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

Effectiveness of an Artificial Intelligence-Assisted App for Improving Eating Behaviors: Mixed Methods Evaluation

BACKGROUND

A plethora of weight management apps are available, but many individuals, especially those living with overweight and obesity, still struggle to achieve adequate weight loss. An emerging area in weight management is the support for one's self-regulation over momentary eating impulses.

OBJECTIVE

This study aims to examine the feasibility and effectiveness of a novel artificial intelligence-assisted weight management app in improving eating behaviors in a Southeast Asian cohort.

METHODS

A single-group pretest-posttest study was conducted. Participants completed the 1-week run-in period of a 12-week app-based weight management program called the Eating Trigger-Response Inhibition Program (eTRIP). This self-monitoring system was built upon 3 main components, namely, (1) chatbot-based check-ins on eating lapse triggers, (2) food-based computer vision image recognition (system built based on local food items), and (3) automated time-based nudges and meal stopwatch. At every mealtime, participants were prompted to take a picture of their food items, which were identified by a computer vision image recognition technology, thereby triggering a set of chatbot-initiated questions on eating triggers such as who the users were eating with. Paired 2-sided t tests were used to compare the differences in the psychobehavioral constructs before and after the 7-day program, including overeating habits, snacking habits, consideration of future consequences, self-regulation of eating behaviors, anxiety, depression, and physical activity. Qualitative feedback were analyzed by content analysis according to 4 steps, namely, decontextualization, recontextualization, categorization, and compilation.

RESULTS

The mean age, self-reported BMI, and waist circumference of the participants were 31.25 (SD 9.98) years, 28.86 (SD 7.02) kg/m2, and 92.60 (SD 18.24) cm, respectively. There were significant improvements in all the 7 psychobehavioral constructs, except for anxiety. After adjusting for multiple comparisons, statistically significant improvements were found for overeating habits (mean -0.32, SD 1.16; P<.001), snacking habits (mean -0.22, SD 1.12; P<.002), self-regulation of eating behavior (mean 0.08, SD 0.49; P=.007), depression (mean -0.12, SD 0.74; P=.007), and physical activity (mean 1288.60, SD 3055.20 metabolic equivalent task-min/day; P<.001). Forty-one participants reported skipping at least 1 meal (ie, breakfast, lunch, or dinner), summing to 578 (67.1%) of the 862 meals skipped. Of the 230 participants, 80 (34.8%) provided textual feedback that indicated satisfactory user experience with eTRIP. Four themes emerged, namely, (1) becoming more mindful of self-monitoring, (2) personalized reminders with prompts and chatbot, (3) food logging with image recognition, and (4) engaging with a simple, easy, and appealing user interface. The attrition rate was 8.4% (21/251).

CONCLUSIONS

eTRIP is a feasible and effective weight management program to be tested in a larger population for its effectiveness and sustainability as a personalized weight management program for people with overweight and obesity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04833803; https://classic.clinicaltrials.gov/ct2/show/NCT04833803.

Why we struggle to make progress in obesity prevention and how we might overcome policy inertia: Lessons from the complexity and political sciences

Despite evidence for the effectiveness of policies that target obesogenic environments, their adoption remains deficient. Using methods and concepts from complexity and political science (Stock-and-Flow analysis and Punctuated Equilibrium Theory) and a qualitative literature review, we developed system maps to identify feedback loops that hinder policymaking on mitigating obesogenic environments and feedback loops that could trigger and sustain policy change. We found numerous self-reinforcing feedback loops that buttress the assumption that obesity is an individual problem, strengthening the biomedical and commercial weight-loss sectors' claim to "ownership" over solutions. That is, improvements in therapies for individuals with obesity reinforces policymakers' reluctance to target obesogenic environments. Random events that focus attention on obesity (e.g., celebrities dismissing soda) could disrupt this cycle, when actors from outside the medical and weight-loss sector (e.g., anti-weight stigma activists) successfully reframe obesity as a societal problem, which requires robust and politically relevant engagement with affected communities prior to such events taking place. Sustained prioritization of policies targeting obesogenic environments requires shared problem ownership of affected communities and nonhealth government sectors, by emphasizing cobenefits of policies that target obesogenic environments (e.g., ultraprocessed food taxation for raising revenue) and solutions that are meaningful for affected communities.

An exploration of the determinants of overweight and obesity and the capacity to intervene in North-West Tasmania: A stakeholder consultation

ISSUE ADDRESSED

The capacity of communities to develop effective obesity prevention initiatives varies and should be a focus for obesity prevention intervention planning and investment. This research aimed at engaging and consulting local community stakeholders to identify determinants, needs, strategic priorities and capacity to act on overweight and obesity prevention in North-West (NW) Tasmania.

METHODS

A series of semi-structured interviews and thematic analyses was implemented to explore the knowledge, insights, experiences and attitudes of stakeholders.

RESULTS

Mental health and obesity were identified as major concerns and were often reported to share similar determinants. This study has identified health promotion capacity assets (existing partnerships, community capital, local leadership and some pockets of health promotion activity), and a range of capacity deficits (limited investment in health promotion, a small workforce, limited access to pertinent health information).

CONCLUSIONS

This study has identified health promotion capacity assets (existing partnerships, community capital, local leadership and some pockets of health promotion activity), and a range of capacity deficits (limited investment in health promotion, a small workforce, limited access to pertinent health information). SO WHAT?: Broad upstream socio-economic, cultural and environmental determinants underpin the conditions by which the local community develops overweight/obesity and/or health and wellbeing outcomes. Including stakeholder consultations as a significant technique within a comprehensive plan of action aimed at achieving a sustainable, long-term strategy for obesity prevention and/or health promotion, should be considered in future programs.

Development of an action programme tackling obesity-related behaviours in adolescents: a participatory system dynamics approach

System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10-14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system's structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice.

Elusive boundaries: using an attribute framework to describe systems for population physical activity promotion

The cost of physical inactivity is alarming, and calls for whole-of-system approaches to population physical activity promotion (PPAP) are increasing. One innovative approach to PPAP is to use a framework of interdependent attributes and associated dimensions of effective systems for chronic disease prevention. Describing system boundaries can be an elusive task, and this article reports on using an attribute framework as a first step in describing and then assessing and strengthening a provincial system for PPAP in British Columbia, Canada. Interviews were conducted with provincial stakeholders to gather perspectives regarding attributes of the system. Following this, two workshops were facilitated to document important stories about the current system for PPAP and link story themes with attributes. Results from interviews and workshops were summarized into key findings and a set of descriptive statements. One hundred and twenty-one statements provide depth, breadth and scope to descriptions of the system through the lens of an adapted framework including four attributes: (i) implementation of desired actions, (ii) resources, (iii) leadership and (iv) collaborative capacity. The attribute framework was a useful tool to guide a whole-of-system approach and turn elusive boundaries into rich descriptors of a provincial system for PPAP. Immediate implications for our research are to translate descriptive statements into variables, then assess the system through group model building and identify leverage points from a causal loop diagram to strengthen the system. Future application of this approach in other contexts, settings and health promotion and disease prevention topics is recommended.

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.

Perseverance, partnerships and passion: ingredients for successful local government policy to promote healthy and sustainable diets

BACKGROUND

Local government authorities are well-placed to invest in evidence-based food policies that promote a population-wide shift to healthy and sustainable diets. This study describes the contextual factors that facilitated or impeded policy-making related to healthy and sustainable diets within a 'best-performing' local government in Victoria, Australia.

METHODS

Guided by the Consolidated Framework for Implementation Research (CFIR), data from semi-structured interviews with individuals involved in developing the City of Greater Bendigo's Food System Strategy were analysed using the seven-stage Framework Method.

RESULTS

Semi-structured interviews (n = 24) were conducted with City of Greater Bendigo employees (n = 15) and key stakeholders working for local organisations (n = 6) or at a state or national level (n = 3). Interviewees mostly held positions of leadership (n = 20) and represented diverse areas of focus from health (n = 7), food systems (n = 4) and planning and public policy (n = 3). Data analysis revealed 12 cross-cutting themes; eight facilitating factors and four impeding factors. Facilitating factors included perseverance, community engagement, supportive state policy, effective leadership, a global platform and networks, partnerships, workforce capacity and passion, and the use of scientific evidence. Impeding factors included access to secure, ongoing financial resources, prohibitive state and federal policy, COVID-related disruptions to community engagement and competing stakeholder interests. Overall, this study suggests that the City of Greater Bendigo's success in developing an evidence-based local food system policy is built upon (i) a holistic worldview that embraces systems-thinking and credible frameworks, (ii) a sustained commitment and investment throughout the inner-setting over time, and (iii) the ability to establish and nurture meaningful partnerships with community groups, neighbouring local government areas and state-level stakeholders, built upon values of reciprocity and respect.

CONCLUSIONS

Despite insufficient resourcing and prohibitive policy at higher levels of government, this 'best performing' local government in Victoria, Australia developed an evidence-based food system policy by employing highly skilled and passionate employees, embracing a holistic worldview towards planetary health and harnessing global networks. Local government authorities aspiring to develop integrated food policy should nurture a workforce culture of taking bold evidence-informed policy action, invest in mechanisms to enable long-standing partnerships with community stakeholders and be prepared to endure a 'slow-burn' approach.

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.

An analysis of current obesity strategies for adolescents in NSW against best practice recommendations: Implications for researchers, policymakers and practitioners

ISSUE ADDRESSED

Obesity is a significant health challenge facing adolescents. There is a critical need for government action to support all adolescents to improve risk factors for obesity. This study critically appraised initiatives, guidelines and policies (termed "strategies") from local health districts (LHDs), speciality health networks and Primary Health Networks (PHNs) across New South Wales (NSW), relevant to the prevention and management of obesity amongst adolescents and compare these to best practice recommendations.

METHODS

We critically appraised strategies against best practice recommendations that included support, access, responsiveness to needs, supportive environment, monitoring and evaluation and health equity. Strategies were collected by systematically searching websites of 15 LHDs, one speciality health network and 10 PHNs.

RESULTS

There was evidence of strategies regarding adolescent obesity prevention and management across all best practice recommendations. There was limited evidence of adolescent consumer participation, digital strategies for health services and online health information. There were minimal targeted public or school-based education campaigns and interventions on physical activity or nutrition. Place-based approaches such as sports and recreation facilities were not included in policies regarding the sale of healthy food and drinks. Evaluation evidence across all strategies was minimal.

CONCLUSIONS

Numerous strategies are being implemented across NSW to address adolescent obesity. Despite this, the alignment of strategies with best practice recommendations is poor and evidence of progress in tackling adolescent obesity remains unclear. SO WHAT?: Opportunities to generate and translate best practice evidence within government strategies for obesity must be prioritised with embedded measurement and evaluation plans.

Development of the Systems Thinking for Health Actions framework: a literature review and a case study

BACKGROUND

Systems thinking is an approach that views systems with a holistic lens, focusing on how components of systems are interconnected. Specifically, the application of systems thinking has proven to be beneficial when applied to health systems. Although there is plenty of theory surrounding systems thinking, there is a gap between the theoretical use of systems thinking and its actual application to tackle health challenges. This study aimed to create a framework to expose systems thinking characteristics in the design and implementation of actions to improve health.

METHODS

A systematised literature review was conducted and a Taxonomy of Systems Thinking Objectives was adapted to develop the new 'Systems Thinking for Health Actions' (STHA) framework. The applicability of the framework was tested using the COVID-19 response in Pakistan as a case study.

RESULTS

The framework identifies six key characteristics of systems thinking: (1) recognising and understanding interconnections and system structure, (2) identifying and understanding feedback, (3) identifying leverage points, (4) understanding dynamic behaviour, (5) using mental models to suggest possible solutions to a problem and (6) creating simulation models to test policies. The STHA framework proved beneficial in identifying systems thinking characteristics in the COVID-19 national health response in Pakistan.

CONCLUSION

The proposed framework can provide support for those aiming to applying systems thinking while developing and implementing health actions. We also envision this framework as a retrospective tool that can help assess if systems thinking was applied in health actions.

"An Ounce of Prevention is Worth a Pound of Cure": Proposal for a Social Prescribing Strategy for Obesity Prevention and Improvement in Health and Well-being

BACKGROUND

Social and behavioral determinants of health are increasingly recognized as central to effective person-centered intervention in clinical practice, disease management, and public health. Accordingly, social prescribing (SP) has received increased attention in recent times. The rampant global prevalence of obesity indicates that the customary, reductionistic, and disease-oriented biomedical approach to health service delivery is inadequate/ineffective at arresting the spread and mitigating the damaging consequences of the condition. There is an urgent need to shift the focus from reactive downstream disease-based treatments to more proactive, upstream, preventive action. In essence, this requires more effort to affect the paradigm shift from the traditional "biomedical approach of care" to a "biopsychosocial model" required to arrest the increasing prevalence of obesity. To this end, an SP approach, anchored in systems thinking, could be an effective means of moderating prevalence and consequences of obesity at a community level.

OBJECTIVE

The proposed SP intervention has the following three key objectives: (1) build a sustainable program for Circular Head based on SP, peer education, and health screening to minimize the incidence of obesity and related lifestyle diseases; (2) increase service and workforce connectivity and collaboration and initiate the introduction of new services and activities for obesity prevention and community health promotion; and (3) enhance health and well-being and minimize preventable adverse health outcomes of obesity and related lifestyle diseases through enhancement of food literacy and better nutrition, enhancement of physical literacy and habitual personal activity levels, and improvement of mental health, community connectedness, and reduction of social isolation.

METHODS

This paper describes a prospective SP strategy aimed at obesity prevention in Circular Head, a local government area in Northwest (NW) Tasmania. SP is a prominent strategy used in the Critical Age Periods Impacting the Trajectory of Obesogenic Lifestyles Project, which is an initiative based in NW Tasmania focused on assessing obesity prevention capacity. A social prescription model that facilitates the linkage of primary health screening with essential health care, education, and community resources through a dedicated "navigator" will be implemented. Four interlinked work packages will be implemented as part of the initial plan with each either building on existing resources or developing new initiatives.

RESULTS

A multimethod approach to triangulate insights from quantitative and qualitative research that enables the assessment of impact on individuals, community groups, and the health care system will be implemented within the initial pilot phase of the project.

CONCLUSIONS

Literature is replete with rhetoric advocating complex system approaches to curtail obesity. However, real-life examples of whole-of-systems interventions operationalized in ways that generate relevant evidence or effective policies are rare. The diverse approach for primary prevention of obesity-related lifestyle diseases and strategies for improvement of health and well-being described in this instance will contribute toward closing this evidence gap.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/41280.

An examination of public support for 35 nutrition interventions across seven countries

BACKGROUND

Public support for evidence-based nutrition interventions can be an important determinant of government willingness to develop and implement such interventions. The aim of this study was to assess support for a broad range of nutrition interventions across seven countries: Australia, Canada, China, India, New Zealand, the United Kingdom, and the United States. Assessed interventions included those relating to food availability, affordability, reformulation, labelling, and promotion.

METHODS

Approximately 1000 adults per country (total n = 7559) completed an online survey assessing support for 35 nutrition interventions/policies. ANOVA analyses were used to identify differences between countries on overall levels of support and by intervention category. Multiple regression analyses assessed demographic and diet-related factors associated with higher levels of support across the total sample and by country.

RESULTS

Substantial levels of public support were found for the assessed interventions across the seven countries and five intervention categories. The highest levels were found in India (Mean across all interventions of 4.16 (standard deviation (SD) 0.65) on a 5-point scale) and the lowest in the United States (Mean = 3.48, SD = 0.83). Support was strongest for interventions involving food labelling (Mean = 4.20, SD = 0.79) and food reformulation (Mean = 4.17, SD = 0.87), and weakest for fiscal interventions (Mean = 3.52, SD = 1.06). Consumer characteristics associated with stronger support were higher self-rated health, higher educational attainment, female sex, older age, and perceptions of consuming a healthy diet.

CONCLUSION

The results indicate substantial support for a large range of nutrition interventions across the assessed countries, and hence governments could potentially be more proactive in developing and implementing such initiatives.

Utilizing Causal Loop Diagramming to Explore a Research and Evaluation Capacity Building Partnership

The capacity to engage in research, evaluation and evidence-informed decision-making supports effective public health policy and practice. Little is known about partnership-based approaches that aim to build capacity across a system or how to evaluate them. This study examines the impacts of a research and evaluation capacity building partnership called the Western Australian Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (hereafter, SiREN). SiREN aims to strengthen capacity across a system of clinical and medical services and government and non-government organizations. These organizations are connected through their shared aim of preventing and managing sexually transmissible infections and blood-borne viruses. To examine SiREN, systems concepts and methods were used. Data were collected from SiREN organizational documents (n = 42), a survey tool (n = 104), in-depth interviews (n = 17), a workshop and three meetings with SiREN stakeholders and used to develop two causal loop diagrams. Findings show engagement with SiREN was influenced by a complex interplay of contextual (e.g., organizational capacity) and process (e.g., presence of trusting relationships) factors. SiREN contributed to system level changes, including increased resources for research and evaluation, the development of networks and partnerships that led to more efficient responses to emerging health issues, evidence sharing, and sustainable research and evaluation practice. The use of causal loop diagrams enabled the identification of key leverage points that SiREN can use for continuous improvement or evaluation. The focus on how contextual factors influenced SiREN's ability to create change provides valuable information for researchers, policymakers or practitioners seeking to develop a similar partnership.

Understanding the Influence of Community-Level Determinants on Children's Social and Emotional Well-Being: A Systems Science and Participatory Approach

Healthy social and emotional development and longer-term outcomes for children are shaped by factors across the multiple levels (micro, meso, exo, macro) of a child’s environment. By employing a novel systems science and participatory approach, we were able to co-produce a series of causal loop diagrams that detail the complex relationships between variables operating at the community or neighborhood environment level (e.g., features of the built environment such as: housing type, access, availability, and location; parks and greenspace, facilities such as community services, and other service infrastructure such as transit), and highlight the individual and collective impacts these relationships can have on the subsystem surrounding a child’s social and emotional well-being. Our approach provides a unique lens of knowledge through which communities can identify key leverage points for action and (re)design of community spaces, practices, and policy.

Australian local government policies on creating a healthy, sustainable, and equitable food system: analysis in New South Wales and Victoria

OBJECTIVE

To analyse local government (LG) policies concerned with creating a healthy, sustainable and equitable food system.

METHODS

All relevant policies on LG websites were identified and analysed against a framework of 34 recommendations for LG action on food system issues.

RESULTS

A total of 13 of 207 (New South Wales 128, Victoria 79) LGs had dedicated food system policies. Most actions on food system issues were in general (non-food specific) policies. Most LGs acted on food safety, sustainable local food production, food waste, drinking water access and food system-related education. Few used economic measures to support the consumption of healthier foods, restricted unhealthy food advertising, developed and implemented dietary guidelines in LG-managed settings or influenced the opening of unhealthy/healthy retail food outlets.

CONCLUSIONS

LGs undertook a range of actions relevant to creating a healthy, sustainable and equitable food system. Strategic opportunities for LGs include regulating the sale and marketing of unhealthy food and ensuring policy coherence.

IMPLICATIONS FOR PUBLIC HEALTH

LGs can be supported to act further on food system issues, including through 'joined-up' state and federal policies. Further research should address how relevant LG policies can be developed, implemented and monitored effectively to address the complex challenges created by contemporary food systems.

Critical factors that affect the functioning of a research and evaluation capacity building partnership: A causal loop diagram

Introduction

Public health policy and practice is strengthened by the application of quality evidence to decision making. However, there is limited understanding of how initiatives that support the generation and use of evidence in public health are operationalised. This study examines factors that support the internal functioning of a partnership, the Western Australian Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (SiREN). SiREN aims to build research and evaluation capacity and increase evidence-informed decision making in a public health context.

Methods

This study was informed by systems concepts. It developed a causal loop diagram, a type of qualitative system model that illustrated the factors that influence the internal operation of SiREN. The causal loop diagram was developed through an iterative and participatory process with SiREN staff and management (n = 9) via in-depth semi-structured interviews (n = 4), workshops (n = 2), and meetings (n = 6).

Results

Findings identified critical factors that affected the functioning of SiREN. Central to SiREN’s ability to meet its aims was its capacity to adapt within a dynamic system. Adaptation was facilitated by the flow of knowledge between SiREN and system stakeholders and the expertise of the team. SiREN demonstrated credibility and capability, supporting development of new, and strengthening existing, partnerships. This improved SiREN’s ability to be awarded new funding and enhanced its sustainability and growth. SiREN actively balanced divergent stakeholder interests to increase sustainability.

Conclusion

The collaborative development of the diagram facilitated a shared understanding of SiREN. Adaptability was central to SiREN achieving its aims. Monitoring the ability of public health programs to adapt to the needs of the systems in which they work is important to evaluate effectiveness. The detailed analysis of the structure of SiREN and how this affects its operation provide practical insights for those interested in establishing a similar project.

Diverse Approaches to Creating and Using Causal Loop Diagrams in Public Health Research: Recommendations From a Scoping Review

Objectives: Complex systems thinking methods are increasingly called for and used as analytical lenses in public health research. The use of qualitative system mapping and in particular, causal loop diagrams (CLDs) is described as one promising method or tool. To our knowledge there are no published literature reviews that synthesize public health research regarding how CLDs are created and used. Methods: We conducted a scoping review to address this gap in the public health literature. Inclusion criteria included: 1) focused on public health research, 2) peer reviewed journal article, 3) described and/or created a CLD, and 4) published in English from January 2018 to March 2021. Twenty-three articles were selected from the search strategy. Results: CLDs were described as a new tool and were based upon primary and secondary data, researcher driven and group processes, and numerous data analysis methods and frameworks. Intended uses of CLDs ranged from illustrating complexity to informing policy and practice. Conclusion: From our learnings we propose nine recommendations for building knowledge and skill in creating and using CLDs for future public health research.

Nutritionists as policy advocates: the case of obesity prevention in Quebec, Canada

OBJECTIVE

A core function of the public health nutrition workforce is advocacy. Little is known of the nutritionists' role in policymaking from a policy process theory perspective. The current study analyses the nutritionists' role in advocating for a six-year governmental plan on obesity prevention in Quebec, Canada.

DESIGN

We conducted qualitative research using Quebec's obesity policy as a case study to understand the role of nutritionists in advocating for obesity prevention policies. A conceptual framework combining the Advocacy Coalition Framework with a political analysis model based on the Theory of the Strategic Actor was developed to analyse the beliefs, interests and strategies of policy actors including nutritionists. Data sources comprised semi-structured open-ended interviews with key policy actors (n 25), including eight nutritionists (32 %) and policy-related documents (n 267). Data analysis involved thematic coding and analysis using NVivo 11 Pro.

SETTING

Quebec, Canada.

PARTICIPANTS

Key policy actors including nutritionists.

RESULTS

Nutritionists formed the core of the dominant public health coalition. They advocated for an inter-sectoral governmental plan to prevent obesity through enabling environments. Their advocacy, developed through an iterative process, comprised creating a think tank and reinforcing partnerships with key policy actors, conducting research and developing evidence, communicating policy positions and advocacy materials, participating in deliberative forums and negotiating an agreement with other coalitions in the policy subsystem.

CONCLUSIONS

Nutritionists' advocacy influenced agenda setting and policy formulation. This research may contribute to empowering the public health nutrition workforce and strengthening its advocacy practices. It informs practitioners and researchers concerned with obesity policy and workforce development.

Trial collaborators' perceptions of the process of delivering Healthy Beginnings advice via telephone calls or text messages

ISSUE ADDRESSED

One in four Australian children aged between the ages of two and four are affected by overweight. In New South Wales, the Communicating Healthy Beginnings Advice by Telephone (CHAT) trial delivered an intervention to pregnant women and women with infants via telephone calls and text messages. The focus of the intervention was on infant feeding and establishing healthy habits for infants by building the capacity of mothers. This study investigates trial collaborators' perspectives concerning the implementation of this intervention, to obtain insights that will support future translation and scale-up.

METHODS

This research was undertaken during the intervention phase of the trial. Twenty trial collaborators involved in the planning, implementation or delivery of the CHAT trial were invited to participate. Qualitative interviews were conducted with collaborators using open-ended questions based on Steckler and Linnan's process evaluation framework and the Consolidated Framework for Implementation Research. Inductive thematic analysis was employed to identify themes from the interview data.

RESULTS

Fourteen trial collaborators were interviewed. Collaborators included child and family health nurses (intervention providers), nurse managers with extensive child and family health nursing experience, a paediatrician, dietitians, health promotion experts, health service managers, health and nursing executives, program personnel (project coordinator, research fellow and evaluation officer) and university researchers. Following coding of qualitative data, themes were realised from the data as a result of active co-production on the part of the researcher. Five themes were identified: (a) context (organisational support, engagement and partnerships, communication and project leadership); (b) program receipt, benefit and reach; (c) program delivery (intervention providers' experience and skills, mode of intervention delivery, referral to other services, support and training for intervention providers); (d) implementation (program delivered as planned); (e) opportunities for scale-up. Collaborators perceived that the program was implemented and delivered as planned. This specific research addresses the success of the process of implementing and delivering interventions for infant feeding and establishing healthy habits for children by building the capacity of mothers. Collaborators attributed successful program implementation to contextual factors: strong support by the host organisation; good project leadership; clear communication; collaborative internal and external partnerships; intervention provision by experienced nurses. Remote delivery was convenient to program participants and participants were able to resolve other personal concerns in addition to direct immediate benefits. Because of their capacity to influence policy decisions, the absence of policymakers at project meetings was a shortcoming. Collaborative partnerships with health and research partners, understanding of contextual issues and consumer involvement could lead to program expansion. The program has the potential to be scaled up through integration with existing services and gradual expansion into other health districts prior to state-wide rollout.

CONCLUSIONS

The CHAT trial delivered the Healthy Beginnings intervention which resulted in improvements in infant feeding, active play and sedentary behaviours. This evaluation demonstrated that the involvement of key stakeholders from early planning stages through to implementation of the program and the partnerships that evolved contributed to the successful implementation of the program. An unintended benefit to participants from this program was the social support that was provided. Intervention delivery via telephone and text messages enabled easy access to the program. Most importantly, the program has the potential to be scaled up through integration into existing services and gradual expansion prior to state-wide rollout. SO WHAT?: Strong internal and external partnerships, effective communication systems and integration with existing services create the context for potential translation and scaling up of the program to other health promotion settings.

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.

Policy processes leading to the adoption of 'Jamie's Ministry of Food' programme in Victoria, Australia

This study investigated the policy processes related to the 2012 adoption of the Jamie's Ministry of Food programme by the Victorian Government in Australia. The aim was to provide insight into obesity prevention policy change processes to help strengthen future health promotion action. State-level government policy processes were examined through key informant interviews and a review of relevant documentation. Data were analysed using the Multiple Streams Theory and the Advocacy Coalition Framework in order to understand influences on relevant policy processes and strategies used by policy advocates to facilitate policy adoption. We found that policy adoption was facilitated by dedicated national funding for preventive health at that time, the relatively small number of stakeholders involved in the policy development process and the anticipated support for the programme by the general public due to the association with celebrity chef, Jamie Oliver. We identified that policy brokers aligned the policy with decision-maker ideologies and broader government objectives, and proactively managed potential criticisms. Evidence of intervention effectiveness was not a major driver of policy adoption. We conclude that, iven the complexity of policy processes for obesity prevention, multiple, reinforcing strategies are likely to be needed to facilitate policy change. Support for the adoption of obesity prevention policies is likely to increase when framing of policy options aligns with decision-maker values and has broad public appeal.

An action-oriented framework for systems-based solutions aimed at childhood obesity prevention in US Latinx and Latin American populations

Childhood obesity in US Latinx and Latin American populations is a persistent, complex public health issue and, as such, requires solutions grounded on systems science theory and methods. In this paper, we introduce an action-oriented framework to design, implement, evaluate, and sustain whole-of-community systems changes for childhood obesity prevention in US Latinx and Latin American populations. Our framework covers six action steps: (1) foster multisectoral team; (2) map the system, its context, and drivers; (3) envision system-wide changes; (4) effect system-wide changes; (5) monitor, learn, and adapt; and (6) scale and sustain. We also propose 10 principles that put human and environmental rights and systems thinking at the center of these systems-based solutions. For each action step, we provide a list of concrete activities, methods, approaches, and examples that can be used to guide and inform the work needed to achieve the expected outputs. Finally, we discuss how a wider adoption of systems science for childhood obesity prevention among US Latinx and Latin American populations can be encouraged and sustained.

Building a Prevention System: Infrastructure to Strengthen Health Promotion Outcomes

Prevention systems improve the performance of health promotion interventions. This research describes the establishment of the Australian state government initiative, Healthy Together Victoria's (HTV) macro infrastructure for the delivery of large-scale prevention interventions.

METHODS

This paper reports on findings of 31 semi-structured interviews about participants' understanding of systems thinking and their reflections of the strengths and weaknesses of the HTV prevention system. A chronic disease prevention framework informed the coding that was used to create a causal loop diagram and a core feedback loop to illustrate the results.

RESULTS

Findings highlighted that HTV created a highly connected prevention system that included a sizeable workforce, significant funding and supportive leadership. Operating guidelines, additional professional development and real-time evaluation were significant gaps, which hindered systems practice. For inexperienced systems thinkers, these limitations encouraged them to implement programs, rather than interact with the seemingly ambiguous systems methods.

CONCLUSIONS

HTV was an innovative attempt to strengthen health promotion infrastructure, creating a common language and shared understanding of prevention system requirements. However, the model was inadequate for HTV to achieve population-level reductions in chronic disease as system oversight was missing, as was an intervention delivery focus. Clarity was needed to define the systems practice that HTV was seeking to achieve. Importantly, the HTV prevention system needed to be understood as complex and adaptive, and not prioritized as individual parts.