The effect of Public Health/Pediatric Obesity interventions on socioeconomic inequalities in childhood obesity: A scoping review

Childhood obesity has a strong social gradient. This scoping review aims to synthesize the evidence on the impact on inequalities of non‐targeted interventions to reduce the prevalence of childhood and adolescent obesity in high‐income countries. We updated a review by Hillier‐Brown, searching up to 31 December 2017 on MEDLINE, Embase, The Cochrane Library, CINAHL, and PsycINFO, with no limitations on study design. Fifty‐eight studies describing 51 interventions were included: 31 randomized clinical trials and 27 non‐randomized trials, with sample sizes from 67 to 2,700,880 subjects. The majority were implemented in the school setting at a community level; the others were in health services or general population setting and targeting individuals or the system. Twenty‐nine interventions proved to be effective overall; seven others had an effect only in a subgroup, while 15 proved not to be effective. All types of included interventions can increase inequalities. Moreover, some interventions had opposite effects based on the socioeconomic characteristics. Any kind of intervention can reduce equity. Consequences are difficult to predict based on intervention construct. Complex interventions acting on multiple targets, settings, and risk factors are more effective and have a lower risk of increasing inequalities.     

Youth engagement in research and policy: The CO-CREATE framework to optimize power balance and mitigate risks of conflicts of interest

Including youth in the co-creation of policies that affect them has proven to be particularly impactful in public health. Using youth participatory action research methods, the CO-CREATE project engages European youth 16–18 years old in the co-creation of obesity prevention policies. To discuss the feasibility and implications of the policy, youth are invited to engage in an intergenerational dialogue. Given the youth–adult dynamic and policy discussion, conflicts of interests (COIs) can arise and impact the quality of the dialogue. COI frameworks are a tool that can help identify, mitigate, and address COIs. This paper presents a novel framework to mitigate COIs in intergenerational policy dialogues, with a focus on power imbalance. Following a series of youth consultations, interviews, and examination of existing frameworks, our findings suggest that safe, participatory, and empowering dialogues can take place if appropriate measures are integrated into all phases of a dialogue. The selection of stakeholders, use of accessible language, and youth moderation are all factors that can impact COI risks. Measures that promote mutual empowerment, such as equal representation of youth and adults, were deemed important. This framework provides a roadmap to ensure that youth participation in the formulation of policies is safe and empowering.     

Pharmaceutical interventions for obesity: a public health perspective

The prevalence of obesity, a major risk factor for many chronic diseases, has risen in most developed countries over the past several decades. The economic burden for both public and private health care systems is substantial. Although certain non-pharmaceutical interventions have been proven efficacious in specific populations, the lack of scalability has caused many of these programmes to fail in sustainably decreasing the percent of patients who are overweight or obese. The benefits of other interventions, such as pharmaceutical agents, medical devices and surgery, should therefore be carefully considered: this article focuses on the first of these strategies. Various pharmaceutical products have been plagued with safety concerns or patient non-adherence because of unpleasant side effects. Therefore, the need for additional antiobesity drugs that are both safe and effective is considerable. This article discusses the regulatory landscape for the development of new antiobesity compounds in the United States and Europe and considers the ramifications of greater or lesser regulatory burdens.     

Ethical and public policy aspects of childhood obesity: opinions of scientists working on an intervention study

Scientists working on an obesity intervention project were asked questions, via questionnaire and interviews, relating to ethical and public‐policy aspects of tackling childhood obesity. The main areas of enquiry concerned elements responsible for the rise in childhood obesity, key ethical areas of obesity interventions, helpfulness and effectiveness of policy measures, socioeconomic factors, and media coverage and political debate. Key results from this indicate that: there is disagreement about the amount of information about the causes of obesity that is needed before implementing interventions; an improvement in health and nutrition education of both children and adults through positive messages is seen as highly desirable; scientists regard environment, rather than genetics, as playing the major role in rising obesity levels; the level of individual responsibility being placed on parents and children may be unfair and unhelpful; whole‐system, long‐term and sensitive policy actions are needed rather than relying on quick fixes such as miracle pills; and there are country‐specific issues related to rising obesity levels that need to be considered, though the respondents tended to have a great deal of faith in EU‐wide interventions.     

Religious involvement,social support,and health among African-American women on the east side of detroit

BACKGROUND: A significant body of research suggests that religious involvement is related to better mental and physical health. Religion or spirituality was identified as an important health protective factor by women participating in the East Side Village Health Worker Partnership (ESVHWP), a community-based participatory research initiative on Detroit's east side. However, relatively little research to date has examined the mechanisms through which religion may exert a positive effect on health. OBJECTIVE: The research presented here examines the direct effects of different forms of religious involvement on health, and the mediating effects of social support received in the church as a potential mechanism that may account for observed relationships between church attendance and health. DESIGN: This study involved a random sample household survey of 679 African-American women living on the east side of Detroit, conducted as part of the ESVHWP. MAIN RESULTS: Results of multivariate analyses show that respondents who pray less often report a greater number of depressive symptoms, and that faith, as an important source of strength in one's daily life, is positively associated with chronic conditions such as asthma or arthritis. Tests of the mediating effect of social support in the church indicated that social support received from church members mediates the positive relationship between church attendance and specific indicators of health. CONCLUSIONS: These findings are consistent with the hypothesis that one of the major ways religious involvement benefits health is through expanding an individual's social connections. The implications of these findings for research and practice are discussed.     

Ensuring an optimal environment for peer education in South African schools: Goals,systems, standards and policy options for effective learning

Peer education has long been seen as a key health promotion strategy and an important tool in preventing HIV infection. In South African schools, it is currently one of the strategies employed to do so. Based on both a recent research study of peer education across 35 schools and drawing on multiple previous studies in South Africa, this paper examines the key elements of peer education that contribute to its effectiveness and asks how this aligns with current educational and health policies. From this research, it summarises and proposes shared goals and aims, minimum standards of implementation and reflects on the necessary infrastructure required for peer education to be effective. In light of these findings, it offers policy recommendations regarding who should be doing peer education and the status peer education should have in a school’s formal programme.     

National policies to prevent obesity in early childhood: Using policy mapping to compare policy lessons for Australia with six developed countries

Interventions for obesity prevention in early childhood (first 5 years of life) are likely to have a significant preventive health impact. This mapping review identified recommended policy options for the Australian Federal Government (AFG) by comparing countries with similar population, income, and language to Australia. Policies were mapped in six countries using two matrices. The first matrix examined policy context, describing obesity prevention governance. The second matrix examined policy content, compared with global recommendations. Policies were grouped into downstream (healthcare), midstream (lifestyle and settings), and upstream (determinants of health, including food and built environments). Results identified variance in obesity governance across the six countries including policy coherence, leadership, institutional drivers, and overlapping responsibility across different levels of government. While countries tended to have more downstream or midstream policies, upstream policies were more likely when countries had invested in system‐wide approaches to obesity such as developing a national obesity strategy, having separate food/nutrition and physical activity plans, and a dedicated preventive health agency. This study recommends a range of initiatives for the AFG to strengthen policies for the prevention of obesity in early childhood, including prioritising the development of a national food/nutrition strategy.     

Alcohol policy in South Africa: a review of policy development processes between 1994 and 2009

Background Implementation of effective policies to reduce harmful alcohol consumption requires both a good understanding of the policy development process and which strategies are likely to work. Aims To contribute to this understanding by reviewing four specific policy development initiatives that have taken place in South Africa between 1994 and 2009: restrictions on alcohol advertising and counter‐advertising, regulation of retail sales of alcohol, alcohol taxation and controls on alcohol packaging. Methods Material was drawn from a record of meetings and conferences held between 1994 and 2009 and a database of reports, newspaper clippings and policy documentation. Findings When the policy process resulted in a concrete outcome there was always a clear recognition of the problem and policy alternatives, but success was more likely if there was an alignment of ‘political’ forces and/or when there was a determined bureaucracy. The impact of the other factors such as the media, community mobilization, non‐governmental organizations (NGOs), the liquor industry and research are also discussed. Future avenues for policy research are identified, including the need for more systematic studies that give greater consideration to economic factors. Conclusions Alcohol policy development in South Africa takes place in a piecemeal fashion and is the product of various competing influences. Having a comprehensive national alcohol strategy cutting across different sectors may be a better way for other developing countries to proceed.     

Reappraising the public health benefits conferred by environmental policy: Considerations for an aging society

Although addressing environmental pollution and unprecedented societal aging are concurrent public health challenges, rarely is the relationship between the two considered. Current approaches to valuing the public health benefits conferred by environmental policy may be ill-suited to aging populations. We describe the limitations of the age-invariant approach used by the United States Environmental Protection Agency to estimate the public health benefits corresponding to environmental regulation. These include the poor age-representativeness of the samples informing the valuation of mortality risk reduction, the exclusion of age-related outcomes from valuation, and the omission of age-related third-party expenditures. We offer an empirical framework that could address these limitations. Our recommendations could improve the calibration of environmental regulatory analysis to the changing age distribution of the United States population.     

Framing obesity: the framing contest between industry and public health at the New Zealand inquiry into obesity

Drawing on submissions to the 2006–2007 New Zealand Inquiry into Obesity and Type 2 Diabetes, this article outlines how the food and marketing industries (industry) and the public health sector framed the issue of obesity. The analysis revealed that industry framed obesity as a consequence of poor lifestyle choices attributed largely to knowledge, cultural or other character deficits. Industry argued that lack of physical activity rather than increased food consumption was the dominant cause of obesity. In contrast, public health groups positioned obesity as a normal response to an obesogenic environment, characterized by the ubiquitous marketing and availability of low‐cost, energy‐dense/nutrient‐poor foods. For public health groups, increased consumption of energy‐dense/nutrient‐poor foods was positioned as the dominant cause of obesity. Many public health submitters also suggested that social inequalities contributed to obesity. Industry emphasized education as the key solution to obesity, while public health groups argued for regulation of the activities of the food and marketing industries, and policies to address wider determinants of health and social inequalities. Identifying and documenting these frames, by making transparent the interests of the frame's sponsors, contributes to greater understanding of the wider policy context around obesity and provides useful information for public health advocacy.     

Algorithms for seeding social networks can enhance the adoption of a public health intervention in urban India

Targeting structurally influential individuals within social networks can enhance adoption of health interventions within populations. We tested the effectiveness of two algorithms to improve social contagion that do not require knowledge of the whole network structure. We mapped the social interactions of 2,491 women in 50 residential buildings (chawls) in Mumbai, India. The buildings, which are social units, were randomized to (1) targeting 20% of the women at random, (2) targeting friends of such randomly chosen women, (3) targeting pairs of people composed of randomly chosen women and a friend, or (4) no targeting. Both targeting algorithms, friendship nomination and pair targeting, enhanced adoption of a public health intervention related to the use of iron-fortified salt for anemia. In particular, the targeting of pairs of friends, which is relatively easily implementable in field settings, enhanced adoption of novel practices through both social influence and social reinforcement.

Since knowledge, attitudes, and behavior can spread across interpersonal ties, and since the networks formed by such ties tend to amplify this spread, changes in one person’s behavior can cascade out across a social network, producing behavioral changes in the larger population in which a person is embedded (1–3). Such cascades offer the prospect of increasing the effectiveness of public health campaigns, which could be especially beneficial in low-resource settings (4, 5). While there is a widespread interest in using social contagion to amplify the adoption of health interventions, there are currently few established network-targeting strategies available for straightforward implementation in practice. Here, we report a randomized controlled trial (RCT) of two easy-to-implement strategies designed to improve the likelihood of such behavioral cascades.Deliberately fostering cascade effects requires the identification of a subset of potentially influential individuals among whom to launch an intervention. Simulation results suggest that targeting highly connected individuals in networks could enhance the diffusion of interventions (6–8), and other research suggests more complex methods for the selection of optimal targets (9–11). However, such methods typically require mapping whole social networks in order to identify the targets who might exercise special influence. Such sociocentric data may not be available, or certain algorithms may be simpler or more efficient than relying on whole network data.Previous research has identified two types of seed-selection strategies that do not require knowledge of the underlying social network but that can still significantly accelerate adoption. An evaluation in India found that gossip nomination strategies (asking randomly selected people which community members are good sources of trustworthy gossip and then recruiting the gossipers for the public health intervention) can result in faster diffusion of information, driving up childhood vaccination rates (12). A study in Honduras showed that recruiting the friends of randomly selected residents can effectively accelerate adoption (13), based on the property that, on average, friends have more connections than respondents themselves (14). We refer to this approach as "friend targeting" (we use the term "targeting" as a shorthand for network seed selection more generally).However, in many real-world situations involving public health interventions, it may be unethical or impractical to deny treatment to the original randomly-chosen informants while offering it instead to people they identify. For instance, one might not want to go into a village, ask people who their friends or gossipers are, and then proceed to offer something of value to those other people but not to the people who identified them. Here, we therefore present and evaluate the effectiveness of a seed-selection strategy, whereby both randomly chosen people and also their friends (who, in expectation, are actually more socially influential) are treated with a public health intervention. We refer to this seed-selection approach as pair targeting. The pair may reinforce each other’s behavior and work in tandem (thus potentially raising their own adoption of an intervention) as well as enhance their social influence on others to whom they are connected who did not receive the intervention.We used iron-deficiency anemia in India as our testbed. Iron-deficiency anemia can lead to cognitive impairment in childhood and in old age, physical disability and diminished work capacity in adults, and adverse outcomes of pregnancy for mothers and newborns (15–17). Prevention of anemia in childbearing women is key to preventing low birth weight and perinatal and maternal mortality (18–21). Iron-deficiency anemia among Indian women remains a key public health problem, with 53% of Indian women affected by the condition (22). Unfortunately, recent government attempts to promote nationwide use of iron and folic acid supplements have had limited reach. However, since its introduction to the market, iron-fortified salt has emerged as the major new way to help reduce the prevalence of iron-deficiency anemia in India and achieve the goals of the Anemia-Free India Initiative (Anemia Mukt Bharat), a collaboration between the Indian Ministry of Health and Family Services and UNICEF (23).     

HIV, injecting drug use and harm reduction: a public health response

Injecting drug use is driving HIV epidemics in many countries around the world. There is evidence that such epidemics can be averted, halted and reversed if comprehensive HIV programmes targeting drug users are put into place. The term 'harm reduction' is used widely to describe the goals, policies and interventions of such programmes. However, despite its rapidly expanding use, the term has no universally accepted definition. This paper aims to describe the evolution and branding of the term 'harm reduction' and the adoption of the concept across a wide range of countries. It highlights a range of issues that remain controversial in the harm reduction discourse related to HIV and injecting drug use, including: the definition of 'harm reduction' and related terms; the scope of harm reduction; the promotion of a public health versus drug control dichotomy; the feasibility and appropriateness of harm reduction in low- and middle-income countries; and the strength of evidence on harm reduction interventions. The paper argues that harm reduction should be a core element of a public health response to HIV/AIDS where injecting drug use exists. The effectiveness of policies and programmes targeting drug users should be measured against public health outcomes. This requires the alignment of drug control measures with public health goals. A 'model package' for harm reduction is proposed, which provides guidance to countries on the selection of evidence-based policies and interventions, including: interventions for reducing HIV transmission; treatment of HIV/AIDS and associated comorbidities; appropriate models of service delivery; creation of supportive policy, legal and social environments; and strengthening of strategic information systems to better guide responses.     

Alcohol industry involvement in policymaking: a systematic review

Aims

To summarize the substantive findings of studies of alcohol industry involvement in national or supranational policymaking, and to produce a new synthesis of current evidence.

Methods

This study examined peer‐reviewed journal reports published in the English language between 1980 and 2016 of studies of alcohol industry involvement in policymaking. Included studies were required to provide information on data collection and analysis and to have sought explicitly to investigate interventions by alcohol industry actors within the process of public policymaking. Eight electronic databases were searched on 27 February 2017. The methodological strengths and limitations of individual studies and the literature as a whole were examined. A thematic synthesis using an inductive approach to the generation of themes was guided by the research aims and objectives.

Results

Twenty reports drawn from 15 documentary and interview studies identify the pervasive influence of alcohol industry actors in policymaking. This evidence synthesis indicates that industry actors seek to influence policy in two principal ways by: (1) framing policy debates in a cogent and internally consistent manner, which excludes from policy agendas issues that are contrary to commercial interests; and (2) adopting short‐ and long‐term approaches to managing threats to commercial interests within the policy arena by building relationships with key actors using a variety of different organizational forms. This review pools findings from existing studies on the range of observed impacts on national alcohol policy decision‐making throughout the world.

Conclusions

Alcohol industry actors are highly strategic, rhetorically sophisticated and well organized in influencing national policymaking.