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Bridging Research and Policy to Address Childhood Obesity Among Border Hispanics
Bridging Research and Policy to Address Childhood Obesity Among Border Hispanics A Pilot Study Nelda Mier, PhD, Matthew Lee Smith, PhD, MPH, CHES, David Irizarry, Genny Carrillo-Zuniga, MD, MPH, ScD, Chanam Lee, PhD, Laura Trevino, ME, MPH, Marcia G. Ory, PhD, MPH Background: Mexican-American children are disproportionately affected by obesity compared to other population groups. Although national guidelines recommend using environmental and policy approaches to address this public health issue, the majority of Mexican-American children do not meet physical activity recommendations.
Purpose: To describe a knowledge transfer process involving local decision makers to address childhood obesity and physical activity needs among low-income, Mexican-American children and to examine environmental policy recommendations generated in this process. Methods: This pilot study employed a qualitative research design that included the dissemination of primary research data to local decision makers in the Texas–Mexico border region. Stakeholders attending public meetings were briefed about a research project reporting on the physical activity needs of Mexican-American children from impoverished neighborhoods known as colonias. Seventy-four stakeholders responded to an unstructured questionnaire and proposed policy recommendations. Data were collected January–April 2011 and analyzed July–September 2011. Data were analyzed using a content analysis technique.
Results: Four policy themes emerged from the data: (1) establishing sustainable communitybased health programs; (2) improving neighborhood infrastructure and safety; (3) increasing access to parks; and (4) supporting community organizations to disseminate health education to parents and children. Conclusions: Knowledge transfer processes planned and facilitated by researchers at public meetings with local decision makers are effective methods to influence policy development related to childhood obesity. (Am J Prev Med 2013;44(3S3):S208 –S214) © 2013 American Journal of Preventive Medicine
Introduction From the Department of Health Promotion and Community Health Sciences (Mier, Carrillo-Zuniga), and the Department of Health Policy and Management, School of Rural Public Health, Texas A&M Health Science Center (Irizarry), McAllen; Department of Health Promotion and Community Health Sciences (Smith, Ory), School of Rural Public Health, Texas A&M Health Science Center, College Station; Department of Landscape Architecture and Urban Planning (Lee), College of Architecture, Texas A&M University, College Station; Lower Rio Grande Valley Colonias Program of the Center for Housing and Urban Development (Trevino), College of Architecture, Texas A&M University, Weslaco, Texas; and Department of Health Promotion and Behavior (Smith), College of Public Health, The University of Georgia, Athens, Georgia Address correspondence to: Nelda Mier, PhD, School of Rural Public Health, Texas A&M Health Science Center, McAllen Campus, 2101 S McColl Rd, McAllen TX 78503. E-mail: [email protected] 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2012.11.013
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he prevalence of obesity among young children aged 6 –11 years increased from 6.5% in 1976 to 19.6% in 2008.1,2 Studies show that obesity is more prevalent among Hispanic children than among their non-Hispanic white counterparts.1 Although it is well documented that physical activity reduces the risk of obesity and other chronic diseases among children,3 national data show that about 60% of young MexicanAmerican children aged 6 –11 years do not meet physical activity recommendations,4 in particular, that children aged ⱖ6 years engage in 60 minutes or more of physical activity every day.5 Among multiple factors influencing physical activity, neighborhood characteristics (e.g., access to recreational
© 2013 American Journal of Preventive Medicine • Published by Elsevier Inc.
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facilities, sidewalk conditions, and safety) play an important role.6,7 However, research indicates that communities where low-income and ethnic minority families reside have limited access to recreational facilities.8,9 Eliminating such inequalities affecting minorities requires multifaceted efforts; these include policy development because of its effectiveness in influencing health and obesity rates among underserved groups and increasing their access to physical activity resources.2,10,11 Grantmakers in Health stressed that public policy can change behavioral norms and improve the environment to reduce childhood obesity,12 and the CDC Guide to Community Preventive Services (www. thecommunityguide.org/pa/environmental-policy/index. html) recommended environmental and policy approaches to promote physical activity. Research plays an important role in policy change,13 and knowledge transfer processes can bridge research and policy. Knowledge transfer is defıned as “communicating research results by targeting and tailoring the fındings and the message to a particular target audience.”14 The WHO calls for addressing health inequality through knowledge transfer to close the gap between research and practice and proposes that published and unpublished information be shared with policymakers to link health research and its application to public health.15 Although more robust research is needed to establish the health and policy impact of knowledge transfer processes,16,17 studies have found that knowledge transfer has influenced policy changes on public health issues, including promotion of newborn screenings and immunizations among women18; increased governmental support for childhood programs in various states19; chronic wound care at community settings20; and cardiovascular and mental health initiatives.21 Despite these fındings, there is paucity of research documenting policy development based on knowledge transfer involving researchers and stakeholders to address childhood obesity affecting underserved populations. The current exploratory study aimed to (1) describe a knowledge transfer process that engaged researchers and stakeholders in addressing the physical activity needs and environmental barriers among low-income, Mexican-American children at the Texas–Mexico border; and (2) examine physical activity and environmental policy recommendations generated during this process.
Methods Participants and Setting This exploratory study employed a qualitative research design using short oral presentations, a research brief, and a selfadministered questionnaire at public meetings. Data were collected January–April 2011 in Hidalgo County TX and analyzed July– March 2013
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Table 1. Public meetings attended by researchers to disseminate data to stakeholders (n⫽184) Public meetinga
No. of stakeholders
A Resource in Serving Equality (ARISE) Monthly Meeting
17
Texas A&M Center for Housing and Urban Development (CHUD) Promotora Meeting
15
The City of Edinburg Parks and Recreation Board Meeting
10
Edinburg City Council Meeting
46
Pharr San Juan Alamo Independent School District Health Advisory Council Meeting
9
Edinburg Consolidated Independent School District School Board Meeting
19
2011 Texas Recreation and Park Society Institute Annual Meeting
28
Hidalgo County Border Colonias Program Board and Precinct 2 Officials
5
Lower Rio Grande Valley Development Council Board of Directors
35
All public meetings were held in Hidalgo County TX and lasted ⬃90 minutes. Researchers gave a 10-minute oral presentation at each meeting and handed out a research brief to each attending stakeholder.
a
September 2011. Hidalgo County is the second poorest county in the U.S.,22 and it is estimated that 42% of the 2294 colonias that exist in the Texas–Mexico border region are located in this county.23,24 Colonias are neighborhoods along the U.S.–Mexico border characterized by poor infrastructure.25 Colonia residents are very poor, have low levels of education, and have limited access to health care.26 On average, colonia families have three children.27 Study researchers planned and facilitated a knowledge transfer process in collaboration with one community-based organization that had been a research partner since the beginning of the project. Initially, the researchers invited stakeholders to meet on the university campus to share research data with them and obtain their feedback on policy recommendations; however, stakeholder attendance was minimal. Therefore, researchers tried a different outreach strategy—requesting to be added to the agenda of public meetings where stakeholders met on a regular basis, including board meetings and advisory committee meetings. Stakeholders were county and city offıcials; promotoras (community health workers); community advocates; and school representatives. Public meeting organizers asked researchers to be brief, allotting them not more than 10 minutes to present their research. Table 1 lists the nine meetings attended by researchers. The Science–Policy–Public Evaluation Spectra theoretic framework by Ottoson and colleagues, and used to guide the present study, proposes that policy development is a process not an event and “contributions to policy can be made at multiple points across time in the context of public and scientifıc influences and useful evaluation fındings.”13,28 Policy development is a four-staged process, including pre-policy, policy development, policy enactment, and post-policy enactment.13 Based on the tenets of pre-policy
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(dissemination of research fındings for public and policymaker understanding) and developing policy (promoting awareness and reframing of issues), the researchers systematically shared their research fındings with stakeholders attending the public meetings using a 10-minute PowerPoint presentation and distributing to all meeting attendees a research brief, which was printed in color on letter-size high-quality paper with a two-sided format. Both the PowerPoint presentation and the research brief included a summary of the fındings previously collected by the research team in a qualitative study with 67 Mexican-American children aged 8 –13 years living in colonias (data reported elsewhere).29 Study fındings presented to stakeholders showed that 40% of participating children in the study were obese and that the majority did not meet physical activity recommendations (78.7%). Findings presented to stakeholders also indicated that children perceived that their neighborhoods’ characteristics hindered their ability to be physically active. Neighborhood barriers mentioned by the children included trash on sidewalks, speeding cars, unleashed dogs, dark streets, and lack of access to recreational facilities. Children also voiced that having a park close to their home would help them be active and recommended building football fıelds and basketball courts in their neighborhoods.29 To obtain feedback from stakeholders about their policy recommendations to promote an environment supportive of children’s physical activity, the researchers asked them to fıll out a selfadministered questionnaire at the end of each public meeting. The questionnaire included two open-ended questions and was developed using a question route technique that allows researchers to address the topics to be examined according to the research aims.30 Questionnaire items were (1) What contribution could agencies/ organizations like yours make to develop a built environment that supports physical activity in children? and (2) What policy should be pursued to develop a built environment that supports physical activity in children? The questionnaire was initially administered to 17 stakeholders, and no revisions were necessary. The questionnaire was administered in English or Spanish, according to the preference of participants. The Spanish translation of the questionnaire was completed using a modifıed direct translation technique by a bilingual researcher native from Hidalgo County, and then revised by another bilingual researcher. A total of 184 stakeholders were asked to fıll out the questionnaire and 74 responded. The response rate in this study was 40.21%, similar to that from previous research with stakeholders, which ranged from 34% to 53%.31–36
Data Analysis Participant responses were transcribed verbatim and analyzed in the original language using a content analysis technique by two bilingual researchers; 41.9% of participants completed the questionnaire in Spanish. All respondent identifıers were removed to ensure participant confıdentiality. A focused coding process was used to analyze the data; the text was independently analyzed. An initial coding process was used to generate and compare concepts identifıed. After the initial coding, a focused coding was used to combine or eliminate concepts, and to identify repeated concepts, major themes, and overarching domains. Results were compared,37–39 and in cases of theme and domain disagreement during the analysis process, the issue was discussed until consensus was reached. If no consensus emerged, the principal investigator’s decision prevailed. No major disagreements were
identifıed by the researchers. The initial coding produced 15 concepts, and the fınal coding resulted in four major emerging themes and two overarching domains. The current study was approved by the Texas A&M University IRB.
Results Data were categorized into two domains: (1) institutional contributions and (2) recommended policies. “Institutional contributions” refers to activities that were being implemented or could be implemented by the institutions that the stakeholders represented. “Recommended policies” refers to policies proposed by the stakeholders that should be pursued by institutions in general. Major emerging themes were identifıed for each domain. Table 2 illustrates participants’ quotes by domain and major theme.
Institutional Contributions Stakeholders commented about activities their institutions could do or were currently doing to promote environments supportive of physical activity among colonia children. Two major themes emerged: healthy lifestyle education and infrastructure improvement. Healthy lifestyle education. Most stakeholders said their organizations could engage in promoting nutrition education among parents. Others suggested that community organizations and government agencies should partner with schools to provide health and nutrition education to community members. Some stakeholders reported their organizations were educating parents through home visits and community presentations by community health workers. Other stakeholders reported that their organizations could promote physical activity in neighborhoods and offer afterschool programs. Some respondents stated that they could organize events in which parents could learn about the importance of physical activity, and others indicated that their organizations already offered health education activities for children and adults. One organization offered afterschool activities during summer to promote health and fıtness education at safe and clean facilities, as reported by a stakeholder. Another stakeholder stated that his/her group provided exercise equipment (e.g., jump ropes and soccer balls) and programs such as karate and yoga for neighborhood children. Infrastructure improvement. Many participants reported that their institutions could engage in neighborhood beautifıcation projects and provide communities with exercise equipment and facilities. Some respondents mentioned that they were already improving the infrawww.ajpmonline.org
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Table 2. Emerging themes for each of the global domains and quotes from local stakeholders Emerging themes and quotes INSTITUTIONAL CONTRIBUTIONS DOMAIN Healthy lifestyle education Host more activities that promote physical activity after school Prepare a class to teach parents the importance of physical activity, so that they can go home and teach their children Educating parents about healthy eating habits and on how to correct poor nutritional tendencies. Partner with schools more often to promote activity and educate about health We offer daily access to Kids Café that provides a balanced meal and programming focused on mind, body, and soul, dealing with fitness endurance, healthy eating, and social recreation Take more information and try to get the parents more involved Infrastructure improvement Continue providing a safe and clean settings Putting safe parks in each neighborhood Build parks and playgrounds within neighborhoods, making them accessible to the people of the communities who can’t or don’t want to drive POLICY RECOMMENDATIONS DOMAIN Establish community-based sustainable health programs Mandate either daily or weekly nutrition classes in school Government [should] run afterschool programs at the school gyms Free exercise activities/programs after-school and during the weekends for children and families Bring back physical education to the schools and make it mandatory Kids spend most of their time at schools, so their PE programs should be enforced [by our government] Do not take away PE in schools Hold parents accountable if a child becomes obese (neglect) Fighting childhood obesity should be a signature domestic initiative for the health and wellbeing of future generations. Federal officials should work with states that are now trying to make healthy foods and beverages more widely available, especially in low-income areas Improving the infrastructure and safety of communities Fix the streets Verify if there is sufficient lighting in public recreational areas and sufficient sidewalks Ensure clean streets and paved sidewalks Make the communities safe for the children and residents Improving access to parks There should be more parks and walking trails in rural communities Ideally, public spaces for recreation and physical activity should be within walking distance and accessible to all Public transportation at an affordable price needs to be in place Later closing times for parks and public facilities Parks should close at least by 10:00PM. Assisting community organizations Help the organizations that work with the communities Provide more funding for projects PE, physical education
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ers also proposed making physical education classes mandatory in all schools. Improving the infrastructure and safety of communities. Stakeholders reported that local, state, and federal policy agendas should focus on improving the environment of colonias. They specifıcally stressed the importance of creating and repairing streets and sidewalks, as well as improving lighting conditions. Many stakeholders mentioned the lack of safety as a barrier to physical activity and proposed the enforcement of laws in neighborhoods and public areas to motivate more residents to be active outdoors. The stakeholders expressed a great need for increased police presence during evening hours in the colonias. Improving access to parks. Many respondents suggested building more parks throughout the communities and making exercise equipment available for children. Another suggestion to increase access to parks centered on improving the local transportation system and keeping recreational facilities open to the public until late in the evening.
Recommended Policies
Assisting community organizations. Stakeholders proposed that community organizations receive fınancial support from the government to promote healthy lifestyle programs.
Four policy-related themes emerged from the data.
Discussion
Establishing sustainable, healthy lifestyle programs. Many stakeholders called for policies mandating nutrition and physical activity programs. Stakehold-
This study described a knowledge transfer process through which researchers disseminated research fındings to local decision makers in community settings. This process
structure of colonias with projects involving modifıcations to streets, roads, and drainage structures.
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produced policy recommendations from stakeholders to promote physical activity among low-income, MexicanAmerican children living in border colonias. Although stakeholders were asked to propose policies to improve the physical characteristics of neighborhoods to make them more supportive of physical activity for children, their recommendations were not limited to this strategy. Stakeholders’ recommendations also focused on addressing childhood obesity through multiple solutions and interconnecting healthy lifestyles with community infrastructure and health education. These fındings suggest that recommendations proposed by stakeholders resonate with previous research providing evidence of the social and environmental influences on physical activity behaviors. Research supports the notion that neighborhood characteristics influence physical activity.6,40 – 45 There is strong evidence that children with access to parks are more active than those without such access,7,46 – 48 and that urban designs considering connectivity of sidewalks and streets (as well as neighborhood safety) support physical activity behaviors (www.thecommunityguide.org/pa/environmental-policy/ index.html). Although research shows community interventions are effective in promoting physical activity,49 previous studies suggest that nonprofıt organizations face many challenges sustaining community-based programs in addition to their operational needs.50,51 Stakeholder respondents in the current study recommended increasing physical education in schools, and there is strong research evidence that physical education classes are positively associated with physically active children.49 Further research is warranted to investigate to what degree community stakeholders are knowledgeable about the scientifıc literature and in what ways such information influences their opinions and decisions when addressing childhood obesity. The current fındings show that a knowledge transfer process based on the dissemination of primary research data through PowerPoint presentations and a research brief in community settings is an effective strategy to influence policy development in relation to childhood obesity. A policy framework by Ottoson and colleagues13,28 proposes to examine policy contributions through a continuum of stages, including problem description and understanding, policy development, and policy enactment and implementation. Based on this framework, study results suggest that knowledge transfer planned and facilitated by scientists at public settings can contribute to policy and practice in at least several ways: by disseminating research data for policymaker understanding (pre-policy stage); by raising awareness among decision makers about childhood obesity (pre-policy stage); and by encouraging local decision makers
to frame the issue into policy recommendations (policy development stage).
Limitations This study has several limitations. The number of public meetings attended by researchers and the sample size of stakeholder respondents were small and not randomly selected; therefore, the sample may not be representative of border stakeholders from similarly impoverished geographic areas, and their recommendations cannot be widely generalized beyond this border region. Additionally, it is not clear if these stakeholder groups represented especially low-income or undocumented residents who might be among the most vulnerable populations. Other study shortcomings include the use of a questionnaire not previously tested for internal validity and reliability; no additional triangulation data collection methods; and no calculation of an internal reliability coeffıcient in the data analysis. Finally, a focused content analysis approach was used versus a more systematic audit of transcribed text using qualitative data analysis software.
Conclusion Despite its limitations, this exploratory study responds to a gap in the public health literature underlining the need for obesity-related research that is better aligned with policy and practice.52 A process planned and facilitated by researchers to disseminate primary research data on physical activity issues among local stakeholders in community settings to produce policy recommendations is not a traditional academic practice,53,54 but it is a necessary strategy to address the complex phenomenon of childhood obesity. The need for bridging health research and policy as an effective way to change the obesogenic environment has been highlighted by national and international initiatives that acknowledge that health behaviors are policy-influenced.2,13,52 An International Conference convening obesity experts from 33 countries in 2007 warned that because of the complexity of childhood obesity, it is imperative to use a systemwide approach and produce healthy policies based on evidence.52 The present study documents that a strategy linking research and policy development is a feasible exercise in real-world settings and has practical implications. Other regions with similar characteristics may replicate the methodology used in the current study to mobilize local stakeholders to take policy action. Although investigating whether any policies were developed and enacted as a result of the knowledge transfer process described here is beyond the scope of the present study, a local stakeholder (A. Kass, Proyecto Azteca, personal communication, 2012) said that this process influenced her organization’s decision to design a healthy www.ajpmonline.org
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neighborhood prototype in a colonia in Hidalgo County. The proposed neighborhood design includes a basketball court, a playground, and a community facility to promote physical activity among children and their families. The stakeholder mentioned that the research brief disseminated as part of the current study has been a useful tool to educate their constituents about physical activity needs and barriers among colonia children. Further research on community-based initiatives promoting healthy neighborhood designs is warranted to determine their impact on reducing childhood obesity. The current study shows that researchers can play a critical role in the development of policies addressing childhood obesity by (1) disseminating research fındings among local stakeholders in community settings and (2) mobilizing stakeholders to generate policy recommendations. Further research is needed to investigate the most effective research data presentation strategies among decision makers to influence health policy, and to conduct health impact assessments of existing and proposed policies addressing childhood obesity. Findings from the present study have practical application and the potential to influence policy development beyond this specifıc research effort. A recommended next step is to bring together committed partners in the study region to further reframe the childhood obesity issue, building on the policy recommendations produced by this study. Stakeholders who participated in the current study should be part of an iterative process of mobilization, advocacy, and policy enactment. Previous research shows that building local partnerships with programmatic, promotion, and policy goals is an intermediate step followed by decision-making procedures in the overall policy change process.55–57 Local partnerships must then identify priorities and commit to a sequence of plans and regulations related to urban planning, zoning, land use, pedestrian safety, and/or economic development for improving current neighborhoods and regulating new ones.57–59 Finally, decisions for policy development leading to healthy and active communities should be framed within a socioecologic model, recognizing that health behaviors are not solely individually based but rather influenced by interpersonal, community, and policy factors.60 Particularly, policy development addressing childhood obesity in border Hispanic communities should be comprehensive, targeting not only physical activity behaviors but also nutrition education and urban development as recommended by local stakeholders in this study. Publication of this article was supported by the Robert Wood Johnson Foundation. March 2013
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This study was funded by the Robert Wood Johnson Foundation (RWJF) through its national program, Salud America! The RWJF Research Network to Prevent Obesity Among Latino Children (www.salud-america.org). Salud America!, led by the Institute for Health Promotion Research at The University of Texas Health Science Center at San Antonio, Texas, unites Latino researchers and advocates seeking environmental and policy solutions to the epidemic. The study was also informed by the Texas Childhood Obesity Prevention Policy Evaluation Project – funded by RWJF, which is evaluating statewide policies to reduce childhood obesity. No fınancial disclosures were reported by the authors of this paper.
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37. Charmaz K. Grounded theory. In: Emerson RM. Contemporary fıeld research: perspectives and formulations. 2nd ed. Prospect Heights IL: Waveland Press Inc., 2001:335–52. 38. Morgan DL. Focus groups as qualitative research. Newbury Park CA: Sage, 1988. 39. Morgan DL. The focus group guidebook. Thousand Oaks CA: Sage, 1998. 40. Lopez RP, Hynes HP. Obesity, physical activity, and the urban environment: public health research needs. Environ Health 2006;5(1):25. 41. Gauvin L, Riva M, Barnett T, et al. Association between neighborhood active living potential and walking. Am J Epidemiol 2008;167(8): 944 –53. 42. Saelens BE, Handy SL. Built environment correlates of walking: a review. Med Sci Sports Exerc 2008;40(S7):S550 –S566. 43. McMillan TE. Urban form and a child’s trip to school: the current literature and a framework for future research. J Plann Lit 2005;19(4): 440 –56. 44. Owen N, Humpel N, Leslie E, et al. Understanding environmental influences on walking: review and research agenda. Am J Prev Med 2004;27(1):67–76. 45. Lee C, Moudon AV. Physical activity and environment research in the health fıeld: Implications for urban and transportation planning practice and research. J Plann Lit 2004;19(2):147– 81. 46. Pate RR, Colabianchi N, Porter D, et al. Physical activity and neighborhood resources in high school girls. Am J Prev Med 2008;34(5):413–9. 47. Tucker P, Irwin JD, Gilliland J, et al. Environmental influences on physical activity levels in youth. Health Place 2009;15(1):357– 63. 48. Babey SH, Hastert TA, Yu H, et al. Physical activity among adolescents. When do parks matter? Am J Prev Med 2008;34(4):345– 8. 49. Task Force on Community Preventive Services. Recommendations to increase physical activity in communities. Am J Prev Med 2002; 22(4S):67–72. 50. Walker ET, McCarthy JD. Legitimacy, strategy, and resouces in the survival of community-based organizations. Soc Prob 2010;57(3): 315– 40. 51. Wehrly RA, Mier N, Ory MG, et al. Confronting the diabetes disparity: a look at diabetes, nutrition, and physical activity programs in the Lower Rio Grande Valley. Health Promot Pract 2010;11(3):394 –9. 52. Katzmarzyk PT, Baur LA, Blair SN, et al. International conference on physical activity and obesity in children: summary statement and recommendations. Int J Pediatr Obes 2008;3(1):3–21. 53. Galano J, Schellenbach CJ. Healthy Families America Research Practice Network: a unique partnership to integrate prevention science and practice. J Prev Interv Community 2007;34(1–2):39 – 66. 54. Nyden P. Academic incentives for faculty participation in communitybased participatory research. J Gen Intern Med 2003;18(7):576 – 85. 55. Huberty JL, Dodge T, Peterson K, et al. Activate Omaha: the journey to an active living environment. Am J Prev Med 2009;37(6S2):S428 –S435. 56. Kraft MK, Brown LD. Active living by design as a political project challenges at three levels. Am J Prev Med 2009;37(6S2):S453–S454. 57. McCreedy M, Leslie JG. Get active orlando: changing the built environment to increase physical activity. Am J Prev Med 2009;37(6S2): S395–S402. 58. Dobson NG, Gilroy AR. From partnership to policy: the evolution of active living by design in Portland, Oregon. Am J Prev Med 2009; 37(6S2):S436 –S444. 59. Raja S, Ball M, Booth J, et al. Leveraging neighborhood-scale change for policy and program reform in Buffalo, New York. Am J Prev Med 2009;37(6S2):S352–S360. 60. Richard L, Gauvin L, Raine K. Ecological models revisited: their uses and evolution over two decades. Annu Rev Public Health 2011; 32:307–26.
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Purpose: To describe a knowledge transfer process involving local decision makers to address childhood obesity and physical activity needs among low-income, Mexican-American children and to examine environmental policy recommendations generated in this process. Methods: This pilot study employed a qualitative research design that included the dissemination of primary research data to local decision makers in the Texas–Mexico border region. Stakeholders attending public meetings were briefed about a research project reporting on the physical activity needs of Mexican-American children from impoverished neighborhoods known as colonias. Seventy-four stakeholders responded to an unstructured questionnaire and proposed policy recommendations. Data were collected January–April 2011 and analyzed July–September 2011. Data were analyzed using a content analysis technique.
Results: Four policy themes emerged from the data: (1) establishing sustainable communitybased health programs; (2) improving neighborhood infrastructure and safety; (3) increasing access to parks; and (4) supporting community organizations to disseminate health education to parents and children. Conclusions: Knowledge transfer processes planned and facilitated by researchers at public meetings with local decision makers are effective methods to influence policy development related to childhood obesity. (Am J Prev Med 2013;44(3S3):S208 –S214) © 2013 American Journal of Preventive Medicine
Introduction From the Department of Health Promotion and Community Health Sciences (Mier, Carrillo-Zuniga), and the Department of Health Policy and Management, School of Rural Public Health, Texas A&M Health Science Center (Irizarry), McAllen; Department of Health Promotion and Community Health Sciences (Smith, Ory), School of Rural Public Health, Texas A&M Health Science Center, College Station; Department of Landscape Architecture and Urban Planning (Lee), College of Architecture, Texas A&M University, College Station; Lower Rio Grande Valley Colonias Program of the Center for Housing and Urban Development (Trevino), College of Architecture, Texas A&M University, Weslaco, Texas; and Department of Health Promotion and Behavior (Smith), College of Public Health, The University of Georgia, Athens, Georgia Address correspondence to: Nelda Mier, PhD, School of Rural Public Health, Texas A&M Health Science Center, McAllen Campus, 2101 S McColl Rd, McAllen TX 78503. E-mail: [email protected] 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2012.11.013
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T
he prevalence of obesity among young children aged 6 –11 years increased from 6.5% in 1976 to 19.6% in 2008.1,2 Studies show that obesity is more prevalent among Hispanic children than among their non-Hispanic white counterparts.1 Although it is well documented that physical activity reduces the risk of obesity and other chronic diseases among children,3 national data show that about 60% of young MexicanAmerican children aged 6 –11 years do not meet physical activity recommendations,4 in particular, that children aged ⱖ6 years engage in 60 minutes or more of physical activity every day.5 Among multiple factors influencing physical activity, neighborhood characteristics (e.g., access to recreational
© 2013 American Journal of Preventive Medicine • Published by Elsevier Inc.
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facilities, sidewalk conditions, and safety) play an important role.6,7 However, research indicates that communities where low-income and ethnic minority families reside have limited access to recreational facilities.8,9 Eliminating such inequalities affecting minorities requires multifaceted efforts; these include policy development because of its effectiveness in influencing health and obesity rates among underserved groups and increasing their access to physical activity resources.2,10,11 Grantmakers in Health stressed that public policy can change behavioral norms and improve the environment to reduce childhood obesity,12 and the CDC Guide to Community Preventive Services (www. thecommunityguide.org/pa/environmental-policy/index. html) recommended environmental and policy approaches to promote physical activity. Research plays an important role in policy change,13 and knowledge transfer processes can bridge research and policy. Knowledge transfer is defıned as “communicating research results by targeting and tailoring the fındings and the message to a particular target audience.”14 The WHO calls for addressing health inequality through knowledge transfer to close the gap between research and practice and proposes that published and unpublished information be shared with policymakers to link health research and its application to public health.15 Although more robust research is needed to establish the health and policy impact of knowledge transfer processes,16,17 studies have found that knowledge transfer has influenced policy changes on public health issues, including promotion of newborn screenings and immunizations among women18; increased governmental support for childhood programs in various states19; chronic wound care at community settings20; and cardiovascular and mental health initiatives.21 Despite these fındings, there is paucity of research documenting policy development based on knowledge transfer involving researchers and stakeholders to address childhood obesity affecting underserved populations. The current exploratory study aimed to (1) describe a knowledge transfer process that engaged researchers and stakeholders in addressing the physical activity needs and environmental barriers among low-income, Mexican-American children at the Texas–Mexico border; and (2) examine physical activity and environmental policy recommendations generated during this process.
Methods Participants and Setting This exploratory study employed a qualitative research design using short oral presentations, a research brief, and a selfadministered questionnaire at public meetings. Data were collected January–April 2011 in Hidalgo County TX and analyzed July– March 2013
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Table 1. Public meetings attended by researchers to disseminate data to stakeholders (n⫽184) Public meetinga
No. of stakeholders
A Resource in Serving Equality (ARISE) Monthly Meeting
17
Texas A&M Center for Housing and Urban Development (CHUD) Promotora Meeting
15
The City of Edinburg Parks and Recreation Board Meeting
10
Edinburg City Council Meeting
46
Pharr San Juan Alamo Independent School District Health Advisory Council Meeting
9
Edinburg Consolidated Independent School District School Board Meeting
19
2011 Texas Recreation and Park Society Institute Annual Meeting
28
Hidalgo County Border Colonias Program Board and Precinct 2 Officials
5
Lower Rio Grande Valley Development Council Board of Directors
35
All public meetings were held in Hidalgo County TX and lasted ⬃90 minutes. Researchers gave a 10-minute oral presentation at each meeting and handed out a research brief to each attending stakeholder.
a
September 2011. Hidalgo County is the second poorest county in the U.S.,22 and it is estimated that 42% of the 2294 colonias that exist in the Texas–Mexico border region are located in this county.23,24 Colonias are neighborhoods along the U.S.–Mexico border characterized by poor infrastructure.25 Colonia residents are very poor, have low levels of education, and have limited access to health care.26 On average, colonia families have three children.27 Study researchers planned and facilitated a knowledge transfer process in collaboration with one community-based organization that had been a research partner since the beginning of the project. Initially, the researchers invited stakeholders to meet on the university campus to share research data with them and obtain their feedback on policy recommendations; however, stakeholder attendance was minimal. Therefore, researchers tried a different outreach strategy—requesting to be added to the agenda of public meetings where stakeholders met on a regular basis, including board meetings and advisory committee meetings. Stakeholders were county and city offıcials; promotoras (community health workers); community advocates; and school representatives. Public meeting organizers asked researchers to be brief, allotting them not more than 10 minutes to present their research. Table 1 lists the nine meetings attended by researchers. The Science–Policy–Public Evaluation Spectra theoretic framework by Ottoson and colleagues, and used to guide the present study, proposes that policy development is a process not an event and “contributions to policy can be made at multiple points across time in the context of public and scientifıc influences and useful evaluation fındings.”13,28 Policy development is a four-staged process, including pre-policy, policy development, policy enactment, and post-policy enactment.13 Based on the tenets of pre-policy
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(dissemination of research fındings for public and policymaker understanding) and developing policy (promoting awareness and reframing of issues), the researchers systematically shared their research fındings with stakeholders attending the public meetings using a 10-minute PowerPoint presentation and distributing to all meeting attendees a research brief, which was printed in color on letter-size high-quality paper with a two-sided format. Both the PowerPoint presentation and the research brief included a summary of the fındings previously collected by the research team in a qualitative study with 67 Mexican-American children aged 8 –13 years living in colonias (data reported elsewhere).29 Study fındings presented to stakeholders showed that 40% of participating children in the study were obese and that the majority did not meet physical activity recommendations (78.7%). Findings presented to stakeholders also indicated that children perceived that their neighborhoods’ characteristics hindered their ability to be physically active. Neighborhood barriers mentioned by the children included trash on sidewalks, speeding cars, unleashed dogs, dark streets, and lack of access to recreational facilities. Children also voiced that having a park close to their home would help them be active and recommended building football fıelds and basketball courts in their neighborhoods.29 To obtain feedback from stakeholders about their policy recommendations to promote an environment supportive of children’s physical activity, the researchers asked them to fıll out a selfadministered questionnaire at the end of each public meeting. The questionnaire included two open-ended questions and was developed using a question route technique that allows researchers to address the topics to be examined according to the research aims.30 Questionnaire items were (1) What contribution could agencies/ organizations like yours make to develop a built environment that supports physical activity in children? and (2) What policy should be pursued to develop a built environment that supports physical activity in children? The questionnaire was initially administered to 17 stakeholders, and no revisions were necessary. The questionnaire was administered in English or Spanish, according to the preference of participants. The Spanish translation of the questionnaire was completed using a modifıed direct translation technique by a bilingual researcher native from Hidalgo County, and then revised by another bilingual researcher. A total of 184 stakeholders were asked to fıll out the questionnaire and 74 responded. The response rate in this study was 40.21%, similar to that from previous research with stakeholders, which ranged from 34% to 53%.31–36
Data Analysis Participant responses were transcribed verbatim and analyzed in the original language using a content analysis technique by two bilingual researchers; 41.9% of participants completed the questionnaire in Spanish. All respondent identifıers were removed to ensure participant confıdentiality. A focused coding process was used to analyze the data; the text was independently analyzed. An initial coding process was used to generate and compare concepts identifıed. After the initial coding, a focused coding was used to combine or eliminate concepts, and to identify repeated concepts, major themes, and overarching domains. Results were compared,37–39 and in cases of theme and domain disagreement during the analysis process, the issue was discussed until consensus was reached. If no consensus emerged, the principal investigator’s decision prevailed. No major disagreements were
identifıed by the researchers. The initial coding produced 15 concepts, and the fınal coding resulted in four major emerging themes and two overarching domains. The current study was approved by the Texas A&M University IRB.
Results Data were categorized into two domains: (1) institutional contributions and (2) recommended policies. “Institutional contributions” refers to activities that were being implemented or could be implemented by the institutions that the stakeholders represented. “Recommended policies” refers to policies proposed by the stakeholders that should be pursued by institutions in general. Major emerging themes were identifıed for each domain. Table 2 illustrates participants’ quotes by domain and major theme.
Institutional Contributions Stakeholders commented about activities their institutions could do or were currently doing to promote environments supportive of physical activity among colonia children. Two major themes emerged: healthy lifestyle education and infrastructure improvement. Healthy lifestyle education. Most stakeholders said their organizations could engage in promoting nutrition education among parents. Others suggested that community organizations and government agencies should partner with schools to provide health and nutrition education to community members. Some stakeholders reported their organizations were educating parents through home visits and community presentations by community health workers. Other stakeholders reported that their organizations could promote physical activity in neighborhoods and offer afterschool programs. Some respondents stated that they could organize events in which parents could learn about the importance of physical activity, and others indicated that their organizations already offered health education activities for children and adults. One organization offered afterschool activities during summer to promote health and fıtness education at safe and clean facilities, as reported by a stakeholder. Another stakeholder stated that his/her group provided exercise equipment (e.g., jump ropes and soccer balls) and programs such as karate and yoga for neighborhood children. Infrastructure improvement. Many participants reported that their institutions could engage in neighborhood beautifıcation projects and provide communities with exercise equipment and facilities. Some respondents mentioned that they were already improving the infrawww.ajpmonline.org
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Table 2. Emerging themes for each of the global domains and quotes from local stakeholders Emerging themes and quotes INSTITUTIONAL CONTRIBUTIONS DOMAIN Healthy lifestyle education Host more activities that promote physical activity after school Prepare a class to teach parents the importance of physical activity, so that they can go home and teach their children Educating parents about healthy eating habits and on how to correct poor nutritional tendencies. Partner with schools more often to promote activity and educate about health We offer daily access to Kids Café that provides a balanced meal and programming focused on mind, body, and soul, dealing with fitness endurance, healthy eating, and social recreation Take more information and try to get the parents more involved Infrastructure improvement Continue providing a safe and clean settings Putting safe parks in each neighborhood Build parks and playgrounds within neighborhoods, making them accessible to the people of the communities who can’t or don’t want to drive POLICY RECOMMENDATIONS DOMAIN Establish community-based sustainable health programs Mandate either daily or weekly nutrition classes in school Government [should] run afterschool programs at the school gyms Free exercise activities/programs after-school and during the weekends for children and families Bring back physical education to the schools and make it mandatory Kids spend most of their time at schools, so their PE programs should be enforced [by our government] Do not take away PE in schools Hold parents accountable if a child becomes obese (neglect) Fighting childhood obesity should be a signature domestic initiative for the health and wellbeing of future generations. Federal officials should work with states that are now trying to make healthy foods and beverages more widely available, especially in low-income areas Improving the infrastructure and safety of communities Fix the streets Verify if there is sufficient lighting in public recreational areas and sufficient sidewalks Ensure clean streets and paved sidewalks Make the communities safe for the children and residents Improving access to parks There should be more parks and walking trails in rural communities Ideally, public spaces for recreation and physical activity should be within walking distance and accessible to all Public transportation at an affordable price needs to be in place Later closing times for parks and public facilities Parks should close at least by 10:00PM. Assisting community organizations Help the organizations that work with the communities Provide more funding for projects PE, physical education
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ers also proposed making physical education classes mandatory in all schools. Improving the infrastructure and safety of communities. Stakeholders reported that local, state, and federal policy agendas should focus on improving the environment of colonias. They specifıcally stressed the importance of creating and repairing streets and sidewalks, as well as improving lighting conditions. Many stakeholders mentioned the lack of safety as a barrier to physical activity and proposed the enforcement of laws in neighborhoods and public areas to motivate more residents to be active outdoors. The stakeholders expressed a great need for increased police presence during evening hours in the colonias. Improving access to parks. Many respondents suggested building more parks throughout the communities and making exercise equipment available for children. Another suggestion to increase access to parks centered on improving the local transportation system and keeping recreational facilities open to the public until late in the evening.
Recommended Policies
Assisting community organizations. Stakeholders proposed that community organizations receive fınancial support from the government to promote healthy lifestyle programs.
Four policy-related themes emerged from the data.
Discussion
Establishing sustainable, healthy lifestyle programs. Many stakeholders called for policies mandating nutrition and physical activity programs. Stakehold-
This study described a knowledge transfer process through which researchers disseminated research fındings to local decision makers in community settings. This process
structure of colonias with projects involving modifıcations to streets, roads, and drainage structures.
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produced policy recommendations from stakeholders to promote physical activity among low-income, MexicanAmerican children living in border colonias. Although stakeholders were asked to propose policies to improve the physical characteristics of neighborhoods to make them more supportive of physical activity for children, their recommendations were not limited to this strategy. Stakeholders’ recommendations also focused on addressing childhood obesity through multiple solutions and interconnecting healthy lifestyles with community infrastructure and health education. These fındings suggest that recommendations proposed by stakeholders resonate with previous research providing evidence of the social and environmental influences on physical activity behaviors. Research supports the notion that neighborhood characteristics influence physical activity.6,40 – 45 There is strong evidence that children with access to parks are more active than those without such access,7,46 – 48 and that urban designs considering connectivity of sidewalks and streets (as well as neighborhood safety) support physical activity behaviors (www.thecommunityguide.org/pa/environmental-policy/ index.html). Although research shows community interventions are effective in promoting physical activity,49 previous studies suggest that nonprofıt organizations face many challenges sustaining community-based programs in addition to their operational needs.50,51 Stakeholder respondents in the current study recommended increasing physical education in schools, and there is strong research evidence that physical education classes are positively associated with physically active children.49 Further research is warranted to investigate to what degree community stakeholders are knowledgeable about the scientifıc literature and in what ways such information influences their opinions and decisions when addressing childhood obesity. The current fındings show that a knowledge transfer process based on the dissemination of primary research data through PowerPoint presentations and a research brief in community settings is an effective strategy to influence policy development in relation to childhood obesity. A policy framework by Ottoson and colleagues13,28 proposes to examine policy contributions through a continuum of stages, including problem description and understanding, policy development, and policy enactment and implementation. Based on this framework, study results suggest that knowledge transfer planned and facilitated by scientists at public settings can contribute to policy and practice in at least several ways: by disseminating research data for policymaker understanding (pre-policy stage); by raising awareness among decision makers about childhood obesity (pre-policy stage); and by encouraging local decision makers
to frame the issue into policy recommendations (policy development stage).
Limitations This study has several limitations. The number of public meetings attended by researchers and the sample size of stakeholder respondents were small and not randomly selected; therefore, the sample may not be representative of border stakeholders from similarly impoverished geographic areas, and their recommendations cannot be widely generalized beyond this border region. Additionally, it is not clear if these stakeholder groups represented especially low-income or undocumented residents who might be among the most vulnerable populations. Other study shortcomings include the use of a questionnaire not previously tested for internal validity and reliability; no additional triangulation data collection methods; and no calculation of an internal reliability coeffıcient in the data analysis. Finally, a focused content analysis approach was used versus a more systematic audit of transcribed text using qualitative data analysis software.
Conclusion Despite its limitations, this exploratory study responds to a gap in the public health literature underlining the need for obesity-related research that is better aligned with policy and practice.52 A process planned and facilitated by researchers to disseminate primary research data on physical activity issues among local stakeholders in community settings to produce policy recommendations is not a traditional academic practice,53,54 but it is a necessary strategy to address the complex phenomenon of childhood obesity. The need for bridging health research and policy as an effective way to change the obesogenic environment has been highlighted by national and international initiatives that acknowledge that health behaviors are policy-influenced.2,13,52 An International Conference convening obesity experts from 33 countries in 2007 warned that because of the complexity of childhood obesity, it is imperative to use a systemwide approach and produce healthy policies based on evidence.52 The present study documents that a strategy linking research and policy development is a feasible exercise in real-world settings and has practical implications. Other regions with similar characteristics may replicate the methodology used in the current study to mobilize local stakeholders to take policy action. Although investigating whether any policies were developed and enacted as a result of the knowledge transfer process described here is beyond the scope of the present study, a local stakeholder (A. Kass, Proyecto Azteca, personal communication, 2012) said that this process influenced her organization’s decision to design a healthy www.ajpmonline.org
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neighborhood prototype in a colonia in Hidalgo County. The proposed neighborhood design includes a basketball court, a playground, and a community facility to promote physical activity among children and their families. The stakeholder mentioned that the research brief disseminated as part of the current study has been a useful tool to educate their constituents about physical activity needs and barriers among colonia children. Further research on community-based initiatives promoting healthy neighborhood designs is warranted to determine their impact on reducing childhood obesity. The current study shows that researchers can play a critical role in the development of policies addressing childhood obesity by (1) disseminating research fındings among local stakeholders in community settings and (2) mobilizing stakeholders to generate policy recommendations. Further research is needed to investigate the most effective research data presentation strategies among decision makers to influence health policy, and to conduct health impact assessments of existing and proposed policies addressing childhood obesity. Findings from the present study have practical application and the potential to influence policy development beyond this specifıc research effort. A recommended next step is to bring together committed partners in the study region to further reframe the childhood obesity issue, building on the policy recommendations produced by this study. Stakeholders who participated in the current study should be part of an iterative process of mobilization, advocacy, and policy enactment. Previous research shows that building local partnerships with programmatic, promotion, and policy goals is an intermediate step followed by decision-making procedures in the overall policy change process.55–57 Local partnerships must then identify priorities and commit to a sequence of plans and regulations related to urban planning, zoning, land use, pedestrian safety, and/or economic development for improving current neighborhoods and regulating new ones.57–59 Finally, decisions for policy development leading to healthy and active communities should be framed within a socioecologic model, recognizing that health behaviors are not solely individually based but rather influenced by interpersonal, community, and policy factors.60 Particularly, policy development addressing childhood obesity in border Hispanic communities should be comprehensive, targeting not only physical activity behaviors but also nutrition education and urban development as recommended by local stakeholders in this study. Publication of this article was supported by the Robert Wood Johnson Foundation. March 2013
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This study was funded by the Robert Wood Johnson Foundation (RWJF) through its national program, Salud America! The RWJF Research Network to Prevent Obesity Among Latino Children (www.salud-america.org). Salud America!, led by the Institute for Health Promotion Research at The University of Texas Health Science Center at San Antonio, Texas, unites Latino researchers and advocates seeking environmental and policy solutions to the epidemic. The study was also informed by the Texas Childhood Obesity Prevention Policy Evaluation Project – funded by RWJF, which is evaluating statewide policies to reduce childhood obesity. No fınancial disclosures were reported by the authors of this paper.
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