The process of co-designing a model of social prescribing: An Australian case study.

INTRODUCTION: Social needs such as housing, employment, food, income and social isolation are having a significant impact on individuals, families and communities. Individuals are increasingly presenting to health settings with social needs, which are ill-equipped to address nonmedical needs. Social prescribing is a systematic approach connecting the health, social and community sectors to better address social needs and improve health and wellbeing. Social prescribing interventions are being implemented world-wide. With variability in health and social care systems internationally, it is important that social prescribing interventions are co-designed with key stakeholders to ensure they can be implemented and sustained within local systems. METHODS: This Australian case study provides a detailed description of the process undertaken to co-design a social prescribing service model in a regional area. Four co-design workshops were undertaken, two with health and social care professionals and two with community members. The project followed an iterative process of resourcing, planning, recruiting, sensitising, facilitation, reflection and building for change across the workshops. RESULTS: Through this process, key stakeholders were able to successfully co-design a social prescribing model of care for the region. CONCLUSION: By demonstrating the process and materials used in our project, we aim to open the 'black box' of co-design for social prescribing and provide ideas and resources for others to adapt and utilise. PATIENT OR PUBLIC CONTRIBUTION: The project was designed and undertaken by a steering committee comprising university-based researchers (authors C. O. and S. B.), local government (author D. A.) and health, social and community services (authors B. G., M. W., J. O. and S. R.). Members of the steering committee participated in project design, participant recruitment, workshop facilitation, data analysis and interpretation.

A Food Relief Charter for South Australia-Towards a Shared Vision for Pathways Out of Food Insecurity.

Chronic food insecurity persists in high-income countries, leading to an entrenched need for food relief. In Australia, food relief services primarily focus on providing food to meet immediate need. To date, there has been few examples of a vision in the sector towards client outcomes and pathways out of food insecurity. In 2016, the South Australian Government commissioned research and community sector engagement to identify potential policy actions to address food insecurity. This article describes the process of developing a co-designed South Australian Food Relief Charter, through policy-research-practice collaboration, and reflects on the role of the Charter as both a policy tool and a declaration of a shared vision. Methods used to develop the Charter, and resulting guiding principles, are discussed. This article reflects on the intentions of the Charter and suggests how its guiding principles may be used to guide collective actions for system improvement. Whilst a Charter alone may be insufficient to create an integrated food relief system that goes beyond the provision of food, it is a useful first step in enabling a culture where the sector can have a unified voice to advocate for the prevention of food insecurity.

Should Facebook advertisements promoting a physical activity smartphone app be image or video-based, and should they promote benefits of being active or the app attributes?

Social media provides a convenient platform for health campaigns. However, practitioners designing such campaigns are faced with a number of decisions regarding advertising formats and appeals. This study set out to compare the effectiveness of two advertising formats (image vs. video) and two advertising appeals (benefits of being active vs. app attributes and features) for promoting a physical-activity smartphone app. The advertising experiment was conducted on Facebook and employed a 2 × 2 full-factorial experimental design, examining two advertising formats: image versus video and two advertising appeals: benefit versus attribute. Outcome measures were advertisement cost (number of viewers reached according to the amount spent) and consumer engagement (rates of advertisement click-through and app downloads). Chi-Square analysis revealed that advertisement cost was found to differ according to the type of advertising format used, with image advertisements achieving a greater audience reach than video advertisements (χ 2(1) = 905.292, p < .001). Consumer engagement also differed according to advertising format and appeal: images achieved high rates of advertisement click-through (2.7% vs. 1.9%; χ 2(1) = 196.9, p < .001) and app downloads (0.6% vs. 0.5%; χ 2(1) = 4.0, p = .044) compared with videos. Furthermore, benefit appeal advertisements were more effective than attribute appeals, yielding a greater rate of advertisement click-through (2.8% vs. 1.8%; χ 2(1) = 282.2, p < .001) and app downloads (0.7% vs. 0.4%; χ 2(1) =106.0, p < .001). Overall, image advertisements were seen to be the most cost-effective and engaging. Advertisements employing a benefit appeal achieved greater consumer engagement than and attribute appeal advertisements.

Seasonal Differences in the Cost and Engagement of Facebook Advertisements for a Physical Activity Smartphone App.

PURPOSE: To evaluate the performance of Facebook advertisements for a physical activity smartphone app at different times of the year. DESIGN: A repeated cross-sectional study examined the cost and engagement levels of advertisements during 3 time points: Post-Easter April-May 2019, Pre-Summer October 2019, and New Year January 2020. SETTING: Advertisements were delivered on Facebook. SUBJECTS: The target population was Australian females aged 25-60 years. MEASURES: Cost was evaluated in terms of reach per dollar. Engagement was evaluated in terms of click-through and app downloads per reach. ANALYSIS: ANOVA and Chi-square were used to assess differences in reach per dollar, click-through, and app downloads per reach between time points. RESULTS: Reach per dollar was highest in Post-Easter, but declined in Pre-Summer and New Year (reach/$ 34.8 vs 31.5 vs 27.5; p = .004). Click-through was highest in New Year followed by Post-Easter, then Pre-Summer (click-through 3.2% vs 1.9% vs 1.2%; p < .001). New Year and Post-Easter advertisements achieved higher app downloads per reach than Pre-Summer (downloads 0.9% vs 0.7% vs 0.3%; p < .001). CONCLUSION: Facebook advertisements were cheaper in the first time-point, and appear to be getting more expensive (i.e. declining reach/$). Advertisements in the New Year achieved the highest click-through and app downloads per reach, suggesting a useful time of year to promote physical activity products.

Co-designing a community-wide approach to encouraging healthier food choices.

This research offers a novel perspective on encouraging healthier food choices through a community-wide approach. Using five co-design workshops with consumers and supermarket staff, and the abductive synthesis of qualitative data, this study uncovered the role of community in encouraging greater food well-being and allied behaviours. The results reveal rather critical consumer views on past paternalistic health promotion campaigns and offer alternative strategies for designing more balanced and holistic programs. Such a holistic approach can ensure more sustained programs, as they aim to achieve broader social, mental and physical health, and economic benefits, not just nutrition outcomes. The research offers practical recommendations on modifying retail marketing space, and the broader community setting, to create an environment where consumers find it easier, convenient, more socially desirable and pleasurable to make healthier choices.

Evaluating the effectiveness of a physical activity social media advertising campaign using Facebook, Facebook Messenger, and Instagram.

Technology-based physical activity programs are a novel solution to the major public health issue of physical inactivity. However, to be successful, there must be a large and population-appropriate uptake, which depends heavily on promotion. This study evaluates the effectiveness of an advertising campaign to disseminate a physical activity smartphone app. The experiment used a 3 × 3 × 3 full-factorial design, examining platforms (Facebook; Facebook Messenger; Instagram), selling-techniques (hard-sell-sending viewers directly to (a) Apple Store or (b) Google Play, and soft-sell-sending viewers from an ad to a (c) landing-page, then to an app store) and themes (Health and Wellbeing; Body and Self-Confidence; Social Enjoyment). Outcomes were reach, click-through, and app downloads. Advertisements reached 1,373,273 people, achieving 2,989 clicks and 667 downloads. Instagram and Facebook Messenger had higher reach compared to Facebook (F[2,27] = 27.17, p < .001), whilst Facebook and Facebook Messenger both produced higher click-through (F[2,27] = 8.98, p < .001) and downloads (F[2,27] = 4.649, p = .018). Selling-technique differed, with soft-selling ads producing greater reach (F[2,27] = 4,616.077, p < .001); however, both hard-selling ads (Apple Store and Google Play) had greater click-through (F[2,27] = 10.77, p < .001) and downloads (F[2,27] = 3.791, p < .001). Advertising theme varied, with Social Enjoyment themes producing less click-through (F[2,27] = 5.709, p = .009) and downloads (F[2,27] = 5.480, p = .010). We recommend future studies to consider Facebook and Facebook Messenger, using hard-selling techniques, with themes relating to Health and Wellbeing and Body and Self-Confidence.

Cost effectiveness and cost-utility analysis of a group-based diet intervention for treating major depression - the HELFIMED trial.

Background/objectives: Major depression has a negative impact on quality of life, increasing the risk of premature death. It imposes social and economic costs on individuals, families and society. Mental illness is now the leading cause globally of disability/lost quality life and premature mortality. Finding cost-effective treatments for depression is a public health priority. We report an economic evaluation of a dietary intervention for treating major depression. Methods: This economic evaluation drew on the HELFIMED RCT, a 3-month group-based Mediterranean-style diet (MedDiet) intervention (including cooking workshops), against a social group-program for people with major depression. We conducted (i) a cost-utility analysis, utility scores measured at baseline, 3-months and 6-months using the AQoL8D, modelled to 2 years (base case); (ii) a cost-effectiveness analysis, differential cost/case of depression resolved (to normal/mild) measured by the DASS. Differential program costs were calculated from resources use costed in AUD2017. QALYs were discounted at 3.5%pa. Results: Best estimate differential cost/QALY gain per person, MedDiet relative to social group was AUD2775. Probabilistic sensitivity analysis, varying costs, utility gain, model period found 95% likelihood cost/QALY less than AUD20,000. Estimated cost per additional case of depression resolved, MedDiet group relative to social group was AUD2,225. Conclusions: A MedDiet group-program for treating major depression was highly cost-effective relative to a social group-program, measured in terms of cost/QALY gain and cost per case of major depression resolved. Supporting access by persons with major depression to group-based dietary programs should be a policy priority. A change to funding will be needed to realise the potential benefits.

Analysing how physical activity competes: a cross-disciplinary application of the Duplication of Behaviour Law.

BACKGROUND: Despite the ongoing promotion of physical activity, the rates of physical inactivity remain high. Drawing on established methods of analysing consumer behaviour, this study seeks to understand how physical activity competes for finite time in a day - how Exercise and Sport compete with other everyday behaviours, and how engagement in physical activity is shared across Exercise and Sport activities. As targeted efforts are common in physical activity intervention and promotion, the existence of segmentation is also explored. METHODS: Time-use recall data (n = 2307 adults) is analysed using the Duplication of Behaviour Law, and tested against expected values, to document what proportion of the population that engage in one activity, also engage in another competing activity. Additionally, a Mean Absolute Deviation approach is used to test for segmentation. RESULTS: The Duplication of Behaviour Law is evident for everyday activities, and Exercise and Sport activities - all activities 'compete' with each other, and the prevalence of the competing activity determines the extent of competition. However, some activities compete more or less than expected, suggesting the combinations of activities that should be used or avoided in promotion efforts. Competition between everyday activities is predictable, and there are no specific activities that are sacrificed to engage in Exercise and Sport. How people share their physical activity across different Exercise and Sport activities is less predictable - Males and younger people (under 20 years) are more likely to engage in Exercise and Sport, and those who engage in Exercise and Sport are slightly more likely to Work and Study. High competition between Team Sports and Non-Team Sports suggests strong preferences for sports of different varieties. Finally, gender and age-based segmentation does not exist for Exercise and Sport relative to other everyday activities; however, segmentation does exist for Team Sports, Games, Active Play and Dance. CONCLUSIONS: The Duplication of Behaviour Law demonstrates that population-level patterns of behaviour can yield insight into the competition between different activities, and how engagement in physical activity is shared across different Exercise and Sport activities. Such insights can be used to describe and predict physical activity behaviour and may be used to inform and evaluate promotion and intervention.

Characteristics of Adopters of an Online Social Networking Physical Activity Mobile Phone App: Cluster Analysis.

BACKGROUND: To date, many online health behavior programs developed by researchers have not been translated at scale. To inform translational efforts, health researchers must work with marketing experts to design cost-effective marketing campaigns. It is important to understand the characteristics of end users of a given health promotion program and identify key market segments. OBJECTIVE: This study aimed to describe the characteristics of the adopters of Active Team, a gamified online social networking physical activity app, and identify potential market segments to inform future research translation efforts. METHODS: Participants (N=545) were Australian adults aged 18 to 65 years who responded to general advertisements to join a randomized controlled trial (RCT) evaluating the Active Team app. At baseline they provided demographic (age, sex, education, marital status, body mass index, location of residence, and country of birth), behavioral (sleep, assessed by the Pittsburgh Quality Sleep Index) and physical activity (assessed by the Active Australia Survey), psychographic information (health and well-being, assessed by the PERMA [Positive Emotion, Engagement, Relationships, Meaning, Achievement] Profile; depression, anxiety and stress, assessed by the Depression, Anxiety, and Stress Scale [DASS-21]; and quality of life, assessed by the 12-Item Short Form Health Survey [SF-12]). Descriptive analyses and a k-medoids cluster analysis were performed using the software R 3.3.0 (The R Foundation) to identify key characteristics of the sample. RESULTS: Cluster analyses revealed four clusters: (1) younger inactive women with poor well-being (218/545), characterized by a higher score on the DASS-21, low mental component summary score on the SF-12, and relatively young age; (2) older, active women (153/545), characterized by a lower score on DASS-21, a higher overall score on the SF-12, and relatively older age; (3) young, active but stressed men (58/545) with a higher score on DASS-21 and higher activity levels; and (4) older, low active and obese men (30/545), characterized by a high body mass index and lower activity levels. CONCLUSIONS: Understanding the characteristics of population segments attracted to a health promotion program will guide the development of cost-effective research translation campaigns. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12617000113358; https://www.anzctr.org .au/Trial/Registration/TrialReview.aspx?id=371463. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-017-4882-7.

A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and mental health in people with depression: A randomized controlled trial (HELFIMED).

OBJECTIVES: We investigated whether a Mediterranean-style diet (MedDiet) supplemented with fish oil can improve mental health in adults suffering depression. METHODS: Adults with self-reported depression were randomized to receive fortnightly food hampers and MedDiet cooking workshops for 3 months and fish oil supplements for 6 months, or attend social groups fortnightly for 3 months. Assessments at baseline, 3 and 6 months included mental health, quality of life (QoL) and dietary questionnaires, and blood samples for erythrocyte fatty acid analysis. RESULTS: n = 152 eligible adults aged 18-65 were recruited (n = 95 completed 3-month and n = 85 completed 6-month assessments). At 3 months, the MedDiet group had a higher MedDiet score (t = 3.95, P < 0.01), consumed more vegetables (t = 3.95, P < 0.01), fruit (t = 2.10, P = 0.04), nuts (t = 2.29, P = 0.02), legumes (t = 2.41, P = 0.02) wholegrains (t = 2.63, P = 0.01), and vegetable diversity (t = 3.27, P < 0.01); less unhealthy snacks (t = -2.10, P = 0.04) and red meat/chicken (t = -2.13, P = 0.04). The MedDiet group had greater reduction in depression (t = -2.24, P = 0.03) and improved mental health QoL scores (t = 2.10, P = 0.04) at 3 months. Improved diet and mental health were sustained at 6 months. Reduced depression was correlated with an increased MedDiet score (r = -0.298, P = 0.01), nuts (r = -0.264, P = 0.01), and vegetable diversity (r = -0.303, P = 0.01). Other mental health improvements had similar correlations, most notably for increased vegetable diversity and legumes. There were some correlations between increased omega-3, decreased omega-6 and improved mental health. DISCUSSION: This is one of the first randomized controlled trials to show that healthy dietary changes are achievable and, supplemented with fish oil, can improve mental health in people with depression.

Creating Engaging Health Promotion Campaigns on Social Media: Observations and Lessons From Fitbit and Garmin.

BACKGROUND: The popularity and reach of social media make it an ideal delivery platform for interventions targeting health behaviors, such as physical inactivity. Research has identified a dose-response relationship whereby greater engagement and exposure are positively associated with intervention effects, hence enhancing engagement will maximize the potential of these interventions. OBJECTIVE: This study examined the social media activity of successful commercial activity tracker brands to understand which creative elements (message content and design) they use in their communication to their audience, which social media platforms attract the most engagement, and which creative elements prompted the most engagement. METHODS: Posts (n=509) made by Fitbit and Garmin on Facebook, Twitter, and Instagram over a 3-month period were coded for the presence of creative elements. User engagement regarding the total number of likes, comments, or shares per post was recorded. Negative binomial regression analyses were used to identify creative elements associated with higher engagement. RESULTS: Engagement on Instagram was 30-200 times higher than on Facebook, or Twitter. Fitbit and Garmin tended to use different creative elements from one another. A higher engagement was achieved by posts featuring an image of the product, highlighting new product features and with themes of self-improvement (P<.01). CONCLUSIONS: Findings suggest that Instagram may be a particularly promising platform for delivering engaging health messaging. Health messages which incorporate inspirational imagery and focus on a tangible product appear to achieve the highest engagement. Fitbit and Garmin employed difference creative elements, which is likely to reflect differences in their target markets. This underscores the importance of market segmentation in health messaging campaigns.

Dietary intervention for people with mental illness in South Australia.

BACKGROUND: People with serious mental illness (SMI) have a 25-30 year lower life expectancy than the general population due largely to cardiovascular disease (CVD). Mediterranean diet can reduce CVD risk and repeat events by 30-70%. We conducted a pilot feasibility study (HELFIMED) with people who have SMI residing within a Community Rehabilitation Centre in South Australia, aimed at improving participants' diets according to Mediterranean diet principles. METHODS: During a 3-month intervention, participants were provided with nutrition education, food hampers, and twice-weekly cooking workshops and guided shopping trips. This report presents the results of a mixed method evaluation of the programme using thorough in-depth interviews with participants and support staff (n = 20), contextualized by changes in dietary biomarkers and CVD risk factors. RESULTS: The framework thematic analysis revealed evidence of improvements in participants' knowledge of and intake of the key elements of a Mediterranean-style diet (fruit and vegetables, olive oil, fish, legumes), reduction in poor nutrition habits (soft drinks, energy drinks, take away meals) and development of independent living skills-culinary skills such as food preparation and cooking based on simple recipes, food shopping and budgeting, healthy meal planning and social interaction. These changes were supported by dietary biomarkers, and were associated with reduced CVD risk factors. CONCLUSIONS: A Mediterranean diet-based pilot study achieved positive change in dietary behaviours associated with CVD risk for participants with SMI. This supports a need to include dietary education and cooking skills into rehabilitation programmes for people with SMI.

People with schizophrenia and depression have a low omega-3 index.

Cardiovascular disease (CVD) is higher in people with mental illness and is associated with a 30 year higher mortality rate in this population. Erythrocyte docosahexaenoic acid (DHA) plus eicosapentaenoic acid (EPA) (omega-3 index)≤4% is a marker for increased mortality risk from CVD while >8% is protective. Omega-3 polyunsaturated fatty acids are also important for brain function and may ameliorate symptoms of mental illness. We investigated the erythrocyte omega-3 index in people with mental illness. One hundred and thirty adults aged 18-65 years (32.6% male) with schizophrenia (n=14) and depression (n=116) provided blood samples and completed physiological assessments and questionnaires. Both populations had risk factors for metabolic syndrome and CVD. The average omega-3 index was 3.95% (SD=1.06), compared to an estimated 5% in the Australian population. These data indicate an unfavourable omega-3 profile in people with mental illness that could contribute to higher CVD risk.

Understanding the factors that influence patient satisfaction with ambulance services.

The quality of ambulance services has an immense impact on patients' future well-being and quality of life. Patient satisfaction is one of the key metrics for evaluating the quality of this service. Yet, the patient satisfaction measurement may be limited in its ability to accurately reflect this service quality, and even reflect factors beyond the patient experiences. We analyze 10 years of survey data to reveal a number of factors that systematically bias ambulance satisfaction ratings. Taking into account these biases provides more robust comparison of ambulance performance over time or across different jurisdictions.

Lack of efficacy of a salience nudge for substituting selection of lower-calorie for higher-calorie milk in the work place.

Obesity is a major burden on healthcare systems. Simple, cost effective interventions that encourage healthier behaviours are required. The present study evaluated the efficacy of a salience nudge for promoting a change in milk selection from full-cream to low-fat (lower calorie) in the kitchen of a university-based research institute that provided full-cream and low-fat milk free of charge. Milk selection was recorded for 12 weeks (baseline). A sign with the message "Pick me! I am low calorie" was then placed on the low-fat milk and consumption was recorded for a further 12 weeks. During baseline, selection of low-fat milk was greater than selection of full-cream milk (p = 0.001) with no significant milk-type × time interaction (p = 0.12). During the intervention period overall milk selection was not different from baseline (p = 0.22), with low-fat milk consumption remaining greater than full-cream milk selection (p < 0.001) and no significant milk-type × time interaction (p = 0.41). However, sub-analysis of the first two weeks of the intervention period indicated an increase in selection of both milk types (p = 0.03), but with a greater increase in low-fat milk selection (p = 0.01, milk-type × time interaction). However, milk selection then returned towards baseline during the rest of the intervention period. Thus, in the present setting, salience nudging promoted a transient increase in low-fat milk consumption, but also increased selection of full-cream milk, indicating that nudging was not effective in promoting healthier milk choices.