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Whole of system approaches to obesity prevention: progress and future plans

Whole of system approaches to obesity prevention: progress and future plans. Canberra, January 14 th , 2011. Overview. Background Three generations of obesity prevention research WHO CC interventions Whole of systems Conception and definitions Future plans. G1 characteristics.

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Whole of system approaches to obesity prevention: progress and future plans

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  1. Whole of system approaches to obesity prevention: progress and future plans Canberra, January 14th, 2011

  2. Overview • Background • Three generations of obesity prevention research • WHO CC interventions • Whole of systems • Conception and definitions • Future plans

  3. G1 characteristics • ‘Package Testing’ approach • Conceived, developed and implemented by (academic) experts • Practice experts and local implementers consulted • Suits RCT (usually cluster) methods • High fidelity of package implementation • Very limited local adaptation • High internal validity • Sacrifices external validity • Efficacy outcomes • Needs further research to determine effectiveness • Not implementable or translatable • Usually single setting only • E.g. cluster RCT of nutrition and PA interventions in middle school (42 schools, 4600 participants, $38m USD) (Foster GD et al NEJM 2010)

  4. G2 characteristics • Build the evidence on ‘what works for whom, why, in what contexts and at what cost?’ • ‘Community-Engaged’, participatory, capacity building approach • Interventions conceived and developed in partnership with and implemented by practice and local experts • Suits quasi-experimental or cluster RCT design • Attention to fidelity of processes and relationships • Significant local adaptation • Higher external validity • Risks to internal validity (intervention definition, design effects) • Create proof of principle for ‘translation to scale’ • Effectiveness outcomes • Needs further research to translate into real-world scale • Multiple settings usually possible

  5. Logic model Features and innovation: • Focusing resources into a defined geographical area • Community capacity building • Multi-strategy, multi-setting intervention programs • Monitoring • Evaluation

  6. Romp & Chomp: Under-5s 2 year olds 3.5 year olds • Relative reduction of 1.8 and 2.7 %-points over 3 years (p<0.05) • Low budget ($100k over 3y) for 12,000 children • Changes in behaviours and environments • State prevalence ing % overweight + obese (IOTF) De Silva-Sanigorski Am J Clin Nutr 2010

  7. BMI z-BMI Weight Waist Be Active Eat Well: Primary schools • Reduction of ~1kg, 3cm waist over 3y • Greater effect in lower SES children • No differences in ‘safety measures’ eg self-esteem, dieting under-weight, etc • Sustainability currently being evaluated p = 0.017 p = 0.056 p = 0.014 Units of Change (Int versus Comp) p = 0.000 Sanigorski et al Int J Obesity 2008

  8. It’s Your Move!: Secondary Schools • 5.8 %-points lower relative prevalence over 3 years • Changes in community capacity • Changes in school envs • Few significant changes in behaviours seen Δ% overweight + obese (WHO) Preliminary analyses

  9. Future directions – 3rd (4th?) Generation • Increasing evidence flow on what works and does not work for obesity prevention • Programs, settings, sub-groups, strategies, access to parents, etc • Needs to be captured and translated • Barriers and facilitators • Work between levels • Acknowledge complexity • Need “whole of systems approaches” and integrate into the existing structures

  10. So what’s a system then? A system is an interconnected set of elements that is coherently organized in a way that achieves something. (Meadows 2008) [A systems] perspective stresses the importance, among other things, of linkages, relationships, feedback loops and interactions among the system’s parts. (Hawe 2009)

  11. Nested levels of intervention

  12. Dynamics in systems

  13. An example? Long day care

  14. An example? Long day care

  15. An example? Long day care

  16. Model of Systems Approaches in Obesity Prevention

  17. Conceptual framework for implementation of interventions—combining the “what” with the “how.” Adpated from Glass and McAtee16 and NCI Initiative on the Study and Implementation of Systems.17 Model of Systems Approaches in Obesity Prevention

  18. Four elements of a systems approach to obesity prevention Networks The connections between people, the types of communication and the information that is transferred Organization The structures and techniques used to manage, direct, assess and feed back on action Dynamics The way in which the system adapts and changes over time Knowledge The types of information that are currently used and would need to be used

  19. YES, YES BUT HOW? Lines of authority Activities, meetings Prioritization Training opps. Change and interaction over time Authorising environments Ven Sim Types of evidence/ knowledge PD Benchmarks Consultation Concept workshops Questionnaire Validation workshops Formal and informal networks Movement of knowledge Social network analysis

  20. Change and implementation Current systems practice • Define process to get from current to good practice • indicators • organizing and process • systems organizing and change • etc. Good (best) systems practice Map existing system from settings perspective Define good practice for existing systems in community settings for best practice in obesity prevention

  21. Where we’re headed • ‘Integrated Systems’ approach • Interventions conceived and developed in partnership with and implemented by practice and local experts • Suits systematic grounded, CQI, systems analysis methods (does not suit null hypothesis testing methods) • Attention to fidelity of processes and relationships • Significant local adaptation • High external validity • Internal validity applies to processes • Real world, scalable outcomes • Multiple settings and systems are integral

  22. Three generations of intervention EFFICACY EFFECTIVENESS IMPLEMENTATION WHOLE OF SYSTEMS COMMUNITY DEMONSTRATION PROJECTS TRIALS

  23. Systems Approaches Benefits • New approach in light of many failures of implementation • Makes context central to the design of intervention • Improved effectiveness and sustainability • Potential for translation to scale • Application to other systems and other health problems (e.g. drug policy) • Systemic change • Build capacity & capability in intervention science & research‐policy interface Challenges • Development of new tools • Application of new methodology • Move from theory to practice • First in the world to try it with obesity • Apply retrospective model to prospective change

  24. Where next • Trial methods and tools • Clarify parameters of project • boundaries, stakeholders, expectations • Adapt and pilot systems tools from other work • Develop study protocol • DH Vic pilot • DH Vic COAG • QLD Health • NICE UK • NIH SPORT

  25. Acknowledgements Deakin University Boyd Swinburn Richard Osborne Melanie Nichols Chad Foulkes Katie Lacy

  26. Whole of system approaches to obesity prevention: progress and future plans Canberra, January14th, 2011

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