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

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

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

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

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

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

Using systems science to understand the determinants of inequities in healthy eating.

INTRODUCTION: Systems thinking has emerged in recent years as a promising approach to understanding and acting on the prevention and amelioration of non-communicable disease. However, the evidence on inequities in non-communicable diseases and their risks factors, particularly diet, has not been examined from a systems perspective. We report on an approach to developing a system oriented policy actor perspective on the multiple causes of inequities in healthy eating. METHODS: Collaborative conceptual modelling workshops were held in 2015 with an expert group of representatives from government, non-government health organisations and academia in Australia. The expert group built a systems model using a system dynamics theoretical perspective. The model developed from individual mind maps to pair blended maps, before being finalised as a causal loop diagram. RESULTS: The work of the expert stakeholders generated a comprehensive causal loop diagram of the determinants of inequity in healthy eating (the HE2 Diagram). This complex dynamic system has seven sub-systems: (1) food supply and environment; (2) transport; (3) housing and the built environment; (4) employment; (5) social protection; (6) health literacy; and (7) food preferences. DISCUSSION: The HE2 causal loop diagram illustrates the complexity of determinants of inequities in healthy eating. This approach, both the process of construction and the final visualisation, can provide the basis for planning the prevention and amelioration of inequities in healthy eating that engages with multiple levels of causes and existing policies and programs.

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

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

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

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

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

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

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

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

Factors Influencing the Health Behaviour of Indigenous Australians: Perspectives from Support People.

Disparities between the health of Indigenous and non-Indigenous populations continue to be prevalent within Australia. Research suggests that Indigenous people participate in health risk behaviour more often than their non-Indigenous counterparts, and that such behaviour has a substantial impact on health outcomes. Although this would indicate that reducing health risk behaviour may have positive effects on health outcomes, the factors that influence Indigenous health behaviour are still poorly understood. This study aimed to interview people who support Indigenous groups to gain an understanding of their views on the factors influencing health behaviour within Indigenous groups in Western Australia. Twenty nine people participated in the study. The emergent themes were mapped against the social ecological model. The results indicated that: (1) culture, social networks, history, racism, socioeconomic disadvantage, and the psychological distress associated with some of these factors interact to affect health behaviour in a complex manner; (2) the desire to retain cultural identity and distinctiveness may have both positive and negative influence on health risk behaviour; (3) strong social connections to family and kin that is intensified by cultural obligations, appears to affirm and disrupt positive health behaviour; (4) the separation between Indigenous and non-Indigenous social connection/networks that appeared to be fostered by marginalisation and racism may influence the effect of social networks on health behaviour; and (5) communication between Indigenous and non-Indigenous people may be interrupted by distrust between the groups, which reduces the influence of some non-Indigenous sources on the health behaviour of Indigenous people.

The effect of social support on the health of Indigenous Australians in a metropolitan community.

The factors driving the disparity in health outcomes between Indigenous and non-Indigenous Australians continue to be poorly understood. Despite this, studies confirm that social connections are a very important part of Indigenous life, and it is likely these connections play an important role in influencing health outcomes among this population. Examining the support provided by social connections in relation to health behaviour may assist our understanding of health outcomes among Indigenous Australians. The current study is focused on exploring Indigenous participants' impressions of their social network and social support using Participatory Action Research methodology and qualitative methods. The objective was to identify the influence of social support on the health outcomes of Indigenous people within a Western Australian metropolitan community. Seventeen members of the community were interviewed during the study. The participants had extensive social networks that mainly comprised members of their kinship group. The consequences of this social network included: (1) the positive effects of social support from bonded relationships; (2) the negative effects of social support produced by over-obligation and unidirectional support involving bonded relationships; (3) limited or inadequate social support caused by withdrawal from bonded relationships; (4) lack of social support from bridging relationships; and (5) a strong desire for connection and a sense of belonging.

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

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

Public support for restrictions on fast food company sponsorship of community events.

This study investigated community attitudes to fast food companies' sponsorship of community events. The aim was to inform future efforts to introduce greater restrictions on these marketing activities to reduce child obesity. While previous research has focused on the sponsorship of sporting events, the present study included all community events and gauged public support for fast food company sponsorships in general as well as specific sponsorship activities such as securing event naming rights, advertising on event premises, and distributing free items to children in the form of food and redeemable vouchers. A large and diverse sample of Western Australian adults (n=2,005) responded to a community attitudes telephone survey that included questions relating to event sponsorship. Almost half of the respondents reported that the promotion of fast foods is inappropriate at community events, and only a third considered it appropriate at events where children are likely to be present. Around two-thirds agreed that promoting fast foods at such events sends contradictory messages to children and just a quarter of respondents considered it acceptable for free fast food to be distributed at events or for children to be rewarded for participation with fast food vouchers. The results suggest that efforts to reduce child obesity that involve restrictions on the sponsorship of community events by organisations promoting unhealthy foods may be supported by a substantial proportion of the population.

Stakeholder support for school food policy expansions.

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