Journal of Childhood Obesity Open Access

Keywords

Childhood obesity; Public health practice; Health policy; Government

Introduction

Approximately 17% of U.S. children are obese, which elevates their lifetime risk for numerous chronic health conditions [1-3]. Experts have identified various, synergistic approaches to mitigate childhood obesity, such as altering school food environments, conducting outreach and education to children and families, and improving communities’ green spaces [4-6]. An additional, and related, option involves the use of public policy, such as legislation or regulation. At all levels of government, policy-makers have demonstrated a growing interest in childhood obesity prevention. For example, the number of childhood obesity prevention bills introduced and passed into law by state-level policy-makers has notably increased during the last decade [7-9].

Broad support is key for childhood obesity prevention policies to advance on legislators’ agendas [10]. Studies have confirmed that certain groups – such as policy-makers, nongovernmental organizations (NGOs), and academics – influence legislators by sharing research and anecdotes, giving testimony, and providing a window into constituents’ views [11-14]. This type of activity also gives legislators a sense of the breadth of support for a given piece of proposed legislation [15]. Thus, to promote childhood obesity prevention policies, stakeholder and researcher engagement is critical.

Despite this, the existing literature contains relatively little information about what factors influence stakeholder and research organizations to focus on childhood obesity prevention policies. Several studies have examined how and why health departments engage in obesity prevention activities [16-18].

A separate group of studies has focused on stakeholder opinions about why specific obesity prevention programs or policies are effective [19-21]. For example, Cleland et al. surveyed 304 public health practitioners and policy-makers to better understand their perceptions about obesity prevention programs implemented by their organizations [21].

These studies offer useful contextual information, but they do not contain insights from a wide range of organizations, and they focus on obesity in general rather than childhood obesity. This is an important distinction, as the political science literature has repeatedly confirmed that the motivation to protect children raises discrete concerns within the policy process [22-24]. Therefore, studies that consider obesity policy are not necessarily generalizable to the childhood obesity policy environment.

In addition, prior studies have not explored why stakeholder and research organizations choose to engage in policy work related to childhood obesity prevention. Addressing these gaps in the literature is critical for understanding how to maximize efforts related to childhood obesity prevention given the many competing policy priorities vying for limited resources.

Researchers have noted the potential utility of focusing on a diverse range of organizations to understand what influences them to focus on childhood obesity prevention policies [21].

This type of information would help stakeholders to better anticipate and respond to factors that may promote or inhibit their engagement with childhood obesity prevention and the policy process.

To help fill this gap, we interviewed policy-makers, NGO representatives, and academic researchers from throughout the U.S. about perceived facilitators and impediments to their work on childhood obesity prevention policies. Common themes are identified and opportunities to improve organizational engagement with childhood obesity prevention policies are discussed.

Methods

Creation and recruitment of sample

We conducted semi-structured interviews with policymakers, NGO representatives, and academics to understand the factors that facilitate or impede organizations’ focus on childhood obesity prevention policies.

Within our sample, policy-makers included individuals working in the legislative or executive branches of government at the state or local level (e.g. director-level staff in local government agencies).

NGO representatives were employed by non-profit groups that had no formal governmental affiliation (e.g. senior staff at local, regional, or national organizations).

Academics were individuals conducting childhood obesity prevention research and based in colleges or universities (e.g. professors and research staff).

With input from the American Heart Association and the Robert Wood Johnson Foundation, we created a purposive sample of individuals from these three groups.

All interviewees had at least some prior experience with childhood obesity prevention policies. We sent potential interviewees a recruitment email with information about the project and interview as well as eligibility criteria. For those who accepted our request, we conducted semi-structured interviews from September 2014 to April 2015.

Data collection and analysis

Interviews took 20 to 45 minutes, and followed an interview guide. The guide’s domains included factors that contribute to the organizations’ pursuit of childhood obesity prevention policies and factors that impede it. After securing permission, interviews were audio recorded and transcribed. Interviewees received a Target gift card for their participation in the interview. All transcripts were read in their entirety by members of the study team. We initially organized data in summary matrices in Microsoft Excel. These matrices, which included representative quotations, were used to identify patterns and preliminary themes among the interviews.

Using open coding, we created analytic memos to identify themes that emerged within each domain and among the three groups. The summary matrices and analytic memos were reviewed by members of the study team and interpretations of the data were discussed and refined.An Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health reviewed and approved this study.

Results

Our purposive sample contained 55 individuals, all of whom were contacted by email. Eight did not respond, and four declined our invitation. In total, we interviewed 43 individuals across the three stakeholder groups in 19 states and Washington, DC (12 policy-makers; 24 NGO representatives; 7 academics).

Facilitators of organizations’ work on childhood obesity prevention policies

Collaborations and partnerships

While several distinct themes emerged from each group, all three focused on collaborations and partnerships as facilitators of their work on childhood obesity prevention policies. (Table1). As one policy-maker explained, “It’s very much the… city agencies working together to improve the health of [our state].”

Group	Facilitators of Organizations’ Work on Childhood Obesity Prevention Policies	Representative Quotation
Policy-makers	Community-driven priorities	“I would say that first and foremost is the engagement of the community. We’ve got a steering committee that’s made up of over 50 partners, and that’s been critical to our success.”
	Cross-sector governmental collaboration	“It’s very much the…city agencies working together to improve the health of [our state].”
	Focus on children	“I think the thought of doing something for the kids has certainty, the ability to be able to effect change.”
	Personal priorities	“[T]here’s a lot of…interest even among people who kind of work in a different section of the [organization], they are still supportive and interested, so that helps.”
NGO representatives	Partnerships with other NGOs	“[H]aving the right partners to work with in any given state or city is really a key factor that we found some great partners from both the public health community as well as from other sectors.”
	Funding/capacity	“Funding, technical support, and other things as they relate to capacity. So, having enough staff, for example.”
	Increased awareness of issue	“Well the media is definitely interested in the issue. That has definitely helped, it’s something that folks are interested in…[T]he public profile that the First Lady has brought to this has been helpful.”
	Data	“I think we have really taken science into account on some of the things that we are proposing…so I think having scientific data really does help things.”
Academics	Quality of research	“I would say having high scientific standards, so that the work that gets produced can be trusted.”
	Translation and dissemination of research	“I think having strong advocates at the local, state, and national level that can take the research and really be able to help disseminate the findings and having it reach the policy makers.”
	Interdisciplinary partnerships	“We have sets of fantastic partners composed of the state department of education and the state department of health…I have been exceptionally lucky that our partner in the state level understands research and understands the importance of evaluating.”
	Funding	“Dedicated resources certainly are very important. I don’t think we could have, we would have been able to do the range of studies we have in the way that we’ve done them unless we were funded….”

Table 1: Facilitators of organizations’ work on childhood obesity prevention policies.

Academics valued interdisciplinary partnerships in their childhood obesity prevention work, including “connections with policy makers and legislators.” Finally, NGO representatives viewed partnerships with other NGOs as facilitating childhood obesity prevention efforts. According to one NGO representative, “It’s bringing all those partners together and making that, okay, we have—let’s all focus on the same policy and put our own needs aside. And let’s all put our strength together and focus on one particular thing.”

Community and personal priorities

In addition to collaborations, policy-makers identified three interrelated themes as facilitating their institutions’ work on childhood obesity prevention policies: 1) community-driven priorities; 2) focusing on children; and 3) personal priorities. According to one policy-maker, “[F]irst and foremost is the engagement of the community….We really went to the community and engaged them in identifying what those health priorities were.” Obesity policies that focus on children were found to resonate within government agencies and their surrounding communities: “[Y]ou see a kid, you see case studies, you see improvements, you see a particular child who’s just really taken to it and has made efforts to lose weight and become healthier and see the impact it has on the quality of their life.” Finally, policy-makers’ personal priorities were noted as facilitating their institutions’ work on childhood obesity prevention policies. For example, one policy-maker stated, “[T]here’s a lot of…interest even among people who kind of work in a different section of the [organization], they are still supportive and interested, so that helps.”

Funding

The role of funding in facilitating work on childhood obesity prevention policies emerged as a theme among interviewees in the NGO and academic groups. One academic highlighted the importance of “dedicated resources.” An NGO representative expanded on this idea, noting that facilitators included “funding, technical support, and other things as they relate to capacity. So, having enough staff, for example.”

Research and data

Interviewees in the NGO and academic groups focused on the role of research and data in facilitating their organizations’ work on childhood obesity prevention policies. Several NGO representatives highlighted the role of research in creating evidence-based policy. For example, according to one NGO representative, “[O]ur science and our process to develop policy priorities around an evidence base, singularly is probably the most useful….” Academics discussed research as a facilitator of their organizations’ childhood obesity prevention policy efforts in two distinct ways. First, high-quality research was viewed as particularly important: “I would say having high scientific standards, so that the work that gets produced can be trusted.” Second, academics repeatedly noted the need to translate and disseminate research about childhood obesity to facilitate their organizations’ policy work in this area. One academic described this as “taking the research and putting it to work in a policy framework.”

Increased awareness of childhood obesity

Finally, NGO representatives identified increased awareness of childhood obesity as facilitating their organizations’ policy work. This awareness was largely attributed to media attention: “I think what in general is propelling this, propelling our success is that obesity is in the media, it’s on people’s minds. I mean you really are seeing a lot of news coming out consistently for the last year about how bad sugar, how addictive sugar is, how bad it is for kids, how it’s being overconsumed….” First Lady Michelle Obama’s Let’s Move campaign was also viewed as raising “the public profile” of childhood obesity and facilitating organizations’ policy work in this area.

Impediments to organizations’ work on childhood obesity prevention policies

Lack of resources

Policy-makers, NGO representatives, and academics all perceived a lack of resources as impeding their organizations’ work on childhood obesity prevention policies. (Table 2). As one policy-maker explained, “Public health is pretty much chronically underfunded…you know, the grant-writing process can be cumbersome where you pull all your writers and then you write a grant and then you don’t get funded, so those are tough times definitely.” Similarly, academics identified “money and grant funding” as impediments. Several NGO representatives noted concerns about the unpredictable nature of funding to support their organizations’ policy work on childhood obesity prevention: “It’s the instability of commitment to the issue whether from public sector or private sector funders who may say, ‘We worked on that last year, now we’re going to work on something else.’”

Group	Impediments to Organizations’ Work on Childhood Obesity Prevention Policies	Representative Quotation
Policy-makers	Lack of resources	“We don’t have an exhaustive amount of money…se we have to make choices, so there’s competing needs….”
	Lack of engagement	“I think you get some of these projects rolling and the lack of interest in the community that people don’t want to take the time out of their day….”
NGO representatives	Lack of resources	“I think there’s just so much work to be done. We don’t have enough people and we don’t have enough time to do all that we could be doing, so it can be frustrating.”
	Inability to engage in advocacy	“So just understanding what we’re allowed to do, what we’re not allowed to, what’s considered lobbying, what’s not, just being really careful….”
	Obesity as an emerging issue	“There’s still people who don’t want to make changes or they deny that this is an issue. Sometimes it might be a financial issue with our potential partner if they don’t think they’re going to make as much money selling a healthier option or something like that.”
	Industry involvement	“I mean the food industry is definitely a barrier. The entertainment industry also when it comes to food marketing.”
Academics	Lack of funding	“It would be nice to have more money made available for work on public policy and obesity prevention.”
	Nature of academic research	“I suppose one of the inherent challenges is that you don’t want to do research that’s quick and dirty and have people running around advocating with it.”
	Industry involvement	“The food industry’s ability to try to thwart a lot of strategies that could be really effective in reducing obesity.”

Table 2: Impediments to organizations’ work on childhood obesity prevention policies.

Lack of engagement with childhood obesity

In addition to funding challenges, policy-makers also identified lack of engagement with the issue of childhood obesity as impeding their institutions’ work. One policy-maker noted difficulty in “getting the word out” about the health problems associated with childhood obesity and building local interest and momentum in the issue.

Industry involvement

The role of the food and beverage industry in impeding childhood obesity prevention policy efforts emerged as a theme within the academic and NGO groups. One academic summarized this as the negative influence of the “beverage sector with food industry’s power and money.” Similarly, an NGO representative noted the “well-organized and funded opposition of the industry.”

Institutional barriers

NGO representatives and academics both identified institutional barriers to their organizations’ childhood obesity prevention policy work. NGO representatives repeatedly mentioned NGOs’ limited or complete inability to engage in advocacy as an impediment. For example, according to one NGO representative, “[W]e have to walk that line of non-profit and the policy work….” Academics viewed the research process as impeding childhood obesity prevention policy work. One academic explained, “I suppose one of the inherent challenges is that you don’t want to do research that’s quick and dirty and having people running around advocating with it. So research is slow.”

Childhood obesity as an emerging issue

Finally, NGO representatives perceived childhood obesity’s relatively recent emergence as a public health issue as an impediment. One NGO representative stated, “I would say working specifically on obesity policy it’s just a new issue in general….So I think it’s been harder….” Another NGO representative further explained, “There’s still people who don’t want to make changes or they deny that this is an issue.”

Discussion

Policy approaches have been identified as an important component of childhood obesity prevention efforts, and stakeholder support is vital to their success [10,25,26]. Yet, the factors that lead key groups – including policy-makers, NGOs, and academics – to engage in this work are not well understood. We conducted interviews with individuals from these three relevant groups to explore perceived facilitators and impediments to their organizations’ engagement with childhood obesity prevention policies.

Across all three groups, collaboration was identified as an important facilitator of organizations’ focus on policies related to childhood obesity prevention. This finding is supported by studies concluding that partnerships promote organizations’ obesity prevention activities [17,27]. For example, Hersey et al. found a statistically significant association between state governments with greater numbers of partnerships and the passage of local obesity prevention policies [27]. These partnerships may be within one sector (e.g. several government agencies working together) or they may include representatives from multiple sectors (e.g. NGOs and academics). Scholars and practitioners have described models for such multi-sector partnerships in the context of obesity prevention, which offer useful insights for organizations focused specifically on childhood obesity prevention policies [28,29]. For example, Ziegahn et al. detail a partnership between several NGOs and an academic institution to identify barriers to chronic disease prevention and create strategies to address chronic diseases [28]. Regardless of the sectors represented, interviewees recognized the importance of including interdisciplinary perspectives to advance policy within their collaborations.

Interviewees in all three groups viewed lack of funding as an impediment to their organizations’ work on childhood obesity prevention policies. Without funding, organizations cannot hire new staff, develop materials for policy-makers, or support travel for visits with legislators, among other key activities. A dearth of financial resources is a chronic problem for organizations seeking to focus on obesity prevention: in a survey of local health departments in California, Schwarte et al. found that many respondents indicated an inability to fully staff their nutrition and physical activity projects due to funding constraints [30]. Harris et al. noted that state health department staff who focused on chronic disease prevention had difficulty accessing academic journals due to subscription costs [31]. Coupled with our results, these findings suggest that organizations must identify innovative funding streams to support their work on childhood obesity prevention policies. For example, organizations could consider revenue-generating options, such as charging for webinars, trainings, or reports they have produced, and using the resulting funds to support childhood obesity prevention policy efforts.

Interviewees in the NGO and academic groups mentioned institutional barriers that were viewed as impediments to their organizations’ engagement with childhood obesity prevention policies. NGO representatives mentioned that they perceived their organizations as having a limited ability to engage in advocacy or lobbying, making it difficult to intervene in the policy process [32,33]. Importantly, certain governmental and foundation funding sources may prohibit lobbying activities related to work they support. Academics noted the slow nature of the research process as an impediment to their organizations’ engagement with childhood obesity prevention policies. This is consistent with findings that suggest the promotion and tenure process – which relies in large part on academics’ research – does not encourage communicating with policy-makers [34]. Giles-Corti et al. have offered several recommendations to better bridge academic research on obesity prevention and engagement with legislators, including the use of interdisciplinary research teams that include public health practitioners and policy-makers and capitalizing on natural experiments that result from the implementation of a given policy [35].

This study’s strengths include its geographic diversity and large sample size, but its limitations should be noted. Our purposive sample included individuals already working in the area of childhood obesity prevention. This may have introduced bias into the sample, as these individuals were more likely to be interested in the subject matter. Also, because individuals’ responses reflect the state and local political environment in which their organization operates, our findings may not be generalizable. In addition, our findings are likely not generalizable to obesity policies in general, as childhood obesity policies may raise unique concerns. Finally, our interviewees generally did not discuss concrete solutions to the impediments that they identified, which is an important area for future research concerning organizational engagement with childhood obesity prevention policies.

Conclusion

Stakeholder and researcher engagement brings important issues to policy-makers’ attention and raises the profile of proposed legislation. Despite this, little information is available about what influences these groups to focus on childhood obesity prevention policies. After interviewing policy-makers, NGO representatives, and academics, we identified key facilitators of this work, including collaborations, funding, and available research. Impediments included a lack of financial resources, the influence of the food and beverage industries, and institutional barriers. For organizations that promote childhood obesity prevention policies – or are interested in becoming involved in this work – our findings highlight key factors to consider in strategic planning and related processes.

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