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ADPH London
London Childhood Obesity Exchange
Cultural Insights and the Normalisation of Obesity
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Outline– 14th June
2
Introductory Presentation
9.30 Welcome and Introduction to the event
9.40 Understanding our audiences
10.00 Using Behavioural Insights to Tackle childhood obesity
10.30 Cultural Insights and Application in Lambeth
11.00 Q&A and sharing of insights & projects in the room
11.15 Coffee and Exchange of Knowledge and Ideas
Facilitating Action...
11.30 Working together to understand levers and challenges for communities.
12.00 Developing ideas and commitments to make small changes to make a
big difference.
12.20 Into Action ... Resources and support to implement change
12.30 Close and Ideas Exchange
ADPH London
Introducing the Issue
Sarah Cork – Brilliant Futures & iPiP
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What’s the problem?
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A Health Survey for England finding that 9/10 mothers and 8/10 fathers of
an overweight child described them as being about the right weight.
And with increase in overweight and obesity rising, we are normalising the
Issue, with a rising % unable to recognise when someone is overweight or
Obese and not as concerned.
It’s a complex problem, with many
cultural and attitudinal influences and
influencers...
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• People tend to overestimate what obesity means in terms of adult body
size.
• People who are obese are often the object of stigmatising attitudes.
• The majority (80%) said that those who are obese themselves should
take responsibility, 53% agree that “most overweight people could lose
weight if they tried”
• In relation to the causes of obesity; Overall, 82% feel that modern
lifestyles are too sedentary, while 91% feel that fast food is too easily
available.
• Younger respondents and those from a black or minority ethnic (BME)
background were more likely to feel that healthy food is too expensive
and that people have too little time to make healthy meals
British Social Attitudes Survey, 2015, Public Health England
We need to understand where people ‘are at’...
... Get into their world...
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Great Weight Debate 2016
Motivations
Aspirations
Feelings
Values
Fears
Knowledge?
Facts?
Where from?
Beliefs
Attitudes
Benefits & Buts
Barriers
Who & what influences?
Lifestyle, social norms,
messengers….?
What
Do? Where
Go?
The commercial world sells food
through emotional appeal...
We need to get into their world
too.
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Great Weight Debate 2016
Motivations
Aspirations
Feelings
Values
Fears
Benefits & Buts
Barriers
And understand different cultural
behaviours and influences – the ‘System’
is different for different populations...
• The graph presents national data on
obesity prevalence by ethnicity from
the NCMP.
• The gap between obesity rates in
White British and most other ethnic
groups is widening nationally.
• In London, 41.8% of the population
are from BAME groups, which is
almost 3 times higher than the
England average (14.6%).
• Although there is variation across
London - The proportion of the
population from BAME groups
ranges from 13.6% in Havering to
72.4% in Newham.
Healt
hy W
eig
ht,
Healt
hy L
ives
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Ethnic Minority Communities:
Bangladeshi and Pakistani Families
“My mother-in-law is
obsessed about feeding
my child. She keeps
saying he is too thin when
I know he is healthy and
has a good weight”
“I would love to be able to
go swimming or take the
kids but there is so much
else to do. There’s the
cooking for the mother-in-
law, looking after my
sister who is disabled and
after running around after
four children, I’m
exhausted.”
“The problem isn’t our
home food. Now you have
these halal chicken and
chip places on every
corner. It’s just too easy
when you come home on a
Friday night to grab
something from these
places as a treat for all the
family.”
“I just don’t let him out.
I worry about him going
out on his bike and
then hanging around
the shops with his
friends. You just don’t
know what they will be
tempted to get into.
That’s when they go
bad.”
“I never really thought about it. Now that you mention it, it just
makes you think about how many
people and how many children
there are in my family who have a
weight problem.”
Being ‘big’ is seen as a sign of health
and wealth
Scratch cooking of traditional
meals is widespread but not
all cooking practices are
healthy
Parents do not control children’s
consumption of Western convenience
foods Parents place a high priority on their
children’s educational attainment and
on the maintenance of cultural and
religious values
Physical activity is not a
cultural norm
Mothers and children do
not have time to be
physically active
Great importance is placed on the
provision of sufficient quantities of
food
Cultural Insights from Literature
Study with children from ethnically diverse sample of young
children and parents in London:
• Dislike of school meals
• Lack of knowledge of guidelines and negativity towards physical activity education at school among girls.
• Parents feel physical activity is role of schools.
• Influence of neighbourhood (lack of safety – gangs & dogs, fast food outlets).
• Places of workshop key focal points for social support.
• Want to retain traditional practices.
• Family roles and responsibilities and religion as facilitators and barriers:
- importance of family meals
- reliance on convenience stores for traditional foods.
• In South Asian families homework prioritised over physical activity.
• Black Caribbean and Black African families reporting dads associated with treats / fast food / takeaways and influence of wider family.
• Needing to study food labels for halal ingredients for example as opportunity.
• Places of worship as focal point and often ‘food point’. – more focus between healthy eating and religion than physical activity and religion.
Rawlins et l, 2012 10
Working with different beliefs, values,
attitudes in different communities...
JOGG Rotterdam carried out research on how to encourage Turkish and Moroccan mothers increase childrens’ water consumption. Based on qualitative research they developed the message ‘You are a good and strong mum when you give your children water at least twice a day’
www.epode-international-network.com
www.brilliantfutures.org
An Insight Driven Approach in Action:
White working class families – working full
time, time-poor, ‘just managing’.
Reliant on freezer.
Were ‘cooking’ meals every night – take
something from freezer, put in oven –
therefore ‘cooking’ messages not getting
through.
All shopped at same supermarket – ASDA.
Therefore... Promotion with local ASDA –
using existing offers on frozen food to shift ‘up
a traffic light’ and then make meal from
scratch to freeze.
Working with different beliefs, values,
attitudes in different communities...
Giving people a healthy version of
what they want... In their world..
#FDPHwebinars
Tasty Buds Carribean Takeaway
https://vimeo.com/108575962
ADPH London
Using Behavioural Insights to Tackle Childhood Obesity
The Opportunity
Sarah Golding
Public Health England, Behavioural Insights Team
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Using behavioural insights to
enhance NCMP feedback: a
randomised controlled trial
London Childhood Obesity Exchange, May & June 2017
Sarah Golding
ESRC Research Fellow
PHE Behavioural Insights Team
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‘Behavioural Insights’
Behaviour
Capability
Psychological capability
Physical capability
Motivation
Reflective motivation
Automatic motivation
Opportunity
Social opportunity
Physical opportunity
COM-B Model of Behaviour
Michie et al. (2012) 17
18 Behavioural Insights in Public Health England. 18
Methods:
Developing a behaviourally
enhanced NCMP feedback letter
Study Design
Cluster Randomisation
283 Schools
(10,661 Yr 6 pupils)
Control
Routine (2014/15) feedback letter
Intervention
Behaviourally enhanced feedback
letter
(i) Uptake of WMS
Study Design
Cluster Randomisation
283 Schools
(10,661 Yr 6 pupils)
Control
Routine (2014/15) feedback letter
Intervention
Behaviourally enhanced feedback
letter
(i) Uptake of WMS
Control
Feedback letter
Family Lifestyle Club (FLiC)
flyer (OW / VOW)
Local activities leaflet
Change4Life tips sheet
22 Presentation title - edit in Header and Footer
+ FLiC flyer + A local activities leaflet
Control letter: Overweight and very overweight
+ Change4Life tips sheet
Control Intervention
Feedback letter
Family Lifestyle Club (FLiC)
flyer (OW / VOW)
Local activities leaflet
Change4Life tips sheet
Behaviourally enhanced
feedback letter (incl. social
norms statement)
FliC flyer (OW / VOW)
Local activities leaflet
Chang4Life tips sheet
‘Map Me’ images (OW / VOW)
Pre-populated booking form
(VOW)
24 Presentation title - edit in Header and Footer
Intervention letter: Overweight
+ FLiC flyer + Map Me body image scales
+ A local activities leaflet
+ Change4Life tips sheet
+ A call to action to look at the images
over the page and an explanation about the
images.
GIRLS
+ Social norms statement about
overweight and very overweight children
being in the minority.
Intervention letter: Overweight
+ FLiC flyer + Map Me body image scales
+ A local activities leaflet
+ Change4Life tips sheet
+ A pre-populated booking form with a freepost envelope.
Intervention letter: Very overweight
+ FLiC flyer
+ A local activities leaflet
+ Change4Life tips sheet + Map Me body image scales + Social norms statement
Pre-populated booking form
with FREEPOST envelope
+ Includes child's name, address and
school.
+ Parent to provide details on preferred contact times and
format
30 Behavioural Insights in Public Health England. 30
31 Behavioural Insights in Public Health England. (http://energyskeptic.com/2013/cognitive-bias/) 31
Findings:
Impact of intervention on uptake of
weight management services
NCMP measurements, Year 6:
Leicester City, Leicester County &
Rutland
Population Monitoring Weight Status
Frequency %
Underweight 231 2.17%
Healthy weight 7039 66.03%
Overweight 1436 13.47%
Very overweight 1955 18.34%
Totals 10661 100.00%
Ethnicity – OW & VOW, Year 6:
Leicester City, Leicester County &
Rutland
Ethnicity (ONS Categories)
Control (%) Intervention
(%)
White 858 (65.3) 857 (68.5)
Black 73 (5.4) 65 (5.2)
Asian 306 (22.6) 246 (19.7)
Mixed 88 (6.5) 59 (4.7)
Other 23 (1.7) 12 (1.0)
Unknown 8 (0.6) 12 (1.0)
Main Outcome: Uptake of WMS
2.4% 2.2%
1.0%
4.8% 4.3%
1.9%
First Contact Enrollment Attendance
Uptake of Weight Management Services
Control Intervention
Conclusions & recommendations
Conclusions WMS uptake can be improved by making low-cost, behaviourally
informed changes to feedback letter.
No differential effects for any sub-group
Cannot say for certain which aspects of intervention were most
effective:
• Social norms statement?
• Map me images?
• Pre-populated form?
Recommendation would be to replicate letter & materials in their
entirety
37 Presentation title - edit in Header and Footer
ADPH London
Using Cultural Insights in Lambeth
Bimpe Oki & Vida Cunningham
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Insight into Overweight and Obesity amongst Lambeth
Ethnic Minority Mothers
Bimpe Oki - Consultant in Public Health
Vida Cunningham – Public Health Specialist
London Borough of Lambeth
Ethnic Insight Aims
• To understand knowledge and awareness of overweight and obesity
• To identify attitudes towards overweight and obesity
• To understand knowledge and awareness of healthy eating and physical activity
• To provide insight into behavioural choices related to overweight and obesity
• To identify barriers to healthy behaviour change
Mothers of Primary School Aged Children
Black Caribbean
Black West African
White British (C2DE)
Somali Portuguese
Understanding of Overweight and Obesity
• Very few understand overweight and obesity in terms of BMI
• Most define overweight in aesthetic terms and obesity in health and functional terms
• Obesity is equated with morbid levels of obesity
Overweight Obesity
“I think it’s from size 18, from size 18 upwards it’s overweight.” (Black Caribbean)
“Overweight is when you can’t fit into proper clothes and you have to wear those great big tent like things.” (White British)
“I think an obese person is one of them people who can’t get out of bed or off their chair, you know when their legs is full of rolls of fat.” (White British)
“They’re housebound and they can’t get out of bed and wash themselves so they have to have somebody to clean them. That is obese when you cannot do anything for yourself.” (West African)
“They cannot pray as they are obese.” (Somali)
• Portuguese women had a relative better understanding of overweight and obesity
• West Africans dismiss the concept of overweight
• Some respondents were shocked to learn from their doctor that they are obese
“Five kilos over is overweight but 20 kilos over is obese.” (Portuguese)
“When I see somebody like this (fellow respondent) I never call her overweight, I would call her a healthy lady.” (West African)
“We are not overweight. Overweight people are the ones you push in a wheelchair, they are helpless, they can’t breathe, they can’t move. They are overweight.” (West African)
“I thought I was overweight but when my doctor told me I am obese I thought oh my God, I didn’t know that. I was shocked. I was like oh my God I am clinically obese.” (Black Caribbean)
“Well my doctor said I was clinically obese. I can breathe, I can wash myself but apparently for my height I have got too much weight so I am obese. But I can move.” (White British)
Understanding of Overweight and Obesity
Portuguese
Somali
White
British
Black
Caribbean
West
African
Perception of Ideal Body Size
Portuguese
Somali
White
British
Black
Caribbean
West
African
Perception of Ideal Body Size
Perception of Overweight Body Size
Portuguese Somali
White
British
Black
Caribbean
West African
(Heavier)
Perceptions of, and Identification with, Healthy Lifestyles
Vignate
“I would like you to picture in your mind a [vary ethnicity] family, with a father, a mother and three children - two boys
and a girl – aged between 5 and 10 years-old. They live in Lambeth. They
each eat at least five fruits and vegetables a day as part of their diet, and everyone in the family does at least half
an hour of exercise every day.”
Perceptions of the Healthy Family
• All Somalis and West Africans felt the family could not be from their community. It had to be a White, middle-class family.
• None (except the Portuguese) thought they themselves could have such a lifestyle. Main reasons given were:
• Leading stressful lives
• Having little time
• Being unable to afford this healthy lifestyle
• Children refusing to eat fruit/vegetables
Barriers: Lack of identification - “Not me” White British
Black Caribbean
West African
“I can see the kids probably doing half an hour of exercise a day because they go to school, but I’ve never known a kid to eat five fruits and veg I’m sorry.” (White British)
“The two adults and the three kids all eat five lots of fruit and veg. No. That’s impossible!” White British)
“For a Caribbean I don’t see that going on here. We Caribbean people love our meals. We tend to eat a lot of meat, meat with carbohydrates like rice, yam, dumplings, bananas.” (Black Caribbean)
“If that’s a Black family they have had to have lived here a very long time. And they have got to be well off.” (Black Caribbean)
“You’re eating vegetables and you’re working out, the kids are working out. These guys have got time. I have to go to work, the kids come back, what time do we have to do this routine of exercise and all? You look at this family and either the mum is White and the dad is African because 99.9% of Africans don’t do this.” (West African)
“I look at this family and they can’t be Africans.” (West African)
Barriers: Lack of identification – “Not me” Somali
Portuguese
“This is not a Somali family. Somali family cooks rice and meat and little salad. Somali family does not do a lot of physical activity.” (Somali)
“This family is raised in homes that value healthy eating and exercise and they just continue to do what they were taught in their childhood. Somalis are not raised in that way and do not care about healthy eating or exercising.” (Somali)
“That is a good way to live if you have the time.” (Portuguese)
“We already eat that amount of fruit and vegetables so that doesn’t seem difficult. Doing exercise everyday would be difficult.” (Portuguese)
“They are not a poor White family either because poor White people do not care about healthy eating.” (Somali)
Perception of Children’s Body Image - Overweight
Portuguese Somali
Black
Caribbean
West African
White
British
Children’s body size is perceived to be strongly associated with their health. With the exception of the Portuguese, all communities regarded ‘large’ children as healthy children and ‘thin’ children as unhealthy children.
Many parents believe that obese children would grow out of it. Some parents were concerned about their children being underweight and not eating enough. No one thought their children ate too much.
How Learning from Insight Informed Local Work – Lambeth Level 1 Multi-agency Healthy Weight Training
Informed the Bespoke Training which was designed, amongst other objectives, to empower practitioners to be able to:
• Challenge widespread misunderstandings around obesity, in particular association of overweight and obesity with morbid levels of obesity.
• Challenge the view that ‘large’ children are healthy children. Emphasise the association of childhood obesity with adult obesity.
• Disentangle diet from body image: focus messages on improving health, not (primarily) reducing weight.
• Ensure that health advice is not seen to be exclusive to a small section of the population: White and middle-class.
How Learning from Insight Informed Local Work – Levels 2 & 3 Weight Management Services
Techniques in the delivery of the services:
• Acknowledge lifestyle and cultural barriers and tailor health advice accordingly. Make health promoting actions relevant to people’s lives.
• Include a range of local cultural foods when promoting healthy eating
• Incorporate cultural parenting skills to support parents to support positive behaviour change amongst their children.
ADPH London
So how can we work with social norms and
cultural insights?
54
ADPH London
Activities
55
ADPH London
Wrap Up and Into Action
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Into Action
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Key learnings we can put in practice:
- Small changes across the system, by all players can make a big difference and achieve the tipping point needed to reverse norms.
- Consider ‘what’s in it for me?’ for all stakeholders, we have a role in tackling childhood obesity, and also that childhood obesity has a role in our priorities.
- Consider the changes made and adapt, based on intended and unintended outcomes.
- Make sure we can measure changes and see what is working and isn’t working...
- No blame..... Work together to make the system better...
- And believe it’s possible......
What’s next...
58
Make the Change....Obesity leads co-ordinate action from today’s event...
Access the Website ..(www.....) after election June 9th...
. With presentations, resources, posters examples, toolkit
Feedback progress, challenges and experiences at Ideas Exchange
Wednesday July 12
Share knowledge, examples and activities with wider teams across
Boroughs with materials available on the website.
