Childhood obesity in the ED: A prospective Australian study

OBJECTIVE

To determine (i) the prevalence of overweight and obesity among children presenting to all EDs in a large regional Australian city and (ii) whether age, sex, socioeconomic status (SES) or hospital setting (public vs private) were associated with overweight and obesity.

METHODS

This prospective observational study included children aged ≥2 and <18 years who presented to any of three EDs over an 18 month period who had their height and weight measured. Age, sex and residential postcode were collected. Weight category was determined by sex and age standardised body mass index (BMI) z-score. Weight category was assessed by sex, age, SES and hospital setting with chi-squared tests, and ordinal logistic regression with cluster sandwich error estimators. Results were reported using odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Data were collected for 3827 children, of which 11.6% were obese and 19.8% overweight. The prevalence of obesity was highest in those aged 8-14 years and in those from lower SES postcodes. The likelihood of obesity was higher in the public than the private hospitals (OR 0.66, 95% CI 0.51-0.86), whereas the likelihood of overweight was similar (OR 1.00, 95% CI 0.83-1.22).

CONCLUSIONS

Almost one-third of children who presented to EDs were overweight or obese. Obesity was particularly high in those aged 8-14 years and those from lower SES postcodes. In the evolving obesity crisis, the high proportion of children presenting to EDs above a healthy weight might represent an opportunity for EDs to identify and refer children for body weight and lifestyle management.

Sleep behavioral outcomes of school-based interventions for promoting sleep health in children and adolescents aged 5 to 18 years: a systematic review

Study Objectives

Insufficient sleep is common among children and adolescents, and can contribute to poor health. School-based interventions potentially could improve sleep behavior due to their broad reach, but their effectiveness is unclear. This systematic review focused on the effects of school-based interventions on sleep behavior among children and adolescents aged 5 to 18 years.

Methods

Five electronic databases were searched for randomized controlled trials of sleep health interventions initiated or conducted in school settings and in which behavioral sleep outcomes were measured. Cochrane risk of bias tools were used to assess study quality.

Results

From the 5303 database records and two papers from other sources, 21 studies (22 papers) met the inclusion criteria for this review. These studies involved 10 867 children and adolescents at baseline from 13 countries. Most studies (n = 15) were conducted in secondary schools. Sleep education was the most common intervention, either alone (n = 13 studies) or combined with other initiatives (stress management training, n = 2; bright light therapy, n = 1; health education, n = 1). Interventions were typically brief in terms of both the intervention period (median = 4 weeks) and exposure (median = 200 minutes). Behavioral outcomes included actigraphy-measured and self-reported sleep patterns, and sleep hygiene. All outcomes had high risk of bias or some concerns with bias. Sleep education interventions were typically ineffective. Later school start times promoted longer sleep duration over 1 week (1 study, high risk of bias).

Conclusions

Current evidence does not provide school-based solutions for improving sleep health, perhaps highlighting a need for complex, multi-component interventions (e.g. whole-of-school approaches) to be trialed.

The common drivers of children and young people's health and wellbeing across 13 local government areas: a systems view

BACKGROUND

System dynamics approaches, including group model building (GMB) and causal loop diagrams (CLDs), can be used to document complex public health problems from a community perspective. This paper aims to apply Social Network Analysis (SNA) methods to combine multiple CLDs created by local communities into a summary CLD, to identify common drivers of the health and wellbeing of children and young people.

METHODS

Thirteen community CLDs regarding children and young people health and wellbeing were merged into one diagram involving three steps: (1) combining variable names; (2) CLD merging, where multiple CLDs were combined into one CLD with a set of unique variables and connections; (3) paring, where the Decision-Making Trial and Evaluation Laboratory (DEMATEL) method was used to generate a cut-point to reduce the number of variables and connections and to rank the overall importance of each variable in the merged CLD.

RESULTS

Combining variable names resulted in 290 variables across the 13 CLDS. A total of 1,042 causal links were identified in the merged CLD. The DEMATEL analysis of the merged CLD identified 23 common variables with a net importance between 1.0 and 4.5 R + C values and 57 causal links. The variables with the highest net importance were 'mental health' and 'social connection & support' classified as high net receivers of influence within the system.

CONCLUSIONS

Combining large CLDs into a simple diagram represents a generalisable model of the drivers of complex health problems.

The range of outcomes and outcome measurement instruments collected in multisectoral community-based obesity prevention interventions in children: A systematic review

Multicomponent and multisectoral community-based interventions (CBIs) have proven potential in preventing overweight and obesity in children. Synthesizing evidence on the outcomes collected and reported in such CBIs is critical for the evidence of effectiveness and cost-effectiveness. This systematic review aimed to identify the range of outcomes and outcome measurement instruments collected and reported in multisectoral and multicomponent CBIs for obesity prevention in children. A systematic search updated an existing review and extended the search to 11 academic databases (2017-2023) and gray literature. Outcomes were classified into outcome domains, and common measurement instruments were summarized. Seventeen outcome domains from 140 unique outcomes were identified from 45 included interventions reported in 120 studies. The most frequently collected outcome domains included anthropometry and body composition (91% of included interventions), physical activity (84%), dietary intake (71%), environmental (71%), and sedentary behavior (62%). The most frequently collected outcomes from each of these domains included body mass index (89%), physical activity (73%), fruit and vegetable intake (58%), school environment (42%), and screen time (58%). Outcome measurement instruments varied, particularly for behavioral outcomes. Standardization of reported outcomes and measurement instruments is recommended to facilitate data harmonization and support quantifying broader benefits of CBIs for obesity prevention.

Developing and Evaluating a Data-Driven and Systems Approach to Health Promotion Among Vocational Students: Protocol for the Data Health Study

BACKGROUND

Vocational school students exhibit significant risk behaviors in terms of poor diet, frequent use of nicotine products, inadequate fruit and vegetable intake, low levels of physical activity, and poor mental health. This makes vocational students vulnerable to the development of noncommunicable diseases. Therefore, effective health promotion programs targeting vocational students are required.

OBJECTIVE

The Danish study "Data-driven and Systems Approach to Health Promotion Among Vocational Students" (Data Health) aims to develop, implement, and evaluate a systems approach to support vocational schools, municipalities, and local communities in implementing locally relevant health promotion actions among and for vocational students. This paper describes the Data Health program and how implementation and preliminary effectiveness will be evaluated.

METHODS

The Data Health program offers an iterative 5-step process to develop changes in the systems that shape health behavior and well-being among vocational students. The program will be implemented and evaluated in 8 Danish vocational schools in 4 municipalities. The implementation of the process and actions will be explored using a systems-based evaluation design that assesses contextual differences and the mechanisms through which the program leads to changes in the systems. Preliminary effectiveness at the individual level (students' self-reported health behavior and well-being) and organizational level (school organizational readiness reported by school staff) will be assessed using a quasi-experimental design, and cross-sectional data will be collected at all 8 schools simultaneously 4 times during the 2-year study period.

RESULTS

This study was launched in 2021, and data collection is expected to be completed in June 2024. The first results are expected to be submitted for publication in January 2024.

CONCLUSIONS

We expect that the Data Health study will make significant contributions to complex intervention research by contributing to the paucity of research studies that have used systems approaches in school settings. The study will also provide evidence of successful elements for systems change and effectiveness to determine whether a national scale-up can be recommended.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05308459; https://clinicaltrials.gov/study/NCT05308459.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52571.

Healthy together Victoria and childhood obesity study: effects of a large scale, community-based cluster randomised trial of a systems thinking approach for the prevention of childhood obesity among secondary school students 2014-2016

BACKGROUND

Healthy Together Victoria (HTV) was a Victorian Government initiative that sought to reduce the prevalence of overweight and obesity through targeting chronic disease risk factors including physical activity, poor diet quality, smoking, and harmful alcohol use. The intervention involved a boosted workforce of > 170 local-level staff in 12 communities; employed to deliver system activation around health and wellbeing for individuals, families and communities. A cluster randomised trial (CRT) of a systems thinking approach to obesity prevention was embedded within HTV. We present the two-year changes in overweight and obesity and associated behaviours among secondary school students across Victoria, Australia.

METHODS

Twenty-three geographically bounded areas were randomised to intervention (12 communities) or comparison (11 communities). Randomly selected secondary schools within each community were invited to participate in the trial in 2014 and 2016. Students in Grade 8 (aged approximately 13-15 years) and Grade 10 (aged approximately 15-16 years) at participating schools were recruited using an opt-out approach across July-September 2014 and 2016. Primary outcomes were body mass index (BMI) and waist circumference. Secondary outcomes were physical activity, sedentary behaviour, diet quality, health-related quality of life, and depressive symptoms. Linear mixed models were fit to estimate the intervention effect adjusting for child/school characteristics.

RESULTS

There were 4242 intervention children and 2999 control children in the final analysis. For boys, the two-year change showed improvement in intervention versus control for waist circumference (difference in change: - 2.5 cm; 95% confidence interval [CI]: - 4.6, - 0.5) and consumption of sugar-sweetened beverages per day (< 1 serve: 8.5 percentage points; 95% CI: 0.6, 16.5). For girls, there were no statistically significant differences between conditions.

CONCLUSIONS

HTV seemed to produce favourable changes in waist circumference and sugar-sweetened beverage consumption for boys, however, no effect on BMI was observed. Although the HTV intervention was cut short, and the period between data collection points was relatively short, the changes observed in HTV contribute to the growing evidence of whole-of-community interventions targeting childhood obesity.

TRIAL REGISTRATION

This trial is unregistered. The intervention itself was a policy setting delivered by government and our role was the collection of data to evaluate the effect of this natural experiment. That is, this study was not a trial from the classical point of view and we were not responsible for the intervention.

Adapting the Planetary Health Diet Index for children and adolescents

BACKGROUND

Tools for measuring adherence to sustainable healthy diets among children and adolescents are lacking.

OBJECTIVE

To advance methods for measuring adherence to sustainable healthy diets among children and adolescents by adapting an existing index, compare scores obtained using the original and adapted versions of the index in a sample of Chilean children, and describe the adapted index association with diet characteristics.

METHODS

The Planetary Health Diet Index (PHDI) was adapted to better reflect children's and adolescents' nutritional requirements. The adapted index (PHDI-C) comprises 16 components with a maximum score of 150 points. PHDI-C was piloted among a sample of 958 Chilean children (3-6 years) using dietary data collected in 2016 through single 24-h recalls. A decision tree and food disaggregation methodology were developed to guide the calculation of scores. Scores obtained using the original and adapted versions of the index were compared. Linear regression models adjusted by child's gender and age were fitted to explore associations between total PHDI-C score, dietary recall characteristics and nutritional composition of children's diets.

RESULTS

PHDI accounted for 75.7% of children's total caloric intake, whereas PHDI-C accounted for 99.6%. PHDI & PHCI-C scores were low among this sample of children; however, mean total score was lower when using PHDI compared to PHDI-C [40.7(12.1) vs 50.1(14.6)]. Children's scores were very low for nuts & peanuts, legumes, dark green vegetables, whole cereals, tubers & potatoes, and added sugars components across both indices, but were higher for dairy products and eggs & white meats components when using the PHDI-C due to adjustments made to ensure nutritional adequacy. Mean total PHDI-C score was significantly lower on weekends and special occasions, and significantly higher when children reported having a special diet (e.g., vegetarian). Total PHDI-C score was negatively associated with total sugars, saturated fats, trans fats, and animal-based protein intake, and positively associated with total protein, plant-based protein, total carbohydrates, and total fibre intake.

CONCLUSIONS

This study provides a replicable method for measuring adherence to sustainable healthy diets among children and adolescents that can be used to monitor trends and measure the effectiveness of actions targeting improving children's diets.

Diet-Related Disease Prevention in a Rural Australian Setting: Understanding Barriers, Enablers, and the Role of Rural Health Services in Supporting Changes in Local Rural Food Environments

Bold and comprehensive action is needed to prevent diet-related diseases in rural areas, which includes improving food environments to enable healthier dietary practices. Rural health services are integral to the health of rural populations, yet their role in community disease prevention is not swell understood. This study sought to understand health service, local government, and food outlet stakeholders' perspectives on (1) the drivers of unhealthy retail environments in a rural setting; (2) the role of rural health services in supporting changes in local food environments; and to (3) identify characteristics of potential interventions. Two Group Model Building workshops were held with health service and local government leaders (n = 9), and interviews were conducted with local food outlet participants (n = 13). Key themes included 'enablers to healthier food environments', 'barriers to healthier food environments', 'Rural health services are a leading broker of knowledge for healthy food environments', and 'characteristics of desirable healthy food environment interventions.'. Rural health services can play a key role in addressing the current barriers to healthy food environments in rural areas. Effective promotion of healthier diets in rural populations will require consideration of key stakeholder perspectives and the development of further evidence on the role that rural health services can play in improving the healthiness of food environments.

Potential Mediating Roles of Children's Health-Related Quality of Life and Weight-Related Behaviors in the Relationship Between Socio-Educational Advantage and Weight Status

Background: Socioeconomic status is inversely associated with weight status in developed countries. Underlying mechanisms are still to be clarified. Our aim was to determine if weight-related behaviors and health-related quality of life (HRQoL) mediate the relationship between socio-educational advantage and weight status in Australian children 9 to 13 years of age. Methods: Secondary analysis of data collected by two cluster randomized trials (2019 wave). We measured children's (n = 3978) height, weight, diet, physical activity, sedentary behavior, and HRQoL. Socio-.educational advantage was assessed at school level using the Index of Community Socio-Educational Advantage (ICSEA). A counterfactual framework was used to explore potential mediators in the relationship between socio-educational disadvantage and (1) overweight/obesity and (2) BMI z-score (BMIz). Results: Low socio-educational advantage was associated with increased overweight/obesity and BMIz. The overweight/obesity association was mediated by sedentary behavior (natural indirect effect as a proportion of total, 7.5%) sugar-sweetened beverage (SSB) consumption (12.7%), physical functioning (11.9%), psychosocial health (10.9%), school (6.8%) and social functioning (15.6%), and total HRQoL score (13.8%). The ICSEA-BMIz relationship was mediated by sedentary behavior (5.7%), sleep duration (4.1%), SSB (10.6%), physical functioning (9.9%), psychosocial health (9.1%), school (5.5%) and social (13.7%) functioning, and total HRQoL score (11.7%). Conclusion: Victorian Children with low socio-educational advantage were more likely to be living with overweight or obesity. This relationship was mediated by children's sedentary behavior, SSB consumption, and HRQoL. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616000980437 (registered July 26, 2016, retrospectively registered) and ACTRN12618001986268 (registered December 11, 2018, prospectively registered). https://www.anzctr.org.au/Trial/Registration.

A qualitative system model to describe the causes and drivers of frequent potentially avoidable presentations to the emergency department

Frequent potentially avoidable presentations to Emergency Departments (EDs) represent a complex problem, driven by multiple interdependent and interacting factors that change over time and influence one another. We sought to describe and map the drivers of frequent potentially avoidable presentations to a regional ED, servicing regional and rural areas, and identify possible solutions from the perspectives of key stakeholders. This study used a qualitative, community-based systems dynamics approach utilising Group Model Building (GMB). Data were collected from two 3-h online workshops embedded with small-group discussions and conducted with stakeholder groups operating within a regional health system. Stakeholders were guided through a series of participatory tasks to develop a causal loop diagram (CLD) using Systems Thinking in Community Knowledge Exchange software (n=29, workshop one), identify potential action points and generate a prioritised action list to intervene in the system (n=21, workshop two). Data were collected through note taking, real-time system mapping, and recording the workshops. Each action was considered against the Public Health 12 framework describing twelve leverage points to intervene in a system. A CLD illustrating the complex and interrelated factors that drive frequent potentially avoidable ED presentations was developed and classified into four categories: (1) access to services; (2) coordination; (3) patient needs; and (4) knowledge and skills. Nine action areas were identified, with many relating to care and service coordination. Most actions aligned with lower-level system impact actions. This study provides an in-depth understanding of influencing factors and potential solutions for frequent potentially avoidable ED presentations across a regional health system. The CLD demonstrates frequent potentially avoidable ED presentations are a complex problem and identified that a prevention response should engage with system- and individual-level solutions. Further work is needed to prioritise actions to support the implementation of higher-level system impacts.

Minding our futures: Understanding climate-related mental wellbeing using systems science

INTRODUCTION

Climate change impacts mental wellbeing through complex pathways and young people are among the most vulnerable to climate-related anxiety. Minding our Futures used methods from systems science to explore this issue and identify actions to promote mental wellbeing for young Australians (18-24 years).

METHODS

This qualitative study used Group Model Building via three online facilitated workshops recruiting health, youth and climate practitioners and researchers engaged with young people around climate change and/or mental wellbeing (N = 14). Analysis created a systems map and rich description of the relationships between causal factors and their impact on young people.

RESULTS

Three themes emerged; "Government, Services and Structures" highlighted underlying structural issues including capitalism and political powerlessness; "Social Norms, Communication and Taking Action" reflected social media and misinformation; and "Personal Experience of Environmental Disasters" described the impact of climate-related disasters and importance of nature and place connection. Participants specified connections between the themes and mental health outcomes.

CONCLUSION

This novel applied translational research process supported key informants to design structural responses to a complex and critical public health issue. Their vision was a multi-faceted approach, co-led with young people, drawing on Indigenous knowledges and change-focused policy, community empowerment and nature-based interventions.

National nutrition surveillance programmes in 18 countries in South-East Asia and Western Pacific Regions: a systematic scoping review

Objective

To identify and analyse ongoing nutrition-related surveillance programmes led and/or funded by national authorities in countries in South-East Asian and Western Pacific Regions.

Methods

We systematically searched for publications in PubMed® and Scopus, manually searched the grey literature and consulted with national health and nutrition officials, with no restrictions on publication type or language. We included low- and middle-income countries in the World Health Organization South-East Asia Region, and the Association of Southeast Asian Nations and China. We analysed the included programmes by adapting the United States Centers for Disease Control and Prevention's public health surveillance evaluation framework.

Findings

We identified 82 surveillance programmes in 18 countries that repeatedly collect, analyse and disseminate data on nutrition and/or related indicators. Seventeen countries implemented a national periodic survey that exclusively collects nutrition-outcome indicators, often alongside internationally linked survey programmes. Coverage of different subpopulations and monitoring frequency vary substantially across countries. We found limited integration of food environment and wider food system indicators in these programmes, and no programmes specifically monitor nutrition-sensitive data across the food system. There is also limited nutrition-related surveillance of people living in urban deprived areas. Most surveillance programmes are digitized, use measures to ensure high data quality and report evidence of flexibility; however, many are inconsistently implemented and rely on external agencies' financial support.

Conclusion

Efforts to improve the time efficiency, scope and stability of national nutrition surveillance, and integration with other sectoral data, should be encouraged and supported to allow systemic monitoring and evaluation of malnutrition interventions in these countries.

How healthy and affordable are foods and beverages sold in school canteens? A cross-sectional study comparing menus from Victorian primary schools

OBJECTIVE

Government policy guidance in Victoria, Australia, encourages schools to provide affordable, healthy foods in canteens. This study analysed the healthiness and price of items available in canteens in Victorian primary schools and associations with school characteristics.

DESIGN

Dietitians classified menu items (main, snack and beverage) using the red, amber and green traffic light system defined in the Victorian government's School Canteens and Other School Food Services Policy. This system also included a black category for confectionary and high sugar content soft drinks which should not be supplied. Descriptive statistics and regressions were used to analyse differences in the healthiness and price of main meals, snacks and beverages offered, according to school remoteness, sector (government and Catholic/independent) size, and socio-economic position.

SETTING

State of Victoria, Australia.

PARTICIPANTS

A convenience sample of canteen menus drawn from three previous obesity prevention studies in forty-eight primary schools between 2016 and 2019.

RESULTS

On average, school canteen menus were 21 % 'green' (most healthy - everyday), 53 % 'amber' (select carefully), 25 % 'red' (occasional) and 2 % 'black' (banned) items, demonstrating low adherence with government guidelines. 'Black' items were more common in schools in regional population centres. 'Red' main meal items were cheaper than 'green'% (mean difference -$0·48 (95 % CI -0·85, -0·10)) and 'amber' -$0·91 (-1·27, -0·57)) main meal items. In about 50 % of schools, the mean price of 'red' main meal, beverages and snack items were cheaper than 'green' items, or no 'green' alternative items were offered.

CONCLUSION

In this sample of Victorian canteen menus, there was no evidence of associations of healthiness and pricing by school characteristics except for regional centres having the highest proportion of 'black' (banned) items compared with all other remoteness categories examined. There was low adherence with state canteen menu guidelines. Many schools offered a high proportion of 'red' food options and 'black' (banned) options, particularly in regional centres. Unhealthier options were cheaper than healthy options. More needs to be done to bring Victorian primary school canteen menus in line with guidelines.

BMI and the Food Retail Environment in Melbourne, Australia: Associations and Temporal Trends

Research into the link between food environments and health is scarce. Research in this field has progressed, and new comprehensive methods (i.e., incorporating all food retail outlets) for classifying food retail environments have been developed and are yet to be examined alongside measures of obesity. In this study, we examine the association and temporal trends between the food environment and BMI of a repeated cross-sectional sample of the adult population between 2008 and 2016. Methods: Food retail data for 264 postal areas of Greater Melbourne was collected for the years 2008, 2012, 2014, and 2016, and a container-based approach was used to estimate accessibility to supermarkets, healthy and unhealthy outlets. Data on BMI for postal areas was obtained from the Victorian Population Health Survey (n = 47,245). We estimated the association between the food environment and BMI using linear mixed models. Results indicated that BMI increased as accessibility to healthy outlets decreased by up to -0.69 kg/m2 (95%CI: -0.95, -0.44). BMI was lower with high and moderate access to supermarkets compared to low access by -0.33 kg/m2 (-0.63, -0.04) and -0.32 kg/m2 (-0.56, -0.07), and with high access to unhealthy outlets compared to low access (-0.38 kg/m2: -0.64, -0.12) and moderate access (-0.54 kg/m2: -0.78, -0.30). Conclusion: Our results show that increasing access and availability to a diverse range of food outlets, particularly healthy food outlets, should be an important consideration for efforts to support good health. This research provides evidence that Australia needs to follow suit with other countries that have adopted policies giving local governments the power to encourage healthier food environments.

Measuring Shifts in Mental Models in the Prevention of Childhood Obesity in Rural Australia

Group model building is a participatory workshop technique used in system dynamics for developing community consensus to address complex problems by consensus building on individual assumptions. This study examines changes in individual mental models of the complex problem of childhood obesity following participation in group model building (GMB), as part of a larger community-based system dynamics project. Data are drawn from GMB participants across six community sites in the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS) in rural and regional Victoria, Australia. Each community participated in two GMB sessions resulting in a causal loop diagram (CLD) of drivers of childhood obesity for each community. Presurvey and postsurvey captured participants' perspectives before and after (n = 25) participation in both GMB sessions and a blend of inductive and deductive qualitative content analysis was used to code individual responses. Three calculations were used to determine the number of responses, whether responses were a result of persuasion from others, and comparison of responses to those found in the CLD. Our study found participant mental models shifted during the course of the GMB sessions, with some responses persuaded by others and 75% of new insights identified in CLDs created by communities. The GMB process created a platform for participants to share ideas and learn from each other. In addition, participants listed new insights about childhood obesity in their community through developing CLDs.

Cultural adaptations and methodological innovations to group model building for the systems actions to reduce malnutrition in all its forms in Southeast Asian countries and China (SYSTAM CHINA-SEACS International Consortium) project

BACKGROUND

Group Model Building (GMB) is a participatory system dynamics method increasingly used to address complex public health issues like obesity. GMB represents a set of well-defined steps to engage key stakeholders to identify shared drivers and solutions of a given problem. However, GMB has not yet been applied specifically to develop multi-duty interventions that address multiple inter-related issues such as malnutrition in all its forms (MIAIF). Moreover, a recent systematic review of empirical applications of a systems approach to developing obesity interventions found no published work from non-western, low- and middle-income countries (LMICs). In this paper we describe adaptations and innovations to a common GMB process to co-develop systemic MIAIF interventions with Chinese decision-makers.

METHODS

We developed, piloted and implemented multiple cultural adaptations and two methodological innovations to the commonly used GMB process in Fang Cheng Gang city, China. We included formal, ceremonial and policy maker engagement events before and between GMB workshops, and incorporated culturally tailored arrangements during participant recruitment (officials of the same seniority level joined the same workshop) and workshop activities (e.g., use of individual scoring activities and hand boards). We made changes to the commonly used GMB activities which enabled mapping of shared drivers of multiple health issues (in our case MIAIF) in a single causal loop diagram. We developed and used a 'hybrid' GMB format combining online and in person facilitation to reduce travel and associated climate impact.

RESULTS

Our innovative GMB process led to high engagement and support from decision-makers representing diverse governmental departments across the whole food systems. We co-identified and prioritised systemic drivers and intervention themes of MIAIF. The city government established an official Local Action Group for long-term, inter-departmental implementation, monitoring and evaluation of the co-developed interventions. The 'hybrid' GMB format enabled great interactions while reducing international travel and mitigating limitations of fully online GMB process.

CONCLUSIONS

Cultural and methodological adaptations to the common GMB process for an Asian LMIC setting were successful. The 'hybrid' GMB format is feasible, cost-effective, and more environmentally friendly. These cultural adaptations could be considered for other Asian settings and beyond to address inter-related, complex issues such as MIAIF.

Enhancing healthcare at home for older people in rural and regional Australia: A protocol for co-creation to design and implement system change

BACKGROUND

World-wide, health service providers are moving towards innovative models of clinical home-based care services as a key strategy to improve equity of access and quality of care. To optimise existing and new clinical home-based care programs, evidence informed approaches are needed that consider the complexity of the health care system across different contexts.

METHODS

We present a protocol for working with health services and their partners to perform rapid identification, prioritisation, and co-design of content-appropriate strategies to optimise the delivery of healthcare at home for older people in rural and regional areas. The protocol combines Systems Thinking and Implementation Science using a Consensus Mapping and Co-design (CMC) process delivered over five workshops.

DISCUSSION

The protocol will be implemented with rural and regional healthcare providers to identify digital and non-digital solutions that have the potential to inform models of service delivery, improve patient experience, and optimise health outcomes. The combination of system and implementation science is a unique approach for optimising healthcare at home for older populations, especially in the rural context where need is high. This is the first protocol to integrate the use of systems and implementation science into one process and articulating these methods will help with replicating this in future practice. Results of the design phase will translate into practice through standard health service planning methods to enhance implementation and sustainability. The delivery of the protocol will include building capacity of health service workers to embed the design, implementation, and evaluation approach into normal practice. This protocol forms part of the DELIVER (Delivering Enhanced heaLthcare at home through optImising Virtual tools for oldEr people in Rural and regional Australia) Project. Funded by Australia's Medical Research Future Fund, DELIVER involves a collaboration with public health services of Western Victoria, Australia.

Systems thinking in local government: intervention design and adaptation in a community-based study

BACKGROUND

Systems thinking approaches are increasingly being used by communities to address complex chronic disease. This paper reports on the VicHealth Local Government Partnership (VLGP) which sought to co-create improvements in the health and well-being of children and young people by working with local government in Victoria, Australia.

METHODS

The VLGP included a series of health promotion modules, aimed at creating policy, programme and practice changes across local government. One of these modules, Connecting the Dots - creating solutions for lasting change, aimed to build capacity for systems thinking in municipal public health and well-being planning across 13 councils. The approach was adapted and data were collected on the stimuli for, and results of, adaptation.

RESULTS

The council adapted the systems thinking approach to meet geographic characteristics, priority health issue/s and participant target group needs. Adaptions applied to workshop materials, training delivery, existing and new resources, and to align with other community-based approaches. Stimuli for adaptation included the COVID-19 pandemic, needs of children and young people, capacity of council to deliver the workshop series, and time available within the project or for the participant group.

CONCLUSIONS

Systems thinking was used and adapted by councils to improve the health and well-being of children and young people and increase the voices of children and young people in decision-making. Flexible delivery is critical to ensure communities can adapt the approach to meet local needs.

System dynamics simulation models on overweight and obesity in children and adolescents: A systematic review

It has increasingly been recognized that developing successful obesity prevention policies and interventions requires understanding of the complex mechanisms driving the obesity pandemic and that models could be useful tools for simulating policies. This paper reviews system dynamics simulation models of mechanisms driving childhood overweight and obesity and/or testing of preventive interventions. A systematic literature search was conducted in six databases from inception to January 2023 using terms related to overweight/obesity, children, and system dynamics. Study descriptives, mechanisms, and where to intervene (the leverage points), as well as quality assessments of the simulation models were extracted by two researchers into a predetermined template and narratively synthesized. Seventeen papers describing 15 models were included. Models describing the mechanisms ranged from only intrapersonal factors to models cutting across multiple levels of the ecological model, but mechanisms across levels were lacking. The majority of interventions tested in the simulation models were changes to existing model parameters with less emphasis on models that alter system structure. In conclusion, existing models included mechanisms driving youth obesity at multiple levels of the ecological model. This is useful for developing an integrated simulation model combining mechanisms at multiple levels and allowing for testing fundamental system changes.

CO-Creation and Evaluation of Food Environments to Advance Community Health (COACH)

Introduction

Food environments are a key determinant of food intake and diet-related health. This paper describes the development of an iterative, adaptive, context-specific framework for health-enabling food environments embedded in cocreation theory.

Methods

A 3-stage multimethod framework for the coproduction and prototyping of public health interventions was followed in an iterative manner during the development of the framework. These 3 stages were (1) evidence review, including systematic review, consultation with experts, and observation of current work; (2) codesign of the framework prototype with multiple stakeholders; and (3) coproduction through refinement of the prototype through stakeholder workshops and expert reviews with incorporation of researcher notes and workshop evaluation. We use the term prototype during the development phase and the term framework to report on the final product.

Results

COACH (CO-creation and evaluation of food environments to Advance Community Health) is a process framework that describes what best practice application of cocreation in health-enabling food retail environments should involve. COACH consists of 10 interdependent factors within a 4-phase continuous quality improvement cycle. The 4 phases of the cycle are engagement and governance establishment, communication and policy alignment, codesign and implementation, and monitoring and evaluation.

Conclusions

Utilizing cocreation theory represents an innovative step in research and practice to improve the healthiness of food retail environments. COACH provides a specific, unique, and comprehensive guide to the utilization of cocreation to improve the healthiness of food environments in practice.

A systematic review of economic evidence for community-based obesity prevention interventions in children

Multicomponent community-based obesity prevention interventions that engage multiple sectors have shown promise in preventing obesity in childhood; however, economic evaluations of such interventions are limited. This systematic review explores the methods used and summarizes current evidence of costs and cost-effectiveness of complex obesity prevention interventions. A systematic search was conducted using 12 academic databases and grey literature from 2006 to April 2022. Studies were included if they reported methods of costing and/or economic evaluation of multicomponent, multisectoral, and community-wide obesity prevention interventions. Results were reported narratively based on the Consolidated Health Economic Evaluation Reporting Standards. Seventeen studies were included, reporting costing or economic evaluation of 13 different interventions. Five interventions reported full economic evaluations, five interventions reported economic evaluation protocols, two interventions reported cost analysis, and one intervention reported a costing protocol. Five studies conducted cost-utility analysis, three of which were cost-effective. One study reported a cost-saving return-on-investment ratio. The economic evidence for complex obesity prevention interventions is limited and therefore inconclusive. Challenges include accurate tracking of costs for interventions with multiple actors, and the limited incorporation of broader benefits into economic evaluation. Further methodological development is needed to find appropriate pragmatic methods to evaluate complex obesity prevention interventions.

Combining systems thinking approaches and implementation science constructs within community-based prevention: a systematic review

BACKGROUND

Systems science offers methods for designing population health interventions while implementation science provides specific guidance for successful implementation. Integrating systems and implementation science may strengthen implementation and enhance and sustain systemic change to achieve system-level outcomes. Little is known about the extent to which these two approaches have been integrated to date. This review aimed to identify and synthesise the peer-reviewed literature that has reported the combined use of systems thinking approaches and implementation science constructs (within the same study), to deliver population health interventions.

METHODS

A systematic literature search of peer-reviewed original research was conducted across six databases from 2009 to 2021. Journal manuscripts were included if they: (1) reported on a population health study conducted in a community, (2) reported the use of a systems method in the design of the intervention, and (3) used an implementation science theory, framework or model in the delivery of the intervention. Data extracted related to the specific systems methods and definitions and implementation science constructs used. The Mixed Methods Appraisal Tool (MMAT) was used to assess study quality.

RESULTS

Of the 9086 manuscripts returned, 320 manuscripts were included for full-text review. Of these, 17 manuscripts that reported on 14 studies were included in the final extraction. The most frequently reported systems methods were a 'whole of community systems approach' (n = 4/14) and 'community-based system dynamics' (n = 2/14). Nineteen different implementation science theories, frameworks and models were used for intervention delivery, with RE-AIM being the only framework used in more than one study.

CONCLUSION

There are few published peer-reviewed studies using systems thinking and implementation science for designing and delivering population health interventions. An exploration of synergies is worthwhile to operationalise alignment and improve implementation of systems thinking approaches. Review protocol registration PROSPERO CRD42021250419.

Lived experience of participants who engaged in the co-creation of initiatives to improve children's health in a rural Australian community

OBJECTIVE

To describe participants' lived experience of co-creating and implementing initiatives to improve children's health.

DESIGN

This manuscript reports an embedded case study design, which aims to describe participants' lived experiences of co-creating community-based initiatives. Information was gathered from an online survey and two focus groups. The two transcribed discussions from the focus groups were analysed using a 6-step phenomenological process.

SETTING

Mansfield, Australia, population 4787, is one of ten local government areas (LGA) participating in the Reflexive Evidence and Systems Interventions to Prevent Obesity and Non-communicable Disease (RESPOND) project.

PARTICIPANTS

Participants were purposively selected from established community groups previously engaged by RESPOND using a co-creation approach. The recruitment for the focus groups was a convenient sampling from participants that provided their email addresses in the online survey.

RESULTS

Eleven participants completed the online survey. A total of ten participants attended the two focus groups of 1-h duration: five participants in each. Participants reported feeling empowered to create unique, locally relevant and readily adaptable community-wide change. They were supported by a strong partnership that mobilised funding for a part-time health promotion employee. Strengthened social connections were an unexpected though highly valued outcome.

CONCLUSION

Co-creation processes may assist stakeholders in delivering prevention strategies in ways that are empowering for them, responsive to the changing needs of the community, strengthen organisational partnerships and enhance community participation, social inclusion and engagement.

Perceived impacts of COVID-19 and bushfires on the implementation of an obesity prevention trial in Northeast Victoria, Australia

BACKGROUND

Calls for the adoption of a systems approach to chronic disease prevention date back at least ten years because of the potential to empower communities to identify and address the complex causes of overnutrition, undernutrition and climate change. Australia, like many countries, has high levels of obesity and extreme climate events. The Reflexive Evidence and Systems interventions to Prevent Obesity and Non-communicable Disease (RESPOND) trial aims to prevent unhealthy weight gain in children in 10 intervention and two pilot communities in north-east Victoria, Australia using community-based participatory approaches informed by systems science. Intervention activities co-designed in 2019 were disrupted by COVID-19 and bushfires. This paper explores the impacts of these 'shocks' on the local prevention workforce to implement actions within communities.

METHODS

A case study design involving one-hour online focus groups and an on-line survey (November 2021-February 2022). Purposive sampling was used to achieve diverse representation from RESPOND stakeholders including local council, health services, primary care partnerships and department of health. The focus group interview schedule and survey questions were based on Durlak and DuPre's implementation factors.

RESULTS

Twenty-nine participants from seven different communities participated in at least one of nine focus groups to discuss the impacts of COVID-19 and bushfires on localised implementation. Twenty-eight participants (97% of focus group sample) also completed the on-line survey. Implementation of RESPOND stalled or stopped in most communities due to bushfires and/or COVID-19. These shocks resulted in organisational priorities changing, loss of momentum for implementation, redeployment of human resources, culminating in fatigue and exhaustion. Participants reported adaptation of RESPOND, but implementation was slowed due to limited resources.

CONCLUSION

Further research is needed to advance risk management strategies and protect resources within health promotion. System shocks such as bushfires and COVID-19 are inevitable, and despite multiple adaptation opportunities, this intervention approach was not 'shock proof'.

Participatory systems science for enhancing health and wellbeing in the Indian Ocean territories

Objectives

Co-creation of diabetes and obesity prevention with remote communities allows local contextual factors to be included in the design, delivery, and evaluation of disease prevention efforts. The Indian Ocean Territories (IOT) comprise the Christmas (CI) and Cocos Keeling Islands (CKI) and are remote Australian external territories located northwest of the mainland. We present results of a co-design process conducted with residents of IOT using realist inquiry and system mapping.

Methods

Interviews with 33 community members (17 CI, 14 CKI, 2 off Islands) on causes and outcomes of diabetes (2020/21) comprising community representatives, health services staff, dietitians, school principals and government administrators. Interviews were used to create causal loop diagrams representing the causes of diabetes in the IOT. These diagrams were used in a participatory process to identify existing actions to address diabetes, identify areas where more effort would be valuable in preventing diabetes, and to described and prioritize actions based on feasibility and likely impact.

Findings

Interviews identified 31 separate variables categorized into four themes (structural, food, knowledge, physical activity). Using causa loop diagrams, community members developed 32 intervention ideas that included strengthening healthy behaviors like physical activity, improving access to healthy and culturally appropriate foods, and overcoming the significant cost and availability limitations imposed by remoteness and freight costs. Interventions included relatively unique Island issues (e.g., freight costs, limited delivery timing), barriers to healthy food (e.g., limited fresh food availability), physical activity (e.g., transient workforce) and knowledge (e.g., multiple cultural backgrounds and language barriers, intergenerational knowledge).

Developing Co-Creation Research in Food Retail Environments: A Descriptive Case Study of a Healthy Supermarket Initiative in Regional Victoria, Australia

Research into the co-creation of healthy food retail is in its early stages. One way to advance co-creation research is to explore and understand how co-creation was applied in developing, implementing, and evaluating a heath-enabling initiative in a supermarket in regional Victoria, Australia. A case study design was used to explore and understand how co-creation was applied in the Eat Well, Feel Good Ballarat project. Six documents and reports related to the Eat Well, Feel Good Ballarat project were analyzed with findings from the focus groups and interviews. Motivations to develop or implement health-enabling supermarket initiatives differed among the participants. Participants considered that initial negotiations were insufficient to keep the momentum going and to propose the value to the retailers to scale up the project. Presenting community-identified needs to the supermarket helped gain the retailer's attention, whilst the co-design process helped the implementation. Showcasing the project to the community through media exposure kept the supermarket interested. Retailers' time constraints and staff turnover were considered significant barriers to partnership building. This case study contributes insights into applying co-creation to health-enabling strategies in food retail outlets using two co-creation frameworks.

Dietary patterns in rural and metropolitan Australia: a cross-sectional study exploring dietary patterns, inflammation and association with cardiovascular disease risk factors

OBJECTIVES

This study sought first to empirically define dietary patterns and to apply the novel Dietary Inflammation Score (DIS) in data from rural and metropolitan populations in Australia, and second to investigate associations with cardiovascular disease (CVD) risk factors.

DESIGN

Cross-sectional study.

SETTING

Rural and metropolitan Australia.

PARTICIPANTS

Adults over the age of 18 years living in rural or metropolitan Australia who participated in the Australian Health survey.

PRIMARY OUTCOMES

A posteriori dietary patterns for participants separated into rural and metropolitan populations using principal component analysis.

SECONDARY OUTCOMES

association of each dietary pattern and DIS with CVD risk factors was explored using logistic regression.

RESULTS

The sample included 713 rural and 1185 metropolitan participants. The rural sample was significantly older (mean age 52.7 compared with 48.6 years) and had a higher prevalence of CVD risk factors. Two primary dietary patterns were derived from each population (four in total), and dietary patterns were different between the rural and metropolitan areas. None of the identified patterns were associated with CVD risk factors in metropolitan or rural areas, aside diet pattern 2 being strongly associated with from self-reported ischaemic heart disease (OR 13.90 95% CI 2.29 to 84.3) in rural areas. There were no significant differences between the DIS and CVD risk factors across the two populations, except for a higher DIS being associated with overweight/obesity in rural areas.

CONCLUSION

Exploration of dietary patterns between rural and metropolitan Australia shows differences between the two populations, possibly reflective of distinct cultures, socioeconomic factors, geography, food access and/or food environments in the different areas. Our study provides evidence that action targeting healthier dietary intakes needs to be tailored to rurality in the Australian context.

Understanding weight status and dietary intakes among Australian school children by remoteness: a cross-sectional study

OBJECTIVE

To determine whether primary school children's weight status and dietary behaviours vary by remoteness as defined by the Australian Modified Monash Model (MMM).

DESIGN

A cross-sectional study design was used to conduct secondary analysis of baseline data from primary school students participating in a community-based childhood obesity trial. Logistic mixed models estimated associations between remoteness, measured weight status and self-reported dietary intake.

SETTING

Twelve regional and rural Local Government Areas in North-East Victoria, Australia.

PARTICIPANTS

Data were collected from 2456 grade 4 (approximately 9-10 years) and grade 6 (approximately 11-12 years) students.

RESULTS

The final sample included students living in regional centres (17·4 %), large rural towns (25·6 %), medium rural towns (15·1 %) and small rural towns (41·9 %). Weight status did not vary by remoteness. Compared to children in regional centres, those in small rural towns were more likely to meet fruit consumption guidelines (OR: 1·75, 95 % CI (1·24, 2·47)) and had higher odds of consuming fewer takeaway meals (OR: 1·37, 95 % CI (1·08, 1·74)) and unhealthy snacks (OR = 1·58, 95 % CI (1·15, 2·16)).

CONCLUSIONS

Living further from regional centres was associated with some healthier self-reported dietary behaviours. This study improves understanding of how dietary behaviours may differ across remoteness levels and highlights that public health initiatives may need to take into account heterogeneity across communities.

Co-creation of health-enabling initiatives in food retail: academic perspectives

INTRODUCTION

Co-creation of healthy food retail comprises the systematic collaboration between retailers, academics and other stakeholders to improve the healthiness of food retail environments. Research into the co-creation of healthy food retail is in its early stages. Knowledge of the roles and motivations of stakeholders in intervention design, implementation and evaluation can inform successful co-creation initiatives. This study presents academic experiences of stakeholder roles and motivations in the co-creation of healthy food retail environments.

METHODS

Purposive sampling of academics with research experience in the co-creation of healthy food retail initiatives. Semi-structured interviews conducted between October and December 2021 gathered participants' experiences of multi-stakeholder collaborative research. Thematic analysis identified enablers, barriers, motivations, lessons and considerations for future co-creation of healthy food retail.

RESULTS

Nine interviewees provided diverse views and applications of co-creation research in food retail environments. Ten themes were grouped into three overarching areas: (i) identification of stakeholders required for changes to healthier food retail; (ii) motivations and interactions, which included the intrinsic desire to build healthier communities along with recognition of their work; and (iii) barriers and enablers included adequate resourcing, effective and trusting working relationships and open communications.

CONCLUSION

This study provides insights that could help future co-creation in healthy food retail environments. Trusting and respectful relationships and reciprocal acknowledgement between stakeholders are key practices in the co-creation process. These constructs should be considered in developing and testing a model that helps to systematically co-create healthy food retail initiatives that ensure all parties meet their needs while also delivering research outcomes.

A longitudinal study of lifestyle behaviours in emerging adulthood and risk for symptoms of depression, anxiety, and stress

BACKGROUND

Little research has examined how lifestyle behaviours cluster together to contribute to mental health outcomes. The current study aimed to identify latent classes of emerging adult lifestyle behaviours (diet, physical activity, sedentary time, smoking, alcohol, cannabis, and other drug use) at age 20 years and their associations with depression, anxiety, and stress symptoms at age 22 and 27 years.

METHODS

Participants were 616 emerging adults enrolled in the Raine Study. Lifestyle classes at baseline were identified using latent class analysis. Longitudinal associations between latent class membership and risk of depression, anxiety, and stress symptoms were examined using logistic regression models.

RESULTS

Three lifestyle classes were identified: Class 1 (healthier pattern, n = 399 [64.8 %]), Class 2 (predominantly female, high substance-use, low physical activity pattern, n = 121 [19.6 %]), and Class 3 (predominantly male, high substance-use, poor diet pattern, n = 96 [15.6 %]). Following adjustment, Class 2 were at a higher risk of depression, anxiety, and stress symptoms at age 22 years, and a higher risk of anxiety and stress symptoms at age 27 years, compared to Class 1.

LIMITATIONS

This study was limited by reliance on self-report data, lack of available indicators for parental socioeconomic status, and some measurement inconsistencies across variables. Adherence to lifestyle clusters over time was not assessed.

CONCLUSIONS

Latent classes of lifestyle behaviours were identified among emerging adults, and differences in mental health outcomes were found among the classes at two prospective time points. Future research and prevention strategies for common mental disorders should target emerging adults and focus on lifestyle patterns.

Double- and triple-duty actions in childhood for addressing the global syndemic of obesity, undernutrition, and climate change: A scoping review

Obesity, undernutrition, and climate change constitute a global syndemic that disproportionately affects vulnerable populations, including children. Double- and triple-duty actions that simultaneously address these pandemics are needed to prevent further health, economic, and environmental consequences. Evidence describing the implementation and evaluation of such actions is lacking. This review summarized the literature on whole-of-population actions targeting children that were designed or adapted to be double or triple duty. Six academic databases were searched (January 2015-March 2021) using terms related to 'children', 'intervention', 'nutrition', 'physical activity', and 'climate change'. Data were extracted from 43/15,475 studies, including six randomized controlled trials. Most (58%) described triple-duty actions targeting food systems in schools such as implementing guidelines for healthier and environmentally sustainable school meals programs, and 51% reported engaging community in the design, implementation, and/or evaluation of actions. Changes in dietary intake, diet composition, greenhouse gas emissions, and food waste were the most frequently reported outcomes and 21 studies (three randomized controlled trials) showed positive double- or triple-duty effects. This review is the first to demonstrate that double- and triple-duty actions for addressing the global syndemic in childhood have been implemented and can have a positive impact on obesity, undernutrition, and climate change.

Community coalition efforts to prevent childhood obesity: two-year results of the Shape Up Under 5 study

BACKGROUND

Cross-sector collaborations and coalitions are promising approaches for childhood obesity prevention, yet there is little empirical evidence about how they affect change. We hypothesized that changes in knowledge of, and engagement with, childhood obesity prevention among coalition members can diffuse through social networks to influence policies, systems, and environments.

METHODS

We studied a community coalition (N = 16, Shape Up Under 5 "SUU5 Committee") focused on early childhood obesity prevention in Somerville, MA from 2015-17. Knowledge, engagement, and social network data were collected from Committee members and their network contacts (n = 193) at five timepoints over two years. Policy, systems, and environment data were collected from the SUU5 Committee. Data were collected via the validated COMPACT Stakeholder-driven Community Diffusion survey and analyzed using regression models and social network analysis.

RESULTS

Over 2 years, knowledge of (p = 0.0002), and engagement with (p = 0.03), childhood obesity prevention increased significantly among the SUU5 Committee. Knowledge increased among the Committee's social network (p = 0.001). Significant changes in policies, systems, and environments that support childhood obesity prevention were seen from baseline to 24 months (p = 0.003).

CONCLUSION

SUU5 had positive effects on "upstream" drivers of early childhood obesity by increasing knowledge and engagement. These changes partially diffused through networks and may have changed "midstream" community policies, systems, and environments.

Participatory System Dynamics Approach Targeting Childhood Health in a Small Danish Community (Children's Cooperation Denmark): Protocol for a Feasibility Study Design

BACKGROUND

Improving childhood health is complex due to the multifactorial nature and interaction of determinants. Complex problems call for complex intervention thinking, and simple one-size-fits-all solutions do not work to improve childhood health. Early awareness is important, as behavior in childhood often is manifested across adolescence and into adulthood. To facilitate shared understanding of the complex structures and relationships that determine children's health behavior, participatory system approaches in, for example, local communities have shown promising potential. However, such approaches are not used systematically within public health in Denmark, and before being rolled out, they should be tested for their feasibility within this context.

OBJECTIVE

This paper describes the study design for Children's Cooperation Denmark (Child-COOP) feasibility study that is aiming to examine the feasibility and acceptability of the participatory system approach and the study procedures for a future scale-up controlled trial.

METHODS

The feasibility study is designed as a process evaluation of the intervention with the use of both qualitative and quantitative methods. A local childhood health profile will provide data for childhood health issues, for example, daily physical activity behavior, sleep patterns, anthropometry, mental health, screen use, parental support, and leisure-time activities. Data at system level are collected to assess development in the community, for example, readiness to change, analysis of social networks with stakeholders, rippled effects mapping, and changes in system map. The setting is a small rural town in Denmark, Havndal, with children as the primary target group. Group model building, a participatory system dynamics method, will be used to engage the community, create consensus on the drivers of childhood health, identify local opportunities, and develop context-specific actions.

RESULTS

The Child-COOP feasibility study will test the participatory system dynamics approach for intervention and evaluation design and survey objective measures of childhood health behavior and well-being among the ~100 children (6-13 years) attending the local primary school. Community-level data will also be collected. We will assess the contextual factors, implementation of interventions, and mechanisms of impact as part of a process evaluation. Data will be collected at baseline, at 2 years, and 4 years of follow-up. Ethical approval for this study was sought and granted from the Danish Scientific Ethical Committee (1-10-72-283-21).

CONCLUSIONS

s: The potential of this participatory system dynamics approach includes opportunities for community engagement and local capacity building to improve children's health and health behavior, and this feasibility study holds the potential to prepare an upscaling of the intervention for effectiveness testing.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43949.

Using Agent-Based Modeling to Extrapolate Community-Wide Impact from a Stakeholder-Driven Childhood Obesity Prevention Intervention: Shape Up Under 5

Objective: Whole-of-community interventions are a promising systems-based approach to childhood obesity prevention. A theorized driver of success is "Stakeholder-Driven Community Diffusion" (SDCD): the spread of knowledge about and engagement with obesity prevention efforts from a committee of stakeholder representatives. We focus on the potential of SDCD to affect the broader community. Methods: We use an agent-based model of SDCD to dynamically represent the interpersonal interactions that drive community diffusion of knowledge and engagement. We test its explanatory power using longitudinal data from a sample of community members and then use simulations to extrapolate from this limited sample to the unobserved community at large. We also consider counterfactual scenarios that show how changes in implementation strategy might have led to different patterns of community change. Results: Our model can reproduce real-world patterns of diffusion. Simulations show a substantial increase in knowledge (an approximate doubling) and a slight increase in engagement throughout the broader community. A relatively small amount of this change in knowledge (∼10%), and all the change in engagement is attributable to direct intervention effects on committee members. Conclusions: SDCD is premised on creating preconditions for sustainable change. Previous work has estimated impact on small samples closely linked to the stakeholder committee, but the degree to which this translates into the much broader diffusion envisioned by SDCD theory is unknown. This analysis demonstrates the potential of interventions to do just that. Additionally, the counterfactual scenarios suggest that simulation can help tailor implementation of SDCD interventions to increase impact.

A mixed-methods evaluation of a health-promoting café located in a small health service in rural Victoria, Australia

INTRODUCTION

Residents of rural areas internationally typically experience chronic disease risk profiles worse than city dwellers. Poor diet, a key driver of chronic disease, has been associated with unhealthy food environments, and rural areas often experience limited access to healthy, fresh and affordable food.

OBJECTIVE

This study aimed to evaluate the first three years of a health promoting social enterprise café established in a small rural health service.

DESIGN

A mixed-methods evaluation study. Quantitative sales data, surveys and key informant interviews that included both quantitative and qualitative responses.

FINDINGS

Three years of sales data were included; 111customer surveys and five key informant interviews were conducted. Food and beverages on displayed and sold consistently met or exceeded the healthy criteria set by policy. Stakeholders supported the traffic light system, the social enterprise model and rated the likelihood of sustainability of the café as high.

DISCUSSION

Customers used the 'traffic light' system to inform food choices, placed value on the warmth of the staff and on the welcoming environment created through the social enterprise model. Resources remain tight although all stakeholders are committed to the sustainability of the YarriYak café.

CONCLUSION

The study shows the acceptability, feasibility and sustainability of a health promoting social enterprise café in a rural area.

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.

System mapping with adolescents: Using group model building to map the complexity of obesity

Public health research and practice is increasingly employing systems thinking to help grapple with complex issues, from obesity to HIV treatment. At the same time, there is growing recognition that to address a given problem it is essential collaborate with those most at risk of or affected by it. Group model building (GMB), a process grounded in system dynamics, combines systems thinking and participatory methods to structure and address complex issues. As part of the CO-CREATE project we conducted GMB sessions with young people in six countries to create causal loop diagrams showing the factors that they believe drive obesity. This paper describes the background to GMB and the process we used to construct causal loop diagrams; it discusses how GMB contributed to generating noteworthy and useful findings, and the strengths and limitations of the method. Using GMB, we identified areas of concern to adolescents in relation to obesity that have so far had little attention in obesity research and policy: mental health and online activity. In using GMB, we also helped answer calls for a more participatory approach to youth involvement in research and policy development.

Success of community-based system dynamics in prevention interventions: A systematic review of the literature

Systems thinking approaches are increasingly being used to help communities understand and develop responses to preventing complex health problems. Less is known about how success is characterized and what influences success in these approaches. We present a systematic review of how concepts of success are understood and evaluated in the peer reviewed literature of studies using systems thinking in community prevention. We searched five databases for peer-reviewed literature published between 2000 and 2022, with search terms related to systems thinking, prevention and community. Studies were included if they; reported using community-based systems thinking to prevent a public health problem; described the engagement and empowerment of community members to address a public health issue; and, were published in English. Thirty-four articles were identified from 10 countries. Twenty-one aimed to prevent a chronic disease (e.g., obesity) and 16 measured success using specific tools, 10 of which used semi-structured interviews or surveys. Measures of success included implementation processes, cultural appropriateness, the number or type of actions implemented, effectiveness of community action, and changes in individual thinking or mental models, population health outcomes, data collected, or systems level measures. Implementation factors influencing success included the capacity to engage participants, composition and experience of facilitators, strength of coordination teams, allocation of resources, adaptation to participant feedback, use of multiple systems approaches, workshop process providing time and methods to allow new insights, flexible delivery, and diversity of perspectives. Findings from each of the articles indicated that approaches increased a range of outcomes including community action, strategic thinking, future planning and evaluation, community buy-in, community voice, contribution and leadership, in addition to developing shared visions and goals and creating new, ongoing collaborations, among many others. Measures of success varied, suggesting more empirical reporting of proposed outcomes of system science in communities would be valuable. While the measurement of success in the use of systems thinking in community-based prevention efforts is limited, there are helpful examples we can look to for future measurement of success.

Shifting the social determinants of food insecurity during the COVID-19 pandemic: the Australian experience

We aimed to explore experiences of government-led actions on the social determinants of food insecurity during Australia's COVID-19 pandemic response (which included novel, yet temporary, social protection measures to support Australians facing hardship during state-wide lockdowns). During November-December 2020, we conducted in-depth interviews with 24 Victorians who received government income support (prior to COVID-19) and the temporary COVID-19 specific payments. Interviews were guided by a theoretical understanding of the social determinants of health and health inequities, which we aligned to the social policy context. Data were audio-recorded, transcribed, inductively coded, categorised and thematically analysed. Our sample included mostly women (n = 19) and single parents (n = 13). Interviews reflected four key themes. Firstly, participants described 'battles all around them' (i.e., competing financial, health and social stressors) that were not alleviated by temporary social policy changes and made healthy eating difficult to prioritise during the pandemic. Secondly, housing, income, job, and education priorities rendered food a lower and more flexible financial priority - even with 18 participants receiving temporary income increases from COVID-19 Supplements. Thirdly, given that food remained a lower and more flexible financial priority, families continued to purchase the cheapest and most affordable options (typically less healthful, more markedly price discounted). Finally, participants perceived the dominant public and policy rhetoric around income support policies and healthy eating to be inaccurate and shaming - often misrepresenting their lived experiences, both prior to and during COVID-19. Participants reported entrenched struggles with being able to afford basic living costs in a dignified manner during COVID-19, despite temporary social protection policy changes. To reduce inequities in population diets, a pre-requisite to health, all stakeholders must recognise an ongoing responsibility for adopting long-term food and social policies that genuinely improve lived experiences of food insecurity and poverty.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12571-022-01318-4.

Building capacity for the use of systems science to support local government public health planning: a case study of the VicHealth Local Government Partnership in Victoria, Australia

OBJECTIVE

To present an approach to build capacity for the use of systems science to support local communities in municipal public health and well-being planning.

DESIGN

Case study.

SETTING

Local government authorities participating in the VicHealth Local Government Partnership in Victoria, Australia.

PARTICIPANTS

Local government staff members were trained in community-based system dynamics (CBSD), and group model building (GMB) techniques to mobilise local community efforts. The trained local government facilitation teams then delivered GMB workshops to community stakeholder groups from 13 local government areas (LGA)s.

MAIN OUTCOMES

Training in CBSD was conducted with council facilitation teams in 13 LGAs, followed by the local delivery of GMB workshops 1-3 to community stakeholders. Causal loop diagrams (CLD) representing localised drivers of mental well-being, healthy eating, active living or general health and well-being of children and young people were developed by community stakeholders. Locally tailored action ideas were generated such as well-being classes in school, faster active transport and access to free and low-cost sporting programmes RESULTS: Overall, 111 local government staff participated in CBSD training. Thirteen CLDs were developed, with the stakeholders that included children, young people and community members, who had participated in the GMB workshops across all 13 council sites. Workshop 3 had the highest total number of participants (n=301), followed by workshop 1 (n=287) and workshop 2 (n=171).

CONCLUSIONS

Local facilitation of the CBSD process has developed community informed and locally relevant CLDs that will be used to lead local action to improve the well-being of children and young people. Training employees in CBSD is one approach to increase systems thinking capacity within local government.

Leadership for systems change: Researcher practices for enhancing research impact in the prevention of chronic disease

Introduction

Strengthening systems for chronic disease prevention is essential. Leadership for systems change is an important key to strengthening systems. Leadership in prevention research for supporting systems change remains a relatively abstract concept and there is limited empirical information about the leadership practices of prevention research teams when viewed through a complexity lens. In this paper we examine and describe some systems leadership practices for creating change through prevention research, as identified in a series of six case studies.

Methods

A qualitative approach incorporating semi-structured interviews, participant observation, and document review was used to facilitate an in-depth investigation of the research topic.

Results

Several researcher practices for enhancing research impact in the prevention of chronic disease were distilled from the data pertaining to how they sought to create change. These included persuasive communication, compassion and deep listening, reflective practice, and embedding themselves within the systems they sought to change.

Discussion

The findings provide insights that may assist prevention researchers and other practitioners dedicated to creating change in chronic disease prevention.

Research protocol for impact assessment of a project to scale up food policies in the Pacific

Background

One of the challenges for countries implementing food policy measures has been the difficulty in demonstrating impact and retaining stakeholder support. Consequently, research funded to help countries overcome these challenges should assess impact and translation into practice, particularly in low-resource settings. However, there are still few attempts to prospectively, and comprehensively, assess research impact. This protocol describes a study co-created with project implementers, collaborative investigators and key stakeholders to optimize and monitor the impact of a research project on scaling up food policies in Fiji.

Methods

To develop this protocol, our team of researchers prospectively applied the Framework to Assess the Impact from Translational health research (FAIT). Activities included (i) developing a logic model to map the pathway to impact and establish domains of benefit; (ii) identifying process and impact indicators for each of these domains; (iii) identifying relevant data for impact indicators and a cost–consequence analysis; and (iv) establishing a process for collecting quantitative and qualitative data to measure progress. Impact assessment data will be collected between September 2022 and December 2024, through reports, routine monitoring activities, group discussions and semi-structured interviews with key implementers and stakeholders. The prospective application of the protocol, and interim and final research impact assessments of each project stream and the project as a whole, will optimize and enable robust measurement of research impact.

Discussion

By applying this protocol, we aim to increase understanding of pathways to impact and processes that need to be put in place to achieve this. This impact evaluation will inform future projects with a similar scope and will identify transferable and/or translatable lessons for other Pacific Island states and low- and middle-income countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00927-x.

Relationship between "Blue Space" Proximity and Children's Weight Status, Health Behaviors, and Health-Related Quality of Life among a Sample of Regional Victorian Primary School Children

Background: Access to green space (e.g., parks and gardens) has been associated with child health and wellbeing, whereas blue space (e.g., coasts, lakes, and rivers) is understudied. Our aim was to determine whether proximity to the coast was associated with primary school children's weight status, modifiable health-related behaviors, and health-related quality of life (HRQoL). Methods: Exploratory cross-sectional analysis of baseline data from the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHOSTOPS) study, to estimate gender-specific differences in weight and behaviors across four bands of distance from the coast (<5 km, 5 to <25 km, 25 to <50 km, ≥50 km). Linear and logistic models, with robust standard errors, adjusted for school year level, area-level socioeconomic position and rurality, and allowing for distance by gender interaction were fitted on data from 1216 children (aged 8.5-13 years). Main outcomes were weight status (categorical), physical activity (PA) (categorical), and global HRQoL score (continuous). Results: Compared with girls living in towns ≥50 km from the coast, those living within 5 km had lower odds for overweight/obesity [odds ratio (OR) = 0.50; 95% confidence interval (CI): 0.37-0.67] and higher mean moderate-to-vigorous PA minutes (accelerometry) (β = 8.7; 95% CI: 2.0-15.5) and global HRQoL (β = 3.2; 95% CI: 1.4-5.0). Compared with boys living ≥50 km from the coast, those living within 5 km had higher odds of meeting self-reported PA guidelines (≥60 minutes/day) for ≥5 days (OR = 2.33; 95% CI: 1.75-3.10), and higher mean global HRQoL scores (β = 5.6; 95% CI: 1.9-9.3). Conclusions: Living close to the coast was associated with some favorable health outcomes and behaviors, which differed between girls and boys.

System dynamics modelling to engage community stakeholders in addressing water and sugar sweetened beverage consumption

Background

Participatory approaches to develop community-based system dynamics models to tackle complexity are promising, but research is needed in how simulation models can be developed with community stakeholders to yield significant system insights. This study presents the results of a community-based system dynamics modelling process to increase water consumption and decrease sugar sweetened beverage consumption in Portland, Victoria, a regional town in Australia.

Methods

A series of group model building workshops with 11 community stakeholders addressing the topic of water and sugar sweetened beverage consumption was conducted in Portland. A simulating system dynamics model was built with stakeholders to inform action planning.

Results

A system dynamics model was created to provide insight into water and sugar sweetened beverage consumption in Portland. The model included six feedback loops describing the causal effects of sugar sweetened beverage consumption habits and norms, water taste, water consumption norms, public water availability, and public health benefits. For example, the sugar sweetened beverage consumption norm loop modelled how people overestimating others’ consumption may motivate an increase in their own consumption, feeding back and further amplifying an increase in sugar sweetened beverage consumption. The model contributed to the foundation of a strong partnership to improve the taste of water and educate the public on water consumption.

Conclusions

Engaging stakeholders in system dynamics modelling about water and sugar sweetened beverage consumption increased engagement and collaboration to address the problem among community stakeholders.

Co-creation of healthier food retail environments: A systematic review to explore the type of stakeholders and their motivations and stage of engagement

OBJECTIVE

To synthesize peer-reviewed literature that utilize co-creation principles in healthy food retail initiatives.

METHODS

Systematic review of six databases from inception to September 2021. Screening and quality assessment were carried out by two authors independently. Studies were included if they were conducted in food retail stores, used a collaborative model, and aimed to improve the healthiness of the food retail environment. Studies excluded were implemented in restaurants, fast food chains, or similar or did not utilize some form of collaboration. Extracted data included the type of stakeholders engaged, level of engagement, stakeholder motivation, and barriers and enablers of the co-creation process.

FINDINGS

After screening 6951 articles by title and abstract, 131 by full text, 23 manuscripts that describe 20 separate studies from six countries were included. Six were implemented in low-income communities and eight among Indigenous people groups. A common aim was to increase access to, and availability of, healthy products. A diverse range of co-creation approaches, theoretical perspectives, and study designs were observed. The three most common stakeholders involved were researchers, corporate representatives or store owners, and governments.

CONCLUSIONS

Some evidence exists of the benefits of co-creation to improve the healthiness of food retail environments. The field may benefit from structured guidance on the theory and practice of co-creation.

Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND): protocol and baseline outcomes for a stepped-wedge cluster-randomised prevention trial

INTRODUCTION

Systems science methodologies have been used in attempts to address the complex and dynamic causes of childhood obesity with varied results. This paper presents a protocol for the Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND) trial. RESPOND represents a significant advance on previous approaches by identifying and operationalising a clear systems methodology and building skills and knowledge in the design and implementation of this approach among community stakeholders.

METHODS AND ANALYSIS

RESPOND is a 4-year cluster-randomised stepped-wedge trial in 10 local government areas in Victoria, Australia. The intervention comprises four stages: catalyse and set up, monitoring, community engagement and implementation. The trial will be evaluated for individuals, community settings and context, cost-effectiveness, and systems and implementation processes. Individual-level data including weight status, diet and activity behaviours will be collected every 2 years from school children in grades 2, 4 and 6 using an opt-out consent process. Community-level data will include knowledge and engagement, collaboration networks, economic costs and shifts in mental models aligned with systems training. Baseline prevalence data were collected between March and June 2019 among >3700 children from 91 primary schools.

ETHICS AND DISSEMINATION

Ethics approval: Deakin University Human Research Ethics Committee (HREC 2018-381) or Deakin University's Faculty of Health Ethics Advisory Committee (HEAG-H_2019-1; HEAG-H 37_2019; HEAG-H 173_2018; HEAG-H 12_2019); Victorian Government Department of Education and Training (2019_003943); Catholic Archdiocese of Melbourne (Catholic Education Melbourne, 2019-0872) and Diocese of Sandhurst (24 May 2019). The results of RESPOND, including primary and secondary outcomes, and emerging studies developed throughout the intervention, will be published in the academic literature, presented at national and international conferences, community newsletters, newspapers, infographics and relevant social media.

TRIAL REGISTRATION NUMBER

ACTRN12618001986268p.

Four-Year Accelerometry Outcomes from a Cluster Randomized Whole of Systems Trial of Prevention Strategies for Childhood Obesity

Background: We investigated the effect of the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS) intervention on children's objectively measured physical activity and sedentary time (ST). Methods: We conducted a cluster randomized controlled trial with children in grades 4 (∼9-10 years old) and grade 6 (∼11-12 years old) from 10 communities in the Great South Coast region of Victoria, Australia. Communities were randomly allocated (1:1) to receive the WHO STOPS intervention in 2015. WHO STOPS was a whole of community systems-based approach to preventing childhood obesity. Outcome data were collected using a repeat cross-sectional design in 2015, 2017, and 2019. Children were asked to wear a hip-mounted accelerometer for 7 days. Age-specific Axis 1 activity counts were converted into duration (minutes/day) spent engaged in moderate-to-vigorous physical activity (MVPA), light physical activity (LPA), and ST. Linear mixed regression models were fitted to estimate the effects of the intervention on the three activity outcomes across the study period. Results: Analyses were based on valid accelerometer data from 1406 children (intervention n = 745; control n = 661). Results for MVPA, LPA, and ST were nonsignificant. Between 2015 and 2017, there were positive, but nonsignificant, changes in mean MVPA favoring intervention boys [3.7 minutes/day; 95% confidence interval (CI): -5.7 to 13.1] and girls (5.5 minutes/day; 95% CI: -1.5 to 12.6). By 2019, these effects had attenuated. Conclusions: Although the WHO STOPS intervention did not significantly change activity levels, the magnitudes of the effects on MVPA suggest that further research with whole-of-community interventions in larger samples would be worthwhile. Clinical trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR.org.au) identifier 12616000980437.