A Systems Innovation Perspective on Implementation and Sustainment Barriers for Healthy Food Store Interventions: A Reflexive Monitoring in Action Study in Dutch Supermarkets.

BACKGROUND: Healthy food store interventions (HFIs) are an important health-promotion tool, but face implementation and sustainment barriers. This paper aims to explore the underlying factors that produce these barriers using an innovative systems innovation perspective, through the case study of a multi-component HFI. The HFI was implemented in a minor, national, cooperative supermarket chain, in the Netherlands, a competitive market where price-based competition is the norm. METHODS: The HFI was implemented for 6-12 months, in six stores. It was implemented by the researchers, and maintained by store employees. The study applied a Reflexive Monitoring in Action (RMA) approach, meaning that the researchers monitored stores' adherence to the HFI, via store visits, to identify potential issues. Subsequently, the researchers interviewed the store managers responsible for the intervention, to have them reflect upon the barriers leading to these adherence issues, underlying systemic factors, and potential solutions. The stores implemented these solutions, and during the next monitoring visit the researchers evaluated whether the barrier had been resolved. RESULTS: We found that the HFI often clashed with regular activities of the stores (eg, competing over the same spaces) and that store managers generally prioritized these regular activities. This prioritization was based on the greater commercial value of those regular activities (eg, selling unhealthy products) according to store managers, based on their beliefs and assumptions about commerce, health, and consumer preferences. Due to the limited resources of supermarkets (eg, people, time, space), and the HFI often not fitting within the existing structures of the stores as easily as traditional practices, store managers often neglected the HFI components in favor of regular store activities. CONCLUSION: Our findings illustrate the systemic factors that produce implementation barriers for HFIs, and the dynamics by which this production occurs. These insights help future researchers to anticipate and respond to such barriers.

Shape-shifting versions of class in Australia and the pursuit of equity in public health.

The COVID-19 pandemic and current cost of living crisis have highlighted socioeconomically patterned health disparities, bringing renewed focus on equity in public health. Despite political rhetoric invoking cultural narratives of egalitarianism and opportunities for class mobility, social class remains a significant factor in health outcomes in the Australian context. For social scientists, class (despite robust critiques) is a key analytical concept that has been theoretically broadened to encompass social and cultural practices (habitus). In public health, however, concepts of social disadvantage have expanded toward frames such as health equity and socioeconomic status in ways that can obscure 'class' and habitus. Understandings and operationalization of concepts of class and equity not only impact collaborative and interdisciplinary relationships, but also the framing of public health problems and health promotion interventions and policies. In this article, we draw on our experiences as anthropologists conducting ethnography in and of Australian health promotion programs to map and re-evaluate the intersection of concepts of social class and equity. We trace how representations of class emerged in these programs, and the versions of class and equity that materialized across different public health contexts. We argue for a conceptual repositioning of class that recognizes its shape-shifting qualities and of its materializations in different politics, disciplines and everyday contexts. In doing so, we highlight 'class' as a salient dimension of the design, implementation and evaluation of health promotion programs.

Home Together: A Multi-Level Community-Based Health Promotion Program Supporting Families Experiencing Homelessness.

Home Together (HT) is a multi-level multi-component health promotion program, co-led by academic and non-profit partners in Arkansas that sought (1) to improve access to and family acceptance of social services and health care among women experiencing homelessness who have a diagnosed mental health condition and a child younger than six years and (2) to increase service provider capacity to engage with this population. A socioecological perspective was used to detail program components and lessons learned. Home Together enrolled 345 women representing unduplicated families. Of these, 214 completed six-month reassessments and 111 completed discharge assessments. Representative of the area and population served, most self-identified as belonging to racial minorities (87.0%), being younger than 35 years (80.1%), experiencing violence (76%), and being heterosexual (82%). Pre-post testing indicated positive changes for HT families, including improvements in mental health, health care access, and housing. Yet, even the most coordinated comprehensive programs are no substitute for policy-level changes that help families reach stability.

Promoting nutrition literacy in children: a case study of a community partnership between a university and an elementary school.

Background: Health literacy outreach is commonplace within public and hospital libraries but less so in academic libraries, where it is often viewed as not integral. Academic health science libraries may collaborate with public libraries to provide public health information literacy programming or "train the trainer" sessions, but examples of academic health science librarians leading community health initiatives are still limited. Case Presentation: This case report discusses a collaborative project between Gonzaga's Foley Center Library, the School of Nursing and Human Physiology, and a local elementary school to promote health literacy for students and their families, led by an Academic Health Sciences Librarian. The project scope included delivering nutrition education to elementary school students and their families, but pandemic closures limited plans for in-person programming. Conversations with stakeholders led to additional project opportunities, including tabling at the local block party, collaborating on a campus visit for 5th and 6th graders, supporting middle school cooking classes, and the creation of a toolkit for elementary and middle school teachers to support curriculum about healthy body image and potential disordered eating. Conclusion: This project demonstrates one example of how academic libraries can partner with other campus departments to support health literacy outreach in their local communities. The pandemic made planning for in-person programming tenuous, but by expanding meetings to include staff from other areas of the university, the project team was able to tap into additional outreach opportunities. This work fostered close relationships with the local elementary school, providing the groundwork for collaborative health programming in the future, though more thorough assessment is suggested for future projects.

Towards an integrative approach of healthcare: implementing positive health in three cases in the Netherlands.

BACKGROUND: The healthcare system is under tremendous pressure. One possible solution towards relieving some of this pressure is to use Positive Health, which takes 'health' as a starting point, rather than 'illness'. Positive Health provides opportunities for stimulating integrated care. METHODS: Three cases in the Netherlands are studied in this paper. Their way of working with Positive Health is investigated through semi-structured and narrative interviews, using realist-evaluation and thematic analyses. RESULTS: Seven 'working elements' are identified that enhance the chances of successfully implementing Positive Health in practice (part 1). The interviews show that healthcare professionals have noticed that people adopt a healthier lifestyle and gain a greater degree of control over their own health. This boosts job satisfaction for healthcare professionals too. The organisations and professionals involved are enthusiastic about working with Positive Health, but still experience barriers (part 2). CONCLUSIONS: The results of this study imply that implementing Positive Health in practice can facilitate collaboration between organisations and professionals from different disciplines, such as healthcare, welfare, and municipal health services. Operating from the perspective of a shared goal, professionals from different disciplines will find it easier to jointly organise activities to foster citizens' health. Additionally, more attention is paid to non-medical problems affecting people's well-being, such as loneliness or financial problems.

The Perils of Partnership: Interactions Between Public Health England, Drinkaware, and the Portman Group Surrounding the Drink Free Days Campaign.

BACKGROUND: There is growing evidence that the alcohol industry seeks to obstruct public health policies that might affect future alcohol sales. In parallel, the alcohol industry funds organisations that engage in "responsible drinking" campaigns. Evidence is growing that the content and delivery of such campaigns serves industry, rather than public health interests, yet these organizations continue to be the subject of partnerships with government health departments. This study aimed to examine the nature and potential impacts of such partnerships by analysing the practices of the alcohol industry-funded charity Drinkaware during the establishment of the Drink Free Days campaign. METHODS: A case study based on an inductive analysis of documents revealed by freedom of information (FoI) request regarding communications between Drinkaware, Public Health England (PHE), and the Portman Group, in the years running up to, and during, the Drink Free Days campaign, a partnership between alcohol industry-funded charity Drinkware, and PHE. RESULTS: This study reveals a range of less visible, system-level effects of such partnerships for government departments and civil society. The tensions observed, as exhibited by discrepancies between internal and external communications, the emphasis on managing and mitigating the perception of negative consequences, and the links to wider alcohol industry initiatives and bodies, suggest the need for wider considerations of organizational conflicts of interest, and of possible indirect, harmful consequences to policy-making. These include the marginalization of other civil society voices, the displacing of more effective policy options, and strategic alignment with other industry lobbying activities. CONCLUSION: The findings have implications for how public health practitioners and health organisations might better weigh the potential trade-offs of partnership in the context of health promotion campaigns.

Culture circle in primary care: dialogues with managers on health promotion.

OBJECTIVE: To identify health promotion strategies used by managers in primary health care. METHOD: Qualitative research, of a participant action nature, which adopted the Culture Circle proposed by Paulo Freire as its methodological reference. Eleven primary health care managers from a medium-sized municipality in southern Brazil took part. RESULTS: Nine generative themes emerged, categorized into four themes that highlight the interconnection between health promotion, social determinants and primary health care. These themes highlight preventive approaches, healthy habits and underline the need for a multidisciplinary approach to health care, recognizing the complexity of the dimensions involved, the influence of social determinants, environmental and health issues. These aspects call for intersectoral policies and actions, demonstrating the viability of health promotion in line with the principles of the Unified Health System. FINAL CONSIDERATIONS: The autonomy of professionals working in primary health care services is highlighted, especially that of nurses, who play a central role in connecting and organizing health promotion actions.

A Conceptual Primer on the Potential of Adaptive Policies to Reduce Physical Inactivity.

BACKGROUND: Despite the existence of physical activity policies across many countries, insufficient physical activity remains a major global public health problem. Physical inactivity is an emergent feature of complex systems; it results from a wide range of factors at multiple levels that interact to influence behavior. Traditional approaches to public policy often fail within complex systems, largely due to unpredictability in how the system will respond. Adaptive policies, which are designed to allow for uncertainty about future system behavior and to change over time, may offer a promising solution. In this paper, we introduce the concept of adaptive policies and illustrate how this innovative approach to policy making may be beneficial for reducing physical inactivity. DESIGN: Drawing on existing literature and guiding principles for policy making, we provide 3 examples to illustrate how the concept of adaptive policies can be applied to address physical inactivity. DISCUSSION: The examples illustrate how changes to the way policies and interventions are developed, implemented, and evaluated could help to overcome some of the limitations in existing practices. A key challenge will be engaging policymakers to take a broader perspective of the physical activity system, develop policies that are designed to be adaptable across a range of different future scenarios, and embrace uncertainty and long-term adaptability. CONCLUSION: Adaptive policies may support decision makers globally to achieve the widespread and sustained changes necessary to increase population levels of physical activity.

A Comprehensive Planning Framework for Designing Effective Physical Activity Interventions in Youth.

BACKGROUND: Effective physical activity (PA) interventions are needed to counter the insufficient and declining levels of PA in youth. These require an updated, comprehensive planning framework that consolidates recent decades of progress in promoting PA in young children, children, and adolescents. Effective PA interventions require program planning and conceptual model development that target a coordinated and multilevel set of age-specific PA determinants. Accordingly, this paper presents a comprehensive planning framework that researchers can use to design intervention research to promote PA in youth. METHODS: The first author conducted targeted searches through Google Scholar to compile PA models/frameworks/guides applicable to youth, a comprehensive set of PA determinants, and determinant-linked strategies to promote PA focusing on review articles. The information was summarized in tables, synthesized, and used to create a planning framework, all of which were reviewed by coauthors. RESULTS: The APPLE Framework for Planning PA Opportunities for Youth (APPLE = Age, PA focus, Place and time, Leverage relevant influences and strategies, and ensure Enjoyable PA opportunities) incorporated all core elements from targeted reviews to create a comprehensive planning framework. The APPLE Planning Framework has a set of questions/prompts that guide the intervention planning process and conceptual model templates to organize planning efforts for designing intervention research. CONCLUSIONS: The APPLE Framework for Planning PA Opportunities for Youth will enable researchers to develop comprehensive conceptual models to guide the design of PA interventions for youth. Future research should refine the model and its components to enable PA intervention research in youth to move forward.

A community case detection tool to promote help-seeking for mental health care among children and adolescents in Ugandan refugee settlements: a stepped wedge cluster randomised trial.

BACKGROUND: Strategies to promote mental health care help-seeking among children are needed, especially in low-income and middle-income countries and in complex settings. The aim of this trial was to compare a vignette-based, community-level, proactive case detection tool (CCDT) against standard awareness raising for promoting mental health help-seeking among children and adolescents. METHODS: This stepped wedge cluster randomised trial was conducted in the Bidi Bidi, Kyaka II, Kyangwali, Omugo, and Rhino refugee settlements in Uganda. Community gatekeepers received a 2-day training session on using the CCDT to proactively detect children with mental health concerns and encourage children (or their caregivers) to use the mental health-care service run by Transcultural Psychosocial Organization Uganda. At baseline, organisations implemented routine detection or mental health awareness-raising activities. At cross-over to CCDT implementation, gatekeepers used the tool in their daily activities. The primary outcome was mental health-care service use by children and adolescents. Child population size estimates at the zone level were not available. Therefore, service use was calculated using total population size. We report the effect of CCDT implementation as an incidence rate ratio (IRR), which we produced from a model that accounts for calendar time, exposure time, and person-time. IRRs were estimated for the analysis of effect over time in the per-protocol and intention-to-treat populations. The trial is registered with the ISRCTN registry, number ISRCTN19056780. FINDINGS: 28 administrative zones were selected for trial participation by October, 2021. Between Jan 1, and Nov 8, 2022, seven clusters of four zones sequentially crossed over from routine care to CCDT implementation in 1-month intervals. The CCDT was implemented by 177 trained community gatekeepers. In 9 months, 2385 children visited a mental health-care service; of these, 1118 (47%) were girls and 1267 (53%) were boys (mean age 12·18 years [SD 4.03]). 1998 children made a first or re-entry visit to a service; of these, 937 (47%) were girls and 1061 (53%) were boys (mean age 12·08 years [SD 4·06]). Compared to standard awareness-raising activities, CCDT implementation was associated with an increase in mental health-care service use in the first month after implementation (20·91-fold change [95% CI 12·87-33·99]). Despite a slight decline in service use over time in both the CCDT and pre-CCDT zones, CCDT zones maintained a time-average 16·89-fold increase (95% CI 8·15-34·99) in mental health service use. INTERPRETATION: The CCDT enabled community gatekeepers to increase mental health-care service use by children and adolescents. Vignette-based strategies rooted in the community could become a valuable contribution towards reducing the mental health-care gap among children, especially when accompanied by accessible mental health-care services. FUNDING: Sint Antonius Stichting Projects. TRANSLATIONS: For the Arabic, French and Spanish translations of the abstract see Supplementary Materials section.

Inuit youth health and wellbeing programming in Canada.

Inuit youth face challenges in maintaining their wellbeing, stemming from continued impacts of colonisation. Recent work documented that urban centres, such as Winnipeg Canada, have large Inuit populations comprised of a high proportion of youth. However, youth lack culturally appropriate health and wellbeing services. This review aimed to scan peer-reviewed and grey literature on Inuit youth health and wellbeing programming in Canada. This review is to serve as an initial phase in the development of Inuit-centric youth programming for the Qanuinngitsiarutiksait program of research. Findings will support further work of this program of research, including the development of culturally congruent Inuit-youth centric programming in Winnipeg. We conducted an environmental scan and used an assessment criteria to assess the effectiveness of the identified programs. Results showed that identified programs had Inuit involvement in creation framing programming through Inuit knowledge and mostly informed by the culture as treatment approach. Evaluation of programs was diffcult to locate, and it was hard to discren between programming, pilots or explorative studies. Despite the growing urban population, more non-urban programming was found. Overall, research contributes to the development of effective strategies to enhance the health and wellbeing of Inuit youth living in Canada.

Roles, Responsibilities, and Functions of Village Health, Sanitation, and Nutrition Committees in India: A Qualitative Evidence Synthesis.

National Health Mission instituted the Village Health, Sanitation, and Nutrition Committees (VHSNCs) in 2005, with an aim of ensuring health and well-being for local communities in India. There is a lack of concrete evidence on the functioning of VHSNCs at a national level. Thus, this study was undertaken to outline the roles, responsibilities, and functions of VHSNCs in India. We conducted a comprehensive data search in Medline, Cochrane Library, ScienceDirect, EMBASE, and Google Scholar between 2005 and August 2021. All peer-reviewed qualitative studies that reported the roles, responsibilities, functions, and good practices of VHSNCs from India were included in our review. Critical Appraisal Skills Programme checklist was used to assess the quality of individual studies. In total, we included 15 studies (including 1100+ VHSNCs) from various states of India. Our review highlighted that the majority of the VHSNCs functioned without a clear-cut definition of roles and responsibilities had irregular meetings and workforce shortage. There was a lack of inclusivity, accountability, and delay in the processing of untied funds. The included studies have showed that VHSNCs were involved health promotional activities such as formulation and implementation of village health plans, delivery of services through public distribution systems, ensuring safe drinking water and sanitary supervision, and identification and referral of malnourished children. Our review highlights the crucial role that VHSNCs play in improving the health outcomes of rural populations and underscores the need for continued support and capacity-building efforts to ensure their effectiveness.

Narcanazo: Community Activation of Antiracist Epidemiology.

The Latinx (Hispanic) social construct obscures differences in the overdose risk levels of groups within this category. When national data are disaggregated, stateside Puerto Rican mortality increases exponentially, so much that this community has the highest rates of overdose deaths across years. Developed by Bronx-based Puerto Ricans, Narcanazo is an empowered upstander campaign that uses local overdose data to mobilize community members as trained naloxone dispensers. This health promotion campaign was grounded in antiracist epidemiological analysis. (Am J Public Health. 2024;114(S6):S463-S466. https://doi.org/10.2105/AJPH.2024.307605) [Formula: see text].

Talents, Tears, Stories of Our Identities, and Community Building: Toward Community-Based Ecosystems of Latiné Health Driven by Promotores.

This essay describes a process for integrating US Latiné communities as drivers of a grassroots vision for healthy Latiné communities and health equity planning that addresses racial injustices. Transforming structural conditions to promote Latiné community health happens alongside creating conditions for community-level self-determination to foster community-based ecosystems of health. Integrating a life course perspective, we describe a vision for community-based ecosystems of Latiné health that is rooted in forging connections and cultivating community; building community power to address structural drivers of health; leveraging the expertise and assets of promotores to reach, engage, and mobilize communities; scaling solutions through policy, system, and environment changes; and grounding research processes in community-driven priorities. Such processes must affirm the expertise of promotores and Latiné communities and recognize the interconnectedness of communities and systems (e.g., food, housing, living wages) to nurture health at local levels. Research can advance the science and evidence-based models that support community-based ecosystems of Latiné health. (Am J Public Health. 2024;114(S6):S525-S533. https://doi.org/10.2105/AJPH.2024.307763) [Formula: see text].