The 2023 report of the MJA-Lancet Countdown on health and climate change: sustainability needed in Australia's health care sector.

The MJA-Lancet Countdown on health and climate change in Australia was established in 2017 and produced its first national assessment in 2018 and annual updates in 2019, 2020, 2021 and 2022. It examines five broad domains: health hazards, exposures and impacts; adaptation, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. In this, the sixth report of the MJA-Lancet Countdown, we track progress on an extensive suite of indicators across these five domains, accessing and presenting the latest data and further refining and developing our analyses. Our results highlight the health and economic costs of inaction on health and climate change. A series of major flood events across the four eastern states of Australia in 2022 was the main contributor to insured losses from climate-related catastrophes of $7.168 billion - the highest amount on record. The floods also directly caused 23 deaths and resulted in the displacement of tens of thousands of people. High red meat and processed meat consumption and insufficient consumption of fruit and vegetables accounted for about half of the 87 166 diet-related deaths in Australia in 2021. Correction of this imbalance would both save lives and reduce the heavy carbon footprint associated with meat production. We find signs of progress on health and climate change. Importantly, the Australian Government released Australia's first National Health and Climate Strategy, and the Government of Western Australia is preparing a Health Sector Adaptation Plan. We also find increasing action on, and engagement with, health and climate change at a community level, with the number of electric vehicle sales almost doubling in 2022 compared with 2021, and with a 65% increase in coverage of health and climate change in the media in 2022 compared with 2021. Overall, the urgency of substantial enhancements in Australia's mitigation and adaptation responses to the enormous health and climate change challenge cannot be overstated. Australia's energy system, and its health care sector, currently emit an unreasonable and unjust proportion of greenhouse gases into the atmosphere. As the Lancet Countdown enters its second and most critical phase in the leadup to 2030, the depth and breadth of our assessment of health and climate change will be augmented to increasingly examine Australia in its regional context, and to better measure and track key issues in Australia such as mental health and Aboriginal and Torres Strait Islander health and wellbeing.

Legal and regulatory instruments for NCD prevention: a scoping review and descriptive analysis of evaluations in OECD countries.

CONTEXT: Public health law is an important tool in non-communicable disease (NCD) prevention. There are different approaches available for achieving policy objectives, including government, co-, quasi- and self-regulation. However, it is often unclear what legal design features drive successes or failures in particular contexts. This scoping review undertakes a descriptive analysis, exploring the design characteristics of legal instruments that have been used for NCD prevention and implemented and evaluated in OECD countries. METHODS: A scoping review was conducted across four health and legal databases (Scopus, EMBASE, MEDLINE, HeinOnline), identifying study characteristics, legal characteristics and regulatory approaches, and reported outcomes. Included studies focused on regulation of tobacco, alcohol, unhealthy foods and beverages, and environmental pollutants. FINDINGS: We identified 111 relevant studies evaluating 126 legal instruments. Evaluation measures most commonly assessed implementation, compliance and changes to the built and lived environment. Few studies evaluated health or economic outcomes. When examining the design and governance mechanisms of the included legal instruments, government regulation was most commonly evaluated (n = 90) and most likely to be reported effective (64%). Self-regulation (n = 27) and quasi-regulation (n = 5) were almost always reported to be ineffective (93% and 100% respectively). There were few co-regulated instruments evaluated (n = 4) with mixed effectiveness. When examining public health risks, food and beverages including alcohol were more likely to be self- or quasi-regulated and reported as ineffective more often. In comparison, tobacco and environmental pollutants were more likely to have government mandated regulation. Many evaluations lacked critical information on regulatory design. Monitoring and enforcement of regulations was inconsistently reported, making it difficult to draw linkages to outcomes and reported effectiveness. CONCLUSIONS: Food and alcohol regulation has tended to be less successful in part due to the strong reliance on self- and quasi-regulation. More work should be done in understanding how government regulation can be extended to these areas. Public health law evaluations are important for supporting government decision-making but must provide more detail of the design and implementation features of the instruments being evaluated - critical information for policy-makers.

POLICY POINTS: Government regulation is reported as more effective than co-regulation, quasi-regulation or self-regulation. Voluntary approaches, including voluntary government regulation, are reported less effective due to low uptake and limited accountability. In public health law mandated government regulation should be strived for.Food and alcohol sectors are more likely to adopt self- or quasi-regulation and are frequently reported as ineffective. More work should be done to support government regulation in these areas.Many public health law evaluations are lacking critical design information for policy makers. This may make it difficult to learn from successes or failures and replicate interventions in other jurisdictions.

Combining public health evidence, policy experience and communications expertise to inform preventive health: reflections on a novel method of knowledge synthesis.

Knowledge synthesis methods help summarize evidence and utilize content expertise to draw out key messages to aid knowledge mobilization and translation. Systems thinking and coproduction can support this by facilitating a multiperspective view and ensuring that knowledge is mobilized and translated in a useful and meaningful way for policy-makers and practitioners. In this paper, we describe the development of a knowledge synthesis approach that utilizes coproduction with policy-makers to combine the findings of a programme of research with policy knowledge to support decision-makers working in chronic disease prevention. The process developed by The Australian Prevention Partnership Centre combined the expertise of research, policy and science communications experts. We reflect on how we used coproduction processes to embed policy-makers as partners in the evidence synthesis process via research-policy dialogues, and embedded science communication into the development and presentation of the findings. This differs from a more common approach of researchers generating evidence for policy with limited input from policy-makers themselves. By collaborating with policy-makers and using coproduction, we can better inform policy-relevant research and generate policy-relevant knowledge. We describe the development of our knowledge synthesis approach using two case studies: the first drawing on a body of work in public health law, and the second on a body of work focused on the first 2000 days of life. We consider how these case studies demonstrate the value of working with policy partners as part of a knowledge synthesis process, and discuss how this process could be adapted and used in future.

The Effect of Retail Food Environment Interventions on Dietary Behavior in Postsecondary Education Settings: A Systematic Review and Meta-analysis.

BACKGROUND: Postsecondary education institutions, where hundreds of millions of people work and study globally, are a key setting for retail food environment interventions. OBJECTIVE: We aimed to synthesize the evidence for the effectiveness of retail food environment interventions in improving the healthiness of dietary behavior of students and staff in postsecondary education settings. METHODS: Academic databases were searched for randomized controlled trials (RCTs) and quasi-experimental studies published until August 2023. Studies were eligible if they assessed the impact of a retail food environment intervention on healthiness of dietary behavior (purchases or consumption) in students or staff in postsecondary education settings and targeted one of the following food environment elements: placement, price, product, or promotion. Business-related outcomes (total sales, profit, or revenue) were included as secondary outcomes. Findings were synthesized in narrative form, organized by retail food environment element. Where comparable dietary outcome data were available from ≥10 interventions, findings were pooled using random effects meta-analysis. RESULTS: Of 10,126 studies initially identified, 55 (76% quasi-experimental) were included, describing 71 separate interventions (n = 49 single-element and n = 22 multi-element). Two-thirds (n = 47, 66%) of interventions (n = 32 single-element and n = 15 multi-element) demonstrated significant improvements in dietary behavior. Single-element interventions targeting placement (n = 1) and price (n = 3) improved dietary behavior. Most (n = 9/10, 90%) interventions targeting product availability or convenience (product element) improved dietary behavior, while n = 19/35 (54%) targeting promotion did. Pooled findings from 12 interventions reporting changes in energy content demonstrated a significant decrease in purchased or consumed energy (-7.9%; 95% confidence interval: -10.3%, -5.6%). Almost all interventions (n = 11/12, 92%) that evaluated the impact on business-related outcomes found either a significant increase or no change following the intervention. CONCLUSIONS: We established encouraging evidence supporting the role of retail food environment interventions in postsecondary education settings to support healthy dietary behaviors of students and staff. REGISTRY: PROSPERO (International Prospective Register of Systematic Reviews, URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=295836; registration number CRD42022295836).

Priority setting for non-communicable disease prevention - Co-producing a regulatory agenda informing novel codes of practice in Australia.

There are a range of priority setting methods for non-communicable disease (NCDs) prevention. However, existing methods are often designed without detailed consideration of local context and political economy- critical success factors for implementation. In Australia, codes of practice under state government Public Health Acts could be used for NCD prevention. To inform the potential development of codes of practice under Public Health Acts, this study aimed to co-create a priority setting framework that accounts for local context and the prevailing regulatory agenda. A priority setting framework was co-produced by a multidisciplinary technical advisory group consisting of government representatives, public health lawyers and academic experts. It incorporated general prioritisation criteria (evidence, cost-effectiveness, equity, burden of disease) and local contextual criteria (legal compatibility, unmet-needs, political acceptability, structural and technical feasibility, community support). The framework was then applied in practice through surveys and policy dialogue workshops to discuss political economy factors. Policies were limited to nutrition, alcohol and physical activity risk factors. Through the prioritisation process, the most impactful, feasible and acceptable policies for NCD prevention via state government codes of practice were: restrictions on in-store placement of unhealthy products, enhancing data systems and capabilities for health surveillance and implementation monitoring, removal of unhealthy foods and drinks sold and supplied in public institutions, prohibition of marketing of unhealthy foods and drinks on assets controlled by government, and implementation of subsidies or grants to increase fruit and vegetable intake. The process illustrated that explicit consideration of local context, legal compatibility and the political economy had a substantial influence on the prioritised list of actions. The proposed priority setting framework is designed to be flexible and adaptable to varying contexts, can be embedded in government processes or utilised by researchers and practitioners to co-produce a regulatory agenda that is locally relevant.

Influencing and implementing mandatory alcohol pregnancy warning labels in Australia and New Zealand.

Alcohol labelling laws and policy are contentious and highly politicized. Very few countries have been able to implement health warnings on alcohol labels due to complex legal and governance systems and coordinated industry lobbying. In 2020, Australia and New Zealand implemented a mandatory and evidence-based legal standard for pregnancy warning labels on alcohol products. This article discusses some of the challenges faced in achieving policy change and how these barriers were overcome by public health advocacy groups to build the evidence, counter industry conflicts of interest, consumer test health messages, mobilize community support and gather political support. Reflecting on the decades of ineffective regulation and politicization of this health issue, lessons for other countries include the importance of creating and maintaining relationships with decision makers and regularly updating them with evidence and recommendations, highlighting industry failures and tactics, building broad-based coalitions and sharing lived-experiences.

"No Alcohol, No Risk. #FASD"- Twitter Activity on Alcohol and Pregnancy among Australian Organizations.

Objective: Research has suggested that information communicated by public health and industry-funded organizations differ, as organizations linked to industry have tended to downplay risks with alcohol more broadly and pregnancy specifically. There is limited knowledge of how alcohol use in pregnancy and associated risks are communicated on social media in Australia. This study set out to describe communication of health risks associated with alcohol use during pregnancy on Twitter by Australian-based organizations and stakeholders. Methods: We searched for "alcohol" and "pregnancy", "pregnant", or "FASD" on Twitter accounts belonging to potentially relevant organizations, of which 17 had tweeted on the topic. Content analysis was undertaken on all tweets and summarized under eight themes. Results: A total of 347 tweets were identified, posted between 2010 and 2019 mainly by public health and disability nongovernmental organizations. Tweets generally focused on FASD, but other potential consequences of maternal alcohol use were infrequently mentioned and tended to be generic. We found infrequent mentions of direct advice around alcohol use during pregnancy and official guidelines. Overall, tweets reflected ongoing policy debates in Australia - including alcohol warning labeling, disability policy and increased activity was seen particularly before the second parliamentary inquiry into FASD. Conclusions: The limited number of tweets from relevant organizations over a nine-year period suggests focus has been on FASD while less discussion of alcohol use during pregnancy was evident. We identified an opportunity for more and consistent communication of trusted national health guidance.

The 2022 report of the MJA-Lancet Countdown on health and climate change: Australia unprepared and paying the price.

The MJA-Lancet Countdown on health and climate change in Australia was established in 2017 and produced its first national assessment in 2018 and annual updates in 2019, 2020 and 2021. It examines five broad domains: climate change impacts, exposures and vulnerability; adaptation, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. In this, the fifth year of the MJA-Lancet Countdown, we track progress on an extensive suite of indicators across these five domains, accessing and presenting the latest data and further refining and developing our analyses. Within just two years, Australia has experienced two unprecedented national catastrophes - the 2019-2020 summer heatwaves and bushfires and the 2021-2022 torrential rains and flooding. Such events are costing lives and displacing tens of thousands of people. Further, our analysis shows that there are clear signs that Australia's health emergency management capacity substantially decreased in 2021. We find some signs of progress with respect to health and climate change. The states continue to lead the way in health and climate change adaptation planning, with the Victorian plan being published in early 2022. At the national level, we note progress in health and climate change research funding by the National Health and Medical Research Council. We now also see an acceleration in the uptake of electric vehicles and continued uptake of and employment in renewable energy. However, we also find Australia's transition to renewables and zero carbon remains unacceptably slow, and the Australian Government's continuing failure to produce a national climate change and health adaptation plan places the health and lives of Australians at unnecessary risk today, which does not bode well for the future.

A political economy analysis protocol: Case study implementing nutrition and sustainability policy into government food procurement.

Most Australian state and territory governments have healthy food provisioning policies targeting availability of unhealthy food at the retail level, and sustainability policies promoting a life-cycle approach to procurement. However, it remains unclear if health and sustainability are important considerations in awarding contracts, and whether these high-level policies are implemented into supplier contracts. A political economy analysis framework has been developed to prospectively identify and explain barriers and enablers to policy implementation. Using food procurement in Queensland and South Australia as case studies, the political economy analysis seeks to understand the structural and contextual factors, bargaining processes, stakeholders, and incentives and ideas surrounding food procurement. It involves a desktop and content analysis of existing policies and food contracts, and key informant interviews with government and industry stakeholders. Participants will be targeted across different departments (e.g. health, environment, treasury) and in varying roles from policy design, contract management and food service, and industry suppliers in different food and drink categories (e.g. meat, packaged foods, beverages, fruit & vegetables). Participants will be recruited using purposive sampling. Thematic analysis of interview transcripts will be undertaken, informed by the political economy analysis framework. The study will identify current food procurement policy implementation barriers and enablers, including why high-level policies aren't embedded into contracts, mechanisms for achieving policy coherence and future opportunities for addressing barriers and incorporating socio-economic, public health and environmental considerations into purchasing practices. Ultimately, the study will achieve impact by informing a whole of government approach to health and the environment by elevating the priority of health and sustainability in procurement (short term), increasing the availability of healthy and sustainable foods (medium term), and improving health and environmental outcomes (long term). To our knowledge this is the first political economy analysis of food procurement in Australia.

Regulating Alcohol: Strategies Used by Actors to Influence COVID-19 Related Alcohol Bans in South Africa.

South Africa has used intermittent alcohol prohibitions and restrictions as a strategy to relieve hospitals of alcohol-related trauma cases and spare services for COVID-19 caseloads. Alcohol regulation is highly contested and involves a diverse range of actors who influence policies to align with their interests. This study sought to examine the strategies used by these actors to shape the COVID-19 related alcohol regulation in South Africa as presented by online news media. We found that the voice of pro-regulation actors is smaller and fragmented compared to opponents of the regulation as each actor seeks to advance their own interests. Despite the regulations initially being framed as a COVID-19 public health measure, pro-regulation government ministries, such as police and transport, perceive the regulations as a way of reducing existing (pre-pandemic) alcohol-related harm, such as crime, road-traffic injuries, and gender-based violence. The pre-existing failures in the alcohol regulatory environment and the current policy momentum created by COVID-19 could present an opportunity to retain components of the new laws and improve alcohol regulation in South Africa. However, there is a dominant and cohesive alcohol industry voice that strongly opposes the regulations, citing economic impacts, illicit trade and lack of evidence on the positive effects of the alcohol bans. Strategies employed by industry include lobbying, framing, and litigation. The regulations implemented under the guise of COVID-19 prevention have presented valuable lessons for alcohol regulation more generally. However, whether these regulations translate to sustainable policy changes will depend upon how and if the strong industry voice is countered.