Pediatric obesity studies a good community participation model
"We try to help them solve their problems even if this doesn't result in research."
The trend of community-based participatory research (CBPR) has become more popular as funding agencies and national organizations have called for more studies that include the public's active engagement from protocol creation to study completion.
In recent years, there have been a number of studies addressing pediatric obesity that have used a CBPR model. Since pediatric obesity has become an epidemic in the United States, it makes sense that its solutions would require a community approach rather than an individual or family approach, experts say.
Rural communities have used a public decision-making process model for more than two decades, which has provided residents a way to be involved in choosing health care services for their communities. CBPR carries this model a step further by giving residents the opportunity to suggest and collaborate with research projects that also meet their needs, says Paul McGinnis, MPA, community health quality and practice development director at the Oregon Rural Practice-based Research Network of the Oregon Health & Science University in Portland, OR.
"The actual involvement of the community started with the straight community health development model," McGinnis says.
"We're adding research to work that we're already doing in the communities and building upon a relationship that is based on service," McGinnis adds.
"Rather than have researchers drop in and do helicopter research or drive-by research where they don't have a relationship with the community, we want to build up the community," he explains. "We try to help them solve their problems even if this doesn't result in research."
Investigators train community members to assist in the research process. They assist with recruiting participants, obtaining informed consent, removing barriers to obtaining specific study data, and finding solutions and conclusions in study results.
This trust-building process eventually will lead to studies where both parties benefit, but sometimes researchers have to serve the community's needs first, McGinnis adds.
Use existing networks
Another CBPR study involving adolescents and obesity was made possible only because of long-term community work with the target population and the community at large.
Investigators used an existing community-university infrastructure of trust to launch a study that required some sensitivity and a great deal of community trust, says Robert Branch, MD, professor of medicine and pharmacology and director for the center for clinical pharmacology at the University of Pittsburgh in Pittsburgh, PA.
Since youths already had been working in groups to promote their own scientific knowledge and academic success, it was fairly simple to meet with them for the purposes of gaining their support in a community research project on obesity and diabetes, health issues their own families struggled with. (See related story, p. 99.)
Research institutions first should work with community members to identify priorities for study projects.
"These are just citizens who are motivated by things other than peer-reviewed articles," McGinnis says. "They want things to be better for their children, families, and communities."
So when researchers first enter the community to speak with residents about their priorities and needs, or even to suggest a particular type of study such as pediatric obesity research, they will find that community members have ideas and needs they might not have anticipated.
For example, the community might be most concerned with health care quality at the local hospital or the recruitment and retention of clinicians in their rural area, McGinnis says.
"Those kind of issues come up, and we want to address them quickly while at the same time identify opportunities for clinical research," he adds.
Pediatric obesity is an issue that particularly interests rural and other communities. Plus communities often have at least some organizations and resources addressing this issue, a recent study has found.1
For instance, a Nashville, TN, study that identified community-based pediatric obesity programs found 36 such entities.1
Some programs focused on healthy lifestyles as a general goal, but 70% had the explicit goal of tackling obesity prevention/treatment.1
"One implication from this study is it exemplifies the value of innovative community-based participatory research," says Eli Po'e, a research assistant with Vanderbilt University Medical Center in Nashville, TN.
Po'e is the principal investigator of the study of pediatric obesity community programs. The study's purpose was to gain insight into community organizations' needs and to learn more about the obstacles and gaps they had in building coalitions and achieving programmatic success.
"Obesity is complex, and there needs to be a multilevel systems oriented approach in combating obesity," he says. "Teaming up with different types of organizations and building research capacity helps contribute to solutions in preventing obesity."
The Nashville community program study found that project funding is a major barrier for research. So it's conceivable that investigators who build innovative alliances through CBPR would have grant proposals that are more appealing to government grant funders, he adds.
Research resulting from CBPR can cover areas that are difficult to study traditionally because of privacy and informed consent barriers.
For example, the Oregon Health & Science University worked with community members to obtain a good baseline of children's body mass index (BMI). Typically, these are determined through self-reports which could be fairly inaccurate since people tend to under-report their weight.
But these baseline BMI numbers were derived from accurate measurements made by trained members of the community in the public schools, McGinnis says.
"We trained people on how to have children take off their shoes and coats before being weighed," he says. "We had a digital scale that read out the numbers remotely so the children couldn't see what their weight was."
Without the trust-building period under CBPR, this might have been a difficult task to accomplish.
"A member of our original partnership was a school nurse, and we had a superintendent involved," McGinnis says. "After our first year of planning we figured out a way to weigh kids and have people opt out."
BMI charting, focus groups
With another grant, investigators could study three school activities. One of the activities involved plotting the children's BMIs on a Centers for Disease Control and Prevention (CDC) growth chart and sending the information home in a letter to parents, he says.
"This community is big in terms of the percentage of kids who are at risk or who are overweight," McGinnis says. "We held focus groups with parents and students in a research model that said, 'Did you look at the letter we sent and understand it, and do you think schools should be doing this as a policy?'"
Another piece was to hold reverse recesses in schools. Instead of elementary school children playing on the playground right after lunch, they were sent out to play before they ate.
"We did plate waste studies and measured the food consumed before play and after play," McGinnis explains. "We haven't published the results, but basically the kids who played recess first had better calcium consumption and slightly ate better."
And focus groups that consisted of food service staff and teachers provided information that school staff felt as though the children behaved better in the afternoon if they didn't go straight from the playground to the classroom, he adds.
The CBPR relationship also facilitated parental consent for one-on-one interviews with middle school students about their caloric intake. Trained community members provided informed consent.
"We labeled all the food they ate at school with calorie amounts," McGinnis says. "In the one-on-one interviews with students we were surprised at how few respondents could identify how many calories they could eat in a day."
This led researchers to theorize that putting up calorie labels isn't enough. Cafeterias also need to educate students on the context of what those numbers mean.
CBPR is a more realistic research approach for studies involving societal health problems, McGinnis notes.
"I think research needs to take place in more real world settings and not in academic tertiary settings where it has taken place traditionally," he says. "The problems in our health system are due to where people live and because of their family environment, and so if we want to solve prevention and promotion activities, then we have to involve people who are a part of it."
Reference
- Po'e EK, Gesell SB, Lynne Caples T, et al. Pediatric obesity community programs: barriers & facilitators toward sustainability. J Community Health. 2010;[Epub ahead of print].
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