Generating political commitment for ending malnutrition in all its forms: A system dynamics approach for strengthening nutrition actor networks

Barriers and facilitators of severe acute malnutrition management at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, North West Ethiopia, descriptive phenomenological study

BACKGROUND

Malnutrition is a clinical condition that affects all age groups, and it remains a major public health threat in Sub-Saharan Africa. As a result, this research aimed to investigate the barriers and facilitators of treating severe acute malnutrition at Felege Hiwot Comprehensive Specialized Hospital in Bahir Dar City, North West Ethiopia.

METHODS

A descriptive phenomenological study was conducted from February to April 2021. The final sample size taken was fifteen based on data saturation. In-depth and key informant interviews were conducted with nine caregivers, three healthcare workers, and three healthcare managers supported by observation. A criterion-based, heterogeneous purposive sampling technique was used to select the study participants. Each interview was audio-taped to ensure data quality. Thematic analysis was done to analyze the data using Atlas. ti version 7 software.

RESULTS

Two major themes and six sub-themes emerged. Barriers related to severe acute malnutrition management include subthemes on socio-economic and socio-cultural conditions, perceived causes of severe acute malnutrition and its management, and the healthcare context. Facilitators of severe acute malnutrition management include severe acute malnutrition identification, service delivery, and being a member of community-based health insurance.

CONCLUSIONS

Effective management of severe acute malnutrition was affected by a multiplicity of factors. The results reaffirm how socioeconomic and sociocultural conditions, perceived causes of severe acute malnutrition (SAM) and its management and the health care context were the major barriers, while able to identifying severe acute malnutrition, service delivery, and is a member of community-based health insurance were the major facilitators for SAM management. Therefore, special attention shall be given to SAM management.

Citizen science approaches to crowdsourcing food environment data: A scoping review of the literature

Globally, the adoption and implementation of policies to improve the healthiness of food environments and prevent population weight gain have been inadequate. This is partly because of the complexity associated with monitoring dynamic food environments. Crowdsourcing is a citizen science approach that can increase the extent and nature of food environment data collection by engaging citizens as sensors or volunteered computing experts. There has been no literature synthesis to guide the application of crowdsourcing to food environment monitoring. We systematically conducted a scoping review to address this gap. Forty-two articles met our eligibility criteria. Photovoice techniques were the most employed methodological approaches (n = 25 studies), commonly used to understand overall access to healthy food. A small number of studies made purpose-built apps to collect price or nutritional composition data and were scaled to receive large amounts of data points. Twenty-nine studies crowdsourced food environment data by engaging priority populations (e.g., households receiving low incomes). There is growing potential to develop scalable crowdsourcing platforms to understand food environments through the eyes of everyday people. Such crowdsourced data may improve public and policy engagement with equitable food policy actions.

Using System Dynamics to Understand Transnational Corporate Power in Diet-Related Non-communicable Disease Prevention Policy-Making: A Case Study of South Africa

BACKGROUND

Complex interactions between political economy factors and corporate power are increasingly recognized to prevent transformative policy action on non-communicable disease (NCD) prevention. System science offers promising methods for analysing such causal complexity. This study uses qualitative system dynamics methods to map the political economy of diet-related NCD (DR-NCD) prevention policy-making aiming to better understand the policy inertia observed in this area globally.

METHODS

We interviewed 25 key policy actors. We analysed the interviews using purposive text analysis (PTA). We developed individual then combined casual loop diagrams to generate a shared model representing the DR-NCD prevention policy-making system. Key variables/linkages identified from the literature were also included in the model. We validated the model in several steps including through stakeholder validation interviews.

RESULTS

We identified several inter-linked feedback processes related to political economy factors that may entrench different forms of corporate power (instrumental, structural, and discursive) in DR-NCD prevention policy-making in South Africa over time. We also identified a number of feedback processes that have the potential to limit corporate power in this setting.

CONCLUSION

Using complex system methods can be useful for more deeply understanding DR-NCD policy inertia. It is also useful for identifying potential leverage points within the system which may shift the existing power dynamics to facilitate greater political commitment for healthy, equitable, and sustainable food system transformation.

Sabounchi N. Application of group model building in implementation research: A systematic review of the public health and healthcare literature

BACKGROUND

Group model building is a process of engaging stakeholders in a participatory modeling process to elicit their perceptions of a problem and explore concepts regarding the origin, contributing factors, and potential solutions or interventions to a complex issue. Recently, it has emerged as a novel method for tackling complex, long-standing public health issues that traditional intervention models and frameworks cannot fully address. However, the extent to which group model building has resulted in the adoption of evidence-based practices, interventions, and policies for public health remains largely unstudied. The goal of this systematic review was to examine the public health and healthcare applications of GMB in the literature and outline how it has been used to foster implementation and dissemination of evidence-based interventions.

METHODS

We searched PubMed, Web of Science, and other databases through August 2022 for studies related to public health or health care where GMB was cited as a main methodology. We did not eliminate studies based on language, location, or date of publication. Three reviewers independently extracted data on GMB session characteristics, model attributes, and dissemination formats and content.

RESULTS

Seventy-two studies were included in the final review. Majority of GMB activities were in the fields of nutrition (n = 19, 26.4%), health care administration (n = 15, 20.8%), and environmental health (n = 12, 16.7%), and were conducted in the United States (n = 29, 40.3%) and Australia (n = 7, 9.7%). Twenty-three (31.9%) studies reported that GMB influenced implementation through policy change, intervention development, and community action plans; less than a third reported dissemination of the model outside journal publication. GMB was reported to have increased insight, facilitated consensus, and fostered communication among stakeholders.

CONCLUSIONS

GMB is associated with tangible benefits to participants, including increased community engagement and development of systems solutions. Transdisciplinary stakeholder involvement and more rigorous evaluation and dissemination of GMB activities are recommended.

The use of participatory systems mapping as a research method in the context of non-communicable diseases and risk factors: a scoping review

CONTEXT

Participatory systems mapping is increasingly used to gain insight into the complex systems surrounding non-communicable diseases (NCDs) and their risk factors.

OBJECTIVES

To identify and synthesize studies that used participatory systems mapping in the context of non-communicable diseases.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Peer-reviewed studies published between 2000 and 2022.

STUDY SELECTION

Studies that focused on NCDs and/or related risk factors, and included participants at any stage of their system's mapping process, were included.

CATEGORIES FOR ANALYSIS

The main categories for analysis were: (1) problem definition and goal-setting, (2) participant involvement, (3) structure of the mapping process, (4) validation of the systems map, and (5) evaluation of the mapping process.

RESULTS

We identified 57 studies that used participatory systems mapping for a variety of purposes, including to inform or evaluate policies or interventions and to identify potential leverage points within a system. The number of participants ranged from 6 to 590. While policymakers and professionals were the stakeholder groups most often included, some studies described significant added value from including marginalized communities. There was a general lack of formal evaluation in most studies. However, reported benefits related mostly to individual and group learning, whereas limitations described included a lack of concrete actions following from systems mapping exercises.

CONCLUSIONS

Based on the findings of this review, we argue that research using participatory systems mapping would benefit from considering three different but intertwined actions: explicitly considering how different participants and the power imbalances between them may influence the participatory process, considering how the results from a systems mapping exercise may effectively inform policy or translate into action, and including and reporting on evaluation and outcomes of the process, wherever possible.

Systems Thinking and Complexity Science Methods and the Policy Process in Non-communicable Disease Prevention: A Systematic Scoping Review

BACKGROUND

Given the complex determinants of non-communicable diseases (NCDs), and the dynamic policy landscape, researchers and policymakers are exploring the use of systems thinking and complexity science (STCS) in developing effective policies. The aim of this review is to systematically identify and analyse existing applications of STCS-informed methods in NCD prevention policy.

METHODS

Systematic scoping review: We searched academic databases (Medline, Scopus, Web of Science, EMBASE) for all publications indexed by 13 October 2020, screening titles, abstracts and full texts and extracting data according to published guidelines. We summarised key data from each study, mapping applications of methods informed by STCS to policy process domains. We conducted a thematic analysis to identify advantages, limitations, barriers and facilitators to using STCS.

RESULTS

4681 papers were screened and 112 papers were included in this review. The most common policy areas were tobacco control, obesity prevention and physical activity promotion. Methods applied included system dynamics modelling, agent-based modelling and concept mapping. Advantages included supporting evidence-informed decision-making; modelling complex systems and addressing multi-sectoral problems. Limitations included the abstraction of reality by STCS methods, despite aims of encompassing greater complexity. Challenges included resource-intensiveness; lack of stakeholder trust in models; and results that were too complex to be comprehensible to stakeholders. Ensuring stakeholder ownership and presenting findings in a user-friendly way facilitated STCS use.

CONCLUSION

This review maps the proliferating applications of STCS methods in NCD prevention policy. STCS methods have the potential to generate tailored and dynamic evidence, adding robustness to evidence-informed policymaking, but must be accessible to policy stakeholders and have strong stakeholder ownership to build consensus and change stakeholder perspectives. Evaluations of whether, and under what circumstances, STCS methods lead to more effective policies compared to conventional methods are lacking, and would enable more targeted and constructive use of these methods.

Generating Political Commitment for Regulatory Interventions Targeting Dietary Harms and Poor Nutrition: A Case Study on Sugar-Sweetened Beverage Taxation in Australia

BACKGROUND

Sugar-sweetened beverage (SSB) taxes are an effective public health policy intervention for improving nutrition and public health. Although implemented in over 50 jurisdictions worldwide, this intervention remains vastly underutilised, and in Australia political commitment for such a tax is low. The aim of this study is to understand the politics of SSB taxation in Australia, what factors have constrained political commitment for a tax, and what might enable such commitment in future.

METHODS

We adopted a case study design, guided by a theoretical framework developed from the political economy of nutrition literature. Data were collected from 16 interviews with informants from multiple sectors, supported by media articles, journal articles, and grey literature. Data were coded and organized by thematic analysis, and synthesised into the final results.

RESULTS

Nutrition actors have made significant progress in generating commitment for a SSB tax by producing relevant evidence, raising awareness, advocating for action, employing resonating frames, collaborating with civil society organisations, and forming coalitions increasing their overall cohesion. Nevertheless, political commitment for a SSB tax is low and was found to be impeded by the powerful influence of the food, beverage, and sugar industries, opposition from both major Australian political parties, ideological resistance to regulation, a low quality monitoring and surveillance system for food and nutrition, and limited public advocacy. The influence of nutrition actors was also impeded by weak connections to key policy-makers and missed collaborative opportunities with pro-SSB tax organisations.

CONCLUSION

The identification of several impediments provides an explanation for why political commitment for a SSB tax is low in Australia and reveals several opportunities for how it might be generated in the future. Political commitment may come about through, for example, actions to limit the influence of industry in policy decision-making, and by strengthening the existing pro-SSB tax coalition.

Changes in Nigeria’s enabling environment for nutrition from 2008 to 2019 and challenges for reducing malnutrition

Key 2025 global nutrition targets are unlikely to be met at current rates of progress. Although actions necessary to reduce undernutrition are already mostly known, knowledge gaps remain about how to implement these actions in contextually appropriate ways, and at scales commensurate with the magnitude of the problem. This study describes the nutrition enabling environment in Nigeria, a country that contributes significantly to the global undernutrition burden, and identifies potential entry points for improving the enabling environment that could facilitate implementation and scale-up of essential intervention coverage. Study data were obtained from two sources: content analysis of 48 policies/strategies from agriculture, economic, education, environment, health, nutrition, and water/sanitation/hygiene sectors; and interviews at federal level (16) and in two states (Jigawa (10) and Kaduna (9) States). The study finds that aspects of the enabling environment improved between 2008 and 2019 and facilitated improvements in implementation of nutrition-specific and nutrition-sensitive interventions. Enabling environment components that improved included the framing of nutrition as a multisectoral issue, nutrition advocacy, political attention, evidence around intervention coverage, civil society involvement, and activity of nutrition champions. These factors have been especially important in creating and sustaining momentum for addressing malnutrition. While challenges remain in these aspects, greater challenges persist for factors needed to convert momentum into improvements in nutrition outcomes. Research and data that facilitate shared understanding of nutrition; improved multisectoral and vertical coordination; increased and improved delivery and operational capacity; and increased resource mobilization will be especially important for achieving future progress in nutrition in Nigeria.

Prevalence and associated risk factors of chronic malnutrition amongst children under five in Eswatini

Background

About 20 million children under fi-ve in Southern Africa have chronic malnutrition. This study determines the prevalence of chronic malnutrition and associated risk factors amongst children under five.

Aim

To determine the proportion of children with chronic malnutrition and investigate associated risk factors of chronic malnutrition.

Setting

The study was conducted in communities in the four regions of Eswatini.

Methods

This study is a retrospective cross-sectional study that used data from a Multiple Indicator Cluster Survey (MICS) conducted in 2014. The study involved 3261 children who are under 5 years of age. Data on nutritional status and household characteristics were used. Logistic regression was used to identify factors associated with chronic malnutrition in the univariable and multivariable models, respectively.

Results

Results showed that 18.1% (confidence interval [CI]: 18.5–21.5) of children under five have chronic malnutrition. The highest prevalence was 20.8% (CI: 17.4–24.7) in the Shiselweni region, followed by the Manzini region with 17.6% (CI: 14.5–21.1) and the Lubombo region with 17.2% (CI: 13.9–21.2). The lowest prevalence of chronic malnutrition at 16.7% (CI: 13.6–20.3) was the Hhohho region. The results indicated that low birth weight (odds ratio [OR] = 4.63, CI: 1.12–19.2), mothers’ lack of education (OR = 1.50, CI: 1.04–2.17) and children aged 12–24 months (OR = 1.28, CI: 0.88–1.87) were significantly associated with chronic malnutrition.

Conclusion

The findings showed that malnutrition is an important public health problem in children under five and needs a multisectoral response. Low birth weight, mothers’ education and the child’s age are risk factors associated with chronic malnutrition.

Contribution

The results inform evidence-based programming for the prevention of chronic malnutrition in children thus assist the country to meet sustainable development goals.

Using group model building to frame the commercial determinants of dietary behaviour in adolescence - proposed methods for online system mapping workshops

BACKGROUND

Group model building (GMB) is a participatory approach whereby diverse stakeholders can share their views about a problem to create a collective understanding of a complex system. In this article we report our methodological approach to adapt face-to-face GMB processes to an online format to explore the mechanisms by which commercial drivers influence adolescents' dietary behaviour. We use our experiences to make recommendations on how online GMB could be delivered.

METHODS

We planned, adapted, piloted, delivered, and evaluated a series of online GMB workshops with adolescents, policymakers and public health practitioners to create a system map of the commercial determinants of dietary behaviour in adolescence. We adapted face-to-face GMB workshops to a series of 3 online GMB workshops with 11 adolescents (16-18 years) living in the Southwest of England, and one GMB workshop with policymakers and public health practitioners.

RESULTS

In our experience, adapting, and delivering GMB online is feasible, engaging, cost-saving and an enjoyable experience. Participants gave positive feedback in terms of engagement and enjoyment, and it allowed them to recognise different points of view about the same problem. Participants became familiarised with system thinking and system dynamics concepts, developed a shared understanding of a complex issue and portrayed it in a system map that depicted the most important factors in a causal structure as well as their interactions at various levels.

CONCLUSIONS

We recommend using process mapping to understand the overall GMB process in an online environment and piloting the workshops to test the timings and flow between online platforms. For facilitation and delivery, facilitators need to ensure they can create an inviting and engaging online environment, even for participants who decide to have their cameras off. Separating GMB activities into different workshops allowed participants to reflect on the problem being discussed and bring new ideas to subsequent workshops. Evaluating the workshops enabled us to build evidence on the trade-offs between the effectiveness, quality and efficiency of online GMB workshops, and how this might be enhanced to identify leverage points and achieve systemic changes in complex issues.

ETHICAL APPROVAL

The research was approved by the University of Bristol's Faculty of Health Sciences Research Ethics Committee (Ref: 99,003) and written consent was received from all participants.

Holding no-one back: The Nutrition Equity Framework in theory and practice

Equity remains poorly conceptualised in current nutrition frameworks and policy approaches. We draw on existing literatures to present a novel Nutrition Equity Framework (NEF) that can be used to identify priorities for nutrition research and action. The framework illustrates how social and political processes structure the food, health and care environments most important to nutrition. Central to the framework are processes of unfairness, injustice and exclusion as the engine of nutrition inequity across place, time and generations, ultimately influencing both nutritional status and people's space to act. The NEF illustrates conceptually how action on the socio-political determinants of nutrition is the most fundamental and sustainable way of improving nutrition equity for everyone everywhere, through 'equity-sensitive nutrition'. Efforts must ensure, in the words of the Sustainable Development Goals, that not only is "no one left behind" but also that the inequities and injustices we describe do not hold anyone back from realising their right to healthy diets and good nutrition.

Benchmarking for accountability on obesity prevention: evaluation of the Healthy Food Environment Policy Index (Food-EPI) in Australia (2016-2020)

Objective:

Despite broad agreement on the need for comprehensive policy action to improve the healthiness of food environments, implementation of recommended policies has been slow and fragmented. Benchmarking is increasingly being used to strengthen accountability for action. However, there have been few evaluations of benchmarking and accountability initiatives to understand their contribution to policy change. This study aimed to evaluate the impact of the Healthy Food Environment Policy Index (Food-EPI) Australia initiative (2016–2020) that assessed Australian governments on their progress in implementing recommended policies for improving food environments.

Design:

A convergent mixed methods approach was employed incorporating data from online surveys (conducted in 2017 and 2020) and in-depth semi-structured interviews (conducted in 2020). Data were analysed against a pre-defined logic model.

Setting:

Australia.

Participants:

Interviews: twenty stakeholders (sixteen government, four non-government). Online surveys: fifty-three non-government stakeholders (52 % response rate) in 2017; thirty-four non-government stakeholders (36 % response rate) in 2020.

Results:

The Food-EPI process involved extensive engagement with government officials and the broader public health community across Australia. Food-EPI Australia was found to support policy processes, including as a tool to increase knowledge of good practice, as a process for collaboration and as an authoritative reference to support policy decisions and advocacy strategies.

Conclusions:

Key stakeholders involved in the Food-EPI Australia process viewed it as a valuable initiative that should be repeated to maximise its value as an accountability mechanism. The highly collaborative nature of the initiative was seen as a key strength that could inform design of other benchmarking processes.

Breastfeeding, first-food systems and corporate power: a case study on the market and political practices of the transnational baby food industry and public health resistance in the Philippines

BACKGROUND

The aggressive marketing of breastmilk substitutes (BMS) reduces breastfeeding, and harms child and maternal health globally. Yet forty years after the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes (The Code), many countries are still to fully implement its provisions into national law. Furthermore, despite The Code, commercial milk formula (CMF) markets have markedly expanded. In this paper, we adopt the Philippines as a case study to understand the battle for national Code implementation. In particular, we investigate the market and political strategies used by the baby food industry to shape the country's 'first-food system', and in doing so, promote and sustain CMF consumption. We further investigate how breastfeeding coalitions and advocates have resisted these strategies, and generated political commitment for a world-leading breastfeeding policy framework and protection law (the 'Milk Code'). We used a case study design and process tracing method, drawing from documentary and interview data.

RESULTS

The decline in breastfeeding in the Philippines in the mid-twentieth Century associated with intensive BMS marketing via health systems and consumer advertising. As regulations tightened, the industry more aggressively promoted CMFs for older infants and young children, thereby 'marketing around' the Milk Code. It established front groups to implement political strategies intended to weaken the country's breastfeeding policy framework while also fostering a favourable image. This included lobbying government officials and international organizations, emphasising its economic importance and threats to foreign investment and trade, direct litigation against the government, messaging that framed marketing in terms of women's choice and empowerment, and forging partnerships. A resurgence in breastfeeding from the mid-1980s onwards reflected strengthening political commitment for a national breastfeeding policy framework and Milk Code, resulting in-turn, from collective actions by breastfeeding coalitions, advocates and mothers.

CONCLUSION

The Philippines illustrates the continuing battle for worldwide Code implementation, and in particular, how the baby food industry uses and adapts its market and political practices to promote and sustain CMF markets. Our results demonstrate that this industry's political practices require much greater scrutiny. Furthermore, that mobilizing breastfeeding coalitions, advocacy groups and mothers is crucial to continually strengthen and protect national breastfeeding policy frameworks and Code implementation.

From Understanding to Impactful Action: Systems Thinking for Systems Change in Chronic Disease Prevention Research

Within the field of chronic disease prevention, research efforts have moved to better understand, describe, and address the complex drivers of various health conditions. Change-making is prominent in this paper, and systems thinking and systems change are prioritised as core elements of prevention research. We report how the process of developing a theory of systems change can assist prevention research to progress from understanding systems, towards impactful action within those systems. Based on Foster-Fishman and Watson’s ABLe change framework, a Prevention Systems Change Framework (PSCF) was adapted and applied to an Australian case study of the drivers of healthy and equitable eating as a structured reflective practice. The PSCF comprises four components: building a systemic lens on prevention, holding a continual implementation focus, integrating the systemic lens and implementation focus, and developing a theory of change. Application of the framework as part of a systemic evaluation process enabled a detailed and critical assessment of the healthy and equitable eating project goals and culminated in the development of a theory of prevention systems change specific to that project, to guide future research and action. Arguably, if prevention research is to support improved health outcomes, it must be more explicitly linked to creating systems change.

The framing of malnutrition by parliamentarians in Uganda

The quest for political commitment to reducing malnutrition in sub-Sahara Africa draws attention to the role of national parliamentarians. Whereas parliamentarians have the authority to ratify legislation, monitor policies and budgets and transform behaviour, to date little is known about how malnutrition is understood and debated in sub-Saharan African political arenas. This study addresses that gap by exploring how (mal)nutrition has been framed by parliamentarians in Uganda between 2001 and 2017. Applying framing theory we performed a qualitative content analysis of 131 Parliament Hansards transcripts to determine the different meanings of nutrition. Our analysis distinguishes seven co-occurring frames that entail different, sometimes competing, understandings of the drivers and possible solutions of malnutrition. The frames are: (i) the emergency nutrition frame, (ii) the chronic vulnerability frame, (iii) the school feeding frame, (iv) the disease-related frame, (v) the diversification frame, (vi) the overnutrition (among politicians) frame and (vii) the poverty and inequality frame. These frames are sponsored by different groups of parliamentarians, most notably politicians representing constituencies with high degrees of malnutrition, the president, some ministers and politicians in parliamentary forums concerned with children and women issues. Our analysis helps to understand why policy measures get prioritized or disregarded by policymakers. Overall, we show that frame sponsors prioritize short-term tangible solutions, such as food assistance and agricultural inputs, over longer term solutions. We suggest that a more comprehensive policy frame is prerequisite to developing a more effective governance approach to malnutrition in Uganda.

Facilitating Factors and Opportunities for Local Food Purchases in School Meals in Spain

The objective of this study is to explore the facilitating factors and opportunities that can promote the implementation of local food purchase (LFP) in Spanish school meals in the opinions of key informants (IK). A qualitative study was carried out based on in-depth interviews with 14 KI capable of influencing Spanish food policy (Representatives of consumers and/or producers, representatives of organizations that promote LFP, and representatives of the government and/or academics). They were asked about opportunities and facilitating factors for implementation of LFP. Interviews were recorded and transcribed. A qualitative content analysis was carried out with Atlas ti. The analysis of the interviews produced two categories that include factors that- in the interviewees' opinions- can promote LFP (social fabric and policy) and three categories that bring together the factors that represent opportunities for implementation in school meal programs in Spain (the policy agenda, regional characteristics and regional context). The overlap between social and political demands were considered to be facilitating factors for LFP. Furthermore, in the opinions of KI, the presence of health and sustainability issues on the public agenda, the existence of a structured productive system and political changes represent an opportunity to implement LFP.

Understanding the dynamics of obesity prevention policy decision-making using a systems perspective: A case study of Healthy Together Victoria

INTRODUCTION

Despite global recommendations for governments to implement a comprehensive suite of policies to address obesity, policy adoption has been deficient globally. This paper utilised political science theory and systems thinking methods to examine the dynamics underlying decisions regarding obesity prevention policy adoption within the context of the Australian state government initiative, Healthy Together Victoria (HTV) (2011-2016). The aim was to understand key influences on policy processes, and to identify potential opportunities to increase the adoption of recommended policies.

METHODS

Data describing government processes in relation to the adoption of six policy interventions considered as part of HTV were collected using interviews (n = 57), document analyses (n = 568) and field note observations. The data were analysed using multiple political science theories. A systematic method was then used to develop a Causal Loop Diagram (CLD) for each policy intervention. A simplified meta-CLD was generated from synthesis of common elements across each of the six policy interventions.

RESULTS

The dynamics of policy change could be explained using a series of feedback loops. Five interconnected balancing loops served to reduce the propensity for policy change. These pertained to an organisational norm of risk aversion, and the complexity resulting from a whole-of-government policy approach and in-depth stakeholder consultation. However, seven virtuous reinforcing loops helped overcome policy resistance through policy actor capabilities that were improved over time as policy actors gained experience in advocating for change.

CONCLUSION

Policy processes for obesity prevention are complex and resistant to change. In order to increase adoption of recommended policies, several capabilities of policy actors, including policy skills, political astuteness, negotiation skills and consensus building, should be fostered and strengthened. Strategies to facilitate effective and broad-based consultation, both across and external to government, need to be implemented in ways that do not result in substantial delays in the policy process.

Ultra-processed foods and the nutrition transition: Global, regional and national trends, food systems transformations and political economy drivers

Understanding the drivers and dynamics of global ultra-processed food (UPF) consumption is essential, given the evidence linking these foods with adverse health outcomes. In this synthesis review, we take two steps. First, we quantify per capita volumes and trends in UPF sales, and ingredients (sweeteners, fats, sodium and cosmetic additives) supplied by these foods, in countries classified by income and region. Second, we review the literature on food systems and political economy factors that likely explain the observed changes. We find evidence for a substantial expansion in the types and quantities of UPFs sold worldwide, representing a transition towards a more processed global diet but with wide variations between regions and countries. As countries grow richer, higher volumes and a wider variety of UPFs are sold. Sales are highest in Australasia, North America, Europe and Latin America but growing rapidly in Asia, the Middle East and Africa. These developments are closely linked with the industrialization of food systems, technological change and globalization, including growth in the market and political activities of transnational food corporations and inadequate policies to protect nutrition in these new contexts. The scale of dietary change underway, especially in highly populated middle-income countries, raises serious concern for global health.

Novel participatory methods for co-building an agent-based model of physical activity with youth

Public health scholarship has increasingly called for the use of system science approaches to understand complex problems, including the use of participatory engagement to inform the modeling process. Some system science traditions, specifically system dynamics modeling, have an established participatory practice tradition. Yet, there remains limited guidance on engagement strategies using other modeling approaches like agent-based models. Our objective is to describe how we engaged adolescent youth in co-building an agent-based model about physical activity. Specifically, we aim to describe how we communicated technical aspects of agent-based models, the participatory activities we developed, and the resulting visual diagrams that were produced. We implemented six sessions with nine adolescent participants. To make technical aspects more accessible, we used an analogy that linked core components of agent-based models to elements of storytelling. We also implemented novel, facilitated activities that engaged youth in the development, annotation, and review of graphs over time, geographical maps, and state charts. The process was well-received by the participants and helped inform the basic structure of an agent-based model. The resulting visual diagrams created space for deeper discussion among participants about patterns of daily activity, important places for physical activity, and interactions between social and built environments. This work lays a foundation to develop and refine engagement strategies, especially for translating qualitative insights into quantitative model specifications such as ‘decision rules’.