Programme framework

This PhD research was integrated into a programme that aimed to improve food intake, nutrition and health in Ecuadorian adolescents, i.e. the Food, Nutrition and Health Project. The latter was implemented through an inter University Collaboration (http://www.vliruos.be/en/) between Ghent University/University of Leuven (Belgium) and Cuenca University (Ecuador) (from 2008 to 2018).

Based on literature, expert opinions, and meetings with the local research team, the programme identified unhealthy body weight in young adolescents (11 to 15 years old) as a major health problem. It consequently aimed to tackle this problem using a school-based intervention to prevent unhealthy body weight within this population group.

A stepwise and systematic approach for intervention development has been advocated to ensure meaningful and sustainable changes in health behaviour (57). Health promotion has adopted rigorous planning processes, and different models can be used to guide this process (58-60). To reach the objectives of the programme, a framework was developed using the stepwise approach described by Green and Kreuter in the simple Model for Planned Health Promotion and Education (Figure 3) (61). This framework involved a thorough epidemiological analysis of the health problem and needs assessment (Phase A-C). As this framework does not provide detail on how to develop a complex intervention to achieve behaviour change, both the Intervention Mapping (IM) and the Comprehensive Participatory Program and Evaluation (CPPE) protocols were used to guide the development, implementation, evaluation and dissemination processes of the intervention (Phase D) (62;63). Phase E involves the implementation of the intervention. Using the findings from phases A - E, an evaluation study design was developed. Responding to obesity and chronic diseases requires in each society proper understanding of the local context and factors involved. Local data on the prevalence of unhealthy body weights and current dietary and PA patterns and their determinants were collected to account for the different contexts in a LMIC. Theory, local evidence and participation were the three main pillars of this programme framework. The following paragraphs detail each step of this programme framework.

3.2.1 Phase A: Analysis of the health problem in Ecuadorian adolescents

Dietary risk factors such as diets low in fruit, vegetables, and whole grains and physical inactivity collectively accounted for 10% of global DALYs in 2010 (2). These dietary risk factors and high Body Mass Index (BMI) have increased in relative importance over the past decades and are now leading risks of disease in Latin America (2;64). Obesity affects a large amount of Latin American adolescents

Figure 3 Programme framework for a school-based intervention in Ecuadorian adolescents (after Green and Kreuter, 1999 (61)). IM: Intervention Mapping and CPPE: Comprehensive Participatory

Planning and Evaluation.

Phase C: Identification and analysis of factors influencing

risk behaviors

CO N TEXT

Phase D: Intervention development using IM and

CPPE based on Phases A-C Phase B: Identification and analysis of risk behaviors of the

health problem

Phase E: Implementation of the intervention

Phase A: Identification and analysis of the health problem

Need s as ses smen t

DISS EM INATI ON EVAL U ATIO N

with national prevalence estimates ranging from 16.6% to 35.8% (16.5 to 21.1 million) (19). Obesity and chronic diseases are complex multifactorial problems with genetic, lifestyle, cultural, medical, social and moral causes (65). Hence, adequate and culturally-appropriate evidence on its current prevalence and clear insight into its behavioural causes are needed.

A cross-sectional study was carried out as such data were lacking for the Ecuadorian adolescent population (in 2008). This study included 770 school-going adolescents (aged 10-16 years old) from an urban (Cuenca) and rural area (Nabón). Data on anthropometry, blood pressure, socio-demographics, and current dietary and PA patterns and their driving factors were collected. The study also assessed fasting blood glucose and lipid profiles in a subsample of 334 adolescents. The study protocol was approved by both Ecuadorian and Belgian Ethical Committees (no. 2008100-97/

no. B67020084010). Detailed information on the design and results of this study has been published elsewhere (66-68).

The findings of the cross-sectional study indicated that 18.0% and 2.1% of the adolescents (both Cuenca and Nabón) were classified as being overweight and obese, respectively. Other important risk factors were dyslipidemia (34.2%) and high levels of blood pressure (6.2%). Importantly, a considerable share (19.7%) of adolescents in this study were diagnosed with central obesity (67).

Children living in the rural area were 2.8 times (P = 0.002) more likely to have dyslipidemia than those from the urban area. Boys were found to have a lower BMI than girls, and the difference in overweight prevalence was marginal between socio-economic groups (67). With similar obesity prevalence as for example Mexico (69), these figures clearly show that Ecuador is in full epidemiologic transition. Such findings justify spending time, money and resources on the development, implementation and evaluation of preventive interventions as proposed by the programme. Recent data from the “Encuesta Nacional de Salud y Nutrición 2011-2013” further support such investments (Figure 4); The Azuay Province (34.5%) has the highest childhood obesity prevalence.

Figure 4 Prevalence of underweight, overweight and obesity in adolescents (12-19 years old) per province (70)). (a) Stunting (height for age< -2SD), (b) Overweight and obesity (BMI per age > +1SD)

3.2.2 Phase B: Risk behaviours associated with the health problem in Ecuadorian adolescents The following dietary and PA behaviours have been (independently) associated with a high risk of obesity and/or chronic diseases: over-consumption of energy-dense foods (71), high intakes of specific foods such as sugary drinks (72) and processed foods (73), erratic behaviours such as skipping breakfast (74), diets low in fruit and vegetables and whole grains, nuts and seeds, and seafood omega-3 fatty acids (2), and an increasing sedentary lifestyle and low PA levels (2;71).

Behavioural influences on obesity can differ between cultures, and specific dietary and PA behaviours need to be identified prior to designing interventions. Additionally, a valid and feasible assessment of these behaviours is crucial to examine the risk for chronic diseases.

Validity and reliability of a PA record to measure sedentary and PA behaviour was examined (see Chapter 3); dietary behaviour was evaluated using a 24-hour dietary recall during which a validated food recall kit was used. The cross-sectional study conducted in the adolescent population identified

several specific risk behaviours. Intake of unhealthy snacks, sugary drinks, and processed foods was found to be high, while fruit and vegetables, fibre, and fish consumption was low. It also showed that sodium, added sugar, and refined cereals were important constituents of the diet. Some erratic behaviour such as skipping breakfast was highly prevalent (68). Moreover, the adolescents were highly involved in sedentary behaviour and had low PA levels. The majority of the adolescents (59%) exhibited unhealthy levels of physical fitness (66).

The question rises what approaches are effective in preventing such risky behaviours in adolescents in LMICs? What are the possible successful pathways of change and thus potentially interesting for future interventions in LMICs? To provide an answer to these questions, the current evidence-base on implementing school-based interventions in LMICs was analysed and evaluated using a systematic review (see Chapter 2).

3.2.3 Phase C: Factors influencing the identified risk behaviours in Ecuadorian adolescents

It has been argued that acquiring an insight into the drivers of adverse behaviours is an integral part of the systematic process of developing interventions (75-77). Unhealthy diets and physical inactivity are influenced by inter-related factors reflecting the environment and personal, social and cultural experiences (78-81). These influences, including facilitators and barriers of change, on dietary and PA patterns are culture-specific and context-dependent. Unfortunately, most of the studies investigating such influences have been conducted in HICs, and are often focusing on a restricted set of influences (78). Adequate knowledge of potential culturally-specific influences on dietary and PA patterns is currently missing in LMICs. This is unfortunate as this is crucial to preventing non-recognition of health problems, understanding discrepancies in food intake and activity, guiding the intervention formulation and increasing the intervention’s effectiveness, and finally in avoiding incorrectly formulated policies in these countries. A theory-based approach to identify influences on (un-) healthy eating and PA patterns has been recommended (76) and has been adopted by this programme. A qualitative study identified such influences from the perspective of parents, school staff and adolescents using the ‘Attitude, Social influences and Self-efficacy’ ASE-model and socio-ecological model. It also allowed to develop comprehensive conceptual frameworks for adolescents’

eating and PA choices to guide the development of health promotion interventions in the context of systematic obesity prevention (see Chapter 4 and 5).

3.2.4 Phase D: Intervention development

The previous three phases (A to C) involve an in-depth needs assessment of the health problem and its causes in Ecuadorian adolescents. The results of these phases should be used for the development of an intervention. To minimize methodological and conceptual problems, a theory- and evidence-based approach, such as the Intervention Mapping (IM) protocol, has been recommended (57). Using partnerships and co-operative approaches have also shown to be key in developing successful interventions (82;83), particularly in LMICs (84). Therefore, interventions promoting dietary and PA behaviours require the use of theory and local participation to help account for cultural characteristics and requirements. As mentioned above, theory, local evidence and a participatory approach were the three pillars of the programme framework and were used as a basis for the intervention development in Ecuadorian adolescents (see Chapter 6).

3.2.5 Phase E: implementation of the intervention

The last phase of the framework concerns the implementation of the intervention. Participatory research methods have been advocated to enhance applicability of intervention strategies (85). The CPPE protocol can be used intensively during the implementation of an intervention to enhance communication, judge the acceptability of the intervention, and help identify opportunities and barriers.

3.2.6 Evaluation and Dissemination

Rigorous evaluations are needed and process evaluations need to be performed. An evaluation study design should follow the CONSORT statement (86), a checklist for Randomised Controlled Trials (RCTs). Built in process evaluations provide a way to evaluate if a programme is accomplishing what it is expected to accomplish. It also helps to monitor and evaluate intervention strategies of a programme in a transparent way. Finally, the use of a systematic programme framework may enhance the potential for future dissemination of the intervention. Understanding contextual elements and enabling pathways is key to evaluate, not only the current, but also the potential impact of an intervention (85).

4 Research question, hypothesis and objectives