Bridging Research and Policy to AddressChildhood Obesity Among Border Hispanics

A Pilot Study

Nelda Mier, PhD, Matthew Lee Smith, PhD, MPH, CHES, David Irizarry,Genny Carrillo-Zuniga, MD, MPH, ScD, Chanam Lee, PhD, Laura Trevino, ME, MPH,

Marcia G. Ory, PhD, MPH

Background: Mexican-American children are disproportionately affected by obesity compared toother population groups. Although national guidelines recommend using environmental and policyapproaches to address this public health issue, the majority of Mexican-American children do notmeet physical activity recommendations.

Purpose: To describe a knowledge transfer process involving local decision makers to addresschildhood obesity and physical activity needs among low-income, Mexican-American children andto examine environmental policy recommendations generated in this process.

Methods: This pilot study employed a qualitative research design that included the dissemina-tion of primary research data to local decision makers in the Texas–Mexico border region.Stakeholders attending public meetings were briefed about a research project reporting on thephysical activity needs of Mexican-American children from impoverished neighborhoodsknown as colonias. Seventy-four stakeholders responded to an unstructured questionnaire andproposed policy recommendations. Data were collected January–April 2011 and analyzedJuly–September 2011. Data were analyzed using a content analysis technique.

Results: Four policy themes emerged from the data: (1) establishing sustainable community-based health programs; (2) improving neighborhood infrastructure and safety; (3) increasingaccess to parks; and (4) supporting community organizations to disseminate health education toparents and children.

Conclusions: Knowledge transfer processes planned and facilitated by researchers at public meet-ings with local decision makers are effective methods to influence policy development related tochildhood obesity.(Am J Prev Med 2013;44(3S3):S208–S214) © 2013 American Journal of Preventive Medicine

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From the Department of Health Promotion and Community Health Sci-ences (Mier, Carrillo-Zuniga), and the Department of Health Policy andManagement, School of Rural Public Health, Texas A&M Health ScienceCenter (Irizarry), McAllen; Department of Health Promotion and Com-munity Health Sciences (Smith, Ory), School of Rural Public Health, TexasA&M Health Science Center, College Station; Department of LandscapeArchitecture and Urban Planning (Lee), College of Architecture, TexasA&MUniversity, College Station; Lower Rio Grande Valley Colonias Pro-gram of the Center for Housing and Urban Development (Trevino), Col-lege of Architecture, Texas A&M University, Weslaco, Texas; and Depart-ment of Health Promotion and Behavior (Smith), College of Public Health,The University of Georgia, Athens, Georgia

Address correspondence to: Nelda Mier, PhD, School of Rural PublicHealth, Texas A&M Health Science Center, McAllen Campus, 2101 SMcColl Rd, McAllen TX 78503. E-mail: nmier@tamhsc.edu

0749-3797/$36.00http://dx.doi.org/10.1016/j.amepre.2012.11.013

S208 Am J Prev Med 2013;44(3S3):S208–S214 © 2013 Amer

Introduction

The prevalence of obesity among young childrenaged 6–11 years increased from 6.5% in 1976 to19.6% in 2008.1,2 Studies show that obesity is

more prevalent among Hispanic children than amongtheir non-Hispanic white counterparts.1 Although it isell documented that physical activity reduces the risk ofbesity and other chronic diseases among children,3 na-

tional data show that about 60% of young Mexican-American children aged 6–11 years do not meet physicalactivity recommendations,4 in particular, that childrenged �6 years engage in 60 minutes or more of physicalctivity every day.5

Among multiple factors influencing physical activity,

neighborhood characteristics (e.g., access to recreational

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facilities, sidewalk conditions, and safety) play an importantrole.6,7 However, research indicates that communitieshere low-income and ethnic minority families resideave limited access to recreational facilities.8,9 Elimi-ating such inequalities affectingminorities requiresmulti-aceted efforts; these include policy development because ofts effectiveness in influencing health and obesity ratesmong underserved groups and increasing their access tohysical activity resources.2,10,11 Grantmakers in Health

stressed that public policy can change behavioral norms andimprove the environment to reduce childhood obesity,12 andthe CDC Guide to Community Preventive Services (www.hecommunityguide.org/pa/environmental-policy/index.tml) recommended environmental and policy approaches toromote physical activity.Research plays an important role in policy change,13

and knowledge transfer processes can bridge researchand policy. Knowledge transfer is defıned as “communi-cating research results by targeting and tailoring the fınd-ings and the message to a particular target audience.”14

The WHO calls for addressing health inequality throughknowledge transfer to close the gap between research andpractice and proposes that published and unpublishedinformation be shared with policymakers to link healthresearch and its application to public health.15

Although more robust research is needed to establishthe health and policy impact of knowledge transfer pro-cesses,16,17 studies have found that knowledge transferas influenced policy changes on public health issues,ncluding promotion of newborn screenings and immu-izations among women18; increased governmental sup-ort for childhood programs in various states19; chronic

wound care at community settings20; and cardiovascularnd mental health initiatives.21 Despite these fındings,here is paucity of research documenting policy develop-ent based on knowledge transfer involving researchersnd stakeholders to address childhood obesity affectingnderserved populations. The current exploratory studyimed to (1) describe a knowledge transfer process thatngaged researchers and stakeholders in addressing thehysical activity needs and environmental barriersmong low-income, Mexican-American children at theexas–Mexico border; and (2) examine physical activitynd environmental policy recommendations generateduring this process.

MethodsParticipants and Setting

This exploratory study employed a qualitative research designusing short oral presentations, a research brief, and a self-administered questionnaire at public meetings. Data were collected

January–April 2011 in Hidalgo County TX and analyzed July– a

March 2013

eptember 2011. Hidalgo County is the second poorest county inhe U.S.,22 and it is estimated that 42% of the 2294 colonias thatexist in the Texas–Mexico border region are located in thiscounty.23,24 Colonias are neighborhoods along the U.S.–Mexicoborder characterized by poor infrastructure.25 Colonia residentsre very poor, have low levels of education, and have limited accesso health care.26 On average, colonia families have three children.27

Study researchers planned and facilitated a knowledge transferprocess in collaboration with one community-based organizationthat had been a research partner since the beginning of the project.Initially, the researchers invited stakeholders to meet on the uni-versity campus to share research data with them and obtain theirfeedback on policy recommendations; however, stakeholder atten-dance was minimal. Therefore, researchers tried a different out-reach strategy—requesting to be added to the agenda of publicmeetings where stakeholders met on a regular basis, includingboard meetings and advisory committee meetings. Stakeholderswere county and city offıcials; promotoras (community healthworkers); community advocates; and school representatives. Pub-lic meeting organizers asked researchers to be brief, allotting themnotmore than 10minutes to present their research. Table 1 lists thenine meetings attended by researchers.The Science–Policy–Public Evaluation Spectra theoretic frame-

work by Ottoson and colleagues, and used to guide the presentstudy, proposes that policy development is a process not an eventand “contributions to policy can be made at multiple points acrosstime in the context of public and scientifıc influences and usefulevaluation fındings.”13,28 Policy development is a four-staged pro-ess, including pre-policy, policy development, policy enactment,

Table 1. Public meetings attended by researchers todisseminate data to stakeholders (n�184)

Public meetingaNo. of

stakeholders

A Resource in Serving Equality (ARISE)Monthly Meeting

17

Texas A&M Center for Housing and UrbanDevelopment (CHUD) Promotora Meeting

15

The City of Edinburg Parks and RecreationBoard Meeting

10

Edinburg City Council Meeting 46

Pharr San Juan Alamo Independent SchoolDistrict Health Advisory Council Meeting

9

Edinburg Consolidated IndependentSchool District School Board Meeting

19

2011 Texas Recreation and Park SocietyInstitute Annual Meeting

28

Hidalgo County Border Colonias ProgramBoard and Precinct 2 Officials

5

Lower Rio Grande Valley DevelopmentCouncil Board of Directors

35

aAll public meetings were held in Hidalgo County TX and lasted �90minutes. Researchers gave a 10-minute oral presentation at eachmeeting and handed out a research brief to each attending stake-holder.

nd post-policy enactment.13 Based on the tenets of pre-policy

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(dissemination of research fındings for public and policymakerunderstanding) and developing policy (promoting awareness andreframing of issues), the researchers systematically shared theirresearch fındings with stakeholders attending the public meetingsusing a 10-minute PowerPoint presentation and distributing to allmeeting attendees a research brief, which was printed in color onletter-size high-quality paper with a two-sided format. Both thePowerPoint presentation and the research brief included a sum-mary of the fındings previously collected by the research team in aqualitative study with 67 Mexican-American children aged8–13 years living in colonias (data reported elsewhere).29

Study fındings presented to stakeholders showed that 40% ofparticipating children in the studywere obese and that themajoritydid not meet physical activity recommendations (78.7%). Findingspresented to stakeholders also indicated that children perceivedthat their neighborhoods’ characteristics hindered their ability tobe physically active. Neighborhood barriersmentioned by the chil-dren included trash on sidewalks, speeding cars, unleashed dogs,dark streets, and lack of access to recreational facilities. Childrenalso voiced that having a park close to their home would help thembe active and recommended building football fıelds and basketballcourts in their neighborhoods.29

To obtain feedback from stakeholders about their policy recom-mendations to promote an environment supportive of children’sphysical activity, the researchers asked them to fıll out a self-administered questionnaire at the end of each public meeting. Thequestionnaire included two open-ended questions and was devel-oped using a question route technique that allows researchers toaddress the topics to be examined according to the research aims.30

Questionnaire items were (1) What contribution could agencies/organizations like yours make to develop a built environment thatsupports physical activity in children? and (2)What policy should beursued to develop a built environment that supports physical activ-ty in children?The questionnaire was initially administered to 17 stakeholders,

nd no revisions were necessary. The questionnaire was adminis-ered in English or Spanish, according to the preference of partici-ants. The Spanish translation of the questionnaire was completedsing a modifıed direct translation technique by a bilingual re-earcher native fromHidalgo County, and then revised by anotherilingual researcher. A total of 184 stakeholders were asked to fıllut the questionnaire and 74 responded. The response rate in thistudy was 40.21%, similar to that from previous research withtakeholders, which ranged from 34% to 53%.31–36

Data Analysis

Participant responses were transcribed verbatim and analyzed inthe original language using a content analysis technique by twobilingual researchers; 41.9% of participants completed the ques-tionnaire in Spanish. All respondent identifıers were removed toensure participant confıdentiality. A focused coding process wasused to analyze the data; the text was independently analyzed. Aninitial coding process was used to generate and compare conceptsidentifıed. After the initial coding, a focused coding was used tocombine or eliminate concepts, and to identify repeated concepts,major themes, and overarching domains.Results were compared,37–39 and in cases of theme and domain

disagreement during the analysis process, the issue was discusseduntil consensus was reached. If no consensus emerged, the princi-

pal investigator’s decision prevailed. Nomajor disagreements were

dentifıed by the researchers. The initial coding produced 15 con-epts, and the fınal coding resulted in four major emerging themesnd two overarching domains. The current study was approved byhe Texas A&M University IRB.

ResultsData were categorized into two domains: (1) institutionalcontributions and (2) recommended policies. “Institu-tional contributions” refers to activities that were beingimplemented or could be implemented by the institu-tions that the stakeholders represented. “Recommendedpolicies” refers to policies proposed by the stakeholdersthat should be pursued by institutions in general. Majoremerging themes were identifıed for each domain.Table 2 illustrates participants’ quotes by domain andmajor theme.

Institutional ContributionsStakeholders commented about activities their institu-tions could do or were currently doing to promote envi-ronments supportive of physical activity among coloniachildren. Two major themes emerged: healthy lifestyleeducation and infrastructure improvement.

Healthy lifestyle education. Most stakeholders saidtheir organizations could engage in promoting nutritioneducation among parents.Others suggested that commu-nity organizations and government agencies shouldpartner with schools to provide health and nutrition ed-ucation to community members. Some stakeholders re-ported their organizations were educating parentsthrough home visits and community presentations bycommunity health workers.Other stakeholders reported that their organizations

could promote physical activity in neighborhoods andoffer afterschool programs. Some respondents statedthat they could organize events in which parentscould learn about the importance of physical activity,and others indicated that their organizations alreadyoffered health education activities for children andadults. One organization offered afterschool activitiesduring summer to promote health and fıtness educa-tion at safe and clean facilities, as reported by a stake-holder. Another stakeholder stated that his/her groupprovided exercise equipment (e.g., jump ropes andsoccer balls) and programs such as karate and yoga forneighborhood children.

Infrastructure improvement. Many participants re-ported that their institutions could engage in neighbor-hood beautifıcation projects and provide communitieswith exercise equipment and facilities. Some respondents

mentioned that they were already improving the infra-

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structure of colonias with projects involving modifıca-tions to streets, roads, and drainage structures.

Recommended PoliciesFour policy-related themes emerged from the data.

Establishing sustainable, healthy lifestyle pro-grams. Many stakeholders called for policies mandat-

Table 2. Emerging themes for each of the global domainsstakeholders

Emerging themes and quotes

INSTITUTIONAL CONTRIBUTIONS DOMAIN

Healthy lifestyle educationHost more activities that promote physical activity after schoPrepare a class to teach parents the importance of physicalhome and teach their childrenEducating parents about healthy eating habits and on how ttendencies.Partner with schools more often to promote activity and eduWe offer daily access to Kids Café that provides a balanced

focused on mind, body, and soul, dealing with fitness endsocial recreation

Take more information and try to get the parents more involInfrastructure improvement

Continue providing a safe and clean settingsPutting safe parks in each neighborhoodBuild parks and playgrounds within neighborhoods, making t

of the communities who can’t or don’t want to drive

POLICY RECOMMENDATIONS DOMAIN

Establish community-based sustainable health programsMandate either daily or weekly nutrition classes in schoolGovernment [should] run afterschool programs at the schooFree exercise activities/programs after-school and during thfamiliesBring back physical education to the schools and make it mKids spend most of their time at schools, so their PE progragovernment]Do not take away PE in schoolsHold parents accountable if a child becomes obese (neglectFighting childhood obesity should be a signature domestic in

being of future generations. Federal officials should workto make healthy foods and beverages more widely availabareas

Improving the infrastructure and safety of communitiesFix the streetsVerify if there is sufficient lighting in public recreational areaEnsure clean streets and paved sidewalksMake the communities safe for the children and residents

Improving access to parksThere should be more parks and walking trails in rural commIdeally, public spaces for recreation and physical activity shoand accessible to allPublic transportation at an affordable price needs to be in pLater closing times for parks and public facilitiesParks should close at least by 10:00PM.

Assisting community organizationsHelp the organizations that work with the communitiesProvide more funding for projects

PE, physical education

ng nutrition and physical activity programs. Stakehold-

March 2013

ers also proposed makingphysical education classesmandatory in all schools.

Improving the infrastruc-tureandsafetyof commu-nities. Stakeholders re-ported that local, state,and federal policy agen-das should focus on im-proving the environmentof colonias. They specifı-cally stressed the impor-tance of creating andrepairing streets and side-walks, aswell as improvinglighting conditions. Manystakeholders mentionedthe lack of safety as a bar-rier to physical activity andproposed the enforcementof laws in neighborhoodsand public areas to moti-vate more residents to beactive outdoors. The stake-holders expressed a greatneed for increased policepresence during eveninghours in the colonias.

Improving access toparks. Many respon-dents suggested buildingmoreparks throughout thecommunities and makingexercise equipment avail-able for children. Anothersuggestion to increase ac-cess to parks centered onimproving the local trans-portation system andkeeping recreational facili-ties open to thepublic untillate in the evening.

Assisting community organizations. Stakeholders pro-posed that community organizations receive fınancialsupport from the government to promote healthy life-style programs.

DiscussionThis study described a knowledge transfer process throughwhich researchers disseminated research fındings to local

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produced policy recommendations from stakeholders topromote physical activity among low-income, Mexican-American children living in border colonias. Althoughstakeholders were asked to propose policies to improvethe physical characteristics of neighborhoods to makethem more supportive of physical activity for children,their recommendations were not limited to this strategy.Stakeholders’ recommendations also focused on address-ing childhood obesity through multiple solutions andinterconnecting healthy lifestyles with community infra-structure and health education.These fındings suggest that recommendations pro-

posed by stakeholders resonate with previous researchproviding evidence of the social and environmental influ-ences on physical activity behaviors. Research supportsthe notion that neighborhood characteristics influencephysical activity.6,40–45 There is strong evidence that chil-ren with access to parks are more active than thoseithout such access,7,46–48 and that urban designs con-idering connectivity of sidewalks and streets (as well aseighborhood safety) support physical activity behaviorswww.thecommunityguide.org/pa/environmental-policy/ndex.html).Although research shows community interventions

re effective in promoting physical activity,49 previousstudies suggest that nonprofıt organizations face manychallenges sustaining community-based programs in ad-dition to their operational needs.50,51 Stakeholder re-spondents in the current study recommended increasingphysical education in schools, and there is strong re-search evidence that physical education classes are posi-tively associated with physically active children.49 Fur-her research is warranted to investigate to what degreeommunity stakeholders are knowledgeable about thecientifıc literature and in what ways such informationnfluences their opinions and decisions when addressinghildhood obesity.The current fındings show that a knowledge transfer pro-

ess based on the dissemination of primary research datahrough PowerPoint presentations and a research brief inommunity settings is an effective strategy to influence pol-cy development in relation to childhood obesity. A policyramework by Ottoson and colleagues13,28 proposes to ex-mine policy contributions through a continuum of stages,ncluding problem description and understanding, policyevelopment, and policy enactment and implementation.ased on this framework, study results suggest that knowl-dge transfer planned and facilitated by scientists at publicettings can contribute to policy and practice in at leasteveral ways: by disseminating research data for policy-aker understanding (pre-policy stage); by raising aware-ess among decision makers about childhood obesity

pre-policy stage); andbyencouraging localdecisionmakers i

to frame the issue into policy recommendations (policy de-velopment stage).

LimitationsThis study has several limitations. The number of publicmeetings attended by researchers and the sample size ofstakeholder respondents were small and not randomlyselected; therefore, the sample may not be representativeof border stakeholders from similarly impoverished geo-graphic areas, and their recommendations cannot bewidely generalized beyond this border region. Addition-ally, it is not clear if these stakeholder groups representedespecially low-income or undocumented residents whomight be among the most vulnerable populations. Otherstudy shortcomings include the use of a questionnaire notpreviously tested for internal validity and reliability; noadditional triangulation data collection methods; and nocalculation of an internal reliability coeffıcient in the dataanalysis. Finally, a focused content analysis approach wasused versus a more systematic audit of transcribed textusing qualitative data analysis software.

ConclusionDespite its limitations, this exploratory study responds toa gap in the public health literature underlining the needfor obesity-related research that is better aligned withpolicy and practice.52 A process planned and facilitatedby researchers to disseminate primary research data onphysical activity issues among local stakeholders in com-munity settings to produce policy recommendations isnot a traditional academic practice,53,54 but it is a neces-ary strategy to address the complex phenomenon ofhildhood obesity. The need for bridging health researchnd policy as an effective way to change the obesogenicnvironment has been highlighted by national and inter-ational initiatives that acknowledge that health behav-ors are policy-influenced.2,13,52

An International Conference convening obesity ex-perts from 33 countries in 2007 warned that because ofthe complexity of childhood obesity, it is imperative touse a systemwide approach and produce healthy policiesbased on evidence.52 The present study documents that atrategy linking research and policy development is aeasible exercise in real-world settings and has practicalmplications. Other regions with similar characteristicsay replicate the methodology used in the current study

o mobilize local stakeholders to take policy action.Although investigating whether any policies were de-

eloped and enacted as a result of the knowledge transferrocess described here is beyond the scope of the presenttudy, a local stakeholder (A. Kass, Proyecto Azteca,ersonal communication, 2012) said that this process

nfluenced her organization’s decision to design a healthy

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neighborhood prototype in a colonia in Hidalgo County.he proposed neighborhood design includes a basketballourt, a playground, and a community facility to promotehysical activity among children and their families. Thetakeholder mentioned that the research brief dissemi-ated as part of the current study has been a useful tool toducate their constituents about physical activity needsnd barriers among colonia children. Further research onommunity-based initiatives promoting healthy neigh-orhood designs is warranted to determine their impactn reducing childhood obesity.The current study shows that researchers can play a

ritical role in the development of policies addressinghildhood obesity by (1) disseminating research fındingsmong local stakeholders in community settings and2) mobilizing stakeholders to generate policy recom-endations. Further research is needed to investigate theost effective research data presentation strategiesmong decision makers to influence health policy, and toonduct health impact assessments of existing and pro-osed policies addressing childhood obesity.Findings from the present study have practical appli-

ation and the potential to influence policy developmenteyond this specifıc research effort. A recommended nexttep is to bring together committed partners in the studyegion to further reframe the childhood obesity issue,uilding on the policy recommendations produced byhis study. Stakeholders who participated in the currenttudy should be part of an iterative process of mobiliza-ion, advocacy, and policy enactment. Previous researchhows that building local partnerships with program-atic, promotion, and policy goals is an intermediatetep followed by decision-making procedures in the over-ll policy change process.55–57 Local partnerships musthen identify priorities and commit to a sequence of plansnd regulations related to urban planning, zoning, landse, pedestrian safety, and/or economic development formproving current neighborhoods and regulating newnes.57–59

Finally, decisions for policy development leading tohealthy and active communities should be framed withina socioecologic model, recognizing that health behaviorsare not solely individually based but rather influenced byinterpersonal, community, and policy factors.60 Particu-larly, policy development addressing childhood obesityin border Hispanic communities should be comprehen-sive, targeting not only physical activity behaviors butalso nutrition education and urban development as rec-ommended by local stakeholders in this study.

Publication of this article was supported by the Robert Wood

Johnson Foundation.

March 2013

This study was funded by the Robert Wood Johnson Foun-ation (RWJF) through its national program, Salud America!he RWJF Research Network to Prevent Obesity Among La-inoChildren (www.salud-america.org). SaludAmerica!, led byhe Institute for Health Promotion Research at The Universityf Texas Health Science Center at San Antonio, Texas, unitesatino researchers and advocates seeking environmental andolicy solutions to the epidemic.The studywas also informed by theTexasChildhoodObesityrevention Policy Evaluation Project – funded by RWJF, whichs evaluating statewide policies to reduce childhood obesity.No fınancial disclosures were reported by the authors of thisaper.

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