Community Interventions to Promote Proper Nutrition and Physical Activity among Youth PDF

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Preventive Medicine 31, S138–S149 (2000) doi:10.1006/pmed.2000.0632, available online at http://www.idealibrary.com on Community Interventions to Promote Proper Nutrition and Physical Activity among Youth Russell R. Pate, Ph.D.,*,1 Stewart G. Trost, Ph.D.,* Rebecca Mullis, Ph.D.,† James F. Sallis, P...

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Preventive Medicine 31, S138–S149 (2000) doi:10.1006/pmed.2000.0632, available online at http://www.idealibrary.com on

Community Interventions to Promote Proper Nutrition and Physical Activity among Youth Russell R. Pate, Ph.D.,*,1 Stewart G. Trost, Ph.D.,* Rebecca Mullis, Ph.D.,† James F. Sallis, Ph.D.,‡ Howell Wechsler, Ed.D., M.P.H.,§ and David R. Brown, Ph.D.§ *Department of Exercise Science, School of Public Health, University of South Carolina, Columbia, South Carolina 29208; †Georgia State University, Atlanta, Georgia; ‡San Diego State University, San Diego, California; and §U.S. Centers for Disease Control and Prevention, Atlanta, Georgia

INTRODUCTION

In recent years a compelling body of knowledge has been accumulated to support the belief that physical activity and dietary behaviors carry important health consequences for young people. It has long been known that adequate nutrition and physical activity are essential for normal growth and development [1]. Recently, however, clear evidence has emerged that diet and physical activity during childhood and adolescence also affect an array of physiological factors associated with risk for developing chronic diseases; these factors include body composition (e.g., adiposity), blood lipid concentrations, blood pressure, and bone mineral density [2]. It also appears that physical activity and dietary behaviors and the physiological outcomes associated with them often track from childhood and adolescence into adulthood [3–6]. Thus, risky health behaviors adopted early in life may negatively influence health in adulthood by having both a short-term effect on physiological risk factors and a long-term impact on health behavior. Population-based surveys indicate that a sizable fraction of U.S. youngsters engage in inappropriate dietary practices and participate in less physical activity than recommended [7–13]. Consequently, promoting physical activity and proper nutrition among youth has become a priority for public health authorities. Indeed, nine of the nation’s health objectives presented in Healthy People 2000 [1] relate to dietary behaviors among youth, and another eight relate to physical activity behaviors among youth. To date, most of the intervention research on promotion of proper diet and physical activity among children and youth has been based 1 To whom reprint requests should be addressed at the Department of Exercise Science, School of Public Health, University of South Carolina, Columbia, SC 29208. Fax: (803) 777-8422. E-mail: [email protected].

in school settings. However, as public health agencies have become more involved with promoting good health behaviors, recognition has grown that intervention strategies involving the community at all levels have the greatest potential to improve physical activity and dietary behavior in this age group. A community has been defined as a group of people who share values and institutions. Communities are social groups that operate as a functional spatial unit, a unit of patterned social interaction, or a symbolic unit of collective identity [14]. Communities are based on shared interests or characteristics, which often include locality, an interdependent social group, interpersonal relationships, and a culture that includes values, norms, and attachments [15]. This paper will consider the process by which positive health behaviors such as proper diet and regular physical activity can be promoted through interventions that are based in communities. Typically, community health promotion combines organizing the community and involving citizens with strategies of lifestyle, policy, and/or environmental interventions. Such efforts frequently bring together multiple networks of public and private organizations and special interest groups to channel and coordinate their resources in a range of interpersonal, group, and mass communication strategies [16]. Community health promotion programs regularly involve many kinds of institutions, organizations, and groups in the delivery of a variety of reinforcing interventions. Settings involved in such efforts typically include the mass media, health care providers, schools, religious institutions, community-based organizations, fraternal organizations and social clubs, worksites, government agencies, businesses, and the streets and parks of the community.

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0091-7435/00 $35.00 Copyright q 2000 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.

COMMUNITY INTERVENTIONS AMONG YOUTH

This paper summarizes the existing body of knowledge on community-based promotion of physical activity and proper diet among children and youth. Specific purposes are as follows: (1) to present the rationale for these interventions, their characteristics, the theoretical basis for using them, and accepted general guidelines; (2) to review the available research on community interventions to promote physical activity and proper nutrition among children and youth; and (3) to recommend directions for future practice and research. COMMUNITY INTERVENTIONS

Rationale for Community Interventions among Youth The community approach to health promotion is based on the following suppositions [16,17]: (1) behavior is greatly influenced by the environment in which people live and by local values, norms, socioeconomic factors, and behavior patterns; (2) causes of some chronic diseases (i.e., diseases for which improper nutrition and insufficient physical activity have been shown to be leading causes) are complex and rooted in cultural phenomena that need to be addressed by community interventions; (3) permanent, large-scale behavior change is best achieved by changing the standards of acceptable behavior in a community (i.e., community norms); (4) community approaches increase the likelihood of effecting permanent change because the interventions are built into existing community structures and because local ownership generates continuing responsibility; and (5) community approaches promote the efficient use of limited resources. Although most physical activity and nutrition intervention programs directed at youth are conducted in school settings, broader, community-wide programs are also needed for several reasons. First, children and adolescents spend considerable amounts of time in community settings that are conducive to physical activity, and they eat in multiple settings throughout the community. Second, community-based programs have the capacity to involve parents and other adult role models (e.g., relatives, religious leaders, sports coaches) from the community who can strongly influence the dietary and physical activity behavior among children [18,19]. Third, community activities, in contrast with school programs, often involve children in informal activities that are not affected by the pressures of grades and competition. Thus, children may feel more comfortable learning in a community-based environment. Fourth, decisions to choose active recreation and healthful foods are affected by community characteristics (e.g., governmental policies, environment), such as physical activity facilities and the availability and cost of healthful foods. Appropriate modifications of these community characteristics should make it easier for youngsters to implement the knowledge and skills they learn in school.

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Characteristics of Community Interventions Individual-oriented approaches to health promotion, such as risk factor screening, behavioral counseling, and small-group health education classes, may be included in community-based health promotion interventions. The goals of community-based programs, however, extend beyond individual behavior change to include changes in the physical and social environment, regulatory policies, and organizational norms. Thus, in addition to the face-to-face interactions characteristic of individual approaches, community-based intervention programs call upon mass media campaigns; policy, regulatory, and legislative initiatives; and environmental changes to initiate, facilitate, and support individual behavioral change. Programs oriented to individuals are typically delivered in clinical or commercial settings where the format, location, and scheduling of the intervention activities are determined by the practitioner or instructor. In this respect, the practitioner is said to be in a “waiting stance” and individuals are expected to seek out programs that meet their particular needs and interests [20,21]. In contrast, community-based interventions adopt a “seeking stance” to program development and implementation. Efforts are made to collect the necessary information that will enable program staff to target intervention activities specifically toward segments of the population. Differences between individual and community approaches to health promotion are summarized in Table 1. Theoretical Support for Efficacy of Community Interventions for Health Promotion Several theoretical models of behavior change have provided the conceptual framework for intervention programs targeted at children and adolescents. Among these, Bandura’s Social Cognitive Theory [22] has been the most extensively used theory in the physical activity and nutrition domains. This theory posits that personal and environmental factors interact bidirectionally with behavior in a manner referred to as reciprocal determinism. In brief, the individual can influence the physical and social environment to facilitate behavior change, and simultaneously, the physical and social environment can influence individual behavior [23]. Community-based interventions often attempt to modify the existing social and physical environment to promote the adoption of healthful behaviors at the individual level. For example, if the physical environment is changed so that hiking trails and park areas in the community are made freely available, a child may be more likely to engage in physical activity. Similarly, healthy food choices placed in community food vending areas can promote healthy eating among youth. The social environment also can be changed to reinforce the

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PATE ET AL.

TABLE 1 Differences between Individual and Community Approaches to Health Promotion Target

Individual approach

Initial goal

Individual behavior change

Long-term goal

Individual maintenance of target behavior

Level of intervention

Personal, interpersonal

Theories/perspectives

Psychosocial, behavioral (focused on the person or small groups)

Professional stance Location Method

Waiting Setting-based Health professional (face-to-face)

Intervention time frame

Usually time limited

Community approach Community change in behaviors, social networks/milieu, organizational norms and policies, physical environments, laws Institutionalization of programs; structural or environmental changes Personal, interpersonal, organizational/environmental, institutional/societal Psychosocial, behaviorial; public health (who to reach); social marketing (how to reach); communication, diffusion, system approaches Seeking/proactive Settings, non-setting specific Health professional, community agencies or organizations, legislators, mass media Usually long term

Note. Adapted from the table presented by King et al. [20,21].

types of behavior that are considered acceptable. For example, if children perceive their parents or peers to be physically active or if the children are positively reinforced when they are physically active, they may be more apt to participate in regular physical activity. Similarly, parents who eat well-balanced diets and healthy foods (e.g., fruits and vegetables) can be role models who positively influence the food choices that their children make [23]. GENERAL GUIDELINES

In planning community-based interventions to promote healthy eating and physical activity among children and adolescents, we can obtain valuable insights from community-based interventions that have targeted other risk behaviors in other audiences. Research and experience from community-based health promotion programs related to family planning, immunization, and cigarette smoking indicate that, with reasonable resources, community-based intervention programs are likely to succeed if program planners and practitioners adopt the following guidelines [24]: • Begin from a base of community ownership of problems and solutions. • Use relevant theory, data, and local experiences to systematically plan, implement, and evaluate the intervention program. • Assess what types of intervention are acceptable and feasible for specific populations and circumstances. • Establish an organizational and advocacy program to orchestrate multiple intervention strategies into a complementary, cohesive program. • Conduct appropriate evaluation activities during and after the intervention period. Guided by these principles, Bracht and Kingsbury

[25] outlined a five-stage model to organize and implement community-based intervention programs. These stages and their key elements or tasks are presented below. Stage 1: Community Analysis Successful implementation of community-based intervention programs depends on accurately analyzing and understanding the communities needs, resources, social structure, and values. Thus, key elements within this stage include (1) defining the community of interest; (2) compiling a “community profile” that describes community resources, history, and readiness for action; (3) assessing community capacity to support a comprehensive health promotion project; (4) identifying potential barriers to successful implementation; and (5) assessing community readiness for change. Stage 2: Design and Initiation Following the community analysis stage, formal activities to mobilize citizens begin with the establishment of an infrastructure to promote community-wide participation. Key elements within this stage include (1) establishing a core planning group and selecting a local organizer or coordinator; (2) selecting structure to organizing community involvement and participation (e.g., advisory boards, coalitions, and informal networks); (3) recruiting citizens from all major community institutions and groups, including business, volunteer associations, political leaders, minority organizations, recreation, churches and synagogues, medicine, public health, and media; (4) defining the organization’s mission and devising reasonable short- and long-term goals; (5) clarifying the roles and responsibilities of board members, staff, and volunteers; and (6) providing

COMMUNITY INTERVENTIONS AMONG YOUTH

appropriate training and public recognition to all staff, volunteers, and participants. Additional detail on designing community interventions is provided in the next section of this paper. Stage 3: Implementation Implementation plans should maximize the use of available resources and existing institutions and should also conform to local constraints and values. Elements within this stage include (1) planning activities that generate widespread community participation; (2) developing a sequential work plan for intervention staff and volunteers; and (3) devising comprehensive, synergistic intervention strategies that have the potential to influence community norms. Stage 4: Program Maintenance–Consolidation At this stage, the intervention activities should have been refined so that community members and staff alike are satisfied with the results obtained. Elements include (1) integrating activities into established community structures; (2) establishing a positive organizational culture; (3) creating a systematic plan to constantly identify, recruit, and involve new people in the project; and (4) disseminating early results to promote visibility, community-wide acceptance, and involvement. Stage 5: Dissemination–Reassessment In this stage, evaluations are undertaken to assist the intervention planners in reassessing both strategies that have worked and those that have experienced difficulty. Elements within this stage include (1) updating the community analysis; (2) assessing the overall impact of the intervention program; (3) charting of future directions and modifications; and (4) summarizing and disseminating final results to program participants, community leaders, media representatives, funding agencies, and other influential organizations within the community. Designing a Community-Based Intervention While Bracht and Kingsbury’s model provides a process for planning and implementing a community-based intervention, it provides relatively little information about designing a community intervention. Issues related to designing community-based interventions include the selection of target behaviors, potential mediating variables, intervention activities to effect change in the mediating variables, target audiences, and intervention channels. The first step in the design process is to identify the specific target behaviors the intervention will address. Focusing the intervention on specific target behaviors

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rather than broad behavioral outcomes will increase the likelihood of successful behavioral change [26]. For example, an intervention targeted at increasing physical activity levels among adolescent females may focus on increasing participation in moderate-intensity physical activity (e.g., walking) rather than vigorous physical activity (e.g., running or swimming). Likewise, a physical activity intervention involving middle-school students may focus on increasing participation in community sports and recreational programs on weekends and after school. With respect to dietary behavior, a community-based intervention might focus on increasing fruit consumption while another could address reductions in saturated fat intake. When selecting target behaviors, consideration should be given to: (1) the prevalence of the behavior in the community; (2) its link to disease prevention (i.e., the biological plausibility); (3) the empirical knowledge base concerning the social and environmental determinants of the target behavior; and (4) the cultural values and beliefs associated with performing the target behavior. Having selected the appropriate target behaviors, the next steps in the design process are to (1) identify the factors/skills that mediate change in the target behavior and (2) devise intervention activities/education programs that maximize change in these mediating variables. In accordance with the “mediating variable framework” described by Baranowski and colleagues [26], priority should be given to effecting change in the personal, social, and environmental factors supported by theory-based empirical research. For example, research utilizing social cognitive theory has demonstrated physical activity self-efficacy to be an important mediator of physical activity behavior among youth [27,28]. Consequently, interventions aimed at increasing physical activity among youth should endeavor to enhance perceived self-efficacy by providing enjoyable, developmentally appropriate activities that enable all participants to experience success. Similarly, a dietary intervention aimed at increasing fruit and vegetable intake among youth should include strategies that increase children’s liking of fruits and vegetables, since fruit and vegetables preferences are significant predictors of fruit and vegetable consumption among children [29]. Community-based interventions have the capacity to deliver intervention activities to several target audiences via multiple delivery channels. Therefore, an important part of the design process is to stipulate the target audiences for the intervention components and the delivery channels that will be used to reach each target audience. For interventions to promote proper nutrition and physical activity among youth the target audience would include children, parents, teachers, businesses, food service administrators, recreation directors, physicians and ...