Telephone and Web-Based Delivery of Healthy Eating and Active Living Interventions for Parents of Children Aged 2 to 6 Years: Mixed Methods Process Evaluation of the Time for Healthy Habits Translation Trial.

BACKGROUND: Few translational trials have provided detailed reports of process evaluation results. OBJECTIVE: This study reported on findings from a mixed methods process evaluation of a large translational trial comparing 2 remotely delivered healthy eating and active living interventions with an active control, targeting parents of young children. METHODS: Mixed methods process evaluation data were collected as part of a 3-arm, partially randomized preference trial targeting parents of children aged 2 to 6 years from New South Wales, Australia. Recruitment strategies were assessed through the participant baseline questionnaire and a questionnaire completed by the health promotion staff involved in recruitment. Data on participants' intervention preferences were collected at baseline and after the intervention. Intervention acceptability and demographic data were collected via a postintervention questionnaire (approximately 3 months after baseline), which was supplemented by qualitative participant interviews. Implementation data on intervention fidelity and withdrawal were also recorded. Differences in intervention acceptability, fidelity, and withdrawal rates between telephone and web-based interventions and between randomized and nonrandomized participants were analyzed. The significance level was set at P<.05 for all tests. The interview content was analyzed, key themes were drawn from participant responses, and findings were described narratively. RESULTS: Data were collected from 458 participants in the baseline survey and 144 (31.4%) participants in the 3-month postintervention survey. A total of 30 participants completed the qualitative interviews. A total of 6 health promotion staff members participated in the survey on recruitment strategies. Most participants were recruited from Early Childhood Education and Care services. There was a broad reach of the study; however, better take-up rates were observed in regional and rural areas compared with metropolitan areas. Parents with a university education were overrepresented. Most participants preferred the web-based medium of delivery at baseline. There was high acceptability of the web-based and telephone interventions. Participants found the healthy eating content to be the most useful component of the modules (web-based) and calls (telephone). They regarded text (web-based) or verbal (telephone) information as the most useful component. A high proportion of participants completed the telephone intervention compared with the web-based intervention; however, more participants actively withdrew from the telephone intervention. CONCLUSIONS: This is one of the first studies to comprehensively report on process evaluation data from a translation trial, which demonstrated high acceptability of all interventions but a strong participant preference for the web-based intervention. This detailed process evaluation is critical to inform further implementation and be considered alongside the effectiveness outcomes.

Translation of two healthy eating and active living support programs for parents of 2-6 year old children: a parallel partially randomised preference trial protocol (the 'time for healthy habits' trial).

BACKGROUND: Parents are key decision makers and role models in establishing and maintaining healthy behaviours in their children. Interventions involving parents have been shown to be more effective than those that do not, but there are barriers to participation. Efficacy trials have previously been conducted on two such parent-focussed healthy eating and active living interventions with the potential to overcome these barriers - Healthy Habits (telephone-based) and Time2bHealthy (online) with promising results. Further research is now required to determine the effectiveness of these interventions in a real-world context. The Time for Healthy Habits study is a 3-arm partially randomised preference trial which aims to evaluate the effectiveness and cost-effectiveness of two theory-based programs to promote healthy eating and appropriate levels of movement behaviours (physical activity, sedentary behaviour and sleep) for parents of 2- to 6-year-old children (Healthy Habits Plus telephone-based program and Time2bHealthy online program), when compared to a comparison group receiving written materials. METHODS: Participants will be recruited across five Local Health Districts in New South Wales, Australia. The partially randomised preference design initially allows for participants to decide if they wish to be randomised or opt to select their preferred intervention and has been recommended for use to test effectiveness in a real-world setting. Both interventions incorporate multiple behaviour change techniques and support parents to improve their children's healthy eating, and movement behaviours (physical activity, sedentary behaviour and sleep) and run for 12 weeks, followed by a 3-month and 9-month post-baseline follow-up. Participants will also be asked to complete a process evaluation questionnaire at the completion of the intervention (3-months post-baseline). Outcomes include fruit and vegetable intake (primary outcome), non-core food intake, weight status, physical activity, sedentary behaviour, and sleep habits. DISCUSSION: To our knowledge, this is the first translational research trial evaluating the effectiveness and cost-effectiveness of a healthy eating and active living intervention in the 2- to 6-years age group. The results will build the evidence base in regard to translation of effective childhood obesity prevention interventions and inform the implementation and delivery of community based childhood obesity prevention programs. TRIAL REGISTRATION: UTN: U1111-1228-9748, ACTRN: 12619000396123p.

Results of a mixed methods evaluation of the Make Healthy Normal campaign.

The Make Healthy Normal obesity prevention mass media campaign was implemented in New South Wales, Australia from 2015 to 2018. This study evaluated Phase 2 (2017-18) of that campaign, using three cross-sectional online surveys with men aged 18-54 years (n = 4352) and six focus groups with men aged 35-54 years and parents with children aged 5-12 years (n = 38), reflecting the campaign's target audiences. We used linear and logistic regressions to examine changes over time in key outcomes, consistent with the campaign's theorized hierarchy of effects. Focus group data were analysed thematically and integrated with survey results at the interpretation stage. Survey results showed reasonable prompted recognition, although unprompted recall remained low, and there were no consistent, positive shifts in other outcomes, including behaviour. Focus group results suggested that this was because the campaign's messages, while considered clear and relevant, did not address the constraints participants experienced that made change difficult. Hence, the campaign by itself was unlikely to lead to behaviour change. We need to reconsider the role of campaigns in addressing multi-determined and complex problems. Evaluations should reconsider metrics of success, as they may not immediately result in behaviour change, especially in the absence of complementary policy and environmental strategies.

Campbelltown - Changing our Future: study protocol for a whole of system approach to childhood obesity in South Western Sydney.

BACKGROUND: In Australia, around 67% of adults and 25% of children (5-17 years) are currently overweight or obese (Australian Bureau of Statistics, 4364.0.55.001 - National Health Survey: First Results, 2017-18, 2018). The Campbelltown - Changing our Future study will translate 'a whole of system' approach, previously trialed in rural communities in Victoria and the Australian Capital Territoty, to Campbelltown Local Government Area (LGA), a socioeconomically and ethnically diverse urban community in south western Sydney, NSW. METHODS: The study intervention will use a five-step approach; 1 - set up a childhood obesity monitoring system by collecting baseline data from children in primary schools across Campbelltown LGA to give a local context to the community when developing the systems map; 2 - key stakeholders develop systems maps which inform the development of the interventions; 3 - key stakeholders and community groups identify priority areas for action and form working groups; 4 - implementation of the interventions; 5 - evaluation of the interventions. The study will adopt a longitudinal pre/post design with repeated measures at baseline, 2 years and 4 years. Both qualitative and quantitative methods will be used to collect and analyse the data. DISCUSSION: Addressing childhood overweight and obesity is complex and requires a multifaceted intervention. This approach has the capacity to impact a range of factors that influence childhood overweight and obesity utilising existing capacity of multiple partners with broad community reach. Findings will develop local responses which capture the complexity of obesity at a community level and further our understanding of the interrelationships and relative importance of local factors impacting childhood overweight and obesity. This study aims to provide evidence for systems methods and approaches suitable for adaption and scaling and may provide evidence of successful community intervention elements.

The effect of sugar-sweetened beverage front-of-pack labels on drink selection, health knowledge and awareness: An online randomised controlled trial.

PURPOSE AND AIM: Sugar-sweetened beverages (SSBs) provide little nutritional value and are associated with an increased risk of diet-related diseases. Despite this, SSB consumption is high globally. One emerging strategy aimed at reducing SSB consumption involves the use of front-of-pack (FOP) labels that clearly identify the risks associated with SSB consumption. The aim of this research study was to determine whether FOP labels with a graphic warning, text warning, sugar information (with the number of teaspoons of added sugar) or Health Star Rating (HSR) reduces intended choice of a SSB in an online choice experiment with young Australian adults. RESULTS: 994 participants were recruited and completed the online choice experiment. Compared to the control group who were not exposed to a label, the graphic warning, text warning, sugar information and HSR labels all significantly reduced selection of a SSB in the choice scenario. The magnitude of effect was greatest for the graphic warning label (OR 0.22 95% CI 0.14-0.35). Compared to the control group, only the HSR label significantly increased selections of the high HSR drinks (OR 2.18 95% CI 1.20-3.97). CONCLUSIONS: FOP labels, particularly those with graphic warnings, have the potential to reduce intended SSB purchases. Labels that also identify healthier alternatives may influence consumers to substitute SSBs with healthier drinks.

Integrating relationship- and research-based approaches in Australian health promotion practice.

We examine the perspectives of health promotion practitioners on their approaches to determining health promotion practice, in particular on the role of research and relationships in this process. Using Grounded Theory methods, we analysed 58 semi-structured interviews with 54 health promotion practitioners in New South Wales, Australia. Practitioners differentiated between relationship-based and research-based approaches as two sources of knowledge to guide health promotion practice. We identify several tensions in seeking to combine these approaches in practice and describe the strategies that participants adopted to manage these tensions. The strategies included working in an evidence-informed rather than evidence-based way, creating new evidence about relationship-based processes and outcomes, adopting 'relationship-based' research and evaluation methods, making research and evaluation useful for communities, building research and evaluation skills and improving collaboration between research and evaluation and programme implementation staff. We conclude by highlighting three systemic factors which could further support the integration of research-based and relationship-based health promotion practices: (i) expanding conceptions of health promotion evidence, (ii) developing 'relationship-based' research methods that enable practitioners to measure complex social processes and outcomes and to facilitate community participation and benefit, and (iii) developing organizational capacity.

Evaluation of a mental health screening tool using cross-sectional surveys in a workplace setting.

OBJECTIVES: The Brief Health Check (BHC) is a health screener used by the Get Healthy at Work programme, which identifies workers with chronic disease risk and provides them with advice and referrals to support services. The BHC was revised to include mental health to provide a holistic approach to workplace health. This study aimed to evaluate the acceptability and appropriateness of the revised BHC by comparing the results around psychological distress and future risk with previous research, and a participant feedback survey. METHOD: Data collection took place between October 2018 and May 2019. The study used data that were collected as part of programme delivery, as well as a participant feedback survey that was administered after the health check was completed. RESULTS: BHCs were completed by n=912 workers, out of which, n=238 completed the feedback survey. The mean Distress Questionnaire 5 score was 10.5, and 10% of participants met the threshold for 'high' future risk. The feedback survey revealed that the majority of participants found the mental health advice to be useful (76%), agreed with their mental health distress and risk ratings (92%-94%) and most intended on using the referred services (62%-68%). CONCLUSION: The findings around mental health risk were comparable to previous findings in employed samples. The inclusion of mental health assessments, advice and referral pathways into the BHC was found to be acceptable and the subsequent referrals were appropriate, indicating that this approach could be scaled up and implemented to help address worker's mental ill health.

Translation of Two Healthy Eating and Active Living Support Programs for Parents of 2-6-Year-Old Children: Outcomes of the 'Time for Healthy Habits' Parallel Partially Randomised Preference Trial.

This translation study assessed the effectiveness of two remotely delivered healthy eating and active living interventions for parents of 2- to 6-year-old children in improving child fruit and vegetable intake, non-core food intake, body mass index (BMI), physical activity, screen time, and sleep. Parents (n = 458) were recruited to a partially randomised preference trial comprising three intervention groups. Healthy Habits Plus comprised six telephone calls, Time2bHealthy comprised six online modules, and the active control comprised ten information sheets and a summary booklet. Data were collected from parents via a telephone questionnaire at baseline and nine months post-baseline. Data were analysed for randomised participants alone (n = 240), preference participants alone (n = 218), and all participants combined (n = 458). There was no significant improvement in fruit and vegetable intake (primary outcome) when comparing the telephone and online interventions to the control. In both the randomised only and all participants combined analyses, there was a significant improvement in non-core food intake for the telephone intervention compared to the control (p < 0.001). Differences between interventions for other outcomes were small. In conclusion, the telephone and online interventions did not improve child fruit and vegetable intake relative to written materials, but the telephone intervention did improve non-core food intake.

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.

Generating Engagement on the Make Healthy Normal Campaign Facebook Page: Analysis of Facebook Analytics.

BACKGROUND: Facebook is increasingly being used as part of mass media campaigns in public health, including the Make Healthy Normal (MHN) campaign in New South Wales, Australia. Therefore, it is important to understand what role Facebook can play in mass media campaigns and how best to use it to augment or amplify campaign effects. However, few studies have explored this. OBJECTIVE: This study aimed to investigate usage of and engagement with the MHN Facebook page and to identify influential factors in driving engagement with the page. METHODS: We examined both post-level and page-level analytic data from Facebook from the campaign's launch in June 2015 to September 2017. For post-level data, we conducted a series of negative binomial regressions with four different outcome measures (likes, shares, comments, post consumers), including some characteristics of Facebook posts as predictors. We also conducted time series analyses to examine associations between page-level outcomes (new page likes or "fans" and number of engaged users) and different measures of exposure to the page (number of unique users reached and total count of impressions) and to television advertising. RESULTS: Of the 392 posts reviewed, 20.7% (n=81) received a paid boost and 58.9% (n=231) were photo posts. We found that posts that received a paid boost reached significantly more users and subsequently received significantly more engagement than organic (unpaid) posts (P<.001). After adjusting for reach, we found the effect of being paid was incremental for all outcome measures for photos and links, but not videos. There were also associations between day of the week and time of post and engagement, with Mondays generally receiving less engagement and posts on a Friday and those made between 8 AM and 5 PM receiving more. At the page level, our time series analyses found that organic impressions predicted a higher number of new fans and engaged users, compared to paid impressions, especially for women. We also found no association between television advertising and engagement with the Facebook page. CONCLUSIONS: Our study shows that paying for posts is important for increasing their reach, but that page administrators should look to maximize organic reach because it is associated with significantly higher engagement. Once reach is accounted for, video posts do not benefit from being paid, unlike the other post types. This suggests that page administrators should carefully consider how they use videos as part of a Facebook campaign. Additionally, the lack of association between television advertising and engagement suggests that future campaigns consider how best to link different channels to amplify effects. These results highlight the need for ongoing evaluation of Facebook pages if administrators are to maximize engagement.

From awareness to behaviour: Testing a hierarchy of effects model on the Australian Make Healthy Normal campaign using mediation analysis.

The Make Healthy Normal mass media campaign was a three-year campaign launched in 2015 in New South Wales (NSW), Australia to address community norms around overweight and obesity. It was underpinned by a hierarchy of effects model; a commonly used framework in campaigns but one that has rarely been tested. The campaign evaluation included a cohort study of NSW adults, surveyed three times over 12 months (n = 939 at Wave 3). This study tested the campaign's hierarchy of effects model, which theorized that participants would move from recognition to behaviour change via understanding, knowledge, attitude, social norms, self-efficacy, and intention, using these data. We used the moderation and mediation of effects method proposed by Baron and Kenny, adjusting for age and sex, to test for progression through the hierarchy of effects for two outcomes: physical activity and fast food consumption. We found a clear progression through the theorized model, from recognition through to behaviour change, via the intermediate variables for both outcomes. We also found several effects not predicted by the theorized model, with consistently strong associations between understanding and attitude, understanding and self-efficacy, attitude and self-efficacy, and self-efficacy and behaviour change in both outcome models. Our study provides support for the hierarchy of effects as a conceptual model in campaign planning and evaluation of social marketing campaigns. To our knowledge, this is the first study to compare the hierarchy between two behavioural outcomes and the consistency observed between the models adds to the potential usefulness of the hierarchy of effects.

Impact of the Make Healthy Normal mass media campaign (Phase 1) on knowledge, attitudes and behaviours: a cohort study.

OBJECTIVE: To determine the impact of the first phase of the Make Healthy Normal mass media campaign on NSW adults' active living and healthy eating knowledge, attitudes, intentions and behaviour. METHODS: Cohort design with NSW adults, followed up three times over 12 months, with n=939 participants completing all three waves. We used generalised linear mixed models to examine campaign awareness, knowledge, attitudes, intentions and behaviours over time. RESULTS: Campaign recognition built to a reasonable level (45% at Wave 3), although unprompted recall was low (9% at Wave 3). There were significant increases in knowledge of physical activity recommendations (46% to 50%), the health effects of obesity (52% to 64%), and weight loss benefits (53% to 65%), with stronger effects in campaign recognisers. Conversely, we found declines in self-efficacy and intention to increase physical activity (39% to 31%) and decrease soft drink consumption (31% to 24%). CONCLUSIONS: Overall, there are some positives for the campaign but intentions need to be a focus of future campaign phases. Continued investment over the medium- to long-term is needed. IMPLICATIONS: Mass media campaigns can play a role in obesity prevention but robust evaluations are needed to identify the characteristics of effective campaigns.