A systems framework for implementing healthy food retail in grocery settings.

BACKGROUND: Food retailers can be reluctant to initiate healthy food retail activities in the face of a complex set of interrelated drivers that impact the retail environment. The Systems Thinking Approach for Retail Transformation (START) is a determinants framework created using qualitative systems modelling to guide healthy food retail interventions in community-based, health-promoting settings. We aimed to test the applicability of the START map to a suite of distinct healthy food marketing and promotion activities that formed an intervention in a grocery setting in regional Victoria, Australia. METHODS: A secondary analysis was undertaken of 16 previously completed semi-structured interviews with independent grocery retailers and stakeholders. Interviews were deductively coded against the existing START framework, whilst allowing for new grocery-setting specific factors to be identified. New factors and relationships were used to build causal loop diagrams and extend the original START systems map using Vensim. RESULTS: A version of the START map including aspects relevant to the grocery setting was developed ("START-G"). In both health-promoting and grocery settings, it was important for retailers to 'Get Started' with healthy food retail interventions that were supported by a proof-of-concept and 'Focus on the customer' response (with grocery-settings focused on monitoring sales data). New factors and relationships described perceived difficulties associated with disrupting a grocery-setting 'Supply-side status quo' that promotes less healthy food and beverage options. Yet, most grocery retailers discussed relationships that highlighted the potential for 'Healthy food as innovation' and 'Supporting cultural change through corporate social responsibility and leadership'. CONCLUSIONS: Several differences were found when implementing healthy food retail in grocery compared to health promotion settings. The START-G map offers preliminary guidance for identifying and addressing commercial interests in grocery settings that currently promote less healthy foods and beverages, including by starting to address business outcomes and supplier relationships.

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.

Healthy weight, health behaviours and quality of life among Aboriginal children living in regional Victoria.

OBJECTIVE: To report the prevalence of healthy weight and related behaviours among Victorian Aboriginal and non-Aboriginal children and explore associations between these factors and health-related quality of life (HRQoL). METHODS: Analysis of cross-sectional data from two cluster randomised controlled trials using logistic and linear mixed models. The sample included Aboriginal (n=303) and non-Aboriginal (n=3,026) children aged 8-13 years. RESULTS: More than two-thirds of Aboriginal children met guidelines for fruit (75.9%), sweetened drinks (66.7%), sleep (73.1%), screen time (67.7%) and objectively measured physical activity (83.6%); and 79.1% reported consuming take-away foods less than once per week. Aboriginal children were more likely to meet vegetable consumption guidelines (OR=1.42, 95%CI: 1.05, 1.93), but less likely to have a healthy weight (OR=0.66, 95%CI: 0.52, 0.85) than non-Aboriginal children. Mean HRQoL scores were significantly higher among non-Aboriginal children and both Aboriginal and non-Aboriginal children meeting health guidelines. CONCLUSIONS: Most Aboriginal children in this study met guidelines for fruit, physical activity, screen time and sleep, and those meeting these guidelines had significantly higher HRQoL. IMPLICATIONS FOR PUBLIC HEALTH: Promoting nutrition, physical activity and sleep is likely to benefit all children. Aboriginal community-controlled organisations can use these data to design culturally-specific programs that may improve disparities in healthy weight and HRQoL.

Co-creation, co-design, co-production for public health - a perspective on definition and distinctions.

Collaboration between community members, researchers, and policy makers drives efforts to solve complex health problems such as obesity, alcohol misuse, and type 2 diabetes. Community participation is essential to ensure the optimal design, implementation and evaluation of resulting initiatives. The terms 'co-creation', 'co-design' and 'co-production' have been used interchangeably to describe the development of initiatives involving multiple stakeholders. While commonalities exist across these concepts, they have essential distinctions for public health, particularly related to the role of stakeholders and the extent and timing of their engagement. We summarise these similarities and differences drawing from the cross-disciplinary literature, including public administration and governance, service management, design, marketing and public health. Co-creation is an overarching guiding principle encompassing co-design and co-production. A clear definition of these terms clarifies aspects of participatory action research for community-based public health initiatives.

Tracking implementation within a community-led whole of system approach to address childhood overweight and obesity in south west Sydney, Australia.

BACKGROUND: Obesity is a chronic disease that contributes to additional comorbidities including diabetes, kidney disease and several cancers. Change4Campbelltown implemented a 'whole of system' approach to address childhood overweight and obesity. We present methods to track implementation and stakeholder engagement in Change4Campbelltown. METHODS: Change4Campbelltown aimed to build capacity among key leaders and the broader community to apply techniques from systems thinking to develop community-led actions that address childhood obesity. Change4Campbelltown comprised development of a stakeholder-informed Causal Loop Diagram (CLD) and locally-tailored action plan, formation of key stakeholder and community working groups to prioritise and implement actions, and continuous monitoring of intervention actions. Implementation data included an action register, stakeholder engagement database and key engagement activities and were collected quarterly by the project management team over 2 years of reporting. RESULTS: Engagement activities increased level of community engagement amongst key leaders, the school-sector and community members. Community-led action increased as engagement increased and this action is mapped directly to the primary point of influence on the CLD. As action spread diversified across the CLD, the geographical spread of action within the community increased. CONCLUSIONS: This paper provides a pragmatic example of the methods used to track implementation of complex interventions that are addressing childhood overweight and obesity.

Understanding the healthfulness of outlets providing lunch and dinner meals: a census of a rural food retail environment in Victoria, Australia.

OBJECTIVE: To undertake a census of the healthfulness of food venues providing lunch or dinner meals in a rural Australian setting and compare healthfulness by remoteness, using two measurement tools. METHODS: A census of the rural local government area food venues was undertaken using two validated tools: the Healthfulness Rating Classification System (HRCS) and the Nutrition Environment Measures Survey (NEMS-R). Data were collected covering an area of 3,438 square kilometres in Victoria, Australia, with a population of >21,000. Healthfulness by remoteness was described and variability between tools was explored. RESULTS: Data were collected from all 95 eligible food venues. Both tools classified the food venues as relatively unhealthy. The mean HRCS score was -2.9 (unhealthy) and the mean NEMS-R score was 10.8 (SD 7.0; possible range -27 to 64). There were no significant differences in healthiness of venues by remoteness (as measured by the Modified Monash Model), although the outer-rural region had lower scores. CONCLUSIONS: This census of a rural food retail environment showed low access to healthy menu options along with minimal provision of nutrition information and promotion of healthy food in food venues. This environment has the potential to affect the dietary intake of more than 21,000 rural-dwelling Australians and action to improve rural food environments is desperately needed. Implications for public health: If unhealthful rural food environments are not addressed, inequalities in the diet-related disease burden for rural Australians will continue to persist. This study shows that interventions are needed for independent venues that could be targeted by researchers, local health promotion officers, community nutritionists or community education programs.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia.

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. STUDY DESIGN: Rapid review of articles published between January 2000 and May 2020. DATA SOURCES: We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries. DATA SYNTHESIS: Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding. CONCLUSION: Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries. STUDY DESIGN: We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references. DATA SOURCES: We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence. DATA SYNTHESIS: Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle. CONCLUSION: There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia. STUDY DESIGN: Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews. DATA SOURCES: We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria. DATA SYNTHESIS: Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma. CONCLUSION: We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities. STUDY DESIGN: Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km2 . DATA SOURCES: We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway. DATA SYNTHESIS: We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3). CONCLUSION: Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce. STUDY DESIGN: We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool. DATA SOURCES: We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites. DATA SYNTHESIS: During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool. CONCLUSION: We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings. STUDY DESIGN: Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards. DATA SOURCES: English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing,deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar. DATA SYNTHESIS: Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation. CONCLUSION: Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

You Can't Find Healthy Food in the Bush: Poor Accessibility, Availability and Adequacy of Food in Rural Australia.

In high-income countries, obesity disproportionately affects those from disadvantaged and rural areas. Poor diet is a modifiable risk factor for obesity and the food environment a primary driver of poor diet. In rural and disadvantaged communities, it is harder to access affordable and nutritious food, affecting both food insecurity and the health of rural residents. This paper aims to describe the food environment in a rural Australian community (approx. 7000 km² in size) to inform the development of community-relevant food supply interventions. We conducted a census audit of the food environment (ground truthing) of a local government area (LGA). We used the Nutrition Environment Measurement tools (NEMS-S and NEMS-R) to identify availability of a range of food and non-alcoholic beverages, the relative price of a healthy compared to a less healthy option of a similar food type (e.g., bread), the quality of fresh produce and any in-store nutrition promotion. Thirty-eight food retail outlets operated at the time of our study and all were included, 11 food stores (NEMS-S) and 27 food service outlets (NEMS-R). The mean NEMS-S score for all food stores was 21/54 points (39%) and mean NEMS-R score for all food service outlets was 3/23 points (13%); indicative of limited healthier options at relatively higher prices. It is difficult to buy healthy food beyond the supermarkets and one (of seven) cafés across the LGA. Residents demonstrate strong loyalty to local food outlets, providing scope to work with this existing infrastructure to positively impact poor diet and improve food security.

Gratitude, resignation and the desire for dignity: lived experience of food charity recipients and their recommendations for improvement, Perth, Western Australia.

OBJECTIVE: The present study explored recipients' perceptions of food charity and their suggested improvements in inner-city Perth, Western Australia. DESIGN: In-depth interviews were conducted with charitable food service (CFS) recipients. Transcripts were thematically analysed using a phenomenological approach. SETTING: Interviews were conducted at two CFS in inner-city Perth. SUBJECTS: Fourteen adults. RESULTS: The recipients' journeys to a reliance on CFS were varied and multifactorial, with poverty, medical issues and homelessness common. The length of time recipients had relied on food charity ranged from 8 months to over 40 years. Most were 'grateful yet resigned', appreciative of any food and resigned to the poor quality, monotony and their unmet individual preferences. They wanted healthier food, more variety and better quality. Accessing services was described as a 'full-time job' fraught with unreliable information and transport difficulties. They called for improved information and assistance with transport. 'Eroded dignity' resulted from being fed without any choice and queuing for food in public places, often in a volatile environment. 'Food memories and inclusion' reflected a desire for commensality. Recipients suggested services offer choice and promote independence, focusing on their needs both physical and social. CONCLUSIONS: Although grateful, long-term CFS recipients described what constitutes a voluntary failure. Their service improvement recommendations can help meet their nutritional and social needs. A successful CFS provides a food service that prioritises nutritious, good-quality food and individual need, while promoting dignity and social inclusion, challenging in the current Australian context.

Parental Translation into Practice of Healthy Eating and Active Play Messages and the Impact on Childhood Obesity: A Mixed Methods Study.

Childhood obesity is a significant health issue worldwide. Modifiable risk factors in early childhood relate to child healthy eating and active play, and are influenced by parents. The aim of the study was two-fold. Firstly, to determine the weight status of children aged between birth and 3.5 years in a rural and remote area of Australia. Secondly, to explore the relationship between child weight status and translation of advice on healthy eating and active play provided to parents by local, nurse-led, Maternal Child Health (MCH) services. Measured anthropometric data (n = 438) were provided by MCH services. Semi-structured interviews were conducted with two MCH nurses and 15 parents. Prevalence of overweight/obesity was calculated. Local childhood overweight/obesity prevalence was lower than the national average at age 3.5 years (11.38%; 20%). Parents identified the MCH service as a key source of healthy eating and active play advice and reported mostly following recommendations but struggling with screen time and fussy eating recommendations. We observed a relaxation in parent attitudes towards healthy child behaviours which coincided with a trend towards obesity from 12 months (p < 0.001). MCH services provide useful and effective advice to parents but ongoing support is required to prevent obesity later in childhood.

Safety and utility of magnetic resonance imaging in patients with cardiac implantable electronic devices.

BACKGROUND: Off-label magnetic resonance imaging (MRI) for patients with cardiac implantable electrical devices has been limited owing to concerns about safety and unclear diagnostic and prognostic utility. OBJECTIVE: The purpose of this study was to define major and minor adverse events with off-label MRI scans. METHODS: We prospectively evaluated patients with non-MRI-conditional cardiac implantable electrical devices referred for MRI scans under a strict clinical protocol. The primary safety outcome was incidence of major adverse events (loss of pacing, inappropriate shock or antitachycardia pacing, need for system revision, or death) or minor adverse events (inappropriate pacing, arrhythmias, power-on-reset events, heating at the generator site, or changes in device parameters at baseline or at 6 months). RESULTS: A total of 189 MRI scans were performed in 123 patients (63.1% [78] men; median age 70 ± 18.5 years; 56.9% [70] patients with implantable cardioverter-defibrillators; 33.3% [41] pacemaker-dependent patients) predominantly for brain or spinal conditions. A minority of scans (22.7% [43]) were performed for urgent or emergent indications. Major adverse events were rare: 1 patient with loss of pacing, no deaths, or system revisions (overall rate 0.5%; 95% confidence interval 0.01-2.91). Minor adverse events were similarly rare (overall rate 1.6%; 95% confidence interval 0.3-4.6). Nearly all studies (98.4% [186]) were interpretable, while 75.1% [142] were determined to change management according to the prespecified criteria. No clinically significant changes were observed in device parameters acutely after MRI or at 6 months as compared with baseline across all patient and device categories. CONCLUSION: Off-label MRI scans performed under a strict protocol demonstrated excellent short- and medium-term safety while providing interpretable imaging that frequently influenced clinical care.

Sleep duration and risk of obesity among a sample of Victorian school children.

BACKGROUND: Insufficient sleep is potentially an important modifiable risk factor for obesity and poor physical activity and sedentary behaviours among children. However, inconsistencies across studies highlight the need for more objective measures. This paper examines the relationship between sleep duration and objectively measured physical activity, sedentary time and weight status, among a sample of Victorian Primary School children. METHODS: A sub-sample of 298 grades four (n = 157) and six (n = 132) Victorian primary school children (aged 9.2-13.2 years) with complete accelerometry and anthropometry data, from 39 schools, were taken from a pilot study of a larger state based cluster randomized control trial in 2013. Data comprised: researcher measured height and weight; accelerometry derived physical activity and sedentary time; and self-reported sleep duration and hypothesised confounding factors (e.g. age, gender and environmental factors). RESULTS: Compared with sufficient sleepers (67 %), those with insufficient sleep (<10 hrs/day) were significantly more likely to be overweight (OR 1.97, 95 % CI:1.11-3.48) or obese (OR 2.43, 95 % CI:1.26-4.71). No association between sleep and objectively measured physical activity levels or sedentary time was found. CONCLUSION: The strong positive relationship between weight status and sleep deprivation merits further research though PA and sedentary time do not seem to be involved in the relationship. Strategies to improve sleep duration may help obesity prevention initiatives in the future.

A snapshot of the scope of obesity prevention practice in Australia.

Community-based initiatives (CBIs) that build capacity and promote healthy environments hold promise for preventing obesity and non-communicable disease, however their characteristics remain poorly understood and lessons are learned in isolation. This limits understanding of likely effectiveness of CBIs; the potential for actively supporting practice; and the translation of community-based knowledge into policy. Building on an initial survey (2010), an online survey was launched (2013) with the aim to describe the reach and characteristics of Australian CBIs and identify and evaluate elements known to contribute to best practice, effectiveness and sustainability. Responses from 104 CBIs were received in 2013. Geographic location generally reflected population density in Australia. Duration of CBIs was short-term (median 3 years; range 0.2-21.0 years), delivered mostly by health departments and local governments. Median annual funding had more than doubled since the 2010 survey, but average staffing had not increased. CBIs used at least two strategy types, with a preference for individual behaviour change strategies. Targeting children was less common (31%) compared with the 2010 survey (57%). Logic models and theory were used in planning, but there was low use of research evidence and existing prevention frameworks. Nearly, all CBIs had an evaluation component (12% of budget), but dissemination was limited. This survey provides information on the scope and varied quality of the current obesity prevention investment in Australia. To boost the quality and effectiveness of CBIs, further support systems may be required to ensure that organizations adopt upstream, evidence-informed approaches; and integrate CBIs into systems, policies and environments.

A Community Based Systems Diagram of Obesity Causes.

INTRODUCTION: Application of system thinking to the development, implementation and evaluation of childhood obesity prevention efforts represents the cutting edge of community-based prevention. We report on an approach to developing a system oriented community perspective on the causes of obesity. METHODS: Group model building sessions were conducted in a rural Australian community to address increasing childhood obesity. Stakeholders (n = 12) built a community model that progressed from connection circles to causal loop diagrams using scripts from the system dynamics literature. Participants began this work in identifying change over time in causes and effects of childhood obesity within their community. The initial causal loop diagram was then reviewed and elaborated by 50 community leaders over a full day session. RESULTS: The process created a causal loop diagram representing community perceptions of determinants and causes of obesity. The causal loop diagram can be broken down into four separate domains; social influences; fast food and junk food; participation in sport; and general physical activity. DISCUSSION: This causal loop diagram can provide the basis for community led planning of a prevention response that engages with multiple levels of existing settings and systems.