Methods of defining best practice for population health approaches with obesity prevention as an example
Food Safety Authority Of Ireland, Dublin, Leinster, IrelandProceedings of The Nutrition Society (Impact Factor: 5.27). 12/2006; 65(4):403-11. DOI: 10.1079/PNS2006520
Childhood obesity has reached a crisis stage and has become a population health issue. The few traditional systematic reviews that have been done to identify best practice provide little direction for action. The concept of evidence-based practice has been adopted in health care, and in medicine in particular, to determine best practice. Evidence-based medicine has its origins in the scientific method and for many researchers this concept means strict adherence to standards determining internal validity in order to justify a practice as evidence based. Practitioners addressing population health face challenges in identifying criteria for determining evidence, in part because of the nature of population health with its goal of shifting the health of whole populations. As well, the type of evidence provided by more traditional critical appraisal schema is limiting. Expanded approaches in finding and defining evidence have been proposed that use: expert panels; broad and inclusive search and selection strategies; appraisal criteria that incorporate context and generalizability. A recent synthesis of 147 programmes addressing childhood overweight and obesity provides a concrete example of using a broader approach to identify evidence for best practice (Flynn et al. 2006). Incorporating evaluation and population health frameworks as criterion components in addition to traditional methodological rigour criteria, this synthesis has identified programmes that provide contextual information that can be used to populate what Swinburn et al. (2005) have described as the 'promise table'. Using this approach a range in 'certainty of effectiveness' and a range in 'potential for population impact' are integrated to identify promising strategies. The exercise can provide direction for agencies and practitioners in taking action to address obesity.
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ABSTRACT: The increasing prevalence of obesity in children is an issue in many countries across the world. While undernutrition (in terms of deficient nutrient intake) continues to be a problem for many children, overnutrition (in terms of energy intake in excess of needs) is an increasing public health concern. Our genetic make−up has evolved to deal with an environment where food is scarce at times and plentiful at other times. In this type of environment the capacity for fat deposition means that we are more likely to survive through periods when food is scarce. Our bodies may also seek to minimise energy expenditure in order not to expend too much of our fat stores. Children today are faced with an environment where food is of a high quality and plentiful, and there are many opportunities to limit physical activity. Play is often focused on sedentary games and entertainment,such as watching television. Many children today are, therefore, dealing with an environment which promotes obesity.
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ABSTRACT: In clinical medicine, due to the widening gap between the demand and delivery of healthcare services in the 1970s and 1980s, priority-setting in health policies began to focus on efficiency and service costs. This situation, which is frequent inWestern societies, led to the emergence of the clinical practice known as evidence-based medicine. This is usually defined as "the conscious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Historically, the health promotion field has been slow in embracing the use of evidence, and this hesitation may be connected with the Ottawa Charter for Health Promotion (Evans, Hall, Jones, & Neiman, 2007). The Ottawa Charter (World Health Organization, 1986), considered a milestone in the development of health promotion, did not prioritize the use of evidence to measure effectiveness. It was only in 1998 that the World Health Organization launched an appeal to connect health promotion strategies with the production of health promotion evidence (Evans et al., 2007). InWestern societies, where healthcare expenditures account for a large portion of government budgets, there is continuous pressure to demonstrate that health promotion is a good investment (Evans et al., 2007), and this pressure is growing. Evidence is required to lessen the uncertainty of decision-makers and to guide action priorities (Raphael, 2000). In addition, practitioners in the field have a legitimate desire to show that their work brings tangible benefits (McQueen, 2007a). So the health promotion field really has no choice but to continue trying to assess the effectiveness of its interventions. There is an important gap between interventions that are deemed effective on the basis of evidence and interventions that are actually implemented in practice (Glasgow & Emmons, 2007). For instance, the complexity of health promotion interventions poses significant conceptual and methodological challenges for the assessment and production of results syntheses that would provide a rational basis on which to guide practices. Moreover, users of research results, such as practitioners and decision-makers, raise a broader range of questions than those addressing intervention effectiveness (Glasgow & Emmons, 2007; Petticrew & Roberts, 2003; Rychetnik & Wise, 2004). Among others, they formulate questions concerning the social, political, and economic settings in which the interventions are developed, implemented, and assessed, as well as the development and implementation of the intervention itself, and the conditions required to maintain interventions over time (Armstrong et al., 2008). So how can we respond to the challenge of producing systematic reviews that capture the essence of the practices that are transferable to other contexts (Potvin & McQueen, 2008)? This chapter presents a pragmatic reflection intended for practitioners who must incorporate evidence in their dayto- day decisions. Systematic reviews, which are large-scale projects considered to have high scientific value, also have their limitations. The objective here is to present these limitations and to propose an alternate approach to producing them. The first section describes the paradigm shift in the concept of evidence, which has been under debate for the past fifteen years. Second, an explanation is given for why systematic reviews in this field do not appear to have effectively impacted health promotion practices or policies. Third, we propose four types of criteria to include when assessing systematic reviews in order to encourage transfer of their contents to health promotion practices. In light of these criteria, we suggest a realist approach to the production of systematic reviews. Combining the generation of evidence and social values, it is a promising tool to guide intervention planning and implementation.
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ABSTRACT: To explore the everyday consumption of meals and snacks from the child's perspective, among those with healthier v. less healthy dietary habits. The sample in this qualitative study comprised two groups of Danish schoolchildren aged 10 to 11 years, one with a healthier diet (n 9) and the other with a less healthy diet (n 8). Both groups were recruited from respondents to a dietary survey. Semi-structured interviews took their starting point in photographs of their meals and snacks taken by the children themselves. Both subgroups of children had a meal pattern with three main meals and two to four snacks. We found a connection between the nutritional quality of the diet and the social contexts of consumption, especially with regard to snacks. Among children with healthier eating habits, both snacks and meals tended to be shared social events and items of poor nutritional quality functioned as markers of a special social occasion. This was not the case among children with less healthy eating habits. All children described particular rules governing food consumption within their families. Although only some of them had participated in the development of these rules, and despite the fact that rules were different and were perceived as having been developed for different reasons, children from both subgroups tended to accept them. The results of the study suggest that dietary interventions designed to promote children's health should focus more on the different social contexts of consumption and more on the role of parents.