Relevance and Uses of the Getting to Equity in Obesity Prevention Framework

Despite pervasive racial/ethnic and socioeconomic disparities in obesity among adults and youths in the United States,^1,2 evidence of successful intervention approaches for obesity prevention among higher risk populations is limited. Racial/ethnic disparities in obesity are shaped in part by structural racism and discriminatory policies (e.g., redlining)³ that have systematically and unjustly positioned communities of color in environmental contexts less favorable to healthy eating and physical activity. A framework that explicitly and intentionally acknowledges social injustices in developing policy, systems, and environmental interventions to prevent obesity, such as the Getting to Equity (GTE) in Obesity Prevention Framework proposed by Shiriki Kumanyika (p. 1350), is necessary to address the upstream causes of obesity that disproportionately affect disadvantaged populations.

RELEVANCE

One of my research projects targets disparities in sugar-sweetened beverage (SSB) consumption and childhood obesity risk through a community-based behavioral intervention (H₂GO!) in partnership with local Boys & Girls Clubs of America (BGCAs). The 12-session group-based intervention was delivered by BGCA staff to low-income and racial/ethnic minority BGCA youths and targeted knowledge, attitudes, and skills related to SSB and water intake through interactive health sessions, youth-produced narratives, and youth-led activities.⁴ The intervention was behavioral by design; thus, the GTE quadrants “increase healthy options,” “decrease deterrents,” and “improve social and economic resources” (p. 1353) from a policy, systems, and environmental standpoint were not quite relevant. However, the philosophy of applying the GTE framework and the focus on building community capacity are highly relevant and similar to how my study team and I developed and implemented the intervention in the following three ways:

1. Applying a health equity lens. Racial/ethnic minority children experience targeted marketing for SSBs and have (unsurprisingly) higher SSB consumption and obesity risk.⁵ Our intervention was intentionally designed to acknowledge the context, resources, and constraints this population experiences; it targeted reduction of SSB consumption and promoted water consumption, a low-cost, low-burden obesity prevention strategy for lower-income and racial/ethnic minority families.

2. Identifying context-specific intervention design and implementation issues. We worked collaboratively with our BGCA community partners in designing the intervention for integration into BGCAs, which maximized our capacity to design intervention activities that used existing BGCA resources and facilities (computer labs, recording studios and equipment) and infrastructure (dedicated staff). In pretesting the intervention, we addressed implementation issues (e.g., timing and frequency of intervention sessions to fit with BGCA scheduling) and tailored intervention activities to enhance intervention engagement, fidelity, and acceptability in our pilot study.

3. Understanding people and their circumstances. We used youth-produced narratives (stories) as a strategy to understand youths’ lived experiences and facilitate empowerment. This process recognized that motivations for behavior change vary across individuals and families. Guiding youths to develop their own stories related to SSB and water intake, combined with health sessions targeting knowledge, attitudes, and skills, allowed youths to identify strategies for change that were relevant to their lived experiences. On the basis of BGCA staff feedback, we tailored how intervention materials were delivered to include more youth-led and peer learning activities—empowerment and learning strategies shown to be particularly effective for youths of color.⁶

Although the pilot study is now concluded, I foresee using the GTE framework in refining intervention implementation and evaluation to maximize healthy equity impact in a larger efficacy trial across multiple BGCA sites.

USES

Although the GTE framework naturally lends itself to application for public health researchers and practitioners already engaged in obesity prevention, the tenets of this framework may also be useful for engaging other key sectors who may play critical roles in reversing the obesity epidemic. Engaging critical players (e.g., food producers and distributors, policymakers, urban planners) in the process of developing, implementing, and evaluating policy, systems, and environmental interventions is not yet common practice in obesity prevention research. This framework provides a conceptual model and a set of tools for researchers and practitioners to engage stakeholders in health equity obesity work. For example, in considering the opening of a supermarket to improve healthy food access in an underresourced neighborhood, this framework encourages partners to identify strategies to minimize unintended consequences (e.g., residential displacement) and proactively engage the community to maximize intervention success. The health equity lens of the GTE framework is also relevant to researchers, organizations, and institutions working on obesity treatment and related chronic conditions (e.g., diabetes, heart disease) and lends itself well to adaptation across multiple health outcomes.

USING IN OTHER SECTORS

The emphasis on measuring outcomes other than health can be critical in engaging key stakeholders who influence the spread and adoption of policy, systems, and environmental obesity interventions. For example, increasing healthy food access by opening new grocery stores can provide opportunities for urban revitalization. Researchers who pursue policy, systems, and environmental interventions should consider expanding the types of metrics assessed beyond health outcomes and behaviors to generate findings that are also useful to policymakers, business owners, and community members, such as jobs created, community tax revenue, and neighborhood livability. The tools and resources provided in the GTE framework can be used by multisectoral partnerships to consider key questions and methods during intervention and evaluation development.

Another critical opportunity for using this framework outside public health is to shape the narrative of conversations of accountability for obesity at the community and population levels. In our nationally representative survey of US mayors, participants most frequently cited obesity as the top health concern facing their city, yet they perceived obesity as the health issue for which they believe constituents hold them least accountable.⁷ Although a number of factors influence perceptions of accountability for obesity, we have a role in public health to shift this perception. Outside public health, social work, and American studies, most individuals in the United States are not familiar with the social determinants of health or levels of racism. Discriminatory policies and practices that contribute to racial/ethnic disparities in obesity, such as redlining, remain poorly understood—or not known at all—among the general public. This framework brings accountability to the forefront and justifies why a health equity lens is necessary in obesity prevention—and in public health.

CONTEXT OF USE

Although public health researchers and practitioners have worked toward reducing obesity disparities for decades, the GTE framework is a critical step in conceptually advancing the design and implementation of health equity obesity interventions and provides a structured set of tools and resources for researchers and practitioners to engage in multisectoral collaborations in the pursuit of health equity. This framework also calls for accountability across sectors by recognizing their roles in the obesity epidemic and highlighting the potential for new collaborations and strategies to address a multifaceted condition.

To be sure, the applicability and relevance of this framework will vary depending on the research design, intervention type, intervention setting, populations of interest, and resources and barriers present. Bringing a health equity lens to obesity interventions will be a challenging but necessary commitment if we are to address the persistent inequities in obesity. This framework positions us to seek out and work toward proactive collaborations that span multiple sectors and levels of influence—and provides a toolkit for doing so. I’ll be coming back to this framework in my obesity research, teaching, and practice.