Obesity program development and implementation strategies

Obesity Prevention Program: Project Planning

Stakeholder identification

Childhood obesity-prevention demonstration projects

The ANGELO process

Socio-cultural contextual analyses

Stakeholder engagement

Engagement workshops

Action plan formulation

The Budget

Financial Analysis

Evaluation methods

The Trans-theoretical model

The evaluation plan

Economic evaluation

Obesity prevention is best carried out through community-based arrangements. This paper provides a guide on the setting of priorities, with regard to the prevention of childhood obesity among the culturally and socially diverse populations of Pinole, Laurel Park and Marina Bay. The literature offers a report on the processes involved in planning and developing efficient projects aimed at preventing obesity among children and young adults. It combines relevant workshops with the processes of stakeholder-involvement to come up with plans of action for six obesity-prevention projects within the named areas. The target population is; children below the age of 12 and adolescents between the ages of thirteen and twenty-one. Analyses of the various socio-cultural contexts will be carried out to determine the environmental, skill, knowledge, and behavioral causal elements. These findings will then be the focal points of discussion during the three-day workshops immediately following the various site visits. Projects involving adolescents will engage youthful individuals, whose needs will be incorporated into the plans of action, as a way of creating a sense of ownership. The plans of action will be designed as to offer convenience and opportunities for innovation to all stakeholders. Ours is an inclusive plan, combining knowledge from the local, as well as the international arena, to offer guidance that promotes the well-being of the community by responding to societal needs.

Introduction

Childhood obesity is a leading health concern for many families and administrators alike, and hence comprehensive obesity-prevention programs, effectively designed to provide long-term solutions to obesogenic environmental components are the only way to control childhood obesity (Brugg & Klepp, 2007, Hughes & Margetts, 2010). These programs should appreciate variations in socio-cultural contexts, and make use of diversified, yet collaborative response strategies (Hughes & Margetts, 2010). Quite often, the effect of socio-cultural factors is under-estimated, resulting in poorly-designed, inefficient, and incomprehensive obesity-prevention programs. Socio-cultural factors play a key role in determining not only an individual's eating habits, but also their attitudes towards body size and physical activity (Hughes & Margetts, 2010). A program that comprehensively responds to these factors is the only solution to the childhood obesity pandemic.

Although past intervention studies have provided crucial obesity-prevention evidence, a bulk of these studies have done little in demonstrating any impact on the target groups (Bauer, 2011). This could be attributed to the fact that most of these have made use of single, rather than diverse, collaborative strategies in their interventions (Bauer, 2011). A significant number of these have, for instance, focused on increasing children's physical activity levels, most times in a single setting such as primary schools. Such an intervention ignores crucial causal factors such as a child's eating habits, both at home and at school, and their attitudes towards body size and obesity (Hughes & Margetts, 2010). This ineffectiveness in program designing explains why there is insufficient literature on what exactly the community needs to do to essentially fight childhood obesity (Bauer, 2011). This insufficiency of evidence, coupled with the challenges of developing a comprehensive strategy makes the setting of priorities in the fight against obesity a challenge (Bauer, 2011).

Demonstration communities could be used to test the effectiveness of strategy prioritization, action implementation and impact evaluation processes of intervention projects, if a defined geographical area is selected, and then resources and expertise designed so as to focus on that particular area (Brugg & Klepp, 2007). It is on the basis of this perspective that we seek to provide guidelines for the development of all-inclusive demonstration projects, through which the community can effectively set actionable priorities.

The ANGELO (Analysis Grid for Environments Linked to Obesity) framework provides the basis for the planning process in this literature. The framework is a two-axis grid that categorizes the environmental components of obesity as socio-cultural, political, economic or physical on one grid, and as micro and macro settings on the other (Brugg & Klepp, 2007, Hughes & Margetts, 2010). The ANGELO framework has been accepted as a viable tool for assessing the environmental components that promote the intake of excess energy, and low levels of physical activity (Brugg & Klepp, 2007). The framework provides a system though which identified environmental components are ranked, and priorities set (Hughes & Margetts, 2010). In this literature, we integrate the ANGELO framework into the priority-setting process for the prevention of childhood obesity. Due to the central use of the ANGELO framework in this text, the priority-setting process will be herein referred to as the ANGELO process.

The ANGELO process will be integrated into each of the six all-inclusive obesity-prevention projects in Pinole, Laurel Park and Marina Bay areas of California. Ours will be a practice-based process, following from the health promotion action areas and principles, and inclusive, in a due process, of evidence from the relevant technical assignments; with the ultimate aim of reaching agreed priorities.

Stakeholder Identification

The success of any project is dependent upon the effectiveness of the stakeholder management strategies adopted in optimizing the needs and satisfactions of stakeholders (Karim, 2007). El-Gohary, et al. (as cited in Karim, 2007) defines a stakeholder as any party with a legitimate interest in a venture. Stakeholders share the meanings and understandings of the developments of any particular project, and therefore enjoy non-negotiable and moral rights to influence the outcome (Karim, 2007). Stakeholders, therefore, have to be actively involved in all developmental aspects of a project, and their needs and satisfactions addressed in the best possible manner. Karim (2007) holds that the success of any project is not primarily dependent upon the effectiveness of its operations, but on the ability of its managers to establish and maintain "cooperative dialogue with all relevant internal and external interest groups that may influence its activities" either positively or negatively.

Efficient stakeholder management involves proper stakeholder identification and efficient relationship management.

Various stakeholder theories have been put forward to govern the process of stakeholder identification (Karim, 2007). Goodpaster (as cited in Karim, 2007), for instance, lays out three approaches to stakeholder identification;

i) The strategic approach -- advocates for the identification of shareholders on the basis of their economic, rather than moral content (Karim, 2007).

ii) The multiple trustee approach -- advocates for the fair recognition of all stakeholders as equals (Karim, 2007).

iii) The new synthesis -- incorporates both moral content and economic value into the shareholder identification process. It advocates for the identification of owners on the basis of their economic content, and non-owners on the basis of moral content (Karim, 2007).

One significant feature, common to the three approaches, is the existence of key and non-key stakeholders. Key stakeholders are those stakeholders whose needs must be recognized, failure to which, the project will be unsuccessful (Karim, 2007).

Influential community members, including religious leaders and politicians command a large following in the study areas and would also be a source of valuable information on existing projects, networks and funding opportunities, key community settings and the overall contexts of their communities. Local champions such as school teachers, sporting champions, etc. will be utilized as visual (influential) tools.

The creation and maintenance of effective relationships with stakeholders has been proven to produce positive financial results, as well as create value for the stakeholders (Karim, 2007). Effective relationships can only be maintained through the formulation and effective implementation of suitable management strategies. Different scholars have proposed different types of stakeholder-management strategies. Frooman (as cited in Karim, 2007), proposes indirect usage, indirect withholding, direct usage and direct withholding, as the possible stakeholder management strategies that project developers could adopt. Bunn, et al. ( as cited in Karim, 2007), suggest six strategies; monitor, educate, defend, involve, collaborate and lead.

Ours is an all-inclusive plan that will engage all stakeholders in consultative processes, to build the levels of stakeholder loyalty and enthusiasm, and then ride on this enthusiasm and satisfaction to realize improvements in the levels of physical activity, and eating habits among the Pinole, Laurel Park and Marina Bay populations. On this basis, we intend to make use of the defensive, accommodative and proactive stakeholder management strategies, as postulated in Freeman, Harrison, Wicks, Parmar & De Colle (2010).

Program Design

The visual representation of the program design is available in the appendices section (appendix 3).

Demonstration Projects: Prevention of Childhood Obesity

The structural organizations of the all-inclusive demonstration projects (six to be precise) are as outlined in appendix 2. Being part of the CCROPP (Central California Regional Obesity Prevention) program, the three projects are, integrated into the California Project Lean, which was founded with the aim of providing training facilities, funding and technical assistance to school-sector obesity-prevention projects within the state. The three projects will be driven by normative needs, following from the experience and opinion of experts, derived from the findings of recent studies.

The three projects will be largely quasi-experimental, with each tailored into a design that best responds to its target comparison group - Hispanic-Americans, Asian-Americans, Native Americans, Black Americans.

The ANGELO Process

The ANGELO process will be a sequential four-phase arrangement, involving socio-cultural contextual analyses in the three areas of interest, stakeholder involvement, engagement workshops and action plan creation. The 'environmental' aspect of the ANGELO framework collectively stands for the possible target behaviors, the gaps in skill and knowledge that would need to be addressed, and factors likely to pose hindrances in addressing the same (Hughes & Margetts, 2010). These will incorporate prioritization and needs assessment in formative evaluation and capacity building.

Socio-cultural Contextual Analyses

Preliminary studies on the socio-cultural contexts of the selected sites will be conducted to identify, and rank the possible environmental obesogenic factors. This reconnaissance will also help in the identification of possible barriers to developing healthy eating habits, engaging in physical activity and developing positive attitudes towards a healthy body size. Previous studies, both within and without California, have revealed that traditions such as over-eating during occasions, linking large body sizes to good health, and equating responsibility - especially with regard to girls - to household chores (disregarding sporting activities) pose serious barriers to obesity prevention.

Socio-cultural interviews will be conducted among willing participants. The interview structure will include ten females, and an equal number of males aged between 12 and 21, and ten representatives, guardians or otherwise, for children under the age of five, in each of the study areas. Researchers will be representative of each of the cultural groups, and will first work separately and then together in the identification of factors. The interviews will be recorded by a researcher conversant with the participant's first language and translations made, when necessary.

Four basic focus groups will be conducted in each of the study areas, with differentiations based on the cultural group (Hispanic-Americans, Asian-Americans, Native Americans, and Black Americans) and gender. The factors identified during the socio-cultural interviews will not only be integrated into the ANGELO framework but also shown or displayed to the respective communities. The said presentation can be done during the engagement workshops.

Engagement of Stakeholders

' Stakeholder involvement will begin with project advocacy efforts via holding of discussions (initial) with key entities including local governments and churches, the education and health sections of relevant governmental organizations, and school heads. A snowballing procedure will be used to plan for and hold discussions with crucial community champions including sporting personalities and representatives from the California Lean and CCROPP programs. The engagement aspect will also incorporate the listing and discussion of possible behavior, gaps in skill and knowledge and potential barriers.

Advocacy and engagement will last for approximately one month, during which project staff will be employed and facilitative structures set up. We expect to build crucial relations with all stakeholders during this period, to ensure their active engagement in project procedures, and their collaboration in the development of action plans.

Engagement Workshops

Engagement workshops will bring together the projects' stakeholders, and the different projects' students' representatives, and will mainly focus on updating the stakeholders on the contextual analyses obtained from preliminary socio-cultural interviews, relevant information on the target groups, and the latest pieces of international obesity-prevention related evidence. Workshop facilitators will include researchers with relevant expertise. The workshop will involve a five-stage procedure involving situational analyses, scanning, rating and prioritization, element merging and action plan formulation.

Stage 1 (situational analyses) will involve the presentation of information obtained from community consultations, preliminary socio-cultural interviews and experts' assessments (for instance, the progress of similar projects that are ongoing). Stage 2 (scanning) will involve holding brief discussions with stakeholders and participants on the identified factors and barriers as presented in the pre-prepared worksheets. This will provide avenues for the development of common grounds and the identification and inclusion, if necessary, of new factors. The worksheets will be designed differently, for different cultural groups, based on the evidence obtained, the number of key factors, etc.

In Stage 3 (rating and prioritization) workshop participants will be expected to rate the behaviors presented, and discussed on the basis of relevance, importance, possible impact, and changeability. The ranking will be done on a scale of 1 to 5; where 1 and 5 will represent 'unimportant' and 'extremely important'; 'extremely difficult to change' and 'easily changeable' respectively (a worksheet detailing this process is provided in the appendices section - appendix 1). The total scores for each of the behaviors will be obtained by multiplying the changeability and importance scores attached to it. Ranking will then be done using the collated scores. The highest ranked factor will be assigned five points and the lowest, one point.

The barriers will, after the scanning stage, be prioritized under the four environment types of the ANGELO framework; socio-cultural (the cultural practices, expectations, values, perceptions, beliefs and attitudes), political (the governing rules), economic (the financial constraints involved), and physical (the availability of crucial elements, for instance, healthy foods, time for physical activity, etc.) (Hughes & Margetts, 2010).

Action Plan Formulation

Stage four of the engagement workshop (element merging) will involve pulling together the highest ranked environmental components, skill, knowledge and behavioral elements as causes of action. These action causes will then be discussed by workshop participants, and the elements that will be mutually accepted as priorities structured into a plan of action, in the final stage of the engagement workshop. The projects' objectives will be created from the target behaviors identified in the action plan, and the strategies from the skill and knowledge gaps.

At the end of each engagement workshop, the action plan (a draft of it) will be returned to the community. As the plan continues to evolve, accountabilities, processes and timelines by coordinators will be continually assigned. Measures of evaluation will be assigned once the analysis of baseline data is completed. This way, the plan will continue to evolve as a guide to implementation during the project's life.

The Budget

The proposed project's costs and revenue budget, for the six months following start of activities, and the associated break-even analyses are available in the appendices section (appendices 6 and 7).

Financial Analysis

Three significant factors can be taken into consideration in determining the health benefits that could, upon the successful implementation of the program, accrue to the California community. These are; childhood obesity's persistence into adulthood, the chances that obese children and their families would have adopted any intervention measures in the absence of the project, and the returns on investment (ROI) (Bauer, 2011). Childhood obesity, in most cases, persists into adulthood, and is even more difficult to deal with at that point (Bauer, 2011). This can be attributed to the busy work schedules, and increased family responsibilities that come with adulthood (Brug & Klepp, 2007). Chances are that the affected families would do nothing to improve their conditions - first, because of cultural and social misperceptions, and wrong attitudes towards body size brought about by the existence of knowledge gaps (Hughes & Margetts, 2010) and secondly, due to ignorance; if they have in the past not take any steps to better their conditions, then it goes from logic that they have no problem with it, and would do nothing about it in future.