To stem the growing epidemic of childhood obesity, what children eat and the way they physically engage with their home, school and neighborhood environments needs to change. However, for healthy eating and physical activity to become the norm, the places where children live, learn and play need to provide the cognitive, social and economic resources to foster changes in existing behavior. This will not occur if the knowledge and skills remain with the public health specialists, government officials and researchers currently driving efforts to prevent the epidemic. It will occur if the collective capacity, knowledge and resources of children, parents, residents, community sector organizations, government agencies and health experts are harnessed in order to understand the problem and make changes. The process of building the competencies, structures and resources in civil society, as opposed to relying on market forces or state intervention, is known as “community capacity building” and the aim of this chapter is to describe how the components of community capacity building apply to childhood obesity prevention.

Community

Definitions and uses of the term “community” are various, and with time there has been little agreement or consistency. Over 50 years ago, the sociologist Hillery, found over 90 different meanings of the term “community” and concluded that the only commonality between the meanings was that they were about people.¹ In reference to “community capacity building” the term community has in the past been applied to a specific geographical community. However, our experience suggests, a broader definition of community is typically used and that it may or may not have a geographical boundary but may simply be a group that shares a common goal interest or identity.

Capacity building

Like community, “capacity building” also has various meanings. Hawe et al described it as one of those terms that is given to a loose or wide concept, where professionals in the field can give an impression of understanding and consensus of the concept but differ in their definition.² Close inspection, however, reveals similarities in the definitions. For example, NSW Health defined capacity building as “an approach to the development of sustainable skills, organizational structures, resources and commitment to health improvement in health and other sectors, to prolong and multiply health gains many times over”.³ Similarly, Bush et al defined community capacity building as “a collection of characteristics and resources which, when combined, improve the ability of a community to recognise, evaluate and address key problems … the work that is done to develop the capacity of the network of groups and organizations”.⁴

Community capacity building in health promotion

Within health promotion, community capacity building has evolved from the traditions of community development. Its roots can be linked to international aid efforts and it shares its origins with the associated concepts of community organization, community action and community empowerment. ⁵ In essence, rather than being a mere “site” for interventions, the “community” is a resource for change. Community capacity building first became prominent in the health promotion arena in the mid-1990s, although its development can be tracked from the 1986 Ottawa Charter.⁶ Elements of capacity building clearly underpin the charter’s concept of empowerment and subsequent declarations further articulate capacity building. The Jakarta Declaration in 1997 specifically identified the need to “increase community capacity and empower the individual” and conveys both the rationale and requirements for capacity building. ⁷

More recently, the Bangkok Charter called for all sectors and settings to act to “build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy” thus recognizing the need to integrate capacity building strategies into health promotion.⁸ Helpfully, the term “capacity building” is now included in the World Health Organization’s (WHO) Health Promotion Glossary (Box 27.1).⁹ The value in such a glossary is that definitions are underpinned by a process of deliberation including a literature review and expert feedback which helps to provide at least a starting point for developing health promotion interventions.

The glossary goes on further to say that capacity building at the community level may include raising awareness about health risks, strategies to foster community identity and cohesion, education to increase health literacy, facilitating access to external resources, and developing structures for community decision making. It is noted that for action at the community level to be successful, there needs to be a social and political response to secure support for such interventions. Collectively, these components provide a means by which “stakeholders” in health promotion can consider how they may develop effective interventions that link micro-level change at the individual level, meso-level changes at the neighborhood level and macro-changes at the political and policy level.

Having arrived at a definition for community capacity building within the context of health promotion, it should be noted that the discourses have not been without their criticisms. Community capacity building has been criticised as being a smokescreen for more subtle forms of social control because proponents claim that it is an alternative to economic regeneration but does little to challenge structural forms of inequality. ^10–12 For instance, concerns reflected in UK urban regeneration policy that community capacity building is about “expecting groups of people who are poorly resourced to pull themselves up by their collective bootstraps”,¹³ are mirrored by those who feel that similar approaches in primary health care policy in Australia depoliticize “Indigenous health, whilst legitimising and mystifying relations of white dominance”.¹⁴ Such critiques, however, give little space for collective human agency, condemning “the poor” and disenfranchised to what Bourdieu called “the weight of the world” without acknowledging that, where formal politics have failed, such approaches may provide a mechanism through which people can be authors and co-authors of transformations of their local, social, economic and cultural worlds.¹⁵

The Jakarta Declaration ⁷ answers this question in its justification for health promotion by stating that “it improves both the ability of individuals to take action, and the capacity of groups, organisations or communities to influence the determinants of health”. What can be inferred here is that health promotion principles are about increasing the ability and building the capacity to affect health determinants. Put simply, community capacity building has the power to influence individual and population health outcomes through empowering people and making changes sustainable. Although this is largely agreed upon, the rationale of empowerment and sustainability is not always made explicit.

In assessing community capacity building approaches to preventing childhood obesity we find ourselves at the heart of a charged political and theoretically contested arena. Discourses on the “childhood obesity epidemic” are themselves framed, on the one hand, as problems of individual behavior and on the other, as a consequence of structural inequalities. Also, while there are a growing number of successful interventions, ^16–18 we do not yet know what works to prevent overweight and obesity in children at a population level. However, we do know that multiple strategies are required in multiple settings, ¹⁹ and that this cannot be achieved in a sustainable way unless communities take on the problem themselves. Indeed, given the pervasiveness of the epidemic, it is likely that communities will not only need to take on the problem but also link with other communities and harness the support of governments so that they can overcome the sectoral (e.g. transportation) and global (e.g. fast-food franchising) contributors to the epidemic. In other words, communities need to move from the current state of disengaged awareness of childhood obesity, through recognizing and owning the problem, to accessing expertise and external resources, to intervening so that it becomes easy for children to be active and eat well. Community capacity building is the process through which this can occur.

For action to be taken on health risks, the scale of the problem needs to be meaningful for communities and they need to have an understanding of who is most at risk. In Australia, as in other Western countries, about a quarter of children are either overweight or obese and this continues to increase steadily.²⁰ Generally, there are minimal differences in prevalence by gender. However it is usually higher among children from lower socio-economic status backgrounds.²¹ Behavioral determinants, in line with findings from other countries, include sweetened drinks, energy-dense food consumption, sedentary behavior and environments that encourage these behaviors.²² Owing to extensive and continued media coverage of obesity in many countries, most people are generally aware of the problem but it is difficult to demonstrate how the problem (its size, rate of increase, who it affects, determinants and consequences) applies at a community level. Unless there is a sense that the problem has relevance at this level, then it is unlikely that communities will have any interest or motivation to seek solutions, and capacity builders run the risk of “looking down” on the community.¹² This may go part way towards explaining a lack of community ownership when it comes to childhood obesity prevention, as it raises the potential for stigmatizing a community as a “problem community” and for implying blame for nurturing a generation of obese children.²³

The problem of countering the understandable resistance of people to community capacity research initiatives was acknowledged in a Welsh government funded action research programme, the Sustainable Health Action Research Programme (SHARP), to support sustainable changes in health.²⁴ The problem, which cut across all seven target areas in Wales, was that local people had research and initiative fatigue.²⁵ People saw researchers as “parachutists” who “dropped in” from above, collected data and then disappeared without implementing any long-term change. One project site effectively overcame this fatigue and associated resistance around the chronic problem of poor diets. O ’ Neill et al described how a process was implemented which sought to understand how people conceptualized and experienced healthy eating and the barriers to its achievement. ²⁶ They theorized that the meaning of food goes beyond “nutrition” and “healthier eating” but holds personal and social meanings which need to be understood in order to develop strategies for change. They then incorporated this broader meaning into both the research and intervention strategies, which were built around opportunities for engagement and mutual exchange (see Box 27.2).

The key to community engagement is a bottom-up approach involving the community in the translation of the problem²⁷ and in decision making regarding initial investments.²⁸ Communities need to be able to define the problem in their own context and contribute to how it is resolved. This approach has been adopted in a number of community-based prevention programs in Australia where normative needs are assessed through a consultative process. This allows the community to be informed of the issues, through expert interpretation of research findings (based on local data, where possible, and expressed in terms relevant to the community) and to build a joint plan of action. (Refer to the ANGELO process in Chapter 26.) Interestingly, some communities have been happy to use the words overweight/obesity in their strategic goals while others have not because of the potential risks of stigmatization. Community input into how resources are allocated is an important part of empowerment.

In light of earlier comments, strategies to foster community identity and cohesion should clearly acknowledge the diverse definitions of community and recognize that they are influenced by self-identification, geography, politics and religion.²⁹ This is best achieved by allowing communities to define themselves. However, for closely evaluated demonstration projects, it does help to define a community’s boundaries. This was the case for three Australian demonstration projects:³⁰ “Be Active Eat Well”, a prevention program for primary school children in a rural town in Victoria (populatio~ 11,000),³¹ “Romp & Chomp” where the community was defined as “the children attending preschool and their parents or carers” in the City of Greater Geelong, and “It’s Your Move!” in five secondary schools in East Geelong. Efforts to promote healthy eating, physical activity and healthy weight were then tailored to meet the needs of that particular community. It is important to identify who can speak on behalf of the community,³² who can provide leadership and who can become stakeholders committed to the goals of the program. There is also a need to foster program identity.³³ This brings tangibility to the program early on and fosters community ownership so that the program can become an integral part of what the community is about.

“Te Whanau Cadillac—A Waka for Change”, is an example of a program that used a number of strategies to foster community identity and cohesion. This action research project from New Zealand aimed to bridge the gap between research and practice and to improve health and well-being through working with communities to increase their capacity to deal with alcohol and drug issues. ³⁴ Central to the project, which had a strong focus on Maori youth, was an agreement that this goal could only be met through a kaupapa Maori (Maori worldview and philosophy) approach. This included allowing communities to operate in their own style, involving more informal meetings and having project workers who provided skills in Maori cultural practices, as well as in identifying with youth.

Education, or training, is fundamental to community capacity building and the aim, similar to that of a school teacher for literacy, is to give a community knowledge or competence in health. What makes it distinct from awareness-raising is the ongoing transfer of knowledge on how to do something about the problem. For example, sports coaches need to know how to ensure that every child who shows up for practice develops fundamental movement skills; while school canteen managers need to know what foods are healthy choices for children or adolescents and how best to market them. Parents need to know that watching more than two hours a day of television is not recommended for children and what strategies can be put in place to reduce overall viewing time. “Good for Kids Good for Life” in New South Wales ³⁵ is Australia’s largest community-based program promoting healthy eating and physical activity for children up to 15 years of age.

Training on “how to” prevent obesity is central to each of the settings (preschools, schools, sports clubs, community services, health services and media) where the program is operating, and importantly, this is tailored to the specific needs of each of the settings. For example, to support the introduction of fruit and water breaks and healthier school canteen menus in primary schools, training was provided by both experts (dietitians) and education consultants for school champions (a representative from the school who would champion the program), and was designed so that it complemented and contributed to the curriculum in a range of subjects and school stages (see Box 27.3).

There is a temptation to make community capacity building synonymous with education. However, education on its own it is not enough and there is growing evidence that attention also needs to be paid to community awareness, community cohesion, facilitating access to resources, decision-making structure and social and political support aspects of capacity building. ^36,37