Improving cultural competence of healthcare workers in First Nations communities: a narrative review of implemented educational interventions in 2015-20.

BACKGROUND: Cultural competency is often promoted as a strategy to address health inequities; however, there is little evidence linking cultural competency with improved patient outcomes. This article describes the characteristics of recent educational interventions designed to improve cultural competency in healthcare workers for First Nations peoples of Australia, New Zealand, Canada and the USA. METHODS: In total, 13 electronic databases and 14 websites for the period from January 2015 to May 2021 were searched. Information on the characteristics and methodological quality of included studies was extracted using standardised assessment tools. RESULTS: Thirteen published evaluations were identified; 10 for Australian Aboriginal and Torres Strait Islander peoples. The main positive outcomes reported were improvements in health professionals' attitudes and knowledge, and improved confidence in working with First Nations patients. The methodological quality of evaluations and the reporting of methodological criteria were moderate. CONCLUSIONS: Cultural competency education programs can improve knowledge, attitudes and confidence of healthcare workers to improve the health of First Nations peoples. Providing culturally safe health care should be routine practice, particularly in places where there are concentrations of First Nations peoples, yet there is relatively little research in this area. There remains limited evidence of the effectiveness of cultural education programs alone on community or patient outcomes.

Reflections on an evaluation of the 'Remote Health Experience' - an interprofessional learning, cultural immersion program.

INTRODUCTION: Cultural immersion can be an effective method of health professional student cultural learning, and part of interprofessional learning. This evaluation aimed to report the views of staff and Aboriginal and Torres Strait Islander contributors about a cultural immersion program, as well as the student perspective. METHODS: Semi-structured interviews with staff (11 non-Aboriginal, 3 Aboriginal) and Aboriginal contributors (n=3) were conducted after the 2020 immersion program. Data were collected from 138 student participants following the 2018 (n=45), 2019 (n=33) and 2020 (n=60) remote health experience immersion weekends in Katherine, in the Northern Territory of Australia. Seven staff of the 2020 weekend provided written feedback about their experiences. Qualitative data were analysed thematically, and quantitative results scored from ratings on a five-point scale were presented as means, standard deviations and percentage of respondents agreeing or strongly agreeing with evaluative statements. RESULTS: Results are presented under the four themes that were identified: (1) understanding remote practice, (2) Aboriginal culture, (3) working together and learning from each other, and (4) ongoing opportunities. Feedback from students and staff was overwhelmingly positive, with learning occurring in each of the intended areas. Relationship building and embedding Aboriginal and Torres Strait Islander culture and knowledge throughout the weekend were seen as invaluable components. CONCLUSION: The Katherine Remote Health Experience is a valuable, immersive introduction to remote health practice for students from multiple disciplines. As a standalone event it has developed positive relationships, improved knowledge, and encouraged students to consider practising outside of metropolitan areas. There is scope to further develop pathways into remote practice for interested students.

Interactivity, Quality, and Content of Websites Promoting Health Behaviors During Infancy: 6-Year Update of the Systematic Assessment.

BACKGROUND: As of 2021, 89% of the Australian population are active internet users. Although the internet is widely used, there are concerns about the quality, accuracy, and credibility of health-related websites. A 2015 systematic assessment of infant feeding websites and apps available in Australia found that 61% of websites were of poor quality and readability, with minimal coverage of infant feeding topics and lack of author credibility. OBJECTIVE: We aimed to systematically assess the quality, interactivity, readability, and comprehensibility of information targeting infant health behaviors on websites globally and provide an update of the 2015 systematic assessment. METHODS: Keywords related to infant milk feeding behaviors, solid feeding behaviors, active play, screen time, and sleep were used to identify websites targeting infant health behaviors on the Google search engine on Safari. The websites were assessed by a subset of the authors using predetermined criteria between July 2021 and February 2022 and assessed for information content based on the Australian Infant Feeding Guidelines and National Physical Activity Recommendations. The Suitability Assessment of Materials, Quality Component Scoring System, the Health-Related Website Evaluation Form, and the adherence to the Health on the Net code were used to evaluate the suitability and quality of information. Readability was assessed using 3 web-based readability tools. RESULTS: Of the 450 websites screened, 66 were included based on the selection criteria and evaluated. Overall, the quality of websites was mostly adequate. Media-related sources, nongovernmental organizations, hospitals, and privately owned websites had the highest median quality scores, whereas university websites received the lowest median score (35%). The information covered within the websites was predominantly poor: 91% (60/66) of the websites received an overall score of ≤74% (mean 53%, SD 18%). The suitability of health information was mostly rated adequate for literacy demand, layout, and learning and motivation of readers. The median readability score for the websites was grade 8.5, which is higher than the government recommendations (

Economic evaluation of the Communicating Healthy Beginnings Advice by Telephone trial for early childhood obesity prevention.

OBJECTIVE: This study aimed to conduct an economic evaluation of the Communicating Healthy Beginnings Advice by Telephone (CHAT) trial to prevent childhood obesity. METHODS: Cost-effectiveness analyses were conducted for the telephone and short message service (SMS) delivery of Healthy Beginnings advice, compared with usual care, which included child health services unrelated to Healthy Beginnings. Costs were valued in 2018 Australian dollars, and costs and outcomes were discounted at 5% per year. The costs of upscaling both delivery modes to all yearly births in New South Wales, Australia, were estimated and compared with the original Healthy Beginnings home-visiting intervention. RESULTS: At child age 2 years, the SMS delivery was more cost-effective ($5154 per unit BMI and $979 per 0.1 BMI z score units avoided) than the telephone delivery ($10,665 per unit BMI and $2017 per 0.1 BMI z score units avoided). The costs of upscaling the SMS ($7.64 million) and the telephone delivery modes ($37.65 million) were lower than the home-visiting intervention ($108.45 million). CONCLUSIONS: SMS delivery of Healthy Beginnings advice was more cost-effective than telephone delivery but less cost-effective than the original home-visiting approach ($4230 per unit BMI avoided, as calculated in an earlier study). Both the SMS and telephone interventions were more affordable than the home-visiting approach.

Intergovernmental policy opportunities for childhood obesity prevention in Australia: Perspectives from senior officials.

BACKGROUND: Early childhood (from conception to five years) is a key life stage for interventions to prevent obesity. In the Australian Federation, policy responsibility for obesity prevention sits across all levels of government and several intergovernmental institutions, rendering a complicated policy space. There is a gap in our understanding of the role of intergovernmentalism in developing obesity prevention policy in Australia. Given the complexity of intergovernmental structures and initiatives influencing childhood obesity prevention policy, it is important to understand the perspectives of senior health officials within the bureaucracy of government who through their roles may be able to influence processes or new strategies. METHODS: Document analysis relating to obesity prevention in the intergovernmental context provided material support to the study. This analysis informed the interview guides for nine interviews with ten senior health department officials (one interview per jurisdiction). FINDINGS: Several opportunities exist to support nutrition and obesity prevention in early childhood including marketing regulation (discretionary choices, breastmilk substitutes, commercial complementary foods and 'toddler milks') and supporting the early childhood education and care sector. This study found a widening structural gap to support national obesity policy in Australia. New public management strategies limit the ability of intergovernmental institutions to support coordination within and between governments to address complex issues such as obesity. Subnational informants perceived a gap in national leadership for obesity prevention, while a Commonwealth informant noted the commitment of the national government to partner with industry under a self-regulation model. In this gap, subnational leaders have pursued nationally consistent action to address obesity, including the development of a national obesity strategy as a bipartisan endeavour across jurisdictions. Public officials calculate the strategic possibilities of pursuing opportunities within state agendas but note the limited chances of structural change in the absence of national leadership and funding.

Trial collaborators' perceptions of the process of delivering Healthy Beginnings advice via telephone calls or text messages.

ISSUE ADDRESSED: One in four Australian children aged between the ages of two and four are affected by overweight. In New South Wales, the Communicating Healthy Beginnings Advice by Telephone (CHAT) trial delivered an intervention to pregnant women and women with infants via telephone calls and text messages. The focus of the intervention was on infant feeding and establishing healthy habits for infants by building the capacity of mothers. This study investigates trial collaborators' perspectives concerning the implementation of this intervention, to obtain insights that will support future translation and scale-up. METHODS: This research was undertaken during the intervention phase of the trial. Twenty trial collaborators involved in the planning, implementation or delivery of the CHAT trial were invited to participate. Qualitative interviews were conducted with collaborators using open-ended questions based on Steckler and Linnan's process evaluation framework and the Consolidated Framework for Implementation Research. Inductive thematic analysis was employed to identify themes from the interview data. RESULTS: Fourteen trial collaborators were interviewed. Collaborators included child and family health nurses (intervention providers), nurse managers with extensive child and family health nursing experience, a paediatrician, dietitians, health promotion experts, health service managers, health and nursing executives, program personnel (project coordinator, research fellow and evaluation officer) and university researchers. Following coding of qualitative data, themes were realised from the data as a result of active co-production on the part of the researcher. Five themes were identified: (a) context (organisational support, engagement and partnerships, communication and project leadership); (b) program receipt, benefit and reach; (c) program delivery (intervention providers' experience and skills, mode of intervention delivery, referral to other services, support and training for intervention providers); (d) implementation (program delivered as planned); (e) opportunities for scale-up. Collaborators perceived that the program was implemented and delivered as planned. This specific research addresses the success of the process of implementing and delivering interventions for infant feeding and establishing healthy habits for children by building the capacity of mothers. Collaborators attributed successful program implementation to contextual factors: strong support by the host organisation; good project leadership; clear communication; collaborative internal and external partnerships; intervention provision by experienced nurses. Remote delivery was convenient to program participants and participants were able to resolve other personal concerns in addition to direct immediate benefits. Because of their capacity to influence policy decisions, the absence of policymakers at project meetings was a shortcoming. Collaborative partnerships with health and research partners, understanding of contextual issues and consumer involvement could lead to program expansion. The program has the potential to be scaled up through integration with existing services and gradual expansion into other health districts prior to state-wide rollout. CONCLUSIONS: The CHAT trial delivered the Healthy Beginnings intervention which resulted in improvements in infant feeding, active play and sedentary behaviours. This evaluation demonstrated that the involvement of key stakeholders from early planning stages through to implementation of the program and the partnerships that evolved contributed to the successful implementation of the program. An unintended benefit to participants from this program was the social support that was provided. Intervention delivery via telephone and text messages enabled easy access to the program. Most importantly, the program has the potential to be scaled up through integration into existing services and gradual expansion prior to state-wide rollout. SO WHAT?: Strong internal and external partnerships, effective communication systems and integration with existing services create the context for potential translation and scaling up of the program to other health promotion settings.

An implementation intervention to increase the routine provision of antenatal care addressing gestational weight gain: study protocol for a stepped-wedge cluster trial.

BACKGROUND: Weight gain during pregnancy that is outside of recommended levels is associated with a range of adverse outcomes for the mother and child, including gestational diabetes, pre-eclampsia, preterm birth, and obesity. Internationally, 60-80% of pregnant women report gaining weight outside of recommended levels. While guideline recommendations and RCT evidence support the provision of antenatal care that supports healthy gestational weight gain, less than 10% of health professionals routinely weigh pregnant women; discuss weight gain, diet, and physical activity; and provide a referral for additional support. This study aims to determine the effectiveness of an implementation intervention in increasing the provision of recommended gestational weight gain care by maternity services. METHODS: A stepped-wedge controlled trial, with a staggered implementation intervention, will be conducted across maternity services in three health sectors in New South Wales, Australia. The implementation intervention will consist of evidence-based, locally-tailored strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training, and monitoring and feedback. Primary outcome measures will be the proportion of women who report receiving (i) assessment of gestational weight gain; (ii) advice on gestational weight gain, dietary intake, and physical activity; and (iii) offer of referral to a telephone coaching service or local dietetics service. Measurement of outcomes will occur via telephone interviews with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost, cost-consequence, cost-effectiveness, and budget impact of the implementation intervention. Receipt of all care elements, acceptance of referral, weight gain during pregnancy, diet quality, and physical activity will be measured as secondary outcomes. Process measures including acceptability, adoption, fidelity, and reach will be reported. DISCUSSION: This will be the first controlled trial to evaluate the effectiveness of a implementation intervention in improving antenatal care that addresses gestational weight gain. The findings will inform decision-making by maternity services and policy agencies and, if the intervention is demonstrated to be effective, could be applied at scale to benefit the health of women and children across Australia and internationally. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12621000054819 . Registered on 22 January 2021.

How equitable are the distributions of the physical activity and accessibility benefits of bicycle infrastructure?

BACKGROUND: Cycling for transport provides many health and social benefits - including physical activity and independent access to jobs, education, social opportunities, health care and other services (accessibility). However, some population groups have less opportunity to reach everyday destinations, and public transport stops, by bicycle - owing in part to their greater aversion to riding amongst motor vehicle traffic. Health equity can therefore be improved by providing separated cycleway networks that give more people the opportunity to access places by bicycle using traffic-free routes. The aim of this study was to assess the health equity benefits of two bicycle infrastructure development scenarios - a single cycleway, and a complete network of cycleways - by examining the distributions of physical activity and accessibility benefits across gender, age and income groups. METHODS: Travel survey data collected from residents in Sydney (Australia) were used to train a predictive transport mode choice model, which was then used to forecast the impact of the two intervention scenarios on transport mode choice, physical activity and accessibility. The latter was measured using a utility-based measure derived from the mode choice model. The distributions of the forecast physical activity and accessibility benefits were then calculated across gender, age and income groups. RESULTS: The modelled physical activity and accessibility measures improve in both intervention scenarios. However, in the single cycleway scenario, the benefits are greatest for the male, high-income and older age groups. In the complete network scenario, the benefits are more equally distributed. Forecast increases in cycling time are largely offset by decreases in walking time - though the latter is typically low-intensity physical activity, which confers a lesser health benefit than moderate-intensity cycling. CONCLUSIONS: Separated cycleway infrastructure can be used to improve health equity by providing greater opportunities for transport cycling in population groups more averse to riding amongst motor vehicle traffic. Disparities in the opportunity to access services and economic/social activities by bicycle - and incorporate more physical activity into everyday travel - could be addressed with connected, traffic-free cycleway networks that cater to people of all genders, ages and incomes.

Service provider perspectives on implementing the NSW Get Healthy at Work program.

Purpose: One approach increasingly used by governments to deliver on public initiatives is to partner with private enterprise through public-private partnerships. This study is a qualitative process evaluation of an Australian state-wide workplace health programme "Get Healthy at Work" from the currently under-researched perspective of the private service providers. Methods: Semi-structured interviews were conducted with nine service providers. Interviews were transcribed and analysed inductively. Results: Service providers reported an alignment of motives and skills between the programme and their organizations as a benefit of the partnership. However, they also described misalignments: between the potential and realized value of the programme to businesses and service providers; the programme cycle and business operational processes; and the capacity building approach and businesses' expectations of the service.Conclusions: Although several hallmarks of a well-functioning private-public partnership were evident, misalignments of process and expectations challenged sustained partnership involvement by providers. Careful consideration must be given to the ongoing management functioning of cross-sector engagement and partnering in health promotion practice in order to ensure public health goals are being met, but also that the model is mutually sustainable.

Strong support for broad policies to prevent childhood obesity among mothers in New South Wales, Australia.

ISSUE ADDRESSED: Support for broad policies to prevent childhood obesity is not clear. This study aimed to investigate the level of support for state government health promotion policies among mothers with infants and its associated factors. METHODS: This secondary analysis of data from 1155 mothers in NSW assessed approval for six policy options derived from public health approaches to obesity. Descriptive statistics were used to show the extent of policy approval across the cohort. Logistic regression models tested associations between perceived susceptibility and perceived severity of childhood obesity and approval of each policy option. RESULTS: The proportion of mothers who felt these policy options were 'about the right amount' (56%-68%) or 'not going far enough' (24%-36%), collectively represented 89%-95% approval of government intervention. In comparison, 5%-11% felt that these policies were 'going too far'. Factors associated with their levels of support varied between each policy option, based on mothers' characteristics and perceptions of childhood obesity. CONCLUSION: These findings indicate high support for government intervention to prevent obesity among mothers in NSW and support health promotion advocacy in this area. SO WHAT?: Governments should give due consideration to implementing each of the six policy options and prioritise the implementation of restrictions on fast food advertising in publicly owned or controlled areas.

Navigating infant feeding supports after migration: Perspectives of Arabic and Chinese mothers and health professionals in Australia.

Optimal feeding practices can establish lifelong, transgenerational and global health benefits. Migration and cultural factors impact infant feeding practices and the support mothers receive for optimal infant feeding. This qualitative study explored support for infant feeding among Arabic and Chinese speaking migrant mothers in Australia. Semi-structured focus groups were conducted in language with 24 Arabic and 22 Chinese-Mandarin speaking migrant mothers with children under five years of age. Individual interviews were conducted in English with 20 health professionals working with Arabic or Chinese speaking migrant families. Data were thematically analysed using the framework method. Traditional family networks and trusted bi-cultural doctors were influential infant feeding supports for mothers. Health professionals perceived maternal and child health services to be poorly understood, and some mothers who accessed services felt they were not always culturally sensitive. Mothers sought additional information and support through online sources and peers. Both mothers and health professionals recognised the challenges of managing conflicting infant feeding advice and seeking best-practice support. The findings of this study highlight opportunities for health professionals to better support migrant mothers' infant feeding practices, for example through engaging families and working with doctors. There is a need for greater cultural sensitivity within maternal and child health services and culturally relevant programs to support healthy infant feeding practices among migrant communities.

Implementation of an Early Childhood Healthy Eating and Physical Activity Program in New South Wales, Australia: Munch & Move.

Background: Childhood obesity is an important public health issue. Approximately 20% of 2-4 year olds are overweight or obese, meaning 1 in 5 Australian children start school above a healthy weight. In the state of New South Wales (NSW) the combined prevalence of childhood overweight and obesity is significantly higher among children from low socioeconomic status backgrounds and children from regional, rural and remote areas. This paper describes implementation of a healthy eating and active play program (Munch & Move) for center-based early childhood education and care (ECEC) services aimed at influencing healthy behaviors in young children in NSW, Australia. It shows changes over time including a focus on disadvantaged, Aboriginal and remote communities. It also discusses the challenges and future opportunities for the program. Methods: Routine data in relation to service delivery (reach) and implementation indicators are collected by Local Health District staff. Fifteen implementation indicators (known as practices) were introduced to monitor the implementation of Munch & Move (six related to promoting and encouraging healthy eating, four related to improving physical activity, two related to small screen recreation; and three related to quality of service delivery). Results: As of 30 June 2017, 88.4% of ECEC services have staff trained in Munch & Move. Of the 15 practices related to promoting and encouraging healthy eating, increasing physical activity and improving the quality of service delivery 13 practices saw significant improvements between 2012 and 2017. This was consistent for services with a high proportion of Aboriginal children and for services in disadvantaged and remote communities. There has been a statistically significant increase in the proportion (37.6-81.0%, p < 0.0001) and type of ECEC services (preschools 36.1-81.3%, p < 0.0001, long day care 38.6-81.0%, p < 0.0001, and occasional care 34.0-74.6%, p < 0.0001) that have implemented the program since 2012 as well as in services with a high proportion of Aboriginal children (33.6-85.2% p < 0.0001), services in disadvantaged communities (37.4-83.3% p < 0.001), and services in remote communities (27.8-59.4% p < 0.0139). Discussion: This paper demonstrates that Munch & Move has seen large improvements in the delivery of training, practice achievements and program adoption in ECEC services across NSW including services in disadvantaged and remote communities and that have a higher proportion of Aboriginal children.

The equitable reach of a universal, multisector childhood obesity prevention program (Live Life Well @ School) in Australian primary schools.

OBJECTIVE: The Live Life Well @ School program aims to establish, reinforce and support primary school students (aged 5-11 years) and their families to adopt healthy eating and physical activity behaviours through the implementation of an evidence-based program that focuses on the school curriculum, the school food and physical activity environment, and teacher professional development. This paper examines Live Life Well @ School monitoring data to provide practical insights into program adoption and changes in primary school environments across NSW, particularly in schools characterised as disadvantaged. Type of program: The Live Life Well @ School program provides a universally delivered, state-wide approach to childhood obesity prevention in the primary school setting. The program is a joint initiative between health and education sector agencies. METHODS: The program includes health promotion strategies for primary schools relating to physical activity and nutrition. Adoption of the program is indicated by achievement of evidence-based desirable practices, which are monitored routinely by local health promotion staff using a purpose-built online Population Health Information Management System. Monitoring data are used to provide feedback to schools and identify a staged approach to achieving more desirable practices. Health promotion staff tailor support locally to suit school and community needs, and have additional funding to support socio-economically disadvantaged schools. RESULTS: The program has achieved high reach to schools (82.7%percnt; of the 2570 schools in New South Wales, Australia). Adoption of desirable practices within schools participating in 2017 was 72.9%percnt;. Equitable reach was achieved for schools in areas of socio-economic disadvantage, schools in remote areas and schools with a high propotion of Aboriginal students, who are likely to have higher rates of childhood overweight and obesity. Curriculum-based strategies were more frequently adopted; environmental changes and teacher professional development components were less well adopted. LESSONS LEARNT: The desirable practice approach allows health promotion officers to tailor support by building on school strengths and taking a staged approach to change. Ongoing monitoring of the program provides useful insights that inform quality improvements to the program and implementation process, as well as information on progress towards outcomes. State-wide program targets were adjusted to strengthen impact and focus on desirable practices that were less well achieved. Intentional targeting and tailoring in areas of disadvantage are required to achieve equitable adoption of such a universal health promotion program. Strong relationships at the local level between school champions (teachers and principals) and health promotion staff characterise success.

An assessment of program evaluation methods and quality in Australian prevention agencies.

ISSUE ADDRESSED: This study aimed to examine evaluation methods and quality in Australian health promotion agencies and the factors associated with this. The evidence base for prevention strategies is limited, with the evidence generated through program evaluation by health promotion and disease prevention agencies lacking rigour. Despite the need to improve the quality of evaluation, there is limited evidence of what influences evaluation quality in the prevention field. METHODS: Data were collected using the Evaluation Practice Analysis Survey and an audit and appraisal of evaluation reports. Descriptive analysis was used to examine evaluation characteristics and multivariable regression was used to explore the association between evaluation and organisational attributes and evaluation quality. RESULTS: In total, 392 evaluation reports were reviewed from 78 government and non-government agencies. Process evaluation was conducted most frequently, followed by impact evaluation. Overall evaluation quality was low (median 24.5%). In multivariable regression analysis, only two factors were associated with evaluation quality: health promotion budget (ratio of geometric means 1.53 [95% CI 1.02-2.29]); and, conducting statewide or national prevention programs (1.38 [95% CI 1.05-1.82]). CONCLUSIONS: The findings show that the potential to improve evaluation quality is greatest in smaller organisations that deliver health promotion at a local or regional scale. SO WHAT?: By improving the rigour of existing evaluation, there is opportunity to build the evidence base for prevention strategies, which highlights the importance of embedding the enablers of program learning and evidence generation within health promotion and prevention organisations.

Protocol for an effectiveness- implementation hybrid trial to assess the effectiveness and cost-effectiveness of an m-health intervention to decrease the consumption of discretionary foods packed in school lunchboxes: the 'SWAP IT' trial.

BACKGROUND: At a population level, small reductions in energy intake have the potential to contribute to a reduction in the prevalence of childhood obesity. In many school systems, there is the potential to achieve a reduction in energy intake through modest improvements in foods packed in children's school lunchboxes. This study will assess the effectiveness and cost-effectiveness of a multi-component intervention that uses an existing school-based communication application to reduce the kilojoule content from discretionary foods and drinks consumed by children from school lunchboxes whilst at school. METHODS: A Type I hybrid effectiveness-implementation cluster randomised controlled trial will be conducted in up to 36 primary schools in the Hunter New England, Central Coast and Mid North Coast regions of New South Wales, Australia. Designed using the Behaviour Change Wheel, schools will be randomly allocated to receive either a 5-month (1.5 school terms) multi-component intervention that includes: 1) school lunchbox nutrition guidelines; 2) curriculum lessons; 3) information pushed to parents via an existing school-based communication application and 4) additional parent resources to address common barriers to packing healthy lunchboxes or a control arm (standard school practices). The study will assess both child level dietary outcomes and school-level implementation outcomes. The primary trial outcome, mean energy (kJ) content of discretionary lunchbox foods packed in children's lunchboxes, will be assessed at baseline and immediately post intervention (5 months or 1.5 school terms). Analyses will be performed using intention to treat principles, assessing differences between groups via hierarchical linear regression models. DISCUSSION: This study will be the first fully powered randomised controlled trial internationally to examine the impact of an m-health intervention to reduce the mean energy from discretionary food and drinks packed in the school lunchbox. The intervention has been designed with scalability in mind and will address an important evidence gap which, if shown to be effective, has the potential to be applied at a population level. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN:12618001731280 registered on 17/10/2018. Protocol Version 1.

National policies to prevent obesity in early childhood: Using policy mapping to compare policy lessons for Australia with six developed countries.

Interventions for obesity prevention in early childhood (first 5 years of life) are likely to have a significant preventive health impact. This mapping review identified recommended policy options for the Australian Federal Government (AFG) by comparing countries with similar population, income, and language to Australia. Policies were mapped in six countries using two matrices. The first matrix examined policy context, describing obesity prevention governance. The second matrix examined policy content, compared with global recommendations. Policies were grouped into downstream (healthcare), midstream (lifestyle and settings), and upstream (determinants of health, including food and built environments). Results identified variance in obesity governance across the six countries including policy coherence, leadership, institutional drivers, and overlapping responsibility across different levels of government. While countries tended to have more downstream or midstream policies, upstream policies were more likely when countries had invested in system-wide approaches to obesity such as developing a national obesity strategy, having separate food/nutrition and physical activity plans, and a dedicated preventive health agency. This study recommends a range of initiatives for the AFG to strengthen policies for the prevention of obesity in early childhood, including prioritising the development of a national food/nutrition strategy.

The association between physical activity and hospital payments for acute admissions in the Australian population aged 45 and over.

Physical activity (PA) is a key component of a healthy life, and it is hypothesised that individuals with higher levels of PA utilise fewer hospital resources. Quantifying the association between PA and hospital resource use is of interest to both payers and planners but estimates of its size in the general population are rare. In this paper we provide estimates of the association between PA and payments to hospitals in the Australian population over age 45. We use data from 45 and Up Study, a survey that contains health and lifestyle factors information about approximately 260,000 individuals over age 45 living in NSW, linked to hospital and death data. The linked data set allows to define a unique indicator for the level of PA over the week prior to the survey interview and to calculate payments to hospitals over the next year. We use Coarsened Exact Matching and multivariate analysis to study the relationship between PA and hospital payments, controlling for chronic health conditions, risk factors, standard socioeconomic variables and death. Our results clearly indicate that there is a statistically significant association between PA and lower hospital payments. While the size of the association depends to some extent on the covariates used in the model the conclusions are robust to changes in model specification. We also perform a sub-group analysis and show that the cost savings associated with PA are significantly larger for older and lower income populations. This study shows that if one is interested in lowering hospital expenditures then increasing PA levels is a policy that has the potential of being effective. It also shows that one does not need to target the entire population to achieve cost savings but can limit the intervention to the older population and/or the one in the lowest socioeconomic status.

Linking two randomised controlled trials for Healthy Beginnings©: optimising early obesity prevention programs for children under 3 years.

BACKGROUND: Beginning in 2017 we have conducted a 3-arm randomised controlled trial (RCT) to determine the effectiveness of an early obesity intervention in the first two years of life using either telephone or Short Message Service (SMS) support for mothers. The trial recruited 1155 mothers from their third trimester of pregnancy. This protocol is for a new trial to build on the existing trial using the mother-child dyads retained at 24 months for recruitment to the new RCT. The aim of this new trial is to test whether use of a combination of telephone and SMS interventions is effective in promoting healthy eating and physical activity, as well as reducing child body mass index (BMI) at 3 years of age. METHODS: We will conduct a parallel RCT with an estimated sample of 750 mother-child dyads retained from the existing trial at 24 months. Mothers who completed the 24 months survey, including a telephone survey and measurement of child's height and weight will be invited to participate in the new trial. Informed consent will be obtained at the 24 months survey. The participating mother-child dyads will then be randomly allocated to the intervention (combined telephone and text messaging intervention) or the control group. The intervention will comprise three staged telephone consultations and text messages after each of the three intervention booklets is mailed to mothers at specific time-points between two and three years of child age. The main trial outcome measures include a) BMI and BMI z-score measured at 36 months, b) diet, physical activity and screen time c) cost-effectiveness, and d) feasibility and acceptability of the intervention. DISCUSSION: This unique opportunity to link two studies will expedite project start up time, utilise existing research infrastructure and systems to run the study, and optimise the use of an already engaged population of study participants. It can address a significant knowledge gap regarding early obesity prevention for children aged 2 to 3 years. The feasibility and effectiveness of the combined telephone and SMS intervention will indicate whether this is a scaleable, broad-reach and low-cost early obesity intervention. TRIAL REGISTRATION: The trial was registered with the Australian Clinical Trial Registry ( ACTRN12618001571268 ) on 20/09/2018.

Understanding the factors that influence health promotion evaluation: The development and validation of the evaluation practice analysis survey.

The demand for improved quality of health promotion evaluation and greater capacity to undertake evaluation is growing, yet evidence of the challenges and facilitators to evaluation practice within the health promotion field is lacking. A limited number of evaluation capacity measurement instruments have been validated in government or non-government organisations (NGO), however there is no instrument designed for health promotion organisations. This study aimed to develop and validate an Evaluation Practice Analysis Survey (EPAS) to examine evaluation practices in health promotion organisations. Qualitative interviews, existing frameworks and instruments informed the survey development. Health promotion practitioners from government agencies and NGOs completed the survey (n = 169). Principal components analysis was used to determine scale structure and Cronbach's α used to estimate internal reliability. Logistic regression was conducted to assess predictive validity of selected EPAS scale. The final survey instrument included 25 scales (125 items). The EPAS demonstrated good internal reliability (α > 0.7) for 23 scales. Dedicated resources and time for evaluation, leadership, organisational culture and internal support for evaluation showed promising predictive validity. The EPAS can be used to describe elements of evaluation capacity at the individual, organisational and system levels and to guide initiatives to improve evaluation practice in health promotion organisations.