Prevenir la obesidad en contextos de precarización: respuestas locales a estrategias globales / Preventing obesity in precarious contexts: local responses to global strategies

RESUMEN El objetivo de este artículo es analizar la estructura conceptual subyacente de los modelos preventivos sobre la obesidad implementados en Argentina, Brasil y España. En un contexto culturalmente distinto, pero epidemiológicamente similar, los tres países han diseñado sus estrategias, reproduciendo el diagnóstico global sobre sus causas y replicando algunas de las medidas propuestas a nivel mundial. Mientras que los denominados "ambientes obesogénicos" son considerados los principales responsables de estas tendencias, las acciones de educación alimentaria y nutricional promueven la autovigilancia y la racionalización de las prácticas como herramienta principal para lograr cambios en la dieta y la actividad física. Aunque las medidas propuestas a nivel local han sido variadas, fueron menos plurales en cuanto a su naturaleza y alcance, y apenas se incorporan las limitaciones que dificultan adoptar estilos de vida saludables. En contextos de precarización social y alimentaria, esto ha supuesto desconsiderar a los grupos sociales con mayor prevalencia de obesidad.

ABSTRACT The aim of this article is to analyze the conceptual structure underlying the models of obesity prevention implemented in Argentina, Brazil, and Spain. In their culturally distinct but epidemiologically similar contexts, the three countries have devised strategies that reproduce global diagnoses of the causes of obesity and replicate some of the measures proposed at the global level. While so-called "obesogenic environments" are considered primarily responsible for these tendencies, efforts to raise awareness about food and nutrition tend to promote self-monitoring and behavior rationalization as the main tools for achieving changes in diet and physical activity. Although a variety of measures have been proposed at the local level, they have been less diverse in terms of their nature and scope, barely taking into account the constraints that hinder the adoption of healthy lifestyles. In contexts of social and food precarity, this has meant neglecting the social groups with the highest prevalence of obesity.

Evaluation of the Effectiveness of the Fun FRIENDS Program / Avaliação da Eficácia do Programa Amigos Divertidos (fun FRIENDS) / Evaluación de la Eficacia del Programa Amigos Divertidos (fun FRIENDS)

Abstract Anxiety and depression are the main complaints related to mental health in childhood and constitute a public health problem. In Brazil, there are few studies that describe evidence-based early intervention actions for these psychopathologies. Considering the problems related to anxiety and depression in childhood and their relative stability in development, health promotion and prevention actions are justified. One of the evidence-based programs directed toward health promotion and prevention of anxiety and depression in childhood is the FRIENDS Program (Fun FRIENDS). Therefore, this study sought to evaluate the effectiveness of the FRIENDS program regarding the reduction in symptoms of anxiety and depression and increase in socioemotional skills, in a city of Paraná state. A total of 25 children, aged from 5 to 7, and their caregivers participated. The CBCL (Child Behavior Checklist), SDQ (Strengths and Difficulties Questionnaire) and SCAS (Spence Children's Anesthesia Scale) were used as the evaluation instruments. The results demonstrated increases in socioemotional skills and reductions in anxiety and depression symptoms. Thus, it was concluded that there is evidence that supports the effectiveness of the program for the Brazilian population.

Resumo A ansiedade e a depressão são as maiores queixas encontradas em relação à saúde mental na infância, sendo um problema de saúde pública. No Brasil, poucos são os estudos que descrevem ações, baseadas em evidência, para intervenções precoces quanto a essas psicopatologias. Frente as problemáticas relacionadas à ansiedade e depressão na infância, e sua relativa estabilidade no desenvolvimento, justificam-se as ações de promoção e prevenção de saúde. Um dos programas, baseados em evidências, que visam a promoção de saúde e prevenção de ansiedade e depressão na infância é o Método FRIENDS (Amigos Divertidos/Fun FRIENDS). Nesse contexto, esta pesquisa buscou avaliar a eficácia do programa Amigos Divertidos quanto a diminuição de sintomas de ansiedade e depressão e aumento de habilidades socioemocionais, em uma cidade do interior do Paraná. Participaram 25 crianças, com idade entre cinco a sete anos, e seus cuidadores. Como instrumentos de avaliação, utilizou-se os instrumentos CBCL (Child Behavior Check List), SDQ (Strengths and Difficulties Questionnaire) e SCAS (Spence Children's Anxiety Scale). Os resultados demonstraram aumentos das habilidades socioemocionais e redução de sintomas de ansiedade e depressão. Com isso, conclui-se que há evidências que apoiam a eficácia do programa para a população brasileira.

Resumen La ansiedad y la depresión son las mayores quejas en relación en relación a la salud mental en la infancia, sendo uno problema de la salud pública. En Brasil, pocos son los estudios que describen acciones basados en evidencia, para intervenciones temprano cuanto a esas psicopatologias. Frente a las problemáticas relacionadas a la ansiedad y depresión en la infancia, y su relativa estabilidad en el desenvolvimiento, justificanse las acciones de promoción y prevención de la salud. Uno de los programas basados en evidencias que visan la promoción y la prevención de ansiedad y depresión en la infancia es lo Método FRIENDS (Amigos Divertidos/Fun FRIENDS). Nese contexto, esta pesquisa buscou valuar la eficacia del programa Amigos Divertidos en una ciudad del interior del Paraná. Participaran 25 niños, con edad entre los cinco y siete años, y sus cuidadores. Como instrumiento de avalación, utilizouse los instrumientos (Child Behavior Check List), SDQ (Strengths and Difficulties Qustionnaire) y SCAS (Spence Children's Anxiety Scale). Los resultados demonstraran aumento de las habilidades socioemocionales y reducción de los sintomas de la ansiedad y depresión. Con eso, concluise que hay evidencias que apoyan la eficacia del programa a la población brasileña.

Análisis conductual de niños brasileños que participan del "Programa boquita del bebé" ­ Gurupi/Tocantins / Behavioral analysis of Brazilian children participating in the "Baby's Little Mouth Program" at Gurupi-Tocantins / Análise comportamental de crianças brasileiras participantes do "Programa Bo-quinha do Bebê" ­ Gurupi/Tocantins

La respuesta del comportamiento del niño ha sido estudiada en algunas investigaciones y es útil para predecir cómo el niño reacciona al tratamiento odontológico, especialmente los bebés y los niños más pequeños, que es donde se encuentra uno de los mayores desafíos de la odontopediatría. Objetivo: Evaluar el patrón de comportamiento de niños de 3 a 5 años de edad, en un programa preventivo de la municipalidad de Gurupi/Tocantins, Brasil. Materiales y métodos: Este estudio fue evaluado y aprobado por el comité de ética e investigación. Un total de 60 niños, con diferentes perfiles de participación del programa "boquita del bebé" fueron analizadas. Entre ellos, 20 frecuentaban el programa, 20 habían desistido y 20 nunca participaron anteriormente. El perfil de comportamiento fue analizado por un examinador externo en el momento de la higiene bucal (profilaxis) por medio de la escala de comportamiento de Venham. Los datos fueron analizados mediante la regresión de Poisson (α=5%). Resultados: Los niños que presentaron peor comportamiento fueron aquellas que nunca participaron del programa "boquita del bebé" (OR: 3.80 / p=0.008), así como, los niños que no permitían el cepillado en casa (OR: 4.17 / p=0.001) y aquellos que sólo permitían el cepillado en ocasiones (OR: 3.07 / p=0.010). Conclusión: Existe una influencia positiva del programa en el condicionamiento psicológico, en la ansiedad de los niños y en la adopción de hábitos correctos en sus rutinas diarias.

The behavioral response of the child has been studied in some researches and is useful to predict how the child reacts to dental treatment, especially infants and young children, which is one of the greatest challenges of pediatric dentistry. Ob-jective: To evaluate the behavioral pattern of children from 3 to 5 years of age in a preventive program in the municipality of Gurupi /Tocantins, Brazil. Materials and methods: This study was evaluated and approved by the Ethics and Research Committee. A total of 60 children, with different participation profiles of the program "Baby's Little Mouth" were analyzed. Of these, 20 were frequent program participants, 20 were dropouts and 20 had never participated in the program before. The behavioral profile was analyzed by an external examiner, at the time of oral hygiene (prophylaxis), through the behavioral scale of Venham. Data were analyzed using Poisson regression analysis (α = 5%). Results: The children who presented the worst behavior were those who had never participated in the "Baby's Little Mouth" program (OR=3.80; p=0.008), as well as children who did not allow brushing at home (OR=4.17; p=0.001) and those that only allowed brushing someti-mes (OR=3.07; p=0.010). Conclusion: There is a positive influence of the program on psychological conditioning, on the anxiety of children and on the adoption of correct daily habits in their routines.

A resposta comportamental da criança tem sido estudada em algumas pesquisas e sendo útil para prever como a criança reage ao tratamento odontológico, especialmente os bebês e as crianças mais novas, que é onde se encontra um dos maiores desafios da odontopediatria. Objetivo: Avaliar o padrão comportamental de crianças de 3 a 5 anos de idade, em um programa preventi-vo do município de Gurupi/Tocantins, Brasil. Materiais e métodos: Este estudo foi avaliado e aprovado pelo Comitê de ética e pesquisa. Um total de 60 crianças, com diferentes perfis de participação do programa "Boquinha do bebê" foram analisadas. Dentre elas, 20 eram frequentadoras assíduas do programa, 20 eram desistentes e 20 nunca participaram anteriormente. O perfil comportamental foi analisado por um examinador externo no momento da higienização bucal (profilaxia) por meio da escala comportamental de Venham. Os dados foram analisados mediante a Regressão de Poisson (α=5%). Resultados: As crianças que apresentaram pior comportamento foram aquelas que nunca participaram do programa "Boquinha do bebê" (OR: 3,80 / p=0,008), assim como, as crianças que não permitiram escovação em casa (OR: 4,17 / p=0,001) e aquelas que só permi-tiam a escovação às vezes (OR: 3,07 / p=0,010). Conclusão: Existe uma influência positiva do programa no condicionamento psicológico, na ansiedade das crianças e na adoção de corretos hábitos em suas rotinas.

Cobertura de programas preventivos en Chile / Coverage with preventive programs in Chile

Introducción: Los Programas de Medicina Preventiva para que tengan un impacto en el nivel de salud deben tener una alta cobertura poblacional. Objetivo: Estudiar la cobertura de los programas preventivos que se realizaron en el Sistema de Salud Público Chileno el año 2007. Material y Métodos: Se revisó la cobertura de los programas preventivos en las bases de datos del Departamento de Estadísticas e Información en Salud del Ministerio de Salud de Chile del año 2007. Resultados: La cobertura global de los programas preventivos medido a través del Índice de Medicina Preventiva fue de0.202. El programa de salud dirigido a los < de 6 años (infantil) fue el que registró una mayor cobertura (0.84), un nivel de cobertura intermedio se observó en los programas de la mujer (0.34) y del adulto mayor (0.29), por su parte los programas dirigidos a la población escolar, adolescente y adulto fueron los que presentaron menores coberturas (<0.1). Discusión: La alta cobertura observada en el programa preventivo dirigido a la población infantil, ha sido un factor que ha favorecido la mejoría en el nivel de salud de este grupo poblacional, particularmente ha contribuido a reducirla mortalidad infantil en Chile. El país debe crear estrategias que permitan incrementar la cobertura en programas preventivos dirigidos a la población escolar, adolescente y adulta, solo de esta forma podrá seguir avanzando en la senda de mejorar el nivel de salud poblacional.

Introduction: In order to have an impact on the level of health, Preventive Medicine Programs should have high population coverage. Objective: To study the coverage of preventive programs which were conducted in the Chilean Public Health System in 2007. Material and Methods: The coverage of preventive programs in the databases of the Department of Health Statistics and Information of the Chilean Ministry of Health in the year 2007 were reviewed. Results: The overall coverage of preventive programs as measured by the index of Preventive Medicine was 0.202. The health program aimed at < 6 years (children) was the one that recorded a greatest coverage (0.84). An intermediate level of coverage was observed in the women’s program (0.34) and in that of elderly (0.29). Programs conducted for school children, teenagers, and adults presented a low coverage (<0.1). Discussion: The high coverage observed in the child health preventive program, has been a factor that has led to the improvement of the health status of this population group. Particularly, it has contributed to reduce the infant mortality in Chile. The country must create strategies to increase the coverage of preventive programs aimed at schoolchildren, teenagers and adults. Only in this way we can go on improving the level of population health.

Avaliação de programas preventivos: relato de experiência / Preventive programs evaluation: experience story / Evaluación de programas preventivos: relato de experiencia

A análise criteriosa de um projeto permite refiná-lo identificando seus aspectos dificultadores e facilitando a inclusão de estratégias efetivas para correção dos problemas. Alguns autores sugerem que a avaliação de programas preventivos seja feita considerando-se as etapas: análise do problema, delineamento do programa, realização de teste-piloto, realização de teste avançado, disseminação ou ampliação para outros contextos. O presente artigo, observando as referidas etapas, procurou avaliar um projeto preventivo que visa a estimular o desenvolvimento de habilidades sociais em crianças de 6 a 8 anos. Constatou-se que o projeto analisado tem vários aspectos positivos: promove mudanças sutis no comportamento das crianças e sensibiliza os pais para que estimulem condutas pró-sociais. Por outro lado, permitiu detectar que a não-utilização de uma estratégia efetiva de recrutamento e retenção dos participantes pode comprometer a transformação deste projeto em um programa.

A critical analysis of a project allows refining it by identifying the aspects that make it difficult in order to facilitate the inclusion of effective strategies for the correction of the problems. Some authors suggest that the evaluation of preventive programs is made, considering the stages: analysis of the problem, delineation of the program, accomplishment of test-pilot, accomplishment of advanced test, dissemination or enlargement for other contexts. The objective of this paper is to evaluate a preventive project that aim to stimulate the development of social abilities in children from 6 to 8 years old. It was observed that the analyzed project has some positive aspects: it promotes subtle changes in the behavior of the children and sensitizes the parents in order to stimulate pro-social behaviors. On the other hand, it allowed to detect that a non use of an effective strategy of recruitment and retention of the participants can compromise the transformation of this project in a program.

El análisis riguroso de un proyecto permite refinarlo, identificando aspectos dificultadores del mismo y facilitando la inclusión de estrategias efectivas para corrección de los problemas. El presente artículo procuró evaluar un proyecto preventivo que busca estimular el desarrollo de habilidades sociales en niños de 6 a 8 años. El análisis fue hecho tomando por base las etapas: análisis del problema, delineamiento del programa, realización de test piloto, realización de test avanzado, diseminación o ampliación para otros contextos. Se constató que el proyecto analizado tiene varios aspectos positivos: promueve cambios sutiles en el comportamiento de los niños y sensibiliza a los padres y profesores para que estimulen conductas pre-sociales. Por otro lado, permitió detectar que la no utilización de una estrategia efectiva de reclutamiento y retención de los participantes puede comprometer la transformación de este proyecto en un programa.

Capacidad predictiva de la Teoría de la Conducta Planificada en la intención y uso de drogas ilícitas entre estudiantes mexicanos

resumen está disponible en el texto completo

Summary The need of cost-effective drug abuse prevention programs has derived in a growing interest to develop scientific based alternatives. On this context, this study forms part of a project for the design and evaluation of a theoretical and empirically sustained intervention for illicit drug abuse prevention among Mexican junior high school students. Starting with the revision and assessment of different theoretical models that could be adapted to the conditions of the institutional context wherein the intervention will be developed, the Azjen and Fishbein's Theory of Planned Behavior was chosen. This theory includes proximal cognitive and attitude factors directly related to the initiation of drug use. In accordance with it, the experimental use of substances is a result of the intention of consuming them, which, in turn, depends on three elements: a) the attitude toward the drug use, b) the normative beliefs on this matter (subjective norm) and c) the perceived behavioral control regarding drug use or, in turn, confronting social pressure. In a first instance, several items were developed adapting the constructs of the Theory of Planned Behavior to the target population's characteristics. On this base, the reliability and validity of a self-applied questionnaire for the measurement of the variables of the model was proved. In this work are reported the findings of the evaluation of Theory of Planned Behavior's potential to predict both behavioral intention of using illicit drugs and consumption of substances among Mexican high school students, in order to set a precedent to apply the model later on in the design and evaluation of a preventive intervention directed to such population. Method: The study was carried on with an ex post facto, correlational design, and with a non-probabilistic sample of 1,019 subjects. Sample. The sample size was estimated considering the possibility of selecting a subsample of drug users and comparison subjects for a post-stratified analysis, assuring a statistical power of 80% and adequate sensibility and stability. Therefore, this work includes the performed analyses with a sample of 75 drug users and 75 non users, paired by gender, age, school grade and occupation. Instrument. The instrument was a self-applied questionnaire specially developed for the study, according to information obtained in previous focal groups interviews with high school students. The questionnaire showed a global realiability of 0.9154 and between 0.62 and 0.94 in each one of its scales, which included: behavioral beliefs (0.9121), attributed value to behavioral beliefs (0.7964), normative beliefs (0.6480), subject's disposition to adjust to normative expectations (0.8564), descriptive norm (0.6254), drug use opportunities (0.8129) and perceived behavioral control coping with such opportunity situations (0.9442). A factorial analysis of principal components yielded 16 factors of at least three items each, with factorial weights higher than 0.4, and closely attached to Theory of Planned Behavior's variables, with an explained variance of 59%. Analysis. Previous to data analysis, normality tests (Kolmogorov- Smirnov) were performed, indicating the necessity to apply nonparametric tests of differences and to transform the data to be adapted to the requirements of later parametric analyses. A correlation analysis was carried out to prove the association between behavioral intention and drug use, as well as between the different components of the Theory of Planned Behavior. Finally, linear and logistic regression analyses were conducted to determine the explicative potential of the model and the predictive weight of each variable on the model with regard to the behavioral intention and the consumption of drugs. Findings: According to the Mann-Whitney test, compared with students who had not used drugs, subjects that used them at least once in their life showed more favorable attitudes toward consumption (median= 6.9 vs. 3.9, z=-5.22, p=0.000), perceived more social tolerance (median=3.8 vs. 3.5, z=-2.27, p=0.023), were more willing to give in to social pressure for using substances (median=2.0 vs. 1.0, z=-5.598, p=0.000), perceived a higher number of users among their significant others, and less negative consequences Salud Mental, Vol. 30, No. 1, enero-febrero 2007 69 of drug use in themselves (median=16.3 vs. 7.1, z=-4.246, p=0.000), and felt less capable of behavioral control when coping with opportunities for consumption, which, in turn, are more frequent in their case (median=5.7 vs 1.8, z=-6.76, p=0.000). The correlation between the intention and the behavior of drug use (r=0.41, p<0.000) was allocated inside the range reported in other populations. Drug use intention correlated with attitude toward drug use at r=0.45 (p=0.000), with subjective norm, including additional components at r=0.48 (p=0.000), and with perceived behavioral control at r=0.59 (p=0.000). Drug use correlated with attitude at r=0.51 (p=0.000), with subjective norm at r=0.28 (p=0.001), and with perceived behavioral control at r=0.37 (p=0.000). Linear regression analysis yielded that the model explained 34% of the variance of drug use intention, which increased to 38% when adding personal and descriptive norm elements to the subjective norm construct. Behavioral control (measured on the basis of the product of exposition to drug use facilitating situations punctuations by perceived behavioral control to cope with these situations punctuations) was identified as the best predictor of drug use intention (B=0.32, p=0.001), followed by attitude toward drug use (B=0.24, p=0.004) and subjective norm, which originally showed a non-significant effect but increased its predictive weight when additional elements were added (B=0.24, p=0.004). According to the logistic regression analysis, behavioral control is also the best predictor of illicit drug use on the model (odds ratio= 1.42, p<0.000). On the contrary, subjective norm (including personal and descriptive norm) and attitude (odds ratio=1.144, p=0.06) were not significant predictors of drug use. Discussion: In general, this findings indicate that the Theory of Planned Behavior showed an acceptable predictive capacity (similar to that found in other populations), and can be taken as a valid theoretical ground to develop a preventive intervention directed to Mexican students of high school education. As is the case with other populations, the variable in the Planned Behavior Theory with more predictive weight was perceived behavioral control, followed by attitude to drug use and, in third place, by subjective norm. Despite it could be supposed that subjective norm would have a higher predictive weight in Mexican teenagers, findings probably reflected idiocentric and individualistic tendencies reported in other studies. Results also point out to the convenience of including it in the program of intervention informative components to produce an awareness effect and an impact in the intention of using drugs. Still, they indicate above all, the need to integrate components directed to the development and reinforcement of behavioral control abilities that have an effect in the use of drugs itself. Specifically, it is considered the convenience of including components for the development of group pressure resistance abilities and assertive communication, appropriate to the contexts in which young people face drug abuse risk situations.