Be Our Voice Blog
Blog Entries from 05/2012
Wednesday, May 23rd, 2012
When it comes to local advocacy, there is no one-size fits all approach. However, Be Our Voice has developed a framework that can help guide advocates through the process of creating an Advocacy Plan to steer their work. Having a clear, detailed plan is one of the most important components of effective advocacy—without a plan, it can be much more difficult to stay focused, measure your success, and meet your goals.
Over the next several weeks, we’ll be talking about the different steps in this advocacy framework and how each step can help advocates amplify their impact in the community.
Step #1: Define the community/communities in which you will focus your advocacy activities!
Pediatric healthcare professionals have a large patient population that includes kids from newborns to eighteen year olds and all those in between (and even some past the age of eighteen). Their patient population also includes parents (adult and teen) since healthcare professionals give support and guidance to the parents as well as the pediatric patients who come through their offices. In addition, this patient population can be racially/ethnically mixed or homogenous, rich or poor, English-speaking or non-English speaking, etc.
And obesity can affect any or all of the patients in this population.
So given the diversity of the pediatric patient population, how do healthcare professional advocates choose where to focus their advocacy efforts? After all, there’s so much that could be done for so many!
The answer? Group advocacy—tailoring advocacy activities and interventions to address problems that members of a group have in common.1 A group can be defined by age, gender, race, ethnicity, socioeconomic status, language, location, school, health outcome, etc. But the more clearly defined the group, the easier it is to tailor advocacy and interventions. Defining a specific group for interventions may make obtaining funding easier. And focusing at first on a specific group means advocates can start small, see successes, and build on these successes later.
There are several considerations when choosing a focus population for advocacy efforts: passion, personal practice experience, data, or all of the above. Healthcare professional advocates might choose a target population based on one served by existing coalitions or advocacy activities in their community. For example, a pediatric care provider with a longtime passion for breastfeeding might focus on new moms in the community. Someone in an area with high rates of obesity among African-American children might join with others in the community who already focus on African-American families in specific neighborhoods. Such collaboration among advocates amplifies advocacy.
According to Dr. Judith Palfrey, a professor of pediatrics at Harvard University Medical School, “The most successful group programs concentrate energy on one type of child or problem, but they derive that energy from multiple sources. To battle childhood obesity, the staff members in the clinic, the teachers in the school, the YMCA director, the church pastor, and the families all deliver the same message. They serve the same balanced nutrition. They all show up at the fitness fair.”1
A great example of collaborative advocacy can be seen in NICHQ’s Collaborate for Healthy Weight project, where diverse partners from public health, primary care, and community organizations bring their expertise and energy together to address local community problems with a consistent message. For instance, the Collaborate for Healthy Weight team from Fairfield County, South Carolina, is focusing on a population defined by geography: pediatric and adult patients at two specific health centers.2
Many obesity prevention advocacy activities clearly target specific populations. Highlighted here are some that will hopefully give healthcare professional advocates ideas for novel ways to use creative advocacy and interventions to target specific populations.
Target Population: 60 Latino families participating in Head Start
Location: Lubbock, TX
Description: Through the Texas Tech University Health Sciences Center, promotoras (community health workers) will make home visits for 6-12 weeks to teach families about health eating and exercise, providing social support and education as part of an obesity prevention study.
Target Population: Obese pediatric patients in the Healthy Hearts Clinic at the North Oakland Children’s Hospital
Location: Oakland, CA
Description: The hospital and Phat Beats Produce host an on-site Farmer’s Market, provide patients with market vouchers, and cooperate on a garden that is shared and worked by hospital patients and neighborhood families.
Target Population: Northeastern Ohio children ages 8-13 who are overweight/obese
Location: Akron, OH
Description: Akron Children’s Hospital offers Future Fitness Clubs in community fitness club locations for children and teens to learn about exercise and nutrition in a group setting.
Target Population: Residents in food deserts and project youth
Location: Nashville, TN
Description: Vanderbilt Children’s Hospital is involved in The Veggie Project, which organizes youth-run produce markets at community host sites in food deserts. The program also involves nutrition education.
Target Population: Pregnant and postpartum moms
Location: Scottsdale, AZ
Description: Gestational diabetes can affect both mom’s and baby’s health, increasing baby’s risk of obesity. Scottsdale Hospital’s Gestational Diabetes Education Program helps moms control their gestational diabetes during pregnancy, and provides postpartum follow-up care and a diabetes prevention class.
Target Population: Grandparents who regularly care for their grandchildren
Locations: Houston, TX; Chicago, IL; New York City, NY
Description: Healthy GrandFamilies educates grandparents about kids’ nutrition and exercise. Pediatric healthcare providers offer education at community sites in large cities like Chicago and Houston.
- Palfrey, Judith. Child Health in America: Making a Difference Through Advocacy. Baltimore: The Johns Hopkins University Press, 2006.
- The Herald Independent. “Eat Smart, Move More Fairfield receives grant.” Published April 21, 2012. http://heraldindependent.com/view/full_story/18048988/article-Eat-Smart--Move-More-Fairfield-receives-grant
Thursday, May 17th, 2012
Healthcare professional advocates beware! Your patients not only see Cartoon Network, Nick Jr., and Disney Channel characters on TV and online, but also at grocery and convenience stores on food packaging.
The list of characters that can all be found in the aisles of supermarkets seems endless: Dora the Explorer, My Little Pony, Disney Princesses, Madagascar’s Penguins, Nemo, Super Mario, Veggie Tales, Alvin and the Chipmunks...And these particular characters are just the ones gracing packages in the fruit snack and cereal aisle.
But why should we care? What is the impact of putting cartoon characters on food packaging? Research has shown this marketing tactic leads to a lot of results, and most of them aren’t good for kids’ health.
First, kids as young as 2 or 3 can recognize and identify the characters1, and these character-covered boxes are often placed on lower shelves so it’s easy for kids to notice these food items (and to beg mom and dad to buy them). Second, when they see character-covered boxes, many kids automatically prefer these foods over and above the same foods marketed without the characters. 1 In one prominent study, researchers gave children three pairs of identical foods, and within each pair there was one package with TV characters on it. Guess which foods 50-55% of the children thought tasted better? You guessed it: the ones with recognizable characters on the packaging.1
Young children can’t understand the persuasive intent of advertising, and they can’t think critically about marketing messages. Kids see their favorite characters on food packaging and automatically equate the food with being good and “cool.” The food industry knows this all too well, and they also know that children are big influences on their parents’ wallets.
The food industry has repeatedly fought regulation of advertising aimed at kids, sometimes defending this kind of marketing as a First Amendment right. But a recent article in Health Affairs argued that case law history shows the First Amendment does not offer protection to “inherently misleading” commercial speech, that all commercial speech is “inherently misleading” to children who can’t understand its messages, and that it can be regulated by government.2
However, currently, there is little regulation of this massive industry. Food marketing to kids is big business: $1.6 billion is spent per year, much of it on TV commercials.3 Kids see 11 ads for every hour of TV watched, and more than 80% of ads in children’s programs are for fast food or snacks.4 Many of the foods advertised—and many of the packaged in character-covered boxes— are processed foods high in fat, sugar, and salt. And as any healthcare professional can tell you, foods like these contribute to childhood obesity.
So what can healthcare professional advocates do? In the office, talking with families about media literacy and screen time is a good starting point. At a practice-wide level, TV’s viewable in waiting rooms can show DVDs instead of TV stations to reduce exposure to food commercials. Community advocacy could involve urging grocery stores to practice responsible marketing, such as not putting junk food at kids’ eye level and keeping healthy foods in the checkout aisles instead of candy.
Advocacy on a broader level could yield changes in how marketing practices are used, perhaps to market healthier foods instead of junk food. In a previous Be Our Voice blog post, we explored a few companies that have found novel, profitable ways to package and advertise healthy foods. Regulating, limiting, and eliminating unhealthy food marketing to kids is not easy, but it is necessary and possible, with the combined efforts of many advocates. After all, TV characters belong on TV—not on our food.
- Roberto et al. “Influence of Licensed Characters on Children's Taste and Snack Preference.” Pediatrics. 2010; 126; 88-93.
- Graff et al. “Government Can Regulate Food Advertising To Children Because Cognitive Research Shows That It Is Inherently Misleading.” Health Affairs. February 2012 vol. 31 no. 2 392-398.
- Yale Rudd Center for Food Policy and Obesity. “Food Marketing to Youth.” http://www.yaleruddcenter.org/what_we_do.aspx?id=4
- Council on Communications and Media. “Children, Adolescents, Obesity, and the Media.” Pediatrics. 2011; 128; 201.
Further Advocacy Resources & Information
- AAP Media Matters Campaign: http://www2.aap.org/advocacy/mediamatters.htm
- Center on Media and Child Health at Children’s Hospital Boston: http://www.cmch.tv
- Prevention Institute’s “We’re Not Buying It” Campaign: http://preventioninstitute.org/focus-areas/supporting-healthy-food-a-activity/supporting-healthy-food-and-activity-environments-advocacy.html
- Yale Rudd Center on Food Policy and Obesity: http://www.yaleruddcenter.org/
Thursday, May 10th, 2012
Pediatric providers practicing in safety net settings—such as community health centers, free clinics, and public hospitals—face multiple and unique challenges when it comes to childhood obesity. First, they tend to care for more kids from low-income families, and since poverty and obesity are connected in multiple and complex ways,1-5 providers working in a safety net setting must address poverty-related barriers to healthy lifestyles. Second, safety net facilities are often themselves cash-strapped as a result of having to rely on uncertain federal grants and decreasing Medicaid payments, which makes sustaining obesity programming very difficult.
Pediatric providers and other healthcare professionals can have different roles within obesity programs. Some working in safety net settings are actively involved in conducting such programs, while others in more mainstream settings might refer patients and their families to these programs. For example, a 5-year old child who is overweight, a US citizen, and enrolled in Medicaid may be eligible for a referral to a private hospital’s pediatric fitness program. But if his 12-year old sister, who is also overweight, was born in Mexico—and therefore not eligible for a referral to a private hospital through Medicaid—she could instead be referred to a community health center’s fitness program.
Pediatric providers in mainstream settings can also collaborate with their safety net counterparts to meet the needs of a broader sector of the population beyond those normally seen in their clinics. So what can providers working in safety net settings do to support obesity programming for their patients?
Some safety net facilities across the country are finding creative ways to implement childhood obesity programs in their neighborhoods and communities without relying on uncertain funding sources. These facilities are partnering with other organizations and groups to build on each other’s strengths, resources, and ability to reach kids and their families. Here are just a few examples of innovative childhood obesity programs being implemented at safety net facilities:
Educating Patients and Families:
- Petaluma Health Center (California) has a garden onsite and pediatric patients in the Petaluma Loves Active Youth program help raise plants and harvest the food. There are weekly cooking demos, and classes on healthy eating with exercise for the kids.
- Charles Drew Health Center (Omaha, NE) hosts a 12-week Healthy Families class so children and parents can learn about healthy eating and exercise, and benefit from the attention of multidisciplinary clinical teams. Incentives such as YMCA memberships are offered.
- Community Health Center, Inc. (Meridien, CT) offers a six-week program for teen girls and women concerned about weight called “Food Smart and Fit.”
- The Community Health Centers Alliance (CHCA, Florida) plans to conduct electronic and chart surveillance of childhood obesity and to promote best practices among providers. They hope to create a Childhood Obesity Practice Manual with clinical guidelines and other resources.
- CHAMPS (Community Health Association of Mountain/Plains States) has a website of obesity resources for member CHC’s and their providers.
There’s no need to reinvent the wheel when trying to build up an obesity program! Both Be Our Voice and the American Academy of Pediatrics provide childhood obesity advocacy resources that are relevant in safety net settings. The Obesity Society and the National Association of Community Health Centers also created a resource specifically for providers in safety net settings entitled Childhood Obesity Resource Guide. The National Association of Children’s Hospitals and Related Institutions (NACHRI) developed the Survival Guide to Planning, Building, and Sustaining a Pediatric Obesity Program as a tool for healthcare professionals who are ready to roll up their sleeves and move their weight management program to the next level.
- Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among United States adults, 1999–2008. JAMA 303:235–41. 2010.
- National Institutes of Health. Clinical Guidelines on the identification, evaluation, and treatment of overweight and obesity in adults-The evidence report. Obes Res 6 Suppl 2:51S–209S. 1998.
- Sobal J, Stunkard AJ. Socioeconomic status and obesity: A review of the literature. Psychol. Bull 105:260–75. 1989.
- McLaren L. Socioeconomic status and obesity. Epidemiol Rev 29:29–48. 2007.
- Centers for Disease Control and Prevention. National Center for Health Statistics. National Health and Nutrition Examination Survey. Available from: http://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htm
Tuesday, May 1st, 2012
Most pediatric care providers talk about healthy eating and exercise when patients and families are in the exam room. And while this is an important part of obesity prevention, providers can actually start promoting healthy habits even earlier in the visit: when patients and families first enter the healthcare facility. Be Our Voice advocates can help to create a practice environment that is designed to support obesity prevention by making sure that their healthcare facility not only “talks the talk” but also “walks the walk.”
The AAP Policy Opportunities Tool lists evidence-based, practice-level interventions according to the 5-2-1-0-Breastfeeding-BMI healthy message framework. Some of these recommendations are discussed here, along with examples of facilities currently implementing them. But please note that these facilities are not the only ones putting these recommendations into practice—they are just examples!
Healthy Eating Strategy: Require menu labeling in hospital cafeterias and vending sites to provide consumers with calorie information on menus and menu boards.
This strategy helps empower consumers to make healthier food choices. The information provided may range from complete nutrition information to a simple display of the number of calories in a particular food item. As part of a research study, Massachusetts General Hospital in Boston implemented a red-yellow-green stoplight system to help cafeteria customers know which foods and drinks were the healthiest (“green” items offered the best nutrition, “yellow” items offered nominal nutrition, and “red” items were the least healthy options). During Phase 1 of the study, there were statistically significant reductions in sales of “red” food items and increases in sales of “green” food items. Throughout Phase 1 and Phase 2, there were significant reductions in sales of “red” beverages and increases in sales of “green” ones.1
Screen Time Reduction Strategy: Limit the use of televisions in practice and hospital waiting rooms.
Many pediatric providers tell patients to limit TV at home, but this advice may ring a little hollow when patients are allowed to watch big-screen TV’s in waiting rooms or to spend their entire hospital stay glued to video games. Pediatric care providers will gain credibility with the “limit TV” message by following the AAP’s recommendation to “serve as good role models by using television appropriately and by implementing reading programs using volunteer readers in waiting rooms and hospital inpatient units.”2 Waiting room books and reading activities are frequently part of Reach Out and Read practices, but they are feasible in other practices as well.
Physical Activity Strategy: Create opportunities for physical activity in clinical settings for employees, patients, and their families via events or design/built environment.
Practice-level interventions to increase physical activity may differ depending on the target audience, whether it consists of employees or patients. But all interventions should be designed to get people to move more! For employees, there are many ways to support exercise and to promote physical activity. One example comes from Cleveland Clinic, which offers exercise classes and discount/free health club memberships as part of employee wellness efforts. In pediatric settings, patient-focused events will, out of necessity, target parents and families as well as children. These events could include walks and runs that offer opportunities for fun family exercise and health education, such as the Super Kids Sunday 5K and Fun Run organized by Miller Children’s Hospital in Long Beach.
Limit Sugar-Sweetened Beverages Strategy: Restrict sugar sweetened beverages from cafeterias and mobile vending machines in practices and hospitals.
Pediatric care providers can ensure that their practices set good examples by providing healthy beverages. This means limiting the availability of soda and other sugar-sweetened beverages while increasing more nutritious options. A practice could start on a small scale by having a Soda-Free Summer event and go soda-free for one summer along with other community organizations. Hospital-wide possibilities include no-soda policies, such as the one implemented in January 2011 at Nationwide Children’s Hospital in Columbus, Ohio. In Boston, 10 hospitals recently pledged to get rid of all high-sugar beverages, offer healthier beverage options, install free water dispensers, and educate patients and staff about nutritious beverages.
Breastfeeding Strategy: Provide lactation room and adequate breaks for nursing mothers.
Providing private lactation rooms and sufficient breaks to pump breast milk are ways for practices to support breastfeeding, both among mothers of patients and among employees. This is becoming an increasingly common practice in healthcare facilities. One of the first milestones in Boston Medical Center’s journey to Baby-Friendly Designation was opening a breastfeeding and pumping room in 1998—their Breastfeeding Center is now one of the foremost programs of its kind in the country. A simple Internet search will yield many other examples of places that do it (and do it very well)!
BMI Strategy: Advocate for payment by public and private insurance for obesity related services.
This practice-level intervention for BMI involves advocating for insurance and Medicaid plans to cover ongoing, multidisciplinary obesity care. Two studies conducted by the Robert Wood Johnson Foundation found that the groundwork is in place for Medicaid, but most state Medicaid manuals do not provide clear or adequate information about coverage levels and appropriate reimbursement codes for specific elements of care. 3 Therefore, providers remain uncertain about which services they can provide and if they can be reimbursed. Individual practices can make use of the AAP’s Obesity Practice Management Resources that provide information and tools so providers can ensure payment for multidisciplinary obesity care for their patients.
The strategies mentioned above are only a sampling of the many practice-level interventions recommended by the AAP. There are also other interventions related to the 5-2-1-0-BF-BMI areas that are not mentioned in the Policy Opportunities Tool. For instance, several of the teams participating in NICHQ’s Collaborate for Healthy Weight initiative aren’t focusing on payment models in their BMI-related interventions, but rather on aiming to consistently assess BMI, help patients understand it, and incorporate it as part of obesity prevention efforts for both children and adults.
Practices can, and should, think creatively when it comes to creating an office environment that supports healthy eating and active living for their patients. While the interventions recommended in the AAP Policy Opportunities Tool are by no means exhaustive, they are a great place to start thinking about ways you can transform your practice into a part of your obesity prevention strategy!
- Thorndike, AN et al. American Journal of Public Health. 2012 Mar;102(3):527-33. Epub 2012 Jan 19. Erratum in: Am J Public Health. 2012 Apr;102(4):584. http://www.ncbi.nlm.nih.gov/pubmed/22390518
- AAP Committee on Public Education. “Children, Adolescents, and Television.” Pediatrics Vol. 107 No. 2. 02/2001. pp. 423 -426. http://pediatrics.aappublications.org/content/107/2/423.full
- Robert Wood Johnson Foundation. “Study of State Medicaid Resources for Childhood Obesity Prevention.” 2005/2006. http://www.rwjf.org/reports/grr/053842.htm