Mobilising civil society
Learning from previous social change
In this section, we focus on lessons from public health actions that have been addressed through social change processes. Many of these apply to The Global Syndemic, but a number of examples relating to obesity illustrate the potential of these approaches for broader application. Changing obesogenic environments is central to reducing obesity. Accomplishing this task will require broad and sustained changes in policies, beliefs, and practices within and across several societal sectors. A focus on the underpinning systems and institutional drivers of unhealthy environments also recognises the challenges individuals, families, communities, and populations face in achieving a healthy weight while exposed to a constant barrage of appealing inducements to overeat and live sedentary lives.279 The potential for population-wide, long-lasting changes in the behaviour of individuals in the absence of widespread environmental changes has serious limitations.19
Social change efforts that focus on obesity alone might reinforce negative attitudes about people with obesity, which are common in many countries and, perhaps paradoxically, might increase with the rise in the prevalence of obesity.280 Combining obesity prevention efforts with efforts to address undernutrition and climate change as part of The Global Syndemic will help avoid that risk. The concept of stealth interventions281 was proposed to show that other social movements for action on climate change, sustainability, liveable communities, safe streets, social justice, human rights, animal rights, and food sovereignty have the potential to contribute to obesity prevention. Awareness that social pressure for change on one issue can benefit others can broaden the base of support for change.
Social change and public health
Complex social, environmental, and health challenges have been addressed successfully through social change processes, leading to cultural shifts in values and to public policy actions that have changed population behaviours. Case studies of tobacco control, alcohol, infant nutrition, gun control, and traffic safety offer insights into how pressure has been applied to achieve government actions affecting relevant personal behaviours (table 3). These changes have often been the result of collective actions that fostered the transformation of social institutions and the redistribution of power and resources, while challenging widely held beliefs and social norms over years or decades.282 Social movements and civil society networks often form around shared values, interests, and principled ideas that evolve over time and lead to common agendas and unified actions.168, 283 Movements and networks are more likely to grow when they frame problems in ways that resonate with their supporters and external audiences.284 Effective framing can convey the nature and severity of a given problem, the costs of ignoring it, and the benefits of taking action (appendix p 35). Some frames might have broad cross-cultural resonance (eg, minimising harm to children), whereas others might align more with the dominant beliefs and cultural symbols of a given locality, such as reclaiming local food sovereignty, rebuilding indigenous food systems and cultural practices, and rejecting the invasions of foreign fast food chains.168
Although some cultures tolerate or hold positive attitudes about larger body sizes, negative attitudes about people with obesity predominate in many societies. In such contexts, people with obesity can be subjected to ridicule, discrimination, or other forms of social disapproval, such as blaming them for having the condition despite the now well-established recognition that obesity is a disease.285 Commentary in the media can readily reinforce weight bias. Social marketing and other campaigns need to be well researched and evaluated so that they similarly do not exacerbate social bias,286 but the evidence from confronting social marketing campaigns in Australia, which show graphic images of intra-abdominal fat, is that they can be effective in stimulating behaviour change without exacerbating social bias against people with obesity.287
Strategic considerations
The strategies employed by some large food and beverage corporations to oppose public health policies focused on obesity prevention — eg, fiscal policies, front-of-pack labelling, and regulating food and beverage marketing aimed at children — are similar to those used by the tobacco industry, which have served to create a battle between the health community and large corporations. Although it is important to hold these corporations accountable and regulate their practices, these actors should be distinguished from small-sized and medium-sized food companies that could collaborate in the social change process. The heavy-handed lobbying tactics by the processed food and beverage industries against the prevention efforts of communities and governments means that those companies are seen as the enemy and the social movements around obesity prevention draw energy from this demonisation. This dynamic has been particularly visible when sugary drinks taxes are proposed. Thus, the practices of this sector of the food industry become seen as primary causes of obesity and the primary obstacle to the development of health-promoting food policies.167, 288 Nevertheless, food industry behaviours that support food as foundational to culture, social interactions, and health and wellbeing, in addition to contributing to economic prosperity, should be celebrated. A syndemic approach that articulates and drives shifts in food systems on the basis of issues complementary to obesity, such as climate change, will be part of these solutions.
Although the potential to achieve synergism among different causes often works when those involved can find common ground to support each other,289 some linkages encounter ideological or tactical conflicts. For example, in low-income countries, the coexistence of obesity and undernutrition and their relevance to food systems facilitates common actions addressing both problems. However, anti-hunger advocates might have alliances that facilitate receipt of unhealthy food donations from many of the same food companies that are viewed as problematic by advocates in the obesity arena. Acceptance of the principle that charitable food should be healthy food would resolve this conflict. Another example of such a conflict is obesity-related initiatives that depend on the promotion of bottled water over sugary drinks, whereas environmentalists are opposed to the promotion of bottled water on ecological grounds. Both groups might find common ground by supporting government action to ensure the availability of safe drinking water for the public good.
Mobilising demand for change
In the broadest sense, social change might result from many interacting forces: the adoption of new technologies, changes in government and policy agendas, long-term changes in societal conditions (eg, economic growth), short-term events (eg, natural disasters), and related shifts in belief systems, values, and norms. However, change might also be provoked by spontaneous social movements or through more structured collective actions directed by civil society organisations that incidentally or deliberately alter social dynamics.290 Social change is more likely to be sustained when governments adopt comprehensive policies and establish institutions that enshrine the goals of collective action.291 Fostering and sustaining changes is of paramount importance for securing long-term improvements in the health and wellbeing of communities.
Huang and colleagues292 emphasised the importance of a combined top-down and bottom-up framework for effective social change in which public pressure drives both public-sector and private-sector policy actions across non-regulatory, regulatory, and legislative spheres and stimulates new types of innovation (appendix p 36). Mobilisation through a bottom-up approach can be achieved through collective actions and political movements to develop effective strategies and reprioritise resources to address The Global Syndemic.
Collective actions are actions taken in concert or in a coordinated manner to protect a public good.293 Such actions require a critical mass of highly engaged and resourceful people, group heterogeneity, interdependence of actors, and a direct relationship between the level of contribution and pursuit of a well-defined public good.294 These actions might take the form of social movements and involve coalitions, networks, and other structures that emerge among individuals and organisations concerned about a societal issue.
To date, no transformative social movement exists that addresses obesity. The lack of common strategies might divide advocates. For example, the groups that promote breastfeeding have little in common with physical activity advocates. Additionally, stigmatisation and self-blame might contribute to the challenges of forming patient advocacy groups. However, several councils or coalitions have emerged recently in which patient advocates work together with health and research professionals to educate the public about obesity, support policies that ensure payment for science-based treatments, and advocate for the elimination of weight bias and discrimination.
Political movements
Major, concerted efforts in the form of coordinated campaigns directed by consumer advocacy groups (eg, non-governmental or civil society organisations) that include engagement of consumers can be viewed as political movements. Political movements create political pressure, move public opinion, and lobby on behalf of public health. Examples of these movements include tobacco control campaigns, automotive safety, mandatory use of bicycle helmets, and banning asbestos, DDT, and other harmful chemicals in the environment. This type of advocacy in the area of obesity is most well-developed in relation to food and beverage corporations whose business model is in direct opposition to measures recommended for obesity prevention.167, 288 The movement calls for policy change and is empowered by medical and public health sciences and civil society organisations to confront corporate power and its deep economic resources.
The four essential strategies used by political advocacy movements are generalisable to a focus on obesity. These strategies include: (1) building strength from scientific evidence; (2) exposing the human drama of the situation, including economic costs and how the problem will worsen in the future to create urgency for change; (3) exposing the principal causes of the problem (eg, changes in the food supply and patterns of food marketing for certain products) to foster a strong public voice; and (4) presenting specific and feasible actions. Proposed actions for obesity prevention typically include regulations to protect children from marketing of unhealthy foods, creating healthy food environments in schools, fiscal measures, clear front-of-pack labelling for consumers, and improved access to fresh, healthy, affordable food.295 A successful political movement must include a wide variety of civic groups from very different fields, such as those working on nutrition, children’s rights, and environmental protection, those representing small farmers, and those fighting hunger. Because science and scientific integrity are fundamental to the fight against obesity, the movement must also include academic societies, individual researchers, and health professional associations. Legislators and stakeholders from civil society must also be mobilised in the effort to win the debate in terms of public opinion.
Social change and political leaders with roles in civil society, policy, and the private sector should mobilise active participation of all strata of targeted societies, including the impoverished and disadvantaged, who are likely to be more severely affected by The Global Syndemic.
Implications
Effective and sustainable social change efforts target key mediators of change and can be driven by a combination of collective actions, taken at various levels, to generate and voiced demand from within civil society to influence governance structures, industries, and cross-sector collaborations (panel 13). Thus decreasing the prevalence of obesity requires a focus on building momentum for social change for goals, such as reducing undernutrition and mitigating climate change, that share common policy inertia challenges.
Panel 13: People’s experience — making local change happen20 years ago I was Secretary of Health for Sorocaba, a city of approximately 500 000 inhabitants, when I participated in a presentation of Agita São Paulo from the Government of the State of São Paulo. The programme emphasised the benefits of moderate physical activity, such as 30-minute walks, at least five times a week. Recognising the benefits of the programme on chronic disease prevention and control, and physical, mental, and quality-of-life improvement, I implemented a programme to encourage physical activity in Sorocaba. I started by encouraging patients using primary health care to walk. I asked all Basic Health Units (Unidades Básicas de Saúde; UBS) to create walking groups with training of physicians, nurses, and nursing assistants. The groups had one or two employees from UBS. We also set up treatment protocols for hypertension and diabetes, where all patients were advised to walk at least five times a week. Patients with depression were also targeted. As we did not yet have lanes specifically designed for walking on our streets, I asked a group of physical education teachers to identify paths along flat, well-signposted paths, offering groups more comfort and safety in walking. Walking groups leaders were trained to provide recreational and motivational tasks in addition to physical activity. The walking groups grew. Some had hundreds of participants, who became friends, improving their social wellbeing. Parties, requests for participation in civic parades, and excursions to other cities were among the activities carried out by the walking groups. Significant improvements were perceived by the health professionals involved, especially among the elderly, who improved their skills, were happier, and reduced their medications. Improved control of hypertension and diabetes reduced hospitalisations for diabetes and stroke, according to data from the Federal Government. These results led the groups to request the construction of walking trails, parks, and green areas in the city, demonstrating that if people feel they can improve their quality of life, they will start demanding it. We have a 24-hour walk every year on the path that goes around Sorocaba. Thousands of people participate, with groups including municipal secretariats, military youth, firefighters, universities, and other institutions. The Agita São Paulo programme, which trained thousands of health professionals, promoted a social movement where people became aware of importance of physical activity for a healthy life. The programme contributed to the reduction and control of chronic diseases at practically zero cost to the population through physical activity. Contributed by Dr Vitor Lippi, medical doctor and current Federal Deputy at the National Congress. |
Cultural influences and indigenous approaches
Progress will not be made on The Global Syndemic unless sociocultural contexts are taken into account. We examine this first from the perspective of the sociocultural determinants of obesity and then more broadly examine how The Global Syndemic affects indigenous and traditional people (hereafter called traditional peoples) and how their heritage knowledge can be a force for renaissance in their own communities and provide the foundations for global 21st century thinking for addressing The Global Syndemic.
Sociocultural determinants of obesity
The enormously wide variations in obesity prevalence between countries relate closely to the wide differences among cultures. Despite many visible differences between cultures that relate to obesity, such as cuisines, use of food in social exchanges, perceptions of body size, fashion, and value placed on physical activity, surprisingly little research has been done on these determinants compared with research on genetic, metabolic, and behavioural determinants. There are also less visible, latent characteristics of cultures, which have been developed and measured for about 90 countries.296 Significant associations exist between these quantitative dimensions of culture and the trajectories of BMI over 40 years.1 Preliminary ecological analyses suggest that a higher BMI is significantly associated with societies that have a greater awareness of and intolerance of inequalities (lower power distance), a more individualistic than collective world view, less tolerance of the unknown and the different (higher uncertainty avoidance), a more conservative and traditional orientation (higher short-term orientation), a more competitive, money-based orientation (higher masculinity), and a greater fulfilment of leisure and pleasure with less restraints (higher indulgence). Together, the six cultural dimensions explain more than 50% of the variance in mean BMI between countries over the 40 years. Much more research is needed to explore these cultural dimensions and to develop a coherent theory about how cultural factors modify the effects of globally acknowledged drivers of obesity among different nations.
Several international comparative studies of the differences in body size perception have been done (appendix p 37), and the effects of acculturation processes on the bodyweight of immigrants has also received some attention.297 In general, when migrants from lower-income countries move to higher-income countries, they acculturate to the host culture, and their risk of obesity increases.298 The added effects that colonisation and societal marginalisation have had on indigenous populations also predisposes them to greater obesity.299, 300, 301 Many other dimensions of culture warrant much greater research attention, such as cultural attitudes to food, the effects of religion, media influences, cultural parenting styles, and societal values placed on physical activity and sports participation.
Indigenous and traditional peoples and The Global Syndemic
The UN estimates that more than 370 million self-identified indigenous and tribal peoples live in some 90 countries representing as many as 5000 diverse cultures. Even though they constitute only 5% of the world’s population, they account for 15% of the global poor.302, 303 With reduced opportunity for viable incomes, they collectively represent the severe effects of global poverty and disparities, including high rates of obesity and undernutrition and loss of their traditional territories and lifestyles due to climate change.302, 303 Traditional peoples are of special interest not only because they are disproportionately experiencing The Global Syndemic, but also because they have traditional knowledge, understandings, and practices that might contribute to addressing these challenges for their own people and more broadly.
Traditional peoples are custodians of many traditional knowledge bases, including knowledge of the world’s invaluable biodiversity of plants and animals in the ecosystems that are the foundation of global food systems, medicines, and ecosystem knowledge.302 However, worldwide these peoples have experienced dispossession and destruction of their traditional lands and territories.304 The most severe effects of climate change are documented for lands occupied and depended upon by traditional peoples. Examples include diminishing levels of sea ice in Inuit territories of the circumpolar Arctic that reduce traditional food acquisition, extreme desertification and drought in sub-Saharan and east African regions that compromises herd viability of pastoralists, and rising sea levels in the coastal zones of Pacific Island nations that flood traditional farm areas.303 Traditional peoples living in high-income countries also have high rates of obesity and NCDs compared with other ethnic groups in those countries. In LMICs, traditional peoples also have higher rates of undernutrition and stunting,299 in addition to obesity and NCDs.
Learning from traditional peoples’ approaches for systemic action
Traditional peoples’ knowledge contains many of the keys to understanding how to address The Global Syndemic. Custodianship of the environment, nurturing, and sustainably using nature’s resources and ecological relationships between communities and their environments create a collective responsibility for the common wealth that the planet provides. The renaissance of traditional peoples’ concepts, knowledge, and practices around the world could provide a powerful global resource and a basis for 21st century thinking to replace the extractive, polluting, individualistic, and materialistic concepts that are driving The Global Syndemic. Individuals and communities are already drawing upon these traditional approaches to improve the health of themselves, their communities, and their environments (panel 14).
The documentation and application of this traditional knowledge should be a global goal, and worthy of substantial investment for indigenous scientists to support their populations’ rights to heritage, health, and wellbeing, and through them, the wellbeing of the planet. The Iroquois concept of seven generation stewardship urges the current generation of humans to live and work for the benefit of the seventh generation into the future. The Commission proposes the establishment of a Seven Generations Fund for Traditional Peoples’ Science to build an international traditional peoples’ knowledge platform for decision making and action for seven generations to come. Resuscitating traditional peoples’ knowledge of sustainable food systems, use of biodiversity, world views, and collective approaches will not only strengthen their ability to meet the challenges for their own people, but also provide ways forward for all humanity to meet the challenges of The Global Syndemic.
Community-based actions
The classic framing of “Think global, act local” to convert, otherwise daunting, global problems into community action could be applied to The Global Syndemic with the added catch line of “reorient systems”. People can leverage their individual agency better within their local school, grocery store, or workplace for small changes than they can in the education system, the food system, or businesses at large for big changes. However, many small changes in communities can build into wider social change, especially if the local actions spread by creating virtuous cycles of mutual learning between communities. This section illustrates contemporary approaches to reducing childhood obesity, where there is growing evidence and experience on how to activate systems change that is of relevance to The Global Syndemic.
Past interventions for prevention of unhealthy weight gain in childhood have reported variable effects, with little evidence of long-term sustainability of programmes or effects.305, 306 These interventions are undergoing an evolution in design and concepts with increasing upstream and complexity-oriented approaches. We characterise and compare three broad types of approaches (table 4) and then demonstrate several relatively well-developed examples of systems-based approaches from Victoria, Australia. The typologies outlined in table 4 are general categories and characteristics and it is important to note that any given community intervention can demonstrate a mix of these approaches. However, the majority of obesity prevention studies in systematic reviews are characterised as package delivery. This approach refers to an expert-led package of evidence-based interventions aimed at changing the proximal determinants of obesity, such as knowledge, behaviours, and local environments, and is delivered with a high implementation fidelity within a robust scientific design, such as a cluster randomised controlled trial, in settings such as schools. Intervention periods are often short-term, typically 1–2 years to match the duration of research-funded projects, and very few interventions are extended across a state or country, even if successful at the research stage.
Table 4 Characteristics of the three broad types of interventions for prevention of childhood obesity
| Package delivery | Capacity building | Systems-based | |
|---|---|---|---|
| Research question (effects) | What intervention package works? | What works for what community? | What works for what systems in what contexts? |
| Research question (process) | How can the package best be implemented with fidelity? | How can existing community capacity best be built? | How can existing systems best be strengthened? |
| What is the intervention? | Package of individual and environmental interventions | Building community capacity | Activating and re-orienting existing systems |
| Who develops it? | Content experts consulting local experts | Local experts and content and process experts | Local experts facilitated by content and process experts |
| Engagement and role of community | Consulted; co-implement | Engaged; co-design and implement | Owned; design and implement |
| Role of experts | Create and co-implement | Co-design; support implementation | Facilitate design and implementation |
| Usual funding source | Research bodies (investigator initiated) or government departments | Research bodies or government departments | Government departments or communities |
| Resources applied to | Package delivery | Capacity building in community organisations | Supporting change agents in leveraging systems |
| Evaluation design | Randomised controlled trial, cluster randomised controlled trial | Cluster randomised controlled trial, quasi-experiments | Quasi-experiments, natural experiments |
| Evaluation measurements | BMI, individual * environments † | BMI, individual, environments, community ‡ | BMI, individual, environments, community, systems§ |
| Fidelity priority | Package implementation | Process and relationships in building capacity | Process and relationships in activating systems |
| Validity | Internal: strongest; external: weakest | Internal: moderate; external: moderate | Internal: weakest; external: strongest |
| Application to at-scale action | Marginally relevant | Proof of principle | Directly applicable |
BMI=body-mass index.
* For example, behaviours, attitudes, or knowledge.
† For example, food and physical activity environments in schools.
‡ For example, community capacity and community readiness to change.
§ For example, social networks and systems dynamics.
Some studies have used a more whole-of-community approach and characterised their interventions as community capacity-building,307 meaning they focused on actions to support community leadership, mobilising resources, increasing workforce skills, creating partnerships, and strengthening monitoring and evaluation.308 Capacity-building creates stronger partnerships between research and practitioner communities and is more encompassing of multiple settings, multiple strategies and longer duration. These research designs often use quasi-experimental methods and so have weaker internal validity (table 4). This approach has been effective in reducing childhood obesity in some communities,309, 310, 311 has proven sustainable, and has spread to surrounding areas,312 but it has not been effective in other communities, such as Pacific adolescents.313, 314, 315
In recognition of obesity as an unwanted outcome or emergent property of complex, adaptive systems, systems science methods are being increasingly applied to community obesity prevention efforts. A systems-based approach to obesity prevention starts with the community’s current systems and contexts and works collaboratively to understand the multilevel drivers of obesity and to identify ways that the existing systems can be used or reoriented to create better health outcomes (table 4).316 A range of methods exist to support the community through these processes,317 including development of causal maps across all stages of system conceptualisation and intervention development, delivery, and evaluation.
Poor implementation is often cited as a major impediment to the effectiveness of community interventions316, 318 and a greater application of implementation science might help to overcome these barriers. Foster-Fishman319 identified a range of systemic factors such as social, economic, leadership, organisational culture, or political climate that might impede or promote implementation. Deliberate consideration of these factors within a complex systems approach might optimise implementation.320 For example, recently developed tools can guide the sensemaking processes so that teams can routinely and systematically assess implementation challenges and identify approaches to guiding action. The process is congruent with complex adaptive systems because it respects non-linearity, and is interactive and relationship-focused.321
Examples of systems activation approaches from Victoria, Australia
Healthy Together Victoria (HTV) was an effort to apply systems approaches to obesity prevention at the policy and community levels across the state of Victoria, Australia. During a brief, single term of state government (2011–15), a substantial boost in funding for prevention, a solid existing base in prevention experience, strong intellectual leadership within the Department of Health, and supportive political leadership combined to create a step change in prevention approaches in Victoria. A change of government and political commitment ended HTV just as it was gaining momentum at the local level and across the state within and beyond the initial HTV intervention areas (appendix p 38).
This increasing interest within Victorian communities for systems interventions and the demise of HTV left a vacuum. A number of community-academic partnerships grew to continue the efforts, but in a more bottom-up fashion and based on the community’s own capacity, interest, and remit to make systems changes within their settings (appendix p 39). This collective community approach generates coherence and positivity among health promotion professionals because it gives them traction to engage with other sectors (panel 15), and can initiate a community-based reorientation of systems for other aspects of The Global Syndemic.
Panel 15: People’s experience — community-based health promoterIn 2014, agency leaders who had been delivering obesity prevention programmes for many years, agreed that business as usual wasn’t having an impact on our community’s health. We needed to find a better approach to leverage our relatively small government funding to achieve long-lasting population level improvements. We found that 38% of our primary school children had overweight or obesity and this reinforced our resolve to act collectively and fearlessly. Deakin University facilitated some systems mapping workshops and from the community buzz that was created, we grew the number of community participants with smaller workshops in schools, workplaces, and professional networks. Our systems map visually demonstrated that if you change one factor, many other connected factors alter and change with it. It was like magic, watching these maps being made. The energy levels in the room rose as participants started to visualise the complexity of the causes of obesity. This led to a shared understanding and realisation that if we made a lot of small changes across many of these factors, we could make a real impact. Conversations quickly turned to the recognition that there is no silver bullet, that the whole community needs to work together to solve the problem, and that different players could use the map to identify their roles in taking action. Blaming and finger pointing quickly dissolved into joint ownership. What was so crucial was that this newly enhanced understanding of complexity led to the ability to identify concrete actions to most effectively influence the systems. What was so exciting for me was that I could not have predicted many of the actions that these workshops produced. The snowball effect within the community has been even more amazing. We are now learning of changes made within the community by people who were not involved or connected to the initial workshops. I learned that flexibility and participant control empowers the community and gives them ownership of both the problem and action. The strong focus on action has also resonated well with participants. Too often, we have sought input from the community for planning and prioritising but rarely given them ownership of the solution. Participants responded that by coming together and sharing ideas and commitments to act, they felt supported, braver, and bolder by being part of a bigger approach. Between 2015 and 2017, we have seen improvements in physical activity, active transportation, fruit, vegetable, and sugary drinks consumption and a decrease in BMI of primary school children. Whilst it is very exciting to have these preliminary changes all heading in the right direction, for me, the most rewarding part was to be able to share these timely data with the community. By doing so, I sensed the participants are now feeling even further empowered and, not surprisingly, the next wave of community actions has started. Contributed by Janette Lowe, Executive Officer at Southern Grampians Glenelg Primary Care Partnership, Australia. |
