Obstacles and Enablers on the Way towards Integrated Physical Activity Policies for Childhood Obesity Prevention: An Exploration of Local Policy Officials' Views.

Background. Limited physical activity (PA) is a risk factor for childhood obesity. In Netherlands, as in many other countries worldwide, local policy officials bear responsibility for integrated PA policies, involving both health and nonhealth domains. In practice, its development seems hampered. We explore which obstacles local policy officials perceive in their effort. Methods. Fifteen semistructured interviews were held with policy officials from health and nonhealth policy domains, working at strategic, tactic, and operational level, in three relatively large municipalities. Questions focused on exploring perceived barriers for integrated PA policies. The interviews were deductively coded by applying the Behavior Change Ball framework. Findings. Childhood obesity prevention appeared on the governmental agenda and all officials understood the multicausal nature. However, operational officials had not yet developed a tradition to develop integrated PA policies due to insufficient boundary-spanning skills and structural and cultural differences between the domains. Tactical level officials did not sufficiently support intersectoral collaboration and strategic level officials mainly focused on public-private partnerships. Conclusion. Developing integrated PA policies is a bottom-up innovation process that needs to be supported by governmental leaders through better guiding organizational processes leading to such policies. Operational level officials can assist in this by making progress in intersectoral collaboration visible.

Barriers to and Facilitators of the Evaluation of Integrated Community-Wide Overweight Intervention Approaches: A Qualitative Case Study in Two Dutch Municipalities.

To prevent overweight and obesity the implementation of an integrated community-wide intervention approach (ICIA) is often advocated. Evaluation can enhance implementation of such an approach and demonstrate the extent of effectiveness. To be able to support professionals in the evaluation of ICIAs we studied barriers to and facilitators of ICIA evaluation. In this study ten professionals of two Dutch municipalities involved in the evaluation of an ICIA participated. We conducted semi-structured interviews (n = 12), observed programme meetings (n = 4) and carried out document analysis. Data were analyzed using a thematic content approach. We learned that evaluation is hampered when it is perceived as unfeasible due to limited time and budget, a lack of evaluation knowledge or a negative evaluation attitude. Other barriers are a poor understanding of the evaluation process and its added value to optimizing the programme. Sufficient communication between involved professionals on evaluation can facilitate evaluation, as does support for evaluation of ICIAs together with stakeholders at a strategic and tactical level. To stimulate the evaluation of ICIAs, we recommend supporting professionals in securing evaluation resources, providing tailored training and tools to enhance evaluation competences and stimulating strategic communication on evaluation.

Recommendations and Improvements for the Evaluation of Integrated Community-Wide Interventions Approaches.

Background. Integrated community-wide intervention approaches (ICIAs) are implemented to prevent childhood obesity. Programme evaluation improves these ICIAs, but professionals involved often struggle with performance. Evaluation tools have been developed to support Dutch professionals involved in ICIAs. It is unclear how useful these tools are to intended users. We therefore researched the facilitators of and barriers to ICIA programme evaluation as perceived by professionals and their experiences of the evaluation tools. Methods. Focus groups and interviews with 33 public health professionals. Data were analysed using a thematic content approach. Findings. Evaluation is hampered by insufficient time, budget, and experience with ICIAs, lack of leadership, and limited advocacy for evaluation. Epidemiologists are regarded as responsible for evaluation but feel incompetent to perform evaluation or advocate its need in a political environment. Managers did not prioritise process evaluations, involvement of stakeholders, and capacity building. The evaluation tools are perceived as valuable but too comprehensive considering limited resources. Conclusion. Evaluating ICIAs is important but most professionals are unfamiliar with it and management does not prioritise process evaluation nor incentivize professionals to evaluate. To optimise programme evaluation, more resources and coaching are required to improve professionals' evaluation capabilities and specifically the use of evaluation.

Perspectives of Fijian Policymakers on the Obesity Prevention Policy Landscape.

In Fiji and other Pacific Island countries, obesity has rapidly increased in the past decade. Therefore, several obesity prevention policies have been developed. Studies show that their development has been hampered by factors within Fiji's policy landscape such as pressure from industry. Since policymakers in the Fijian national government are primarily responsible for the development of obesity policies, it is important to understand their perspectives; we therefore interviewed 15 policymakers from nine Fijian ministries. By applying the "attractor landscape" metaphor from dynamic systems theory, we captured perceived barriers and facilitators in the policy landscape. A poor economic situation, low food self-sufficiency, power inequalities, inappropriate framing of obesity, limited policy evidence, and limited resource sharing hamper obesity policy developments in Fiji. Facilitators include policy entrepreneurs and policy brokers who were active when a window of opportunity opened and who strengthened intersectoral collaboration. Fiji's policy landscape can become more conducive to obesity policies if power inequalities are reduced. In Fiji and other Pacific Island countries, this may be achievable through increased food self-sufficiency, strengthened intersectoral collaboration, and the establishment of an explicit functional focal unit within government to monitor and forecast the health impact of policy changes in non-health sectors.

Design of CIAO, a research program to support the development of an integrated approach to prevent overweight and obesity in the Netherlands.

BACKGROUND: The aim of this paper is to describe the research aims, concepts and methods of the research Consortium Integrated Approach of Overweight (CIAO). CIAO is a concerted action of five Academic Collaborative Centres, local collaborations between academic institutions, regional public health services, local authorities and other relevant sectors in the Netherlands. Prior research revealed lacunas in knowledge of and skills related to five elements of the integrated approach of overweight prevention in children (based upon the French EPODE approach), namely political support, parental education, implementation, social marketing and evaluation. CIAO aims to gain theoretical and practical insight of these elements through five sub-studies and to develop, based on these data, a framework for monitoring and evaluation. METHODS/DESIGN: For this research program, mixed methods are used in all the five sub-studies. First, problem specification through literature research and consultation of stakeholders, experts, health promotion specialists, parents and policy makers will be carried out. Based on this information, models, theoretical frameworks and practical instruments will be developed, tested and evaluated in the communities that implement the integrated approach to prevent overweight in children. Knowledge obtained from these studies and insights from experts and stakeholders will be combined to create an evaluation framework to evaluate the integrated approach at central, local and individual levels that will be applicable to daily practice. DISCUSSION: This innovative research program stimulates sub-studies to collaborate with local stakeholders and to share and integrate their knowledge, methodology and results. Therefore, the output of this program (both knowledge and practical tools) will be matched and form building blocks of a blueprint for a local evidence- and practice-based integrated approach towards prevention of overweight in children. The output will then support various communities to further optimize the implementation and subsequently the effects of this approach.

'Are we there yet?' - operationalizing the concept of Integrated Public Health Policies.

OBJECTIVES: Although 'integrated' public health policies are assumed to be the ideal way to optimize public health, it remains hard to determine how far removed we are from this ideal, since clear operational criteria and defining characteristics are lacking. METHODS: A literature review identified gaps in previous operationalizations of integrated public health policies. We searched for an approach that could fill these gaps. RESULTS: We propose the following defining characteristics of an integrated policy: (1) the combination of policies includes an appropriate mix of interventions that optimizes the functioning of the behavioral system, thus ensuring that motivation, capability and opportunity interact in such a way that they promote the preferred (health-promoting) behavior of the target population, and (2) the policies are implemented by the relevant policy sectors from different policy domains. CONCLUSION: Our criteria should offer added value since they describe pathways in the process towards formulating integrated policy. The aim of introducing our operationalization is to assist policy makers and researchers in identifying truly integrated cases. The Behavior Change Wheel proved to be a useful framework to develop operational criteria to assess the current state of integrated public health policies in practice.

Proposing a conceptual framework for integrated local public health policy, applied to childhood obesity--the behavior change ball.

BACKGROUND: Childhood obesity is a 'wicked' public health problem that is best tackled by an integrated approach, which is enabled by integrated public health policies. The development and implementation of such policies have in practice proven to be difficult, however, and studying why this is the case requires a tool that may assist local policy-makers and those assisting them. A comprehensive framework that can help to identify options for improvement and to systematically develop solutions may be used to support local policy-makers. DISCUSSION: We propose the 'Behavior Change Ball' as a tool to study the development and implementation of integrated public health policies within local government. Based on the tenets of the 'Behavior Change Wheel' by Michie and colleagues (2011), the proposed conceptual framework distinguishes organizational behaviors of local policy-makers at the strategic, tactical and operational levels, as well as the determinants (motivation, capability, opportunity) required for these behaviors, and interventions and policy categories that can influence them. To illustrate the difficulty of achieving sustained integrated approaches, we use the metaphor of a ball in our framework: the mountainous landscapes surrounding the ball reflect the system's resistance to change (by making it difficult for the ball to roll). We apply this framework to the problem of childhood obesity prevention. The added value provided by the framework lies in its comprehensiveness, theoretical basis, diagnostic and heuristic nature and face validity. SUMMARY: Since integrated public health policies have not been widely developed and implemented in practice, organizational behaviors relevant to the development of these policies remain to be investigated. A conceptual framework that can assist in systematically studying the policy process may facilitate this. Our Behavior Change Ball adds significant value to existing public health policy frameworks by incorporating multiple theoretical perspectives, specifying a set of organizational behaviors and linking the analysis of these behaviors to interventions and policies. We would encourage examination by others of our framework as a tool to explain and guide the development of integrated policies for the prevention of wicked public health problems.

Towards health in all policies for childhood obesity prevention.

The childhood obesity epidemic can be best tackled by means of an integrated approach, which is enabled by integrated public health policies, or Health in All Policies. Integrated policies are developed through intersectoral collaboration between local government policy makers from health and nonhealth sectors. Such intersectoral collaboration has been proved to be difficult. In this study, we investigated which resources influence intersectoral collaboration. The behavior change wheel framework was used to categorize motivation-, capability-, and opportunity-related resources for intersectoral collaboration. In-depth interviews were held with eight officials representing 10 non-health policy sectors within a local government. Results showed that health and non-health policy sectors did not share policy goals, which decreased motivation for intersectoral collaboration. Awareness of the linkage between health and nonhealth policy sectors was limited, and management was not involved in creating such awareness, which reduced the capability for intersectoral collaboration. Insufficient organizational resources and structures reduced opportunities for intersectoral collaboration. To stimulate intersectoral collaboration to prevent childhood obesity, we recommend that public health professionals should reframe health goals in the terminology of nonhealth policy sectors, that municipal department managers should increase awareness of public health in non-health policy sectors, and that flatter organizational structures should be established.

Interventions to promote an integrated approach to public health problems: an application to childhood obesity.

Experts stress the need to bring the childhood obesity epidemic under control by means of an integrated approach. The implementation of such an approach requires the development of integrated enabling policies on public health by local governments. A prerequisite for developing such integrated public health policies is intersectoral collaboration. Since the development of integrated policies is still in its early stages, this study aimed to answer the following research question: "What interventions can promote intersectoral collaboration and the development of integrated health policies for the prevention of childhood obesity?" Data were collected through a literature search and observations of and interviews with stakeholders. Based on a theoretical framework, we categorized potential interventions that could optimize an integrated approach regarding children's physical activity and diet. The intervention categories included education, persuasion, incentivization, coercion, training, restriction, environmental restructuring, modeling, and enablement.