Why do Organizations Focus on Health Equity in their Childhood Obesity Policy Work?

Lainie Rutkow, JD, PhD, MPH

Associate Professor Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health 624 N. Broadway Room 592, Baltimore, MD 21205, USA; Tel. 410-614-6404; E-mail: lrutkow@jhu.edu

INTRODUCTION

Obesity affects nearly one in five US children, increasing their likelihood of developing chronic diseases.^1,2,3,4,5 The Institute of Medicine (IOM), Centers for Disease Control and Prevention (CDC), and academic researchers have recognized that socio-economic, racial, and ethnic disparities exist relative to childhood obesity.^{6,7,8,9,10,11} To address this, advocates and policy-makers should consider health equity and the differential impacts that a childhood obesity policy may have.

Equity (also known as human equity) is the absence of avoidable or preventable differences between groups with varying levels of social advantage/disadvantage (i.e., wealth, power, prestige).¹² Health equity falls under this broader umbrella and refers to the absence of systematic differences in social conditions or other modifiable determinants of health between more and less advantaged social groups.¹³ Despite the importance of promoting equity, and health equity in particular, many policies that address childhood obesity fail to explicitly consider health equity. In fact, Bleich et al¹⁴ recently found that from 2012-2013, among statelevel bills related to childhood obesity, only one-third focused on health equity. For example, a community’s policy to improve walkability may enhance parks and other walking spaces situated in higher but not lower income neighborhoods. In doing so, the policy allows children in higher income neighborhoods to benefit from these improvements while those in lower income neighborhoods do not. On the other hand, childhood obesity prevention policies that explicitly consider health equity are more likely to help all children achieve their full potential. For example, a policy designed to improve access to primary care and health promotion services for children at high risk of developing obesity ensures that those most in need of specific health services receive them. These two contrasting examples raise several important points: 1) while childhood obesity prevention inherently involves health equity, policies to address this public health challenge do not always account for health disparities; 2) well-intentioned policies (e.g., to improve walkability) may further entrench a community’s health disparities if they fail to account for health equity; and 3) not all stakeholders in the policy-making process will prioritize health equity concerns (e.g., some stakeholders will want to improve walkability in specific neighborhoods to encourage tourism).

In light of this, it is important to understand what drives organizations to focus on health equity when working in the area of childhood obesity. By learning why some groups prioritize health equity and others do not, we can gain insights about how to incentivize the inclusion of health equity concerns in the policy-making process. Due to the rapid proliferation of policies to address childhood obesity, this information is critical to inform current policy formulation and implementation debates. To answer this question, we interviewed policy-makers, non-governmental organization (NGO) representatives, and academics to explore factors that lead these groups to focus on health equity when working in the area of childhood obesity policy.

MATERIALS AND METHODS

Using a semi-structured format, we interviewed policy-makers, representatives of NGOs, and academics to explore why organizations focus on health equity within their childhood obesity work. Academic interviewees worked in college or university settings and conducted research about childhood obesity. NGO interviewees worked for non-profit groups and had some personal experience with childhood obesity-related policies. Policy-maker interviewees worked in state or local legislatures or administrative agencies and had previously worked on issues related to childhood obesity. Our purposive sample was developed with participation from the American Heart Association (AHA) and the Robert Wood Johnson Foundation (RWJF).

We initially contacted potential interviewees via email and provided project information and eligibility criteria to participate in an interview. We conducted semi-structured interviews with those who accepted our invitation from September 2014 to April 2015. We used an interview guide for all interviews, which contained domains concerning factors that lead organizations to focus on issues related to health equity within their childhood obesity policy work. Each interviewee was asked the following questions: 1) To what extent does your childhood obesity policy work specifically focus on issues related to health equity? “Health equity” generally refers to all people having the opportunity to attain their full health potential. In this initiative, we are focusing primarily on racially, ethnically, and socio-economically disadvantaged individuals and communities; and 2) To what extent and how do you consult with or partner with communities of color and low-income communities in your work to reduce childhood obesity? Interviews lasted from 20 to 45 minutes, and were recorded and transcribed. Participants received a $50 Target gift card.

Members of the study team read all transcripts in their entirety. To organize the data, summary matrices with representative quotations were created in Microsoft Excel. These matrices allowed for the initial identification of themes and patterns within the interviews. Open coding was used to develop analytic memos, which identified themes across the three groups and within each group. Members of the study team reviewed the matrices and analytic memos, allowing for iterative data interpretation.

This research was reviewed and approved by a Johns Hopkins Bloomberg School of Public Health Institutional Review Board, MD, USA.

RESULTS

We contacted 55 individuals, and 12 declined to participate or did not respond (78% participation rate). Our final sample consisted of 43 individuals from 19 states and Washington, DC, USA. Within this group, there were 12 policy-makers, 24 NGO representatives, and 7 academics.

Interviewees from all three groups identified their organization’s focus area or mission as involving health equity (Table 1). As a result, their work approached childhood obesity policies through this lens. As one NGO representative stated, “All of our work addresses health equity”. Similarly, one academic noted, “I don’t think we do anything that isn’t proportionately focused on low-income people”.

Academics and NGO representatives explained that their funding encourages or requires them to prioritize health equity in their childhood obesity policy work. According to one NGO representative, “We’re funded entirely by grants and contracts within that world, we certainly spend a lot of time thinking and talking about this issue of health equity”.

Policy-makers noted that direct engagement with the communities in which they are situated has led to an increased focus on health equity in their childhood obesity policy work. As one policy-maker stated, “It’s working in that neighborhood and with that community that’s really got the health problems and trying to build them up and help them help themselves to work on their health issues”. Finally, several NGO representatives stated that concerns about health equity inherently arise in any efforts related to childhood obesity policies.

Policy-makers and academics found that they could not pursue these interests without relevant data that allowed them to focus on health equity within their broader work on childhood obesity policies. For example, a policy-maker explained, “The big challenge of ours is getting data at the neighborhood levels that is critical for developing strategies and initiatives and then evaluating outcomes as well, what our impact is”.

DISCUSSION

NGO representatives and academics noted that certain funding streams encourage or require a health equity focus within their childhood obesity policy work. Because some organizations may overlook or not prioritize health equity research, public and private funders should consider whether they want to require a health equity focus when developing calls for proposals.

Policy-makers and academics discussed how availability of data influences whether their childhood obesity policy work accounts for health equity. This suggests that, even if an interest in health equity exists, it may not be pursued if data are lacking or difficult to access. Governmental and other groups that manage large data sets should identify opportunities to engage with researchers (e.g., conferences, webinars) to share information about opportunities to incorporate health equity data into analysis relevant to childhood obesity policy.

Our study’s strengths include the geographic and professional diversity of our interviewees, but several limitations should be noted. The generalizability of our findings may be limited to individuals who fit into one of the groups on which we focused: academics, NGO’s, and policy-makers. Also, the individuals in our purposive sample had a demonstrated interest in childhood obesity. They may have been more likely to find the subject matter, and thus participation in the interview, more appealing than individuals without similar experience.

CONCLUSION

Well-documented disparities among socio-economic, racial, and ethnic groups underscore the importance of incorporating health equity considerations into childhood obesity policies. Yet, to date the factors that motivate organizations to focus on health equity within the broader context of childhood obesity policy have remained unclear. Our interviews identified several factors-including organizational mission, funding requirements, and data availability as influencing this decision.

These findings can influence current activities and policy debates in several ways. First, funders may sway academics and NGO’s by explicitly requiring a focus on health equity when they issue a call for proposals related to childhood obesity policy. Second, processes for easily sharing large data sets that incorporate health equity data-such as those maintained by the federal government-with academics should be developed and promoted. Finally, community-based NGO’s should actively engage with their local and state representatives, as these officials have noted the importance of such interactions in shaping their focus on health equity within childhood obesity policy.

ACKNOWLEDGEMENTS

This work was supported by a grant from the Robert Wood Johnson Foundation (ID 71767). The authors thank Laura Leviton at the Robert Wood Johnson Foundation and George Grob at the Center for Public Program Evaluation for helpful feedback on manuscript drafts.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to disclose.

1. Skinner AC, Mayer ML, Flower K, Weinberger M. Health status and health care expenditures in a nationally representative sample: How do overweight and healthy-weight children compare? Pediatrics. 2008; 121(2): e269-e277. doi: 10.1542/peds.2007-0874

2. Juonala M, Magnussen CG, Berenson GS, et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. New Engl J Med. 2011; 365(20): 1876-1885. doi: 10.1056/NEJMoa1010112

3. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012; 307(5): 483-490. doi: 10.1001/jama.2012.40

4. McCrindle BW. Cardiovascular consequences of childhood obesity. Can J Cardiol. 2015; 31(2): 124-130. doi: 10.1016/j.cjca.2014.08.017

5. Berentzen NE, van Rossem L, Gehring U, et al. Overweight patterns throughout childhood and cardiometabolic markers in early adolescence. Int J Obes. 2016; 40(1): 58-64. doi: 10.1038/ ijo.2015.196

6. Blanck HM, Kim SA. Creating supportive nutrition environments for population health impact and health equity: An overview of the nutrition and obesity policy research and evaluation network’s efforts. Am J Prev Med. 2012; 43(3 Suppl 2): S85-S90. doi: 10.1016/j.amepre.2012.06.005

7. IOM, Institute of Medicine, Committee on Childhood Obesity Prevention. Creating equal opportunities for a healthy weight: Workshop summary. Washington, DC, USA: National Academies Press; 2013.

8. Dodd AH, Briefel R, Cabili C, Wilson A, Crepinsek MK. Disparities in consumption of sugar-sweetened and other beverages by race/ethnicity and obesity status among United States school children. J Nutr Educ Behav. 2013; 45(3): 240- 249. doi: 10.1016/j.jneb.2012.11.005

9. Kimbro RT, Denney JT. Neighborhood context and racial/ ethnic differences in young children’s obesity: Structural barriers to interventions. Soc Sci Med. 2013; 95: 97-105.doi: 10.1016/j. socscimed.2012.09.032

10. Shih M, Dumke KA, Goran MI, Simin PA. The association between community-level economic hardship and childhood obesity prevalence in Los Angeles. Pediatr Obes. 2013; 8(6): 411-417. doi: 10.1111/j.2047-6310.2012.00123.x

11. Payne GH, James SD Jr, Hawley L, et al. CDC’s Health Equity Resource Toolkit: disseminating guidance for state practitioners to address obesity disparities. Health Promot Pract. 2015; 16(1): 84-90. doi: 10.1177/1524839914538967

12. World Health Organization. Health systems: Equity. 2006. Website. http://www.who.int/healthsystems/topics/equity/en/. Accessed August 3, 2016

13. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003; 57: 254-258. doi: 10.1136/ jech.57.4.254

14. Bleich SN, Jones-Smith J, Jones H, O’Hara M, Rutkow L. The voices for healthy kids campaign and U.S. state legislation to prevent childhood obesity. Am J Public Health. 2016; 106(3): 436-439. doi: 10.2105/AJPH.2015.303002