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

BACKGROUND: World-wide, health service providers are moving towards innovative models of clinical home-based care services as a key strategy to improve equity of access and quality of care. To optimise existing and new clinical home-based care programs, evidence informed approaches are needed that consider the complexity of the health care system across different contexts. METHODS: We present a protocol for working with health services and their partners to perform rapid identification, prioritisation, and co-design of content-appropriate strategies to optimise the delivery of healthcare at home for older people in rural and regional areas. The protocol combines Systems Thinking and Implementation Science using a Consensus Mapping and Co-design (CMC) process delivered over five workshops. DISCUSSION: The protocol will be implemented with rural and regional healthcare providers to identify digital and non-digital solutions that have the potential to inform models of service delivery, improve patient experience, and optimise health outcomes. The combination of system and implementation science is a unique approach for optimising healthcare at home for older populations, especially in the rural context where need is high. This is the first protocol to integrate the use of systems and implementation science into one process and articulating these methods will help with replicating this in future practice. Results of the design phase will translate into practice through standard health service planning methods to enhance implementation and sustainability. The delivery of the protocol will include building capacity of health service workers to embed the design, implementation, and evaluation approach into normal practice. This protocol forms part of the DELIVER (Delivering Enhanced heaLthcare at home through optImising Virtual tools for oldEr people in Rural and regional Australia) Project. Funded by Australia's Medical Research Future Fund, DELIVER involves a collaboration with public health services of Western Victoria, Australia.

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

OBJECTIVE: Government policy guidance in Victoria, Australia, encourages schools to provide affordable, healthy foods in canteens. This study analysed the healthiness and price of items available in canteens in Victorian primary schools and associations with school characteristics. DESIGN: Dietitians classified menu items (main, snack and beverage) using the red, amber and green traffic light system defined in the Victorian government's School Canteens and Other School Food Services Policy. This system also included a black category for confectionary and high sugar content soft drinks which should not be supplied. Descriptive statistics and regressions were used to analyse differences in the healthiness and price of main meals, snacks and beverages offered, according to school remoteness, sector (government and Catholic/independent) size, and socio-economic position. SETTING: State of Victoria, Australia. PARTICIPANTS: A convenience sample of canteen menus drawn from three previous obesity prevention studies in forty-eight primary schools between 2016 and 2019. RESULTS: On average, school canteen menus were 21 % 'green' (most healthy - everyday), 53 % 'amber' (select carefully), 25 % 'red' (occasional) and 2 % 'black' (banned) items, demonstrating low adherence with government guidelines. 'Black' items were more common in schools in regional population centres. 'Red' main meal items were cheaper than 'green'% (mean difference -$0·48 (95 % CI -0·85, -0·10)) and 'amber' -$0·91 (-1·27, -0·57)) main meal items. In about 50 % of schools, the mean price of 'red' main meal, beverages and snack items were cheaper than 'green' items, or no 'green' alternative items were offered. CONCLUSION: In this sample of Victorian canteen menus, there was no evidence of associations of healthiness and pricing by school characteristics except for regional centres having the highest proportion of 'black' (banned) items compared with all other remoteness categories examined. There was low adherence with state canteen menu guidelines. Many schools offered a high proportion of 'red' food options and 'black' (banned) options, particularly in regional centres. Unhealthier options were cheaper than healthy options. More needs to be done to bring Victorian primary school canteen menus in line with guidelines.

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

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

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

BACKGROUND: Calls for the adoption of a systems approach to chronic disease prevention date back at least ten years because of the potential to empower communities to identify and address the complex causes of overnutrition, undernutrition and climate change. Australia, like many countries, has high levels of obesity and extreme climate events. The Reflexive Evidence and Systems interventions to Prevent Obesity and Non-communicable Disease (RESPOND) trial aims to prevent unhealthy weight gain in children in 10 intervention and two pilot communities in north-east Victoria, Australia using community-based participatory approaches informed by systems science. Intervention activities co-designed in 2019 were disrupted by COVID-19 and bushfires. This paper explores the impacts of these 'shocks' on the local prevention workforce to implement actions within communities. METHODS: A case study design involving one-hour online focus groups and an on-line survey (November 2021-February 2022). Purposive sampling was used to achieve diverse representation from RESPOND stakeholders including local council, health services, primary care partnerships and department of health. The focus group interview schedule and survey questions were based on Durlak and DuPre's implementation factors. RESULTS: Twenty-nine participants from seven different communities participated in at least one of nine focus groups to discuss the impacts of COVID-19 and bushfires on localised implementation. Twenty-eight participants (97% of focus group sample) also completed the on-line survey. Implementation of RESPOND stalled or stopped in most communities due to bushfires and/or COVID-19. These shocks resulted in organisational priorities changing, loss of momentum for implementation, redeployment of human resources, culminating in fatigue and exhaustion. Participants reported adaptation of RESPOND, but implementation was slowed due to limited resources. CONCLUSION: Further research is needed to advance risk management strategies and protect resources within health promotion. System shocks such as bushfires and COVID-19 are inevitable, and despite multiple adaptation opportunities, this intervention approach was not 'shock proof'.

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

We aimed to explore experiences of government-led actions on the social determinants of food insecurity during Australia's COVID-19 pandemic response (which included novel, yet temporary, social protection measures to support Australians facing hardship during state-wide lockdowns). During November-December 2020, we conducted in-depth interviews with 24 Victorians who received government income support (prior to COVID-19) and the temporary COVID-19 specific payments. Interviews were guided by a theoretical understanding of the social determinants of health and health inequities, which we aligned to the social policy context. Data were audio-recorded, transcribed, inductively coded, categorised and thematically analysed. Our sample included mostly women (n = 19) and single parents (n = 13). Interviews reflected four key themes. Firstly, participants described 'battles all around them' (i.e., competing financial, health and social stressors) that were not alleviated by temporary social policy changes and made healthy eating difficult to prioritise during the pandemic. Secondly, housing, income, job, and education priorities rendered food a lower and more flexible financial priority - even with 18 participants receiving temporary income increases from COVID-19 Supplements. Thirdly, given that food remained a lower and more flexible financial priority, families continued to purchase the cheapest and most affordable options (typically less healthful, more markedly price discounted). Finally, participants perceived the dominant public and policy rhetoric around income support policies and healthy eating to be inaccurate and shaming - often misrepresenting their lived experiences, both prior to and during COVID-19. Participants reported entrenched struggles with being able to afford basic living costs in a dignified manner during COVID-19, despite temporary social protection policy changes. To reduce inequities in population diets, a pre-requisite to health, all stakeholders must recognise an ongoing responsibility for adopting long-term food and social policies that genuinely improve lived experiences of food insecurity and poverty. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-022-01318-4.

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

INTRODUCTION: Systems science methodologies have been used in attempts to address the complex and dynamic causes of childhood obesity with varied results. This paper presents a protocol for the Reflexive Evidence and Systems interventions to Prevention Obesity and Non-communicable Disease (RESPOND) trial. RESPOND represents a significant advance on previous approaches by identifying and operationalising a clear systems methodology and building skills and knowledge in the design and implementation of this approach among community stakeholders. METHODS AND ANALYSIS: RESPOND is a 4-year cluster-randomised stepped-wedge trial in 10 local government areas in Victoria, Australia. The intervention comprises four stages: catalyse and set up, monitoring, community engagement and implementation. The trial will be evaluated for individuals, community settings and context, cost-effectiveness, and systems and implementation processes. Individual-level data including weight status, diet and activity behaviours will be collected every 2 years from school children in grades 2, 4 and 6 using an opt-out consent process. Community-level data will include knowledge and engagement, collaboration networks, economic costs and shifts in mental models aligned with systems training. Baseline prevalence data were collected between March and June 2019 among >3700 children from 91 primary schools. ETHICS AND DISSEMINATION: Ethics approval: Deakin University Human Research Ethics Committee (HREC 2018-381) or Deakin University's Faculty of Health Ethics Advisory Committee (HEAG-H_2019-1; HEAG-H 37_2019; HEAG-H 173_2018; HEAG-H 12_2019); Victorian Government Department of Education and Training (2019_003943); Catholic Archdiocese of Melbourne (Catholic Education Melbourne, 2019-0872) and Diocese of Sandhurst (24 May 2019). The results of RESPOND, including primary and secondary outcomes, and emerging studies developed throughout the intervention, will be published in the academic literature, presented at national and international conferences, community newsletters, newspapers, infographics and relevant social media. TRIAL REGISTRATION NUMBER: ACTRN12618001986268p.

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

BACKGROUND: One of the challenges for countries implementing food policy measures has been the difficulty in demonstrating impact and retaining stakeholder support. Consequently, research funded to help countries overcome these challenges should assess impact and translation into practice, particularly in low-resource settings. However, there are still few attempts to prospectively, and comprehensively, assess research impact. This protocol describes a study co-created with project implementers, collaborative investigators and key stakeholders to optimize and monitor the impact of a research project on scaling up food policies in Fiji. METHODS: To develop this protocol, our team of researchers prospectively applied the Framework to Assess the Impact from Translational health research (FAIT). Activities included (i) developing a logic model to map the pathway to impact and establish domains of benefit; (ii) identifying process and impact indicators for each of these domains; (iii) identifying relevant data for impact indicators and a cost-consequence analysis; and (iv) establishing a process for collecting quantitative and qualitative data to measure progress. Impact assessment data will be collected between September 2022 and December 2024, through reports, routine monitoring activities, group discussions and semi-structured interviews with key implementers and stakeholders. The prospective application of the protocol, and interim and final research impact assessments of each project stream and the project as a whole, will optimize and enable robust measurement of research impact. DISCUSSION: By applying this protocol, we aim to increase understanding of pathways to impact and processes that need to be put in place to achieve this. This impact evaluation will inform future projects with a similar scope and will identify transferable and/or translatable lessons for other Pacific Island states and low- and middle-income countries.

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.

The impact of coalition characteristics on outcomes in community-based initiatives targeting the social determinants of health: a systematic review.

BACKGROUND: Coalitions are a popular mechanism for delivering community-based health promotion. The aim of this systematic review was to synthesize research that has quantitatively analyzed the association between coalition characteristics and outcomes in community-based initiatives targeting the social determinants of health. Coalition characteristics described elements of their structure or functioning, and outcomes referred to both proximal and distal community changes. METHODS: Authors searched six electronic databases to identify peer reviewed, published studies that analyzed the relationship between coalition characteristics and outcomes in community-based initiatives between 1980 and 2021. Studies were included if they were published in English and quantitatively analyzed the link between coalition characteristics and outcomes. Included studies were assessed for quality using the Joanna Briggs Institute analytical cross-sectional studies assessment tool. RESULTS: The search returned 10,030 unique records. After screening, 26 studies were included from six countries. Initiatives targeted drug use, health equity, nutrition, physical activity, child and youth development, crime, domestic violence, and neighbourhood improvement. Community outcomes measured included perceived effectiveness (n=10), policy, systems or environment change (n=9), and community readiness or capacity (n=7). Analyses included regression or correlation analysis (n=16) and structural equation or pathway modelling (n=10). Studies varied in quality, with a lack of data collection tool validation presenting the most prominent limitation to study quality. Statistically significant associations were noted between community outcomes and wide range of coalition characteristics, including community context, resourcing, coalition structure, member characteristics, engagement, satisfaction, group facilitation, communication, group dynamics, relationships, community partnership, and health promotion planning and implementation. CONCLUSION: Existing literature demonstrates that coalition characteristics, including best practice health promotion planning and evaluation, influence community outcomes. The field of coalition research would benefit from more consistent description and measurement of coalition characteristics and outcomes, and efforts to evaluate coalitions in a wider range of countries around the world. Further research using empirical community outcome indicators, and methods that consider the interrelationship of variables, is warranted. TRIAL REGISTRATION: A protocol for this review was registered with PROSPERO ( CRD42020205988 ).

The Sleep-Obesity Nexus: Assessment of Multiple Sleep Dimensions and Weight Status Among Victorian Primary School Children.

Purpose: To examine the association between sleep and weight status across multiple dimensions of sleep (duration, efficiency, quality and timing) and assess the cumulative influence of these dimensions on the overall sleep-obesity association. Participants and Methods: Cross-sectional data from 2253 students aged 8.8 to 13.5 years participating in two monitoring studies across regional Victoria was analyzed. Students were invited to have measures of height and weight taken and to complete a self-report electronic questionnaire on demographic characteristics and health behaviors. Logistic regression models were used to assess association between sleep dimensions and BMI z-scores. Results: Beyond sleep duration, poor perceived sleep quality, delayed sleep initiation, later bed times and sleep-wake timing, all significantly increased the odds of overweight/obesity (OR 1.47, 95% CI: 1.07-2.01; OR 1.25, 95% CI: 1.02-1.55; and OR 1.70. 95% CI: 1.28-2.28, respectively). Additionally, a cumulative effect of having multiple poorly scored sleep dimensions was found, where four or more poorly scored sleep dimensions more than doubled the odds of overweight/obesity among children (OR 2.25, 95% CI: 1.41-3.58). Conclusion: This study highlights the importance of measuring and considering multiple dimensions of sleep, along with the individual and additive influence of the sleep dimension on the sleep-obesity nexus.

Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation.

BACKGROUND: There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific. METHODS: Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions. DISCUSSION: The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.

Participatory research with a rural Aboriginal Community Controlled Health Organisation: lessons learned using the CONSIDER statement.

CONTEXT: In Australia, Aboriginal Community Controlled Health Organisations (ACCHOs) are geographically proximal to where Aboriginal and Torres Strait Islander People reside and are valued for providing holistic and culturally safe primary health care. Partnering with ACCHOs in research is appropriate for redressing health inequities experienced by Aboriginal and Torres Strait Islander People, which includes a high burden of chronic disease. Historically, some approaches to Aboriginal and Torres Strait Islander health research have been unethical. Greater accountability in the research process, transparency in reporting, and use of culturally appropriate research methodologies are key recommendations to improving the ethical integrity of research. The need for strengthening the reporting of health research involving Aboriginal and Torres Strait Islander People and Indigenous peoples globally led to the development of the CONSolIDated critERia for strengthening the reporting of health research involving Indigenous peoples (CONSIDER statement), which is a synthesis of international ethical guidelines. This project report uses the CONSIDER statement to critically reflect on participatory research undertaken in partnership with an ACCHO in the rural context and to identify lessons of value for future research. ISSUE: By using the CONSIDER statement as a tool for critical reflection, it was identified that processes used to establish a research partnership with an ACCHO were key to setting the research agenda, including identifying ethical issues, the needs of local Aboriginal and Torres Strait Islander People, and expectations from the research. The participation of Aboriginal community members throughout the entire research process was not only methodologically important but was also ethically appropriate. Research activities in this project included opportunities for Aboriginal community members to directly share their perspectives and experiences and develop local solutions to issues affecting them. Outcomes included evidence to support future funding applications, community-derived priorities that assisted with government reporting, and locally identified methods for addressing chronic disease management. Key to this was building the research capacity and capability of local Aboriginal community members, which also reflected the ethical principles of reciprocity and equity. This also provided opportunities for non-Indigenous researchers to learn from local Aboriginal community members and develop skills in culturally appropriate research. LESSONS LEARNED: Using the CONSIDER statement was beneficial in enabling researchers to critically reflect on a participatory research project undertaken in partnership with a rural ACCHO. Researchers identified that participatory approaches can be used to generate research of relevance to local Aboriginal community members and their ACCHOs, and to support health service reporting, and future funding applications. Research timelines and activities needed to be flexible and adaptable, to allow for staff turnover and unforeseen events of cultural significance. Similarly, it is important for researchers to be receptive to change and open to learning. Although research partnerships are established on trust and mutual respect, it is recommended that greater formal provisions are required to protect the intellectual property of Aboriginal and Torres Strait Islander communities involved in research. These lessons are likely to be transferrable to other settings and are of value to researchers seeking to partner with ACCHOs in research.

The impact of a community-based intervention on weight, weight-related behaviours and health-related quality of life in primary school children in Victoria, Australia, according to socio-economic position.

BACKGROUND: Approximately a quarter of Australian children are classified as overweight or obese. In high-income countries, childhood obesity follows a socio-economic gradient, with greater prevalence amongst the most socio-economically disadvantaged children. Community-based interventions (CBI), particularly those using a systems approach, have been shown to be effective on weight and weight-related behaviours. They are also thought to have an equitable impacts, however there is limited evidence of their effectiveness in achieving this goal. METHODS: Secondary analysis was conducted on data collected from primary school children (aged 6-13 years) residing in ten communities (five intervention, five control) involved in the Whole of Systems Trial of Prevention Strategies for Childhood Obesity (WHO STOPS) cluster randomised trial in Victoria, Australia. Outcomes included Body Mass Index z-score (BMI-z) derived from measured height and weight, self-reported physical activity and dietary behaviours and health related quality of life (HRQoL). Repeat cross-sectional data from 2015 (n = 1790) and 2019 (n = 2137) were analysed, stratified by high or low socio-economic position (SEP). Multilevel linear models and generalised estimating equations were fitted to assess whether SEP modified the intervention effect on the outcomes. RESULTS: There were no overall changes in BMI-z for either SEP strata. For behavioural outcomes, the intervention resulted in a 22.5% (95% CI 5.1, 39.9) point greater improvement in high-SEP compared to low-SEP intervention schools for meeting physical activity guidelines. There were also positive dietary intervention effects for high SEP students, reducing takeaway and packaged snack consumption, although there was no significant difference in effect between high and low SEP students. There were positive intervention effects for HRQoL, whereby scores declined in control communities with no change in intervention communities, and this did not differ by SEP. CONCLUSION: The WHO STOPS intervention had differential effects on several weight-related behaviours according to SEP, including physical activity. Similar impacts on HRQoL outcomes were found between high and low SEP groups. Importantly, the trial evaluation was not powered to detect subgroup differences. Future evaluations of CBIs should be designed with an equity lens, to understand if and how these types of interventions can benefit all community members, regardless of their social and economic resources.

Systems thinking for Aboriginal Health: Understanding the value and acceptability of group model building approaches.

Systems thinking is increasingly applied to understand and address systemic drivers of complex health problems. In Australia, group model building, a participatory method from systems science, has been applied in various locations to engage communities in systems-based health promotion projects. To date there is limited evidence regarding GMB use with Australian Aboriginal communities. This study aimed to determine the value and acceptability of group model building (GMB) as a methodological approach in research with Aboriginal communities and identify any adaptations required to optimise its utility. Semi-structured interviews were undertaken with 18 Aboriginal health and university staff who had prior experience with a GMB research project. Interview transcripts were inductively analysed using thematic analysis and key themes were organised using an Indigenous research framework. Participants reported that GMB methods generally aligned well with Aboriginal ways of knowing, being, and doing. Participants valued the holistic, visual and collaborative nature of the method and its emphasis on sharing stories and collective decision-making. Group model building was viewed as a useful tool for identifying Aboriginal-led actions to address priority issues and advancing self-determination. Our findings suggest that by bringing together Aboriginal and non-Aboriginal knowledge, GMB is a promising tool, which Aboriginal communities could utilise to explore and address complex problems in a manner that is consistent with their worldviews. In adapting group model building methods, non-Aboriginal researchers should aspire to move beyond co-design processes and enable Aboriginal health research to be entirely led by Aboriginal people.

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.

Inequalities in early childhood body-mass index Z scores in Victoria, Australia: a 15-year observational study.

BACKGROUND: Early childhood overweight and obesity increased substantially in high-income countries throughout the 1980s and 1990s. The flattening or reversal of this trend since the early 2000s might conceal widening inequalities. This study aimed to identify trends in body-mass index Z score (BMIz) among children aged 1-3·5 years in Victoria (Australia), by socioeconomic status and geographical location. METHODS: This repeated, cross-sectional study used deidentified records of height, weight, and demographic information from electronic databases in the Victorian Maternal and Child Health system. Data from the consultations for children aged 1, 2, and 3·5 years were included in this analysis. We removed duplicate records; records with missing data for sex, age, weight, height, or postcode; and records with postcodes that were outside of Victoria. The coprimary outcomes were trends in mean BMIz (continuous linear models) and prevalence of high BMIz (>+1; generalised linear models), estimated for six independent age-sex groups. Secondary analysis was done for the prevalence of BMIz greater than 2. Effect modification by socioeconomic status and remoteness was evaluated. FINDINGS: Electronic data were available for 48 local government areas collected between Jan 1, 2003, and Dec 31, 2017, representing approximately 63% of the Victorian population. Overall, 1 329 520 measurements from 675 991 children were included in the analysis. There were small, significantly decreasing trends in mean BMIz across all six age-sex groups, overall and in major cities. Similar patterns were observed for some subgroups in prevalence of high BMIz. These decreasing trends appear to be partly explained by migration. Conversely, in regional areas the trends in BMIz were consistently increasing in all age-sex groups and across socioeconomic strata, although not all groups were statistically significant. Inequalities in BMIz according to socioeconomic status persisted throughout the study period, such that the children from more advantaged areas had lower mean BMIz. INTERPRETATION: This study showed that at a state level, mean BMIz and prevalence of high BMIz decreased in children aged 1, 2, and 3·5 years in Victoria between 2003 and 2017. We found metropolitan-regional differences to be key source of inequality in early childhood BMIz trends, alongside area-level socioeconomic status. These findings highlight the risk that analysis of overall trends in childhood BMIz might obscure important inequalities according to, for example, remoteness, socioeconomic status, and ethnicity. Future research requires monitoring data with large population samples to adequately examine differences in prevalence and trends between population subgroups. FUNDING: None.

The Impact of COVID-19 on Rural Food Supply and Demand in Australia: Utilising Group Model Building to Identify Retailer and Customer Perspectives.

Prior to the 2020 outbreak of COVID-19, 70% of Australians' food purchases were from supermarkets. Rural communities experience challenges accessing healthy food, which drives health inequalities. This study explores the impact of COVID-19 on food supply and purchasing behaviour in a rural supermarket. Group model building workshops explored food supply experiences during COVID-19 in a rural Australian community with one supermarket. We asked three supermarket retailers "What are the current drivers of food supply into this supermarket environment?" and, separately, 33 customers: "What are the current drivers of purchases in this supermarket environment?" Causal loop diagrams were co-created with participants in real time with themes drawn afterwards from coded transcripts. Retailers' experience of COVID-19 included 'empty shelves' attributed to media and government messaging, product unavailability, and community fear. Customers reported fear of contracting COVID-19, unavailability of food, and government restrictions resulting in cooking more meals at home, as influences on purchasing behaviour. Supermarket management and customers demonstrated adaptability and resilience to normalise demand and combat reduced supply.

Socio-economic and Regional Differences in Walkability and Greenspace Around Primary Schools: A Census of Australian Primary School Neighbourhoods.

Socio-economic inequality in the physical activity environment surrounding primary schools may contribute to socio-economic gradients in physical activity and childhood obesity levels. Using a cross-sectional study design, ordinary least squares and logistic regressions were fitted to assess variation in walkability and greenspace within 1 km of primary schools (n = 7133) according to area-level socio-economic position (SEP) and remoteness. Effect modification by school location (major cities or regional/remote) was assessed through stratified analyses. Walkability scores significantly increased from low to high school neighbourhood SEP (p < 0.01) and from remote/very remote to major city locations (p < 0.01). Greenspace area (hectares) in the school neighbourhood was greater in highest compared to lowest SEP areas (ß = 18.75, 95%CI 6.63, 30.87) and less in major cities compared to remote/very remote locations (ß = - 23.9, 95%CI - 39.7, - 8.1). Schools in highest SEP areas and major cities had higher odds of having any greenspace in their neighbourhood, compared to those in lowest SEP and remote/very remote locations (OR 5.93, (95% CI 4.50, 7.05), OR 20.19, (95% CI 16.05, 25.39) respectively). Stratified results (major cities or regional/remote locations) found the highest SEP school neighbourhoods had higher walkability scores and more greenspace compared to lowest SEP school neighbourhoods in both strata, although overall SEP gradient in walkability and greenspace area only remained in major cities. Walkability and greenspace infrastructure in the school neighbourhood could be improved in areas of lower SEP so that all school children have the opportunity for physical activity.

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.

Responsibility for evidence-based policy in cardiovascular disease in rural communities: implications for persistent rural health inequalities.

Objective The aim of this study was to understand, from the perspective of policy makers, who holds the responsibility for driving evidence-based policy to reduce the high burden of cardiovascular disease (CVD) in rural Australia. Methods Qualitative interviews were conducted with policy makers at the local, state and federal government levels in Australia (n=21). Analysis was conducted using the Conceptual Framework for Understanding Rural and Remote Health to understand perceptions of policy makers around who holds the key responsibility in driving evidence-based policy. Results At all levels of government, there were multiple examples of disconnect in the understanding of who is responsible for driving the generation of evidence-based policy to reduce CVD in rural areas. Policy makers suggested that the rural communities themselves, health services, health professionals, researchers and the health sector as a whole hold large responsibilities in driving evidence-based policy to address CVD in rural areas. Within government, there was also a noticeable disconnect, with local participants feeling it was the federal government that held this responsibility; however, federal government participants suggested this was largely a local government issue. Overall, there seemed to be a lack of responsibility for CVD policy, which is reflected in a lack of action in rural areas. Conclusion There was a lack of clarity about who is responsible for driving evidence-based policy generation to address the high burden of CVD in Australia, providing one possible explanation for the lack of policy action. Clarity among policy makers over shared roles and leadership for policy making must be addressed to overcome the current burden of CVD in rural communities. What is known about the topic? Rural health inequalities, such as the increased burden of CVD in rural Australia are persistent. Such health inequalities are unjust, with global theory suggesting political processes have facilitated, in part, the inequalities. With similar examples observed internationally in rural areas, little is known about the influence of the perspectives of policy makers regarding who is responsible for addressing health issues in rural areas, in the government context. What does this paper add? This paper provides empirical evidence, for all levels of government in Australia, that there is a lack of clarity in policy roles and responsibilities to address the unequal burden of CVD in rural Australia, at all levels of government. The paper provides evidence to support the urgent need for clarity within government around policy stakeholder roles. Without such clarity, it is unlikely that national-level progress in addressing rural health inequalities will be achieved in the near future. What are the implications for practitioners? Addressing ambiguity around who is responsible for the development of evidence-based policy to address the high burden of CVD in rural areas must be a high priority to ensure health disparities do not persist for future Australian generations. The results reported here are highly relevant to the Australian context, but also reflect similar findings internationally, namely that a lack of clarity among policy stakeholders appears to contribute to reduced action in addressing preventable health inequalities in disadvantaged populations. This paper provides evidence for policy makers and public health professionals to advocate for clear policy roles and direction in rural Australia.