This chapter will address the following American College of Graduate Medical Education competencies: practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.

Practice-Based Learning and Improvement: A growing number of pediatric health care providers embrace their role as change agents for creating a healthy environment. This chapter will help providers understand community advocacy within the context of the socioecological model so that they can help communities make sustainable and effective change.

Interpersonal and Communication Skills: This chapter will enable the practitioner to enhance effective exchange of information, collaboration with patients and families as well as with other health professionals.

Professionalism: Professionalism is important in advocacy just as it is in clinical care, and this chapter will address the principles of community-based participatory research (CBPR) which includes commitment to professional responsibilities, acting on ethical principles, and sensitivity to diversity and values of respect.

Systems-Based Practice: Engagement in advocacy demonstrates that the pediatric health care provider has an awareness of the larger system of health care delivery, and this chapter will highlight examples of the ways providers can interact with the system to optimize patient outcomes.

Pediatric health care providers feel very comfortable in the confines of an examination room. Cocooned in a 12 × 12 ft² room with a familiar family, they can address the most sensitive issues with skill and compassion. The patient and family then leave this space, which is equally secure though less familiar and comfortable for them, to return back to their real world. For patients and families, their real-world environment includes not only their familiar household, but also their child’s school, neighborhood, community, the state, nation, and larger world. This wider nonmedical home is obviously where day-to-day living takes place and health is determined. Providers, from the security and elevated status of their office, are frequently guilty of thinking that what happens in their confines translates seamlessly to their patients who live in what can either be a supportive or antagonistic environment. Unfortunately, this is not the case. As illustrated by the obesity epidemic, families return to environments of increased portion size, reduction in opportunities for physical activity, decreased cost of sugar-sweetened beverages, and other factors that can make following the advice and achieving the goals set in the examination room difficult and challenging.

What are pediatric health care providers to do with this reality? A growing number of providers embrace their role as change agents for creating a healthy environment. As valued and respected members of society, pediatric health care providers have a unique and powerful voice to make healthy and easy choices for their patients. An understanding of community advocacy within the context of the socioecological model can lead to sustainable and effective community changes.

Whether one believes that “it takes a village” or that personal responsibility is the critical element in healthy behavior change, the fact that obesity and health are affected by family, school, workplace, community, and governmental factors is established.^1,2 The socioecological model describes this process in a series of nesting zones (Figure 20-1). Used to describe other processes such as violence prevention and smoking cessation, the model acknowledges an interwoven relationship between a person and their surroundings. Furthermore, the model illustrates that personal choice is central to behavior change, but that lifestyle changes are maintained or ended under the influence of social factors such as friends, workplace programs, state laws, regulations, and the like. Conversely, barriers to healthy behaviors are shared across sectors. Ultimately, acknowledging these cross-sectional relationships, the most effective programs and interventions will involve all areas and will consistently promote the desired behavior in unison.

For example, what might a strategy to improve health by reducing sugar-sweetened beverage consumption look like within the socioecological model construct? In pediatrics, sugar-sweetened beverages are generally defined as beverages containing nutritive sweeteners. This includes soft drinks, sports drinks, sweetened iced teas, fruit drinks, and juices, including 100% juice. It does not include milk, water, or beverages containing nonnutritive sweeteners, such as aspartame, sucralose, or stevia derivatives. Certainly, the ultimate goal is a personal commitment to eliminating sweetened drinks. Depending on the patient’s age, the patient or family needs to understand the importance of the behavior and must feel empowered to make a change. The extended family can be supportive by providing healthy alternatives such as water, low-fat milk, and by patterning healthy drinking habits. The pediatric health care provider can deliver important knowledge and enhance personal motivation. The patient’s child care facility or school can provide ample water, encourage water consumption through the provision of character-embossed water bottles and through the limiting of vending options to water and milk. The local neighborhood, working with the local grocery store, can make sure that sporting events are stocked with bottled water at eye level at check-out counters. The local chamber of commerce could embark on a social media campaign encouraging citizens to drink healthy beverages on buses, in movie theatre promos, and on cable access television. The local soda bottling company can work with advocates to adjust the per ounce cost differential between small serving size and jumbo size drinks, essentially eliminating the financial incentive to drink more while preserving company profitability. The local government can change vending policies to promote water and eliminate sugary drinks, and the state government can consider an excise tax where sugar-sweetened beverages are taxed on a per ounce basis to reduce their access to children and adolescents and to fund other aspects of the campaign to reduce consumption of sugar-sweetened beverages.

The role of the pediatric health care provider in this equation can take several forms. The health care provider can exercise grassroots advocacy through support for local initiatives and patterning of healthy vending in the medical office building. Supporting local child care programming, filming local television spots, or participation in national programming like Let’s Move! can represent meaningful advocacy. Political advocacy, while initially intimidating, can also effect major change. Whether speaking to mothers of preschoolers or members of a legislative subcommittee, pediatric health care providers are respected authorities and are viewed as altruistic and unbiased when addressing child welfare (Figure 20-2).

When thinking about policy opportunities in an area as complicated and multifaceted as pediatric obesity, it is easy to get overwhelmed. Not only must patients and communities select what behavior to address, they must also decide on what sector to address. The American Academy of Pediatrics (AAP) has designed a useful interactive tool to help in this process. Policy tools are available from the AAP that suggest evidence-based interventions and also provide references and resources for selected policy activities at all levels of the socioecological model (http://ihcw.aap.org).

When so many behaviors can be targeted, how much intervention is enough to bring about benefit? On the community (Somerville, MA),³ larger city (Philadelphia, PA; Nashville, TN)^4,5 and state level (Maine),⁶ greatest benefit occurs with comprehensive, multisectorial interventions. In addition, interplay of various sectors creates a greater effect. The total effect does indeed seem to be greater than the sum of the parts.⁷ Having said this, lack of a comprehensive approach should never be an excuse for inaction.

In the early experience of obesity prevention in Arkansas, universal school body mass index (BMI) screening alone, without any organized intervention, resulted in relative stabilization of obesity rates when compared to neighboring states with no screening.^8,9 In this case, making sure that health care providers did not contradict simple messaging sent home from school regarding BMI percentile and weight status was critical. Early in the Arkansas experience, there was significant pushback from parental and even medical groups who did not feel it was the schools’ prerogative to tell parents that their children were “fat.” Health care providers were critical in making sure that parental concerns about school BMI screening were addressed without minimizing the meaning of the screening results. Later, because BMI screening came under continued attack in the state legislature as an unfunded mandate and a cause for unnecessary stress for parents, health care providers were critical in keeping the mandate from repeal.⁹ Continued screening has afforded Arkansas ongoing, reliable data to track the effectiveness of other programs seeking to prevent and treat obesity inside and outside school walls.

People are usually more convinced by reasons they discovered themselves than by those found by others.

—Pascal

Obesity care is predicated on patient readiness to change. The futility of working with a patient or family who needs to address healthy habits, but has no interest, has frustrated health care providers for centuries. National recommendations support the use of motivational interviewing (MI) for counseling children with obesity in the clinical setting.¹⁰ In this approach to promote positive behavior change, patient autonomy is honored, patient values are evoked, and a collaborative relationship with the provider is established. The patient’s ambivalence to change is explored, and the patient’s available resources are assessed. The patient and/or his or her family embark on behavior changes they choose and can handle at that point in time. Patients unready for or disinterested in change are not coerced into action. According to MI experts, coercion is counterproductive and impedes the beneficial change. If a behavior change is not embraced, it is neither effective nor sustainable.¹¹