Public Health Lessons Learned

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The purpose of this paper is not to suggest specific intervention strategies to prevent childhood obesity, but rather to learn from other public health experiences and to glean lessons that might help inform efforts to prevent childhood obesity. There is certainly no shortage of theories, models, and approaches to help guide public health program planning. There are multiple health behavior theories that are commonly used to guide public health efforts (Glanz et al., 2002), and popular planning models have been designed to help diagnose health problems (Green and Kreuter, 2000), identify the factors that contribute to these problems, and devise appropriate interventions. In general, these theories and models recommend taking a broad view of changing health behaviors and conditions, suggesting multi-factorial, comprehensive interventions that address multiple aspects of the problem. Recently, the Institute of Medicine (2002) endorsed this broad approach to public health interventions, recommending the adoption of an "ecological model" for viewing public health problems and interventions, where the individual is viewed within a larger context of family, community, and society. Overall, there is increasing interest in public health interventions being comprehensive, addressing the multiple factors that influence the health problem, and striving to strike a balance between efforts directed at the individual and the social-environmental context in which people live. It is likely that this approach will be as relevant for the prevention of childhood obesity as it is for other contemporary public health challenges. However, as previously stated, the purpose here is not to propose a comprehensive intervention program for childhood obesity, but rather to identify the factors associated with success in other public health areas, both as a result of planned interventions and also corresponding to social, cultural, or temporal factors.

Despite the notable successes in public health over the past century, there are no generally agreed on approaches or interventions that can be applied to multiple public health problems, with the same intervention effect seen with different problems. There are general guidelines and recommendations, core functions for public health, but no generic model program, best practices, or common lessons learned that could be applied to most or all public health problems.

There are "best practices" for specific public health problems, but little research or insight of the extent to which these categorical approaches are generalizable to other public health challenges. For example, the Centers for Disease Control and Prevention's (CDC's) Best Practices for Comprehensive Tobacco Control Programs (CDC, 1999a) describes nine programmatic areas (i.e., community programs, school programs, statewide programs, etc.) that have been shown to be effective in reducing tobacco use.2 In practice, these programs are typically delivered "comprehensively," and it is difficult, if not impossible, to tease out the relative impact of specific program components within these comprehensive, real-life campaigns. For this reason, program evaluations of large-scale public health campaigns tend to assess the collective effort, rather than the impact of individual program components. Because of the difficulty in teasing out the effect of one component of a comprehensive program, evaluations have tended to focus on the overall program impact and on the relationship between financial investment in program activities and changes in health behaviors. Data on the impact of comprehensive programs is strong, both in terms of changes in health behavior, as well as in terms of health outcomes (CDC, 2000). Recent analysis has confirmed that the greater the investment in comprehensive programs, composed of evidence-based programs, the larger the public health benefit (Farrelly et al., 2003).

In addition to tobacco control, recent review articles have analyzed the evidence for the effectiveness of public health interventions for a variety of public health problems, including dietary behavior, underage drinking, and motor vehicle injuries, to name just a few. For example, a recent review by Bowen and Beresford (2002) concluded that although much has been learned about trying to change dietary practices clinically, it is particularly important to learn how to transform the successes obtained from interventions aimed at the individual to community and public health settings. Gielen and Sleet (2003) reviewed the injury prevention literature and concluded that a simplistic belief that imparting information would result in behavior change and injury risk reduction resulted in an over-reliance on engineering solutions alone as the basis for injury prevention programs. These authors reinforce the need for interdisciplinary approaches to injury prevention, using behavioral science theory, coupled with engineering solutions.

These observations from other public health problems (e.g., determining how to expand clinical success to communities, combining behavioral

2For example, in 1999, the CDC's Best Practices for Comprehensive Tobacco Control Programs was developed to guide state health departments in planning and allocating funds from the Master Settlement Agreement. The Best Practices document does not explicitly recommend policy or regulatory actions, such as an increase in the excise tax on tobacco products, or clean indoor air laws, because they did not require budget expenditures.

and environmental approaches) are informative and relevant for the development of programs to prevent childhood obesity.

Ten Greatest Public Health Achievements in the 20th Century

To begin to understand the potential generalizability of "best practices" for specific health problems, it is useful to look at the evidence for the specific success stories and determine if there are any common elements, or lessons learned, that tend to span multiple problems.

In 1999, acknowledging public health successes, CDC published a list of the ten greatest public health achievements of the 20th century (CDC, 1999b) (Box D-1).

The subsequent Morbidity and Mortality Weekly Reports (MMWR) documented the reason these achievements were selected and described the progress made in each area in terms of death and disease prevented. Although efforts were made to account for the reasons for the progress, there was no systematic effort to attribute improvements in health status to specific interventions, and no attempt was made to determine if there were common interventions that contributed to the amelioration of multiple health problems.

A preliminary review of the MMWR reports reveals a pattern of categories of interventions that appear to have played a role in accomplishing multiple achievements. The goal was to identify instances, across achievements, of community intervention categories found in the past to have strong evidence of effectiveness with multiple health behaviors or problems. As Table D-1 shows, intervention categories identified most frequently included community-wide campaigns, mass-media strategies, changes to

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