Progress in Preventing Childhood Obesity How Do We Measure Up? (2007) / Chapter Skim
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2 Framework for Evaluating Progress
2 Framework for Evaluating Progress
Pages 32-73
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. The challenge presented in this report is to take the next step toward developing a robust evidence base of effective obesity prevention interventions and practices.
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Many types of evaluations can contribute to the knowledge base by identifying promising practices and helping to establish causal relationships between interventions and various types of indicators and outcomes. Evaluations can also enhance understanding of the intrinsic quality of the intervention and of the critical context in which factors can moderate4 or mediate5 the interventions' effect in particular ways.
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report is to encourage and demonstrate the value for conducting an evaluation of all childhood obesity prevention interventions. The committee strongly encourages stakeholders responsible for childhood obesity prevention policies, programs, and initiatives to view evaluation as an essential component of the program planning and implementation process rather than as an optional activity.
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This type of approach encourages the classification of obesity prevention interventions on the basis of their estimated population impact and the level of promise or evidence-based certainty around these estimates (Gill et al., 2005; Swinburn et al., 2005)
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. A comprehensive review of childhood obesity prevention interventions examined a variety of selection criteria for interventions including methodological quality, outcome measures, robustness in generalizability, and adherence to the principles of population health (e.g., assessments of the upstream determinants of health, multiple levels of intervention, multiple areas of action, and the use of participatory approaches)
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vided adequate information about their implementation that could be used to identify promising practices for childhood obesity prevention based on chosen criteria (Flynn et al., 2006)
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Fourth, evaluation is valuable at all phases of childhood obesity prevention actions, including program development, program implementation, and assessment of a wide range of outcomes. In particular, evaluation can contribute to an improved understanding of the effects of different types of strategies and actions -- leadership actions, augmented economic and human resources, partnerships, and coalitions -- on the short-term, intermediate-term, and long-term outcomes.
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. It was not surprising to find that at the community level, where the great majority of obesity prevention strategies are expected to be carried out, the capacity for conducting comprehensive program evaluations is limited.
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A Evaluation Technical Assistance and State B Mutual Support Government and federal Surveillance agencies and Monitoring Research B Foundations Centers Academic Institutions Research Centers Opportunities to Strengthen Evaluation Capacity Evaluation Capacity FIGURE 2-1 Closing the evaluation gap at the local level.
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As discussed in Chapter 4, the Centers for Disease Control and Prevention (CDC) 's Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases is focused on state capacity building, implementation, and enhanced training opportunities.
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. The evaluation framework also illustrates the range of important inputs and outcomes while giving careful consideration to the following factors: • The interconnections and quality of interactions within and among the multiple sectors involved in childhood obesity prevention initiatives; • The adequacy of support and resources for policies and programs; • The contextual appropriateness, relevance, and potential power of the planned policy, intervention, or action; • The relevance of multiple levels and types of outcomes (e.g., struc tural, institutional, systemic, environmental, and behavioral for in dividuals and the population and health outcomes)
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OUTCOMES RESOURCES & INPUTS STRATEGIES & SECTORS ACTIONS • Programs Structural, Leadership Health Cognitive • Policies Institutional, Strategic Planning Outcomes and Social • Surveillance Systemic Government Political Commitment Outcomes Reduce BMI and Monitoring Outcomes Industry Levels in • Research Communities the • Education Schools Population • Partnerships Home Behavioral Adequate Funding and • Coalitions Reduce Outcomes Environmental Capacity Development • Coordination Obesity Outcomes • Dietary • Collaboration Prevalence • Physical • Communication Activity Reduce • Marketing Obesity and Promotion Related • Product Morbidity Development • New Technologies Crosscutting Factors that Influence the Evaluation of Policies and Interventions Age; sex; socioeconomic status; race and ethnicity; culture; immigration status and acculturation; biobehavioral and gene-environment interactions; psychosocial status; social, political, and historical contexts. FIGURE 2-2 Evaluation framework for childhood obesity prevention policies and interventions.
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Evaluation should also provide a better understanding of the problem and meaningful, effective, and sustainable ways to address it. Sectors The first column in the framework delineates the specific sectors in which childhood obesity prevention actions can be undertaken and evaluated -- government, industry, communities, schools, and home.
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Adequate and sustained funding through government appropriations and philanthropic funding and capacity development are needed to initiate and sustain effective obesity prevention efforts. Evaluation of these two sets of factors can provide information about the adequacy of the leadership and the resources committed to a specific childhood obesity prevention initiative (Chapter 4)
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A systems approach to health promotion and childhood obesity prevention offers the opportunity to develop and evaluate interventions in the context of the multiple ongoing efforts (Green and Glasgow, 2006; Midgley, 2006)
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The interactions among complex social, economic, and cultural factors, combined with the varying availability of resources, require that interventions should be adapted to meet the particular needs, circumstances, or contexts of a community or setting. In the absence of generalizable solutions, effective planned childhood obesity prevention efforts will consist of a variety of potential strategies and actions based on an assessment of local needs, assets, conditions, and available resources.
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offered health promotion activities and resources (Kansas State Department of Education, 2004; Greg Kalina, Coordinator of the Goddard School District Nutrition Program, personal communication, April 24, 2006) with the dual goal of benefiting both students and school staff: • A mapped walking course on elementary school playgrounds and inside school hallways; • Monday morning stretch exercises led by trained teachers on closed circuit television at the intermediate school; • The provision of pedometers and walk-run and marathon events for students, faculty, staff, and community residents; • Nutritious snack options at staff and district committee meetings and the introduction of low-calorie and high nutrient snack options in schools; • Two annual teacher in-service programs on healthful nutrition choices and physical fitness; • A fitness center for staff, established with equipment donated by staff members and expanded with locally raised funds; and • Training for staff on the proper use of the fitness center equipment.
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An example from West Virginia illustrates how attention to strategies and actions (the third column of the evaluation framework in Figure 2-2) provides support to local-level obesity prevention program activities.
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Furthermore, obesity prevention activities are often consistent with the goals of a wide range of other health initiatives, including those concerned with supporting chronic disease prevention, school health, work site health promotion, and urban planning strategies such as Smart Growth. Outcomes The evaluation outcomes selected will depend on the nature of the intervention; the timeline of the program or intervention; and the resources available to program implementers and evaluators to collect, analyze, and interpret outcomes data.
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Children and youth cannot choose to spend their after-school time engaged in physical activities if they do not have safe spaces to engage in those activities or places to play. Nor will they increase their in-school physical activity in the absence of school policies that mandate and monitor requirements that children and youth engage in a specified level of physical activity each school day or week.
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• Revise the mission of a community health center or community coalition to include obesity prevention as an area of programmatic responsibilities and outreach. • Create or enhance a company's employee wellness program by incorporating obesity prevention into its activities.
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cCognitive outcomes are changes in an individual's knowledge, awareness, beliefs, and attitudes about the importance of healthful diets and regular physical activity to reduce the risk of obesity and related chronic diseases. Social outcomes are changes in social attitudes and norms related to dietary and physical activity behaviors that support healthy lifestyles.
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. Behavioral outcomes include changes in dietary patterns and physical activity for children and adolescents to achieve energy balance at a healthy weight.
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All of these factors should be taken into account when obesity prevention initiatives are designed, monitored, and evaluated, as depicted in Figure 2-2 (Hopson, 2003) (Chapter 3)
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Although some of the evaluation capacity gap can be filled through collaborative partnerships between local agencies and academic institutions, a large portion of locally implemented interventions will occur with no opportunity for conducting a full-scale evaluation. Yet all promising childhood obesity prevention interventions deserve some level of evaluation.
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How does the action contribute to preventing childhood obesity? What are the rationale and the supporting evidence for this particular action as a viable obesity prevention strategy, particularly in a specific context?
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Evaluating the implementation of programs is often called process evaluation. A process evaluation is defined as the means of assessing strategies and actions to reveal insights about the extent to which implementation is being carried out with regard to expected standards, the "dose" of the intervention received, and the extent to which a given action or strategy is working as planned.
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More methodologically sophisticated methods relevant to larger-scale interventions may involve: • A correlational methodology that seeks to establish associative rela tionships between participation in or exposure to an intervention and subsequent changes in structures or environments, attitudes, or behaviors; • A case study approach, which seeks to provide an understanding in some depth of the dynamics of change in selected contexts, with special attention to important contextual influences; and • Experimental and quasiexperimental methodologies that focus on establishing defensible causal relationships between an intervention, action, or program, on the one hand, and changes in structures and environmental factors or individual attitudes, knowledge, and be haviors, on the other hand. The larger the scope and the higher the level of resources devoted to the initial intervention, the more important it is to consider the value of using more sophisticated evaluation methods at the outset.
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evaluation designs9 can be useful for catalyzing thoughtful, creative, and innovative changes and identifying promising childhood obesity prevention interventions. Connecting the Key Evaluation Questions to the Evaluation Framework It is helpful to think about the components of the evaluation framework -- sectors, resources and inputs, strategies and actions, and outcomes -- in light of the four evaluation questions (Box 2-4)
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• To what extent and in what ways is the program connected or linked to other obesity prevention efforts in the contexts being served? Outcomes What difference did the action make in terms of increasing the availability of foods and beverages that contribute to a healthful diet, opportunities for physical activity, other indicators of a healthful diet and physical activity, and improving health outcomes for children and youth?
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, these causes include the uneven distribution of low-calorie and high nutrient foods, and lack of affordable fresh fruits and vegetables in communities and schools; the easy availability and access to foods and beverages that are high in total calories, fat, saturated and trans fats, added sugars, and sodium; the marketing of products to children and youth that appeal to their tastes but that have limited nutritional value; community settings that do not naturally support and encourage children and youth to be physically active; school policies that do not support or enforce the requirements for adequate time for physical activity; and social norms that reinforce both a sedentary lifestyle and the consumption of high-calorie processed foods and beverages. These problems are related to the distribution, access, and costs of healthful diets and the availability of safe places for children to play.
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Surveillance and monitoring will provide the data needed for these types of assessments. Measuring Dietary Patterns and Physical Activity Behaviors Current methods of measuring dietary patterns and activity behaviors are insufficiently precise to accurately detect subtle changes in energy balance that can influence body weight (IOM, 2005, 2006; NRC, 2005)
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The task of evaluation will be greatly facilitated by research on and the development of more accurate measurement tools, indicators, and performance measures. CDC is in an early phase of developing the Obesity Prevention Indicators Project, which will identify and select potential indicators and performance measures for the evaluation of obesity prevention programs and interventions.
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Innovative approaches to evaluation design that measure the relative impact of multiple changes to the built environment on a population's behaviors are needed, for example, methods that assess the collective impact of designing sidewalks, walking trails, and public parks on physical activity levels (TRB and IOM, 2005)
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. The knowledge generation, exchange, and uptake sequence can be used to generate, translate, and transfer or adapt the results of obesity prevention research and program evaluations to present promising practices to different target audiences.
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childhood obesity prevention efforts. As obesity prevention programs, strategies, and actions continue to be initiated around the country, evaluation can play a critical role in furthering our collective understanding of the complex character and contours of the obesity problem and of meaningful and effective ways to address it.
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Since the need for effective evaluation is ongoing, both the capacity and quality of evaluation will be positively influenced by the presence of a national commitment to support obesity prevention research and the rapid dissemination of research findings -- across the geographical landscape -- to stakeholders involved in prevention efforts in states and communities. The health outcomes will not be achieved by any single obesity prevention program or action and, consequently, fall outside the boundaries of most program and policy evaluations.
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Each of these recommendations is further expanded upon in Chapters 4 through 8, in which the committee recommends specific implementation actions that should be taken to ensure the availability of adequate resources and a focus on strengthening childhood obesity prevention efforts and their evaluation. An exception is Chapter 3, which only includes recommendations 2 and 3 because they explicitly identify the need to account for diverse perspectives when designing culturally relevant interventions that address the special needs of diverse populations and high-risk groups.
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Additionally, parents and caregivers should monitor changes in their family's food, beverage, and physical activity choices and their progress toward healthier lifestyles. Recommendation 4: Government, industry, communities, schools, and families should foster information-sharing activities and disseminate evaluation and research findings through diverse communication chan nels and media to actively promote the use and scaling up of effective childhood obesity prevention policies and interventions.
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2002. Physical Activity Evaluation Handbook.
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2005. Preventing Childhood Obesity: Health in the Balance.
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2003. Economic analysis of a school-based obesity prevention program.
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