Multi-Level, Multi-Component Approaches to Community Based Interventions for Healthy Living—A Three Case Comparison
Abstract
:1. Introduction
2. Materials and Methods
- Case 2: Environmentally focused community randomized intervention trial for young child obesity prevention: Children’s Healthy Living (CHL) for Remote Underserved Minority Populations of the Pacific [29].
- Case 3: B’More Healthy Communities for Kids (BHCK): a multi-level obesity prevention program for low income urban African American children [30].
- The SoL—Health & Local Community program was approved by the Institutional Review Board, the Ethical Committee of the Capital Region with the Project Identification Code: 3-2013-036.
- The Children’s Healthy Living program was approved by the University of Hawaii at Manoa Committee on Human Studies number 18915.
- The B’More Healthy Communities for Kids program was approved by the Johns Hopkins School of Public Health Institutional Review Board. IRB number 00004203.
3. Results
3.1. Similarities
3.2. Differences
3.3. Key Components
3.3.1. Need to Build Collaboration and Partnerships from the Beginning
3.3.2. Plan for Sufficient Intensity/Dose
3.3.3. Emphasize/Create Consistency across Levels and Components of the Intervention
3.3.4. Build Synchronization across Levels
3.3.5. Plan for Sustainability
4. Discussion
4.1. Policy
4.2. Implementation
5. Conclusions
Acknowledgments
Author Contributions
Conflicts of Interest
References
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Setting/Component | SoL/Health & Local Community | Children’s Healthy Living | B’More Healthy Communities for Kids (BHCK) |
---|---|---|---|
School/Kindergarten/Preschool | Taste workshops, gardening, lunch box workshops, food store educational tours, fish and fruit and vegetable eating promotion | Preschool Wellness Policy evaluation, Gardening, Role Model Training, SPARK physical activity training for teachers (Sports, Play, and Active Recreation for Kids) | Not applicable in this program |
Family | Gardening, flyers, Social Media | Gardening, Heroes for Health cards | Not applicable in this program |
Food stores/corner stores/Road side stands | Taste workshops, price reductions, interior design, space management, décor adjustments and choice architectures | Food cost assessment, Healthy food assessment, healthy food makeover | Increased access to healthy, affordable foods in corner stores and carryouts. Wholesalers stocked and promoted healthier foods. Point of purchase promotions in each venue (shelf labels, posters, interactive sessions). |
Social marketing-TV networks/text/email/web | Just a little healthier TV series, strategic media partnership agreement, press releases, feature stories, Social Media groups | Email/Web/paper Newsletter, text reminders for activities, sandwich boards | Facebook and Instagram accounts targeted adults. Twitter account targeted city stakeholders. Text messaging program targeted adult caregivers of intervention youth. |
Training in Obesity prevention skills | Not applicable in this program | Scholarships for University degrees for 21 selected citizens, Role model training, SPARK physical activity training | Trained 28 high school and college students to be youth mentors |
Municipality/Community | Health policy provisions. Local action group establishment | Coalition development, Role model training, Community Leader readiness for change assessment | Policy working group brought together city council members, representatives from city health department, schools, recreation and parks, and other key stakeholders to plan policy initiatives and sustain program activities |
Parks/Recreation Centers | Not applicable in this program | Playground building, sports equipment exchange | Recreation centers served as venues for mentor-youth interactions and training. Youth mentor-led nutrition/cooking lessons for adolescents (aged 10–14 years). |
Characteristic | SoL/Health & Local Community | Children’s Healthy Living | B’More Healthy Communities for Kids |
---|---|---|---|
Primary aim(s) | To increase healthy eating and decrease sedentary behavior | To facilitate the development of and to support social/cultural, physical/built and political/economic environment to promote active play and intake of healthy food to prevent young child obesity | To increase affordability, availability, purchase, and consumption of healthy foods by low income AA children, and reduce obesity |
Setting | 3 villages, middle income, above average rates of overweight, high blood pressure | 27 predominantly indigenous Pacific island and Alaska communities in 5 Pacific Jurisdictions (Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Hawaii) | 30 low income, urban communities/neighborhoods in Baltimore City, MD, USA |
Study Design | Community trial, baseline, follow-up 1 and 2 | Community randomized trial | Neighborhood randomized controlled trial |
Institutions involved in intervention | Supermarket/retail, schools/daycare and media (TV, Radio, Print media) | Preschools, stores, parks, Physical Activity facilities, Fastfood restaurants, community-based agencies | Recreation centers, corner stores, carryouts, wholesalers |
Target population | Children aged 3–8 years and their families 1st target. Other islanders 2nd target | Indigenous 2–8 year-old children and their families, preschool and native communities | Low income African American children, aged 10–14 years, and their adult caregivers |
Duration of intervention, months | 24 | 24 | 8–10 months in 2 overlapping waves |
Key stakeholders | Representatives from health, youth/school and culture/leisure. Elected and civil servant level. High level and local management level of retailers. Local school and daycare headmasters. Local TV station manager and other local media actors. The three academic partners. | Preschool teachers, school administrators, health center personnel, parents, community not-for-profit agencies, elected officials, store owners, park officials, community leaders, role models, local college/university faculty staff and students. | Policymakers, city agency staff, wholesale store managers, small store and carryout owners, recreation center directors and staff, youth leaders, low income families. School of public health faculty, staff and students. |
Forms of engagement of policymakers and key stakeholders | Three local village based citizen actions groups (CAGs). One island wide loosely couple partnership alliance consisting of key stakeholders from market, public and civil society | Guided by local advisory committees, support community role models from different sectors, support and facilitate action by community coalitions, convene stakeholder groups, enhance work of preschools and other community groups working with young children; provide scholarships to college for 2 students from each Pacific jurisdiction | Policy working group, Use of systems science modeling for engagement, regular meetings with key stakeholder groups, trainings (in person and online) of food source owners and youth leaders, social media |
Characteristic | SoL/Health & Local Community | Children’s Healthy Living | B’More Healthy Communities for Kids |
---|---|---|---|
Levels evaluated | Supermarket, schools/daycare, child, family, citizen | Individual child and adult caregivers, community stores, community parks, physical activity facilities, fast food restaurants, preschool teachers and administrators, community leaders; Community; Pacific jurisdiction | Child, adult caregivers, youth leaders, small food source, recreation center, wholesaler, policy makers |
Process measures | Action competency, program awareness, perceived barriers for compliance among citizens and mediators | What, where, how many and who participated in each intervention activity—aimed at each of 6 target behaviors; quality assessment of implementation of each intervention activity; post-intervention assessment of intervention exposure | Reach, dose, fidelity of implementation at each intervention level (SMS, social media, youth leader, small food source, recreation center, wholesaler, policy) |
Psychosocial/socio-cultural measures | Knowledge and attitudes in families | Cultural affiliation, household characteristics and food security | Knowledge, self-efficacy, intentions, outcome expectations of youth (aged 10–14 years) and their adult caregivers |
Behavioral measures | Dietary intake and sedentary behavior | Two-day food and activity logs, sleep questionnaire, screen time questionnaire, accelerometry | Youth diet (FFQ), food purchasing and preparation; adult food preparation and purchasing |
Health outcomes | Anthropometric status Weight, height, skinfold measurements waist- and hip circumference | Child weight, height for BMI, waist circumference, acanthosis nigricans | Change in youth and adult caregiver weight and height (BMI) |
Other measures | Retail sales and public procurement figures | Community food (thrifty food) and utility costs; community food and PA environment assessments (120 stores, 150 schools; 88 physical activity facilities; 119 fast food locations; 102 churches; 227 food stores; 203 food store environments; 48 walking environments), community readiness for change in leaders | Stocking and sales of promoted foods in participating food sources |
Sample size | In 6 high intensity villages: 841 children enrolled from 12 schools and kindergarten (total in case and control) In the low intensity areas: 1500 in case and in control (3000 in total) | 27 communities (9 intervention, 9 matched control, 9 temporal) in 5 jurisdictions; 4483 indicator child-caregiver households at baseline * | 30 urban neighborhoods; 724 child-adult dyads (24/neighborhood); 1 recreation center/neighborhood; 3 cornerstores/carryouts/neighborhood |
Creation of | SoL/Health & Local Community | Children’s Healthy Living | B’More Healthy Communities for Kids |
---|---|---|---|
Collaboration and partnerships | Key stakeholders identified in a series of participatory kick-off meetings. These became organized in loosely coupled community wide partnerships. At village level local community groups were formed (CAGs) | Key leaders/role models identified in each community and jurisdiction (e.g., state, territory) for partnership; coalitions developed; scholarships provided for education in obesity prevention; policy work groups | Community engagement process (policy working group, sequential workshops, etc.) designed to provide adaptation and sustainability |
Intensity | Relations management across intervention settings and neigbourhoods Based on a participatory action research approach | Monthly progress/activity reports utilizing the RE-AIM framework | Reinforcement by having each intervention level linked to other levels; Limit the number of promoted foods, behaviors, messages and repeat them throughout multiple components of the B’More Healthy Communities for Kids. |
Consistency | Frequent meetings with stakeholders and visits to intervention settings to assure compliance with protocol | Quality assurance visit and weekly conference calls | Criteria for approval of each intervention component; Develop and uphold minimum delivery standards; Training of staff, youth leaders, food source owners and staff; develop Interventionist Manual of Procedures |
Synchronization | Addressed through advance planning of activities and in cooperation with CAGs as well as with facilitators at intervention settings | Template of activities according to stage of change theory | Intervention in a series of phases, with specific targets; Intervention team negotiates between intervention levels to ensure timing and readiness |
Sustainability | Development and maintenance of relations with CAGs and the community partnerships. Creation of municipality commitment and integration of SoL/Health & Local Community approach in municipal health strategy | Add value (salary/training) to community workers/agencies. Provide degree training. Policy advocacy for change with data. Community coalitions; adoption of activities by community partners; capacity building through training and role model development; improvements to the environment. Colleges as backbone organizations. | Policy working group tasked with sustainability; Trainings to enhance capacity-building |
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Mikkelsen, B.E.; Novotny, R.; Gittelsohn, J. Multi-Level, Multi-Component Approaches to Community Based Interventions for Healthy Living—A Three Case Comparison. Int. J. Environ. Res. Public Health 2016, 13, 1023. https://doi.org/10.3390/ijerph13101023
Mikkelsen BE, Novotny R, Gittelsohn J. Multi-Level, Multi-Component Approaches to Community Based Interventions for Healthy Living—A Three Case Comparison. International Journal of Environmental Research and Public Health. 2016; 13(10):1023. https://doi.org/10.3390/ijerph13101023
Chicago/Turabian StyleMikkelsen, Bent Egberg, Rachel Novotny, and Joel Gittelsohn. 2016. "Multi-Level, Multi-Component Approaches to Community Based Interventions for Healthy Living—A Three Case Comparison" International Journal of Environmental Research and Public Health 13, no. 10: 1023. https://doi.org/10.3390/ijerph13101023