Adolescents' Perspectives on the Drivers of Obesity Using a Group Model Building Approach: A South African Perspective

Utilizing Group Model Building to Identify Barriers and Facilitators of Hypertension Management in Primary Health Care, China

Purpose

Group Model Building (GMB) is a qualitative method that refers to a participatory process. This project aims to identify barriers and facilitators of hypertension management in primary health care in China, through which, the leverage point for intervention may be found.

Methods

The GMB was used to identify the factors influencing hypertension management. Graphs over time and causal loop diagram (CLD) were main tools of GMB. To propose the influencing factors, key stakeholders were invited to participate in a workshop. During the workshop, stakeholders were encouraged to plot the graphs over time of the variables about research issues and give a descriptive explanation. And based on this, a CLD was initially developed to establish a model of the interaction of factors. After the workshop, the research group further improved the CLD through repeated mutual discussions, and gave feedback to the participants. The Vensim PLE 9.0 software package was used to build CLD.

Results

A total of 14 key stakeholders were invited to participate in the workshop. Finally, 26 influencing factors were identified, which were divided into three dimensions, including the institutional, the community health workers (CHWs), and the patient level. And 5 reinforcing loops and 4 balancing loops were formed in the CLD. Promoting the building of the Medical Community/Regional Medical Association, implementing the family doctor contract service (FDCS), and enhancing the motivation of CHWs may be potential leverage points for hypertension management in China.

Conclusion

By using GMB, we have identified key factors in the management of hypertension in primary health care and provided comprehensive suggestions to overcome the obstacles.

Youth-centred participatory action approach towards co-created implementation of socially and physically activating environmental interventions in Africa and Europe: the YoPA project study protocol

INTRODUCTION

The majority of adolescents do not meet guidelines for healthy behaviours, posing major risks for developing multiple non-communicable diseases. Unhealthy lifestyles seem more prevalent in urban than rural areas, with the neighbourhood environment as a mediating pathway. How to develop and implement sustainable and effective interventions focused on adolescent health and well-being in urban vulnerable life situations is a key challenge. This paper describes the protocol of a Youth-centred Participatory Action (YoPA) project aiming to tailor, implement, and evaluate social and physical environmental interventions.

METHODS AND ANALYSIS

In diverse urban environments in Denmark, the Netherlands, Nigeria and South Africa, we will engage a dynamic group of 15-20 adolescents (12-19 years) growing up in vulnerable life situations and other key stakeholders (eg, policy makers, urban planners, community leaders) in local co-creation communities. Together with academic researchers and local stakeholders, adolescents will take a leading role in mapping the local system; tailoring; implementing and evaluating interventions during participatory meetings over the course of 3 years. YoPA applies a participatory mixed methods design guided by a novel Systems, User perspectives, Participatory co-creation process, Effects, Reach, Adoption, Implementation and Maintenance framework assessing: (i) the local systems, (ii) user perspectives, (iii) the participatory co-creation process, (iv) effects, (v) reach, (vi) adoption, (vii) implementation and (viii) maintenance of interventions. Through a realist evaluation, YoPA will explore why and how specific outcomes were reached (or not) in each setting (n=800-1000 adolescents in total).

ETHICS AND DISSEMINATION

This study received approval from the ethics committees in Denmark, the Netherlands, Nigeria and South Africa and will be disseminated via various collaborative dissemination activities targeting multiple audiences. We will obtain informed consent from all participants. We envision that our YoPA co-creation approach will serve as a guide for participation of adolescents in vulnerable life situations in implementation of health promotion and urban planning in Europe, Africa and globally.

TRIAL REGISTRATION NUMBER

NCT06181162.

Longitudinal relationship between adolescents' mental health, energy balance-related behavior, and anthropometric changes

Energy balance-related behaviors (EBRBs) are considered the immediate causes of adolescents' body weight increases, but adolescents have identified mental health as a contributor. Cross-sectional studies have reported associations between adolescents' mental health and obesity, but causal relationships and the role of EBRBs within this can only be established using longitudinal studies. This systematic review summarizes the findings of longitudinal studies investigating this relationship, in addition to the role of EBRB in the relationship. Multiple electronic databases were searched for longitudinal studies using keywords related to the adolescent population, mental health, EBRB, and body weight. In total, 1216 references were identified and screened based on previously defined eligibility criteria. Sixteen articles met the inclusion criteria. Most studies indicated that mental health-related measures like depression, anxiety, and body dissatisfaction were related to an increase in body weight later. As this review is focused on behavioral mediators, six studies reported associations between mental health-anthropometry dyad and EBRBs such as eating habits, screen time, physical activity, and sleep-as well as stressors like peer victimization. Future studies may focus on streamlining mental health measures and body weight outcomes to assess this relationship. Furthermore, more longitudinal investigations are needed to provide insight into the role of EBRBs in the mental health-body weight relationship during adolescence.

Co-creating obesity prevention policies with youth: Policy ideas generated through the CO-CREATE project

Despite growing recognition of the importance of applying a systems lens to action on obesity, there has only been limited analysis of the extent to which this lens has actually been applied. The CO-CREATE project used a youth-led participatory action research approach to generate policy ideas towards the reduction of adolescent overweight and obesity across Europe. In order to assess the extent to which these youth-generated policy ideas take a systems approach, we analyzed them using the Intervention Level Framework (ILF). The ILF ascribes actions to one of five system levels, from Structural Elements, the least engaged with system change, up to Paradigm, which is the system's deepest held beliefs and thus the most difficult level at which to intervene. Of the 106 policy ideas generated by young people during the CO-CREATE project, 91 (86%) were categorized at the level of Structural Elements. This emphasis on operational rather than systems level responses echoes findings from a previous study on obesity strategies. Analyzing the distribution of systems level responses using the ILF has the potential to support more effective action on obesity by allowing identification of opportunities to strengthen systems level responses overall.

Understanding the dynamics emerging from the interplay among poor mental wellbeing, energy balance-related behaviors, and obesity prevalence in adolescents: A simulation-based study

Both obesity and poor mental wellbeing have a high prevalence in European youth. Adolescents in six countries identified mental wellbeing factors as main drivers of youth obesity through systems mapping. This study sought to (1) explore the dynamics of the interplay between poor mental wellbeing, energy balance-related behaviors, and adolescent overweight and obesity prevalence and (2) test the effect of intervention point scenarios to reduce adolescent obesity. Drawing on the youth-generated systems maps and a literature synthesis, we built a simulation model that represents the links from major feedback pathways for poor mental wellbeing to changes in dietary, physical activity, and sleep behaviors. The model was calibrated using survey data from Norway, expert input, and literature and shows a good fit between simulated behavior and available statistical data. The simulations indicate that adolescent mental wellbeing is harmed by socio-cultural pressures and stressors, which trigger reinforcing feedback mechanisms related to emotional/binge eating, lack of motivation to engage in physical activity, and sleep difficulty. Targeting a combination of intervention points that support a 25% reduction of pressure on body image and psychosocial stress showed potentially favorable effects on mental wellbeing-doubling on average for boys and girls and decreasing obesity prevalence by over 4%.

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.

Use of qualitative systems mapping and causal loop diagrams to understand food environments, diet and obesity: a scoping review protocol

INTRODUCTION

Food systems can shape dietary behaviour and obesity outcomes in complex ways. Qualitative systems mapping using causal loop diagrams (CLDs) can depict how people understand the complex dynamics, inter-relationships and feedback characteristic of food systems in ways that can support policy planning and action. To date, there has been no attempt to review this literature. The objectives of this review are to scope the extent and nature of studies using qualitative systems mapping to facilitate the development of CLDs by stakeholders to understand food environments, including settings and populations represented, key findings and the methodological processes employed. It also seeks to identify gaps in knowledge and implications for policy and practice.

METHODS AND ANALYSIS

This protocol describes a scoping review guided by the Joanna Briggs Institute manual, the framework by Khalil and colleagues and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist reporting guidelines. A search strategy was iteratively developed with two academic librarians and the research team. This strategy will be used to search six databases, including Ovid MEDLINE, Embase, EmCare, Web of Science, Scopus and ProQuest Central. Identified citations will be screened by two independent reviewers; first, by title and abstract, and then full-text articles to identify papers eligible for inclusion. The reference lists of included studies and relevant systematic reviews will be searched to identify other papers eligible for inclusion. Two reviewers will extract information from all included studies and summarise the findings descriptively and numerically.

ETHICS AND DISSEMINATION

The scoping review will provide an overview of how CLDs developed by stakeholders have been elicited to understand food environments, diet and obesity, the insights gained and how the CLDs have been used. It will also highlight gaps in knowledge and implications for policy and practice. The review will be disseminated through publication in an academic journal and conference presentations.

Overweight and obesity prevention for and with adolescents: The "Confronting obesity: Co-creating policy with youth" (CO-CREATE) project

The CO-CREATE project focuses on the need for research on obesity prevention in adolescents to move away from studies of single interventions, toward the investigation of systems-based research incorporating youth involvement. This paper provides an overview of the project, presenting the objectives, design, and novel methodologies applied, as well as findings to date and anticipated outcomes. Adolescents (16-18 years old) in five European countries participated. Methods applied in the project include monitoring and benchmarking of policies, systematic literature reviews, epidemiological surveillance, linking observed overweight and obesity trends to observed policy landscapes, group model building to identify perceived drivers of obesity, alliance building with adolescents, dialog with stakeholders, and system dynamics modelling to explore the potential impact of policy options. Outcomes include tools for developing policy ideas and investigation of prevention strategies with adolescents, including policy databases, system maps of drivers of obesity, protocols for organizing youth alliances, an intergenerational policy dialog tool, and system dynamic models exploring the impacts of cocreated policy ideas. These outcomes make an important contribution to building a pan-European infrastructure for designing and evaluating policies and for providing youth with the opportunity to make their voices heard in the development and implementation of obesity prevention measures.

Trends in prevalence of overweight and obesity among South African and European adolescents: a comparative outlook

BACKGROUND

South Africa has several national surveys with body weight-related data, but they are not conducted regularly. Hence, data on longitudinal trends and the recent prevalence of adolescent obesity are not readily available for both national and international reporting and use. This study collectively analysed nationally representative surveys over nearly 2 decades to investigate trends in prevalence of adolescent obesity in South Africa. Furthermore, it compared these data with similar continental report for 45 countries across Europe and North America including United Kingdom, Norway, Netherland, Sweden, Azerbaijan, etc. to identify at-risk sub-population for overweight and obesity among adolescents.  METHODS: The study included primary data of adolescents (15 - 19 years) from South African national surveys (N = 27, 884; girls = 51.42%) conducted between 1998 and 2016. Adolescents' data extracted include measured weight, height, sex, parent employment status, monthly allowance received, and family socioeconomic-related variables. Data were statistically analysed and visualized using chi-square of trends, Wald statistics, odds ratio and trend plots, and compared to findings from European survey report (N = 71, 942; girls = 51.23%). South African adolescents' obesity and overweight data were categorized based on World Health Organization (WHO)'s growth chart and compared by sex to European cohort and by family socioeconomic status.

RESULTS

By 2016, 21.56% of South African adolescents were either obese or overweight, similar to the 21% prevalence reported in 2018 among European adolescents. Girls in South Africa showed higher trends for obesity and overweight compared to boys, different from Europe where, higher trends were reported among boys. South African Adolescents from upper socioeconomic families showed greater trends in prevalence of overweight and obesity than adolescents from medium and lower socioeconomic families. Mothers' employment status was significantly associated with adolescents' overweight and obesity.

CONCLUSIONS

Our study shows that by 2016, the prevalence of adolescent obesity was high in South Africa - more than 1 in 5 adolescents - which is nearly similar to that in Europe, yet South African girls may be at a greater odd for overweight and obesity in contrast to Europe, as well as adolescents from high earning families. South African local and contextual factors may be driving higher prevalence in specific sub-population. Our study also shows the need for frequent health-related data collection and tracking of adolescents' health in South Africa.

Community Co-Design of Regional Actions for Children's Nutritional Health Combining Indigenous Knowledge and Systems Thinking

Children's nutrition is highly influenced by community-level deprivation and socioeconomic inequalities and the health outcomes associated, such as childhood obesity, continue to widen. Systems Thinking using community-based system dynamics (CBSD) approaches can build community capacity, develop new knowledge and increase commitments to health improvement at the community level. We applied the formal structure and resources of a Group Model Building (GMB) approach, embedded within an Indigenous worldview to engage a high deprivation, high Indigenous population regional community in New Zealand to improve children's nutrition. Three GMB workshops were held and the youth and adult participants created two systems map of the drivers and feedback loops of poor nutrition in the community. Māori Indigenous knowledge (mātauranga) and approaches (tikanga) were prioritized to ensure cultural safety of participants and to encourage identification of interventions that take into account social and cultural environmental factors. While the adult-constructed map focused more on the influence of societal factors such as cost of housing, financial literacy in communities, and social security, the youth-constructed map placed more emphasis on individual-environment factors such as the influence of marketing by the fast-food industry and mental wellbeing. Ten prioritized community-proposed interventions such as increasing cultural connections in schools, are presented with the feasibility and likely impact for change of each intervention rated by community leaders. The combination of community-based system dynamics methods of group model building and a mātauranga Māori worldview is a novel Indigenous systems approach that engages participants and highlights cultural and family issues in the systems maps, acknowledging the ongoing impact of historical colonization in our communities.