a plethora of energy dense foods, with few physical activity and many sedentary options.12 Community membership, residential proximity, and the tendency of norms to converge may also be part of the solution to shared problems. Community membership fosters frequent contact and channels through which to share information, thereby allowing for widespread recognition of problems and facilitated diffusion of solutions to those problems. Involving the community in the research process provides benefits for both the community and the researchers. Involving the community in development allows for more relevant, culturally appropriate interventions to be implemented, which ultimately increases their chances for success. Cultural sensitivity and competency is an essential component in any cross- cultural intervention attempts.13 Establishing partnerships in the community breeds trust, acceptance, and investment in the research agenda.14

The Community Health Promotion Grant (CHPG), sponsored by the Kaiser Family Foundation,15 demonstrated this community partnership more than 15 years ago. This major health initiative established 11 community health promotion projects (not specifically obesity- related behaviors) and represented an early model of shifting a large part of the design, planning, and implementation of health promotion to the communities in which the programs were to operate.16 Successful implementation was characterized by several critical factors, including intervention activities, community activation, success in obtaining external funding, and institutionalization.17 While measurable, positive effects of these early community research efforts were minimal, they served to highlight the intricacies and challenges unique to this form of investigation, and informed the many similar efforts that followed. The researchers in this study concluded that community research efforts should be theory-based; must provide for adequate power, intervention dose, control procedures, and follow-up time; and must implement solid data collection plans and methods.

Community research, when conducted appropriately, increases the breadth of the audience targeted by an intervention in a cost- effective manner. Involving the community helps researchers pinpoint their specific needs and wants and may even uncover untapped solutions that alreadyexist. Evidence now strongly supports that involving communities in the intervention or project development process is, in and of itself, a motivating factor. Community-Based Participatory Research (CBPR) is a promising collaborative approach that helps researchers achieve that goal by combining systematic inquiry, participation, and action to address urban health problems.18 CBPR is increasingly being recognized as an effective means to bridge the divide between rigorous academic research and practical neighborhood application.19 CBPR aims to systematically collaborate with those most directly affected by the matters being studied. It increases both the relevance and acceptance of the work by acting from the bottom up, rather than the top down. Likewise, a similar research model, Practice Based Research Networks (PBRN) endeavors to tap into the opportune setting of physician practices for both research ideas and participants. Further, there has been a push for PBRN to expand to other community members such as patient advocacy groups, health insurers, and university members.20 Multiple examples now exist to testify to the effectiveness of CBPR in meeting the needs of diverse communities.21

Indeed, recognizing community as a unit of identity and taking the time to understand the unique needs, resources, and strengths that exist there will facilitate the identification of critical motivators. Reaching individuals and communities via messages and interventions focused on traditional foods, cultural exercise patterns, and modes of healing builds not only trust, but a sense of connectedness and investment in the message behind the proposed behavior and the reasons given for taking action.22 Further, it has been suggested that creating a sense of camaraderie and belonging in an intervention, whether based on race, ethnicity, or group or organization membership, heightens the potential for positively changing not only immediate behaviors, but subsequent interpersonal patterns of influence.23

A Social-Ecological Approach to Understanding Obesity

The complex, multifaceted etiology of overweight and obesity necessitates comprehensive systematic studies of environmental approaches to obesity prevention.24 Successful obesity interventions are contingent on targeting multiple aspects of individual environments.25 Nicholas Pronk and J. Boucher propose orienting obesity prevention approaches toward the identification and integration of relationships between and among individuals, environments, and resources. They recommend a "systems approach" that develops strategies across a range of individual and institutional stakeholders.26 Interventions and educational messages pertaining to obesity must be viewed against a backdrop of broad social, economic, and political systems that influence behavior on both individual and societal levels, and may either promote or constrain adherence to desired health behaviors.27 As such, environments serve as powerful contexts for change and, with the proper frameworks in place, provide the ability to monitor that change. Likewise, given that children in low-income families reside in environments that limit social and economic opportunities, access to healthful foods, and opportunities for physical activity, interventions in these populations are of the highest priority.28 More interventions focusing on multifaceted community-based environmental change approaches using key elements of other successful social change models (a recognized crisis, economic impact, evidence based, government involvement..., etc.) are needed.29

Despite the many assets available in communities, such as recreation centers, food banks, and farmers' markets, in reality, many cannot be tapped due to barriers including financial constraints, issues of access and safety, lack of education or skills, entrenched negative perceptions, a sense of learned helplessness or hopelessness, and/or lack of time and support to make necessary changes. For these reasons, community work often fails.30

Community connectedness can be a blessing (if harnessed as a vehicle to disseminate healthy messages and behaviors) or a curse (if such connectedness fosters prejudice or negative perceptions of the target health behaviors). Likewise, the physical, built environment may serve to enhance community wellness (for example, if safe sidewalks, parks, and organized sports are available) or may be the single biggest detractor to accessing nutritious food and physical activity within a community. Further, many ideas that seem beneficial in theory, such as introducing farmers' markets and fitness facilities, fail utterly due to the high costs associated with them, whether monetary, temporal, or logistical. For instance, the prices of items at a farmers' market may be disproportionate to average incomes in the community in which it operates, or a single parent may work two jobs and lack the time and/or transportation to bring his/her children to a fitness facility. In the same manner, carefully crafted messages and community advertising campaigns often miss their mark due to lack of sensitivity to cultural and educational conditions.

Much progress has been made in addressing these issues and successful community interventions now stand as examples of what may be achieved if community work is conducted appropriately.

Community Interventions, Progress and Promise

There are very few examples of community-based interventions focused on obesity, due to the complex nature of both the etiology and the solution. A number of community studies addressing cardiovascular risk and disease and smoking among adults provide a foundation on which to build future work. For example, several clinical trials have been launched,31 such as the Multiple Risk Factor Intervention Trial,32 to test disease reduction in high-risk individuals. While such studies are valuable and certainly add to the body of medical knowledge, focusing on high-risk individuals limits the degree to which results may be generalized to the greater population. Further, they preclude the opportunity for prevention by ignoring the underlying motivations for behaviors and failing to study behaviors in vivo, where such underlying motivations can be addressed and positive alternative behaviors can be introduced, maintained, and supported.

Evidence in support of health improvement and disease reduction by way of community involvement began gaining ground by the 1970s. The North Karelia Project and the Stanford Three Community Study33 were among the first to break ground in this area. Each proved effective in translating educational messages to significant positive changes and cardiovascular disease risk reduction in the populations that received the interventions, as compared to control populations.

The intervention strategies of these projects used mass media, low-cost lifestyle modifications and the involvement of community members. Subsequently, the National Institutes of Health (NIH) financed three major community-based intervention projects in the 1908s, the Stanford Five-City Project,34 the Minnesota Heart Health Program,35 and the Pawtucket R.I. Heart Health Program.36

These trials essentially provided community-wide health education over several years. The Stanford Project provided a comprehensive program using social learning theory, a communication-behavior change model, community organization principles, and social marketing methods.37 Minnesota's multiple strategy approach provided systematic population screening for hypertension, mass media campaigns, adult and youth education programs, physician and health professional programs, and community organization efforts.38 The Minnesota project community intervention strategies for adult obesity reduction included39 weight control activities such as adult education classes, a worksite weight control program, a home correspondence course for weight loss, and a weight gain prevention program. Weight changes produced by these methods were modest in magnitude and the overall effects were disappointing, despite high participation in select programs.40 Pawtucket provided multilevel education, screening, and counseling programs throughout the community.41

Another randomized, controlled community-based intervention was undertaken by the National Cancer Institute (NCI) from 1989-1993 in an attempt to address smoking behavior. The Community Intervention Trial for Smoking Cessation (COMMIT) featured 11 matched pairs of communities from across the country in a multi-faceted intervention aimed at smoking cessation. Significant reductions were achieved, although only among light-moderate smokers.42

The recent media and government agency attention to the obesity epidemic has been followed by a surge in related programs and initiatives to combat this health crisis, particularly among children. In 2003, Shaping America's Youth (SAY) network was founded to act as a clearing house and a centralized source of information and programs in the area of childhood overweight and inactivity. SAY also initiates "cross-talk" among individuals and organizations to form a more concerted and informed effort. In its initial 2003-04 survey round, 1,891 programs registered, 575 of which were school, community, or youth programs. Through dialogue and interaction of those involved, SAY will be instrumental in determining what is working and what could be done better, and ultimately in developing a national plan of action for improving the well-being of our country's children.

The modest numbers of community-based childhood obesity interventions are paving the way for future approaches to managing the childhood obesity epidemic. The Pathways intervention was a randomized controlled trial conducted within the Native American communities, the first of its kind to take into account cultural, theoretical, and operational viability in the study populati\on and to operate on a large scale (1,704 participants) in 41 schools over the span of six years, including three years of feasibility testing and three years of intervention. The aim of the project was to reduce body fat by promoting behavioral change and a holistic view of health among Native American children in third, fourth, and fifth grades.43 Although the intervention was largely carried out within the schools, care was taken to enlist the support of community and tribal leaders, as well as parents. The intervention was developed through a collaboration of universities and American-Indian nations, schools, and families. The focus was on individual, behavioral, and environmental factors and merged constructs from the social learning theory with American-Indian customs and practices. Pathways was successful in reducing the energy density of foods consumed by changing the school food environment.44 While the main outcome of the study, change in percent body fat, produced no significant difference between intervention and control schools, other measurable benefits were demonstrated. Twenty-four-hour dietary intake measures showed a significantly lower total daily energy intake (1,892 compared with 2,157 kcal/d) and percentage of energy from total fat (31.1% compared with 33.6%) in the intervention group than in the control group. Further, the percentage of energy as fat shown in school lunches was 28.2% in the intervention schools, compared to 32% in controls, and self-reported physical activity (as assessed via Physical Activity Questionnaire) and healthy food choice intentions were conversely higher for intervention verses control schools. Finally, Pathways curricula knowledge increased significantly in children involved in the intervention. The Pathways study demonstrated a successful marriage of theoretical underpinnings, community and family involvement, and cultural and situational appropriateness. In this manner, Pathways provided an excellent community research framework upon which to build.

Informed by this and other efforts, "Shape Up Somerville (SUS): Eat Smart, Play Hard," conducted in Somerville, MA, was one of the first CBPR initiatives45 designed to change the environment to prevent obesity in early elementary school-aged children. Academics partnered with community members of three culturally diverse urban communities to conduct a controlled trial evaluating whether an environmental change intervention could prevent a rise in Body Mass Index (BMI) z-scores (number of standard deviations above or below the mean) in young children through enhanced access and availability of physical activity options and healthy food throughout their entire day. The SUS intervention focused on creating multi-level environmental change to support behavioral action and maintenance and to prevent weight gain among early elementary school children through community participation. Specific changes within the before- , during-, and after-school environments provided a variety of increased opportunities for physical activity. The availability of lower energy dense foods, with an emphasis on fruits, vegetables, whole grains, and low-fat dairy was increased; foods high in fat and sugar were discouraged. Additional changes within the home and the community, promoted by the intervention team, provided reinforced opportunities for increased physical activity and improved access to healthier food. Many groups and individuals within the community (including children, parents, teachers, school food service providers, city departments, policy makers, health care providers, before- and after-school programs, restaurants, and the media) were engaged in the intervention.46 These changes intended to bring the overall energy equation into balance. Specifically, this intervention aimed to result in an increased energy expenditure of up to 125 kcals per day beyond the increases in energy expenditure and energy intake accompanying growth. A central aim of the intervention was to create a community model that could be replicated nationwide as a cost-effective, community-based action plan to prevent obesity at local levels. This approach addressed the complex environmental influences on energy balance and ensured maximal reach within a population of children. This project is ongoing, and results are currently being analyzed.

Summary and Conclusions

Community research increases the breadth of the target audience in a cost-effective manner. Communities share proximity and problems; they also share resources and unique attributes that can be harnessed and used in positive ways. The Social Ecological model provides an excellent structure for framing change efforts on multiple levels, and is the most effective manner in which to support and maintain positive behavior change in individuals. Involving the community in any initiative helps researchers pinpoint the specific needs of the community, as well as to identify assets and untapped resources and solutions. Additionally, involving communities in the intervention or project development process can be, in and of itself, a motivating factor. To date, few research- based community interventions have addressed obesity, despite the need for this work emphasized in the literature, and calls for such efforts from government agencies and private foundations. Advanced community-based research approaches to turn the tide on childhood obesity will require training future leaders in community research methodology, increased funding to conduct rigorous trials, and acceptance of the study model as viable from the broad scientific community.

It has been shown that the probability of being overweight or obese is significantly associated with land use and the layout of the community in which an individual lives. Known colloquially as suburban sprawl, many community layouts now cater primarily to motorists, leaving walking or biking to destinations either precarious or altogether impossible.

The complex, multifaceted etiology of overweight and obesity necessitates comprehensive systematic studies of environmental approaches to obesity prevention. Successful obesity interventions are contingent on targeting multiple aspects of children's environments.

Community-based interventions built on theory and informed by community members produce potent, sustainable change. This intervention model mobilizes inherent community assets and pinpoints specific needs. Advancing community-based research to address obesity will require training of future leaders in this methodology, funding to conduct rigorous trials, and scientific acceptance of this model.

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44. B. D. Caballero, C. E. Davis, B. Ethelbah, M. Evans, T. Lohman, L. Stephenson, M. Story, and J. White, "Pathways: A School- based Program for the Primary Prevention of Obesity in American Indian Children" Journal of Nutritional Biochemistry 9 (2003): 535- 543; see COMMIT, supra note 3.

45. See Johns Hopkins, supra note 18. (see http:// nutrition.tufts.edu/research/shapeup for details.)

Christina D. Economes, Ph.D., M.S., is the Associate Director at the John Hancock Center for Physical Activity and Nutrition. She is also the New Balance Chair in Childhood Nutrition at the Dorothy R. Friedman School of Nutrition Science and Policy at Tufts University. Sonya Irish-Hauser, M.S., is a doctoral fellow at the Dorothy R. Friedman School of Nutrition Science and Policy at Tufts University.

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