How does whole of government action address inequities in obesity? A case study from Australia.

BACKGROUND: There are many factors across different sectors that contribute to inequities in obesity levels. This implies the need for action across different government departments and policy domains (hereafter referred to as whole of government multisectoral action). In this study we explored the public policy attention given to inequities in obesity using an Australian case study. METHODS: Interviews were conducted with 33 stakeholders involved in the development and implementation of the whole of government Healthy Weight Initiative (HWI). A thematic analysis was undertaken to identify ways in which government policy makers and implementers explicitly or implicitly described how actions delivered through the HWI addressed inequities in obesity within the population. RESULTS: The analysis revealed that the focus of the HWI was predominantly aimed at the general population, with minimal attention given to addressing the social distribution of obesity. The reasons for this were explained in terms of five themes: (1) rationale for a population wide approach; (2) when to apply an equity lens, (3) issues of government responsibility, (4) philosophically opposing concepts of equity, and (5) tensions across departments as a result of competing concepts of equity. CONCLUSIONS: It is important to create a shared understanding plus a concern for addressing inequities in public policy, regardless of whether or not a universal population-wide or a targeted approach is being applied. It is also important that policies and programs address the social distribution of obesity while understanding local contexts and needs. In striving to develop policy that brings an explicit focus on health equity, policymakers must consider the sociological, political, economic, and philosophical tensions at play between different policy actors and government departments, and identify how to navigate these without reverting to siloed working.

Part-time in general practice-a remedy to a time-based problem?

BACKGROUND: Increasing numbers of GPs are reducing the hours they work in clinical practice. The reasons for and implications of this are not well-understood. OBJECTIVE: To investigate how the demands of general practice, especially new time pressures, impact GPs' professional and personal lives and work hour choices. METHOD: Using a grounded theory approach, we conducted 26 in-depth interviews with GPs working in Australia. RESULTS: Time-bound consultation windows, the complexity of patients presenting to general practice and consequent administrative and emotional burdens placed upon GPs combined to increase time pressures and an intensifying clinical load. Many GPs also strove to sequester time for family and reported burnout and poor health along with abiding concerns for quality of care. CONCLUSION: This study suggests a need for new policies on how clinical consultations are timed and remunerated in keeping with a changed GP demography, new demands and a more complex patient care profile.

Extending the paradigm: a policy framework for healthy and equitable eating (HE2).

OBJECTIVE: The current short communication aimed to provide a new conceptualisation of the policy drivers of inequities in healthy eating and to make a call to action to begin populating this framework with evidence of actions that can be taken to reduce the inequities in healthy eating. DESIGN: The Healthy and Equitable Eating (HE2) Framework derives from a systems-based analytical approach involving expert workshops. SETTING: Australia. SUBJECTS: Academics, government officials and non-government organisations in Australia. RESULTS: The HE2 Framework extends previous conceptualisations of policy responses to healthy eating to include the social determinants of healthy eating and its social distribution, encompassing policy areas including housing, social protection, employment, education, transport, urban planning, plus the food system and environment. CONCLUSIONS: As the burden of non-communicable diseases continues to grow globally, it is important that governments, practitioners and researchers focus attention on the development and implementation of policies beyond the food system and environment that can address the social determinants of inequities in healthy eating.

Culture, management and finances as key aspects for healthy workplace initiatives.

The aim of this study was to qualitatively explore the barriers and enablers to implementing healthy workplace initiatives in a sample of workplaces based in Perth, Western Australia. In-depth interviews were conducted with representatives from 31 organizations representing small, medium and large businesses in the Perth metropolitan area which reported having healthy workplace initiatives. In total, 43 factors were mentioned as influencing the implementation of healthy workplace initiatives. Factors appearing to exert the most influence on the implementation of health promoting initiatives in this sample were culture; support from managers and staff; collaboration with industry providers; financial resources circumstances and the physical environment. These factors appeared to be mutually reinforcing and interconnected. Findings suggest there may be merit in applying an organizational development lens to the implementation of workplace health promotion initiatives as this could assist in leveraging enablers and minimizing barriers.

Understanding barriers to fruit and vegetable intake in the Australian Longitudinal Study of Indigenous Children: a mixed-methods approach.

OBJECTIVE: To identify barriers to fruit and vegetable intake for Indigenous Australian children and quantify factors related to these barriers, to help understand why children do not meet recommendations for fruit and vegetable intake. DESIGN: We examined factors related to carer-reported barriers using multilevel Poisson models (robust variance); a key informant focus group guided our interpretation of findings. SETTING: Eleven diverse sites across Australia. SUBJECTS: Australian Indigenous children and their carers (N 1230) participating in the Longitudinal Study of Indigenous Children. RESULTS: Almost half (45 %; n 555/1230) of carers reported barriers to their children's fruit and vegetable intake. Dislike of fruit and vegetables was the most common barrier, reported by 32·9 % of carers; however, we identified few factors associated with dislike. Carers were more than ten times less likely to report barriers to accessing fruit and vegetables if they lived large cities v. very remote areas. Within urban and inner regional areas, child and carer well-being, financial security, suitable housing and community cohesion promoted access to fruit and vegetables. CONCLUSIONS: In this national Indigenous Australian sample, almost half of carers faced barriers to providing their children with a healthy diet. Both remote/outer regional carers and disadvantaged urban/inner regional carers faced problems accessing fruit and vegetables for their children. Where vegetables were accessible, children's dislike was a substantial barrier. Nutrition promotion must address the broader family, community, environmental and cultural contexts that impact nutrition, and should draw on the strengths of Indigenous families and communities.

Can the sociology of social problems help us to understand and manage 'lifestyle drift'?

Lifestyle drift is increasingly seen as a barrier to broad action on the social determinants of health. The term is currently used in the population health literature to describe how broad policy initiatives for tackling inequalities in health that start off with social determinants (upstream) approach drift downstream to largely individual lifestyle factors, as well as the general trend of investing a the individual level. Lifestyle drift occurs despite the on-going efforts of public health advocates, such as anti-obesity campaigners, to draw attention to the social factors which shape health behavior and outcomes. In this article, we explore whether the sociology of social problems can help understand lifestyle drift in the context of obesity. Specifically, we apply Jamrozik and Nocella's residualist conversion model to the problem of obesity in order to explore whether such an approach can provide greater insight into the processes that underpin lifestyle drift and inform our attempts to mitigate it.

Factors Affecting Indigenous West Australians' Health Behavior: Indigenous Perspectives.

The factors driving the disparity in health outcomes between Indigenous and non-Indigenous Australians include socio-economic factors, racism, and history. The current study focused on exploring Indigenous participants' perspectives of the factors that affect the health behavior of their community members. Participatory action research methodology and a grounded theory approach were utilized. In total, 120 members of two urban West Australian Indigenous communities participated in focus group discussions. There was substantial similarity between the themes that emerged within the discussions held in the two communities. Factors relating to culture, social connections, racism, communication, and personal aspects were particularly salient to health behavior of the participants. Several of the themes including culture, racism, communication, and distrust highlight the tension caused by being a member of a minority cultural group that has been marginalized by the practices and attitudes of the dominant cultural group. Personal choice was sometimes prioritized over health.

Beyond fun runs and fruit bowls: an evaluation of the meso-level processes that shaped the Australian Healthy Workers Initiative.

Issue addressed The Australian National Partnership Agreement on Preventive Health (NPAPH) charged states and territories with the development and implementation of the Healthy Workers Initiative (HWI) to improve workplace health promotion. Most evaluation efforts focus on the setting (micro) level. In the present study the HWI at the meso-level (state program development) was examined to understand how jurisdictions navigated theoretical, practical, and political priorities to develop their programs, and the programmatic choices that support or hinder perceived success. Methods Interviews with HWI program coordinators and managers across seven Australian jurisdictions explored decision-making processes related to developing and implementing the HWI and the impact of defunding. Interviews were audio-recorded, transcribed and analysed using thematic analysis. Results Despite taking a variety of approaches to the HWI, jurisdictions had common goals, namely achieving sustainability and capacity for meaningful change. These goals transcended the performance indicators set out by the NPAPH, which were considered unachievable in the given timeframe. Four ways jurisdictions sought to achieve their goals were identified, these were: 1) taking an embedded approach to workplace health promotion; 2) ensuring relevance of the HWI to businesses; 3) engaging in collaborative partnerships with agencies responsible for implementation; and 4) cultivating evolution of the HWI. Conclusions This meso-level evaluation has provided valuable insights into how health promotion program coordinators translate broad, national-level initiatives into state-specific programs and how they define program success. The study findings also highlight how broader, contextual factors, such as jurisdiction size, political imperatives and funding decisions impact on the implementation and success of a national health promotion initiative. So what? When evaluating the translation of complex initiatives, a meso-level analysis can reveal valuable principles for informing program effectiveness and sustainability. It can also identify alignment between macro- and meso-level goals and where macro-level specifications may hinder or assist those goals.

Employers' views on the promotion of workplace health and wellbeing: a qualitative study.

BACKGROUND: The evidence surrounding the value of workplace health promotion in positively influencing employees' health and wellbeing via changes to their health behaviours is growing. The aim of the study was to explore employers' views on the promotion of workplace health and wellbeing and the factors affecting these views. METHODS: Using a qualitative phenomenological approach, 10 focus groups were conducted with employers selected from a range of industries and geographical locations within Western Australia. The total sample size was 79. RESULTS: Three factors were identified: employers' conceptualization of workplace health and wellbeing; employers' descriptions of (un)healthy workers and perceptions surrounding the importance of healthy workers; and employers' beliefs around the role the workplace should play in influencing health. CONCLUSIONS: Progress may be viable in promoting health and wellbeing if a multifaceted approach is employed taking into account the complex factors influencing employers' views. This could include an education campaign providing information about what constitutes health and wellbeing beyond the scope of occupational health and safety paradigms along with information on the benefits of workplace health and wellbeing aligned with perceptions relating to healthy and unhealthy workers.

Predictors of positive outcomes of a school food provision policy in Australia.

This study identified predictors of parents' and school principals' perceptions of the impact of a Western Australian school food policy. An initial qualitative phase involving focus groups with parents and interviews with school principals, teachers, canteen managers and Parents & Citizens Committee members provided general feedback on the policy and identified various factors that appeared to be related to its successful implementation. In the following quantitative phase of the study, 1200 parents responded to a telephone questionnaire and 310 principals responded to an internet-based questionnaire. The primary outcome variables were, respectively, the extent to which parents reported that their children's diets were healthier as a result of the policy, and the extent to which principals reported that their schools complied with the policy. Logistic regression models were generated for the parent and principal samples. Those parents reporting that their children's diets were healthier were more likely to agree that the policy reflected their beliefs and their children's dietary needs and preferences, that their child talked about the traffic light food classification system and that this system influenced their food choices in the supermarket. Those principals reporting full compliance with the policy were more likely to agree that implementing the policy was not overly difficult. Specific factors facilitating school compliance were canteen manager training and conducive kitchen setup. Provision of appropriate information and training prior to implementation may assist schools in implementing new food policies, thereby enhancing their impact beyond the school environment.

Treats: low socioeconomic status Australian parents' provision of extra foods for their overweight or obese children.

ISSUE ADDRESSED: Child obesity is a global issue, with rates highest among disadvantaged groups. Overconsumption of treats is a contributor to children's weight problems. The objective of this study was to explore low socioeconomic parents' beliefs and behaviours relating to their provision of treat foods for their overweight or obese children. METHODS: Qualitative methods were used to collect data; these included introspections, interviews and focus groups. A total of 37 parents of overweight or obese children aged between 5 and 9 years took part in the 12-month study. RESULTS: Most parents provided their children with treats on a daily basis. Factors affecting parents' provision of treats included parents' desire to control their children's behaviour, to demonstrate love and affection, and to address deprivation beliefs. CONCLUSION: There is considerable scope for improving these parents' treating behaviours by understanding the relevant factors underpinning their situations and choices. SO WHAT? The findings provide an indication of the kinds of health promotion interventions that may be needed to assist in addressing treating behaviours among disadvantaged parents with overweight or obese children.

'I know it's wrong, but...': a qualitative investigation of low-income parents' feelings of guilt about their child-feeding practices.

In the developed world, child overweight and obesity rates are highest among the disadvantaged. This has resulted in calls for more research with low socio-economic families to better understand their experiences with disadvantage and how they might lead to poorer weight outcomes. The present study, conducted in Australia, adopted a qualitative approach to investigate the factors affecting low socio-economic parents' child-feeding practices. Methods used to collect data were introspections, interviews and focus groups. In total, 37 parents of overweight or obese children aged between 5 and 9 years took part in the 6-month study. Guilt emerged as an emotion that parents regularly experienced when allowing their children to consume too much food or foods high in fat, salt and/or sugar. Parents attributed their guilt-inducing child-feeding practices to both external and internal factors. Time scarcity and cost were factors that were primarily characterized by an external locus of control. The factors characterized by an internal locus of control were fear of their children experiencing hunger, the perceived need to secure their children's affection through the provision of treat foods, perceptions of their ability to balance their children's diets across eating situations and perceived laziness. Recommendations are provided for addressing guilt-inducing child-feeding practices.

Investigating parents' food-provision behaviours via the sensitisation method.

In this article, the sensitisation method is introduced as an approach suited to investigating nutrition-related issues affecting disadvantaged families. Using a longitudinal design, sensitisation is a combination of self-introspection, memory work, observation, individual interviews, and focus groups. The method was applied to child obesity as experienced in low socioeconomic families to generate information about parents' food provision attitudes and behaviours. Data were collected in Western Australia between May 2010 and May 2011. The outcome was a large quantity of data that provided deep insight into the food-related experiences of parents of overweight children. The growing awareness produced by the sensitisation process also resulted in reported behavioural change in many of the study participants, thus indicating that the method may effectively constitute an intervention in its own right.

Developing a systems thinking guide for enhancing knowledge mobilisation in prevention research.

Knowledge mobilisation aims to increase research impact in policy and practice. 'Mobilising' knowledge implies a social interaction and involves an iterative, collaborative process. We argue that this process is strengthened when underpinned by systems thinking. Previous research has integrated systems thinking with knowledge mobilisation. We built on this to develop an applied tool to support prevention researchers seeking to incorporate systems thinking into their knowledge mobilisation work. We refer to this tool as the 'systems thinking guide for knowledge mobilisation'. Our guide was developed through a stepwise process that included: 1) An inductive thematic synthesis of previous research in this area; 2) Reflexive deliberation to identify critical focus areas, drawing on the synthesis and the authors' experiences of applying systems approaches to knowledge mobilisation; 3) Development of a set of questions designed for end users to consider against the backdrop of their own research and contexts; 4) Trialling these questions through a series of workshops; and 5) Revision based on user feedback. The proposed systems thinking guide includes 13 questions and 18 subquestions to help researchers frame their knowledge mobilisation strategies using a systems perspective. Our next steps are applying this guide to other research projects and reviewing and reporting on its implementation and real-world use. In the meantime, we invite other research teams to test this tool and contribute constructive feedback on its usefulness and potential further development.

Stakeholder support for school food policy expansions.

The aim of this study was to assess the extent to which parents and school-based stakeholders (principals, teachers, canteen managers and Parents & Citizen Committee presidents) are supportive of potential expansions to a new school food policy. Eight additional policy components elicited in preliminary focus groups with parents and 19 additional policy components elicited from interviews with school stakeholders (including the eight also elicited from parents) were presented to 1200 parents and 607 school stakeholders, respectively. Each of the 8 potential policy components presented to parents was supported by more than two-thirds of parents, and 13 of the 19 policy components presented to school stakeholders received support from around two-thirds or more of the school stakeholder respondents. For all eight common policy components, parents exhibited significantly higher levels of support than school stakeholders. This information is of value to policy makers in their deliberations relating to the appropriate nature and timing of school food policy modifications.

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.

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.

The Music Engagement Program for people with Alzheimer's disease and dementia: Pilot feasibility trial outcomes.

Alzheimer's disease and dementia are common, highly disabling conditions frequently requiring residential care. This exploratory proof-of-concept study aimed to determine if the specialised Music Engagement Program (MEP) was sustainable, acceptable, and effective in improving quality of life, emotional wellbeing, and depression symptoms in this population. Sixteen residents, six staff members, and three family and community members took part in the evaluation of the MEP for people living with dementia in a residential aged-care nursing home in Canberra, Australia. Multiple methods were used. Quantitative evaluation assessed residents' depression symptoms (Cornell scale) at pre- and post-intervention, and emotional wellbeing pre- and post-session. Qualitative interviews with staff, and family and community members addressed the MEP's acceptability and potential sustainability. Results showed residents' mean depression scores were reduced from pre- to post-intervention (p = .039; dz = 0.72). Interviews established multiple benefits for residents including improved mood, calmness, and reduced aggression. However, staff did not believe it was feasible to continue the MEP sessions beyond the trial period without an external facilitator, citing potential difficulties in adhering to internal activities due to time constraints. This pilot study provides encouraging preliminary evidence for the MEP's acceptability and potential effectiveness for improving depression and wellbeing in this group.

Factors influencing overweight children's commencement of and continuation in a resistance training program.

BACKGROUND: In light of the child overweight and obesity problem in Australia, resistance training programs have been trialled as an innovative way of assisting children increase lean body mass and reduce body fat. The purpose of this study was to investigate the factors influencing overweight children's participation in a resistance training trial program. METHOD: Parent-child pairs who participated in the trial program were invited to take part in a follow-up individual interview to discuss their program experiences. In total, 22 semi-structured interviews were conducted with 11 parent-child pairs. RESULTS: The factors found to be most relevant to program commencement among parents were a desire for their child to lose weight and gain confidence, the proximity of the venue, and no cost for participation. For children, the most relevant factors were the opportunity to build strength and improve fitness and having supportive parents who facilitated program initiation. The factors most relevant to continuation for parents were the quality of the program management, being able to stay for the sessions, the child's improved weight status, coordination, and confidence, and no cost for participation. Weight loss and improved confidence were also motivators for continuation among the children, along with pleasant social interaction with peers and trainers and ongoing parental support. CONCLUSION: Different factors variably influence program commencement and program continuation in both parents and children. This has important implications for future interventions that aim to successfully recruit and retain intervention participants.