Health promotion in youth as a global public health challenge: Effective strategies to encourage healthy lifestyles
- Autores: Magaly Aceves Martins
- Directores de la Tesis: Montserrat Giralt Batista (dir. tes.), Rosa Solà i Alberich (dir. tes.)
- Lectura: En la Universitat Rovira i Virgili ( España ) en 2016
- Idioma: español
- Tribunal Calificador de la Tesis: Anna Pedret Figuerola (presid.), Esteve Llargués Rocabruna (secret.), Luis Gracia Marco (voc.)
- Programa de doctorado: Programa de Doctorado en Biomedicina por la Universidad Rovira i Virgili
- Materias:
- Enlaces
- Tesis en acceso abierto en: hdl.handle.net
- Resumen
INTRODUCTION Health-compromising habits that emerge during childhood and adolescence could result in health issues such as high rates of obesity. Existing strategies have not been enough to tackle this problem. Research and implementation of new strategies that motivate and improve healthy habits that improve lifestyles among young people are needed.
HYPOTHESIS The combination of more than one methodological and environmental strategy may increase the effectiveness of engaging young people in health interventions aimed at encouraging healthy habits and lifestyles.
OBJECTIVES General Objective To provide innovative, effective and quality evidence-based environmental and methodological strategies that promotes healthy lifestyles in young people.
Specific Objectives 1) To assess the effectiveness of social marketing in European school-based interventions to prevent obesity relative to the social marketing benchmark criteria included in the intervention.
2) To implement and evaluate an innovative and comprehensive intervention aimed at increasing adolescents’ fruit and vegetable consumption and physical activity while reducing sedentary behaviours in a socioeconomically disadvantaged area in Spain.
3) To describe youth involvement as a health promotion strategy and to provide recommendations for health promoters, researchers and policy makers interested in successfully involving young people in health-related programmes to encourage positive working synergy.
4) To analyse the self-reported data on weight and height, including the missing data, from a cross-sectional study and to determine the dietary behaviours, physical activity practices and sedentary behaviours that influence the non-reporting of weight.
5) To analyse and explain the relation of daily physical activity practice over perceived physical and psychological health complaints and its possible variation explained by health behaviours, acting as potential moderators.
6) To compile, describe, and analyse the dietary conditions, physical activities, socioeconomic status (SES), and cultural factors that create and exacerbate an obesogenic environment among young people in Mexico.
7) To promote healthy diets by implementing a restaurant-based intervention through nutritional value and allergen listings on restaurant, take-away and snack bar menus in a resort and camping family holiday environment.
8) To provide general knowledge to relevant stakeholders and policy makers in a manner that fosters a participatory and inclusive multidisciplinary approach for long-lasting and effective results.
METHODS Study 1: Effectiveness of social marketing strategies to reduce youth obesity in European school-based interventions: a systematic review and meta-analysis.
The PubMed, Cochrane, and Education Resources Information Center (ERIC) databases were used to look up for school- based nonrandomized and randomized controlled trials conducted in Europe from 1990 to April 2014 in participants aged 5 to 17 years were included. After the study selection, the 8 domains of the Social Marketing Benchmark Criteria were assessed in each included study.
Study 2: The “Som la Pera” school-based, peer-led social marketing intervention for Spanish adolescents: a parallel cluster randomized control study.
High schools in disadvantaged neighbourhoods of Reus, Spain were randomly assigned to intervention (n=130 adolescents) or control groups (n=199 adolescents) of 13- to 16-year-old adolescents. The 12-month-long social marketing intervention spanned two academic years (2013-2015) involved 10 challenges that 5 adolescents created and implemented for their 125 schoolmates. In the control group, no intervention was implemented. The self-reported Health Behaviour in School-Aged Children (HBSC) survey was used by both groups to self-report their lifestyles.
Study 3: Young people's involvement in health promotion, research and policy making: recommendations This study compiled recommendations from reputable institutional guidelines and programme toolkits. These recommendations are presented in time-stages, (design, implementation and evaluation of health-related programmes) to facilitate the implementation of youth involvement as a sequential process.
Study 4: Self-reported weight and predictors of missing responses in youth: evidence from the Scottish HBSC Study Self-reported data on weight for 11-, 13-, 15-year-old children the Scottish HBSC Study 2014 were analysed. Dietary behaviours, physical activity and sedentary behaviours that may be associated with non-response to questions regarding self-reported weight were analysed using multivariate logistic regression.
Study 5: Daily physical activity practice and health behaviours that influence adolescents’ perceived physical or psychological health complaints: An analysis of potential moderators.
Data from the 2014 Health Behaviour School-Aged Children (HBSC) Scotland, 15-years old sample was used (n=2919, 50.2% boys and 49.8% girls). Sequential multiple regressions were executed to determine the explained variance of the relationship between PA practice and physical or psychological health complaint scores, and to characterise the relative contribution of each of the potential moderators (such as dietary, sedentary behaviours, and risky behaviours).
Study 6: Obesity-promoting factors in Mexican children and adolescents: challenges and opportunities A narrative review was performed using PubMed and the Cochrane Library databases, as well as grey literature data from the Mexican government, academics, and statistical reports from nongovernmental organizations, included in electronic formats.
Study 7: A restaurant-based intervention to facilitate healthy eating choices in a resort and camping family holiday environment From May 2014 to September 2015, Cambrils Park Resort (3 restaurants, 1 take-away, and 5 snack bars with 3,500 customers/day) and Camping Sangulí, Salou (1 restaurant, 1 take-away and 6 snack bars with 5,000 customers/day) in Catalonia (Spain) implemented a restaurant-based intervention based on 3 components: 1) providing nutritional and allergen analyses (Spanish regulation 1169/2011) of the dishes offered at the restaurants, 2) offering healthy gastronomic choices and 3) training staff on healthy eating and allergens. Moreover, the restaurant-based intervention adopted the following 6 strategies to increase customers’ healthy choices: 1) increasing availability, 2) increasing accessibility, 3) offering reduced prices, 4) providing point-of-purchase (POP) information, 5) improving catering policies and 6) engaging in promotion and communication.
RESULTS Study 1: Thirty-eight publications were included in the systematic review. For the meta-analysis, randomized controlled trials (RCTs) reporting body mass index (BMI) or prevalence of overweight and obesity were considered. Eighteen RCTs with a total of 8681 participants included at least 5 Social Marketing Benchmark Criteria (SMBC). The meta-analysis showed a small standardized mean difference in BMI of -0.25 (95%CI, -0.45 to -0.04) and a prevalence of overweight and obesity odds ratio (OR) of 0.72 (95%CI, 0.5–0.97).
Study 2: After the implementation, 38.5% of the intervention group adolescents consume ≥1 fruit/day compared with only 26.6% of the control group (p=0.024). Specially, 43.1% of the intervention females achieved the internationally recommendations of fruit consumption. Moreover, 35% in the intervention group practiced ≥6 hours/week physical activity compared with 18.6% of the control group (p=0.001). Conversely, vegetable consumption and sedentary behaviour did not significantly differ between groups at the end of the study.
Study 3: Youth involvement has the potential to be a “win-win” health strategy in which young people benefit by being included, and health promoters, researchers and policy makers profit from youth participation. If not properly done, however, such involvement could result in an unnecessary or hazardous experience for participants. Thus, a proper strategy for youth involvement in health processes is necessary but challenging. Recommendations were obtained from reputable institutional guidelines and programme toolkits. Such recommendations are presented in time stages (the design, implementation and evaluation of health-related programmes) to facilitate the implementation of youth involvement as a sequential process.
Study 4: A high percentage of cases were missing weight data (58.9%). The data were not randomly omitted; according to Little’s Missing Data at Random Test. Age, gender and family affluence were associated with the participants’ self-reported weight response. Those who reported practicing 60 minutes of physical activity per day for 3-4 days (OR .662, p<.001) and 5-7 days (OR .832, p<.001) per week were more likely to provide their weight compared with those who report engaging in less than two hours of physical activity per week. Those who reported consuming vegetables 2-4 days per week (OR .678, p<.001) or once or more a day (OR .838, p<.001) were more likely to provide their weight compared with those who reported consuming vegetables less than once a week. Those who reported approximately 3-4 hours of computer gaming per day on weekdays (OR 1.389, p<.001) are more likely to not providing their weight than those who spent approximately 6 hours a day or more (OR 1.232, p=.008) and those who reported spending less than 3 hours a day playing computer games.
Study 5: For the prediction of physical health complain scores, the inclusion of gender (β=.-0.249), sedentary behaviours (i.e. using computers for purposes other than gaming less than two hours per day (β=0.067) or less and being sitting less than two hours per day outside school (β=0.042)), not smoking (β=0.123) and not consuming alcohol (β=0.071), delivered a statistical significance in R2 of .025, β=0.043 (p<.001). Moreover, for the prediction of psychological health complaints score, the inclusion of gender (β=-0.262), Family Affluence Scale (β=0.070) sedentary behaviours (i.e. using computers for purposes other than gaming less than two hours per day (β=0.133) or less and being sitting less than two hours per day outside school (β=0.059)), not smoking (β=0.115) and not consuming alcohol (β=0.071), delivered a statistical significance in R2 of 0.031, β=0.074 (p<.001). These results suggest that these potential moderators included through each models could explain the variance of these scores.
Study 6: The recent socioeconomic and nutritional transition has resulted in reduced healthy meal options at public schools, high rates of sedentary lifestyles among adolescents, lack of open spaces and playgrounds, socioeconomic deprivation, false or misunderstood sociocultural traditional beliefs, misconceptions about health, a high percentage of overweight or obese adults, and low rates of maternal breastfeeding. Some of the factors identified are exacerbating the obesity problem in this population. Current evidence also shows that more policies and health programs are needed for prevention of childhood and adolescent obesity. Mexico presents alarming obesity levels, which need to be curtailed and urgently reversed.
Study 7: The family customer profile is parents with two children younger than 18 years. The restaurants increased the number of healthy dishes offered to obtain the Spanish government’s Mediterranean Diet certification (AMED). Furthermore, the kitchens and restaurants adapted gluten-free food criteria to obtain the Catalan Celiac Association’s (SMAP) certification. The ingredients of all 360 of the offered dishes were analysed and adapted based on healthy recommendations. Additionally, allergen-free and lactose-free dishes were offered. A new proposal of 10 healthy characteristics checklist for restaurant-based interventions is presented.
CONCLUSIONS 1) Social marketing is a methodological strategy. Including its 8 benchmark criteria domains increases the quality of research regarding the design and implementation of school-based interventions to prevent obesity. Current evidence indicates that the inclusion of at least 5 SMBC domains, regardless of which domains are chosen, must be included in the design of school-based interventions so that these interventions can benefit weight-related measures in young people.
2) A school-based, peer-led social marketing intervention developed by adolescents effectively improved the fruit consumption and physical activity practice of their peers by engaging them in making healthy choices, which consequently increased the number of young people in a socioeconomically disadvantaged area of Spain who achieved international health recommendations.
3) Youth involvement in health promotion should follow a well-thought-out procedure that encourages the appropriate synergy among young people and health promoters, researchers and policy makers. This synergy should catalyse conjoint efforts aimed at improving the health of youth. The proposed recommendations may be useful during the design, implementation and evaluation of health promotion efforts aimed at improving the health of young people.
4) Physical activity practice, vegetable consumption and computer gaming may be lifestyle factors that influence the non-response to self-reported weight questions in young people.
5) The relation between physical activity and perceived physical or psychological health complaint in adolescents can be positively moderated by reduced sedentary behaviours (i.e. using computers for purposes other than gaming less than two hours per day and being sitting less than two hours per day outside school) and reduced health risk behaviours (i.e. no smoking tobacco and not consuming alcohol), meanwhile, this relation is negatively moderated by gender. Furthermore, family affluence could also explain the variance in psychological health complaint scores.
6) Several dietary conditions, physical activity, SES, and cultural factors create and exacerbate an obesogenic environment among young people in Mexico. All the identified factors and how they influence the obesity epidemic should be considered in any health effort to reduce obesity in Mexico.
7) Healthy dishes can be promoted through a restaurant-based intervention of modifying nutritional values and allergens of restaurant, take-away and snack bar offerings within a resort and camping family holiday environment. A restaurant-based intervention increases the opportunities to encourage healthy choices among families and meet specific nutritional needs; thus, it could reinforce health promotion efforts to improve youth’s health.
Global Conclusion Factors with diverse origins influence the worldwide epidemic of youth obesity. Reversing or stopping the increasing obesity rates is a global challenge. In response to this challenge, the combination of multiple methodological and environmental strategies increases the effectiveness of engaging young people in health interventions that encourage healthy lifestyles. These strategies lead to a stronger, higher-quality research approach that is helpful for the scientific community, stakeholders and policy makers and promote a participatory and inclusive multidisciplinary approach for long-lasting and effective results that improve youth health worldwide.
